Patient Education Essential in Underserved Communities
The nurse practitioner allowed burnout to affect her work and to cause her to make assumptions about her patient.
Ms D, 42, was a nurse practitioner (NP) working in a federally funded clinic in a low-income area. When she first became an NP, about 15 years prior, she had big dreams about her role in improving patients' health. She knew right away that she wanted to work in an underserved community and began her career with great enthusiasm. Ms D had begun her current position with the clinic 10 years ago. She had been optimistic when she started, imagining that she was going to make a big difference in her patients' lives, and sometimes she did. But after a few years, she started to feel irritable at work. She was annoyed when patients were noncompliant with their medication or did not show up for follow-up appointments. She began to feel taken advantage of — she could have taken a job in a better area or with higher pay, but she had chosen to do this.
After 10 years in her job, her heart was no longer in it. Ms D functioned as a primary care provider, treating patients for a variety of conditions. She typically saw between 15 and 20 patients per day. Although she worked under the direction of a collaborating physician, she did not find it necessary to consult with him that often.
Every day was starting to feel like the next, a series of patients, mostly uneducated, some barely speaking English, who did not listen to her recommendations, did not follow her advice, and did not heed her warnings.
One day in the spring of 2008, a new patient came in. Mr K was a heavy-set, 28-year old, African-American man who had been referred to the clinic after a pre-employment screening revealed very high blood pressure. At the clinic, Mr K's blood pressure was 210/170 mm Hg. Ms D gave the patient clonidine in the office, which immediately lowered his blood pressure to 200/130 mm Hg. “You need to watch what you eat,” she told him. She ordered routine lab work, noted “hypertension and obesity” in his file, and gave him some blood pressure medication to take home. She told him to come back in a week. When he did not return, Ms D was not surprised.
But 2 years later, Mr K showed up again. He had not taken any blood pressure medication within the last 2 years. Again, his blood pressure was flagged during a screening at work, and he returned to the clinic. Ms D quietly wrote “noncompliant” in his file. Mr K's blood pressure was 240/150 mm Hg. Ms D gave the patient clonidine, which lowered his blood pressure to 200/110 mm Hg and wrote him a prescription for hypertension medication. She instructed the patient to return in a week, but he did not return for 3 weeks. Ms D saw the patient 10 times between July 2010 and October 2012. His blood pressure was consistently extremely high. The patient and clinician occasionally argued about his medication. Periodically, he would stop taking one of his medications because he thought it was not working or was causing side effects. Ms D noted in his file that his hypertension was “uncontrolled” and that he was noncompliant.
Mr K's original lab work was done in 2008. Ms D did not order any new lab work until 2011, but she failed to look at the results, which never made it into the patient's file. In 2012, Ms D ordered lab tests and reviewed the results a few days later. They showed extensive kidney damage. Again, Ms D never told the patient about his results. Two months later, Mr K collapsed at work and was hospitalized. He was diagnosed with stage V chronic kidney disease due to poorly controlled hypertension. For the next 3 years, Mr K required hemodialysis until he was able to receive a kidney transplant.
After his years of medical treatment, Mr K consulted with a plaintiff's attorney who advised Mr K to sue. “The clinic is federally funded, so we will actually be suing the United States in Federal District Court,” the attorney stated.
Although Ms D was not being individually sued, the lawsuit was based on her negligence, so she spoke to the defense attorney. After reviewing all the information, the patient's medical records, and the reports from the medical experts, the attorney looked grim. “Honestly, I don't think we have a great case here, but our best argument is that Mr K contributed to his own kidney disease by being noncompliant,” he said.
The case went to trial in front of a federal judge.
At trial, Mr K testified that he was never told that there was a connection between high blood pressure and kidney disease, that he was not given any patient education, and that he had not known there was a risk of kidney disease if he did not take his medication daily (even when he was feeling fine). He thought that if he felt okay, it meant that he did not have to take his medication.
Ms D testified that she had provided patient education, but the notes in the chart included nothing other than a 2008 notation of “healthy eating habits.”
The judge believed the plaintiff's medical experts who testified that Ms D had deviated from the standard of care in numerous ways, including the failure to: provide proper education, recommend home blood pressure monitoring, order labs or respond to lab results, and consult the collaborating physician or refer the patient to a specialist. The experts were also critical of Ms D's decision to give Mr K clonidine in the office on multiple occasions. The judge dismissed the defense's argument that Mr K contributed to his own medical condition. Ultimately, the court awarded more than $29 million in damages to Mr K.
Ms D allowed burnout to affect her work and to cause her to make assumptions about her patient. What care should she have given Mr K? The standard of care required:
- Patient education and consistent re-education, including: basic information about hypertension, risks of uncontrolled hypertension, the fact that Mr K had an increased risk of kidney damage from uncontrolled hypertension because he was a young African-American male, lifestyle modifications, the importance of taking medications daily, and attending follow-up appointments
- Recommendation and instruction for home blood pressure monitoring
- Ordering lab tests at least 1 to 2 times a year to monitor for organ damage
- Appropriate action in response to lab results
- Consultation with the collaborating physician if there is difficulty controlling blood pressure
- Referral to a nephrologist when she was unable to control the patient's blood pressure.
In addition, Ms D failed to appropriately document information in the patient's file.
Ms Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, NY.