Appendix 1. DVD Example of a Clinical Case: Effective and Ineffective Approaches
Scenario
Joe Porter is a 62-year-old man here to see you for follow-up regarding his appendectomy. You discharged him from the hospital seven days ago after an uneventful surgery. He called you five days after discharge complaining that his mouth was dry and that he wasn’t putting out much urine. It was very hot that day, and Joe told you that his air conditioner wasn’t working and he wasn’t drinking much. You were very busy in the office and didn’t check his chart. You told him he needed to drink more: eight glasses of liquid per day. Later, you learned from an emergency room resident’s phone call that Joe wound up in the emergency room with acute urinary retention secondary to an enlarged prostate.
After the call from the emergency room resident, you went back and checked Joe’s chart. It revealed that he had a long history of benign prostatic hypertrophy. In fact, in the hospital he complained that it was giving him more trouble than usual, but that he did not want any medication.
The patient is sitting in your office and says to you, “I gotta tell you doc, I’m not happy with you. All that water you told me to drink landed me right in the emergency room at the hospital. They told me I wasn’t dehydrated at all. They said my bladder was blocked because my prostate was enlarged.”
Effective Clinician Approach
Doctor: I’m sorry Mr. Porter, I made a mistake. What I thought was going on was related to you being dehydrated. What did they tell you in the emergency room as it relates to your prostate?
Joe: Basically they told me I couldn’t pee because my bladder was being blocked by my prostate being enlarged, which I thought you guys knew about. I thought it was in my records.
Doctor: I made a mistake, Mr. Porter. What I thought when I talked to you on the phone was your air conditioning was off, you were dehydrated, so I thought that the way to best manage that was to encourage you to drink fluids. That was my thought process. I wasn’t trying to neglect you, but I wasn’t thinking along those proper lines and I had forgotten that you had prostate problems. The issue is really related to your appendectomy and having your surgery. It’s not unusual for the prostate and your urinary stream to get a little lazy, and what I was thinking is that it is not unusual for you to get dehydrated after an operation like this.
Joe: So you were making an assumption.
Doctor: I was, and that was a mistake. I’m sorry. I think that in the future, it would have been better if I had brought you in when you had that complaint and assessed you and evaluated you. It would have allowed us to look at your record again and we would have recognized that the prostate was a problem that you had and I could have intervened. I’m sorry that happened. I think what we are hoping to do in the future and what I would certainly tell our students and residents is that in patients after they have had an appendectomy or any gastrointestinal surgery, and certainly in men in your age bracket, we need to think about the prostate as a problem related to low urine output, and not just dehydration in this situation.
Joe: Can you put that in English?
Doctor: I can. I’m sorry. What I think we will have to do is instead of just making the assumption that you are having a problem related to dehydration and not getting enough oral intake and enough fluids, we need to think about the prostate as a problem because it is so common in men and especially in men over the age 50 or 55. I simply neglected to think about that. I’m sorry. Certainly, we have already discussed this in our department and we would be happy to compensate you for your time and effort, and cover the cost for your emergency room visit. And again, I am very sorry for the inconvenience and the problems that were caused.
Ineffective Clinician Approach
Doctor: Mr. Porter, I don’t know quite what you are getting so upset about here. We discussed your operation, your appendectomy, in detail and all the bad things that can happen after an operation.
Joe: You didn’t say anything about the prostate getting enlarged and blocking the bladder.
Doctor: Well, yeah, I didn’t do that because it is not a major complication. I mean the things that could have gone wrong were serious wound infections. You could have had peritonitis. We got in there, we took your appendix out, we did all the right things, and I’ve got to be honest…
Joe: I’ve got this tube shoved up me and I’ve got a bag strapped to my leg. I think that’s pretty bad.
Doctor: Well let me tell you something, Mr. Porter. In the big scheme of things, this will get better. Now, ok, I’m sorry this happened. But let’s just get over this thing because this will get better.
Joe: Easy for you to say.