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A fresh look at clinical excellence

Noel J. Genova, MA, PA-C

The author works at Mercy Primary Care, Portland, Me, and is Adjunct Assistant Professor in the PA program at the University of New England. She is a member of AAPA’s Education Council and the JAAPA editorial board. The author has indicated no relationships to disclose relating to the content of this article.

What skills are needed to be the kind of clinician who usually arrives at a diagnosis quickly, delivers a good treatment plan, comforts patients well, and rarely makes mistakes? Delivering excellent clinical care in all settings requires much more than the traditional competencies of knowledge, skill, and clinical acumen. PAs must develop and continuously improve their abilities in communication and systemsbased practice in order to avoid errors and delays in providing care. In addition, attention to teamwork is essential because no clinician working in isolation can provide “state of the art,” quality care for the many diseases and conditions we each encounter over our careers.

Achieving clinical excellence requires ongoing learning in several content areas, as the following case illustrates. I include comments regarding aspects of achieving a good outcome that are not usually mentioned in a case presentation—such as the prognoses associated with potential diagnoses and communication of their implications, access to ancillary services in a timely manner, the clinician’s recognition of personal strengths and weaknesses, and clarification of roles between primary care and specialty clinicians.

Case presentation—“My eyes were yellow”

A 46-year-old mother of two presented for a routine gynecologic examination. Her last examination was 2 years ago. She reported no intervening illnesses or complaints, except that her “eyes had been yellow” for a few weeks. The yellow eyes had since resolved. The patient had no nausea, vomiting, diarrhea, loss of appetite, or other symptoms of liver disease. She denied foreign travel. She had eaten “bad sushi” (her first experience, and not one she planned to repeat) about 5 weeks ago. No other potential exposure to hepatitis could be identified.

The physical examination was completely benign except for a slight yellowing of the frenulum under the tongue. No jaundice, scleral icterus, or liver tenderness or enlargement was noted.

Although I suspected only Gilbert’s syndrome or, possibly, resolving viral hepatitis, I ordered a complete metabolic panel. AST and ALT levels were both near 1,000 IU/L; bilirubin was 1.8 mg/dL; total protein, 9.8 g/dL; albumin, 3.6 g/dL; and alkaline phosphatase,258 U/L. The results of the CBC were normal. Because of the abnormal results on the metabolic panel, follow-up viral hepatitis testing and abdominal ultrasonography were ordered. The results of both were negative. There was no sign of biliary obstruction or parasitic infection.

What is your diagnosis and associated prognosis?

Alcoholic hepatitis (treatable with cessation of alcohol use)
Drug toxicity (treatable but potentially fatal)
Autoimmune liver disease (serious if not treated but treatable with oral prednisone followed by immunomodulator therapy)
BuddChiari syndrome (treatable but rarely may result in fulminant hepatitis)

We will return to the diagnosis and treatment plan later. First, let’s discuss how easy it is to end up with a bad outcome because of systems failures, errors, or delays in diagnosis and treatment.

Attention to systems pays off

In the months before this patient’s visit, we had experienced several episodes of late reporting of abnormal laboratory test results, resulting in “near-miss” poor outcomes. Many options for rectifying the situation were considered. Ultimately, discussions with our administrators and lab personnel led to the promise that we would receive all lab results within 4 hours of when the test was performed. In this case, the initial abnormal lab values were placed in front of me within a few hours, allowing me to act on them the same day. I was not expecting abnormal lab values and would not have tracked them down. Valuable time was saved, and I immediately arranged the next phase of the patient’s workup.

The need for teamwork

Although my supervising physicians and I investigated the differential diagnosis for elevated liver function tests in the textbooks on our shelves, we all agreed that our community standard of care required that we consult a gastroenterologist regarding the next appropriate steps in the evaluation. Previous experience had shown us that major delays in care (weeks to months) often occur when we ask staff simply to call a specialist’s office for an appointment. Hoping to avoid this pitfall, I faxed the lab values, with a brief description of the clinical scenario, to a local liver specialist.

While waiting for a return call from the gastroenterologist, I received a phone message that the patient could be seen in “viral clinic” (the local clinic for the treatment of hepatitis C) in 7 months. Although this message was confusing and irrelevant, I called back and found that the booking secretary at the clinic had been unable to read the fax she received from the consultant’s private office. (Unfortunately, medical errors are often this simple and basic.) Together, we realized that the gastroenterologist’s secretary had faxed the information about my patient to the physician, who was working that day at the clinic. Although it was late in the day, the clinic secretary arranged for the consultant to call me back, well after usual office hours were over.

The consultant rapidly oriented me to the differential diagnosis and an appropriate workup, to be arranged by me and carried out by the interventional radiologists at my hospital. He wanted them to use their expertise in deciding on the appropriate imaging studies to be done (MRI, CT, ultrasonography) and to perform a liver biopsy the same or the following day, if possible. No investigation of the literature could have substituted for this gastroenterologist’s judgment and experience.

Confirmation of the need for speed in completing the workup came when the specialist told me that tests for prothrombin time and an international normalized ratio needed to be done daily, as the patient could decompensate very fast and become anticoagulated, increasing the risk of performing the liver biopsy that was required to make a diagnosis.

Communication and professionalism

What about the patient? I spoke with her once or twice daily, making sure that she knew what needed to be done and why. I reported to her the results of each of my conversations with a physician—by now the internist, the gastroenterologist, and the interventional radiologist. I checked on her mood and on how she was handling the uncertainty surrounding her workup and diagnosis.

All of us have encountered delays in scheduling—in this case, the delay was in scheduling MRI. One of my failings is arrogance—and a quick temper when my patients do not get what I want for them, when I want it. After years of attention to this weakness, I was able to politely ask the MRI tech to check with the radiologist before she declined my request for an appointment for the next day. Within minutes, my patient had an appointment at 8:00 AM the next day.

The outcome

Within 2 weeks, the workup was completed, the diagnosis made, and treatment started. Further historygathering over the phone ruled out alcoholic hepatitis or drug toxicity (including toxicity from acetaminophen). MRI ruled out BuddChiari syndrome. Immune globulin levels were very high, as was the ASM (anti-smooth muscle) antibody level. Liver biopsy confirmed autoimmune hepatitis, which had been the gastroenterologist’s initial suspicion based on the patient’s age and sex and the gap between the total protein and albumin levels. Treatment with oral prednisone was initiated, followed by azathioprine (Imuran) after several weeks. The liver enzymes rapidly returned to normal, and the patient is doing well, now under the care of the gastroenterologist.

Lessons learned

By now, most PAs are aware of the need for good communication, attention to avoidance of errors, teamwork, professionalism, systems-based practice, and process improvement in their delivery of clinical services. Many of us refer to this set of skills as “the art of medicine,” which we try to pass on to our students by serving as good role models. However, methods for putting this awareness into practice—or for improving our artistic skills—are not obvious. We must notice our successes and failures in these aspects of caring for our patients and attend to their improvement, in addition to the traditional need for continuing education in the competencies of medical knowledge and skills.

Acknowledgment

Thanks to Rick Davis, PA-C, for his expertise in gastroenterology and his assistance with this manuscript.