When Metrics and Testing Replace Listening and Physical AssessmentJune 13, 2014
By Gail M. Pfeifer, MA, RN, AJN news director
I was appalled as I read the Narrative Matters column by physician Charlotte Yeh in the June issue of Health Affairs, for two reasons. Aside from the compassion I felt for her suffering at being hit by a car on a rainy Washington, D.C., evening in 2011, I was dismayed that most of her story took place in an ED, one of the settings in which I used to work. While there, she met with a series of omissions that included not just medical care omissions but also—though she never explicitly connects the dots—basic and serious nursing care omissions.
It saddens me to think that one of the things I fought so hard to implement on our unit more than 20 years ago—transforming the staff’s automatic labeling of arriving patients (an MI, an MVA, a gunshot wound) into a unique picture of who that patient really was under those traumatic circumstances—has still not come to pass. Yet that change of vision is so important to completing the picture and arriving at an accurate diagnosis. Noting that her care demanded a better balance of necessary test-based care and “an understanding of me as a person and what mattered to me,” Yeh points out how, for many providers, the clinical measures “can become more important than the patient.”
She narrates her view from the hallway stretcher as the ED team looks at cursory objective data only—some negative test results, the fact that she was not lying in the street when EMTs arrived (she had been moved by bystanders at her request, to avoid being run over by oncoming traffic), and that meds relieved her pain. But the objective signs that could have been gotten only from listening to her and from a solid nursing assessment were ignored for far too long.
I would expect a Level 1 trauma center team to know that clinical measures form only the tentative outline of a complete patient picture. Yet Yeh did not even receive a thorough history and physical from any member of the team. Yeh is a physician and understandably focuses her finger-pointing on medical care, which failed to order the tests that might have clarified the outline of what was happening with this particular “auto-ped.”
What ultimately should fill in that outline and make it more than just a sketch, however, is the ED nursing team. As I see it, the real crux of her problem was the nursing care she did not receive. Yeh observes that “not once had anybody come by to ask how I was doing, what I needed, what I wanted, or whether I had any concerns.” Later in the essay, she adds, “My reports about my own condition did not seem to matter to anyone else.”
These comments sound familiar, don’t they? And to me, they are all the more damning because we knew about this problem 20 years ago and are still failing to adequately address it.