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Charlotte ER case shows challenges of patient satisfaction

Miserable and desperate, Denise Schafer sought help at the Carolinas Medical Center-Pineville emergency room one Saturday in June.

Four days earlier, she had swallowed something that seemed to have sharp edges and lodged in her throat.

Doctors at the Pineville hospital eventually found, and removed, the cause of Schafer’s pain. But it was only after a long, frustrating day in the ER and the serendipitous appearance of a ham sandwich.

Schafer and Lenore Foote, a friend who drove her to the ER, later complained to hospital officials – and then to the Observer – about their experience. They haven’t accused anyone of malpractice. But they feel like no one really listened to their appeals for help. Months later, they remain dissatisfied, feeling patronized and dismissed.

Schafer’s ER doctor and her superiors have apologized that the experience didn’t meet her expectations. But they insist she received good care.

These differing views demonstrate the importance of communication – and the potential for miscommunication – between busy doctors and vulnerable patients.

As the American health care system undergoes massive change, hospital systems across the country have begun talking more about “patient-centered care.” In the Charlotte area, Carolinas HealthCare System and Novant Health tout their scores on patient satisfaction surveys. And they’ve created jobs with titles such as “patient experience officer.”

Despite that, patients such as Schafer sometimes leave angry. Hers wasn’t even the most complicated medical case. There was no blood or trauma. And it was eventually resolved successfully. Another patient might have shrugged it off and never said a word.

But Schafer and her friend pursued a complaint and wanted to share their story with the public, through the Observer. After Schafer signed a consent form, her doctors agreed to discuss their treatment decisions. That access allows us to offer this unusual glimpse into the complexities of diagnosis and treatment in today’s emergency room.

So we offer this anatomy of a patient encounter. You may have tales of your own. We can probably all agree they’re more complicated than any patient satisfaction survey could ever reveal.

The patient’s story

Denise Schafer, 62, was on a business trip in Gulfport, Miss., on Tuesday, June 24, when during lunch with a client, she swallowed something that felt sharp in her throat. She thought it might have been a shard of glass that slipped through her straw. Drinking more water didn’t help. Whatever it was seemed stuck.

At a local emergency room, an X-ray didn’t show anything abnormal. The doctor said something may have scratched her esophagus on its way down and that it would probably heal in a few days.

The next day, Schafer felt worse and returned to the same ER. Another doctor prescribed pain medicine to keep her comfortable through the flight home to Pineville.

For several days, Schafer got by on liquids, hoping her pain would let up. But even sips of protein shakes were difficult to swallow. She continued going to work as client coordinator for a hospital management group based in Charlotte. And that Friday, she saw a Charlotte gastroenterologist who scheduled an endoscopy – a look down her throat with a tube – for Monday. She thought she could wait through the weekend.

But by Saturday morning, four days after her business lunch, Schafer was so weak and in such pain that she changed her mind. She called her friend Lenore Foote, 71, of Indian Trail, who drove Schafer to the CMC-Pineville emergency room.

They arrived about 11 a.m. and were quickly seen by Dr. Jennifer Callaway. Schafer described her experience, explaining that she’d been to the ER in Mississippi twice earlier in the week, that an X-ray was normal, that she had trouble swallowing liquids and that her pain had worsened.

Callaway ordered blood tests and another X-ray. Like the one in Mississippi, this one failed to show a foreign body but did rule out a perforation of her esophagus. Blood tests were normal except for elevated liver enzymes. That finding and Schafer’s upper chest discomfort led the doctor to wonder whether the gallbladder might be the culprit. Callaway ordered an abdominal ultrasound, but it also was normal.

Asked to rank her pain on a scale of 1 to 10, Schafer recalled saying it was a 12. But she refused the doctor’s offer of pain medicine because she prefers naturopathic remedies and didn’t want to mask the problem. She and Foote asked repeatedly for an endoscopy. They didn’t think it could wait until Monday.

Callaway consulted with Dr. Preston Purdum, the gastrointestinal specialist on call. Schafer and Foote recall that Callaway returned and told them the GI specialist would not be coming. When they asked why, they said Callaway told them it “wasn’t a matter of life or death.”

Foote, who admits she has the feisty nature of a native New Yorker and former newspaper reporter, continued to push for an endoscopy, asking Callaway to call the GI specialist again. But she said Callaway explained “there was nothing she could do. He has the final say.”

With tests and procedures completed, Schafer and Foote spent awhile alone in the exam room. It was about 4:30 p.m. when they both began to feel that Schafer was going to be released. Foote vowed to herself that she’d call 911 and have Schafer transferred to another hospital before she’d take her home untreated.

Then about 6 p.m., after they’d been in the ER for seven hours, someone delivered a box lunch to the room.

Schafer hadn’t eaten solid food since Tuesday. That morning she’d had several sips of pureed broccoli-cheese soup. She was so hungry that she opened the box and took a small bite of the ham sandwich inside. When she swallowed, she froze and then winced in pain. She shut her eyes and reached for her throat.

Foote, sensing her friend’s panic, jumped up to get help.

“Now do you believe us?” Foote recalled asking Callaway.

The ER doctor acted quickly, calling Purdum, the GI specialist, a second time, and he agreed to come right in. He performed an endoscopy at 6:56 p.m., almost eight hours after Schafer and Foote arrived at the ER.

What the procedure found in Schafer’s esophagus surprised everyone: A pill still wrapped in its plastic blister pack, with four pointy corners.

“It all made sense once we did the endoscopy,” Purdum told the Observer later. “Those edges are potentially very damaging.” He said it could have perforated her esophagus, requiring surgery.

It’s unclear why the blister pack didn’t show up on two separate X-rays. Metal and bone usually would; plastic may not. The blister pack also may have been positioned in a way that camouflaged its presence.

Learning that she had swallowed a blister pack surprised even Schafer. Until then, she hadn’t connected her pills to her pain. She said she normally swallows eight or 10 supplements, all at once, each day. Because she was traveling, she had kept one of the pills in its packet so it would stay fresh. Distracted during lunch, she popped the pills in her mouth and forgot that one was still wrapped.

It was about 9 p.m. Saturday before Schafer’s sedation wore off and she could leave the hospital. Foote drove her home, stopping to buy applesauce, Jell-O and Italian ice. Schafer wolfed down two of the Jell-O cups. And this time, she swallowed without pain.

The women were relieved, but angry that it took so long to get the endoscopy.

Schafer summed it up: “They don’t listen to the patient.”

The patient’s complaint

The day after the ER visit, on Sunday, June 29, Foote called the hospital to complain. She spoke to the charge nurse in the ER who said she couldn’t talk about Schafer’s care because of privacy laws that protect the patient.

Several days later, Schafer said she got a call from a hospital official who said she was “sorry that I didn’t have a good experience.”

Then Schafer received a patient satisfaction survey in the mail. But she didn’t fill it out. She felt there was no way to convey her feelings through multiple-choice questions. Instead, she wrote a note that she was unhappy and wanted to lodge a complaint.

In August, Schafer received a letter from Teresa Gaskin, nurse manager at the Pineville ER: “Our goal is to provide excellent care to all of our patients. I truly regret that we did not meet your expectations for care. I would like to apologize that you felt the physician who treated you did not truly listen to your concerns.”

Gaskin’s letter didn’t mention Callaway by name but said the ER doctor had done “a thorough assessment.”

Unsatisfied, Schafer and Foote complained to the Observer, and Foote also made several calls to the hospital to find out how to speak at a meeting of the board of Carolinas HealthCare System, the public nonprofit group that owns the Pineville hospital.

Foote never heard back about the board meeting, but she did get a call from Connie Bonebrake, the system’s chief patient experience officer, a position created in 2012.

Understanding that the patient and her friend felt passionate about the issue, Bonebrake responded with an offer she doesn’t often make. She arranged for Schafer and Foote to meet with her and two other top-level hospital officials: CMC-Pineville President Chris Hummer and Chief Medical Officer Dr. Michael Ruhlen.

During their two-hour meeting on Aug. 29, Schafer and Foote repeated their complaints that they didn’t feel were heard by the ER doctor. Schafer said she felt “insignificant” during her visit. She asked the group: “Where else should I have gone?”

Again, hospital officials said they had reviewed the case and concluded Callaway acted appropriately. “Chris Hummer gave them, I thought, a sincere acknowledgment that we hadn’t met their expectations, and he was regretful about that,” Bonebrake told the Observer.

But both Schafer and Foote objected to Hummer’s use of the word “expectations.”

“It’s not a question of ‘expectations,’ ” Foote told the Observer. “ When you pay $200 for a meal and the salmon’s dry, that didn’t meet my expectations. That’s fluff when people don’t meet your ‘expectations.’ This is life and death. They were not willing to admit anything bad happened.”

ER doctor responds

After meeting with Schafer and Foote in August, the Observer contacted the two doctors, Callaway and Purdum. Both said they felt Schafer received appropriate care.

Callaway, who has worked in the Pineville emergency department for four years, said her first goal was to make Schafer comfortable, which is why she ordered intravenous fluids and offered pain medicine.

She said Schafer’s description of having eaten soup that morning was important because it meant she didn’t have a complete obstruction of her esophagus.

Callaway said she ordered the abdominal ultrasound because she wondered whether there could be “something else going on with (Schafer’s) gallbladder” that might cause both elevated liver enzymes and the pain she was describing.

Another reason Callaway didn’t focus exclusively on Schafer’s throat was that she said she “did not get a clear history that (Schafer) had specifically swallowed something.”

This seems to contradict what the doctor wrote in the medical record: “The patient states that she was eating at a restaurant in Mississippi, while she was drinking from a straw, she felt like she swallowed something sharp. She does not know what it was. The pain is worsened with eating. She has been on a liquid diet which she is tolerating. She presents to the emergency department today because she states that she does not think she can wait to have the endoscopy done in 2 days.”

Asked about this apparent discrepancy, Callaway acknowledged that Schafer and Foote spoke about “the possibility of a swallowed foreign body” but never said “she had specifically swallowed something.”

Callaway added that she had trouble getting information from Schafer “because her friend was really kind of driving the encounter.” While Callaway agreed it’s important for patients to have someone accompany them to the hospital, she said in this case, she felt like “the friend was really kind of intrusive.”

After calling the GI specialist to ask about an emergency endoscopy, Callaway explained to the women why he wasn’t coming. “I spent a lot of time talking to both of them. I felt like I listened to them very carefully and tried to get as much information and history from them as possible. In the end, I’m sorry that they’re unhappy. But I do think she received good care.”

Another reason Callaway thought the endoscopy could wait is that she had seen it happen before. She recalled seeing patients whose X-rays showed definite foreign bodies in the esophagus, and “if they’re not terribly uncomfortable and not perforated or obstructed, then sometimes the specialists will say, ‘I’ll see them tomorrow,’ rather than doing something on an (emergency) basis.”

Scott White, a marketing representative who sat in on the Observer’s interview with Callaway, said the doctor’s patient satisfaction scores are 90 percent and above. “She’s a good clinician, but she’s also a good patient advocate,” White said.

“This has been reviewed by many people,” he added. “There is nobody who has raised any red flags and said we didn’t do a good job with this.”

He reiterated that hospital officials had apologized to the patient and her friend. “But the apology would be for the fact that they were dissatisfied,” White said, “not because we had not done everything we could do.”

The GI specialist responds

Purdum, the GI specialist who was on-call that weekend, spoke to the Observer separately. He remembered the first phone call about Schafer.

He said Callaway, the ER doctor, told him the patient felt pain when she swallowed, but “she was drinking liquids off and on.” It wasn’t a classic “food bolus” that would have kept her from swallowing at all.

Because the patient’s throat wasn’t totally obstructed, Purdum said it appeared she had an injury that would heal with time. If Schafer couldn’t have swallowed at all, “it would have been a different story,” he said.

When Callaway called him a second time and the patient wasn’t getting better, Purdum said he “readily and willingly” came in to do the procedure.

In the end, he said, “Things got done, and that’s what counts.”

The sandwich mystery

Then there’s the mystery of the ham sandwich.

Why was Schafer, who was having trouble swallowing liquids, served a sandwich?

Callaway, the ER doctor, said she didn’t specifically order it. She said she asked a nurse to bring Schafer something to eat and drink because Schafer’s friend had asked her to. Callaway said Foote “told me her friend (Schafer) was really hungry because she hadn’t eaten anything since that morning, and was asking if we could get her something to eat.”

If Schafer couldn’t eat what was served, Callaway said she assumed the patient would ask for something else.

Both Schafer and Foote recall repeatedly telling the ER doctor that Schafer was weak and hungry because she hadn’t eaten anything substantial for days. That’s why they were pushing for the endoscopy.

In the end, it was the sandwich that led to the procedure – and discovery of the blister pack.

Schafer got a bill for $10,000 for her ER visit. With other bills from radiology and gastroenterology, the total came to about $12,000. Most will be covered by insurance.

Collaboration is key

So what happened here? Instead of a happy ending, with the blister pack removed and the patient restored to health, this encounter resulted in hard feelings on both sides.

“It’s an example of how difficult medicine can be,” said Dr. Nortin Hadler, a UNC Chapel Hill medical school professor and author of “The Citizen Patient: Reforming Health Care for the Sake of the Patient, Not the System.”

“People think medicine is nothing but a bunch of tests and procedures, but it’s human interaction all the way through.”

He and Rosemary Gibson, a patient safety expert at the Hastings Center in New York, agreed to share their perspectives after hearing a description of the case. Both concluded communication could have been better.

“The art of listening to a patient should not be understated,” said Gibson, author of “Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans.”

“When patients report that there’s something wrong, it’s wise to tend to that.”

Even though the Pineville doctor was seeing Schafer for the first time, the patient had visited the Mississippi ER twice before. “If a patient keeps coming back, there’s a reason,” Gibson said. “Three times over five days. That tells you there’s a problem. Something has not been addressed.”

That’s why Gibson said it was understandable for the patient’s friend to “become more assertive. There’s a reason people get agitated. And a seasoned professional has to look through that and ask, ‘What are they saying here?’ ”

Consulting with an on-call specialist can also have its challenges, depending on personalities and hierarchy, Gibson said. Sometimes ER physicians may be reluctant to press for a specialist to come in on a weekend if it appears the problem is not that serious and the patient could be seen Monday morning, she said.

After hearing Schafer’s case, Hadler said: “It is unfortunate and doesn’t get high marks, but it’s not inexplicable in the context of health care.” Doctors don’t see cases like Schafer’s very often, he said. “How do you push the uncommon through a system that is designed to deal with the common?”

Hadler, who has practiced at UNC Hospitals for 40 years, called Schafer’s ER care satisfactory, but said it would have been much better if she had been treated sooner. Things might have ended differently if the doctors and the patient had a more collaborative relationship, he said. “There’s very little anger when you’re collaborative.”

In the case of Denise Schafer, it’s fortunate for everyone that the swallowed blister pack caused no permanent harm. She keeps it in a clear specimen jar from the hospital.

It’s a reminder that, even in a health care system trying hard to be patient-centered, the challenge is as much about understanding people as it is about understanding medical science.

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