no better reason

It was still winter and she had recently been admitted to hospital for the flu. This past season the flu, which usually just kills sickly babies and old people, was killing healthy young adults. She was still in her twenties, but nowhere near healthy. The kidney transplant she received 8 years ago was failing. And if another kidney wasn’t found for her in the next year, she would be back on dialysis—if our carelessness didn’t kill her first.

She didn’t get the flu shot.

She didn’t get the flu shot, though 3 times that fall, she had been seen in our clinic for patients with advanced chronic kidney disease. The first time she was seen by the physician assistant and I was the attending nephrologist, supervising her work. I had listened to the physician assistant tell me about the history of the patient’s illness, how she had been feeling recently, what medications she was taking, her blood test results. I had listened to the physician assistant’s plan for the patient’s care; what medications needed to be adjusted, added, stopped. What steps, if any, needed to be taken now to prepare her for dialysis. I had agreed to or modified the plan as I saw appropriate. I had followed her into the exam room where the patient waited, introduced myself as the supervising kidney doctor in clinic that day, told her of how I agreed with the physician assistant’s plan for her health, shook her hand smiling and left the room confidently, believing I had delivered excellent care.

A fellow on his way toward becoming a nephrology attending saw her the second time while a colleague supervised his work. The third time, a different fellow saw the patient and I again was the attending.

Five different providers in our clinic had laid eyes and hands on her during flu season, and no one thought to offer her a flu shot. And she could have died because of it. My heart sank like a smoldering stone into the pit of my belly where it lay there, singeing.

Now I suppose one could argue that making sure the patient got a flu shot was the primary care doctor’s responsibility, something a medical assistant should have been trained to automatically take care of, or even something the patient herself should have seen to. After all, as the kidney experts we spent our time with the patient focused on her making sure her blood pressure was controlled, no fluid pooled at her ankles, her phosphorus level remained normal, her anemia was properly managed, and that no other providers were prescribing medications too high for her kidney function. We were busy attending to getting her back on the wait-list for another kidney transplant, estimating how rapidly her kidney function was declining, and such.

Whatever. Somebody should have thought to at least check to see if the others we could point our fingers at had followed through on a simple flu shot, considering all the things we were so focused on don’t matter for the dead.

But, hey, we are mere humans, prone to distraction and forgetfulness. But what if we had a template, a standard way of writing our notes? A trigger to help us remember all the things that are not at the forefront of our brains. Like a flu shot once a year.


A standard way of writing our notes could also help communicate all the things that happened when I saw the patient to the fellow who sees the patient next time to the physician assistant who sees the patient the visit after that, since this is the way it goes. A different provider, a different style, a different conversation. Each time. So at least the next provider could pick up where the last left off and give the patient a sense that even though they are seeing a different provider every time they walk into our clinic to talk about the life and death around their advanced kidney disease, that the providers are communicating with one another.

Yes, a note template in our clinic that could be easily copied and updated from note to note in the patient’s electronic medical record. Yes, such a thing could help us do better. Improve how we take care of patients. Ease the burning in my belly.

Or. We could continue to do things as we have always done them for no better reason than because that is the way we have always done them.

Not my call.