Last week we discussed the concept of systems-based practice, and as promised, we’re going to round off this topic with a case that demonstrates various aspects of this in podiatry.

As a quick review, systems-based practice includes the following:

1. Working effectively in various healthcare delivery settings and systems relevant to their clinical specialty.
2. Coordinating patient care within the health care system relevant to their clinical specialty.
3. Incorporating considerations of cost awareness and risk-benefit analysis in patient and/or population-based care, as appropriate.
4. Advocating for quality patient care and optimal patient care systems.
5. Working in interprofessional teams to enhance patient safety and improve patient care quality.
6. Participating in identifying system errors and implementing potential systems solutions.

Here’s our patient, which I’ll fondly call "I Just Have to Keep on Walking"

Mrs. "I Just Have to Keep on Walking" was a 60-year-old diabetic on hemodialysis that presented to me with a right ankle deformity after having her right ankle fracture repaired by a local orthopedic colleague. She had fallen while getting into her car, sustained a bimalleolar ankle fracture that was repaired without complications. She was discharged to a skilled nursing facility. While at the facility, she removed the dressing and proceeded to walk on the fractured ankle. The image below shows the ankle’s appearance at two weeks postop. Notice the complete hardware failure with lateral dislocation.

The patient related that she did not have support at the nursing facility and had to bear weight in order to go to the bathroom. She was a morbidly obese and quite sick lady who needed more support. Clearly there was a system’s error at the nursing facility.

My orthopedic colleague referred her to me to attempt limb salvage. After a long discussion, during which I offered her a below knee amputation and reiterated multiple times the need for her to remain compliant, the patient decided on limb salvage. I performed a tibiotalocalcaneal fusion, the results of which you can see in the images below. The patient underwent this procedure without immediate complication and was discharged after two days to another nursing facility. Here’s where things got difficult.

On postop day three the patient and her daughter smelled an odor from the cast but did not tell anyone. None of the facility’s staff noted the malodor, and this went on for ten days when the attending physician finally noticed the malodor and returned her to the hospital.

Clearly there are multiple systemic issues at work here. The patient and family did not communicate. It turns out the patient’s primary caregiver (her daughter) was overwhelmed by other family responsibilities and was not able to keep a close eye on her mom. The nursing facility failed at multiple levels, including not communicating well and providing poor care to my patient. There is likely a multifaceted reason for this lack of care at the facility. When systems fail, we generally see this occurring at multiple levels. Perhaps if this patient’s health care system had followed the above competencies, her complications could have been minimized.

A systems-based approach to medicine requires each of us to have a more expansive vision of how our patients fit into the greater medical and social community. We need to understand that the choices each of us make has a potentially greater impact on our medical system as a whole, but also rounds back to and affects the care of each of our patients.