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Clinical Case in Integrative Health—How Many Visits Does It Take? A Conversation With Albert Rundio, PhD, DNP, RN, APRN, NEA-BC, FNAP, FAAN, Clinical Professor and Nurse Practitioner

Donnelly, Gloria F. PhD, RN, FAAN, FCPP

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doi: 10.1097/HNP.0000000000000387
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A patient's experience accessing care for symptom relief highlights the question of whether timely, holistic clinical care is possible given the configuration of the current health care system and the mindset of providers. Consider the following case. A male patient with frequent and burning urination, particularly at night, notifies his primary care provider through the requisite “health care portal messaging system” with no response. Experiencing another sleepless night, he visits Urgent Care, where the MD orders a urine analysis and prescribes Cipro. The Cipro seems to work but the next morning the Urgent Care MD calls to report “no infection in the urine” and directs the patient to stop the Cipro and see a urologist. After calling several urologists, the patient secures an appointment 20 days out, the soonest available time. The patient's symptoms continue to worsen with 2 sleepless nights. He calls Urgent Care to seek advice from the treating physician. He is advised to visit Urgent Care for another evaluation since the treating physician “is not available.” The patient returns to Urgent Care where the same, treating physician appears in the examination room. The patient asks about a prescription for Flomax. Instead of prescribing Flomax, the physician recommends that the patient visit the local emergency room (ER) for a “bladder scan,” since the necessary equipment is not available in Urgent Care. The patient drives to the local ER but has such severe urgency, he empties his bladder before the scan. The subsequent scan reveals a “normal amount of residual urine.” The ER physician examines the patient and diagnoses possible prostatitis given the patient's history with benign prostatic hyperplasia. He recommends that the patient finish the Cipro prescription and sit in hot baths until he can see a urologist. He thinks Flomax might be necessary but does not order it.

After another difficult night with 9 trips to the bathroom, the patient calls his primary care provider the next morning and is offered an appointment with a nurse practitioner (NP). The NP examines the patient, does another urine test, which is clear, and tries to get the patient a sooner urology appointment but with no success. The NP orders a 30-day prescription for Flomax and tells the patient to call if he does not get relief in 1 day. Flomax relieved the symptoms.

Dr G. Donnelly:Given your deep practice experience as a nurse practitioner and as a teacher of nurse practitioner students, please comment on this case—a patient's 4 visit quest to get symptom relief before seeing a specialist. How might the principles of holistic care (ie, the attention to body, mind, and spirit) have been effectively applied?

Dr Rundio: From my perspective, our health care delivery systems need to be much more focused on responding to a patient's needs in a timely way. When any male patient presents with urgency and frequency of urination, there are key elements of the assessment and examination. The first is to get a thorough history of the present illness (HPI) as well as the patient's past and current medical history, surgical history, and social history. For example, is this the first time that the patient has experienced these symptoms? Or are they recurring symptoms? Has the patient ever been treated for diseases of the prostate gland, such as prostatitis? One of the more sensitive but important questions to ask one is if the patient has been in a monogamous sexual relationship or has other sexual partners (question is vital since it can assist in determining the most likely micro-organism that might be infecting the prostate). In addition to a urine analysis, one of the key examinations is a digital rectal exam in order to assess the position and size of the prostate gland.

Given the nature of the patient's symptoms and the level of discomfort including sleep deprivation, prescribing medication(s) is critical. The fluoroquinolones are the most frequently prescribed medication for treating a prostatitis and most often, in the case of prostatitis, it is prescribed empirically as most providers do not conduct prostate aspirates for culture and sensitivity. Depending on the patient's age, one must consider Benign Prostatic Hypertrophy (BPH), the enlargement of the prostate that comes with aging. Besides an antibiotic for acute prostatitis, the best initial medication for symptomatic patients is Flomax 0.4 milligrams once daily each evening. Flomax relaxes the smooth muscle in the prostate and the bladder neck thus easing urination.

Treating the patient holistically is vitally important. But how can a holistic framework apply in this situation and complement medical model interventions? A few factors should be considered. The prostate gland's size, location and poor vascularity make it difficult for antibiotics to reach the gland. Antibiotics are usually prescribed for about 3 to 4 weeks. Most providers hopefully will recommend taking a warm bath at least daily or a sitz bath, promoting vasodilation so that the medications are more effective. Avoiding spicy foods such as, hot peppers and chili is also recommended.

Other holistic measures and prevention strategies for acute prostatitis include saw palmetto, an herbal intervention found to decrease prostate gland size, pumpkin seeds, stinging nettle, pygeum (African plum extract) and Lycopene. It is also important to teach patients to avoid riding a bicycle with a narrow seat since that position places too much pressure on the prostate gland.

Many advanced practice nursing programs do not include complementary and integrative health interventions in the curriculum. Given the growing integration of Complementary/Alternative medicine not only among consumers but in hospitals and clinical practices,1 the need for educating clinicians on holistic interventions is even more pressing. There is a definite need for universities and colleges to incorporate content on complementary and integrative therapies into advanced practice curricula. Practicums could be arranged at institutions and practices that incorporate complementary/alternative interventions into practice.

Dr G. Donnelly:It took this patient 4 visits and many sleepless nights to get a prescription for symptom relief after infection was ruled out. It also took an additional 3 weeks before securing an appointment with a urologist. What is your assessment of this situation from a health care system perspective?

Dr Rundio: First, let me circle back to the importance of the “history”—since a comprehensive history can point to interventions with positive and quick outcomes. Consider this case.

I have a colleague, a male nurse practitioner, who had a total hip replacement. He also is a non-insulin-dependent diabetic. He was in the hospital for 1 overnight stay for the total hip replacement. He had to be catheterized with a Foley catheter for around 12 hours. Ten days postoperatively, he developed a urinary tract infection (UTI). He went to his primary care physician the next day, and both he and the physician speculated that the UTI was most likely secondary to having been catheterized. He was prescribed Bactrim DS every 12 hours for 10 days. His symptoms began to resolve on around day 2 of taking the antibiotic. He did complete the course of antibiotic therapy. A few weeks later he developed another urinary tract infection and was again treated with Bactrim. A few weeks after that he again developed a urinary tract infection and was treated. With the third infection, and after much discussion between patient and physician, the patient speculated that the recurrent UTIs might be caused by one of his diabetic medications. One of the common classes of diabetic medications that can cause UTIs are the SGLT2 inhibitors, such as dapagliflozin. The physician discontinued this medication since UTIs are among its adverse events. The patient has had no recurrence of a UTI since discontinuing this diabetic medication. This case illustrates the vital importance of thinking broadly about the patient's experience and the necessity for a thorough HPI and history in treating any patient. Patients know their bodies and their history best and health providers need to delve and listen.

In closing, it is vital that all health care providers be well versed in the most common diseases that affect both men and women. There also needs to be well established and coordinated referral systems so that patients can be seen expeditiously by a specialist when indicated to get relief. Providers also need to educate patients about holistic practices that in the long run may prevent or ameliorate many common illnesses.

POSTSCRIPT: After 2 urgent care visits, one ER visit and a visit with the nurse practitioner in the primary care practice, the patient saw a urologist after waiting 3 weeks for an appointment. Wait times to see US specialists have increased from 18.5 to 24 days and more,2 and among 11 countries, the United States is third from last in providing timely care.3 Fortunately, the nurse practitioner prescribed Flomax as a stop gap measure to give the patient relief, and after a thorough assessment by the urologist, including a bladder scan, the prescription for Flomax medication was reissued. The question for clinicians is, “How many visits should it take and how long should a patient wait before getting symptom relief?”

—Gloria F. Donnelly, PhD, RN, FAAN, FCPP
Editor-in-Chief

REFERENCES

1. American Hospital Association. Fenwick M and Hutcheson D, More Hospitals Offering Complementary and Alternative Medical Services. www.aha.org/system/files/presscenter/pressrel/2011/110907-pr-camsurvey.pdf. Published September 7, 2011. Accessed February 11, 2020.
2. Rege A. Patient Wait Times in America: 9 Things to Know, Becker's Hospital Review. https://www.beckershospitalreview.com/hospital-physician-relationships/patient-wait-times-in-america-9-things-to-know.html. Published June 9, 2017. Accessed February 11, 2020.
3. Carevoyance Blog. Health Care Wait Times by Country. https://www.carevoyance.com/blog/healthcare-wait-times-by-country. Published July 19, 2019. Accessed February 11, 2020.
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