The home health nurse texts me on a busy afternoon. A caregiver thinks her mother has another UTI because she is more confused, the nurse already collected a urine sample while she was there, and they are wondering if they can get antibiotics called in before the weekend.
I know this caregiver. She calls when something is off, and she is almost always right that something is off. I am grateful for people like her in my work. She gives me the information I need to make good medical decisions, and I trust that she will get things done the way we plan. I find myself wishing that I could just call in the prescription. I know I should call her and get more information, but an antibiotic feels to both of us like the easy, quick solution. I know her; I know she is tired and could use such a quick and easy solution. Admittedly, I could too.
That is the honest truth of where the quick answer often comes from. We all are juggling all of the time. It's hard to be curious and still keep the balls in the air.
Still, here, we need to pause and resist that quick answer. It may not be a UTI.
Many UTI diagnoses in older adults are wrong. A large share of older adults carry bacteria in their urine without any infection at all. This is called asymptomatic bacteriuria. Decades of evidence are clear: it does not harm the people who have it, and treating it exposes them to real risks (C. difficile colitis, antibiotic resistance, tendon rupture, dangerous interactions with other medications) without evidence-based benefit. The confusion-UTI link that sends everyone reaching for the urine test when an older adult seems off is not scientifically well-established. A 2019 systematic review of the evidence found it so poorly studied that the authors named their paper: "The scientific evidence for a potential link between confusion and urinary tract infection in the elderly is still confusing."
What is well-established is that confusion in an older adult has a long list of possible causes: medication toxicity, dehydration, an early stroke, a metabolic change, pain, sleep deprivation, a new cardiac event. When the urine test comes back positive and the workup stops there, those diagnoses don't get found because we satisfy ourselves that we "found it." The thing that may have actually needed attention doesn't get it.
I've seen a different version of this UTI easy-answer temptation and the damage it can do up close, not just as a doctor but as a daughter. My mother called me recently, exhausted and miserable, thinking she had "another" UTI. She is not elderly and was not confused, but had decided that this answer was the right one for her symptoms based on her prior experience. The providers she saw, over and over, agreed without asking any other questions. I asked what was going on. I listened the way you listen to someone you love, with no agenda and nowhere else to be. The more she told me, the clearer it was that something else was happening. I asked her to see her specialist and told her how to explain her symptoms to them, and which ones worried me in particular. Her doctors confirmed my suspicion; she did not have a UTI. The diagnosis had stuck, visit after visit, because no one had slowed down to question it.
When I practiced with a home-based primary care team at the VA, I had the opportunity to work in a model of care that allowed me to practice medicine with genuine curiosity and patience. I could approach each situation with an open mind rather than a ready answer. When a caregiver called worried, I had real time to do a full assessment, name what I didn't know, talk through the possibilities, build a contingency plan, educate on the risks of over-treatment. When what we needed wasn't tests or drugs but time to watch and wait, I could follow up in two or three days. "Here is what I'm watching for. Call me if any of these things happen. I'll check in Thursday." That kind of medicine can build trust, catch things that fall through the cracks otherwise, and it allows us to take our time learning about what's going on rather than settling on a diagnosis prematurely. It also saves healthcare systems money.
The follow-up call that catches a serious diagnosis and the clinical infrastructure that makes it possible is, in most payment systems, not paid for in a way that reflects what it is worth. The contingency planning and caregiver education conversations that might prevent a hospitalization don't immediately generate significant revenue for anyone. A provider running at full capacity and beyond (as many, if not most, in large health systems now are) has little if any time or space to truly attend to a situation that needs to be monitored and revisited, or that involves education and relationship building with a trusted caregiver. The people rushing to inappropriate UTI diagnoses are not careless. They are doing the most reasonable possible thing inside unreasonable constraints. The reasonable thing, a lot of the time and especially in our current healthcare system, is the fast answer that requires the least possible follow-up.
I am not exempt from this pull. I have written antibiotic prescriptions in moments when I chose efficient and cautious over thorough and thoughtful. There are cases where that is a reasonable, if not the correct, clinical decision. There are cases where it is just the easier one.
The tendency to reach for a quick answer is not limited to UTIs. It is everywhere in and outside of medicine, and it is not going anywhere any time soon. There is satisfaction in filling the blank and finding an answer. It makes one feel like an expert. But we cannot all be experts in every situation, and the ability to slow down and think through a problem is something that we have to practice to keep. The tools we use to learn and find information shape the way we think. When those tools (right now, AI, for example) surface quick, nice-sounding, confident answers on minimal inputs, it is tempting to run with them. We should be skeptical of using mental or technological shortcuts that bypass thinking. In doing so, we allow our ability to second-guess ourselves, and thus our ability to find the truth of the matter, to atrophy.
We need a world where doctors are able to slow down on a busy afternoon and think: I wonder if this is really a UTI (or whatever-the-first-thing-is). And then call the caregiver and have a human conversation. "Hey, thanks so much for reaching out. Tell me what is going on."
What else in our lives are we handing to the quick answer, when what we need is a little more patience and curiosity? How can the systems we build allow people to slow down and think again?
I'd love to know what you're thinking. Reply to let me know.
P.S.
If you're reading this in your email, I appreciate you. Thank you for supporting my nerdiness and please feel free to share with anyone you think may be interested.
What I'm reading:
The Lathe of Heaven by Ursula K. Le Guin
Have a book recommendation? I'd love to hear it.
Photo: Raspberries taking over my garden this month. The closest thing I could find to cranberries.
