Tuesday, February 26, 2013
Hospitals are still awful: movement toward patient centered care and Eric Topol's idea
First a disclaimer: People often receive compassionate, considerate and effective care at hospitals. They have countless interactions which impart the miracle of human caring and enrich their lives. It is also institutionally prevalent to have haphazard care with poor communication, near misses and avoidable misery.
I have been working at a university hospital emergency room as part of a mini-fellowship in bedside ultrasound. It is the first time I have spent significant time entirely dedicated to an emergency room since I was a medical resident about a quarter of a century ago. As an internal medicine physician who works in hospitals, I have spent one or two hours at a time relatively often in emergency rooms taking care of patients who were admitted to me on their way to the medical floor, but that is not the same as staying there, seeing the more and the less ill, the folks who may go home and may get admitted, watching the rhythm of the department over time.
People come to emergency rooms for many reasons. Often they come because they need to see a doctor, but can't get in to one in an office because the doctor is busy or doesn't accept their insurance, or they don't have any way to pay, no money and no insurance. They come in because there is something wrong that they have decided needs to be dealt with now. The problem may be a true emergency, something that if left another day will lead to death or disability, or just something that has become intolerable and appears, from the patient's view, to have reached a level where any delay in treatment is unthinkable.
They also come in, brought by ambulances or police or concerned family or friends, for drug overdoses, stab wounds, car and motorcycle accidents, assaults. They come in with no regard to whether the doctors in the emergency room are already busy, and they do not pace themselves. Three patients with stab wounds may arrive in 15 minutes, topped by a cardiac arrest. Usually the universe doesn't do this to us, but milder versions happen all the time. The acute treatment of the critically ill patient is often beautifully choreographed, efficient and successful. Treatment of the less critical patient, not so much.
Patients are brought back to the actual department where, in this ER, they are evaluated in curtained bays, with privacy of their stories ensured only by the ambient noises of crashing and yelling and beeping. Some newer emergency departments actually have rooms with doors, but not the one I'm hanging out in now.
They are evaluated by resident physicians, attending emergency room doctors and sometimes students. They are cared for by nurses whose attention is constantly pulled in many directions by a constant flow of patients with varying urgency of need. After a patient is evaluated and an initial treatment plan is developed, they get IVs, usually, medications, sometimes, lab tests usually, radiological procedures frequently, and often a bedside ultrasound by someone like me, in training. Then they wait. And wait. And their relatives, who have to go to work in the morning, which is now only a few hours away, sit and wait. Occasionally someone comes by to tell them what they are waiting for, but not very often.
Their labs are completed, and if there is nobody else more critically ill, some doctor in the team checks them and thinks again about what should be their ultimate outcome. And they wait, not knowing what is happening. They wait, lying on plastic covered gurneys which are covered with sheets that slide down and bunch up underneath them. Sometimes, but not often, primary doctors or consultants who are familiar with them are contacted. If they are admitted to the hospital they are moved to a more comfortable room in a new building (which must seem like heaven in contrast with the ER) but they have to wait hours to be seen by the admitting physician and moved to said room.
After 25 years in internal medicine practice, I am much more familiar with what happens to patients when they do reach the hospital wards. They tell their story, which they have told at least five times already, with multiple interruptions, to a new crew of people, nurses, specialists, new doctors from a different shift. They worry that the whole story that they told before has not been communicated and that what is being done to them may be wrong or unnecessary because of miscommunication. They hear about planned tests, have tests, wait for hours for results, or days, or never hear the results at all. They get treatments delivered by nurses along with explanations given by the nurses, which only occasionally bear any resemblance to what they doctor was thinking when the treatment was ordered. (This is not the fault of the nurse, but due to the system in which nurses and doctors rarely discuss treatment plans in any meaningful way.) They also get explanations from specialists which differ from those given by hospitalists, and maybe get to spend a little more time talking to social workers or discharge planners who sometimes have a better idea of the big picture than anyone else on the team.
The inevitable result of all of this is that patients, except those who are unusually generous of spirit, are frustrated and often grouchy, occasionally spitting mad. They are also not made well in the most expedient of manners, and often are made sick on the way to being made well, or instead of being made well.
Eric Topol, MD, a renowned cardiologist and inventor of novel medications, and more recently a questioner of tradition, employed by the Scripps Research Institute studying innovative medicine, has given a brief video talk about ways in which hospital stays and doctor visits might be replaced by video chats and remote transmission of physiological data. I think that he is being short sighted and has forgotten that many people who end up in hospitals do so because there is no unpaid human who will or can care for them outside of a hospital, either because they have become so darn sick they can't even make it to the bathroom, or because they are homeless or marginally housed, and that three-dimensional health care is fundamentally what humans do for each other. Still, I love the fact that he is talking about ways to radically change medicine.
Many organizations are developing systems to make medical care more "patient centered." This term was initially coined in the 1960s and was defined as systems that "take into account the patient, the social context in which he lives, and the complementary system devised by society to deal with the disruptive effects of illness."
We physicians sometimes think of this kind of thing as fluff, and unworthy of our skills in fighting off death and disease in their myriad forms. Movement in the direction of patient centeredness, with attention to the systems which make medical care unkind, is vitally important, and should legitimately absorb a significant portion of physicians' considerable problem solving skills.
Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health care so expensive?, where this post originally appeared.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
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Suneel Dhand, MD, ACP Member
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