Blog | Monday, March 31, 2014

Observation versus inpatient is a different world for today's medical residents

Like a lot of physicians right now I sometimes have to stop and take a few deep breaths when I realize how quickly the world of medicine is changing. Having been out of residency and in clinical practice for just over 5 years, the pace of new developments is staggering. One of the biggest changes to take place over the last decade is the increased emphasis on cost containment and delivering real value for our patients. It simply wasn’t even talked about not so long ago. This is manifesting itself in various ways, and much of it is truly needed (like ordering tests and investigations like confetti without solid medical evidence and necessity).

One example of a new and stricter Medicare administrative distinction is whether a hospitalized patient is admitted under “inpatient” or “observation” status. Any doctor practicing in the hospital medicine environment, including a lot of specialists who see hospitalized patients, constantly now hear about the importance of this decision. For those of you not in the medical world, the decision basically hinges on the patient’s acuity level, and can have large financial implications for the patient and hospital alike. The issue is gaining national media attention, as evidenced by this recent New York Times article. Because of the controversy and perceived unfairness, there are many who believe that this distinction should be done away with altogether. It would be far simpler to have all patients either admitted to hospital or not, with no further delineation.

Sadly, I’ve already noticed a handful of patients and their relatives worried about their “status”. Thankfully, these have been few and far between so far, but will inevitably become a bigger concern as more awareness of the issue is raised. Is it right that a 90+ year-old World War 2 veteran who landed on Normandy Beach be subjected to this additional stress after they come into hospital with a bad fall, and are told that their observation stay will mean paying more?

But to the main point of this article. As a teaching attending, I always feel a bit sorry for my interns and residents whenever they present a case to me and finish up with a statement explaining whether the patient should be made observation or inpatient. Ultimately of course it is the attending physician’s decision, but sometimes I hear the intern or resident getting into overly precise details about their thoughts behind the decision. “This patient should be placed in observation status because …” “This patient is too sick to be made observation status because …” “This patient should be made inpatient because …” All very well and good; they are recognizing an important part of a modern day hospital stay. There’s the reasonable argument that this next generation of physicians should be well-versed in the realities of the medical environment they are about to enter.

To be fair, residency programs across the country have at least tried to provide some education about this pressing issue for hospitals. However, a large part of me believes that the job of an intern, resident, or indeed a medical student is to learn good medicine and not burden themselves with administrative decisions. Oh, how things have changed over the last few years! Most doctors practicing today didn’t have to even think about many of these things when they were residents. It used to be that we just saw the patient and presented our history, physical, assessment and plan. Isn’t that as it should be?

It gets into a broader debate about how much we should involve our doctors in training when it comes to the central administrative side of medicine. How do we balance this with the need to focus on medical education and how can we shield these young doctors as much as possible from the realities that will inevitably hit them after they finish their residences? Surely some more intense education in the final year of their residency about such things should suffice.

When it comes to the observation versus inpatient decision, I always try to encourage those that I am teaching to just scratch the surface of the issue. My advice to all doctors in training: Just know the bare basics and one sentence is enough at the end of your assessment. A few seconds of time only please, and no lengthy discussions or debates about this in the intern’s presentation. Your attending physician can figure out the rest. If there’s any confusion, whoever else is dealing with this decision and any “status flips”—typically case managers—can put additional energy into this. Focus on being a good and competent doctor first and foremost. You’ve got the rest of your career to understand the administrative (and political) side of medicine.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.