All the decisions are made somewhere else: observations made while working in the hospital
Most of the time I take care of patients in the clinic, but I regularly admit patients to the hospital as well. I try and notice what makes me uncomfortable when I see them there. (Which is probably not as completely or acutely noticed by me as by the patient – but, hey, you take what you can get on this blog. Obviously, there are no shortage of patient blogs to read as well.)
No one knows anything. The attending – me – doesn’t know discharge time because it depends on when the meds are filled and the appointments are made. The patient doesn’t know their discharge time because they are under the mistaken impression the exact time is up to me.
Decisions are made elsewhere. The patient’s wife, who is on top of things and asks impressively detailed questions which have improved care for her husband, asks what a certain specialty service is going to do about a procedure. I don’t know, and I’ll ask them. But any decisions they make are not going to be done in the room, while talking to the patient and his wife. They’ll be made in some corridor somewhere, and then transmitted to me by page or phone. Everything gets to the patient and their family third-hand.
The endpoint isn’t clear. We try to identify, at the beginning of the admission, what is the goal for discharge, but when the active issues change, as they have many times in this case, the patient can find themselves in the hospital for longer than they had expected.
Outpatient versus inpatient. The patient is understandably concerned about missing the clinic appointments he can’t keep because he’s cooped up here in the hospital. He wants to know if those services can come by. No, I start to say, by instinct, because they deal in the hospital with urgent or severe matters. But then I thought: couldn’t we do it that way after all? We do counsel smoking cessation, and do other preventive services or counseling, for patients who might not get them any other way.
An esteemed senior physician who I knew in New York says that every patient is an opportunity to do research, i.e. learn about the course of disease. Whenever I see a patient in the hospital, it feels like health services research in miniature. This is what the hospital is like: bewildering, inefficient, and at cross-purposes with itself.
No false modesty here: we have a great team, and the gentleman is getting better! Not without, though, teaching us important lessons in efficiency, patient-centeredness, and humility.
