Thursday, April 3, 2014

Discrepancy between percentage of time Residents spend in the hospital training and percentage of time patients spend in the hospital

I have been thinking about the discrepancy between percentage of time Internal Medicine Residents spend in the hospital training and percentage of time our patients spend in the hospital.

My patient with the most hospitalizations this year is Mrs S. She has had 8 hospitalizations adding up to about 1016 hours in the hospital. She is definitely an extreme outlier in terms of frequent hospitalizations and yet she has spent 88% of her time OUT of the hospital.  This is in contrast to the resident who has spent 75% of his training IN the hospital this year (approximately 2304 hours in the hospital and 768 hours training in the outpatient setting). His inpatient learning is intense and he is well equipped to take care of the very sick patients in that setting.  But our patients (with rare exceptions) spend proportionately very little time in the hospital.

Would patients get better care if residents had more exposure to the patients’ out of hospital environments? Here are a couple of examples where knowledge of the patient’s environments would probably decrease unnecessary interventions and cost.

We couldn’t seem to keep Mrs B out of the hospital. She had repeated asthma exacerbations and was hospitalized 11 times in one year. Each time, she was treated appropriately and sent home but the scenario repeated about every month.  When we thoughtfully reviewed her home setting, we discovered her twenty-something year old grandkids would come over and smoke in her house. After having them stop smoking in her house, the next year she was not hospitalized once!

When doing a home assessment, I found Mr G compliant with all of his meds but the only food he had in the kitchen was some neck bones stewing. He said he couldn’t afford more food because his medications were so expensive. We realized that he really didn’t need all of the meds he had been prescribed and others could be switched to less expensive formulations.

Then there was the lady with advanced dementia who during an admission for urosepsis, was deemed to have a high aspiration risk and ended up with a feeding tube. In retrospect, she was always in bed in the hospital and attempts at feeding were made when she was in this suboptimal position. When I visited her at home after the hospitalization, she was up in her chair bright eyed and smiling after finishing a whole breakfast of ooey-gooey pancakes and maple syrup. Instead of making a decision about tube feeding in the hospital while sick, it would have been preferable to have her go back to her own environment to assess.

Have you ever seen a home set up like a nursing home? We just saw one today—the daughter has a bedroom set up PERFECTLY with a bed, supplies, shelving unit and pictures on the wall but free of clutter. As we watched her, we saw that she has trained herself to be as good as any practical nurse I’ve ever seen. The patient has been very stable so she doesn’t qualify for hospice care though we are still giving her palliative/hospice-like care.

While financial incentives push us to teach in the hospital, I but I think residents could be better doctors by exposing them to where the patient spends most of their time and helping them to consider this when they are in the hospital.  

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