My annual month of teaching internal medicine on the wards has always given me a yearly reminder of the changes in inpatient medicine: the increasing presence of "hospitalist" physicians, the proliferation of shift work among doctors-in-training, and a growing emphasis on quick discharge of patients.
But this year's experience has been jarring. My hospital at times seems like a factory. Admitted patients receive a battery of tests that lead to provisional diagnoses even as discharge planning has begun. Even though medical care needed to change, we are in danger of losing a type of interaction that was basic to both medical education and patient care.
Patients used to stay in hospitals for too long. Doctors mistakenly prescribed bed rest for heart attacks and mandated long in-hospital courses of intravenous antibiotics. "Interesting cases" were admitted for educational purposes.
There were, however, advantages to this system. Doctors got to know their patients, learning not only about their illnesses, but about their families, personal histories and even idiosyncrasies. By following inpatients over long periods, doctors-in-training, known as residents, learned how to diagnose and treat complicated conditions.
Rounds emphasized these goals. My professors insisted that we withhold the results of X-rays or other tests that might "give away" the diagnosis. The key was contemplating a case, and then developing a "differential diagnosis," a list of possible diseases. It was an intellectual exercise that attracted many students to specialize in internal medicine.
One often admiringly heard the phrase "clinical judgment." It was a skill possessed by the finest doctors, who could not only make correct diagnoses and prescribe effective treatments, but also seemingly had a sixth sense about which patients were recovering and which were deteriorating.
We have moved farther and farther away from these traditions. For one thing, the need to limit excessive work hours by tired residents -- a legitimate concern -- requires hospitals to constantly change how residents admit and cover patients. Whereas once residents admitted all of their patients and followed them daily, now the patient is handed off among a series of ever-changing individuals with "sign-out sheets" summarizing the medical issues.
Of more concern is the growing lack of time devoted to ascertaining patients' true diagnoses, physical and emotional. Emergency room physicians, who are supposed to quickly evaluate patients and decide if they require admission, too often set the tone for the eventual diagnostic work-up through their initial impressions. Inpatient doctors used to review new cases from scratch, but this no longer occurs with the same intensity. Rather, we examine the patient, review his or her tests and ask whether any further work-up needs to be done in the hospital.
This process is fostered by the appearance of a specially-trained nurse and social worker on our rounds, charged with "coordinating care." These individuals ensure that consult services come quickly, tests get performed and -- most important -- that discharge planning not be delayed due to bureaucracy.
Don't get me wrong. Patients at New York Presbyterian Hospital, where I work, still receive stellar care. I am routinely impressed by the commitment of the residents, nurses, social workers and other staff members. Indeed, it can be argued that New York Presbyterian and other medical centers, by focusing on cost-efficiency and rapid discharges, actually benefit their patients by keeping the institutions solvent in tough times. Once the Affordable Care Act becomes fully implemented, hospitals will be under even greater pressure to justify to insurers why admissions are warranted.
Still, something crucial is being lost here. Doctors-in-training become excellent physicians by seeing patients over time. Initial impressions are often wrong. Making diagnoses and choosing proper treatments is a subtle process, especially for patients sick enough to require admission. Today's residents, experts at moving patients along, will suffer if they cannot learn from their mistakes.
And, more importantly, patients will suffer, too. In recent years, medical educators have warned that hospitals are growing more impersonal and have urged young doctors to treat patients as people -- not diseases. Even the most educated and empowered patients have difficulty asking questions and understanding their conditions. The current system, with its emphasis on time management and its ever-changing cast of characters, only makes this worse.
So what is to be done? First, we need to face the fact that rushed admissions lead to provisional diagnoses. Many discharged patients will do fine but others will not get better. Improving the information we give to them and bridging the gap with their ongoing care is crucial.
Second, since primary care providers will increasingly be asked to follow up on these brief admissions, we need to improve outpatient medical practice. Although physicians in these settings are also pressed for time, team-based care, which uses nurses, nurse-practitioners and physician assistants to their maximal potential, can free up doctors to focus on disease management and improving communication with patients. It is the least we owe our increasingly transient hospital guests.
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