Sunday, July 31, 2022

Were You Discharged from the Hospital Too Early?

You sent my father home from the hospital too soon.  Three days later, he was worse than ever and needed surgery!

I’ve heard similar lamentations from patients and their families over decades.  Every doctor and hospital nurse has also.  And I acknowledge that sometimes families are correct; folks were sent home too soon. However, in my long experience, most patients are not sent to the street too soon despite some folks feeling otherwise, usually after the fact.  

First, let’s all agree that the medical profession – like your own occupation – is a human endeavor which means that perfection is aspirational.  An imperfect outcome or a catastrophic development does not mean that medical carelessness or negligence has occurred.  Medical malpractice is a real issue, but that is distinct from adverse medical outcomes, which is what I am focusing on in this post

Medicine is not mathematics.  There is no formula or set of proofs that will reliably bring us the desired result with a calculation.  If you disagree, kindly send me the formulas so I can improve my performance. Medicine is an art where judgments are rendered based on moving targets and incomplete data.  When a sick patient is before us today, we must make decisions and recommendations without knowing the future.  Should we prescribe antibiotics to a patient with a cough even if the chest x-ray doesn’t clearly show that a pneumonia is present?  Perhaps, the patient will recover on her own without any treatment?  Should I wait a day or two and simply monitor the patient?  What if I withhold antibiotics and she ends up in the intensive care unit 3 days later?  Will the patient and the family understand if I prescribe an antibiotic, which I am not completely certain she needs, and she develops a severe side-effect from it? Would I be accused then of reckless over-treatment?

'I should have known it was going to rain.'

If you present the above patient vignette to 10 experienced clinicians, there will be no consensus.  The conservative practitioners may hold their fire while more aggressive physicians will pull the treatment trigger. Physicians with divergent recommendations may all be correct, a fact that is mystifying to the public who tend to believe that there is one best answer to a medical issue. 

We cannot foretell the future.  If you leave your home on a sunny day to walk in the park, and it starts raining later, is it really your fault that you didn’t bring an umbrella with you?

When I am wallowing in the medical gray area, a daily occurrence, I do my best to convey the vagaries of medical science and judgment to patients and their families.  I review the options with their respective advantages and drawbacks. But I emphasize that we all have to be at peace once the informed decision has been made.  If a patient makes a considered and informed decision to proceed with surgery, and a post-operative complication ensues, we should not challenge the original decision ex post facto.  The time to debate, question and challenge is best timed prior to the decision, not afterwards. 

Physicians are also mindful of the risks of keeping folks in the hospital -a building full of germs and other demons - a minute longer than is necessary.   Families, however, rarely gripe that we are keeping granny in too long, as they are less aware of these risks which may include. falling, an infection or a medication reaction.  

If we could foretell the future we would make better decisions.  (Think stock market or Las Vegas!) Might this futuristic objective be in the realm of artificial intelligence?  

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