In 1990, Desert Storm was initiated by President George H.W. Bush,
along with coalition partners to reverse Saddam Hussein’s aggression
with respect to Kuwait. As American and
allied forces moved into Iraq, many hawks wanted these forces to advance to Baghdad,
and drive out Saddam Hussein. As we all
know, President Bush pulled us out as he did not feel this objective was part
of the mission. He knew when to get out.
Now, physicians are not military strategists, but there are
parallels between military strategy and patient care, particularly when a
patient is hospitalized. Consider the following schema.
The Conflict: A
patient arrives in the emergency room with a cough and a fever.
The Mission: Disease eradication
The Tactics:
Hospitalization
Exit Strategy:
Getting the patient out.
Physicians, just like the generals in the Situation Room in
the White House, need a sound battle plan.
The plan must be flexible enough to adapt to changing contingencies and
unforeseen events. I have found that
explaining the Exit Strategy to patients and their families can be a
challenging undertaking, in contrast to explaining the tactical decision to
hospitalize someone. For example, if a
physician recommends hospitalization because this option is felt to be safer
and appropriate, then patients and families readily accept this. (Ordinary folks would not be expected to
consider the risks of hospitalization with regard to infections, errors, sleep
deprivation and excessive medical testing, but let’s leave this aside for now.)
In my experience, patients and their families need and
deserve a detailed explanation from the doctor when hospital discharge is
advised. Here are some points that I
cover during my Exit Strategy discussion.
Choose a Physician Who Can Predict the Future
Discharge home does not mean that the individual is 100%
cured. It means that the medical team
believes that the recovery can safely continue at home or at an interim
facility. Hospitals are now equipped
with teams of home care medical professionals, social workers and therapists to
continue care and treatment after discharge. In the olden days, patients would be fully recovered during their hospital stay, and might even linger a day or two longer because they could.
Every extra hospital day, as I noted above, carries direct
health risks to the patient. Feel free
to Google, C diff, and you will readily understand my point. Most families are not fully aware of the risks of hospital life.
Despite our extensive medical training, physicians were not
taught the art of clairvoyance. This is
a serious oversight by medical educators as this skill would have enabled us to
be much better physicians. Hopefully, as
medical education reform continues, students will be taught this practice so
they will know exactly when to prescribe, when to operate, when to observe and
when to refer to a colleague. I take
special effort at discharge to explain to patients and families that we are not
fortune tellers. We know only what we know, not what will be. If we knew, for example, that Granny would
take a turn for the worse 3 days after we sent her home, then we would not have
discharged her. While physicians can certainly discharge a
patient too soon, the fact that a patient’s condition worsens after discharge
does not automatically mean the decision to discharge was wrong or premature. I think it’s important that patients and
their families buy in to the rationale and timing of hospital discharge. If they haven't, and Granny's condition goes south in a few days, then the physician may face an irate family or be relieved of command.
The best generals and the best physicians are those that know when their mission has been accomplished and how to extract their people out safely.
The best generals and the best physicians are those that know when their mission has been accomplished and how to extract their people out safely.
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