Posts etiquetados ‘inadequate care’

I recently read a wonderful article in the New Yorker which is a very poignant reminder of our values in health care. Many health care professionals start out with high ideals and a deep desire to help every patient. However, unfortunately this often quickly dissolves into disillusionment, cynicism and in an isolated hospital/clinical environment into ignorance of the real underlying problem and needs.

Ask any doctor about their worst or “heart-sink” patients and they will easily identify the frequent flyers, the poorly controlled diabetics that visit the ER every other week, the ones that don’t take control of their physical illness – often those with social issues and little social support.

In the isolated world inside a hospital it is all to easy for management and health care staff to focus on the numbers, the physical illness, the test results, the hospital outcomes and performance in terms of mortality and discharge rates. But without leaving our comfortable safety net of the hospital indicators and biomedical medicine we can not understand nor identify the actual underlying problems and make a difference to those patients that need it the most. And ironically, those patients we are treating inadequately and dismissing as frequent flyers are costing us the most.

Sometimes the more cost-effective solution to a patients poorly controlled diabetes is not frequent readjustments to their medication, frequent admissions due to decompensation but linking them in with social workers and community support to assist with obtaining adequate housing, understanding their medication and autocontrol of their illness and improving social support.

To quote Gawande in the New Yorker – Lower Costs and Better Care for Neediest Patients

… You might decide to increase his insulin dose and change his blood-pressure medicine. But you wouldn’t grasp what the real problem was until you walked up the cracked concrete steps of the two-story brownstone where he lives with his mother…

Gawande further develops his argument by saying that

…“Emergency-room visits and hospital admissions should be considered failures of  the health-care system until proven otherwise,” he told me—failures of  prevention and of timely, effective care….

This last statement is slightly provocative and thought-provoking, but has an element of truth. There is much scope for preventative measures and health promotion. Social and community issues are vital parts of an individuals and community health and should not be forgotten. Although arguably we can shift responsibility for this from the hospital to primary care medicine or public health. We can and should be using the ER admissions and re-admissions as indicators of areas of need in the community and identify social and health needs of a community. In treating each patient we need to remember the importance of the psychosocial factors influencing their health.  And ultimately in economic and managerial terms it may be beneficial for a hospital identify problem areas and to invest in their catchment zone – either directly or indirectly.

We need to get out of our doctors office and reconnect with our community. We should try to identify and understand the underlying issues of our patients remembering that the solution to a health problem may be better solved from a social context,

and ignoring this is costing us more.

— MT —