Among the most difficult and powerful experiences we hospitalists have is delivering life-altering information. While some news can be good, most is bad, given the age of our patients. These have to be among the most challenging and even surreal conversations, given the mortality that we are all staring at. At the end of the day, our ability to be defined as a good doctor comes down to our skill in providing this information with genuine compassion and empathy, as much as any other.
Recently, however, I have had to deliver a new type of diagnosis to a patient. While my introductory comments clearly are a testament to the gravity and importance of what we do, what follows is a lighthearted attempt to describe an increasingly important reality in our job.
Backdrop: any ER USA, a hospitalist and, of course, a patient.
Dr. H: Good morning, Mrs. Returner, how are you today? I see you are back for the fourth time this month. It looks like your respiratory symptoms are already improving after the initial treatment proffered by your friendly ER physician, Dr. Al Mitem. In fact, you look like you could already go home, but given your recurrent admissions, we probably still need to bring you in for a couple of days to tune you up again.
Mrs. Returner: What exactly is my diagnosis?
Dr. H: I must break this to you gently, as this is never easy to do. And it is important that I be open, honest and direct with you. Mrs. Returner, you have readmissionitis.
Mrs. Returner: That sounds dreadful. What is it?
Dr. H: It is the condition of recurrent need to be admitted to a hospital for heart failure. We have known about this disease for years, but only recently have we discovered how dangerous it can be to the both of us. Medicare–our lifeline–has decided that in the future, each time you come down with acute readmissionitis, we aren’t going to be paid in full.
Mrs. Returner: Give it to me straight, doc. Is there a cure?
Dr. H: Well, unfortunately, the only guaranteed cure is death.
Mrs. Returner: Oh my, that is serious, but you doctors are a smart lot. Surely, you must have found something with a slightly better outcome. I mean, that would be a very tough pill to swallow, no matter how minor the other side effects might be.
Dr. H: Well, it is true we have been working on a cure for years. We made sure you were getting an ACE or ARB at discharge, or we would be sure to document why not. We would tell you not to eat too much salt, watch your weight, quit smoking, exercise, take all your medicines exactly as prescribed, and follow-up with your primary doctor within seven days. We would of course write all of this out, and make sure the discharge medication reconciliation exactly aligned with what was dictated in the discharge summary.
Mrs. Returner: Wow, that makes me feel better already. I like to accumulate discharge instructions; I have a lovely collection at home. But I don’t think those have cured me yet.
Dr. H: Yes, good point. Early trials of this therapy weren’t all that successful. That is why this time, you will go home with a nurse navigator who will help ensure that all of the above is actually carried out.
Mrs. Returner: Great! Do the studies support this?
Dr. H: Yes and no. Recidivism does seem to improve under this model. But it is expensive and not all trials demonstrated clear benefit. In fact, a large hospital system in the Midwest provided excellent care coordination after discharges and found that people who were followed closely actually came back to the hospital more often, not less. So the treatment may be worse than the cure.
Mrs. Returner: Well, anything that helps, doc. I certainly don’t want to be cured by dying. That is a terrible option.
Dr. H: Funny thing you mention dying again. While I don’t trust anything that comes out of California, a large observational study did demonstrate that those who come back to the hospital for their CHF more often–rather than less–actually tend to survive longer.
Mrs. Returner: You must be kidding! This validates everything I have already been doing. See you next week!
Dr. H: Oh boy, Mrs. Returner, you are a tough nut to crack. We’ll see you soon. And remember, if you can wait 30 days or more, we will automatically upgrade you to our new CHF suite! It may seem excessive to have a king bed, 60-inch plasma TV and 24-hour masseuse, but trust me, no options are off the table when it comes to curing this disease!