Many medically oriented TV shows and books take place in hospitals. They often start with the screaming sirens of an ambulance pulling up to a hospital and end (at least, the happy stories) with people walking out, better for it. In the middle, the stories revolve around extravagant technology, heroic surgeries, and harrowing “life and death” moments.
However, most medical care isn’t provided in hospitals. As diseases move from acute to chronic (think cancer, diabetes, heart failure), patients receive a larger proportion of their care in the community. They rely increasingly on services such as CCAC (Community Care Access Centre), which maintain a relatively limited presence in the hospital. In-patient admissions tend to be reserved for patients who cannot safely be discharged home, and even then, the emphasis is on treating an acute medical condition.
Physicians now devote considerable time to navigating patients toward the most appropriate discharge destinations. The possibilities seem endless: patients may be sent to rehab centres, nursing homes, retirement homes, complex continuing care facilities, or home with community supports, for example. But where to send any given patient?
This is not an easy question — and it is complicated by the fact that many physicians do not know how these sites and services work, beyond a superficial understanding.
As internal medicine residents we came to recognize this while on the clinical teaching unit of a busy downtown Toronto hospital. A patient presented in florid heart failure, unable to walk or even breathe because of the extra fluid pooling in his legs and lungs. We admitted him and finally, after days of treatment, he was able to move and breathe again; his acute medical condition had resolved.
Despite his motivation to walk independently again there was still much work to be done. We submitted an application for transfer to physical rehabilitation, and prepared ourselves for the arduous wait for a placement.
One afternoon the patient asked, “What does rehab look like?” Silence. “I’m just nervous about it,” he said. “What does a day in rehab look like? What kind of food do they give us? Will my wife be able to visit me everyday?” More silence. “How many weeks are they planning on keeping me? I wonder when they’ll take me — when will I go?”
We always seem to have an answer for his medical concerns. But now, when asked about how his care would look outside the hospital, there were no answers. We didn’t truly understand where he was going.
This story is, unfortunately, not unique. As trainees, we learn to manage patients on medical wards and in office clinics. We become proficient at recognizing their maladies and manipulating their biology: our exams and training prepare us well for this. But we are less prepared to understand how community services — arguably the crucible of modern health care — will pick up where we have left off.
This is problematic. Patients rely on physicians to guide their health care trajectories. While the expertise of other health specialists — physiotherapists, occupational therapists, speech pathologists, social workers and others — is invaluable, physicians are legally and practically the most responsible providers for patients in the hospital.
Yet, most physicians get little to no exposure to rehabilitation institutions, long-term care facilities and nursing homes. How can they make safe, appropriate and informed discharge decisions without insight into how those destinations look, and what they have to offer?
To remedy this problem, medical residents and early doctors should be encouraged to spend part of their training learning how community establishments function — for instance, by directly participating in clinical placements. They should follow their patients to better understand the services they receive beyond hospital walls.
By experiencing the day-to-day lives of patients, residents may embrace the opportunities and limitations these community avenues offer. The next patient they discharge will have a safer, more nuanced care plan when they leave, and a better understanding of where they are going.
It is no stretch to imagine that failed disposition plans or delays in establishing reliable discharges are what keep patients in hospital significantly longer than necessary, or bring them back all too often. Almost 4,000 beds are occupied by patients awaiting transfer to long-term care, rehabilitation, or other such institutions. Medically inactive patients can fill up to 10 large hospitals in Ontario alone.
To make these changes possible, medical training paradigms should evolve to impart knowledge of community services. Moreover, experience beyond the walls of the hospital should be valued in the same way as traditional ward-based clinical experience. While this is not an easy proposition, such changes would not only help physicians, but would improve patient care — and that is reason enough.
Arnav Agarwal and Shaurya Taran are internal medicine resident physicians at the University of Toronto.
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