In or Out?

Short White Coat is a blog about learning to be a doctor. Posts appear here as part of White Coat Notes. Ishani Ganguli is a third-year Harvard medical student. E-mail her at shortwhitecoat@gmail.com.

It’s no secret that hospital stays are shorter than they used to be. How is this trend reflected in day to day practice and what does this mean for medical education?

On adult internal medicine, inpatients have complicated histories, with lists of past and current medical issues that span columns in their medical records. As the teaching goes, our job is to think about what’s keeping this patient in the hospital -- is it the diabetes, acute-on-chronic kidney disease, or new-onset heart failure? What are our goals for this hospital admission? (Usually, it’s to get the patient back to baseline.) Every morning on my rotation at Brigham and Women's Hospital, our team would meet with the nursing care coordinator to run through our list of patients and discuss how to get them out.

In sorting through our plans for these patients, the major decision point rests on where the action should happen -- in the outpatient vs. inpatient setting. We think primarily about the patient’s medical stability and are often swayed by socio-cultural and other factors that lower the threshold for inpatient stay: concerns that a patient won’t show up for a crucial follow-up CT scan, for example, or that she is unsafe in her home or doesn’t have one in the first place.

The distinction between outpatient and inpatient isn’t taught in the classroom, it’s the sort of thinking that we acquire by observing the system. I’m often compelled to get every diagnostic test done right then and there, and in fact, it’s what patients often expect. (While I’m here, do you mind checking…?) But as my seniors remind me, certain tests and procedures can wait (either that, or it takes so long to get an opening in the cystoscopy suite or the MRI center that outpatient is the only way).

From a cost-savings standpoint, it’s a critical thought process (though cost-efficient care is about more than shortened stays). At the Brigham, for example, every extra day spent in the hospital adds upwards of $3,000 to the bill.

But as medicine makes a shift towards the outpatient setting, the inevitable correlate is that trainees miss out on seeing the natural course of a patient’s diagnosis and treatment. Senior physicians trained in the era of lengthier inpatient stays echo this concern.

I have several patients that I continue to follow -- I check their computerized records for updates and attend outpatient visits when I can fit them into my schedule, but test results get lost in the inevitable jumble of outpatient care and this follow-up is necessarily spotty. As Washington sorts out this growing tension between cutting costs and training the next generation of doctors, something’s gotta give.