By Jessica Jou
During the four weeks of my ICU rotation, I came to know Mr. S well. I was the medical student on the intensive care team, managing patients alongside the primary surgeon. Mr. S was on the road to recovery when I started to follow his hospital course. Every morning we rounded, one more of the numerous tubes attached to his body were removed. He grew stronger, gradually able to speak clearly in the days following his extubation, and meet the usual post-operative milestones of a surgical patient. Eventually, I noticed my progress notes were becoming repetitive, almost replicas of the day before. The intensivist ceased making new medical decisions for his care and eventually even stopped rounding on him all together. The one-on-one nursing staff took longer coffee breaks, complaining that they were being called into his room only to change the TV channel. It became increasingly difficult for the social worker to plan his discharge. Every time she secured a bed at a Long Term Acute Care (LTAC) facility, his discharge would be postponed by the surgeon for one reason or another. However, Mr. S showed all the indications that he was out of the woods. Even he asked whether it was time to go home. Every morning, multiple caretakers made their case to the surgeon about discharging to the regular medicine floor. However, the primary surgeon insisted on keeping a close eye on him. He remained on the ICU floor after completing my rotation.
Without delving into the details of Mr. S’s insurance coverage, the medical waste in this case is obvious. The financial repercussions to the patient, hospital, and insurance company are difficult to calculate. However, what was most surprising to me was the absence of discussion regarding cost-conscious decision-making. Other than discussing overnight events and medication changes, a culture of reassessing appropriate level of care for patients did not exist. The efforts required to instill such practices became apparent to me one day as I sat in the ICU conference room. Surrounded by posters about hand-washing, listening to a talk about fighting nosocomial infections in the hospital, I realized that the success of hospital-wide campaigns often rely on the investment of time and resources by organizations such as the CDC. To implement a culture of routine hand-washing at this hospital, it took years of clinical research, numerous posters, and multiple lectures led by the ICU director. But most importantly, it was the sense of responsibility and communication between medical staff members that made the ultimate difference.
I imagine that cultivating the practice of assessing appropriate levels of care as well as providing cost-effective care would require similar organizational efforts and involve all levels of healthcare delivery to effect change. To start, cost education should involve students, nurses, physicians, and even administrators. For example, integrating cost research into the problem-based learning curriculum in medical school can raise awareness early. Implementing cost data into hospital EMRs can aid physicians in making real-time clinical decisions for their patients. A downloadable checklist of minimal requirements for intensive care from a nurse’s, social worker, or physician’s point of view may promote interdisciplinary rounds and can serve as a simple notification system to reassess the patient accordingly. ICU directors of faculty could hold relevant journal clubs covering articles provided by the website to uniformly educate faculty, residents, nurses, and medical students. More importantly, it will be the sharing and discussion of this information that develops a culture. Video vignettes, podcasts, and lectures may facilitate this by simulating constructive feedback mechanisms, creating an open learning environment, and emphasizing communication strategies. As we remain humble learners and good listeners, I think Mr. S’s story can teach us a lesson in communication and its importance in improving costs of care and medical decision making.
Jessica Jou is currently a fourth year medical student at Tufts University. She is interested in promoting medical student education on cost-awareness of healthcare.