Matt Morgan: Hospital doctors should step outsideBMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4914 (Published 06 August 2019) Cite this as: BMJ 2019;366:l4914
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Misconceptions and misdirection: time for medical schools to involve more community experience than simply delegate their teaching obligations to the hospitals
I am unsure of the current teaching curriculum in certain medical schools nowadays but I am disappointed to see authors from Imperial College London (Ref 1) parroting the misconceived notion that doctors are the sole determinant (and hence bear full responsibility) of how patients are discharged back to community care.
I am certain for at least the last generation or two, most general medical services have been using a multi-disciplinary team (MDT) approach in the care of the patient within the hospital as well as when planning the transition from the hospital to community care. Key activities like discharge planning utilitise information and assessement from social work, home visits by allied health proessionals, community nursing reviews, weekly MDT meetings and community/GP liason officers; all these are part and parcel for almost all admitted patients except for the simple and straightforward episodic care. Granted some specialities do this better than others, but the irony is that those most involved in MDT planning are for those who are the most likely to readmitted within 30 days of hospital discharge.
I did not spend too much time in outreach and community services in my student years but the few weeks I spent tagging along with occupatonal therapists for home visits and community services (like meals on wheels) opened my eyes to a world outside the hospital but hidden behind the front doors of the homes of individuals who are fiercely guarding their independence despite their living conditions and limited support within their four walls. I was humbled by special privileges granted to me to access their personal space and learned to assume nothing; just because someone lives alone does not mean their lives are lonely, and vice versa, living with family members does not mean they are properly cared for. Some junior colleagues seemed surprised (and sometimes frustated) by my routine questioning to assess post-discharge needs in my busy (and often prolonged) clinic, particularly when my approach does not fit the typical perception of a fast-moving go-getting orthopaedic speciality.
I subscribe to the mantra that if we fail to plan, we plan to fail; discharge planning starts on the first day of emergency admission, and the day of booking for surgery for elective admission.
Perhaps medical schools should ensure students participate in discharge planning, MDT meetings and home visits so that we do not end up having more super-specialised hospital doctors unaware of their hospitalist colleagues who are aware of the drastic change faced by vulnerable patients between the hospital and their homes in the community. Otherwise, articles like this would not have been portrayed as some new revelation and ideas to those who should know better. Perhaps it is time for some of my colleagues to step out of their silos and see what our geriatric colleagues do in the coal-face of discharge planning.
There are simply not enough doctors around compared to allied health professionals to do community outreach, which is why the latter are more experienced and often better trained to assess patients' function and capabilities in their own environment.
Finally, adequate care should be taken when making statements like "a 2017 NHS report showed that over the previous four years, readmission within 30 days increased by more than 20% ", particuarly when the Healthwatch "report" (Ref 2) so referenced is neither an official NHS document (Healthwatch being a consumer entity) nor NHS-endorsed statistics. Their data are interestingly presented by comparing absolute numbers of readmission (hence a increase of 22.8%) rather than the rate of readmission as a proportion of total admissions (which also increased by 9.3% in the same period) which would have worked out as about a 1.1% increase in rate of readmission. Inconveniently for the authors of the Healthwatch report and Imperial College London, this 1.1% difference is pretty much what is annouced by NHS Digital in March 2019 (Ref 3), but I guess a mere "1.1%" increase in readmission rate does not attract as much attention as "20%" more readmission in numbers.
Don't forget that in the same period, NHS England lost 6000 overnight beds (4.5%) to 131 000 (Ref 4) so it is amazing work by the NHS health professionals that not more patients are affected by the shrinking admission capacity.
So what is all this about? Fake news? Lies, damned lies and statistics? Massaging the truth for political gains? I will let my fellow readers decide.
It is true that the NHS is under seige from people who want their pound of flesh from health professionals, to do more for less by politicians, to maintain medical standards when doctor staffing and recruitment is in crisis, to take the blame for not providing what the scheme was never set up or budgeted to do and for missing the shifting goals and meaningless targets where unnecesary paperwork and technological fetish does not translate to real outcomes that actualy matter.
But the last thing we need is the rot to start from within the fraternity through misguided ideas and failure to look at what other people are actually doing because of having a silo mentality.
2. Healthwatch NHS needs to do more to understand why people are returning to hospital after being discharged. London: Healthwatch, 2017.
Competing interests: No competing interests
This article demonstrates the stark contrast between seeing a patient in hospital and at home, and the potential to re-evaluate their needs.
Discharge plans from hospital often do not fully encompass patients’ needs that are outside the medical realm. Hospital readmissions have continued to rise at an accelerating rate; a 2017 NHS report showed that over the previous four years, readmission within 30 days increased by more than 20% (1). A more integrated approach between hospital care and the community in patient follow-up is needed. A meta-analysis of methods to reduce readmission to hospital showed that interventions such as visits by healthcare professionals in the community and continuity of care post-discharge do significantly lower readmission rates (2). This gap could be bridged if hospital doctors step into a patient’s world to truly understand their needs.
Growing more familiar with the hospital environment over the last few years has made me realise how uncomfortable I was initially. It felt so busy with doctors and nurses rushing around attending to important jobs and it used to make me feel insignificant even as a medical student. Doctors may be at home in hospitals, but patients are not. At a time in someone’s life when they are seriously ill and are anxiously waiting to see the doctor, hospital is a scary place. For doctors to take time to walk out of the hospital and into the real life of somebody that they are treating, the patient becomes much more of a human being rather than just a name on a long morning list. Home visits reveal much more about underlying problems that affect patient recovery and factors that must be addressed in order to provide more holistic care for our patients and reduce readmission to hospital.
1. Healthwatch NHS needs to do more to understand why people are returning to hospital after being discharged. London: Healthwatch, 2017. www.healthwatch.co.uk/news/nhs-needs-do-more-understand-why-people-are-r....
2. Leppin AL, Gionfriddo MR, Kessler M, et al. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Intern Med 2014;174:1095–107.
Competing interests: No competing interests
Dear Dr Morgan
Thanks for sharing your experience with us.
I worked as a community old age consultant psychiatrist in a deprived town of Greater Manchester and always love to see an elderly person thriving in their community after discharge from in patient treatment of depression. Social isolation is the leading causative factor for old age depression. I came to know that many patients who did not have visitors would prepare tea and may go out to buy biscuits for my visit. Relationship with their hospital consultants may be helpful in their recovery and show better compliance with their treatment. I have observed elderly clients talking very fondly about their hospital stay and wished to see staff more often after discharge and successful recovery. I think this may reduce the duration of hospital stay after reassurance of a home visit by a hospital consultant within two weeks of their discharge from hospital. Appropriate referrals and better communication with primary care staff may also result with this extra effort from hospital consultants.
So glad to to read your experience.
Keep up the good work.
Competing interests: No competing interests