Dealing with the social issues, insurance companies, and other none medical parts of healthcare were aspects that I never expected to be a large part of my future as a physician. During the first couple of years of medical school, we focus on learning the basic science behind all the diseases we will encounter over the course of our careers. During third and fourth year clerkships, we start to apply knowledge that we’ve learned towards diagnosis, treatment, and safe discharge. The part that is rarely mentioned in lectures however, is what goes into ensuring a safe discharge for some patients, whether we’re dealing with social issues, attempting to discharge a homeless patient, or perhaps dealing with an insurance company that is refusing to pay for medical equipment that is required for the patient to make a complete recovery.
One place where it became evident to me how much “non-medical” issues affect patient care and outcomes was during my first third year inpatient rotation at Nationwide Children’s. Hospital. We constantly had patients who would otherwise be cleared medically to be sent home, but couldn’t be discharged due to an unsafe home environment. During the rotation, we had a failure to thrive child admitted due to failure to gain weight over a few outpatient pediatric visits. Further work up eventually revealed a subdural hematoma, which heightened our suspicions for potential child abuse, at which point we had to get social work and child protective services involved.
Another patient I took care of at NCH was a 12 year old with a neural tube defect causing paraplegia. He was initially admitted for urosepsis, and after a prolonged hospital stay, had worsened his pre-existing decubitus ulcers which developed osteomyelitis. After a few weeks of antibiotics, he was cleared medically to go home, at which point his main barrier to safe discharge was a special air bed costing about $3000 that was needed for his osteomyelitis and decubitus ulcers. After initially being denied the bed, the patient’s hospital stay proceeded to get longer and longer. By the end of his hospital stay he had been waiting for more than 3 weeks just for the bed, with no medical reason for being in the hospital. While I was on the team, I offered to write a letter to the insurance company explaining the need for the bed (draft below), and I acted as a liaison between the patient and the insurance company in regards to getting the bed paid for. I ended up leaving the service before the matter was resolved, but I learned a great deal from the experience of dealing with the insurance company.
“Farhan consistently read about his patients’ disease processes and quickly applied new knowledge to the care of his patients. He was always well-prepared and actively engaged in all aspects of patient care. Farhan followed his patients closely, actively sought feedback, and quickly incorporated suggestions into his work. He consistently offered house staff assistance with daily tasks and went above and beyond to write a letter to an insurance company advocating for a medical bed for one of his patients. He was compassionate and caring, and developed excellent rapport with patients, families, staff, and colleagues.” –Pediatrics Evaluation
So far during my M4 year, I’ve made sure to keep an eye out for similar types of issues that may arise during a patient’s stay. While I have not had the opportunity to be directly involved in situations as I was at NCH, I have always made sure to talk with social work when planning patient’s discharges on my mini-I, for example. As a prospective radiologist, I may not have to deal with safe discharges like my peers in IM and Surgery will, but I will still have to have dealings with insurance companies, billing departments, not to mention the fact that I will be doing a transition year where I hope I will be able to put what I have learned over my clerkships into practice.
CEO 5.2: Appropriately use system resources to assist patients in accessing health care that is safe, effective, patient-centered, timely, efficient and equitable.