This weekend, I just finished another 2 weeks on service – the first 2 weeks of 2011 in fact. This time, I had also had a shadower, but one of a different kind. As part of our Institute for Healthcare Improvement (IHI) Open School, we are making an effort to have collaborative learning opportunities for our medicine and health administration program students. Achieving true interprofessional learning is challenging for schools like ours without a pharmacy or nursing school.
To jumpstart our collaboration, a team of us traveled to at the Institute of Healthcare Improvement conference. It was there over dinner that Jeff Kunkel, one of the Social Work students, asked me if a lot of social work issues came up in hospital care rounds. I laughed momentarily and reassured Jeff there would be lots of social issues and invited him firsthand to witness them on rounds. Unlike the premeds that I sometimes take on the weekend, I wanted him to come during the week so that he could also attend the multidisciplinary rounds with our case managers and social workers that our attendings go to daily.
The opportunity presented itself that first Friday – our team was on call so it was a perfect day since we did not have many patients and were able to delve into their problems. While there are social issues every day, dealing with them becomes exponentially harder over the weekend when you only have social workers on call. This makes Friday an especially important day to advance care or facilitate any discharges. While some believe that doctors don’t work on weekends, the truth is that they do. The problem is that not everyone else works on the weekend making the hospital inefficient over the weekend and nothing gets done.
I introduced Jeff to our housestaff team as a social work student who was especially interested in the social issues. For each of the presentations, they started with a one liner to brief our student on the patient’s problem but also described the social issues. In doing so, the social issues that sometimes plague our rounds (and our residents) all of a sudden became the highlight of rounds. The patient that leaves AMA, the patient who was homeless, the patient who did not want to go to rehabilitation but was too weak to go home, the patient who was uninsured and could not afford his medications… the list goes on.
Afterwards, we had an opportunity to debrief. It was fascinating to hear what Jeff found interesting. He noted that I sometimes have to ‘talk patients’ into leaving the hospital. I told him that the sad truth is that patients often expect to stay in the hospital longer than they can and should. Not only is staying in the hospital dangerous and costly due to hospital-acquired infections and other hazards, hospitalizations are increasingly scrutinized to ensure that each hospital day is ‘medically necessary’ by auditors who are incentivized to penalize. Given this, managing patient expectations becomes very important and something that the attending often ends up participating in.
As we think about the increasing pressure to ensure that patients who don’t need hospital care go home, it is equally important to ensure a safe care transition to avoid a preventable readmission. While optimizing these decisions requires clinical judgment, it cannot be done without thinking through and addressing the social issues. This makes having a great social worker even more important for the future. Unfortunately, like many other healthcare fields, there is an impending social work shortage as highlighted by a major capitol briefing held by the National Association of Social Workers. While many of us tend to focus on the need to train competent physicians and nurses, we must not forget the that we need good social workers too.
–Vineet Arora MD