Each morning this week, I am rounding on a busy inpatient general medicine service in an academic hospital seeing real patients. Each night this week, I am also studying for the internal medicine recertification exam where I am doing countless MKSAP questions which present the diagnostic and management conundrums of “fake patients.” While there are a variety of things I could say about the process, one thing is clear- the real patients don’t ever come as neatly wrapped and easy to figure out as the pithy and succinct questions based on fake patients in the prep questions! Perhaps the most distinct differences are that real patients suffer from real problems that plague real people…and that is of course why one of the most important lessons for our medical students is that being a good doctor is more than just how well you do on a standardized exam. It is knowing how to mobilize a team and resources to tend to all of these problems in the same patient. Here are just a few ways in which the real patients we see differ from testable “patients.”
- Social problems trump medical problems – Many of the patients we see suffer from poor health literacy, lack of insurance, access to safe housing, affordable healthy food, and access to healthcare outside of the hospital that prevents optimal care and treatment of their medical conditions. Understanding how to bring up and address these problems is equally important to design a customized care plan for a patient that will ensure their most optimal recovery and health outside of the hospital.
- Caregiver support- Many older patients who are chronically ill are cared for by family members who suffer a lot of stress. This stress manifests in different ways and sometimes you see that sigh of relief when they come to the hospital since they are in need of as much care and support as their family member. Arranging home services and providing and ensuring caregiver support is a key part of hospital care these days.
- Insurance compatibility – Most patients require services that go beyond hospital discharge, such as home IV antibiotics or short-term rehabilitation stays after hospitalization to recover. In addition, patients often require close follow up after hospitalization. Unfortunately, arranging such things for patients who are uninsured or underinsured is increasingly difficult. Perhaps this is one thing that we can hope to change with the implementation of the Affordable Care Act- lets at least hope so. But for now, it’s sometimes a guessing game how to piece together the most logical plan that will also be optimally covered.
- Medical necessity – These days, patients can’t stay in the hospital to “recover” unless it meets strict criteria for inpatient admission. This process is audited by private contractors so hospitals are required to follow strict guidelines or face harsh penalties from Medicare. The challenge is that for a variety of social issues documented above, patients may not be ready to go home (caregiver not ready, patient lacks understanding regarding illness, etc.) but they have to go home or be faced with footing the bill for their stay. Given that rock and a hard place, it’s a difficult position for any doctor to be in.
Because medicine does change and evolve very quickly, we refresh our medical knowledge every 10 years by testing our clinical acumen through ‘caring’ for fake patients on a written exam. But, a written exam can only go so far…Given the sea changes occurring on a daily basis in our healthcare delivery system, it is equally important to stay up-to-date on systems-level changes that influence how we can actually provide care for real patients. After all, both are necessary for good doctoring.
Vineet Arora, MD