Remarkable improvements in advanced life-saving therapies have brought chronic disease management to the forefront of American health care. Today, we see more patients that have complicated conditions. Often, these patients are admitted to the hospital with acute symptoms related to chronically managed conditions such as heart failure, lung diseases or cancer.
These patients can end up in the intensive care units and require critical care such as ventilators, dialysis and other support devices. Recovering from long-term dependence on these therapies could take months or even years, if patients are able to recover at all.
The financial and the ethical ramifications of chronic diseases and prolonged hospital admissions must continue to be examined and discussed. However, something missing from this debate is the impact this change in our patient population can and already has significantly influenced medical education.
While advancements in life-prolonging therapies have undoubtedly improved patients’ longevity, the corollary has been that the complexity and frequency of their hospital stays have gone up. The number of hospital admissions involving patients with chronic illnesses is growing. In 2010, 81 percent of all hospital admissions involved patients with chronic illnesses, as compared to 50 years ago when only a small percentage of hospital admissions were for chronic patients. This number is only projected to increase. The number of critical care beds, and days admitted in critical care have increased at a much faster rate than the rate of overall growth.
As patients now need longer hospital stays with relatively slower recoveries, the turnover of patients, especially in the ICU, has decreased.
Hospital units that once admitted several patients in a day now admit the same number in a week. One study showed patients requiring long-term stay accounted for 15.7 percent of total admission days despite being 1.6 percent of the hospital census.
For medical students, residents, and fellows who grow from encountering a wide range of treatment experiences, longer length of stay implies a different type of learning – management of complex, chronic comorbidities. For these patients, milestones are more gradual, usually comprised of making stepwise progress through minor adjustments, optimization or weaning of therapies. Instead of breadth in seeing a high volume of patients, dealing with chronic diseases encourages students to learn depth in managing their multiple, interweaving disease processes.
Additionally, as complexity increases among these patients, whose chronic conditions are often already familiar to and followed by a team of specialists at the institution, the trainees’ level of autonomy in caring for them is increasingly replaced by strict oversight and early involvement of specialists. Patients who have received transplants or advanced therapies, such as heart pumps, frequently present with more frequent complications such as infection or dangerous amounts of bleeding requiring re-admissions. While trainees technically first encounter these “new” patients, their own ideas and plans are immediately superseded by those of specialists who are already familiar with patient’s case.
The roles of trainees in these scenarios are limited to coordination and execution of plans that are not their own. Even in the emergency room where residents should learn to triage all types of medical conditions with independence, patients are often first seen by consultants or specialists who are notified that a chronic patient has been admitted to the ED. Although this structure may be the most reasonable in safely coming up with a complex management plan commensurate with the patients’ clinical state, it has inevitably consequences in medical education because it limits trainees’ opportunities to come up with a treatment plan independently.
Lastly, from the psychological standpoint of trainees, encountering chronically ill patients who often stay from the beginning until the end of their rotations can be disheartening over time. Many of these patients are intubated or mechanically supported for significant portions of the trainees’ encounters with them. Their uncertain mental status and progress that is so gradual that it appears stagnant and can sometimes take a heavy toll on the trainees’ mood and perceptions of health care. Also, the reward and pride trainees derive from taking care of patients throughout the entirety of their admission are unfortunately lost when patients’ timelines far surpass those of trainees, making their encounters seem relatively transient and incomplete.
As providers and educators, we must remain cognizant of the effects of the changing patient population on not only our health care system but our educational experiences. That should entail ensuring that there’s a balance between the number of acute and chronic cases that trainees encounter. Some of the more stable, chronic issues such as ventilation wean or dosing long-term medications could perhaps better be managed by specialized units in the hospital, freeing up time for trainees to encounter a greater variety of patients that will foster the autonomy and the knowledge base that will prepare them for success.
Simultaneously, we can incorporate a more robust curriculum centered on palliative care, especially in ICU settings. Trainees can learn the intricacies of goals-of-care discussions and end-of-life decision making. Instead of focusing only on the medical aspects of patient care, educators can help cultivate skills related to empathy and humanism through these chronic encounters.
Inevitably, learning to manage chronic complex problems will be an essential skill-set for any aspiring physician. After all, as we get better at our jobs in taking care of patients by discovering and implementing new medical therapies, disease management will continue to grow more chronic and complex. Surely, there are invaluable lessons we can take away from caring for this patient population from the medical to the psychosocial and ethical challenges that arise with navigating this dynamic.
Jason J. Han is a cardiothoracic surgery resident.
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