Moving beyond safety, the economic imperative for cost-effective care should not be a foreign concept by now. I shudder to think about how the child in Bangladesh might have gotten better for a few pennies, while the child in the U.S. was billed for an ED visit and overnight stay for “poor follow-up.” Waste also comes in forms other than direct costs: Think of how much drug companies spend on marketing drugs for cough and cold medicines instead of investing funds into more research for effective antimicrobials.
As physicians, we know we are doing too much. In a recent report in the Archives of Internal Medicine (2011;171:1582-1585), nearly half of the doctors surveyed felt that their patients received too much care, as opposed to only 6% that felt that they were receiving too little. Reasons for overtreatment included malpractice concerns, clinical performance measures, and inadequate time to spend with patients. The bottom line is that it is often easier to do more than to justify a safer, more cost-effective, and evidence-based course of less intense care. We know what we do.
Our Hospitals, Our Plight
Returning, then, to the wards in winter, how is a lone and oft-overworked hospitalist to solve these problems? Evidence helps, a little. Guidelines built into the flow of care help, a little. Agreement amongst your colleagues helps, a little. But ultimately, I see this as a communication issue.
And by communication, I do not mean beating people over the head with the AAP guidelines (believe me, I’ve tried it and the guidelines just aren’t thick enough).
If we are to enlist the support of families, nurses, learners, respiratory therapists, and other physicians in doing what’s best for the patient, then we must make this work much in the same way that we get others around us change behavior. Think about the PCP who must impact obesity in the family or vaccine distrust. We have to build relationships based on trust. We must elicit others’ goals and describe ours as a shared agenda. Similarly, we need input from everyone around us as to how to move forward. There are far too many humans involved for this to work without constant attention to creating a well-functioning team.
This will not be an easy task, which is perhaps why moving to Montana or a deserted island seems so much easier. But anytime medicine involves more than just one person, there will be a need to communicate effectively. This becomes critically important as the amount of gray regarding risks and benefits increases.
More is less. Less is more. Our patients deserve that we dedicate ourselves to providing them the best possible care.
Dr. Shen is The Hospitalist’s pediatric editor and medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas.