Hey everyone, I'm Brandon Odo.
And I'm Brian Bowling.
And this is Critical Care Scenarios, the podcast where we use clinical cases, narrative
storytelling, and expert guests to impact how critical care is practiced in the real world.
Hey everyone, welcome back, it's Brandon Odo with another Turbo.
Let's talk today about the role of patient follow-up for your own growth, training, and
I think happiness as a provider of medicine.
What I'm talking about is the idea of essentially seeing how your patients are doing after you
are no longer taking care of them.
Here's the basic problem.
As providers of critical care medicine, our phase of care is relatively narrow.
In other words, the diseases and certainly the patients were treating exist over a much
longer time course than we are actually seeing them.
So for example, a patient who has sepsis and comes to the ICU, critically ill, we do
a lot to resuscitate them, hopefully stabilize them and get them out of the ICU.
But the trajectory of that disease, even only looking at that most acute phase, is much
longer than the time that we're seeing them.
Really, we of course are only seeing people when they're sick enough to need to be in
the ICU.
Our type of medicine is defined by the severity of illness, and therefore it's just a slice
of the longer course of that disease.
Of course, it also may extend prior to seeing them as well.
A lot of problems start before they're sick enough to come to the ICU.
And of course, many diseases really are acute flare ups or exacerbations of what really
are chronic diseases, and certainly we're not following the chronic problems.
So that's what we're into.
That's the kind of thing we like to treat, but it can be really valuable to see what
is happening over a longer time period than the time we actually see the patients.
This is for a number of reasons, but I think there are a few that are particularly important.
One of the key ones is just that in order to grow as a medical decision maker, you need
to have feedback on the outcome of your decisions.
And this is easy enough when the feedback comes right away.
Oh, I think we'll give a fluid bolus over the next few minutes or hours.
You see how the patient responds to that bolus.
That's fine.
But a lot of decisions, their outcomes take longer to present.
And if they take long enough that the patient leaves the ICU or even as simply as long
enough that you are no longer on shift.
You know, we are by and large shift workers.
And while we may do a stretch of shifts at a time, you're still going home in between
and your stretch of shifts only lasts so long.
The patient could still be in the ICU, but you left six hours ago so you don't know what's
happening with them or you know, you're off for a handful of days so you don't know.
These are the times when it may be valuable for you to go out of your way to basically see
how that patient is doing.
That gives you the ability to ask those questions like, I made a series of decisions managing
this difficult, complex patient who was quite sick or perhaps had problems or diseases
that are not as familiar with.
So you know, I made some calls.
I made some judgments and I'd like to know if they were right.
Of course, you can make a decision that was right as far as accounting for the best
information you had and you know, weighing the probabilities and you know, making your
best guess and nevertheless, they could have a poor outcome, nothing of a certain, but
you're never going to have any of that data if you don't go and see.
So how does this work?
Probably it means something like just pop it into the chart and seeing how the patient
is doing.
Of course, you could physically check on the patient, but that's harder to do for most
of us and is not usually necessary.
Often you can just look in the electronic medical record, which is what we're pretty much
all using now and seeing what's going on, what were the most recent events, you know,
how are their numbers doing and so on.
You could do this on your next shift.
So you took care of the patient 12 hours ago or yesterday, how are they doing today?
This is very commonly something I will do.
Again, after I went home, maybe got some rest, you know, how are they doing today?
That real sick patient I had.
Of course, you're always what you hate to see as you log in and the patient passed away
or something like that, but you know what, that's feedback too.
And maybe you check the next day as well, you know, the most important feedback is usually
the earliest and then over time, what's going on becomes less relevant to you and perhaps
less relevant to critical care.
The other thing that this can be really valuable for is honing your diagnostic skills.
When you're faced with a confusing or undifferentiated presentation, you may have to make some guesses
about what's going on and that may not bear any fruit early on, whether it's just too complicated
early in the course to figure out what the patient really has or you make some guesses,
maybe you send off some tests, but those may take time to come back, especially we
order tests that maybe you have to be sent out and so on, or the time for the workup
may just be a little later.
Once they're stable, maybe even have left the ICU.
But still, you might like to know what did that patient have?
These are the kind of things you'll have to follow up later and see, you know, some
workups may not even be done until the patient leaves the hospital.
So if you ever want to know and ever want to do better the next time you come across
that situation, you need that feedback.
You can't just throw up your hands and say, well, that patient was a mystery.
I guess I'll never know merely because they've left your care before you find out the answer.
I mean, you could do that, but that's not the way you're going to get better.
The other thing I think is valuable, even outside of our own effect on the patients, is
just understanding what the longer term arc of disease looks like.
When we only take care of this small slice, it gives us a, that's to very narrow and
it works a kind of warped impression of what these diseases are all about.
And yet it can be very helpful to have a bigger picture.
So treating something like heart failure or sepsis to understand what is probably going
to be happening with that patient in a day, a week, a month, a year, even if we only
took care of them for 12 hours, I think informs our understanding of critical illness and
the context that exists within.
And of course, even on a bigger level, understanding these chronic diseases and how this particular
episode of it sits within that bigger picture of recurrent organ failures and so on.
I think these are the kind of things that really make us capable of treating disease in
the context that it lies within.
You know, hypocrite supposedly said, it's more important to understand the person who
has the disease than to understand the disease the person has.
Obviously, they're both important, but the final thing I think this sort of follow-up
can do for us is reward us not just as decision makers or diagnosticians or prognosticians,
but as humans.
And that's because when we purely practice critical care in that hyperacute phase, it's
easy to forget that we're treating human beings because we don't often see their human
side.
We treat people who are unconscious, intubated, hypersick, we're doing procedures and things.
We may never be able to speak to them and hear them speak back to us.
And certainly, it's hard to see them as people who before coming to us and hopefully
after leaving us have lives, have families, have passions, hobbies, frankly have anything
that goes on outside of the hospital or even outside of the bed that we saw them in.
But when we're able to follow up longer term, you could start to see that patient who
was so sick went home, came back to the clinic for follow-up and talked about this ongoing
symptom that pain they had, the things that have been going on with them, the struggles
they're having.
Again, it informs us to understand the longer term sequela of critical illness, but
I think it also rewards us to see that the patient who we thought was going to die,
they're back to their life and they're back to being people again.
It reminds us that some diseases that seem like they have very dire prognoses because
we only ever see the dire part of it, people can actually do well and it rewards us by
helping us realize that the things we're doing do matter.
We're not just, quote, rearranging deck chairs in the Titanic, we're helping human beings
get back to being human beings.
I think that can help prevent things like burnout.
What do you do?
Again, short term, see how your patients, there's no ownership here, but the patient who
you felt so involved with because you did a lot with them, how they're doing, how the
decisions you made, the diagnoses you made, how they panned out, and then longer term, how
those patients are doing overall.
Longer term, you're probably going to have to track these patients in some other way.
That's in the easiest way in your EMR is just to keep a list.
Patients who you thought were interesting, who you want to see how they're doing, and
then that makes it easy in a week, a month, a year to pop back and check in on them.
Otherwise, you're going to forget.
One question you could ask here in this world of laws and compliance is whether this sort
of follow-up is consistent with privacy regulations like HIPAA.
You could argue you're no longer taking care of these patients, so perhaps you shouldn't
be accessing their records.
You could have an argument about this, but my perspective, and I think that of most people,
and this is very widely done.
This may not be a sound argument, but at least on a practical level, people do this all
the time.
I would argue this is compliant with HIPAA because HIPAA does allow for access to protected
healthcare information for reasons of quality improvement and training.
I would argue that's what this is.
You are accessing these records for your own training, and that's a valid operational
reason to do that.
Again, should you go and ask your compliance people if this is okay, I bet I know what
they're going to tell you.
I don't want to promote a don't-ask, don't-tell approach to regulations, but whenever
you ask a regulatory person, if you should do something, the answer is probably going to
be no.
Let's just say many people do this.
I've never heard of anyone having a problem with it, and I think there was at least a solid
lake to stand on arguing why it is within the allowed reasons for accessing healthcare
information.
That is just my perspective.
Your mileage may vary.
Anyway, long story short, I really do recommend this sort of thing for all the reasons that
I said, and I really think that both for practical reasons of clinical growth and for kind of
your own purposes of maintaining some context and a healthy perspective on the work we do,
I think this stuff is a really good idea.
Only taking care of patients for the short amount of time that you see them on a shift may
be healthy as far as maintaining work life balance, but I think really promotes the fragmentation
of care, which has become a real challenge with modern medicine and is really an obstacle
to you becoming a stronger and more nuanced provider of medicine.
Medical care is about treating people in a certain phase of their care, but just like
interventional radiology is about doing procedures and the surgical specialties are about doing
surgery and so on.
While those are all true, if that's all those people ever see or understand, it's really
hard to tie those in to the bigger goal, which is about treating the patient.
You need to see the things that are outside your immediate window to understand how your
thing ties in to the rest of it.
That's just my opinion.
I could be wrong.
Let me know what you guys think, and I'll talk to you next time.