Clinical competences hidden in the curriculum and in coding

Gustavo Tolchinsky
 

José, 85, has a fever again. His wife is no longer worried; she knows that what has always worked is taking her husband to the emergency room. On the way she writes in the family chat that they are on their way to the hospital, but no one should move until she’s told if he gets admitted or remains under observation. Her children live in the suburbs and they always volunteer so that she doesn’t have to spend the night with José. Dementia has taken its toll on José and everything is more complicated; his urine infections, which previously warned with recognizable symptoms, have now become something abstract, but the fever is what always alerts the family. In the last year, José has been admitted several times for processes similar to this one, that started with urinary infections due to the underlying urological pathology. This time, on arrival at the emergency room, his wife thinks he is worse than ever, although his vital signs are OK and the Labs are quite anodyne, except for a slight worsening of kidney function. Again, as always, José is prescribed antibiotic treatment (guided by the latest available antibiogram) and fluid therapy, fever control and nursing care. But on this occasion, despite the fever disappearing, he is exhausted, probably due to delirium, he doesn’t cooperate with the care, the peripheral line is removed several times, he refuses to eat and the fever reappears. The family doesn’t cope well with this situation, José either. Family members are informed that imaging test could be performed, to asses  again with the urologist, and even to perform a procedure such as placing a urostomy could be considered if they suspect that there is an obstructive process. However, Jose's deterioration is not solved by treating only the current episode. The family and the healthcare team agree to make one more attempt with some changes in the treatment and, if he doesn’t improve, assume that only palliative treatment will be carried out.

José died two weeks after admission, with many clinical questions floating in the air. However, the family is satisfied and grateful to the healthcare team; Dr Martínez, who has attended him, and the nurses and assistants who took care of him are the usual ones, with whom relationship has been always cordial. The family values the time that Dr Martínez has devoted to talk about clinical problems, technical options, possible expected results, as well as getting to know the opinion of both José's wife and their children. There have been conversations with the lifelong urologist, to whom José in his best days carried a basket of oranges every time he visited her when he returned from out of town. His urologist already knew that the "fixes" they could do wouldn’t guarantee considerable results and would further complicate José's care.

When faced with the uncertainty of the end of life, be honest

Predicting the moment when a patient enters a process that can lead to end of life is complex. My first reflection on this blog was how doctors should act in the case of a patient who is facing the biological opportunity of teath and the risks that overacting implies. The solution is to face these situations honestly, both with patients and with their families, managing uncertainty and, above all, analysing the pros and cons of decisions to always respect the principle of beneficence. The objectives can be different for different patients in similar clinical situations according to individual values and preferences. A recent publication in the British Medical Journal analyse this situation, highlighting precisely how complex it can be to predict patient mortality in the following 72 hours by physicians specialized in palliative care.

Up to 25% of healthcare spending on patients is made in the last 12 months of life and the level of complexity of an end-of-life process can be highly variable - not only due to the underlying pathology but also due to the attitude of the professional and their way of facing this process. Therefore, we must understand which are the actions that most benefit patients and at the same time the system.

Avoiding unrealistic expectations 

The experience of the professional when detecting the potentially taxing pathology of highly complex technology in certain circumstances can lead to attitudes such as those described in the Harvard Magazine article on the "Cowboys Doctors" mentioned by Dr Varela in a 2015 post. This work, makes it clear that we have the possibility of applying techniques and technology in situations near the end of life; this is reflected in the quantitative tools. And this clinical attitude can occur even if it doesn’t improve the prognosis of these people and threatens the quality of the process and against the responsibility of professionals when performing futile procedures that generate greater health costs. Not to mention that testing generates unrealistic expectations and, finally, misunderstanding of families when, after a complicated process, they reach an end of life that has not been well explained to them and, therefore, they don’t understand why so much suffering.

The coding doesn’t reflect the complexity of the clinic

The clinical journey of a patient at the end of life who finally dies is followed by the issuance of an epi-crisis report that will later be coded to quantify and classify the procedures and costs of the care received.

Pathologies, procedures, treatments and complications are transferred in the coding process. Since it migrated from ICD-9 to ICD-10, the detail with which the hospital “bill” is broken down is even greater and helps to understand the accounting of morbid processes and patient mortality. This accounting measures has its limitations. Jordi Varela explains it better than me in other posts. It reminds us, for instance, that the financing model encourages the fragmentation of care where, rather than rewarding good management of the care process, the more torpid the process is paid for. Therefore, it’s clear that the financing model focuses on measuring the amount of care that is provided and not the value that it brings.

To end this post, I want to highlight two basic ideas. First, that the GRDs and the CMBD can be used to analyse and draw some conclusions about activity, but it’s clear that the coding of the CIE, whether it’s 9 or 10, is not capable of representing fundamental things such as clinical judgment, managing uncertainty, delivering bad news and controlling symptoms, among others. Therefore, the basic clinical competencies, which are precisely those that determine that the healthcare process is of quality, are not only hidden in the training curriculum but also the operating accounts of Healthcare organizations. It would be nice to make them visible in some way. And secondly, I am left with the feeling that when managers are concerned about the low complexity of their mortality in an internal medicine service, the clinicians are most likely doing just the right thing.

I leave you with the cover image of the album The Dark Side of The Moon, by Pink Floyd, in honour of the hidden face, the clinical skills of professionals in healthcare processes.