Next Generation is a Brigham Clinical & Research News (CRN) column penned by students, residents, fellows and postdocs. If you are a Brigham trainee interested in contributing a column, email firstname.lastname@example.org. This month’s column is written by Amanda Lucier, MD, a fourth-year resident in the Department of Medicine. Late last year, Lucier completed a two-week elective with Mass General Brigham’s Home Hospital program, which provides hospital-level care to eligible acutely ill adults in the comfort of their home. Find out more about the program here. Please note that some patient details may have been altered to protect patient privacy and confidentiality.
As a supervising resident on the inpatient general medicine service, every day is a test of efficiency and time management. I arrive to our small workroom tucked in the 14D tower pod at 7 a.m. and review overnight events and data for our 16 patients. I craft a rounding order, attempting to prioritize new and sicker patients while also streamlining our movement between different floors and pods. When I switch gears to the daily care coordination e-mail, I make note of who needs a physical therapy evaluation or new specialist referral. It’s 8:30 a.m. when we start rounding and I am aiming to finish by 11:30 a.m. I keep a brisk pace between rooms and am often guilty of interrupting patients when I sense we are falling behind. I know we need time — time to review old records, coordinate imaging studies, discuss care plans with consultants, and update family members. We need time to admit new patients and teach medical students. I structure my day on the principle that time is a valuable and limited resource, but rarely did I think about my patient’s time in the same way.
When I chose to do a Home Hospital elective, I found respect for patients’ time to be one of the most meaningful and understated aspects of the program. The time I spent in patients’ homes was enjoyable in and of itself, but it was the hints of what fills the time when we are not there that had the biggest impression on me. When we entered the living room of an older gentleman admitted for IV antibiotics, the first thing I noticed was the sheer volume of family photos. Framed photographs covered the walls and every surface, from end tables to the ottoman. Where he’d run out of space, there were newer printed photos tucked into the bottom corners of older frames. He gestured to favorite photos of his children and grandchildren as older versions of the same faces entered from the kitchen to join. We discussed the plan for the day as one daughter took detailed notes and another repositioned the blanket across his lap. We spent no more than 20 minutes in his home, but it was clear that the following hours would be full of familiar faces, attentive care, and homecooked meals.
In another home, we entered as a patient quickly wrapped up her weekly Zoom call with a group of girlfriends, setting her iPad against a stack of books recently pulled from the bookshelf to pass the time. There was a bottle of Ensure next to some nausea medication on a nearby tray table, and the front door was propped open to allow a breeze through the screen door. It was quiet and restful, and she told us she was feeling better each day. A few days later, we discussed diuretic dosing with a patient as she directed family members to ready the house for out-of-state relatives visiting in a few days. She stood in the doorway to her bedroom, a solid wooden doorway too tall, narrow, and beautifully hand-crafted to be from this century, as she recounted the last time she had seen all her nieces and nephews.
We ran into our next patient’s Door Dash delivery on the front porch, bringing the aroma of hashbrowns in with us before assessing a resolving case of cellulitis. We finished our exam in front of a paused video game, the sounds of which echoed into the stairwell on our way out.
It is true that you learn a lot about patients by seeing them in their home environment, but I would argue that the most important thing you can learn is that being a patient is a small, time-limited, situationally dependent part of who they are. Being a patient rarely fills an entire day. It takes minutes to administer most IV medications and to collect labs. The first time I learned about Home Hospital I was reflexively skeptical about the idea of providing an inpatient level of care at home. If a patient is sick enough to warrant admission to the hospital, don’t they need to be at the hospital? Often, but not always. A patient may need vital sign monitoring, oxygen, serial exams, daily labs, IV medications, wound care, physical therapy or occupational therapy — all of which the Home Hospital team can provide at home if it is determined to be safe to do so. The silver lining is that when the patient is not being a patient, their time is their own. How they get to spend that valuable and limited resource is now, fortunately, out of my hands.
This is my fourth and final year of residency, and I am excited to transition from a primarily inpatient schedule to a full-time job as a primary care provider next fall. I am very appreciative of my experience with Home Hospital, both for how it has made me a more cognizant inpatient provider and for how it has forced me to rethink the primary care space. Home Hospital encourages primary care physicians to rethink what our boundaries truly are in an ambulatory setting. As I start the next phase of my career, I’m excited to think of outpatient and inpatient levels of care as a spectrum rather than two discrete entities. Working to keep patients out of the hospital may be a challenge, but it will never be a waste of my time or my patients’ time.