Navigating Physician Advocacy in the Hospital: A Conversation with Dr. Monique Nugent

Transcript

SPEAKER_01: 0:00

When hospital administration and insurance companies muddy the healthcare industry waters, it can be really difficult as a physician to advocate for your patients. There’s so many moving parts to caring for your patients, especially in a hospital setting. So today we are putting the spotlight on physicians and how you can effectively advocate for your patients. This is Know Your Regulator. I’m Simone Murphy, your host, and I am proud to introduce Dr. Monique Nugent, a practicing hospitalist and physician leader in the Boston metro area. She’s dedicated her career to improving the care of hospitalized patients, focusing on safety, equity, and experience. Dr. Nugent understands how frustrating and confusing the hospital can be for patients and their loved ones to navigate. And her book, Prescription for Admission, is actually interactive. It gives you an inside view of hospital care and her tips on how to improve communication with the medical team, as well as a focus on the mental health issues that can arise while in the hospital. Dr. Nugent, thank you so much for joining me to discuss such an important topic.

SPEAKER_00: 1:03

Thank you. I’m here and I’m excited because you’re right. Advocating for our patients and how we advocate for patients is really, really important.

SPEAKER_01: 1:11

Absolutely. Well, let’s start to break it down. Um, what does advocacy really look like in hospital practice? I know that it can be potentially messy and really complex, obviously. Um, and you know, most of us are used to seeing these kind of TV versions of medicine. So can you break down what advocacy really does look like in those really crazy moments in the hospital?

SPEAKER_00: 1:37

Yeah. So I think you really hit the nail on the head when you said TV version of hospitals. So as a hospitalist, someone who only focuses on hot inpatient hospital care, there’s a real disconnect between what goes on and what people think should go on, right? So people feel like when you come into the hospital, it’s this like medical ticket, like magic ticket, like Willy Wonka, right? Right. And so you can get in everything, right? And no one’s gonna push back on the hospital. You know, every test is covered, every clinician that you see is under your plan. And that’s just not the case, right? I am under just as much scrutiny about the amount of care, the cost of care, the quality of care that I’m delivering in a hospital setting as my patients’ uh physicians are in the outpatient setting where they’re filling out prior authorizations, right? So I don’t have to fill out prior authorizations for new medications. I have a pharmacist that just fills them. But then at the end, it’s like, well, can the patient still access this medicine? Like I can I can give them the medicine in the hospital, but can they access it out of the hospital? I have to like always be thinking about setting people up for success after a hospital stay. I have to always be thinking about how I’m advocating for them during their hospital stay with their insurer to say, yes, this patient deserves to still be here. Yes, this patient is still getting care. Um, and I have to always be thinking about how I’m advocating with my colleagues to say, hey, you know, we have a sick patient. How can we help this patient? Or like, how can we help this patient longer term? How can we think about the next steps? Because it isn’t a golden ticket in the hospital. We still have to ask and those same questions everyone else does. We still have to give the same answers and um answer to our our like bodies who are looking down and saying, like, hey, doc, what are you doing in there?

SPEAKER_01: 3:30

Mm-hmm. Yeah, no, it sounds like it can be very complex. And, you know, it extends, like you said, beyond the hospital that you’ve got to think about long term, can the patient continue, continue this outside of the hospital? Will that plan of care be able to be enacted? And the the golden ticket is such a good analogy because a lot of that is so invisible. It’s not something that you really think about, especially when you are um in in the uh hustle and bustle of the day-to-day, whether you are the patient or you are the physician. It can be hard to really see everything that’s going on all the time and be so in tune to those things. But you know, the advocacy is really crucial to making sure that that um plan of care gets enacted. And let’s pull that curtain back just a little bit. Can you give us some examples of of how hospitalists like yourself can advocate for their patients during a typical day-to-day shift and what kind of coordination? Um, you touched on it with the pharmacist, but what other kind of coordination goes on to make sure that the the right orders get executed and that the patient can continue that care outside of the hospital?

SPEAKER_00: 4:41

Yeah, the biggest person who’s my partner in that is the case management team. Some people call them um caseworkers, I’ve heard uh care progression teams, whatever it is, uh, they’re usually nurses, sometimes they’re social workers who really understand the ins and outs of the patient’s insurance, what is available in the community, and how we can work to really make sure the patient is able to always get the care that they need. And I spent a lot of time working with case management saying this is where we are in the patient’s day, and this is what’s going on. What are the next steps? How can we set them up for success? Where are they going after here? Oh, if are they going home? Uh, I don’t really feel like that’s a safe plan.

SPEAKER_01: 5:24

Yeah.

SPEAKER_00: 5:24

Or they’re going home because they’re out of days for um short-term care rehab. They’re out of days on their insurance. No, actually, if we get them to the VA, they can do this, they could do that. It’s really that logistics and understanding that I have got to set someone up for success. The average hospital saying this country is about four and a half to five days. Um, using the word average, of course, there are people who are in there much longer, and then there are people who are in and out of the hospital in about 24, 36 hours, right? But the average day is around four to five days. I am just with you. That’s a short amount of time in your life, right? And in like in a year, 365 days, right? That’s a really short amount of time. So, what is going to keep you healthy and out of the hospital or successfully out of the hospital is everything outside of the walls of the hospital. I’ve got to focus on that. And that means I have to make sure you can access these things financially, logistically, socially, and bringing together all of the points of people who are involved in your care to help navigate that. And so I’ve had some really interesting cases, and most recently I had a case of someone end-of-life care is a lot of advocacy. It’s a lot of logistics that we go through. Uh, and this person needed end-of-life care, and their family could not support them in their home for several days. And so now I’m in a place where I have to advocate to say, yes, even though this person technically should be at home in hospice and they can’t get there, the best and safest plan is to keep them here until they can get home hospice. So if I did nothing for their care, then the insurance agency would say, Well, you’re not doing anything, and they can be discharged.

SPEAKER_01: 7:13

Yeah.

SPEAKER_00: 7:14

Um, if I’m doing too much for their care, then the insurance agency says, Well, I thought you this was end of life care. This looks like more than You’re doing too much. Yeah. You’re doing too much, right? But caring for someone at the end of their life is just as much uh as an interventional type of care. And so it really came down to me sitting down with the case management team, the hospice team, to say, hey, how can we help them to be comfortable and their family to simultaneously get ready to have them at home? And it took some logistics, but really that’s where the the art of what I do comes in as because to help them be successful to them, success meant going home to pass away. Uh, and so to do that, I’ve I’ve got away their current medical status, what’s safe at home, time frame, uh, insurance, uh, what they get in the house. Logistics isn’t like one can deliver a bed, right? Yeah. That’s a big thing. Totally. Yeah. And so it is about really working closely with the people who understand what’s in the community and what insurance agencies have given patients access to. Even if your insurance agency doesn’t give you access to something, people often may have other financial means of getting the things that they’re looking for. Sure. Or if they don’t, how can we maybe tap into community resources? Uh, community resources like Meals on Wheels is a great community resource for people to help keep them in their home who may have some financial constraints. So it is all about working with that case management team.

SPEAKER_01: 8:53

Yeah, no, it sounds like it. It sounds like it’s a a lot of people who who um have a have a big hand in how successful the outcome um of the advocacy is. And when you’re working with these, these the case management team, and it, I’m sure it’s just a lot of moving parts. Are there any major challenges that that you see that happen during that?

SPEAKER_00: 9:19

So the major challenges are often when people cannot access things or and we don’t know about it. That’s the harder part. I have had it happen many times that patients will call back and say, I’m at the pharmacy, and they say that this isn’t covered. You know, we we didn’t know. And so now we have to go back and and remake a plan. Or when people run out of an access to something, particularly short-term rehab or access to skilled nursing facility care. Not everyone can be cared for in their home. And then other for other people, those places are a pit stop before they get home. Yeah, that makes sense. Yeah, but if you’re not safe in your home at the time that I’m ready to discharge you, I also can’t just be like, hey, go out into the wild and like we’ll see what happens. You’re good. Yeah. You’re good, right? Um, the last thing I want is for people to get hurt in their home. But we often think about returning to the hospital for illness as the only way that people fail a discharge. We often say, like, oh, well, the pneumonia wasn’t treated, they still had fevers, they were still coughing, they came back to the hospital. Um, and we consider that a failed discharge. But if you’re not safe in your environment, if you can’t walk around your house, if you can’t use the toilet, the shower, get out of bed, things like that, the last thing you want is for someone to come back injured because they are not safe in their environment. Or their loved ones who are caring for them get injured. And I I’ve again recently had a caretaker who came in after breaking several bones um caring for a patient in the home because they were unsafe. Uh, and it is it is hard to to balance that when I have zero control over that. Right. Um, and then at the same time, you may medically be coming to a point where you no longer require inpatient acute hospitalization level of care, but then you don’t have access to the things you need to no longer be hospitalized. Or the hardest cases are people who who have no supports, financial supports, logistic supports, family supports, and may end up in the courts. We have this idea that only children end up in the courts, and that is not the case. We there are oftentimes people who are elderly who need guardians or conservators, or even people who are not elderly, but they’re not able to care for themselves for lots of different reasons. And if they don’t have both the financial support and then also the logistics support, somebody who can make decisions for them or with them, someone who can drive things forward, unfortunately, those cases will end up in the courts. And those are extremely difficult.

SPEAKER_01: 12:17

Yeah. No, I can cannot imagine how difficult those are. What are ways that they can get involved in in their case management or in their care and assist in advocating alongside their physician?

SPEAKER_00: 12:32

That is not only a great question. It’s one of my favorite questions. Um, because it’s gonna start with an answer nobody likes. Uh, you need to start thinking about discharge when you were admitted to the hospital. And when I say that, what people sometimes hear is, you’re thinking about getting rid of me. No.

SPEAKER_01: 12:50

Yeah. I can see how they would say that, but yeah, no, you’ve got to be thinking about the end game too when you begin.

SPEAKER_00: 12:58

What am I going to need to successfully leave this hospital? That’s the thing I want you to start thinking about for you and your loved one. When you meet someone like me that says, hey, I’m Dr. Nugent, and you are going to be admitted to the hospital because you’re too sick to be home right now. You the wheels should start turning as to what am I going to need to be safe in my environment? What am I going to need to get back home? And that looks different for everybody. So you’ve got to start thinking about discharge as soon as you’re even considering admission, right? And then the other thing is don’t do it alone. Please, please find your support system. So this is the visual I give people. Imagine you have an upcoming meeting with the IRS, right? That’s a pretty stressful meeting. Absolutely, yeah. High stakes meeting. IRS says, hey, you have to come answer these questions. Um, right before you get to the meeting, uh, you get a fever, you start vomiting, someone steps on your toes, and you hit your head, and you have a headache. Would you go to that meeting?

SPEAKER_01: 14:09

Probably no, I would not want to go to that meeting.

SPEAKER_00: 14:13

You would not want to. Now you’re in an emergency room department with a fever and you’re vomiting. You probably have a headache, you know, aches and pains somewhere else. And I walk into the room and I’m gonna ask you a series of questions that are no less high stakes than the IRS meeting. Right? Because I need to know your medical history for your safety so I can plan. So these questions are no less high stakes, but you don’t have a choice. You have to be there. Right. And this is why I say to people, don’t do it alone. Because you should have someone there to be an extra set of eyes, ears, and an extra mouth to help speak for you at the times where you’re feeling too ill, you may not remember things, uh, things may be too discombobulated, too much in pain, to give a whole picture and then to wholly advocate for yourself. So I advocate for people to have what I term a care partner. Traditionally, that’s your spouse, you know, or your significant other, your parent, uh, someone who in your life supports you and kind of knows a thing that’s going on in your world, particularly health-wise, right? It may be your uh child, if you’re an older person, you know, but lots of families and friends look different for lots of uh reasons. And so whoever that person is, if you are going to the emergency department, if you feel that you need to be hospitalized, please try and have that person with you. Uh, and I know that’s hard because people’s lives move at the speed of light. And, you know, just because you’re sick in the emergency department doesn’t mean someone else can take time off, right? But whatever ways you can get support or you can be support to somebody, please do that. It is extremely hard to be hospitalized by yourself. Uh, and so those are the two biggest things is start thinking about what we need to get you to help you be successful once you’re ready to be discharged, as soon as you think you’re coming in. Because for some people, it may be just let me stop vomiting and I’m out of here. That’s easy. Right. Uh, but for other people, you know, it may require new equipment, uh, new specialists, things like that. So you’ve got to start thinking about that so that when the case manager comes and talks to you, you already put it all on the table. Oh, if I’m gonna need a cardiologist, I’m in between insurance agencies right now. So how can I plan for that? Things like that, right? Yeah. Uh and don’t do it alone. Have someone there who can help advocate for you and help navigate, particularly the points that you’re feeling really sick.

SPEAKER_01: 16:46

Yeah. I would not wanna be trying to think about my entire medical history or, you know, the the very specific questions that sometimes get asked. And like you said, when you’re thinking about that end game, you’re thinking about, okay, if I’m between insurance agencies or this is across town and I’m not gonna have transportation to make it to this particular office, that maybe there’s something that you guys can come up with. It sounds like it can be pretty straightforward sometimes and that there can be a plan. But we know that health systems and insurance companies and time constraints especially can really complicate things. And so on the physician side of things, what are some of the common barriers that physicians may run into when they’re trying to advocate for their patients? And and I would assume in navigating those challenges, they’ve got to really call upon that that case management team, right?

SPEAKER_00: 17:44

Yeah, I’d say the most complicated ones are where there’s a mix of legal issues and insurance issues. Uh, when we start having questions of saying, how can we really care for this patient moving forward? We don’t have a clear support system, or moving forward, you know, we’re working within constraints that are not medically appropriate anymore. And getting the legal team involved uh can sometimes be the answer. It’s not once they’re involved, it tends not to be a fast answer. Yeah. That tends to mean that things are going on that require a lot more care um outside of the hospital legally. Uh, but really leaning on the case management team and give them your most appropriate medical plan for the patient and really work with them and listen to what they’re saying. And then push back and try to demand that you know the places that you’re sending patients to or the insurance agency or something rise to the occasion and give the patients the things that they need. I have been known to call nursing home medical directors. Hey, this is what this patient will need. Will you be able to do that? Uh if not, I need to know because I’m not, I can’t send someone off to a place where they can’t get their care.

SPEAKER_01: 19:04

Yeah.

SPEAKER_00: 19:05

And you’ll be surprised at the amount of care that can go on in skilled nursing facilities and acute rehabs. The fact that a lot of these places will specialize in things, right? So my area has a place that specializes in TBIs and Parkinson’s and strokes. And we know that this is a great institution for that because they can get patients everything that they need. And same thing, if you’re getting a call from an insurance doc that wants to do a doc-to-doc, I always say, like, take a deep breath. Get your teeth your headset already. Um, but remember that it’s not that you’re reporting to them. This is a conversation between peers to get a patient the care that they need. And you should be able to and feel empowered to push back on them if you feel like the thing the insurance agency is asking for or uh Um, not able to fulfill really isn’t appropriate. Uh it it sounds daunting, and it is, uh, but it is the one of the biggest ways we can advocate for our patients.

SPEAKER_01: 20:13

I know that that’s a really tough um maybe point of contention for lack of a better word, with physicians and insurance companies is that dreaded peer-to-peer call. And I know that it can be such a heavy weight to have to really push so, so, so hard nowadays for your patients. What are some ways that physicians can maybe continue to advocate and push for their patients’ care without getting burnt out?

SPEAKER_00: 20:41

So, in hospital medicine, our record really has to stand for itself because the record is not just the way that we communicate to each other, but it’s also the way that we’re communicating and to you know everyone else who’s reading the chart, how sick the patient is and what’s going on. So, one of the things that I learned really early is to really document to the best of your ability all of the things you’re doing for the patient. And it often to us, because we do things so often, right, it may feel like, oh, that’s not worth putting in. Oh, you know, you I went up this much on their synthroid, so but it’s not that big a deal. But no, it is. It is showing that you’re thinking about the patient in a total way, you’re caring for the patient, the uh types of intervention that you’re doing, uh, and document as much as you can and as accurately as you can about the amount of care that you’re giving to the patient. So when you do have to have one of these doc-to-doc calls, and I I take for me, I try to do the first thing possible. Like if I get like pinged early in the morning, such and such wants a doc-to-doc. I do what my parents taught me, which is like do the thing you don’t want to do first and do everything else. And also, I have the energy that morning, but it also helps me know where I have to go through the rest of the day with that patient to help get them the thing that they need.

SPEAKER_01: 22:09

Yeah.

SPEAKER_00: 22:10

And so get that done as soon as you can so it’s off of your plate, and then you can plan for the next steps after that conversation. But remember, it is a peer-to-peer. You are not reporting to them, you are discussing with them and you’re advocating with them to get the patient the thing that they they need. Sometimes they can kind of come across kind of brusque, but no, you’re you you’re there as the patient’s advocate, you’re there as a patient’s mouthpiece at that point in time. You have every right to have a collegial and appropriate peer-to-peer conversation.

SPEAKER_01: 22:44

Fantastic advice. Absolutely. I hope physicians will really heed that advice, you know, and feel empowered the next peer-to-peer they have. And your book and your podcast prescription for admission, this talks about navigating the complex world of hospitals, whether you’re a patient, caregiver, or a healthcare professional, right?

SPEAKER_00: 23:04

Yes, yes. It’s it’s a very strange labor of love. Some people like kind of bristle when they think about talking about hospital stays. But I love hospitals because they’re they’re like the DMV of healthcare. Like we’re all gonna show up there at some point in time. Yeah. And you you really have to get through it, but you want to get through it in one piece, right? And we often silo hospitals in people’s healthcare journey as like this offshoot, like, oh, you once got hospitalized, and it’s over there. Uh, but really know the amount of things that we’re doing in hospitals and the way that we’re caring for patients. We’re caring for sicker patients, we’re caring for more complex patients, we’re caring in a caring in a more complex financial and legislative world.

SPEAKER_01: 23:55

Yeah.

SPEAKER_00: 23:55

Uh, and so it is a really important part of healthcare that we should be talking about and giving people the skills to understand and navigate. The last thing I want is when people get through a hospital state and feel like just as confused and used and abused at the end than they did when they first showed up looking for help. Like a hospital should be a place for help and support. And oftentimes do not get that experience. And so I’m trying to give people a window into hospital care, a window into how they can think about advocating for themselves and their loved ones. And also healthcare providers should be listening too and understand what people are going through in the hospital. So you can change your practice to be as supportive as you possibly can.

SPEAKER_01: 24:44

Yeah, absolutely. More patient-centered care, you know. Yes. And we will have a link to more about Dr. Nugent, her podcast and her book in the description below. Dr. Nugent, before I let you go, do you have any advice for a physician who may be listening right now who might be struggling with advocating or um, you know, navigating some of these complex systems?

SPEAKER_00: 25:09

Yeah, I I think it’s first really important to acknowledge that what we do is hard. It is extremely hard to meet people, oftentimes on their worst day at their worst moment. Extremely hard to guide patients and their family members through new and scary things, oftentimes things that may change their function, the way life was the time before. And then also death and dying is part of our work too, and helping navigate patients and their loved ones through that process is hard. And the first thing we need to do is acknowledge that you go into that hospital as a hospitalist doing your shift, your 10, 12 hour shift, and you’re on for those hours, right? You have to put the best face on at the same time that you’re thinking at the top of your game, at the same time as you’re writing at your top of your game. And if you can acknowledge that the thing that you’re doing is hard, then the next step is to acknowledge that you deserve a break. You deserve boundaries in your care. That when you leave the hospital, try your best to actually leave the hospital. Try your best to give yourself some separation and put up some healthy boundaries so that you can recuperate. Try your best to find other things that are in exciting and encouraging in your practice so that you’re bringing other parts of you into work and you’re being fed emotionally and psychically in different ways. Oh, find do your best to find things outside of hospital that is also really fulfilling. Yeah. And this person does them around the world. Do that. Find a way to be a whole version of you at all points in time. And then for the days that you aren’t, give yourself the space and grace to try again another day.

SPEAKER_01: 27:19

Yeah. Love it. Love it. That can that can be pouring into yourself and um and giving back to yourself can feel can really transform you, you know. So well, Dr. Nugent, thank you so much for joining me today and sharing your experience and your insights. Yeah, it’s very clear that effective advocacy comes when physicians can communicate clearly, they can lean on their case management team, and they can really speak up for their patients. Everyone is safer that way.

SPEAKER_00: 27:49

Yes. This was a wonderful conversation. Thank you for having me.

SPEAKER_01: 27:53

Absolutely. Thank you so much. To our viewers, you can learn more from Dr. Nugent through her book and her podcast, both called Prescription for Admission, and both linked below in our episode description. Be sure to subscribe to know your regulator so you never miss an episode and continue to protect your license and livelihood. Until next time, stay inspired and continue engaging and advocating with your regulatory agency.