Discharge is the time patients feel most vulnerable, and healthcare providers must give them the support and resources they need. Unfortunately, this is an area in medicine that is overlooked, and often there is a failure to provide appropriate discharge instructions. 

In a study published in the Annals of Internal Medicine, physicians analyzed patients after three weeks of being discharged from the hospital, and 19% had adverse events. With sufficient discharge planning and instructions, nearly two-thirds of those events could have been prevented or reduced in severity. 

Incorporating the simple strategies outlined below into your discharge instructions can help alleviate the burden placed on patients and families during this challenging time. 

Early Planning 

A successful discharge begins with early planning. The article, Discharge Planning and Transitions of Care, published in 2020, states, "an early discharge preparation process can significantly decrease hospital length of stay, readmission risk, and mortality risk." It is also important to note that many patients reported feeling that their discharge was rushed, while many providers overestimated their time spent with patients/caregivers. This critical step in patient care should begin as soon as possible, preferably when the patient walks into the hospital. Furthermore, instructions should be provided continually throughout the hospitalization. Then, on the day of discharge, the patient's comprehension of the instructions should be confirmed. 

Consider the points below: 

 
1. Interactive Discharge Checklist: 
Health care providers are given numerous responsibilities they must juggle simultaneously. This can potentially lead to human error or miscommunication during the discharge process. However, if hospitals require essential documentation to be filled out prior to the patient leaving, this can be avoided entirely and lead to a safe discharge. The checklist provided should include reminders and steps that must be completed for the transition to flow smoothly. 

 
2. Teach-Back Method: 

Patients are often asked whether they understand the provided instructions using a simple "yes" or "no." And often, patients respond with "yes" when they do not fully comprehend the information given. 

This simple but effective technique can be used to confirm that the patient understands their discharge instructions. Before leaving the patient interaction, the provider should ask the patient to explain what they understood about the conversation. The material is clear if the patient states back all pertinent information. 

Improving The Discharge Process 

Patients must fully understand the reasoning for their hospitalization and everything that has occurred throughout their stay. This includes all appropriate information regarding their medical condition and what must be done to care for their specific needs outside of the hospital. 

The following are essential and should be taken into consideration: 

1. Patients often become non-compliant due to the simple fact that they do not understand. This can be overcome by removing communication barriers. 

○ Remove medical jargon and incorporate patient-friendly terminology. There should be consistent, easy-to-read wording used throughout both verbal and written communications. 

○ Cultural Targeting should be considered. Customize your communication approach and content based on the population you are caring for. 

○ Always begin by explaining verbally, then provide written information the patient can take home. All wording should be written at the understanding of 8th-grade level or below. 

○ Include pictures, videos, simulations, or 3-D models to enhance patient understanding. 

○ To encourage patients to read through the printed discharge instructions, consider updating the layout, font size, and use of color. 

○ An electronic copy of the handout should be provided additionally in case the actual papers get misplaced. 

2. Most discharge instructions ask patients to follow up regarding their previous medical condition. Many patients are unaware of why this is necessary or how to make the appointment. Ultimately, this leads to the appointment never being made. 

○ There must be clear instructions provided on the handout. 

○ The exact dates, times, and places of the follow-ups should be included. 

3. Medication Reconciliation 

○ Always provide a written list of medications the patient must take. All details must be included (how often, whether to take with meals, warning signs). 

4. Contact: 

○ It is necessary to provide a 24-hr phone number and the provider's name. 

○ A list of warning signs should be listed that prompt the patient to contact the provider before their next appointment. 

Summary 

The role of communication and presenting clear discharge instructions must not be understated. 

The recommendations above offer an incredible opportunity to improve the discharge process and reduce the readmission rate, ultimately improving patient satisfaction and safety. 

Additional Resources 

1. The 8P Screening Tool 

2. Teach-Back Training toolkit 

3. Discharge Instructions & Outcome Measures 

References: 

1. Bajorek, Sarah, & McElroy, Vanessa. (2020, July 22). Discharge Planning and Transitions of Care | PSNet. Patient Safety Network. Retrieved May 25, 2020, from https://psnet.ahrq.gov/primer/discharge-planning-and-transitions-care#4
2. Forster, Alan, Murff, Harvey, & Peterson, Josh.(2003, February 4). ACP Journals. Annals of Internal Medicine. https://www.acpjournals.org/action/cookieAbsent 

3. Readmissions and Adverse Events After Discharge. (2019, September 8). PSNet. https://psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge 

Interviewer: Kunal Aggarwal, M.D. (KA)

Interviewee: Michael Natter, M.D. (MN)

Date: April 17th, 2022

• linktr.ee/Mikenattermediacal
• Instagram - @mike.natter

Background on Dr. Michael Natter

• Hometown: New York City
• Undergraduate Degree: Skidmore College where he studied art 
• Post Bac: Columbia University
• Medical School: Jefferson Medical College (now Sidney Kimmel) in Philadelphia - Graduated in 2017
• Residency: Internal Medicine at NYU Belview 
• Fellowship: NYU Endocrinology 
• Current Position: Attending Endocrinologist at NYU Men’s Health Center

Interview

KA: How did you get interested in art and medicine, and was there a critical point where you saw art and medicine intersect?

MN: I grew up almost entirely in the arts. I never considered medicine as something I could or would do, despite me having an interest in the field both personally because of my own Type 1 Diabetes, but also from an interest in medical science. So, I kind of came at medicine from what I would call a very nontraditional background. I brought a perspective to it that was different, which at first felt very scary. There was a bit of imposter syndrome with that. I initially utilized art in medical school as a way to teach myself medicine, and it became more apparent that there was something there. I started to do really well. My colleagues who started to see some of my cartoons, comics, and illustrations were starting to utilize them as study aids, and they were doing really well. Shifting into the clinical world in my third and fourth year and residency, I realized there was this cathartic piece to my artwork and it was really helpful for therapeutic reasons because as I’m sure you’re realizing, going through your clinical rotations can be difficult emotionally and very stressful. I found that my art was kind of bleeding into my medicine both in my didactic and cathartic ways.

KA: I would say that at least up until this point, for me, art has been this cathartic release. Since college, I have used art as a way to counter the rigidity of becoming a doctor, and just letting my mind go wild and create something. But, I think now I am starting to try and find creative ways to explain complex medical topics in a manner that is understandable to the average person. I have not done this a whole lot, but one specific instance where I have done this was when I was on a PM&R rotation. There was a patient that had a traumatic brain injury, and it seemed like she didn’t understand what her diagnosis was. I took out a piece of paper and drew the layers of the skull and explained the various types of hematomas, and where hers was, and how that affected her functionality.

MN: That’s amazing! There is so much that comes from that. You’re educating her about her own pathophysiology, which I believe every patient has the right to know. But outside of that you are creating this rapport with her. There is also something to be said about patient education when it pertains to barriers to understanding these complex medical topics, whether it be education level or language barriers. When you utilize visual aids you get rid of many of them.

KA: I look at the healthcare field as whole, and I see so many instances where patients do not have a good grasp of what is wrong with them, and there is this viscous cycle of mistrust where they feel that the healthcare system is out to get them, and they may not seek further medical care in the future. You look at COVID and misinformation as it pertained to vaccines, I think some of the responsibility lies on us as healthcare providers to properly explain how immunity and vaccines work. I think moving forward, patient education is something providers should place more of an emphasis on.

MN: Absolutely! These are very difficult topics to understand, and most people at best have a 9th grade biology understanding. You’re right its really on us to properly explain these topics especially when there is so much misinformation out there.

KA: Moving on from that, can you talk a little bit more about your preferred medium and subject matter?

MN: Prior to going into medicine, I really enjoyed large scale figure drawings using charcoal. Charcoal is very messy, and because I was doing large scale, I did not have the proper space when I started medicine. I then transitioned into small scale pen and ink stuff, and about two years ago I switched into the digital world. This was a really big leap for me because I really loved the feel and tactile qualities of art. The iPad procreate app allows you to draw in a very similar manner. I would say my subject matter with respect to my pen and ink work in medical school focused on anatomy and medical illustration. For didactic purposes, I then transitioned into more of a comic style. I would create cartoons that would revolve around anatomy and physiology or some kind of pathology with the intent of making these complex topics more understandable for me. 

KA: Who are your influences?

MN: Growing up one of my biggest influences was Egon Schiele. I enjoy a lot of 1920s and 1930s artists as well. I’m also a big fan of Jackson Pollock and the 1950’s abstract expressionists. When I got into medicine, obviously Frank Netter was a big influence and the name similarity is pretty humorous to me. He really showed how both art and medicine play hand in hand.

KA: Speaking as a creative myself, what fuels your own creativity?

MN: There’s that saying that life imitates art and art imitates life. I think everything that you experience and everything that you come into contact with has the potential to influence you and inspire you in some way. This is true for me with respect to my training, but I also found that there was a processing that needed to happen. Sometimes there were not words to articulate what I was going through, especially during COVID or seeing certain things in the hospital. This would create a cognitive weight that would sit on me. Even though I did not have the words to articulate these experiences, I was able to draw them. In drawing these experiences, I was able to put it into something that was tangible I could walk away from and take that weight off. 

KA: We talked about your art being used for didactic purposes as well as it being your cathartic release, but are there any other ways you have managed to incorporate art and your creativity into medicine and your practice as a whole?

MN: I have found that my medicine and my art are intertwined. I can’t take one out without the other. We discussed this earlier, but on the practical day to day when I see my patients, I draw things for them. I believe that my background in art has also instilled a subconscious quality in me. As artists we are trained to observe things in a different perspective and lens, and that picks up a lot of subtlety. I may notice something on a physical exam or in a patient’s body language that I can’t say for sure is because of my background as an artist, but I think a lot of how I go about my day, and how I see the world, is because I see it through an artist’s lens. But speaking more generally, being thoughtful and even being able to think outside of the box are important attributes in medicine. 

KA: I completely agree! You mentioned thinking outside of the box, it’s funny I always found similarities between coming up with differential diagnoses for a presentation and that creativity test where you are asked how many ways you can use a specific object such as a brick.

MN: Yeah you have to weigh them obviously, you don’t want to rush to the zebras. But that does not mean that zebras don’t exist. Interestingly, as an endocrine fellow coming from three years of internal medicine where you assume everything is a horse, now I feel like I am in a zebra farm. I see a lot more pheochromocytomas.

KA: On behalf of a lot of my friends in medicine who claim to not be artistic or creative, what is some advice you would give to a medical student, or anyone in the field of healthcare, to fully unlock their creative potential?

MN: I believe everyone is inherently creative. People are born with that inherent visual sense. If you think about it, everyone grew up painting and drawing with crayons and finger paints. That was something we gravitated toward naturally. There were no formal classes or courses that we had to do. Unfortunately, as we get older, I think we become aware of others around us and that what we drew does not necessarily look good to others. Therefore, we become self-conscious and stop. I also don’t think our society puts as much of the same value on the creative arts as it does on math and science. So, for those reasons, people put art on the back burner and change course. This doesn’t mean that your creative potential is not there. I think there are still opportunities for people to utilize that and supplement it, kind of like how you and I do with respect to medicine.  One thing I have noticed is that a lot of people in medicine are very type A. To get to that point you had to be the top of the top. So many people are not used to being great at something from the get go. If someone wants to start utilizing their creativity in some way, there are two things you can do. The first is to ask yourself this question: what is your goal in trying to be creative? If you are trying to use it for didactic purposes, it’s important to realize that the actual process is more important than the product. The visual spatial pathways that you are using in your brain are going to get you to the end goal of learning, retaining, and retrieval of that information. You could effectively throw away that drawing once you are done because you have already gotten that benefit from the process. The second thing I would say is practice. Like anything else, the more you do something the better you become, and if you are enjoying it, you will practice more.

KA: I guess to conclude this interview, are there any specific large-scale projects that you are currently working on?

MN: You are hitting on a topic that is very near and dear, and a little bit sore, because I want to do a lot of things and I have a lot of plans but if I am being honest, time has been my biggest issue. As you probably already know, you can’t schedule time to be creative. Sometimes it is there and sometimes it is not. But to answer your question, I have two books I want to make. The first is an autobiographical graphic novel about my art, my journey through becoming a doctor, and the COVID experience. The other thing I want to make is a didactic visual textbook for medical students. There are some products that exist like sketchy, but I really want to utilize my experience and piggyback off of that to help others.

KA: Awesome! Thank you for taking the time to speak with me, it was an absolute pleasure!

MN: Of course! It was a pleasure speaking with you.   

Medical school has often been described as drinking from a fire hose of information. The study guide which outlines the basic information that is required for the STEP1 exam, or more colloquially known as “First Aid” has grown nearly 100% in size in just the last 20 years. Every year it seems that medical students need to know more cytokines, biochemical pathways, and monoclonal drugs than the year before. While this quickly scaling knowledge represents the technological advances that medical science has made over recent decades, this crushing amount of knowledge can threaten our opportunities to explore being a good physician-in-training rather than a good memorizer-in-training.

One opportunity to better grasp the challenges in healthcare at large, explore cognitive biases, and become a well-rounded physician is to read books that are related, but not directly, to medicine. Between my one year of MPH and my first 2.5 years of medical school, I’ve gotten through nearly 50 nonfiction books in a variety of subjects. In this list below, I share my top 5 books I would recommend for fellow medical students, specifically from my past readings, as well as a few honorable mentions, the latter do not need a thorough reading, but rather share a few core messages which can be surmised from their summaries. The list is not all encompassing, but rather a personal categorization of books that have been most directly meaningful to my medical education.

1. Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life

Dr. Louise Aronson, a Harvard-trained geriatrician, makes the case that medicine is missing the mark for vast swathes of people, most notably, our older adults. She notes that “it's the best of times in medicine and the worst of times in medicine” commenting on the power that technology has placed in medicine, but how simultaneously, physicians are burned-out as the healthcare system financially disincentivizes strategies of good medical care — conversations with patients, focusing on prevention, and health adjuncts such as hearing aids and walkers. Ultimately, we are all growing old and our patients are as well. Dr. Aronson’s take on elders provides relevant insights into the failings of medicine and its culture.

2. When Breathe Becomes Air

Dr. Paul Kalanithi, a final-year Stanford neurosurgery resident diagnosed with metastatic lung cancer, shares his experiences on being both a physician and a terminal patient. He explores important philosophical questions such as the purpose of life, while simultaneously sharing the realities of a terminal diagnosis. It is rare that someone so highly trained in medicine is able to eloquently describe what it means to be a patient, and share how the words of physicians are so deeply impactful during fragile times. 

3. The Emperor of all Maladies

Dr. Siddhartha Mukherjee, an oncologist at Columbia, writes about the history of cancer. By peering into the history of its discovery and many attempts at cures, he reveals the inspiring possibilities of medical passion. In parallel, cancer’s history reveals tales of medical hubris, misconduct, and misrepresentation. Billions of dollars and decades of research were spent in chasing the therapy rather than chasing an understanding of the disease. Finally, this book places perspective on the number of players beyond medicine that are required for the advancement of medical sciences, from politics to nonprofits to university leadership.

4. How Doctors Think

Dr. Jerome Groopman, a professor at Harvard, offers a book written with patients as the core authorship audience. He explains how mistakes are made in the healthcare system, and open patients’ eyes to the logical fallacies that physicians are privy to. The book is largely spent answering a question that he received during a grand rounds lecture: “There are primary care physicians in every hospital who speak with great sensitivity and concern, and their longtime patients love them, but clinically they are incompetent--how is a patient to know this?”

5. Man’s Search for Meaning

Dr. Viktor Frankl, a psychiatrist and holocaust survivor, shares the stories of his times in Nazi concentration camps. Unlike his brother, parents, and pregnant wife who all unfortunately succumb to Nazi murder, he is the lone survivor of his family. He ultimately establishes a psychiatry practice and a form of therapy he terms “logo-therapy” that focuses on finding meaning during trying times. Medical training is trying, as are the conditions of patients — I regularly find myself revisiting quotes from this book to muster strength to overcome the next challenge.

Honorable Mentions:

Deep Work - Cal Newport

Being Mortal - Atul Gawande

Checklist Manifesto - Atul Gawande

Editing Humanity - Kevin Davies

Educated: A Memoir - Tara Westover

On my medical-related to-read:

The Logic of Scientific Discovery - Karl Popper

Do No Harm - Henry Marsh

The Gene: An Intimate History - Siddarth Mukherjee

House of God - Samuel Shem

Inflamed: Deep Medicine and the Anatomy of Injustice - Rupa Marya & Raj Patel