Continuity of Care
“I would want you as my doctor. I just wouldn’t want your life,” I said to the thoracic surgeon. It was after midnight and we were standing in the intensive care unit. I, having urgently intubated a critically ill patient; he, having finished a surgery on a patient we shared. This particular patient had had a lung abscess that ruptured and infected his chest. Dr. Mike Collins had taken him to the operating room to clear out the infection. The patient was now septic and had been transferred to the ICU and Mike had come to tell me about him.
I’m a pulmonary and critical care doctor, and that means that in a large hospital, like Intermountain Medical Center with over 80 ICU beds, we have two intensivists in-house, 24/7. It also means that the handful of doctors who do this for a living spend the night in the hospital several times a month. Most of us do this by working our “regular” job during the day and staying for the full 24 hours, many of us stay on for 36. But what it also means for us is that if a patient in the ICU gets sicker and needs something that second night (hour 45, as it were), we wouldn’t get called. One of our intensivist colleagues would be there to take care of the patient. Even doctors need sleep… sometimes.
I had been on-service recently, which means that I was the pulmonologist taking care of patients in the hospital for seven days without a day off. For most of us, this also means that we worked our regular work week before we picked up the service on Friday. I had shared several patients with Mike while on-service, and I was impressed by the attention he gave his patients. On Saturday he had spent no less than half an hour counseling a woman and her family about why she should stop putting oil in her nose for aromatherapy (it can lead to lipoid pneumonia when the lungs fill up with the oil and the body doesn’t have a way of removing it). That Saturday afternoon I had called him directly, even though another surgeon was supposed to be on-call, because I had a woman who was coughing up blood and might need to go for surgery urgently.
“Actually,” he said, “I’m not on-call. This is supposed to be my weekend off. If you think she needs surgery this weekend, you should contact the on-call surgeon.” He wasn’t angry that I had disturbed him. Rather, he was apologetic for not offering to come in and take care of my patient. I called the cardiothoracic surgeon and he agreed she would need surgery the following morning. By the time I came in that Sunday morning, my patient was already in the operating room.
Around noon, Mike got in touch with me. He was the one, in fact, who had done the surgery. It makes sense. Cardiothoracic surgery is a specialty that takes care of heart surgery such as heart bypass or valve replacement, and also lung surgery, such as what my patient needed. We are not all equally good at everything, and the surgical literature has shown what we intuitively know in this respect: the more you practice, the better you get. Furthermore, even if you’re good at something, when you stop doing it, you get worse.
Surgeons and hospitals that have higher volumes of a certain procedure, i.e. they do it more often, have better outcomes. Some surgeries are common and most surgeons can do the procedure well. Some surgeries, such as the one my patient required, are not only high risk, but are also uncommon. A cardiac surgeon who mostly works on the heart would likely have a much higher rate of complications than a surgeon experienced in this lung procedure. The surgeon on-call was an excellent cardiac surgeon, to be sure, but he didn’t do much pulmonary surgery. So he had done the humble, and smart thing: he had called Dr. Collins. And Mike, on his weekend off, had come in to do the surgery on Sunday morning.
There has been a lot said and written recently about long work hours in medicine. Increased awareness of decreasing physician performance with sleep deprivation, as well as some terrible and well-publicized patient deaths, have led to the adoption of resident work-hour rules. Under these rules residents – physicians who are training in a specialty – are not allowed to work more than 24 hours in a row, they are required to have at least 10 hours of time off between shifts, and at least one day off a week. Not on average, but a day off a week, every week.
These rules have thrown a wrench in residency and training programs across the country. Program directors spend the majority of their time ensuring that the complex schedules of the residents who cover different aspects of the hospital are adherent with these work-hour rules, while also taking care of patients. Attendings – physicians no longer in training to whom these rules do not, and cannot, apply, if we are to have physicians covering the hospital at all hours, have had to pick up the slack. Interns, once the people who knew the patient best, are now turned into shift workers who gather information, put in some orders, and come back some hours later for another shift to dictate a discharge summary and fill out the discharge paperwork. Educational programs and lectures have been severely affected, as those periods of time seem “easiest” to cut, because they do not interfere with immediate patient care. And studies have not convincingly shown any improvement in patient outcomes as a result, though, of course, a lot is changing about medicine.
When I round as an attending now, I’m struck sometimes by the shift-work mentality of the trainees I work with. We order lab tests and studies, and off they go, never once wondering to see what the test showed. Or perhaps they wonder, but they have started some other shift. And here’s the kicker, because as detrimental as cutting formal curriculum lectures and presentations is to resident education, it is the lack of follow-up that is the most devastating. If you never look at the CT of the chest you ordered that showed a rare type of lung cancer, carcinoid, you will never find out how wildly you misdiagnosed your patient in the first place. You won’t think back to how he told you about his flushing and diarrhea, which you ignored because he had already told you about a million and one other things, and these didn’t seem related to his shortness of breath. You won’t learn that you should’ve listened better, or considered a broader differential diagnosis.
Mike must feel something similar when he looks at me and sees me sign out to my colleagues in the evening or on weekends. He laughed politely when I said I’d want him as my doctor, but he knew it was true. For although we do not perform our best when sleep deprived, tired, or stressed, in medicine, an imperfect science, these decrements on neurocognitive testing or reaction times may not be the main source for error. Far, far, more important, it seems, is having a doctor who knows you, and who knows what to do. I would much rather have Dr. Collins, awake for 24 hours straight performing this type of complex lung surgery on me, than have another, rested surgeon who is inexperienced in the procedure. For 24 hours, yes. For 36 hours even, because I’ve experienced it and my perception, which research tells us is not representative of reality, is that we still function well. But for 72 hours or 96 hours, pushing against the limits of human ability, I might take my chances with the rested novice.
And there’s the rub. For medicine has changed significantly in the past several decades. It is not just that a younger generation of doctors is less committed, or doesn’t care as much about patients or medicine. It is that medicine and what we do for people has intensified. In the 1970’s, if you got admitted to the hospital with a heart attack, the main treatment was bed rest, and you would stay for weeks to get it. If you come to the hospital with a heart attack today, there is a complex system of physicians, nurses, and technicians working to get you from the door of the Emergency Department to an open coronary artery in the cardiac catheterization lab in under 90 minutes.
If I were a physician in the 1970’s and I was on service for a week, I would likely manage to sleep at home at night. If the nurse called about a patient with a heart attack, or many other things, I could manage things over the phone and see the patient the next morning. Today, I’d never leave the hospital. This intensity of medical care is part of the reason for the rise of the new specialty of “hospitalist.” Previously, a primary care doctor could come to the hospital in the morning and round on his patients, then go to clinic and see his clinic patients. Then, he could come by in the afternoon again to round on the hospital patients. The pace of hospital medicine today is such that we often admit and discharge people within a day or two, and we do A LOT to them while they are in the hospital. A primary care doctor seeing patients in clinic is simply not able to manage this, and so, here too, we sacrifice the continuity of care, and ask a hospital doctor, the hospitalist, to take care of the patient.
No doubt medicine will evolve and continue to change as we grapple with how to make patient care safer, more effective, and less expensive. We will need to keep the physician-patient relationship at the center. Indeed, we desperately need to improve it, for although the intensity of medicine has increased, the satisfaction of patients and physicians with their lot in medicine has not. Improving communication and continuity of care as patients are passed from one physician to another is key, not only to improving the quality of care, but also to improving the patient, and physician, satisfaction. And we will need to figure out how to do all this while expecting our physicians to be only human.