It’s increasingly rare in everyday life to have someone take responsibility for caring for you or serving you.
If you sign up for a new account at a bank, the smiling salesman doesn’t end up being the person you interact with when you stop in to make a deposit. Most of us no longer have personal relationships with our grocers or butchers or farmers.
And the field where this change seems the most dramatic is medicine. As we’ve all experienced, the last few decades have shown a shift in medicine from everyone having a family doctor to… almost the opposite of that. Hour caps for residents, the rise of hospitalists, an emphasis on advanced practice nurses, and a change from medicine-as-a-calling to medicine-as-a-career-path have all contributed to a more fragmented, less personal relationship between patient and doctor.
So do these changes mean that medicine is now shift work? And are the outcomes of these changes negative across the board?
As a surgeon, I always believed that the person who does the surgery is the person who checks on the patient after surgery. In my life, that sometimes meant my kids waiting in the hallway while I checked on a patient right on the way to a restaurant for Saturday night spaghetti. The generation before me might have done house calls and likely knew whole families, over generations.
A recent New York Times article looks at the shifts that have occurred recently. These shifts have pushed medicine dramatically away from each person “having their doctor” to care being provided in a way that’s agnostic of who is giving the care and is more about who is responsible during any given hour, or for any given problem. The interaction described by the doctor and author of the article is emblematic of precisely these changes:
“Will you be my regular doctor?” a new patient seeing me in my primary care clinic asked.
“Sort of,” I honestly answered.
She looked back at me quizzically.
“Technically speaking I will be your doctor,” I explained. “But you may have trouble scheduling an appointment with me and may have to see another doctor here at our group clinic at times. And if you need to get admitted to this hospital, other doctors who work there will take care of you.”
Although I think that this change is positive in many ways -- and ultimately necessary -- I also worry about some of the "side effects" of the shift to shift work.
Specifically, I think that there are a few specific negative consequences of the change from medicine being a calling, with ultimate personal responsibility, to medicine being a career path, made up of people primarily doing a kind of shift work:
- Lower satisfaction for healthcare providers. If you're handing off patients to a colleague once you complete your shift or role in care, you don't see the "welcome home party", hear about the happy return to a hobby, or see the relief in a daughter's eyes. Frequent handoffs in medicine often make it less satisfying to doctors because you don’t see the real life outcomes of your patients.
- Less holistic care. The more we know about our patients' lives, families, circumstances, goals, and passions, the more we can make their care smart and holistic. The more fragmented care becomes, the less holistic it becomes -- the third provider in the handoff chain may have no idea about a key personal circumstance that could affect care or compliance.
- More coordination mistakes. More handoffs mean more cracks for things to fall between. So often, signing out to a colleague is the crucial link in the chain to avoid problems -- but this step doesn't always or can't always happen.
- Decreased trust in healthcare system. I've noticed that one reason patients trust medicine, and doctors specifically, less than they used to is that there isn't any one person to trust.
So is good care possible within this fragmented system? I think it is -- but it involves a key shift in perspective. And I believe that the shift in perspective is this:
We must evolve from shift work to team work.
We can't go back to the old model of medicine as solo work. It looks like, for most of the population, we're not going back to house calls or family doctors. But even within the current medical framework, we can change from a handoff mentality, to a team mentality – we can evolve from shift work to team work. On a team, each of us is not always carrying the ball or responsible for the patient. But we're all always responsible for the outcome as a whole. That means that as medicine has changed, healthcare collaboration and care coordination has become not a "nice to have" but an absolute "must have" in order to provide adequate care to our patients. Ultimately, team work is about taking responsibility for the outcome of every single person we care for, even if we collaborate with colleagues on portions of that care.
It's not about handoffs, it's about collaboration.
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