Or, Whose Patient is it – Anyway?

By Dr. David Edward Marcinko MBA, CMP™

www.CertifiedMedicalPlanner.org

[ME-P Publisher-in-Chief]

Ok, I admit it; I may be an aging curmudgeon [just ask my wife and daughter] who has not regularly seen patients in the office for the last decade. A consult here, Independent Medical Examination [IME] there, or a surgical assist when needed has been the extent of my patient experience since my transition out of direct care medicine in 2000-01.

Moreover, I admit to not being an ardent fan of hospital-based medicine [with all due respect to colleague and uber-hospitalist Robert Wachter MD, who I admire and have frequently mentioned in my books, white papers, speaking engagements and here on this Medical-Executive Post].

I am also not completely in favor of the many new-fangled “specialties” and medical business models.  And, as recent models and linguistic evolution occurred, the nomenclature designation of hospitalist was followed by that of hospital-intensivist, hospital-proceduralist and hospital-nocturnalist, etc [http://medinnovationblog.blogspot.com and personal communication Richard L. Reece MD].

Enter the Team-Based Hospital Doctors

And now – for the last five years or so on my radar – there is a new term to add to the lexicon: team-based hospital medicine [practice], or similar. But, I ask, whose patient is it? Who is accountable? Where does the buck of responsibility stop?

The Quintessential Example

On Friday, May 9, 2003, a 5-year-old boy was undergoing diagnostic testing for his epilepsy at Children’s Hospital in Boston when he suffered a massive seizure. Two days later, on Mother’s Day, he died. Despite the fact that he was in intensive care at one of the world’s leading pediatric hospitals, none of the physicians caring for him ordered the treatment that could have saved his life.

The death was tragic, but even more troubling from an organizational perspective was the series of events that led up to it. The Massachusetts Department of Public Health investigated the death, and The Boston Globe reported on the results that, “the investigation portrays a situation where lines of authority were deeply tangled, and where no one person had accountability for the patient. Each of the doctors who initially worked on the case–two at the bedside and one consulting by phone–told investigators that they thought one of the others was in charge.” In the end, no one was in charge.

This is a striking example of how even the most talented clinicians in one of the world’s best hospitals can fail not only to provide adequate care, but to save a savable life—all because the lines of authority were unclear. The lack of clarity resulted in this team’s inability to collaborate effectively at a time when the stakes couldn’t have been higher.

Here are two other benign, but more personal, examples circa 2011.

My Personal Experiences

My Sister

This past summer, my sister was in a VA hospital [extremity injuries, nothing serious] for about a week. She was seen by 13 different physicians who were on her “team”; not to mention the plethora of other allied healthcare “team-members”. Me, my wife [RN], and/or her boyfriend [Army Medic and a PA] were at her bedside at least 12-15 hours each day. She was rarely left alone, by design, as we all recalled the admonition of former AMA President Tom R. Reardon MD, to always have a bedside advocate while in the hospital.

Yet, she was offered the wrong medications on one occasion, personally mis-identified twice, and it was obvious that her team-members rarely communicated or discussed her case [by their own admission], or even reviewed her electronic medical records [vistA system] before rounds. Here, the “system is down” was cited as causative: https://medicalexecutivepost.com/2009/09/21/what-is-a-client-server-system

My Dad

Now, later this same year and under the same patient advocate approach, my dad was in two different hospitals sequentially, both using the “team-based” care model. In each, members did not know, or were loathe acknowledging, who was in charge of his case! Malpractice phobia was apparent despite the coterie of, no doubt brilliant, MD/PhD interns, residents and fellows making daily rounds by starring at their shoes. One physician even cited her hectic return from vacation as the reason she examined my dad – for the first time – without reading his paper chart. “Doctors need vacations, too”, was her flippant response when challenged.

Outcomes

Fortunately, our insider knowledge and – shall we say – “charming swagger” was helpful in avoiding major complications with the continuity-of-care in the above two examples. But, most patients are not so blessed!

Our Newest Book

These stories reflect just one of many difficult collaboration challenges in healthcare, today.

In her textbook chapter, Collaborating to Improve Operating Performance in a Changing Healthcare Landscape [Opportunities for Improvement Widespread], contributing author Jennifer Tomasik MS, Principal at CFAR [Center For Applied Research Inc, in Cambridge, MA], focuses on the increasing need for collaboration among physicians, clinicians, hospital executives, and administrative leaders in the dynamic, complex healthcare environment. She looks specifically at collaboration along three different dimensions, including

• inter-professional teams,
• institution to institution, and
• physicians and administrators.

In each instance, she describes useful tools that can be applied to improve collaboration and overall institutional performance—all in the service of providing better patient care.

Assessment

To me, it seems pretty obvious that “hospital team-based” medical care is an oxy-moron. On one hand, it appears to reduce risk, but on the other hand, it appears to reduce quality care as well. Moreover, it also seems to be an invoice generating machine, and revenue enhancing mechanism

And so, beyond this individual ME-P, and its’ tragic and trivial examples, it is important for hospitals and healthcare organizations to improve collaboration. Our patients depend on us to get the philosophy of “hospital team-based” care right, if it is to continue. Otherwise, it will become another good intention, gone awry, in the changing hospital ecosystem that is domestic health care.

Pre-Order Here:

“Healthcare Organizations” [Management Strategies, Tools, Techniques and Case Studies]

In-Process, 425 pages, est., from (c) Productivity Press 2012
http://www.crcpress.com/product/isbn/9781439879900

Conclusion

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Filed under: "Doctors Only", Book Reviews, Op-Editorials, Quality Initiatives, Risk Management | Tagged: CFAR, david marcinko, hospitalist, Jennifer Tomasik, Robert Wachter, Team-Based Medicine | 26 Comments »