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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
Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.
Link: http://feeds.feedburner.com/HealthcareFinancialsthePostForcxos
Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com
OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:
LEXICONS: http://www.springerpub.com/Search/marcinko
PHYSICIANS: www.MedicalBusinessAdvisors.com
PRACTICES: www.BusinessofMedicalPractice.com
HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
BLOG: www.MedicalExecutivePost.com
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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 |
The Leading Business Education Network for Doctors, Financial Advisors and Health Industry Consultants 
The Day the Electronic Medical Record Died
A doctor’s story: It’s never supposed to happen of course. But, it happened today – the computer froze and could not be resurrected – a brief interlude into the daily clinic routine.
http://thehealthcareblog.com/blog/2011/09/20/when-the-electronic-medical-record-died/
Sorry to hear about your bad experience, Dr. Marcinko. But, this is just another example of a good theoretical idea, gone awry, in the pragmatic everyday world of health care delivery.
Sheila
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Patient Advocacy as a Career
Sometimes we are asked about job opportunities for patient advocates. So, here is a related essay from Dr. Kevin Pho, MD.
http://www.kevinmd.com/blog/2011/10/patient-advocacy-career.html
Ann Miller RN MHA
[Executive-Director]
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But There Are No Pit Crews
Dr. Marcinko, you are so correct!
In fact, Atul Gawande MD says that we’re used to doctors working like “cowboys” – rugged individualists who are responsible for making sure your care gets done right. We don’t need cowboys, he says. We need “pit crews” – teams of doctors working together toward a common goal, with each playing their own role.
It’s an appealing idea. Pit crew-like teams work, and work well, in trauma units across the country.
http://thehealthcareblog.com/blog/2011/11/16/but-there-are-no-pit-crews/
Stanford
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More on Team Based Health Care [TBHC]
Dr. Marcinko – Here is an article exploring new, team-based clinical care models like TBHC, the evolving responsibilities of chief medical officers and the increasing reliance on nurses to provide primary care in hospitals.
http://www.hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay.dhtml?id=8790009063
Dana
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Med Schools Shift Focus to Team-Based Care
In their first year of medical school, students at the Medical University of South Carolina join with students from all of the university’s degree programs, including nursing, pharmacy, and health administration. During a semester, the students work in teams to solve a hypothetical patient sentinel event. They must determine what went wrong and come up with multiple recommendations for the patient’s care.
The exercise is part of a required course implemented in 2009 to give students their first exposure to interprofessional care. In addition, six national associations of health professionals have formed the Interprofessional Education Collaborative. The group’s goal is to better integrate and coordinate the education of nurses, physicians, dentists, pharmacists, and other health professionals to provide more collaborative care.
Source: Carolyne Krupa, AMNews [3/19/12]
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It’s Team Based Care – Not More Experts!
Here is a study that shows how awful physicians are (“Doctors Fall Short”) and, according to the press release, “why expert geriatric care is needed.”
http://diseasemanagementcareblog.blogspot.com/2012/04/its-team-based-care-not-more-experts.html
Helen
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Why isn’t shared decision making standard practice?
http://www.kevinmd.com/blog/2012/06/isnt-shared-decision-making-standard-practice.html
Here is why?
Dr. Daniel
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Malpractice Threats in Patient Hand-off
Dr. Marcinko – Life changing errors in the patient handoff from one doctor to another are becoming more frequent, and they are increasingly occurring among doctors with good intentions who think they’re providing fine care; according to MedScape.
But, some insurers say they’ve noticed a disturbing spike in the number of lawsuits stemming from avoidable failures when patients are transferred or handed off. The exact increase is difficult to quantify because malpractice cases take years to work through the legal system.
Mike
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Medical Team Responsibility?
Much like the just released Benghazi report without a named culprit; when there is a team approach in any endeavor – often times no one is held accountable.
Can you here me Hillary Clinton?
Analise
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Too Many Doctors Can Hurt Patients
[The Bystander Effect]
An acutely ill man with mysterious symptoms — a nasty rash, kidney and lung failure — was admitted to Yale-New Haven Hospital where he was treated by 40 of its finest doctors. But, because so many cared for him, two of the attending residents say, the 32-year-old patient actually got sicker.
http://abcnews.go.com/Health/doctors-hurt-patient-bystander-effect/story?id=18116808#.UOcDAk_WYmV
That’s because of the so-called “bystander effect,” they say in an article published today in the New England Journal of Medicine. Authors Dr. Robert R. Stavert and Dr. Jason P. Lott argue that because of changes in health care, more specialists get involved, leading to “decay in coordination of care.”
So, this is why I Still Rue the Hospital “Team-Based Medicine” Approach to In-Patient Care.
Dr. David Edward Marcinko MBA
[Editor-in-Chief]
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Team Medical Care
Does shared decision making really increase health costs?
http://www.kevinmd.com/blog/2013/06/shared-decision-making-increase-health-costs.html
When everyone is in charge; who is responsible?
Billy
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On physician team liability
[Your team – Your legal risk]
When health care team members drop the ball, it’s often doctors who end up in court.
http://www.amednews.com/article/20130729/profession/130729942/4/
So, how can physicians improve such care and avoid risks?
Stan
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The VA remains a mess
Dr. Marcinko – interesting story and POV. And, the big picture still seems to remain true.
http://usnews.nbcnews.com/_news/2013/10/30/21250261-va-official-who-resigned-in-spending-scandal-repeatedly-pleads-fifth-at-hearing?lite&ocid=msnhp&pos=3
VA official who resigned in spending scandal repeatedly pleads fifth at hearing.
Kurt
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The importance of team?
http://www.kevinmd.com/blog/2013/11/medicine-importance-team.html
Medicine then – and now.
Guido
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Docs Say V.A. Punished Whistleblowers
Staff members at dozens of Department of Veterans Affairs hospitals across the country have objected for years to falsified patient appointment schedules and other improper practices, only to be rebuffed, disciplined or even fired after speaking up, according to interviews with current and former staff members and internal documents.
Dr. Marcinko – After reading this, and following the story on TV and in the news press, I now understand your thoughts on team based medical care – no accountability.
Edgar
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From piecework to collaborative teamwork with mobile computing
To take advantage of the productivity potential of mobile devices, health professionals need to be able to use EHRs on many different form factors.
http://www.microsoft.com/health/ww/blog/Pages/post.aspx?postID=245&aid=61&postTitle=From
Ann Miller RN MHA
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Team-based care needs to be more than a buzzword
Team-based care is one of today’s buzzwords without real substance, because unless the payment systems change, only the physician members of the team can bill for their work.
http://www.kevinmd.com/blog/2014/10/team-based-care-needs-buzzword.html
Ann Miller RN MHA
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TEAM based Ebola care
Is the current Ebola situation an example of team-based US national healthcare? Just “say no” to the team; give me a physician-leader.
Micha
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Too many health coordinators means less care for patients
Dr. Marcinko and Micha – How many health coordinators does it take to screw in a lightbulb?
Four. But, none actually do any screwing. One is your point of contact for screwing lightbulbs. One helps the bulb get screwed. One goes between those two. And, one manages the other three, raises funds and writes reports.
http://www.kevinmd.com/blog/2014/10/many-health-coordinators-means-less-care-patients.html
Now, what does this say about team health care and the new Ebola Czar – Ron Klain?
Haiam
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Too many cooks in the kitchen can spoil medical care
Dr. Marcinko – There are times when a common cliché may be the best way to describe academic medicine in today’s medical centers.
http://www.kevinmd.com/blog/2014/10/many-cooks-kitchen-can-spoil-medical-care.html
In fact, I have heard patients and their families complain about this, way too often. Simply put, there are many occasions when it seems that there are too many cooks in the kitchen.
Joan RN
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How about Big [box] medicine?
http://thehealthcareblog.com/blog/2014/10/30/big-box-medicine/
Kurt
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Redundancy in Responsibility or Authority
Redundancy occurs when more than one person (or committee) has the responsibility to make a decision or assume a task. Redundancy becomes a problem when it allows tasks to be overlooked or decisions to be avoided. This happens when a person or committee assumes that someone else with responsibility for the same task will make the necessary decisions. This can be due to a misunderstanding, or it can be due to an intentional dodging of the task or decision.
Redundancy is best avoided by having only one person (or committee) responsible for each task or decision. Since this is impossible in a large organization, there must be an unambiguous protocol for allocating tasks and decisions among the responsible personnel. The protocol must also establish a system for handling problems that the assigned personnel cannot solve. It is important that such problems be brought to the attention of a supervisor for reassignment to new personnel. Reassignment should not be done by first level personnel; reassignment at that level will make it impossible to prevent the dodging of unpleasant tasks.
Edward P. Richards III JD MPH
via Ann Miller RN MHA
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Interprofessional Teams Learn PCMH Principles, Improve Diabetes Care at LSU
Medical, nursing, pharmacy, and social work students were brought together in an innovative interprofessional training program at Louisiana State University School of Medicine to deliver diabetes care in a patient-centered medical home model.
http://wingofzock.org/2014/11/11/interprofessional-teams-learn-pcmh-principles-improve-diabetes-care-at-lsu/
Karl
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Film zooms in on patient-centered care
“Rx: The Quiet Revolution” focuses on the quest for enhanced public health initiatives.
http://www.medicalpracticeinsider.com/news/new-film-zooms-physicians-and-patient-centered-care?email=%%EmailAddress%%&GroupID=90115&mkt_tok=3RkMMJWWfF9wsRojuqjOZKXonjHpfsX56O0kXK6zlMI%2F0ER3fOvrPUfGjI4EScRlI%2BSLDwEYGJlv6SgFQ7LHMbpszbgPUhM%3D
The film’s director hopes doctors who view it will ask: Is there a way I can better practice team-based care?
So, should I re-evaluate my opinion on team-based medical care?
Dr. David Edward Marcinko FACFAS MBA
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Update on Your New Medical Team
[Algorithms and Physicians]
Machines have their limits, but automation can outperform doctors in a few areas.
Dr. David Edward Marcinko MBA CMP™
http://www.CertifiedMedicalPlanner.org
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More on Medical Teams
If surgery is a team sport, should surgeons bear sole responsibility for errors?
http://www.kevinmd.com/blog/2015/12/surgery-team-sport-surgeons-bear-sole-responsibility-errors.html
So, is medicine a team or solo sport?
Dr. David Edward Marcinko MBA CMP™
http://www.CertifiedMedicalPlanner.org
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