The sequel to House of God entitled “Man’s 4th Best Hospital” hit the shelves in November 2019. The author Samuel Shem brings all of his original characters back into the modern-day reality of all-for-profit healthcare. They reunite to form a small, comprehensive care clinic adjacent to one of the large, university hospitals. Their goal: to create a personalized, human-centered healthcare experience for as many patients as possible. Primary care physician, speaker, and social media presence Dr. Zubin Damania (ZDoggMD) calls this revolution Health 3.0. This system gives physicians and healthcare workers the autonomy, space, and tools to effectively take care of patients. Doctors, not insurance companies, will assign value to tests and treatments. And to measure their success, evidence-based outcomes are tracked, not risk-averse hospital metrics. Most importantly, physicians will collaborate to restore patient continuity.
For the last 50 or so years, healthcare has become increasingly fragmented on multiple levels. The sheer volume of information amassed within that time frame has brought about more specialized training. The model succeeds at providing focused, high-quality care within a single domain, but has inadvertently created a compartmentalized labyrinth that patients find confusing, even daunting. Hospital and group policies make it difficult for physicians to provide care for patients in multiple settings (i.e. the family practice doctor who wants to round and manage his patient admitted to the hospital). These, and many other developments, have created a piece-meal system of care that rarely communicates with its other parts. As a result, patients often feel lost at sea, tossed from specialist to specialist with no one to call “my doctor”. They rarely feel listened to since EMRs are mostly incompatible and the conversation they had with their outpatient gastroenterologist was not conveyed to their surgeon and vice versa. The situation is even bleaker as an inpatient. Once admitted, it’s a who’s who of hospitalists and ‘nocturnalists’, with various specialists thrown into the mix. All the while, the patient is still unsure who their doctor is. I find that I usually spend the first 5 minutes of any surgical consultation explaining the complexity of hospital care (“You have a primary team, they are a mix of residents and staff. I am your surgical consultation. No, that was medical student you saw this morning. Yes, the gentleman from earlier was a doctor too, but he only deals with the GI tract,” and so on and so forth). For better or worse, this is the reality of outpatient and inpatient care. The detriment to patients is real, and should be addressed. But I started to think, what is the impact of this model on physicians?
Fifty years ago, a primary care doctor would be called in the middle of the night because one of their long-time patients was admitted to a local hospital with pneumonia. Thirty years ago, a surgery resident would see the patient in clinic, counsel them and perform the operation, be responsible for their post-operative course, and manage any and all complications (prior to hour restrictions, night teams, shift work, etc). These changes are not all bad, some may even be good, but the results – intentional or not – was a break in the continuity of patient care. Imagine an assembly line at a car manufacturer. Each worker is responsible for creating and attaching their piece to the car. But imagine none of the employees were given a chance to see the final product and so had no clue how their piece fit into the bigger picture. In fact, none of them really knew what the other employees contributed, except that they also worked in the same factory. What if ‘burnout’ is the result of practicing medicine within a vacuum? When a consultant contributes an element of care for the patient, is it with an understanding of how that service fits into the big picture? Or has patient care been disassembled and rearranged so many times that we’ve forgotten what the final product even looks like? Physicians are busy practicing within their lanes, burdened and weighed down by system and administrative requirements and I think burnout is the very real result of this environment.
Until healthcare evolves into a more intelligent form, we are forced to practice within tiny little rooms, on floors with no elevators, in a metaphorical building that can only be accessed with insurance or in the case of an emergency. What I have found in my own practice, is a kind of fulfillment from reaching out to other physicians. It gives me an appreciation for what others contribute and how my part fits into the grand scheme. And in doing so, I have witnessed some downstream effects. For patients, they perceive this collaboration as seamless, patient-centered care. For example, even if there is already a note uploaded in the EMR, when I begin an encounter with “I just got off the phone with your cardiologist, we spoke about your upcoming surgery…” the patient instantly feels the system working for them. Or when a patient is about to be discharged from the hospital, “I spoke to your primary care doctor – very lovely person – they would like to see you in their office next week to go over a few things.” It brings credibility back into the system.
Besides the very obvious patient benefits that this kind of communication brings, I have found that it is personally fulfilling for the physicians involved. And this is an important lesson that I rarely see emphasized in graduate medical education. It is easy for young physicians to feel like cogs in a machine. I think learning to create these connections early on in training will benefit patients, but equally as important, it can counteract the feeling of helplessness that comes from working in a broken system. It restores a sense of continuity. Now I’ve made it a practice to text or call residents, even interns, when I see their post-ops. I text the operating staff every time a see a patient of theirs in the ED, even if they are not on call. I try as much as I can to talk to internists or oncologists about patients prior to surgery. It’s a theme that I’d like to see carried on in my program, because I think it highlights the need for community in medicine. Physicians talk less now than ever before, but I suspect these conversations are just as therapeutic for us as for our patients.