Just what duty, if any, exists for doctors to keep tabs on their sickest patients?
“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.”
The patient seemed disappointed.
“I’m sorry,” I said. “But I’ll do my best to be available for you.”
It was not long ago that such words, coming from a doctor, would have been almost heretical. But logistical and philosophical changes in medicine have dramatically altered the doctor-patient relationship.
In clinic-based practices such as mine, patients may be told they may need to wait weeks or months in order to see their doctor. In the world of private medicine, some physicians now charge their patients extra annual fees for the privilege of seeing or speaking with their doctor more promptly.
Just how bad is this situation? Do patients followed by just one doctor do better or worse? And just what duty, if any, exists for doctors to keep tabs on their sickest patients?
My father, an infectious diseases specialist who practiced medicine from the 1950s to the 1990s, would have answered these questions: “Very bad,” “worse” and “a tremendous duty.” My dad was constantly vigilant, going to the hospital seven days a week, giving patients our home phone number and staying in touch with covering physicians when we were on vacation.
But things were different then. For one thing, it was expected that my father would follow his patients both in and out of the hospital. Today there are hospitalists — specialists in inpatient medicine who are in charge of admitted patients and specially trained to diagnose and treat illnesses requiring hospitalization. And my mother, like most doctors’ wives of a generation ago, did not expect my dad to be a co-parent. Medicine, after all, was a calling.
The reasons for the changes are diverse. For one thing, the growing number of women in medicine has helped bring a better work-life balance among physicians. In addition, the 1984 Libby Zion case, in which a young woman died while under the care of young doctors working 36-hour shifts, pointed out the potential dangers of sleep-deprived providers.
When I was a medical resident in the 1980s, the first “night floats”— doctors who covered the wards at night so other physicians could sleep or go home — appeared. To many doctors of my father’s era, this development was heresy. Medicine, they feared, was becoming “shift work.” Patients were passed from doctor to doctor, none of whom really “knew” them. With the advent of hospitalists, this fragmentation has gotten worse.
Fortunately, researchers are studying how well patients do in these competing types of systems. The 2016 FIRST trial, which received a lot of attention, found that patient safety was not compromised when doctors in training worked longer shifts.
But even when the data show that limiting work hours leads to as good or better care, physicians should not be content to play “doctor tag,” in which a physician or clinic simply designates a new provider to “take over” treatment. Just because a physician takes good care of someone during his or her shift does not mean that responsibility ends there.
It may be helpful to think about specialties within medicine that have long been associated with limited continuity, such as emergency or intensive-care medicine. In both of these venues, patients move in and out of treatment quickly and follow-up may be difficult. But it is not impossible.
In her new book, “You Can Stop Humming Now,” Dr. Daniela Lamas, a critical care specialist, recounts visits she made to patients after they had left her unit. In one case, she attends a party thrown by a man whose severe West Nile virus infection had initially made it unlikely he would ever return home. But now there he was, eating, chatting, “working the crowd” and reminding his son to videotape the event.
Dr. Lamas did this on her own time. But she found it immensely rewarding. “We rarely have the opportunity,” she writes, to follow patients “through long-term acute care hospitals, infections, delirium, readmissions, and maybe, if they are very lucky, back home to a life that looks something like what they left.” The patient and his wife seemed thrilled that she had come — not as his current doctor but as his past doctor who still cared.
And what of my patients? I have made a decision not to try to imitate my father, as much as I admire the type of doctor that he was. But patients deserve to have a “doctor,” despite the caveat to my new patient. Plus I have found that most physicians, at the end of the day, are control freaks, wanting to be in charge of their own patients.
So I try to stay in touch, by phone, computer or other messaging strategies. Patient portals, being implemented at many hospitals, now allow patients to leave messages for their physicians in secure ways that do not threaten confidentiality. And I “sneak in” patients with urgent issues when I am not scheduled in clinic but there are open rooms, such as early in the morning or during lunch. The generous staff members at my clinic help make this happen by registering these patients and getting their vital signs. My clinic is also pursuing strategies to increase the chance that patients can see their regular doctors.
My patients seem pleased when I go the extra mile. If I am willing to squeeze them in, they are willing to move around their schedules to come. But I just can’t promise I can or will always be available.