“Who Is Responsible for My Care?”

In the Hospital: Continuity of Care a Challenge

Working in the hospital on the psychiatric consult service, I noticed an interesting phenomenon with people who were admitted for long stays and/or have multiple admissions: no one person is tasked with primary longitudinal responsibility for care. 

Every day, patients encounter medical students, residents, fellows and attending physicians – and these patients have no clear idea who among all of those specialists is the responsible person for them during their stay.  Patients have different nurses every 1-3 days.  The hospitalist MD (medical doctor), NP (nurse practitioner) or PA (physician’s assistant) who has coordinated all of the patient’s care changes every week – and all the aggregate knowledge and relationship they have built with the patient has to now be transferred to a stranger. 

When multiple admissions are involved, frequently the patients are not sent back to a unit that knows them, but instead to whatever unit that generally meets their criteria and has a bed.  When I was on the consult service for psychiatry, often we were the service who knew this patient wherever they were in the hospital and through multiple admissions.  Often, I was explaining to “the team of the week” what they were seeing.  That is, if the unit had requested psychiatry, and if I was working that day. 

In Outpatient Care: Still a Challenge

We see it in outpatient too.  Ever go to an appointment where the overburdened provider is late – sometimes significantly late?   You may get a student first.  Then the provider comes in at the end of the session for just a few minutes.  As for keeping up the momentum, when is your follow up appointment?  A month?  Three months?  A year? 

What’s Missing? The Relationship.

Institutional medicine has dispensed with the idea of relationship.  The current theory is that any provider can just pick up and read the chart (who has time to really go through it?) and understand enough to know this patient.

Really?

As though the patient is willing and comfortable telling these intimate, often embarrassing, sometimes shaming parts of their lives to just anyone – over and over.  It is as though the patients’ alarm and lived experience that everything that has just been learned with the last provider will have to be relearned by the new one is unimportant. 

That is simply not the case. And it most certainly should not be the practice.

Relationship means that you get to know who this person is, and you get a window into what is really happening.  You also learn over time what a person is really willing and able to do, to take care of themselves.  You learn what things are dealbreakers for them in terms of treatment. 

For instance, without the critical information you obtain through a real sustained relationship, you may not know that “just going for a walk” may be impossible because the patient’s neighborhood isn’t safe. Or that setting aside time for self-care isn’t so easy, because they are a single parent with small children to watch.

One of my family members is going through this experience of lack of continuity of care, of having no substantive relationship with their healthcare providers right now with a very painful condition.  Not one of the providers he has seen has taken responsibility to make sure that there is a systematic trial of treatment to keep him constantly and consistently pain free.  The doctor can’t even be bothered to monitor the number of pills he is taking – as in giving two 30 mg tablets, when a 60 mg will do.  Or 2 or 3 capsules three times a day, when 1 capsule three times a day will do.  This, despite well-documented studies on “pill fatigue” and failure to adhere to treatment: we know quite clearly that patients will not take multiple doses a day and too many pills. 

This situation of no one taking responsibility, of not creating a sustained mutual relationship, is hampering healing in every sphere.

So: Who Is Responsible for Your Care?

You – and Me. Together.

My method is simple.  You are the captain of your body.  You get to decide what you are willing to try and do.  And I, as the medical practitioner partner in this relationship, offer a frequent and systematic approach to your care.  We look at evidence and science to develop a plan to test the most likely medication and non-pharmacological changes for symptom management.

Then you come back – and we re-assess, and we tweak.  We begin this process by meeting often at first, so that we build a clear relationship, and you feel safe telling me what you have been afraid to tell anyone else.  We measure if you are feeling better, week over week, month over month.

If something is worrying you, I want to hear from you both at appointments and even between appointments (during business hours please—not on nights, weekends or holidays unless it’s an emergency.) You don’t have to be afraid to tell me if a medication isn’t working.  We have lots of choices. You don’t have to be afraid to say you want to come off a medication. If you are stable, maybe we can do it.  

So in this healing relationship, you are the one who chooses to show up, to build a relationship, to work the process. And who is responsible for your longitudinal care in my office?  As long as I feel I can make a difference in your health, I am.  For as long as you’ll have me.