Shuzan, a Buddhist monk of the tenth century, once held up a bamboo stick before his disciples. “Call this a stick,” he bellowed, “and you assert; call this not a stick, and you negate. Now, do not assert or negate, what would you call this stick? Speak! Speak!”
From out the ranks, a young monk ventured forth, grabbed the bamboo, and, breaking it in two, exclaimed to Shuzan, “What is this?”*
Team-based patient care, that is, care involving multiple attending physicians from multiple services, multiple residents under work-hour restrictions, and a compendium of pharmacists, nurse practitioners, social workers, physical therapists and occupational therapists and the like — seems to be the latest, greatest fad in medical care these days, especially in large health care systems. While there are many advantages in this approach, there is also a disturbing shortcoming that I seem to be observing: something I’ll call dilution of responsibility.
This phenomenon should not be confused with the “hand-off” errors we’ve heard so much about. Rather, this phenomenon is more insidious. Today, more attending physicians have responsibility for an individual patient at varying times during their inpatient treatment than ever before. For instance, there are ICU attendings, ward/teaching attendings, hospitalist attendings, outpatient attendings (who may or may not want to participate in inpatient care), and specialty attendings – each with their niche of inpatient care.
These days as a consulting physician, for instance, I often wonder after writing my consult that contains recommendations for therapy if I should also write the orders on a patient. In the past, this never happened. Back in earlier times, the senior residents served as the “Commander and Chief” of inpatient care. Attendings were not allowed to enter orders on a patient. That way, the senior resident, in concert with his responsible attending, knew what was and wasn’t to happen with a patient. Everyone caring for the patient knew who had ultimate responsibility to make things happen. With our new model of “team-based care” our Commander in Chief is lost. It is becoming increasingly difficult to know if team caregivers are reading my recommendations and deciding to ignore them or just figuring someone else will implement them. How do I, as a “consultant,” know? Too often, omissions of therapy and the rationale for such are not communicated by today’s disparate and tunnel-visioned caregivers. Leadership is not easily assumed when everyone feels they are the leader.
With the trend of larger health systems under growing price pressures, I also see a growing trend to cross-train clinical and technical personnel across disciplines. No where is this more evident than in the cardiac catheterization and electrophysiology laboratories, for instance. From a manpower standpoint, this makes good sense. But we also risk making these clinical and technical personnel slaves to many but masters at none. It is a fine line that is constantly challenged these days: quantity of care over quality of care. Larger health systems with multiple hospitals, each with their separate laboratories amplify these challenges. In such a construct, not only are personnel required to know many areas of expertise, but also the many locations where the same piece of equipment might reside as well. Checklists, in cases like this, can only go so far.
These are the challenges doctors face going forward as physicians ultimately responsible for our patients’ well-being in our new era of team-based care. In many respects, these challenges are not new. But administrators squeezed by cost concerns should also be sensitive to the growing challenges caregivers encounter in this environment.
And doctors, like the young monk who steps forward in the story at the beginning of this post, mustn’t forget how to take the stick.
After all, the computers won’t do it for us.
* From: An Introduction to Zen Buddhism, by D.T. Suzuki (Grove Press, 1964).