Saturday, June 4, 2011

Every Pit Crew Has a Chief

In his address to Harvard Medical School Graduates, Dr. Atul Gawande asserts medicine has gotten more complex with time and that the model of care has to change from one where one heroic doctor saves the day (“the cowboy”) as opposed to one where a team of health care providers (“the pit crew”) work together towards a common goal.

After publication in the New Yorker there has been some pro/con comments about this address in the blogsphere between Buckeye Surgeon & Maggie Mahar:

Buckeye surgeon comments on how we physicians are more than just an anonymous member of a team and that the message from Gawande is missing out on the issue of patient ownership which is something that is lost in the current face of medicine.

"His essential message is this: Healthcare is far too complex for any one doctor anymore. So gear up to be an interchangeable part, a faceless drone who performs menial tasks... Not a word about being a better physician, about recapturing the old ethic of patient ownership. Nothing about the challenges individual doctors face to stay on top of new medical developments and how they can be surmounted. Nothing about personal accountability. Nothing about putting your heart and soul into this noble calling. "

Maggie Mahar responds to his criticism in this post which essentially reiterates Gawande’s points and implies that patient ownership can actually hamper care since not all opinions are considered. For example, the cancer patient who cannot see a palliative care specialist because their oncologist wants to keep treating their end stage cancer.

I have never practiced medicine, but my impression is that under the new model, a hospitalist would be the "co-ordinator"-- who was in touch with everyone. This doesn't make him the team leader. There is no leader. Different people lead in different spheres."

I am a pediatric intensivist and practice team based medicine. I have more than a pit crew; I have the whole pit lane at my disposal. A typical complex patient in my ICU may be seen by 3-4 subspecialists (each with a cadre of residents plus attending), the social worker, case management, OT, PT, nutrition, etc, etc. As the attending of record I feel that it is more than my responsibility to just “coordinate” these various personnel, but to distill what everyone has to say and then sit down with the patient (or the parent for the most part) and work out a cohesive plan of care.

What I think Ms. Mahar does not realize is that medicine is not practiced by majority vote. In the end there is one person responsible for the care of the patient at a given time. I give all my complex patients a quick primer on how things work. They will be visited by multiple doctors but in the end the decisions are made by the ICU team after we put what everyone has to say together.  Even their own primary doctor cannot make the final decisions (but they are more than welcome to contribute). I am upfront with them that different doctors can say different things, but as each doctor is merely looking at a piece of the medical puzzle it is my job to put it all together coherently. Where it is appropriate I will actually let the family know about the various opinions and allow them a hand in making the decisions especially when it comes to decisions where there is more than one “right answer” or those decisions made at the end of life.

One point that Dr. Gawande brought up is that as medicine is more complex we need more and more doctors involved in the care of a given patient. While I think this is true to some extent as our hospitalized patients are getting sicker, I find as the old saying goes that “too many cooks spoil the broth.” I think that we are breeding doctors who call “kneejerk consults”. Patient wheezing? Call the pulmonologist. Creatinine elevated? Call the nephrologist. I find that despite being in a tertiary care center with all of the mechanic’s tools at my disposal sometimes less is more. Part of being a good general physician (be it medicine, pediatrics, or surgery) involves knowing a little about each of our subspecialites and working up a problem before we refer. Also, the more specialists that get involved the more unnecessarily complex the work up and treatment plan can become.

Another issue with regard to ownership is the mentality put forth with the current work hour rules. While I am not going to debate the pros and cons of work hour restrictions, I do feel that for many residents it is easy to “pass the buck.” In the current model everyone has deniability of responsibility since there is less continuity of care. This is not a stab at residents as there are many residents who I feel make an effort to take responsibility, but I think it takes more effort to do this in the current climate.

One side issue in all of this is the surgical patient who is in the ICU. One of the comments referenced Dr. Chris Johnson, (another pediatric intensivist who blogs regularly) who said:

"I have to say that, from my prospective Buckeye Surgeon , represents an example of the kind of problems I encounter every day. For those of us who work in the ICU, the irritation of dealing with surgeons who truly believe they know everything I know (as an intensivist), and they can do surgery, too. On the other hand, I do appreciate the kind of proceduralist, be it surgeon, cardiologist, gastroenterologist, or whatever, who stops by regularly after they have done whatever they needed to do to see how the patient is doing and if we need any more of their help. Patient families really appreciate this, too, since often they have questions the proceduralist is best suited to answer."

Over my career I have had some skirmishes with my surgical colleagues and can understand both sides of the argument here. For the post op patient in the ICU I can understand why the surgeon would want to be involved in the care and I’m glad they are. I’d much prefer that over the surgeon who operates and then is nowhere to be found (especially when there are issues that require further surgical management). However, I think the biggest asset we possess as intensivists in addition to our expertise is time and availability. Even the best and most dedicated surgeons cannot spend the time at the bedside that I can.  When I’m running the ICU, that’s all I am doing. They maybe able to check on on a patient between cases, but cannot devote that time I can. Also, the Pediatric and Neonatal ICUs are unique super-specialized areas.  I don’t think there are many pediatric surgeons who feel that they could manage the minute to minute critical care needs (vents, drips, sedation) of a critically ill child. A pediatric surgeon at the end of training has spent nowhere near as much time in the PICU and NICU as a pediatric intensivist or neonatologist.

I think there are a few strategies/concepts that lead to better care of the surgical patient in the ICU:

  1. The surgeons and intensivists have to trust each other as medical professionals. (this can be easier said than done depending on the personalities involved)
  2. There has to be a clear division of responsibility. My current ICU is a “closed” ICU where all patients are on the PICU service. My usual approach is that I will defer surgical decisions to the surgeons (when to feed, wounds, tubes, drains, etc) but still maintain oversight of the critical care (vents, pressors, fluids, sedation). I’ve worked in the opposite environment as well (all patients on surgical service, and the surgeons defer the critical care decisions to the ICU team). Obviously, I prefer the former, but you call me on my bias.
  3. Communication is key. I need to know what their plan is with the drains, feeding, return trips to the OR. They need to know when I think the patient can realistically be extubated or when they will be off pressors. There has to be a minimum daily communication with the attending leads on both teams involved.
  4. There has to be a captain of the ship. In the end someone has to make the final decisions for the patient when there is a difference of opinion. Again, medicine is not practiced by a majority vote.

Reflecting on this whole issue, I think that while better collaboration in medicine is a good thing, it is important to realize that there is an importance in having one go-to doctor for a patient to help them coordinate care and lead them down the right path.