Blogfinger

Keep an eye on that “team” connection between doctor and patient. Don’t assume that it is working.

By Paul Goldfinger, MD, FACC.   Editor @Blogfinger

Several years ago I  predicted on Blogfinger  that the doctor-patient relationship and quality care would be compromised by the new medical system.  I turned out to be right, but I never imagined what is happening now, and the public is totally clueless.

Corporate entities such as Hackensack-Meridian have introduced a new way to practice medicine, and one of the core strategies is to carve out physicians from the dynamics of patient care.  This divide and conquer approach, called “team based medical care”  has succeeded in changing everything, and you, if you haven’t  noticed it, will get a shock when you do.

Here is an true example.  A man  (let’s call him X) is in a terrible car crash and is taken to the Emergency area at (Hackensack-Meridian) Jersey Shore University Medical Center.  He is sent to the Trauma ER where his care is turned over to the Trauma Team.  But that team has no physician in a hands-on role.  During this patient’s hours spent in the trauma area of the ER and later in the Trauma ICU, no physician came in to see him.

A variety of members of the team came around including medical assistants and  physician assistants but no doctor.  As a result the diagnosis of pelvic damage was delayed by hours, and that is a serious mistake.    It was simply missed by the team, each of which had certain tasks, but no one actually took charge and explained anything of substance to the patient or the family.   There was no physician involved.

About 7 hours after arrival, a man in a white coat arrives in the ICU and says that he is the “physician assistant” for the orthopedic trauma surgeon  on the team.  He tells the patient/family that the lower body CT scan reveals a broken pelvis.   Why was that CT result not mentioned hours before?  Which team member missed it?   The P.A. tells the family that surgery is scheduled for the next morning.  He explains the diagnosis and the surgery; it’s a scary problem.    But why doesn’t the doctor show up to discuss the diagnosis and treatment of such a serious problem?

The next morning the surgeon shows up just before wheeling X to the OR.  He speaks to the family and the patient. The surgery takes 3 hours and involves screws and steel plates.

A similar pattern of fragmented care is evident post-op.   The surgeon doesn’t make rounds—only “the team.”      There are no serious complications, and a few days later, X is transferred to a sub-acute rehabilitation center where similar communication issues develop, and physicians are missing  in a team approach.    As a result, a significant problem is missed.  Eventually the surgeon gets involved, and only then is the correct diagnosis made.

According to the AMA, “Team-based care is a strategic redistribution of work among members of a practice team. In the model, all members of the physician-led team play an integral role in providing patient care. The physician (or in some circumstances a nurse practitioner or physician assistant) and a team of nurses and/or medical assistants (MAs) share responsibilities for better patient care.”   But in our sample case, the “physician led” element was AWOL.

Healthcare planners associated with large corporations  like H-M love to talk like this, because they save money while providing, they say, more efficient, higher quality  and less expensive care,  but they don’t understand how medicine is traditionally  practiced:  tried and true methods with the patient at the center of a medical situation and with a physician engaged with the patient and  integrating all aspects of the case—just the opposite of what these team members did.  I do not trust those corporate types to place the patient first, and that is central to Hippocrates’ and Maimonides’ values for doctors.

Many doctors like this approach because it takes considerable pressure off them, reducing burnout, but I fear that it will allow all sorts of errors to fall between the cracks, as occurred in our sample case above. Physicians need to insist that they not be replaced by “mid-level” practitioners who think that they are as good as physicians. Such physician helpers need to be just that, and their name tags should say so.

Such examples of a broken system in a  hospital, at an inpatient sub-acute rehab center, and in an office-based setting must be identified and fixed.

When you are interacting with medical environments that use the “team based care” approach, keep your eyes peeled for mistakes, missed details, absent physicians, and over-emphasis on physician extenders who do not receive appropriate oversight.  Be skeptical and ask questions to be sure that all details are covered.  You may not be a doctor, but you may have enough common sense to actually identify a real problem.   I know that some institutions such as the Mayo Clinic have achieved success with this approach, but don’t assume anything at your local provider.

Below is a quote from an AMA article about physician led team based care:

“Physicians should maintain authority for patient care in any team care arrangement to assure patient safety and quality of care, since the ultimate responsibility for each individual patient’s medical care rests with the physician. In addition, physicians must be responsible and have authority for initiating and implementing quality-control programs for non-physicians delivering medical care in team-based practices.”

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