February 12, 2007
Student Scene
Weak Links in the Chain of Care
Photo by Jeff Cleary Tarayn (Grizzard) Fairlie |
After nearly seven months as an intern, I see the experience as a life-altering transition, one that brings with it an array of revelations about the profession, physician lifestyle, and one’s own abilities. For me, the most troubling of these is the realization that I and I alone, with rare exceptions, am personally responsible for guaranteeing that my clinic patients receive follow-up on lab results, medication refills, home services, and other ancillary aspects of outpatient care. Our excellent office staff reviews records to make sure, for instance, that critical or other important lab results are reported to whichever attending is in the clinic that day so necessary action can be taken. This ensures patient safety for sicker patients. Yet at the end of the day, the responsibility for all but the most critical ancillary care falls squarely on my own or another resident’s shoulders.
This is a risky situation for several reasons. Number one is that I’m a resident, a trainee, and therefore might have little or no idea at first how to make sure this follow-up care gets delivered appropriately. Patients may suffer while I fumble through their disability paperwork, check off the wrong box on the form for WIC (the Women, Infants, and Children Program), thus “losing” their benefits, or spend a week looking for an appropriate home care referral for them while they have to make due with family helpers. Even though our faculty attendings are a wonderful resource for us, a lot of these tasks require skills and knowledge acquired only by personal experience. Even those issues that could be resolved with specific information from a faculty attending may pose problems because the attendings aren’t available 24-7. Residents are so busy that we have to squeeze the tasks in when we have time to do them, which might mean 3 a.m. on a slow call night when typically no attending is around. Equally important is that residents often are not in or near the clinic. On any given day, they are out at any one of nine different institutions, focused on obstetric, surgical, medical, or subspecialty inpatient care, all of which are time-consuming and difficult and have their own pressing priorities.
Stopping to call or link to the clinic computers electronically to check messages often just isn’t an option. This means that I either violate duty hours by calling patients or filling prescriptions from home or wait until I’m back in clinic and hope that I have time between seeing patients to take care of the work. So patients might wait for three or four days before getting a call back or a prescription refilled.
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Most primary care physicians spend the bulk of their career scrambling to take care of the nonmedical tasks generated by their patients while still providing the care that maintains them and their practices financially. |
The result is that patients may not get optimal care. Sometimes I find myself running in circles and learning very little except that I don’t want to be a primary care physician (PCP). Even if being a hospitalist means longer duty hours, I can’t imagine being a PCP like our own overworked faculty attendings, who despite being experienced and mostly clinic based, still seem to have a tough time taking care of the ancillary clinical tasks—the forms, the paperwork, the refill requests, prior authorizations—while caring for patients. And while some practices choose to hire nurses or physician assistants to do this work, for most practices, reimbursement is often too low or profit margins too narrow to support extra staff. The shortfall leaves attendings to manage for themselves as best they can.
In short, while I am obviously one of the weakest links at the clinic, it seems that the rest of the chain sometimes just barely holds up. Most PCPs spend the bulk of their career scrambling to take care of the nonmedical tasks generated by their patients while still providing the care that maintains them and their practices financially.
It’s no surprise that physician burnout is epidemic and that many PCPs leave outpatient medicine to work in industry or hospital-based medicine or to retrain in another specialty. It’s equally unsurprising that so many young physicians—myself included—opt not to be a PCP. For my part, although I do love being a primary care physician, I’d much rather work a 75-hour week, pulling shifts as a hospitalist than devote my career to being a PCP who spends just as much time scrambling to do paperwork as providing care and has little or no help or financial support. That sort of challenge, after all, should be saved only for residency.
The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.
Copyright 2006 by the President and Fellows of Harvard College