Sept. 1, 2008

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Taking Ownership of Patient Care

Graham Ramsay Joseph Ladapo

The structure of the typical medical care team in teaching hospitals is classic: two interns, one resident, and an attending physician who supervises care and provides the team with additional support when needed. While many care decisions are made by the interns—with or without input from the resident—major decisions about patient management are usually made at the group level, often in conjunction with the attending. This organizational framework facilitates the delivery of high-quality care, but its caveat is that it buffers interns from important management decisions, thus potentially hindering their development into independently operating physicians.

Critical though this framework is to patient care and safety, it is wise for interns to remain conscious of its limitations and earnestly claim ownership of their patients’ care for the sake of their future development—even when that care requires decisions that are not ultimately theirs to make. A mere two months into internship, I have taken this tenet to heart—and the result of this newfound consciousness is already affecting the care I deliver to my patients in a positive way.

Mrs. P was a 63-year-old woman admitted to the hospital because she had suddenly become extremely lethargic at home. She had a history of a brain tumor that had been resected and irradiated over 10 years ago, but her cognitive status and alertness had gradually declined since then. Infections are common causes of behavioral changes in adults, and our investigation uncovered an area of opacification on a chest X-ray. We diagnosed Mrs. P with pneumonia and treated her with antibiotics, but I remained concerned that something else was awry. She was requiring supplemental oxygen to keep the oxygen levels in her blood at a safe level—a requirement she had not had during previous hospitalizations. Moreover, her heart rate was abnormally elevated, though the change was subtle and borderline. Both of these findings are frequently observed in patients with pneumonia, but as I reviewed her chest X-ray again, I was unconvinced that the small area of inflammation visualized on the X-ray film could account for her symptoms. I began wondering whether she might have a blood clot in her lungs. Patients with these pulmonary emboli can have similar symptoms to patients with pneumonia, and it is often challenging to make the distinction and, ultimately, the diagnosis. Yet it is a critical diagnosis to make because the condition is often deadly when left untreated.

The rest of my team felt comfortable with Mrs. P’s current treatment plan, and their sentiments were reasonable: we had identified a clear cause for her decompensation, and we were treating her appropriately with antibiotics. Had I met Mrs. P before arriving at my personal decision to diligently take ownership of the care of my patients, I would have likely acquiesced. After all, my resident and attending physicians were far more experienced than I. However, I remembered my commitment, so I continued to make a case for exploring further the possibility of a pulmonary embolus—she was my patient and I felt uncomfortable.

My team heeded my request, and we performed a computed tomography angiography of her lungs (an exam that enhances the appearance of the lung vasculature, allowing blood flow—and blood clots—to be visualized). Minutes after her exam was complete, I received a page from the radiologist: she had found large pulmonary emboli in Mrs. P’s lungs.

Mrs. P’s clinical presentation was the first time that, as an intern, I had independently thought through a serious problem and arrived at a clinical diagnosis and decision without the input of my resident or attending. The two intern–one resident model for medical care is important, but my experience with Mrs. P reinforced my sentiments about the importance of taking personal ownership of each patient’s care. A key element of the practice of medicine is the act of decision-making, and I hope my tenet keeps me actively involved in the decision-making process and continues to serve me and my patients well.

—Joseph Ladapo, HMS ’08, is an intern in internal medicine at Beth Israel Deaconess Medical Center.

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Copyright 2008 by the President and Fellows of Harvard College