Specialization in Health Care and Its Impact on Patients – Who is Taking Responsibility for the Patient’s Care?

This post was authored by Jon Stefanuca and posted to The Eye Opener on June 15th, 2010.

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Recently, I wrote a blog encouraging patients to ask more questions of their physicians. One of the comments in response to this blog raised an issue of particular interest to me – how does specialization in health care impact patients?

Specialization seems to be the name of the game for most physicians today.  For example, a century ago, there were surgeons. Now there are neurosurgeons, orthopedic surgeons, cardiac surgeons, colorectal surgeons, pediatric surgeons, eye surgeons, hand surgeons, dental surgeons, plastic surgeons, trauma surgeons, vascular surgeons, breast surgeons, transplant surgeons, cancer surgeons, just to name a few.  Yes, I know, I am beginning to sound like Bubba talking to Forest Gump about shrimp. Contrary to what Bubba may say, I am convinced that there are more medical specialties than there are shrimp recipes. That’s a good thing. A cancer patient should be able to go to an oncologist who has specialized training in cancer. The same is true of all patients who have a particular medical problem that would benefit by a specialist’s care. Simply put – would you want your vision problem being treated by a general internist? Specialization has real advantages.

On the other hand, what if you don’t know what specialist to go to because you really don’t know what your medical problem is? I suspect that for as many patients seeking treatment for a known medical problem, there are probably as many patients trying to just have their medical problem diagnosed. For patients in the latter category, encountering specialized physicians may not always be the best thing.

A situation we encounter in our practice way too often speaks to this issue. We have found that patients with underlying co-morbidities (e.g. lung problems, diabetes, etc.) present to hospitals with acute medical problems which may or may not be directly related to the reason they are admitted. The primary care physician is listed in the medical record as the primary attending physician (i.e. the one in “charge”) in many instances. That physician, ill-equipped to handle some of these complicating co-morbidities, brings in a host of sub-specialties (e.g. endocrinology, infectious disease, gastroenterology, etc.) to deal with this complicated patient. Should the patient also have a potential surgical issue, the internist, acting as the so-called “captain-of-the-ship” properly calls for a surgical consult as well. Depending on the rules, regulations and by-laws of any given hospital, these “consultants” may come and go on an “as-needed” basis leaving the ultimate diagnosis and treatment plan to the “attending” primary care physician. Their notes in the chart often read: “Thank you for permitting me to see your patient…(recommendations noted). Please call on me should the need arise.”

The clinical course of the patient many times gets further complicated when one or both of the following scenarios occurs: the primary care of the in-hospital patient is left to house-staff or resident staff and nursing and/or partners of the “attending” physician are called upon to “cover” for this patient whom they may never have met before.

What many times follows leads to disastrous consequences for the patient. Consultants come and see the patient and leave their thoughts and recommendations in “consult notes” for other members of the team to review and consider. At times, these consultants take no responsibility for the on-going care of the patient; they are just consultants giving their impressions from their sub-specialty perspective. They come and go at the behest of the attending physician, who brought in these consultants to help manage the patient’s overall care. Often, we have found, these consultants never even speak to one another. Their consult notes, if they are read at all, may well be in conflict with another specialist’s recommendations for care or diagnostic testing. This haphazard come-and-go scenario plays out for days if not weeks while the patient’s underlying presenting problem worsens. Yet we rarely find, albeit from our limited perspective, when we question these consultants and the attending physicians, that they have ever met or even spoken with one another to coordinate care and work-through the myriad issues each has identified as potential causes for the patient’s condition. What results more times than not – at least from what we see too often as lawyers – is a complete failure to come to a timely, meaningful diagnostic approach resulting in proper patient care. The pieces of the puzzle simply are never put together, they remain just that – unconnected pieces.

We as lawyers are then asked to deal with the unfortunate outcomes in such situations. When we question the physicians under oath (i.e. a deposition) we hear defenses that go like this: From the attending physician“I called in the right consultants and was relying on them to help me figure out what needed to be done.” From the consultants the following mantra: “I was just the consultant. I gave my recommendations. It was for the attending to make the ultimate decisions and to follow or not follow my recommendations as they saw fit.” The classic follow-up question to each is: “Did you ever talk to the attending (or consultants – when the attending is being questioned) and work-out a unified, comprehensive diagnostic work-up or treatment plan?” The response is usually – “Well no, but I reviewed all of the consultant’s reports and considered them.” What is often discovered is that tests that may have ruled-in or ruled-out a key component of a differential diagnosis may not have been done at all. Why? At times they are overlooked. At times one consultant’s recommendations are at odds with another consultant’s recommendations. A conference involving the attending and the consultants is the rare exception rather than the norm. Who suffers? – the patient!

Sure, we all recognize that reimbursement rates, especially in governmental third-party payor situations (e.g. Medicare and Medicaid) are abysmal. That is simply no excuse for these failures to communicate meaningfully. There is absolutely no doubt many physicians put the patient’s interests first and foremost and communicate with other members of the ‘team.’ This simply needs to occur universally; there is no justifiable reason for it not to occur in complicated medical treatment situations. If consultants are called-in, then consult with them. If a consultant makes a recommendation, then follow-up and determine if your recommendation has been followed and if not, why not.

As a patient, have you encountered this problem? As a physician, what has your experience been and what recommendations do your have when these clinical scenarios present themselves? Let us know.

Contributed to and edited by: Brian Nash

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