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Wednesday, September 1, 2010

Continuity of Care, Lost in the Shuffle

Guest post by Kreton Mavromatis, MD, FACC, Director of Cardiac Catheterization Laboratory, Atlanta VA Medical Center, Emory University

As I entered the clinic room I saw my patient for the first time, an elderly man, slumped in his wheelchair, thin, breathing rapidly, appearing tired both physically and mentally. I wished that I had seen him before. How long had he been this way? Had he been getting worse in the last week? The last day? The last few hours? What was his attitude towards his illness? At his advanced age, how hard did he want to fight to live, to feel better? How much medical and/or surgical treatment was he willing to endure?

It was not the first time I knew of my patient. I had spoken extensively with his referring physician about his heart failure, his other medical problems, and his attitudes. Yet, despite my in depth conversation with another experienced and caring physician, I still had so many questions. If only I had had a relationship with my patient before he became so threateningly ill.

Continuity of care is “the process by which the patient and the physician are cooperatively involved in ongoing health care management toward the goal of high quality, cost-effective medical care.” In today’s healthcare systems, physicians recognize it as a single physician caring for a single patient over time. Yet in today’s healthcare systems, this has been greatly lost. From part-time ambulatory care physicians only available certain days of the week, to groups of obstetricians who have a call system where one physician covers all the others on nights and weekends, to residents whose work-hour limits force them to turnover care to another resident, continuity of care is being destroyed. And it cannot be entirely replaced by careful “sign-outs” and EMRs.

Part of the practice of medicine is a “science.” Much can be communicated in the form of words and numbers describing symptoms, physical exam findings and test results. Yes, I knew my patient was short of breath a week ago when my referring physician had last seen him. But was he short of breath at rest and was he tachypnic? What was his respiratory rate? Was he using any of his accessory muscles to breath? Was he using inter-costal muscles, or just the diaphragm? For each symptom, each physical exam finding, each test result, multiple descriptors could be used to enhance the total clinical picture of a patient. As physicians, we note many of these consciously. But all the details are rarely documented in their entirety in our notes, as doing so would not be “time-efficient.” Furthermore, even with EMRs, these details cannot be conveyed in a practical and timely manner from physician to physician.

Part of the practice of medicine is an “art.” How stoic is a patient? How fearful? How much denial does the patient have? How much fatigue is the patient experiencing? What is the patient’s attitude toward his or her current illness and treatment in the context of his or her current life? Experienced physicians can recognize the answer to these questions through repeated encounters with patients and their families, encounters which involve conversation, the assessment of the body language and facial expressions. However, expressing it verbally to another physician in a detailed qualitatitive and quantitative way is rarely possible.

The evolution of our health care system has resulted in fantastic advances in health care delivery. The use of specialists, with their knowledge of large amounts of complex information and technology, has led to the better treatment of certain individual diseases. Work-hour restrictions have reduced physician fatigue as a source of medical errors, and led to a better quality-of-life for healthcare providers. Increased physician documentation requirements have resulted in data collection that can be analyzed for the purpose of quality improvement. Yet these same “advances” are destroying continuity-of-care, and the single doctor-patient relationship over time, which I believe is so essential to the highest quality of medical care. A new emphasis on preserving and revitalizing continuity of care must be made as our healthcare system continues to evolve.

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