Because everything around us usually works, it can be easy to forget how fragile some of the workings are. My patients see this with their bodies, as they fail, but not so apparent to them are the fragilities of the health care system that we doctors get to see.
Despite what the if-it-bleeds-it-leads press might have you thinking, our health care system is pretty good. Good, however, is never good enough, at least not for doctors.
Medical schools select people who have always aimed to be better than good. So, we all entered the doctor-making factory with that predilection, and having matters of life and death thrust into our hands daily pushes us all to be more than just a “good” doctor.
Meanwhile, we’re all horribly busy.
Suppose a specialist has diagnosed a patient with something rare.
The patient’s primary care doctor has not heard about this condition since medical school. It’s late in the day.
He’s tired, or dinner is waiting, or the kids have a soccer game. The doctor is pretty sure
he doesn’t really need to look it up to make sure that memory serves, at least not right now.
Many doctors keep a list of things to investigate on the weekend and things like this might go on it, but some weekends, other tasks such as writing notes, responding to refill requests and writing lab letters are more pressing, and the to-do list might not get done or might not get done until next week.
For this particular patient, there might be three pieces of information that need to be held simultaneously in attention.
1. The patient has condition X.
2. Medication Y is bad for people with condition X.
3. The patient is taking medication Y.
The patient will be safe if someone has all three simultaneously.
When the patient is at the specialist, many things could go wrong, preventing the patient from conveying the fact that he is taking medication Y. Patients often don’t remember the complicated names for their medications. Many patients need written lists of them,
but like all written lists, these can be misplaced, forgotten, outdated, or made in error, never obtained in the first place or not asked for. Occasionally specialists don’t have that vital third piece of information about what medications the patient is taking.
Meanwhile, the patient may know what condition they have and what medications they’re taking but have no idea that they’re taking a medication that’s bad for their condition unless the specialist mentions it, and does so in a way that the patient can
Alternatively, when the patient gets home after their appointment, they’ll realize that they failed to tell the specialist about their medication and will have somehow been alerted to the fact that it might be bad for them. This is more sophistication than should ever be expected of a patient, but it occasionally happens.
What usually happens is that an electronic note of the visit to the specialist is generated, which is automatically sent to the patient’s primary care doctor to review. Primary care doctors see about forty of these a day. The note says that the specialist has diagnosed the patient with condition X. The specialist might also mention in the note
that medication Y is a problem for such patients, or the primary care doctor will happen to remember this.
Next, the primary care doctor has to check the list of medications the patient is on to ensure that they’re okay to take. This may require an extra step of looking up detailed information about those medications with respect to the patient’s new condition. In one of these ways, all three of our necessary facts finally appear together. Once this happens, the primary care doctor can call the patient or the specialist and make a plan.
The astonishing thing about this whole process is how fragile it is. It relies on one brain having all three pieces of information at once and recognizing their significance. And this is a simple case! Sometimes there are five or ten pieces of information, some of which come from one organ system’s needs and some of which come from another’s.
As I write this and notice the fragility of a system that relies ultimately on the contents of one brain — mine! — to keep a patient safe, I see that it is no wonder I feel stressed and insufficient so much of the time.
What I do matters. I like that. I chose this job because I wanted what I did to matter. Now, I have gotten what I wished for, and am trying to figure out how to balance that my provision of perfect care matters with the fact that I cannot be perfect and that my imperfections need to be allowed, somehow.
Making peace with this fact, loving it some days, hating it others, and respecting it always, is what needs to be done in order to be a sane primary care doctor.
Mary Braun is an internal medicine physician.
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