As a first-year medical student, I have the privilege of observing medical practice from two perspectives: as a patient and as a student learning how to think like a doctor. I interview patients with deliberation and overthink every part of the physical exam and every detail of the patient’s history. I attempt to convey the patient’s condition, feelings, and pain as I present to my attending. I also marvel at how many professionals are involved in a coordinated care effort: valets, physicians, receptionists, nurses, physical therapists, janitors, and psychologists, among others. Interacting with the team creates a sense of purpose for me, knowing that I play a role in how these patients experience health care.
It wasn’t until I attended a staff meeting this year in my preceptorship at a clinic that I realized how unorganized the internal workings of the team I was working with was. It was a meeting of about ten professionals, including nurses and physicians. As I learned later, these meetings were an experimental attempt to create office staff teams and to better address patient care by empowering nurses and physicians to take action external to administrative personnel. However, as these meetings were a new addition, none of them wanted to be there, and it was apparent that this was merely a requirement and not viewed as an opportunity to make clinic coordination better.
One of the focuses of this and subsequent monthly meetings was gathering resources for patients. These resources ranged from finding an affordable yoga studio to finding aquatic physical therapy near where they lived. These resources could mean the difference between sleeping on a bench or in a shelter for some patients who need more than prescribed medications and lab tests.
In these meetings, people volunteered to gather resources, but hardly anything happened from one meeting to the next. Nobody contacted a social worker to help facilitate a more systematic method of distributing up-to-date resources for patients. Two months later, only five resources with one copy each were in one binder for over ten physicians. Ultimately, everyone was too busy to take on yet another responsibility.
Health care team management and organization is one of the most important criteria for an optimal patient outcome. Quality care requires the cooperation of, communication between and the expertise of nurses, social workers, physicians and many more. In a brief, describing a five-year update on the ACA’s progress, authors discussed a primary care transformation through “medical homes,” which emphasize patient-centered care3. The importance of comprehensive coordination of care and discrete care teams is emphasized. Any disruption in this coordination can lead to an unsatisfied patient, unorganized health care, delays or a medical error that can lead to death.
Medical errors are no joke — they are the cause of nearly 10 percent of deaths annually, at over an estimate of 250,000 deaths per year. A Johns Hopkins surgeon defines death due to medical error as caused by “an error in judgment, skill or coordination of care …” This includes what can result from not spending enough time thinking about a patient’s problem, creating an environment that discourages patients to show up to their appointments or from lack of organization or communication between the health care team members.
I observed an immediate result of this lack of coordination in care. I spoke to a patient recently who had severe anxiety and depression. The first thing she said was how nervous she was waiting alone for over an hour past her appointment time. A deep sense of guilt flooded through me; one of the main reasons her physician was late was because he was doing such a great job teaching me.
How can coordination of care in this clinic be addressed and improved? How can clinics like this one reconcile with their teaching obligations, patient obligations, and hospital obligations?
One solution is to increase psychological safety by encouraging the expression of concerns or ideas for improvement. This could be in the form of having an “improvement box,” where people can write down ideas for improvement or express concerns that can be addressed at staff meetings. I’ve seen clinics with successful “shout out” boards, where they recognize a team member on something that was helpful for patient-centered care. Having a safe place to express honest, good-intended concerns is critical for creating an environment of creativity, innovation, and cooperation. Further, requiring training on communication and morning huddles would be beneficial for patients, clinic morale and to advance the clinic’s communication.
Although I’m considered merely a bystander as a first-year medical student, I’m still interacting with patients and participating in the health care team. I still have the perspective of a patient, as I have also been to the doctor as a patient. And I still have a bright vision and hope for patients in this current, chaotic health care system.
So, is it my duty as such to speak up and take a leadership role in getting those resources for patients or contacting a social worker to help with the efforts? After all, I went into medicine to not only learn medicine, but to advocate for patients’ well being and their right as a human to high-quality, coordinated medical care.
Rachel Bigley is a medical student.
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