So many moving parts.
Just last week, a patient I’ve cared for over 20 years came to see me, and she was despondent over a number of issues.
First and foremost was that her partner of over 60 years has had progressive dementia, and finally things got so bad that he had to be transferred to a long-term care facility, no longer safely able to be cared for at home despite all the resources that have been marshalled around them.
But she told me during her office visit that she was on her way there that morning to take him home.
Over the past few weeks, she’d noticed a rapid physical decline in this man who before this placement had been fit as a fiddle except for his fading cognitive capacity. Bedsores, urinary tract infections, falls, an aspiration pneumonia, and finally — the last straw in her eyes — hands and feet so swollen she couldn’t get the wedding ring off his finger.
But even worse than all of this was how she was treated when she complained, or asked to speak to someone, or reached out for help. “That’s not my job, but I’ll pass this on to the nurse/doctor/supervisor.” How can we claim to have a functioning health care system when we can’t even take care of those who come to us seeking care and relief from suffering?
So many moving parts.
On that same day, I saw another patient, an elderly gentleman who was there for follow-up of his multiple medical conditions, all of which seemed quite well managed.
He relayed a recent frustrating experience in which he had to see a new eye doctor because the ophthalmologist who had been caring for his eyes for several decades had passed away. He had told the new doctor of some worsening vision, and they told him he had dry macular degeneration and a minor cataract, and that he just needed new glasses.
He was given his prescription, which he took to a nearby optician, but when he finally received the glasses several weeks later they made things worse, not better. It took several visits back to the eye doctor before they finally realized that they had fitted his eyeglasses frame with his wife’s prescription, not his.
So many moving parts.
Once a week in our practice, we have a dedicated bit of time set aside where the supervising attendings get to meet one-on-one with the interns and residents who are doing their ambulatory rotations. It’s their time to go over issues related to patient care as well as administrative issues, to fill out some paperwork, and to get a little teaching in, get a little learning in.
Our senior residents do an outstanding job of helping the new interns along, teaching them the ropes, helping them navigate the harrowing electronic medical record, learning how to get things done.
As we talked about the obstacles that one of the interns was facing trying to get a patient the care they needed, I was struck by how much more needed to be done to get stuff done — exponentially more, I think — than when we had to do this so many years ago.
When did we allow a system to be created that made an intern who is trying to learn how to take care of people — how to address their needs and health concerns, how to manage their acute and chronic health problems and soothe their pain — become about so many forms they need to fill out, so many boxes they need to click, so many arcane ways of doing things that are really just barriers to learning and caring?
This poor intern was trying to follow up on a patient she had never met, someone seen a few weeks ago by a different resident, with a new complaint of crescendo angina and recurrent syncope, for which a diagnostic evaluation had been initiated.
Suddenly this intern was being told to figure out how to get an echocardiogram scheduled, how to find this patient a cardiologist who took her insurance, how to get a stress test authorized by her insurance company, and how to get prescription medicines authorized by an insurance company that has no idea what it’s like to take care of human beings.
Working together, our whole team moved these different parts forward, delegating tasks and trying to make sure that each person practiced up to their license as much as humanly possible, in our current resource-strapped health care environment.
Remembering that getting the patient the care they need is our ultimate goal, everyone pitched in and we were eventually able to get everything set up, authorized, approved.
But it shouldn’t have to be this hard. Doctors should get to doctor. Nurses should get to nurse. Interventionalists should get to intervene. Community health workers should get to work in the community.
And all of the rest of the stuff that gets in the way of the patient being in the center of all our care needs to be moved aside.
To truly fix our health care system, we need to get rid of all of this, to relieve those trying to help and make a difference of the burdens of what’s leading to provider burnout, to patient frustration, and to systems that are destined to fail.
Unless we fix things, then patients admitted to long-term care facilities that are unable to provide the care they promise will never thrive and continue to live with the dignity they deserve.
And patients will get the wrong prescriptions and be told to live with blurry vision.
And interns will find the life of a primary care physician one that just doesn’t seem that palatable, a career path they might not ever choose.
Too many moving parts.
Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home.
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