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Dr. Who?

Robert_wachterA study in this week’s Archives of Internal Medicine
by Vinny Arora and colleagues found that vanishingly 
few hospitalized
patients could name any of their hospital doctors. Should we care?

I think we should. Vinny
is one of the nation’s up-and-coming researchers in the field of
hospital medicine, and a good friend. In this clever study, she and
colleagues at the University of Chicago interviewed over 2800
hospitalized patients over 15 months. Three-fourths were unable to name
even a single doctor caring for them; of those who “could” name a
doctor, the majority of names were wrong. Sobering stuff.

There
are multiple issues at play here.

At a place like the University of
Chicago Hospital, hospitalized patients on the teaching service are
cared for by gaggles of residents, students, and others who are
increasingly working in shifts and running for the exits because of
duty hours limits.

Although the limits have made the housestaff better
rested (and less ornery – my interns this month on the wards at UCSF
were 10 times more pleasant than I was in late January of my
internship), patients are now being covered by all sorts of “floats,”
anonymous problem-solvers who are mostly putting fingers in clinical
dikes.

On top of that, at the U of C (and UCSF, for that
matter), all the ward attendings are full-time faculty members who lack
continuity relationships with their inpatients. Many people will say
“Oh, it’s those damn hospitalists,” but I’m reasonably certain that a
fair percentage of the U of C attendings aren’t hospitalists, but
rather are generalists or subspecialists doing their one-month-per-year
stint on the wards. Unfortunately, the paper doesn’t break the “Could
you name?” data from the teaching service down by hospitalist vs.
non-hospitalist attending – that would have been interesting. I hope
the hospitalists did a particularly good job in making an initial
connection, but I wouldn’t be surprised if they were no better than
everybody else. This is a skill that we all need to work on.

A few other fascinating findings:

  • The
    predictors of not being able to name any of the hospital doctors
    included some patient-related factors (being male, African-American,
    older, and less well educated) and some system-related ones (being
    admitted through the ED or by a night float resident). None of that is
    too surprising.
  • Most patients claimed to understand our
    Byzantine hierarchy (residents, interns, students, attendings…). Those
    who said they did were a bit more likely to correctly identify one of
    their docs than those who didn’t.
  • Patients were called a month
    after discharge to check on their satisfaction with their hospital
    stay. Guess what? Patients who could name one of their doctors were
    significantly less likely to be satisfied. Perhaps they
    scribbled down the physician's name in order to lodge a complaint or to
    call their favorite malpractice attorney.

In their
discussion, Vinny and friends describe interventions that have been
tried to increase the likelihood that patients will be able to identify
their doctors. One study
showed that placing the docs' pictures in the room (no darts, please)
helped. And – in response to a campaign by a family who blamed their
15-year-old son’s death on a dearth of attending supervision and an
inability to tell who was a trainee – the state of South Carolina
recently passed a law
that requires all doctors and trainees to wear large badges with their
names and their roles (“attending”, “resident” “intern”) prominently
displayed. I get it, but the slippery slope problem is real. As Gawande
wrote in Complications,

By
traditional ethics and public insistence (not to mention court
rulings), a patient’s right to the best care possible must trump the
objective of training the next generation. We want perfection without
practice. Yet everyone is harmed if no one is trained for the future.

But
let's return to the matter at hand, the strange case of Dr. Who? Does
any of this matter? When I get on a plane tomorrow, I’m not going to be
paying much attention to the pilot’s name (unless it is “Sully
and we’re flying over a river), since I know that flying is so safe
that, from a risk perspective, which pilot is at the helm doesn't
really matter. (This, by the way, is the scary side for providers of
“systems thinking” – if the system succeeds in guaranteeing safety, the
workers inevitably become commoditized, accompanied by the downdraft on
wages and prestige that commercial pilots have experienced.)

But
it seems to me that patients need to have a personal connection to
their physicians, particularly at times of great need and uncertainty.
Lest you think this is non-controversial, it turns out that not
everyone agrees. In a series of comments he may now be regretting, a
federal spokesperson told Karen Barrow of the New York Times that he didn’t think this was such a big deal:

“Do
you really need to know who your doctor is, or is it more important to
know some processes that will help you get at the information you
need?” said Dr. Ernest Moy, medical officer at the federal Agency for
Healthcare Research and Quality."

Responding to the finding that dissatisfied patients were more likely to be able to name their doc, he continued,



“In
some ways ignorance is bliss,” said Dr. Moy. “We assume when you walk
into a hospital you are going to be taken care of, but maybe we put a
little too much faith in hospitals.”

Hmmmm. I
don't buy it, particularly in the case of hospitalists. After all, when
we first meet our patients, we are encountering an anxious and ill
person who is often wondering who the hell we are and why their primary
care doctor isn’t here instead.

To navigate that tricky initial
encounter, I’ve developed a sort-of standard intro, which seems to work
well. If you’re a hospitalist who struggles with how to handle this
awkward moment, you might try something like it:

“Hi, I’m Bob Wachter [Note: You should probably insert your own name],
and I’m going to be your attending physician during your hospital stay.
I work with a whole team of young doctors and trainees – you’ve already
met some of them – and we’ve spoken about your case. I’ll be in touch
with them throughout your hospitalization, and I’ll be seeing you at
least once a day myself, sometimes more. I’ll also be in touch with
your regular doctor, Dr. XXX, to be sure that she remains in the loop
and that I know all the key things about your medical history. Big
hospitals are really confusing, and you’ll be seen by many different
doctors and trainees. A few weeks after you leave here, the hospital is
going to send you a survey asking ‘Did you know who the doctor in
charge of your care was?’ I need you to answer that question, ‘Yes’, because that’s me!”

And then I hand the patient my card, and try to write my name on their room’s whiteboard. I think most of them do remember my name, and I haven’t been sued yet.

Interestingly,
3-4 times in the past few years a funny thing has happened after I’ve
recited my schpiel, which is designed to describe what a hospitalist is
without invoking the confusing and clunky name.

“Oh, so you must be a hospitalist,” patients have said on these occasions, bringing joy to my soul.

Anyway,
folks, let’s work on this one. It’s not that hard to do, and it seems
pretty crucial, notwithstanding Dr. Moy’s comments. I’d love to hear
from any of you hospitalists (or residents) who have developed even
better ways to make that vital initial connection with your patients.

Robert Wachter is widely regarded as a leading figure in the modern
patient safety

movement. Together with Dr. Lee Goldman, he coined the
term "hospitalist" in an influential 1996 essay in The New England
Journal of Medicine. His most recent book, Understanding Patient
Safety, (McGraw-Hill, 2008) examines the factors that have contributed
to what is often described as "an epidemic" facing American hospitals.
His posts appear semi-regularly on THCB and on his own blog "Wachter's World."

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10 replies »

  1. There is no disrespect intended. My encounter with the fellow included no reflexive sarcasm on my part. The genuflection comment was a musing of mine long after the event.
    The point lost in the mad scramble to punish my impudence is that the “Fellow” did not provide a name. He disrespected me.
    The relationship between doctor and patient is symbiotic. Each requires the other. Respect is due in equal measure. Introductions and modes of address are symbols of that respect.

  2. I think all anon is saying is that practicing medicine, especially in America, requires a skill set and dedication that a finite # of people possess.
    Like Liz herself, those folks naturally want to be treated with a modicum of respect and not reflexive disdain from the folks they are serving. If you think about it, anyone who would go through the expense and training that fellow went through deserves a little respect right off the bat, not sarcasm.
    I don’t blame anon for preferring to treat folks who have simple respect for him just based on his decision how to employ his talents. He is not asking for genuflection, just noting that if the country wants good doctors, it needs to respect them for what they are, not caricaturize them as heirarchical status seekers. The fellow could have become a lawyer or an EMR consultant and then what kind (if any) of fellow would be calling on Liz?
    A basic premise that comes through reapeatedly on this blog, especially from non-doctors, is that physicians are simple economic creatures. Any reform that stems from that premise is doomed to inadequacy. A “system” is only as good as the providers. The doctors who possess both the intellect to practice and the drive to serve will go elsewhere. They already are.

  3. Wow – Anon – I have enormous respect for the hard work it takes to be a physician and have always been grateful for the care I receive. Even hours after a 14 hour surgery I managed to thank the fellow I had never met and whose name I didn’t know before he left my room.
    My story was meant to illustrate Dr. Wachter’s point about patients not knowing the names of their doctors. This one didn’t even have a name. Just a title. And, most of the public have no idea what a Fellow is. Step out of your ivory tower now and again and look at the world from another POV.
    Really, thank you for your hard work and your commitment to providing care for those you deem worthy of it.
    Oh, and I think you meant “climes” not “climbs.”
    xo – Liz

  4. No-one will dispute the need for teamwork in managing complex care, but where is the fabled “doctor-patient relationship” is all this? Who does the patient and family hold accountable not only for making good decisions on their behalf but answering their questions and involving them in the decisions which affect the patient’s life and health?
    The reality is that in a lot of teaching hospitals, it is far from obvious that anyone is in charge- a big part of the problem with these places. The patient’s role in all this was, historically, that of “the breathing brick”- it was our job not to notice that no-one was really in charge of managing our problem. The hospitalist role was designed in part to address this problem, a role complicated in the teaching hospital setting by turf issues.
    How troublesome for the faculty attending, who almost certainly will not remember the PATIENT”S name or be able to recall crucial details of their case, to then turn around and claim a right to bill insurers a fee based on the “doctor-patient relationship”. The reality is that in instances like those in this study, the “relationship” barely existed.
    PS Don’t blame “Liz” for being pissed off. She has a point.

  5. “At a place like the University of Chicago Hospital, hospitalized patients on the teaching service are cared for by gaggles of residents, students, and others who are increasingly working in shifts and running for the exits because of duty hours limits.”
    “On top of that, at the U of C (and UCSF, for that matter), all the ward attendings are full-time faculty members who lack continuity relationships with their inpatients. Many people will say “Oh, it’s those damn hospitalists,” but I’m reasonably certain that a fair percentage of the U of C attendings aren’t hospitalists, but rather are generalists or subspecialists doing their one-month-per-year stint on the wards.”
    Kinda takes the steam out of “consumer driven healthcare”.

  6. A very nice post Dr. Wachter. I work near Houston practicing Ob-Gyn and still take Medicare and Medicaid patients in my private practice. I am amazed at how many patients (when the topic of surgery or procedures comes up) will ask, “Doctor will you be the one doing the case?” This happens multiple times weekly, and honestly I don’t know where this comes from. I also hand out my business card whenever I am consulted by the Internists and expect the same when I ask someone to see my patients.

  7. Liz’s attitude, indicative of so many of the patients I have cared for, suggests one reason why so many students go for high procedure/low patient contact specialties,or are leaving the country to practice in friendlier climbs.
    I do mission work overseas and each time I return, I find it harder to get acclimated to the rudeness and impatience of folks back here in the US. I am asked why I go overseas for mission work instead of staying here and working for a free clinic?
    My answer is that in Ghana, Mexico or even Bulgaria, I am greeted with a kindly hello and thanked, even when there is nothing I can do. I know I am going to get hammered for this for this type of comment in this type of blog, and generate reams of stories of rude or presumptuous clinicians, but one of the reasons the “Fellow” is introduced as such is because he has earned a measure of respect because of his dedication and williness to serve and in part to protect himself against the withering and apparently reflexive disrespect from “Liz”. I am not saying that a patient should genuflect, but how about giving the guy one second for the benefit of the doubt, he is, after all trying to help you.
    I have found this attitude far more prevalent on the coasts than the midwest but it is leaching into there too as well.

  8. Hmm
    I wonder if a board certified family physician providing seamless comprehensive care both in and out of the hospital could address this problem. Nah, if it could, society would actually pay them to do so.

  9. I was pleased to see that you introduce yourself as “Bob Wachter” and not “Dr. Wachter.” My experience (unfortunately a lot of experience) in the hospital system is that almost every doctor I meet has the first name of “Doctor,” and only “Doctor.” I am always inclined to remember the ones that include their first names when they introduce themselves for the first time.
    It seems to me to indicate more confidence on the part of the physician – that he/she doesn’t need to impress upon the lowly patient their high status. The worst ones are those that introduce themselves as “Doctor” and immediately start calling me “Liz.” (I’ve never been called Liz in my life – by anyone who actually knows me).
    Of course the biggest impression I had from the gaggle of residents that entered my room one morning is when the “Fellow” introduced himself as “The Fellow” of Dr. Soandso. I could hear the quotes in his voice, and wondered if expected me to arise from my sickbed to genuflect.

  10. Interestingly, the very first patient “bill of rights” involved the issue of doctor’s names. No, not the “bill of rights” with the evil health plans, but, back in the 1970s, where the threat of federal legislation was needed for hospitals to finally draw up a patient bill of rights. Among the entitlements: being given the name of the doctor(s) treating you.
    One might suspect that in the era of “ghost surgery” and similar arrangements, there was a financial benefit to patient ignorance. Or, perhaps, in the “good old days” patients were just treated as fee-for-service inputs. Having studied the popular press and medical literature from that period, it turns out that our current doctors are actually a lot more attuned to patients’ emotional and other human needs in the hospital than many of their predecessors.
    I know Bob and colleagues like him will continue to help us make progress.

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