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Wednesday, January 24, 2007

Hand off problems or lack of personal responsibility by physician

Here is an interesting and alarming story of what went wrong at teaching hospital allegedly because of problems in the system of "handing off" patients.Handing off or "signing out" has become a hot topic since the increased restrictions on house staff working hours has brought about more time doctors have a shift change and hand off their patients to the next shift.

Here is a much truncated version of what happened.

A 83 year old had a pacemaker inserted without incident and his post procedure chest x ray revealed no pneumothorax.Since he was on a "non-house staff" service" a nurse practioner (NP) apparently was the "doctor" in charge of care of the patient in the recovery unit. Noting increasing dyspnea a floor nurse called the doctor which is now a nurse practioner (NP) but it was after hours and apparently interns cover for the NP. At the floor nurse's suggestion a chest x-ray was ordered but never seen by the intern as before that could occur he signed out on the "night float resident". Ultimately someone recognized the pneumothorax, a chest tube was inserted almost a day after the onset of dyspnea and the patient probably suffered no long term ill effects.

The article's author then described steps taken to improve the system of handoffs which may well be a well designed and worthwhile project but...

Although there are obvious problems that occur with handoffs, my take on this situation is that the story would not have evolved as it did if the procedure doctor took responsibility for the post procedure care of his patient. When we did procedures-bronchoscopies, pleural biopsies, etc we would write on the order sheet, "Call me if there are questions or if problems arise". Just as surgeons- at least in my day- were in charge of the post op care, so were procedural internists in charge of and responsible for the patients after the procedure.

Apparently at this hospital after a procedure the patient goes to recovery where the NP is the "doctor" in charge of care- at least until their shift ends. This seems to be so much the usual way things are done that the author did not even consider why the cardiologist was not called.This is not surprising as the author, a young hospitalist, has likely never known any other way than their current system.

We seem to be replacing personal physician responsiblity with "systems".

What lessons are being implicitly taught to the house staff? The procedure doc seems to have no post procedure responsibility but is content to delegate care to a NP. In that environment how surprised could you be to learn the intern signs out without seeing the chest x-ray. End of shift-end of responsiblity.End of procedure-end of responsibility.

With so much rhetoric about instilling professionaism in medical students and house officers how can individual responsiblity be given such short shrift? In 2003 the ACGME eliminated the following statement from their pronouncements:

Physicians must recognize their obligation is not discharged at any given time or any given day.

No, that is not a typo -they eliminated the fundamental principle of the doctor-patient relationship,that the physician is responsible for his patient.

It is not coincidental that the ACGME 2003 general core competencies statement mentions "systems" or "system" seven times but saw fit not to include the above quoted sentence. To my reading the authors of the competencies seems much more concerned with team play, group dynamics,system blather, and conserving society's resources than inculcating physician responsiblity for their individual patients, which is what I thought it was all about.


Anonymous said...

If you want to send the house officers home at a certain time to meet ACGME time- on- job restrictions,it makes good operational sense to disabuse them of any archaic notion of a doctor being personally responsible for their patients.Otherwise they are liable to sneak back to the hospital to check on patients.

Anonymous said...

So tonight, in the 15th hour of my day, I signed out a lumbar puncture. And, as I often do after sign out, I finished up putting orders in and did a little paperwork. Then I overheard that my encephalopathic patient was refusing the LP, the LP I'd consented her for, and night float was thinking about starting empiric IV antibiotics. I walked out to the parking lot wondering what the patient would look like Sunday, after my day off, after day float had a day to ignore whatever night float was going to do. The real answer is not strict adherence to this magical idea of an 80-hour week but less patients per resident. Because when I'm carrying 12 patients and signing out to night float who carries three or four times that many, nobody's 3 a.m. labs get checked correctly.

james gaulte said...

Dr. Van Tessel-thanks for your thoughts.Good to hear from you again.

Anonymous said...

I am an intern. I've seen the problems inherent in signout. I know how difficult it is to communicate all the important points about a patient to the nightfloat intern/resident, let alone making sure they follow my overnight "to-do/to follow-up" list. I've also been on the flip side of things as the nightfloat intern. Despite what the critics say about the dangers of handoffs to nightfloat personnel, I think the "system" does work at my institution. My nightfloat rotation taught me how to be a better ward intern and make signouts effective. It is not uncommon at my institution that interns and residents ask that they themselves be notified about their patients even when they're signed-out and gone home and nightfloat is on the job---even for residents in the ICU.

My residency program is constantly looking for ways to improve patient care and to do so without unnecessarily extending work hours. And I personally am always looking for ways to improve the way I care for patients, including thoughtful and effective handoffs. As the nightfloat intern, I found it useful to read all of my patient lists and highlight things to do or follow-up on, even if the ward team hadn't indicated that I do so. Then I'd make my own to-do list, including the times that I expected labs to be back. I also learned to be proactive and call the floors to alert them that Mr./Mrs. So-and-so had a lab draw scheduled for "x" o'clock. It can be frustrating to expect a lab result at 4am, only to find that it was never drawn.

Sid Schwab said...

Having many friends in academic surgery, the theme seems pretty universal: concern about where we're headed (or, rather, are being taken) in the training of physicians. They are alarmed at the "shift-worker" mentality, and the loss of personal responsibility. (Of course, we see that at the national political level in spades). Not to mention the diminished experience of those completing training.

Anonymous said...

Residents aren't the only ones "signing out." A lot of PCPs hand their patients over to hospitalists when they are admitted, because they just don't have time or energy to admit patients to the hospital and write inpatient orders after a full day crammed with outpatients. A patient calls at 2 AM with SOB - is the PCP going to run over to the patient's house? Please - he's going to say, appropriately, "Go to the ER," where they are most able and ready to take care of this patient, and go back to sleep.

Plus it's probably safer having a doctor in the hospital at all hours rather than relying on the private physician, even though he/she's "their doctor."

Doctors want the kind of comfortable lifestyle that they deserve, and if that's going to be the case, someone has to come up with a reliable system of handing off patient care to other doctors - there's no way around it.