Continuity of care in hospital is a hot topic. It is well recognised that reductions in the hours worked by junior doctors have resulted in a fracturing of the traditional team structure and more frequent handovers between staff as they come off shorter shifts. The Royal College of Physicians published a survey on the subject in February 2012, their press release saying,
‘…over a quarter (28%) of consultant physicians surveyed rate their hospital’s ability to deliver continuity of care as poor or very poor. In addition, over a quarter (27%) believe that their hospital is poor or very poor at delivering stable medical teams for patient care and education.’
Althought improved safety on the wards was a driver for change, a document published by the Royal College of Surgeons, ‘Do reduced doctors’ working hours create better safety for patients? – assessing the evidence’, challenged the assumption that working to the European Working Time Directive (48 rather than 56) led to greater alertness and fewer mistakes. The author Matthew Worral wrote,
‘There is a much greater evidence base to suggest the full-shift system being brought in increases patient harm through greater handovers and stratification of hospital staff. The potential for important information to be missed and inability to access senior expertise at key times are a greater problem for patients.’
Accompanying the move from long on-call periods to shifts has been a reconfiguration of the way patients are assigned to teams. In a soon to be published book ‘The Changing Role of Doctors’ (Radcliffe Health, May 2013), the main strength of the ‘old way’ is neatly described;
‘This firm structure, with the associated working pattern, meant there was a high level of understanding of one another’s strengths, weaknesses, training needs and personality. When this medical team was working at its best, all members of staff felt supported and there was a genuine sense of camaraderie and team spirit.’
‘Continuity of patient care was of a very high level. Most patients were clerked in by a member of a firm (usually the most junior doctor) and then remained under the same team of doctors for the duration of the stay, regardless of where the available beds were.’
This contrasts with the new ‘ward based’ model, where,
‘…the junior doctor and consultant who first admit a patient will usually pass over the responsibility of care for the patient to another team as soon as the patient moves to an inpatient ward.’
The ward based model has significant strengths, not the least of which is that patients are directed to teams with expertise in their particular disease, rather than remaining with the ‘random’ team who happened to be on-call on the day they were admitted. Another strength is that work intensity remains constant, rather than fluctuating with the ebb and flow of admissions either side of an on-call day. A major downside is that whenever the patient moves within the hospital (into a side room because of infective diarrheoa, for example), her or she becomes the responsibility of another team. That team will have to review all that has gone before, check the results, get up to speed, and carry on delivering appropriate care seamlessly. The process of developing a full understanding of the patient’s needs and goals must be repeated. Rapport must be rebuilt. Subtleties may be lost. Errors can be made.
What is at the heart of these errors? System failures, ‘dropped batons’, poor communication…all are likely contributors. Professor Roy Pounder, contemplating the effects of reduced working hours, highlighted these factors in advance of the EWTD changes:
“Seeing a patient once or twice before handing over to the next doctor, who then does the same after a short period, means it is difficult to detect a subtle deterioration in a patient’s condition.”
But I wonder if there is a deeper issue, related to the way doctors understand their patients. The psychology of discontinuity. This needs to be adressed from the point of view of both patients and doctors.
Patient experience: anchorage
A 2002 BMJ paper, ‘Continuity of hospital care: beyond the question of personal contact’ offered some good insights into patient experience, using the following quotes;
“They keep asking the same questions…”
“My file was not present and new doctors were not informed of my situation”
“You always get different orders from new doctors”
“Too many doctors! A second opinion is OK, but the sixth and seventh are quite frustrating…”
These are the more obvious symptoms of discontinuity, but they do not describe fully the sense of vulnerability and frustration that I have sometimes detected. When I see a patient in the emergency department or acute admissions ward, a common question is,
“Are you going to be my doctor now?”
“Will you be coming back to see me again? Will I see you tomorrow?”
I interpret such questions as an appeal for permanence or anchorage in the huge, complex system into which they have been delivered. Patients, it seems to me, are desperate to make a connection that can be relied on. If I know that the patient will come to my ward, I can answer ‘Yes, I’ll be along to see you tomorrow…’ and there may be a visible relaxation in their anxious expression. But if not, I have no choice but to explain, ‘No, it won’t be me who sees you from now on…but one of the other teams, lung specialists…’ Sometimes, if I have spent a good deal of time speaking with them, digging down in important medical or social details, I will add, ’But we will make sure they know all about you…about everything we have discussed…’ If it is a crucial fact I will make a point of telling the new team, but more often than not such hand-over of information will occur on paper, in the notes. This requires a clear handwritten entry, a transparent narrative. It is not uncommon for me to see what has been written by the junior doctor accompanying me only to realise that they have not interpreted the patient’s words in the same way I have. The emphasis is not quite right. So I re-write it, and leave the ward hoping and expecting that whoever receives that patient will see my note and make sense of it. This is an attempt to maintain the chain of continuity.
I wonder if the psychological distress that derives from uncertainty, not knowing if someone in the machine ‘owns’ you, if someone is personally invested in your wellbeing, may be sufficient to undo the benefit of technically correct, well timed medical interventions.
Fast track empathy
How do lack of continuity and the diminished feeling of ownership that follows, influence doctors in a way that jeopardises safety? It may hinge on empathy.
Serious illness requires the application of powerful medical interventions. These bring with them the potential for hazard. Recent debate about ‘zero harm’ culture has crystallised the notion that medicine and its tools can do as much harm as good. To avoid harm staff must be vigilant; they need to keep an eye on the details, spot irregularities, check the blood tests, double check the drug charts, maintain the ‘housekeeping’ (as it is sometimes called), and anticipate complications. These duties should be automatic, but they are done better if the doctor knows the full story. If they have gained a full appreciation of the patient and their background they will understand better the true impact of those potential harms. Risks and harms can appear abstract, but when they are imagined in the context of the whole person they become tangible, transforming from theoretical ‘adverse events’ to personal tragedies. A better understanding of those risks may motivate doctors to work harder in ensuring that each job is done properly. Otherwise they will not be letting down, ‘…the lady in bed 25, acute kidney injury…’, but ‘Mrs Jones…she was hoping to get out in time to attend her grand-daughter’s wedding this weekend…’ Continuity encourages personalisation, personalisation permits the exercise of empathy, and empathy gives our actions relevance.
The challenge for doctors working to shift patterns and caring for patients who arrive to their ward areas on a daily basis, is to learn the practise of empathy in compressed timeframes. This requires active listening, generous emotional investment…energy. But to ensure that connections between patients and doctors are made within the restrictions of the modern hospital environment this has to happen. Otherwise patients will flow through wards without knowing if anyone really ‘owned’ them, or who that person was. And doctors will float from patient to patient without understanding quite how much trust was being put in them.