Sunday, July 23, 2017

After Hours and Weekend Medical Care - The Doctor's Perspective

Today's patients must adjust to seeing many physicians, many of whom are strangers.   If you need a doctor on the weekend, at night or just need a ‘same day appointment’, you may very well not be seen by your physician.  This is not your father’s medical practice.  The days of the physician house call have vanished.   There are many reasons responsible for this evolution (?devolution) in medical care.  Patients have by and large adjusted to this new reality.

Housecall with some Old Fashioned Bloodletting

We physicians have had to adjust as well.  Formerly, we took care of our patients exclusively, with rare exceptions when we were out of town.  If you went to the hospital, we were there.  Same day appointment needed?  We squeezed you in.   There was no nurse practitioner to pick up the slack.  While I’m not making a judgment on the mediical merits, physicians of yesteryear were more devoted to their patients and their profession than they were to their own lifestyles, a fact that their families would attest.  Times have changed.

Nowadays, physicians regularly see patients whom we do not know.  Consider that for a moment.  On a regular basis, doctors treat patients whom they have never seen.  While this challenge is obvious from the patient’s perspective, it’s not easy for us either.  In my own practice, this experience usually occurs on the weekends when I am covering my partner's hospitalized patients. This is much more complex than if I were seeing my own patients whom I know well.  Here’s why.
  • I have no personal relationship or rapport with the patient or the family.  If I have a serious recommendation, such as surgery, will I have sufficient credibility?
  • I may be reluctant to aggressively intervene on a Sunday morning, opting instead to tide the patient over until Monday, when my partner who knows the patient will be back on the case.  This phenomenon of a benevolent stall is commonplace when a doctor is temporarily on the case.  
  • Although I may be ‘in charge’ of the patient on the weekend, I am not as knowledgeable of the nuances of the medical situation as would be the doctor of record.  For example, if I palpate a patient’s abdomen on Saturday morning, and it is tender, it may be very difficult to ascertain if it is worse or better, as it was someone else’s hands that were on the belly on Friday.  Additionally, doctors who are active on the case have knowledge of the patient that can never be recorded in the medical record.
When a patient meets me for the first time, he may be wary as I have not yet earned his trust.  I understand this.  Similarly, when I see another doctor’s patient for the first time, it is harder for me as the covering physician.  How could it not be?   I'm not sure that patients reliably recognize this, assuming that the covering doctor can cover it all.

We covering doctors do our best on the weekends, but it’s not ideal.  In a perfect world, every physician who sees a patient would know all.  But, the medical world must operate in an imperfect system and with imperfect professionals.  If patients and physicians both accept this, then our doctor-patient relationships will be more robust.  Let's all keep our expectations in the real world.  

2 comments:

Anonymous said...

the other issue I've encountered (as a patient) is that docs who are covering may disagree with the care my regular doctor provides. This usually happens in the context of the ER (which I avoid like the plague but it happens). They may not provide different care but will throw shade. Oh, you haven't had an echo in over a year. Really? Things like that that make me question my reg doc even if the covering doc is just thinking out loud. It is hard for the patient to sort through such comments. The other issue is that some doctors leave NO ONE covering. All you get is an answering machine message that says it if it is an emerg call 911 or go to the ER.

Michael Kirsch, M.D. said...

@anonymous: Excellent points. Words matter and we all need to be cognizant of how a stray phrase may affect someone, particularly in the medical universe.

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