By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient's cultural and gender contexts, will be able to...
Today I worked my last Saturday call shift of my first year of residency on the Family Practice Teaching Service at St Paul's Hospital. And it felt really good. It felt good because I felt like I was getting things done - I was working as a doctor. I got a list of all the patients who were admitted under the service, and I cared for them in full, as a real doctor is expected to do. I scanned patients' medical charts for pertinent information and reviewed any recent and/or relevant investigations and consultation notes. I then clinically assessed patients using history and physical examination skills. I addressed new symptoms or signs of disease that patients developed since they were previously assessed by the physician the day before, racking my brain for possible reasons for these new concerns, and I came up with plans to investigate and hopefully confirm what I thought were the most likely reasons for these problems*, to quantify their consequences, or to follow up with previous concerns as communicated by other members of the health care team. I made referrals to specialists or allied health care professionals when I thought it was indicated, and I called them on the phone if they were already involved in patient care in order to address select issues more urgently if they fell under their purview. For less urgent concerns that specialists were involved in managing, I left notes for them to consider in the patient's chart. I made choices regarding patient management. I then summarised and communicated the information I gathered and the impression I formed with all of the facts available to me in a progress note in the patient's chart, finishing with orders to materialise my plans for treatment. I managed patients across the lifespan, from their early 20s all the way through to the 103 year old who I wrote a blog post about last week and who was still kicking. I received pages from nurses who were concerned about the patients under their care for various reasons, and decided if I could safely give an order over the phone, if instead only reassurance was needed, or if I needed to pay a visit to reassess the patient and gather more facts. Near the end of my day, a code blue indicating cardiac arrest was called for a patient in a nearby room, and being the first doctor at the beside, I asked the nurse next to me to start chest compressions and apparently started to run my first code. The ICU team did arrive only moments later, thank all the good lords, but I did start the process of what ended up resulting in a return of life. I was legit doctoring.
This may not sound as though I was participating in providing continuity of care considering I flew in for one shift this week to cover call for patients not under my care Monday through Friday. In some ways this is true. Or perhaps it instead reflects the fact that continuity of care exists on a continuum, and reflects the reality that the care of patients tend to happen in teams, as it ought to, and so long as information is being effectively communicated, it actually means more eyes, ideas, biases, perspectives, and possible solutions can participate in patient care. There does, however, need to be one most responsible physician who coordinates a given patient's care in order to be accountable to ensuring their needs are being met as much as is humanly practical. I can't wait to be the family physician who is held to this account.
The care of patients in hospital is very special to me in that this team-based care is front and centre. In private clinics, it tends to consist more of a physician-patient dyad, with allied health professionals and specialists recruited for particular concerns. This also works, and the degree of patient illness is also less acute and so tends to warrant less intensive interventions. Team based care requires more work, really, because it also means spending the time communicating information to different parties, and taking the time to consider other opinions and suggestions. But I really do believe this enhances patient care, and that although the degree of interdisciplinary involvement in a hospital is likely not warranted in outpatient care, that there is a balance that can be struck in having outpatient clinics that host an abbreviated interdisciplinary model. This is essentially the same this as The Patient Medical Home as advocated for by the CFPC. I almost certainly see myself working in a family practice office with these values and deliverances. At Three Bridges, the community clinic where I am currently working that serves marginalised populations, there is a host of interdisciplinary members of the care team who also work there and collaborate with the physicians or other professionals, sometimes skipping the need to involve a physician at all. There are psychologists, addictions counselors, nurses that range in skills from LPNs to practitioners, medical lab technicians, social workers, and project managers overseeing advocacy initiatives. And then there are the front-line staff and clinic managers keeping everything functioning. It is incredible work, is certainly enhancing patient care, and provides a strong sense of community that impacts the wellbeing of patients and health care workers beyond that which can happen from a set of orders on a piece of paper.
*Admittedly, there were some things I was unsure about. But I coped. Strategies I used to aid in my management of clinical uncertainty included reviewing my own notes I have collated for different disease presentations, UpToDating how to work up a given lab finding, or using my pharmacopeia to confirm that a medication dose I was going to administer was safe for the patient in front of me. In other words, I used material references for support. I also made use of my team of human resources. I reviewed my plan of action with my attending physician if I had doubts about the balance of harm vs benefit for the patient, as well as the utility of an intervention for a given patient and whether it was a reasonable or unreasonable cost to the health care system. When there was clinical dissonance (aka the story and facts didn't add up), I made like a detective and dug deeper into patients' stories, and I asked patients' family members, nurses and other allied health professionals for their thoughts on the matter. I listened more intently with my stethoscope. I decided if there was a test I could run to provide clarity, or when the issue wasn't urgent, I communicated the uncertainty in my note to the next resident in my position and let the issue declare itself further (or dissipate in insignificance) with a tincture of time. Sometimes a trial of empiric medication with little harm but possibly great benefit was tried, and other times, when medications were possibly but not certainly causing more harm than benefit, a trial of cessation or decreasing the dose was employed. In these grey areas of medicine, of which there are so many, trial-and-error is the standard of care. I believe this is why the dogma of "First do no harm" is ever-relevant today and probably will be as long as physicians exist.