The patient in intensive care had kidney, liver, and lung failure, plus a rash. Nine specialty groups were called in to consult. During 11 days on the unit, at least 40 doctors were part of the man’s care. But none pinned down a diagnosis.
In a perspective piece in the New England Journal of Medicine this week, two Yale doctors involved in the man’s care cited the case as an example of “the bystander effect” in medicine. Just as strangers who witness a crime may do nothing, willing to dismiss the incident as someone else’s problem, doctors without ownership in a patient’s care may not act, write Drs. Robert Stavert and Jason Lott, residents in dermatology at Yale School of Medicine. They write:
The lack of consensus among his providers was exacerbated by a sheer overgrowth of testing-related data. On average, more than 25 diagnostic laboratory tests and two imaging procedures were performed daily, many of which were, in retrospect, duplicative and unnecessary. Efficacious patient care gave way to diagnostic chaos and incremental delay. None of us were certain what was wrong with him, and therefore each of us continued to wait for someone else to do something.
The case wasn’t unique, they said in an interview. They had seen such an effect before, they said, and friends and colleagues they spoke with said they had experienced similar things at other institutions. Increased specialization among doctors plus new rules limiting how many hours residents can work have led to a greater number of doctors being involved in a single patient’s care, they said, but there has not been of a response to ensure that doctors know each other and have the skills to work as a team.
“Getting everyone together can be challenging if there’s not systems in place that can make that happen,” Stavert said.
Some medical schools have begun investing time in team-building and communications. Brown University’s Alpert Medical School last year introduced a transitional program for students between their second and third years, before they begin working on hospital wards.
The students spend time getting to know the culture of certain specialties, including surgery and pediatrics, and go through training on how to communicate with specialists about patient needs and to ensure proper follow-up.
Dr. Paul George, a family physician and a course leader for the clerkship, said it’s a start, but more such training is needed. He echoed a theme the Yale physicians wrote about: The growth of accountable care organizations, in which doctors are rewarded for collaborating with each other to keep their patients healthy, could help.
“I’m now getting more notes from specialists than ever before,” George said.
Hospital programs aimed at helping doctors get to know one another, such as interdisciplinary grand rounds, also could improve communication, the authors said.
As an example of good coordination among specialists, they cited a recent face transplant procedure at the University of Maryland Medical Center that required more than 150 medical professionals.
It seemed to me that a face transplant—a high-profile, high-stakes procedure often preceded by months of careful planning—is inherently different from a case involving a patient admitted through the emergency department with a mystery illness.
It doesn’t have to be, Stavert and Lott said. Hospitals can create plans for working with those patients too.
“Achieving coordination is difficult,” Lott said. “It behooves all of us to try to find examples where we’re doing a really good job in medicine.”