Bioethics Discussion Blog: Tired Doctors: Solution?: Outsourcing In House and Out of House

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Monday, June 19, 2006

Tired Doctors: Solution?: Outsourcing In House and Out of House

The issue seems simple but it really is complex as hinted at by a letter to the editor of the New York Times by a physician Martin J. Blaser, M.D. and published June 16, 2002.
Dr. Blaser wrote in response to an editorial about “Sleep-Deprived Doctors”:

Surely most patients would prefer a fully alert doctor to one who is sleep-deprived. However, consider a different question: Would you prefer a tired doctor who knows you well to one who has never seen you before? The complexity and the stakes involved in this issue are high.

Also, the values we cherish -- including being available to people in need and the ability to take responsibility -- are inculcated in training programs where doctors are taught that ''the buck stops here.'' Will Americans be better off with a group of shift workers who, not fully understanding the natural history of illness, order more tests, and pass care to the next level of specialist? Or with doctors whose schedule is determined by the demands of the clock, not the needs of the patient?


The question of “outsourcing in house” including the use of hospitalists is one medical practice that might need further evaluation. Another,as summarized at the website of Healthcare Financial Management Association today deals with outsourcing out of house, actually to another country, perhaps one where it is daytime while it's night and time to sleep in the U.S.:


Outsourcing Radiology Abroad Eases U.S. Radiologists’ Stress, Night Call

It’s just a matter of time before more specialists rely on outsourced assistance, predicts the Los Angeles Times, which examined the trend of radiologists working in Switzerland, England, France, Australia, and the Middle East making and confirming diagnoses for patients in the U.S. Hospitals are using the outsourcing to relieve stress and night hours for radiologists here; however, there is also the potential for cost savings. Although the contract radiologists abroad are American trained, board certified, and licensed from the state where the images are taken, critics of the outsourcing worry that the practice is damaging quality of care, that lines of accountability are unclear, and that hospitals will be held liable for malpractice committed abroad.


Do you think that “tired doctors” deserve a rest and how best can this be done so that the care of the patient is better served? ..Maurice.

4 Comments:

At Tuesday, June 20, 2006 10:35:00 AM, Anonymous Moof said...

Dr. Bernstein, there has to be a balance achieved somehow between physicians who are exhausted and burned out, and the complete disintegration of continuity in the doctor/patient partnership.

Of course physicians need to be able to rest ... and have free uninterrupted family time ... days off ... etc. ... anything less, is asking too much of people who are, after all, human like the rest of us.

Continuity of care, however, is extremely important. Lack of continuity feeds directly into the demise of our health care system.

While it should be fine to have Radiologist from a different country reading tests and making diagnoses, having the entire care of a patient fall into the hands of a stranger while they're at their sickest, is not.

I've written about my view of hospitalists before, and although the discussion has moderated my view somewhat, I still don't think the direction we're heading in is the answer to our health care problems.

When a patient keeps the same physician for a length of time, the doctor/patient relationship can become one of the most intimate relationships in that patient's life. Of course it's not so for the physician, who sees thousands upon thousands of people in his career, and that's the way things should be. However, the trust rendered to the physician needs to be taken into account.

Imagine nurturing a relationship with a friend, and as long as things are just fine, the friend is there for you. But just as soon as something goes badly wrong, the friend pawns you off on another person, saying: "Don't worry! They have a lot of experience at being friends with people!"

While that's not the best analogy, the feeling of having a trust broken is pretty much the same. The continuity also suffers -- both sensibly, and affectively, and that is a deeper issue.

Rather than outsourcing the care, why can't new physicians temporarily enter the already existing relationship as "helpers," rather than as temporary replacements for the primary physician? This would strengthen health care, give physicians room for their own private space and time, and allow patients to feel as if their "trusted friend" is still at the helm. This would be the feeling they're left with, even though more people are involved in the actual care, and they perhaps may not even see the primary care very often while being treated.

Although some of that is more approach and illusion than actuality, it would still have an impact on continuity in a concrete way.

Outsourcing tests to be read ... fine. Completely outsourcing patient care ... not fine. Collaborating in patient care to ensure that no one has an overload of work, and no one ends up with shoddy care because of a lack of continuity, or a lack of interaction by the physician who knows the patient ... I believe that would work all the way around.

 
At Tuesday, June 20, 2006 11:25:00 AM, Blogger Maurice Bernstein, M.D. said...

Communication is the outstanding issue regarding problems in any "outsourcing" of patient care. Failure to adequately and satifactorily communicate about the patient as a whole, patient history, physical and course of illness, workup and treatment and prognosis between physicians limits the quality of care to be rendered. This goes both ways when a patient is "turned over" to another physician and when the patient returns. Then there is failure of communication between the patient and the new responsible physician. Since the previous doctor-patient relationship and trust cannot be readily and instantly transferred between the patient and the new physician, this can affect how and what is communicated between the two. Even if both physicians are medically competent and the patient is understanding and satisfied with the medical practice of temporary transfer of care, the handicaps to communication can only deminish that care. On that pessimistic note, we must now balance the harms to care of the "tired" doctor. This problem is a problem because it is a human problem. ..Maurice.

 
At Wednesday, June 21, 2006 9:23:00 AM, Blogger Hans G. Engel, M.D. said...

Sleep deprived doctors, outsourcing, long waits and brief visits are the result of a physician shortage in the US.
Greater stress from constantly increasing regulations and "paper work", fear of malpractice suits and lower relative income have decreased the desire to become a physician.
More demand is made on doctors for minor complaints that resolve spontaneously and unneccesary reassurance that happens to be fully covered by insurance.
Today we have no simple answers.

 
At Sunday, November 26, 2006 6:29:00 AM, Blogger Debyyntodd said...

As a recent inpatient and RN for many years I would like to comment on my experience on the recieving end of hospitalists care. I had been a patient of my internal med doctor for many years so imagine my surprise and dismay finding out on the first and worse day of my hospital stay he would not be caring for me. I had developed a case of necrotizing fascaiitis, was febrile, nauseated beyond belief and here was this stranger who knew nothing about me obviously since I had a hysterectomy 10 years ago asking me "when was the date of your last period?" and telling me he would be in charge of my care not my PCP. After a lengthly history (which I am sure I left out a lot due to delirium) and throwing up on his shoes he ended up putting me on a host of meds including insulin which I had never been on or needed wihtout much of an explanation. He seemed like a nice caring person but I can attest to the fact it made my hospital stay very stressful and my care disjointed not having my PCP included in my care. About the over worked PCP's ...here's an idea... how about actually limiting the number of patients in your care?

 

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