Care Dis-integration

The May 3rd edition of the New England Journal of Medicine brings us a powerful story. It is a tale of a patient, named Kenneth, written by his physician brother.

Central to the story is a delay in diagnosis, brought on by unfamiliarity with the patient as a whole person, biases against those with mental illness, presumptions and other errors familiar to those of us with an inside view of what can go wrong. The healthcare system allows these to occur through its “dis-integration.” From the story:

Rosenbaum highlights the larger problem: “Care integration is an attitude.” But this “attitude problem” affects countless U.S. patients, not just those with mental illness (or severe physical disabilities, like quadriplegia).Whose attitude, then, needs adjustment? Many doctors and nurses seethe about the profit-driven dis-integration of our health care “market” yet insist they can’t fix this mess themselves. Kenneth, no stranger to cognitive dissonance, said, Well, if they can’t fix it, who the hell can? This question becomes more urgent as our health care system’s balkanization becomes increasingly “normalized.”

I have just seen this up close. A friend of mine has a terminal illness. While he has long been well-served by his family physician, the onset of the illness brought specialty care, extensive and repeated imaging, hospitalizations, a rehabilitation facility, and no more contact with his physician. It also brought delayed diagnoses which seemed avoidable had he been seen regularly by someone who knew his story and his usual condition.

Wasn’t such familiarity what we always had hoped would come from the “specialty” of family medicine? And that years of familiarity would lead to an understanding no stranger could have? Such an understanding would give us what we longed for in medicine, such as more efficiency, avoidance of excessive and intrusive testing, smoother transitions of care, more acute perception of changes (and quicker diagnoses), and better advice.

Increasingly, however, the family physician of today can no longer fulfill the promise of the profession from decades past. Financial constraints keep him in the clinic exam room, efficiently churning through patients within a narrowing scope of practice— no longer on the wards, or in the nursing home, or performing obstetrics, or even seeing children under two. Unable to venture out because time (equals money) would be lost, he is no longer involved in the care of his patients when they need something beyond his clinic. And it is in those intense moments that he is needed the most.

I would like to have a simple answer. Kenneth’s question stings: “Well, if they can’t fix it, who the hell can?” The financial pressures are enormous, however. Costs are up for countless reasons, and to keep the money flowing, a physician becomes the engine that must keep running… inside the engine room that is the modern day clinic.

Perhaps nothing short of a major disassembling of our medical system will change that. Such change may only come from catastrophe; even then any rebuilding would take a level of insight and courage…and preparation…that are unlikely to appear in future leadership under modern pressures. If we’re ever to move toward a dream of “care integration,” however, we’ll have to start somewhere– with understanding where we are, how we got here, and where we ought to go.

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