In our health system, who “owns” patients?
When talking with patients – particularly those with multiple, complicated medical issues – it often doesn’t take very long to hear about their increasingly suboptimal and sometimes harrowing interactions with our health care system.
Examples include inpatient experiences in which care is provided by a constantly shifting team consisting of individuals from multiple medical disciplines who focus on only one narrow aspect of their condition, with treatment being implemented without clear coordination or discussion of the goals of care, the benefits and potential harms of different interventions, and the patient’s desires and wishes. In ambulatory settings, patients may be seen by multiple different clinicians within the same primary care practice with variable degrees of communication between them, and are often referred from one consulting specialist or subspecialist to another who focus only on their particular area of expertise, often with little consideration of how all the pieces of their health care puzzle fit together.
These experiences, unfortunately, reflect the movement of health care toward being more “high tech but low touch,” which results in patients often feeling lost and alone as they navigate our complex health care system, perceiving that no one individual involved has either an interest in or understanding of their overall medical picture or commitment to ensuring that their care is comprehensive, individualized, and has continuity.
Although there are certainly many factors driving these changes, I worry that a significant contributor may be that as physicians we are drifting away from the concept of “ownership” of our patients.
What is meant by patient “ownership”?
Although the definition of ownership (the act, state, or right of possessing something) seems highly transactional and even paternalistic, in a medical context it reflects a rich, complex, and multifaceted concept that has served as a foundation on which medical practice has been built over the course of history.
At its core, patient “ownership” implies a commitment by the physician to approach each patient with a sense of personal responsibility for ensuring that their health care outcomes are the best possible for their given circumstances and fully accepting and embracing their role in the care of the patient. Some have boiled the concept down to describing patient “ownership” simply as the practice of “responsibility-based medicine.”
The fundamental importance of this concept can be seen in medical education where developing increasing levels of “ownership” of patients under their care has always been a key metric in assessing trainees for preparation for eventual independent practice. And it is considered a universal value for all physicians and not limited to certain specialties or practice settings such as primary care where the concept of “ownership” may be more intuitive; in fact, it may be even more important for physicians in highly specialized and subspecialized settings where “ownership” of patient care may be less obvious.
So why does it seem that there is less “ownership” of patients these days than in the past?
Some believe that changes in medical training are at least partially responsible, particularly with the shift away from more traditional models of medical education in which a culture of “ownership” was created or at least encouraged through intense immersion in patient care.
With the introduction of duty-hour restrictions, there was concern that shortened work periods and more frequent transfers of responsibility for care to others might erode the development of a sense of “ownership” of patient care and potentially lead to development of a “shift mentality” – the perception that the clock governs a trainee’s interactions with patients rather than their needs. Although this may have had some influence, I don’t detect a significant loss of caring, dedication, commitment, or sense of responsibility toward patients in my younger colleagues who did not train under the old system.
Rather, I suspect that other changes to our health care system have been more powerful drivers of this apparent decline of patient “ownership.” As it is not reasonable, feasible, or healthy for a single physician to attempt to provide direct 24-hour, 7 day-a-week care for patients, our systems have evolved toward shared models of patient care that may make lines of responsibility and accountability for health outcomes less clear.
Technological advancements requiring increased input of those with very specialized knowledge also contribute to diffusion of care across multiple clinicians who may see themselves as appropriately addressing only one aspect of a patient’s care within the context of their overall health care experience. And as certain care settings have become more specialized and focused, such as emergency departments and hospital-based services, medicine has become increasingly compartmentalized and fragmented. Add on increasing time pressures that rob of us of the ability to meaningfully interact with patients, new technologies that interfere with the patient encounter, and burdensome administrative requirements, it is no wonder that none of us feels as though we are in a position to “own” the care of an individual patient. And you can just imagine how this feels to them.
It is imperative to the future of medicine that as physicians we reclaim and recapture this fundamental concept of “owning” the care of the patients we encounter in our daily practice. We can do this by constantly reminding ourselves that each of us is personally responsible for the comprehensive, individualized, and personalized care of each patient, regardless of how large or small our particular role may be in the process.
When we do this, medicine’s culture of “ownership” of patient care provides a distinguishing feature and form of natural leadership in a health care system where responsibility and accountability may be more diffuse and less clear, and our “ownership” as physicians can serve to effectively counteract the increasing compartmentalization and fragmentation of care.
Accepting personal responsibility for the health outcomes of each of our patients not only refocuses the patient as being central to what we do, but also reflects the core tenet that as physicians we are committed to acting in the best interests of our patients and affirms the healing bond we seek to create with those under our care.
Philip A. Masters is vice-president, Membership and International Programs, American College of Physicians. His statements do not necessarily reflect official policies of ACP.
