I Care (Coordinate) About You

You don't have insurance, so I call the pharmacy to find out how much your prescriptions will cost, because I know what you can afford. I imagine you arriving at the pharmacy and being told your medicines are too expensive, and the choices you might have to make.

You are homeless and have been living out of your car. You are next in line to get low-income housing, but you become hospitalized with an infection in your foot that has spread to the bone. You need surgery and weeks of intravenous antibiotics. You are going to miss the deadline to sign your lease if you have the surgery when it's currently scheduled. I call the surgeons and make sure it's safe to perform the procedure sooner, then pressure them to reschedule. I know the only chance you have for recovery is housing.

You were on a downward trajectory in the intensive care unit and not eating well. The intern asked what you would most like for lunch. You said a strawberry milkshake, and the intern despaired because they aren't available at the hospital. So I had a diner deliver strawberry milkshakes (one for you and one each for the intern, your nurse, and me, of course). The next strawberry milkshake I had alone a week later, in your honor, the day after you died.

None of these tasks happened at the bedside.

I do a lot of tasks like this these days. I am in my last year of residency. The first year of residency is a lot of face time with patients—interviewing, examining, reexamining, talking, listening, listening some more. In time, skills and efficiency multiply, and the role changes. There is more reading, more thinking, more delving into patients' problems. And more of the behind-the-scenes work we physicians do for patients, which falls under the ambiguous title of “care coordination.” Few patients know that these things are being done in the background all the time, and few know who is doing them.

What is care coordination? It's the nitty gritty, the life stuff, the things that can make or break whether a patient feels taken care of. It's seeing patients' needs and filling them. It's entering orders, talking with nurses, ensuring tests and scans happen, collaborating with consultants, and when working in a hospital, making the next step after hospitalization safe. It's a lot of time on the telephone, a lot of time on hold. A lot of time finding the right person to talk to, or the right form to fill out. It still involves sending faxes and dialing pagers. It's follow-through and multitasking and mental energy.

Many studies have found that physician (and specifically resident) burnout increases as time with patients decreases.¹ Residents spend half their time in front of a computer screen,² decreasing job fulfillment proportionally. Electronic health records are blamed for increased documentation requirements that take physicians away from the bedside, but for the most part, it is necessary and potentially life-saving documentation, because medical care has increased in complexity. There's more to coordinate. It's easy to say it's more fulfilling to be at the bedside. It's easy to get frustrated when there are obstacles. It's easy for residents to feel overwhelmed and build walls against “scutwork.” Buying into burnout might be the new “buying into busy,” a perspective which discounts a lot of very real external factors that promote burnout. But as Avedis Donabedian, MD, said, “Many doctors seek refuge in the allegation that they are good clinicians but the system is wrong, without realizing that they are the key aspect of the system.”³

Be mindful when you are in the midst of coordination, be frank with yourself: this is the job right now, this is my service. While the hold music plays, imagine your patient happy, healthy, at home. But do more than that. Care coordination is about loving people, making things happen, and making things better. It's more than “a spoonful of sugar” because it's not just performing the “job that must be done”—it's creativity in the service of the patient's best experience. Frustration that you are not practicing at the limit of your “physician-ship” can feel selfish when you realize how much you can help. Bring meaning to the day-to-day trials of residency and you can find equanimity.

This doesn't always work. Have I yelled at the bed manager when he told me that a patient with imaging highly suspicious for a new diagnosis of metastatic ovarian cancer was being transferred at 2 am from the emergency department on the campus where the ovarian cancer specialists work to be admitted on the campus where they can't see patients? Yes. Did I yell because I imagined this poor frightened woman with her daughters holding her hand, waiting to talk to someone who could tell them what was wrong? Yes. Was it because I knew that when her diagnosis was confirmed the following day she would need to be transferred back to the other campus, and this back-and-forth might taint the trust she needed to have in her physicians at the beginning of this difficult cancer process? Yes. But then I pulled myself together and talked to the emergency department physicians and made sure she stayed at the right campus and that the oncologists would see her first thing in the morning (also I called the bed manager back to apologize). Some would call this refusing an admission; I say it's care coordination at its most human. This took me 2 hours in the middle of the night. I never met her, and she will never know that I did this. Was it worth it? It's one of my proudest patient care moments.

The most fulfilling times are when I have spent time with patients and got to know them, done something for them and got to see the result. But more often I just have to use my imagination. I walked by your room earlier and heard you coughing. I know all about your pneumonia, and your son in Florida who begs you to come live with him, who is worried that you're depressed, but also understands you're 92 years old and just want to go when God takes you. I don't see your face light up when you get your favorite cup of lemon tea with honey to help with your cough. It's the nurse's aide who brought it to you—I asked her to because I had to finish my notes before work hours are up. I can imagine you closing your eyes and inhaling lemony steam as I ride out into the night on my bicycle, toward home.