'Not Mine Yet': The Problem of Patients Under Nobody's Care

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During a busy shift in the emergency department not long ago, I tried something new: I walked out of the double doors and into the waiting room. For a physician, the waiting room is an uncomfortable place — patients are restless and anxious, some are in pain, none have seen a doctor yet. For the patient, it's obviously worse. So I had planned to do some customer service, to communicate to the crowd that we knew they were waiting and that we were working to get everybody seen as quickly as possible, starting with the sickest.

But when I got back behind the doors again, into the main treatment area, something felt different: I felt an unexpected surge of responsibility for the people in the waiting room.

Of course, as the supervising physician I am responsible for patients in the waiting room and I have always known this. I'm always worried about the sick people sitting out there. But the simple act of putting faces to the names on the list had changed things. These were no longer potential patients — they were real and they were mine. And so I rejiggered my treatment plan for the patients whose care in the ED had already begun, in order to hasten aid for the next person in the waiting room.

This is the problem of the potential patient-in-wait — the faceless patient who is "not mine yet" in the doctor's view, and whose needs are often trumped by those of patients already under the physician's direct care. In part, this bias of possession is to be expected. The virtues of high-quality health care — namely, empathy and personal connections between caregivers and patients — mean that good nurses, doctors and other health-care professionals act as advocates for their patients, often going the extra distance to make sure that Mrs. Jones is comfortable, fed, reassured and cleaned up. But you can imagine that sometimes these activities conflict with the needs of the next patient, with whom a caregiver relationship has yet to be established.

Potential patients exist not only in the ED, but in all departments of the hospital. And their predicament, while partly a byproduct of good ongoing care, is largely due to another attribute of the health-care system: siloed care, or that which is divided by specialty or hospital section. When such specialization limits medical teams from extending care to the general patient in the waiting room, it can lead to mixed-up resource allocation, delays in care and sometimes worse outcomes.

In the hospital, teamwork is essential. But teams usually work within individual fiefdoms — say, a particular floor of a hospital devoted to cardiology. The team that works on this floor is rewarded for, and indeed expected to, take the best possible care of its own patients, and that is usually a good thing. It's common to find on any given hospital unit a trophy or certificate that says something like: "Smith Pavilion Floor 2/Cardiology Service: Highest Patient Satisfaction 2003. Congratulations!"

Now say Mrs. Jones, a cardiology patient who has been admitted to the hospital, is in need of an MRI. It would be convenient, though not necessary, for Mrs. Jones to receive that test during her hospital stay, and it would expedite her treatment plan. The problem is that the MRI machine is backlogged. So Mrs. Jones could stay another eight hours in the hospital or she could vacate her hospital bed. In the latter scenario, the empty bed could be given to another patient — a faceless, potential patient — who is in fact sicker than Mrs. Jones. But what's likely to happen is that the care team will advocate for keeping Mrs. Jones in the hospital so she can get her MRI, and they will be rewarded for helping her, at the expense of other unseen patients in within the system.

So how do we tear down the walls that hinder care within health care systems? First, we could literally do just that: tear down the walls. Take the problem of an overcrowded emergency department. The conventional solution is to build a bigger ER and a larger waiting room. But some innovative emergency departments are instead shrinking or eliminating their waiting rooms altogether. In these ERs, patients are brought immediately into the treatment area regardless of how acute their illness. This solution may seem radical, but it eliminates the problem of the potential patient by placing them directly in doctors' and nurses' lines of sight and into their care; right away, it reduces door-to-doctor time and creates ownership among the staff.

Another option is to implement policies that encourage health providers to claim a stake in the entirety of a patient's care, not just the care delivered on their turf. In theory, bundled payments, in which hospitals are paid a lump sum for the patient's entire episode of care during a hospital stay — as opposed to à la carte for individual treatments or tests — could motivate teams to work across medical disciplines or hospital locations.

More proven are policies that require the measurement and reporting of processes that involve more than one team or silo within a health system. For example, the federal government now publicly compares hospitals based on how quickly they can get certain types of heart attack patients from the front door of the emergency department into the lab for the balloon angioplasty that will restore blood flow to the heart muscle. The best strategy for speeding this process involves a single phone call (sometimes from the ambulance) to mobilize the many hospital teams needed to take care of this potential patient. Here, caregivers must trust the cross-disciplinary team and begin treatment of that patient before they actually meet or evaluate him on their own. Ownership begins with the phone call.

Patients too can seek ownership from their providers. If you are a patient in the hospital and your care is being handled by multiple teams, it would be wise to find out who is responsible for coordinating your care. Push the teams to work together. Sometimes, the most important aspects of your care will be handled by the next set of caregivers — the doctors and nurses who will be inheriting you. If you are in the emergency department waiting for an inpatient bed, ask to meet or speak to the team that will be taking care of you once you move to the new floor — it will establish ownership and accountability. That way, for the new team, you will go from being a potential patient to a real one.

Dr. Meisel is a Robert Wood Johnson Foundation clinical scholar and an emergency physician at the University of Pennsylvania.