Blog | Monday, August 14, 2017

The doctor's perspective on after hours and weekend medical care


Today's patients must adjust to seeing many physicians, many of whom are strangers. If you need a doctor on the weekend, at night or just need a same-day appointment, you may very well not be seen by your physician. This is not your father's medical practice. The days of the physician house call have vanished. There are many reasons responsible for this evolution (devolution?) in medical care. Patients have by and large adjusted to this new reality.

We physicians have had to adjust as well. Formerly, we took care of our patients exclusively, with rare exceptions when we were out of town. If you went to the hospital, we were there. Same day appointment needed? We squeezed you in. There was no nurse practitioner to pick up the slack. While I'm not making a judgment on the medical merits, physicians of yesteryear were more devoted to their patients and their profession than they were to their own lifestyles, a fact that their families would attest. Times have changed.

Nowadays, physicians regularly see patients whom we do not know. Consider that for a moment. On a regular basis, doctors treat patients whom they have never seen. While this challenge is obvious from the patient's perspective, it's not easy for us either. In my own practice, this experience usually occurs on the weekends when I am covering my partner's hospitalized patients. This is much more complex than if I were seeing my own patients whom I know well. Here's why:
• I have no personal relationship or rapport with the patient or the family. If I have a serious recommendation, such as surgery, will I have sufficient credibility?
• I may be reluctant to aggressively intervene on a Sunday morning, opting instead to tide the patient over until Monday, when my partner who knows the patient will be back on the case. This phenomenon of a benevolent stall is commonplace when a doctor is temporarily on the case.
• Although I may be in charge of the patient on the weekend, I am not as knowledgeable of the nuances of the medical situation as would be the doctor of record. For example, if I palpate a patient's abdomen on Saturday morning, and it is tender, it may be very difficult to ascertain if it is worse or better, as it was someone else's hands that were on the belly on Friday. Additionally, doctors who are active on the case have knowledge of the patient that can never be recorded in the medical record.

When a patient meets me for the first time, he may be wary as I have not yet earned his trust. I understand this. Similarly, when I see another doctor's patient for the first time, it is harder for me as the covering physician. How could it not be? I'm not sure that patients reliably recognize this, assuming that the covering doctor can cover it all.

We covering doctors do our best on the weekends, but it's not ideal. In a perfect world, every physician who sees a patient would know all. But, the medical world must operate in an imperfect system and with imperfect professionals. If patients and physicians both accept this, then our doctor-patient relationships will be more robust. Let's all keep our expectations in the real world.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.