In Appreciation of Acute Care and Norman Rockwell

October 20, 2015

The days of acute care are changing, and with it, the doctor’s role is going from classical caretaker to air-traffic controller.

I am coming to the end of 96 hours on-call.  As a primarily outpatient-only family physician, the call is light, although I see patients in clinic throughout the weekend.  I am mentally fatigued.  Over the last four days, I have seen all kinds of interesting and mundane things, and this much acute care compressed into a short period of time reminds me why I went into family medicine.  I love the ability to follow up with the newborn I just discharged from the hospital, the connection I can make seeing one of my own patients acutely for a run-of-the-mill type problem, and the curious patients that make me run to my textbook for a diagnosis or figure out the next step in the treatment plan.

I actually look forward to my on-call days the most, because it gives me a break from the sometimes monotonous wellness and chronic disease visits that make up the rest of my clinical time. On-call visits challenge me to think critically, be wise in choosing the degree of diagnostic work-up necessary, and occasionally allow me to actually cure someone during an office visit. I like being able to express empathy when a patient is just feeling rotten, and I enjoy the appreciation patients usually show for being able to get into an appointment on a weekend or at the last minute.

As medicine changes, the days of acute care seem threatened by telehealth and retail clinics, making me wonder how long I will be able to enjoy an entire afternoon of these kinds of appointments. I suspect that my future practice will have very little acute care and certainly very little straightforward acute care, such as strep throat and rashes, which allow me a mental break in the middle of my clinical day. Instead, I expect that it will look more like complex acute care (chest pain, abdominal pain, neurologic symptoms) and have a heavy dose of preventive health visits and chronic disease management. Instead of looking at a specific medical problem, I will be managing someone’s entire health status by coordinating home visits by a nurse case manager, nurse management of chronic disease by protocol, and referrals to behavioral health or a pharmacist. 

Instead of the Norman Rockwell-esque vision of me, a patient, and a stethoscope, I picture instead the work of an air-traffic controller trying to manage multiple competing inputs while doing technically difficult and risky work.  Just thinking about it makes me tired.

I hope that, despite all the changes in healthcare, I can continue to enjoy seeing patients in acute visits, including the occasional sore throat.