The Whole Is Greater Than the Sum in Patient Care


No matter how hard I work or how well I think I'm doing as a family physician, there are still areas where I fail my patients.

Last week, my healthcare organization attempted something quite ambitious. A group of about 12 to 16 clinicians were brought together for a day and a half to define five characteristics of minimally acceptable care for 17 different chronic conditions ranging from atrial fibrillation to osteoporosis. I was skeptical that we'd be able to accomplish this massive undertaking in the time provided but we actually did it; and I think everyone felt confident that the work we did helped to better define the standards of care in a way that will help clinicians provide better care to their patients.

After the event, I tried out a few of our 5-item checklists to see how well they applied to my own patients. I was humbled and surprised to find that I was sometimes missing the mark in even providing minimally acceptable care. I tended to find gaps - a patient with diabetes who wasn't on a statin or a patient with chronic kidney disease who hadn't had a urinalysis in the past year - in medically complex patients, those in whom I was already trying to address multiple conditions during each 20-minute visit. The checklists helped me to briefly refocus on the bigger picture and remember that even if a patient had an A1C over 10, there are other aspects to his care to which I could attend with perhaps greater success. I was also surprised to find a patient that made it through an acute myocardial infarction, a CABG, and visits to me, the cardiothoracic surgeon, and the cardiologist without being put on an important medication.

While it can be frustrating to realize that no matter how hard I work or how well I think I'm doing as a family physician, there are still areas where I fail my patients; I think it is important to ponder why. While there were a few items I did not know about, most of the items were neither surprising nor unfamiliar. I believe that it was the complexity of patients with multiple medical issues combined with the curve balls they sometimes like to throw me during their visits that derailed their care. As their physician, I allowed myself to focus too much on elements of their care rather than the whole picture. As such, important and sometimes relatively easy things to do remained missing.

This is the case in many aspects of physicians' lives - we lose the forest for the trees. We overly focus on certain aspects of our professional or personal lives without realizing that we are neglecting other essential parts. So how can we do better?

Well, much like our five- item checklists, we must first define those essential elements of our lives. For our personal selves, that might include sleep, good nutrition, time with our family, exercise, and pursuit of hobbies. Beyond just identifying those parts, we need to focus not only on the specifics but on the whole. We also need to periodically run the checklist to see what might have become neglected.

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