by Carol A. Westbrook
In a recent editorial in the New England Journal of Medicine1, Drs. Stavert and Lott used the tem, "The Bystander Effect," to describe a new health care phenomenon, in which multiple physicians particip...
by Carol A. Westbrook
In a recent editorial in the New England Journal of Medicine1, Drs. Stavert and Lott used the tem, "The Bystander Effect," to describe a new health care phenomenon, in which multiple physicians participate in the care of a patient, while none acknowledges primary responsibility for managing it. In their example, a patient was hospitalized with an undiagnosed, complicated illness, and over 40 physicians were involved in his care, yet none stepped forward to take charge.The term "Bystander Effect" was coined after the 1964 stabbing murder of Kitty Genovese in New York City, which was witnessed by 38 people, none of whom intervened or called for help. The term refers to the tendency of people to be less likely to offer help in emergency situations when other people are present. In other words, it's not my problem, someone else can take charge. Stavert and Lott argued that the Bystander Effect is becoming prevalent because of the way our system of hospital care has evolved. But I have noticed it is beginning to appear in the outpatient setting as well, where it is eroding the quality of medical care while increasing its expense. Consider Mr. Miller, a fictional patient referred to me for anemia. I ordered blood tests, referred him for a colonoscopy, and scheduled a return visit in 2 weeks. During those two weeks, he also saw his cardiologist (heart), his orthopedist (joints), his urologist (prostate), his internist (blood pressure), his primary care physician (cholesterol). Mr. Miller is elderly and retired. When I asked him what he does with his leisure time, and he replied, "What free time? My wife and I spend most of our day in the doctor's office." From my perspective, Mr. Miller received the expert attention of 7 highly trained medical specialists, and the best possible medical care in the world. From his perspective, he has to deal with two more doctors, more prescription medications to use up his limited income, and no assurance that any of this will make him feel better or live longer. It is disheartening to see an elderly couple who measure out their days by the number of doctors' visits in a week. It is frustrating for their caregivers, who try their best to attend these multiple clinic visits. And it is dangerous, as multiple physicians may give contradictory recommendations, prescribe medications that interact, and overlook test results ordered by another doctor.Mr. Miller is definitely getting more medical care than he would have received, say, 10 years ago. But is he getting better care? For that matter, is he even getting care?
Think back to a simpler time when a patient had one doctor whom he knew personally and trusted, and who provided him with care, one human being to another. Today it takes many more doctors to provide the same amount of care. There are several reasons that our health care system has evolved in this direction. The major reason is economic. There is a limit to how much Medicare or insurance will pay for a clinic visit, but there is no limit to the number of clinic visits. Thus, the economic imperative tends toward increasing the number of doctor visits rather than the quality of the visits. Today's doctor may have a quota of 15 to 25 patients per day if he wants to keep his job. Consequently, he does not have much time between appointments to make calls or send emails, and has little opportunity to get to know his patients as human beings. Care suffers. Physicians become bystanders. Another force leading to fragmentation is specialization. Treating a relatively healthy patient who has a single problem--such as a sore throat--is straightforward. The patient is examined, boxes are ticked in the electronic chart, and the prescription is electronically sent to the pharmacy. But when a patient has health issues that cross the boundaries of many specialties, such as Mr. Miller, it is easier to reduce him to a collection of unr