ti SPECIAL ARTICLE

Responsibility for Patient Care: Where Does the Buck Stop? MARK J. DINUBILE, M.D., Camden, NewJersey

CLINICAL VIGNETTE Primary Attending Physician: How is Mr. Jones do-

ing? Resident Physician: GI is going to see him today. Primary Attending Physician: Whatever they want

to do is fine. Comment: If you are not at least mildly disturbed by

this familiar scene, please read on.

THE CIRCUMSTANCES Collective responsibility for the patient is a funda-

mental concept underlying the practice of medicine at teaching hospitals. The primacy of individual respon- sibility, especially among senior physicians, is often de-emphasized by this team approach. It is universally accepted that legal and moral responsibility for the patient ultimately belongs to the attending physician [l]. However, in the operation of teaching hospitals, housestaff, fellows, and (to a lesser but sometimes sig- nificant degree) consultants actively participate in data gathering and decision-making. The extent to which the attending physician relinquishes control of the patient to these other caregivers often primarily depends on whether the patient is “private” or “ward.” Other variables, such as the reliability and experience of the relevant colleagues, the social mores and political climate of a specific hospital, and eco- nomic motives, also influence this behavior.

THE CHALLENGES Our system of medical practice challenges us with

certain ethical imperatives, which are seldom explicit- ly confronted. Particularly as related to the attending physician, these issues include: (1) the degree to which the attending physician can forfeit the direct care of the patient; (2) the apparent double standard by which an attending physician (in a relative sense) closely supervises the care of some patients, while is only peripherally involved in the care of others; and (3) the financial pressures and other extraneous factors that discourage time-consuming involvement with the patient and promote dispersion of responsibility for the patient.

AFFERENT CARE Certainly, delegation by senior physicians of certain

tasks required for patient care is a practical necessity in contemporary medicine. Such a cooperative effort is

I I From the Unlverslty of Medlclne and Dentistry of New Jersey/Robert Wood Johnson MedIcal School at Camden, and the Division of Infectious Disease, Department of Medicine, Cooper Hospital/University Medical Center, Camden, New Jersey. Requests for reprints should be addressed to Mark

Cooper Hospital/Umverslty Medtcal Center, 3 Cooper Plaza, Camden, New Jersey 08103. Manuscript submltted December 11, 1989. and accepted

commonly misinterpreted as obviating the need for personal verification by the attending physician of critical data upon which management decisions are to be based. In fact, an intrusion by a more senior physi- cian into the realm of data collection is often viewed by subordinates as evidence of mistrust, if not blatantly insulting.

The arguments voiced in support of this strict divi- sion of labor involving the “afferent limb” of patient care usually focus on issues of efficiency and redun- dancy. The principle of diminishing returns is cited as the dominant consideration. Despite these protesta- tions, examples of how an inaccurate or neglected ob- servation by a less experienced subordinate could pro- foundly and negatively influence patient care are easily imagined (innumerable case illustrations avail- able upon request). Errors of this type, with their un- fortunate consequences, occupy much of the agenda of quality assurance programs.

I shudder to recall my inadvertent mistakes as a house officer and fellow. As an attending physician, I routinely uncover important details that have previ- ously been overlooked by multiple observers. Still, crucial observations that have eluded me are detected by other meticulous clinicians, including the much maligned but utterly compulsive medical students (formerly “us”).

Direct involvement in afferent care by attending physicians with the resultant close supervision of less experienced colleagues allows for confirmation of data and re-enforcement of appropriate skills, while errors or discrepancies can be remedied without unnecessary morbidity. The educational process (as well as the pa- tient) is thus well served.

EFFERENT CARE The training of young physicians requires that they

learn to assume responsibility for patients. This con- cept is sometimes loosely translated into “allowing” less senior physicians substantial freedom in decision- making, i.e., autonomy in the “efferent limb” of pa- tient care. Many attending physicians believe that this policy provides adequate supervision for their “ward” cases but reserve these prerogatives for themselves in the care of private patients.

When senior physicians are intimately involved in daily patient management, it is casually assumed that the sense of responsibility felt by housestaff and fel- lows is diminished. It follows then that the learning experience becomes less intense. Such expectations beget self-fulfilling prophecies. If the role model we offer is an attending physician who participates in the care of certain patients only at a distance, we betray the ideals of commitment and obligation we seek to teach. The pedagogic value of example should not be underestimated. In my experience, the understanding that all physicians (from attending to student level)

April 1990 The American Journal of Medicine Volume 88 405

RESPONSIBILITY FOR PATIENT CARE / DINUBILE

TABLEI

Practical Guidelines for Responsible Patient Care

1. The patient always comes first. 2. Don’t trust anybody. 3. When you’re 100% sure, check twice more.

share fully and independently in the responsibilities of patient care creates more careful and attentive doc- tors.

PARALLEL RESPONSIBILITY The philosophy enunciated here embodies the con-

cept of”paralie1 responsibility,” in contrast to the hi- erarchical delegation and diffusion of responsibility in both afferent and efferent patient care that character- izes medical practice in most teaching hospitals. By its nature, this compulsive approach does not permit

double standards in patient care. It discourages formal consultations for marginal indications [2] and pro- motes more direct participation and control by the primary team in the care of their patients. Table I summarizes some practical guidelines derived from these principles.

Despite the current economic forces that reward quantity without regard to quality, our challenge is to preserve the sanctity of the individual physician-indi- vidual patient relationship. Shared responsibility for patient care does not negate or diminish our individual obligation to the patient. The buck always stops with each one of us.

REFERENCES 1. American College of Physicians: American College of Physicians ethics manual. Part I: History; the patlent; other physicians. Ann Intern Med 1989; 111: 245-252. 2. DlNubile MJ: Subspecialty consultations in internal medicine: uses, misuses and abuses. J Gen Intern Med 1988; 3: 589-592.

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