Do We Really Need a Village?

Helen's story is commonplace. Sudden onset of shortness of breath in this 82-year-old widow forced a trip to the emergency room. One breathing treatment later Helen felt better, but ongoing weakness and suspicion of a heart attack forced an admission to the intensive care unit, then a regular hospital floor and later transfer to a rehabilitation facility.

Over a seven-day course of treatment Helen was handed from one doctor to the next, accumulating a patchwork team of six doctors who worked sequentially rather than together. Thus, both her blood thinner and antidepressant were never re-started by the rehabilitation doctor because he was given instructions from the hospitalist who was holding the medications upon the advice of the cardiologist, and none of these clinicians ever communicated with Helen's primary care physician who actually knew her best.

Helen's nephew tried his best to speak with each doctor along the way, but without a medical background it was impossible for him to catch the discontinuities in care. It may indeed take a village to provide optimal care for an elderly patient, but this is a village where success depends upon how well medical information is passed from one doctor to the next through verbal communication and medical records that are often long on data and short on narrative. And in this case with six doctors over seven days, such communication may unfold like a game of telephone in which subtle changes and omissions in each successive call render the last story of Helen significantly different from the first. Such a process may significantly increase the risk for medication errors and leave patients and their families without a clear idea of who is actually managing the care.

A 2006 study by the Institute of Medicine emphasized how unfortunately common medication errors are, injuring an estimated 400,000 patients per year and exacting an extra $3.5 billion in medical costs. And yet these errors are largely preventable with better patient education and improved communication and interactions among health care providers.

Electronic prescribing will certainly help decrease the rate of medication errors, but this addresses only one source of such errors and does little to humanize the system. The bottom line is that the fractured medical care provided to Helen is now an intrinsic part of an increasingly diversified health care system. But that doesn't mean patients and their loved ones are powerless to intervene.

My number one suggestion -- especially for older individuals -- is for the patient and/or caregivers to write up a concise and portable profile which lists all medical problems, medications, allergies, and informants and can be carried with them or, if necessary, securely emailed or faxed to a doctor in emergency situations. Include a small narrative about who the person is in order to humanize him or her for the doctor. Remember to update it whenever medications are changed.

For example, details about Helen's recent depression might have prompted her doctors to understand the importance of her antidepressant medication. A description of her interests and activities might have inspired more empathy in her doctors and prompted them to ask about her life and get to know her better, which in turn would have left Helen and her family feeling less confused and more confident in her care.

Such an approach is echoed in a handy fact sheet for preventing medical errors developed by the Agency for Healthcare Research and Quality. These recommendations emphasize the importance of informing your physician about your medications and medical history and asking questions when you don't understand something. For cognitively impaired individuals, these responsibilities extend to caregivers.

Sometimes small but necessary personal facts will enable each doctor to fulfill Sir William Osler's famous maxim, "It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has" -- and its associated data points. This act of actively humanizing our medical care takes effort but is universally appreciated by health care specialists who are well-intentioned but increasingly burdened by a system which both overwhelms one with data while simultaneously demanding rapid decision-making.