When patients fall between shifts
A neurosurgeon is baffled by a dispute between two of her surgeon colleagues. She explains the scenario:
What would you do? Dr. A covers from 7:00am-5:00pm in hospital. Dr. B is on-call off site 5:00pm-7:00am. Patient presents to the ER with a large subacute subdural hematoma at 4:40pm. Realistically the case will not start until 5:00pm-5:30pm. Dr. A attempts to sign the case off to Dr. B who objects since the patient presented before 5:00pm. The two surgeons argue and higher ups get notified. How would you resolve this conflict? Issues similar to this arise around “shift changes”.
Scores of healthcare professionals posted their thoughts on Figure 1. You can join the discussion here. Here are some excerpts from the continuing conversation.
Many healthcare professionals responded with tough love, disappointed in the way these physicians handled the shift change.
“It’s Dr. A’s case. Also, tell both doctors to grow up, stop bickering about who doesn’t want the honour of saving a life, and start acting like the responsible and caring surgeons they are supposed to be.” Family Medicine Physician “The problem of physicians viewing medical care as “shift work”. Be a doc, Doc. Caring for your patients often extends beyond the end of your day.” Plastic Surgeon “Seriously. It sucks when things happen right at your shift change, but this is not a profession where things are done for your convenience. Probably should have gone into something else if you want nice hours and to just punch out and leave when your time is up. You stay until the job is done, period — a human life demands no less.” EMT “My policy has always been patient first. I have lost friends, wasted concert tickets, canceled reservations, etc. In this field, it goes with the responsibility.” Neurosurgeon
The patient belongs to Doctor A
For those who took a stance, it was obvious to some that the patient belonged to Dr. A, as the patient arrived during his allotted shift.
“He arrived during Dr. A’s shift, so he’s Dr. A’s patient. Also, if handed off to Dr. B, resulting in a perceived delay in treatment, there may be liability issues.” Family Medicine Physician “Patient belongs to Dr. A. All this could have been avoided by setting the ground rules when call schedules are formed. Yes at times inconvenient but it all evens out. That’s what you do to have the benefit of not being on-call 24⁄7. So take care of the patient.” Orthopedic Surgeon
It’s Doctor B’s case
The answer wasn’t so obvious of course. Other medical professionals took sides with the physician on shift.
“Dr. B should do. My Logic: 1. Patient will be ready after 5:00pm = on call. 2. On call surgeon is (presumably) more rested, fresher. 3. Clearly the case will go way past Dr. A’s hours. 4. Be a good colleague! Or maybe a less resentful, agitated surgeon should do it for patient’s sake!” Medical Educator “Dr. B would be fresher in surgery than Dr. A who just finished a 10 hour shift, with the surgery making it a 12+ hour day for him. Having worked in neurosurgery, I realize doctors train to work long shifts and long surgeries. However, as a patient, I’d want someone who was fresh.” Licensed Practical Nurse
A New Perspective
One member of the community shifted everyone’s perspective by thinking of the physicians’ state of health, noting that their behavior could be a sign of burnout.
Very sad that it had to get to that stage. I appreciate the frustration and concern for patient safety which people have raised. I’d just like to add that a senior Doctor should probably check on the wellbeing of Doctors A & B. Sometimes incidents like this can be a sign of burnout. Maybe one of them is not ok. Advanced Clinical Practitioner
As it turns out, she was right. The neurosurgeon who posted the case (and eventually took over the case from both physicians) shares that Dr. A burned out shortly after the episode.
It takes two
Many physicians well accustomed to working with critical care patients agreed that practicing medicine isn’t a one-person job. Colleagues need to work together to determine how to provide optimal care.
“The ICU where I worked had a rule about this issue. Any new case arriving in the last two hour of a shift would be treated by Dr. A at first, and Dr. B would take over when his/her shift started. Of course, there were exceptions. (Dr. A wants to gain experience, Dr. A has seen this patient before and established a doctor/patient relationship, Dr. A already started operation, etc).” Emergency Medicine Physician “Decisions like this are easy when you put the patient first. Dr. B should be informed that there’s a case that will be happening at the beginning of his shift. He comes in to support, or take over (depends on experience, who’s best to perform the operation given Dr. A and Dr. B’s fatigue, how long the surgery will take etc.). there’s no I in TEAM.” Obstetrics and Gynecology Physician
What rules are set in place at your hospital? Read the full discussion on Figure 1 to share your thoughts.