Meeting Needs In The Hospital: Who Is In Charge?

By Mark G. Kris, MD

Hello. It's Mark Kris, from Memorial Sloan Kettering. Being an academic physician, I spend a large amount of time on airplanes. One thing I've noticed and which has comforted me over the years is that, as the plane is getting ready to take off, when you look out the window, you see the pilot walking around and inspecting the plane.

I take a lot of comfort in that — not that the pilot can fix anything that's out of whack, but that the pilot, who literally has our lives in his hands, takes personal responsibility to make sure, to his understanding and satisfaction, that that plane is intact and ready to take off. I really like the idea that he is in charge and sees himself as being in charge. I say "he," but obviously, in 2024, it may be a she as well.

There was a very provocative article that was startling and shocking to me. This article was written by Janet Gilsdorf, and it's about an experience of Dr Gilsdorf in an airplane, sitting next to a retired military man who just lost his wife to cancer. The title of the article is “ No One in Charge.”

She reports how this career military officer always lived in an organization that had a hierarchy. No matter what, at least in the military and in his experience, there was a person in charge and you knew who was in charge. What hit him almost as hard as his wife's death is that in the 6 weeks of her illness, he never had contact with the person in charge and it wasn't clear who was in charge.

I think all of us who are in this situation see how this could happen. We've had a huge change in how people are treated in the hospital. For most of us, hospitalists do the heavy lifting. Advanced practice practitioners, nurses, nurse practitioners, and physician assistants do it as well. They're very specialized and they do a good job. One part of their job, though, and one attraction of the job, improving the decency of their lifestyle, is that it is finite times. There's more shifting of personnel.

The other thing that's happened over time is that there has been a rethinking of the whole idea of medical hierarchy. People have tried to empower folks at every— I think the term Dr Gilsdorf used was "tier of care." They've empowered them more and it's less clear who is in charge.

The unintended consequence here of these changes in process is that it is frankly much better for doctors; again, individual specialists get treated with more respect. However, it's not better for patients. In the switching of personnel and the lack of a clear hierarchy, people don't know who's in charge, and at least for this patient that Dr Gilsdorf talked about, it was absolutely devastating for him.

Other things that have happened from a practical standpoint include attending physicians as not really part of the care team now. As I said, you have advanced practice practitioners and you have hospitalists, and they are in charge day-to-day while the actual physician who has managed the patient is not physically there and is not necessarily the head of that care team.

Please remember that in modern oncology, most people are cared for outside a hospital. I would guess it's more than 95% of the time in the healthcare system that they're not in the hospital. They look to the attending doctor to be in charge of them.

The other problem is that, when they're in the hospital, it's a time of crisis. They're at their most vulnerable, and their families are at their most vulnerable moments with the attending doctor who has cared for them for years and has a relationship with them. The people in the hospital work very hard and they're very specialized, but they don't have a relationship with that patient. Patients have, over time, an understanding with their attending doctors.

What are we going to do about this? It's not an easy solution. I can offer a couple of thoughts. Number one, just realize that this is happening. I mean, it just kind of happened. I don't think anybody planned for this, and in many ways it's an unintended consequence of how our processes of care have changed.

The other important thing is that when you have somebody who has one of these devastating illnesses — again, the case described in the paper was a 6-week course from diagnosis to death, and I assume that the person was in the hospital the entire time — you need to be very careful as the doctor in charge to make yourself available. Frankly, you don't have second chances. You have to take every chance to meet with the patient, to meet with the family, and try your best to guide care.

The other thought is about consultation nowadays. We used to have a rule at our institution that only an attending physician, except in an emergency, could call a consultation. The advantages of that are that consultants were called only when the attending doctor thought they were needed, and they reported to that attending doctor. The attending processed the information and then hopefully relayed it to the patient and the rest of the care team.

We need to rethink that. Unfortunately, for most consultants, their metric is to do the consultation, do it completely, and report it to the chart, not necessarily to a human being who's in charge of the case. We need to rethink how the results of consultations get reported, and we need to think about reporting it to the person more than to the chart.

The last thing is that this is a great opportunity for telemedicine. I understand how an attending physician who has a very busy practice — and frankly, that's where the majority of the patients are — is not physically in the place where the person is when they're being hospitalized. What about using telecommunication for those situations where, at the very least, there can be contact? The patients, in my experience, have really appreciated even telephone contact, let alone a video.

I thank Dr Gilsdorf for reminding us how we can do a much better job of meeting patients’ and families’ needs while they're in the hospital. It's hard. We don't have a clear path forward, but we really have to try to do a better job.

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