Seriously ill patients should have only one doctor to relate to during their hospitalisation
Photo: Einar Nilsen
Last summer, Norwegian media reported about the cancer patient Jan Skåring, who had met 90 different doctors in the course of six years and four cancer diagnoses (1). Skåring is not the only patient to have been treated by such a mass of doctors, according to Knut Fredrik Thorne, patient ombudsman in Akershus county. New doctors come to see the patients every day. Many patients report that the doctors have not even read their records. The patients must spend a lot of time telling each new doctor what the records contain, and this makes them apprehensive. They feel that the doctor is busy and just rushes onward without caring about them or their condition, Thorne stated (1). Akershus University Hospital accepted the criticism: «Too many doctors have been involved, and we do not wish this situation to persist,» said Pål Wiik, director of one of the hospital’s divisions. He gave the assurance that the hospital is making efforts to ensure that «each patient should have his or her own coordinator» (1).
This issue is not new. In 2011, Per Fugelli, professor of social medicine, warned against what he referred to as «one-time only doctors» (2). During his cancer illness he had met 37 doctors, most of them only once. «None of the consultations lasted for more than six minutes. I don’t want to say a single bad word about any of these doctors, but I would like to utter a bad word about a culture that makes objectification of the patient into a consistent system. The personal doctor has disappeared from Norwegian hospitals,» Fugelli wrote. He claimed that there was little continuity that could help establish a doctor-patient relationship over time. Instead, he had encountered «a succession of one-time only doctors who only offer a distant level of contact. They don’t know you, or your illness, beyond a mere glimpse. You are left in a state of Kafkaesque apprehension. You feel like an alien object in the world.»
The Director of Health and the Minister of Health and Care Services both drew attention to the fact that ever since 2001, patients had been entitled to a so-called named doctor while in hospital (3). The only problem was that this provision was not being adhered to. Then Director of Health, Bjørn-Inge Larsen, argued that the time had come to repeal this provision, while Minister of Health and Care Services Strøm-Erichsen wished to «impress on all health enterprises that seriously ill patients should be provided with this right». She took a serious view of the fact that many hospitals had neglected to do this (5).
In the ensuing debate it was pointed out that most cancer patients do not actually perceive it as a problem to relate to a large number of doctors (6). One patient who had encountered a whole series of doctors wrote that she had not perceived it as problem, nor as a lack of continuity in her treatment (6). August Bakke, head of the surgical clinic at Haukeland University Hospital, pointed out that having many doctors involved may also be a positive factor: «It goes to show how good we are, not how bad. That we have a lot of different skills, which are often required for treatment of cancer,» he stated. Even if the patient does not meet with the same doctor every day and does not receive all information by way of one and the same doctor, this does not mean that there is not one, single person who is responsible. «Of course one might wish to have more frequent contact with the patients, but the most important thing is that they recover,» said the head of clinic, who emphasised that this is actually what happens to most patients (7).
We should readily agree that having to relate to ninety different doctors is unfortunate. It is useless to blame enterprise models, performance-based funding, management by objectives or poor leadership. Not everything amiss in the health services is the system’s fault. There is much that we doctors can change for the better if we only give it sufficient priority. We have great influence over how the work is organised. Continuity in the treatment of patients is key to the doctor-patient relationship – including in hospitals. Here we are largely in a position to put matters right ourselves. «It would be in the patients’ best interest, and it would also leave us stronger in our resistance to poorly conceived measures dictated from above,» Torgeir Bruun Wyller, professor of geriatrics, wrote on the Health Service Action’s email list on 22 July 2013.
In his hospital address in January 2014, Bent Høie, Minister of Health and Care Services, promised that a coordinator will be appointed for patients in need of complex or long-term coordinated services. «Cancer patients should have a permanent doctor who maintains an overview of their treatment and the progression of their disease,» he said (8). According to the cabinet minister this goal will be achieved by 2014. Is there any reason why the patients should believe it this time? That will depend on us doctors keeping our own house in order.