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Letters to the Editor  |   July 2009
Where is the “Captain of the Ship”?
Author Affiliations
  • David Stuart Tabby, DO
    Drexel University College of Medicine, Philadelphia, Pa ♦
    Associate Professor
Article Information
Hypertension/Kidney Disease / Neuromusculoskeletal Disorders / Pain Management/Palliative Care / Physical Medicine and Rehabilitation
Letters to the Editor   |   July 2009
Where is the “Captain of the Ship”?
The Journal of the American Osteopathic Association, July 2009, Vol. 109, 386-387. doi:10.7556/jaoa.2009.109.7.386
The Journal of the American Osteopathic Association, July 2009, Vol. 109, 386-387. doi:10.7556/jaoa.2009.109.7.386
To the Editor:  
I vividly remember a lecture during my first year of osteopathic medical school in which I was taught the concept of the “captain of the ship.” 
It goes like this: the attending physician is the captain of the ship. He or she is ultimately responsible for everything that happens to his or her patient. If the attending physician misdiagnoses the patient's condition, resulting in a bad outcome, that attending physician is responsible. If the wrong medication is given to a patient by a nurse, the attending physician is responsible. If the patient falls out of bed and breaks his or her hip, the attending physician is responsible. 
In March, my father, a retired osteopathic family physician, received a routine outpatient injection of methyl-prednisolone in his right knee for arthritic pain. He said he felt better the next day. By the following day, however, the knee was so swollen and painful that he could not stand. 
Emergency medical services personnel brought my father to the closest emergency department, which is part of a large, financially successful community hospital with several university affiliations in suburban Philadelphia, Pa. Aspiration of the knee produced frank pus. Two arthroscopic lavage procedures were performed. After 3 days, Streptococcus viridans grew from culture of the joint aspirate. 
Conforming to current standard hospital procedures, my father was informed of his discharge by the hospital's “discharge planner” the following morning, and he found himself placed in a nursing home by the afternoon. He needed this placement because he was still unable to stand. While in the nursing home, he became progressively lethargic. Although the staff was instructed not to dispense additional opiate analgesics to him, his level of consciousness failed to improve. 
My father was readmitted to the intensive care unit of the hospital—again through the emergency department—in a condition of acute renal failure with urinary retention. His level of consciousness improved with a single dialysis treatment and Foley catheterization. He soon improved enough to be transferred to the in-house rehabilitation unit. 
While my father was in the rehabilitation unit, I became upset that I could not determine the identity of his attending physician. My father's nurse of the day informed me that my dad was on the “rehab service” and that a different attending physician was in charge each day. I took a deep breath because I knew what this meant. It meant that no one human being was in charge of my father's care—a prescription for disaster. 
My dad's knee pain was relentless. The pain interfered with his ability to participate in his physical therapy sessions, and he became increasingly depressed at his lack of progress. Two trials to remove his Foley catheter failed. His blood urea nitrogen levels continued to fluctuate. 
I was finally able to speak with one of his “attending physicians of the day” by telephone. While we spoke, she had my father's electronic medical record in front of her. She knew his laboratory “numbers,” but she did not know him. She offered resistance when I requested follow-up visits from the hospital's urology and orthopedics services. I had to ask specifically for magnetic resonance imaging for the problematic knee. The physician I spoke with indicated that no one in my father's treatment team believed that anything was out of the ordinary in his course of rehabilitation. 
Growing more and more frustrated, I placed a call to the chief executive officer of the hospital. I wanted him to know that in his hospital, reasonable follow-up procedures were not occurring, and patient problems were not being adequately addressed. His secretary told me that she would see that he got my message. However, I received a call back from a “patient advocacy specialist” (another nonphysician disseminator of information). I thanked her for her involvement but reminded her that I, as a physician, had asked to speak with the CEO. She replied, “Oh, he won't call you back.” 
She was right. He did not call me back. Perhaps he would have returned my call if I had been an attorney. 
This is a travesty of modern medicine! To accommodate the desires of current-day physicians—who are seemingly more interested in their own lifestyles than in caring for their patients—we have created a world of “treatment teams.” Today's physicians want jobs, not careers. They want to get to work at 9:00 am and leave by 5:00 pm. They do not want to work nights or weekends. They want the patient's electronic medical record to serve as a surrogate for actual personal knowledge of the patient and his or her health status. 
There was no physician's name on my father's patient identification bracelet in the hospital. There was no one physician in charge. This type of patient management system has come about, no doubt, as a response to market forces. It is based on the assembly line, in which any one worker is interchangeable with any other worker. 
The “physician employees” of today's healthcare system are able to maximize their personal compensation while minimizing their involvement with patients as human beings who have their own needs and concerns. Although some physicians may think this is a “win-win situation,” it is not. Patient care is suffering profoundly. But perhaps the general public does not yet realize the extent of this problem. Fortunately, many patients can heal without the “benefit” of learned medical intervention. 
I have listened to many sad stories from my own patients who have been admitted to other hospitals at which they—or perhaps their family members—have received shoddy care. I commiserate with them as best I can. 
In 1988, Nancy M.P. King, Larry R. Churchill, and Alan W. Cross recorded similar observations in their book, The Physician as Captain of the Ship: A Critical Reappraisal (Boston, Mass: D Reidel Publishing Co). I believe that, since the publication of that book, this matter has become an even more serious problem. 
Where was my father's “captain of the ship”? If he—as a retired physician with a son and daughter-in-law who are also physicians—received medical care that was this paltry, what happens to the poorly educated patient who does not have a knowledgeable personal advocate? 
Physicians have earned the public's distrust—and they should be ashamed of themselves. The medical system is broken. We need to return the ultimate responsibility for the patient's welfare to the individual physician. 
I know that “treatment teams” will not go away. Nonetheless, we must make the extra effort to ensure that the transfer of critical information from one team to the next is seamless. This effort will require an additional investment of time by physicians. A single dedicated and passionate human being has to be at the helm of a patient's care at all times. 
We all need our “captains of the ship.”