There was a time when your doctor often knew more than your diagnosis.

They knew your history. They knew what had happened the last time you were sick. They may have known your spouse, your children, the medications you had tried before and the things you were afraid of.

And when you became sick enough to go into the hospital, that same physician might have followed you there.

That model of medicine has largely disappeared.

I began nursing in the mid-1980s, and over the decades I watched that change happen.

This isn’t about saying healthcare was better then. Medicine has advanced in extraordinary ways. We can diagnose and treat diseases today that we could barely understand decades ago.

But something else changed along the way.

Continuity became harder to find.

When Your Doctor Followed You to the Hospital

For many patients, particularly those cared for by community physicians, there was once a fairly simple line connecting care outside the hospital with care inside it.

Your primary physician saw you in the office. If you became sick enough to require hospitalization, that physician might admit you, visit you in the hospital and coordinate your care there.

That physician already knew your story.

By the 1990s, that model was becoming increasingly difficult to maintain.

Primary-care practices were busy. Physicians had full days of office appointments while hospitalized patients might be scattered across one or more hospitals.

At the same time, hospital care itself was becoming more complex.

A different model began to emerge.

The Arrival of the Hospitalist

In 1996, the term hospitalist entered the medical literature to describe physicians whose primary professional focus was caring for hospitalized patients.

The idea made sense.

Instead of a community physician leaving a busy office practice to drive to the hospital, another physician would be there, dedicated to caring for hospitalized patients.

Hospitalists could respond to changes quickly, coordinate complicated inpatient care and become experts in navigating an increasingly complex hospital environment.

Hospital medicine grew rapidly.

It filled a real need.

But it also changed something fundamental for patients.

The physician caring for you during one of the most frightening moments of your life might now be someone you had never met before.

And when you left the hospital, your care would be handed back to someone else.

Meanwhile, Primary Care Changed Too

Your primary-care physician didn’t suddenly stop caring.

Their working world changed.

A doctor’s day is no longer simply a series of conversations with patients.

There are appointments, test results, prescription requests, referrals, electronic messages, documentation, insurance requirements, prior authorizations and an electronic medical record that continually demands attention.

Much of that work happens when the patient isn’t even in the room.

So when your physician walks into an examination room already running behind, it may be easy to think:

They don’t have time for me.

Sometimes the truth may be closer to:

They don’t have enough time for anyone.

That doesn’t make a rushed appointment less frustrating.

But it changes the way we understand what is happening.

We Became Very Good at Dividing Care

Modern medicine is filled with expertise.

A cardiologist manages the heart.

A pulmonologist manages the lungs.

A neurologist manages the nervous system.

A gastroenterologist manages the digestive system.

A hospitalist manages the hospitalization.

A primary-care physician tries to keep track of everything outside it.

Each professional may be doing exactly what they are supposed to do.

And still, a patient can feel as though nobody is seeing the whole person.

That is one of the strange contradictions of modern healthcare:

You can have more experts involved in your care than ever before and still feel completely alone in the middle of it.

The Handoff Nobody Sees

Every transition creates another opportunity for information to move from one person to another.

Hospital to primary care.

Primary care to specialist.

Specialist back to primary care.

Emergency department to hospital.

Hospital to rehabilitation.

Rehabilitation back home.

Most of the time, healthcare professionals are trying to make those transitions work.

But the patient experiences something different.

You tell your story again.

Then again.

Then again.

You assume one doctor spoke to another.

You assume everyone can see the same records.

You assume someone knows why a medication was stopped or why another one was started.

Sometimes they do.

Sometimes they don’t.

And suddenly the patient—or the family—is carrying pieces of the story that no single professional seems to have in one place.

There Are People on Both Sides of the Exam Room

It is easy for frustration to become blame.

Patients say doctors don’t listen.

Doctors are trying to care for patients within a system that asks them to see more people, document more information and manage an enormous amount of work outside the examination room.

Neither experience cancels out the other.

A patient who feels unheard is still unheard.

A physician who has too little time is still overwhelmed.

Both things can be true.

Most people who choose medicine don’t begin their careers dreaming about electronic records, insurance authorizations or productivity requirements.

They begin because they want to practice medicine.

They want to diagnose.

They want to treat.

They want to help.

And patients don’t enter an examination room wanting to be difficult.

They enter because something hurts, something has changed, or something has frightened them.

Somewhere between those two people sits an increasingly complicated healthcare system.

Maybe We Need to Understand Each Other Again

We aren’t going back to the healthcare system of the 1980s.

And perhaps we shouldn’t.

Medicine has changed too much, and many of those changes have saved lives.

Hospitalists serve an important purpose. Specialists bring extraordinary expertise. Technology gives healthcare professionals access to information we could once only imagine.

But progress doesn’t mean we shouldn’t acknowledge what may have been lost along the way.

Continuity matters.

Being known matters.

Being heard matters.

And having someone who can step back from all the individual diagnoses and see you still matters.

The answer isn’t to blame doctors.

And it isn’t to tell patients to simply accept rushed, fragmented care.

Maybe the first step is simply understanding what has happened.

Because behind the hurried doctor is a person trying to practice medicine.

And sitting across from that doctor is another person who needs to know that, for however many minutes they have together, they are more than the next appointment.

References

Agency for Healthcare Research and Quality (AHRQ). Patient and Family Engagement in Primary Care: Discussion of Findings.

Wachter RM. The Comprehensivist Model of Care: A Hospitalist’s View. AHRQ Patient Safety Network.

Wachter RM. Reflections: The Hospitalist Movement a Decade Later. Journal of Hospital Medicine.

American Academy of Family Physicians (AAFP). Techniques to Reduce Your EHR Inbox Burden.