It was the early 1980's, budding minds eagerly awaited their clinical years in medicine after two grueling years pouring over books, workshops and cadavers. Gone were the fumes of formaldehyde replaced instead with the pungent smell of penicillin-infused carpets where nurses had primed IV lines. Teams of residents, medical students, and the omnipotent attending rounded from room to room - everyone knew who was in charge.
But back then in academic medical centers, there was an interesting twist: residents wrote all the orders on their patients. It was part of their training, to be sure, but also a critical requirement for proper patient care and communication. "Too many cooks can spoil the broth," we were told when it came to discussing complicated care plans with patients. Senior resident and attending worked together much as a commanding officer and executive officer do on board ship, so all consultation recommendations were either agreed to or rejected by these ultimate arbiters and coordinators of care.
That was then.
Now fast forward thirty years in our new era of dispersement of information, location, and personnel: the era of the electronic medical record.
Today, care can be rendered anywhere, my anyone. Increasingly we've seen the erosion of the "primary care giver" and the exploitation of a strange new concept: a "medical home" or "medical team" model. Who is in charge at any one time or episode of care is uncertain. In fact, the term "consultation" has vanished from our lexicon of billing codes in favor of a more ubiquitous designation of "level of care" and with it, any semblance of understanding of who's recommending care and who's delivering it. Increasingly, if a specialist feels strongly that an order should be performed on a patient, he is expected to write the electronic order rather than recommending it be performed. With that move, all other care-givers are out of the decision loop and instead, mere information consolidators.
The end result?
A diffusion of responsibility.
Suddenly no one is responsible, yet thanks to the wonders and permanence of the electronic record, everyone's responsible.
Many argue that since two heads are better than one, then many heads must be better than two.
But for a moment, imagine the potential disasters what could happen if the Navy ran their ships that way.