During the initial interviews, many physicians told their narratives as experiences with specific individuals and did not describe their observations as system-level issues. During the analysis, however, it became clear that the common themes reflected system-level characteristics. When the physicians were re-interviewed, there was universal agreement that the structure of the health care system contributes to poor communication by individual care providers and to medical errors. This observation focuses on the challenge of changing individual provider behavior without addressing the system within which the provider works.
We feel that our sample of 8 physicians was sufficient for a key informant analysis. The pool of potential informants was limited by their unique position and the requirement of having a parent with a recent serious illness episode. This physician sample was deliberately and purposefully selected. The stature of the respondents created a potential bias, a “VIP syndrome” for these physicians’ fathers.3 Rather than receiving excessive care, however, some of these patients received suboptimal or even antagonistic care.
As sons and daughters, it is possible that these physicians may be embittered about their fathers’ care, leading them to exaggerate or overstate their observations. The illness of a parent evokes intense emotions, but it also tends to rivet attention to the care being received.7 Because our informants also acted as participant-observers, it is possible that their observations lacked insight into the harm they may have caused by intervening in their fathers’ care. Despite these factors, the themes of advocacy and rescue were common to all of the physicians. The theme of abiding inner discord was strengthened by its enduring nature over time. By confirming these themes through re-interviews, we are confident that they are robust and valid for each individual as well as for the entire sample. Although these physicians’ reports of their experiences should not be considered generalizable to the population at large, they are informed expert opinions that raise serious concerns about how well the health care system is serving patients.
Our results are consistent with the burgeoning demand for improvement in our current health care system. Health care systems could affirm the continued presence of one physician who is in charge of the patient’s care and accountable to the patient and the patient’s family. Payment systems and health plan rules should not force discontinuity across different care settings. Physicians who have a relationship and previous experience with patients should be encouraged to remain involved in their care during hospitalizations. Health care begs to be rebalanced to emphasize the importance of knowing the patient at least as well as the disease process and medical technology.
We also found that these physicians’ experiences had a profound personal impact. The study physicians expressed a sense of being silenced by the system and were grateful for the relief afforded by telling their stories. This suggests that physicians and the systems they work in should create mechanisms for the discussion of troubling patient care events.
The personal experiences of these physicians hold special importance to other physicians, because they highlight the critical roles physicians are expected to play in a superior health care system. Many of the problems identified by these senior family physicians were manifest in physicians’ behaviors. Physicians should be able to express their ambivalence about problematic health care processes and encourage an environment that avoids blaming and promotes improvements. Rather than waiting for system-level change to improve health care, physicians could examine and change their own behaviors and practices.
Acknowledgments
Our paper is dedicated to Mary Lou Green, whose care at the end of her life inspired this study. The authors are indebted to Priscilla Noland and Michelle Perez for their assistance with the manuscript.