What's the next song you're conducting?
One hundred years ago, George Gershwin put pen to paper and composed the instant American classic “Rhapsody in Blue.” The story is much more interesting than that, as he was surprised to read in the newspaper that he was going to be part of an upcoming concert he had already turned down! Having just five weeks to come up with something, he got a vision for the song during a train ride to Boston.1 Shortly after, this jazzy concerto debuted to acclaim and has been captivating audiences ever since.
“Rhapsody in Blue” has been my favorite song since I was a kid — weird considering my favorite band is The Rolling Stones. But something about it mesmerizes me. You can imagine how happy I was when I went to a recent performance of “Rhapsody” by the Cleveland Orchestra. (If you get a chance to visit historic Severance Music Center, do it. You won't be disappointed.)
Since the concert, I've been thinking about how family physicians are like orchestra conductors. Think of an orchestra without the conductor; each musician, while highly talented, would be on stage playing their music completely out of rhythm with the other musicians. The result would be a hodgepodge of sounds akin to a city full of random dogs barking and horns honking. Then the conductor steps on stage and leads the orchestra, balancing out their skills and guiding them in their artistry — all for the goal of producing something harmonious.
That's what we do in family medicine. We coordinate the activities of many health care professionals, all for the goal of delivering better patient care. And it works. The more primary care that is available, the better the outcomes.2 And when primary care is delivered by physician-led teams, it's the equivalent of a beautifully tuned orchestra led by a skilled conductor.
This reminds me of a recent patient. “Bob” (not his real name) is an 89-year-old male with metastatic cancer who has been in and out of the hospital for months, most recently for aspiration pneumonia and diabetic ketoacidosis. He was discharged to inpatient rehab, where he spent two weeks trying to get stronger. Along the way, two things happened that would require a team to manage. First, he was made NPO (nothing by mouth) and had a percutaneous endoscopic gastrostomy tube placed. Keep in mind he has spent 89 years swallowing without difficulty, and now he's expected to get all nutrition via tube feeds. As a diabetic on insulin. And on chemo. For stage IV cancer. And with questionable benefits to enteral feeding.3 Second, he was discharged over a weekend without any prior notification to me or my team. So, Monday morning arrives, and I'm welcomed with a flurry of messages from the patient: Can I have ice chips? Some of the pills they gave me won't go down the tube. What do I do? How much insulin should I take, and when?
This was the ambulatory equivalent of a “code blue.” I activated everyone to help. My medical assistant called the patient to make sure our medication list matched what he was actually taking. The scheduler got him an appointment with me later in the week. The RN care manager arranged for home care. A dietitian helped us with tube feed types and amounts. And a pharmacist helped us figure out which meds could go down the tube and which meds needed to be changed.
This patient was walking the knife's edge after discharge, and I had several moments when I thought to myself, “I can't do all this. I'm going to send him back to the hospital.” But that's the point. I don't have to do all this. I'm the conductor. I've got a stage full of musicians expertly playing their instruments.
That was all a month ago. Since then, my patient has been doing well and hasn't been readmitted. In fact, I'm seeing him in the office tomorrow. The next “song” I'll be conducting is helping him manage all his chronic conditions as he heads south for the winter. But I've got a bunch of musicians around me, and I'm confident the music we'll make will be a chart-topper.
