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In healthcare, is it better to be centralized or decentralized? Focused or dispersed? Local or regional? Specialized or generalized?

Lately, it seems like we keep changing how we're doing things, but somehow we never seem to get it quite right. Take, for instance, our phones.

Over the years, as I've reported often in this column, one of the major challenges of our large practice has been getting the phones answered. So many phone calls, so many patients, so many providers. Such a wide diversity of the types of calls that keep coming, who needs to pay attention to them, who is assigned to handle each particular issue, and who's covering whom.

Recently our institution decided to pull the phones away from our practice, and have them answered by an off-site centralized call group, highly scripted but not working directly in our electronic health record. In many ways, this feels like it has led to more problems than it has solved. We keep giving them helpful rules, but no one seems to follow them.

In the old days, I had a phone number where my patients could always reach me. And patients knew who was going to be answering the phone, and if she was not there then another familiar voice would be. This person got to know my patients, got to know me, and got to know many, if certainly not all, of my quirks and peculiar practice idiosyncrasies.

They knew when to squeeze patients in before and after practice, working through lunch hour: "Yes, I know the system says they need 30 minutes for a pre-op visit, but we're just going to have to squeeze them in wherever we can, add on a video visit, whatever it takes." But when you move this all off-site, and take away that personal edge, the special relationship of working day-to-day with somebody, we become much more anonymous -- and our patients are no doubt more anonymous to the people answering the phones.

Another example of this is the assignment of roles within certain areas of our practice. Just the other day, I was talking to colleagues at another academic medical center,and they mentioned how each small group of residents, or pod, was assigned their own nurse who takes first call on their patients, and also takes care of their refills, minor health issues, test results, and much of their paperwork.

Wait, what? Each small group of residents gets its own nurse?

At our practice we've dispersed these things, not had the nurses assigned to a specific group of residents, faculty, or even a geographic area of the practice. We decided -- or should I say someone has decided -- somewhere up the line, to disperse the nursing job by roles, with one nurse doing clinical triage, one doing prescription refills, one serving as charge nurse, one getting point-of-care testing, one doing patient education, and so on.

Every morning, there is a staff announcement that tells everybody in the practice who is doing what. But in the heat of the moment, when you're looking for someone to help you out, it's always a pain to try and remember who was assigned to what task and how you are supposed to reach them.

Many years ago, when there was a nurse assigned to a smaller section of the practice, we all got to know each other. The providers knew how the nurse would help, and the nurse would know what we needed, often before we did. And even more importantly, patients got to know the nurses -- "their nurse". They developed strong and meaningful bonds with them, and often listened to their nurse more than they would listen to us.

Another type of work that has been dispersed, with somewhat questionable benefit, has been our group coverage of out-of-practice providers by the nurse practitioner team. It used to be that we had a duo of NPs assigned to each of our geographic practices (Red, Green, Blue, and Purple, each comprised of around eight attendings and 40 residents), helping provide coverage when folks were out of the office, or if they were tied up when urgent issues arose.

But to help cover staffing shortfalls and daily absences among the NPs, we lumped them all together to provide coverage by roles, no longer by specific providers. And once again the personal is lost. An NP who previously knew so many of a smaller group's patients now finds their coverage dispersed, and they are feeling the loss of the personal bonds and connections they had with both providers and patients.

For many types of tasks, it certainly does seem like dispersing a task across among a group of people makes sense -- perhaps certain less personal tasks such as processing referrals, helping out with paperwork, or getting prior authorization for imaging or medications. But when it comes to the things in healthcare that matter -- the human relationships, the prior knowledge of what a patient has been through, how ornery any particular provider can be after a busy day, or at what stage the young doctor-in-training is and what they're ready and able to handle -- it probably benefits us all to move towards the local, the specialized, the non-dispersed model of care, no matter the cost.

If not, I fear we stand to make healthcare less personal, more institutional, more anonymous, less caring.

And we already have more than enough of that to go around.

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