In almost all organizations, an employee has a supervisor responsible for guiding the employee in doing their job. This requires good communication between the two.

Currently, in medicine, especially during stays in the hospital, there is a similar relationship between physicians: The attending physician recruits the necessary specialist physicians to provide care for the patient and supervises their care. The difference is that this relationship is just for the patient, and the relationship is a less permanent one.

I call such a relationship a” virtual organization.”

In the future, I predict that greater support will be provided for virtual organizations.

Although a virtual organization is less permanent than an employee-supervisor relationship, it could have much more consequences. It could negatively affect a person’s health or even mortality if there is no proper communication between the supervising physician and the other physicians or if the supervising physician has not recruited the right physicians.

An example of a virtual organization that previously existed was one for a recoverable bout of sepsis for my now deceased paraplegic wife. She was confined to bed for a while. And without our knowing it, she developed a pressure ulcer that spread down to her hip resulting in the infection of the hip bone. Pressure ulcers (also called pressure sores) are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin.

Upon entering the hospital, the attending physician recruited an orthopedic surgeon to remove the infection from her hip bone and an osteomyelitis infection specialist to determine the antibiotics to be given to her. See figure 1.

My wife was put on a ventilator in the ICU and given the antibiotic together with a large amount of fluid to raise her blood pressure. After a while, the attending physician diagnosed her with congestive heart failure due to water in her lungs.

I asked the attending physician why he did not assign a cardiologist. The attending physician said he did not think this was necessary.

My wife indicated she wanted to be off the ventilator, and a nurse called me up saying, “Your wife wants to die” — I rightly said she just wants to get off the ventilator.

My wife was taken off the ventilator and transferred to a regular hospital bed, putting her into hospice care. I noticed that she was not being given antibiotics. At the same time, the osteomyelitis infection physician came in to visit. He was not told my wife was taken off antibiotics and restarted them again, possibly saving her life.

My wife also had a hard time breathing and could only whisper. According to the attending physician, this was due to congestive heart failure. The osteomyelitis specialist said that the department next door drains fluid from a person’s lungs.

My wife was taken next door, and they removed a tremendous amount of fluid from her lungs. Thereafter, even after returning home, she had no trouble breathing or speaking. I had read a medical journal article that said that, often, when a patient has severe sepsis, because of the large amount of fluid to raise the patient’s blood pressure, that the patient develops fluid in the lungs independent of a heart problem. Apparently, this was the case. Perhaps, if a cardiologist was assigned, they would have recognized this problem. The journal article also stated that this situation of too much fluid in the lungs could cause a patient’s death, even when it is not due to a heart problem.

So, because the attending physician did not communicate with the osteomyelitis physician about my wife being taken off antibiotics, she could have died. Moreover, because the attending physician did not recruit a cardiologist, my wife unnecessarily suffered from having a hard time breathing and speaking. There was the chance she could have died due to this excess fluid.

Communication between the supervising physician and other physicians, in any case, is essential for good care. But providing an automated capability connected with a virtual organization could help in this communication. The supervising physician could be told of any medical records created for the patient by a supervised physician and vice versa, and messaging between physicians could be supported. For any physician, an associated episode of care could be identified, with an episode of care being a data structure defined in my book A Blueprint for Medicine.

For self-protection, patients and family members should be aware of virtual organizations and support this communication between physicians by communicating with the physicians themselves.

Figure 2 shows another example of a virtual organization in a hospital. It is based upon an example presented in the Great Courses video The Human Body: Why We Fail, How We Heal by Anthony A. Goodman.

A 75-year-old man had a heart attack while driving and ran into a tree. He broke his leg, had head trauma and fractured his ribs resulting in a collapsed lung. A general surgeon was assigned who determined that the leg fracture was the least critical medical condition and recruited three surgeons: a cardiologist, a chest surgeon and a neurosurgeon. As long as the leg was immobilized, an orthopedist was not yet needed. The general surgeon would supervise and determine the order of interventions, including surgeries but would not do surgery himself. This is the usual way a general surgeon works, supervising surgeons, not doing surgery himself or herself.

So far, all these physicians in a virtual organization have been in the same medical organization. I project that in the future, virtual organizations will be needed that include physicians who work in different medical organizations.

Medical care is becoming so complicated that patients may need to go to remote medical organizations to get the proper care.

One reason for this greater complexity is that medicine can now look at disease processes occurring at the cellular level, including the interactions with genes, in addition to looking at the tissue level. This will identify diseases more specifically and result in more tailored diagnoses and treatments.

As a current example of this increase in types of diseases: Whereas breast cancer used to be considered to be a single disease, now it is considered to be many different ones (e.g., estrogen receptor-positive or negative breast cancer, and progesterone receptor-positive or negative breast cancer). One medical center may not be able to diagnose or treat these many new categories of disease. (This process of finding more specialized categories of disease is referred to as personalized medicine).

In addition to these many new categories of disease, some medical procedures may be so complex that only a very few medical organizations may be able to perform them. For example, UCLA can use stem cells to treat some forms of macular degeneration, a complex and risky procedure.

Thus, because of the future greater complexity of medical care, a patient may have to visit a remote medical organization to be treated. Further, the treatment may require follow-up care at the patient’s home medical organization. If the follow-up care itself is complex, the follow-up care may have to be given at a third medical organization. This may involve physicians from a number of medical organizations who need to communicate with each other, with some physicians who supervise the others; this is, in essence, a virtual organization across medical organizations.

Michael R. McGuire is the author of A Blueprint for Medicine.

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