On a United States submarine, the officer of the watch hands over responsibility at the end of a shift by asking his replacement, “Do you have the conn*?” And the relieving officer replies, “I have the conn.”1

This exchange ensures there is no doubt at all that responsibility has changed hands and no doubt where the responsibility for the submarine now lies. A recent experience has made me realise that we in medicine could learn something from this protocol.

My patient was suffering from a life-threatening illness and, after my initial referral to the specialist of my choice, he was jointly managed in hospital by three senior clinicians. After a while, although still far from fully recovered, it was appropriate to discharge him home to the care of his family and general practitioner, but with frequent specialist reviews by all three attending clinicians.

This is where the potential problems arose. Neither the patient nor the GP had a clear idea of who was in fact in charge of the patient’s management after leaving hospital. And while the GP was advised by his colleagues as to what had happened, that advice often failed to arrive for several days because of secretarial delays and the vagaries of Australia Post.

The lines of responsibility were not clearly defined. Who was responsible for arranging and reviewing any further postdischarge investigations? What ongoing surveillance was necessary, and upon whose instigation? There was a real chance that gaps would appear in this patient’s care, with each of the four people involved in his management believing one of the others had dealt with any particular aspect.

In fact, this is what happened, and it was left to the patient to return to me, more by chance than direction, and a serious relapse in his condition was identified. (In fact, I don’t think that the relapse could have been identified any sooner, but the potential for a delayed diagnosis was there.)

The patient, too, had nothing but praise for each of the doctors involved, but commented, “You don’t seem to function as a team, but as loosely connected individuals”.

Each patient we encounter is different, and it’s not possible to suggest hard and fast guidelines that should be applied to every patient. But somebody has to be in charge of the whole patient, rather than his or her constituent bits and organs. That obligation must be made clear when one clinician feels it appropriate to transfer that responsibility to another. This experience has reminded me of the potential for serious mistakes to occur when talented and skilled colleagues fail to work as a cohesive team.

And, in my view, the biggest single error is failing to identify “who has the con”.

* Con, (US) conn: direct steering of ship [The Australian Concise Oxford Dictionary].