Heart Health

Physician Communication

May 9, 2011

Physician Communication

I remember my very first pager vividly, just not fondly. I was a medical student on a surgery rotation at the VA Medical Center and was issued a heavy, bulky device that looked like a cross between a transistor radio and a toaster. It was equipped with a clip that theoretically allowed it to be attached to the waistband of surgical scrubs, an option made impractical by the heft of the device and which led to the risk of inadvertent mooning of bystanders during morning rounds. It was a voice pager, meaning there was no digital read-out, only a squawking speaker that transmitted whatever message was called into the system. Anyone interested in reaching me would simply dial the number and leave a voice message. Within a moment or two the small speaker would emit a piercing screech, followed by a distorted voice punctuated by garbled static. “Please call 555-5555” would come out sounding like the intersection of a goose squawk and fingernails on a blackboard. Of course this system proved to be an irresistible source of amusement for medical students and residents wanting to wake each other in the middle of the night with auditory practical jokes.

That was my first experience with peer-to-peer communication. Since then I’ve graduated through a series of advancing technologies but with only minimal improvement in the level of interaction between professional colleagues.

I think patients have a perception that has been instilled in them from watching medical shows on television. Take House, MD, for example. I don’t usually watch this show but I’ve caught a couple episodes. The typical scenario is this: random patient presents with bizarre symptoms. A team of crack doctors (all youthful and attractive, with conflicted personalities and full of witticisms and pithy dialogue) examines the patient and then convenes to an office to sit around and debate the possibility of various rare diseases. Other specialists are brought in and more discussion ensues. Finally, the group of a half-dozen medical professionals surrounds the bedside to render a decision, only to be proven wrong by a binge-drinking gimpy genius who strikes upon the real culprit based on an obscure rash on the bottom of a foot and an understanding of botanical toxicology (or something like that).

Television programs like this lead us to believe that, when we are ill, a team of dedicated doctors will huddle together and pool their expertise to come up with the best treatment plan possible. This idea is further perpetuated by what patients see at academic facilities. When you are admitted to a teaching hospital you will indeed be visited by a cavalcade of white coats, but the truth about this is that most of the team’s members are doctors in training (medical students, interns, residents) and your care is still directed mainly by one overworked attending physician.

The unfortunate reality is that, with rare exception, we doctors rarely convene huddled meetings to discuss the care of hospitalized patients. While you may have numerous experts consulting on your case they generally communicate their opinions to one another by dictating summaries or jotting notes in the daily chart.

Such a system—where caregivers rarely collude in person to reach a consensus on a plan of treatment—is hardly optimal but is unfortunately the reality of medicine in today’s environment.

When I was a cardiologist in the Air Force I frequently took phone calls from my primary care colleagues to see patients in the hospital. They would summarize the patient’s case and explain their rationale for involving my services. After seeing the patient I’d visit their office to report on my opinion. Anytime we wanted a radiology scan more involved than a regular x-ray we would typically call the radiologist and get their input before ordering the study.

When I left the military and entered private practice in the civilian world I was surprised to learn that the preferred method for requesting a specialist consult is to simply write an order in the chart and have the nurse contact the targeted doctor. To make matters worse, most often there is limited documentation in the chart to explain the logic behind the request for my services. Once I see the patient I frequently have a difficult time reaching the referring doctor by phone and often have to rely on my dictated summary to communicate my recommendations.

The difference between military and civilian practice comes down to money and time. The modern doctor, especially those in primary care, is burdened with both clinical and administrative work to the point that almost all else becomes excluded. In the fictionalized world doctors have the time and resources to confer with colleagues and endlessly belabor every case—in real life such an approach would be impossible so long as the day remains composed of 24 hours.

You would think that modern technology would simplify and streamline communication between doctors, but in my experience this has not been the case. Smart phones allow us to keep up with moment-to-moment sports scores and world events; Facebook keeps us in contact with people we barely knew (and frequently avoided) in high school; Twitter allows us to be voyeurs into the daily lives of our favorite celebrities; and e-mail manages to keep us posted about the latest money-making opportunity out of Nigeria. I have begun incorporating text messaging more into my personal practice as I find that it is easier to reach some of my colleagues with this feature than by phone or in person. E-mail is sometimes helpful. I have previously made my feelings known about communication via the electronic medical record.

But when it comes to discussing patients with other doctors, however, there is unfortunately no app that frees up enough time for the pertinent specialists and primary doctors to discuss the care of each patient in person. I believe the medical profession recognizes this problem (the cardiology group to which I belong frequently discusses and reinforces our policy to attempt verbal communication with primary doctors who refer patients to us) and would like to do better, we just don’t know how to. The patients certainly know that our communication is lacking—I frequently hear patients complain about the mixed messages they get from their various specialists: “I get the feeling that none of my doctors are talking to each other.”

As much as I know that the fictionalized world of television doctors is nothing more than the imaginings of Hollywood screenwriters I’d still love to work in an environment where I can sit for hours with other doctors and debate diagnostic possibilities. Until we reach that level of clinical utopia I’ll just have to settle with being grateful I don’t wear a pager big enough to pull my drawers around my ankles.

  1. Jena

    You mean in the real world, an ER doc doesn't take care of the patient in the ER, operate on them in the OR, do rounds on them in the recovery room, and then see them for their follow-ups in an office? Weird.

  2. Larry

    This is one of the most amazing things that I have seen since I began working in healthcare. When you take a step back and see the nurses, pharmacists, physical therapists and others meeting on each patient on a daily basis without the person controlling the overall care of that patient is is amazing. I look forward to the day that the physicians have the want and the time to work in an open collaborative environment. Great article, very much enjoyed it.

  3. Arie

    For not watching much House, your review was spot on. Much like the number of detective shows with a brilliant, socially-inept protagonist (Psych, The Mentalist, etc.); the sole job of the rest of the cast seems to be to get it wrong so as to highlight how brilliant the hero is.

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