Pick Up the Phone Save

In the beginning, we were given beepers and integrated into teams of physicians. We followed and learned from our interactions with peers, mentors, and experts about how to care for patients. Patient care resulted from the collaboration of many. The more complex the patient and problem, the more frequent and critical the interchanges, research and attention to detail.

Was residency the glory days of communication and integrated care?

Fast forward 30 or 40 years, and most of us care for patients in a vacuum. Most patient care occurs without knowledge or detail of what the PCP, nephrologist or orthopedist did before your visit. This may be a non-issue if you work in an academic center, teaching hospital or are part of a “medical team”. While infopenia doesn’t slow down most practitioners, it is a grave concern that seems inappropriate in this new electronic age of medicine. Maybe my metropolitan practice may not be norm, but it’s still shocking to me that I see patients and frequently have:

• No prior notes, physician records or hospital discharge summaries;
• No clear written or verbal reason for consultation;
• No access to labs, imaging results or biopsy findings; and
• Limited patient recall on past medical history or medications.

It is generally assumed that most patient referrals to a rheumatologist are to “rule-out” a rheumatologic diagnosis that underlies the patients complaints or lab results. I’m a firm believer in the necessity of my own independent history, exam and acumen to arrive at the correct diagnosis and plan. Hence, the infopenia I refer to is not for diagnosis and decision-making as much as it is needed to avoid patient confusion, misdiagnosis or unnecessary testing.

There are many challenges in patient care. Time demands, resource limitations, and healthcare delivery systems stretched beyond reason will often detract from optimal patient care. The consequence of infopenia is the disconcerting and widening gap in peer-to-peer physician communication. This leads to disconnected care, compromises in patient safety, patient dissatisfaction, assumed responsibilities, and duplicitous and unnecessary efforts or investigations.

The ramifications of poor communications between physicians are large. Miscommunication accounts for 60-80% of all serious medical errors. Denson et al showed significantly higher mortality rates were seen when inpatients were “handed off” from one resident team to another (Am J Med.2015 Apr 8. pii: S0002-9343(15)00279-X. doi: 10.1016/j.amjmed.2015.03.023. [Epub ahead of print]). A recent NY Times blog writes about the poor care and injustice that accompanies noncommunication (http://well.blogs.nytimes.com/2015/06/18/when-doctors-dont-talk-to-doctors/?smid=pl-share&_r=0). A review by radiologists showed the legal malpractice payouts were 2-15 times higher when malpractice payments were based on physician miscommunication.

It used to be standard for physicians to dictate lengthy and explicit communiques to other doctors to establish diagnoses, common understanding or unified plan of care. Nowadays, referral letters and information sharing are scarce and have been replaced by lengthy, unrevealing EMR reprints or patient print-outs from EMR patient portals. For nearly 20 years, my policy has been to make the patient the expert of themselves by providing them with copious copies of the visit note, labs, medication lists and patient instructions. This coupled with the directive that patients must be the vector and share this important information with their PCP and other consultants.

Yet my current efforts to share information are not enough. I don’t have the time or resources to write peer-to-peer letters. I don’t have the staff support to fax or mail all my notes to everyone in the loop. My EMR is not connected to your EMR and won’t be for at least a decade. Clearly, I have to do more such that I don’t become part of this communication morass.

What I intend do is the following:

1. Promote myself. Let my peers know what I do, what/who I want to see, and how they can best use my services and expertise;
2. Align with Core Providers. As a small group practitioner, it’s easier for me to align myself with few subspecialists and a core of primary care providers who I can effectively share info with and whom I can voice the expectation of a reciprocal effort;
3. Make Patients Carry Notes. Continue to make the patient his/her own expert; instruct them on how to make and maintain their own chart and how and who they need to share my medical notes with;
4. Use Technology Wisely. Install a network direct fax from my computer to PCPs or collaborating physicians;
5. Use the Smartphone. Nearly 90% of physicians have smart phones capable of texting, taking 10+ megapixel photos and transmitting X-rays, documents, PDFs, etc. Nearly 60% of physicians currently use their personal phones to text each other patient information over insecure channels. Although the benefits of efficiency seem to outweigh privacy concerns, physicians need to be vigilant in protecting patient privacy when using smartphones to consult or communicate with peers. In our practice, we can send text messages to an anxious PCP about our consultation, or refer an urgent consult to the hand specialist or take a non-identifying rash photo and get a spot differential diagnosis or instructions from the dermatologist.
6. Pick Up the Phone. It takes two minutes to call the referring doctor or the much needed liver consult to deliver a clear and concise message about your patient. A small effort can go a long way in establishing better communication between doctors for better care of the patient.