When physicians don’t communicate about their patients

One of the gripes that patients have about the medical profession is that we physicians don’t communicate sufficiently about our patients. In my view, this criticism is spot on.

Patients we see in the office often have several physicians participating in their care. The level of communication among us is variable. While electronic medical records (EMR) has the potential to facilitate communication between physicians’ offices and hospitals, the promise has not yet been realized. The physicians in our community, for example, all have different EMR systems which simply can’t talk to each other. We can access hospital data banks from our office, but this is cumbersome and burns up time. Ideally, there should be a universal system, an Esperanto approach where all of us utilize the same EMR language.

On the day I wrote this post, I participated in a direct conversation with the treating physician at the hospital bedside which vexed me. This scenario would seem to be ideal from the patient’s perspective. At the bedside were the attending physician, the gastroenterologist and the anesthesiologist who were conferring about the next appropriate diagnostic step in a patient who had experienced upper gastrointestinal (UGI) bleeding.

I was asked to evaluate this patient with UGI bleeding and to arrange an expeditious endoscopy to examine the esophagus and stomach region in order to identify a bleeding source. Hours prior to seeing the patient, I scheduled the procedure that I knew would be needed, a short cut that every gastroenterologist will do in order to be efficient. As the patient had other medical conditions, I requested that the sedation be administered by an anesthesiologist, rather than by me, to provide greater safety to the patient.

I arrived and became acquainted with the medical particulars. I agreed with the diagnosis of UGI bleeding and also that an endoscopy was the next logical step in this patient’s care. These observations are not sufficient, however, to proceed with the examination. There are other criteria that must be considered.

  • Does the procedure need to be done now?
  • Do the risks justify performing the procedure?
  • Has the patient provided informed consent for the procedure?

After I arrived on the scene, the anesthesiologist approached me and advised me that the anesthesia risks were extraordinarily high. He was concerned that performing the case could have a disastrous outcome. My reaction to his frank assessment? Thank you! The decision then fell to me to decide on whether to proceed. For me, this was an easy call. The patient did not need an endoscopy at that moment to save his life, the only reason that would justify subjecting him to the prohibitive risks of the procedure.

Before discussing this decision with the family, who were awaiting an endoscopy, I summoned the attending hospitalist to relate to him our revised plan. In my view, when an anesthesiologist and the gastroenterologist advise an attending doctor that it would be unsafe to proceed with a planned procedure, the response should be, “thank you!”

But, it wasn’t. This physician wanted the test and seemed irritated that the set diagnostic plans had been set aside. He wanted a diagnosis, and we declined to proceed after concluding that the risks exceeded the benefits. I was as comfortable with this medical decision as I have been with any other decision I had made in my career. On other cases, when a consultant advises me against a planned course of action for safety reasons, I am so grateful that a patient has been spared from danger.

We got to the right answer here, but had to set aside an unforeseen obstacle to get there. Communication means listening to another point of view and being able to change your mind. As a doctor, when it’s my finger is on the trigger, I call the shots.  I this case, a doctor misfired.

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.

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  • RICARD DONAHUE

    Nothing erodes confidence as much as when i speak to physician A about the findings of physician B and he has no clue about what i am speaking to. If you think Physicians have a protocol about communicating about patients you may be wrong.

    Here’s some advice i got that has a ring of truth; Secure yourself with a young doctor and an older lawyer. You have a better chance with a young doctor that should be up to date on medical treatments and an older attorney who has the experience of the laws behind him.

    • MKirschMD

      Richard, wouldn’t you also desire an older physician who would have decades of experience? Do you value current medical knowledge over this?

      • Suzi Q 38

        Doctors even within the same teaching hospital rarely contact or call each other about the patient…me. This was the case at the cancer teaching hospital.
        I was frustrated one day and wrote a summary to my first doctor at the facility. I then wrote in the letter a question: “What is my next step?” I thought that he would consider it a wake-up call and call me, or contact the other doctors for a phone meeting.
        Instead, he was very offended and did not answer my letter and did nothing.
        To make a long story short, my health declined considerably, and I was very upset, to say the least.
        I ended up getting a nurse navigator to make sure that the remainder of my stay at that hospital was O.K.
        She ended sending a letter of concern about me to that doctor. The other doctors were surprised at what happened to me.
        She also made sure the rest of my appointments went more smoothly.

        Older/VS younger?? Sometimes yes, sometimes no.
        I can only talk about my doctors.
        My older doctors say what they think, then they want to know what you think or what you feel. They tend to spend a little more time with me, maybe 5 or 10 minutes more.

        I got a really good younger surgeon at the new teaching hospital ask me a lot of good questions a couple of months ago. He actually looked at me while he talked to me and waited for me to answer.
        Sometimes, doctors like to answer for me…. guess what I am feeling rather than wait for me to say what I am feeling.
        He had a vulnerability to him. He said: “I know you need surgery because of the blockage, but I want to know why first.
        I am going to have you see an internal medicine doctor next, and then I will also talk to the neuroradiologist after your MRI.”
        “If we are all in agreement, we will schedule your surgery.”

        This surgeon was about 36 or 38, I think…maybe 40. He had completed a fellowship in neurosurgery at Johns Hopkins, so you can tell me how old he is.

        I liked that. I was given the phone number of the nurse practitioner for the neurosurgeon. I was given the email numbers of both the M.S. neurologist and the fellow that was working with him. I found out the email adress of the neuroradiologist, and I emailed him to remind him to contact the surgeon with a few questions about the radiology report that I had, as OPLL is quite rare.

        The communication with the doctors at the neuro teaching hospital was fairly good. I realize that I helped push that along a bit.
        Now that I have experienced problems, I assume that the doctors may not be talking to each other.

      • RICARD DONAHUE

        I guess beyond the glib remark, there is no easy answer. From my perch i am in the midst of an amazing array of choices here in the Boston area. It’s not too difficult to find ones way to the top notch. Yet, living so close to such a major hub of health care, i know people whose main criteria for a physician has nothing to do with health care but more to do with convenience,location, or some comfort issue and less to do with any experience or special connection to medicine.
        So to answer your question, age should not be at the top of the list, experience and indication of being current with new methods is the optimal choice. Since there is no check list or rule book, my own comfort level is to be in the care of someone who is affiliated with a teaching hospital and is practicing within peer reviewed groups. It’s not perfect but it’s a good way to hedge your bet for good health care.
        How i would navigate my way through the system if i lived in an area far from the madding crowd i do not know. My standards would be the same based on what i know but, my perspective would be different. I do know this; when people travel from distances half way around the world to be treated at a center that is within a few hundred miles from me, i wouldn’t consider it inconvenient to make that trek.
        However in an emergency, it’s any port in a storm.

        • meyati

          We consider going to the teaching hospital to be a death sentence here. I should just shoot myself and get the agony over with. The nurses are mean, the techs sloppy-I had my fillings burn my gums, inner cheeks, and tongue during an MRI, and the doctors are greatly overworked.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    I think you need a compulsive and thorough doctor who is compassionate and current. I think you are discussing a difference of opinion not a communication problem.
    Last year I had 92 year old patient with a history of paroxysmal atrial fibrillation who fell and broke her hip. She was seen by me and by her cardiologist and electrophysiologist. We noted that she was in atrial fibrillation with a rate between 100 and 110 but stable hemodynamically and felt to be as tuned up for her hip pinning as possible. The patient went down to the OR at 7am and the family went to the surgical waiting room. The anesthesiologist cancelled the case as being too high risk when he noted her ventricular rate was 110. . The patient was sent back to the floor The surgeon did not ca]] the attending physician or the cardiologist or the electrophysiologist to say that the case was cancelled and to discuss re starting her meds or feeding her.. The surgeon did not go to the surgical waiting room and tell the family the case was cancelled. The first I or the cardiologist became aware of the problem is when the family called from the surgical waiting room at 6:15PM to say that even the volunteer was going home and they had no information on their mother who had been back in her room for six hours already. That is a failure in manners and communication putting the patient in jeapordy. The patient went to surgery the next day after a conference between all the cardiologists , medical doctors and the anesthesiologist actually assigned to the case. With smartphones and cellphones and text messages and computers there is no reason for doctors not talking to each other about the patients welfare!

    • Suzi Q 38

      I would have been angry.

    • Jen S

      How would you recommend finding one?

  • Jen S

    As everyone was obviously not on the same page, it is obviously, in part, a communication problem.

    Kudos to you, Dr. Kirsch, for having the “right” (guess being right can be subjective) attitude in the above situation. And, of course, truly keeping the patients’ best interests in mind and not being dead set on doing what you think you have to do without looking at the patient as a whole.

    As a patient, I do wish more doctors were this way.

    Almost 3 weeks ago I had a liver tumor/wedge resection. I saw a physiatrist a few days ago for other issues and he recommended PT and some meds. One of the meds is a NSAID and I was somewhat apprehensive to start core strengthening so soon after surgery.

    I asked the physiatrist twice to check with the liver surgeon (same hospital, EMR system, etc.) and that I was ok with it if the surgeon was, especially as part of my incision has yet to fully close. At the end of the visit the physiatrist’s nurse gave me the prescriptions and PT appointments. At the risk of being redundant, I asked the nurse if the surgeon was ok with it. She went to check with the physiatrist, came back, and said yes it is okay. So, I scheduled 2 PT appointments for this week.

    Not understanding how fast the doctors could’ve collaborated, I called my surgeon’s office today. And. He does not want me to do core strengthening PT until 6-8 weeks post-op…

    Unfortunately, not all patients would’ve done that and would’ve moved forward with whatever the physiatrist recommended.

    And this is at MSKCC where they have a decent EMR system. I have worked there and at another large academic hospital. I can’t imagine what it is like elsewhere.

    All the millions of dollars spent on technology is obviously not improving communication among providers and is negatively impacting patients. But as long as it looks good on paper and administrators are steering the ship instead of helping to create the ship, nothing will change.

    • margo

      I thought I was alone in thinking that technology is not improving communication and i.e. care. It seems like an unpopular idea since everyone seems interested in the most cutting edge techniques and that seems to be the only thing important–and that seems synonomous to good care to most.

      • meyati

        I actually got a flu shot over a month ago, and it’s still not on my electronic record. I have an incurable, aggressive cancer- and as a medical condition that is not listed. I’m undergoing radiation therapy and that’s not listed. If I fall and start vomiting-it would be nice for them to know that I’m having radiation.

        • margo

          OMG I am so sorry!! What hospital are you going to? My wish for you is that you could go somewhere you felt a reasonable amount of care and oversight!!

  • http://www.facebook.com/drtaher Taher Kagalwala

    As a pediatrician, I have always felt the need for proper communication between the various professional and non-professional people that work in a hospital. Just as it is helpful for the patients and their relatives to have the medical administration stay in touch and be updated about the patient, it is also helpful to the professionals themselves as they come on and go off duty, proceed on leave or vacation, or be unavailable for work for some temporary reason. If the lines of communication fail, it can be disastrous for the doctor too, as the then attending doctor may carry out a procedure or test that may have been contraindicated for some reason.

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