Communication in the time of COVID

I stirred awake when my husband’s cell phone rang.  It was early, and we had gone to bed late, and slept little.  My father-in-law was in the ICU in a hospital in Baton Rouge, Louisiana.  He was now intubated, hooked up to a ventilator, victim to COVID-19.  We would eagerly await phone calls from the ICU physician or nurse, wanting updates on how he was doing.   Did his oxygen saturation improve with proning?  Was his FiO2 able to be turned down?  There was so much we wanted to know, as any family with a critically ill family member would.  Part of the problem was that my mother-in-law, his wife, could not be with him in the hospital to speak directly and frequently with the doctors and nurses, who were working tirelessly to save many lives.   We would play phone tag with his care team, and would often have to leave messages.  The doctor always did call us back, each time relaying the numbers, the plan,   the status.  We were grateful but also felt helpless.  Helpless, due to a lack of good communication.

Communication is key to healing and embodies the art of medicine.  A good physician can help heal by listening, empathizing, and explaining.  In past generations of medicine, there were often private physicians who contracted directly with patients.  They built trust with people by seeing them long-term, often seeing many members of the same family.  The origins harken back to the days of the old-time country doctor, who made house calls.  This transitioned to private family and internal medicine practices, where the doctor was often a one-person operation, handling all of the needs of a patient from managing their hypertension and diabetes, to tackling some select specialty care, and even seeing them in the hospital.  This led to a deep knowledge of the patient on the side of the physician, and a deep trust of the doctor on the patient’s end.  It led to better provider and patient satisfaction.

Many changes have swept the landscape of medicine, which have impacted patient and physician communication.  First and foremost, the takeover of private practices and university medical centers by hospital systems has changed the practice of medicine.  Medicine has become a business and one that is not run by physicians.  A bigger system can translate into less personal interaction.  One example is patients having to call centralized call centers rather than being able to directly speak with their doctor’s staff.  This can lead to frustration on the part of patients, who want and deserve easy access and communication with their care team.  There are ways that hospital systems are trying to turn this around, but it is not easy.  Bigger is not always better.

The second piece that hampered communication was the rise of the electronic medical record, which ironically had the goal of increasing communication.  While the goal was to make people’s medical records portable, the reality is that hundreds of EMR systems exist, and they do not talk to each other.  Even EPIC, one of the largest and most widely used EMR systems, has many different versions that do not necessarily communicate with each other.  With the development of the EMR also comes significantly increased documentation requirements.  Some of what is documented is effective and important, and some is bloat.  Many physicians, myself included, find themselves in a game of tug of war between the computer and the patient.  In the end, physicians spend significant time documenting both during and after the patient visit.  The increased time spent with documentation directly affects the face-to-face interaction with patients.

Technology in medicine is a double-edged sword.  It can increase efficiency if used correctly and increase patient safety.  And now, more than ever, it has allowed for increased patient communication.  Many EMR systems now have patient portals, where patients have access to their lab and test results.  Moreover, they can directly message their care team with questions that often get answered within a day, without having the hassle of waiting on the phone.  Telehealth, which had been used in a limited capacity, has exploded with the rise of COVID.  I personally have enjoyed the experience of telehealth, despite the minor technical glitches.  It has allowed me to connect with my patients on a very personal level, as if being invited into their homes.  It is the modern house call.  Seeing people in their own environment gives me insight into their lives and helps me better understand their needs.  On the flip side, the patients themselves feel more comfortable, which lends itself to a more open discussion.  It is no wonder that patients have been reporting increased patient satisfaction with telehealth visits in general.

Technology to help patients, families, and their care teams communicate in the hospital, and in particular, the ICU, is lacking and is the next step to bridging the communication gap.  I keep thinking of my father-in-law being taken to the hospital, dropped off by his wife and son, and then left alone.  I imagine how scared he must have been when they quite suddenly had to intubate him.  While we know he had many caring people by his side, it was not the right people.  His family should have been there.  This is the sad reality for so many individuals and families today.  And even in pre-COVID times, the ability of the family to physically be with the patient at all times is impossible.  This is where technology could act as a bridge.  A virtual patient portal that could help remotely engage family members in many ways, from updating them on their loved one’s progress to allowing them to virtually be there with the patient.  It could also, in turn, help the care team better understand a non-verbal patient’s preferences and needs.  Because we know that sick patients are anxious and need support, and we know that family members can help heal.

It has been three months since my father-in-law’s death.  There is not a day that goes by that we do not remember him in one way or another.  We are and will continue to be forever grateful for the doctors, nurses, and aides who cared for him, and who acted as a surrogate family to him while he was hospitalized.  We also know that thousands of others in this country have gone through similar situations.  With one of the most advanced health care systems in the world, however, I know we can do better.  We can do better for our physicians who are not only over-burdened caring for sick patients, but also taking extra time calling relatives daily.  We can also do better for our patients and their families, who are anxious and overwhelmed.  We need to leverage the technology we have to improve communication.  It is the key to healing.

Tina Mahajan is a rheumatologist.

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