Why are We Straining to Communicate?

A few days ago, just after dawn, while I was out walking the dog, our home phone rang and my wife answered it.

She's used to my pager, cell phone, and home phone ringing at all hours, and so she was not all that surprised when an unidentified voice said,"We're looking for the methadone dose for patient John Q. Smith."

She told him I was out of the house at the moment, but to hold until I return, which they patiently did. On my return, somewhat puzzled, I spoke to the person on the other end, and they repeated this request: "What is his dose of methadone?"

I told him that I didn't know who this patient was, and I certainly didn't know his methadone dose.

"Isn't this the methadone clinic at Lenox Hill Hospital?"

"No," I told him, "This is not the methadone clinic, this is my home phone. I think you have the wrong number."

"But this is the number the nurse gave me," he said.

"Nonetheless, this is not the methadone clinic; this is my home."

I told him what the possibilities were: the nurse gave him the wrong number, or he had dialed the number wrong. Either way, I could not tell him this patient's methadone dose.

The Fax Form

Yesterday, at the end of my morning practice session, a patient of mine was squeezed onto the schedule, and simultaneously a fax arrived from another hospital where he gets specialized care for another condition.

The fax was a preoperative evaluation form, and he was scheduled for a surveillance upper endoscopy in 2 weeks.

Written on the cover sheet, in somewhat exuberant handwriting with lots of asterisks and exclamation points, was a declaration, "Please disregard previous fax, corrected form, please advise – procedure may need to be rescheduled based on your comments." On the form itself was a handwritten note that said they were seeking advice regarding management of his anticoagulation and his diabetes in the peri-procedural period.

He arrived at his appointment a little late -- it turns out he had been seeing his cardiologist that morning because she had received a similar request.

He said, she wants to talk to you, and pushed over across the table to me a big wad of papers, which was his after-visit summary which had been printed at the end of her visit.

Her direct office number was written on it, and she wanted to talk about his upcoming procedure, share her thoughts and recommendations, and very quickly we were able to come up with a safe plan for him.

The Communications Jumble

What do these situations have in common? They're all about the challenges and barriers and solutions to communication that is necessary in this modern world to really take care of our patients.

To truly provide patient-centered care, we need to rethink how those involved in the global care of our patients interact with the patient, their health information, and each other, to optimize the care of that patient, to prevent errors, to always lead to the best outcomes.

One of my least favorite (and most memorable) preoperative evaluations involved a patient with advanced heart failure, with an ejection fraction in the single digits, who spent his entire life above 45°, because if he ever reclined past that point he went into florid heart failure and had to go to the critical care unit for intravenous diuretics.

He was scheduled for cataract surgery, and our team cleared him with very specific instructions about his ability to lie flat; the surgery could proceed, but the staff needed to accommodate him in this way.

I'll never forget the call from the ophthalmology clinic, when they yelled at us, saying they were trying to push him flat on the table and he refused; he was yelling at them to call Dr. Pelzman. Why had we cleared him for surgery when he would not lie flat for their procedure?

I told the staff person to pull out the paper form we had faxed over to them, where our recommendations were clearly written and explained -- circled and highlighted in yellow -- "Please accommodate him and don't force him to lie flat, because he'll end up intubated."

A Better Encounter

One of my favorite pre-op surgical consultations, if there is such a thing, happened about 15 years ago, when an elderly patient of mine with multiple medical comorbidities developed acute cholecystitis. After seeing him in the ER, his surgeon called me on my direct line and said, "Fred, is he safe to go to the operating room?"

"Yes, let's just continue his beta blocker through the perioperative period; I think he is as good as we can get him," I said. "Thanks," he said, and straight to the OR they went.

No long forms to complete, no echo or stress test, no elaborate CYA -- just doing what's best for the patient, where we both were making sure he had the best outcome, not so worried about everything that all too often goes along with this.

Using our electronic health records in the most efficient way, and new technologies that will allow us faster and safer communication across institutions, will ultimately help smooth the way towards a better way of taking care of our patients.

How It Should Work

How, in the 21st century, can we not know what a patient's methadone dose is, what all of his medications are, who all his providers are, and how to reach them all 24 hours a day, 7 days a week?

First of all, in my 20 years of practice, I've never had a patient lie to me about their methadone dose. Their Fentanyl dose, or their Dilaudid dose, sure, but if the patient is on methadone maintenance, give it to them at the dose they say they're taking; confirmation can come later.

But all of this information should exist in a way that is easily retrievable, and every system should be able to speak to every other, so that we can see every last dose of medicine the patient has taken, who prescribed it, and how to reach them to discuss the issues that may arise around the care of our patients.

When someone has some questions about the perioperative management of a patient, I can assure you that handwritten scrawls across the cover sheet of a fax (that may lie in a fax machine somewhere and not get delivered to the appropriate eyes for hours or days) are not the best way to ensure that the procedure goes smoothly.

Telephones and emails and faxes may not be the best way, but there has to be a way that we can have all of the healthcare information we need to be closely related to our patients, and that we as the providers who are interacting with them can give our recommendations and have others quickly see them and follow them to lead to the best possible outcome for each patient.

Just this week, our hospital's Pre-Anesthesia Evaluation Center (I didn't even know we had one of these), sent out a survey to the entire Department of Medicine, seeking information to help them understand the common assumptions made by internists and cardiologists when preparing their patients for surgery. Their hope is to improve education efforts they make moving forward, but I worry that this is really just something that they are going to use to create more rules and guidelines that we need to follow.

Much preferred would be a more direct, open line of communication, with all of us working to help prepare our patients for whatever surgery they have planned in their life.

Call me any time you like. Just maybe not at 6:30 in the morning, about a patient I don't know, about a medicine I did not prescribe him.

Comment