In a previous blog, I discussed the importance of patient-centric communication and its direct correlation with patient experience and care quality. The reality is, it’s not just patient communication that’s impactful. Every interaction, including interactions with physician colleagues, staff, and consultants impacts patient experience and quality of care. One common opportunity for communication improvement with hospitalists is face-to-face communication with specialty consultants.
As patients are increasingly being admitted to the hospitalist service as the primary inpatient provider, hospitalists are serving as universal admitters for all varieties of medical and surgical conditions. During many of these hospitalizations, a patient may be managed by multiple providers. The theory is that each specialist adds their expert input and together the best clinical care can be provided to the patient. However, too frequently, the various specialists and the primary hospitalist are not actually talking to each other. Although the goal may be to coordinate a multispecialty approach to the patient, there really is very little coordination.
Too often, hospitalists only communicate via documentation in the chart. Hospitalists may request a specialty consultation but may ask the unit clerk to call and arrange it. After the consultant sees the patient, they may leave a note, but rarely talk directly to the physician who requested the consult. However, I would argue that we are actually not communicating at all.
Two definitions of communication are:
- “the imparting or exchanging of information or news”
- “a means of connection between people or places”.
Truly communicating would involve each party reading each other’s notes, clarifying any questions, and agreeing on a mutual plan. In the pre-EHR era, we “communicated” via written notes. However, we all have had multiple instances where the handwriting was illegible, and we had little idea what the consultant was actually recommending. Conversely, the consultant may not be able to read the hospitalist’s note and decipher what we are asking of the consultant.
In theory, moving to EHRs should have caused an improvement in this process. However, it’s common for physicians to rely on cut-and-paste to carry notes forward day to day, and it may be difficult or impossible to figure out what the actual plan is that a physician is considering. Again, we have all read a hospitalist colleague or consultant’s EHR note and realized that the assessment and plan have not changed in days despite the patient’s condition clearly changing.
Communicating by handwriting notes or typing in an EHR too often does not achieve the purpose of “imparting information or news,” and perhaps only achieves the purpose of justifying creating a bill for that day. These notes do not replace the need for actual face-to-face communication to clarify clinical questions and discuss recommendations and plans.
I often wonder if patients realize how little their physicians actually speak to one another. When asked by a patient or family what a specialist thought or recommended, I have never had the nerve to state, “well, I didn’t speak to them, but their note said that I should order this test for you. I’m not sure why he/she recommended it, but I ordered it anyway.”
I have been involved in courses teaching emergency and hospitalist physicians to better communicate with one another. Patients and families would be aghast if they truly knew how infrequently the emergency department and hospitalist physicians reached mutual agreement on the clinical impression or diagnostic and treatment plans.
There is increasing emphasis placed on the importance of hospitalists coordinating care better between day rounders and nocturnists, and between providers handing off patients to one another when they go off service. As hospitalists improve their efforts to exchange information with each other and provide a consistent message to patients and families, it is essential that we not ignore the importance of also improving our coordination of care with our specialty consultants. Only then can we hope to improve our ability to provide a consistent message to patients and families about the care that they are receiving.