Leora Horwitz and Allan Detsky published a commentary in the March 16, 2011 issue of JAMA about the pitfalls and promise of modern communication modes entitled Physician Communication in the 21st Century: To Talk or to Text? (Subscription is required for full text; extract available to all.) They note the impact that technological advances enabling the proliferation of asynchronous, non-interactive communication modes including email and texting have had on how physicians transmit and share clinical information. I like this succinct definition:
The fundamental purpose of clinical communication is to generate a shared mental model of a patient and to transfer responsibility for some aspect of care from the communicator to the recipient.
They point out that there clearly are advantages and disadvantages to both modern, asynchronous text-based communication and traditional, synchronous "talk-based" interaction, and that physicians need to be trained to understand when to use which form. They propose six different communication reforms for modern medicine. I particularly agree with #4:
Build clinical information systems to help synthesize data at the time of communication, not to overwhelm the observer with individual data points.
When I was in private practice, I came to loathe the frequent interruptions of phone calls during the days on call from other physicians and health care personnel - and regrettably I'm sure my irritation showed - even though the calls were largely appropriate and the interactions with referring physicians important for building the practice. At the time, I wished some of the messages could simply have been sent via email, but my group was not part of an integrated network with our hospitals and referral base and email penetration was otherwise low. Now that I practice in an academic medical center with the vast majority of my referrals being internal, we communicate predominantly by email, so I am rarely interrupted while seeing patients. While I think this is superior to the old way, there are still plenty of times I wish I could more easily pick up the phone and just ask someone a question instead of typing it!
This commentary reminds me that there is an important science to understanding the optimal ways for physicians to communicate with each other, and we need more thoughtful analysis like this to further the goals of patient-centered care.
(Listen to a short audio podcast of author Allan Detsky discussing this work on the JAMA web site.)
Comments
John V. Cox
Apr, 06 2011 6:11 PM
Bob.... I find that practicing good medicine is getting harder. AND yes maybe it is because I am getting older. PRIME amongst the levers driving me nuts is the ability to communicate with others in the care of a given patient. I practice in a community hospital - the bulk of the physicians are in private practice. There is no overarching messaging / email system available. Phone calls are the primary way of grabbing folk... Yet, no primary care office will accept my call - they will take a message and occasionally return it. Offices are often closed - as I try to return calls at noon / or after hours. Inevitably whoever is on call is not who I need to speak to. ((( and while my rant continues - have you noticed that lunch breaks are longer and longer.... it is not uncommon for an office to close its phones at 11:30 A till 2 PM!!))) AND what of the folk that call, pull me out of the exam room - then their staff politely asks me to 'hold' for the doc who is calling me -- have to admit that drives me nuts.
Soo, I am one that envies you!! Asynchronous, reliable communication that email / messaging offers has to win the day.
OH but I feel another rant --- HIPPA!!!
Michael A. Thompson, FASCO, MD, PhD
Apr, 07 2011 11:19 AM
These are great comments.
A primary MD who refers to me but does not share our EMR/email system called because he was upset with some communication lapses.
In a fragmented, heterogeneous health system formed with patch worked communications and laboratory systems it is very difficult to provide cohesive care and communication.
My prior experiences at Mayo and MD Anderson Cancer Center prepared me for coordinated "same system" care. In those settings it is much easier to communicate without trying as hard.
In the community setting like Dr. Cox describes a shared EMR/communication tool is helpful, but without that people have been trying various things:
1) phone - difficult to connect, but most personal, can be time consuming (however, this works well at Mayo)
2) email - useful if everyone has each others email addresses, but in most instances non-HIPPA compliant
3) faxes - often buried in a stack of papers
4) non-MD to non-MD communication - "telephone" game like errors may occur
5) Other - eg Doximity or other communication systems.
I have tried Doximity, but -- at least now -- there aren't many out of communication net MD's on it reliably enough.
I look forward to hearing others comments on potential solutions.
Michael Clarage
Jul, 15 2011 3:11 PM
My partner and I head two hospitalists groups in the Boston area, one acute care, the other a rehab hospital. For years our handoff communications went through paper mail or fax. We were very diligent about communication. Even so, specialist from acute care settings and primary care physicians in the community complained that our group was like a black box – that they were not getting good communication about the care we were providing. The hospital even setup a physician portal so that any on-staff doctor could log in remotely and access their patient’s information. But this “pull” model never caught on, as most doctors expect data to be “pushed” out to them.
One of our new physicians suggested we look at Concentrica, which is an online network for secure clinical communication. This is free to physicians to communicate with each other. The national directory of physicians meant that we could quickly send to any physician, without having to know their fax or email. Like an online email system, recipients can reply and forward messages, so now we could get immediate feedback from colleagues in other locations, and in important cases, have a real dialog about patient care. The “Group Discussions” feature allows the specialist in town, the hospitalist, and the PCP to all join in an online dialog about one patient.
The application works well on our smartphones.
www.concentrica.com