Clarity & Craftsmanship – Peter S Kibbe, MD FHM

As Director of Patient Experience in our group of physicians, my job is to promote better patient communication. However, it increasingly appears to me that physician to physician communication is generally deteriorating and in need of remediation as well. Perhaps as my years advance I am forgetting that poor communication has always existed. Please help me out: are a lot of medical people speaking gibberish today, or is it just my imagination? As a group of hospitalists, we care for patients in the hospital. We admit patients into hospital beds principally after they have been evaluated and treated in the emergency department of our hospitals, but we also receive them from other emergency medical facilities, clinics and doctors’ offices.

Historically when these transfers occur it is convention that the referring physician verbally “presents” the patient case to the accepting physician. This allows the accepting physician to establish the seriousness of the illness, to be sure that the hospital where we practice has the capacity to care for the patient’s illness and to establish what kind of medical floor the patient will re-quire(intensive care, regular medical floor, monitored bed) and so forth.

And, time out of mind, this presentation of the case by the referring physician has been an important expression of the craftsmanship of the referring doctor. What he or she says proves that she knows why the patient has been brought to a doctor, who the patient is in terms of age, chronic and past medical problems, what the patient exhibits on physician examination, and what, if any, laboratory studies and imaging studies show. This usually includes a description of what treatment has been rendered.

Just last week I received a call from a physician at a clinical location outside the hospital, to accept a transfer to our hospital of a man this physician was evaluating. The physician was clearly a native English speaker but after several minutes of listening to him I had no notion of who the patient was or why he was being transferred to me. I knew I was in trouble when the referring physician began with an introduction, “Well, I have a guy here who, I don’t know, had a fever and, well, maybe there is a pneumonia….his white count is 24 thousand…He played eighteen rounds of golf yesterday and then felt bad…”

This frustrating, unorganized “hand-off” conversation degenerated into a sort of game of twenty questions. I had to ask the patient’s age, race, current medical problems and whether he was diabetic (the physician did not know). The physician gave me the laboratory and imaging data before telling me about the findings on physical examination. There was talk of fever and a pos-sible pneumonia. I concluded by simply accepting the patient after determining he could go to a regular medical floor.

When I went to see him and asked him what was troubling him his wife told me he had a recurrent soft tissue infection in his leg. He was a morbidly obese, insulin resistant diabetic with hypertension and obstructive sleep apnea and a body mass index of forty five. He was hospitalized two years ago for cellulitis of the right leg. And, indeed, he had a swollen and erythematous right leg.

This sort of communication failure seems to be happening to me more frequently. The following day I was called to accept a patient from an emergency facility because she used heroin and needed to have an observation admission to rule out bacterial endocarditis. Not only did she have no complaints to suggest bacterial infection, she had never used intravenous heroin. She had a long history of ingesting heroin via the nasal route, but never had used a vein. I could imagine sinusitis secondary to heroin inhalation, but endocarditis?

These frustrating hand-off encounters suggest that the basics of practice are being ignored. The basics, of course, include the step by step process of evaluating a patient—the reckoning of who the patient is, what chronic and past medical conditions exist, what the complaints are, what the physical findings are, then what the laboratory findings tell.

This process is then articulated by verbal presentation of the patient to another physician. That presentation is effective only if the information within it is accurate and also has coherence. So the first patient I mentioned above can be medically described well in a couple of sentences: “This is a 68 year old, very morbidly obese, white, male, hypertensive diabetic with a complaint of malaise and fever.” When one hears that last sentence one has an immediate picture of the “who” of the patient, at least in the medical sense.

I would also urge colleagues to consider including in that first sentence any information that medically defines the patient. If a patient suffers from a severe cardiomyopathy, or is being treated for a malignancy, or has a major ongoing series of morbidities, those should appear in the opening first or second sentence. “This is an 85 year old with advanced dementia, DNRCCA status and an ejection fraction of 25 percent who was brought to the hospital due to fever from the nursing facility where she is a resident.” I find that more typically when an ED clinician calls regarding that same person, I am told about an 85 year old patient with fever and a urinary tract infection and a high white blood count. Verbally expressing the “who” of the patient is critical to better communication. It is essential to treating people rather than processing patients.

The issue of the heroin addict implies poor patient communication but also implies that she was evaluated without the craftsmanship demanded by competent practice. If you are practicing in an emergency facility, particularly one in a state and nation known for its huge epidemic of deaths from opiate abuse, you have to be able to have a competent conversation with people who use opiates. That includes finding out their method of ingestion—prescriptions, intravenous ingestion or nasal ingestion; one of the oldest methods of ingestion is to smoke it. You need to know how often they need to take it to avoid withdrawal. Then you can employ “harm reduction” strategies which include questions about needle exchanges, Narcan availability, instruction about the safest ways to injectand also question the patient about previous rehab attempts, street Fentanyl issues and ask for a social service consult regarding treatment venues for the patient. (see SHM’s website:
http://www.hospitalmedicine.org/Web/Quality___Innovation/Implementation_Toolkit/Radeo/radeo_home.aspx  

This particular patient who regularly used opiates was fully employed, demonstrated insight into her addiction, recognized that at this point she was  using heroin pretty much to avoid withdrawal symptoms and had been thinking of finding some treatment options to “get clean.” She “used” several times a day. Since she had spent about twelve hours within the other hospital and our own it was pretty clear that she was dosing herself while in the hospital and she had no withdrawal symptoms.

As I listened to her describe the symptoms that had brought her to an emergency department in the first place(which were fairly trivial) and heard what she had to say about her life it struck me that subconsciously she was most likely looking for some help with the primary problem of her life, opiate dependence. Sadly our society has this problem in spades and our medical /social system seems flummoxed about what to do with it. We are unable to employ models successfully employed in other countries, but that is the subject of another of my screeds and tirades. In any event, her “who” was much more in need of some counseling and support than blood cultures and antibiotics.