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Thursday, July 4, 2013

The pitfalls of spoken communciations

In my most recent blog, I highlighted a recent piece in the BMJ addressing the use of CT angiograms in the diagnosis of pulmonay embolism. Beside the major point of the piece discussed in my previous blog piece,  I was really struck by one set of comments by Dr. Daniel Cornfeld, a radiology professor at Yale:
“We sometimes find small pulmonary embolisms in a very distant vessel,” he said. “Oftentimes, I’ll tell them on the phone that it’s probably not significant. This sort of discussion probably happens very frequently, but I don’t make it part of the report. But maybe that makes me part of the problem.”
This is not unique. Discussions regarding test interpretation happen all the time yet they their conclusions fail to make it into the medical record.  Better to not have documented such uncertainties. They just get in the way of making decisions quickly. There is also a legacy mindset regarding the most effective way to communicate with medical teammates.  I am often told, just pick up the phone and call. What could be wrong with this?

The health care delivery environment is increasingly complex with multiple team members. We recognize that communications is a key activity in delivery safe and effective health care, but our appreciation of what it takes to accomplish effective communication is superficial at best. So we are implored to just "call" our colleagues, much like Dr. Cornfeld at Yale. The question is, just what are we trying to communicate when we pick up the phone and call?  Furthermore, what part of that spoken communication should be converted to the written word?

Similar issues arise with other support services. Anatomic pathology comes to mind. Similar to radiology, pathology often works on informatics platforms in separate silos from the electronic health records in which the rest of the health system works. Diligent pathologist will often call with particular diagnostic information, and discuss cases with bedside clinicians. They then go on to record some but not all of the detail in their reports with the clinician who sent the specimen recording what they heard of the conversion in a separate electronic record. The two are almost never reconciled and may bear limited resemblance to whatever the original conversation contained.

At the heart of the problem of communication in health care lies ambiguity of roles. What is the role of the radiologist or the pathologist? Is it their job to simply look at the images or slides rendered? How much history should they have access to or be required to review? Is it their job to convey the test limitations to the bedside physician if they believe that individual does not sufficiently understand the limitations of the test as applied to a given patient or does this create to much of a conflict of interest. Clinicians do not want their pathologists or radiologists to waffle. Just give me the diagnosis....

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