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Tuesday, July 12, 2016

Movement from informal to formal processes in medicine

I have had a robust exchange with colleagues regarding how one should acknowledge another physician's opinion in the medical record. I am of the mind that the only opinion that one should write in the record is your own. I have no desire for any of my colleagues to record my opinion in their notes, unless they forward those for me to sign or write an addendum.
However, my opinion on this activity is not held universally, not by a long shot. Within other fields, especially radiology and pathology, there is a long tradition of bedside clinicians visiting and consulting these specialists, in their "houses". Rounds used to start in radiology and there would be extensive discussions with care teams, resulting in radiologist opinions being paraphrased in the medical record. Whether what the radiologist intended to communicate routinely ended up in the notes on the floor is not so clear.Similarly, glass slides routinely circulate in Pathology departments and colleagues are called upon to render inter-departmental consults, ranging from formal to very informal. The language incorporated into various reports may include a host of concurrences from physicians whose signature never appears on the final report.
Historically, critical decisions in medicine, especially in the most challenging of cases, were often made after generating a form of consensus, whether that consensus was derived from Grand Rounds, tumor board, or informal solicitation of opinions. The transcripts from these conferences and informal activities were generally non-existent and the consensus recorded tended to be ephemeral and biased through the lens of whomever wrote something in the chart. It may have been heavily influenced by one or a few strong and charismatic clinicians who would sway the audience based upon their confidence and experience. 
All of these activities were highly informal processes. Individual attendees tended to take away what they wanted to take away and the patients cared for had little or now idea what actual conclusions were drawn and how they were arrived at. They were simply informed that we had a conference and the agreement of the group was, whatever. Individual accountability and hard evidence was not something on the radar. 
Looking back nostalgically, we believe that these activities enhanced patient care, irrespective of the actual outcomes. They certainly made the care teams feel better and there was a certain simplicity and finality which appeared to be achievable which does not appear to be achievable now.  While the human contact did unquestionably facilitate communication, the model was not scalable. It depended on small groups who were familiar with everyone involved. The decision trees were not so arborized. The information to be managed was on a much more limited scale.
It is a different world now. We aspire to do more, much more which requires much more complex systems to manage. The teams are larger and the workloads more specialized. Communication becomes even more essential under these conditions and when communication fails, we ascribe those failures to leaving the informal systems behind. However, when systems become more complex, informal communications will not suffice. Each decision branch point, which may be dependent upon particular fidelity on terms of information transition, becomes a possible pitfall. A process with three steps has a much lower failure rate than one with five, or ten, or fifteen. Informal verbal communications are fraught with error and should not serve as the foundation for critical information flow.


  1. I agree that our more complex health system, with increasingly complex medical patients, has evolved past the informal processes of days past. Yet, the question remains - how do we proceed? It is easy enough to say that we simply should not quote other professionals in our notes - point taken. Should we also endeavor to document transcripts from tumor board meetings (and other such ilk) to show a consensus? Should we refrain from informally discussing patients with colleagues and perhaps restrict communications to formal messages in the EMR? I think the latter point would certainly reduce the chances of miscommunications being perpetuated throughout a patient's record. Yet, I feel many clinicians, especially those who are older and more experienced, have reservations about engaging in more formal communication processes. Ironically, it is the very aforementioned clinicians whose insight is so valuable and often needed for more complex patients.

    1. Thank you for your comments. I don't think that informal discussion is an issue, only informal discussion that becomes immortalized in a legal and management document taking on the form of medical hearsay. My opinions may be swayed by informal discussions but when I write my opinion, it is conveyed as my opinion and no one else's.

      How to handle tumor boards is another story. If important management decisions are based upon discussions, someone has to own the decisions made. Someone will counsel the patient, get the consent, and write the orders. If tumor board owns the decision, those who participate need to understand what it means. If there are dissenting opinions they need to presented to the patient as well.

      From a practical perspective, it makes sense for the decision to be owned by whomever executes the plan. Going forward, dealing with these issues will be critical to deploying real team based care. We only pay lip service to this now.

      I am afraid I don't understand the hesitation for someone who is older and more experienced to express their opinion in an unambiguous way. One of my colleagues believes that vagueness can be used for control purposes.