Tuesday, November 27, 2012
Does doctor-to-doctor communication ensure patients safety?
One of the gripes that patients have about the medical profession is that we physicians don't communicate sufficiently about our patients. In my view, this criticism is spot on.
Patients we see in the office often have several physicians participating in their care. The level of communication among us is variable. While electronic medical records (EMR) have the potential to facilitate communication between physicians' offices and hospitals, the promise has not yet been realized. The physicians in our community, for example, all have different EMR systems which simply can't talk to each other. We can access hospital data banks from our office, but this is cumbersome and burns up time. Ideally, there should be a universal system, an Esperanto approach where all of us utilize the same EMR language.
On the day I wrote this post, I participated in a direct conversation with the treating physician at the hospital bedside which vexed me. This scenario would seem to be ideal from the patient's perspective. At the bedside were the attending physician, the gastroenterologist (the Whistleblower) and the anesthesiologist, who were conferring about the next appropriate diagnostic step in a patient who had experienced upper gastrointestinal (UGI) bleeding.
I was asked to evaluate this patient with UGI bleeding and to arrange an expeditious endoscopy to examine the esophagus and stomach region in order to identify a bleeding source. Hours prior to seeing the patient, I scheduled the procedure that I knew would be needed, a short cut that every gastroenterologist will do in order to be efficient. As the patient had other medical conditions, I requested that the sedation be administered by an anesthesiologist, rather than by me, to provide greater safety to the patient.
I arrived and became acquainted with the medical particulars. I agreed with the diagnosis of UGI bleeding and also that an endoscopy was the next logical step in this patient's care. These observations are not sufficient, however, to proceed with the examination. There are other criteria that must be considered.
1) Does the procedure need to be done now?
2) Do the risks justify performing the procedure?
3) Has the patient provided informed consent for the procedure?
After I arrived on the scene, the anesthesiologist approached me and advised me that the anesthesia risks were extraordinarily high. He was concerned that performing the case could have a disastrous outcome. My reaction to his frank assessment? Thank you! The decision then fell to me to decide on whether to proceed.
For me, this was an easy call. The patient did not need an endoscopy at that moment to save his life, the only reason that would justify subjecting him to the prohibitive risks of the procedure. Before discussing this decision with the family, who were awaiting an endoscopy, I summoned the attending hospitalist to relate to him our revised plan.
In my view, when an anesthesiologist and the gastroenterologist advise an attending doctor that it would be unsafe to proceed with a planned procedure, the response should be, 'thank you'! But, it wasn't. This physician wanted the test and seemed irritated that the set diagnostic plans had been set aside. He wanted a diagnosis, and we declined to proceed after concluding that the risks exceeded the benefits.
I was as comfortable with this medical decision as I have been with any other decision I had made in my career. On other cases, when a consultant advises me against a planned course of action for safety reasons, I am so grateful that a patient has been spared from danger.
We got to the right answer here, but had to set aside an unforeseen obstacle to get there. Communication means listening to another point of view and being able to change your mind. As a doctor, when it's my finger is on the trigger, I call the shots. I this case, a doctor misfired.
This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Contact ACP Internist
Send comments to ACP Internist staff at firstname.lastname@example.org.
- QD: News Every Day--Virtual diagnoses cost less, b...
- Raw food diet hype is overheated
- QD: News Every Day--Task Force recommends screenin...
- Pass on the horseradish for urinary tract infectio...
- Organic medical homes (that are gluten-free)
- Vastly different roles in health care
- QD: News Every Day--Routinely repeating tests too ...
- States a new source of overreaching medical legisl...
- QD: News Every Day--Top 10 technology hazards in h...
Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.
Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.
Reflections of a Grady
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.
The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.
Technology in (Medical)
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.
Peter A. Lipson,
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.
Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.
World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.
Other blogs of note:
American Journal of
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.