What We Have Here is A Failure To Communicate

What we’ve got here is failure to communicate

Communication is dead. Very dead. No detectable pulse at all. We need to figure out how do get CPR under way – at 100 beats per minute, performed to the rhythm of “Stayin Alive”. And avoid thinking of the other song with the right CPR rate “Another one Bites the Dust”. Because we want this resuscitation to work.

The communication that is hurting so badly is the communication between hospitalist and PCP. It just doesn’t happen any more. It is so rare that you should look out the window for a rainbow when it occurs because it is a very special day.

But our patients think and expect things very differently. They assume they are entitled to and get smooth and seamless useful exchanges between their outpatient and inpatient physicians. That is also what we would and should expect when and if we or our family members are hospitalized. The right answer is yes they are entitled to this, but no virtually no one ever gets this. This is not a problem just in Buffalo, it occurs everywhere, and it has been created by the evolution of medical care from the comprehensivist model – one doctor, 2 worlds – to the schizophrenic model – 2 doctors in unconnected silos. More efficient for everyone’s time, but paid for with the deletion of appropriate communication.

There is similarly 2-sided accountability for this catastrophe. It is not only the hospitalists who have abandoned communication but the primary care physicians. Hospitalists complain that outpatient doctors are hard to reach, don’t seem appreciative of or interested in communicating with them, and appear satisfied with the sounds of silence. “Just fax me the discharge summary” seems to be a lowest common denominator that too many are willing to accept. As a primary care physician myself, I am embarrassed to say that these complaints are valid. I have talked to many of my peers to confirm this is our current state more often than not.

Yet the paradox is that a good PCP has a lot to offer to improve inpatient care. Obviously there is a wealth of useful data the PCP has that is unknown to the hospitalist. Everything from testing and consultations, exam findings and diagnoses, allergies and medications, idiosyncrasies and personal preferences, and much more. But there is also the personal information that emanates from a longitudinal caring patient-centered relationship of trust between the patient and the doctor. Not only can such insights assist in many aspects of management but also gives the hospitalist a very powerful tool. They will be able to say “I have discussed this with your doctor” and let the patient know that they are part of the decision making team during their inpatient stay.  It makes every hospital stay markedly better when this happens.

Communication takes many forms. The best one is direct conversation, but we know that is difficult. Finding 2 busy people who are both free and reachable at the same time is not likely. It certainly works in some situations. Sometimes the EHR can help. When a hospitalist has direct access to the outpatient EHR, they can not only access a wealth of information but they can have good and effective electronic dialog through the triage function in the record. A very good choice that is not available very much in our community.

The best alternative for everyone else is secure text messaging. It is widely available in our system, and even lets both physicians “pick a time to talk” that saves all the wasted time on hold or interruptions at the wrong time that happen when we try and use the phones with secure texting to lead the way. Does this work? Simply look at what the younger generations are doing to communicate. They text all the time. Not sure it is commendable but it shows how this is superior communication to calling first, not unlike how phones surpassed smoke signals once upon a time. But we have been abysmally slow to adopt this as the cornerstone of PCP-hospitalist communication that it should be right now. Maybe a little CPR will help, as this may be the thready pulse we need to try and keep alive.

Cool Hand Luke’s last words before he was shot in the neck by Boss Godfrey were “What we got here is a failure to communicate”. He did not survive the ordeal. We need to change that ending for our story to turn out better than things did for Luke – and we need to do it for our patients.