“The Patient Can’t Remember (?)”
Scouring Soarian Clinicals recently for a cardiology consult on a very sick patient of mine – I found the report, eagerly anticipating the recommendations for managing my patient. This was a very appropriate consult, not a “hu-hum” request because the patient was legitimately complicated. Here’s the profile, very familiar to anyone working on the inpatient side of care – chest pain, labile diabetes, abnormal echo (low EF and wall motion abnormalities), very low GFR, elevated troponins, polypharmacy, depression, and variable patient compliance. Clearly complex decision making was needed as to how to evaluate the risks and benefits of medical and interventional care of his heart disease without exacerbating his advanced renal disease. His personal values were adamant about avoiding risk of ESRD and dialysis. So the active and knowledgeable input from cardiology was needed to develop an appropriate management strategy involving the patient, family, hospitalist and nephrologist – a typical high acuity inpatient consult with many moving parts.
Among other things in this Cardiology Consultation was a succinct description of the patient’s cardiac history as follows – “He recalls having a coronary angiogram several years ago but cannot remember if he had previous stenting.” Later in the same consultation report was the analysis and recommendation section in which was opined: “Initially it may be (italics added) worthwhile to obtain records from his cardiologist.” I had to read it twice to make sure that I did not misread these 2 comments. Realizing they made the same point twice about not getting the information, I appreciated that it was not a typographical error, but a philosophy of how to do things. Made me wonder how far I would have made it into my first medical school presentation if I had written or spoken those words.
But rather than focus on an individual, we really need to look at our processes and our standard of care. We do not like to admit this, but this example probably surprises no one because we constantly see notes virtually identical to this every day. This is not limited to any individual or specialty, and various reports of hospitalists and consultants are seen with variations of this same theme. And that is even sadder – we have a new norm, and it is not pretty, and it is certainly not the way we would like our relatives or ourselves to be treated.
Communication and information exchange are high priorities these days, and electronics have been designed to make this process better, smoother and seamless. Patients believe that we have data exchange that should be as smooth as our Amazon transactions and banking records, because anything computers can do with financial data, they can do with medical data.
But the missing piece here is the interest and the effort, and that is where we have failed. Looking at it from the analytical perspective of the resources we have easily available, the cardiology consultant had to make 3 separate decisions after learning the patient did not personally know his angiogram results before writing their note. First was deciding not to contact the cardiologist (who is easy to reach on Tiger Text and by phone) to find the results. Second decision was not to contact the PCP (me) for any information about the patient. And the 3rd decision was not to go onto HEALTHeLink where the report was available to any provider to see. All 3 decisions came out the same – they elected to do the consultation and make recommendations about treating and managing the patient without knowing the results of a prior angiogram that was readily available to them.
Of course, the excuses as to why this didn’t happen are obvious – and first among non-equals is time. The complaint is that no one has enough time. And this always-first defense for such deficiencies is both true and untrue at the same time. There are inefficient ways to get information such as calling on the phone and waiting to reach someone or leaving messages with lots of telephone tag or waiting for callbacks with interruptions at all the wrong times. Some ER physicians and consultants say they are discouraged from using this approach, which still remains with us from the last century, so they do not contact physicians as often as they should. However, going on Soarian or HEALTHeLink are quick approaches that blend into the workflow rather than interrupting it. And any physician who uses Tiger Text is easy and fast to reach with no delays and HIPAA-secure responses. There are faster processes in the 2010’s than the 1980’s that save a LOT of time.
But people schedules tend to be very busy and they perceive that even a small amount of time is too pressing. This may or may not be true but is more a matter of judgement and priorities than being “actually true”. We always find time for things we believe are needed, and put off the things we view as optional. Somehow critical pieces of cardiac history became elective to critical decision making in complex cardiac patients. Shame on us. It’s not just the consultant who is involved here, but all of us who accept this standard of care and don’t work to change it.
It is time (that word again) for all of us to do better. Lesson 1, use the efficient tools of information exchange we have available fully and push your colleagues to get and use Tiger Text and HEALTHeLink if they are not already on board actively using both. Lesson 2, from the Good Book, is treat your patients (neighbors) the way you would expect to be treated yourselves. We need a beacon to work toward as we model our workflows. I cannot think of a better one than that. Just these 2 things will make us better.
