Perspective and Communication

by Dr. Jon Hart

OK, this is probably not new to some of you, but I had an epiphany the other day as to why US Healthcare delivery generates higher cost and poorer outcomes than expected.

Ours is not necessarily a problem of greed (though it contributes), and these results definitely aren’t created by lack of knowledge, technology, and expertise. At its root, I believe healthcare in the US is undercut by the problems of perspective and communication. 

Many physicians, providers, and facilities appear to practice medicine from a perspective of isolation. Professional isolation has been named as a contributor to physician burnout and disillusionment, but this goes further. The thought that we are on an island with the patient, solely reliant on what’s in front of us with no contact to the outside world – either where the patient’s been or where they’re going – can cause drastic problems for the patient and those seeking to control medical costs. Redundant care, gaps in services, incorrect clinical judgements, and patient harm all arise from this problem of perspective.

We have grown to think that all the information needed on this patient is here on our island, our office, our hospital. If it’s in our EHR, it must be the whole truth, right? Why would we need to spend time and effort looking for different information? If it’s not in our EHR, we’ll order it and put it there. The patient says they had a brain MRI, but it’s not in our EHR. Repeat it. The patient had an admission and workup for this same problem 3 months ago in another state. Start over. Our EHR says they are these medicines, but the patient says they aren’t. We go with our list. 

I have a story that illustrates that last example. 

I know a physician whose 89-year-old dad with advanced kidney disease (Stage “4.75” CKD) went into the hospital with vomiting and dehydration. On admission, his medications were “reconciled” by the admitting Nurse, but there were two drugs on the hospital’s list, in their EHR, that the patient was no longer taking. A centrally acting antidepressant had been stopped about 6 months prior. Aspirin had been stopped over a year ago because of bleeding complications and to avoid worsening CKD from an NSAID. The physician son spoke up and relayed this information, requesting the meds come off the list.

When the patient was ready for discharge back to his Assisted Living Facility (ALF), the same Nurse went over discharge instructions with the patient and his physician son. The instructions included a med list with the two previously discontinued meds still on it. The son again asked for this to be changed. The Nurse replied that they couldn’t do it but would put a clinical note in the chart for the Hospitalist to see.

The Nurse went on to suggest that the patient have his PCP update the med list at followup. To that, the son made an interesting observation. “Dad’s PCP is on a different EHR than the hospital. On the PCP’s list, in their EHR, the medications are correct. The problem is on the hospital’s EHR list.” (Hmm. Interoperability and the promise of the EHR – still unfulfilled. EHR companies apparently live in the same state of isolation. “Interoperability is when everyone using our product can see the patient’s entire medical record that’s in our product.”)

Unfortunately, the story doesn’t end there. Despite the son’s information about the med list, the ALF chose to simply go with the hospital’s list of meds, continuing the Aspirin and the centrally acting antidepressant from the hospital. 

It wasn’t until his dad started bleeding that the son realized a problem existed.

A patient’s health journey is more than their brief stay on our island. They bring their previous travel experience and will move on to other locations before perhaps a revisit to our landmass. 

What about communication? Before EHRs and even Hospitalists, doctors and facilities relied on modes of communication now deemed to be slow and cumbersome – faxes, phone calls, and even face-to-face conversations. We have allowed technology and the further segmentation of care (necessary as it may be) to wash out the land bridges between care destinations and physicians, creating islands that have apparently forgotten how to communicate with one another.

I suppose the phone system could have been down in the hospital and the ALF, preventing them from picking it up to clarify meds with the PCP or his office. Doubtful. It either didn’t cross their minds or they “didn’t have time for that.” The feeling that the patient is in our house, and we have all the records in our house has clouded our wisdom, preventing us from considering that there’s another world beyond our island. This apparently even happens when the patient gives information contrary to our records. We’re right, of course. We are Healthcare. They’re just the patient.

The academic folks would classify this as a combination of Expedience Bias, Experience Bias, and Distance Bias (look them up for further clarity of meaning). Bias occurs when our perspective blinds us to input and information or distorts our view.

With technology, many in the medical profession have cropped their medical perspectives down to an inward-only facing view, focused on their healthcare delivery system, not the patient. To further complicate this, we have either forgotten the importance of communication across our islands, forgotten how to communicate, or we simply choose not to do it. 

Either way, despite this age of technology, the Risk Managers would say, “The Swiss cheese holes are lining up!” (https://psnet.ahrq.gov/taxonomy/term/3460) Tests and procedures will be needlessly duplicated. Mistakes will happen. Patients will be harmed. 

Slow down. Assess your perspective. Phone-a-friend more often. Provide more efficient, more effective, and less expensive care.