February 17th, 2015

Barriers

brick wallIn an era of near-instantaneous transmission of data, where multi-billion dollar financial transactions are completed in the blink of an eye and where the worldwide web will answer any question in less than 0.19 seconds, communication during patient encounters remains a thorny issue.

 

One recent afternoon, I saw Mrs. D in the medicine clinic. She originally had a 9 am appointment to (among other things) check her INR. She misunderstood the need to have her blood drawn prior to the visit but was directed to have blood work done and to return to be seen in the afternoon. When she arrived, we chatted as I worked my way down a seemingly endless list of primary care to-do’s and focused problem assessments. Having reviewed and communicated the significance of pertinent lab work and imaging, reconciled and e-prescribed medications, counseled her on smoking cessation/weight loss/exercise/low-salt diet, and made appropriate referrals, I considered it a successful 45-minute visit (yet well over my allocated scheduled time). I hurriedly explained medication adjustments I had made, bid Mrs. D farewell, and raced to grab my next patient’s chart.

It was a busy clinic day, and we ended late. While walking back to the hospital, I saw Mrs. D in the clinic waiting area. My heart sank. She looked so tired. She said she was waiting for a ride home. The medical transportation she had set up to take her back was for the morning, and the company would not reschedule. She hated being a burden on her kids, but she had swallowed her pride to call her daughter to ask for a favor. Tears started flowing as she said she had been waiting for me to finish so we could talk. She had tried to pick up insulin at her pharmacy, but I had prescribed Novolog, and her insurance carrier would only cover Humalog unless they received physician pre-approval. She had stayed in the waiting room for longer than an hour, waiting for me, because she was scared to go home without insulin or to navigate our labyrinthine resident clinic phone system to reach me. It took less than 3 minutes for me to reach, and speak with, the pharmacist to release her insulin. Overall, her time spent for a follow-up medicine visit and prescription pick up? 6 hours and 3 minutes

Our medical students take semester-long courses on effective doctor–patient communication. In residency, we have formal and informal discussions centering on cultural competency, identifying disparities in health literacy, and answering as basic a question as “can your patient read?” But sometimes, despite our best intentions, the challenges in delivering patient care are not apparent. We race through gathering, assembling, and synthesizing all the information present in an electronic medical record that is bloated with myriad notes, evaluations, medications, images, and lab information. (Don’t get me wrong! I can’t count the number of times I have been grateful for an EMR, especially at 2 am, while trying in vain to decode a consultant’s cryptic scribble). But our need to parse this data to help synthesize our treatment plans is time-consuming. Certainly, it is useful to review a trusted colleague’s prior note about the patient in front of you, but no amount of searching the record provides knowledge of the patient’s family, finances, or access to transportation.

A question to consider: How many of your patients neglect their preventive and follow-up care because it might jeopardize their jobs? Do you know?

How do we navigate a bulky healthcare delivery system that includes charges from managed care organizations, HMOs, and private insurers and costs for the private payer and still provide patients with the care they require? The interplay between these components and the need for their symbiosis for healthcare delivery is too complicated for even the most robust EMR. Residents and patients in a busy primary care clinic can feel both overwhelmed and underserved. New (and not-so-new) physicians have a limited knowledge of the complicated system that regulates what care patients have access to and of how to facilitate efficient treatment in an environment centered on cost (not necessarily care). The challenge of keeping patients at the center in a rapidly evolving healthcare environment remains.

One of my wisest clinic preceptors always underlined two things: the need to prioritize problems and the power of good conversation. I would argue that ticking check boxes for every screening recommendation and medical item over the span of a few visits, instead of cramming them all into one encounter, is a far better use of time. Learning that your patient can’t make a screening colonoscopy appointment because he doesn’t have transportation is more efficient than referring him multiple times without ever addressing the real problem. Turning away from your computer and talking to your patient (and not just about his diseases) initially might feel far less productive, but a few carefully chosen questions in fact could be the single best way to ensure your patient’s health.

As healthcare professionals, we have to connect with and understand our patients. Only then can we be successful at treating them.

 

One Response to “Barriers”

  1. J. William says:

    And completely ignore what made up the situations in the first place, physician inaction.

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