Everyone talks a lot about communication among members of the healthcare team, but usually they’re referring to communication between doctors and nurses. In my experience, most doctors do a decent – or at least a passable job – at this, since you usually have to tell the nurse what needs to be done in order for it to happen. Also, as in the old military paradigm, the troops do a better job if they know what the plan is, so they can make intelligent adjustments to unexpected circumstances.
I’m a little more puzzled by the communication between different groups of doctors – or lack of communication. It’s not at all uncommon for an ICU patient to have anywhere from three to six different specialists “following” him (I always cringe when I write that – it sounds like a stalker is loose in the hospital), and floor patients, if complicated, will have their own small entourage. These specialists rarely talk to each other, or even to the primary (ie, admitting) service. They all round at random hours of the day, and leave notes in the chart, and expect these notes to enlighten everyone else as to their thoughts.
Of course, since the notes are illegible, no one is very enlightened. I’ve decided that it saves time not to try to read the subjective part, or the physical exam, or the labs. If I can just sort out a few key phrases in the plan section of the note – continue, stop, start some medication or other – I’ve got enough to report on. Then, if I can figure out the signature, I can even tell whom I might page if I have urgent questions. It’s gotten so I recognize the handwriting of all the ID specialists (I think the whole group buys special pens), the critical care attendings we see most often, and the endocrinology and urology PAs. For the rest, if I recognize what their plan is, it might give me a clue as to which specialist would be interested in that subject, and then I see if the operator knows which resident is involved with that specialist.
The only times we actually talk to each other are as follows: 1) Two attendings meet each other at lunch; in this case they will discuss the patient in detail, and mysteriously produce a plan, and then blame their residents for not acting on it, already. 2) An attending decides to round so early that his path and mine actually cross, in which case I’ll ask a great many questions, for my education, and to figure out the plan. This is indeed very informative, but if I don’t time it just right, I won’t see him the next morning, and so will lose track of his plans. 3) There’s something so critical going on that I play tag via the operator, paging every resident and fellow who seems connected to the attending we originally consulted, until I track down someone who knows what the plan is. 4) The consulting service has such an important idea that they page me to tell me to act on it. This is fairly rare, and usually annoying when it happens: is it really that much simpler to page the intern to tell me to write orders, than to just write the orders yourself? But I’m glad to hear from them, so I don’t complain.
My approach is: 1) To write very neatly. I actually scare myself because mine are almost the only legible notes in the chart, so everyone always reads mine for information, and I can only hope that I’ve correctly interpreted and quoted everyone else’s chicken scratch. I would hate to be the only person the lawyers can pin down as saying xyz. But at least no one is in doubt as to what I thought; my attending may have thought something different, and his note below mine may be a beautiful arabesque of loops and squiggles; but my plan is what counts, since that’s what everyone reads. 2) To call other services quickly when I have questions, and especially when we have any plans for patients who are admitted to a medicine service. I can only imagine how frustrating it would be to come in and find that the surgeons have kidnapped your patient into the OR, so I try to let them know what our plans are. 3) To hang around the patients’ rooms whenever feasible, since this makes it more likely that I will actually catch the other services as they round.
I’m not sure what better approach there could be. Legibility is the holy grail of medical records – desirable, and unattainable. But at least one’s pager number should be written legibly, so it’s not such a daunting task to track the writer down and ask what he was thinking – or some other diplomatically worded question which doesn’t imply that the time spent writing in the chart was worthless. (Also, this is where talking to the nurses comes in handy. If everyone talks to the nurse, she (or he) then serves as a repository of easily accessible information – if you can find the nurse. Sometimes this is easier than finding the chart, other times vice versa.)
Oh yes. And everyone politely writes at the end of their note, “appreciate consult,” or “appreciate cardiology input,” or “will follow endocrine’s recommendations.” At least we’re courteous in our illegibility. (Sometimes this helps because you know what letters have to be involved there, so, like the old codes, you can extrapolate back to the main body of the note.)