Collaboration with our colleagues can be one of the most gratifying parts of taking care of patients, especially when things go well. In an idealized world, everybody taking care of the patient, across the entire healthcare team, would communicate with each other about that patient, what we were thinking about, what we were worried about, and what we wanted to put into place to help move them along, and everyone would know what everyone else was doing. These interactions and interventions need to take place at the time of an office visit, but also, significantly, during the massive amounts of time our patient isn't actually sitting there in front of us in the office. For many of us in primary care, the unpleasant end of the collaboration spectrum is often that silly administrative stuff that occurs when we get the message, "Patient saw their cardiologist and you need to put in a new referral for the cardiologist for 10 visits, one for their EKG, one for their echocardiogram, one for their stress test, and one for their event monitor, because her insurance company says these need to be entered not by the specialist who ordered them, but by their PCP [primary care physician]." True, this may alert us to the fact that our patients saw the cardiologist, and we can get a sense of what they needed based on the tests that doctor is ordering, but nothing really replaces the old phone call or email or electronic health record message that gives us a heads up to tell us what they were thinking about and what they wanted to do next for our patient. No Apology Needed I can't tell you how many times I've been paged by the emergency room, about a patient of mine that's there and that they are evaluating, and the first thing the provider does when they get on the phone is apologize. "Sorry for bothering you, Dr. Pelzman, but we have Mrs. Jones here, and I had a few questions about what's going on and what you were thinking, and how we should move forward." Nothing to apologize for there. Even though this may take me away from something else I need to do, this is a doctor communicating with me about my patient, and while I may not have a lot of time to engage in a lengthy discussion, this contact is invaluable, this desire to collaborate effectively, is what is often missing from our healthcare system today. The reasons for this are multiple, and often have to do with how overloaded we all are, how burdensome the life of seeing patients is, how many incredibly annoying rote tasks we have to take care of. The actual chance to sit down and think about a patient, to think about what's going on, and to reach out to others for some insights and opinions, is what we really need and is often missing in our clinical lives. Just the other day, I was paged by a colleague about a patient. The colleague was evaluating the patient for a particular medical concern at my request, and she had hit a wall, a clinical conundrum, a difficult branch point in clinical care, and she felt that she needed some advice. Now, I'm no expert in the field that she works in, and ultimately she's the most qualified to pick an option, the best option, for this patient, but I was both flattered and honored that she wanted my opinion, since I knew the patient so well after taking care of them for over 20 years, and may have something to add to the mix. Rethinking the EHR I remember the old days, at the end of clinic, we would sit down with our thick paper charts in a conference room at the end of the hallway, and talk about the cases we'd seen that day, bouncing ideas off of each other, thinking about alternatives, opening up our differential diagnoses, and generally helping each other out to move the care of our patients along. This is helpful within a practice -- especially if you have access there to specialists and subspecialists -- but in this modern world where we're all so intensely siloed, we've got to figure out a way to break down these barriers and improve the communication and collaboration across primary care and all the other fields of medicine our patients touch and need. Thinking about the best way to accomplish this, in a truly patient-centered way, makes me think that we need to redesign how we think of and use the electronic health record as a place that we all work on this patient in, so that we can more effectively see what each of us is doing, and how it might impact the others, as well as our patient. Every day, I get cc'ed on dozens and dozens of charts, as my patients and the patients of our residents get seen by specialists and others across the institution, and we get their notes back for us to see what they were thinking. But wouldn't it be great if, instead of just copying notes back to each other, we actually communicated? Sometimes my favorite thing is when a surgeon will cc me their office note, but then tag a little personal message onto the end of it, something along the lines of, "Fred, I think she's going to do great with surgery, and I'm going to refer her to our subspecialist group who can help manage this condition after she recovers. Thanks so much for sending her over." Perhaps rethinking the electronic medical record such that the patient sits in the middle, and each of us offers an opinion tagged on to it, so we can all see what we're all thinking, here's what her eye doctor thinks, here's what the neurologist thinks, here's what her cardiologist is worried about, here's what the gynecologist wants to do next, so that we can all see these medical interventions and how they affect our patients over time and space. What We Don't Want As electronic health records evolve, I think it's critically important that we stand up and say we don't want an endless, cluttered, useless collection of data poured on top of the patient at every provider's office they see. When I send the patient to see a specialist, really all I'm interested in is what they think about that particular problem, what they got on history related to that, what they found on physical examination, what testing they did and other tests they recommend, and how they want to move forward to help that patient. When my patient goes to see a urologist, for instance, I have no need to read through a physical examination that says that their head is normocephalic and atraumatic, that their lungs are clear to auscultation, that their neurologic exam is intact. I just want to see what they thought of their urologic exam Sure, if there are things that are related to the implicated body area, pertinent positives and negatives, they can add those in. But a normocephalic and atraumatic head, when you're there about your prostate? Just give me the genitourinary exam. All of this extra stuff has been built up as we have been forced to create a compliant note that clicks all the right boxes and lets us bill at a high level of care, when all it really should be is a communication and collaboration document that answers the questions they were sent there for and offers up an opinion. We need to change the rules so that we can build a better system to more safely and efficiently take care of our patients, and do the work we think we need to do. So give me what I need -- just the facts -- and never apologize for reaching out. Source
