Resources & Information

Since beginning publication in 1996, the Forum has featured numerous articles on the importance of effective physician-patient communication. There is, however, another aspect of communication that has not received sufficient attention, but has even greater potential for resulting in bad patient care. This is communication among physicians and their professional colleagues.

The Joint Commission Sentinel Event database suggests poor communication contributes to nearly 70 percent of sentinel events, surpassing other commonly identified issues such as patient assessment and procedure compliance. Other studies have demonstrated that poor teamwork was the predominant cause of preventable quality of care problems and malpractice claims.

Effective communication is the foundation of any healthcare team. Conversely, poor or nonexistent communication among health care professionals can negatively impact patient care, as the following examples illustrate.

Example 1
An elderly, but otherwise generally healthy patient was referred to and admitted by a hospitalist service for evaluation of a possible TIA. During hospitalization the patient was found to have a moderate degree of anemia, which was attributed to chronic iron deficiency. The patient’s neurologic condition rapidly improved. At hospital discharge, two days after admission, prior orders for stool occult blood testing had not been completed. This went unnoticed by the discharging physician, who had not admitted the patient nor ordered the stool occult blood test. The patient was instructed to call her primary care physician for follow-up of the anemia. No direct communication with the primary care physician about the anemia or need for follow-up evaluation occurred, and the patient later indicated she did not understand what required “follow-up.” When the patient called her primary care physician for an appointment she was asked if her speech and numbness were improved. After replying “yes,” the patient was scheduled to be seen in one month. Records from the recent hospitalization were not reviewed, and the primary care physician remained unaware of the patient’s anemia, which had not been previously identified. One week later the patient was re-admitted to the hospital for an acute life threatening GI diverticular bleed. No direct communication occurred at any time among the various physicians caring for this patient.

Example 2
A 58-year-old underwent a seemingly uneventful radical prostatectomy. Postoperatively the patient was stable, although there was elevation of his creatinine levels, which was thought possibly to be due to the combined effects of prerenal and medications. On postoperative day three, the patient’s care was turned over to the covering weekend physician. If concerns regarding the elevated creatinine were discussed at hand-off, it was not documented. Although the patient had complaints of abdominal pain over the next two days, it was not felt to be out of the ordinary and he was only seen very briefly by the on-call physician. No mention of the elevated creatinine was made. The patient was discharged over the weekend by the on-call physician without instructions for follow-up of creatinine levels. The patient later returned with increasing abdominal pain and renal failure. He was found to have a ureteral obstruction. A professional liability payment was made in the names of both physicians.

The Board has highlighted the importance of adequate communication among health care professionals by adopting a position statement on the subject in January 2010. The statement, entitled Collaborative care within the healthcare team, recognizes that the manner in which licensees interact with professional colleagues can significantly impact patient care. Further, it notes that miscommunication among physicians and others involved in treatment results in avoidable error, patient harm, malpractice suits, and not least, complaints to the Board from patients and physicians that have the potential to result in disciplinary action.At the same time, it would be naïve to suggest that improving communication across the health care team can be easily accomplished.

Increasing, indeed seemingly endless, demands are being placed on physicians and other health care professionals that do not contribute to a culture of collegiality and effective communication. There are significant, and at times seemingly deliberate, barriers to communication at all levels of patient care. Accordingly, physicians are frequently required to deal with frustrating communication problems. Stress, exhaustion, professional dissatisfaction and even depression are additional impediments to effective communication among colleagues.

Barriers to effective professional communication exist at multiple levels. For instance, lack of a suitable location or process to exchange up-to-date, crucial information at the time of patient hand-off or transfer is a common barrier. The Board encourages licensees to promote an effective communication environment and to support their hospital, practice or other health care organizations in identifying and correcting circumstances that lead to poor communication.

Other instances of poor communication are related to individual physician behavior. Chronic inability to communicate is a form of disruptive behavior, and this behavior should not be ignored. If a physician cannot address the problem with his or her colleague on a direct basis then the physician should discuss his or her concerns with persons better positioned to deal with the problem. This may be other physicians or the medical director of the facility or institution involved. If the physician with the communication issue is felt to be otherwise impaired, an informal discussion with the NC Physicians Health Program may provide useful guidance.

Other problems that lead to miscommunication include use of nonstandard terminology, informal, rushed or inattentive interaction during hand-off or transfer, including at hospital discharge, and simple lack of coordination of care. Use of a standardized form of communication, possibly through the use of checklists that provide a common and predictable structure regarding patient circumstances, should be considered. The emphasis should be on unequivocal transfer of, and acceptance for, patient care responsibility.
When errors of communication are discovered, the error or misunderstanding should be addressed immediately and corrected.

Of course, effective communication involves more than interactions with other physicians. Inextricably linked with effective communication is a culture that promotes respect, value and appreciation for the work and skills of all team members. Physicians must communicate with and demonstrate respect for other health care team members, across all disciplines. All members of a health care team should be encouraged to participate in the exchange of information regarding a patient’s care.

Improved communication is not easy. Barriers to communication are difficult to overcome and improvement requires sustained effort.

Improving collaborative and interactive communication will strengthen relationships with colleagues, enhance professional satisfaction, improve patient care outcomes and reduce the likelihood of litigation and Board scrutiny.

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NCMB POSITION STATEMENT
Collaborative care within the healthcare team

The North Carolina Medical Board (“the Board”) recognizes that the manner in which its licensees interact with others can significantly impact patient care.

The Board strongly urges its licensees to fulfill their obligations to maximize the safety of patient care by behaving in a manner that promotes both professional practice and a work environment that ensures high standards of care.

The Accreditation Council for Graduate Medical Education highlights the importance of interpersonal/communication skills and professionalism as two of the six core competencies required for graduation from residency. Licensees should consider it their ethical duty to foster respect among all health care professionals as a means of ensuring good patient care.

Disruptive behavior is a style of interaction with physicians, hospital personnel, patients, family members, or others that interferes with patient care. Behaviors such as foul language; rude, loud or offensive comments; and intimidation of staff, patients and family members are commonly recognized as detrimental to patient care. Furthermore, it has become apparent that disruptive behavior is often a marker for concerns that can range from a lack of interpersonal skills to deeper problems, such as depression or substance abuse. As a result, disruptive behavior may reach a threshold such that it constitutes grounds for further inquiry by the Board into the potential underlying causes of such behavior. Behavior by a licensee that is disruptive could be grounds for Board discipline.

The Board distinguishes disruptive behavior from constructive criticism that is offered in a professional manner with the aim of improving patient care. The Board also reminds its licensees of their responsibility not only to patients, but also to themselves. Symptoms of stress, such as exhaustion and depression, can negatively affect a licensee’s health and performance. Licensees suffering such symptoms are encouraged to seek the support needed to help them regain their equilibrium.

Finally, licensees, in their role as patient and peer advocates, are obligated to take appropriate action when observing disruptive behavior on the part of other licensees. The Board urges its licensees to support their hospital, practice, or other healthcare organization in their efforts to identify and manage disruptive behavior, by taking a role in this process when appropriate

(Adopted January 1, 2010)