Communication Problems

I was reading a post at this blog and thought I would make a comment on it here. I would have left a comment on that site however every time I have attempted to comment there the comment mysteriously disappears. It's not that I am accusing the blog owner of removing my comments it's probably some local temporal anomaly in the Interwebtubes as the senile Senator from Alaska would say.

We all have issues with communication when it comes to patient care. The first problem I can identify is that the patients often lie to the providers. This is compounded by the patients telling the nurse one story and the doctor another story. This is especially problematic for me as I have "Nurse Practitioner" in the title of my credential. The patients get as far as hearing the term "Nurse" and don't hear or understand the second part of the credential. Patients assume that they are going to be seeing the physician and only tell me a portion of the story. In my practice setting that could mean they are going to have to wait sixty days before they see the physician to tell him their story.

The reason it might be sixty days before they see the doctor is that I practice in Long Term Care (Nursing Home) which is really a misnomer because my patients die at a rate of 25% per year nationally.  Statistically my patients live an average of 2.8 years from the time of admission.

The post I linked to above discusses communication between physicians, NP's and PA's and the lack thereof. A question that comes to mind and one I cannot answer is; do doctors prefer to speak to an NP or PA who knows the patient well or do doctors prefer to speak to the attending even if they only have a cursorily knowledge of the patient?

In my practice setting I am usually the one seeing the patient and ordering and interpreting the tests and making the decision when and who to send the patient to. I don't have the luxury of having a unit secretary or even a case manager to make the numerous tedious phone calls necessary to get a patient seen by another provider. What I have found is that it is nearly impossible to get some physicians on the phone when I have called their office to give report on a patient. If I'm lucky there may be a NP or PA willing to listen to report on the patient but that is also a rarity. The company I work for has a policy that when sending a patient to the Emergency Room we must call the ER and give report on the patient. In two years I have been allowed to speak to a physician once and a Nurse Practitioner once when I have called the ER to give report.

At one point I followed the ambulance to the ER and went inside to give report to the physicians on a fairly complicated patient. I stood directly in front of the Physicians and both of them refused to speak with me because I am a Nurse Practitioner. I no longer send patients to that ER even though it is listed as a "magnet" facility.

When I send a patient out I try and write a note detailing what has been done to that point whether they are going to an ER or for a specialists visit. I include my cell phone number and a "Please call with any questions" comment. Occasionally I will receive an angry call from a physician asking why I didn't send the patients list of medications etc... I gently ask them to speak with their MA and ask them what they did with the packet of information I sent along with the patient. Many times I have heard rustling after requesting this and then a curt "never mind" followed by a quick hang-up. But calls from the provider from an office setting are rare and dictation or notes from the visit are even rarer. Most of my patients have some kind of dementia or other memory problems and don't remember what the provider at the office was going to do. I end up having to call the office and beg them to send me the notes so I can follow along with the plan. That is unless it's an Eye doctor, it's impossible to figure out what they are doing even with the notes.

*Side note

If you work in an office it is not necessary to get a release of medical records to send the notes to the referring provider.

From A Chance to Cut speaking of NP/PA's

"This is a beef I have with some physicians who utilize them, IMHO, in an unprofessional manner. The basis of this is the growing (some may say epidemic) communication problem among physicians today. We don't talk to each other. It is a rarity that I receive a call from a physician asking me to consult on a patient. More often a clerk calls me or my answering service. In fact some physicians act irritated when I ask for them to call me to discuss the patient."

While one could pick this apart and manage some faux insult out of it I have to agree with him. I have many times been put in the position of speaking with a physician about a patients care or presentation when it should have been the attending speaking with them.

In answer to his question "Am I being petty" I would say no. There are things doctors do and there are things PA's and NP's do. Some of these things we all do, and some of these things I feel only physicians should be doing. It is that last category I feel needs to be confined to physician to physician consultation though I would have to be living in an alternate reality to believe we are going to go back to that type of a health care system.