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Finding the elusive Dr. X

March 2010

One of the issues I believe many of us confront concerns the infamous order: “D/c home if OK with Dr. X.”

Those of us familiar with this practice know that “X” is a big variable. X could be the pulmonologist, cardiologist or any “-ist” in the hospital who may have been involved with a case. Occasionally, X is plural, which serves to only complicate matters even more.

Often, X is just the first factor in a complex algorithm that may run something like this: “OK to d/c if OK with X,” followed by “X is OK with d/c if and only if Y & Z will sign off on d/c.” That often means that, “Y & Z will sign off if A & B do so as well,” is fast on its heels. By the time you reach the endpoint, the original equation may have completely changed: The patient may have acquired a nosocomial complication, which means that an equally complex formula–with entirely new variables–must be put in place.

I believe that the driving force behind this Rube Goldberg-like math, at least as far as my experience is concerned, is a culture of poor communication that is so endemic in health care.

In fact, as we all know too well, poor communication is not limited to discharge orders; indeed, it permeates all aspects of patient care. It is remarkable that, in a field where communication is so critical, communication breakdowns are so often the norm, no matter where a program is located or what its make-up is.

Every lecture I have attended on this subject offers the airline industry as a model of effective communication protocol, the foundation for an excellent safety record. Although I have never worked in air traffic control or landed a plane, I suspect that is a fair comparison. I’m sure very few control towers issue the following order: “OK to land on runway 4, if OK with Fred when he gets back from lunch.”

So, how do we improve the system? Perhaps the most important step is to ensure that communication is easy.

Most of us at present operate in an inefficient system, with too much room for crossed or missed signals; when we ask for Dr. X, we have him or her paged to a phone, holding us captive to that phone until Dr. X calls back. To resolve this waiting game at my program, we have ordered in-house phones that all the hospitalists can carry, in addition to pagers. Now, we can page the physician directly to our phones, making it easier to get a direct, fast connection.

The second step on the path to improving communication is a simple one: recognizing that good communication begets good communication. I find that the more we talk to consultants, the more we foster collegiality–and the more frequent and productive our dialogue becomes. In my experience, good communication among hospitalists, consultants, and the case management and social work teams stands as the No. 1 way to reduce length of stay and ensure quality care.

Here at Virtua, we put in those calls to specialists and hold regular meetings with case managers and social workers. Even more importantly, we’ve made it clear to case management that they should call us at any time to comment on a patient’s condition or to ask questions. We’ve also started care coordination rounds that involve every member of the health care team. Too early to know for certain if the program is a success, but the early dividends look promising.

All told, I hope that these changes, along with any others that we devise, will improve communication within the hospital. On the one hand it seems so simple. Yet I am reminded of this deceptive simplicity when watching my son play the game in which he and his classmates sit in a circle and whisper a sentence into each other’s ear, only to find the final version does not remotely resemble the initial one. Why is it that the simple things are always so complicated?