To Call, or Not to Call? Collaborative Communication Across Medical Specialties

Daniel Kent Cassavar, MD, MBA, FACC, Medical Director, The Doctors Company and TDC Group

ARTICLE AT A GLANCE
As medical knowledge sprints ahead, we can increase safety and manage clinician workload by collaborating with colleagues in other specialties to plan when, how, and why we refer and consult.

Patient A is 68 years old, has a known history of coronary disease, and had a stent placed years ago. Their blood pressure is high, and their cholesterol is not ideal.

Patient B is an 18-year-old athlete who just survived a car crash with minor injuries.

Let’s say that Patient A reports to an emergency department with chest pain: Their history should ring bells in a practitioner’s head that are different from the bells that ring when Patient B experiences chest pain. The emergency medicine practitioner may say to themselves, “I don’t have labs back, but they’re the right person singing the right song. I’m going to get ahold of the cardiologist sooner rather than later. We just talked about this scenario last week.”

That thought—“We just talked about this scenario last week”—is one I’d like us all to have more often. We can help improve our patient care if we proactively illustrate for our colleagues in other specialties which scenarios warrant immediate action, and which don’t.

Swimming Through a Flood of Information

It was once projected that beyond 2020, medical knowledge would double every 73 days. Even if new scientific discoveries are overturned as quickly as they’re found, it should be clear that none of us can stay afloat alone.

As medicine evolves, we can revisit our shared expectations with colleagues in other specialties: What are the clinical indications that a patient should be referred on an urgent or emergent basis, rather than on a more relaxed timeline? By mindfully adjusting our thresholds for urgent communication, we can foster more cognitive bandwidth for ourselves, with greater safety for patients.

Although our collegial conversations may be ad hoc and informal, we can craft our mindset for these interactions out of the same ingredients as formal risk management programs. Specifically, we can draw from the principles for conducting a successful root cause analysis.

Root Cause Analyses and Actions, or RCA² (“RCA squared”), created by James P. Bagian, MD, PE, member of The Doctors Company Board of Governors, and promoted by the Institute for Healthcare Improvement, abandons vagueness and blame in favor of identifying and acting upon specific solutions—especially to systems-level problems. RCA² also modifies the meeting process to reduce distress for participants, which in itself facilitates greater participation. RCA² has inspired many related efforts.

One hospital is conducting root cause analyses of their root cause analyses, because an RCA of RCAs (another form of RCA²) draws connections between events in order to see patterns and address systems safety issues. I’m all in favor of this approach.

A Mindset for Risk Management, Together

The same broad principles that guide RCA² and related efforts can guide our successful collaborative communications with colleagues (CCC). We can call them C³, or “C cubed.”

Right people in the room: If we find a root cause of events, we want someone at the table who can deploy ways of protecting against it.

C³: Pause to ask: Who is actually the best contact? If I’ve been receiving repeated middle-of-the-night phone calls regarding patients with routine complaints, I might wonder: Who is directing that I be called at 2:00 AM? Is this timing for perceived patient urgency, or to complete documentation? Is someone confused about the clinical indications for an urgent referral? If so, who?

Right atmosphere: We’re trying to learn, not to reprimand. This understanding grounds any examination of a safety event, whether an actual event, a near miss, or just two clinicians who’ve been talking past each other. Unfortunately, many clinicians have reported a safety concern at their organization, only to receive a reprimand. The adversarial relationship this creates between healthcare system leaders and frontline clinicians dampens reporting and hampers solution-finding.

C³: Take a breath. Although frustrations may run high, start with the question: Why is this happening? We can only end the frustration once we find the answer.

Right confidentiality: A proper patient safety conversation is not an exercise to find out who did wrong, so we can see who will get sued. Confidentiality ensures that we’re going to talk about things so that we can learn—not so that we can be punitive. The minute it becomes punitive, we lose our audience, because the people who were involved in whatever happened don’t want to discuss it.

C³: Indicate to your counterpart that you’re seeking them out to make life easier, not to make trouble.

Right cycles: Create positive feedback loops, not negative feedback loops. Trust is earned over time—practitioners will bring concerns where previous concerns have been well received.

C³: Focus on the feedback loops that occur between clinicians. We can each become a person others find easy to approach.

For instance, I’m a plumber: I fix arteries. When I see patients with serious rhythm disturbances, I refer those patients to the electricians of the heart, the electrophysiologists. When they call me back after reading my notes, sometimes it sounds like they want to say, “What were you thinking?” But they at least don’t say this aloud.

Here we are, all cardiologists, but in medicine, we now possess so much knowledge on each topic that we’re becoming sub-subspecialists, and we need to remember that when we communicate with each other.

Cultivating a Culture of Respect

Emergency room physicians know many disease states, and they’re trying to put out a lot of fires at the same time. The same goes for the nurse in a step-down unit who is juggling one patient with cholecystitis, one with fractures, and one with urinary retention—it doesn’t help when calling a specialist results in a blowup. Nurses are likewise trying to manage multiple issues and do a good job.

Primary care physicians (PCPs) are also managing a variety of patient situations. When specialists provide swift and respectful responses to PCPs, we create positive feedback loops, and our patients benefit. Recently, a PCP requested my input regarding our shared patient’s arthralgias and myalgias, which appeared to be a medication side effect. She proposed a series of steps toward an alternate prescription, and in moments, I had confirmed my support for this plan. This PCP and I can easily collaborate in the future, and the patient can experience relief.

Still, in spite of best efforts, not everything goes according to plan. When we see evidence of confusion or miscommunication, we can take a moment to reflect—which will be an ongoing process for all of us, regardless of expertise or years of experience, because healthcare is changing so fast that we’ll have to continuously recalibrate, whether we want to or not.

When We Know Things Can Go Better

Although full RCAs are still needed, we should not overlook opportunities for small, friendly conversations. Collaborative communication with colleagues helps us move toward increased safety for patients and sanity for ourselves. These conversations are an integral part of building our culture of collegiality and respect.

We will have many small moments of reflection along the way where we say to one another, “You know, that could have gone better.” If I receive a call from a colleague asking me to reconsider the clinical indications for referral, there’s no need for me to take this feedback personally. The ground keeps shifting under all of our feet. Let’s rely on each other and realize it will lead to better patient outcomes and less clinician burnout.

The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.

The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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