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Fragmented Care Requires Clarification Of Roles By Each Member Of The Medical Team

Jessie GrumanThe most important thing I learned was that different doctors know different things: I need to ask my internist different questions than I do my oncologist.”

This was not some sweet ingénue recounting the early lessons she learned from a recent encounter with health care.  Nope.  It was a 62-year-old woman whose husband has been struggling with multiple myeloma for the last eight years and who herself has chronic back pain, high blood pressure and high cholesterol and was at the time well into treatment for breast cancer.

Part of me says “Ahem.  Have you been paying attention here?” and another part says “Well of course!  How were you supposed to know this?  Have any of your physicians ever described their scope of expertise or practice to you?”

I can see clinicians rolling their eyes at the very thought of having such a discussion with every patient.  And I can imagine some of us on the receiving end thinking that when raised by a clinician, these topics are disclaimers, an avoidance of accountability and liability.

But all of us – particularly those receive care from more than one doctor – need to have a rudimentary idea of what each clinician we consult knows and does. Why is this clinician referring me to someone else? How will she communicate with that clinician going forward? How and about what does she hope I will communicate with her in the future?

Why does our clinician need to address these questions?

Because in the absence of real guidance we will guess.  Some of us will make informed guesses and be mostly right. Others of us will leave our primary care provider in the dust and seek care for routine health matters from our specialist, whom we see more frequently and who seems to know us better. Some of us, like my friend above, will ask for help from whichever physician is handy and will call back, regardless of the problem.  And some of us will throw up our hands in frustration and head for the local emergency department when we find we can’t breathe and don’t know which of our doctors to consult about those damn allergies.

These ad hoc solutions are a waste of our time and surely contribute to a poor use of clinician and institutional resources.

Fragmentation of health care and lack of coordination of services are widely recognized as problems.  Considerable efforts now aim to improve communication among providers when a person leaves the hospital, for example, and great stock is placed in the potential of the new patient-centered medical homes to “coordinate” our care (although the parameters of such coordination have yet to be defined).

There has been little or no recognition, however, of the fact that we patients and our families and loved ones are the main coordinators of all care: We decide when a threshold of discomfort has been crossed and we need professional help.  We decide from whom and in what setting to seek such help.  And for the foreseeable future, unfortunately, we choose to share the test results and treatment plans from one of our clinicians with another – or not.  And we are doing this without guidance.

What would guidance look like?

Well, it doesn’t look like a website.  More likely it has clinicians taking these small steps:

Clearly introducing their expertise, their experience and their role relative to other clinicians caring for us.  This needn’t be highly technical or take a lot of time but it does need to differentiate one clinician’s role from other specialists’ or primary care provider’s, anticipating that I and my caregivers may be confused about which problem is best addressed by which doctor.  Connie Davis, a geriatric nurse practitioner in British Columbia, says, “When I introduce myself to the patients I serve, I say, ‘I’m a geriatric nurse practitioner. Have you ever worked with a nurse practitioner before?’ If they haven’t, I tell them that I am a nurse with additional training, so I am somewhere between a nurse and a doctor and that I work with older adults to address common health concerns and make sure everything is working as well as possible.”

Giving simple but full explanations about referrals: why, to whom, for what, expectations about ongoing care and future communication, both between physicians and between the referring clinician and the patient.  Such an explanation lays out a template for us to more easily find the right solution to the current problem.  Further, many of us assume that because the receptionist uses a computer, our records are automatically electronically (and magically) transmitted to every other physician to whom we are referred.  We can’t do our part to support inter-physician communication if we believe it is being done for us already.

Saying “That’s not my area of expertise.” As someone who is “doctored up” with about 15 physicians treating me right now, I sometimes guess wrong about what any one of them considers within their expertise.  I get a little frustrated but am ultimately reassured when one of them responds to my question with “Not my body part,” or “You need to talk to your primary care provider about that.”  A survey released this week by the National Alliance on Mental Illness found that patients and family members are concerned when their doctors don’t tell them they lack expertise about a condition: 75 percent of parents of kids with mental illness who were surveyed doubt their primary care providers’ abilities to treat their kids effectively.  It’s difficult to establish a “continuous healing relationship,” as the Institute of Medicine report Crossing the Quality Chasm encourages, when questions about clinician competencies are not directly addressed.

Don’t get me wrong. System-level fixes such as  tailored online information, interoperable electronic health records with good patient portals and enhanced primary care will ease some of the redundancy and fill some of the gaps that now by default (and often without our recognition) fall to us to patch together.  But at the end of the day, it’s my mom deciding whether to call the cardiologist, the neurologist, the geriatrician or 911 about my disabled dad’s sudden dizziness.  She’s the one who coordinates his care.

She also needs help from her clinicians to fulfill this responsibility.  As do we all.

*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*


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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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