Friday, October 15, 2004

Colleagues, Conferences, Clinical Guidelines and Communication: Collaborative Medical Practice Today

Mornings are not my favorite time of the day, but I’m finding myself in the cafeteria before 7:00 AM several days a week now. No, I’m not getting coffee before an early shift, but I am doing so before the Surgery Morbidity and Mortality or Multi-specialty conference or just sitting down with a pack of proceduralists in radiology, GI, cardiology and other specialties.

I started back at this ritual, one I undertook for several years when I first started at Maimonides because I was hearing a growing number of complaints about our practice. Several physicians complained about the number of unnecessary cardiac enzyme studies drawn at triage, another complained about the one set of blood cultures rather than two, a third complained about antibiotic selection. What’s going on here?

In addition to breakfast, I went to meetings with the complaining physicians and the Chairman of Medicine. I went to meetings with the Chairman of Pediatrics and his staff. Our COO visited with physician staff and shared his observations about the complaints. At the sessions I attended, I listened, I took notes and mostly I heard about communication. Listening to the anecdotes and recounted (one-sided) telephone conversations, I realized that our colleagues were focused on their one patient, while our attending (or resident) was often distracted by other concerns and information even when they were on the telephone. Or worse yet, the call was “intended” but never completed.

I’m not saying that the clinical concerns originally raised as the issue don’t have merit and aren’t happening. In ~46,000 adult visits and ~20,000 admissions, more than 20% over age 65, I’m sure that clinical errors have and will happen. The real problem is that our admitting physicians don’t know our emergency physician staff well enough. It is a huge medical staff with over 400 internists and we’re a group of more than two dozen, but that’s no excuse. Sure we’re distracted and constantly interrupted while working in the ED; “You chose that practice,” our colleagues remind us.

Where would you go from here? I’m interested in your ideas since as leaders and members of your practice you’re challenged to introduce your newer colleagues to long-time medical staff members.

The usual advice we’ve all taught and heard is that the relationship between emergency physician and voluntary primary care physician is formed over the patient. Certainly this was my experience. Today, with most physicians in the hospital less, the telephone has become more important, perhaps we should train our emergency physician staff for telephone communication.

One thing I see, is as hospitalist practices develop and solo and small group practices diminish in number, my emergency physician colleagues are focusing on those physicians they see the most. Perhaps this is an artifact of our community teaching hospital and those of you practicing in non-teaching hospitals continue to see your primary care colleagues regularly. I’m sure diverse practice environments and hence professional relationships with colleagues foster different approaches to the problem.

We’re going to use the regulator’s growing evaluation of adherence to practice guidelines as one tool for improving communication. I’m not quite clear on the details—in fact we’re still working them out—but reminding colleagues of the JCAHO “Core Measures” for pneumonia (Figure 1) which includes evaluation of the timing of antibiotic administration allows us to put the emergency physician on the same team as the internist who is charged with assuring pneumococcal and influenza vaccination among other requirements. It will also present an opportunity to suggest that if they prefer a different antibiotic, they need not continue the antibiotic we’ve started—a choice we make using our infectious disease division’s recommendations as built into our ordering pathway.

I’m hoping that we can pull together a joint conference on the combined emergency department and inpatient management of the several core measure related disease processes we care for together: pneumonia, myocardial infarction and heart failure. Discussing our processes may enable learning that can improve the way we work, but will at least develop an appreciation for the difficulties we each face in our own clinical milieu.

With these efforts we’ll have precipitated a discussion around clinical pathways which is a pretty good place for physician colleagues to start learning about each other. Certainly it will be more productive than arguing over the timing of calls for notification of patient admissions.

If you’ve been coping with similar challenges I’d love to hear from you. Please share your problems and solutions with me by email and I’ll share them with all readers if you’ll let me.

In the meantime, I expect I’ll be dragging myself to surgical morbidity and mortality conference on Friday mornings at 7:00 AM for many years to come.

Figure 1. Pneumonia Core Measure as of April 2004

  • Oxygenation assessment

  • Pneumococcal vaccination

  • Blood cultures

  • Adult smoking cessation advice/counseling

  • Antibiotic timing

  • Initial antibiotic received within 8 hours of hospital arrival

  • Initial antibiotic received within 4 hours of hospital arrival

  • Initial antibiotic selection for PN immunocompetant – ICU

  • Initial antibiotic selection for PN immunocompetant – Non ICU

  • Influenza vaccination

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