Safety of care
Improving communication between physicians
An article for physicians by physicians
Originally published June 2011
Communication forms the basis of every relationship, and the basic components of communication — effective speaking and listening, feedback, non-verbal signals, and emotional effect — all pose their own unique challenges. Effective verbal, non-verbal, and written communication can optimize patient outcomes.1
This case illustrates various communication challenges that can occur between physicians.
At the end of the day, a mother arrived home to find her 14-year-old daughter had a pain in her right eye, nausea, and vomiting. The girl wore contact lenses and glasses, and her family physician had warned that she might encounter problems. Their family physician's office being closed, the mother took the girl to a walk-in clinic. The clinic's family physician took a history and thoroughly examined the eye although she was not able to use a slit lamp as the clinic was not equipped with one. Using fluorescein/cobalt blue she detected a small lesion, at 11 o'clock away from the visual axis. She called the nearest hospital and spoke to the on-call ophthalmologist who told her to send the patient to the emergency department. After faxing the patient's history and physical assessment to the emergency department, the physician checked to ensure the transmission was successful. She told the girl's mother that the ophthalmologist had been contacted and "everything would be taken care of." She documented the visit and the discussion.
At 7:30 p.m., the girl and her mother arrived in the emergency department. The patient's symptoms were unchanged. At 8:30 p.m., the triage nurse examined the patient and wrote the following in her notes: acuity 20/40 in both eyes, Ø glasses. She then put her in a regular exam room as the eye room was occupied. The fax from the clinic physician was not attached to the patient record.
At 10:30 p.m., the emergency physician saw the patient. The mother informed him her daughter had been examined by a family physician at a walk-in clinic. She said the family physician had faxed the girl's history and physical assessment to the emergency department, and they were there to see the eye specialist. The emergency physician, who was tired after working a full shift, commented, "Who do they hire at these walk-in clinics? Can't anyone make a diagnosis?" Before he could complete his examination, he was called away to a trauma case. He returned at 11:00 p.m. Ophthalmoscopic examination with fluorescein showed a small punctuate lesion at 11 o'clock. The abdomen was soft. The emergency physician diagnosed a corneal abrasion and gastroenteritis, and prescribed ophthalmic drops and clear fluids. His discharge instructions, which were not documented, were to see the family physician if there was no improvement.
Four days later, the girl returned to the emergency department with a bad eye infection. She was examined by the ophthalmologist who disparagingly asked why he hadn't seen the patient earlier. The ophthalmologist noted the patient now had 20/400 acuity. He took a culture and arranged for antibiotics. Nine months later the patient required a corneal transplant.
A legal action was started naming the walk-in clinic family physician, the emergency physician, and the hospital. The walk-in clinic family physician was dropped from the suit when it was shown she had undertaken a thorough examination, had verbally contacted the on-call ophthalmologist, had faxed the documentation, and had carefully documented her care in the patient's medical record. The CMPA settled on behalf of the emergency physician with a contribution from the hospital for the failure to produce the fax from the clinic family physician. The fax was later found buried in paper at the back of the emergency department.
CMPA's research findings
A review of the CMPA's files found that communication problems led to delays in assessment and diagnosis, failures to identify the most responsible physician, inadequate monitoring of a patient's condition, failures to follow up on investigations, inappropriate treatments, and inappropriate conduct and behaviour. Inadequate communication between physicians occurred most often during patient handovers, diagnostic investigations, and treatment plans.
Regardless of the experience or type of practice, communication between physicians should be clear, comprehensive, and timely.
All physicians should encourage open, respectful, collegial, and professional communication. Active listening, including acknowledging the ideas and emotions of others, is an important communication skill. It is also a good idea to summarize or read back key messages, particularly when there are language barriers or significant differences in communication style.
Handover of care
The transfer of responsibility for some or all aspects of care includes handovers for discharge from care, transitions in care, shift changes, and holidays.
Potential barriers to effective handovers include communication impediments (e.g. hierarchy, language, communication style). When possible, care handovers should be face-to-face and focus on the transfer of key information such as the patient's diagnosis, test results, and treatment plan. Particular care should be paid during end-of-shift, end-of-day, and end-of-week periods when time pressures and fatigue may be greater. Strategies to overcome these barriers include spending time on the patients with the greatest needs, limiting noise and interruptions, using face-to-face verbal updates that allow for questions and read-back, and the use of standardized templates or communication approaches.
In high-risk situations such as clinical crises, emotional or distressing situations, and conflict, physicians should place particular emphasis on clear, comprehensive, and timely communication.
Structured communication tools can encourage the transfer of information. Physicians should also consider communication techniques to escalate concerns across authority levels or gradients to match the seriousness of the clinical situation2.
Communication between referring physicians and consultants
Poor communication between referring physicians and consultants can lead to disruptions in continuity of care, delayed diagnoses, unnecessary testing, iatrogenic complications, and frustrated physicians and patients.
Challenges to effective referrals and consultations include lack of time; unclear reasons for referral; failure to include key information or investigative reports; patient self-referral; and disrespectful, inadequate, or missing consultation letters. Appropriate communication between referring and consulting physicians can make care safer. Referring physicians should be aware of the core elements of a good referral, including information about the problem; the clinical question to be answered; patient details; and relevant investigations, treatments, and medications. Consulting physicians should provide answers to the specific questions. A management plan, including designation of the most responsible physician for follow-up management of the patient, should also be provided. Using templates for referral letters and consultation reports may enhance communication3.
Given the link between referrals and wait times, members may wish to consult the CMPA publication, Wait times: A medical liability perspective. This resource includes recommendations for referring and consulting physicians regarding medical liability considerations related to treatment wait times4.
Commenting on the care provided by colleagues and other healthcare professionals
A single, thoughtless comment often forms the basis for dissatisfaction and complaints by patients and their families. Physicians should never insult other physicians (or any other healthcare professionals) by using disparaging comments or behaving dismissively.
Feelings of intimidation may stem from fear and a lack of understanding of one's rights and responsibilities. Physicians are not immune to intimidation and it can affect their ability to practise. While patients and family members may be sources of intimidation, most of the calls the CMPA receives about intimidation involve physician-to-physician conflict.
Physicians need to understand the environment in which they are practising, and ensure their own behaviour does not contribute to conflict or intimidation. When feeling intimidated, physicians should remain calm and professional, evaluate the situation to identify what the issues are, and deal with others respectfully.
Talk to the CMPA
If you, as a CMPA member, have specific concerns about intra-professional communication, you should contact the Association for advice. The medical officers will be able to discuss the case with you and provide appropriate guidance. We encourage you to call us at 1-800-267-6522 or submit a medico-legal assistance/web mail form available on our website at cmpa-acpm.ca. You are also encouraged to review previous CMPA publications about effective intra-professional communication (click on the Education link on our website).
1. Frank, J.R., Brien, S., (editors) on behalf of the Safety Competencies Steering Committee of the Canadian Patient Safety Institute, The Safety Competencies: Enhancing Patient Safety Across the Health Professions, 2008
3. The College of Family Physicians of Canada, The Royal College of Physicians and Surgeons of Canada, Guide to Enhancing Referrals and Consultations between Physicians, October 2009
4. The Canadian Medical Protective Association, Wait times: A medical liability perspective, 2007 14pp