Nothing Much to Lose

Reading the ER Stories blog is often a guilty pleasure for me. Today's post, however, struck a nerve: 

Very often I ask patients about their recent visits to other doctors.  While I am taking a history, it’s important for me to know if you’ve recently been seen by another provider for the same or similar complaints and what they did, what they diagnosed you with, what they prescribed, etc.  
I often get a kind of irritated response such as “Oh, he didn’t do anything” or “he said it was nothing” or “he didn’t say anything to me”.  Although I know my share of layzee doctors, I bet the vast majority of times, the doctor DID do something and DID say something.
Just not what the patient either wanted to hear or that their perception or comprehension was wrong.  ...
... Now, maybe he is not a good communicator. Maybe he doesn’t have the time to sit there and explain the pathophysiology of viruses or something like benign peripheral vertigo  – and thus you feel short changed. After all he “just asked me a few questions, listened to my lungs and told me to go home and rest”.
Early on in my training I was fortunate to be taught that proper communication is the responsibility of both doctor and patient. So when a patient shows up in my ED and says their last doctor "did nothing"  -- when I can see with a few clicks that they got labs, a CT, and two prescriptions -- well, there's a failure to communicate. And the other doctor carries at least some of the blame for this.
Certainly, the patient is dissatisfied (because they're still seeking care, in an ED). You could argue that they're consciously downplaying what was done elsewhere in the hopes we enthusiastic ED docs can take a fresh look at the case. Maybe that's it -- but I bet from the patients' perspective, since they've still got a complaint, they've figured that nothing successful was done. 
From the ED physician's perspective, however, ruling out a bunch of life threatening conditions is a success. Or at the very least, not nothing. Same with providing symptomatic relief until clinic followup.
Communicating this to patients takes time, and constant effort. So many things in the department are working against a meaningful conversation about the visit -- the interruptions, the stress, the duty to document. Even discharge, which should be a chance to clarify and communicate, is often a rush job. A colleague of mine has a first-author paper in Annals this month, on what gets said when discharge instructions are provided. The sobering stat: 
"Only 22% of providers confirmed patients' understanding of instructions."
I would have thought that the emergency medicine, which is gifted with so many talented bloggers and podcasters, would do better at communicating with patients. If comprehension of discharge instructions is so infrequently done (and there's supporting evidence), it's not hard to imagine how hours of complex diagnostic workup gets interpreted by the patient as "the doctor did nothing."

What can help reverse this situation? I don't want to be Johnny-One-Note with my espousal of technology, but the iPad is proving helpful in reviewing a visit with a patient, at the bedside. You can go over lab reports, show x-rays, and clarify prescriptions before they're printed. I think it seems more tangible to the patient than just saying "everything came back normal."

Even the iPad, efficient as it is, requires time. And there are certainly some shifts where time isn't readily available. So another thing some of my friends in EM have done is share their email addresses in discharge summaries, and invite followup questions on their care.

This used to give me pause, for a lot of reasons. But when I think about the fair chunk of my non-clinical time I spend on quasi-medical communication -- to colleagues, in print, and on blogs and social media, I've got to ask: what kind of communication is most important? Wouldn't some of that time be better spent going clarifying care, with my patients?

After all, while composing this blog post, plenty of people could say "this doctor did nothing."