Lack of communication skills in medical profession?

Pre-Med & Medical School Pre-Med Topics
1

<p>I have worked in an emergency department (regional trauma center) as a secretary for a couple of years and am applying to medical schools this summer. I have noticed a concerning trend of overall poor quality communication skills amongst the ER staff where I work. Two specific examples are regular problems/head-butting between the trauma mid-levels and radiology department (ER doesn't have its own radiology techs but shares the entire hospital's). There are also occasional frustrations and misunderstandings between ER physicians and internal med hospitalists that handle most admits.</p>

<p>Are these patterns pretty standard throughout the whole medical profession? How important are good communication skills? Is it hard, as a physician, to constantly be switching communication modes between written and verbal, patient/family, nurses, "allied health professionals", other physicians, supervisors, etc.?</p>

<p>Poor communication and unnecessary misunderstandings really frustrate me... does anyone have advice for someone like me that could help me avoid these problems down the road?</p>

2

<p>I agree with you that there are a lot of communication issues within the profession although I don’t think it’s from a lack of skills per se. The admissions process does a good job screening for applicants with decent social skills. And medical schools emphasize communication as part of their medical school curriculum much more so than ever. Just 25 years ago, most medical schools didn’t have communication or ethics courses in their curriculum. It was only science classes all day long.</p>

<p>However, there are ways that we can change the system to improve communications. For example, when we write up our H&P for a hospitalized patient, as part of the template, it’ll say “primary care physician contacted by…” This is a reminder for us to call the primary care physician of EVERY hospitalized patient on admission to give them a heads up. I feel like at my hospital, we do a good job at this but from talking to some of the local primary care physicians, they only get a call around 50% of the time. Thus, rather than blame it on “poor communication skills,” I see this as more of a systems issue and there are things we can do that will augment communication, such as inserting a reminder when people are tying up their H&P’s.</p>

3

<p>Regarding “a reminder for us to call the primary care physician” and “more of a systems issue”:</p>

<p>In our experience as patients, the physicians rarely have time to call each other. The best hope you may have is that their lower-paid assistants or nurses or even just the front desk clerks call each other. This is the result of the physician having too little time. (I also suspect that they want to see more patients – in order to pay back their sizable student loan?) Heck, they (especially the specialists) often do not have enough time to talk to their patients…like allocating < 5 minutes for each patient on average.</p>

<p>Our primary care doctor even did not like one of our specialist doctor. Unless they are long-time “partners”, from what I see it, it is often a conflict of interests: Who is responsible for taking care of a specific aspect of the patient’s illness (e.g., blood pressure.) At one time, the primary care doctor complained that the specialist took away one of the tasks she had been doing without her consent. (regarding prescribing a particular kind of medicine.)</p>

4

<p>Hence, I’ve begun to shift more towards academic medicine as a career. I’ve really become disillusioned with what private practice has become. A lot of the medicine isn’t evidence-based. The other day, I saw a lady who’s 70 and has diabetes and many other disorders come back after being prescribed azithromycin for her pneumonia. She should’ve been on something better (a respiratory fluoroquinolone like moxifloxacin) given her age and comorbidities but I didn’t tell my preceptor that. I’ve seen private practice docs write “doing well” as their only documentation of the visit. The notes that these people write is just pitiful. Of course, a lot of it has to do with the fact they have to cram patients into 15 minute blocks.</p>

<p>In academic medicine, you make substantially less money (although still good money) but you often have more time to see patients, see fewer patients, and see more interesting cases. I also would enjoy teaching as part of my future career. Overall, I just feel like it’s so much more rewarding to do medicine as an academic physician.</p>

5

<p>Dedication is really one of the most important factors that patients must consider when selecting a doctor. The clinic that I go to has just computerized their records. It is pretty easy for doctors to search for lab results on a patient. Doctor’s comments and prescriptions are also stored. Some specialist doctors even create check lists. I think that mindless “doing well” comments along with some questionable lab results could be the basis of a mal-practice lawsuit.</p>

6

<p>

Hmmm. Where you are now is the way mine is and she’s just starting into this thing. I just wonder if she won’t make the step all the way out of seeing patients. She is making her decision soon as to her research position this summer and only interviewed with academic physicians who have some combo of practice/research and/or teaching.</p>

7

<p>Not to hijack the thread but the PCP could have been fully justified in prescribing Zithromax. Avelox is not an innocous medication and it’s use should be limited to appropriate medical situations:</p>

<p>Adverse effectsSee also: Adverse effects of fluoroquinolones
The serious adverse effects that may occur as a result of moxifloxacin therapy include irreversible peripheral neuropathy, spontaneous tendon rupture and tendonitis,[54] acute liver failure or serious liver injury, QTc prolongation/torsades de pointes, toxic epidermal necrolysis (TEN), and clostridium difficile-associated disease (CDAD),[55] as well as photosensitivity/phototoxicity reactions.[56] Hepatitis, pseudomembranous colitis, psychotic reactions and Stevens-Johnson syndrome have also been associated with moxifloxacin therapy.[57]</p>

<p>There has been a number of regulatory actions taken as a result of such adverse reactions, which include published warnings,[58] the issuance of numerous “Dear Doctor Letters”,[4][6][7][59] the restrictions regarding the use of moxifloxacin instituted by the European agency’s Committee for Medicinal Products for Human Use (CHMP),[10] as well as the recent addition of Black Box Warnings.[60] On March 22, 2010 Health Canada issued a notice to health care professionals and Canadians regarding the recent changes to the labeling information for Avelox (moxifloxacin). The 2010 Canadian updated labeling now includes information regarding the risk of severe liver injury during moxifloxacin therapy.[61]</p>

<p>These serious events may occur with therapeutic or with acute overdose. Such adverse reactions may manifest during, as well as after moxifloxacin therapy.[62]</p>

<p>Most recently, the German regulatory authorities placed additional restrictions on the use of oral moxifloxacin in patients with acute bacterial sinusitis (ABS), acute exacerbation of chronic bronchitis (AECB), and community-acquired pneumonia (CAP) stating that in case of these diseases moxifloxacin should only be prescribed when other antibiotics that have been initially recommended for treatment cannot be used or have failed. Additional notice was given that rhabdomyolysis, the exacerbation of symptoms of myasthenia gravis and the risk of cardiac arrhythmia in women and older patients, was associated with moxifloxacin.[7] Currently the German regulatory authorities are investigating the association of severe and life threatening QTc prolongation/torsades de pointes with moxifloxacin therapy, which the FDA had raised serious concerns about during the initial drug approval process back in 1999.[63][64][65]</p>

<p>Serious visual complications have also been reported to occur with ophthalmic fluoroquinolone therapy, which may also occur with Vigamox, especially corneal perforation, but also evisceration and enucleation. Corneal perforation occurred most commonly in elderly patients with deep ulcers. This increased incidents of corneal perforation may be due to fluoroquinolones’ causing alterations in stromal collagen, leading to a reduction in tectonic strength.[66][67]</p>

<p>[edit] InteractionsAntacids containing aluminium or magnesium ions inhibit the absorption of moxifloxacin. Drugs that prolong the QT interval (e.g., pimozide) may have an additive effect on QT prolongation and lead to increased risk of ventricular arrhythmias. The INR (International Normalised Ratio) may be increased or decreased in patients treated with warfarin. Moxifloxacin has been shown in a number of case reports to interact with warfarin.[68] The exact mechanism for the warfarin-quinolone drug interaction is unknown.[69] A precautionary measure would be to monitor the INR more closely and, if necessary, adjust the anticoagulant dose as necessary. Moxifloxacin does not appear to inhibit theophylline metabolism.[70] However, caution may be warranted when using theophylline with all of the fluoroquinolones, including moxifloxacin. Drug Interaction Facts notes that some fluoroquinolones, especially ciprofloxacin, enoxacin, and norfloxacin, interact with theophylline</p>

<p>There are only two listed contraindications found within the 2008 package insert:</p>

<p>“Nonsteroidal anti-inflammatory drugs (NSAIDs): Although not observed with moxifloxacin in preclinical and clinical trials, the concomitant administration of a nonsteroidal anti-inflammatory drug with a fluoroquinolone may increase the risks of CNS stimulation and convulsions.” [46]
“Moxifloxacin is contraindicated in persons with a history of hypersensitivity to moxifloxacin, any member of the quinolone class of antimicrobial agents, or any of the product components.”[46]
Though not stated as such within the package insert, ziprasidone is also considered to be contraindicated, as it may have the potential to prolong QT interval. Moxifloxacin should also be avoided in patients with uncorrected hypokalemia, or concurrent administration of other medications known to prolong the QT interval (antipsychotics and tricyclic antidepressants).[47]</p>

<p>Moxifloxacin should be used with caution in patients suffering from diabetes, as glucose regulation may be significantly altered.[47]</p>

<p>Moxifloxacin is also considered to be contraindicated within the pediatric population, pregnancy, nursing mothers, patients with a history of tendon disorder, patients with documented QT prolongation,[7] and patients with epilepsy or other seizure disorders. Coadministration of moxifloxacin with other drugs that also prolong the QT interval or induce bradycardia (e.g., beta-blockers, amiodarone) should be avoided. Careful consideration should be given in the use of moxifloxacin in patients with cardiovascular disease, including those with conduction abnormalities.[47]</p>

<p>Recently (2008), Bayer issued a Europrean Dear Doctor Letter concerning moxifloxacin-associated liver damage, and, as such, the use of moxifloxacin would now be considered contraindicated in patients with impaired liver function</p>

<p>I do not know the comorbid conditions of your patient, but a 70 year old with diabetes most likely has coronary artery disease, is taking a NSAID, may be on coumadin etc. Also, Avelox is substantially more expensive than Zithromax. </p>

<p>My main point is there are many variables to consider when choosing any medication and simply choosing the most potent antibiotic (esp initially) may not be in the best interest of your patient and I suspect your preceptor knew as much. Not trying to bash but just trying to help point out a few other things to consider. By the way, my son is also planning on a career in academic medicine for many of the reasons you have delineated.</p>

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<p>^You bring up excellent points.</p>

<p>I’m not so naive as to think that actual medicine is always practiced like the way studies or textbooks say it should be practiced. I know there are times physicians will do things just to placate the patient (such as giving an antibiotic for an uncomplicated bronchitis or diarrhea) or to just cover their own @$$. </p>

<p>The problem is that I’m not sure when they’re doing what. Are they simply incompetent or are there factors I haven’t considered yet? My preceptor ordered a CT angio and dopplers on a patient with a Wells Score of 1. There are times I want to ask him questions about why he does certain things (as he may have a rationale for it) but I am afraid of embarrassing him. Maybe he knows it’s not evidence based but he’s doing it to reassure himself. </p>

<p>For our primary care clerkship, some of the students have to travel quite far despite the fact the medical school is located in a big city. This is because, by the director’s own admission, many of the private practice docs they’ve had in the past simply were poor teachers or set poor examples. When I was on inpatient, half the time we had to undo the meds that the patient’s private practice doc had put him on. I just feel overall, there is less evidence based medicine being practiced out in the community and there is a great heterogeneity in the quality of doctors. </p>

<p>The doc ended up putting the patient on 10 days of Avelox so maybe there was a reason he wanted to try azithromycin first or maybe he just made a mistake. Who knows? But, I’m afraid to ask, especially since these are my evaluators.</p>

9

<p>I’ve never felt that the people who were grading me thought my questions were disrespectful - in fact, I think my evaluations generally reflected a positive attitude towards asking questions because it demonstrated interest and critical thought. If I were you, I’d simply ask (at a good time), “Why did you decide to use Avelox instead of azithromycin?”</p>

10

<p>You make excellent points. In the surgeons lounge today we were discussing evidence based medicine and the validity of Level III based evidence in many situations. More and more, insurance companies are attempting to demand level I evidence prior to precertifying procedures or tests. While this is admirable, medicine is rarely so “clean”. Their motives, as you know, are primarily centered around profits (ie denying tests and procedures to save money) and not the best interests of the patients.</p>

<p>With that being said, your observations are quite astute. There is definately less evidence based medicine practiced in the community. I suspect this is primarily do to one of three things. The physician does not stay current with the literature, the physician was never cost conscience, the physician was never a good physican (although he/she may be competent) or the physician has experience in handling a problem and in their hands this is the best treatment. You will find community physicians treat a much larger number of patients and work much longer hours than most of their academic counterparts. This in no way absolves them of providing the best possible care to their patients, but may explain some of their treatment decisions. I think the mandatory maintenance of certification is a step in the right direction.</p>

<p>I think you are being prudent in being cautious with questioning your preceptor, but it really is sad such a teaching opportunity is lost. In the ideal world, he would explain why he is ordering certain tests or utilizing certain medications, but I had the same experience. The key is when you are in his position, you take advantage of these teachable moments. However, time is money. Such is life even in medicine.</p>

<p>One last comment, I would love to have you for a medical student. I like students who are inquisitive for the correct reasons and not simply to attempt to earn a better grade. Keep on asking the questions you have delineated here, and you will be well on your way to a succesful and fulfilling medical career. Best of luck!</p>

11

<p>“Level III based evidence”</p>

<p>Welcome to the world of pediatrics…</p>

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<p>Bigred reminded me of one other point of contention: the practice of medicine versus the science of medicine. You need both, but does one trump the other? If the science of medicine is primarily important, then “science” students should account for the majority of medical students. If the practice of medicine is primarily important, then “other” students should account for the medical school class. I think the balance achieved in the current medical school classes reflects the appropriate balance between the science of medicine and the practice of medicine. Although evidence based medicine is important and should be utilized, there is certainly a necessary place for the practice of medicine apart from evidence based medicine.</p>

13

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<p>This was the way I felt when I was on inpatient medicine. The attendings always asked one question, “what’s the evidence behind it.” It forced me to do a ton of reading of research articles and I loved doing it. I loved investigating when you would use moxi vs. azithromycin for outpt. treatment of pneumonia or when you would use 81 mg ASA vs. 325 mg ASA vs. plavix vs. plavix + ASA for secondary prevention of stroke. I’ve always gotten excellent marks on fund of knowledge and clinical reasoning and I wasn’t afraid to suggest to my team, for example, that we should’ve just checked a TEE on a specific patient instead of a TTE because I found a paper which showed that TEE in someone with 13%+ chance of endocarditis is more cost-effective than TTE. That’s why I feel like I would love academic medicine. This is the stuff I’m interested in. I feel like I read way more papers than most of my classmates.</p>

<p>However, since being on primary care, there’s just so much stuff I don’t really agree with. We had a patient today who had some “floaters” (which both the attending and I agreed on) but the attending still volunteered to make a referral to an ophthalmologist if the patient wanted. For floaters that’s not impairing vision? Seriously? It just adds so much cost. If I concentrate, I can see floaters. We all have floaters. The attending said he has floaters. So, why this is worthy of a referral?</p>

<p>I’m very appreciative of my outpatient experience. I know time is money in private practice and a medical student on average adds 30% more time to an attending’s day. My preceptor (a new one) let me see 7 patients by myself today and let me write all the notes. I’m very appreciative of my experience. And this attending was much more into quoting studies, which is what I’m used to and what I like. I know these doctors know way more than me and it’s probably not due to incompetence that they do the things they do. I know a lot of times, to keep patients, they have to do things that are not necessarily cost-effective or evidence-based. It is a business after all.</p>

14

<p>I think you have an accurate view of the “system” and know how you want to practice.</p>

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<p>Back to the original question, a study was done at my school that surveyed nurses and doctor’s perception of communication. Not surprisingly, most of the doctors thought they were doing a good job communicating while only a portion of the nurses thought that communication was optimal. The difference in perception was especially pronounced when they surveyed surgeons vs. OR nurses. Nothing too surprising here.</p>

16

<p>My kids have been watching the TV series - HOUSE. Has anyone seen that? Is that (the exchange of diagnostic ideas) real to some degree? What kind of hospital would provide such environment for physicians to work as a team like that?</p>

17

<p>Candyland? ;)</p>

18

<p>Minus the lack of ethics and the breaking and entering of patient’s houses, yea, it’s exactly like House ;)</p>

<p>But, that is the kind of stuff we (the medical students and residents) get pimped on. After you admit a new patient, you present the patient to the attending. They will ask you for your impression (ie what you think it could be), what further diagnostic tests you would order, and what your plan for management is. As the medical student, you are usually wrong but, if the attending is nice, they will teach you something. If not, then they’ll just tell you you’re an idiot. </p>

<p>Obviously most of the cases in the hospital are not as exotic as the cases you see on House.</p>