Can the Inpatient Communication Gap Be Bridged?

The adage that says the more things change, the more they stay the same may apply—for better or for worse—to inpatient and physician communications. In a study at a Connecticut hospital, two physicians found that fellow providers who thought they were doing a good job talking and explaining facts to their patients actually found they were falling short of their medical goals.

While much has appeared in the medical literature about how to communicate better with patients, the job is still challenging, physicians say. "Compared to a decade ago patients are sicker, the time they are in the hospital is shorter, and having them involved in their care and getting them to understand their care is increasingly more important and increasingly more difficult," says one of the physicians, Douglas Olson, MD, a chief resident in the primary care program at the 367-bed Waterbury Hospital, private, not-for-profit community teaching facility.

The idea for the study came from the experiences at the hospital of Olson and Donna Windish, MD, MPH, associate program director of the primary care program at Waterbury. "Despite spending time with patients...and despite telling patients why they were in the hospital and telling them what medications they were receiving, we both had the idea that patients just weren't getting it on a daily basis," he says.

"We wondered if this was our own experience or something more of a systemic problem that all physicians are facing," Olson adds. So they decided to see what gaps in understanding existed and in particular how that differed from physician assessments. Their findings appear in the Aug.9 issue of the Archives of Internal Medicine.

They surveyed corresponding internal medicine residents and attending physicians—asking them to report on their care of hospitalized patients and their understanding of their patients' perspectives on the care received. For the study, 89 patients and 43 physicians participated.

What they found was an "impressive disconnect" in the communication and the perceptions of patients and physicians on the care that was provided:

• Although 73% of patients thought there was one main physician taking care of them, only 18% were able to correctly name that physician—compared with 67% of physicians who thought patients knew their names.

• Most physicians (77%) believed patients knew their diagnoses; however, only 57% of patients said they did.

• While 81% of physicians stated that they described adverse effects of medications at least some of the time, only 10% of patients receiving new medications reported being told of any adverse effects.

• Although almost all of the physicians stated that they at least sometimes told patients when new medicines are prescribed, only 75% recalled ever being told of these new medications.

• Almost all of the physicians stated that they at least sometimes discussed their patients' fears and anxieties, but 54% of patients said they never did this.

So what this means is that "despite the increase attentiveness to involving patients in their care and teaching patients about why they are in the hospital—and they're still not getting the take home message and how it applies to them," Olson says.

This may call for rethinking how to communicate better with patients, he notes. For instance, when patients are admitted to the hospital, they may be told by physicians about the diagnosis, but they usually do not receive written information about that diagnosis, which could help.

Then on discharge, "we give them a lot of instructions that are written, but maybe don't go over things in a very systematic and comprehensive way verbally," he says. "Sort of marrying these two methods of patient communication—the written and verbal—from the moment they hit the door, would be one way of improving patient comprehension."

Also, with increasing use of computer and electronic medical records while the patient was in his or her room, this could help patients learn more about their diagnoses as well, he says.

Getting more involvement with a patient's family also could help greatly when it comes to communication, says Windish, who is also an assistant professor of medicine at Yale, but that has it's own challenges as well in today's medical environment.

In the past, for instance, the hospital residents were likely to be with their patients day and night. But with new work hour limitations coming into place, this is less likely to occur. Similarly, hospitalists have shifts as well. "They are only here for a limited amount of time," she says.

"The problem is that the people who are primarily responsible for taking care of patients are here during the day time—the same time when families are working. So that also limits the communication—particularly if someone is sick and many of the patients in the hospital today have more than one medical issue," she says.

"I think in medical education we're going to need to rethink how to communicate with patients based on more of a team approach," she says. "We need to rethink how inpatient care is given."

With patients admitted to the hospital now being sicker and in for shorter time periods, communication between physicians and patients will remain a challenge, Olson says. "If anything, our results show that we're doing things well, but there's a lot of room for improvement. But as more minds that come to the table about how to improve it, hopefully we'll come out with better solutions."