Have you ever switched from one Doctor to another? Have you ever had a single health problem or any records that you need to get from one place to another? Maybe you’ve been hospitalized and now your primary care doctor is asking for details on what happened? Or, maybe the other way around and you’re admitted in an emergency and the one that can help out best is far away? Maybe you’ve jumped from specialist to specialist and haven’t quite figured out an answer – each time, are you starting completely over?
Have you ever had to deal with rotating through a myriad of providers in a short period of time? More than 1 doctor in a year… A month… A week… Maybe even within the same 24 hour period?
In medical training, we are so entrenched in the concept of learning medicine that sometimes the importance of adequate “hand-off” “sign-out” “checkout” is overlooked. I will never forget as a medical student and then later as an interviewee shadowing resident physicians at one amazing program in particular, watching how people pass on information from one end to the other – working in Medicine, we play a complicated game of Telephone but the stakes are peoples’ lives. A good sign out can make or break short term care for a patient but also longer term messages that need to get passed on. I’m well aware of my own distraction and tangentiality during sign out and am constantly seeking to improve both my giving and receiving of information, but the critical aspect of how important these things are has become much more visceral in the last several months working as a Locum Tenens.
I remember my first day in clinic a couple of months ago, my MA told me, as I spent too long documenting, “Ha, that’s definitely not outpatient/private practice charting you’re doing.” I tend to be verbose, detailed and sometimes overbearing – but i mean, if you’re here you already knew that since i’m writing a blog! But I realized as a short term worker that some of the decisions I made and the conversations I had with patients were important to pass on in a way that the next provider would be able to piece together an adequate picture of what happened, what I was thinking, what I did and why, and sometimes where I thought things were going. In a few short months I came across clinic patients that had bigger problems than could be fixed at 1 visit and I tried my best to convey this in text and medical records, just hoping that the next provider could read my mind and go down the trail I was hoping to lead them. Simultaneously, too much information takes away from the important points and can just cause distraction and a jumbled mess. In the last month alone, I received a sign out with repetition and overt focus on minute details that went on for what seemed like hours – at the end I had so many puzzle pieces, I just tossed most of them and started over with the edges. Simultaneously, I received another sign out with a simple, “Oh, nothing, normal baby,” and was stuck trying to figure out what puzzle I was working on and how many pieces were even there.
Often individual lab values don’t matter, but the trend from the last week may. The history, is sometimes able to be retold, but maybe we just need the important milestones of the storyline. There are the things that happen between the lines, the things that don’t make the chart, that can be difficult to really pass on. Noticing big pictures, how things have changed that can’t be seen so obviously and a sense sometimes of there being “something missing.” Of course, there’s the little things you may not be able to say and especially not write in the EMR, like how hard someone’s medical course has been for them emotionally and psychologically, for their family or their marriage; how every day someone comes to visit and the small, little things that, honestly, probably matter more than you’d think.
So, as I hop from hospital to hospital or clinic to clinic, I continually focus on streamlining and maximizing my efficiency for what is probably going to be said and what needs to be said when i’m giving or receiving information. Of course this skill is important to all aspects of life, whether someone is covering your shift at a job, or coming on to relieve you, or literally leaving a message by telephone, but in taking care of health for people it can not be emphasized enough how continuity of care can alter or change an entire life or disease course.
At the end of the day, particularly pungent as I move towards the end of another stint of an assignment and pass on My Patients to another provider, I can only leave bits and pieces, small breadcrumbs, and hope that the trail will lead to the best care we can give.