Referring patients? Keep these tips in mind

October 3, 2008

At a time when communication with patients is being identified as a key component in increasing quality of care and decreasing medico-legal risk, perhaps we should intensify our endeavors to teach our students, residents, and colleagues to communicate with each other.

Have you ever been called at 9 a.m. about a patient fall? If you have, it was probably someone at a nursing home who slid out of a wheelchair, the soft thud of his briefed bottom barely audible. Worst-case scenario? A skin tear that needs some Bacitracin and Kling.

At midnight, it's a whole different ball game. One particular night, I roused myself from a nightmare in which my pager was going off, only to realize that my pager was going off. After straining to read the number on the display, I called the medical-surgical floor of our small critical-access hospital. "Dr. Switzer?" gasped the nurse who answered the phone. "Do you know Dr. Davis's patient, Mr. Franklin?"

"Uh, No."

"X-ray the CT . . . hip his head . . . be right there."

Like you, I render some of my highest quality care and demonstrate impeccable driving skills within seconds of being awakened from Stage 2 sleep. I was at the patient's bedside in no time, viewing his oozing parietal integument and externally rotated left leg.

"Fudge," I muttered. Or something like that.

The CT showed a subdural hematoma, and the hip film showed a comminuted femur fracture. The family wanted the patient transferred to the university hospital 65 miles away. This seemed reasonable to me. Although we had an orthopedist, we had no neurosurgeon, no anesthesiologist, and no intensive care unit.

I phoned the ivory tower and relayed the events of the preceding hour to the orthopedist on call-who responded that I didn't need his services because transfer was dangerous and we had an orthopedist on the premises. Undaunted, I called again, asked for the neurosurgeon, and breathed a sigh of relief when he said, "I'll be happy to help." I was about to confirm his first name so that my wife and I could name our gestating child after him, but then he added, "Get your hospital to send me the films through your teleradiology system and I'll look at them."

"Fudge," I muttered, or something like that. I then called our radiology department to make the necessary arrangements.

When I finally got a callback, the neurosurgeon assured me, "Call ortho and tell them it's no problem." Suffice it to say, the orthopedist did think there was a problem. In fact, he said the patient had to go to the trauma surgery service or face certain death. With my last ounce of courtesy and deference, I phoned the trauma surgeon on call and presented the case again.

"What did ortho say?" he mumbled. I explained Mr. Franklin's meteoric rise from alleged EMTALA violation to tertiary-care multispecialty patient.

"Fudge."

Pause.

"All right, send him over. We'll take care of it." Finally, the patient was on his way to getting the care he needed.

It is not my intention to blast orthopedists, other specialists, or academic medicine. As a primary care physician, I have great respect for those who treat my patients when I've reached the limits of my expertise and resources. Rather, as I look back on this and similar transfer and referral experiences, I marvel at how dysfunctional physician-to-physician communication can be. Given the limits of a small critical-access hospital (our average daily census is around nine) and the wishes of the patient's family, transfer was the obvious step in this patient's care. Why did that take so many conversations?