Communication Issues in Physical Medicine and Rehabilitation

Overview and Description

Effective interprofessional collaboration is defined as a process of communication and decision-making that enables the separate and shared knowledge and skills of health-care providers to synergistically influence patient care.¹ Communication is an essential foundation of any healthcare team to solve complex and multifaceted patient-care problems. Since 1999, the Accreditation Council for Graduate Medical Education has mandated communication as one of the six required core clinical competencies to be achieved during residency. “Residents must care for patients in an environment that maximizes effective communication. This must include the opportunity to work as a member of effective interprofessional teams that are appropriate to the delivery of care in the specialty”.^2,3

As an interdisciplinary field, physical medicine and rehabilitation relies on communication among multiple healthcare professionals in a variety of settings (inpatient, outpatient, community), in addition to patients and their families.

Table 1: Team Members in Physical Medicine and Rehabilitation

Barriers to communication have the potential to exist within each component of the interdisciplinary team, making effective communication a difficult but attainable goal of quality patient care. The Joint Commission showed that communication problems were the root cause of 68 percent of reported sentinel events from 2010 to 2012.⁴ Research suggests that improved communication leads to better patient outcomes, high levels of patient and family satisfaction, safer work environments, decreased adverse events, improved symptoms control, decreased transfer delays, and shortened lengths of stay. ^5,6 The following is an overview of six different levels of communication barriers: the individual, the interdisciplinary team, the environment, the medical records, and patient education.

Relevance to Clinical Practice

Individual

Given the increasing and seemingly endless demands placed on healthcare professionals, physicians must learn more effective communication skills and coping strategies to provide better patient care. In Physical Medicine and Rehabilitation Patient-Centered Care: Mastering the Core Competencies, Sorush Batmangelich reviews the components of communication–listening, speaking, body language, emotions, needs, empathy, styles, and preferences–and offers self-reflective exercises for better communication strategies.⁷ 

Table 2: Individual Communication Barriers and Strategies for Improvement

Team

Patient’s impairments, activity limitations and participation restriction affect many parts of their lives. making a well-functioning team equipped with a variety of essential healthcare professionals (see table 1) essential to improve function and quality of life.

Table 3: Team Communication Barriers and Strategies for Improvement

The Donebedian Framework

Kuzemsky et al. has proposed a communication model, called the Donebedian framework, that can be used to assess interdisciplinary teams by focusing on a range of factors that affect teamwork and communication.⁵

Within the framework, there are three dimensions:  structure, process, and outcomes.

The structure of the team is subcategorized into:

1. Internal Concepts (individual health-care providers, hospital procedures, and policies)
2. External Concepts (external contacts, health-care services, and social services).

Team success relies on awareness and implementation of policies and procedures of both external and internal structures.

Within the structure, there are six team processes:

1. Care Planning
2. Information Exchange
3. Teaching
4. Decision-Making
5. Negotiation
6. Leadership

The structure and process ultimately influence five team outcomes:

1. Patient Discharge Planning
2. Reintegration into the Community
3. Effective Disease Management
4. Patient/Family Satisfaction
5. Achievement of Goals and Objectives

An efficient rehabilitation team has defined roles with a recognizable leader, clear information exchange between all members of the team, a collaborative decision-making process, and quality patient education.

Kuzemsky identifies electronic data support and video conferencing as potential tools to enhance the accurate and up-to-date transmission of health-care information between multiple providers.  A convenient system should include an electronic patient record that would allow the health-care team in one setting to update the patient’s data while simultaneously granting real-time access to all providers involved in the patient’s care. This would be most feasible with a secure web-based electronic patient record system. Video or web conferencing can be used for real-time discussions about patient care when not everyone can physically attend a meeting. Many physicians feel it is more convenient and efficient to have real-time communication with external team members to address patient care problems.⁴

Environmental Context

Physical medicine and rehabilitation at the inpatient level is unique due to its ability to exist in multiple different environments– as a stand-alone acute rehabilitation hospital, as a unit in a larger acute care hospital, a long-term care center and as a subacute skilled nursing facility (SNF).

Table 4: Communication Advantages and Disadvantages of Inpatient PM&R Settings

In an ethnographic study at a single inpatient spinal cord rehabilitation care unit in Canada, the authors concluded that the physical layout of the unit influenced the quality of communication between team members. In that particular hospital, the therapy gyms, meeting spaces and clinicians’ offices were located off the unit. “…Separation appeared to exacerbate distinctions between clinicians and nursing staff and made collaborative decision making difficult”.¹

Medical Records and Documentation

Documentation and medical record keeping also pose threats to effective and efficient communication.

Table 5: Medical Records and Documentation Communication Barriers and Strategies for Improvement

Patient and Family Education

At the patient level, language barriers, use of medical jargon, and language or cognitive deficits caused by medical conditions may impede effective patient education strategies. In a cross-sectional study from 2008-2009 Waterbury Hospital in Connecticut, 18 percent of patients were unable to name their primary physician when hospitalized, 43 percent of patients did not know their actual diagnoses, and 90 percent of patients started on a new medication were not told about the adverse events of the medication.⁹

Table 6: Doctor-Patient Visit Communication Barriers and Strategies for Improvement

When patients and families are unclear about treatment plans, frustration ensues, leading to poor management of physical symptoms, function, pain control, medical comorbidities, and potential lawsuits.⁷

Cutting Edge/Unique Concepts/Emerging Issues

In recent years, technology has revolutionized all aspects of medical rehabilitation, from developments in the provision of cutting-edge treatments to the actual delivery of the specific interventions. Telemedicine is defined by the World Health Organization (WHO) as the delivery of health-care services, where distance is a critical factor, by all health-care professionals, using information and communications technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and the continuing education of health-care workers, with the aim of advancing the health of individuals and communities.¹⁰ As a result of the current COVID-19 pandemic and the recommended social distancing restrictions, telerehabilitation use has grown significantly over the last year.

Telerehabilitation uses may include therapeutic interventions, remote monitoring of progress, education, consultation, training and a means of networking for people with disabilities. The technology can also facilitate communications between members of the care team, thus improving coordination of care. Positive outcomes associated with telerehabilitation included reduction of hospitalization admissions, mortality, and possible cost effectiveness.¹² Despite these advantages, there are serious concerns about how the adoption of telemedicine may impact care. Limitations of telehealth include barriers in establishing relationship between medical provider and patient, ability to perform limited physical examination, and differences in payment models and liability coverage.¹³

While telerehabilitation is great medium for communication, individual and team communication strategies are still vital. Ensuring that telemedicine is ethically acceptable will require good communication to maintain a strong patient-doctor relationship, protect patient privacy and promote equity in access and treatment.¹¹

Gaps in Knowledge

Future research is required to evaluate methods to best use telehealth for specific patient populations, as there are promising applications for telehealth for PM&R in both inpatient and outpatient settings.^{13, 14}

Future research should investigate alternative ways to overcome communication barriers at the individual, team, environment, record-keeping and patient-education levels to ultimately improve patient satisfaction, discharge planning, and minimize adverse outcomes.

References

1. Sinclair L. Lingard L. Mohabeer R. What’s so great about rehabilitation teams? An ethnographic study of interprofessional collaboration in a rehabilitation unit. Arch Phys Med Rehabil 1009; 90: 1198-201
2. Accreditation Council for Graduate Medical Education (ACGME). Teamwork Section VI.F. Common Program Requirements Effective July 1, 2013. ACGME website. Http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/CPRs2013.pdf. Accessed December 5,2015.
3.  NEJM Knowledge Team. Exploring the ACGME Core Competencies. Available at: https://www.knowledgeplus.nejm.org/blog/exploring-acgme-core-competencies/#:~:text=The%20six%20ACGME%20Core%20Competencies%20are%20as%20follows%3A,Knowledge%205%20Interpersonal%20and%20Communication%20Skills%206%20Professionalism. Accessed August 17,2021.
4. Kirby SG. Communication among health-care professionals: an essential component of quality care. Newsletter 2010: (No. 4). February 2, 2011 posting: North Carolina Medical Board website. Http://www.ncmedboard.org/articles/detail/communication_among_health_care_professionals_an_essential_component_of-qua. Accessed December 3, 2015.
5. Kuziemsky C. Borycki E. Purkis M. Black F. Boyle M. Cloutier-Fisher D. Fox L. MacKenzie P. Syme A. Txchanz C. Wainwright W. Wong H. An interdisciplinary team communication framework and its application to healthcare ‘e-teams’ systems design. BMC Medical Informatics and Decision Making 2009; 9:43.
6.  Merlino J. Communication: A Critical Healthcare Competency. PSQH Patient Safety and Quality Healthcare. Nov 6, 2017. Available at: Https://www. .psqh.com/analysis/communication-critical-healthcare-competency/ Accessed March 4^th, 2021.
7. Batmangelich S. Cristian A. Physical Medicine and Rehabilitation Patient-Centered Care: Mastering the Competencies. Demos Medical Publishing 2015; 16-26.
8. Christakis D. Feudtner C. Temporary matters: the ethical consequences of transient social relationships in medical training. JAMA 1997; 278:739-43.
9. Olson DP, Windish DM. Communication discrepancies between physicians and hospitalized patients. Arch Intern Med. 2010; 170 (15) 1302-7.
10. World Health Organization Coronavirus disease (COVID-19) advice for the public. 2020. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public\
11.  Mehta SJ. Telemedicine’s Potential Ethical Pitfalls. Virtual Mentor. 2014;16(12):1014-1017. doi: 10.1001/virtualmentor.2014.16.12.msoc1-1412.
12. A.M. Totten, D.M. Womack, K.B. Eden, et al. Telehealth: Mapping the Evidence for Patient Outcomes From Systematic Reviews. Technical Brief No. 26. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No. 16-EHC034-EF. Rockville, MD: Agency for Healthcare Research and Quality. June 2016, Available atwww.effectivehealthcare.ahrq.gov/reports/final.cfmAccessed November 222016.
13. Tenforde AS, Hefner JE , Kodish-Wachs JE , et al . Telehealth in physical medicine and rehabilitation: a narrative review. Pm R 2017;9:S51–8.doi:10.1016/j.pmrj.2017.02.013 pmid:http://www.ncbi.nlm.nih.gov/pubmed/28527504
14. Alexander, Marcalee. Telerehabilitation: Principles and Practice. Elsevier (in print).To be published : December 20, 2021. ISBN 0323824862

Original Version of the Topic

Jeffrey Oken, MD, Kristen Jost, MD. Communication Issues in Physical Medicine and Rehabilitation. 5/2/2016

Author Disclosure

Kareen A Velez, MD
Nothing to Disclose