Communication Issues in Physical Medicine and Rehabiltiation

Author(s): Jeffrey Oken, MD, Kristen Jost, MD

Originally published:05/02/2016

Last updated:05/02/2016

1. 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 2013, 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

As an interdisciplinary field, physical medicine and rehabilitation relies on communication among physicians, nurses, nursing aids, physical therapists, occupational therapists, speech therapists, therapeutic recreationists, psychologists, secretaries, social workers, pharmacists, spiritual leaders, and, of course, patients and their families. Barriers to communication have the potential to exist within each component of the multidisciplinary 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 2012.3 Research suggests that good communication leads to improved patient and family outcomes, resulting in high levels of patient and family satisfaction, better symptom control, and reductions in length of stay and hospital costs.4 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.

2. 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.5 Aside from the stress of the health-care profession, personal resistance to change and ingrained beliefs create additional barriers to open and nonjudgmental communication. As the health-care system is evolving into a more collaborative and less hierarchical framework, seasoned physicians face the challenge of accepting a new culture of medicine that holds the physician responsible for creating an environment of equality, in which each team member is respected as a valuable and critical component.5

Team

Each member of the rehabilitation team plays an important role in providing quality patient care. Patients’ disabilities affect many parts of their lives, making a well-functioning team equipped with physiatrists, consulting physicians, nurses, social workers, dietitians, psychologists, occupational and physical therapists, speech therapists, and case managers essential.  If the structure of the team is hierarchical rather than collaborative, there is a higher potential for communication error.5 Failure to speak up and conflicts between professions are among the more common communication issues seen in physical medicine and rehabilitation teams.5 As an example, a physical therapist who is feeling undermined by a physician is less likely to bring up concerns in the future.  There is also potential for role duplication and inappropriate task assignment when collaborating with a large team. Each team member should have a defined role and a clear understanding of the responsibilities of each member to avoid redundancy and ensure task completion.  A cohesive and well-informed team that meets frequently will have better success in terms of consistency in patient education and smooth discharge planning.4

Outside the rehabilitation team, physiatrists often consult physicians from other specialties for assistance with complex medical patients, creating potential for conflicting opinions about appropriate medical management.  Multiple physicians involved in a single patient’s care can lead to confusion about the extent of the role of each physician. Furthermore, the trend toward a shift-work structure, with physicians potentially rotating coverage on a weekly basis, jeopardizes continuity and consistency of care, risking inadvertent omission of information at each transition of care.6  Furthermore, the transient nature of staffing might impede the development of deep professional relationships that have traditionally facilitated more effective communication.6

Environmental Context

Physical medicine and rehabilitation at the inpatient level is unique with regard 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, and as a subacute skilled nursing facility (SNF). The advantage of existing within a larger hospital is the availability of consulting physicians and a uniform system of recording medical information that is easily accessible to all involved in the patient’s care. However, issues may arise with regard to who is the primary and final decision-maker. In a stand-alone rehabilitation hospital, where the physiatrist assumes the primary role, the potential for leadership confusion is eradicated but at the cost of decreased availability of consulting physicians who are familiar with the structure and medical record system of the specific rehabilitation hospital.

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. “…[S]eparation 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. The availability of multiple communication and documentation modalities-the electronic medical record, paper charting, emails, texts, phones calls, faxes- has the potential to impede a streamlined universal way of relaying important information.4 Each member of the team may have different methods of documentation, and oftentimes the same medical information is documented inconsistently by several different team members. Furthermore, the patient’s medical records may be transferred across different settings and updated independently within each setting, creating potential for inaccurate and incomplete data.  Consulting physicians may be unfamiliar with the electronic medical record system at a certain hospital and information may be relayed inaccurately with failure to document appropriately in a timely manner.

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.7 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.5 Longer lengths of stay in the rehabilitation setting provide the advantage of more time for patient education from every provider involved in the patient’s care: physicians, nurses, therapists, pharmacists, and social workers. With so many resources for information, it is imperative that each member of the team is well-informed and up-to-date. This can be achieved with weekly meetings and a uniformed methodology of daily communication (i.e. electronic medical record, secured emails and text messaging, phone calls, etc.)

3. CUTTING EDGE/UNIQUE CONCEPTS/ EMERGING ISSUES

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.4

Within the framework, there are three dimensions:  structure, process, and outcomes. The structure of the team is subcategorized into internal concepts (individual health-care providers, hospital procedures, and policies) and 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–care planning, information exchange, teaching, decision-making, negotiation, and leadership—that ultimately influence five team outcomes: patient discharge planning, reintegration into the community, effective disease management, patient/family satisfaction, and 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 processes, 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

4. GAPS IN KNOWLEDGE

Currently, there are no payment systems in place to reimburse interdisciplinary teams for time spent communicating and discussing patient care. To be cost-effective, meetings must be efficient, timely, and productive. A reimbursement system for the time spent discussing patients’ care may create greater incentive for frequent interdisciplinary team meetings and thorough communication, ultimately leading to better medical treatment, less legal ramifications, and improved patient satisfaction.

Many of the studies about communication issues in the interdisciplinary health-care setting were focused on the palliative care specialty rather than the physical medicine and rehabilitation specialty, though many of the same principles apply. To date, there has been little research that focuses on how team communication occurs and how to design technology to support effective communication. Many of the studies about team communication are limited by a single observer’s experiences and interactions and are not an objective depiction. A majority of the studies were done at single facilities with single teams and small sample sizes, and they may not be generalizable to other clinical settings. Future research should investigate alternative ways to overcome these 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. 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.
  4. 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.
  5. Batmangelich S. Cristian A. Physical Medicine and Rehabilitation Patient-Centered Care: Mastering the Competencies. Demos Medical Publishing 2015; 16-26.
  6. Christakis D. Feudtner C. Temporary matters: the ethical consequences of transient social relationships in medical training. JAMA 1997; 278:739-43.
  7. Olson DP, Windish DM. Communication discrepancies between physicians and hospitalized patients. Arch Intern Med. 2010; 170 (15) 1302-7.

Author Disclosure

Jeffrey Oken, MD
Nothing to Disclose

Kristen Jost, MD
Nothing to Disclose

Related Articles