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AAOS Now

Published 11/1/2018
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Michael R. Marks, MD, MBA

Communication Breakdown: A Personal Account

Ski accident illustrates the importance of communication and shared decision making

Editor’s note: This article concludes a two-part series on shared decision making and patient-centered care. The previous article, “Communication Skills Are Critical to Improving Patient-centered Care and Shared Decision Making.”

In 2018, my wife was involved in a serious skiing accident and had to be taken down the mountain in a sled by the ski patrol and transported by ambulance to a local hospital. Having sustained a two-part intertrochanteric fracture in her left hip and seven right rib fractures with a hemothorax, which fortunately did not require a chest tube, she was transferred to a Level I trauma center for treatment. Upon her arrival, the trauma team reviewed her electronic medical records from the first hospital, which included a CT of the chest and abdomen and plain radiographs of her pelvis and left hip.

With my wife’s permission, I am sharing her experience, as it illustrates the importance of effective physician-patient communication and shared decision making.

Case study

My wife had been transferred to the emergency department (ED) at the second hospital on a plastic sliding board. She repeatedly requested that the board be removed but was told it had to stay in place until another radiograph—a complete femur requested by the orthopaedic team—was taken. It took 4.5 hours for that to occur.

Because I was not present when my wife was assessed, I requested to speak to the trauma surgeon or residents about their findings and treatment plan, which I discovered had never been discussed with her. The admittance orders included pneumatic stockings and the anticoagulant enoxaparin. Three hours later, when the nurse arrived to administer the enoxaparin, I again asked to speak to a trauma team—this time about the reason for the medication. The nurse replied, “They are done with you in the ED; you will see them again in the intensive care unit [ICU] step-down unit. They won’t come back to see you here.”

Due to my wife’s impending hip surgery, multiple rib fractures, and hemothorax, she and I were uncomfortable proceeding with the enoxaparin. According to the nurse, the trauma surgeon said that enoxaparin was their protocol and there was nothing to discuss. I then asked the nurse about the pneumatic stockings that were ordered and was told they would be placed when my wife was admitted.

My wife was finally admitted to the ICU step-down unit at 12:15 a.m., seven hours after her arrival at the trauma center. Eight hours later, she was taken to the operating room. Beforehand, I had multiple collegial conversations with the orthopaedic team. My wife’s surgeon reviewed with me his operative plan and outlined the potential risks and benefits. Nothing was assumed. At 10:45 a.m., he called to tell me that the surgery had gone well. I told him that my wife and I preferred that aspirin be prescribed as the postoperative anticoagulation. He said that my wife was on the trauma service and that the service controlled all orders, even the postoperative ones.

Because my wife is allergic to penicillin, she was given intravenous clindamycin as antibiotic prophylaxis. When the 24-hour period passed, as the nurse hung another bag of clindamycin, I requested that it be discontinued, but he and the on-call trauma resident said that the order stated it was to be administered continuously. I asked to speak to the resident, but he said he was too busy. I told the nurse that I didn’t care what orders were written; my wife was not to receive any more antibiotics. The last thing she needed was a Clostridium difficile infection. Postoperatively, the trauma service still wanted her to receive enoxaparin. We refused every dose and each time requested aspirin as an alternative. Finally, at the end of postoperative day one, my wife received her first dose of aspirin. However, her discharge papers stated that enoxaparin and clindamycin were her medications, as they were never discontinued in the orders.

When my wife arrived in the ED, her hemoglobin (Hgb) was 9.1. On postoperative day one, it was 7.6; however, her vital signs were stable—normal blood pressure and not tachycardic. On day two, her Hgb was 6.9. After having a lengthy discussion with the residents outside my wife’s room, the rounding, covering trauma surgeon came in and told her, “Your Hgb is low; we’re going to transfuse you.” My wife immediately called me to speak with the trauma surgeon. I said that although I fully understood the concern, I had several questions. Was my wife hemodynamically unstable? Had her hemothorax increased, or was her thigh demonstrating increased swelling? Was she still losing blood? Her response was, “I really don’t know; I haven’t examined your wife.” After her examination, she stated that all my wife’s vital signs were stable, there was no evidence of increased thigh swelling, and that a chest radiograph would be ordered.

After much consideration, my wife and I elected to go ahead with the transfusion. We wanted to leave the hospital and didn’t want to find out the next day that her Hgb may have drifted lower. Throughout the day, we continuously requested that the resident update us on the results of the chest radiograph and post-transfusion Hgb. The nurse told us that the resident said he was much too busy to come by and talk to us.

Eleven hours after the chest radiograph and eight hours after the transfusion, we phoned the on-call attending trauma surgeon’s answering service. When he returned our call and heard our plight, he was very cordial and appropriately empathetic. He told us that the chest radiograph looked good, with no expanding hemothorax and only a bit of blunting at the right base; that my wife’s post-transfusion Hgb was 8.8, meaning that the 6.9 was probably spurious and that more attention should have been paid to the vital signs; and that he was mad as hell at the residents for not performing their responsibilities. Finally, he thanked us for calling him.

When we left the hospital the next day, we were greatly relieved that my wife had not developed any apparent hospital-acquired infections or complications. During my wife’s stay, the nurses were outstanding and always our advocates. However, the residency staff and trauma attending who wanted to transfuse my wife were undoubtedly frustrated by our many inquiries.

Takeaways

This story highlights many take-home points for orthopaedic surgeons. We must remember that when we counsel patients, we make recommendations and quote statistics based upon large pools of data. But every patient is an individual, and, in most cases, he or she is scared. In some circumstances, patients have been referred to as “strangers in crisis.”

When it comes to communicating with our patients, even the best of us can improve our skills. I encourage all of you to consider reaching out to the AAOS Communication Skills Mentoring Program (CSMP). Along with the program’s many workshops, CSMP mentors can provide orthopaedic surgeons with a refresher on the nontechnical skills needed to make patient encounters less frustrating and improve patient satisfaction.

Nonverbal communication tips from the AAOS Communication Skills Mentoring Program

Communication skills are important in the patient-physician relationship and can lead to improved satisfaction, adherence to treatments, outcomes, and reduced liability. Public opinion surveys conducted by the Academy reveal that Americans view orthopaedic surgeons as “high tech, low touch,” so orthopaedic surgeons should strive to improve communication skills throughout their careers. The Institute for Healthcare Communication has trained a select group of AAOS Communication Skills Mentors, who will conduct interactive workshops based on the Institute’s educational model at local, state, regional, and residency programs.

The Communication Skills Mentoring Program also offers recommendations for remembering and adapting nonverbal communication skills in daily practice, using the acronym S.O.F.T.E.N.:

Smile: This helps set patients at ease and generates positive feelings about you and your practice. This in turn breaks down barriers so you can uncover issues more quickly and openly.

Open posture. Open posture means no crossed legs, arms, or hands. This says that you are approachable and willing to interact.

Forward lean. This slight lean—so that you’re not in the other person’s body space—tells the patient, “I’m trying to get closer because I really want to hear what you have to say.”

Touch. As you walk into the room, shake hands with the patient in a warm and friendly manner. By shaking hands with the patient, the doctor not only sends a friendly nonverbal message, he or she can also learn lot about the patient’s psychological state. Is the hand warm, cold, jittery, sweaty?

Eye contact. This is probably the most important nonverbal communicator after smiling. Eye contact conveys that you are paying attention to the individual, not being distracted by your notes or something else on your mind. However, if eye contact is maintained 100 percent of the time, it can be uncomfortable for both the communicator and the receiver. Try to maintain eye contact about 80 percent of the time.

Nod. As your patient speaks, it is important to nod occasionally, not necessarily in agreement, but rather as a nonverbal way of saying, “I hear you. I understand what you’re saying.” Nodding also encourages the patient to move along with his or her story.

Nonverbal cues to avoid include:

  • tapping fingers, pens, pencils
  • clenching fists
  • yawning
  • looking out the window
  • tapping your feet
  • crossing arms or legs
  • shifting weight from one foot to another

Michael R. Marks, MD, MBA, is a member of the AAOS Medical Liability Committee, member of the AAOS Patient Safety Committee, and mentor for the AAOS CSMP. He can be reached at mmarks1988@gmail.com.