Editor’s Note: Vineet Arora, MD, MPP, is an Associate Program
Director for the Internal Medicine Residency and Assistant Dean of
Scholarship & Discovery at University of Chicago’s Pritzker School of
Medicine. She blogs about medical education at FutureDocs.
My work studying handoffs began back in 2003, after I was chief resident at the
University of Chicago. Through our research, we found that even in optimal
situations (dedicated room, dedicated time, attending supervision, etc.), 60
percent of the time, the handoff receiver was not able to name the top issue
for the patient as determined by the sender–despite having access to the
written record. Part of the problem may be information overload; people simply
cannot decipher the importance of various items when faced with so much
information. Therefore, there’s a need for training in how to communicate
better.
Imagine you’re writing a shopping list for somebody. If you’re putting it
together for a stranger, chances are you’ll be much more detailed in your
instructions than you would be with your spouse, who implicitly knows whether
“buy milk” means 2% or skim, thanks to your rich history of shared experiences.
What may be going on in hospital handoffs is that people are assuming that
they’re seeing the same things–so there’s that illusion of shared
experiences–but since those experiences are in reality happening successively,
there’s no opportunity to create a shared mental model of them. As a result,
directions may be vague and not precise enough for someone who does not
know a patient sufficiently to understand what to do.
In addition to verbal communication issues, there are also problems with the
written records. Eighty percent of handoff notes, for instance, contain a
medication omission of some kind. Electronic health records that integrate with
medications can certainly solve this problem. However, there are downsides to
integrating with EHRs. The ease of the copy-paste function means that handoff
notes are getting longer and longer. What you see is text that looks more like
a wiki than it does a synthesized problem list.
The best handoffs, both verbal and written, are concise and strike the right
balance between pertinent and thorough. They’re composed of a one-liner
diagnosis, followed by clear and specific anticipatory guidance that include
enough rationale so the recipient doesn’t have to guess at what the sender was
thinking.
Along with in-hospital shift handoffs, effective handoff communication is also
the cornerstone for continuity between a hospital-based physician and a primary
care physician. Mobile HIPAA-secure messaging, such as what’s used on
Doximity, has the potential to promote real time physician communication
during these care transitions, such as keeping primary care physicians
up-to-date during a patient’s hospitalization, or to alert them that their
input is needed on a specific question. Some of our other work has shown that
hospital-based physicians spend a lot of time looking up contact information
for primary care physicians–so certainly there is also potential to tighten up
that side of the process and facilitate timely communication. So, whether
it’s in-hospital or out of the hospital, it’s important to remember to handle
the handoff with care.