The Art of the Message

Sometimes I wonder if I am wired differently from other doctors, in terms of what I remember on my own and what I need some help with.

The other day I got a “medical call” that simply said, “Mr Brown called to report his blood pressure is 120/80”.

With more than fifty calls in my inbox and no memory of what the issue was with Mr Brown’s current blood pressure, I replied “seems like a random fact, is there a back story?” I never heard back.

Seeing up to thirty patients a day and receiving at least fifty each of EMR “documents”, messages and lab results, my mind doesn’t retain the details of each clinical plate swerving in the air above my head. Mr. Brown could have stopped his blood pressure pill because he was lightheaded with a low blood pressure, or he might have stopped his valsartan because he was caught up in the fears of cancer causing ingredients in Chinese generics, or he could have had an abnormal potassium and stopped the medicine that could influence potassium levels. Or, perhaps he got a home blood pressure cuff to prove that he has white coat hypertension.

In my world view, in light of the productivity requirements in primary care, messages need to be anchored in a clinical scenario so that the provider can make a decision without doing several minutes of research during time stolen from scheduled patient visits, lunch, bathroom breaks or life in general.

“Tell me why you were asked to call in your readings” would have been the way to handle that call, but I have a vague suspicion that the medical assistant who took the call felt pressured by the list of other calls that needed attention, for example the mandatory ER Followup calls that are a quality indicator for us. The quality of clinical calls doesn’t count, so they might be a lower priority. Everyone in the medical office has their own hoops to jump through and sometimes we are tempted or have no choice but to do the minimum and pass the buck just to get through our day.

I had hoped, naively as many readers commented back then, that the Patient Centered Medical Home concept would foster a reengineering and a clearer focus on what really matters. Like so many other quality enhancements in medicine, it has created another layer of superficial check-offs that has made it harder to see the patient and the clinical issues at hand.

I still wonder what the deal was with Mr. Brown, which is not his real name; I forgot the name the instant I hit “reply” and got the incoherent message off my already full plate.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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