Tuesday, September 18, 2007

Communicating With Your Physicians - Part 1

Communication between patient and physician is an important factor in the diagnosis process. At one time, I thought that verbal communication was the only form of communication necessary, when communicating with my physicians. I have since changed my opinion.

There was a time when I only saw my Primary Care Provider for an annual exam. I was normally a healthy person, and I was not prone to automatically seeing a physician for minor illness. Therefore, a quality doctor / patient relationship was not established with my primary care physicians during my healthy years.

Once I began having medical problems, I went through two Primary Care Physicians, prior to finding a patient friendly physician who was willing to work with me. Since I had become a frequent visitor to my Primary Care Physician’s office, the development of a good doctor / patient relationship was able to take root. Familiarity, as well as communication during appointments, helped to solidify a good working relationship between us. Unfortunately, he retired prior to my symptoms progressing enough for him to render a differential diagnosis.

My current Primary Care Physician inherited me because of my previous physician’s retirement. In the beginning, I was not sure that he and I would be a good match for an acceptable doctor / patient relationship. However, I did not throw in the towel. One afternoon we engaged in an intense verbal discussion by phone, which turned the potentially disastrous doctor / patient relationship into probably the best doctor / patient relationship I have had to this date. Clear communication and some human emotion had turned this relationship around.

While I was a patient of the now retired Primary Care Physician, I incorporated written communication into my doctor / patient relationship. As it became clear that I was potentially dealing with a chronic illness, I wanted to insure that every symptom I experienced was communicated and documented. My previous Primary Care Physician was very thorough at taking notes, but for my own peace of mind, I wanted my symptoms and other health related concerns, documented in writing from my perspective as the patient. Additionally, not all physicians are thorough when taking notes, and there are often key pieces of information that are left out. Therefore, when a patient brings up a previously discussed symptom at a future date, and if that symptom never made it into the notes, the physician is very likely not to recall ever discussing the symptom. Physicians see so many patients, that it is impossible for them to remember every word of every verbal communication with every patient.

It is now my standard practice to communicate with physicians verbally, as well as in writing. The type of circumstance dictates whether I utilize verbal communication, written communication, or both forms of communication. The following is a list of various scenarios, and the type of communication I will normally use:

1. Office visit with Primary Care Physician for minor illness or basic follow-up appointment – verbal communication

2. Initial visit with a Movement Disorder Specialist or other specialist – verbal and written communication. If time permits, I send a letter of introduction and copies of my medical records, prior to the appointment. I also make sure to bring backup copies with me to the appointment, in the event that my letter and medical record copies somehow did not make it into the physician’s hands.

3. Follow-up visit with a Movement Disorder Specialist or other specialist – verbal and written communication. Prior to the appointment, I write a brief summary including symptoms, changes in symptoms, medication problems, etc., to give to the specialist during the appointment. This summary not only helps me to remember the topics I want to verbally discuss during the appointment, but also serves as a permanent record that the information was provided to the physician on that date.

4. Non-office visit follow-up with Primary Care Physician after seeing a specialist – verbal and written communication. Following a visit with a specialist, I write an informational short report detailing the visit. This includes information pertaining to symptoms, treatment, topics discussed with the specialist, and future visits. Additionally, I include a copy of any written communication I had given to the specialist. I then fax these items to my Primary Care Physician’s office, and call to make sure they were received.

5. New concerns, which may or may not be related to my spinal condition or Parkinsonism, that I want my Primary Care Physician to be aware of – verbal and written communication. I call my Primary Care Physician’s office and provide a brief description of my concerns to his office assistant. I then write a more detailed summary of my concerns and fax it to my Primary Care Physician’s office. Again, I then place a call to his office to confirm that my fax was received.

Why do I now communicate with physicians both verbally and in writing?

Verbal Communication

Verbal communication is obviously the primary form of communication used during a visit with a physician. During a visit with a specialist, a patient verbally describes his / her symptoms, duration of symptoms, differential diagnosis, diagnostic tests performed, and current treatment(s) to date. Likewise, a physician may verbally ask questions for clarification, explain his / her findings after examining the patient, present a need for further diagnostic testing / evaluation, and render a preliminary diagnosis with a treatment plan. A patient will normally be able to ask questions, in order to make sure he or she fully understands what the physician has said. Even if the specialist does not render a diagnosis during the visit, if the verbal communication is adequate, the patient will understand the physician’s course of action necessary to assist with the diagnosis process.

Written Communication

I have found that written communication is an important tool, especially for the patient who has an undiagnosed chronic condition. Additionally, for patients who do have a diagnosis, written communication is a great way to keep your Primary Care Physician, as well as your entire team of physicians, informed on any changes in your condition, in between appointments. Aside from and including some of the situations that I have previously listed, here are a few examples of the benefits of establishing written communication with your physicians:

1. Patient provided written documentation of symptoms gives an exact description and complete information that leaves little room for misinterpretation. Verbal communications have the potential to allow incorrect interpretation and potentially incorrect note documentation with respect to the patient’s symptoms. Patient provided written documentation eliminates these issues, because it is the patient’s accurate, first hand account that can be added to the patient’s chart for future reference by the physician.

2. Patient provided written documentation of changes in the chronic illness helps in two manners. First, if it is provided to a physician during a visit, it gives an accurate, first hand account of those changes. Again, a patient can request that the documentation be added to the patient’s records / chart. If the patient is in-between visits, he / she can fax the written account of the changes to the physician’s office. This allows the physician to determine whether or not the issues need to be addressed immediately, or if the issues can be addressed at the patient’s next appointment. I have found that my Primary Care Physician will often call me to discuss my correspondence, and then he will determine the necessity for an earlier visit.

3. Patient provided written documentation provides security for the patient. In my experience, there are times when a physician may not recall a specific issue of a verbal conversation with a patient, and may not have taken detailed notes of that conversation. For example, a patient may be at an appointment and wants to talk about a symptom that had been discussed six months ago. The patient goes on to describe changes involving that symptom. The physician states he / she does not recall discussing this particular symptom and it is not noted in your patient file. In this scenario, a patient may then remind the physician of the previous verbal conversation and can offer to provide him / her with another copy of the written documentation. Providing written documentation to your physician and having it added to your patient file provides the patient the security of knowing that there is an accurate record of any concern, new symptom, medication issues, etc. in the physician’s possession.

Another aspect of security provided to the patient who provides written documentation, is that it tells the story of your “history” with respect to the diagnosed or undiagnosed medical condition. This history becomes a great asset if the patient applies for permanent disability through Social Security. When the Social Security Administration sends out a request for your medical records, your written documentation / correspondence with your physician, can assist in establishing degree of disability, progression, length of chronic illness, etc. It also provides evidence that the medical condition causing the disability has existed for an extended period of time, and it is likely to continue.

Here is my personal example of how written documentation saved me from an incorrect differential diagnosis that could have potentially caused an enormous delay is my search for a diagnosis. I have written of this previously, but it deserves additional attention at this point.

When my symptoms progressed to a point where every aspect of my daily life was affected, I made an appointment with my Primary Care Physician. My physician had previously not observed most of my symptoms, due to their intermittent frequency in the beginning. Being the master procrastinator that I am, by the time I finally went to see my physician, my symptoms were not only constant, but also profound. The most prominent features were my extremely slow walking pace and the quality of my speech, which was low in volume and slow. By this time, I had virtually no facial expressions or bodily animations when speaking.

When my physician saw me in this condition, he was shocked. After speaking to my husband and me and performing an exam, he stated that I was possibly bi-polar. He also did not recall ever hearing about these symptoms before this particular visit. My husband was with me for this appointment, and he began to explain to my physician that my symptoms reminded him of his mother, who had been diagnosed with Parkinson’s Disease prior to her death. He also let my physician know that he had never observed any signs of depression, bi-polar disorder, or any other mental health related condition in the six years that he has known me. My physician agreed to prescribe Sinemet, which I still take today. He also believed an appointment with a Psychiatrist was needed.

That afternoon someone from my physician’s office called me to give me the name of a Psychiatrist that my physician wanted me to see. I was annoyed that he was still going down this trail, but I wrote the name of the Psychiatrist down. At this point, the biggest thing that was bothering me was that I was certain I had previously told my physician about all of the symptoms.

That evening I began going through all of my copies of written correspondence that I had given to my physician on previous occasions. I not only found written correspondence from two years prior that had detailed many of the symptoms to that date, but also written correspondence to my previous physician that noted a few of the symptoms that had emerged during that time period. Both correspondences should have been in my patient records file at my physician’s office. So, at this point I became even more upset about the initial bi-polar opinion. I composed a new written correspondence, detailing the beneficial effect of Sinemet on my symptoms, as well as referencing my previous correspondences. I faxed this new correspondence along with the previous correspondences to my physician’s office. Within an hour of that fax, my physician called to apologize and let me know that I would receive a referral to a Movement Disorder Specialist, and that there was not a need to see the Psychiatrist at this time.

Had I not implemented written communication into my relationship with my physicians, I believe that valuable time might have been wasted while chasing after a mental health disorder that did not exist. Of course, a few months later I took the steps necessary, as I noted in a previous post, to insure that in the future, mental health conditions could not be offered as the source of my condition. Additionally, had I not retained copies of my previous written communications, I would not have been able to offer proof that I had already shared that information with my physician. I also would not have had the ability to prove that the symptoms even existed prior to the most recent appointment.

In the second part of communicating with your physicians, I will better define some key elements that can assist a patient on how to be more effective in communicating both verbally and in writing. I will also post a “sample” written correspondence.


Anonymous said...

Nicole, I just spent some time updating myself on your blog writing. I was very excited to see how much you have accomplished in a little bit of time, and the thoroughness and clarity of your writing are both strong. I find that you have such a grasp on the medical aspects and are so in tune with your own body and mind.

I know that there is a lot of pain, disillusionment and distress that accompanies such a disease. I thank you for giving so much to others during a difficult struggle. Also, thanks for being a partner in the fight to overcome. God bless, Dan

Patient With A Plan said...

Thank you so much for your encouragement once again. I fully agree that pain, disillusionment and distress are unfortunately associated with chronic illness. Ironically, sharing the story of my illness as it relates to the diagnosis process, helps to lessen the negative emotions that accompany the illness.

Thank you again for your support.