Getting in Touch, Figuring It All Out

— It's great to have more than one way to ask for help on a difficult case

A photo of a female physician talking to a male physician during a video conference.
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    Fred Pelzman is an associate professor of medicine at Weill Cornell, and has been a practicing internist for nearly 30 years. He is medical director of Weill Cornell Internal Medicine Associates.

When in the course of taking care of our patients we often come across a sticking point, a time where we don't know what to do next.

Being able to admit this is incredibly important. It can help our patients achieve the best state of health and prevent bad outcomes or missed opportunities and delays.

Turning to our colleagues, whether that be another primary care doctor in the same office to run things by, or an outside specialist or subspecialist who may help recognize an unusual presentation of a common illness -- or a common presentation of an unusual illness -- can be quite fruitful. Having the right mechanisms for all of these ways of communicating and seeking assistance is critical for the successful care of our patients.

Sometimes it's hard to admit, "We're there now; I've tried A, B, C, D, and maybe even E and F, but I'm still not getting to an answer, and the patient is still not getting better." Sometimes more testing is the answer, sometimes trying a different medication is the answer, but sometimes turning to a colleague is the right choice. Sometimes it's wandering into the office next door, or across the hall, or picking up the phone.

Recently I sent a patient for a very specialized test, one I'd rarely ordered in the past, but was recommended by all the guidelines as the next step in management of the particularly vexing problem this patient was having. Unfortunately, the old adage of "Never order a test when you won't know what to do with the answer you might get" held true in this case. The report I got back was several pages long, full of a lot of complicated data and findings, and no matter how many times I read it, I still felt like I didn't know what the final impression on the report was telling me.

So I sent a quick chat through our electronic medical record to the subspecialist who had provided the interpretation of this particular study, asking if they'd mind talking it out with me on the phone. Their immediate response and the enlightening explanation they provided helped guide me to the next step to take for my patient. Knowing who we can turn to, knowing who we can trust, and knowing when we've reached our limits are all critical to the successful practice of medicine.

Group chats are also an efficient and often quite useful mechanism, getting several members of the care team for a patient into an online discussion right in the electronic medical record, where everyone can toss out ideas and parse out tasks. I recently did this with a particularly complicated patient, chatting simultaneously with their neurosurgeon, radiologist, oncologist, cardiologist, and infectious disease specialist -- everyone bouncing ideas off each other, taking on responsibilities, working as a team.

Besides the chat feature (and of course the old fashioned "picking up the phone"), another really powerful and useful tool that we are still under-utilizing in our electronic medical record is the e-consult. This electronic consultation mechanism replaces the old curbside consult, when we'd walk down the hallway, or go by a specialist's office, or stop a colleague we see on the street after work, to ask for their opinion about a case that had been bugging us, something they may have more experience managing.

In the current healthcare environment, access to our subspecialist colleagues has been extremely restricted, with wait times to get folks in to see somebody of several months or more. But with the e-consult, for a wide variety of specialties, we can put a question into a consult in the chart, and instead of waiting for an open appointment with that specialist, they will review the chart and render an opinion back to us, usually within 24 to 48 hours.

Being able to send a photograph of a concerning skin lesion, or a description of a clinical conundrum, and coupling this with all the information available to them in our notes and in the test results sections of the electronic medical record, allows these consultants to more efficiently answer a question, while also giving them the opportunity to be reimbursed for their work. Having these additional outlets and opportunities has often been a huge relief, and makes us more comfortable than just trying to take an educated best guess on what to do next.

Someday soon, I imagine a world where these sorts of questions and consults will take advantage of artificial intelligence to review a patient's entire chart, to capture all of their data -- whether that be lab results, radiology images, pathology slides, or even real-time video of the patient themselves - and then to compare all of this to the vast medical literature out there to search for a connection, a clue, and help come up with an action plan for moving forward.

For now, I'm grateful for my colleagues who don't mind me sticking my head in their office and saying, "Have you got a minute to talk about a patient? This one's been puzzling me for a while now." But for more complicated issues, for the heavier lifting, it never hurts to pick up the phone, to send a chat, to put in that formal e-consult that can happen in a timely manner.

And get the getting done, done.