Physician Communication: What, When, How
By Jessica Reichl, PT, DPT, CDP
Geriatric Clinical Resident
As a clinician treating patients in their homes, one is faced with a different set of challenges compared to a clinician working in a clinic. As a newly graduated professional starting out in the home setting, one of my biggest concerns was, “What if there’s an emergency?”
With FOX, our typical patient is 75 percent more medically complex than the average older adult. They are, on average, 83 years old, and have four or more chronic conditions. The most prevalent conditions our patients present with include hypertension, stroke, arthritis, dementia, and diabetes. However, when dosed properly, exercise poses little risk of adverse event in the older adult. 1
It is important to understand when the patient’s health may be at risk, and when reaching out to our patient’s physician is warranted. Communicating with our patients’ physicians, as well as other clinicians involved in the person’s care, is an important part of working as an interdisciplinary team. This is especially true in the case of medical complications or emergencies, in order to create an appropriate plan of action in response to the current situation. True medical emergencies are rare when treating in the home, but when they present, appropriate identification and response can save a life.
At FOX, our clinicians are provided with a “cardiac protocol” that outlines vital signs would contraindicate physical activity. We also utilize a clinical decision-making tool that guides a clinician’s decision making when someone with diabetes, congestive heart failure, or COPD is experiencing concerning symptoms, or if the clinician believes their patient may have pneumonia. These resources indicate symptoms that would warrant a phone call to the physician, or whether it’s more appropriate to seek emergency medical services.
WHEN TO CALL A patient’S PHYSICIAN
Vitals are vital.
One of the most important times to call a physician is when our patient’s vital signs are outside of the normal range, and contraindicate exercise. Some of the most generally recognized examples related to the older adult include systolic blood pressure above 200, or below 90 mmHg, diastolic blood pressure above 110, or below 50 mmHg, and oxygen saturation below 90 percent, whether at rest or in response to exercise. Other components of vital signs to look out for include a resting pulse above 100 bpm or a change in the pulse characteristics. For example, if the patient has a normal, consistent pulse at rest, but then with activity they start experiencing heart palpitations, it’s time to give the physician a heads up.
Reporting your findings relating to vital signs response or pulse characteristic changes to the physician is important as these numbers may indicate increased risk of stroke or heart attack. Doing so will allow the physician to decide whether medical management is warranted.
Much like vital signs, red flags are something to be mindful of as they may indicate the need for referral for medical management or more emergent care. Eighty percent of people with acute low back pain present with at least one red flag. That doesn’t mean we are going to get the physician on the phone immediately. In fact, in people with acute low back pain and one red flag, the prevalence of osteoporotic fractures is 4 percent and malignancy is 0.7 percent. In these instances, it’s important to dig a little deeper and collect more information before making a decision on whether to call or not. When only one red flag is present, it may be more appropriate to suggest that the patient bring it up to their physician at their next appointment, but it wouldn’t warrant a phone call to the physician.
A case where low back pain may cause concern is in the presence of other red flags. One of my previous patients was referred to physical therapy due to onset of low back pain. This man also presented with an ataxic gait pattern and reported periods of double vision while at rest. He also mentioned that he would get profuse night sweats, to the point where he would have to change his sheets, and had just lost ten pounds without trying. This was a guy who was frequently found eating cookies and other baked goods. Once I was able to receive and analyze all of this information, I realized it was time to call the physician and report my findings, as this group of symptoms may indicate cancer. In identifying this cluster of symptoms, and referring them back to their primary physician, I knew that I did everything I could to ensure this patient got the best care possible.
Other red flags to keep in mind are signs and symptoms of a deep vein thrombosis, which can be identified with the use of the Well’s clinical prediction rule.
Another important reason to get in contact with a patient’s physician is in the presence of yellow flags. Physical therapists, occupational therapists, and speech-language pathologists have the privilege of seeing patients more frequently than our physician counterparts. It is because of how frequently we see our patients that we can build relationships that other clinicians may not be able to. Our patients tend to feel most comfortable reporting symptoms of depression or anxiety to us first, as there tends to be a stigma with mental illness. Yellow flags may hinder a patient’s ability to make progress throughout their plan of care, so it’s important to refer to another source when these flags are identified so they may be properly addressed. Other examples of yellow flags may include onset of increased edema, maladaptive pain coping, low general health status, and poor work satisfaction.
WHAT TO SAY/IDENTIFY TO A patient’S PHYSICIAN
When calling a physician, it’s important to know how to frame our message in order to give them the entire picture clearly and succinctly.
When calling about abnormal vital signs, we should give the office staff or physician themselves as much information as possible. Calling to say that a patient’s blood pressure is 200/100 mmHg isn’t enough.
Is this the resting pressure?
Is this after walking or activity?
How far did they walk or how much of that activity did they do?
What was their heart rhythm or rate, and oxygen saturation response to this activity?
Did their blood pressure return to resting levels? How long did it take to return to resting levels?
These are the types of questions that should guide our thought process to determine if we need to call the physician or not. Then the communication with the physician becomes easy.
I had a patient with a history of orthostatic hypotension, whose resting blood pressure was 90/50 mmHg, and upon standing was 75/50 mmHg. When in supine, his pressure elevated to 94/50 mmHg. These levels were not uncommon for him, despite his standing blood pressure contraindicating exercise. At first, the physician instructed me to stop therapy for today and to tell the patient to lie supine. Once I alerted them to the person’s current symptoms, such as recent onset of chest tightness and nausea, and we discussed his history of stroke, they instructed me to send this person to the emergency room. In the event that I could not get a hold of the physician, my response would have been to send this person directly to the emergency room.
The same idea goes for identifying red flags in people with chronic conditions. One of the most well-researched conditions that can present with red flags is acute low back pain. As stated previously, 80 percent of people with acute low back pain present with one red flag.
So let’s say an older adult reports severe night pain in their low back.
One red flag may not indicate a serious pathology. In fact, a recent study reported that those with one red flag only had a 1% chance of serious pathology. 2 It’s important to then continue with a thorough history including demographics, social and health habits, medications, family history, any bowel or bladder changes, and to perform a thorough physical and systems review. This way, we get the entire picture of the patient’s complaints and nature of symptoms, and any factors that may contribute to those symptoms before deciding whether it’s time to call the physician or not.
When addressing a yellow flag such as patient reported symptoms of depression, The Geriatric Depression Scale is a great tool that both quantifies the severity and can help start the conversation about depression with someone experiencing depressive symptoms. It’s never an easy conversation, but using this scale can help guide us and can also provide the patient with insight into their symptoms. Once we identify someone who is depressed using this scale, it also facilitates a conversation with the physician as to what symptoms the older adult is experiencing and provides the physician with an objective measure of the patient’s severity of symptoms.
HOW TO BEST COMMUNICATE WITH OUR patientS’ PHYSICIANS
So we’ve identified a problem that warrants reaching out to the physician. We completed a thorough assessment and have all of the facts to provide the physician with the full picture of what’s going on.
Now what? Do we call? Email? Go to their office?
In my experience, I always start with a phone call to the physician. However, if the situation is a true medical emergency, it would be more appropriate to seek emergency medical services first. There have been times where I left a message with office staff or a nurse, and there have been times I spoke directly with my patient’s physician. Either way, again, it’s so important to get our entire message across, so that the physician has the full picture. It’s also important to document what occurred in the patient’s medical record via communication note, including your message to the physician, who you left the message with, and what action was taken. There have been times where the physician’s office preferred email communication, in which I had my communication note sent directly to them.
Reaching out to a physician can feel intimidating. We know that their schedules are packed. But for that reason, it’s so important to have all of the facts in front of us when calling or writing so that we’re fully prepared to get our entire message across.
More times than not, I’ve had physicians personally thank me for calling them to let them know what was going on, whether it was during our initial conversation or during a follow-up phone call. In fact, I had a patient whose oxygen saturation would drop with light activities, so I called the physician to let him know about her vital signs response and to create an appropriate plan of action. It turns out that this woman was later diagnosed with pulmonary hypertension. The next time I spoke to the physician, he actually thanked me and praised me for identifying that something was wrong.
Keeping our patient’s physicians informed keeps them in the know of how their patients are doing and can improve the patient’s care. Being prepared for your conversation with the physician is imperative in order to be able to have an intelligent conversation about your patient’s so that the appropriate action can be taken.
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