How to fix the broken telephone

As soon as the words were out of her mouth, she regretted them: while returning phone calls for a colleague, Anna B. Reisman, M.D., assistant professor of medicine, told the woman who answered the call that her husband had tested positive for gonorrhea. Not only should Reisman have declined to share test results with a family member, but as it turned out, she had misread the patient’s chart. The family accepted Reisman’s apology, but she’ll never forget her indiscretion, and in the seven years that have passed she’s often asked herself how it could have been avoided.

Communication failures have been shown to play a key role in medical mishaps; telephone encounters, which account for 25 percent of interactions between physicians and patients, are particularly tricky. There are no visual cues to tell the physician how the patient is feeling, how he or she is reacting to a diagnosis or whether the patient can speak freely—all of which can set the stage for preventable errors.

In a paper published in the October issue of the Journal of General Internal Medicine, Reisman and co-author Karen E. Brown, M.D., assistant professor of medicine, outlined scenarios in which communication errors commonly occur, providing strategies to minimize mistakes. The scenarios involve sensitive test results, requests for narcotics, patients who are unwell but not sick enough for the emergency room, late-night calls, communicating with unintelligible patients and calls from patients’ family members. In one scenario, a patient calls his physician in the middle of the night with back pain. Irritated at being awakened for a seemingly petty concern, the doctor terminates the call before the patient can explain that his symptoms include chest pain; the patient ends up hospitalized with a mild heart attack. In this situation, Reisman and Brown discuss the importance of careful questioning and suggest ways of drawing out hidden concerns. They advise giving the patient time to describe the chief complaint before interrupting, asking the patient why he or she is calling at that time and finding out if there is anything else the patient wants to communicate. In another scenario regarding sensitive test results, the strategies include scheduling an office visit (which can later be cancelled) when ordering tests that might have significant results; ensuring that patients can speak freely if the test findings are given over the phone; and not leaving results with family members or recorded on an answering machine. (Since the passage of the Health Insurance Portability and Accountability Act in 1996, all hospital staff have received training in protecting patient confidentiality.)

Physicians assess patients by observing aspects of their appearance, but the opportunity for visual inspection is missing in phone encounters. Improving phone skills can help doctors fill in some of that information. “Better communication improves doctor-patient relationships, decreases lawsuits and improves outcomes,” said Reisman.

Despite advances in other communication technologies, the telephone will continue to play a major role in doctor-patient relationships, yet according to a 1995 survey, telephone medicine is taught in only 6 percent of residency programs. Reisman began teaching it to residents and physicians when she noticed how frequently residents talked about mistakes they had made when dealing with patients over the phone. By teaching the best way to handle telephone encounters, she hopes to help others avoid mistakes similar to the one she made almost a decade ago.

(For a different view of the clinical use of phones, see “Cell Phones Reduce Errors.”)