How to fix the broken telephone

Phone conversations are a major source of miscommunication between doctor and patient.

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.”)

—Jill Max

Study finds sleep apnea is a major risk factor for stroke and death

Although previous studies have suggested links between sleep apnea and stroke, it was never clear whether the increased risk of stroke was related to such other factors as hypertension or diabetes. Now, in a study published in The New England Journal of Medicine in November, a Yale team has found that, regardless of other factors, sleep apnea can put people at risk for stroke—the third leading cause of death in the developed world.

“Our study shows that sleep apnea doubles the risk for development of stroke and death, and severe sleep apnea more than triples the risk,” said H. Klar Yaggi, M.D., assistant professor of medicine and principal investigator of the study. “We know that this risk was independent of other risk factors, including high blood pressure.”

As many as one in five adults in the United States suffer from sleep apnea, which causes them to stop breathing temporarily while they sleep. Their bed partners may notice such symptoms as loud snoring, gasping or pauses in breathing. Men are more at risk for sleep apnea than women; obesity is also a risk factor.

The new study, conducted between January 1997 and December 2003, enrolled 1,022 patients over the age of 50 who had gone to the Yale Center for Sleep Medicine for treatment. About 68 percent, 697 patients, had been diagnosed with obstructive sleep apnea syndrome. Hypertension, diabetes and obesity were more prevalent in this group. The mean apnea-hypopnea index—the number of episodes of breathing cessation per hour—of those with the syndrome was 35. Those in a comparison group who did not have obstructive sleep apnea syndrome had a mean index of 2.

An unadjusted analysis found an association between obstructive sleep apnea syndrome and stroke or death from other causes. Age and diabetes, for example, were significant factors. But even after adjusting for age, sex, race, smoking, alcohol consumption and diabetes or cardiovascular disease, the study still found a significant link between sleep apnea and stroke or death. Only 16 in the comparison group suffered stroke or death, but 72 patients with obstructive sleep apnea syndrome had a stroke or died.

The study was supported by the National Institutes of Health, the Department of Veterans Affairs and the Yale Center for Sleep Medicine.

—John Curtis

et cetera

Pesticide linked to infertility

A common pesticide may interfere with the reproductive tract, leading to reduced fertility in women, according to Yale researchers.

In an article published in Endocrinology last August, the researchers reported that in studies in mice and in human tissue, methoxychlor (MXC), a substitute for the banned pesticide DDT, alters an estrogen-regulated gene in the reproductive tract and reduces the ability of the uterus to support embryo implantation. MXC, which is applied to crops, livestock, home gardens and pets, is one of several chemicals that can mimic the action of hormones and sometimes interfere with endocrine function.

“MXC has an adverse effect on these mice similar to that of DES, a synthetic estrogen,” said senior author Hugh S. Taylor, M.D., HS ’92, associate professor in the Division of Reproductive Endocrinology and Infertility in the Department of Obstetrics, Gynecology and Reproductive Sciences. “Female offspring of women exposed to des were more likely to have an abnormally shaped cervix and were more prone to cancer of the vagina, miscarriages, early labor and other complications.”

—J.C.

Cell phones reduce errors

Cell phones have long been banished from hospitals over fears of interference with medical devices. A study by a Yale anesthesiologist and colleagues, however, suggests that mobile phones speed communications and reduce medical errors. And digital phones rarely cause interference.

For a study published in Anesthesia & Analgesia in February, Keith J. Ruskin, M.D., associate professor of anesthesiology and neurosurgery, surveyed attendees at the 2003 meeting of the American Society of Anesthesiologists. Based on more than 4,000 responses, Ruskin found that 65 percent of anesthesiologists relied on pagers to communicate and 17 percent used cell phones. Of those who used pagers, 45 percent reported delays in communications. Only 31 percent of those who relied on cell phones reported delays.

—J.C.


			Originally published in Yale Medicine, Spring 2006. Copyright © 2006 Yale University School of Medicine. All rights reserved.