In this study of the communication practices of hospitalists employed by a large integrated delivery system, we found that on average, physicians spent very little time communicating directly with patients, nurses and other physicians. Instead, the majority of communication appeared to take place through reading and writing of notes and by placing and receiving patient care orders. We found that physicians and nurses disagree about the plan of care more than 25% of the time about key issues such as the admitting diagnosis and the anticipated discharge date. Agreement between physicians and patients about the plan of care was worse than between physicians and nurses. We also found a lack of correlation between the amount of time the physician spent communicating and the level of agreement between physicians and either nurses or patients about the plan of care. Finally, we observed no statistically significant correlation between the amount of time physicians spent communicating and patients’ evaluations of the quality of the physicians’ communication.
Previous studies describing how hospitalists spend their time have been conducted in various settings, yet report similar time spent in direct patient care (analogous to our verbal communication with patients and families), ranging from 10% to 18% of a shift.1–3,5,6
Similarly, we found that physicians spent 5.3 minutes per patient—about 13% of an 8-hour shift. We also found that communication times varied substantially by provider, from a mean of 2 minutes per patient to greater than 12 minutes per patient.
Other studies have measured duration of communication between doctors and nurses or communication outcomes, but none has linked the two. Tipping et al. found that doctors spent an average 2.2 minutes per patient communicating with nurses.3
O’Leary et al. has studied agreement on the plan of care, using the same metrics we employed.7,8,10
They found that agreement between physicians and nurses was greatest for procedures planned (89%) and least for discharge date (64%)—almost identical to the proportions we observed. Agreement between physicians and patients was also poor, and similar to what we observed.8
There was no communication reported between physicians and nurses 38% of the time; agreement was not associated with reported communication but duration of communication was not measured.7
Our study has a number of limitations. First, it was conducted at a single institution with a relatively limited number of hospitalists. Even so, the total amount of time spent communicating and the time spent on verbal communication with patients is similar to that reported by others, so the amounts of time spent in other forms of communication (i.e., writing notes, speaking with nurses) may also be generalizable. Further, our hospitalists were not performing admissions during the shifts when they were observed. Hospitalists engaged in admitting patients may have different patterns of communication. Second, the scores we observed for communication satisfaction were uniformly high, making it difficult to differentiate among providers. We relied on questions from the HCAHPS survey, but an instrument with greater discrimination might have revealed an association between more communication and higher patient satisfaction. Alternatively, if we had observed a larger number of encounters, the observed association may have reached statistical significance. Third, our response rate was less than 50%, and there was substantial missing data about the plan of care for both nurses and patients who either could not or chose not to complete the forms. Their experiences may have differed from those nurses or patients who chose to complete them. Here, too, our findings were almost identical to studies with much higher response rates. Finally, the physicians in our study knew that they were being observed and this might have affected their behavior. We think it would be challenging for them to alter their clinical practice in the hectic hospital environment, but if they did so, they would likely have spent extra time in verbal communication. In that case, our findings may represent the upper limits of communication and agreement on plan of care.
In a recent poll of US adults aged 50 years and older, almost 75% said they wished their doctors talked to each other.11
Our finding that hospitalists did not speak to any other physician involved in the patient’s care in 62% of encounters is disappointing in this regard. Instead, doctors communicated via written notes without the opportunity to ask clarifying questions. Subsequent decisions may be made without complete information, and patients may receive contradictory information from different consultants unaware of each others’ plans.
Presumably, patients would also like their doctors and nurses to speak with one another. Patients interact primarily with nurses and expect the nurse to be a knowledgeable member of the healthcare team. We suspect that many patients would be surprised to learn that their physician often did not speak to their nurse at all, and when they did, the median time was only 30 seconds. However, we found no correlation between physician–nurse communication times and agreement on the plan of care, so presumably this communication centers around something else. This same disconnect existed for physician–patient communication. Doctors who spent more time with patients did not receive higher ratings on communication skills, nor were their patients more likely to correctly understand the plan of care. If hospitalists wish to improve understanding, they cannot simply spend more time communicating, they have to communicate more effectively.
Communication is important for two reasons. First, hospital care is complex, requiring coordination of a therapeutic team, under the leadership of a hospitalist. Without effective communication, teamwork suffers and errors are likely to occur. Although 87% agreement between physicians and nurses on planned procedures may seem high, the 13% error rate would not be tolerated in other industries. For example, airlines’ lost luggage rates are less than 0.3%. In contrast, medical procedures are frequently postponed because a patient was allowed to eat due to a lack of communication. Second, although patients have always participated in their care, there is a growing belief that patients should be involved in shared decision making, and even to participate as an active member of the healthcare team. Such participation is not possible without consistent exchange of reliable information.
Efforts to improve communication will have to balance hospitalists’ other responsibilities. Although physicians generally prefer synchronous communication (e.g., direct communication in person or by telephone), such communication is disruptive to work flow.12
We found, however, that most communication took place through asynchronous means, such as alphanumeric paging, electronic notes, and orders. This lack of opportunity to clarify may partly explain the frequent disagreement about the plan of care. Communication might be improved through multidisciplinary rounding, which has been shown to improve care quality and decrease mortality in intensive care units.13,14
Such rounds also appear to improve communication between hospitalists and nurses, though implementation remains a challenge, and the effects on length of stay and costs are mixed.15,16
In conclusion, we found that while hospitalists in one academic center spent limited time communicating directly with patients, nurses and other physicians, the quality of the communication, as reflected in agreement on the plan of care and patient satisfaction, was not associated with the amount of time spent communicating. Future studies should address ways to improve the effectiveness of communication without increasing the time burden on hospitalists.