Exploring current physicians’ failure to communicate clinical feedback back to transferring physicians after transitions of patient care responsibility: A&nbsp;mixed methods study

Judith L. Bowen; Joseph Chiovaro; Bridget C. O’Brien; Christy Kim Boscardin; David M. Irby; Olle ten Cate

doi:10.1007/S40037-020-00585-1

Figures & Tables

Table 1

Conditions of interest (predictor variables) and the outcome variable, and associated structured interview questions for quantitative and qualitative strands

		Quantitative data	Qualitative data
	Definition	Structured interview questions
Condition of interest (Predictor variable)
Perceived transferring physicians’ uncertainty	The current physician perceived the transferring physician to express uncertainty about clinical decisions at the time of the care transition	Did the transferring hospitalist express uncertainty about the diagnosis or management for this patient at the time of transition? (yes/no)
Perceived transferring physicians’ request for communication	The current physician perceived the transferring physician to request communication back about the case at the time of the care transition	Did the transferring hospitalist request communication back about this patient? (yes/no)
Changed clinical decision	The current physician changed the transferring physicians’ diagnosis or management plan after the care transition	Did you change the patient’s diagnosis or management plan after the transition? (yes/no)
Outcome variable
Communication occurred	The current physician reported the status of communication with the transferring physician	Did you communicate back about this patient? (yes/no)	If yes, what was the primary reason for the communication? Who initiated the communication? What was the method of communication? If no, what was the primary reason communication did not occur?

Table 2

Study site comparisons for numbers and frequency of communication occurrences and conditions of interest for all 618 patients transitioned during the study period in two academic hospitalist practices in 2018

	Site 1 N, %	Site 2 N, %	Total N, %
Patients transitioned during study period	260, 42%	358, 58%	618, 100%
Communication occurrences	39, 15%	68, 19%	107, 17%
Frequency of condition of interest
Current physician perceived transferring physician’s uncertainty	69, 26%	84, 23%	153, 25%
Current physician perceived transferring physician’s communication request	23, 9%	25, 7%	48, 8%
Current physician changed transferring physician’s clinical decision(s)	95, 36%	74, 21%	169, 27%

Table 3

Mixed effects logistic regression analysis examining the conditions associated with communication occurrence

	Mixed effects bi-variable logistic regression			Mixed effects multivariable logistic regression
	OR	95% CI	P-value	OR	95% CI	P-value
Perceived uncertainty	6.1	3.7, 10.4	<0.001	3.0	1.6, 5.8	<0.001
Perceived communication request	41.4	15.8, 108.3	<0.001	22.2	8.3, 59.0	<0.001
Changed clinical decision	3.7	2.3, 6.3	<0.001	1.4	0.7, 2.7	0.290

Table 4

Current physicians’ communication frequency and rationales for communicating back to transferring physicians for 107 out of 618 cases where communication occurred in two academic hospitalist practices in 2018

		Condition of interest
		Perceived transferring physicians’ uncertainty		Perceived transferring physicians’ communication request		Changed transferring physicians’ clinical decisions
		Yes	No	Yes	No	Yes	No
Communication occurred	Yes	59, 9%	48, 8%	38, 6%	69, 11%	50, 8%	57, 9%
Communication occurred	No	97, 16%	414, 67%	12, 2%	499, 81%	119, 19%	392, 64%
Frequency of rationales by category for communication		For all 59 communication occurrences when transferring physician expressed uncertainty (n, %)		For all 38 communication occurrences when transferring physician requested communication (n, %)		For all 50 communication occurrences when clinical decisions changed (n, %)
Case contextual factors		46, 78%		33, 87%		38, 76%
Structural factors		2, 3%		0, 0%		3, 6%
Interpersonal factors		8, 14%		4, 10%		7, 14%
Other		3, 5%		1, 3%		2, 4%
Category		Examples of rationales for communication across 3 conditions
Case contextual factors^a		– Provided update on clinical course – Clarified how current physician figured out complex medication refill history – Discussed challenging management situation – Updated and educated on rare diagnosis – Obtained more information about big picture to execute discharge – Explained reason for stopping antibiotics
Structural factors^b		– Ran into each other – Secondary to discussion of other patients
Interpersonal factors^c		– Discussed and co-managed, allowed nuanced tailoring of treatment – Provided reassurance that nothing was missed – Based on prior working relationship, knew she would want to know – Transferring physician wondered about current physician’s perception of his decision-making; conversation supportive, debriefed patient’s death
Other^d		– Kept everyone in the loop – Provided clinical update in front of physician assistants; pointed out work up recommended but not carried out – Communicated “thanks” back to transferring physician at family’s request

^aRationales pertaining to the clinical case, including judgments about the learning value for the transferring physician

^bRationales pertaining to structural barriers including clinical information not yet available, no opportunity to communicate (i.e. on vacation), time constraints, or communication is scheduled in the future because the current physician will be transitioning patients back to the same physician

^cRationales pertaining to interpersonal factors including barriers related to hierarchy, familiarity with how the transferring physician will react, or no established relationship

^dRationales that did not fit into the above categories including references to the culture of communication or hedging efforts to communicate.

Table 5

Current physicians’ frequencies and rationales for no communication back to transferring physicians for 228 out of 618 transitioned patients in two academic physician practices in 2018

		Condition of interest
		Perceived transferring physicians’ uncertainty		Perceived transferring physicians’ communication request		Changed transferring physicians’ clinical decisions
		Yes	No	Yes	No	Yes	No
Communication occurred	Yes	59, 9%	48, 8%	38, 6%	69, 11%	50, 8%	57, 9%
Communication occurred	No	97, 16%	414, 67%	12, 2%	499, 81%	119, 19%	392, 64%
Frequency of rationales by category for no communication		For all 97 occurrences of no communication when transferring physician expressed uncertainty (n, %)		For all 12 occurrences of no communication when transferring physician requested communication (n, %)		For all 119 occurrences of no communication when clinical decisions changed (n, %)
Case contextual factors		38, 39%		1, 8%		38, 32%
Structural factors		25, 26%		8, 67%		36, 30%
Interpersonal factors		14, 14%		0, 0%		22, 19%
Other		20, 21%		3, 25%		23, 19%
CATEGORY		Examples of rationales for no communication across 3 conditions
Case contextual factors^a		– Mild shift in plan, course as expected – Expected clinical evolution, anticipatory guidance was clear – Nothing substantive, no major report to give back – Low yield learning opportunity – Clinically uninteresting – Final diagnosis was in the realm of expected
Structural factors^b		– Transferring physician on vacation, no opportunity to discuss – Too soon, just made the change today – Not enough information back to make the call – Waiting for the final path report – Too busy, diagnosis already on transferring physicians’ differential – Will sign patient back over to transferring physician
Interpersonal factors^c		– Expected transferring physician was chart stalking because he would be curious – It would be uncomfortable [for me] to tell my boss he was wrong – “Felt uneasy about our relationship” – Didn’t want transferring physician to feel judged about missing the issue – Because of defensive posture, I only communicate major issues – “She didn’t ask, I didn’t seek her out”
Other^d		– Planned communication not yet occurred – New work flow will [indirectly] come back to the group – Not a priority to communicate – Would potentially chat with transferring physician about this one – Didn’t think of it [communicating] – It’s how we operate [no communication culture]