Shirah Vollmer MD

The Musings of Dr. Vollmer

Doctor/Nurse Communication: The System Breaks Down…Old Fashoioned Medicine Prevails!

Posted by Dr. Vollmer on October 20, 2014

Ebola hospital

 

 

 

“The diagnostic team that treated Duncan — who had symptoms of headache, abdominal pain and fever consistent with the Ebola virus — did not know he told a receiving nurse that he had traveled from Africa. On that day, Duncan was sent home with antibiotics. He returned to the hospital by ambulance two days later.”

 

http://www.latimes.com/nation/nationnow/la-na-ebola-hospital-20141003-story.html

 

As the Ebola virus continues to make world news, I am struck that one important aspect of this story is not getting enough press. The nurse got the history of possible Ebola exposure, but the doctor did not. Nor did the nurse adequately communicate this VITAL piece of information to the doctor. This viral scare, from my point of view, highlights the prime importance, once enforced in medical training, and now less so, that a doctor MUST always take his/her own history. The idea of relying on other professionals for a history of present illness, as in this tragic case of Thomas Duncan, can cause fatal mistakes, History taking is/was the foundation of good medical care. This was the most important thing I learned in medical school, in rotation after rotation. Yet, today, there is a notion that professionals should work to the highest aspect of their license, meaning that one does not need an MD to take a history. Physicians are needed to prescribe, to order tests, but not to get background information. This background can be obtained by medical assistants and nurse practitioners.

Oh, no no, I say, learning of this paradigm change in health care delivery. With all due respect to nurses, there is the art to history taking with leads to accurate diagnosis and treatment. My professors, rightly, and repeatedly, taught me this. 80% of the diagnostic information is from the history, they would say, which became the often mocked mantra. Yet, almost thirty years later, those words come painfully alive, as we discover that the doctor did not do a “travel history” on Mr. Duncan. This pertinent omission of the history has sent this country into anxiety, reaching near panic levels in some. The focus has been on politics, on travel bans, on protective gear training, and yet, where are the doctors yelling about the need to reinstitute history taking as the vital art in medicine? Yes,in  most cases, the history is less critical and symptoms can point the physician in the right direction. However, once in a while, a critical case will come in the Emergency Room, and like Chelsey  Sullenberger,  the pilot who landed the plane in the Hudson, with  rarely used, but critical skills, doctors need to have history training for that, perhaps one time in their career, where it really matters.

4 Responses to “Doctor/Nurse Communication: The System Breaks Down…Old Fashoioned Medicine Prevails!”

  1. Jon said

    Yes, indeed this is a sad case of a breakdown of communication. A nurse practitioner or medical assistant can take backgrounds; however, it is indeed best if the attending physician also takes the background. This is a tragically fatal example that redundancy is a good thing. Redundancy is a good thing.

  2. Shelly said

    I agree with you but have to ask: Wasn’t Thomas Duncan the first patient diagnosed with Ebola in the US? If so, then isn’t there an adage, “If you hear hoof beats, don’t think zebra?” Why should the doctor think Ebola when flu is far more common? Isn’t it rare that a nurse takes a case history and passes it off to the physician–except in the ER.

    • A travel history is a basic part of a comprehensive emergency room evaluation. This involves one question..”where have you travelled in the last six months?” That is basic to medical care. It is not that the doctor should have thought about Ebola, per se, but that he should have inquired about travel and documented those findings such that there would be a clear record of how this case was evolving. Once Mr. Duncan would have said he was in Liberia, then the known Ebola virus, would probably have popped up in this doctor’s mind. In our more modern age, the history is now relegated to people who assist physicians, and most of the time, that works out fine, but in these rare, but life-threatening situations, the physician’s history and understanding of the patient is absolutely critical, not just to the care of this patient, but to those exposed to him. Thanks.

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