How Communication Helps Us Know When To Go “All In”

Some wise poker advice: never go “all in” before you have all your cards. That seems obvious, but as physicians, we are asked to make life and death decisions without knowing all the cards.

I was going through my daily mountain of paperwork when I received a call from an orthopedic surgeon:

“Hi Dr. Krebs, I just wanted to let you know that I saw Ann Smith today for severe right knee arthritis. We want to do a total knee replacement, but…she’s complicated.”

Ann is a delightful lady with grit and a witty sense of humor. When I met her 13 years ago, her asthma was out of control. She was admitted to the hospital at least monthly until we got it under better control.  She also has diabetes, high blood pressure, kidney disease and many other conditions. She is also the only caretaker for her husband with dementia. She has been having trouble walking due to severe knee pain.

“Yes, she is. We will reach out to her and get her in for an appointment. I’ll let you know how it goes and when we can have her in good enough shape for surgery.”

“Great. I wanted to start her on meloxicam for her knee pain in the meantime. Is that ok with you?”

“No, I really don’t want her on that. She has stage three kidney disease and that could make it worse. What do you think of diclofenac gel?”

“Sounds good, thanks.”

“No, thank you. I really appreciate you taking the time to keep me in the loop. She’s such a lovely patient.”

“She is. Thanks, bye.”

The conversation was less than two minutes, but critically important. Had the surgeon started the medication he originally wanted, it could have damaged Ann’s kidneys, leading to dialysis. If Ann had surgery without getting her other medical problems under control, this could have gone badly. Her asthma and diabetes put her at high risk of complications including poor wound healing, infection, and trouble getting off the ventilator from surgery.

As a busy physician, it’s hard to be interrupted. As a family physician, I love these calls. We want to give our patients the best. That is difficult when we don’t know what is going on with them. Patients deserve to have all the members of their team working together for the optimal outcome.  Unfortunately, these calls are rare. It is difficult for a busy surgeon to find the time to make these calls, and despite their incredible value, physicians and surgeons are not usually compensated for these communications. This communication is even more difficult when the primary care physician and surgeon use a different electronic medical record.

When I saw Ann in the office, we worked to give her the best result from surgery. We adjusted her medications and made sure she had an anesthesiologist dedicated to her procedure. I spoke with the anesthesiologist and we created a plan. Ann and I were both concerned about her care after surgery and the care of her husband (who is also my patient). She had no one to look after her. I worked with her surgeon to get her to rehab after surgery. Ann and I brainstormed solutions for her husband’s care. Her cousin was able to help Ann’s husband.

Ann’s surgery went as smoothly as we had hoped. With her husband’s care addressed, she was able to focus on her rehabilitation and proudly showed off her knee to me at her next appointment. I am thankful that her surgeon took the time to make sure all her physicians were working together.  When physicians know all the cards in their hand, patients win.