Modules

Communicating with adolescents

Part 4

  • Receptionist: Eating Disorder Centre, Elaine Brower speaking.

    Dr. Burnside: Hello, this is Dr. Burnside calling from Humphrey’s Harbour. I’d like to refer a patient to you.

    Receptionist: Okay, is this a patient who’s been previously diagnosed?

    Dr. Burnside: It’s a 15 year old girl who I think may have anorexia. She hasn’t been to see you before.

    Receptionist: I see. Well we do out-patient assessments to determine the type of problem and the treatment that might be required. The assessment is done by the team, it takes about a day and a half. Our first available appointment is in about two months.

    Dr. Burnside: But that’s a long time. I’m worried that this girl is very sick and may get sicker.

    Receptionist: Well that’s our earliest appointment. These assessments are extensive and take time. I can put you on the waiting list, but frankly it’s unlikely that an earlier appointment will come up.

    Dr. Burnside: Look I’m really worried that this is going to take too long. Is there a chance that I can speak to one of the doctors there and explain the situation?

    Receptionist: Of course. Just a moment please.

    Nurse practitioner: Hello Dr. Burnside, I’m Jennifer Bryant, the nurse practitioner on the team. How can I help you?

    Dr. Burnside: Well your secretary tells me that your earliest appointment to see you is in two months. And I’m worried that this patient may be more urgent than that. She’s been losing weight for six months now.

    Nurse practitioner: That isn’t unusual in eating disorders Dr. Burnside. I see that she’s 15. Is she still going to school and functioning relatively normally?

    Dr. Burnside: Yes she’s still in school but her marks are dropping.

    Nurse practitioner: That also is quite common. Two months isn’t an unusual wait for us. We can put you on the waiting list and I’ll send you a form with the tests and other assessments that should be done to monitor her condition. You can call if she shows evidence of significant metabolic problems. That might be a reason for inpatient treatment. How does that sound?

    Dr. Burnside: But … yes alright, thank you.

    Nurse practitioner: Good. Be sure to send a copy of your chart along with your patient. The history of her childhood development is important.

    Dr. Burnside: Yes I’ll do that, thank you very much.

Part 4, continued

  • Dr. Burnside: Hello Mrs. Cournoyer?

    Beth: Hello?

    Dr. Burnside: It’s Dr. Burnside.

    Beth: Oh Dr. Burnside.

    Dr. Burnside: I’ve got the letter from the family therapist.

    Beth: Oh Dr. Burnside, I don’t think that did any good! Kelsey didn’t like him, and she says she won’t go back. She’s gotten even more secretive about her weight and she certainly isn’t gaining. And my husband was really angry with the appointment. I’m not sure whether it was because of the money, because you know it wasn’t covered by the insurance, or just the sheer embarrassment of seeing a therapist …

    Dr. Burnside: Oh dear, Mrs. …

    Beth: I don’t know what to do!

    Dr. Burnside: It really sounds like things have deteriorated. Um, I’m going to speak to the eating disorder clinic at the medical centre. You may have to take Kelsey down there.

    Beth: Okay. You know at this point I’m just ready to do anything.

Reflective exercise 5

Inter/Intra-professional telephone communication

A great deal of inter- and intra-professional medical communication takes place by telephone. As with electronic communication, the lack of visual cues may make this form of information exchange more difficult. In this telephone conversation we can review the difference in worldview between two health professionals. What is the source of tension in this conversation? Think about how different cultures view time. In this case, Dr. Burnside thinks two months is a long time, the nurse thinks differently. Do they understand each other’s concerns? Do they find common ground?

Knowledge check

Legal and management issues related to medical records and other clinical information

Policies concerning medical records vary from province/territory to province/territory. This quiz is based on Ontario policies and regulations. While it brings up issues that are common to practice anywhere, the answers provided here may not be applicable in other provinces or territories.

Check only one answer unless instructed otherwise.

    Check as many as apply.

Commentary

Most of the information needed to answer these questions for the province of Ontario is found in the College of Physician and Surgeons of Ontario Policy # 5-05. (If you are not in Ontario, there is a similar policy in effect that would be available through the medical regulatory authority in your province or territory.) Read these policies and the additional literature suggested to thoroughly understand issues related to written medical communication and patient confidentiality (e.g., the Personal Information Protection and Electronic Documents Act).

The answer to Question 1 is 10 years, by regulation. However, the College recommends retaining records for 15 years because, in some instances, physicians may be legally liable for that period of time.

Question 3 is addressed in the College Policy on Confidentiality. Voice messaging and email are frequent methods of communicating with patients. However, the possibility of breaching confidentiality is a major concern. One should not leave a voice message without asking the patient first if that is acceptable, since you do not know who else may hear it. The same is true of email communication with patients, which will also become more frequent, especially for routine work such as appointment reminders.

For Question 4, either fax or emailing a form may be acceptable, so long as you know that the process is secure. If you have concerns then give the information to Kelsey who can share it with her mother if she wishes. In Ontario, if a child’s or adolescent’s chart is released to any third party, all reference to family members is to be excluded. (See CPSO Policy on Confidentiality.) Similar policies are in place in the guidelines of the medical regulatory authorities in each province and territory. Also, in giving any office chart to any patient, whether sealed or not, make sure there is nothing written in the chart (e.g., derogatory remarks) that you do not want the patient to read.

Questions 5 and 6 are discussed in individual provincial and territorial medical regulatory authority policies on medical records and Question 7 is discussed in Dodek and Dodek. With regard to Question 8, it is also discussed in medical records policies, but the answer is of course, maybe — it depends upon Dr. Burnside’s assessment of his daughter’s maturity and understanding of confidentiality. In a small town, physicians and office staff can often know some patients personally as well as professionally. The distinction must be carefully maintained in terms of both confidentiality and boundaries.

The case continues

For the next six weeks, Dr. Burnside does not see Kelsey or her mother. Then one day …

  • Dr. Burnside: Mrs. Cournoyer, is Kelsey okay?

    Beth: It’s me this time doctor. Um, I just can’t sleep. Um, well, I guess you probably figured out that my husband and I are having some problems. Um, he’s, he’s not understanding the situation very well, and, um, he’s not even talking to Kelsey anymore. And he’s quite angry with me because he says I just nag all the time. And, um, he, um, left about a week ago. He moved out of the house. Sorry.

    Dr. Burnside: It’s alright.

    Beth: I just … I’m exhausted, I’m not sleeping, and um, I just need something to help.

    Dr. Burnside: I’m sorry Mrs. Cournoyer.

    Beth: Thanks.

    Dr. Burnside: I didn’t know things were so difficult between you and your husband. How are you managing?

    Beth: Oh he’s supporting us. But he wants a divorce so … yeah. And the boys are on his side. Kelsey, she’s just in her own world. I don’t know how I’m going to get her down to that eating clinic.

    Dr. Burnside: It will be difficult. Is there anyone who can help you?

    Beth: Well, I guess my mom can come down. I don’t know. All my friends are busy with their own lives.

Dr. Burnside sees Mrs. Cournoyer again. She is calmer and has arranged for her mother to help out while she takes Kelsey to her appointment. Dr. Burnside gives her a sealed envelope that contains a copy of Kelsey’s chart. On the train trip to the Medical Centre, Mrs. Cournoyer opens the envelope and reads the chart.


 

Next: Part 5

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