“As I went through medical school and into residency, I was noticing ways in which communication wasn't as ideal as it could be with patients,” said Austin Wesevich, MD, MPH, a medicine-pediatrics resident at Duke at the time of this project. “I felt that patients didn't have much of an opportunity to express what they wanted.”
He saw whiteboards being used in patient rooms to try to communicate plans and goals between patients and clinicians, but there were common pitfalls. “Maybe you don't have a dry erase marker, or maybe you can't erase the whiteboard because it's so old,” said Dr. Wesevich, who is now a hematology/oncology fellow at the University of Chicago. “I was trying to think of quick or easy ways to improve communication that wouldn't require more time in the room.”
Having noticed these communication issues in both pediatric and adult care, Dr. Wesevich came up with a strategy that could be adapted to each patient population: texting.
How it works
Thirty adult patients and thirty caregivers of pediatric patients were enrolled in a pilot study, with half assigned to an intervention arm and half to a control group. Each morning of hospitalization, a text to both intervention and control participants asked for a personal daily goal. In the intervention arm, any text response went to the intern caring for the patient. A text then asked the interns in the intervention group for the team's clinical daily plan in layman's terms, and patients or caregivers received that response by text. All participants used their own phones, but their phone numbers were masked.
Response rates to the texts were 58% for adult patients and 70% for caregivers, according to results published Feb. 25 by the Journal of General Internal Medicine. Trainees texted plans between 67% and 80% of the time. “I was impressed by how much people were using the intervention,” said Dr. Wesevich.
To test the effects of the intervention, the researchers asked patients and caregivers at the end of the day about their knowledge of the plan and asked interns about their understanding of patient goals. Compared to patients and caregivers in the control group, those in the intervention arm better understood medication changes (50% vs. 76%; P=0.02) and new consultations (61% vs. 90%; P=0.002), and interns were more likely to know their goals (40% vs. 93%; P<0.001).
“It was really encouraging to me that something very simple … can actually improve both patient and physician understanding,” said Dr. Wesevich.
The intervention ended after the pilot due to the time required to run it while keeping everyone's phone number confidential. “The sending of text messages to the other party was done manually by me,” said Dr. Wesevich. “It was a labor of love as a resident to monitor the system every single day.”
While technology could likely simplify the process, there were also a few practical obstacles on the patients' end, he noted. “There are some adult patients who maybe felt too sick to check their phone … or just weren't as familiar with technology,” he said. “In hindsight, I think it's probably easier for caregivers because they tend to be younger than adult patients, and they're not actually the one who's sick. But on the flip side, the caregivers were speaking for their children about their goals rather than hearing it directly from the patient.”
Dr. Wesevich has ideas about how to avoid both of these problems by developing a new version of the system once he becomes an oncologist. “My goal is to treat teenagers and young adults with cancer,” he said. “If you think about a population who might have [a] heavy interface with the health care system and also be comfortable with technology and text messages, it's them.”
Words of wisdom
Texting shows promise as a method to lower existing barriers in patient-physician communication, Dr. Wesevich said. “Right now, when a outpatient has a concern, they either have to call the triage number or they have to send a [patient portal] message. … A text doesn't require you logging into an app.”
Some physicians already give patients their phone numbers, and formalizing a system would avoid some of the inherent problems, such as limited availability, he noted. “It'd be more of a pooled resource that you could access through text message, as opposed to an individual clinician who may be on vacation or with their family,” Dr. Wesevich said.