Deadly Divide in Medicine: The Human Cost of Communication Breakdown in Healthcare
July 21, 2024
Deadly Divide in Medicine: The Human Cost of Communication Breakdown in Healthcare
By Iverson Jurey Abellaneda, UPCM Class of 2028
In the hectic pace of the ward, a small error in the doctor’s order caused a giant stir. A resident, drained beyond reason, mistakenly prescribed a doubled dosage of polymyxin, twice the intended amount.
This order found its way to a young nurse, who immediately felt a wave of uncertainty wash over her as she read the prescription. Deep down, she had a strong hunch that the dosage was dangerously wrong. Yet, despite her intuition screaming at her to speak up, fear held her tongue. The weight of hierarchy and the dread of overstepping her bounds chained her into silence. It was a moment frozen in time, where the right words hung temptingly close but ultimately remained unsaid.
As a consequence, a 200% overdose of antibiotics coursed through the veins of a helpless patient. In the end, the invisible walls between the resident and the nurse seemingly posed a greater threat to the life of the patient than the bacteria ravaging his body.
Dr. Diana Tamondong-Lachica recalled this particularly chilling anecdote, which was a medication error report she received as the Department of Medicine’s Quality Improvement and Patient Safety (IM-QuIPS) Coordinator. This incident serves as a harrowing reminder that the unseen yet ever-present barriers between medical professionals continually compromise patient care one mistake at a time.
Dr. Diana Tamondong-Lachica addresses the challenge of medical silos.
Despite its profound implications for patient care, the divide continues to be a skeleton in the closet, an issue that many have avoided confronting due to its controversial nature. Indeed, this difficult conversation has been buried for far too long. Now, it is time to unearth it.
Different Disguises of Division
Throughout her diverse career as a clinician, educator, project leader, and patient safety coordinator, Dr. Tamondong-Lachica has gained firsthand insight into the spectrum of division that exists within various realms of medicine.
“Services working together such as [doctors from] internal medicine getting the perspectives of subspecialists in infectious disease or colleagues in the surgical units are actually very limited,” she stresses, “I realized how much we underutilize the collaborations we could have had with our colleagues.”
This unspoken understanding that one should keep to their own unit has led to a regrettable but all too familiar problem within the Philippine healthcare system — thick towering walls of silence limit collaboration among healthcare professionals, medical departments, hospitals, and other health components.
Dr. Tamondong-Lachica vividly remembers numerous occasions where nurses and doctors functioned as a mere "group" rather than a cohesive "team." She exclaims, “errors could have been avoided in plenty of instances if they had simply spoken [to one another.]”
This highlights the great divide in healthcare known as "medical silos," a metaphor drawn from tall cylindrical agricultural storage units that meticulously separate grains and seeds within isolated compartments. Notably, this is an offspring of deep-rooted fragmentation in the country — a strong predilection to isolate as shown by the lack of synchronization across branches of government, disjointed private infrastructure and public urban planning sectors, and even discordant agencies within the education units.
Thus, medical silos are a testament to the fact that greater systemic issues eventually mutate when left unchecked.
The indoctrination to these silos begins early in the course of medical education and gradually deepens throughout clinical exposure, Dr. Tamondong-Lachica admits. She confides that as a medical clerk, intern, and first year resident, she was both told and shown by example that one must simply stay in their own lane.
Students participating in the IPE activity.
This became a habit that ultimately proved difficult to unlearn.
Unfortunately, the framework of medical silos has not only corrupted perceptions of collaboration but has also permeated fundamental medical concepts, including the separation of physical and mental health. This disconnect inevitably hinders holistic patient care and delays treatment outcomes.
Thus, medical silos are not merely self-contained matters, but rather metastatic issues that require urgent and aggressive treatment.
Cracks Concealed by Comforts
Compartmentalization in medicine was originally a well-meaning adjustment that allowed for a more focused specialization in a progressively expanding craft. For instance, it empowered internists to delve deeply into complex medical conditions and surgeons to master intricate surgical techniques.
However, over time, compartmentalization evolved into fragmentation and eventually led to isolation. The segregation of various medical specialties fostered the emergence of distinct norms and practices within each specialization, leading to decreased cooperation among them.
Dr. Tamondong-Lachica remarks that modern medical silos seem to be fueled by the organic tendency to form groups and sustained by the need to belong to a familiar and comfortable niche. “I think benefit-wise, silos are formed due to the sense of comfort … and [the desire] to share a common thing,” she explains.
Thus, dismantling silos inherently means having to give up accustomed comforts and bravely venturing into the unknown.
Moreover, she notes that perspective silos, defined by specific beliefs and behaviors, ultimately foster professional silos within the workplace. “For instance, we [medical doctors] may have different perspectives from nurses and pharmacists …. which makes us have different communication styles,” she adds.
As a social group gradually becomes insular and homogenous, less and less opposing views also circulate. This gives birth to echochambers wherein ideas, no matter how faulty, are echoed along without being challenged.
“This is how misinformation spreads … which makes collaboration between [different] silos harder,” she emphasizes.
Students from the Colleges of Medicine, Nursing, and Pharmacy interview a patient in the PGH medical wards as a team.
Rethinking Reactive Responses
The stark truth is that the significance of communication often becomes apparent only in moments of failure.
“There are actually times during the residency program wherein I had to communicate with our nurses, but usually the communication only happens when there are problems,” she reveals, “[it was only when] medications that I ordered were not administered or the procedures I requested were not facilitated.”
“It was always reactive,” she sighs.
Eerily, the cultivated practice of simply rescuing a terminal communication line bears resemblance to treating diseases with curative drugs rather than employing preventive measures. Since the messages passed along different silos are almost exclusively reactive to problems, communication loses its proactive charm and serves solely to troubleshoot. This shift casts a somber hue over conversations and further discourages the active pursuit of collaboration.
When interaction becomes a chore, there is a decreasing incentive to weave the words together and express one’s thoughts before it becomes too late. This places a strain on the relationship of individuals belonging to different silos and thus further inhibits harmonious communication.
Dr. Tamondong-Lachica recalls instances wherein she only enlisted the aid of otolaryngologists when a patient already desperately needed a tracheostomy after being on a ventilator for a very long time. “There really was not a point wherein we (herself and an otolaryngologist) were together right from the start [despite] the patient needing multidisciplinary care,” she shares.
It leaves one to wonder, how many lives would be changed if healthcare professionals just spoke to each other more?
Transition Towards Tomorrow
When asked about the future of medical silos, her eyes glistened as she spoke about the strides her department has made to slowly but surely change the system that had also ensnared her all these years.
Interprofessional activity with CP and CM students and faculty last December 7, 2022
“In our department, we [now] have safety huddles,” she explains, “doctors, nurses, dieticians, and pharmacists regularly meet for ten minutes [to align information] about our patients.”
She reports that these huddles, though brief, have significantly enhanced communication and aided in addressing blind spots among individual team members.
“[One time], a nurse expressed a concern that a patient’s veins were small. So we immediately thought that perhaps, a bigger catheter or central line was needed,” she narrates, “important information that may not necessarily be deemed appropriate for [electronic records] are now easily conveyed.”
Dr. Tamondong-Lachica envisions a future where collaborative treatment approaches will encompass not just healthcare professionals but also patients and their families. She recalls an incident where a patient astutely noticed an error in their chemotherapy regimen, highlighting the potential value of enhanced collaboration with patients.
In addition, strengthening primary healthcare will undoubtedly help decimate medical silos. A robust primary healthcare system reduces reliance on specialized care, thereby breaking down medical partitions and promoting integrated healthcare services.
However, to truly stand a chance at breaking the barriers that have long factioned our healthcare units, the doctors of tomorrow must play a big part in resetting the culture of unhealthy partitions in medicine. Recognizing this, the University of the Philippines College of Medicine has taken measures to pioneer the change our fellow Filipinos deserve. Notably, the Organ System Integrated (OSI) curriculum seeks to bridge conceptual silos in the study of medicine.
Moreover, UPCM instituted a stronger emphasis on Interprofessional Education (IPE), wherein students of the college are given the chance to work with learners from the College of Public Health, College of Pharmacy, College of Nursing, and College of Allied Medical Professions, among others. This seeks to equip future healthcare professionals with communication skills even before graduation.
After an IPE session, a UPCM student said, "I have learned that each profession has its own expertise, and each one of us needs one another to fill in the gaps of their practice in order to help the patient."
Thus, in the quest to dismantle medical silos, it is crucial to acknowledge that change begins by engaging in these challenging and sometimes uncomfortable conversations, and by acknowledging the shortcomings of our current practices.
As we reflect on the stories of missed opportunities and the consequences of fragmented communication, it becomes evident that the path forward requires courage, collaboration, and a commitment to transparency.
Truth be told — in a nation already divided, we, as healthcare professionals, cannot afford anything less than complete unity in our communication.