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Family physician Pamela Buchanan discusses her article, “How poor communication is killing patients and burning out doctors,” exploring the devastating impact of unclear or avoided conversations in health care. Pamela shares firsthand experiences from the emergency room, where patients often arrive not just for treatment but for clarity about their diagnoses and prognoses. She highlights the systemic failure of communication between specialists and patients, leading to unnecessary ER visits and emotional distress. Pamela urges specialists to take responsibility for having difficult but essential discussions about prognosis, treatment expectations, and palliative care. She provides actionable steps for improving patient education, reducing miscommunication, and alleviating the burden placed on ER physicians. This conversation is a call to restore trust and humanity in medicine through clear, compassionate communication.
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Transcript
Kevin Pho: Hi, welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Pamela Buchanan. She is a family physician, and today’s KevinMD article is “How poor communication is killing patients and burning out doctors.” Pamela, welcome back to the show.
Pamela Buchanan: Hey, Kevin. Thanks for having me. Always enjoy it.
Kevin Pho: All right. So tell us what your latest article is about.
Pamela Buchanan: So I’m family physician trained, but I’ve worked in the emergency room the last 15 years. And so what I noticed is that I’m not quite sure what’s going on systemically. I do know that fewer primary care doctors are available, but many patients come in undereducated or uneducated about their disease processes, and I find myself quite often in the ER explaining the minutiae and the detail of what’s going on with them.
They completely don’t understand. I think they hear it, and I find it hard to believe that it was explained to them this way, but they’re like, just take this pill and something’s wrong with your liver, but they don’t understand the full gravity of the situation. My most recent one that really sticks out in my mind is an elderly woman who came into the ER, and she had significant metastatic cancer. I couldn’t see a way this was curable—many major organs—and she did not look well.
When she came in, she did not look well. As I was talking to her and her husband about what was going on, I told her, well, you have cancer. It’s lung cancer, but it’s also in your liver, it’s in your bones, and generally speaking, this is not survivable. She was shocked, like she’d never heard this before.
Part of me wants to think that maybe she was just in denial, but I’ve seen it more often than not that they just don’t understand the disease processes. So I had to give her information about hospice, which I think she should have had that conversation quite some time ago.
Kevin Pho: And in that particular case that you mentioned—that patient and her family—did they have a primary care physician? And who was taking care of her when she saw you in the emergency department?
Pamela Buchanan: She had a primary care physician, she had an oncologist, and she had had some radiation. She had multiple touch points in the health care system, so I don’t know why that realistic conversation never happened. Her husband was taking care of her, and he said, I thought that was what was going on. I thought this was really bad, but nobody really just explained it like you do. And the other thing we have to realize as health care professionals is that we’re smart people.
So my line I use is I say, I’m going to give it to you in doctor terms so you know the medical terminology. You can write it down if you want to, but then I’m going to talk like a real person. I kind of just break it down like you’re a two-year-old because I really want you to leave understanding what has happened.
That’s one instance. And I also see people coming in quite often postsurgically, mainly urological and gynecological surgeries, saying a complication that happens with this surgery is happening, and they didn’t have anybody to call. They didn’t have an exchange to call. They’re like, well, I had blood in my urine. I’m like, yeah, you just had a urological procedure, that’s normal.
And so now they’ve wasted an ER visit for that. They spent five hours waiting, and that’s not a good experience for anybody. In our hospital system, we’ve worked to speak with the specialist to try to shore that up and say, we’re seeing multiple of your patients after their procedures come in. We got a nurse navigator, and then we’ll be there to answer those questions so we stop the ER visits that are not necessary.
Kevin Pho: So you have the unique perspective of both being a family physician who works in the emergency department. So you get that primary care view, but you also have that emergency department view. First, you talk about that lady with hepatocellular carcinoma. Can you speculate, perhaps, on some reasons why her oncologist and primary care physicians may not have given her the prognosis or not made her understand her prognosis? What are some reasons you think could have happened?
Pamela Buchanan: I know patients go through denial when something like that happens, but her disease process was so progressed that I just believe someone should have had that very sincere, deep conversation about what was likely impossible. I always respect people’s faith, and I’m in the Midwest, the Bible Belt. There’s a lot of Christianity, so there’s a lot of faith, and I get that. I have a lot of faith, too, but sometimes there are just some frank realities. I think it’s time, too. I know for primary care, you get 15 minutes—you don’t have time. And in the ER, yeah, there’s a five-hour backup, but you work until you get the job done. I just feel like I have to let the patient know that, hey, this is serious. It’s in your bones now, so unlikely. But I think it’s probably a time factor.
Kevin Pho: You also wrote that the fact these difficult conversations weren’t being had in the primary care setting leads to burnout down the line. So talk about the impact it has on you in the emergency department to have some of these conversations in that setting.
Pamela Buchanan: So, thinking about the nature of what an ER doctor does—we’re in that position where emergencies come in, and when the ambulance comes to the door, you hear the tones over the radio, you get ready. It never changes: you become a big ball of energy, buzzing, cortisol levels up, and you’re thinking, if this, then that. And if this doesn’t work, what if I have a difficult intubation? It’s a lot of stress.
That in and of itself is stressful. It depends on what kind of ER you work in as to what kinds of stress. If you’re in a level one trauma center, then there are gunshots and car accidents. If you’re in a rural community—I’m in a rural community—you have severe cases that need specialty care, and we have to find transfer and airlift out. And so that’s stressful.
I have that stress of being the ER doctor, and then you add to that the stress of being a primary care doctor, and now I just feel overwhelmed. I do have regulars who come to the ER and they think I’m their doctor. And I—because I know their history, I had three of them yesterday when I was working—it gets to the point that I’m becoming more and more like their primary care doctor. And if they have a primary, then I call that primary and try to arrange care: let’s get them on the books, let’s get them back into the fold.
Kevin Pho: And how do those conversations go when you talk to your primaries?
Pamela Buchanan: They go well. I just think the primary is overwhelmed. I know in my area they’re just overwhelmed and say, oh yeah, I haven’t seen them. And then the patients are impatient. You call your doctor and think, my issue needs to be taken care of now. And most of the time, it doesn’t. The appointment may be two weeks from now.
I had a patient day before yesterday, and she had a minor issue, and she came to the ER. She said, yeah, he couldn’t see me until the next day. After I saw her, I took care of the thing; it was minor. And I said, OK, now keep the appointment with your primary care. I’m going to call him, and you need that because you’re going to need continuity. This one little thing I did in this snapshot is not enough. This is going to be something that has to be managed over continuity. Your primary care is your quarterback. No team survives without a quarterback.
Kevin Pho: Now, of course, time is a common factor here, and we’ve talked about that many times on the podcast—how time is just not valued in our health care system, especially in a primary care setting. Other than giving more time, are there any tips that primary care physicians can use to prevent these situations from happening? Any questions they should ask their patient? Any tips that you could give?
Pamela Buchanan: You know what I’m thinking? We can’t make a doctor quickly. These patients need education and want a point of contact, but I don’t think it always has to be a doctor. I think we can leverage allied health—nurse navigators—and have everyone working to the full extent of their license when the patient just needs education and reassurance.
In our system, we use nurse navigators to keep them from coming to the ER postoperatively, and I think that’s something we need to tap into. That, and then things like automated AI systems, where we can take care of the simple things that people think they need to come to the ER for.
Kevin Pho: What about patients themselves, empowering them to do their own research, Googling information? As you know, a lot of health information is available online. Now we have AI—you mentioned ChatGPT—where they can certainly just ask it about health information. So what’s your thought on that, about patients doing their own research? Because it seems like we as a medical profession are falling short in that regard.
Pamela Buchanan: It’s hit or miss because you and I both know ChatGPT can be wrong, and you and I both know that if you Google one disease process, you might find five or six different answers because there’s no regulation. It’s not always academic. And so we still have to be there as the health care resource to—
Kevin Pho: We’re talking to Pamela Buchanan. She’s a family physician. Her KevinMD article is “How poor communication is killing patients and burning out doctors.” Pamela, let’s end, as always, with some take-home messages you want to leave with the KevinMD audience.
Pamela Buchanan: I think that it’s just important that we do as much as we can to empower and educate our patients, all while protecting our own health and self-care. And then I can be reached at drpstrong.com.
Kevin Pho: Pamela, as always, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.
Pamela Buchanan: Thank you.
