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Communication among providers is a crucial aspect of patient care. Poor communication is well documented and can lead to erosion of interspecialty relationships and suboptimal patient outcomes.1,2 The Accreditation Council for Graduate Medical Education identifies interpersonal and communication skills as core competencies, setting broad expectations to teach and model ideal communication.3 However, there is currently little evidence to guide teaching about optimal modes of communication. We conducted a mixed-methods study to measure the impact of an interprofessional education program on interspecialty communication at an academic medical center.4 This report describes providers' preferences and practices related to interspecialty communication. Our intervention was a 60-minute interprofessional education program addressing multidisciplinary approaches to diagnosing prosthetic joint infections. Thirty infectious disease (ID) and orthopedic surgery (OS) providers participated (47% [n = 14] trainees, 40% [n = 12] attendings, 13% [n = 4] midlevel providers). A preintervention survey elicited ratings of the perceived effectiveness and use of various modes of communication, including telephone, in-person, consultation notes, e-mail, and pager. Three months after the intervention, we held a focus group of 12 total providers (25% trainees, 58% attendings, 17% midlevel providers) to explore perceptions of communication. In the survey, most providers rated verbal communication (phone or in-person) as “most effective” (87% OS providers, 85% ID providers) and communication via consultation notes as “least effective” (50% OS providers, 69% ID providers). In practice, however, a minority of both groups (35% OS providers, 23% ID providers) reported using in-person communication “often.” In contrast, ID providers used communication via patient chart “often,” unlike OS providers (61% ID providers, 30% OS providers). Although few identified e-mail as effective (7% OS providers, 15% ID providers), this mode was used often (77% ID providers, 53% OS providers). Focus group participants described scheduling constraints as the primary obstacle to verbal communication. They also described communication via patient chart as suboptimal because it was unlikely to be read, for example: “You just have to make the assumption that [OS providers] are not reading…your note,” said one ID physician, and “If the patient is really having troubles [the OS provider] will put the [ID provider's] note up…and look at the last four lines,” said an OS physician. Participants discussed benefits of e-mail communication, including speed, ease of use, and ability to communicate with multiple providers, for example: “It's a lot easier…to shoot back an e-mail than to call or page me and wait,” said an ID physician, and “I [copy] it to my resident…and it won't fall through the cracks,” said an OS physician. However, integrating e-mail communication into the medical record remained controversial. Opinions ranged from opposition to including e-mail communications because “they're not medical records,” according to an OS physician to feelings of “personal discomfort about…[e-mail] communication…outside of the medical record,” said an ID physician. Our study investigated perceptions and practice of communication between 2 subspecialty groups. Although verbal communication was perceived as superior, many providers used notes in patient charts to communicate. Moreover, despite concerns about e-mail communication, it was used frequently. These findings highlight provider ambivalence regarding the most appropriate modes of interdisciplinary communication and suggest a need for further investigation to identify optimal communication practices and ways to integrate these into competency-based education, thereby potentially enhancing interspecialty relationships and patient care.

A 59-year-old man with diabetes mellitus, prior hepatitis B infection and recently diagnosed cirrhosis with prior Babesiosis presented to our institution from an outside hospital with six months of worsening abdominal pain, myalgias and fevers. On admission, physical examination revealed jaundice, hepatosplenomegaly and diffuse lymphadenopathy. Laboratory investigations demonstrated mild anemia, thrombocytopenia, hyperbilirubinemia and elevated lactate dehydrogenase. Tests for human immunodeficiency virus, and active Babesia microti infection were negative, however Epstein-Barr virus DNA by quantitative PCR was markedly elevated. CT scan revealed features suggestive of a cirrhotic liver without focal mass lesions as well as massive splenomegaly with axillary, retroperitoneal and inguinal lymphadenopathy. Bone marrow and lymph node biopsies were obtained which ultimately revealed hepatosplenic T-cell lymphoma. The patient’s initial liver biopsy from five months prior to presentation was re-evaluated by our institution’s pathologists. Histologic analysis showed hepatic sinusoidal and portal infiltration of atypical lymphocytes morphologically identical to those present on the more recently excised lymph node tissue. The hepatic sinusoidal lymphoid cells were strongly positive for CD2, CD3 and CD5 whereas CD4, CD8 stained only minor subsets of the T cells. Subsequent flow cytometric immunophenotypying of peripheral blood identified T-cell receptor alpha/beta positive cells that lacked CD4 and CD8 (double negative alpha/beta T cells). Given the established bone marrow involvement, he was diagnosed with stage IV disease and treated with chemotherapy. His clinical course involved multiple hospitalizations complicated by hyponatremia, neutropenic fevers and pulmonary emboli. Following his fourth cycle of chemotherapy, he developed worsening liver failure and expired approximately three months after initial diagnosis of lymphoma. Hepatosplenic lymphoma of alpha/beta T cells is a rare malignancy with largely unclear risk factors and varied clinical presentations. Notably, diffuse infiltration of liver parenchyma is a prominent feature and the disease can mimic cirrhosis clinically as well as radiographically. Early recognition of this aggressive lymphoma is important and should be considered in the evaluation of patients in whom the etiology of cirrhosis remains in question.

Toxic megacolon is a severe complication of Clostridium difficile (C. difficile) colitis. As the prevalence of C. difficile colitis increases and treatments become more refractory, clinicians will encounter more patients with C. difficile associated toxic megacolon in the future. Here, we review a case of toxic megacolon secondary to C. difficile colitis and review the current literature on diagnosis and management. We identify both clinical and radiologic criteria for diagnosis and discuss both medical and surgical options for management. Ultimately, we recommend using the Jalen criteria in conjunction with daily abdominal radiographs to help establish the diagnosis of toxic megacolon and to make appropriate treatment recommendations. Aggressive medical management using supportive measures and antibiotics should remain the mainstay of treatment. Surgical intervention should be considered if the patient does not clinically improve within 2-3 d of initial treatment.

Objective: Poor communication between medical and surgical specialists negatively impacts patient care and represents a serious challenge for medical educators. The objective of this study was to measure the effect of a brief interspecialty education program on perceived communication between medical and surgical specialists at a US medical center. Methods: In 2011, an interspecialty education program (“Diagnosing Prosthetic Joint Infections”) was developed and administered by orthopaedic surgery (OS) and infectious diseases (ID) faculty to members of both divisions. The 60-minute program included a review of diagnostics followed by small mixed-group discussions about optimal diagnostic approaches. Surveys (immediately pre- and post-intervention) and a focus group (3 months post-intervention) assessed the impact of the program on interspecialty communication and collaboration. Results: Seventeen OS (41% of whom were trainees) and 13 ID (46% trainee) providers participated. Twenty-nine percent of OS and 62% of ID providers were female. Postintervention, the proportion of participants perceiving that “other” specialty providers were often “effective communicators” (p=0.014) and “effective collaborators” (p=0.025) increased. All participants believed interspecialty education would improve communication. Focus group participants perceived that the program improved interspecialty communication, organizational practice, and patient care. Conclusions: These findings demonstrate that brief interspecialty education programs can improve communication between medical and surgical specialists and could enhance patient care.

Kawasaki disease is a common systemic vasculitis of childhood that may result in life-threatening coronary artery abnormalities. Despite an overlap of clinical features with toxic shock syndrome, children with Kawasaki disease generally do not develop shock. We report two cases of older children who presented with a toxic shock-like illness, and were diagnosed with Kawasaki disease when coronary artery abnormalities were found on echocardiography, in keeping with the recently described 'Kawasaki disease shock syndrome'. Clinicians should consider Kawasaki disease in all children presenting with toxic shock and assess for coronary artery damage.