Category: Communication

Discharge Communications (2023)

Discharge Communications
~ iEM Education Project Team ~ Leave a comment

by Dominique Gelmann, Bret Nicks

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Introduction

The process of emergency department (ED) discharge provides critical information for patients regarding the next steps of their care. Discharge instructions are often required by hospital accreditation and governmental organizations for quality or monitoring metrics. However, studies show that many patients do not fully understand or recall the instructions they receive [1,2]. In addition to patient-specific factors contributing to lack of comprehension and care compliance, the myriad situational challenges inherent to every emergency department as well as individual clinician skills and knowledge of best discharge practices further impact patient experience, understanding, and subsequent outcomes.

In many instances, the discharge process is often limited to a brief exchange of documents, prescriptions, and verbal description of the diagnosis, frequently leaving patients with uncertainty about their care plan. Understanding discharge instructions can be very challenging for a variety of reasons. Physical or emotional discomfort can impact receptiveness to and comprehension of imparted information, for example. Patients or family members eager to leave may be less interested in the instructions; conversely those presented with a devastating diagnosis may be less able to process specific details.

Moreover, a significant number of patients have low literacy and/or health literacy levels. In addition, the busy ED setting may distract the patient’s attention from such instructions. Understanding the challenges surrounding discharge communications in the ED from the patient’s perspective and having a clear approach and purpose is essential. Much more critical than an afterthought, discharge is the first step of a patient’s care transition and greatly impacts quality outcomes, litigation, experience, and team morale [3,4]. 

Understanding the Challenges

Emergency physicians face unique challenges while ensuring high-quality care due to distractions and time limitations that are common throughout ED settings. In most cases, emergency physicians have little or no previous knowledge of their patients and are unlikely to partake in the follow-up process, making effective communication paramount when patients are discharged from the ED.  Providing clear and consistent communication throughout the entire patient care encounter, including the discharge process, is an important aspect of quality and patient-centered emergency medical care.

Unfortunately, many patients are discharged from the ED with an incomplete understanding of the information needed to safely care for themselves at home or when to promptly return to the ED [1, 5-6]. Patients have particular difficulty comprehending post-ED care instructions regarding medications, home care, and follow-up expectations.  And while all patients discharged from the emergency department should be provided instructions for ongoing management of their medical condition, studies demonstrate that patient recall and understanding of diagnosis, treatment, and follow-up plan are generally quite poor [1,2,5-9].  This raises significant concerns for care plan adherence and medical outcomes, which studies show are poorer in cases of low health literacy.  Given current trends toward value-based care and the fact that nearly half of the lawsuits in emergency medicine revolve around discharge instructions and plans, ongoing improvements in the discharge communication process is essential [3,4].

While some of this relates heavily to the ability of the provider to establish a trusting and positive patient-provider relationship within the ED constraints, several additional strategies can be used to enhance the recall of instructions, improve compliance, and minimize litigation.

Discharge Essentials

Effective discharge communication provides an opportunity for the emergency department team to summarize a patient’s visit, teach them how to safely care for themselves at home, and provide specifics regarding the next steps in their care process. It also gives ED physicians a chance to address any remaining questions or concerns, often augmenting patient and family understanding while improving care plan retention.  Although patient education at discharge typically begins with initial assessments and conversations with patients and family, other factors can also influence the success or failure of how information is transmitted at discharge.

Common interventions promoting an effective ED discharge process include using a standardized approach to relaying content, providing various modes of information delivery and tailoring them to the individual patient, confirmation of comprehension, post-discharge care follow-up planning, review of vital signs, and a patient-centered closure (Table 1) [8,9].

Table 1: Interventions in the ED Discharge Process

Domain

Intervention

Content

Standardize approach

Delivery

Verbal instructions (language and culture appropriate)

 

Written instructions (mindful of lower literacy levels)

 

Basic Instructions (including return precautions)

 

Media, visual cues, or adjuncts

Comprehension

Confirm comprehension (teach-back method)

Implementation

Resource connections (Rx, appointment, durable medical supplies, follow-up)

 

Medication review

Content refers to the education provided to our patients related to their ED testing, procedures, and treatment, as well as further education on diagnosis, expected course of illness, post-ED treatment and follow-up plan, and medication reconciliation. Instructions should specifically highlight time-sensitive next steps in care plans, including when and how to schedule follow-up appointments with whom and why. Further, emergency physicians should assist in arranging critical follow up prior to discharge as able.  Precautions regarding when to return to the ED versus waiting for any follow-up appointments should additionally be provided, as well as instructions for how to care for oneself until follow-up. These basic tenants of discharge, often described as the ‘rules of the road’ (Table 2), may serve as a basic framework for the discharge process.

Table 2: Rules of the Road for Successful Discharge

  1. Have the right diagnosis
  2. Time & Action Specific Instructions
    • What to do
    • When to do it
  3. Provider Specific
    • Who to contact
    • Why and When
    • Printed Information
    • Verbally explained
    • Verbally confirmed

In addition to the content itself, the importance of the quality and approach of its delivery cannot be overstated. The ED provider and care team members must consider the wide range in literacy, health literacy, cultural backgrounds, and access to outpatient resources when delivering the ongoing care instructions [6,7]. In many instances, EDs attempt to improve patient and family understanding of discharge instructions through standardization and simplification of written and verbal instructions. Due to literacy variability, current literature recommends instructions are written at a late elementary educational level [10]. Verbal discussions in conjunction with written instructions have been shown to be superior to written instructions alone [11]. For patients with a primary language differing from that of the clinician, use of interpreter services, when available, has been shown to improve quality of discharge communication and clinical understanding [12]. Other approaches that may benefit patient outcomes include providing supplemental written information and using visual and multimedia adjuncts to support understanding [8,9].

Essential to any successful approach is the comprehension of the patient regarding all of the information provided. After all, if the content and delivery are exceptional but the comprehension is poor, this should be seen as a discharge failure as it decreases care compliance and outcome quality.  To address this specific aspect of the discharge process, instituting a read-back or teach-back method is recommended. This method involves asking the patient to repeat back their understanding of the information imparted, which allows the physician to identify any remaining gaps in understanding and provide additional instruction as needed.

The implementation of discharge care processes frequently falls short due to unidentified social and medical factors that prevent the plan from being carried out.  Social factors could include homelessness, low income, uninsured/underinsured status, lack of transportation, or lack of primary care.  Medical factors could include concurrent psychiatric illness, substance abuse, cognitive impairment, inability to care for self, or young/advancing age. Understanding these circumstances will help identify patients at high risk for discharge complications and trigger additional resource considerations for these patients.

The discharge process provides an opportunity to ensure the patient’s condition is well understood, that no additional medical red flags need to be addressed, and that the care plan and follow-up are well understood. In an online video, Dr. Oller provides another process to engage the ‘moment of safety‘ related to discharge and outlines 5 essential steps (Table 3) for any ED discharge [13].

Table 3: ED Discharge: Moment of Safety
  1. Has the medical provider discussed the findings, diagnosis and plan of care (including medications and follow-up plan)?
  2. Confirm the discharge instructions and prescriptions match the patient identifiers
  3. Review all prescriptions and clarify any changes
  4. Review current vital signs
  5. Provide closure

Barriers to Successful Discharge

The barriers to successful discharge are myriad.  Some are intrinsic to the ED work environment and nature of emergency department patient arrival and flow.  Others relate to the challenging or often unidentified social and medical factors that prevent the plan from being completely carried out.  In a recent American College of Emergency Physician Quality Improvement and Patient Safety section meeting, Dr. Pham shared a conceptual framework for understanding the barriers to success and improving the discharge process (Figure 1) [14].

Figure 1: Barriers to Successful ED Discharge

While this framework may not be uniformly representative of all EDs, it addresses many of the operational failures that occur outside of the ED and outlines opportunities for hospitals and health systems to align for improved patient care outcomes.  And while screenings for high-risk discharges in EDs occur, the additional resources needed to ensure appropriate social work or case management care coordination are often limited.

Post-discharge follow-up processes for patients at risk for failing discharge instructions exist in some systems. This may include flagging a patient’s chart for a social work follow-up to assess and assist with the patient’s ability to obtain necessary medications, make and attend follow-up appointments, or address other concerns identified by the provider. Some physician groups routinely call patients the next day to see how the patient is doing and ensure understanding of their discharge instructions and care plan [7,8].

Types of Discharge Information Packets

Discharge instructions vary widely by practice location and resources available. However, there remain 3 primary means of providing discharge information and instruction: a basic care instruction note, a preformatted illness specific instruction sheet, and a templated software-based discharge product [8].

Commonly used, an instruction note is simply a set of instructions handwritten or typed on plain paper, without the assistance of computer programs. In settings with limited resources, this may be the only means of providing essential care information for the patient, their family, and the provider with whom they may follow-up. While uniquely tailored, they may lack substantial content for care, take time to prepare, and be limited by literacy and handwriting.

Information sheets are pre-printed education and instruction documents that describe care information related to one specific illness. They can be developed for the most common medical illnesses for each institution and have essential information regarding plans of care.  Information sheets are immediately available, inexpensive, reproducible, and can be designed to include simple language and or pictorial education.   They are not patient specific, may not provide adequate instruction in difficult or complicated cases, and require computer, printer, and copying capacity.

For settings with an integrated EHR, software products that create discharge packets (including discharge diagnoses, medications, medical care instructions and information regarding the illness, outlined care course after leaving the ED, and essential contact information for those next steps) are available.  These are highly resource dependent and therefore may not be routinely available.

Each form of written discharge materials offers its own unique benefits and drawbacks. Regardless of type utilized, physicians should exercise the basic principles outlined above in ensuring appropriate readability and quality of information provided. While specific details are helpful and important, distilling instructions into a short, high-yield sheet has been shown to be more effective than providing a large stack of superfluous [information] that patients may not entirely review [15].

Leave Against Medical Advice and Elopement

In certain circumstances, patients may request to leave prior to completion of their medical evaluation and treatment. In this situation, it is essential for the last health care professional caring for the patient to clearly document why the patient left and attest that the patient had the mental capacity to make such a decision at that time. While some electronic documentation systems have templates in place to assist with this documentation, Table 4 provides basic information for against medical advice (AMA) discharge documentation that can be used to create a uniform template [3,4,16,17].

Table 4: Documentation for Patients Leaving Against Medical Advice

Component

Description

Capacity

Establish a patient’s decision-making capacity, and clarify aspects of care which may affect capacity (i.e. patient is now clinically sober, etc.)

Risks

Specific condition-associated risks that were discussed (missed diagnosis, potential harms from untreated disease process, etc.)

Verify comprehension

Patient’s understanding of the risks

Patient’s decision

Include the patient’s decision, and any alternative plans (i.e. patient refused admission, but agreed to follow up with the primary physician tomorrow)

Signatures

Patient’s and provider’s signatures

An attempt should be made to provide the patient with appropriate discharge instructions, even in the event that a complete diagnosis may not yet be determined.  Include advice for the patient to follow up with their own physician, strict return precautions, and concerning symptoms that should prompt the patient to seek further care. In addition, it should be made clear that leaving against medical advice does not prevent the patient from returning to the emergency department for further evaluation if their symptoms worsen or if they change their mind about receiving care.  Despite a common notion to the contrary, AMA discharge does not automatically provide the emergency physician with immunity from potential medical liability [16,17]. In the event that a patient lacks decision-making capacity to adequately understand the rationale and consequences of leaving AMA and their condition places them at risk for imminent harm, involuntary hospitalization is warranted and often legally required depending on the location of practice.  In unclear circumstances and if available, a psychiatrist can assist in determining capacity, especially in the case of patients with mental health conditions.

Elopement is a similar process in which patients disappear during the care process. While it is difficult to provide discharge paperwork for these patients, documenting the actions taken to find the patient is essential (e.g. searching the ED, having security check the surrounding areas).  In addition, clinicians should attempt to reach the patient by phone to discuss their elopement and any additional care issues or concerns. Documentation of these attempts or any additional conversation is critical in mitigating legal risks [3,4].

Conclusion

Discharge instructions are a very important part of the emergency department care process and record.  It is essential to ensure each patient has a complete understanding of their instructions in order to promote care compliance and improve transitions in care. Verbal instructions remain more effective than written instructions, but both are needed and a multimodal approach to relaying information is preferable to a single modality. Be explicit, keep it simple, and have the patients repeat back instructions to ensure understanding. These simple steps will improve patient outcomes and compliance, and help clinicians avoid medical and legal pitfalls.

Authors

Dominique GELMANN

Dominique GELMANN

Dominique Gelmann is an Emergency Medicine resident at Wake Forest University. Her interests include patient-physician communication and health literacy. During medical school she completed a one-year research and leadership fellowship investigating health literacy as a social determinant of health, and helped author an institutional white paper with actionable strategies for improving health literacy education. She has given several lectures on the topic to various audiences, and developed a curriculum on health literacy and best-practice patient-provider communication principles for a free student-run health clinic. She looks forward to continuing strengthening her passion for this work throughout her career.

Bret NICKS

Bret NICKS

Bret Nicks, MD, MHA is an emergency physician that embraces the breadth of our specialty. He is a Professor and Executive Vice Chair of Emergency Medicine at Wake Forest University School of Medicine. He is the past president of the North Carolina College of Emergency Medicine. He served as the Chief Medical Officer of the award-winning Wake Forest Baptist Davie Medical Center. Dr. Nicks served as the founding Associate Dean for the Wake Forest Office of Global Health. He has lived, practiced, and led in many resource austere locations globally, although calls the academic tertiary care emergency department his home. He is passionate about, consults and lectures on the interface of clinical quality, leadership and team culture – and is dedicated to developing EM leaders for the future of our specialty and the transformation of healthcare. He loves anything outdoors, enjoys blogging on various life and leadership topics; http://www.bretnicksmd.com/blog, and recently published his first book.

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Cite This Article

Please replace “iEM Education Project Team” below with the author(s) surname and initials.

Cite this article as: iEM Education Project Team, "Discharge Communications (2023)," in International Emergency Medicine Education Project, May 15, 2023, https://iem-student.org/2023/05/15/discharge-communications-2023/, date accessed: October 1, 2023

2018 version of this topic – https://iem-student.org/discharge-communications/

References

  1. Clarke C, Friedman SM, Shi K, et al. Emergency department discharge instructions comprehension and compliance study. CJEM 2005 Jan;7(1):5-11.
  2. Clark PA, Drain M, Gesell SB, et al. Patient perceptions of quality in discharge instruction. Patient Educ Couns. 2005 Oct;59(1):56-68.
  3. Henry GL, Gupta G. (2013). Medical-Legal Issues in Emergency Medicine. In Adams (Ed.), Emergency Medicine Clinical Essentials, 2nd Ed; 1759-65. Philadelphia, PA: Elsevier.
  4. Siff JE. (2011). Legal Issues in Emergency Medicine. In Tintinalli’s (Ed.), Emergency Medicine, 7th Ed; 2021-31. McGraw-Hill.
  5. Crane JA. Patient comprehension of doctor-patient communication on discharge from the emergency department. J Emerg Med 1997;15:1–7
  6. Engel KG, Buckley BA, Forth VE, et al. Patient Understanding of Emergency Department Discharge Instructions: Where Are Knowledge Deficits Greatest? Acad Emerg Med 2012; 19(9):1035-1044.
  7. Sameuls-Kalow ME, et al. Unmet Needs at the Time of Emergency Department Discharge. Acad Emerg Med. 2015 Dec 18.
  8. Taylor DM, Cameron PA. Discharge instructions for emergency department patients: what should we provide? J Acad Emerg Med. 2000; 17:86-90.
  9. Zeng-Treitler Q, Kim H, Hunder M. Improving Patient Comprehension and Recall of Discharge Instructions by Supplementing Free Texts with Pictographs. AMIA Annu Sympo Proc 2008:849-853.
  10. Choudhry AJ, Baghdadi YM, et al. Readability of discharge summaries: with what level of information are we dismissing our patients? Am J Surg. 2016 Mar; 211(3): 631–636. PMID: 26794665.
  11. Al-Harthy N, Sudersanadas KM, Wagie AE, et al. Efficacy of patient discharge instructions: A pointer toward caregiver friendly communication methods from pediatric emergency personnel. J Family Community Med. 2016 Sep-Dec; 23(3): 155–160. PMID: 27625582.
  12. Gutman CK, Cousins L, Gritton J, et al. Professional interpreter use and discharge communication in the pediatric emergency department. Acad Pediatr. 2018;18(8):935–943. PMID: 30048713.
  13. Oller C. Discharge Moment of Safety. Available at: https://www.youtube.com/watch?v=xuLjBWkfomE Accessed January 30, 2016.
  14. Pham JC, Ijagbemi M. Improving the ED Discharge Process. ACEP. Available at: http://www.acep.org/content.aspx?id=90940 Accessed January 15, 2016.
  15. DeSai C, Janowiak K, Secheli B, et al. Empowering patients: simplifying discharge instructions. BMJ Open Qual. 2021 Sep; 10(3).
  16. Levy F, Mareiniss DP, Lacovelli C. The Importance of a Proper Against-Medical-Advice (AMA) Discharge. How Signing Out AMA May Create Significant Liability Protection for Providers.  J Emerg Med. 2012;43(3):516-520.
  17. Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv. 2000;51:899-902.

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, vice-chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Communication and Interpersonal Interactions (2023)

~ iEM Education Project Team ~ Leave a comment

by Nicholas Mackin, Bret Nicks

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Introduction

Emergency Medicine and the situations within the department can present a stressful, rapidly changing environment where it may feel as though there is too little time for effective patient communication, patient-centered care, or the opportunity to establish an appropriate provider-patient relationship. It is also an environment unlike any other in medicine, where a unique team of individuals facing varying degrees of chaos with limited available information work together to address the medical conditions of those presenting to the department. Few would recommend entering such an environment in the absence of an established care process and means of clearly communicating. Understanding that preconceived notions and prejudices must remain at the door from the moment you walk in to the emergency department (ED) sets the tone for the entire shift.

It is no surprise that high-performing emergency departments have high-performing, well-communicating teams. Clearly defining and communicating why we are there and how we care for patients for every member of the team sets the tone for every interpersonal interaction.  This is true not just with our patient-provider interaction, but our interaction with nursing, ancillary, and consultant staff [1].  Establishing a team mentality and acknowledging the value of the contributions of our colleagues and staff to the ED is essential to practicing high-quality, safe emergency medical care.  

The skills that non-physician health professionals bring to the team can help us to better understand our patient’s expectations and needs – facilitating the best care that can be offered in the ED [2].

Essentials of Communication

The approach to provide high-quality patient care in the ED starts with recognizing the inherently mismatched perspective between the patient and physician [3]. It is essential to recognize the patient-physician relationship starts with a large power imbalance. Attempts should be made to normalize or reduce this power imbalance, so as to empower the patient and their families to openly discuss their medical concerns and assist with making informed decisions for their care. Acknowledge the wait or process they have already endured prior to seeing you.  Thank the patient (and family) for coming to the ED and allowing you to address their medical concerns.  Also, take the time to introduce yourself to everyone in the room with the patient and find out who they are in relation to the patient as this can help establish rapport with the patient and those around them [4-6]. When introducing yourself and other members of the care team, be sure to clearly define roles in terms the patient can understand. This is of particular importance when working with trainees. Patients tend to have a poor understanding of medical education and training, but want to know the role and level of training of their providers [7].

While many believe the environment of care is the greatest limiting factor to quality communication, literature would suggest otherwise. Establishing a positive patient-provider relationship is essential. Recognizing that you may not be able to solve the patient’s condition or chronic illness, but using effective communication skills and providing a positive patient experience will assuage many patient fears [8]. Keep in mind, in general, patients remember < 10% of the content (what was actually said), 38% of how you say it (verbal liking), and 55% of how you look saying it (body language) [3]. Effective provider communicators routinely employ these 5 Steps:

1. Be Genuine

Most people are able to quickly intuit when someone is not being forthcoming. Although we are often balancing competing interests for our time and attention, make every effort to ensure that you are taking a genuine, transparent approach to both receiving and providing information. An effective means of achieving this is to take an earnest interest in your patient. This often requires putting aside personal fatigue and bias. If you can entrain a genuine interest in a patient’s concerns, your interaction will be more natural and the patient will be more likely to trust you.

2. Be Present

As emergency providers, we are interrupted more than perhaps any other specialty.  However, for the brief time that we are engaged with the patient or their family, be fully attentive.  If there is a planned interruption upcoming, make it known prior to starting a discussion. Be focused on them and the conversation – and value what they have to share. At the end of your encounter, briefly summarizing what the patient has told you can help to reassure the patient that you were listening and also give them the chance to clarify discrepancies.

3. Ask Questions

To effectively communicate, one must listen more than they talk. After introducing yourself, inquire about the patient’s medical concern Give them 60 seconds of uninterrupted time.  Most patients provide unique insights that may otherwise not have been obtained. Then begin with the specific questions needed to further differentiate the care concern. By asking questions and allowing for answers, you make it about them and give them an avenue to share with you what they are most concerned about and allow you to address those concerns.

4. Build Trust

Given the nature of the patient-provider relationship in emergency medicine, building trust is essential but often difficult. Building trust is like building a fire, it starts with the initial contact and builds with each interaction – and is based on culturally acceptable interactions (e.g. handshake, affirming node, hand-on-shoulder, engaging posture, etc.) [4].

5. Communicate Directly

By the end of the initial encounter, ensure that you have established a clear plan of care, what the patient can expect, how long it may take, and when you will return to reassess or provide additional information. Doing this also allows the patient to be more involved in their care and ask further questions regarding their workup and treatment plan. Additionally, helping the patient to understand what they can expect while in the department can help to alleviate fear associated with unannounced tests or imaging studies, especially when these tests may require them to be temporarily taken out of the department (e.g. a trip to the CT scanner). While patients generally trust physicians to make decisions about advanced imaging such as CT, they still want to be included in the decision-making process [9].

Empathy

When considering this, it is essential to understand that much of this relates to empathy – the ability to understand and share another person’s experiences and emotions. It is often said, try to understand the patient’s agenda: ‘Help me understand what brought you in today’, ‘help me understand what I can do for you’, ‘tell me more’. This will help to normalize the patient’s situation and gain unique insights into their care concerns.  There are 4 easy steps to improve reflective listening and perceived empathy in the ED:

  1. Echo: Repeat what the patient says; this gives the message that you heard the patient.
  2. Paraphrase: Rephrase what the patient says; this gives the message that you understand the patient.
  3. Identify the feeling: Say, for example ‘you seem frustrated’, ‘worried’, ‘upset’ as this produces trust.
  4. Validation: Validate the patient’s feelings verbally such as ‘I can see why you feel that way’.

It is human nature that empathy will be more intuitive for some, but all can practice empathic communication skills to better identify the needs of your patient. By implementing the above approach, physicians can improve their ability to elicit concerns that a patient may not have been able to otherwise articulate. Using a predefined approach may feel mechanical or forced, but standardized communication interventions have been shown to positively impact patients’ perception of the encounter [10].

For those seeking additional structure to practice, there is also a great online module and mnemonic for Empathetic Listening skills development [11]. The RELATE mnemonic is:

  • Reassure – share your qualifications and experience.
  • Explain – describe in clear concise language what the patient can expect.
  • Listen – not just hear and encourage the patient to ask questions.
  • Answer – summarize what they have said and confirm their understanding.
  • Take Action – discuss and define the care steps (and what to expect)
  • Express Appreciation – thank the patient for allowing you to care for them.

The Approach

As with many things, effective communication is the glue that helps establish connections to others and improve teamwork, decision-making, and problem solving. It facilitates the ability to convey even negative or difficult messages without creating conflict or distrust. Recognizing this, the right approach for successful patient communication is essential.  In addition to understanding the above 5 steps of effective communication, the approach to this must also be refined by each individual and adjusted for the unique circumstances of each patient encounter. For a moment, consider seeing the situation from the patient’s perspective regarding your approach and set the tone with these 3 starting points.

The 3 Starting Points:

1)     Approach and Appearance:

  • Sit down next to the patient
  • Maintain an open posture (avoid crossing your arms)
  • Maintain eye contact appropriate to local cultural norms
  • Use non-verbal cues to acknowledge what is being said (e.g. nodding, smiling, using eyes to show interest)
  • Dress appropriately

2)     How to speak:

  • Speak slowly and clearly (given the constraints of the ED)
  • Use a low, calm tone in your voice
  • Be mindful that patients will sense any frustration or impatience in your tone

3)     What to say:

  • Introduce yourself in a culturally appropriate manner
  • Use the patient’s last name, particularly if introducing yourself by your last name (this helps to minimize power imbalance)
  • Acknowledge everyone in the room and clarify their relationship to the patient
  • Adjust medical wording based on patient’s medical literacy

In addition to understanding the 5 essentials of communication and setting the tone with the initial care approach, it is important to understand some of the most common reasons communication is successful and fails in the Emergency Department.  While a single approach framework doesn’t always fit every situation, there are some essential Do’s and Don’ts that must also be considered.

Do's

  • Let the patient tell their story [9].
  • Establish the patient’s goals of the encounter.
  • Elicit any feared conditions or diagnoses, as well as any desired therapeutics or diagnostics (It is generally better to address these pre-existing desires early in the encounter).
  • Provide the patient with information regarding what will happen during their stay. This puts patients more at ease and improves satisfaction [6].
  • Provide honest estimates of expected wait times. Some experts suggest overestimating the time for results and consultant services (Disney Technique).
  • Explain reasons for delays, and readily apologize for
  • Map out the next steps in the process in the ED after your history and physical.

Don'ts

  • Fold your arms over your chest as this displays an aggressive posture
  • Ask why the patient did not come in earlier
  • Say ‘I guess’
  • Repeatedly ask ‘why’
  • Use the words ‘never’ or ‘always’
  • Ignore elephants in the room
  • Dismiss their concerns without explanation

The Difficult Patient

When engaging difficult patients in the emergency department, understanding the situation and the drivers for the patient may help to better navigate the communication challenges that are present.  A difficult patient encounter in the emergency department can often be frustrating for both the physician and the patient. These patients often present with chronic medical issues that are exacerbated by social disparities [13-14]. These are just a few examples of types of patients that one may encounter in the emergency department:

Angry Patient

Don’t ignore that a patient may be angry or upset. Their frustration is often related to delays, expectations, or care concerns. Try to explore this by asking neutral and non-confrontational questions.  If possible, identify and acknowledge their dominant underlying emotion.  Statements as simple as “It seems like you’re frustrated” or “I suspect we’re not meeting your expectations today” can lead to meaningful dialogue when a patient feels acknowledged. A simple but genuine apology can completely change the end of an encounter, such as apologizing for a long wait or for not being able to do more in our limited capacity in the ED.

Manipulative Patient

While these patients may clearly have secondary gain, their medical complaints are often still legitimate. Approach these patients with an open mind and differential, but be prepared to say “no” to requests that are not clinically indicated. When in doubt, give patients the benefit of the doubt rather than prematurely dismissing a legitimate need.

Frequent Fliers / High Utilizers

High recidivism may be frustrating, but it is important to understand that there may be an underlying reason for frequent ED visits. Socioeconomic factors resulting in poor access to care are common reasons. Maintaining familiarity with available resources (e.g. social workers, clinical support nursing) can make a tremendous difference.

Combative, Agitated, or Intoxicated Patient

It is most important to keep both the patient and the staff (including yourself) safe. Redirecting the patient and emphasizing the importance of caring for them medically may help to calm the situation. It is remarkably easy to inadvertently escalate an agitated patient’s behavior. Maintain firm boundaries while maintaining a calm, reserved demeanor. Psychopharmacological intervention may be necessary at times.

In difficult encounters, there are times when an impasse is reached and it is clear that the goals of the patient will not be met. Even if your care is medically appropriate and effort has been made to respect the patient’s autonomy, these scenarios are sometimes unavoidable. In such situations, it is important to emphasize that you are acting in what you feel to be the patient’s best interest. If appropriate, apologize for their frustrations or any misunderstanding. Give the patient time to express themselves, but also practice identifying when it is time to give the patient space.

For a deeper dive into effective patient communication related to managing difficult patients, listen to Episode 51: Effective Patient Communication – Managing Difficult Patients by Anton Helman. http://emergencymedicinecases.com/episode-51-effective-patient-communication-managing-difficult-patients/

The Culturally-Discordant Encounter

The emergency department is a nexus not just for all members of a community, but for anyone in the area needing assistance. Physicians in the emergency department can expect to encounter a diverse patient population, regardless of physical location. Healthcare professionals will therefore invariably encounter those of cultural backgrounds that differ from their own. These cultural backgrounds include race, religion, and nationality, among many others. While an entire chapter could be dedicated to communication in this setting, here are a few key points to form a foundation.

1. Minimize any language barrier

Making efforts to minimize a language barrier is often easier said than done. For any encounter in which the primary languages of the patient and physician are not the same, an interpreter should be offered whenever possible. It can be immensely tempting to over-estimate a patient’s fluency in a language to avoid having to use a language interpreter. However, it is well-demonstrated that language barriers are associated with a variety of negative impacts on patient care including decreased diagnostic confidence, increased ancillary testing, decreased patient satisfaction, and delays in analgesia [15-17]. Family members should not be used as interpreters whenever possible. They can have their own agendas and biases, as well as variable health literacy.

2. Be mindful of one’s own biases

It is an unfortunate truth that implicit biases exist in every person. Healthcare professionals should be mindful of the poorer communication and health outcomes minority races tend to receive [18,19]. Employing a genuine, empathic style of communication is an excellent foundation for mitigating one’s biases.

3. Familiarize yourself with differing cultural norms

There are far too many cultural norms for any one person to know. If there are specific communities of differing cultural backgrounds in your area, make an effort to learn differences in verbal and non-verbal cues. If unsure, it is generally prudent to “be yourself” and exhibit calm, deliberate mannerisms.

The Handoff

Communication between providers and specifically patient care transitions present one of the well-known challenges in patient care and errors in care management. This handoff communication, often perceived as the ‘gray zone’, has been characterized by ambiguity about patient medical condition, treatment and disposition [20]. Communication errors, particularly related to patient hand-offs, account for nearly 35% of ED related care errors.  Establishing a standardized process to ensure quality and clarity of transitions in care are essential.  One such example is the I-CAN format, which is specifically focused on the ED patient population.

I - Introduction

Briefly describe what brought the patient into the emergency department today. For example: Patient is a 53 yo male with past medical history of COPD who presents today with productive cough, wheezing and shortness of breath.

C - Critical Content & Interventions Performed

Relate information that helps the receiving provider understand the ED course. For example: On initial evaluation the patient was unable to speak in full sentences and O2 saturation was 88% on room air. We started him on NIPPV and provided nebulizer treatments and IV steroids.

A - Active Issues

Provide an overview of the patient’s current condition. For example: Patient improved after an hour of NIPPV and was transitioned to high flow nasal cannula with O2 saturation at 93%. We are currently attempting to wean O2 requirements as tolerated.

N - Next Steps & Anticipated Disposition

Describe to the receiving provider what will need to be followed up and anticipated disposition of the patient. For example: The patient will need to be admitted for a COPD exacerbation with a new O2 requirement. He can go to a floor bed if he remains stable on nasal cannula.

While many examples for a unified handoff exist, identifying a defined approach and establishing the expectation for routine use, especially when integrated into the electronic health record at transitions of care, ensure improvement with patient care, quality and throughput [20,21]. If the patient and family are involved with this handoff, not only will they understand care expectations, but better understand issues with delays, next steps, and care updates.

Conclusion

Most agree that providing patient care in the ED poses many challenges. The situations within which we work can present a stressful, rapid environment where it may feel as though we have too little time for effective patient communication, patient-centered care or opportunity to establish a great patient experience. However, it is also evident that improved communication between the care team and patients not only improves the care experience but also improves patient care outcomes. Quality communication improves patient outcomes, compliance and satisfaction – not to mention job and team satisfaction.

While many techniques exist to improve ED communication, establishing a culture in the ED to habitually adapt these practices is essential. The ED is indeed an environment unlike any other in medicine, where a unique team of individuals work in varying degrees of chaos with limited available information working together to address the medical conditions of those presenting to the department. Doing so with effective communication can make a difference.

Authors

Nicholas MACKIN

Nicholas MACKIN

Nicholas Mackin, MD is a Clinical Assistant Professor in the Department of Emergency Medicine at Wake Forest Baptist Medical Center in Winston Salem, NC, USA.

Bret NICKS

Bret NICKS

Bret Nicks, MD, MHA is an emergency physician that embraces the breadth of our specialty. He is a Professor and Executive Vice Chair of Emergency Medicine at Wake Forest University School of Medicine. He is the past president of the North Carolina College of Emergency Medicine. He served as the Chief Medical Officer of the award-winning Wake Forest Baptist Davie Medical Center. Dr. Nicks served as the founding Associate Dean for the Wake Forest Office of Global Health. He has lived, practiced, and led in many resource austere locations globally, although calls the academic tertiary care emergency department his home. He is passionate about, consults and lectures on the interface of clinical quality, leadership and team culture – and is dedicated to developing EM leaders for the future of our specialty and the transformation of healthcare. He loves anything outdoors, enjoys blogging on various life and leadership topics; http://www.bretnicksmd.com/blog, and recently published his first book.

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Cite This Article

Please replace “iEM Education Project Team” below with the author(s) surname and initials.

Cite this article as: iEM Education Project Team, "Communication and Interpersonal Interactions (2023)," in International Emergency Medicine Education Project, May 1, 2023, https://iem-student.org/2023/05/01/communication-and-interpersonal-interactions-2023/, date accessed: October 1, 2023

2018 version of this topic – https://iem-student.org/communication-and-interpersonal-interactions/

References

  1. Gluyas H. Effective communication and teamwork promotes patient safety. Nurs Stand. 2015 Aug 5;29(49):50-7.
  2. Klauer K, Engel KG. Patient-centered Care. Emergency Medicine Clinical Essentials, 2nd Ed. Elsevier, 2013; 1784-89.
  3. Helman A. Effective Patient Communication. Available at: http://emergencymedicinecases.com/episode-49-patient-centered-care/  Accessed December 18, 2015.
  4. Chan EM, Wallner C, Swoboda TK, et al. Assessing Interpersonal and Communication Skills in Emergency Medicine. Acad Emerg Med 2012; 19:1390-1402.
  5. Cinar O, Ak, M, Sutcigil L, et al. Communication skills training for emergency medicine residents. Eur J Emerg Med. 2012; 19:9-13.
  6. Hobgood CD, Riviello RJ, Jouriles N, Hamilton G. Assessment of  communication and interpersonal skills competencies. Acad Emerg Med. Nov 2002; 9(11):1257-69.
  7. Hemphill RR, Santen SA, Rountree CB, Szmit AR. Acad Emerg Med. 1999 Apr;6(4):339-44.
  8. Mole TB, Begum H, Cooper-Moss N, et al. Limits of ‘patient-centeredness’: valuing contextually specific communication patterns. Med Educ. 2016 Mar; 50(3):359-69.
  9. Caoili EM, Cohan RH, Ellis JH, et al. Medical Decision Making Regarding Computed Tomographic Radiation Dose and Associated Risk: The Patient’s Perspective. Arch Intern Med. 2009;169(11):1069-1081.
  10. Custer A, Rein L, Nguyen D, et al. Development of a real-time physician–patient communication data collection tool. BMJ open quality. 2019 Nov 1;8(4):e000599.
  11. The History of Empathy – SMACC. Available at: http://broomedocs.com/2014/09/the-history-of-empathy-from-smacc-gold/ Accessed February 20, 2016.
  12. Roscoe LA, Eisenberg EM, Forde C. The Role of Patient Stories in Emergency Medicine Triage. Health Commun. 2016 Feb 16:1-10.
  13. Hull SK, Broquet K. How  to manage the difficult patient. Family Practice Management. 2007 June: 30-34.
  14. Dudzinski DM, Timberlake D. Difficult Patient Encounters. Ethics in Medicine. Available at: https://depts.washington.edu/bioethx/topics/diff_pt.html Accessed February 20, 2016.
  15. Garra G, Albino H, Chapman H, Singer AJ, Thode Jr HC. The impact of communication barriers on diagnostic confidence and ancillary testing in the emergency department. The Journal of emergency medicine. 2010 Jun 1;38(5):681-5.
  16. Gaba M, Vazquez H, Homel P, Likourezos A, See F, Thompson J, Rizkalla C. Language barriers and timely analgesia for long bone fractures in a pediatric emergency department. Western Journal of Emergency Medicine. 2021 Mar;22(2):225.
  17. Carrasquillo O, Orav EJ, Brennan TA, Burstin HR. Impact of language barriers on patient satisfaction in an emergency department. Journal of general internal medicine. 1999 Feb;14:82-7.
  18. Shen MJ, Peterson EB, Costas-Muñiz R, Hernandez MH, Jewell ST, Matsoukas K, Bylund CL. The effects of race and racial concordance on patient-physician communication: a systematic review of the literature. Journal of racial and ethnic health disparities. 2018 Feb;5:117-40.
  19. Hagiwara N, Slatcher RB, Eggly S, Penner LA. Physician racial bias and word use during racially discordant medical interactions. Health communication. 2017 Apr 3;32(4):401-8.
  20. Akper J, Mallak LA, Gibson SC. Communicating in the “gray zone”: perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med. 2007 Oct;14(10):884-94.
  21. Rourke L, Amin A, Boyington C, et al. Improving residents’ handovers through just-in-time training for structured communication. BMJ Qual Improv Rep. 2016 Feb 8;5(1).

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, vice-chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Thinking Like an Emergency Physician (2023)

~ iEM Education Project Team ~ Leave a comment

by Joe Lex

Author
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Emergency Medicine is the most interesting 15 minutes of every other specialty.

Dan Sandberg, BEEM Conference, 2014

Everyone in medicine knows that Emergency Medicine is different, even if they can’t put the reason into words.  We know why.  We work in an environment that is different, in hours that are different, and with patients who are different more than any other medical specialty.  Our motto is “Anyone, anything, anytime.”  No other specialty of medicine makes that claim.

While other doctors dwell on “What does this patient have? – that is, “What’s the diagnosis?” – emergency physicians are instead thinking “What does this patient need right now?  In 5 minutes?  In two hours?”  

The concept of seeing undifferentiated patients with symptoms, not diagnoses, is alien to many of our medical colleagues. Yet we do it on a daily basis, many times during a shift.  The idea of juggling decisions for several sick people simultaneously is beyond the capabilities of almost everyone else in medicine.  They are used to working with one patient at a time in a linear fashion.

I retired a few years ago after more than 45 years in Emergency Medicine, dating back to my time as an Army medic in Vietnam.  Every time I introduced myself to a patient, I never knew in advance which direction things were going to head.  I never knew whether I could help the patient in 30 seconds or 30 minutes, if at all.  I felt like I should have given this disclaimer.

Hello stranger, I am Doctor Joe Lex.  I will spend as much time with you as it takes to determine whether you are trying to die on me, and whether I should admit you to the hospital so you can try to die on one of my colleagues.  

You and I have never met before today.  You must trust me with your life and secrets, and I must trust that the answers you give me are honest.  

After today, we may never see one another again.  It may turn out to be one of the worst days of your life.  For me, it is another workday.  I may forget you minutes after you leave the department, but you will probably remember me for many days or months, possibly even for the rest of your life.  I will ask you many, many questions.  I will do the best I can to ask the right questions in the right order so that I come to a correct decision.  I want you to tell me your story, and for me to understand that story, I may have to interrupt you to clarify your answers.

Each question I ask you is a conscious decision on my part.  In an average 8-hour shift I will make about 10,000 conscious and subconscious decisions – who should I see next, what question should I ask next, how much physical examination should I perform, is that really a murmur that I am hearing, what lab study should I order, what imaging study should I look at now, and is that really an infiltrate, which consultant will give me the least pushback about caring for you, is your nurse one whom I can trust with the mission of getting your pain under control, and will I remember to give you that work note when it is time for you to go home?  And so on…  So even if I screw up just 0.1% of these decisions, I will make about ten mistakes today.

I hope for both of our sakes you have a plain, obvious emergency with a high signal-to-noise ratio.  Gonorrhea, a dislocated kneecap, chest pain with an obvious STEMI pattern on EKG, shingles, a dental abscess, an eye foreign body … I can recognize and treat those things without even thinking.  If, on the other hand, your problem has a lot of background noise and vague signs and symptoms, I am more likely to be led down the wrong path and come to the wrong conclusion.  

I am glad to report that the human body is very resilient.  We as humans have evolved over millennia to survive, so even if I screw up, the odds are very, very good that you will be fine.  Voltaire told us back in the 18th century that “The art of medicine consists of amusing the patient while nature cures the disease.”  For the most part, this has not changed.  And Lewis Thomas wrote: “The great secret of doctors, learned by internists and learned early in marriage by internists’ wives, but still hidden from the public, is that most things get better by themselves.  Most things, in fact, are better by morning.” On the other hand, the path to dying is rather direct – failure of respirations, failure of the heart, failure of the brain, or failure of metabolism.

Remember, you don’t come to me with a diagnosis: you come to me with symptoms.  You may have any one of more than 10,000 diseases or conditions that we know about, and – truth be told – the odds of me getting the absolute correct diagnosis are small.  You may have an uncommon presentation of a common disease or a common presentation of an uncommon disease.  If you are early in your disease process, I may even miss such life-threatening conditions as heart attack or sepsis.  If you neglect to truthfully tell me your sexual history or your use of drugs and alcohol, I may not follow through with appropriate questions and might come to a totally incorrect conclusion about what you need or what you have.

You may be disappointed when you feel that you are not being seen by a “specialist.”  Many people believe that when they have their heart attack, they should be cared for by a cardiologist.  They think that the symptom of “chest pain” is their ticket to the heart specialist.  But what if the heart attack is not chest pain, but nausea and breathlessness?  And what if the chest pain is aortic dissection?  Or a pneumothorax?  Or a ruptured esophagus?  So, you are being treated by a specialist – one who can discern the life-threatening from the trivial, and the medical from the surgical.  We are the specialty trained to think like this.

We started our training in a state of unconscious incompetence – we were so poor at what we did that we did not even know how bad we were.  We were lucky if we could care for four patients in an 8-hour shift.  But we quickly learned and reached a level of conscious incompetence and multi-tasking – we knew that we were inadequate, but we felt ourselves getting better at our job on a day-to-day basis.  By the time we finished our training we had reached the next level: conscious competence.  We could deal with almost anything, but we still had to think hard about much of our decision making.  After a few more years of practice, we reached our pinnacle of unconscious competence

If you insist on asking “What do I have, Doctor Lex?” you may be disappointed when I tell you “I don’t know what you have, but I do know it is safe for you to go home.”  Sometimes I can do this without doing a single test.  I do know that if I give you a made-up diagnosis like “gastritis” or “walking pneumonia,” you will think the problem is solved.  Worse yet, other doctors will anchor on my false diagnosis, and you may never get the right answers.

Here’s some good news: we are probably both thinking of the worst-case scenario. You get a sudden headache and wonder “Do I have a brain tumor?”  You get some belly pain and worry “Is this cancer?”  The good news is that I am thinking exactly the same thing.  And if you do not hear me say the word “stroke” or “cancer,” then you will think I am an idiot for not reading your mind to determine that is what you are worried about.  I understand that no matter how trivial your complaint, you have a fear that something bad is happening.

While we are talking, I may be interrupted once or twice.  See, I get interrupted several times every hour – answering calls from consultants, responding to the prehospital personnel, clarifying orders for nurses and technicians.  Or I may get suddenly called away to care for someone far sicker than you.  I will try very hard to not let these interruptions derail me from doing what is best for you today.

I will use my knowledge and experience to reach the right decisions for you.  I know that I am biased, but knowledge of bias is not enough to change it.  I know the pathophysiology of pulmonary embolism in excruciating detail, but the literature suggests I may still miss this condition at least half the time it occurs.

And here’s the interesting thing: I will probably make these errors whether I just quickly determine what I think you have by pattern recognition or use analytical reason.  Emergency physicians are notorious for thinking quickly and making early decisions based on minimal information (Type 1 thinking).  Cognitive psychologists tell us that we can cut down on errors by using analytical reasoning (Type 2 thinking).  It turns out that both produce about the same amount of error, and the key is probably to learn both types of reasoning simultaneously.

After I see you, I will go to a computer and probably spend as much time generating your chart as I did while seeing you.  This is to document what I have found and how I have worked up your complaint, so the hospital and I can get paid.  The more carefully I document what you say and what I did, then the more money I can collect from your insurance carrier.  But that chart may be useless in helping other health care providers understand what happened today unless I deviate from the clicks and actually write what we talked about and explained my thought process.  In my eight-hour shift today I will click about 4000 times.

What’s that?  You say you don’t have insurance?  Well, that’s okay too.  The U.S. government and many other governments in the world have mandated that I have to see you anyway without asking you how you will pay.  No, they haven’t guaranteed me any money for doing this – in fact, I can be fined a hefty amount if I don’t do it.  A 2003 article estimated I give away more than $138,000 per year worth of free care because of this law.

But if you are having an emergency, you have come to the right place.  If you need a life-saving procedure such as endotracheal intubation or decompression needle thoracotomy, I’ll do it.  If you need emergency delivery of your baby or rapid control of your hemorrhage, I can do that too.  I can do your spinal tap, I can sew your laceration, I can reduce your shoulder dislocation, and I can insert your Foley catheter. I can float your temporary pacemaker, I can get that pesky foreign body out of your eye or ear or rectum, I can stop your seizure or your nosebleed, and I can talk you through your bad trip.

Emergency medicine really annoys a lot of the other specialists.  I think that it is primarily because we are there 24 hours a day, 7 days a week.  And we really expect our consultants to be there when we need them.  Yes, we are fully prepared to annoy a consultant if that is what you need.

I saw thousands of patients, each unique, in my near-50 years of experience.  But every time I thought about writing a book telling of my wondrous career, I quickly stopped short and told myself “You will just be adding more blather to what is already out there – what you have learned cannot easily be taught and will not be easily learned by others.  What you see as wisdom, others will see as platitudes.”

As author Norman Douglas once wrote: “What is all wisdom save a collection of platitudes.  Take fifty of our current proverbial sayings– they are so trite, so threadbare.  None the less they embody the concentrated experience of the race, and the man who orders his life according to their teachings cannot be far wrong.  Has any man ever attained to inner harmony by pondering the experience of others?  Not since the world began!  He must pass through fire.”

Have you ever heard of John Coltrane?  He was an astonishing musician who became one of the premiere creators of the 20th century.  He started as an imitator of older musicians but quickly changed into his own man.  He listened to and borrowed from Miles Davis and Thelonious Monk, Coleman Hawkins and Lester Young, African music and Indian music, Christianity and Hinduism and Buddhism.  And from these seemingly unrelated parts he created something unique, something no one had ever heard before.  Coltrane not only changed music, but he changed people’s expectations of what music could be.  In the same way, emergency medicine has taken ideas from surgery and pediatrics, critical care and obstetrics, endocrinology and psychiatry, and orthopedics, and we have created something unique.  And in doing so, we altered the world’s expectations of what medicine should be.

Now, how can I help you today?

Author

Joe LEX

Joe LEX

Joe Lex was involved in Emergency Medicine for more than 49 years – as a Vietnam combat medic, ER Tech, Certified Emergency Nurse, and Emergency Physician. For five years he was Education Chair for the American Academy of Emergency Medicine, which renamed their Educator of the Year Award the “Joe Lex Award.” After 14 years in the community, he joined the Emergency Medicine faculty at Temple University in Philadelphia. He is a “godfather” of free electronic open-access medical education and his website (www.FreeEmergencyTalks.net) taught thousands of people worldwide.

Since he retired in 2016 as a Professor of Emergency Medicine, he does a weekly radio show called “Dr. Joe’s Groove,” featuring 60-year-old news and jazz. He writes an occasional blog called “Notes from Nam” based on 170 letters he wrote home in 1968 and 1969. He is also an amateur cemetery historian and volunteer tour guide for Laurel Hill Cemetery in Philadelphia and West Laurel Hill Cemetery in Bala Cynwyd, in addition to researching and producing their monthly podcasts “All Bones Considered: Laurel Hill Stories” and “Biographical Bytes from Bala: West Laurel Hill Stories.”

Joe and his wife Andrea celebrate 50 years together in June. His publicity picture is quite old – add 15 years and 40 pounds.

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Cite this article

Please replace “iEM Education Project Team” below with the author(s) surname and initials.

Cite this article as: iEM Education Project Team, "Thinking Like an Emergency Physician (2023)," in International Emergency Medicine Education Project, March 20, 2023, https://iem-student.org/2023/03/20/thinking-like-an-emergency-physician-2023/, date accessed: October 1, 2023

2018 version of this topic – https://iem-student.org/thinking-like-an-emergency-physician/

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, vice-chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

How To Present Your Case In The ED

how to present your case in the ED
~ Sheza Qayyum, Canada ~ Leave a comment

As a medical student, presenting history and physical exam of a patient to the attending can be nerve-wracking. In the ED, physicians typically prefer an even more succinct presentation than usual, ideally less than 3 min. Case presentations are a great opportunity to show that you understand what the pertinent positives and negatives for the patient’s presenting complaint are and that you can summarize a large amount of information collected in an organized manner. Case presentations are your opportunity to impress your preceptor, so it is an important skill to master. It will also be the mode of communicating with the rest of the healthcare team throughout your career in medicine. Better communication = better patient care!

Ask

Before we get started, it is important to recognize that every physician may have their own preference for how they would like case presentations organized. Some prefer more details, and some prefer a specific order. Therefore, it is always a smart idea to ask your preceptor at the beginning of your ED shift if they have a preference for how they like cases to be presented.

The One Liner

State the patient’s name, age, sex, chief complaint, and any pertinent medical history. E.g., John Doe is a 16-year-old male with a history of eczema presenting with wheezing.

History of Presenting Illness (HPI)

include the details of the chief complaint, as well as any pertinent positives and negatives.
  1. Why did this patient present to the ED today?
  2. What are the details of the chief complaint? I.e. Onset, Duration, Progression, Alleviating and Aggravating Factors, Causes/Triggers, Changes with Position, etc.
    • For pain, it is helpful to describe OPQRSTU – Onset, Position, Quality, Radiation, Severity, Temporal, déjà vU (has it ever happened before).
  3. Any associated symptoms
  4. Any risk factors?
    • Any relevant past medical history (e.g. chronic conditions, hospitalizations, surgeries, etc.), family history, or social history (e.g. habits, living situation, alcohol consumption, smoking history, illicit drug usage)?

Review of Systems

Describe any other symptoms here.

  • Note that some ED physicians may not want a review of systems included in the oral case presentation if it does not include any additional pertinent information, but a review of systems should always be included in your written patient note. 

Medications

Allergies

if the patient states that they do not have any allergies, this can be recorded and/or stated as “NKDA” which stands for No Known Drug Allergies.

Physical Exam Findings

  1. Start off by stating the most updated set of vitals.
  2. Next, state the patient’s general appearance as this helps decide between sick vs. not sick. E.g., patient is alert, oriented, and in no apparent respiratory distress.
  3. Then, delve into the pertinent details of the physical exam. E.g. for a cardiac complaint, it is important to include the specific details of the cardiovascular exam and respiratory exam, but not of all the other systems.
  4. A brief overview of the other systems that a physical exam was conducted for can be useful, but be as concise as possible, and organize information in a head-to-toe fashion if needed. If there were no other findings, you can state that the remainder of the physical exam was unremarkable. 

Summary

In 2-3 sentences, gather the main findings of your history and physical exam. Be sure to restate the initial one-liner sentence, other pertinent positives and negatives, and any important test results so far.

Impression/Assessment

State your differential diagnosis for each problem.

  • Start off by stating what you think the most likely diagnosis is, and why you think it is the most likely.
  • Then, state any other likely diagnoses you are suspecting.
  • Lastly, state the deadly diagnoses that could be possible with this patient’s chief complaint. In some cases, this can be the first thing you may want to say. It is important to specify why you do or do not feel confident in ruling these out. E.g., in a baby presenting with fever of unknown origin, it is important to state why you are not (or are) suspecting meningitis, encephalitis, malignancy, or autoimmune conditions.
  • Many medical students will shy away from stating their impression of what could be going on in terms of differential diagnosis, but this is an important thing to attempt. Preceptors will appreciate your effort in synthesizing what could be going on and be impressed by it, even if your impression is incorrect. This is often what sets apart students that “meet expectations” vs. students that are considered “outstanding”.

Plan

What do you want to do next?

  • Plan includes anything from the tests you want to order (including repeat vitals, bloodwork, and imaging), immediate treatment (including analgesics and fluids), and referrals you want to make (including consults, admission/discharge plan, and referral to allied health professionals such as social work, speech-language pathology, occupational therapy, and physiotherapy).  
  • Do not forget to take the patient’s social history into account when deciding what to do next.

Congrats – you have now completed your oral case presentation! This is a skill you will continue to develop with practice, so do not worry and keep working at it. It is also a good idea to always ask your preceptor for feedback on your case presentation once it is complete, as that will help you identify your strengths and weaknesses.

References and Further Reading

Cite this article as: Sheza Qayyum, Canada, "How To Present Your Case In The ED," in International Emergency Medicine Education Project, December 7, 2020, https://iem-student.org/2020/12/07/how-to-present-your-case-in-the-ed/, date accessed: October 1, 2023

More Blog Posts By Sheza Qayyum

Unmasking communication during COVID-19

Unmasking communication during COVID-19
~ Neha Hudlikar, UAE ~ Leave a comment

As face masks become ubiquitous in our health-care practice due to the COVID-19 pandemic, communication between the patient and health-care provider has become harder than ever before. The challenges posed by COVID-19 have highlighted various areas of deficiencies in the health care industry as well as heightened anxiety among health-care providers as well as patients. Communication with patients has become particularly challenging and ever so more important than before.

Imagine the plight of a patient struggling to breathe, being greeted by someone in full PPE, struggling to understand your muffled speech through the mask amidst the background noise of oxygen hissing through a breathing mask. Earlier, your smile would have worked to ease some of the anxiety by coming across as approachable and friendly; however, your face mask has cost you a brave soldier in your battle of gaining trust. The situation is worse in the elderly, frail, and cognitively impaired patients who may rely on lip-reading and facial expressions to communicate.

Health care workers are forced to have difficult conversations of do-not-resuscitate orders, advance care planning, and break bad news while wearing a face mask and PPE, creating a barrier for effective communication with patients and their family members.

If you have previously relied on a firm handshake and a smile to lessen the anxiety of patients but are now finding it challenging to have clear communication, here are few ways to improve communication with patients.

Unmasking communication during COVID-19
Cite this article as: Neha Hudlikar, UAE, "Unmasking communication during COVID-19," in International Emergency Medicine Education Project, August 10, 2020, https://iem-student.org/2020/08/10/unmasking-communication-during-covid-19/, date accessed: October 1, 2023

A Lens Beyond Emergency Medicine

A lens beyond emergency medicine
~ Leah Sarah Peer, Canada ~ 1 Comment

The emergency room constantly presents challenges, and physicians always have to act with urgency. Patients, on the other hand, fear diagnoses they will hear, being unprepared to deal with the consequences, let alone mustering the strength to inform their loved ones. In this chaotic and busy environment of the emergency department, healthcare professionals often overlook a core value: to facilitate healing beyond medicine.

Physicians strive to express compassion when faced with life and death matters, but doctors are human too! They suffer from many emotions their patients go through, sometimes more than their hearts can contain. On top of that, they are expected to provide care continuously, so they may reach a threshold where dying patients and crying family members seem to not affect them. The danger is physicians’ becoming “machines” lacking human emotions, consideration or care.

The importance of not losing our humanity cannot be overemphasized. Physicians are not only healthcare providers but they are leaders and health advocates. When conventional medicine fails to provide treatment, physicians have a responsibility to assure patients that they will be with them every step of the way. We are responsible for our patients’ lives from the day we take care of them. Let’s not mistake this for disregarding patient autonomy. Patients are entitled to decide for themselves, but a caring practitioner -one that listens and engages in conversation- will make the difference. Our responsibility is to make patients feel empowered. We can make a clinical difference by touching our patients beyond the physical.

Physicians must expand their perspective to see beyond emergency medicine. Conventional medicine has taught us to observe the patient for signs and symptoms but deemphasized patients’ expressions, feelings, ambitions, and dreams. Why should we see patients from just one lens? Medical students, physicians, and other healthcare professionals in the emergency department should remind themselves of perceiving a more subjective but meaningful aspect of patient care, which lies beyond the physical. True healing requires a multidisciplinary effort, including familial, environmental, and socio-economical aspects of care.

Social aspects of medicine play a crucial role and should never be neglected. Our utmost responsibility is to foster solidarity, peace, and humaneness in this world. Compassion must be the center of our every action as we concentrate on understanding the patient as a human, rather than the diseases. Physicians that mind the interconnections between medicine, emotions, and humans, make a difference.

Cite this article as: Leah Sarah Peer, Canada, "A Lens Beyond Emergency Medicine," in International Emergency Medicine Education Project, April 10, 2020, https://iem-student.org/2020/04/10/a-lens-beyond-emergency-medicine/, date accessed: October 1, 2023