Communication and Interpersonal Interactions (2023)

May 1, 2023May 16, 2023 ~ iEM Education Project Team ~ Leave a comment

by Nicholas Mackin, Bret Nicks

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:

Echo: Repeat what the patient says; this gives the message that you heard the patient.
Paraphrase: Rephrase what the patient says; this gives the message that you understand the patient.
Identify the feeling: Say, for example ‘you seem frustrated’, ‘worried’, ‘upset’ as this produces trust.
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, 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, 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: September 27, 2023

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

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Helman A. Effective Patient Communication. Available at: http://emergencymedicinecases.com/episode-49-patient-centered-care/ Accessed December 18, 2015.
Chan EM, Wallner C, Swoboda TK, et al. Assessing Interpersonal and Communication Skills in Emergency Medicine. Acad Emerg Med 2012; 19:1390-1402.
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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.
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Reviewed By

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.

The Importance of the Emergency Medicine Clerkship (2023)

April 17, 2023May 3, 2023 ~ iEM Education Project Team ~ Leave a comment

by Linda Katirji and Farhad Aziz

Introduction

The emergency medicine (EM) clerkship typically takes place during the fourth year of medical school. However, some medical schools may have an optional elective or a core rotation during the third year. Whether or not you plan to specialize in emergency medicine, the rotation is an important part of your medical education that will help you develop unique skills. The emergency room is a unique learning environment which is different than any other setting in the hospital. It provides clinical opportunities that are largely unavailable in other clerkships and rotations, and one of the few places you will encounter a completely undifferentiated patient. During residency, many specialties will also spend a significant amount of time in the Emergency Department (ED). This may be within a structured EM rotation, or while admitting or seeing patients for a certain medical or surgical service. Therefore, it is important to gain an understanding of the flow of the ED as well as the unique thought process that must be employed with emergency department patients. This chapter will discuss some of the unique aspects of the emergency department, some of the skills to acquire during the EM clerkship, as well as how to best be successful and take the most away from your rotation.

Unique Aspects of The Emergency Department Environment

The high volume and acuity of patients in the ED create a time pressure and forces physicians to employ a different style of practice than in most other settings. A steady stream of patients, some of whom may require immediate life-saving measures, means that many times there is little to no time to review history or any medical records prior to evaluating a patient. Most of the time you will need to assess a patient without knowing anything about their background. Therefore, it is important to gain an understanding of what the most important pieces of information to gather are for each patient. This can be difficult since most patients will arrive with completely undifferentiated complaints. Some common examples of these undifferentiated complaints are “chest pain” and “abdominal pain”, where the etiology can range from completely benign to immediately life-threatening, or “weakness”, where the differential diagnosis includes essentially the entire spectrum of medical pathology.

This undifferentiated patient is the standard in the ED. However, they can present in any medical setting. It is important to learn the thought process and develop a strategy for thinking through these types of patients whether you plan on a career in EM or not. Emergency physicians (EPs) must employ and master a completely different style of practice than most physicians. EPs must always think worst case scenarios for each chief complaint and must be knowledgeable and comfortable with associated the workup and treatment. A good example of this is chest pain. Even though many times the complaint of “chest pain” is found to be caused by a non-acutely life threatening etiology, EPs must immediately think of six fatal causes of chest pain: acute coronary syndromes, aortic dissection, pulmonary embolism, pericardial tamponade, pneumothorax, esophageal rupture. Additionally, ED doctors must use a different thought process in determining the disposition, or outcome, of the patient. The ED doctor essentially wants to avoid sending a patient home that is not safe to go home, where as a consultant, or admitting service, does not want to admit a patient who does not need be admitted. This may seem trivial, however this difference in thought process can occasionally create tension between the ED and admitting services.

Teaching in the ED is different than most other settings in the hospital as well. There is usually no time set aside for formal rounds, so most teaching is done actively at the bedside or at the time the student or resident presents the patient to the attending physician. Many times, attending physicians will pick out “teaching points” for each patient. Each physician will have a different teaching style. Your learning will generally be more active than passive, and likely more short and frequent rather than one long teaching sessions or lecture on rounds.

Lastly, the ED is a great place for medical students and first-year residents to learn to take responsibility for their patients. Students often time have an increased level of autonomy compared to other rotations. Many times, the student will be the first person to assess the patient, which is a very important role. It is important to learn to distinguish whether a patient is “sick” or “not sick”, and whether or not at first glance you think this patient could go home or needs to be admitted no matter what the diagnosis may be.

Unique Skills To Take Away From EM Clerkships

Emergency medicine is a wonderful rotation that exposes you to not only different patient populations but also a variety of pathology and diseases. This diverse collection of patients and pathology lends emergency medicine residents and students a unique opportunity to gain a mastery of different skills. These skills range from a knowledge of how to approach critically ill patients, gaining procedural skills, reading radiographs and CT scans, performing ultrasounds and much more.

Often you may be busy doing different tasks when you must drop everything to manage a critically ill patient. This is one of the exciting aspects of emergency medicine. These patients offer students a great opportunity to learn the principles of resuscitation, such as managing airways and circulatory collapse, identifying causes for the patient’s decompensation, and instituting the appropriate treatment. Whether you pursue a career in emergency medicine or choose to pursue a different specialty, critically ill patients will likely always be a part of your patient population. Understanding how to approach and stabilize these patients is an important part of being a physician.

Though learning the art of resuscitation is a vital part of the EM rotation, this is also an opportunity to gain competence in a variety of procedures. Whether you intend to pursue a career in pediatrics, internal medicine, orthopedics, general surgery or any other specialty, your rotation through the ED will expose you to a wide array of procedural skills ranging from intubating and placing central lines and arterial lines in the critically ill to performing lumbar punctures and fracture reductions in children. Autonomy is encouraged with procedures, and you will have the opportunity to improve your skills and techniques under the guidance of residents and attendings. EM is a very hands-on specialty. You should take advantage of medical student and resident didactics as an opportunity to learn. These usually consist of lectures on different subjects but also may include ultrasound practice, procedure labs on mannikins or cadavers and simulation. This will give you an opportunity to practice and provide better patient care during your rotation.

In addition to becoming familiar with a wide array of procedures, your EM clerkship will also allow you to familiarize yourself with a variety of imaging modalities ordered in the ED. There is a tremendous amount of pathology found in the ED which lends itself to a range of imaging. Whether it be learning to perform bedside ultrasonography on a crashing patient or simply learning how to approach reading a chest x-ray or a CT scan of the abdomen on your own, your EM rotation will give you plenty of opportunities to become proficient in a skill you will need later in your career.

Though your EM clerkship gives you exposure to a tremendous amount of skills which will help you become a savvy doctor, no skill is more important than compassion and humility. Every day, you will meet patients on the worst day of their life. Many will have gone through traumatizing experiences, or have a life changing chronic condition, or be in a severe amount of physical or emotional pain. Realizing this and comforting patients and their families is paramount to your success as a physician. You will also encounter a variety of consulting physicians. Speaking with consulting physicians about a patient is an art form in itself that EM physicians must master. While most consultants will be polite and professional, its not uncommon in to meet push-back from a consultant. Occasionally, some may be out right rude. Having a general understanding that they all have knowledge that you can learn from will set you up for a successful career in medicine.

How To Be Successful on Your EM Clerkship

Many of the of the same qualities that allow you to be successful in other rotations will help you to be successful in the ED. It is important to be hardworking, proactive, and knowledgeable. Keep a close eye on your patients, re-evaluate them frequently, and make sure to follow up on any results, including labs, imaging, and any recommendations by consultants. The unique aspects of the ED and EM clerkship discussed previously mean the first few shifts may be stressful and seem chaotic and hectic. For every student and resident that rotates through the ED there is a significant learning curve – with each shift you spend in the ED, things will feel less and less daunting. It’s important during this time that you know your limitations and what you are comfortable and not comfortable with. Many times you will be the first person to assess the patient. You should have a low threshold for alerting an upper-level resident or attending if the patient appears to be sick, or if they present with a complaint you are uncomfortable with. At the same time, you should be confident in what you do know and take the opportunity to learn how to diagnose, treat, and manage your patient.

The best way to build confidence during your EM rotation is to gain experience and knowledge. Try to be proactive in learning new procedures or treatments with attending or resident assistance. Additionally, it’s very important to keep up with reading and studying. In the emergency room, you may see medical pathology you’ve only read about and will be expected to know how to diagnose and treat these diseases properly. When you have the time, use the resources you have at your disposal and look things up before presenting to your resident or an attending, and have a plan to disposition (ie, admission or discharge) already made for the patient.

Good communication is essential for a physician in any specialty, and in the ED, it is an imperative skill to have. You will be working with a large team of nurses, technicians, consulting doctors, social workers, and paramedics, just to name a few. When you see a patient, it is a good idea to speak with the nurse before you enter the room to gain a better understanding of the patient’s complaint, as well as gather any information that was relayed by EMS. By communicating the plan of care to the nurse and supporting staff, you will not only improve patient care and reduce mistakes but also forge relationships that will enrich your experience in the ED. In acute settings such as a patient code or rapidly decompensating patient, good communication with the entire team is critical. As a medical student or rotating resident, this is a great time to practice and improve your communication skills in these acute settings under the direction of residents and attendings.

Your EM rotation will be an exciting, unique experience during medical school and residency. Whether you plan to specialize in EM or not, you will learn many procedural skills, improve your own method of diagnosing and treating patients and be able to practice a different method of medical decision making.

Authors

Linda KATIRJI

University of Kentucky, Department of Emergency Medicine

Farhad AZIZ

The Ohio State University, Department of Emergency Medicine

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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, "The Importance of the Emergency Medicine Clerkship (2023)," in International Emergency Medicine Education Project, April 17, 2023, https://iem-student.org/2023/04/17/the-importance-of-the-emergency-medicine-clerkship-2023/, date accessed: September 27, 2023

2018 version of this topic – https://iem-student.org/the-importance-of-the-emergency-medicine-clerkship/

References

EMRA and CORD Student Advising Guide (https://www.emra.org/books/msadvisingguide/msag/)
EMRA Medical Student Page (https://www.emra.org/students/)
The Emergency Medicine Clerkship Primer (https://www.saem.org/docs/default-source/saem-documents/students/em-clerkship-primer_0_0.pdf)

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Emergency Medicine: A Unique Specialty (2023)

April 7, 2023May 3, 2023 ~ iEM Education Project Team ~ Leave a comment

by Anthony Rodigin

What is EM?

Emergency Medicine (EM) does not claim its own body part or a physiologic system. With Vascular Surgery or Endocrinology things are straightforward. But what do we have?

Most of our procedures are shared with other specialties. We use many of the same tools and instruments. Emergency physicians also value evidence-based practice. And like providers in other fields, we believe in disease prevention, palliation, empathy, the Hippocratic oath and the magic of human touch.

In some places, emergency medicine is confused with the mere lights and sirens of ambulances or with various types of outpost facilities providing as little as vaccinations and screenings. And even if unmistakable emergency departments (EDs) are present, it is not apparent to many ED patients that the doctors seeing them are not just any doctors from somewhere else in the hospital.

It is easy to say that emergency medicine deals with emergencies. True – we initiate life-saving interventions, commence stabilizing treatments and ultimately supervise the patient’s transition to definitive care. But who is best positioned to select out these emergencies in the first place? And in what other settings besides the ED should our skills be called upon and applied? Real essence of modern EM cannot be understood without thinking through these questions.

So once again, who are we and what is EM?

Evolution of EM

History

Both prehospital emergency care and ancestral emergency rooms predate the emergency medicine specialty itself. Out of the many wars and civilian side catastrophes came the realization that competent care was needed before and during transport to a hospital. At the same time, early emergency rooms, often small and inconveniently located in basements or on second floors, served as the natural intersection for walk-ins, ambulances and hospital wards in the early and mid-twentieth century.

The technological boom following the Second World War was in part responsible for the transition from outpatient to hospital-based medicine. More could be done and in a quicker time frame inside of a hospital, and the sickest of the sick now perhaps had a chance of survival. A natural demand for expanded and better-equipped casualty (aka accident- or emergency-) departments was created. At the same time, more patients presenting to EDs with non-traumatic complaints underscored the need to move beyond mere trauma and injury.

Still, as the earlier version of this chapter correctly stated, “Only a few decades ago, emergency departments…were staffed by physicians with a variety of training backgrounds. The vast majority of these physicians had little to no emergency medicine training at all. General surgeons, family physicians, neurologists, and even psychiatrists were among those that staffed emergency departments…throughout the world” [1].

In the 1960s and 1970s things began to change rapidly. As ambulance care and destination decisions improved, in some nations relying on physicians and in others on newly established paramedics, so did the understanding that a dedicated provider specializing in ED services was invaluable. In the United States, pioneer physicians who chose to work exclusively at EDs provided additional advantages to the lifestyles and efficiency of specialists. Freeing up the latter to concentrate on more complex specialty-driven tasks led to their higher reimbursements. Thus, both the absence of competing emergency care physicians in the prehospital domain and economic incentives created by EM for narrow specialties pushed EM development in the US somewhat ahead of other parts of the world. The vast and ubiquitous benefits of EM to the general public were to follow.

From the 1970s and on rapid growth of EM residencies took place, together with the founding and strengthening of EM national boards and EM national and international societies. Brian Zink’s famous “Anyone, Anything, Anytime” comprehensively describes the history of modern EM in the United States [2]. Another excellent resource is this documentary from the Emergency Medicine Residents’ Association (EMRA). Such a trajectory was closely matched by EM’s path in the United Kingdom, Canada, Australia and other culturally Western nations, steadily but surely spreading throughout most of the world.

With every decade that followed, the number of countries developing EM increased exponentially. Arguably, each nation’s own EM chronicles are best regarded and studied in tandem with texts like Ryan Corbett Bell’s “The Ambulance”, which ought to describe the contemporaneous evolution of not only prehospital medicine but of the overall emergency care landscape in each nation as the precise background for EM’s necessity, birth and its coming of age [3].

The Future

Emergency medicine and its place within the emergency care endeavor are not going anywhere, but the scope of EM will undoubtedly change.

We can anticipate with a high degree of probability that, somewhat paradoxically to its origins, EM will continue to expand its reach beyond the emergency department. Very possibly, post-residency training via fellowships will become the norm rather than the exception. Further integration with prehospital services and sharing of EM workplaces with non-physician EM specialists (e.g. Advanced Practice Providers) will persist. Natural and technologically driven disasters will maintain high demand for EM’s unique combination of versatility and focused expertise.

The future may not bring ready solutions to all of the clinging problems. Lack of access to universally accepted standards of emergency care in rural, remote and low-income areas is one. EM’s ambivalently viewed safety net function arising from any healthcare system’s gaps and incapacities in non-EM arenas like primary care and preventative medicine is another example. In addition, proper relationship of EM with other conceptual definitions and terms such as Frontline Medicine, Emergency Medical Services (EMS), Acute Critical Care and Pediatric EM will have to be philosophically teased out further on a global scale.

Finally, an area of medicine that has matured to its most commonly used name of Global Health (GH) needs to be mentioned in this context. Current involvement of EM physicians in GH projects, while not uncommon, is not something universally anticipated. Today it still rests on enthusiasm of individual participants or institutions. The future may call for things to change drastically in the long run.

The prognoses mentioned are not exhaustive, but they should all be met with optimist and eagerness. It is beyond any doubt that unprecedented opportunities await future EM trainees not only through engagement in primary clinical work and research in the ED, but also in domains ranging from local policy making to transnational epidemiology, and vice versa.

The Present

Today it can be surmised with justification and pride that the battle for EM’s existence, its independence and its own standards matching or surpassing those of more traditional medical specialties has been largely won.

Distinctive and concrete advantages of EM include flexibility in work schedules and lifestyles and the balance of individual expertise with teamwork. Further, EM offers multiple areas for gaining additional proficiency – ranging from bedside ultrasound to basic research and from business practices to international health. Last but not least, EM features an unparalleled interconnected global community of people just like you. If in doubt, you should strive to attend an EM International Congress (ICEM) or a regional EM conference in your area. See for yourself!

Of course, visible and hidden currents remain in motion, bringing in tides of new trials. Efforts toward fair employment practices, workplace safety, non-malevolent legal climate, job security and sustainability, EM’s influence on healthcare policies – these are only a few of today’s pressing themes. Still, such challenges are neither unprecedented nor unique to EM, and are not anything to be afraid of for future EM clinicians.

Above all else, one should know that EM is an exciting, versatile and dynamic specialty to consider as one’s top choice for a career in medicine.

Why EM?

Who are EM docs?

Our field is not without its stereotypes. A common one is that all EM physicians are adrenaline junkies and type A immediate gratification personalities. When we are not intubating in the ED, we are skydiving or playing extreme sports. In truth, there are as many characters, hobbies and interests in EM as there are in the world at large. The passion in EM that we all share is to be found it its mission. We believe in equal opportunities to receive competent emergency care world-wide and in EM’s unique approach to the undifferentiated patient.

What sets EM physicians apart?

In the next two chapters, you will discover more words of wisdom and advice about why EM is a great choice for a specialty, and how EM physicians think differently from other providers. Here, we will come back to the two questions mentioned at the beginning of this chapter.

The first had to do with the selection of those patients who truly do have urgent, emergent and even life-threatening conditions. Of course, some selection is self-selection, as it happens at the patient’s own home or wherever they happened to be. At other times, primary care, walk-in or ambulance services may be involved and may even play a great part. All countries differ in how the tiers of access to emergency services are designed and staggered. Interestingly and controversially, the ethics of what and to what extent an emergency care system is allowed to miss also varies by locale depending in part on culture, in part on the level of public education and in part on historical precedent shaping expectations.

In general, however, EM does not rely on or trust other types of medical providers to do this selection for us. Our specialty was designed specifically to work with the population at large presenting with all health concerns, worries or issues. These truly can be anything coming from anyone at any time. Thus, at least a third of our jobs is to figure out who truly is at risk no matter what the actual diagnosis. This task relies on a completely different set of skills than dealing with someone you already know is critical. Afterwards, we have to perform the next crucial step and stabilize our sick patients. Like bread and butter, it is hard to imagine our field without both of these essential components of practice intertwined together. Of course, in reality, we do much more than caring only for the very ill, which is the last third. From bedside psychology and social advocacy to primary pediatrics, second opinions and after-hours dermatology – we do it all.

The other question was about applying ourselves beyond the ED. EM skills are not only for the hospital. Over the last few decades, it has become obvious that EM physicians function superbly in multiple other settings, from ground and helicopter EMS (including direction and planning) to disaster relief and event medicine. EM physicians make excellent wilderness docs, public and organizational consultants, surgical assistants on GH medical missions (sometimes functioning as the only “anesthesiologist”), proceduralists, tactical support physicians, academic researchers, critical care and ICU providers and much more. All of these cojoined fields provide and will continue to provide ample opportunities for worldwide EM practice for generations of EM aficionados to come.

So, would you like to join in on the fun?

Author

Anthony RODIGIN

Anthony has practiced clinical EM in the San Francisco Bay Area since 2010 and has lived in California for nearly thirty years. A fourth-generation doc, he was awed as a kid by his great-grandmother’s ambulance stories spanning decades. EM’s versatility has been a personality match from the get-go.

Since residency, choices for EM projects have been guided mainly by fun and intellectual curiosity, trying to mimic a childhood hero Sherlock Holmes. Anthony does not play a horrible violin, but rather a lousy synth keyboard. He has been passionate about education since a university TA and has comparatively studied nations’ emergency care systems for twenty years instead of sleeping. He continues to work at a busy community ED, volunteers as an EMS medical advisor for the US National Park Service, and has experience with telemedicine, urgent care, academic shifts and admin leadership. He is also a couch househusband with a spouse, two kids and a real scaredy cat.

Listen to the chapter

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, "Emergency Medicine: A Unique Specialty (2023)," in International Emergency Medicine Education Project, April 7, 2023, https://iem-student.org/2023/04/07/emergency-medicine-a-unique-specialty-2023/, date accessed: September 27, 2023

2018 version of this topic – https://iem-student.org/emergency-medicine-a-unique-specialty/

References

Sanderson W., Cuevas D. and Rogers R. “Emergency Medicine: A Unique Specialty”. iEmergency Medicine for Medical Students and Interns. 1^st edition, Version 1, 2018.
Zink, Brian J. “Anyone, Anything, Anytime: A History of Emergency Medicine”, 2nd Edition Hardcover – January 1, 2018
Bell, Ryan Corbett. “The Ambulance: A History”. Reprint edition, McFarland & Company, Inc., 2009

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Why is emergency medicine training important in medical schools?

February 24, 2023February 22, 2023 ~ iEM Education Project Team ~ Leave a comment

The ability to promptly and accurately diagnose and treat patients in critical condition is a crucial skill that students learn in emergency medicine programs. This exposure is especially important for doctors who practice in fast-paced environments like emergency rooms, urgent care clinics, and hospitals immediately after their graduation in some countries.

The ability to promptly recognize and stabilize critically sick patients is a key skill that is taught to prospective doctors as part of emergency medical training. This entails not only the ability to see the warning indications of illnesses like heart attacks, strokes, and septic shock, but also to initiate life-saving treatments like cardiopulmonary resuscitation (CPR) and the administration of antibiotics.

Medical students can learn to function well under pressure by participating in emergency medicine rotations. It’s very common for emergency departments to be noisy and hectic due to the high volume of people who are there for immediate attention. So, in order to offer the best treatment for their patients in situations where time and resources are limited, and many distractors in the environment, all doctors need to be able to think fast and make choices on the fly.

Learning to work with other medical professionals is also a crucial part of emergency medicine education. Patients in emergency departments are usually cared for by a multidisciplinary group consisting of doctors, nurses, and other medical experts. Medical students learn how to interact and coordinate with these other clinicians as part of their emergency medicine training.

In addition, emergency medicine education is crucial because it prepares future doctors to treat patients with a wide variety of acute and chronic disorders. Every doctor should be able to treat patients of different ages, ethnicities, and economic statuses, and they should do so in a way that is respectful of their cultural origins. Therefore, emergency departments create great opportunities with its unique learning environment for medical students.

Last but not least, emergency medicine education is critical since it helps students get a feel for the field. Physicians who have completed emergency medicine training are better equipped to deal with the high-stakes, high-stress scenarios they will experience in practice, as emergency medicine is one of the most rigorous and demanding specialties in medicine. All medical students, including those who want to specialize elsewhere, should acquire emergency medicine skills, familiarize themselves with how the emergency health care system operates, and be prepared to work in this field if necessary.

IFEM, or the International Federation for Emergency Medicine (ifem.cc), is an organization that supports the advancement of emergency medicine globally. One way that IFEM supports emergency medicine training in medical schools is by providing resources and guidelines for curriculum development. IFEM has created a set of guidelines for emergency medicine training, which can serve as a framework for medical schools to develop their own curricula. Additionally, IFEM offers training opportunities and conferences for medical educators to learn from each other and share best practices.

To improve emergency medicine training in their own countries, other nations can look to IFEM’s guidelines as a starting point for developing their own curricula. They can also seek out partnerships with IFEM and other organizations, to share knowledge and resources. Providing opportunities for medical students to gain hands-on experience in emergency medicine, such as through clinical rotations or simulation training, can definitely be effective in preparing them for the challenges they may face in the future clinical practice. Finally, investing in the development of emergency medicine residency programs can help to ensure that there is a pipeline of well-trained emergency physicians to serve the needs of the community.

In conclusion, emergency medicine training is a crucial part of a medical education because it prepares students for the realities of practice by teaching them how to quickly and accurately assess and treat critically ill patients, how to work effectively in high-stress environments, how to collaborate with other healthcare providers, how to care for patients from a wide variety of backgrounds and with a wide variety of medical conditions. Without this exposure, medical students would be less equipped to deal with complicated and challenging circumstances in clinical practice. Therefore, we highly recommend medical schools consider opening emergency medicine rotations or increasing the time of exposure to emergency medicine education.

Key recommendations for medical students interested in pursuing a career in emergency medicine

February 15, 2023February 16, 2023 ~ iEM Education Project Team ~ Leave a comment

Emergency Medicine is a popular speciality among students, and residency programs are receiving an increased amount of applications year by year. However, high competition to get into the residency programs requires successful preparation for the speciality training. In addition, choosing this speciality as a future professional career may fit some individuals while it can not be suitable for others.

Here are some recommendations to be prepared and understand whether emergency medicine is a good fit for you.

Get involved in emergency medicine early: Try to find ways to get involved during medical school, such as volunteering at an emergency department or shadowing an emergency medicine physician. This will give you a better understanding of the field and help you determine if it is a good fit for you.
Seek out opportunities to develop clinical skills: Emergency medicine is a highly clinical field, and you will need to be comfortable managing patients with a wide range of medical conditions. Participating in clinical rotations and other hands-on learning experiences can help you build your clinical skills and prepare you for a career in emergency medicine.
Network with emergency medicine professionals: Building relationships with emergency medicine physicians and other healthcare professionals can help you learn about different career paths in the field and gain valuable insight into the daily challenges and rewards of working in emergency medicine.
Stay up-to-date on the latest developments: Emergency medicine is a rapidly evolving field, and it is important to stay informed about the latest developments in patient care and medical technology. Attending conferences and workshops, reading professional journals, and participating in online communities can help you stay current.
Consider a residency program: Many emergency medicine physicians complete a residency program in the field, which provides in-depth training and hands-on experience in emergency medicine. Consider applying to a residency program if you are serious about pursuing a career in emergency medicine.
Focus on developing your interpersonal skills: Effective communication and interpersonal skills are essential for success in emergency medicine, as you will be working with patients, families, and other healthcare professionals in high-pressure situations. Make an effort to develop your interpersonal skills, and seek feedback from others on how you can improve.
Stay passionate: Emergency medicine can be challenging, but it can also be incredibly rewarding. Make sure to stay passionate about your chosen field and continue to seek out opportunities for growth and learning.

Emergency medicine is a challenging but rewarding field that requires a strong foundation in clinical skills, a commitment to staying current with the latest developments, and excellent interpersonal skills. If you are passionate about helping patients in high-pressure situations and are willing to work hard to develop your skills, a career in emergency medicine may be a great fit for you.

Why do medical students favour emergency medicine experience?

February 8, 2023February 16, 2023 ~ iEM Education Project Team ~ Leave a comment

Emergency Medicine is a challenging and fast-paced speciality that is often considered one of the most popular clerkships among medical students. The appeal of emergency medicine stems from its dynamic nature, which requires medical students to be versatile, adaptable and able to make quick decisions.

One of the primary reasons that medical students like emergency medicine is the opportunity to learn the care for a wide range of patients. In the emergency department, medical students are exposed to a diverse patient population that includes individuals with acute illnesses and injuries, as well as those with chronic conditions that have taken a turn for the worse. This exposure to a wide range of patients allows medical students to develop a broad knowledge base and gain a deeper understanding of the complexities of medical care.

Another factor that attracts medical students to emergency medicine is the fast-paced environment. The emergency department is often the first point of contact for patients experiencing an acute illness or injury, and medical students must be able to assess, diagnose, and treat patients quickly. In addition, this challenging and fast-paced environment helps medical students to develop strong critical thinking and decision-making skills, which are essential for success in any medical speciality.

In addition to the opportunities for hands-on patient care, emergency medicine also provides medical students with the opportunity to work closely with other healthcare professionals. In the emergency department, medical students interact with nurses, paramedics, radiologists, and other specialists and learn to provide comprehensive care to patients. This interdisciplinary approach to care allows medical students to gain a deeper understanding of the role of each healthcare professional and to develop strong collaborative skills.

Emergency medicine is also a highly rewarding speciality for medical students, as it provides the opportunity to make a significant impact on a patient’s health in a short amount of time. Whether being in a team stabilizing a critically ill patient, providing pain relief, or simply offering emotional support, medical students in the emergency department have the opportunity to make a real difference in the lives of patients.

Finally, the training and education opportunities available in emergency medicine are another reason why medical students often favour this clerkship. Emergency medicine residency programs, with a robust training structure, are designed to provide medical students with extensive exposure to the most challenging cases and to provide a strong foundation in critical thinking and decision-making skills. Additionally, emergency medicine residency programs often offer a variety of elective rotations, which allow medical students to tailor their training to their specific interests and career goals.

In conclusion, emergency medicine is a popular clerkship among medical students for many reasons. From the fast-paced and challenging environment to the opportunities for hands-on patient care and interdisciplinary collaboration to the training and education opportunities available, emergency medicine provides medical students with a well-rounded and rewarding clerkship experience. Whether they go on to specialize in emergency medicine or another medical speciality, the skills, knowledge and experience gained in the emergency department will serve medical students well throughout their careers.

Video – Panel Discussion – EM Education in Asia