Teaching and Evaluating Communication in EM

Often, how well we communicate with our teams, our patients and their families, and our consultants (and how well they reciprocate) can determine whether we go home feeling good about our day - not to mention the important relationship between communication and patient outcomes. The same is true of our learners; helping them develop great communication skills and habits now will pay dividends over their careers both in terms of patient care impact and career satisfaction.

Here we offer three contexts for teaching, evaluating, and reinforcing communication skills.

Sign-out

Situation

- Sign-out disposition 

- Pending evaluations

- Illness severity

- Problem/chief complaint

Recommendations

- Next steps

- Pending studies, procedures

- Re-evaluations needed

- Conditional plans

Background

- Relevant PMH

- Relevant HPI

- Relevant exam

Assessment

- Working diagnosis/differential

- Workup & results

- Vital signs

- ED course

We use the SBAR framework as a guide for communicating hand-off information; while it’s by no means perfect, it’s the most validated tool we have and comes recommended by the Joint Commission as an effective method for reducing the most common source of error leading to patient mortality.  

Before your shift

Remind oncoming residents of sign-out best practices:

 - limit interruptions

 - use a structured framework

 - read-back or closed-loop communication

Taking sign-out

Note whether residents acquired necessary information for each patient. Allow the resident receiving sign-out to ask clarifying questions before you step in.

After sign-out

Spend a couple minutes debriefing the sign-out. Did the resident acquire all of the necessary information? Ensure vital signs were communicated? Demonstrate closed loop communication of the plan and follow-up tasks? Are there behaviors the off-going team used that should or shouldn’t be adopted at the end of the shift?

Before sign-out

Review expectations of organization and critical information for sign-out, including the SBAR framework. 

Giving sign-out

It’s tempting to take over, but let the residents give and take their own sign-outs. If they miss crucial information, you should interject. Note whether you had to include other critical information, the oncoming team had confusion, the SBAR framework was used, vitals were included, and closed loop communication was utilized. 

After sign-out

Time for reflection and feedback. Was all of the necessary information communicated in a concise way? What worked well? What was challenging? What would you recommend doing differently in the future? 

Communication with Consultants 

Communication with consulting services can be a major source of frustration for EM trainees. The SBAR format still works here, but there are some best practices that we need to add to our paradigm: The 5C’s of Communicating with Consultants lay out the essential components of these conversations. 

Contact:

Communicate:

Core Question:

Collaborate:

Close the Loop:

Who’s placing the consult (Name, Rank, Team)
Who’s being consulted (Name, Rank, Team)

State essential, accurate components of clinical situation

Provide a specific question or request of consultant
Agree on a reasonable timeframe for consultation

Be open to recommendations or changes in plan
Advocate for the patient if needed

Confirm recommendations or agreed upon timeframe

Thank the consultant

How you approach teaching and giving feedback on these conversations will obviously depend a lot on the learner. Junior learners such as interns and medical students may need to practice how the conversations will go before the consult order is placed. On the other hand, simply listening to the senior resident as she’s on the phone may be sufficient. 
 
As you’re listening to and following consultation calls, identify whether or not residents adhered to best practices. Did they introduce themselves and identify the person they were speaking with? Was essential information omitted? Was the question or request clear? Do you have recommendations for navigating challenging consultations? 
 
As you know, the ability to consult appropriately and efficiently is a life skill for emergency medicine. Your feedback and coaching helps our trainees develop good habits that lead to positive interactions with our colleagues on other services. 

Communication with Patients & Families

We conclude our focus on communication skills with a discussion about communication with patients and their families. In terms of assessing and providing feedback on this skillset, you have two major strategies to choose from, each with its own set of strengths and weaknesses:

DIRECT OBSERVATION

The first and most obvious is direct observation, which allows you to get a first-hand look at how the learner’s interaction with the patient and his or her family went. When directly observing for communication skills, look for the following:
 

  • Nonverbal communication, both on the part of the trainee and the patient/family. Did the trainee send unintentional nonverbal cues? Did they pick up on cues from the patient and family members?

  • Introduction of any visitors and inclusion of their concerns in the conversation.

  • Setting of expectations regarding management, workup and likely outcome(s) of ED visit.

  • Utilization of de-escalation techniques as needed.

            
Direct observation is obviously associated with a Hawthorne effect; your presence will affect the conversation, potentially creating a sense of artificiality. When providing feedback, reinforce the importance of positive behaviors you observed and make suggestions for alternative ways to navigate similar conversations in the future.

INDIRECT OBSERVATION

 

The alternative to direct observation is allowing the trainee to see the patient on his or her own. This provides a greater sense of ownership and authenticity and more closely resembles the conversations the trainee is likely to have later in their career. However, it requires you to use alternative means of assessment. These can include:
 

  • Asking the resident. Were there parts of the conversation that went well? Times when they struggled? Are they able to tell you what the patient’s goal for the visit is? What expectations did they set? Did they follow up to review the results of the workup and discharge instructions?

  • Asking another staff member, such as a nurse, tech, or scribe. Their perspectives can be especially useful when debriefing difficult encounters. This can sometimes be interpreted as adversarial by trainees. One option is to have residents ask these people for perspectives or feedback once it’s clear the conversation didn’t go well. 

  • Asking the patient and family. Did they feel like they were listened to, taken seriously, and communicated with?

How well we’re able to communicate with patients, families, consultants, and each other is a major driver of satisfaction at the end of the shift. Set trainees up for success and career longevity by helping them refine this skillset.