Author: Amy Pound, MD, Case Western Reserve University
Editor: David A. Wald, DO, Temple University
Upon completing this module, the student will be able to:
- Understand the importance of effective communication
- Provide an organized oral presentation of a patient encounter
- Effectively call a consult
- Provide informative discharge instructions
The two best predictors of a successful team are communication skills and the ability to work with others. This is especially true for patient care in the Emergency Department (ED), where fast, efficient care is based on teamwork. Effective teams are reliant on trust, respect and collaboration. Effective communication encourages effective teamwork and promotes continuity and clarity.1
The Joint Commission on Accreditation of Healthcare Organizations has found that the biggest risks for patient safety occur as a result of the following; a lack of critical information, misinterpretation of information, unclear telephone orders, or overlooked change in patient status.2 Good communication keeps patient safe.
The Patient Encounter
Prior to entering the room, it is helpful to eliminate (or at least reduce) any distractions. You want to give your patient your full, undivided attention. Silence your cell phone, pager, etc. Interruptions negatively impact on working memory process for both you and the patient.3-5 You may miss an important detail or have to spend additional time retracing your thoughts or conversation with the patient.
When speaking with the patient, try to sit down and speak to them at their level. Remember, ask open ended questions, and allow the patient to tell their story. As a healthcare provider, you are guiding the interview process, however it is important to let the patient do most of the speaking. The common aphorism states that 80% of your diagnosis comes from the patient’s history.6 Beckman et al found that doctors interrupt their patients after only 18 seconds.7 You will learn more from your patients if you allow them to speak uninterrupted. When gathering your information from the patient, most of the time spent will revolve around obtaining elements of your history of present illness. Remember the mnemonic, “OPQRST”. For most clinical encounters it will be necessary to investigate the following characteristics of the presentation; onset, provocative / palliative, quality, region / radiation, severity, timing and temporal relationships. Addressing these characteristics of the complaint will provide you with a wealth of information and assist in prioritizing your differential diagnosis. It may at times also be helpful to summarize the information that you obtain. This is helpful in situations where the patient has a complicated presentation. Summarizing the information allows you to confirm the time line and clarify the information that you obtained from your patient.
It will always be important to address any concerns that the patient has and before you leave the examination room, let the patient know the next steps and ask them if they have any questions.
Oral Case Presentation
Once you have interviewed your patient, you must present your findings in an organized fashion to the resident or attending. A fourth year medical student from the University of California, San Francisco stated “… no matter how much compassion and warmth I may have with patients, my superiors grade me more on how polished I am, how well-crafted my presentation is.”8 Although this may in fact be true, it should not take away from the need to develop rapport with your patient.
You presentation should be concise, things in the ED are time dependent, so aim for less than 5 minutes, often less than 2-3 minutes.. Beware of the disruptive nature of the ED, and that you may have to pause your presentation more than once before finishing. Do not allow yourself to become distracted – your team members already will be. In addition, understand that your preceptors will have different nuances regarding the style of case presentations that they are accustomed to. Some preceptors will expect a more traditional case presentation that begins with an opening statement that includes the chief complaint and pertinent past medical history. An example would be; “Dr. Jackson, I have a presentation for you; my patient is a 57 year old male with a history of hypertension and diabetes who presents today with 2 hours of epigastric abdominal pain…”. This opening statement sets the tone for the remainder of the presentation. In this brief but directed statement, you have already identified the chief complaint, the onset, the location of the complaint along with pertinent past history, all in one sentence.
An alternative approach, one that is frequently used when talking with consultants or when admitting a patient to the hospital is a variation called an assessment oriented presentation. Using this approach, you would include your assessment up front in the opening statement thereby providing key information early on in the presentation. Below are two examples of cases presentations, one using the traditional model and the other, an assessment oriented style of a patient presenting to the ED with abdominal pain.
Traditional case presentation to the consultant
Student (talking to the surgical consultant): Hi, this is student doctor Michael Severs working in the ED with Dr. Jackson, I have a consult for you. The patient is a 34 year old male; he presented to the ED a couple of hours ago with lower abdominal pain. He describes the pain as crampy. It has been constant but getting worse for the past 4-5 hours. He is nauseous but has not vomited. He has a low grade temperature of 100.7 but didn’t report having a fever….
Assessment oriented presentation to the consultant
Student (talking to the surgical consultant): Hi, this is student doctor Michael Severs working in the ED with Dr. Jackson, I have a consult for you. The patient is a 34 year old male with acute appendicitis identified by CT scan. The patient is previously healthy, he reports lower abdominal pain that started a few hours before presentation to the ED…
As you can see, with a more traditional case presentation, it might be a bit unclear initially to the consultant as to why you are calling them, the case presentation takes longer before you inform the consult as to exactly why you are consulting them. Presenting the case with an assessment oriented approach is a more straightforward way to initiate this type of communication with your consultant. Remember, you can always provide a more detailed history and physical examination to the consultant when they are in the ED examining the patient.
Remember when calling in a consult, the goal of the discussion is often different from the initial presentation to your attending in the ED. Consultations are often goal oriented with regards to some aspect of care that you require assistance with. Below are some general guidelines to consider when calling in a consult.
|Contact – Introduction of consulting and consultant physicians. Building of relationship.||– State Name
– State rank and service
– Identify supervising attending
– Identify name of consulting physician
|Communicate – Give a concise story and ask focused questions||– Present a concise story
– Present an accurate recount of information/case detail
– Speaks clearly
|Core Question – Have a specific question or request of the consultant. Decide on reasonable time frame for consultation||– Specifies need for consultation
– Specifies time frame for consultation
|Collaboration – A result of the discussion between the ED physician and the consultant, including any alteration of management or testing||– Is open to an incorporates consultant’s recommendation|
|Closing the Loop – Ensure that both parties are on the same page regarding plan and maintain proper communication about any changes in the patient’s status||– Reviews and repeats patient care plan
– Thanks consultant for consultation
Remember when talking to your consultant over the phone, speak clearly and slowly, especially if you have woken the consultant from sleep. Introduce yourself as a medical student and name your supervising attending. It is also important to confirm the consultants name and service to verify that you have reached the right individual.9-11
Patient Follow Up
After the initial evaluation, if your patient is undergoing further diagnostic testing (lab studies or diagnostic imaging), it is not uncommon for a patient to be in the ED for hours on end. It is important that you continue to periodically follow up and reevaluate your patient. These simple acts help to further the rapport that you have with your patient. Following your patients closely is also important as you determine their response to therapy; the patient with an exacerbation of asthma receiving a nebulizer treatment, a patient with nausea and vomiting receiving an antiemetic, etc. At times reevaluation may be as simple as just asking your patient if they are feeling better, or if there is anything that you can get for them. Sometimes a sandwich or a warm blanket can go a long way. Remember that your patients want to be informed about their condition, plans for treatment and any delays during their encounter in the ED. Do not hesitate to say “I don’t know, but I can find out” if a patient asks difficult question. Remember to report your findings regarding the follow up of your patient back to your supervisor.
Patients should be provided with both written and verbal discharge instructions. It will be important to clarify these with your supervisor before discussing aspects of follow-up and further outpatient care with your patient. With the increase use of electronic medical records, detailed discharge instructions can easily be provided to patient regarding a number of medical conditions. It is important that when discharging the patient from the ED, that a few things are addressed with your patient. What is the preliminary diagnosis? As simple as this seems to be, many patients seen in the will not be definitively diagnosed with a specific condition. Often our role as emergency physicians is to exclude life or limb threatening conditions. A classic example is the chief complaint of abdominal pain where by many young and otherwise healthy patients may be discharged from the ED without a definitive cause of the presenting complaint. It is ok to explain this to the patient. In addition, it is important to discuss with the patients what the next steps should be; when they should follow up with their primary care physician and when they should return to the ED. If the patient had diagnostic tests performed in the ED, it will be important to discuss the test results with them and in some cases, a copy of the test results should be provided if it will be helpful for their primary physician to receive the results in a timely fashion.
Also remember when talking with your patient about follow up plans, test results, etc. consider the patient’s capacity to understand health related information. This will be based a number of factors including; years of formal education, age and culture of the patient along with you as a healthcare provider relays the information to the patient.
Remember to provide discharge instructions at the 6th grade reading level. 50% of the US population has a low health literacy.12 If the patient has any language barriers, use an interpreter if necessary to promote clear understanding.
Verify that the patient understood the instructions by having them repeat back in their own words. Allow the patient to ask any questions at this time.13
Pearls and Pitfalls and Pitfalls
- Use open-ended questions and allow the patient to provide the initial history without interruption.
- Assume every patient has a life or limb threatening illness and include pertinent positives/negatives in your presentation to support or rule out these diagnoses.
- Follow up on your patients and report back to the team.
- Be a patient advocate.
- Have a specific question or request when calling a consult.
- Written discharge instructions should be at the 6th grade reading level to ensure improved understanding.
- Hughes RG, editor. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. PMID: 21328739
- Joint Commission on Accreditation of Healthcare Organizations.The Joint Commission guide to improving staff communication. Oakbrook Terrace, IL: Joint Commission Resources; 2005
- Coiera, W., Jayasuriya, R., Hardy, J., Bannan, A., Thorpe, M., Communication loads on clinical staff in the emergency department. Medical Journal of Australia, 2002. 176(9):415-418. PMID: 12056992
- Spencer R, Logan P, Coiera E. Supporting Communication in the Emergency Department.. 2002 by the Centre for Health Informatics, University of New South Wales, SYDNEY NSW 2052. Printed and bound by the University of New South Wales. Kreps, L., Organizational Communication. Second ed. 1990, New York:Longman.
- Reason, J., Human Error. 1990, New York: Cambridge University Press.
- Hampton JR, Harrison MJ, Mitchell JR, et al. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. BMJ 1975;2:486–9. PMID: 1148666
- Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med. 1984 Nov;101 (5):692-6 PMID: 6486600
- Sobel RK. MSL–Medicine as a Second Language. N Engl J Med. 2005; 352:1945. PMID: 15888692
- Wald DA, editor. Des Plaines (IL): Emergency Medicine Clerkship Primer: A Manual for Medical Students; 2011
- Kessler C, Kutka BM, Badillo C. Consultation in the emergency department; a qualitative analysis and review. J Emerg Med. 2012 Jun;42(6):704-11. PMID: 21620608
- Kessler C, Tadisina K, Saks M, et al. The 5Cs of Consultation: Training Medical Students to Communicate Effectively in the Emergency Department. J Emerg Med. 2015 Nov:49(5):713-721. PMID: 26250838
- Ruddell J. Effective Patient-Physician Communication: Strengthening Relationships, Improving Patient Safety, Limiting Medical Liability. Lebanon, PA: Westcott Professional Publications, 2006.
- Graham S, Brookey J. Do Patients Understand? Perm J. 2008 Summer; 12(3):67-69. PMID: 21331214