Communication

Communication is one of the most under-appreciated aspects of medicine. We need to communicate with lots of people with different knowledge and backgrounds. It’s easier said than done.

With healthcare professionals

The easiest way to facilitate your calls is to be good to the other team members. I strongly recommend you try your best to remember names (but I’m notoriously bad at it). Before your first call, try to figure out who the following are:

• Unit clerk — they usually know pretty much anything paper-related and they know whom to call to get things done.
• Head nurse — I can’t even begin to describe why you should get along with the head nurse.
• Nurses — Who’s going to help you when the pump starts beeping? When you need that stat IV? When you’re bored and you want to talk to someone who has a life outside the hospital? Pro tip: nurses often have potlucks, and if you’re pleasant enough, you may be able to jump in!
• Respiratory therapist (RT) — When your patient is gasping for air you’ll enjoy their presence tremendously.
• Housekeeping staff — granted, you rarely have to deal directly with the housekeeping staff, but be extra nice to them. Without them, you can’t do your job.
• Pharmacy — I rarely had to deal with the on call pharmacist in person (they tend to be hidden in their pharmacy). I recommend you try to figure out what kind of pharmacy service your hospital provides after hours.
• OT / PT — In my part of the world, they have normal working hours, so I didn’t see them at all at night.

It’s not magic. Being nice to people around you, even if you’re tired and freaking out inside, will reward you time and time again. The saying “what goes around comes around” is extremely true in a hospital setting.

With your colleagues residents and fellows

For a consult

When asking for a consult, ALWAYS make sure you know the basics about the patient’s situation. On call, especially if you’re cross covering, you won’t have time to go through a patient’s entire chart, but at least know a minimum amount of information:

• age
• gender
• major co-morbidities
• reason for admission & how long they’ve been in hospital
• overview of the problem - at least enough to be able to justify why you couldn’t deal with the problem yourself and you need the consultant’s help.

Ultimately, know why you’re calling — funny, but as you get more senior, you’ll get calls that go like this:

–ID? yeah, can you come and see this patient? He has an abscess.
–Ok… How old is the patient?

And then you hear pages flipping…

–hum… 40ish?
–ok; what was he admitted for?
-Well, I don’t really know the patient… I was asked by my senior to call you for his abscess…

You do not want to be that person.

With an attending physician

Communication with an attending physician should be the same as with any other resident. The enthusiasm in answering questions, especially after hours, can be quite different, so residents needs to be ready and prepared for the eventuality of dealing with a grumpy person. I recommend making extra sure that the call is warranted and that you cannot get an answer to your question any other way.

Let’s face it. Contacting an attending physician, a fellow or even a senior resident can be intimidating. However, when you actually need help, it’s important to be able to put that anxiety to one side and put the well-being of your patient first. Just take a deep breath and dial the number!

Handoff (handover)

The most important aspect of communicating with fellow residents and medical students is the handoff (or handover - depending on where you are in the world). A good handoff is an art form. Not too long, not too short. You need to be able to summarize the patient’s issues in a few words. A proper handoff shows respect for your colleagues and, of course, for your patients. Unfortunately, this is often not taught well in medical school and, since it has been associated with surgical errors and malpractice claims, I believe it is an important skill worth developing.

It’s common courtesy for the team leader of the group to contact the resident on call with a well organized handover, ideally they would meet in person to “run the list”.

Despite much research on the topic, there remains much controversy on what is a “good” and “safe” handoff. Using the mnemonic (and we all love mnemonics, don’t we?) SBAR has been recommended.

• Situation
• Background
• Assessment
• Recommendation

However, I found it relatively vague. I personally prefer this version:

• Background clinical information (“He’s a 56 y.o. diabetic with known CAD…”). Add necessary psychosocial information as well. (“He doesn’t want you to discuss his care if family members are around…”)
• Course of the acute illness (“He’s been admitted for renal failure, acute on chronic. His creat has been trending down but still in the 300 range.”)
• Uncertainty (“He was slightly hypertensive last night but his diuretics were held because of his renal failure. However, he rarely sees doctors, so he may have undiagnosed essential hypertension.”)
• Anticipation of events (“If his PB is high again tonight, make sure he’s received his first dose of metoprolol. It it’s still high, consider a nitro patch; he’d been on it in the past.”)

I recommend trying your best to transfer the information Twitter style (i.e. 140 characters or less). This forces you be more efficient and choose your words carefully. At the end of the list, you and the other resident will be glad you did.

Ideally, the same process should take place the next morning. From experience, I have been less consistent, but I tried to do it. Even if I wrote nice notes during the night, I believe every little bit of information helps to make the flow of information as smooth as possible.

References

1. Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. 2003;133:614–621. doi: 10.1067/msy.2003.169. PubMed
2. Gandhi TK, Kachalia A, Thomas EJ, Puopolo AL, Yoon C, Brennan TA, Studdert DM. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med. 2006;145:488–496. PubMed
3. Michael D Cohen, Brian Hilligoss, André Carlos Kajdacsy-Balla Amaral. A handoff is not a telegram: an understanding of the patient is co-constructed. Crit Care. 2012; 16(1): 303. Link