Communication

in Emergency
Medicine
ii
COMMUNICATION
IN EMERGENCY
MEDICINE
EDITED BY

Maria E. Moreira, MD
Medical Director of Continuing Education & Simulation
Denver Health and Hospitals
Associate Professor, Department of Emergency Medicine
University of Colorado School of Medicine
Denver, CO

Andrew J. French, MD
Chief Medical Officer
St. Anthony North Health Campus
Centura Health
Westminster, CO

1
1
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This book is possible because of the support and patience of my
husband, Mark, and my three children, Nicolas, Gabriela, and
Natalia. I would like to dedicate the book to them and all the
patients, residents, faculty, and staff that have helped me develop
and grow as a physician and as a person throughout the years. This
book would not be possible without all their collective teachings.
—​Maria E. Moreira, MD

I would like to dedicate this book to my wife Joy, and to my children

Scarlett and Sawyer for always encouraging me and to the
colleagues and residents who have inspired this work.
—​Andrew J. French, MD
vi
Contents

ix Preface
xi Introduction to Communication in Emergency Medicine
xiii Contributors

Section I Emergency Medicine Communication Principles

3 1. Communication Styles
Matt Rustici
15 2. Conflict Management
Deirdre Goode and Stephen J. Wolf
27 3. Keys to Effective Communication in All Circumstances
Kirsten J. Broadfoot and Todd A. Guth

Section II Patient and Family Interactions

45 4. Patient Communication
Michael Breyer and Lee Shockley
63 5. Communication With Family
Daniel L. Handel and Stefani D. Madison
80 6. Communication With Minors in Emergency Settings
Kevin P. Carney
97 7. Communication in the Era of Telemedicine
Kevin McGarvey

Section III Communication with Providers, Staff, and Personnel

Within the Health Care System
113 8. Provider-​Nurse Communication
Anna Engeln and Hillary Giorgio Lippke
130 9. EMS Communication
Whitney Barrett and Benjamin Fisher
143 10. Communication With Hospital Administration
Christopher M. McStay
156 11. Interactions With Consultants
Taylor Burkholder and Jennie Buchanan
167 12. Communication in Medical Resuscitation and the
Post-​Code Debrief
Sarah M. Perman
180 13. The Art of Communication in Meetings
Melanie Jones
 199 14. Feedback and Communication With Learners in an Emergency
Contents viii
Department
Bonnie Kaplan
209 15. Electronic Health Records
Michael S. Victoroff

Section IV Communication Outside of the Health Care System

259 16. Media Communication
Christopher B. Colwell
268 17. Email and Social Media
Zach Jarou, Matt Zuckerman, and Todd Taylor
294 Communication Scenarios
Maria E. Moreira and Andrew J. French

303 Resources
305 Index
Preface

In a world where outstanding technical skill and left-​brain thinking have become
the norm, the ability to effectively communicate has become not only an absolute
necessity but also a true differentiator among the highest performers and most suc-
cessful individuals. Arguably, there is no other environment in which clear and ef-
fective communication is as necessary or tested more often than in the emergency
department. Similarly, there are few professions or medical specialties wherein the
performance of a team depends so highly on the “how,” “when,” “what,” and “why”
of communication.
As emergency physicians and leaders in academia and administration, we aim
to highlight the many challenges and barriers to communication in one of the
fastest-​paced, highest-​stakes settings of any profession and provide approaches and
solutions to these scenarios that may be extended into many other professions in-
cluding outside of the medical field. In any given day, an emergency care provider
may interact with patients and other care providers of various ages, backgrounds,
and education. They may have to communicate with everyone from hospital ad-
ministration to members of the media, and navigate the nuances of communicating
in person, by phone, or electronically. By emphasizing the complexities and pitfalls
of communication in a multifaceted and at times emotional environment, we hope
that readers can apply the lessons learned to nearly any situation they may encounter
inside or outside the field of medicine.
x
Introduction to
Communication in
Emergency Medicine

Maria E. Moreira and Andrew J. French

George Bernard Shaw said, “The single biggest problem in communication is the il-
lusion that it has taken place.” Perhaps the reason is that we assume communication
is something simple. However, communication is more than the simple transfer of
information. There are multiple other external influences and distractions that can
greatly inhibit communication from creating a shared understanding.
Although various models of communication have been developed to illustrate
the communication process, many fail to include external contributors.1–​3 Such a
model would be too complex to illustrate. It would need to include all the factors
that can contribute to the interpretation of the message being delivered as well as
how the message is delivered. Those factors, at a minimum, include such things as
cultural background, education, emotional state, and previous experiences of all the
participants involved in the communication exchange. We need communication in
medicine to lead to a shared understanding and to develop relationships if we want
to create change.4
The emergency department (ED) environment provides a great opportunity for
multiple communication encounters, all with their own pitfalls and complications.
According to Chisholm et al., ED providers have greater than 30 interactions per
hour,5 providing many opportunities to test communication skills. In this environ-
ment, physicians have to be adept at communicating with varied parties including
patients, families, consultants, nurses, prehospital personnel, hospital administra-
tion, and the media. Additionally, with the growth of technology, physicians need
to have an understanding of how to communicate in the era of telemedicine, social
media, and the electronic health record.
Why is effective communication so crucial in the emergency medicine environ-
ment? It has been shown that communication failures are a leading cause of errors
resulting in patient harm,6–​8 which can have implications for both the patient and
the provider. Thus, providers should work just as hard at honing communication
skills as they do at honing procedural skills. For patients, effective communication
 can lead to improved compliance with treatment9 and better health outcomes.10,11
Introduction to Communication in Emergency Medicine xii
For physicians, it improves clinical effectiveness and job satisfaction.12 Given
these implications, the Accreditation Council for Graduate Medical Education
(ACGME) considers “Interpersonal and Communication Skills” a core compe-
tency in emergency medicine.13
That is why this book is so important. In this book, we explore the general prin-
ciples of communication and their application to emergency medicine. We have
dedicated chapters for communication with various groups that interact with emer-
gency medicine. In each case, we describe effective communication and potential
pitfalls when communicating with each group. Although this book is written from
the standpoint of communication in the emergency department, it is intended to
serve as a reference to all health care providers regardless of specialty or discipline.
Our goal is to provide readers with the tools to communicate effectively and create
shared understanding.

REFERENCES
1. Gavi Z. The Models of Communication. The Communication Process, 19 August 2013,
http://​www.thecommunicationprocess.com.
2. “Communication models.” Simplynotes, 17 Aug 2017, http://​www.simplinotes.com.
3. Simonds SK. Communication theory and the search for effective feedback. J Hum
Hypertens. 1995;9(1):5–​10.
4. Manojlovich M, Squires JE, Davies B, Graham ID. Hiding in plain sight:
communication theory in implementation science. Implement Sci. 2015;10:58.
5. Chisholm CD, Weaver CS, Whenmouth L, Giles B. A task analysis of emergency
physician activities in academic and community settings. Ann Emerg Med.
2011;58:117–​122.
6. Joint Commission on Accreditation of Healthcare Organizations ( JCAHO). Root
cause of adverse events. http://​www.jointcommission.org.
7. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of
effective teamwork and communication in providing safe care. Qual Saf Health Care.
2004;13(Suppl 1):i85–​i90.
8. Patterson ES, Cook RI, Woods DD, et al. Examining the complexity behind a
medication error: generic patterns in communication. IEEE Trans Syst Man Cybern A
Syst Hum. 2004;34:749–​756.
9. Wagner PJ, Lentz L, Heslop SD. Teaching communication skills: a skills-​based
approach. Acad Med. 2002;77:1164.
10. Roter DL, Hall JA. How medical interaction shapes and reflects the physician-​
patient relationship. In: Thompson TL, Parrott R, Nussbaum JF, eds. The Routledge
Handbook of Health Communication. New York, NY: Routledge; 2011:55–​68.
11. Stewart M, Meredith L, Brown J, et al. The influence of older-​patient-​physician
communication on health and health-​related outcomes. Clin Geriatr Med.
2000;16:25–​36.
12. Flin R, Fletcher G, Mcgeorge P, et al. Anaesthetists’ attitudes to teamwork and safety.
Anaesthesia. 2003;58(3):233–​242.
13. “ACGME Program Requirements for Graduate Medical Education in
Emergency Medicine.” ACGME, 1 July 2017, https://​www.acgme.org/​
Portals/​0/​PFAssets/​ProgramRequirements/​110_​emergency_​medicine_​
2017-​07-​01.pdf?ver=2017-​05-​25-​084936-​193
xii

Contributors

Whitney Barrett, MD Kevin P. Carney, MD

Associate Medical Director, Denver Medical Director, Emergency
Health Paramedic Division Department, Children’s Hospital
Assistant Professor, University of Colorado, Aurora, CO
Colorado School of Medicine Assistant Professor of Pediatrics,
Denver, CO Section of Emergency Medicine,
Department of Pediatrics, University
Michael Breyer, MD
of Colorado Denver School of
Director of the Adult Urgent Care
Medicine, Aurora, CO
Clinic and Staff Emergency
Physician, Denver Health & Hospital Christopher B. Colwell, MD
Authority Chief of Emergency Medicine,
Associate Professor of Emergency Zuckerberg San Francisco General
Medicine, University of Colorado Hospital and Trauma Center
School of Medicine Professor and Vice Chair, Department
Denver, CO of Emergency Medicine, UCSF
School of Medicine
Kirsten J. Broadfoot, PhD
San Francisco, CA
Associate Professor, Department
of Family Medicine, University Anna Engeln, MD
of Colorado School of Medicine, Emergency Physician, Denver Health
Anschutz Medical Campus & Hospital Authority
Aurora, CO Denver, CO
Jennie Buchanan, MD Benjamin Fisher, MPA, NRP
Denver Health & Hospital Authority, Arizona Department of Health Services,
Rocky Mountain Poison & Drug Bureau of EMS and Trauma Systems
Center, Denver, CO Phoenix, AZ
Associate Professor,
Andrew J. French, MD
University of Colorado
Chief Medical Officer,
Department of Emergency
St. Anthony North Health Campus,
Medicine, Aurora, CO
Centura Health
Taylor Burkholder, MD, MPH Westminster, Colorado
Assistant Professor of Clinical
Deirdre Goode, MD, MBA
Emergency Medicine,
Resident Physician, Department of
Keck School of Medicine,
Emergency Medicine, University of
University of Southern California,
Chicago Medicine
Los Angeles, CA
Chicago, IL
 Todd A. Guth, MD Kevin McGarvey, MD, MBA, FACEP
Contributors xiv
Assistant Professor, Department of Emergency Physician, CEO, and
Emergency Medicine, University Co-​Founder of Hippo Health,
of Colorado School of Medicine, Boulder, CO
Anschutz Medical Campus
Christopher M. McStay, MD, FACEP
Aurora, CO
Chief of Clinical Operations,
Daniel L. Handel, MD, Associate Professor, Department of
FABFM, ABHPM Emergency Medicine, University
Chief, Division of Palliative Medicine, of Colorado School of Medicine,
Denver Health & Hospital Authority Aurora, CO
Professor, University of Colorado
Maria E. Moreira, MD, FACEP
School of Medicine, Denver, CO
Medical Director of Continuing
Zach Jarou, MD Education & Simulation,
President, Emergency Medicine Denver Health and Hospital
Residents’ Association Authority
Fellow in Administration, Quality, Associate Professor, Department
Informatics, and Policy, American of Emergency Medicine,
College of Emergency Physicians University of Colorado
Clinical Associate, Section of School of Medicine
Emergency Medicine, Department Denver, CO
of Medicine, University of Chicago,
Sarah M. Perman, MD, MSCE
Chicago, IL
Assistant Professor of Emergency
Melanie Jones, RN, BSN Medicine, University of Colorado
President, Front Door Consultants School of Medicine
Gulf Breeze, Florida Aurora, CO
Bonnie Kaplan, MD, MA Matt Rustici, MD
Assistant Professor of Emergency Assistant Professor of Pediatrics,
Medicine, University of Colorado University of Colorado, School of
Hospital Medicine, Denver Health & Hospital
Program Director, Emergency Authority, Pediatric Emergency
Medicine Residency, Denver Health Department, Denver, CO
& Hospital Authority
Lee Shockley, MD, MBA
Denver, CO
Emergency Physician, Denver Health
Hillary Giorgio Lippke, RN, & Hospital Authority
BSN, CEN Professor of Emergency Medicine,
The Denver Hospice University of Colorado School of
Denver, CO Medicine
Denver, CO
Stefani D. Madison, MD,
ABFM, ABHPM Todd Taylor, MD
Assistant Professor, University of Assistant Professor of Emergency
Oklahoma Medicine, Assistant Residency
Director of Palliative Medicine, Director, Department of Emergency
Stephenson Cancer Center, Medicine, Emory University,
Oklahoma City, OK Atlanta, GA
xv

Michael S. Victoroff, MD, FAAFP, CI Matt Zuckerman, MD

xv
Clinical Professor, Family Medicine, Assistant Professor of Emergency

Contributors
University of Colorado School of Medicine and Medical Toxicology,
Medicine, Aurora, CO Department of Emergency Medicine,
University of Colorado School of
Stephen J. Wolf, MD
Medicine, Aurora, CO
Professor and Director of Service of
Emergency Medicine, Denver Health
& Hospital Authority, Denver, CO
xvi
1

SECTION I   
EMERGENCY
MEDICINE
COMMUNICATION
PRINCIPLES
2
3

1 Communication Styles
Matt Rustici

INTRODUCTION
Communication by definition is the exchange of views or information between
2 or more people. In the emergency department setting, communication events
are happening almost constantly with nurses, technicians, trainees, consultants,
patients, and families. On a shift, a provider may call out information to a nurse who
is recording in the medical record during a trauma examination, then solicit details
from a patient about his or her sexual partners, and then give constructive feedback
to a peer or trainee, all in less than 1 hour. Face-​to-​face interactions constitute a
large proportion of communication on a clinical shift and involve both what is said
(words) and the way it is said (vocal elements/​tone and nonverbal elements). In
sentinel work by Mehrabian, nonverbal elements like gestures, posture, and facial
expressions accounted for 55% of the messages conveyed, whereas communicating
feelings and attitudes using vocal elements and words contributed far less (38% and
7%, respectively).1 Given the number of people involved, the variability of the in-
formation being exchanged, the acuity of critically ill patients, and the short time
of most interactions in the emergency department, using effective communication
during a clinical shift is crucial to ensuring good patient care and a functional envi-
ronment for the care team to thrive in.
In this chapter, we will examine some popular frameworks for viewing general
styles of communication and how to increase awareness of times when a particular
style can advance or hinder the exchange of information with others. With a better
awareness of your preferred communication style, you can adjust your style when
communication starts to break down and ensure that everyone remains on the same
page. Additionally, by understanding the communication styles of those around
you, your style can be adjusted to better communicate with them and effect change.
4

Remember that in a communication encounter, the only person you can change is
Emergency Medicine Communication Principles 4
yourself.

COMMUNICATION STYLES
The term communication style has a variety of different meanings in the communica-
tion and medical literature, leadership development materials, and the general ver-
nacular. In this chapter, we will define it as follows:

Communication style: A general manner of communicating that is present in a va-

riety of different contexts.

Most medical practitioners have learned a variety of communication behaviors

and techniques to help engage with patients and clearly convey information.
Communication tools like AIDET (Acknowledge, Introduce, Duration, Explanation,
Thank You)2,3 teach communication behaviors that use a patient-​centered commu-
nication approach, which has been associated with improved patient satisfaction.4–​6
A communication style is somewhat different from a communication tool in that a
style reflects our innate and unconscious way of communicating in various settings.
A communication tool, on the other hand, is used in a deliberate and conscious way
to improve communication in specific scenarios. We can think of an innate style
as being analogous to being right or left hand dominant. Almost everyone has a
preference for generally using one or the other hand, but we may choose scenarios
where it is advantageous to use our nondominant hand, and sometimes after years
of practice, we are able to use either hand interchangeably. Though everyone has a
preferred communication style, we are capable of communicating using a variety of
different styles in different situations. An innate communication style preference
tends to come through when we let our guard down, during stressful situations, or
when we are distracted. Because it is automatic, at times it may be poorly suited for
a specific situation. The goal of learning more about communication styles is to help
train ourselves to recognize the times when our style is not helping in a communi-
cation encounter and empower us to adjust our own communication style to meet
the needs of others.
Models of leadership development are often inseparably intertwined with com-
munication skills training. A foundational principle of all leadership training models
is that the path to better leadership is through learning to adapt the way you interact
(i.e., communicate) with another person to best achieve your goals. In most com-
munication interactions, information passes between parties almost seamlessly.

Provider: Can we start running a 1L bolus over the next hour on this patient?
Nurse: You want to run normal saline, right?
Provider: That would be great.
Nurse: OK, I will go get it started.

However, in times where emotions are running high, the stakes are critical, or con-
flict threatens the integrity of interpersonal relationships, it is important to pay par-
ticular attention to how we are communicating and how it is being received by the
people we are communicating with. To follow we discuss a few common leadership
development frameworks and how to best apply these frameworks to improve com-
munication in the emergency department.
5

ASSERTIVE, AGGRESSIVE, OR PASSIVE

5
Communication Styles
The idea of behaving in an assertive way was studied in the 1970s7 and was found to be
generally superior in obtaining one’s goals to being passive or aggressive. Subsequent
models have added an additional behavioral category (passive-​aggressive).
To follow are examples of how the 4 communication styles could be used when
there is a long delay in a consultant coming down to see a patient in the emergency
department.

Passive
I know you are busy, but if you have a chance would you possibly be able to
come to see our patient Ms. Smith in room 9 in the ER when you are free?
Aggressive
I called you 30 minutes ago and you still haven’t seen Ms. Smith in room 9. You
need to come see her in the next 5 minutes or I am calling the chief medical
officer.
Passive-​aggressive
I know we talked about seeing Ms. Smith in room 9 over 30 minutes ago, but
apparently you guys aren’t that interested in seeing your patients in a timely
manner. We are fine with you not prioritizing our patients; however, I know
that it isn’t going to go over well with your medical director when she finds out.
Assertive
I’m calling you back about Ms. Smith in room 9. We talked 30 minutes ago and
I feel bad that we don’t have a decision to give her yet. We would like to make
a decision with a definitive plan for her in the next 20 minutes. Will that work
for you?

Passive communication tends to leave too much ambiguity in the interaction,

whereas aggressive communication allows little room for dialogue. Passive-​
aggressive communication tends to create distrust because of the veiled threats be-
hind it. In general, being assertive in the way you communicate is helpful in the
emergency department because it helps clarify both your motivation (I feel bad this
patient has been waiting so long) and what you really want (finalize a plan in the next
20 minutes). Communicating in an assertive manner helps everyone know where
you stand and what you are looking for. This model is more helpful as a reminder of
bad habits that you may fall into and is often more closely related to your orientation
to conflict (see “Thomas-​Kilmann Conflict Mode Instrument” section later) than to
the style you tend to communicate in. In many conflict scenarios, using an assertive
communication style is a good strategy for resolving the conflict. If surgery wants to
take a patient with a liver laceration straight to the operating room but you think the
patient needs an electrocardiogram first, being direct about your goals and concerns
is more likely to help you collaborate and get the patient definitive treatment while
ensuring that the patient does not need additional workup for undiagnosed heart
disease that will kill him or her on the table.

MYERS-​B RIGGS TYPE INDICATOR

Unlike the previous model, the Myers-​Briggs Type Indicator (MBTI) provides a
model that does not define a preferred way of interacting. The MBTI was developed
6

in the 1920s and uses 4 personality preference dichotomies to assign people into 1 of
Emergency Medicine Communication Principles 6
16 personality types.8 A person’s type is felt to be present since birth and first notice-
able in early childhood. All dichotomies and personality types are considered equal
but different, with no one type being better than another. The MBTI instrument has
been extensively studied and has demonstrated moderately good reliability with a
coefficient of around 0.89 for any single dichotomy. The reliability concerns and his-
tory of use as a tool to aid students in career counseling have led to significant criti-
cism of the MBTI. Despite the criticism, the MBTI remains one of the most widely
used personality preference instruments in the world. The MBTI is designed to look
at personality preferences that may or may not be correlated with behavior (e.g., just
because I am right handed doesn’t mean I only ever use my right hand). Therefore,
the MBTI is not designed to predict future careers or future behavior. People are
dynamic and often behave differently than their innate preferences depending on
the situation. A more appropriate use of the instrument is to think of it as a prompt
to reflect on how one’s preferences may be different from others. Using MBTI
dichotomies to better understand how others may prefer to take in information and
make decisions can provide helpful insights to improve communication, especially
in conflict situations. The 2 most helpful dichotomies relating to communication
style are the S-​N (Sensing-​iNtuitive) and T-​F (Thinking-​Feeling) pairs.

S-​N Dichotomy
The S-​N dichotomy describes how people prefer to take in information. People
with an S-​type preference prefer to take in information that is detailed, specific, and
concrete.

Director: Our new compensation model is going to give a total of a 10% bonus for
Relative Value Unit (RVU) production above the 70th percentile and will pay
out monthly on your second paycheck.

People with an N-​type preference tend to want information that is focused on the
big picture, holistic, or summative.

Director: We are changing our compensation model to better reward our most
productive providers who have RVU production that is solidly above the na-
tional average.

People with either preference often will want to hear both the specific details (the
what) and the big picture (the why), but in stressful situations, we tend to gravitate
to our preferences for what we want to hear first. After telling a patient’s son that his
father is having a myocardial infarction, you can often get a sense of his preference
by observing the next question he asks: “How bad is it?” or “what are we going to do
next?” (S type) vs. “why did this happen?” or “how could we have known this was
going to happen?” (N type). In this scenario, it is not important whether the person
you are working with identifies as having an S-​or N-​type preference. However,
knowing whether someone prefers details versus the big picture will allow you to
provide the information in such a way that the receiver will be more receptive to
it. Skilled communicators are often capable of providing information in such a way
that it meets the needs of both the S and N personality types. “Your father had a
7

heart attack and his heart is only able to pump about 50% of the blood we would

7
expect. We don’t know why this happened but it was likely from a blood clot that got

Communication Styles
stuck in one of the arteries of his heart.”
There are times when there may be an optimal way to communicate informa-
tion. With many interactions, it is important to deliver information in a more S-​
preferred way and be very detailed and specific.

Provider: Can you please put a posterior long arm splint on the right arm of Mrs.
Smith in bed 13?

This is better than:

Provider: Can you go splint that patient?

In other situations, giving a more N-​preferred big-​picture overview is better:

Provider: I need to prioritize stabilizing the patient in bed 3 who is likely having
a stroke and then I will come answer bed 14’s question about treating bed bugs.

This is better than:

Provider: Mrs. Smith in bed 3 is tachycardic and has altered mental status with a
mini-​mental status exam of 13, right facial droop, and left arm numbness that
has been going on for 1 hour. I am going to repeat a more comprehensive neuro
exam, call IR, and order TPA. After that I will counsel the family on treatment
risks of systemic TPA, IR-​guided TPA, or supportive management because Mrs.
Smith is not competent to make decisions at this point. After that, I will come
and discuss bed bug symptoms and possible extermination options with Mr.
Jones in bed 14.

The benefit of knowing our natural preference is that in times of stress or when we
are not consciously paying attention to how we are communicating, our preferences
often seep out and can be mismatched for the situation. Great communicators are
able to pay attention to the person they are communicating with and quickly change
styles when the message doesn’t appear to be getting through.

T-​F Dichotomy
The other MBTI dichotomy that often comes into play during communication
encounters is the T-​F pair, which focuses on how we make decisions. T-​type-​
preferring people like to make decisions based on objective logic. They tend to take
a step back, look at the individual factors, and make a decision that is optimized
based on a set of objective criteria.
In making a decision about provider shift schedules, a T-​preferring leader may
decide that all holidays are worth 2 shift credits, night shifts are worth 1.5 credits,
day shifts are worth 1 credit, and all weekend shifts are worth an additional 20%.
When communicating this type of decision, a T-​preferring person would often try
to explain the rationale of why this formula is fair and equal for all people. If asked
what constitutes a holiday, this person may look for an objective measure of the
8

holiday’s importance (bank holiday, hospital holiday, the majority of staff celebrate
Emergency Medicine Communication Principles 8
the holiday, etc.).
People with an F-​type preference tend to step in to a decision to better under-
stand the impact the decision will have on the people and systems involved and then
to optimize the choice based on how to create the most benefit and least harm to
everyone involved. When it comes to schedules, an F-​preferring person may want
to poll the group to figure out if each shift means the same thing to everyone. If
some staff prefer to work weekends or nights, this would lessen the total “bad” shifts
that the rest of the group needs to cover. Holidays mean different things to different
people, and an F-​type person may try to see if there is a way to get each person off
for the holiday he or she cares the most about. This style of decision making is fo-
cused on creating a sense of fairness and respect for personal values at the level of
each individual.
When trying to convince someone to change his or her mind, the T-​F dichotomy
often comes out. Because we tend to communicate with others in the way we would
prefer to be communicated to, people will often convey a decision in the same way
in which it was made. T-​preferring people may present a logical progression of why
the “system” they created is either the most efficient or will be the most consistent
in the way it deals with future decisions. F-​preferring people will often present an
argument that focuses on how the system will add to the satisfaction (or minimize
the dissatisfaction) of those involved and may focus on how the decision will ac-
commodate the values and priorities of the people involved.
Many of us will consider logical solutions to problems while at the same time
being cognizant of how these decisions will affect people; however, in situations
where there is a conflict that is emotionally charged or when high-​stakes decisions
need to be made, we often revert to our natural preference and try to convince
others by providing more information that supports the way we came to that de-
cision. If you feel like you are making an argument that isn’t being received well,
consider trying to present the decision in a way that would appeal to someone who
makes decisions using the opposite type preference from you.
T-​preferring people may have problems with being overly direct or seeming
“cold” in communication. This can lead others to avoid discussing conflict or to
delay communication with this person out of fear of being “told off.” F-​preferring
people can have a hard time delivering information that is going to make someone
else upset and may be perceived as unassertive when this type of information is not
conveyed in a very direct or clear way.

Using MBTI to Improve Communication

Knowing your own preference can help you advocate more clearly for how you
like to be communicated to. In a meeting with your supervisor where he or she is
explaining a new and substantial change in the process of admitting patients, you
can start the conversation by saying,

I am really interested in learning more about this. It usually helps me to under-

stand processes better if first I can understand how the process works on the
ground level [S type] OR the goals of what this new process will do [N type].
I also would like to understand better how this is going to impact how we
9

provide care for patients [F type] OR how this is going to improve the way

9
the system works [T type].

Communication Styles
Understanding your own preference can also help you convey information more
effectively to others. We tend to communicate data in the way we like to receive
it, so be cognizant of how your own preference may skew how you expect others
would prefer to receive information. This may mean deliberately approaching an
interaction thinking about how someone with different preferences may want to
hear it. Often this includes addressing the details, big picture, logical approach, and
effect on people early in the conversation. Good communicators are then able to see
where to go next by listening to the types of questions or responses contributed by
the other person. For some people this skill is so well practiced that they don’t even
have to think about it, but for many of us, we may need to stop and purposefully try
to see the situation through a different framework.

DISC
The DISC assessment is an acronym for 4 personality profiles described by the in-
strument: Dominance, Influence, Steadiness, and Conscientiousness.10 Unlike the
MBTI, which describes 4 sets of dichotomous variables where you identify as ei-
ther one (S) or the other (N), the DISC profile is designed to measure strength in
each of the categories. Therefore, people will have a dominant letter but may also be
strong in another letter. The 4 letters are plotted on 2 continuums. One continuum
describes on one side a focus on people (similar to the MBTI F preference) and on
the other side a focus on task (similar to the MBTI T preference). The other con-
tinuum plots behavior on a scale from active to passive. The 4 profiles describe the
most dominant strengths of 2 continuums:

Dominance (task, active)

Influence (people, active)
Steadiness (people, passive)
Conscientiousness (task, passive)

Much of the DISC profile is designed to help understand personal leadership

strengths and weaknesses. The DISC model can also be used to think about what
will resonate with another person most effectively.
Dominant-​type people are interested in the results of the task at hand and may
prefer to have communication that cuts to the chase and is focused on progress and
outcomes. These people may get impatient with discussions around possibilities
that seem unattainable.
Influential-​type people are interested in progress in a big-​picture context. They
may prefer to communicate in a way where it feels like they are working collabora-
tively toward improvement and may not like to get bogged down in details.
Steady-​type people are focused on maintaining peace, consistency, and relia-
bility. They may need time to adapt to change and may engage more freely if they
feel like they are in a safe environment.
Conscientious-​type people are less focused on relationships and are more inter-
ested in details and creating a high-​quality product. They may prefer to understand
10

Table 1.1. Tips for Communicating Using DISC

Emergency Medicine Communication Principles 10 DISC Personality Category Tip

Dominant Be efficient
Get to the point
Set goals and objectives
Talk about results
Influential Talk about people and stories
Use examples
Allow time for talking
Steady Don’t come on strong
Earn trust
Provide reassurance
Fear loss of stability
Conscientious Be well prepared
Answer questions
Have plenty of facts and figures
Allow time for thinking and analyzing

all the intricacies of a project before starting their work and may attempt to prevent
failure by avoiding trying things that are new.
If you have an understanding of others’ DISC personality, you can adapt the way
you communicate with them to improve engagement. Table 1.1 provides communi-
cation tips for each DISC category.
Although DISC is an interesting model that can help expand what you under-
stand about yourself, it is more challenging to apply specific DISC principles to im-
prove communication with people whose type you do not know. If you are prone
to focusing more on tasks than people, or more on people than tasks, you may be
perceived as either cold and insensitive or overly sensitive and weak. To deal with
this, consider communicating both your approach to the task at hand and your con-
cern for the people involved. If you are working with people who seem to have a
more passive style, give them space to think and respond. If they are more active,
engage in dialogue long enough to help them come to a final decision and be careful
that you do not take the first thing out of their mouth as the final truth.

THOMAS-​K ILMANN CONFLICT MODE INSTRUMENT

The Thomas-​Kilmann Conflict Mode Instrument (TKI) is focused more directly
on conflict negotiation and includes 5 styles (competing, avoiding, compromising,
collaborating, and accommodating).11
Competing is a conflict strategy in which getting what you want out of the con-
flict is more important than maintaining or strengthening the relationships of those
involved. It is highly task focused but minimally concerned about the people in-
volved. Using this strategy in the extreme can be thought of as having the goal of
winning the conflict with no concern for the bridges burned along the way.
Avoiding is a strategy that is similarly unconcerned with maintaining
relationships, but as opposed to competing, this strategy is minimally concerned
1

with winning the conflict because the conflict never gets discussed or resolved. If

11
you are using avoiding in a conflict, you are choosing not to engage at all.

Communication Styles
Accommodating is when you give up and relinquish getting what you wanted to
support the relationship. By accommodating, you are saving your energy for a fu-
ture battle that you care more about or choosing to build a relationship rather than
accomplish a goal.
Collaborating uses a deliberative process to try and make everyone happy. This
can be a noble goal but isn’t always possible in certain situations and it often takes a
substantial amount of time. Collaborating may not be worth the time and effort in
situations where either time is short or the goal isn’t that important.
Compromising is a splitting of the differences. You may get half of what you
want but the other person only gets half of what he or she wants. This relationship
is somewhat supported, but often both sides leave somewhat unhappy because nei-
ther side fully got what it wanted.
The TKI is relevant to communication styles in cases where someone is
overusing a certain conflict management approach. For instance, if another provider
in the department chooses to use competing in almost every decision, from the new
compensation model to the color of the header on the discharge instructions, he
or she may be perceived as overly aggressive by other providers in the department.
Likewise, a person who almost always uses accommodating, even in issues he or
she cares deeply about, can be seen as passive. If someone is using accommodating
in a scenario where the outcome is very important, he or she may resort to passive-​
aggressive statements in an attempt to either express discontent or win the conflict
without having to use a different style.
The way to effectively use conflict management styles when communicating
is to ensure that the TKI style you are using is in line with your priorities. If the
conflict is high stakes and you need to keep relationships strong, you must take the
time to find a win-​win outcome via collaborating. If you do not have much time or
there is no apparent win-​win scenario, consider compromising so that each side
accomplishes part of its goal and no relationship is severely damaged in the pro-
cess. Accommodating on things that do not matter much to us personally is a great
way to build relationships in a team. If the stakes are high and losing is not an op-
tion, sometimes you have to use competing and know that relationships are going
to suffer. Lastly, we don’t have time to address all conflicts, and there are many
that will work themselves out if they are just left alone by using avoiding. Effective
communicators are able to choose the conflict resolution style that best fits the
situation. For more information on conflict management methods and tools, see
­chapter 3.

DIRECT VERSUS RESERVED (INDIRECT)

COMMUNICATION
Direct communication is described as using words in a literal and explicit way to
convey one’s desires. In contrast, indirect communication tends to talk around an
issue and use shared understanding to convey information.12,13

Direct communication
Provider: Your father’s liver is failing because he is an alcoholic and finally all the
drinking has killed the tissue in his liver.
12

Indirect communication
Emergency Medicine Communication Principles 12
Provider: Your father’s liver is sick and it is likely related to his lifestyle choices.

Direct Communication
Being direct, or even blunt, has a variety of advantages. It directly expresses an
opinion that can be perceived as transparent. This also can facilitate trust, be-
cause a person’s motives are often explicitly stated. At other times, it may be
perceived as harsh or inflexible because others may perceive that the only way
to disagree with you is to move into competing. Many people who have a direct
style are also very open to feedback or different views. To solicit the opinions
of others, people with a direct style will need to be explicit about their desire to
hear dissenting views and must ensure that they do not always interpret silence
as a sign of agreement.

Indirect Communication
People with a more reserved style of communication tend to use indirect commu-
nication and will often listen first and talk second. They can be perceived as open
and receptive and can be quick to form interpersonal bonds during communication
encounters. At times, indirect communicators may be perceived as having a hidden
agenda and may not give away many clues about what they are thinking, which
can make it harder for others to trust them. This is particularly true when indirect
communicators are in a position of power where direct reports struggle to figure
out how to “give them what they want.” These people may also be seen as weak or
indecisive if the implicit meaning of what they are saying is not understood by all.
Indirect communicators may need to make efforts to more explicitly say things to
avoid potential misunderstandings. For others to follow them, leaders with an in-
direct communication style must make a conscious effort to be explicit about their
goals or plans moving forward.
Both styles can be heavily influenced by different cultural backgrounds, but as
with other styles discussed in this chapter, it is better to ask people whether they are
getting what they want rather than assuming they prefer a certain communication
style. The communication culture of the emergency department may lean toward
directness as compared to some other specialties, but it is important to be aware that
cultural norms (“we just tell it like it is”) can condition us to assume that everyone
sees the world the way we do (everyone knows not to take it personally) when this
is clearly not the case for everyone (some people do take it personally and may not
say anything about it).

DEBUNKED STYLES: NEURO-​L INGUISTIC

PROGRAMMING
Many leadership and self-​help models suffer from critiques around pseudoscience,
and there is a paucity of well-​constructed studies that have evaluated how using
specific frameworks changes how effectively we communicate. This is partly due
to the difficulty of assessing communication in the real world and partly due to
the fact that the proprietors of these for-​profit entities may avoid subjecting their
theories to rigorous assessments that may discredit them. That said, neuro-​linguistic
13

programming (NLP) is a self-​help theory involving communication styles that has

13
been generally discredited by the literature. NLP was popularized in the 1970s and

Communication Styles
is rooted in the belief that people can be assigned to 1 of 4 innate communication
styles (visual, auditory, kinesthetic, and digital). NLP theorists believe that each
of these mental frameworks (“neuro”) manifests itself through the words (“lin-
guistic”) we choose to use. For instance, visual people may use phrases like “I see
what you mean,” “You are looking great,” or “I get the picture” to express themselves.9
The NLP model is overly simplistic and not rooted in a current understanding of
either language processing or learning styles. In addition, there is insufficient data to
back up its assumption that using more “visual words” will help you connect with
visual-​style people. In reviews of NLP as a technique used to treat mental illness, the
evidence appears clearly weighted toward there being no benefit, and in regard to
interpersonal communication, we do not find it to have enough construct validity
to warrant further discussion.14

IT’S ALL IN HOW YOU ARE PERCEIVED

One of the challenges with communication styles is that the style you may identify
with may not be how you are perceived by others. Although I might feel like I am
communicating “assertively,” I may be perceived as both passive and aggressive by
the people I am interacting with. The key point with all communication is that it is a
2-​way process and that the best communicators are able to adapt to the people they
are interacting with.
Signs that you are being perceived as aggressive or overly direct include the
following:

• Withdrawn body posture

• Arms crossed
• Leaning back
• Tight mouth
• Rolling of eyes
• Aggressive rebuttal or pointed comments
• Raising of voice

Signs that you are being perceived as passive or indecisive include the following:

• Pity
• Impatience or expressions of annoyance
• The other person taking over the conversation

When you see these or other signs, it is important to ask questions and learn more
about why the person you are communicating with had that reaction. One tech-
nique uses labeling what you see, guessing at the cause, and asking the other person
for validation. For example: “I noticed you shifted back a little after I made that
comment about not giving this patient narcotics. Did you feel like we should have
written him a prescription for something?”
By clarifying the cause for what you saw happen, you can decide how to change
course. It could be that in this scenario, the nurse was uncomfortable with the plan
because he or she wanted you to be more direct with the patient and talk about
14

substance abuse treatment, and not that he or she was upset that the patient’s pain
Emergency Medicine Communication Principles 14
wasn’t being addressed. Although we constantly make assumptions about what other
people might be thinking to speed communication along, skilled communicators
are good at checking themselves, particularly in times when they can sense that the
other person has a negative reaction to something that was said. No matter what
your communication style, you may be intermittently perceived as assertive, aggres-
sive, or passive. Try to avoid assuming that the people you are communicating with
are perceiving the interaction the same way you are and be quick to ask them to
share their experience. The only way to know what someone else is thinking is to ask
them. When you do this, you can better alter how you choose to communicate next.

REFERENCES
1. Mehrabian A. Nonverbal Communication. New York, NY: Routledge; 2017.
2. Braverman AM, Kunkel EJ, Katz L, et al. Do I buy it? How AIDETTM training
changes residents’ values about patient care. J Patient Exp. 2015 May;2(1):13–​20.
doi:10.1177/​237437431500200104. Epub 2015 May 1. PMID: 28725811.
3. Studer Group. AIDET® Patient Communication. https://​www.studergroup.com/​
aidet. Published 2017. Accessed 3/​14/​19.
4. Dean M, Oetzel JG. Physicians’ perspectives of managing tensions around
dimensions of effective communication in the emergency department. Health
Commun. 2014;29(3):257–​266. doi:10.1080/​10410236.2012.743869.
5. Buckley BA, McCarthy DM, Forth VE, et al. Patient input into the development
and enhancement of ED discharge instructions: a focus group study. J Emerg Nurs.
2013;39(6):553–​561. doi:10.1016/​j.jen.2011.12.018.
6. Slate D, Manidis M, McGregor J, et al. Communicating in Hospital Emergency
Departments. Berlin, Heidelberg: Springer Berlin Heidelberg; 2015.
7. Hull DB, Schroeder HE. Some interpersonal effects of assertion, nonassertion, and
aggression. Behav Ther. 1979;10(1):20–​28. doi:10.1016/​S0005-​7894(79)80005-​2.
8. The Myers & Briggs Foundation—​The 16 MBTI types. https://​www.myersbriggs.
org/​my-​mbti-​personality-​type/​mbti-​basics/​the-​16-​mbti-​types.htm?bhcp=1.
Accessed 3/​14/​19.
9. Capraro RM, Capraro MM. Myers-​Briggs Type Indicator score reliability across
studies: a meta-​analytic reliability generalization study. Educ Psychol Meas.
2002;62(4):590–​602. doi:10.1177/​0013164402062004004.
10. DISC: Personality style primer. https://​discinsights.com/​disc-​theory/​?SID=4k630u
q0679oi80g2ah6raehr3. PeopleKeys, Inc.
11. Understanding the Thomas Kilmann conflict mode Instrument. https://​www.
themyersbriggs.com/​en-​US/​Products-​and-​Services/​TKI
The Myers-​Briggs Company
12. Joyce C. The impact of direct and indirect communication. Newsl Int
Ombudsman Assoc. 2012:1–​4. http://​www.uiowa.edu/​~confmgmt/​documents/​
DIRECTANDINDIRECTCOMMUNICATION.pdf.
13. Direct communication. https://​www.goodtherapy.org/​blog/​psychpedia/​direct-​
communication. GoodTherapy, LLC.
14. Witkowski T. Thirty-​five years of research on neuro-​linguistic programming. NLP
Research Data Base. State of the art or pseudoscientific decoration? Polish Psychol
Bull. 2010;41(2):58–​66. doi:10.2478/​v10059-​010-​0008-​0.
15

2 Conflict Management
Deirdre Goode and Stephen J. Wolf

CONFLICT
We are all familiar with conflict. We experience it in our personal and professional
lives, and although it may have some benefits, it is more often something avoided or
eliminated expediently. Conflict is often associated with hostility, anger, or fighting,
but it can actually be defined more broadly. At the center, conflict is a disagreement.
For the purposes of this discussion, we will define conflict as a disagreement within
oneself or between people that causes harm or has the potential to cause harm.
The harm caused by conflict is multifactorial with far-​reaching effects. At an
organizational level, workplace conflict takes a large toll. In 2008, CPP Inc.—​the
creators of the Meyer’s Brigg Type Inventory—​conducted a global study examining
the various costs of workplace conflict. They discovered that on average, US
employees spend 2.8 hours per week in conflict, which amounts to $359 billion in lost
wages, or about 385 million lost working days.1 In addition to high cost, conflict also
results in higher employee turnover, absenteeism, and increased rates of litigation,
stress, and depression. Unfortunately, health care is not immune to these issues, and
given the higher-​stakes environment the effects of conflict can be graver. Studies
reveal that the high-​stress, high-​conflict environments within health care result in
diminished patient satisfaction, risks for patient safety, and more disrupted patient
care, leading to worse outcomes.2 One national survey of physicians found that over
two-​thirds of respondents witnessed that disruption of patient care through disrup-
tive physician behavior at least once a month. Ten percent of respondents witnessed
that behavior daily.3
Conflict is not always bad. When respectful and supported in a healthy manner,
it can lead to diversity of thought, the sharing of novel or new ideas, and better
solutions. In fact, when conflict arises, it could be a symptom of a larger organizational
16

or interpersonal issue at play that must be addressed that will strengthen the team
Emergency Medicine Communication Principles 16
or the organization overall. Such conflicts are known as functional or constructive
conflicts because they require the group to establish a goal-​oriented plan for reso-
lution.4 How you transform a conflict from team depleting to team enriching is the
focus of this chapter.
Conflict will always be a facet of our personal and professional lives, and al-
though it cannot be avoided, it can be managed and molded to generate benefits.
Experts agree that conflict management is not an intrinsic ability, but rather a skill
that can be taught, learned, and practiced. The remainder of this chapter will de-
scribe different types of conflict and methods to manage it, and will close with case
studies that examine the application of these definitions and techniques.

The Flavors of Conflict

Conflict exists in various contexts, particularly as we interact within our profes-
sional environment. When we consider communication within the emergency de-
partment, it is important to consider not only the duties or tasks we must carry out
as a clinical team but also the interpersonal issues that may arise in the context of
our daily work with peers and patients. As such, we must delineate between 2 types
of conflict, namely, task conflict and relationship conflict.
Task-​based conflict refers to the differences over work-​related issues or ideas; it
is a disagreement about what needs to happen and how steps should be performed.
Research reveals that moderate levels of task conflict can be beneficial and help a
team or organization evolve to become more productive. At healthy levels, task
conflict can encourage diversity of thought, encourage growth, and challenge op-
erations to be more efficient and less wasteful. Consider the development of a new
departmental career development process. The departmental chair, vice chair for
academic affairs, and general faculty may all feel differently about the structure of
such a program. Encouraging debate and working through this type of task conflict
will undoubtedly only make the program stronger and more valuable to the depart-
ment as a whole!
Relationship-​based conflict refers to the emotions surrounding the disagreements;
this type of conflict encompasses how people feel and behave in response to a dis-
agreement. Relationship conflict is often correlated with task conflict and can be
counterproductive because it can steal the focus from the issues requiring resolu-
tion and transfer the conflict to an issue of personal antagonism.5 Unfortunately,
task conflict—​something that can be productive—​usually produces relationship
conflict, which is counterproductive.6
Often the escalation of conflict occurs when members of the group mistake task
conflict with relationship conflict. This transition commonly occurs when the issues
are serious with potential for great personal gain or loss. Thus, health care is an envi-
ronment primed for the interplay between task and personal conflict.
Imagine it’s 2 am in the emergency department (ED) and a patient comes in with
signs of sepsis and is suspected to need medical intensive care unit (MICU) admis-
sion. The MICU resident agrees to come and examine the patient with the know-
ledge that MICU bed space is limited and that the threshold for admissions is high
owing to constrained resources. The resident examines the patient, disagrees with
the ED assessment, and reports that admission to the MICU is inappropriate and
that the emergency resident needs to “learn how to identify sepsis.” The emergency
17

medicine (EM) resident, who has a historically strained relationship with the entire

17
MICU team, feels offended by the denied admission, perceiving the MICU resident

Conflict Management
as undermining her clinical assessment. In response to the curt response from the
MICU resident, the EM resident responds by paging the on-​call critical care fellow
knowing that it will produce a negative backlash for the MICU resident.
In this scenario, what started out as a task conflict—​is this patient septic?—​
quickly transformed into a relationship conflict between the ICU and EM residents.
Because the comments from the MICU resident were perceived as a personal slight,
or a personally motivated criticism, the EM resident responded to ensure that the
MICU resident would be punished. What could have remained a task conflict in
which both residents could have argued for and against sepsis and thus provided
a deeper education to both individuals (and a better outcome for the patient)
devolved into a counterproductive relationship conflict that generated animosity
and made it nearly impossible for the 2 teams to work together in the best interest
of the patient.
This example highlights the value of understanding conflict and its origin (task
vs. relationship). In doing so and labeling the initial perceived conflict as task
oriented, efforts could have been made to mitigate progression. Furthermore, un-
derstanding the origin allows one to consider the vantage point, or conflict style,
each individual is coming from, which will inform our conflict management.

CONFLICT MANAGEMENT STYLES AND FRAMEWORKS

There are many different approaches to conflict management, but for the purposes
of this discussion we will describe 2 methods, one that pertains to the individual’s
approach to conflict management (the Thomas-​Kilmann Conflict Mode Instrument
model) and one that pertains to how groups can approach conflict (the GRPI
[Goals, Roles, Process, and Interactions] model). These approaches can be used to-
gether to complement one another but are described here to establish a framework
by which we can examine and address conflict.

THE INDIVIDUAL: HOW DO YOU APPROACH CONFLICT?

The Thomas-​Kilmann Conflict Mode Instrument (TKI)7 assesses an individual’s
behavior in conflict according to 2 dimensions: assertiveness and cooperativeness. The
assertiveness dimension describes the extent to which an individual attempts to sat-
isfy his or her own concerns relevant to the issue causing the conflict, whereas the
cooperativeness dimension describes the extent to which an individual attempts to
satisfy the other person’s concerns. These 2 dimensions can be used to describe 5
styles of dealing with conflict: competing, collaborating, compromising, avoiding,
accommodating. Table 2.1 describes each style, including consequences of over-​
and underuse.

Is Your Conflict Management Style Fixed?

Research shows that individuals’ conflict management style is not independent of
their environment.8 Instead, the conflict management style employed by individuals
changes depending on the context of the conflict or the situation in which they find
themselves. For example, the quarterback of the football team may employ the
18

Table 2.1. The Thomas-​Kilmann Conflict Mode Instrument

Emergency Medicine Communication Principles 18 Style Description

Competing Used predominantly when a quick, decisive action is needed

“I win” or for an important issue when an unpopular decision
must be made
Signs of Overuse
• Surrounded by “yes” people
• Others afraid to admit uncertainty/​ignorance to you
Signs of Underuse
• Often feel powerless in situations
• Struggle with taking a firm stand on an issue
Collaborating Used when there’s a need for an integrative solution that
“Everybody wins” merges insights
Signs of Overuse
• Spend too much time discussing and debating issues that
do not merit it
• Never reach resolution because of time spent
gathering input
Signs of Underuse
• Difficulty seeing differences as opportunities for joint gain,
learning, problem solving
Compromising Used when an expedient solution is needed and the 2 sides of
“Finding a middle the conflict have equal power and are strongly committed
ground” to individual positions
Signs of Overuse
• Lose sight of the larger issues
Signs of Underuse
• Struggle to make concessions
• Unable to participate in a give-​and-​take from the opposite
side
Avoiding Used when the conflict is unimportant to participants, or they
“I want to delay” perceive no chance of satisfying their concerns
Signs of Overuse
• Decisions about important issues made by default and not
discussed
Signs of Underuse
• Constantly embroiled in conflict
Accommodating Used when the issue is more important to one side or the
“You win” other; useful to build credit for later issues that are
important to you
Signs of Overuse
• You never get what you want
Sings of Underuse
• You gain a reputation for being unreasonable
• You have difficultly admitting that you are wrong
19

competing (or dominating) style when addressing conflict with the team, but is un-

19
likely to take that same approach with the coach.

Conflict Management
Is One Style More Advantageous Than Others?
Conflict management styles within the health care setting have been studied and it
has been revealed that certain styles are more prone to producing or escalating con-
flict and others are less likely to breed conflict.9 In many ways one’s preferred style
of conflict management is significantly related to one’s conflict tolerance. Is con-
flict an annoyance? Does it cause fear or shame? Does it make you feel like you are
advocating and give you energy? Is it an opportunity to improve? Understanding
yours and others’ tolerance will inform the process of resolution. How assertive are
you around conflict? How cooperative are you?
In one study, researchers looked at a modified version of the TKI model in
which they designated 4 primary conflict styles: dominating, avoiding, obliging,
and integrative. The study sought to determine if certain conflict styles shaped
employees’ social environment and how that conflict style affected their experi-
ence of workplace stress. Each of the 85 participants filled out a series of surveys to
designate their individual conflict style and also to rate task and relationship con-
flict. Additionally, researchers measured the participants’ experience of work stress.
They discovered that individuals with a preference for an integrative style identified
lower levels of task-​related conflict and thus lower levels of relationship-​related con-
flict. Conversely, individuals with preference for dominating and/​or avoiding styles
identified higher task and relationship conflict.

THE TEAM: HOW DO WE APPROACH CONFLICT?

There are numerous conflict management frameworks and models utilized across
industries. One in particular, the GRPI (pronounced grippy) model, is of particular
value to medicine because often conflict and disagreement in this environment in-
volve multiple people or teams with seemingly disparate goals of care. GRPI stands
for goals, roles, process, and interactions.
The GRPI model was created by Richard Beckhard to describe the elements of
team cooperation and communication.10 The purpose is to establish a framework by
which teams establish priorities and develop an action plan to achieve goals.

Goals—​establish the core mission of the team and frame the purpose. A
common goal is what makes a team a team.
Roles—​authority, responsibilities, and tasks; should be aligned to defined
goals. Each team member should know who is doing what, who is
responsible for what, and the extent of their authority.
Process—​governance tool to overcome inefficiencies in areas of decision
making, control, coordination, and communication.
Interactions—​outlines relationships and individual styles and is about
establishing trust, open communication, and feedback in support of a sound
working environment.

The components to the GRPI model are purposely sequenced. If there is conflict or
ambiguity at one level, the impacts will be felt on the remaining levels. Essentially, a
20

conflict at one level has a cascading effect on the others. For example, if the goals are
Emergency Medicine Communication Principles 20
unclear, then uncertainty about roles will result. Thus, it is vital for teams to estab-
lish clarity at each level to reach resolution.
Although the GRPI model is frequently used in other industries to help develop
codified action plans for teams, we are using it here as a framework to consider team
dynamics and collaboration in the face of conflict. There are opportunities to incor-
porate this framework into formal task management plans, which would be useful
when approaching hospital administrative tasks, but this discussion is more targeted
to the conceptual application of GRPI. Its primary utility for the health care worker
is helping the team consider the layers of teamwork, and how addressing disagree-
ment at one level will have beneficial ripple effects. The goal of the teams in con-
flict is to determine at which level the problem exists and where to apply a targeted
resolution.

CASES
Case 1: The Non-​Flict
Mrs. Smith comes to the emergency department with a medical condition that
requires the placement of a chest tube. This procedure is a requirement for both EM
and surgery residents. Mark, the EM resident, requests a surgical consult. Evi, the
senior surgery resident, agrees to come and evaluate the patient. In the meantime,
Mark prepares the materials for a chest tube because this is his first opportunity
to perform the procedure. After examining the patient, Evi places the chest tube
without talking to the EM team first. The patient is admitted to the surgical service
for ongoing management. Mark feels sidestepped and very frustrated by the expe-
rience and the lost opportunity to practice a relevant procedure. He approaches his
attending to express his frustrations.

Discussion
So, Why is this a ‘non-​flict’ conflict? Within this example there is no fundamental
difference in opinion between the medical teams as to what needs to happen for
the patient. Everyone is in agreement that the chest tube must be placed; however,
when considering this situation through the lens of the GRPI model, there is no-
tably a failure to define roles and processes and to address interactions that has
resulted in tension and friction between the emergency medicine team and the sur-
gical team. This type of non-​flict is common in the health care setting: a breakdown
in communication that does not result in harm to a patient but does lead to friction
and tension between individuals that can result in future problems with collabora-
tion and teamwork.

How Do You Fix It? This is an opportunity to apply elements of the GRPI model.
Specifically, this scenario demonstrates that when there is a lack of clarity about roles,
problems with process and interactions often arise, which can trigger intense relation-
ship conflict. One practical solution would be for the teams to talk in real time be-
fore anyone performs any procedures. This way, the teams can be certain that they
share the same goals for the patient and everyone has the opportunity to express their
opinions for the care of the patient.
21

Alternatively, because the emergency department is often a busy and hectic

21
environment, it is likely better to address these types of issues by implementing

Conflict Management
overarching policy. In this scenario, the procedure falls within both specialties’
“scope of practice,” and both residents need to develop competence in per-
forming the procedure. Residents often internalize this scope of practice as what
they “need to learn” as core to their educational process, making the topic emo-
tionally charged and at high risk for relationship conflict. Additionally, chest
tubes, like many other types of procedures in the ED, frequently need to be
performed in urgent or time-​constrained conditions, leaving little to no time for
informal discussions about procedural responsibilities. An overarching policy
would allow for both teams to communicate and discuss all related factors to
the scenario in a safer, less pressured manner, ideally resulting in a shared vi-
sion and plan. Perhaps even-​numbered calendar days are when the surgery
team performs procedures (e.g., chest tubes, placing central lines, etc.), and
odd-​numbered days are when the ED staff perform procedures. Using posted
placards alongside a calendar that shows the current day would help sidestep
these issues altogether because everyone would be operating under the same
set of rules. This type of prescribed approach may seem excessive at times, but
its predetermined structure is often ideal for time-​constrained issues, prone to
high relationship conflict.

Case 2: The Passive Observer

During a busy Saturday night shift in the emergency department, Michael, a post-
graduate year 2 (PGY2) resident, was treating a patient that required IV placement.
Unfortunately, after numerous failed attempts by the nursing staff, it was clear that
this patient required an ultrasound-​guided IV. It was still early in Michael’s PGY2
year and he had not mastered the skill, and despite his best efforts, he was also
not able to place the line. Michael knew he had to approach the chief resident,
Nicole, for help. Michael and Nicole had not established a strong working rela-
tionship during his intern year, and she had insinuated to Michael on numerous
occasions that he was not progressing at the same rate as the other interns and that
he was really going to need to “step up his game” for his second year. When Michael
summoned the courage to approach Nicole, his worst anxieties came to fruition.
Nicole immediately responded with an exasperated sigh and rolled her eyes at his
request. She then began to loudly and publicly admonish him: “Michael, I thought
we had discussed this? You’re going to need to learn how to do these things on your
own. I don’t have the time to constantly hold your hand through even the most
basic of procedures. Shall we get a medical student to take your place?” Michael
stood there silently waiting for her to stop yelling. The interaction was witnessed
by 3 other residents standing at the workstation, who tried to look away and com-
plete their charts. Vivian, a fellow PGY2 resident, watched as Nicole “reamed out”
her peer. She knew that Nicole was under a lot of pressure as the chief resident, but
she was also good friends with Michael and knew that he was excellent at treating
patients but, like all residents, had more to learn. Vivian felt compelled to step in
and defend Michael because the public tirade was both cruel and drawing the at-
tention of ED staff and nearby patients. Vivian remained silent, however, because
she did not feel like it was her place to step in, and even if she did, what would
she say?
2

Discussion
Emergency Medicine Communication Principles 22 Everyone has at one time found themselves in a situation where they were the pas-
sive observer to intense conflict, whether it be at work or in their personal lives. For
example, we have all heard the public scolding of an irate child by an equally irate
parent. As observers, this leaves us with feelings of discomfort matched by a com-
plete paralysis to step in and do something to diffuse the conflict. This story serves
as a nice reminder that conflict does not necessarily have to involve 2 people; in-
ternal conflicts can be as destabilizing as the ones we have with others.
In this story, Vivian is faced with 2 problems: a lack of confidence about her role
and an inadequate toolkit for conflict resolution tactics. When it comes to her indi-
vidual conflict management styles, Vivian is employing avoidance. She could take
her cues from the other witnesses and just pretend this conflict is not happening and
continue to let Nicole harass team members. Maintaining avoidance, however, will
have the unfortunate consequence of perpetuating a culture of conflict and creating
a hostile work environment with poor team unity and eventual diminished patient
care. Choosing inaction will tacitly communicate to Nicole that her behavior is ac-
ceptable, which it clearly is not.

How Do You Fix It? This team would clearly benefit from participating in conflict
management training together. First, it would help establish a foundation for the team
approach to conflict management, and would simultaneously help build others’ con-
fidence when raising issues that they fear will not garner support. In fact, there have
been several research studies indicating that professional development courses for
health care providers about conflict management skills have been widely beneficial
and have helped create a more harmonious work environment. These longitudinal
studies indicate that participants retain the lessons and skills for years after completing
the training.11
In the absence of formal training sessions, it would be worthwhile for Vivian to
debrief the incident with the other residents, who would likely confirm that they felt
similarly uncomfortable and wanted to say something. It is easier to intervene when
you know you have some support from other team members, which is why regular
discussions and event debriefs are critical to team building. Although this may not
be a typical “event” like a resuscitation code gone wrong or a missed diagnosis, it is
still worthy of a debrief because it represents a breakdown in the regular activities
of the emergency department. Time spent by team members publicly yelling at and
insulting each other is time not used for caring for patients. That is not time that
anyone can waste.
Once Vivian builds the confidence to intervene, she needs to craft what she is
going to say. She does not want to escalate the conflict but does need to at a min-
imum diminish the intensity and ideally change the location. She can approach
Michael and Nicole and say, “Excuse me, but I need to interrupt. It seems that
voices are being raised, and it is distressing to the patients and staff. Can we move
this conversation to the conference room?” The statement is direct in identifying
the issues (i.e., raised voices), helps clarify why this is inappropriate (i.e., causing
distress to patients and staff), and gives a specific direction as to what happens
next (i.e., move to conference room). The statement will get the conflict moved
but does not assign any blame. It is not Vivian’s role to mediate the conflict be-
tween Nicole and Michael necessarily, but rather to keep the conflict from gaining
momentum.
23

Case 3: The Overworked Servant

23
It’s late in the evening and it has been a busy night in the emergency department,

Conflict Management
particularly for the surgical team. As the EM resident, you have already consulted
them on 3 trauma patients: one elderly gentleman with abdominal pain with a lac-
tate of 5 and a normal computed tomography (CT) scan; a patient with appendi-
citis; and a patient with cholecystitis. The surgical consult resident made it known
how frustrated they were about their workload the last time you called them. Now,
you are anxious about calling a consult on your most recent patient—​a 39-​year-​old
female who is 3 days out from a cholecystectomy, with abdominal pain and a post-
operative wound infection.
The voice on the other end of the phone barks out, “Are you kidding me? This
is ridiculous! Can’t you guys do anything other than pick up the phone and call a
consult?”

Discussion
Relationship conflict is frequently the product of, or at least considerably
exacerbated by, external factors (e.g., excessive workload, burnout, unexpected
personal stress, etc.). These factors often turn an unfortunate task-​related circum-
stance or interaction into an interpersonal catastrophe, as stress and frustration
boil over. Unfortunately, in these situations the conflict can be complicated by the
fact that many of these external factors are hidden to one or both parties. In this
situation, the emergency medicine resident likely was unaware of the consultant’s
family struggles and added sleep deprivation. Similarly, the consultant likely did
not appreciate the fact that the emergency medicine resident had worked through
multiple other complex cases that could have easily resulted in additional consults
had not significant time been spent arranging alternative care plans. In these
situations, our emotions well up, testing our skills to self-​regulate our verbal and
nonverbal communications. Relationship conflict is subsequently catalyzed in
short order, undermining any further communications and, likely on some level,
patient care.
Although in the ideal situation we would all have high levels of resilience, effec-
tive coping skills, and the emotional intelligence to be self-​aware of these external
factors and high-​risk situations, this is not always the case. As an individual, pre-
vention through building skills around emotional intelligence and self-​regulation is
very important. This is beyond the scope of this chapter. Here we will focus on the
conflict itself.

How Do You Fix It?

In the heat of the moment, our “fight or flight” instinct often tells us to bark back
or shut down and become passive-​aggressive, which only serves to allow the con-
flict to persist and fester. Additionally, not addressing the conflict appropriately may
send the message that the consultant’s behavior is acceptable or even required to
get what he or she wants. Worst-​case scenario would be that this conflict results in
compromised patient care by altering a care plan that is needed.
An approach of pausing, acknowledging, empathizing, redirecting, and delayed
readdressing is frequently the best initial response. By pausing, you allow yourself
to overcome your initial visceral reaction, increasing the likelihood that you will
24

be able to have a measured reply. By acknowledging the event as unexpected or un-

Emergency Medicine Communication Principles 24
acceptable, you change the focus of the interaction from the conflict to the ambig-
uous hidden emotion. The importance of doing this with genuine concern cannot
be overemphasized. The goal is not to further contribute to the escalation of the
conflict. Unprofessional transgressions are often not done with conscious aware-
ness and, when consciously identified in an appropriate and nonthreatening way,
result in a break in current, and improved future, behavior. Next, empathizing with
your colleague reinforces that you are on the same team and should be supporting
each other. Finally, redirection reminds everyone of the shared goal and object trying
to be immediately achieved. Depending on the intensity and/​or egregiousness of
the conflict, readdressing the emotions and event in a timely but delayed fashion
can help to reaffirm how the situation, and similar situations in the future, should
go differently.
“Wow . . . [pause] . . . I really was not expecting that response. I am sorry this
night has been so difficult for you; I know you have really been hit hard. If I can rea-
sonably do anything to help I will, but I really think this patient needs your expertise
to get her the care she needs.”
The emergency medicine resident followed this measured response by reaching
out at the end of the shift to readdress and talk about the conflict when the emotions
were less charged.

Case 4: The Myopic Standoff

It’s a busy weekday afternoon. Patients are being sent to your ED from the clinic
for further workup and admission and it is significantly impacting flow, leading to
extended boarding, and stretching the care team. An 85-​year-​old male is referred
from the medicine clinic with abdominal pain and appears septic. The charge nurse
is advocating strongly for sending the patient straight to the MICU, where the pa-
tient can have a surgery consult as part of his additional workup. He argues that his
nursing team is stretched too thin to “watch” another patient while the consultants
take their time. You worry that if the patient goes to the MICU that his additional
workup may not occur quickly enough to minimize morbidity or even death if he
needs an emergent surgery.
When you tell the charge nurse the patient will be coming to the ED, he huffs,
“Typical! You really have no clue as to the flow and safety of this department!”

Discussion
Although on some level this situation could be considered a non-​flict where both
sides want the same end result of “patient safety,” this conflict is really based on
differing priorities and goals that arise through the lens in which each group sees
the situation. In health care, different providers (physician, nurse, etc.) or services
(medicine, surgery, emergency medicine) often view a patient’s visit and care needs
from different perspectives. As such, various priorities can be misaligned, or my-
opic, when compared to a bigger picture. This leads to not only conflict but also
possible patient safety issues. In this case, both providers are aiming to care for the
patient the best they can, but with differing priorities. Each provider may also have
25

Table 2.2. STATE for Conflict

25
Management

Conflict Management
S Share your facts
T Tell your story
A Ask for others’ paths
T Talk tentatively
E Encourage testing

a different appreciation for the magnitude of risk and impact of the other person’s
priorities.

How Do You Fix It? Let’s revisit how an approach of pausing, acknowledging,
empathizing, redirecting, and delayed readdressing could have prevented this task-​based
conflict from evolving into a relationship-​based conflict. If at the first sign of tension
either provider were to pause and acknowledge it as such, displaying an understanding
for the alternative priorities, a joint effort to redirect and better align around the goals
would have likely been successful.
Other conflict resolution models have been described. The best-​selling authors
of the book Crucial Conversations propose using the pneumonic STATE as a way to
approach high-​stakes conversations in which there are opposing opinions and strong

Table 2.3. Models for Approach to Conflict

Model Technique

Courageous •​ Explain the gap—​explain the issue

Conversations •​ Explore the gap—​questioning and listening from both sides,
creating a real dialogue
•​ Eliminate the gap—​reach of consensus on how both sides
will move forward
Other People’s Shoes •​ Position of self—​what are you experiencing about the
conflict situation (how do you see it)?
•​ Position of other—​put yourself in the other person’s shoes:
how would you feel if you were him or her?
•​ Position of neutral observer—​view the situation as a 3rd
party: what do you think?
•​ Position of self—​try using the advice you gained through
this exercise
Conflict Between •​ What is the situation?
People •​ Your feelings and actions
•​ The other person’s perspective
•​ Where does a change need to be made to break the cycle?
Table inspired by the image included Thomas-​Kilmann Conflict Mode Instrument Sample Report.
Thomas K, Kilmann R. The Thomas-​Kilmann Conflict Mode Instrument Profile and Sample Report. https://​
www.cpp.com/​en-​US/​Products-​and-​Services/​Sample-​Reports#tki. Accessed August 15, 2017.
26

emotions.12 Table 2.2 demonstrates the different steps of STATE. Table 2.3 outlines
Emergency Medicine Communication Principles 26
3 other approaches that can be helpful when conflict arises.13 These approaches em-
phasize reflection, imagery, and dialogue.

CONCLUSION
Conflict typically has a negative connotation. Having an understanding of conflict
management styles and models can serve to change the perspective of conflict as
something negative to something that is useful. Good conflict can lead to a rich
exchange of ideas, support an environment of inquiry, and lead to better decisions.

REFERENCES
1. Workplace Conflict and How Businesses Can Harness It to Thrive. Global Human
Capital Report CPP Global. July 2008.
2. Overton AR, Lowry AC. Conflict management: difficult conversations with difficult
people. Clin Colon Rectal Surg. 2013;26(4):259–​264.
3. MacDonald O. Disruptive Physician Behavior. Waltham, MA: Quantia
Communications Inc; 2011.
4. Mills ME. Conflict in health care organizations. J Health Care Law Policy. 2002;5(2):
502–​523.
5. Friedman RA, Tidd ST, Currall SC, Tasi JC. What goes around comes around: the
impact of personal conflict style on work conflict and stress. Int J Conflict Manage.
2000;11(1):32–​55.
6. Simons TL, Peterson RS. Task conflict and relationship conflict in top management
teams: the pivotal role of intragroup trust. J Appl Psychol. 2000;85:102–​111.
7. Thomas K. Kilmann R. The Thomas-​Kilmann Conflict Mode Instrument profile
and sample report. https://​www.cpp.com/​en-​US/​Products-​and-​Services/​Sample-​
Reports#tki. Accessed August 15, 2017.
8. Friedman RA, Tidd ST, Currall SC, Tasi JC. What goes around comes around: the
impact of personal conflict style on work conflict and stress. Int J Conflict Manage.
2000;11(1):32–​55.
9. Ibid.
10. Raue S, Tang S, Weiland C, Wenzlik C. The GRPI model—​An approach to team
development. Systemic Excellence Group. White Paper. 2013.
11. Zweibel EB, Goldstein R, Manwaring JA, Marks MB. What sticks: how medical
residents and academic health care faculty transfer conflict resolution training from
the workshop to the workplace. Conflict Resolut Qtly. 2008;25(3):321–​350.
12. Patterson G, McMillan S. Crucial Conversations. Tools for Talking When Stakes Are
High. New York: McGraw Hill Companies; 2012.
13. Conflict Resolution Models. Crowe Associates Ltd. https://​www.crowe-​associates.
co.uk/​courageous-​conversations/​conflict-​resolution-​models-​2/​. Accessed May 1,
2019.
27

3 Keys to Effective
Communication in All
Circumstances

Kirsten J. Broadfoot and Todd A. Guth

INTRODUCTION
Emergency medicine (EM) physicians spend 80% of their time on shift
communicating, with a minimum of 19 complex communication events occurring
per patient in the emergency department (ED).1,2 Beyond the quantity of
interactions, however, the ED is an unpredictable communication environment that
requires providers to actively engage in situational monitoring to operate respon-
sively. With a high degree of interruption, evolving and often incoherent patient
stories, and multiple patient needs, it is easy for practitioner cognitive processing to
become strained over time, forcing a reliance on default communication approaches
and pattern recognition.3,4
Any omissions, inconsistencies, and inadequacies in patient stories and med-
ical records that result from cognitive overload and default interaction styles have
a ripple effect, interfering with effective clinical reasoning, decision making, and
patient safety as they complicate patient care, particularly at vulnerability points,
such as transitions between providers. Hospital hierarchies bring their own com-
plicated politics of interaction, with more junior providers generally reluctant to
clarify, confirm, or question more senior colleagues, who assume that even in mul-
tiple and fragmented series of actions and interactions, simple systems and requests
for action continue to reliably manage interruptions.5
These interruptions can come from any quarter, including updating and
confirming situational awareness of team members on patient management
28

and professional practice; confirming information and next steps; locating staff,
Emergency Medicine Communication Principles 28
patients, records, or equipment; performing role-​based tasks or responsibilities;
and supervising patients and staff.5 A consistent theme running through the need
for interruptions, however, lies in the need for immediate feedback or providing
updates on changes in the environment, that is, maintaining situational awareness.
A failure to provide feedback, complete tasks as expected, or remain present to the
evolving environment causes significant stress on others in the environment, be
they patients, family, or team members. This stress coupled with the reticence of
junior colleagues creates friction between disciplines as well as an uneven distribu-
tion of access to patient information and care delivery.4,6
Several communication recommendations for EM practice have been made in
response to these challenges, including engaging in symmetrical, 2-​way communi-
cation; centralizing and coordinating communication through technology; encour-
aging mutual understanding and access to decision-​making systems; promoting
inclusion; and avoiding top-​down communication styles. Considerable work has
also been put into constructing highly structured checklists, routines, and scripts to
tightly bind the most complex, consequential, and taxing ED interactions such as
codes and resuscitations.
These risky, crisis, or high-​drama events are sporadic, however, making up
a smaller percentage of ED encounters. Indeed, almost contrary to its definition,
many interactions within the ED are mundane and straightforward, with coherent
and easily transferred patient stories and low-​stakes relationships or care concerns.
But in between these 2 kinds of situations lie patient-​provider and provider-​provider
interactions that, while mundane, do not follow any clear pattern, coherent story, or
clear definition or resolution. These ambiguous and uncertain interactions rarely fit
any clear template or frame of action, and can significantly impact care coordination
with patients, families, departmental care teams, and interdepartmental colleagues.
They also significantly impact the resilience and responsiveness of emergency med-
icine practitioners and the quality of care they provide.
In this chapter, we propose that the key to effective communication in the ED lies
in appropriately interpreting and adapting to evolving circumstances. Appropriate
adaptation in the ED requires emergency medicine practitioners to change their
communication style as situational needs and conditions evolve, requiring a high
degree of situational awareness, as well as self-​and other monitoring, to respond ap-
propriately and professionally in any circumstance that arises.7 Drawing on models
of communication that highlight the ecological nature of the ED as a communica-
tion environment,8 we provide fundamental communication guidelines to first in-
terpret and then adapt to circumstances and communication practices to facilitate
flexible interaction designed to respect self, others, and the context of the ED. Using
examples from recent ED shifts, we illustrate how these communication guidelines
and techniques can be used in particularly vulnerable care processes within the
ED—​testing and evaluation of patients, handoff and admission, and triage.4,7

EFFECTIVE COMMUNICATION GUIDELINES AND

GOALS FOR INTERPRETING AND ADAPTING TO ALL
CIRCUMSTANCES
Effective communication can be described as clear, complete, accurate, timely, and
verified by all parties involved.9 Within a “communication as information transfer”
29

frame, effective communication is determined to have occurred when the meaning

29
of the sent message is understood and agreed upon. However, this model fails to

Keys to Effective Communication in All Circumstances

consider contextual, interpersonal, and organizational dynamics that exert consid-
erable force on action and interaction in the ED context. An alternative perspective
on effective communication considers the ED as a communication environment,
examining it from a narrative and systemic perspective. Similar to Street’s8 eco-
logical approach to communication, such an approach proposes that individuals’
communicative effectiveness lies in their ability to adapt to the complex systemic
dynamics in which they do their work. Within this frame, interactions in the ED are
no longer considered isolated and independent events, but rather dynamic and con-
stantly shifting interactions embedded in particular interpersonal, organizational,
and societal environments.
Reconceptualizing the nature of interaction and communicative practices
in the ED as existing in a particular communication environment, requires effec-
tive communication in the ED environment to be ideally open, unguarded, and
flexible—​that is, adaptive to circumstances. Building provider capacity for interac-
tion skills or techniques that can respond attentively or consciously to a dynamic
environment is critical to providing high-​quality patient care in unpredictable clin-
ical environments. Unlike interaction driven by checklists and routinized scripts,
adapting to circumstances requires providers to communicate in ways that acknowl-
edge that each act, sentence, or utterance is modified by its predecessor. Being
careful and reliable when responding in such situations requires recognizing and
envisioning what and how an individual or team can speak and act in the context of
joint action. This is not to say that everyone needs to agree on what to think or say;
rather, the focus should be on coordinating interaction that recognizes and respects
all perspectives, including those of dissent.7 This requires individuals and teams to
relate to each other carefully, critically, consistently, purposefully, attentively, and
conscientiously.4

Communication Guidelines for Interpreting and Adapting to

All Circumstances
Interactions that do not attend to these guidelines run the risk of being careless,
mindless, or unconcerned—​that is, ineffective. Situational and interpersonal aware-
ness drops with the use of predetermined templates, assumptions, and formulas,
and spaces for reflection and adaptation narrow. When an individual’s attention is
focused on an isolated event, piece of data, or individual at hand rather than the
overall data pattern, series of interrelated actions, or the interpersonal system, it
becomes difficult to recognize and correct missteps or omissions, seeding the po-
tential for error multiplication and complication.4 In these moments, it is important
for individuals, and those they work with, to realize and articulate how individual
and team interpretations of people, data, and interaction are becoming distorted
and unsafe. Box 3.1 details several communicative guidelines to help interpret
situations and begin to adapt to the specific situation as it presents itself.

Respect for Self, Other, and Context as Communication Goals

Having begun to interpret and adapt to the circumstance, the effective communi-
cator in emergency department settings is able to assess the communication milieu
30

Emergency Medicine Communication Principles 30

Box 3.1. Communication Guidelines for Interpreting and Adapting to
All Circumstances
1. All communication is purposeful

All utterances are motivated. Even small talk or what seems to be irrelevant is being
shared for a reason. The question to ask is, why is this person sharing this information
with me at this moment? Remaining curious as to why and what people share allows
for more flexibility and adaptability in directing an interaction so that it meets all needs.
2. Everyone has agency

Agency is the ability to cause a change in another’s behavior and does not require
expression to be present.
3. Interactions are built between 2 or more people and spiral
in trajectory

In every moment, there is a choice on how to respond to what another says or

does and change the direction of the interaction. Conversations are not scripts or
checklists. Conversations are constructed more in the format of “choose your own
adventure.”
4. 2 eyes, 2 ears, 1 mouth

The key to effective and adaptive communication is to listen and watch more than
speak. Words clarify, confirm, or dispel the multiple interpretations and meanings
we deduce from nonverbal cues only.
5. Listen for repetitions

Repetitions indicate another person’s core concerns. Individuals will always repeat
concerns if they feel they have not been heard or addressed. On the third repetition,
it is best to stop the direction of the conversation and address the concern. Further
progress will be impaired otherwise.
6. The body doesn’t lie and it always leaks

Occurring in clusters of distance/​space (proxemics), touch (haptics), body posture

and movement (kinesics), voice use and quality (vocalics/​paralanguage), and time
(chronemics), how we use bodies in space communicates the relational dimension
of any message. Nonverbal cues as our primary and primal form of communication
make up over 90% of all communication and occur largely out of awareness and con-
trol of an individual, providing critical information undisclosed in verbal messages.
7. Much conflict is born from challenges to face

People strive to maintain the face they have created in social situations, and loss of
face results in emotional pain. Many politeness strategies and etiquette rules are ded-
icated to the preservation of face—​be it self or other. To challenge someone’s face or
to lose face is a significant threat to ego and self-​worth.
8. One size does not fit all

An effective communicator is an adaptive communicator, paying attention to inter-

actional changes and adapting their behavior.
31

through the lenses of self, other, and context. These 3 goals allow the effective com-

31
municator to observe the many facets of the communication environment neces-

Keys to Effective Communication in All Circumstances

sary to appropriately interpret the situation and adapt to a particular circumstance
while respecting self, others, and context.

Goal 1: Respect for Self: Exercising Voice and Sustaining

Reflection in Action
Respect for self involves the practice of self-​monitoring and reflection in action.11
Reflection in action reflects on behavior as it happens, whereas reflection on action
means to reflect after the event, or review, analyze, and evaluate the situation. Schon
describes reflection in action as the ability to respond to surprise using improvisa-
tion on the spot.10 To be able to reflect in action, however, requires individuals to
assess their own state (physical, emotional, and mental) and express how that state
is impacting engagement with others. It also requires understanding the beliefs,
values, and ethical or moral grounds articulated in their interactions with others
and how they impact the ways in which interactions progress or not. Finally, respect
for self and reflection in action ask individuals to identify and articulate the inter-
personal, organizational, or social roles they inhabit in any given interaction. This
form of reflection and respect for self enables a careful assessment and expression of
how an individual can contribute meaningfully and carefully on a shift, on a team,
or with a patient or colleague and sustain future action and interaction with others.

Goal 2: Respect for Others: Constructing and Maintaining

Appropriate Relationships
The second communicative goal when adapting to circumstance is respect for others.
Accomplishing this goal involves the practice of other monitoring, or paying careful
attention to interaction partners, be they patients, colleagues, family members,
students, or supervisors. It also involves building trust through clear expectations
around appropriate actions and their effects on all parties involved. One dimension
of other monitoring involves being curious and eliciting perspectives from others to
understand their interests, values, and concerns in the interaction. This form of other
monitoring attempts to understand the why of an interaction—​what is motivating
or driving the interaction in a particular direction—​and asks the specific question
“Why is this person telling me this information now?” A second dimension of other
monitoring involves maintaining awareness of how interaction partners respond
to actions or contributions to the interaction. This form of monitoring requires a
heavier focus on watching and listening to another person in interaction to increase
responsiveness to their evolving state. Focusing on nonverbal reactions to your
contributions in an interaction, no matter how slight, can provide individuals with
guidance on where they most need to direct attention. Do people look away when
a particular topic is raised? Are they silent? Or do they divert your attention away
from the matter at hand?
A final dimension of other monitoring involves the larger interpersonal and
organizational context of the interaction in terms of monitoring the interpersonal
relationships or system in which another individual resides, for example, a family,
team, or department. It requires considering the roles or positions of others as well
as their relationships with others present or absent at the time. In a team, other
32

monitoring may involve paying attention to levels of expertise, familiarity, or even

Emergency Medicine Communication Principles 32
activity; in a family, attention may need to be paid to relational quality, or levels of
connection, authority, and responsibility. This dimension requires a practitioner to
consider who else might be involved “behind the scenes” or alternatively consider
whose rationale the other party is articulating if it seems inconsistent with what that
party has shared before. This dimension of respect for other is particularly impor-
tant when connected to respect for context as described next.

Goal 3: Respect for Context: Problem Setting and Maintaining

Situational Awareness
The third and final communication goal when adapting to circumstance—​respect
for context—​requires sustaining situational awareness and careful problem set-
ting.10 Problem setting, as opposed to problem solving, is the process of defining
the decision to be made, ends to be achieved, and means that may be chosen. Schon
described this process as a reflective conversation with the situation that requires
an individual to ask whether this is the right time, space, or place for an action or
interaction to be initiated or sustained or planned.10 Respect for context involves
continued and collective monitoring of changes in the environment and is often
addressed through teamwork skills of briefing, huddles, and debriefing within such
programs as TeamSTEPPs.11 These 3 actions—​brief-​huddle-​debrief—​support
team awareness and the establishment of a collective mind or shared mental model
when coordinating with other health care professionals. But these practices can be
extended into interpersonal interactions as well.
The premise for the brief is to set expectations, elicit perspective, form a mu-
tual agenda for action, and then preview or set a plan for action for all parties.
The brief usually happens prior to any action and its primary goal is to provide a
common point of reference and ground from which to coordinate action. As a re-
sult, it respects context by calling it into view and naming it clearly for all parties. In
doing so, a brief allows individuals to judge whether actions are appropriate for the
context.
Huddles, usually performed in the midst of action, are used to sustain common
focus, vision, and ground when situations evolve or need to change. A common rule
of thumb in the use of huddles (often called pauses or timeouts) is for them to be
employed when situations change or new information emerges. Here, respect for
context is demonstrated by monitoring and sustaining the visibility of the context
or shifting terrain on which action is taken for all parties to determine appropriate
paths forward. In an interpersonal context, a huddle is often expressed as a summary
of what an individual has heard or understood so far alongside a request for any
questions before proceeding further with the interaction.
Finally, debriefs, usually performed at the end of action or immediately after
it, respect context through reflecting on the appropriate courses of action taken.
Debriefs are critical to the continued learning and development of all parties to an
interaction and provide an important point of closure and connection, whether the
interaction is interpersonal or team based. In an interpersonal context, a summary
is also helpful as a debrief, although it is usually accompanied with some form of
feedback inquiry around what could have been or could be done differently to meet
all needs.
3

Undergirding all 3 of these communication practices is a desire to maintain

33
awareness and stay engaged with others in evolving, uncertain, and unpredict-

Keys to Effective Communication in All Circumstances

able situations. As a result, there are always concerns for safety—​for self, others,
and the team—​and a willingness to know when an interaction has become unsafe,
unconscious, or careless. In these moments, knowing where boundaries of self,
other, and context are under pressure and responding appropriately is paramount
to sustaining coordinated action over the long term. Although interactions can be
considered short term and episodic within the ED, they have knock-​on and long-​
term consequences for others because of the demand for throughput—​that is, the
patient has another destination once he or she departs the ED. With this destination
in mind then, retaining the ability to adapt also requires a capacity for and willing-
ness to stop interacting, reflect on actions taken, rewind if necessary to an earlier
point in time or action and change direction, and deflect or defer action to another
person, department, or time.

Interaction Design Skills for Unpredictable Communication

Environments
Using the guidelines in Box 3.1 can create and sustain effective communication in
the unpredictable communication environment of the ED. With these guidelines
in mind, effective communication or designing interactions to match the needs
of the situation follows a process of remaining in conversation with the situation
as it unfolds so that it accomplishes the goals of respecting self, other, and con-
text. Effective interactions and providers accomplish these 3 goals. In any mo-
ment, any one of the goals can take priority over the others, but they always work
interdependently to moderate and coordinate effective interpersonal and team
action. For example, a provider may disagree with a patient’s family member over
necessary emergent treatment for the patient, and respect for the context and self
as a clinical expert can exert tremendous force in advocating for what the pro-
vider considers to be right in terms of treating the patient quickly; but respect for
other, tempers, and moderates the approach by seeking understanding and finding
common ground and a solution that meets all needs. Committing to concordance
and exploring how individual purposes, concerns, and circumstances intersect can
determine anchors for shared decision making moving forward. In Table 3.1, we
present interaction design skills that accomplish the goals of respect for self, other,
and context while enabling providers to adapt to evolving clinical circumstances.
The right-​hand column outlines steps to take, questions to ask, or considerations to
make when accomplishing each skill.

APPLICATION OF INTERACTION DESIGN SKILLS OF

THE EFFECTIVE COMMUNICATOR IN VULNERABLE ED
PROCESSES
Research on communication in the ED has consistently found the following actions
and interactions as points of vulnerability: testing and evaluation, team huddles and
handoffs and working with other disciplines in the consult or admissions process,
and patient triage.6,7,9,12
34

Table 3.1. Interaction Design Skills That Accomplish the Goals of Respect for Self,

Emergency Medicine Communication Principles 34

Others, and Context
Interaction Design Skills

Set the interaction frame Setting the frame sets roles and
responsibilities, expectations for
participation, and communicative
norms regarding style, content,
and form. It involves asking the
following questions before any
interaction:
1. What kind of situation is this?
2. Who is involved?
3. What assumptions am I walking
in with and need to let go of?
4. What outcome is required?
5. What does the interaction
require of myself and others?
Choose appropriate relationship for the 1. Assess context
context12 a. Is this a chronic, minor,
Context-​appropriate relationships can change everyday situation or condition?
over the course of an interaction. It is b. Is it an emergent, life-​or-​death,
important to monitor 2 dimensions of any unusual situation or condition?
interaction: the nature of the context or 2. Assess competence
condition and whether the other person can a. Is my partner lucid, capable
partner with you. of engaging with me
Context is measured according to its stability, communicatively, capable of
duration, recurrence, and degree of severity. comprehending the information
Competence measures a person’s ability to I need to share?
collaborate and be in a relationship. Within b. Is my partner impaired in some
these 2 dimensions, 4 potential roles are way, unable to comprehend or
possible—​expert in charge, expert guide, unable to act willingly and in an
partner, and facilitator. The expert guide informed manner?
position is appropriate for high-​severity,
emergent situations and/​or a partner who is
unable to collaborate. In contrast, a facilitator
position is appropriate for minor, chronic, or
everyday situations with a competent partner.
Set clear expectations 1. Use nonjudgmental language—​Be
specific and descriptive
2. Structure expectations and/​or
feedback with actual objective,
observable, and modifiable
actions and words in context.
3. Use “when” statements to discuss
impact of behaviors in context.
35

Table 3.1. Continued

35
Interaction Design Skills

Keys to Effective Communication in All Circumstances

Pursue clarity 1. Clearly and frequently assess
what others know and how
others prefer to share and receive
information.
2. Assume nothing and be
curious—​focus on connecting,
gaining trust.
3. Avoid labeling—​it precludes
authentic conversation and
understanding.
4. Be careful how you frame
options and always check for
understanding before moving
to another topic and leaving a
conversation.
Manage the interaction floor 1. Use people’s names to draw their
The interaction “space” between 2 people is the attention or summon them to
floor. The speaker is the person who holds the the floor.
floor. Turn taking results in changes in who 2. Summarizing what someone
“holds the floor” and is signaled by pauses, has shared can “force” a turn to
intonation, and phrasing and is gender, age, end or take the conversation
and culturally inflected. in another direction, especially
Overlap is when 2 people are on the floor at the when followed by a question
same time. (i.e., signpost).
Inadvertent interruptions may occur when one 3. Openly, concretely, and
speaker overlaps another, causing a floor shift consistently elicit the perspective
unintentionally. of all those present.
Violative interruptions occur when one speaker
overlaps another with the intention of taking
the floor. Such interruptions assert dominance
and control over the conversation.
Counter chaos 1. Qualify contributors.
Chaos ensues when interaction rules are not 2. Ask “how did we end up with . . . ?”
followed, either consciously or unconsciously. 3. Reinsert topics for discussion or
return to them.
4. Elicit and introduce the
perspectives of others.
5. Question words/​phrases used—​
“what do you mean by . . . ?”
6. Open up discussions of other
values—​seek plurality and
diversity.
7. Resist pacification.
(Continued)
36

Table 3.1. Continued

Emergency Medicine Communication Principles 36 Interaction Design Skills

Chase concordance Ask-​Tell-​Ask

1. Gather information before
sharing it.
Separate-​Educate-​Negotiate
1. Separate out the issues.
2. Educate or share information
about each one separately,
summarizing after each
point and checking for
understanding.
3. Negotiate next steps—​given
this information, what makes
sense to do/​manage/​engage
with next?
Stay on the same page 1. Maintain proximity.
2. Huddle earlier and more often
to maintain situational
awareness.
3. Play to your strengths—​put
the right people in the right
role.
4. Never step out of a huddle
without knowing who is doing
what, and when.
5. Complete one task before
moving to another.
6. Seek and offer task assistance.
7. Remain quiet and calm at
“below 10,000 feet.”
8. Perform complete handoffs.
Sustain continuity 1. Situation—​what have we
Handoffs are used between team members observed?
and between teams to transfer information, 2. Background—​what do we
knowledge, authority, and responsibility to know about this person/​
maintain continuity of action. situation historically/​up
to now?
3. Assessment—​what have we
done so far? What do we think is
going on?
4. Recommendations—​what
do we need to do next?
Who will do what, when, and
how?
37

In this section, we draw on examples from recent ED shifts to examine how in-

37
teraction design choices can be adapted and combined in different circumstances

Keys to Effective Communication in All Circumstances

while maintaining respect for self, others, and context.

Vulnerability Point 1: Handoff for Admission

A 64-​year-​old male with metastatic bladder cancer has bounced back to your ED
with sepsis after his initial bladder resection and a complicated postoperative course.
His initial surgery did not go well as it was complicated by a ureter leak at the anasto-
mosis to the neobladder and he had an intraabdominal abscess requiring an explor-
atory laparotomy with a washout and open abdomen for several days. This patient
started out as a urology patient but ended up needing to be comanaged with general
surgery in the surgical intensive care unit (ICU) once the complications occurred.
The patient spent 3 weeks in the hospital prior to being discharged to a rehab facility
1 week ago. He presents today febrile to 103°F and tachycardic to 110 but with a
normal blood pressure. He has infected-​looking urine from his nephrostomy tubes
and seems to have developed new, acute renal insufficiency. Computed tomography
(CT) scan shows a small amount of free fluid in the pelvis, but no discrete abscess.
Thankfully, the patient is responding to your initial resuscitation in the ED and has
been given broad-​spectrum antibiotics.
You know that the patient needs to be admitted, probably back to the surgical
ICU. You contact the urology team, which is reluctant to take primary responsi-
bility for the patient as they are feeling unprepared to manage his infection, com-
plicated medical conditions, and new renal failure. They are concerned that he may
need another laparotomy with general surgery. They request that general surgery be
consulted and that the medical intensive care unit manage the patient as no imme-
diate surgical interventions are needed.

Application of Key Practices

The effective communicator sees this patient and the situation as an opportunity
to support and to build trust with a surgical colleague. By setting the frame in your
mind, you quickly see the situation as an important handoff to an inpatient team of
a patient who is critically ill. You clearly know that the patient needs to be admitted
to an intensive care setting; the issue is which service needs to take primary re-
sponsibility for the patient. Fortunately, the patient has responded to your initial
interventions so there is some time to negotiate a successful disposition for your
patient. The department is moderately busy, but you are on top of things currently
and you are feeling calm and centered at the start of your shift. You have a clear goal
for this patient as an admission to the surgical ICU with the urology team as the
primary service.
In choosing the appropriate relationship for the context, you know that the patient
is critically ill and that you need to push the issue about admission for this patient
soon, but you also see the context as being one where the urology consultants are
very competent and can be engaged as partners in the care of your patient. You rec-
ognize that if you position yourself as a partner or facilitator, instead of an expert in
charge, the situation will be more likely to result in a successful outcome for eve-
ryone involved. You see the need to support the urology team on call with capable
consultants that include the general surgery team, intensivist consultation team, and
38

renal medicine. After quick calls to the general surgery team (who flat out refuse to
Emergency Medicine Communication Principles 38
take “this urologic disaster” as the primary team) and the intensivist consultation
team (who remember this patient well from a few weeks ago), both services agree to
support the urology team in managing this patient in the surgical intensive care unit.
You chase concordance and sustain continuity by listening to the opinions of other
stakeholders so that you can negotiate the next steps with the urology team. You
call back the urologists to let them know that you talked with the consultants, but
you and the consultants are recommending that the urology team serve as the pri-
mary team for this patient. The urologist on the phone accepts the patient onto the
urology team and you state that you will call renal to set up dialysis for the patient in
the surgical intensive care unit.
The urologist takes an extra moment at the end of the call to thank you for going
the extra mile to allow the transition from the emergency department to the inten-
sive care unit to be a smooth one. You reflect on the experience briefly and recognize
that you could sustain continuity for the patient by setting the frame for the handoff
and choosing the correct relationship for the context when interacting with the urolo-
gist. You could build consensus and chase concordance about the proper admission
setting and services with the help of the other on-​call specialists. Taking the extra
effort to support the urologist in concluding that the patient needed to be on his ser-
vice in the surgical intensive care unit allowed you to show respect to the urologist
and ultimately do the right thing for the patient.

Vulnerability Point 2: Patient Care and Team Dynamics

It’s not a particularly busy day shift but it is early and you are noticing that flow and
logistics are a bit off today. The ED is not running as smoothly as you are accus-
tomed for it to be, especially when only half the beds are full. You notice that a urine
sample got missed at the bedside and this is delaying a patient’s disposition; a CT
scan that you ordered was delayed an hour because the prep was not started until
long after it was ordered. You are getting frustrated. You cannot seem to find a nurse
or a tech when you need one. A nurse and a tech come back out of breath, and you
ask why they are so out of breath. They tell you that they were taking a 10-​minute
break to run some stairs in the inpatient tower. You look over at the electrocardio-
gram (ECG) tech and she is surfing a travel website and has a social networking site
open on a hospital computer. You are about to say something that you will likely
regret when you think back about being an effective communicator in this moment.

Application of Key Practices

To counter the chaos that seems to have taken a hold on your zone, and recognizing
that you have been likely contributing to the issues in flow today, you call a quick
huddle with your team and decide to check in with everyone to see how things are
going. You pick up on 2 things immediately that you had not noticed earlier. You have
a very junior team with some experience in the ED but not a veteran team by any
stretch. There also seem to be a few team members who you are not used to seeing
and you don’t even know their names. You ask the group, “How are things going so
far today?” “Not bad from my perspective, Doc!” replies one of the nurses. “We are
39

down a couple of nurses today because of illness and we are keeping up pretty well

39
given our staffing shortages.” You continue to manage the floor by providing turns

Keys to Effective Communication in All Circumstances

to all the team members to contribute to the conversation while expressing your
concerns that things seem to be getting missed and flow within the zone is suffering.
The rest of the team relates that they were a bit stressed out being down a few team
members, especially not having many senior techs and nurses working today when
questions come up about how to handle certain situations. After one of the techs
admitted that he was a bit intimidated to ask you a question that came up about a
patient’s care, as he had not worked with you previously, the charge nurse chimed in
that you are acting a bit grumpy today. Everyone on the team, especially you, seems
to have a better understanding of why things were off in the ED this morning.
Before ending the huddle with your team, you describe the vision for the re-
mainder of the shift as needing to center on the need to support each other because
you are down nursing and tech staff, but you add the need to maintain attention to
patient care details. Because you set clear expectations and pursued clarity, the group
agrees to focus on minimizing inefficiencies and improving patient flow. The group
agrees to increase their attention to patient care details and to make a point of asking
questions about uncertainties in patient care to coordinate flow in the department.
You explicitly make the point of ensuring that everyone knows everyone else’s name
and that you are planning to call another team huddle a bit later in the shift to check
in with everyone. One of the techs mentions that she would like to have a debrief
after any patients needing resuscitation as it would help her to understand what is
going on with the patient and what next steps in patient care are. To stay on the same
page, the group agrees to this plan and the huddle ends to get back to patient care
just as a trauma alert gets called overhead.

Vulnerability Point 3: Patient Triage

You are 6 hours into an 8-​hour clinical shift and you are starting to feel exhausted.
It’s an evening shift that started at 5 pm and you had to be up most of the day already
to take care of other administrative responsibilities. This is your third shift in a row
and you are feeling tired. To top it off this is a new clinical shift where you are the “in-
take physician” who is seeing all the new patients who are walking into the ED. This
is a new process for your department and a relatively new role for you as a provider.
You are not feeling completely comfortable with your role in this new clinical shift
and you are starting to question some of the disposition decisions that you have
been making in the last hour.
There are now 8 patients to be seen and you are getting behind. You just got into
a 30-​minute argument with a patient with chronic abdominal pain and an exten-
sive, unremarkable workup in the past. This particular patient wanted you to “find
out once and for all what is causing his pain” and wants a refill of his long-​standing
benzodiazepine and opioid prescriptions as part of his visit. You are about to walk
in to see the next patient when you realize that you have not taken a break from pa-
tient care, used the bathroom, or eaten anything since you started your shift. You are
feeling cognitively overloaded and are starting to get short-​tempered with patients
and numb to their concerns. You need to be able to finish out the few hours that you
have left in your shift without harming yourself or the patients.
40

Application of Key Principles

Emergency Medicine Communication Principles 40 In setting the frame as one of task assistance, you fortunately realize that you work in
an ED with additional provider staffing until late into the evening. Other providers
are available to help in intake once things are getting backed up or bogged down.
Respecting yourself, you decide to call for help from another provider to take a
quick break from patient care to let your brain relax a bit, to take a break to use
the restroom, and to get something to eat. You choose the relationship for the context
as a “partner” as she has equivalent experience working in intake and certainly has
appreciated all the hard work that you have done for the department for the past
several hours. The other provider, your partner, is happy to help, especially as she
realizes that it has been very busy for you in intake and you have been making her
shift much better owing to the reduced volume in the main ED. After some coffee
and a snack, you are feeling quite a bit more refreshed. In setting clear expectations
for your team and staying on the same page, you take a moment to huddle with your
team to let the scribe, the nurses, and the techs with whom you are working know
how you are feeling and that they should speak up if they are seeing something that
doesn’t make sense or if you are missing anything in a patient’s care plan. They men-
tion that they had been noticing that you had been struggling for the past hour and
they all agree to help support you for the last few hours of your shift. In fact, one of
the nurses had already come up to you to see if you needed anything 30 minutes
prior to your break. With 2 providers in intake for 15 minutes, you catch up with
the patients needing to be seen and you feel much better emotionally and physically
after your quick break.

CONCLUSION
As inherently complex, evolving, and stressful communication environments,
EDs require adaptable providers capable of recognizing what kind of interaction
is needed in each circumstance. Individuals in EDs who can exercise situational
awareness and flex interaction design skills can respond appropriately, profession-
ally, and effectively in any circumstance. In this chapter, we have demonstrated how
particular combinations of interaction skills, appropriately chosen to meet patient
testing and evaluation, handoff and admission, and triage circumstances can prog-
ress team interactions while respecting self, other, and context. Shifting provider
perspectives from problem solving to problem setting, remaining in reflective con-
versation with the situation, and exercising voice to ensure clear expectations, roles,
and relationships can reduce misunderstandings, omissions, and errors in the ED.

REFERENCES
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physician activities in academic and community settings. Ann Emerg Med.
2011;58(2):117–​122.
2. Patterson DP, Pfeiffer AJ, Weaver MD, et al. Network analysis of team
communication in a busy emergency department. BMC Health Services Res.
2013;13:109. http://​www.biomedcetral/​com/​1472-​6963/​13/​109.
3. Chisholm C, Dornfeld A, Nelson D, et al. Work interrupted: a comparison of
workplace interruptions in emergency departments and primary care offices. Ann
Emerg Med. 2001;38(2):146–​150.
41

4. Pun J, Matthiessen C, Murray K, Slade D. Factors affecting communication in

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emergency departments: doctors and nurses’ perceptions of communication in a

Keys to Effective Communication in All Circumstances

trilingual ED in Hong Kong. Int J Emerg Med. 2015;8:48.
5. Spencer R, Coiera E, Logan P. Supporting communication in the emergency
department. Report for Center for Health Informatics and UNSW. Sydney, Australia:
University of New South Wales; 2002.
6. Behara R, Wears R, Perry S, et al. A conceptual framework for studying the safety
of transitions in emergency care. In: Henriksen K, Battles JB, Marks ES, et al., eds.
Advances in Patient Safety: From Research to Implementation (Vol. 2: Concepts and
Methodology). Rockville, MD: Agency for Healthcare Research and Quality (US);
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7. Eisenberg EM, Murphy AG, Sutcliffe K, et al. Communication in emergency
medicine: implications for patient safety. Comm Monogr. 2005;72(4):390–​413.
8. Street R. Communication in medical encounters: an ecological perspective.
In: Thompson TL, Dorsey A, Miller KI, Parrott R, eds. Handbook of Health
Communication. London: Lawrence Erlbaum and Associates; 2003:63–​89.
9. Williams K, Rose W, Simon R. Teamwork in emergency medical services. Air Med J.
1999;18(4):149–​153.
10. Schon D. Educating the Reflective Practitioner: Toward a New Design for Teaching and
Learning in the Professions. San Francisco, CA: Jossey Bass; 1990.
11. TeamSTEPPS® 2.0. Agency for Healthcare Research and Quality, Rockville, MD.
http://​www.ahrq.gov/​teamstepps/​instructor/​index.html. Content last reviewed
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patient relationships. Can Fam Physician. 2008;54(8):1089–​1092.
42
43

SECTION II   
PATIENT AND FAMILY
INTERACTIONS
4
45

4 Patient Communication
Michael Breyer and Lee Shockley

INTRODUCTION
Perhaps there is no skill more important for someone who takes care of patients than
communication. The Roman statesman and orator Cicero cautioned: “We should
be as careful of our words as of our actions.” Communication affects quality of care,
patient satisfaction and experience, and ultimately patient outcomes. Effective com-
munication empowers patients, assists in adherence to treatment plans, encourages
a more robust exchange of information, and, perhaps most important, allows the
patient and provider to develop a positive relationship.1,2
Since 2015, the Centers for Medicare & Medicaid Services (CMS) has tied the
Hospital Consumer Assessment of Healthcare Providers and Services (HCAHPS)
scores to its payment system.3,4 The HCAHPS is a multidimensional survey that
encompasses 8 key topics, 3 of which are directly tied to communication:

1. Communication with doctors

2. Communication with nurses
3. Responsiveness of hospital staff
4. Pain management
5. Communication about medicines
6. Discharge information
7. Cleanliness of the hospital environment
8. Quietness of the hospital environment

The Joint Commission recognizes that “a critical focus for patient safety, especially
skilled patient-​provider communication, is essential to creating a safe health care en-
vironment.”5 An analysis of 2455 sentinel events reported to the Joint Commission
46

found that the root cause was communication failure in more than 70% of them.6
Patient and Family Interactions 46
Finally, there is a significant correlation between unsatisfactory patient-​physician
communications and medical malpractice claims.7,8
Many plaintiff attorneys highlight communication problems for health care
workers, including physicians who

• would not listen,

• would not talk openly,
• were not available,
• attempted to mislead patients,
• devalued patient or family views,
• delivered information poorly,
• failed to understand the patient’s perspective, and
• did not warn patients or family members of long-​term neurodevelopmental
problems.

Communication has been targeted as a priority by the highest levels of the med-
ical profession. The American Medical Association (AMA) published a resource
folder, “Strategies for Leadership: Improving Communications With Patients and
Families,” with the goal of enhancing communication among hospital staff, patients,
families, and the community. It provides a quick assessment tool for leaders as
well as multiple case studies demonstrating initiatives hospitals have implemented
leading to positive outcomes.9
Providing episodic medical care in the busy and demanding environment of
an emergency department (ED) makes effective communication challenging.10
However, even in that environment, communication is a skill that can be learned
and attained. One study showed that adept emergency physicians establish rap-
port and trust in just a few minutes while gathering important information from
the patient.11
Understanding how to effectively communicate with patients, recognizing
barriers to doing so, and becoming proficient at this skill is central to the practice
of medicine.

BARRIERS
There are many challenges to establishing effective patient-​provider communica-
tion. Obstacles to effective communication may come from the environment, the
patient, or the provider.

Environmental Barriers
The physical characteristics of the design of an emergency department may lead to a
lack of privacy. Ambient noise may hinder communication. Interruptions to “linear
work flow” are common.12–​14 Interruptions occur more often in EDs than in primary
care settings, and senior doctors and senior nurses are interrupted more often than
other staff.15 Chisolm et al. showed that emergency physicians in a busy ED were
interrupted an average of 9.7 times per hour.16 Frequently, those interruptions are
stacked (interruptions to interruptions). The expectation of rapid patient turnover
47

in EDs, prolonged wait times, and physical plant factors have also been identified as

47
barriers to effective communication.10

Patient Communication
Barriers Characteristic to the Patient
There are currently more than 6 billion people in the world from 191 countries
speaking over 6000 languages. If emergency care providers are going to provide ef-
fective, high-​quality care for members of such diverse populations, they must ad-
dress a number of factors. These include language barriers, cultural barriers, and
previous experiences with the health care system. Patients may also fear the health
care experience or possible discrimination, hold different values from the provider,
and experience varying levels of acculturation.1,2,17 Language barriers lead directly
to delays in care, medical errors, and dissatisfaction for both the patient and the
provider.18–​20
The meaning of illness and health, the acceptance of treatment, and expectations
of the provider all have profound cultural influences.21 Previous negative cross-​
cultural experiences may lead to delays in seeking care. Patients may fear an envi-
ronment where their lifestyles are judged. This may be particularly acute in patients
who have problems with alcoholism, drug dependency, homelessness, sexual orien-
tation, or sexual identification. These fears may also lead to delays in seeking care or
in providing an incomplete or misleading history.
A patient’s level of comprehension should be taken into account. Medical termi-
nology may not be completely understood. The clinician should speak to the patient
with easily understood terms while not being perceived as “talking down.” For ex-
ample, a pediatric patient or an adult with limited education or English familiarity
may not understand, “Do you have abdominal pain?” but may understand “Does
your belly hurt?”

Barriers Characteristic to the Provider

A systematic review of 36 studies exploring physician-​related and physician-​
reported barriers to adequate communication and decision making in an intensive
care unit (ICU) setting found 90 barriers to communication.22 Of those, 46 were
related to physicians’ attitudes, 24 to physicians’ knowledge, and 20 to physicians’
practice. The attitudinal barriers included themes such as lack of consensus and
disagreements within the treating team, lack of autonomy, negative attitudes toward
the patient’s relatives because of their decisions, ethical values, diagnostic uncer-
tainty, and personal beliefs. Identified knowledge gaps included insufficient training
in critical communications, lack of communication within the treating team, lack
of understanding of existing policies and procedures, lack of familiarity with the
treatment options and prognosis, and unfamiliarity with ancillary services available.
The identified barriers from the physicians’ practice included competing
demands for the physicians’ time, the hierarchical medical team, low confidence
in taking responsibility, and the lack of institutional support. Furthermore, some
patients may feel more at ease with the communication style of resident physicians;
however, these physicians may have less time to spend with them. Attending
physicians, in contrast, through experience, may have more tools to communicate
with certain patients, but some could be challenged by an age gap. Both groups have
unique challenges and barriers to effective communication with patients.
48

POSITIVE EXPERIENCES
Patient and Family Interactions 48 The following are the communication-​related skills patients said they value most in
physicians23:

• Empathy
• Careful listening
• An open mind
• Friendliness
• Compassion
• A genuine interest in the patient
• Attentiveness
• Willingness to ask questions and initiate conversations
• Investing time and effort to educate patients and make sure they understand the
illness

Excellent communication leads to a positive healthcare environment (PHE).23 A

PHE, in turn, yields direct benefits for the patient. This results in enhanced safety,
satisfaction, confidence, doctor-​patient relationships, and perceived control for the
patient. PHE has the real potential to reduce a patient’s pain, nausea and vomiting,
learned helplessness, and stress.23
The consequences of a PHE for a provider include better mental, emotional, and
physical health. There is increased productivity, creativity, innovation, and engage-
ment. Reducing negative environments decreases conflicts, exhaustion, depression,
medical errors, suicide, chemical dependency, adverse patient outcomes, job turn-
over, burnout, and utilization of sick leave.23

SPECIAL CIRCUMSTANCES
Hostile Patients
Scope of the Issue
The hostile patient presents a unique challenge to the health care worker, with as
many as 15% of patient-​physician encounters rated as being “difficult.”24 The defini-
tion of a “hostile” patient includes patients with any or all of the following conditions:
alcohol intoxication, drug intoxication, assaultive to staff and others, abusive (phys-
ically or verbally) to staff and others, aggressive with staff and others, or otherwise
contributing to a provider-​patient interaction in an unhelpful or undermining
manner. The Occupational Safety and Health Administration (OSHA) estimates
more than 2500 assaults against hospital staff occur every year.
Furthermore, nearly 75% of all workplace assaults from 2011 to 2013 occurred
in health care settings, with 39% of nurses reporting verbal assaults each year and
13% reporting physical abuse.25 Seventy percent of staff members in mental health
settings reported physical abuse.25 That abuse sometimes continues outside the work
environment; 11.7% of health care workers report that they have been confronted
outside of the hospital, and 3.5% report having been stalked.26 Further complicating
matters, health care workers have widely varying thresholds for recognizing both
hostile patients and responses. Responses may vary from ignoring incidents and
giving in to patients’ requests to immediately calling for security personnel.27
49

Managing a hostile patient can be difficult for staff, taxing to the health care

49
system, and dangerous for all involved. In addition, this is an area in which many

Patient Communication
health care workers receive little training. Communicating in an effective, but safe,
manner with hostile patients is therefore a critically important skill.

Strategies to Manage Hostile Patients

A critically important first step in managing a hostile patient is self-​protection.
Interacting with a hostile patient in a closed room, with one’s back turned toward
the patient, is unsafe and may expose the health care worker to workplace violence.
Such risks must be avoided.
The health care worker should talk to patients from a safe distance while
attempting to determine the reasons for their hostility. Consider:

• Are they upset about a particular event or issue, such as whether they want food,
water, or pain relief?
• Are they agitated because they have had a difficult interaction with another
person?
• Are they upset because of an organic medical problem, such as hypoglycemia, an
acute neurologic condition, intoxication, or an overdose?
• Are they acutely psychotic?
• Are they fearful or frightened?

Using validating statements, such as “I can understand why you feel that way,” can
be helpful in defusing situations and redirecting the conversation toward what the
plan going forward will be. Empathizing with their current plight with statements
such as “Anyone would be scared/​frightened/​upset by what you’re going through”
can be helpful too.
In dealing with difficult patients, it is also important for the health care
worker to choose words carefully to help prevent the situation from escalating.
In their attempts to control the interaction, hostile patients may attempt to en-
courage the health care worker to engage in a highly charged exchange of words
with them. Instead, the health care worker should first remain calm and note
one’s own emotions and preconceptions. Replacing negative language and words
with positive language such as “Yes, I can see how upsetting this is for you” and
“Yes, there are a couple options open to you that I’d like to discuss with you” can
be helpful. These statements validate the patient’s concerns, convey empathy,
and use positive language to give the patient some control in a nonthreatening
manner.28
Body language, posture, and eye contact are all essential during these interactions.
Relaxing your facial expressions so that you are not scowling or grimacing, making
eye contact about half the time (don’t stare down the patient), keeping your hands
and arms placed in front of your body without being crossed, and maintaining a safe
and respectful distance from the patient are all important.
Determining the reasons for patients’ hostility, using nonjudgmental and open-​
ended questions to validate their feelings, and then defusing situations with body
language, all while maintaining a safe environment for the health care worker, are
paramount skills to learn and nurture.
50

TRANSGENDER PATIENTS
Patient and Family Interactions 50 Communication with transgender patients may pose some challenges for health
care providers. The Williams Institute estimates that 3.5% of the US population
identifies as lesbian, gay, or bisexual (LGB) and 0.3% identify as transgender.29
Reports of inappropriate and biased reactions from health care providers are
common; one study found that 21% of transgender respondents avoid going to
emergency departments because they feared negative experiences.30 Furthermore,
the majority of transgender patients felt that they were the ones providing educa-
tion to their providers. A number of organizations have attempted to provide edu-
cation to providers, including:

The Fenway Institute (http://​www.lgbthealtheducation.org/​)

The Joint Commission (http://​www.jointcommission.org/​lgbt/​)
The Center of Excellence for Transgender Health (http://​www.transhealth.
ucsf.edu)

Tips for addressing transgender patients include:

1. Show respect. Ask transgender people which name and pronoun they use in their
daily lives, for example: “How do you identify yourself and how would you like
me to refer to you while we are working together?” This strategy is more re-
spectful and considerate than using the pronoun that had been traditionally used
in the medical record, such as addressing a patient who is dressed as a woman as
“Mister” because the medical record indicates male sex. Some medical record
systems allow the input of a preferred name for display, such as DOE, JOHN
“JOAN” “HER.”
2. Show humility. “I have not encountered this before, so I would like to ask some
clarifying questions so that I can provide you the best care I can.”
3. Be professional. Ask only questions that are relevant to the medical issue at hand.
Avoid asking sensitive questions just out of curiosity.31

PATIENTS LEAVING AGAINST MEDICAL ADVICE

Discharge against medical advice (AMA) occurs when a patient decides to leave the
health care setting before the health care provider recommends discharge. Between
1% and 2% of all medical admissions result in an AMA discharge—​with predictors
of an AMA discharge being younger-​age patients, patients who have Medicaid in-
surance or no insurance, male gender, and substance or alcohol abuse history.32
Leaving AMA exposes the patient to the risk of an undiagnosed or inadequately
treated medical issue.33
There are a number of communication strategies to prevent AMA discharges,
including:

• Discuss substance abuse in a nonaccusatory manner. Health care workers who

maintain an empathetic, positive manner toward patients are more likely to pro-
vide an effective evaluation.34
• Recognize and acknowledge patients’ emotions and feelings behind their desire
to leave AMA. Anger, anxiety, and depression can all contribute to feelings of
51

helplessness,35 underscoring the need for health care providers to remain em-

51
pathic through their speech and interactions with patients.36

Patient Communication
• Communicate in a manner that is proactive, empathic, and nonjudgmental.
Telling patients their care will not be compensated if they sign out AMA or that
they are making a bad decision may be viewed as judgmental. Instead, providers
may try to better understand the unique reasons their patients want to leave AMA
and then address those concerns. Health care providers who are able to forge a
therapeutic alliance with their patients through motivational interviewing can
help patients make the best decisions for their care and build better trust with the
health care system.37

PATIENTS WITH PSYCHIATRIC DISORDERS

Scope of the Issue
There are about 35,000 state inpatient beds for psychiatric patients nationwide;
many psychiatric patients must seek other venues for treatment, including outpa-
tient facilities, outpatient medical management groups, community resources, and
hospital emergency departments.38 The Centers for Disease Control and Prevention
estimates that about 10% of all ED patients present with psychiatric illness.39 In ad-
dition to acute psychiatric emergencies, patients with mental health disorders seek
care for illnesses and injuries that may or may not be directly related to their psy-
chiatric diagnoses. As many as 45% of adult patients and 40% of pediatric patients
who present to the ED with nonpsychiatric complaints have undiagnosed mental
illnesses.40, 41
Surveyed emergency psychiatric patients express their desire for42

• verbal interventions,
• use of oral medications,
• input regarding their medication experiences and preferences,
• peer support services,
• improved discharge planning,
• a better triage process,
• reduced wait time for treatment and
• more privacy.

Strategies for Communicating With Patients With Psychiatric

Disorders
Remember that psychiatric patients in mental health facilities have specific rights.
These include rights that cannot be denied43:

• The right to humane care

• The right to be free from abuse or neglect
• The right to social activities and recreation
• The right to education
• The right to religious freedom and practice
• The right to be free from discrimination
52

They also include rights that can be denied with good cause43:
Patient and Family Interactions 52
• Clothing
• Money
• Visitors
• Storage space
• Personal possessions
• Telephone
• Mail
• Writing materials

Although emergency departments are not mental health facilities, emergency

clinicians must vigilantly protect the rights of all patients by doing the following:

• Recognize that mental illness does not affect patients’ intelligence. To every ex-
tent possible they should participate in their care and medical decision making.
Make an offer rather than a demand. For example, “I can see that you are upset
and agitated. Anybody would be in your circumstance. Would it be okay if I or-
dered a medication for you that will help you calm your mind and make this
easier for you?”
• Restraints, physical or chemical, are only to be used for the safety of the patient
or staff. They are never to be used punitively. In addition, they should be discon-
tinued as soon as the threat has passed.
• Unless patients lack the capacity to make decisions (as judged by their ability to
understand the risks, benefits, and alternatives of the care offered), they are in
charge of their own medical care choices.

VIPS
Scope of the Issue
VIPs are patients who, because of their notoriety, position, or influence, have a ten-
dency to cause clinicians to step out of their usual manner of assessment or treatment.
It may mean excluding important aspects of the history or physical examination be-
cause of perceived embarrassment or discomfort. It may mean overtreatment (“just
to be safe”) or undertreatment (“I don’t think that’s really necessary in this case”).
It may also mean deferring the patients to more senior providers. There may be out-
side pressures from third parties for certain treatments, the involvement of specific
providers, a transfer to another facility, or access to privileged information.

Strategies for Communicating With VIP Patients

Mariano and McLeod suggest 3 directives for caring for VIPs44:

• Vow to value your medical skills and judgment.

• Intend to command the medical aspects of the situation.
• Practice medicine the same way for all your patients.

Guzman et al. describe 9 principles in the effective care of the VIP patient45:
53

1. Don’t bend the rules.

53
2. Work as a team, not in “silos.”

Patient Communication
3. Communicate, communicate, communicate.
4. Carefully manage communication with the media.
5. Resist “chairperson’s syndrome.”
6. Perform care where it is most appropriate.
7. Protect the patient’s security.
8. Be careful about accepting or declining gifts.
9. Work with the patient’s personal physicians.

Not surprisingly, 2 of these principles directly address communication. Clear and

complete communication is important when caring for VIP patients. The VIP pa-
tient, the patient’s family, accompanying physicians, and the care team should all
be included. The media will invariably expect a release of information. However,
the confidentiality of the physician-​patient relationship must be safeguarded. Any
disclosure of health information can only be done with the consent of the VIP pa-
tient or his or her designated surrogate. Generally, having a single, senior physician
spokesperson providing regularly scheduled press conferences held away from the
site of the patient’s care is an efficient method of communicating a message that will
satisfy the media’s need for information.

PRISONERS
The degree of civilization in a society is revealed by entering its prisons.
—​Fyodor Dostoyevsky, The House of the Dead, 1860

. . . the treatment of . . . criminals mark and measure the stored-​up strength of a nation, and are
the sign and proof of the living virtue in it.
—​Winston Churchill, House of Commons speech, given as Home Secretary, July 20, 1910

Scope of the Issue

There are almost 2.3 million people convicted of crimes incarcerated in the United
States. In addition, there are over 536,000 in pretrial detention.46 Further, the av-
erage age of prisoners is increasing, as are their medical needs.47

Strategies for Communicating With Incarcerated Patients

The American College of Emergency Physicians Public Health Committee has
published 9 general guidelines for emergency medical staff in providing care for
detainees.48 Five of the guidelines deal directly with communication:

• Listen carefully to the complaints.

• Provide the detainee with information about required tests, results, discharge
instructions, prescriptions, and so forth as you would for any other patient.
• Instruct the accompanying officer on any medical or physical limitations (e.g.,
shoulder dislocation) that the detainee may have that would influence the way the
detainee is positioned or shackled.
54

• The disposition of the patient must always be communicated as early as possible

Patient and Family Interactions 54
to the accompanying officer.
• Communication options with the correctional facility and the health care serv-
ices available at the detention facility must be known by all ED staff who service
the inmate population in the area.

Just because patients are incarcerated does not mean that they have no say over
their medical care choices. Just as with any other patient, if they have the capacity to
make decisions, prisoners must be given the authority to make their own medical
decisions, including the refusal of care. The difference is that prisoners do not have
the choice of where they are incarcerated: Prisoners can be admitted to a correc-
tional care facility even if they refuse care.
The clinician’s fiduciary responsibility is to the patient. However, one should
avoid prisoner-​institution conflicts. Complaints that prisoners may have about
their treatment should be received and passed along to those in authority without
making promises. For example, if the prisoner says, “Doc, these handcuffs are awful
tight. Can you tell the guards to loosen them?” the response may be, “I understand
that it’s uncomfortable but I have no authority over the guards. I cannot loosen the
handcuffs but I will make sure that the guards know that it’s causing you pain.”
One must always be aware of safety and security. It is a good practice to leave the
timing of upcoming follow-​up visits vague. “We will have you back in a week or so to
have the stitches removed” is better than, “Your stitches need to come out in 7 days.”

NONVERBAL PATIENTS
Patients may become nonverbal as a result of trauma, being deaf and hard of
hearing, stroke, cognitive disability, and psychosomatic illness. These patients pose
a challenge for the health care provider as the provider cannot rely on verbal means
of communication. The use of nonverbal communication tools, including touch,
facial expressions, pupillary dilation, and body language, take priority. However,
many health care providers have not received extensive training in nonverbal
communication cues.
Resource allocation, including the use of American Sign Language (ASL)
interpreters, communication cards, and family members who may be able to better
understand the patient, should be used liberally for these patients. This, of course,
can take additional time, which may be challenging in some health care situations.

COMMUNICATING UNCERTAINTY
Some patients who present to the hospital or health care setting may not have a clear
diagnosis (e.g., the patient may have a diagnosis of abdominal pain of uncertain eti-
ology) or a patient may have an unclear prognosis (e.g., the health care provider may
be uncertain as to the overall cognitive prognosis for a patient with a brain injury).
It is important during these times for the health care provider to do the following:

1. Avoid labeling. Patients given a diagnosis of gastroesophageal reflux disease as

a reason for their chest pain may be less likely to return or seek additional help
when their actual diagnosis is something different.
5

2. Convey honesty and humility. Sometimes we are unable to provide a diagnosis

55
for patients. It is preferable to let patients know that their diagnosis remains

Patient Communication
uncertain and to provide them strict return precautions.
3. Provide medical information about the risk of the most harmful diagnosis.
Patients with chest pain and an initially negative workup may still have a
myocardial infarction or other serious diagnosis. Arming patients with that
health care information to make informed decisions about their condition is
often helpful.

DELIVERING BAD NEWS

They may forget what you said but they will never forget how you made them feel.
—​Carol Buchner, 1971

Scope of the Issue

The practice of emergency medicine presents many challenges; one of these is due
to the fact that emergency practitioners provide “episodic care.” This can be espe-
cially difficult when one must deliver bad news immediately after meeting a patient
or his or her family. It can become very uncomfortable for all involved. The mala-
daptive way of dealing with that discomfort is to limit exposure: delegating the task
to another or spending as little time as possible in the encounter. The problem with
that strategy is that it creates a spiral in which each interaction makes the next worse
until finally there is an important part of the practice that the clinician can’t face.
With preparation, it doesn’t have to be like that.

Strategies for Delivering Bad News

• Setting: Ideally, the ED should have a “family room” dedicated to the task of
speaking with the bereaved family. It should be separate from the waiting room,
close to security personnel, private, and quiet. Preferably, it should have its own
restroom facilities and telephone. It should be furnished with comfortable chairs
and couches. It should be large enough to accommodate at least 10 to 15 people.
• Preparation and introduction: The bereaved family should be greeted when
they arrive and placed in the family room. They should be informed that a cli-
nician will speak with them as soon as possible. After the resuscitation is over,
the team should decide who will speak with the family. That person should be a
physician—​this is not the sort of task that can be delegated to a nurse, chaplain, or
social worker. The person who will be speaking may need to change into a clean
uniform before meeting the family. It is important that the correct family for the
patient in question is identified to avoid giving bad news to the wrong family. The
notifying physician enters the room (sometimes accompanied by other members
of the team) and shakes hands with the family members while introductions are
made: “Hello, I’m Dr. Jones. I was in charge of the resuscitation.” Then everyone
sits down. It is very important to do this seated. The family should feel as if they
have the physician’s complete attention. In effect, this family is the physician’s
next patient.
56

• Past: Some clinicians like to open the encounter by “firing the warning shot.” They
Patient and Family Interactions 56
start with, “I’m afraid I have some very bad news for you.” In general, that strategy
is a physician preference and probably not necessary because the family already
knows that things aren’t good. Another strategy is to invite the family to speak by
starting with, “Tell me what happened at the house.” Or, “Tell me what you have
heard so far.” This allows the family to speak. It shouldn’t go on for long and the
physician doesn’t have to ask questions; this is not history taking. Typically, it is a
few sentences. The physician then “takes over the story” and fills the family in on the
care provided by emergency medical services (EMS) or the ED. Again, this is brief,
just a few sentences: “The paramedics started CPR and put in a breathing tube. We
continued those efforts here and gave medications and shocked her heart.”
• Present: Now comes the death notification. It should be clearly stated without
euphemisms. Rather than saying, “She’s no longer with us” or “She’s passed on,”
the notification could be, “There was nothing further that could be done and so
she died.” At this point there is usually an outpouring of emotion in the room that
waxes and wanes. When there is crying, that is the time for the physician to sit
quietly with the family. If they ask questions, they must be addressed as honestly
but as sensitively as possible. When the emotion wanes and the room quiets, that
is the time for the physician to speak. Reassurance helps here: “You did the right
thing for her.”
• Future: In most jurisdictions, a death in the ED is reportable to the coroner.
The family should be informed that the coroner may investigate the death. This
could include interviews with the family or an autopsy. In most cases, the offer
for the family to see the deceased can be made. In most hospitals, a designated
“requestor” will approach the family to inquire about their interest in organ or
tissue donation. Prior to leaving, the physician should notify the family of who is
coming in to speak with them next (social worker, chaplain, charge nurse, etc.).
Prior to closing the encounter, ask the family, “Is there anything further that I
can be doing for you right now?” Typically, their requests are very simple (drink
of water, use of the telephone, notification of other family members, etc.). Upon
leaving, the physician shakes hands with the family members and says, “I’m sorry
to have to bring you that news.” It’s best to not just say “I’m sorry,” because that
may be interpreted as an apology.
• Via telephone: If the notification must be done via telephone, there is an addi-
tional burden of establishing credibility. Begin the call with something like, “This
is Dr. Jones calling from General Hospital. Before we talk, I want to give you the
phone number here so you can call back if we get disconnected.” That also allows
the family member to call and confirm the true identity of the hospital and caller.
Start the notification with, “Tell me what you’ve heard so far.” The response could
be, “Her neighbor just called me and filled me in on everything.” In that case,
simply cover the past, present, and future as you would have in person. The only
difference is that they know the outcome. If the response is, “I haven’t heard an-
ything. Tell me what happened,” open with the warning shot, “I’m afraid I have
some very bad news for you.” Then go into the past, present, and future as you
would have in person.
• The advantage of this system is that it is easy to remember (the past, the present,
and the future) with a few key phrases to remember to use. It is also “portable” in
that it can be used for all sorts of bad news. Instead of, “There was nothing further
that could be done and so she died,” the physician can substitute, “Her condition
is critical and she is in the operating room.”
57

IMPROVING THE PROVIDER-​PATIENT RELATIONSHIP

57
Medicine is an art whose magic and creative ability have long been recognized as residing in the

Patient Communication
interpersonal aspects of patient-​physician relationship.
—​J.A. Hall, 1981

The patient–​health care provider relationship starts with a large power imbalance.
Reducing this imbalance can empower patients to communicate more openly and
receive better care.49 Patients remember 7% of what was actually said (content), 38%
of how it was said (verbal cues), and 55% of how you looked while saying it (body
language),50 reinforcing the importance of nonverbal communication with patients.
Health care providers in training have a large volume of information and med-
ical facts to absorb. Training schools have historically focused on medical know-
ledge and patient care, with less emphasis on communication as a skill to be taught,
developed, and mastered. This has begun to change; at the American Medical
Association’s annual meeting in 2015,51 the acronym RESPECT was introduced to
help students remember communication skills:

Rapport—​physical appearance, level of eye contact, and giving patients one’s

complete attention and listening carefully help build it.
Explain—​ask patients open-​ended questions that encourage dialogue.
Show—​show patients support by providing educational materials and
information about resources.
Practice—​practice good communication and ask for feedback.
Empathy—​offer encouragement and support to your patients through verbal
and nonverbal cues.
Collaboration—​partner with patients to identify barriers and engage them in
decision making.
Technology—​use technology, but do not overuse it.

Strategies for Communicating Effectively With Patients

1. Appearance: Sit down at eye level or lower, approximately 3 to 5 feet away.
Patients perceived that the time spent with a provider was longer, that the
interaction was more positive, and that they had a better understanding of their
condition when the provider was seated as opposed to standing.52
2. Show an open posture by keeping your arms at your sides. Maintain good
eye contact (3 to 5 seconds) if culturally appropriate, smile, and dress
appropriately.
3. Speaking: Speak slowly and quietly and lower the tone in your voice.
4. Words: Introduce yourself, use the patient’s last name to minimize the
power imbalance, acknowledge everyone in the room, and speak with
easy-​to-​understand words.

Pitfalls in Communicating With Patients

1. Try not to fold your arms over your chest as this can be seen as aggressive to
patients.
2. Do not ask why the patient did not come in earlier or why he or she came
in now as both can be seen as accusatory. Instead, providers may try to use
58

empathy to acquire the same information, such as: “It seems like you had to stay
Patient and Family Interactions 58
home and try to treat yourself over the past week. Can you tell me more about
how your illness has progressed?”
3. Repeatedly asking “why” or using the words “never” or “always” can be seen as
rigid to patients.

Empathy
Empathy, the ability to understand and share the feelings of another, is a critical trait
for health care providers to develop. Reflective listening involves 2 steps: seeking to
understand a speaker’s idea or thought and then offering it back to the speaker to
confirm that it has been understood correctly. They are intertwined in an effective
communication strategy with patients.
To improve empathetic communication:

1. Understand the patient’s agenda by stating, “Help me understand what I can do

for you.”
2. Repeat or paraphrase what the patient says, clarifying that the message received
is the one that was intended.
3. Carefully identify feelings, such as, “You seem frustrated/​worried/​concerned
about . . . ” and then validate them: “I can see why you would feel that way.”

RELATE is a mnemonic for empathetic listening:

Reassure—​explain your qualifications and experience.

Explain—​describe what the patient can expect.
Listen—​and then reflect back to the patient what you heard.
Answer—​and encourage questions.
Take action—​keep the patient informed.
Express appreciation—​thank the patient for trusting you with his or
her care.

The Studer Group has developed another tool for enhancing health care provider–​
patient communication, coined AIDET53:

Acknowledge—​provider greets the patient and all family members/​friends in

the room, preferably using their last name when appropriate.
Introduce—​provider introduces him-​or herself, notes how long he or she has
been practicing, and tells the patient about the team with which he or she is
working.
Duration—​tell the patient the expected length of time tests will take.
Explanation—​explain the tests and treatment plan.
Thank—​thank the patient for trusting us to take care of him or her.

AIDET has been shown to improve communication skills among resident

physicians54 and has been adopted by several hospitals and institutions. This tool
has been shown to improve patient-​centered feedback in the areas of “nurses ex-
plain,” “doctors explain,” and “nurses listen.”55
59

COMMUNICATION BOARDS/​W IPE BOARDS

59
Communication boards tend to be dry-​erase boards with important information

Patient Communication
designed to convey names of the care team, tests, and plans of care for the patient.
Although the effectiveness of these boards has not been extensively studied, anec-
dotal reports from providers and patients note an improvement in the level of en-
gagement and communication among them.

FUTURE TOOLS
With more than 25 million people living in the United States who have limited English
proficiency56 as well as communication challenges with other patients, tools that
help health care workers to communicate better are becoming essential. The Limited
English Proficiency (LEP) Executive Order signed in 2000 directs that people who
have LEP should have meaningful access to federally conducted and federally funded
programs and activities.57 The US Department of Justice published a Policy Guidance
Document, “Enforcement of Title VI of the Civil Rights Act of 1964—​National
Origin Discrimination Against Persons With Limited English Proficiency” (LEP
Guidance), to assist in the proper interpretation of these requirements.58 Language
interpretation assistance can come from on-​site trained interpreters or telephonic or
live video interpreters. The following apps are designed to help:

1. MediBabble Translator, a free medical interpretation app, features thousands of

translated questions and instructions and can be used to direct patients through
a physical exam: http://​medibabble.com.
2. Canopy Speak contains a library of medical phrases in Spanish, Chinese,
French, Arabic, Hindi, Japanese, and several more. Health care workers may
also call a live medical interpreter for free with a one-​button tap: http://​
withcanopy.com/​speak/​.
3. Google Translate translates texts in more than 100 languages, 52 without
needing internet access. It also has a camera mode to translate text in 29
languages: https://​play.google.com/​store/​apps/​details?id=com.google.
android.apps.translate&hl=en.
4. VisualDX may be used by health care workers to educate patients about their
disease and diagnosis: https://​www.visualdx.com.
5. Visual Anatomy Lite, an interactive anatomy reference, contains more than 100
images with 3D rotational models. It can be used as a learning tool for health care
workers or for patients to explain conditions and injuries: http://​myhealthapps.
net/​app/​details/​455/​visual-​anatomy-​litefree.

Communicating in an effective, comprehensive, and caring fashion with patients is

an essential skill for health care workers. It improves patient and staff satisfaction,
prevents medical errors, decreases staff burnout, and improves care. Although many
challenges and barriers to communication exist in the medical environment, there
also exist several tools and strategies to train and assist health care workers.

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patient-​and family-​centred decision-​making towards the end of life in intensive care:

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predictors and outcomes. Arch Intern Med. 1999;159:1069–​1075.
25. Ferguson D. Workplace violence in healthcare: Underreported and often ignored.
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26. Kowalenko T, Walters BL, Khare RK, et al. Workplace violence: a survey
of emergency physicians in the state of Michigan. Ann Emerg Med.
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27. Arik C, Anat R, Arie E. Encountering anger in the emergency department:
identification, evaluations and responses of staff members to anger displays. Emerg
Med Int. 2012 (August):1–​5.
28. Lampert L. How to Handle Difficult Patients. Ausmed, 05 Oct 2016. https://​www.
ausmed.com/​articles/​how-​to-​handle-​difficult-​patients/​. Accessed September
10, 2017.
29. Flores AR, Herman JL, Gates GJ, et al. How Many Adults Identify as Transgender in
the United States? The Williams Institute, June 2016. https://​williamsinstitute.law.
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United-​States.pdf. Accessed September 9, 2017.
30. Bauer GR, Scheim AI, Deutsch MB, et al. Reported emergency department
avoidance, use and experiences of transgender persons in Ontario, Canada:
results from a respondent-​driven sampling survey. Ann Emerg Med. 2014
Jun;63(6):713–​720.
31. Henkel G. Respectful communication key to reducing barriers to care for transgender
patients in the ED. ACEP Now, March 7, 2014.
32. Alfandre DJ. “I’m going home”: discharges against medical advice. Mayo Clin Proc.
2009;84(3):255–​260.
33. Hwang SW, Li J, Gupta R, et al. What happens to patients who leave hospital against
medical advice? CMAJ. 2003;168(4):417–​420.
34. Gallagher RM. Empathy: a timeless skill for the pain medicine toolbox [editorial].
Pain Med. 2006;7(3):213–​214.
35. Schlauch RW, Reich P, Kelly MJ. Leaving the hospital against medical advice. N Engl
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36. Levinson W, Gorawara-​Bhat R, Lamb J. A study of patient clues and physician
responses in primary care and surgical settings. JAMA 2000;284(8):1021–​1027.
37. Epstein RM, Franks P, Shields CG, et al. Patient-​centered communication and
diagnostic testing. Ann Fam Med. 2005;3(5):415–​442.
38. Torrey EF. A dearth of psychiatric beds. Psychiatric Times. 2016;33:2.
39. Centers for Disease Control and Prevention (CDC). Emergency department visits
by patients with mental health disorders—​North Carolina, 2008-​2010. MMWR
Morb Mortal Wkly Rep. 2013;62(23):469–​472.
40. Downey LV, Zun LS, Burke T. Undiagnosed mental illness in the emergency
department. J Emerg Med. 2012;43(5):876–​882.
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emergency department. Pediatr Emerg Care. 2018;34(2):e21–​e23.
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42. Allen MH, Carpenter D, Sheets JL, et al. What do consumers say they want and need
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during a psychiatric emergency? J Psychiatr Pract. 2003;9(1):39–​58.
43. California Department of Health Care Services. Rights for individuals in mental
health facilities. https://​www.dhcs.ca.gov/​services/​Documents/​DHCS_​
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45. Guzman JA, Sasidhar M, Stoller JK. Caring for VIPs: nine principles. Cleveland Clin J
Med. 2011;78(2):90–​94.
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geriatric health-​care challenges in correctional facilities. Int. Rev Red Cross
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48. ACEP Public Health Committee. Recognizing the needs of incarcerated patients
in the emergency department. https://​www.acep.org/​administration/​resources/​
recognizing-​the-​needs-​of-​incarcerated-​patients-​in-​the-​emergency-​department/​#sm.
00000ykzz6yauedqpug1hzxcaqsfr. Published April 2006. Accessed October 6, 2018.
49. Hall JA, Roter DL, Rand CS. Communication of affect between patient and
physician. J Health Soc Behav. 1981;22(1):18–​30.
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review. CMAJ. 1995;152(9):1423–​1433.
51. 6 simple ways to master patient communication. AMA Wire. https://​wire.ama-​assn.
org/​education/​6-​simple-​ways-​master-​patient-​communication. Accessed September
12, 2017.
52. Swayden KJ, Anderson KK, Connelly LM, et al. Effect of sitting vs. standing
on perception of provider time at bedside: a pilot study. Patient Educ Couns.
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studergroup.com/​aidet.
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communication (body language). Personality and emotion tests and software:
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gov/​sites/​production/​files/​2015-​03/​documents/​lepguide.pdf
63

5 Communication
With Family

Daniel L. Handel and Stefani D. Madison

KEY ELEMENTS OF COMMUNICATION

Emergency medicine providers must communicate important information to
families clearly, accurately, and efficiently, often in suboptimal settings and without
the benefit of an established relationship. Families are vulnerable to situational
stressors that limit their abilities to effectively receive information and navigate
medical decision making. Poor communication in these settings can threaten
doctor-​family relationships and invite trauma as part of the health care experience.
This chapter focuses on relatively brief and straightforward approaches to improve
communication, foster trust, and provide opportunities to test comprehension of
shared information. To follow are several tools to facilitate effective communication
with the family.

ETHICAL AND LEGAL CONSIDERATIONS WHEN

TALKING TO FAMILIES
Relationships can enhance confidence and the ability to effectively receive impor-
tant or sensitive information in emergency department (ED) settings. The presence
of family members in ED settings can enhance or jeopardize this relationship. The
presence of family often demands enhanced interviewing skills and careful atten-
tion to legal and ethical mandates.
64

Definition of Family
Patient and Family Interactions 64 The growing diversity of families served in ED settings invites a redefinition of
family as “persons who are connected biologically, emotionally, or legally,” which
includes both traditional and nontraditional family units. Families can also present
as deeply concerned and involved friends, neighbors, hired caregivers, or clergy/​
church members. We recognize the term family as defined by the patient in this
chapter.1

Managing a Visit With Family

A patient’s family can be an appreciated and welcomed source of health information
during an ED visit. Families may serve as advocates for patients incapacitated by
trauma, dementia, or other illnesses. The indecisive patient may invite help from
family to navigate complicated medical decision making. Families can also provide
useful medical information and aid safe discharge planning. However, this thera-
peutic alliance between patient, family, and ED provider is dynamic and demands
constant attention and clear language from the provider.
The physician’s first responsibility is always to the patient, and the ED interview
should focus on the patient’s concerns and needs. This focus can be demonstrated
when beginning the encounter by introducing yourself to the patient first, then to
the family member(s) in attendance, and inquiring about their relationships and
asking the patient who should be present during the interview. Physical position can
also help; be sure to face the patient, but try to position yourself in such a way that
you’re also able to notice others’ body language and expressions. Acknowledging and
naming expressed emotions enhances the sense of “being heard” and can significantly
de-​escalate tension or anger. Recognizing and expressing appreciation for family in-
volvement and advocacy in the patient’s care can rapidly build rapport and facilitate
decision making. This also encourages collaboration through an understanding of the
presenting complaints in the context of the patient’s family, culture, and beliefs. This
has been shown to result in better health care outcomes and patient satisfaction.2,3

Challenges Encountered During Family Encounters

Challenging ED situations can result when encountering families in conflict or with
unhealthy communication patterns, often resulting from past emotional wounds as-
sociated with abuse or neglect. Resulting complicated or disruptive communication
is best addressed through a neutral stance by the provider while guiding the inter-
view back to the presenting problem. Family conflict can interfere with the medical
process in ED settings and distress other patients and staff. Behavioral rules should
be shared with all members in a firm and neutral voice, including the response that
a next infraction will bring. Asking for silence and returning to face the patient are
often sufficient to lessen intrusive behaviors. The following behavioral clues can
alert the provider to potential abuse:

• The family is reluctant to leave the patient alone with the medical team.
• A family member answers for the patient without direct invitation.
• A patient seems reluctant to speak in the presence of a family member.
• There are any physical signs of abuse.
65

The provider can request privacy during the examination, which may pro-

65
vide an opportunity to further explore fears or concerns for neglect or abuse.

Communication With Family

This practice should be guided by local statutes, including statutory reporting
requirements.
Pérez-​Cárceles’s physician survey highlights inadequate knowledge and fre-
quent ethical missteps by physicians that can threaten patients’ “rights to informa-
tion, privacy, and confidentiality, and that they should reflect very carefully on the
fine balance between this and the occasional need for the support and collaboration
of family members in offering care.”4

Patient or Family Request for Nondisclosures

Families sometimes request nondisclosure of bad news to protect the patient
from its attendant distress or from the risk of disheartenment. When the pa-
tient has the capacity for medical decision making, the provider is ethically
bound to inquire of the patient the degree to which the patient desires to di-
rect, or have others direct, his or her medical care. One example of this inquiry
follows: “Are you the kind of person who wants to know all of your test results
and make all of your own medical decisions, or would you prefer I discuss
these with your children?” Asking these questions in the presence of family can
sometimes make clear the patient’s preferences and ease the family’s burden to
protect.5
Sometimes patients request to not disclose health information to family
member(s). The ED provider is bound to honor this request, except under very
narrow and explicit conditions (imminent threat to self or others). The Health
Insurance Portability and Accountability Act states that health professionals may
share relevant health care information with family members only if the patient
agrees to or does not object to the disclosure.6 Maintaining respect and confidenti-
ality should be the priority.

MODELS FOR EFFECTIVE COMMUNICATION

Effective communication can be the catalyst for patient satisfaction and com-
prehension of the plan of care. If thoughtful consideration is not given to patient
interactions, it can impede efforts in gathering or giving information. This nega-
tive example demonstrates language that conveys data (all true): “The blood tests
are abnormal. We’d like to get an echocardiogram. The tech will be here in a few
minutes.” However, it provides no helpful context or reassurance (which tests are
abnormal, how severely abnormal, and of what clinical importance) or expectations
for next steps (when, how, and by whom this test will be done; how it will feel; how
long it will take). Communication models like AIDET and ask-​tell-​ask are proven
to prevent communication breakdowns and improve handoffs, and result in higher
satisfaction as reported by patients and families.
AIDET enhances systematic communication with patients, families and con-
cerned persons, and fellow staff members by facilitating conversations in which all
members feel heard, validated, and informed. AIDET stands for acknowledge, in-
troduce, duration, explanation, and thank you.7
6

Acknowledge: Greet with a smile, eye contact, and use of their name. This first
Patient and Family Interactions 66
impression can set the stage for the rest of the encounter: “Hello, Ms. Smith,
we have been expecting you.”
Introduce: Introduce yourself and tell them how you will help them: “My name is
Dr. Jones. I am an emergency medicine doctor and I will be taking care of your
loved one. We will do our best to figure out what is going on.”
Duration: Set the expected time frame for the conversation or ED visit: “I
wanted to talk to you for about 10 minutes about the test results.” Another
example is: “I am waiting on the results of the blood tests. If everything looks
okay, you should be able to go home in approximately an hour.”
Explanation: Explain in detail the events, procedures, or tests to follow. This
process can facilitate appropriate family expectations of the experience: “We
would like to get an echocardiogram, an ultrasound picture to look at the
heart’s structures and function. The technician will come to your husband’s
room, place warm gel and a probe on the chest, and gather images on a ma-
chine over approximately 30 minutes or less. This can help us to determine
if heart abnormalities are contributing to your husband’s symptoms. Do you
have any questions?”
Thank you: Take time to thank the family for involvement, cooperation, and con-
cern: “Thank you for the information you shared with me. It was very helpful
in knowing how to care for your husband.”

Ask-​tell-​ask is another simple communication model that systematically and reli-

ably improves communication with and eliciting information from families in busy
ED settings:

Ask the family what knowledge they have of their loved one’s health, best accom-
plished through an open-​ended question. This provides insights on the degree
of understanding and intensity of emotions: “What were the circumstances
that brought Mr. Smith here today?” “What do you understand is going on
with your husband’s health?”
Tell the family your information directly and simply. Refrain from medical
jargon and abstain from ambiguous language. It is important to share infor-
mation in clear and concise statements, and not focus on data details. Until
you have assessed health literacy, use language appropriate for a fifth-​grade lit-
eracy level: “Your husband came to the emergency department with difficulty
breathing. Our tests show a mass in his lungs that is worrisome for cancer. We
would like to keep him in the hospital overnight to do more tests.”
Ask the family to restate what you said in their own words to help you understand
if your communication has been clear to them. This can identify missed or
misinterpreted details and offer opportunities to respectfully clarify informa-
tion. This less confrontational approach might include: “Can I ask your help
by telling me what you learned in the ED about your husband’s condition and
treatment, so I can be sure that we have been clear in our communication?”8

These tools can be easily taught and reinforced for all ED staff to foster efficient and
reliable communication to families of important information. Reliably clear and
consistent communication is associated with enhanced satisfaction for providers,
patients, and families.
67

COMMUNICATION TASKS

67
Managing Family Meetings

Communication With Family

A patient’s family is often a welcome source of health information during an emer-
gency department visit. Family members can advocate for or represent patients
in medical decision making under specific circumstances. The indecisive patient
might benefit from supportive guidance to navigate medical decision making, and
family members can assist in developing treatment strategies and safe discharge
plans. Emergency departments must skillfully acknowledge the needs and respect
the boundaries of patients, families, surrogate decision makers, and interested
parties.
The introduction should set a positive tone and establish confidence in the
physician’s interest, respect, and concern. Starting with a self-​introduction by the
ED provider to the patient and to family establishes trust and sets a respectful tone.
Inquiring about relationships to the patient often leads to asking which members,
if any, should remain with the patient for the interview and exam. Body positioning
should allow the examiner to face and speak directly with the patient, while also
noting body language and expressions of all persons present. Beginning with open-​
ended questions establishes rapport and gives some latitude in defining the com-
plaint. Interest and engagement can be most easily demonstrated through posture,
pace, and tone during interviewing.

NONVERBAL COMMUNICATION
Nonverbal communication is the secret weapon in the art of communication.
Observant clinicians’ notice of gestures and body language, coupled with appro-
priate nonverbal and verbal responses, often leads to rapid rapport development
and a sense of “feeling heard.” By noticing a family member’s crossed legs, folded
arms, and furrowed brows as difficult news is shared, a reflective statement can
help to “name the emotion,” thus enhancing rapport and the family member’s
sense of being heard: “I notice your worried face and tense body and wonder if you
are feeling upset or worried by this information?” This often invites the sharing
of more and relevant information while reducing barriers to receiving important
information.
This acknowledgment of emotion is not meant to invite counseling but is in-
stead offered for noticing and reflecting emotion and is an opportunity to learn how
effectively your news is being received. Recognizing and responding appropriately
to nonverbal emotion can improve families’ communication around and support
for or participation in medical decision making. When noting emotional or spiritual
distress, helpful support from chaplains and social workers can be offered to explore
and address this distress.
Self-​awareness and purposeful display of one’s own nonverbal interactions can
lead to enhanced communication and rapid rapport by demonstrating active lis-
tening and full engagement, with demonstrable empathy for patients’ circumstances
and suffering (see Table 5.1). However, even the most skilled and experienced ED
providers experience episodes of clumsy language or struggles with clarity. This
can occur in situations where family values or beliefs conflict with the provider’s
beliefs or when the provider is uncomfortable with conflict either with the family
or within the family. In such situations, it can be helpful to disengage briefly to re-
flect on the emotion, returning with more clarity and lack of bias in your language.
68

Table 5.1. Nonverbal Communication

Patient and Family Interactions 68 Do Don’t

Nod head Roll eyes

Make eye contact Appear bored or glazed look
Use appropriate facial Cross arms across chest
expressions to express
concern or interest
Position body facing toward Lean back
the person
Lean in Fidget
Slow down breathing Check watch or phone

When families make decisions that are permissible but at odds with the values of
the provider, it is important to remember that this represents a fully informed deci-
sion offered on behalf of the patient’s best interests. Although the provider may feel
some distress in this situation, unless the decision clearly breaches ethical or moral
boundaries, the provider should honor the decision.
Effective and respectful communication skills will improve outcomes and satis-
faction by families and more rapidly build rapport, to effectively manage complex or
uncomfortable situations in ED settings. Helpful education in effective communica-
tion can be found in books, videos, podcasts, and live conferences. Skilled mentor-
ship can speed skill acquisition for the motivated learner as well.

EFFECTIVE COMMUNICATION WITH TEAM MEMBERS

Effective communication with ED team members is vital to ensure the accuracy
of shared information. This facilitates proper handoffs and transitions in care, thus
avoiding medical errors and near-​miss events. One way to transmit information is
through SBAR (Situation, Background, Assessment, Recommendation). SBAR is a
tool or technique that is used to communicate clearly between different care team
members, that is, physicians, midlevel providers, nurses, technicians, and support
staff. SBAR includes the following:

Situation: Briefly and clearly state the situation. Often this is a 1-​line statement:
“Mr. Jones is having intractable vomiting.”
Background: Provide a short synopsis and relevant history that relates to the
situation: “Mr. Jones has a history of metastatic cancer and is undergoing
chemotherapy.”
Assessment: State your professional assessment: “I think he has chemotherapy-​
induced vomiting.”
Recommendation: What outcome would you like to see happen? What do you
need the person to do? This results in: “Would you start Mr. Jones’s IV and
give 4 mg of IVondansetron? Thanks.”

Closing the loop is a phrase used in patient handoff. This allows the recipient of the
information to confirm what he or she just heard and verify the recommendation:
69

“It sounds like Mr. Jones has chemotherapy-​induced vomiting. I will start an IV and

69
administer IV ondansetron 4 mg once. Is that correct?”

Communication With Family

SBAR and closing the loop provide a valuable framework for timely and clear
communication with team members and colleagues about issues, assessments, and
task assignments. This style of communication also engenders a sense of respect for
other team members as the communication loop is closed. Additionally, good team
member communication helps assure consistent communication with families.

CROSS-​C ULTURAL CARE

Emergency department staff invariably encounter families from varied backgrounds,
cultures, religions, and beliefs. Families are often defined by blood relations, mar-
riage, or adoption but are often also culturally influenced, and thus defined through
nontraditional committed relationships. Sensitivity to diversity in identity, gender
identification, and familial relationships is demonstrated by ED staff through sen-
sitive and respectful questioning about relationships with “family members” and
preferences for name and gender identity.
Emergency room staff that are trained in patient-​centered approaches to re-
spectfully ask about and utilize culturally appropriate language to discuss gender,
religious, or familial issues demonstrate powerful whole-​person care. Sensitivity to
diversity in personal values and preferences demonstrates respect and empathy and
facilitates trust between families and health care providers. As sociocultural diver-
sity increases, challenges also grow to effective communication in medical settings.
Efforts to improve cultural sensitivity can bridge barriers but also risk oversim-
plification or foster unhelpful stereotyping. However, simply asking patients and
families about their preferred identity, beliefs, and relationships and inquiring as to
their preferred language in these areas have proven reliably helpful.
To fully appreciate a patient’s cultural preference, one must first be aware of rel-
evant cross-​cultural issues. Shephard et al.9 found many cultural influences that im-
pact communication styles in medical settings. These culturally derived verbal and
nonverbal communication preferences determine such preferences as acceptability
of eye contact, appropriateness of physical touch in clinical settings, gender and role
communication differences, and name preferences. Several orthodox and conserva-
tive religions prohibit touch, even in medical settings, between unrelated individuals
of the opposite gender. Mistrust by patients or families in health care settings can
sometimes be lessened by promoting a greater sense of control in choosing treat-
ment options and decisions. Asking about preferences and differences in traditions,
customs, and spirituality is always acceptable and often welcomed. Many families
are generous in offering education in and around their customs, relationships, and
religion that impacts health and health care.
Sources of stress and challenge for ED staff often include uncomfortable family
dynamics. Patient autonomy is not a universally shared cultural norm. In Western
medical settings, it is often distressingly difficult to field and respond to requests
by patients to have all medical information passed to a named surrogate, coupled
with a request to allow the patient’s surrogate to make all medical decisions on be-
half of the patient. Yet in some cultures, female patients often do request the family
patriarch to fill this role, and this expectation is often shared by family members.
Such cultural determinants are often based on gender, age, or stature within families
or communities in ways that feel foreign to those who have Western values. This
70

request should be carefully examined, and if no ethical breaches are found, this re-
Patient and Family Interactions 70
quest should be honored. In addition, asking permission to intermittently ask if this
continues to be the patient’s preference over time can continue to foster a shared
understanding, trust, and open communication.
In every culture, the understanding and meaning of illness are complex. It is es-
sential to explore the meaning of illness in the context of culture and religion, which
may differ greatly from Western medical concepts. Beliefs can include significant
influences on health from external or internal forces. For example, some Caribbean
cultures teach that bathing in the sea while pregnant can produce severe illness in
offspring. Specific nontraditional remedies, and no other remedies, are said to re-
verse such illness. Respectful questioning about such beliefs and nontraditional
treatments can alert the physician to interactions of nontraditional medicines with
prescribed medications.
In many emergency department settings, it is common to serve non-​English-​
speaking families. Medical interpreters provide a vital service in such settings and
can do so in person or through telephonic or video translation. Patients and families
who do not speak English proficiently should routinely be offered professional in-
terpreter services, which are preferred over translation through a family member
or friend. Professional interpreter services provide greater accuracy and reliability.
When using such services, it is often helpful to direct the interpreter to interpret
everything directly said by the medical provider to anyone, and to directly interpret
anything said by the patient or family as well. Speak slowly, pause often, and speak
directly to the family member addressed. Allow time for the interpreter to relay
information, and ask the interpreter to clarify any cultural misunderstandings or
words that do not have direct translation. Avoid using idioms or unfamiliar jargon,
and ensure comprehension by requesting teach-​back. Demonstrating such sensi-
tivity to culture, language, systems, and beliefs through careful language and use of
interpreter services can build rapport, trust, and respect while ensuring adequate
communication of important information.

BREAKING BAD NEWS

Among the many responsibilities of emergency physicians, breaking bad news is one
of the most anxiety provoking. Such news is often shared with persons unknown to
the physician, without the benefit of trust and rapport. This important skill provides
structure to the setting, timing, and communication of essential information. It also
allows adequate time and support for families to process their emotional reactions
to this bad news. The goal is to allow families to process information and emotions
and move on to plan next immediate steps.
There are many different models and protocols to help with breaking bad
news. To follow is a sequence of steps in breaking bad news demonstrated in the
Buckman’s SPIKES protocol.10

Setting
Prepare for the meeting by reviewing medical records, gathering information, and
reviewing medical literature.
Secure a private space with seats for everyone whenever possible.
71

Invite other contributing medical team members (physicians, nurses, chaplains,

71
social workers, etc.). Invite the patient and involved family and friends, as directed by

Communication With Family

the patient. Individuals unable to personally attend can be included telephonically.
Block out time, sign out pager, and ask all attendees to silence their phones so
that the meeting can receive full attention.
Have tissues available and within reach.
Properly designate a surrogate medical decision maker when warranted.

Perception
Establish what is already known by the family: “Tell me what you understand about
your loved one’s condition and health problem(s).” “What have you heard from the
medical team about this?” “What about this is still not clear to you?”
This is a good time to assess health literacy and terminology. Use this same
language when sharing information (e.g., the family describes diabetes mellitus as
“sugars”).

Invitation
Learn how much the patient/​families want to know or be involved: “I have new in-
formation about your loved one. How much detail would you want to know; do you
do best with a big picture or do you usually prefer to hear all of the details?” “Is there
anyone else that should be here or we should call to hear this new information?”

Knowledge
Share with the family the new information. Be straightforward and brief, and avoid
medical jargon. Speak slowly.
Announce a “warning shot”: “I’m afraid I have some important and difficult
news to share with you.” “The test results did not come back as expected.”
Disclose the information: “The cancer appears to have spread to his liver and
lung.” “Your baby in your womb does not have a heart beat and has died.” “The
blood test showed you have a HIV infection.” Pause at this point until you recog-
nize that the patient has received this news (e.g., raising eyes again to meet yours, or
when the family members voice understanding or ask a question).
Many families will ask about prognosis. Answer to the best of your ability and
defer to a specialist if uncertain. Give time frames instead of exact dates—​days to
weeks, weeks to months, months to years.
Pause for responses and questions.

Emotion/​Empathy
Respond and acknowledge the emotion. Often the first questions are emotional
reactions. Do not focus only on scientific or clinical details when answering
questions.
Examples of emotional processing of difficult news include: “How can this be?”
“But I took all of my medications and did exactly as the doctors told me to do.”
“Why didn’t someone catch this sooner?”
72

Silence can be appropriate as families process thoughts and emotions.

Patient and Family Interactions 72
Offer tissues if the family or concerned person begins looking for them, and pro-
vide reassurance and support when sadness or grief or shock is expressed.

Summarize
Review the discussion.
Discuss goals of care; inquire about advance directives or code status, as well as
decisions to undergo or forgo certain treatments.
Discuss next steps/​action plan. This can be as simple as an appointment to a
specialist or a return visit within days to discuss questions or next steps. This should
not include an exhaustive treatment plan for a newly diagnosed cancer.
Have families summarize information. This lets you know that the information
has been understood: “Just so I know we are all on the same page, can you summa-
rize what we just talked about and our plan?”
Ask if there are any questions.
Some families take time to process this new information and may need a follow-​
up encounter to repeat the information.
Delivering serious news to families is an important but challenging task in emer-
gency department settings that can prompt staff feelings of dread or anxiety. It can
be uncomfortable and sad to share hard information. Studies demonstrate more ef-
fective comprehension by families when utilizing the SPIKES protocol by fostering
comprehension of necessary information and processing of emotions, which leads
to the initiation of important next steps to address the new reality accompanying
this news.

DEATH AND DYING NOTIFICATIONS

Notifications of death are best shared with the person closest in relationship to the pa-
tient. This is often the person identified as the medical durable power of attorney, a
contact person, or a close relative as noted in the chart. Some find this task even more
difficult because of a personal discomfort in talking about death, and others fear causing
harm or suffering through this notification. Providers must remember that this conver-
sation will leave a lasting impression on the family. It is best to avoid answering questions
until the relationship of the person to whom you are speaking has been verified. Do not
provide death notifications to minor children. Deliver this news slowly, in simple and
direct language. Avoid rambling, euphemisms, and medical jargon, which can mislead
or misinform. Euphemisms such as “expired,” “passed away,” or “did not make it” should
not be used. Avoid sharing death notifications over an answering machine or voicemail.
If unable to contact the family within a few hours, notify the hospital representative
(e.g., social worker or case manager) to help locate the family.
Most would agree that death notifications should ideally be delivered in person
and as soon as possible after the death. However, families are not always able to
come to the hospital immediately, and telephone notification might be necessary.
Physicians must weigh the benefits of truthfulness with the risk of abruptly shared
bad news by telephone. Considerations when deciding to delay or disclose infor-
mation immediately include context of the death (expected death from chronic
disease vs. sudden and unexpected death), the relationship of the contact person
to the patient, anticipated emotional response, distance to ED and availability of
73

transportation, time of day, and whether the contact person is alone or supported

73
by others. If death was expected owing to a chronic disease or terminal illness, tele-

Communication With Family

phone death notifications might be acceptable. In contrast, for sudden or unexpected
death, it is always advisable to inform through an in-​person discussion. If the clini-
cian decides to delay death notifications, then describe the patient as gravely ill and
request the loved one come to the hospital urgently. Once the family arrives, quickly
explain why the information about death was withheld (e.g., “I am sorry for not
telling you over the phone, but I knew you were driving and would be here soon”).
Before making an in-​person or telephone notification:

Take time to prepare your frame of mind.

Positively identify the patient (hospital ID).
Obtain relevant information (e.g., patient’s name, age, gender, other identifiers).
Review the circumstances of the death and the clinical context, such as terminal
cancer.
Find a quiet and private area with a telephone, if indicated.
Contact the chaplain or bereavement team, if available.

The In-​Person or Telephone Death Notification

Identify yourself and your role in the care of the patient.
Confirm the relationship of the loved one.
Ask if the person is alone or if others could join him or her.
If you have not had prior interactions with the family, ask what they know about
the patient’s condition: “What has the patient or doctors told you about
your loved one’s disease?”

Provide a warning shot: “I have some bad news.”

Deliver the news: “I am sorry that your loved one has just died a few minutes ago.”
Give a brief synopsis. Speak clearly and slowly in answering questions.
Demonstrate empathy through your tone, posture, and responsive answers.
Ask if the family would like to see their loved one in the ED. If they are traveling
to the ED, give directions on where to go and arrange who they will meet
when they arrive. Provide a contact number if they get lost.
If the family cannot come to the hospital, provide contact information for your
institution, the hospital liaison, and/​or the coroner.
Ask if you can contact other family members for them.
Assess their emotional state. Offer condolences and end the conversation: “I
am sorry for your loss.”

Like most communication skills, having a communication template can be

helpful. It is important to provide the news with sensitivity and respect, but also
with accuracy and brevity. Asking for help from a colleague or chaplain can also be
helpful for uncomfortable or inexperienced providers.11,12

Responding to Emotions and Grief

Emotional responses are commonly encountered in ED settings and should be ex-
pected upon learning of the death of a loved one. Acknowledging and normalizing
74

feelings of sadness, anger, shock, or disbelief can help in allowing emotional con-
Patient and Family Interactions 74
tent while anticipating eventual control enough to permit further conversation.13
Ensuring that the contact person is not left alone can help provide comfort and
containment to the bereaved, and offering to notify another can lessen this burden
on the survivors. Propose a follow-​up interview from the social worker, chaplain,
or bereavement specialist in your department who can answer questions and rec-
ommend grief support and other community services. Some family members will
transfer emotions onto the bearer of the bad news, and it is helpful to understand
the nature of this transference without defensiveness.14
When faced with angry or suspicious families in emergency settings, it is
common to feel as if under attack. Common staff reactions include retreating or
withdrawing, attempting to placate, or meeting anger with anger.15 These reactions
are often associated with escalating anger and hostile behaviors, and ignoring anger
often invites escalating anger and irritation. When possible, naming the angry be-
havior in a nonjudgmental way and affirming your intention to its source can some-
times provide validation, invite dialogue, and defuse the anger: “I hear some upset
or anger in your voice and when I hear your words about how the staff is ignoring
you (naming the behavior), I wonder if you are angry or frustrated by this situation
(ask about the underlying feeling). You seem unhappy about something and I am
hoping that I can better understand so I can see what I might do to address this fairly.”
Statements without labels for behavior can include “you look disappointed,” “you
look as though you want to say something,” or “you look frustrated” and can invite
a dialogue about the reasons for such behaviors and potentially helpful responses.
Anger frequently has historical roots and as such can be called forth uncon-
sciously by a tone of voice, small gesture, or perceived attitude. This can result in
confusing and unexpected behaviors. This does not imply that unsafe, profane,
or aggressive and threatening behaviors should be allowed or tolerated. Firm
boundaries that identify such behaviors and quick responses to protect staff (often
protocol driven) are employed. However, even in these situations, a calm and firm
voice offering an invitation to discuss the problem in a private (and safe) setting,
coupled with a firm command to stop the offending behavior, can sometimes be
helpful even as security is called to assist.
Hostile behaviors are often cover behaviors for anxious or fearful feelings within
family members. When hostility is effectively vented and addressed without retri-
bution, cooperation with staff is sometimes possible. Abuse cannot be allowed, but
tolerance of some negative statements and feelings expressed by families in tense
situations can build trust.

MANAGING THE CRYING FAMILY MEMBER

Tears can interrupt interviews and frustrate attempts at effective communication
with families. Common staff reactions might lead to trying to control or stop the
crying or ignoring the tears owing to discomfort in the observing clinician, neither
of which seem helpful. Again, naming the behavior and emotion, such as “I can see
by your tears that you are upset, and our talking together seems to escalate your
emotions,” can demonstrate empathy, foster trust and rapport, and provide an op-
portunity to regain emotional control. If the family reconstitutes, then it is possible
to proceed with the discussion at hand. In situations where the crying does not stop
despite attempts at support, halting the meeting and offering support through other
75

team members may be necessary. It can be helpful to offer a subsequent meeting to

75
effectively continue the discussion in these circumstances. Families are often under-

Communication With Family

standing, as this individual may have had similar past reactions to other disturbing
news. Fear that “the tears will never stop” is often felt by patients, families, and staff
but is seldom true.

SUPPORTIVE COUNSELING
Emergency departments are often frequented by patients with suffering that has
translated into physical symptoms. These patients are suffering and often fear threat
to life or health. However, this “misuse” of ED services is a source of frustration and
burnout for many providers. The fast pace of the ED also places barriers to effective
management. Finding opportunity in such situations can be extremely challenging;
however, use of a few communication skills with families in such situations can
sometimes improve outcomes and lessen personal frustration. First, demonstrate fo-
cused attention and practiced listening skills for the opening minutes of interaction.
One minute of uninterrupted listening often provides clues to the nature and source
of complaints and always enhances the satisfaction and sense of “feeling heard.”
Family concerns often present with emotion, and a calm and measured demeanor
aids in modulating the sharing of concerns. Reassurance that symptoms, though
bothersome and real, do not appear to be life threatening (based on examination or
testing) can foster a discussion of next steps in evaluation and management.
Counseling in emergency settings is often need based and brief but can some-
times lead to insights. Sharing positive or affirming information at the start and end
and negative information sandwiched in between has been shown to enhance pro-
cessing. For the patient presenting with recurrent noncardiac chest pain, you can
provide a statement to concerned family such as follows:

The good news is that your husband’s heart shows no sign of damage and his chest
pain, though severe, does not appear to be a serious threat to his health. This is often
described as “noncardiac chest pain,” and many patients can improve with medications
or training techniques. This recurring pain is disturbing enough to lead to several emer-
gency visits and, I suspect, a significant amount of anxious concern for the entire family.
I recommend follow-​up with your primary care doctor in the next day or 2. Your husband
might benefit also from certain simple mind-​body training techniques that have been
shown to lessen these types of pain problems. I can suggest some trusted providers for
this training if you are interested. This pain is real and can often be improved through
these training techniques. However, his pain has shown no sign of being linked to heart
disease.

It is important to acknowledge the symptom as real, express concern for the patient’s
well-​being, and provide reassurance that there is no sign of organic disease. The
challenge remains to link this symptom to psychological stress, and offering coun-
seling or training opportunities to “improve the symptom” is often a better alterna-
tive than confronting the symptom as fake or unreal. Patients with multiple somatic
complaints often have patterns of behavior that include somatization as an uncon-
scious method of dealing with anxieties. Frustrated families often bear witness to
a series of bewildering “illnesses” without explanation and debility that is out of
proportion to the cause. Direct language in ED settings should label the presenting
76

symptom as “real” and provide reassurance with available data that the source is not
Patient and Family Interactions 76
organic (cardiac in this case). This brings the opportunity to discuss “noncardiac”
causes of such pains and the source of inner stress to cause such pain. Offering re-
ferral for training to “lessen” the symptoms is less confrontational than denial of the
symptom, and reassurance that such techniques have been shown to benefit many
patients is more likely to be received well by patients and families. This conversation
provides a basic mind-​body explanation for the symptom without detailed physio-
logical diagrams and offers support and reassurance, followed by recommendations
and resources for training to improve the symptom.

IDENTIFYING AND DEALING WITH EXISTENTIAL PAIN

Death is a certainty for all of us in life whether we are ready for it or not. Some have
thought about their end-​of-​life wishes and planned circumstances around their
deaths, whereas others have avoided such thoughts and plans for decades.16 Feelings
of despair can lead to questions about the meaning of life and existence. If these
questions go unanswered, they can threaten one’s core values, leading to existen-
tial pain and suffering.17 These can later manifest as physical, spiritual, or emotional
pain and complicated grief. Such questioning is often emblematic of existential suf-
fering and might include: “Why did this happen to me?” “Where is God?” “No one
understands what I’m going through.”
Comfort can be offered through empathetic and validating statements to nor-
malize these questions and thoughts: “I can’t imagine how scary this may feel.” “I
wonder how anyone can make sense of all of this.” “Can you tell me more about
what you are feeling?”
Recognizing and responding to existential distress is a skill that is enhanced with
experience. However, awareness of existential pain is often sufficient to facilitate
supportive comments and opportunities to link with resources. Cumulative expe-
rience can challenge provider well-​being and invite burnout. Helpful strategies to
enhance resilience can include debriefing sessions with others about difficult cases,
journaling, or general supports such as physical exercise, religious prayer, or other
centering practices such as meditation, self-​hypnosis, or imagery.

INTEGRATING THERAPEUTIC SUGGESTION

INTO THE ED
Urgent situations in emergency settings often enhance motivation to respond to sug-
gestion. Language can enhance focus and invite relaxation while lessening the focus
on pain or fear-​provoking thoughts. Suggestions for patients and families can be
naturally integrated into conversation to encourage imagery, distraction, and relax-
ation in preparation for and during procedures. In responsive subjects, subsequent
suggestions can induce helpful phenomena such as analgesia or distancing from this
experience and into past comfortable experience. Although hypnotic talent varies,
the urgency of the ED setting often enhances responsiveness to suggestion.
Anxiety and pain are common experiences in ED settings for patients and
families that can benefit from suggestion-​based approaches. Relaxation approaches
differ widely in philosophical foundations and methodologies, but all share 2 basic
tenets: a narrowing of attentional focus (e.g., to a word, sound, prayer, or thought)
7

and the adoption of a passive attitude toward intrusive thoughts, with a prompt to

77
return to one’s chosen focus.

Communication With Family

Self-​regulatory techniques generally produce autonomic calming and a sense
of relaxation that invites distraction from disturbing thoughts and sensations. Brief
methods can often be quickly learned and include progressive relaxation, paced
deep rhythmic breathing, and medical hypnosis. Deeper methods include autogenic
training, in which 6 suggested sensations are repeated, including limb heaviness,
limb warmth, pulse regulation, breath centering, abdominal warming, and forehead
coolness. Progressive muscle relaxation (PMR) practices tensing and relaxing each
of 15 major muscle groups throughout the body, relying on a systematic body re-
view from head to toe, with suggestions for sequential relaxation for each body part.
Meditation fosters nonjudgmental awareness of bodily sensations and a focus on
“in the present” mental activities. Transcendental meditation uses a “mantra” to in-
itiate this state and return the mental attention to the present moment. Movement
meditations, including yoga, walking meditation of Zen Buddhism, qi gong, and tai
chi all focus on bringing a calm and focused state through prescribed or rhythmic
movement.
The induction invites attentional focus and is followed by specific suggestions
for deepened relaxation, distraction, and imagery and for specific therapeutic
goals, such as analgesia or deep relaxation during a procedure. Posthypnotic
suggestions can enhance subsequent relaxation, improve sleep, or promote on-
going relief from pain. Hypnotic susceptibility, like other human traits and
talents, varies widely throughout the population. However, many patients can
benefit from suggestions during procedures or in “high demand” settings such as
emergency departments.
Applying hypnotic techniques to manage pain is one of the most extensively
studied applications of hypnosis. Crawford18 demonstrated reliable and sometimes
dramatic reductions in clinical pain, and Syrjala19 demonstrated clinically significant
benefits on pain and nausea in cancer patients in her controlled study of hypnosis
and cognitive-​behavioral strategies. Recent neuropsychological studies by Jiang et
al.20 demonstrate that hypnosis seems to uniquely enable changes in “attending” to
pain as well as the “sensory processing” of pain.
Relaxation and cognitive techniques teach patients how to distance or distract
from the painful experience, associated with increased downregulation through
the spinal-​thalamic-​frontal cortex–​anterior cingulate pain transmission pathway.
This pathway plays a role in the subjective psychological, limbic, and autonomic
physiological responses to pain. From this pathway, a descending inhibitory system
involving the periaqueductal gray region modulates incoming pain signals, thus
augmenting (during anxious arousal) or inhibiting (during hypnosis) pain trans-
mission at the level of the dorsal spinal cord.
Hypnotic techniques include hypnotic distraction from pain, analgesia,
displacement, substitution, anesthesia, and amnesia. Specific suggestions can
uniquely invite: reduce or eliminate pain sensation; move pain to a less trouble-
some area; substitute a less bothersome sensation; subsequently not recall pain
or its bother; be more relaxed and thus to not react as much to the sensation.
Each suggestion has the potential to trigger a different internal psychophysiologic
event, with a shared perception of reduced pain or bother from pain. Hypnotic
suggestions can be given to patients and to family members and coordinated with
standard emergency care:
78

As you hear me preparing the materials to reposition the fracture into an optimal

Patient and Family Interactions 78

healing position, take a few deep breath as you listen . . . carefully . . . to my voice, and
remember other times when you were comfortable again, after working hard on some-
thing or enjoying something, like a good movie or a good book. Time to be engaged fully,
as you are now. . . . As you notice my voice, as it carries notice of important things to
pay attention to, such as the growing sense of loose relaxation . . . a spreading wave of
relaxation . . . deep down . . . from your neck and shoulders, into that arm, which had
been bothering you . . . down into your arm and forearm and hand . . . and as that feeling
spreads . . . deep down into your muscles . . . they’ll feel more deeply relaxed . . . as you
begin to notice comfort. As that comfort feeling spreads your eyelids notice that their
weight allows them to comfortably close, and as they close you can be gently surprised
at the return of more complete comfort . . . in that arm . . . as you take another deep
breath . . . and following that next breath your fracture . . . good . . . is now moved into its
proper position . . . as you are all the way, deeply relaxed inside, deep relaxed, hearing
my voice . . . noticing past pleasant memories . . . or comfortably notice nothing at all .
. . as you relax completely. And tonight, as you prepare for bed . . . you can drift asleep
easily, stay asleep well, and return to sleep easily should you awaken for any reason.
Your fracture is already healing and you can trust in its natural healing.

A similar script could be adopted for an anxious parent. This script utilizes the
present experience (sounds, smells, feelings and movement, sights) to trigger and
respond to prior calming experience, which is followed by more direct suggestions
for comfort, reduced tension, and noticing a comfortable distance from pain or
discomfort.
Hypnotic suggestion delivered during stressful or painful experiences to family
members can invite relaxation and a focus away from a fearful situation and pro-
mote trust, confidence, and collaboration. An anxious parent who accompanies the
injured child can be offered suggestions of calm, safety, and confidence even as the
physician prepares the child for suturing:

As the nurse sets up our tools to close this laceration, perhaps your parent can just
settle into that chair, knowing that we have helped so many other children with similar
problems before. Every sound can reassure you of our steady work, as your child feels
the comfort of numbing medicine on that hurt, and that can further reassure you that all
is getting well here, all that needs to be done is being done, and that later you both can
be together on your way home, knowing that healing has already begun. Thanks for all
you have done to get your child here, and as the sutures close this wound, you can know
that your work is almost done, and our work is proceeding well, and your relaxation can
just feel good as you sit more and more comfortably in that chair. Thanks.

Relieving anxiety can lead to improvements in communication, allowing for a better

partnership in care between the patient, family, and provider.

REFERENCES
1. Osmole FS, Sow CM. Interacting with patients’ family members during the office
visit. Am Fam Physician. 2011;84(7):780–​784.
2. Turner JS, Pettit KE, Buente BB, et al. Medical student use of communication
elements and association with patient satisfaction: a prospective observational pilot
study. BMC Med Educ. 2016;16:150.
79

3. Burgener AM. Enhancing communication to improve patient safety and to increase

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patient satisfaction. Health Care Manag (Frederick). 2017;36(3):238–​243.

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4. Pérez-​Cárceles MD, Pereñiguez JE, Osuna E, Luna A. Balancing confidentiality
and the information provided to families of patients in primary care. J Med Ethics.
2005;31(9):531–​535.
5. Cochella SE, Pedersen DM. Negotiating a request for nondisclosure. Am Fam
Physician. 2003;67(1):209–​211.
6. Salas EW, Katherine A. Communicating, coordinating, and cooperating when lives
depend on it: tips for teamwork. Jt Comm J Qual Patient Saf. 2008;34(6):333–​341.
7. French J, Colbert C. Targeted feedbacks in the milestone era: utilization of the
ask-​tell-​ask feedback model to promote reflection and self-​assessment. J Surg Educ.
2015;72(6):e274–​e279.
8. Bodtke S, Ligon K. Hospice and Palliative Medicine Handbook: A Clinical Guide. San
Bernardino, CA: CreateSpace Independent Publishing Platform, 2017:57–​67.
9. Shepherd SM, Willis-​Esqueda C, Newton D, Sivasubramaniam D, Paradies Y. The
challenge of cultural competence in the workplace: perspectives of healthcare
providers. BMC Health Serv Res. 2019 Feb 26;19(1):135.
10. Walter BF, Buckman R. SPIKES: a six-​step protocol for delivering bad news:
applications to the patient with cancer. Oncologist. 2000;5(4):302–​311.
11. Iserson KV. The gravest words: sudden-​death notification and emergency care. Ann
Emerg Med. 2000;36:75–​77.
12. Iserson KV. The gravest words: notifying survivors about sudden, unexpected deaths,
and emergency care. Resident and Staff Physician 2001;47:66–​72.
13. Byock I. The Four Things that Matter Most. New York, NY: Simon & Schuster; 2004.
14. Markowitz AJ, Rabow MW. Caring for bereaved patients: “all the doctors just
suddenly go.” JAMA. 2002;287(7):882.
15. Rando TA. Clinical Dimensions of Anticipatory Mourning. Champaign, IL: Research
Press; 2000.
16. Kissane DW. Demoralization: a life-​preserving diagnosis to make for the severely
medically ill. J Palliative Care. 2014;30(4):255–​258.
17. LeMay K, Wilson KG. Treatment of existential distress in the life threatening illness:
a review of manualized interventions. Clin Psychol Rev. 2008;24:472–​493.
18. Crawford HJ. Brain dynamics and hypnosis: attentional and disattentional processes.
Int J Clin Exp Hypn. 1994;42:204–​232.
19. Syrjala KL, Cummings C, Donaldson GW. Hypnosis or cognitive behavioral training
for the reduction of pain and nausea during cancer treatment: a controlled clinical
trial. Pain. 1992;48(2):137–​146.
20. Jiang H, White MP, Greicius MD, et al. Brain activity and functional connectivity
associated with hypnosis. Cereb Cortex. 2017;27(8):4083–​4093.
80

6 Communication With
Minors in Emergency
Settings

Kevin P. Carney

INTRODUCTION
Of the 137 million patient visits to US emergency departments (EDs) in 2015,
over 27 million (20%) were for children under the age of 15 years.1 In fact,
nearly 17% of US children visited an ED at least once in 2015.2 Nonetheless,
the majority (90%) of pediatric patients seeking emergency care are seen in
nonspecialized facilities for both adults and children. In addition, over half
of EDs in the United States care for fewer than 10 pediatric patients per day.3
These data suggest that pediatric patients are likely to be seen in health care
settings where staff and providers may have less familiarity and experience in
communicating effectively with children. As communicating with minors poses
unique challenges to the health care team, it’s important for health care workers
to understand the basic similarities and differences in how to communicate with
minors as opposed to adults. All approaches will require the health care worker
to be compassionate, flexible, and respondent to the needs of both pediatric
patients and their family members. This chapter will introduce features in the
communication with minors in emergency settings and provide the reader with
examples of commonly encountered clinical scenarios in which knowing these
concepts and skills is crucial.
81

COMMUNICATING WITH MINORS VERSUS ADULTS:

81
THE SIMILARITIES

Communication With Minors in Emergency Settings

Though there are distinct differences and nuances in communicating with minors
in emergency settings, it’s important to recognize that basic rules for successful in-
terpersonal human communication apply to both adults and children. Pediatric
patients and their family’s satisfaction rating of an emergency department visit is
strongly correlated with the quality of provider-​patient interaction and the perceived
adequacy of information provided.4,5 The following are key concepts for successful
communication with both minors and adults.

Know the Goals of Communication

Understanding and acknowledging the goals of communication with minors in an
emergency setting is a simple, but important, concept for successful communica-
tion. These goals may include:

• Fostering a patient-​centered environment

• Showing respect and courtesy to the individual patient
• Establishing rapport to facilitate open, honest dialogue
• Decreasing stress and anxiety in the patient and family
• Obtaining an accurate medical history
• Establishing a comfortable environment for the patient to facilitate a physical exam
• Delivering difficult news in a sensitive way
• Educating the family and patient about a health condition to their level of
understanding
• Improving the likelihood of adherence to a treatment recommendation

Listen
Health care providers in an ED setting are very busy. As such, it’s important to max-
imize your time with pediatric patients and their family while also making them feel
like their concerns have been heard and understood. As with adults, certain basic
listening techniques should be employed when communicating with children and
their families:

• Show that you are listening—​use simple phrases such as “I see,” “I understand,”
and “uh-​huh.” Maintaining eye contact and gently nodding as the patient or his or
her family speaks also conveys a sense of active listening. Be mindful to display a
friendly, relaxed face when communicating with children as it goes a long way to
make them feel comfortable and more likely to speak.
• Don’t interrupt—​the median amount of time it takes before a physician interrupts
a patient is between 18 and 23 seconds.5,6 Although some interruptions may be nec-
essary to clarify a point or help gently guide the interview back to more pertinent
details, it is good practice to allow your patient a chance to speak as much as pos-
sible without interruption. Children are likely to become intimidated and less com-
fortable when interrupted by someone in a position of authority such as a physician.
82

Be Empathetic
Patient and Family Interactions 82 One of the keys to successful communication with any patient and his or her family
is to show empathy. This involves recognizing an emotion and demonstrating to the
family and patient you’ve acknowledged and appreciate it. One simple technique
to convey to patients or their family that you are listening and acknowledge their
concerns is to repeat back to them an important word or phrase that they have just
said. This allows patients to know you are listening and invites them to elaborate on
this aspect of their story.
For example, if you have just explained to a child the tests that you need to con-
duct and you ask the patient what questions he or she have, he or she may respond
tearfully, “I don’t want to do those tests!” It would be inappropriate to ignore this
display of emotion and simply say, “Sorry, but we have to.” Instead, an appropriate
response may be, “I can tell you’re scared and that’s very normal. Tell me what you’re
most worried about.”

Be Honest
Although it is tempting, at times, to tell “little white lies” to children in health care
settings believing it will help to decrease their distress and anxiety, it is preferable
to be honest with children as much as possible. Honesty reinforces the importance
of telling the truth to the child and shows a respect for his or her capacity to be a
valued partner in discussion around health care issues. Establishing with the child
that health care discussions should be an open, honest dialogue will also help with
the child’s future interactions in the health care system.

Don’t Use Medical Jargon

The use of unnecessary medical jargon should be avoided with children. All
attempts should be made to explain test results or medical decision making
with words and phrases a layperson could understand and at the child’s
developmental level.

Body Language
Nonverbal communication via a provider’s body language is very important for a
successful interaction with patients and their families. All attempts should be made
to sit down and face a child and his or her parent in the room. Appear unhurried and
interested by slightly leaning forward and maintaining a relaxed expression. Try not
to cross your arms as this makes you appear “closed off ” to the discussion. Pay at-
tention to your own habits to see if you are someone who frequently taps your foot,
fiddles with papers in your pockets, or constantly shifts while sitting down. These
are nonverbal signs to the patient and family that you’re disinterested, hurried, or
anxious to leave the room. Despite the realities of managing multiple other tasks
that need to be accomplished, make all efforts to calm your face and body so the
family and patient can feel relaxed as well.
83

COMMUNICATING WITH MINORS:

83
BASIC STARTING POINTS

Communication With Minors in Emergency Settings

Triadic Discussion
One of the most obvious differences in the communication with minors in health
care settings is that the discussion is often triadic, meaning the health care provider
is communicating not just with the patient but also with an adult parent/​guardian.
Although mature children and teenagers are likely to contribute meaningfully to the
visit discussion, it is more common for most of the discussion to be between the
clinician and the parent. Nonetheless, it’s important for clinicians to always attempt
to bring the patient back into the discussion and ask about his or her feelings and
concerns. This helps the patient feel validated and allows the adult caregiver to see
that you are patient centered and truly care about the child.
One important related point about discussions with patients and their parents
is that professional medical interpreters should always be used in cases where there
are language barriers. It is never appropriate for a health care provider to utilize the
English-​speaking minor patient or a minor family member (e.g., sibling) to interpret
for the parents.

Provider Appearance
Children are often scared of health care settings because of past experiences in which
they may have experienced pain (e.g., vaccinations), and they are cued to become
fearful when they see clothes or instruments that they associate with health care.
When possible, it may be helpful to avoid wearing the traditional white coat when
working with children. In addition, if the clinical scenario does not necessitate it,
delay putting on personal protective equipment such as masks and gloves until pa-
tient rapport has been established and use only when they are absolutely necessary.

Introductions
As with any health care interaction, introductions with the patient and the family
in an emergency setting are a critical opportunity for developing a respectful and
collaborative tone for the visit. Knowing the name of the patient prior to going in
the room is very important, although, depending on the age of the patient, how you
use this information may change. With a young preverbal child, you are more likely
to introduce yourself to the family first: “Hi, is this Anna? I’m Dr. Carney, one of
the doctors here in the emergency department. Nice to meet all of you.” This intro-
duction allows the family to immediately know who you are and conveys a sense of
warmth and patient centeredness as you’re establishing that you already know the
child’s name. With an older child who you expect to be verbal, it is appropriate to
introduce yourself to the patient first. For example, “Hi, I’m Dr. Carney. Are you
Anna? Nice to meet you!” Addressing the older child first is helpful in several ways:
(1) to immediately establish that the child is the focus and center of attention, (2)
to gauge the child’s level of nervousness depending on how/​if he or she responds,
and (3) to assess the child’s immediate level of medical distress. Ask the child (or
parent if the child is preverbal) what name he or she prefers to go by as this conveys
the message that you are interested in respecting the child’s preferences and wishes.
84

Introductions with family members are also very important for facilitating re-
Patient and Family Interactions 84
spectful dialogue and establishing how the adult is related to the patient. Never as-
sume the adult’s relationship to the patient based on the adult’s age or appearance.
In addition, don’t address the adult by his or her stated relationship to the child (e.g.,
“Hi, you must be Mom”). A tactful way to introduce yourself might be, “Hi, I’m Dr.
Carney and I’m going to help take care of Anna today. May I ask who you are?” If
the child is verbal, it is also appropriate to playfully ask the patient to introduce you
to the people in the room. This helps confirm their relationship to the patient and
establish how they prefer to be addressed. If they do not state their relationship, it
is appropriate to ask. You may certainly refer to adults by their relationship when
speaking with the child (i.e., “Your mom tells me you’ve been complaining of leg
pain. Where does it hurt?”).
Though it takes a few more moments (and requires further hand hygiene),
handshakes are recommended and favorable when introducing yourself to the
family and patient. Young children who are not used to receiving handshakes will
appreciate the chance to be treated “like a grown-​up.” One tip for making young
patients more comfortable and increasing the likelihood of them interacting with
you is for them to first see you engage with their family. For example, when young
patients see you shake the hand of their older sibling and ask their name, they will
very often want to emulate this behavior, thus giving you an opening to start a warm
dialogue with the patient. Be aware, however, that in some cultures shaking hands
should be done with only certain family members or in a particular order.

Body Language
As discussed in the “Similarities” section earlier, many of the same rules regarding
nonthreatening body language apply to kids as well as adults. It’s important to note
that depending on their developmental stage, children will be much more likely
than adults to be fearful and intimidated by health care providers. As such, it’s im-
portant to be mindful of this when walking into the patient room so that you may
minimize actions and behaviors that could increase the patient’s distress level.
Ways to use body language and nonverbal behaviors effectively with children
include:

1. Sit down quickly—​getting down to the patient’s level is important to minimizing

the risk of intimidation, as adults oftentimes tower over pediatric patients. It’s
important that a provider sit in a chair or stool or kneel next to the patient’s bed
as soon as possible after entering the room.
2. Sit across the room initially—​this will allow younger, more nervous patients
a chance to observe you and warm up to your presence. As patients become
more comfortable with you in the room it will be easier to engage them for the
physical exam.
3. Triangular seating arrangement—​children are more likely to engage in the
discussion when the health care provider sits in a way that allows him or her to
face and make eye contact with both the patient and adult caregiver.
4. Have a pleasant facial expression and don’t appear rushed as you answer
questions. Be patient. Maintain pleasant eye contact.
5. Smile and laugh (when appropriate).
85

DEVELOPMENTAL STAGES

85
For health care providers, one of the most challenging—​and often intimidating—​

Communication With Minors in Emergency Settings

aspects of communicating with minors is that as children age, their expressive and
receptive language skills change dramatically based on developmental stages. To
complicate matters, each child is different and the child’s developmental stage does
not always perfectly align with his or her chronologic age. Nonetheless, there are
certain generalities and categories we may use to distinguish the various stages. One
of the goals of a health care worker early in an encounter with a pediatric patient
should be to assess and establish the patient’s developmental stage and level of ma-
turity. This will allow health care workers to tailor their interactions with the patient
appropriately. The following section will focus on the key points of communicating
and interacting with patients in different developmental states in an emergency
setting.

Infancy
Goals in communicating with infants in an emergency setting include assessing
their ability to respond to verbal stimuli and attempting to soothe and relax them
via playful engagement and distraction (where possible). As is familiar to most
health care workers (and certainly parents), crying is an infant’s primary form
of communication. There are many different reasons that an infant may cry, in-
cluding as a function of normal development, discomfort, hunger, and pain. By
about 1 month of age infants start to make eye contact with others, and by 4
months of age they begin to vocalize in response to sounds. Though adults often
talk to infants as if they can understand, the earliest that an infant’s word com-
prehension begins is around 8 months of age.7 With parents and close caregivers,
infants by 9 to 12 months begin to follow simple commands and use commu-
nication to obtain a goal outcome. Such forms of communication may include
pointing or holding up objects.
Two important normal developmental stages that affect infant interactions
with health care workers in emergency settings are stranger anxiety and sep-
aration anxiety. Stranger anxiety is a normal fearful reaction that infants have
when a stranger approaches them. It develops around 8 to 9 months of age and
generally resolves by the age of 2 years. Being aware of this normal stage allows
providers to modify their behavior to minimize the patient’s stress reaction. For
example, when initially interacting with a family and child in this age range, it
may be beneficial to not make eye contact with the patient and allow the patient
a chance to observe you as you engage and talk to the parents and other siblings
in the room.
Separation anxiety also develops around 8 to 9 months of age, peaks by 18 months,
and resolves by about the age of 2 years. This is a stage in which the child becomes
fearful when separated from the parent or primary caregiver because he or she has
not yet developed a sense of object permanence or trust in others. Suggestions for
health care workers dealing with infants in this stage include keeping parents in the
room as much as possible when interacting with the child as well as placing parents
in a position where the child can see and touch them during the physical exam or
during a procedure.
86

Toddlers and Preschoolers

Patient and Family Interactions 86 By the time children reach the age of 2 years, they have started developing the ability
to answer simple questions. Though more able to interact with the health care pro-
vider, a toddler has limited ability to provide beneficial verbal information about the
current medical illness. The goal of most interactions with toddlers will be to put
them at ease by playfully engaging and talking with them.
Between 2 and 5 years of age, a child’s language develops exponentially. Receptive
language in this age group tends to be better than expressive language; however,
most children by the age of 5 years can communicate using basic rules of grammar
and may be able to answer some medical questions reliably. When speaking with
this age group, questions that can be answered with “yes” or “no” are recommended
as younger children often struggle with reliably answering open-​ended questions.

School-​Aged Children
In general, by the time children reach school age (6 years and above), they have de-
veloped the confidence and ability to communicate effectively with strangers though
are still much more comfortable doing so in the presence of their family members.
This stage is noted for rapid development of an expanded vocabulary and ability to
comprehend more abstract ideas and not rely on concrete thinking at all times. It is
therefore appropriate to approach the school-​aged child first when entering the room
to convey the sense you are interested and focused on him or her. Though children
at this age are often able to communicate effectively with health care providers, their
ability and interest in participating meaningfully in discussions around their health
is somewhat limited.8 There are many cultural, social, and family factors that may af-
fect the success with which a child interacts with health care providers. For instance,
in some cultures children may avoid eye contact with someone in a position of au-
thority (e.g., physician, nurse). In addition, some school-​aged children have not had
many experiences being asked direct questions about their feelings, condition, and
experiences and may have trouble knowing how to answer. When working with
school-​aged children, be patient and give the child a chance to comprehend what is
being asked before interrupting. If the child is struggling to answer, be prepared to ask
the question in another way.
Though this age group is generally not able to give full legal informed consent
for medical procedures and tests (discussed further later), all attempts should be
made to gain their assent to participate in the medical evaluation. As this age group is
likely already involved in self-​care at home (e.g., brushing teeth, bathing, preparing
food), it is advisable to involve them in discussions and explanations regarding their
medical care. Care should be taken to evaluate the patient’s willingness and interest
in participating in health care discussions, as many children become more fright-
ened as more medical information is shared with them. One particularly helpful way
this author has opened this discussion with patients is by stating, “Because you’re
old enough and smart enough, I want you to know that you’re allowed to ask an-
ything you want and understand as much or as little as you want, because this is
your body, OK? Be sure to let me know if something doesn’t make sense or if there
is anything you want to ask or share.” This also serves to let the parents/​caregivers
know you are interested in having their child be a participant in the discussions and
keeping the visit patient centered.
87

Finally, it is always important to remember that even if the school-​aged child is

87
not an active participant in the discussion, he or she will listen and attempt to com-

Communication With Minors in Emergency Settings

prehend everything that is being discussed with the parents/​caregivers. Be mindful
of your choice of words, and if you notice a patient is visibly responding to things
that are being discussed, it is appropriate to stop and ask the child what questions he
or she has and what he or she understands about the visit thus far.

Adolescence
The further development of receptive and expressive language is obvious in the ad-
olescent period and allows the health care provider to have much more complex,
nuanced discussions with the adolescent patient. As with school-​aged children, it is
appropriate and recommended to introduce yourself first to adolescents to let them
know they are the priority. In most situations adolescents will be able to provide
the history of present illness and engage fully in the health care discussion. Parent/​
guardians will often still be relied upon to complete past medical history and more
details of what they have observed in their child during this illness. Close all visits
with adolescents by giving them the last word and asking what questions they have
and what they understand is going to happen during the remainder of the visit.
One of the key goals in establishing successful communication with an adoles-
cent is establishing trust that you have their best interests in mind. It is good practice
early in a visit with adolescents to make it clear that you want to work together to
help them. Ask them to share their specific concerns and goals for the visit, as they
will likely not share this information unless asked directly. Active and respectful
listening is of the utmost importance with an adolescent. In addition, a sense of
confidentiality (discussed later) is a critical issue in earning adolescents’ trust. It
is common in emergency settings to have to discuss sensitive topics such as sexual
activity, drug use, and relationships at school and home. For adolescents to discuss
these topics openly and truthfully, it is critical to create an environment where they
do not fear being judged or criticized.

The Use of Child Life Specialists

The use of certified child life specialists (CCLSs) during a patient encounter is a pow-
erful way to improve communication with a child by addressing the psychosocial
concerns that accompany health care experiences. CCLSs work with children of all
ages and families to optimize the visit experience and minimize the stress associated
with the visit. CCLSs use modalities such as therapeutic play, psychological prepa-
ration for hospitalization/​procedures, and teaching of coping strategies to help their
clients. These techniques have been shown to decrease pain during procedures, de-
crease parent and patient anxiety, increase parent satisfaction, and improve the staff
experience. Child life programs have been shown to be cost effective and should be
strongly considered in all institutions where children receive health care.9

CONFIDENTIALITY ISSUES
As mentioned in the “Adolescence” section of development, confidentiality
concerns are of the utmost importance to adolescents when speaking with a
8

health care provider. Without trust in confidentiality, the ability to correctly di-
Patient and Family Interactions 88
agnose and counsel an adolescent in an emergency setting is greatly diminished.
Though not all visits to EDs will require discussions around sensitive topics with
an adolescent, it is critical that providers are knowledgeable in how to create a
confidential environment. Though the clinical scenario may determine when
there is a need to speak with a patient alone, it is more common in patients 12
years of age and above.
Key points regarding confidentiality issues in adolescents include the following:

1. All states have laws regarding the protection of certain topics discussed between
patient and provider, including drug use, sexual activity, sexually transmitted
diseases, and reproductive issues (e.g., pregnancy and contraception). It is im-
portant that providers know the specific laws in their state.
2. Confidentiality can be breached by the provider if patients share that they
are being harmed (physically, emotionally, sexually), at risk of being harmed
by someone, at risk to themselves (e.g., suicidality), or at risk of harming
someone else.
3. Although most parents/​caregivers understand the importance of a private
provider-​patient interaction, it is important that health care providers have
an approach to telling parents and the adolescent patient that they would
like to speak with the adolescent alone. The more that this is stated as just a
normal part of the visit for all patients, the more likely it will be accepted by all
parties. One approach might be, “It’s my routine practice to speak alone with
all patients over the age of 12 for a few moments so I can make sure I’m not
missing anything.”
4. It is important to establish with both the patient and the parent/​caregiver
the specific topics that are considered confidential and in what situations that
confidentiality may be broken. Establishing these expectations is crucial to
gaining the trust of the patient as well as the parent/​caregiver.
5. If the parent/​caregiver resists, it is important to reiterate that this is a
normal part of every visit with an adolescent and that you both have the
same goals—​to take care of the patient the best way possible. If the parent/​
caregiver continues to resist, ask directly about specific concerns so they can be
addressed most effectively.

CONSENT ISSUES
In most states, patients under the age of 18 years are not able to make decisions
about their health care without their parents’ permission. There are, however,
many situations in which a minor patient may consent to health care without
the parents’ approval. These situations typically include if the patient is married,
a parent him-​or herself, active in the military, or an emancipated minor (usu-
ally meaning living separate from parents, over the age of 16, and financially
supporting oneself). “Mature minor” status may also be a reason a patient can
consent to or refuse medical treatments without their parents in certain situations.
This status is often granted when patients have a chronic medical condition and
have demonstrated a history of being involved thoughtfully in their own health
care decisions and able to rationally explain their thought process for a current
health care decision.
89

INVOLVEMENT IN HEALTH CARE DECISIONS

89
Though parents are legally the medical decision makers for the minor patient,

Communication With Minors in Emergency Settings

there is a moral and ethical obligation to include older children and adolescents in
decisions regarding their health. Minor patients are their own ultimate authority,
and understanding their wishes, desires, and concerns is critical to providing
patient-​centered care. Though not all children want to be involved in every deci-
sion regarding their care, attempting to establish their preference for involvement
is very important. Involving both child and parent in health care decisions leads to
increased visit satisfaction, likelihood of treatment adherence, and medical literacy
and retention of the issues discussed.
It is important to note that there may be situations where the patient’s and
parents’ opinions regarding a health care decision are at odds with each other. The
provider’s role in these situations should be to attempt to fully elicit the concerns
and opinions of both parent and patient so that each may understand the other’s
perspective. Most children and adolescents lack the full capacity to make complex
medical decisions, however; thus, final decision-​making authority rests with the
parents. In the event an older teenager is felt to be a competent decision maker by
the provider and there continues to be disagreement between patient and parent,
further discussion is necessary. If there is a failure of resolution, the provider should
ensure the patient has been heard and help advocate for the child. These cases may
result in a hospital ethics consultation or even rarely a judicial hearing.

Case Example: The Reticent Child

The parents of a 4-​year-​old girl bring their daughter to the ED for 3 days of abdom-
inal pain, fever, and 1 day of vomiting. When walking into the exam room you find
the patient walking around the room but she quickly retreats and climbs in her
mother’s lap upon seeing you. You review the history of present illness as provided
by the parents but want to understand from the patient’s perspective the nature and
location of the abdominal pain and proceed with the physical exam. You have already
sat down on a stool at the patient’s eye level and are using a friendly, nonrushed vocal
tone with the parents, but the patient has yet to make eye contact with you or re-
spond to any of your initial questions.

As children age from infancy, there are significant developmental changes that
occur in their willingness to engage and interact with strangers—​even those who are
extremely friendly and well meaning. Though the developmental stage of stranger
anxiety is usually complete by the time the child is a toddler, it is very common
for children to be leery of health care providers and limit their verbal and phys-
ical interactions as much as possible. It’s not uncommon to hear caregivers in these
situations say things like, “Oh, come on, just talk to the doctor” or “I promise he’s
never shy like this; he’s just scared of doctors.” Though you could always proceed
with the physical exam without first establishing a rapport with the patient, you will
undoubtedly have a much less pleasant experience and will miss an opportunity to
earn much-​desired trust from both the patient and family.
When dealing with the reticent child, there are a few communication
techniques—​both verbal and nonverbal—​that often help diffuse the patient’s anx-
iety and make it more likely for him or her to interact with you during the visit.
90

Tips for interacting with the reticent child include the following:
Patient and Family Interactions 90
1. Ask nonmedical questions the child would enjoy answering.
Early in a visit when attempting to establish rapport with the child, don’t
immediately discuss medical topics but instead engage in simple discussion
with children to get them comfortable talking with you. This will allow you to
transition to asking more specific medical questions later. In addition, these
questions are great to use to distract the patient during the physical exam.
Topics and questions that are likely to interest children include:

• Simple introduction topics:

• “What’s your name?”
• “How old are you?”
• “Who is this?” while pointing to family members in the room
• Siblings:
• “Do you have any brothers or sisters?”
• “What are their names?” and “How old are they?”
• “What do you like to do with your brother/​sister?”
• “Do they ever pick on you?” followed by “Do you ever pick on them?”
(with a smile)
• Pets:
• “Do you have any pets?”; “What kind?”; “What are their names?”
• If multiple pets at home ask, “Which pet is your favorite and why?”
• For example: Once, a 6-​year-​old who had been nervous at the start of the
ED visit lit up and excitedly told this author in front of his stunned and
embarrassed mom that he liked his pet fish the most because “when they
fart they make bubbles!”
• School and future plans
• “What grade are you in?” and “What school do you go to?”
• “What’s your favorite subject?”
• “Any ideas what you want to be when you grow up?” and “Why?”
2. Flatter and compliment them.
There are few things that children (and adults) love more than being comp­
limented. This is an easy way to make a patient comfortable with you and be
more willing to engage in the visit. Examples of simple ways to compliment a
child during a visit include:
• “I like your shirt a lot. Is this your favorite color?”
• “Your shoes are super cool. I bet you can run really fast in them.”
• “Your pajamas look really comfy. Are these your favorite to sleep in?”
• “I’m so impressed with you. Are you always this good at the doctor’s office?!”
• “I need to have you teach all the other kids in the ED how to be such a
good patient!”
3. Have little toys available for distraction.
Young children enjoy examining and playing with little toys. Toys that light up
or make noises are particularly intriguing to children and allow you a chance
to interact with them by having them press the various action buttons. Having
little animals attached to your stethoscope or in your pocket allows you to ask
them if they know the type of animal and to give the animal a name. Always be
sure, however, to sanitize the toy after each patient encounter.
91

4. Use other siblings in the room to your advantage.

91
Communication With Minors in Emergency Settings
As opposed to the shy and nervous patient, siblings of young patients in the
emergency department seemingly have no problems engaging with health
care providers and often crave the attention (presumably because they know
they’re not at risk of getting any shots). If the patient is evasive and minimally
interactive with you, try turning your attention to the patient’s siblings and
engage them in conversation. Use siblings to demonstrate physical exam steps
as they will be more than happy to display their cooperativeness and be a
“good example” for the patient. This technique will allow the patient to see
that you can be trusted (because their sibling is readily engaging with you),
plus they will be much more likely to jump in and show how they can do what
their sibling can.

Case Example: The Painful Procedure

An 8-​year-​old boy is in the ED for an injury sustained today when he accidently

slammed a car door on his right index finger. X-​rays reveal a tuft fracture and he
requires removal of the nail to repair a suspected nailbed laceration. He is in a signif-
icant amount of pain following the injury and you decide to perform a digital nerve
block prior to the repair. The patient appears extremely anxious and scared as you
start discussing the planned procedure with him and parents.

Perhaps the most frightening aspect of a visit to an ED for children is the poten-
tial for undergoing a painful procedure. Understanding their perspective and how
much they know about the procedure (and reasons it is indicated) go a long way in
helping your patient through the visit. In cases where a medical procedure is nec-
essary, there are certain ways to communicate with the child that will help decrease
stress (for patient, parent, and provider alike).
Tips for communicating with children about painful procedures include the
following:

1. Ask patients how much they want to know.

Don’t assume that patients want to know every detail about what is going to
happen, but also don’t assume that they’re nervous and don’t want to know
anything. Allowing children a chance to ask questions is a powerful way to
engage them and decrease their stress.

2. Ask children what they know about why they need a procedure.
Allowing children a chance to share their perspective and understanding
will help the health care team tailor their explanations and responses to
questions.

3. Be honest.
Do not lie and say something won’t hurt if it will. This will ruin any trust you’ve
gained with patients and sets a bad precedent for what they can expect in
future health care interactions.
92

4. . . . But don’t be too honest.

Patient and Family Interactions 92
Use soft, carefully chosen words and language when explaining a procedure and
what the patient should expect. Analogies to known situations or objects can
be helpful. For instance, tell patients that an IV is “just a tiny straw” and that the
needle does not stay in their arm (this is a common misconception with children).

5. Offer options when possible.

Much like parenting, giving children a structured choice that both sides can accept
helps allow them to feel like they are in control. For example, it is appropriate
to ask children if they’d prefer to lie down or sit up when placing an IV.

6. Ask the child to be your partner for success.

Make children feel like they are a part of the team and tell them positive, rather
than negative, things they can do to help. For example, instead of saying,
“Don’t move,” try saying, “We’re going to work together to fix your cut. My job
will be to tie the strings, and yours will be to hold still as much as possible, OK?
We’ll do this together!”

Case Example: Delivering Bad News

A 12-​year-​old boy is referred to the ED after he presented to his primary care provider’s
office with 3 weeks of fatigue, easy bruising, and low-​grade fevers. In the ED the pa-
tient is pale and has scattered bruising, diffuse petechiae, and hepatosplenomegaly.
A complete blood count (CBC) reveals pancytopenia and 25% blasts. You suspect
new-​onset leukemia and plan to discuss your concerns with the family and patient.

All health care providers would recognize that disclosing to patients and their
family a new diagnosis of leukemia would be considered “bad news.” It’s impor-
tant, however, to be aware that what we consider trivial when communicating with
pediatric patients and their families may also be considered “bad news” from their
perspective. Consider, for example, you’ve identified a minimally displaced distal
forearm fracture in a teenager. Though you may consider it “good news” that the
fracture is minimally displaced and will heal fully without operative intervention,
your patient may be a high school athlete attempting to secure a college scholarship
and this injury will keep him or her from participating during a key tournament
attended by several college recruits. Another example would be a young child who
must be admitted to the hospital because of bronchiolitis and hypoxemia requiring
supplemental oxygen. This may seem like a straightforward admission and to re-
assure the family many of us would consider telling them, “Don’t worry, he’ll get
better and will probably just be in the hospital for a few days.” This ignores, however,
that an inpatient admission with a child is a hugely stressful event for a family and
often leads to lost time from work, lost wages, and logistical concerns as they try to
coordinate life at home for other children and family members. Being mindful that
lots of news in an emergency setting is “bad news” is the first step in consistently
communicating information in a compassionate and empathetic manner.
Some tips for sharing “bad news” with minors and their families in an emer-
gency setting include the following:
93

1. Ensure the proper environment and timing.

93
All efforts should be made with your staff and other providers to ensure you’ll

Communication With Minors in Emergency Settings

have the appropriate amount of uninterrupted time to talk to the family and
patient. If the patient’s room is not ideally suited to a discussion because of
visibility or noise levels, ask to move to a quieter room. Sit down and have
facial tissues prepared if necessary.

2. Try to have both parents present (or support person if lone parent).
Though the same information can always be shared later with other family
members, it is best if the important people are present for the initial discussion.
This allows for the same information to be heard and questions to be answered,
and allows the family to have support immediately available.

3. Ask what the family knows so far.

Gauging the family’s knowledge of what has happened thus far and the clinical
condition of the child will help define how to start the discussion.

4. Ask what and how much information the parents want the child to know.
This is a particularly difficult aspect of pediatrics as in younger children it will be
primarily the caregiver who is responsible for making medical decisions, but it
is ethically and morally correct to include older children and adolescents into
discussions about their care. Initial discussions regarding bad news may be
very simple and only focus on the diagnosis, whereas some parents may want
to discuss more medical details, prognosis, and so forth. Health care providers
should be prepared for all situations.

5. Be direct and honest and don’t use medical jargon or colloquialisms.

When giving bad news, it is better to be direct and state exactly what has
happened or what the diagnosis is in terms the family can understand. For
example, do not say, “The CBC shows blasts, which means your child probably
has leukemia.” Instead, say, “The initial blood tests are worrisome for leukemia,
which is a type of cancer.”

6. Pause to allow initial information to sink in.

Health care providers may be tempted to talk at length after sharing the bad
news, thinking the parents will immediately want a lot of information. It is
instead much better to pause and allow the initial news to sink in. Empathize
with the family by saying, “I know this is not the news you were hoping to
hear,” and ask the family, “What are you thinking right now?”

7. Acknowledge emotions.
When receiving bad news, families want the provider to be caring and empathetic
with what they are going through. Don’t attempt to sympathize by saying, “I
know what you’re feeling.” Instead, say, “I can only imagine what you’re feeling
right now.”

8. Be prepared to show your emotions.

Though in health care we often think we need to be stoic and emotionless in
medical situations, this may be perceived as aloof behavior for the family. It is
94

appropriate to show emotions to the family and is generally appreciated in

Patient and Family Interactions 94
the right circumstances.

9. Answer all questions you can.

Do what you can to answer all questions the family has, but don’t be
afraid to state when a question is better answered by someone else (e.g.,
a subspecialist like an oncologist) or when the answer is not yet clear.
Families will be grasping for any information, and wrong information is
much worse than no information.

10. State the follow-​up plan and next steps.

Don’t leave the room without the family knowing the next steps. After
receiving bad news, they will be grasping for any semblance of control, so
giving them concrete next steps of what to expect is critical.

Case Example: The Angry Parent

You walk into the room of a patient and her family who have been waiting 2 hours in
the emergency department to be seen. The patient was triaged as a low-​acuity patient
and the nursing team had no concerns, but as you walk in the room the father angrily
says, “It’s about time. We’ve been here forever!”

It’s commonplace in pediatrics—​particularly in a stressful environment such as the

emergency department—​to deal with parents who are upset and angry. It’s important
to remember that most of the time what appears to be anger and frustration directed
at the care team is ultimately a symptom of caregivers being worried about their child
and not having another outlet to vent their concerns and anxiety about the situation.
There are numerous mnemonics to help remember the key steps in dealing with
angry parents/​patients and how to defuse the situation. The critical components of
the various mnemonics include the following:

1. Allow parents to vent their anger without interrupting.

2. Apologize and acknowledge the anger (“I’m really sorry about the wait for your
child to be seen tonight—​I can tell it’s really upset you”).
3. Validate the anger (“I understand your frustration. I can only imagine waiting
this long with my child to be seen”).
4. Ask if there are any other concerns you can help address (“Is there anything
else right now that is upsetting you about the situation?”).
5. State a plan for working together to improve the situation (“I’ll be happy to
share your concerns with our emergency department leadership team. For now,
I want to work with you to help your son and figure out what’s going on.”).
6. Thank them for sharing their concerns.

Other tips for dealing with angry parents include the following:

1. When possible, offer to sit down to convey the sense that you are listening more
intently.
2. Keep a calm expression and body language during the discussion.
3. Use a neutral tone of voice.
95

4. Don’t become defensive and argumentative. Remember, most of the time the

95
parents’ anger and frustration is not with you personally but the situation they

Communication With Minors in Emergency Settings

find themselves in.
5. Know your personal triggers.
6. If a parent is shouting and/​or using vulgarity, it’s appropriate to state, “I can see
and understand you’re very upset, but it’s hard for us to communicate when
you’re shouting and I have to ask you to not use that kind of language here.”

Case Example: The Overtalkative Parent

You are attempting to take a medical history of a 10-​year-​old who has been
complaining of headaches for the past 2 weeks. Every time you ask a question of the
patient, however, the mother immediately answers for him.

It is not uncommon when communicating with children to encounter a parent

who initially monopolizes the conversation. Although there are times when this is
appropriate (e.g., younger children who cannot share an appropriate medical his-
tory), there are times when it is critical to understand from the patient’s perspective
what he or she is experiencing. First, it’s important to not become upset with parents
who speak for their child or disregard them as “helicopter parents.” In working with
these parents most effectively, it’s safer and more appropriate to assume that the
reasons they are answering quickly for the child is they want to get the story told as
soon as possible to expedite care.
In these cases, allow parents a chance to share the story from their perspective,
and then state something to the effect of, “I’m curious to know from Steven’s per-
spective what the headaches feel like as this can be really helpful information. Is that
OK?” Avoid making statements like, “How about we let Steven himself tell us what’s
going on,” as this may be seen by the parent to be a passive-​aggressive order rather
than a gentle request.

PEARLS AND PITFALLS IN COMMUNICATING

WITH MINORS
• Communicate at eye level as much as possible.
• Children love shaking hands “like grownups.”
• Gauge the child’s level of vocabulary and maturity and adjust your verbiage
accordingly.
• Don’t ignore the child and just speak with the parent/​guardian.
• Involve the child in the visit and decision making as much as possible.
• Don’t use a high-​pitched “sing-​songy” voice. Speak to children like an adult—​it
will make them proud and feel respected.
• Don’t lie. If a procedure is going to hurt, tell the patient but explain the impor-
tance of what you’re doing.
• Don’t ask a child a question like “Can I look in your ears?” if you will do it no
matter what. You risk losing the child’s trust for the remainder of the visit if they
answer “no” yet you still do it anyways.
96

REFERENCES
Patient and Family Interactions 96 1. National Hospital Ambulatory Medical Care Survey. National Hospital Ambulatory
Medical Care Survey: 2015 Emergency Department Summary Tables. Hyattsville,
MD: U.S. Department of Health and Human Services, Public Health Service,
Centers for Disease Control and Prevention, National Center for Health
Statistics; 2016.
2. National Center for Health Statistics. Health, United States, 2016: With Chartbook
on Long-​term Trends in Health. Hyattsville, MD: National Center for Health
Statistics; 2017.
3. Gausche-​Hill M, Schmitz C, Lewis RJ. Pediatric preparedness of US emergency
departments: a 2003 survey. Pediatrics. 2007;120(6):1229–​1237.
4. Wissow LS, Roter D, Bauman LJ. Patient-​provider communication during the
emergency department care of children with asthma. Med Care. 1998;36:1439–​1450.
5. Magaret ND, Clark TA, Warden CR, et al. Patient satisfaction in the emergency
department—​a survey of pediatric patients and their parents. Acad Emerg Med.
2002;9(12):1379–​1388.
6. Beckman HB, Frankel RM. The effect of physician behavior on the collection of data.
Ann Intern Med. 1984;101:692–​696.
7. Paul R, Mills S. Development of communication. In: M. Lewis, ed. Child and
Adolescent Psychiatry: A Comprehensive Text (3rd ed.). Philadelphia, PA: Lippincott
Williams and Wilkins; 2002.
8. Cahill P, Papageorgiou A. Triadic communication in the primary care paediatric
consultation: a review of the literature. Brit J Gen Pract. 2007;57(544):904–​911.
9. American Academy of Pediatrics, Committee on Hospital Care and Child Life
Council. Policy statement on child life services. Pediatrics. 2014;133:e1471.

FURTHER READING
• Desai PP, Pandya SV. Communication with children in healthcare settings. Indian J
Pediatr. 2013;80(12):1028–​1033.
• Leveton M. Communicating with children and families: from everyday interactions
to skill in conveying distressing information. Pediatrics. 2008;121(5):e1441–​e1460.
• Locke R, Stefano M, Koster A, et al. Optimizing patient/​caregiver satisfaction
through quality of communication in the pediatric emergency department. Pediatr
Emerg Care. 2011;27(11):1016–​1021.
• Marvel MK, Epstein RM, Flowers K, Beckman H. Soliciting the patient’s agenda:
have we improved? JAMA. 1999; 281:283–​287.
• Palazzi DL, Lorin MI, Turner TL, et al. Communicating with Pediatric Patients and
Their Families: The Texas Children’s Hospital Guide for Physicians, Nurses and Other
Healthcare Professionals. Houston, TX: Texas Children’s Hospital; May 2015. http://​
www.bcm.edu/​pediatrics/​patient-​communication-​guide. Accessed January 13, 2018.
97

7 Communication in the
Era of Telemedicine

Kevin McGarvey

INTRODUCTION
Typically, emergency medicine communication makes some people think of a busy
trauma bay with people coordinating specific critical tasks in a rapid fashion. Other
times people picture a physician collecting data from a number of sources to then
multitask through complex, time-​sensitive problems on the fly, while running from
patient to patient. In the future, our means of decision making and communica-
tion in emergency medicine may look very different, partly owing to the increasing
adoption of telemedicine and related technologies. With the rise of the electronic
medical record (EMR) and mandate by the Department of Health and Human
Services to adopt standardized digital documentation for medical records, we have
already seen a major shift in how we communicate in the emergency department in
just the past 10 years. It will be interesting to see what the next 5 to 10 years brings
in more intuitive information presentation and workflows for clinicians.
Many emergency staff used to run from room to room the entire shift to
handwrite orders. We would talk face to face with patients and staff every time
we collected critical information and potentially walk multiple miles in a shift.
Emergency physicians now spend a significant amount of time sitting down to
type and click their way through a shift. Now, with many EMRs, information is
just a click or 2 away and physicians can avoid walking 50 to 100 feet, dealing with
hard-​to-​read penmanship and handwritten orders, and having time-​consuming
conversations with nurses. The emergency department has turned footsteps and
quick conversations into finger clicks. With telemedicine and related technologies,
98

communication between doctors, nurses, ancillary staff, specialists, and patients

Patient and Family Interactions 98
will likely evolve once again.
Ironically, telemedicine has been a technology formally used in health care for
over 50 years, but despite this timeline, telemedicine is still in its infancy, relative to
its adoption. Why? In my opinion, it is because it has been less than a decade since
the iPhone disrupted the way most Americans communicate today. Medicine has
been ready for telemedicine for some time, and now patients are ready as well. It’s
just a matter of time before a telehealth technology nails the experience for users—​
both patients and clinicians.
The potential impact of telemedicine on the practice of emergency medi-
cine and how we communicate in the emergency department could be huge.
Nonetheless, as of 2018, there were approximately 3M telehealth visits in the U.S.,
based on industry analysis from healthcare investment firms. Although that may
not sound disruptive or impactful, to put this statistic into perspective, we had sim-
ilar utilization rates with the use of the internet in the mid-​1990s by the general
population. As digital health and telemedicine becomes more widely accepted,
these technologies could be defined as disruptive innovations in retrospect that
reshape the standard ways we communicate in the emergency department and out-
side its walls.

WHAT IS TELEMEDICINE?
Although telehealth may sound sexy and cutting edge, it is a very simple tool.
You text and FaceTime with friends and family already, right? Why not do it with
patients? Do you ask your friends and family to come into a formal, expensive
building to talk with you? No.
So what is telemedicine? This is an interesting question that will likely evolve
over the next few years. Today, telemedicine is about providing Health Insurance
Portability and Accountability Act of 1996 (HIPAA)-​compliant clinical informa-
tion exchange between patients and providers. How does that happen? Texting and
video chat or conferencing are the 2 most common tools. In the future, there may
be components of artificial intelligence that help drive clinical decision making via
telemedicine as well.
What is telemedicine tomorrow? Imagine what we have today in other industries
enabled by apps and the internet—​now make them HIPAA compliant and provide
content that is reimbursable by the Centers for Medicare and Medicaid Services
(CMS). That’s where virtual care and telehealth will go in the future.
Still, there will be inevitable shortcomings of telemedicine in many ways. How
can you truly emotionally connect with patients? How can you pick up on their
body language or their demeanor in detail to suggest you need to ask a few more
questions or stay in the room a little longer? For example, the article “An Evolutionary
Examination of Telemedicine”1 highlights how the established workflows and reim-
bursement patterns of well-​trained practitioners are hard to change. Additionally,
the fear of “edge cases” or worst-​case scenarios where patients lose their cellular
connection right after they tell you they have crushing chest pain keeps many
physicians comfortable with the status quo. Furthermore, insurance companies
and Medicare worry about the increased costs from treating the “worried well” and
other self-​limiting illnesses. All of these barriers and shortcomings will be addressed
over time by forward-​looking companies that seek to solve the problem of disparate
9

health care providers trying to intercommunicate on complex medical care issues

99
while spending thousands of dollars per patient, rather than a few pennies.

Communication in the Era of Telemedicine

WHY SHOULD YOU CARE?
If you are reading this book, most likely you’re an emergency physician. You got
trained for years and years on how to put in chest tubes, intubate, resuscitate, and
manage 20 patients at a time while being compassionate, calm, and meticulous.
Why should you pay attention to FaceTime or texting for minor, self-​limiting
medical issues? It’s boring and useless, right? As of today, it is. However, there
will inevitably be new technologies that go deeper into telehealth and give you
critical information before or while the patient is hitting the door, just like you
get from the EMR today.
At the end of the day, economics drives a lot of what happens in patient care. As
we start to climb above 20% of the world’s largest economy in human history paying
for sick care, technology will provide lower-​cost alternatives. Additionally, tech-
nology for telemedicine could extend your reach as a clinician or as an emergency
physician. For example, why keep that weak and dizzy patient overnight when you
can use a tool for follow-​up virtually via video chat the next day or asynchronously
with remote monitoring tools on the patient’s smartwatch?
If payers move to reimburse some of these telehealth tools at a fraction of the
bricks-​and-​mortar facility fees they pay today, you will start to need to care a lot,
because other competing health systems will look to take more of a local geographic
market by using valuable, patient-​pleasing telehealth tools to gain more patient loy-
alty for their system.

WHAT ARE THE PITFALLS TO OVERCOME?

Telehealth will never be as good as the real thing. How can you easily listen to heart
tones, palpate the abdomen, or smell ketones on someone’s breath? Basic tools will
be built to take the physical exam to its next iteration for the 21st century, but the
inability to be present empathically and with all sensory capabilities will always be a
pitfall for telehealth. However, telehealth will always move faster than in-​person care
when the patient is at a distance. Therefore, some of the pitfalls can be compensated
by the ability for telehealth to enable easy, quick access and care. Where we get the
diagnostic luxury of the computed tomography (CT) or the magnetic resonance
imaging (MRI) machine in our emergency department (ED) at times, we do not
get the luxury of time beyond the standard 2-​to 3-​hour window of an ED visit.
Using texting, remote patient monitoring tools, and video as well as team-​based
telehealth care, we can get the diagnostic of time back on our side. Just as we build
ED observation units for those low-​to moderate-​risk patients who are yet to pre-
sent their acute illness, telehealth coupled with home health or mobile care services
could replace the need for many inpatient beds in the future for a fraction of current
hospital charges or costs. Nonetheless, it will still be many years before we can en-
able smartphones to go deep on complex medical care, as was noted in the article,
“Increasing Clinical Presence of Mobile Communication Technology: Avoiding the
Pitfalls.”
10

HOW DO YOU SHOW EMPATHY ONLINE?

Patient and Family Interactions 100 How do you capture the nonverbal cues that get sensed at the bedside? Investigators
have looked at ways to quantify communication events in a telemedicine context.
Some of the considerations of those interactions relate to nonverbal behavior,
missing information, and validity and reliability.2 This may be the biggest pitfall of
telehealth in addition to the lack of ability to lay hands on a patient or do any phys-
ical interventions yourself. Often, your clinical acumen is driven by a simple feeling
from being in the room or a slight change in the appearance of the whole patient
while you are there with them in person.
A study done with 5 internal medicine doctors and 20 patients looked at a
comparison of doctor-​ patient communications in telemedicine consultations
versus face-​to-​face clinical consultations. The investigators noted less “empathy
utterances, praise utterances, and facilitation utterances” in the telemedicine con-
sultation. Additionally, doctors felt hampered by the communication barriers of
telemedicine.3
Perhaps part of the problem is that telehealth can feel transactional. We believe
that physical touch and presence help drive trust and belief in what a clinician is
recommending. How can you effectively treat decompensated drug addiction or
psychosocial dynamics affecting chronic abdominal pain online? It may never be
possible. However, intercommunication at a distance between care team members
and individuals close to a patient might be better empowered via telehealth than can
happen in reality in a busy emergency department.
Additionally, new tools may be developed to enable a better assessment of
whether a patient experiences an empathetic connection with a care provider. It
has yet to be measured, but my guess as a clinician is that empathetic interactions
become more cost effective for quality outcomes, assuming the medicine is good.
In our virtual world today, passive measurements of emotional connection could
become important clinical tools in the future for telehealth and other aspects of
medicine.

DISRUPTIVE INNOVATION
Disruptive innovation tends to start with small, simple trends that go unnoticed
by the majority of an industry until that innovation reaches a threshold of adop-
tion that infiltrates multiple aspects of an industry. Telemedicine poses a poten-
tial disruptive dynamic to our current specialty of emergency medicine for several
reasons. First, it has become an incredibly cheap technology. Low-​cost economics
are a hallmark of disruptive innovations. This is a critical component to a new tech-
nology totally changing an industry, according to Clayton Christensen, author of
The Innovator’s Dilemma.4 Low cost allows for easy, no-​brainer adoption by the end-​
user in most scenarios.
To quote Christensen, “A disruptive innovation is a technologically simple in-
novation in the form of a product, service, or business model that takes root in a tier
of the market that is unattractive to the established leaders in the industry.”4 We are
seeing telemedicine in its current form start to enter into what he would call “un-
attractive” market segments, where there is little disruption like urgent care–​level
medical issues and backing up emergency physicians while evaluating someone for
administration of tissue plasminogen activator (tPA) for an acute embolic stroke.
Neither of these clinical arenas creates a disruptive dynamic, but as more clinicians
10

and patients get exposure to telemedicine, the adoption of the technology could

101
penetrate other aspects of emergency care, making standard communication
streams more instantaneous.

Communication in the Era of Telemedicine

Another reason telemedicine will likely grow is simply because patients and
providers find the modality very easy to use.5 Patients often love the ease of on-​
demand access to care, as do many physicians practicing telemedicine. It cuts out the
multiple layers and delays between the patients and the physician at times, allowing
for direct, simple communication. The technology can be applied in a number
of different ways to fill gaps for care or replace expensive means of accessing care
such as ending up in an emergency department for a nonemergent issue because of
lack of access to care or lack of easy communication with a provider earlier in the
course of an illness. In their study, Polinski et al. found that one-​third of patients that
completed their survey preferred a telehealth visit to a traditional in-​person visit
and 57% liked telehealth.6
In addition to creating a simple, direct communication channel, telemedi-
cine allows for geographic location to be much less of an issue for accessing care.
Communication can become more continuous as well. Telemedicine can allow for
scheduled or unscheduled video conferencing, phone calls, texting, photos, video
recordings, and emailing. All of these modalities can be done without a medical
building, lab, team of staff, or diagnostic. Owing to the often Spartan nature of the
tool, providers must rely heavily on the conversation with the patient for clinical de-
cision making. Over time, telemedicine will become more enabled by ancillary low-​
cost diagnostics. Although expensive diagnostic technology is frequently housed in
the hospital, telemedicine could allow for more decentralized and on-​demand dis-
semination of health care technology and resources as mobile care becomes more
prevalent.
Again, disruptive innovation tends to not appear disruptive initially. Right now,
people tend to ask, “What can I really get treated with telemedicine?” To some ex-
tent, they are right. Traditional telemedicine is somewhat limited in scope right
now, but as the technology improves and new devices enter the market at consumer-​
level prices, office visits and emergency evaluations that don’t require hands-​on
procedures may get addressed in patients’ homes on demand.
Studies looking at emergency department utilization have shown that any-
where between 13.7% and 56% of all care provided in the emergency department
could take place in a lower-​acuity, less resource-​intense setting.7–​9 With health care
approaching 20% of gross domestic product in the United States, all insurance
companies have rushed to adopt telemedicine services that they often offer to their
members for free to avoid unnecessary emergency department visits. This trend in
telemedicine is likely just the first step of major adoption. Integrated and uniquely
specialized telemedicine that offers a personalized care experience beyond the ge-
neric form offered by insurance will open the doors to more valuable care that could
drive communication flows in a new way in emergency medicine.

TELEMEDICINE TODAY
Over the past 10 years, with the adoption of the iPhone, consumer-​facing telemed-
icine has started to take hold in health care and emergency care in interesting ways.
There are now hundreds of companies around the country allowing patients to ac-
cess a physician on their smartphone, computer, or smartpad in a matter of minutes.
102

Physician-​facing telemedicine has also continued to mature as a high-​quality way to

Patient and Family Interactions 102
see and treat major acute medical issues efficiently and effectively, like acute stroke
and tPA candidates. There are now video monitors you can easily bring to the bed-
side to transport a specialist outside your facility directly into a patient’s room.
These 2 forms of telemedicine, consumer facing and physician facing, are still
relatively separate from each other. Some companies are starting to explore team-​
based telemedicine, bringing in multiple experts in person and virtually to address
a complex, evolving patient need. A number of tools strive to enter this form of tel-
emedicine, but none has been widely adopted as of yet.
Consumer-​facing telemedicine is considered more for low-​acuity issues, and
physician-​facing modalities are focused on very specific but often high-​risk clinical
problems, such as whether or not to give tPA to a patient inside the stroke window
or guiding a lower-​level provider in a remote location through a code or intensive
care unit (ICU)-​level care. Therefore, telemedicine is being applied on the edges of
care in emergency medicine: very low acuity or very high acuity. The vast majority
of emergency medicine still goes untouched by telemedicine, whether it is a chest
pain patient, a standard trauma patient, or a complicated abdominal pain patient.
In this way, telemedicine has yet to significantly impact the main ways we commu-
nicate in the emergency department. If the modality enters the mainstream cases
we see and treat daily in the emergency department, communication processes and
flow will definitely change.
There are a number of other unique telemedicine models that are starting to
be offered that will impact our specialty. Care providers driving to meet patients
in their home coupled with telemedicine are starting to become proven means for
accessing quality, more convenient care with less intensive use of health care re-
sources. Virtual team-​based assessments will allow for more complex cases to gain
expert insights more quickly. When practicing telemedicine remotely, cellular con-
nection issues become the cause for care encounter interruption as opposed to
the current emergency medicine system where the arrival of a new patient causes
interruptions in the previous patient’s care.
With consumer-​facing telemedicine growing, the initial point of access to care
may not always be the primary care physician, urgent care, or emergency depart-
ment. Depending on a patient’s copay, deductible, relationship with a care team or
provider, and ease of access to a doctor or care team, a patient may turn to telemedi-
cine first when worried about a possible medical emergency or issue. Again, mobile
care is now allowing for a lot of moderate-​level interventions to take place outside of
the bricks-​and-​mortar hospital and clinic environment. Telemedicine in combina-
tion with in-​person teams holds a lot of promise for disseminating expert resources
with midlevel practitioners. Mobile providers in conjunction with telemedicine will
allow more first-​line interventions to take place outside of the emergency depart-
ment. Additionally, video, phone calls, and texting, or a combination of multiple
modalities, are being used to assess and treat illness on demand.

A SIMPLE TOOL
Telemedicine can help break down barriers imposed by the bricks-​and-​mortar as
well as the silos created by our standard health care delivery models. With telemed-
icine, patients and providers can potentially communicate at any time. “Follow-​up”
is no longer the right phrase for your next visit if you are a patient with access to
103

easy-​to-​use telemedicine. With telemedicine, the conversation can be continuous

103
with your provider or your provider team. For providers, a consult can become
more of a dialogue and discussion between care team members in real time, which

Communication in the Era of Telemedicine

can be refreshing to the emergency physician, who often discharges patients with no
expectation of ever being able to connect with that patient again.
Telemedicine will speed up communication between all the stakeholders in
the care continuum. With a good user interface, providers can directly communi-
cate quickly with each other, as can patients and providers. This makes knowledge
transfer more seamless and less fragmented between multiple care team members.
Nevertheless, telemedicine can become a roadblock as well if done in a fashion
that does not connect the care in detail between multiple providers and locations.
Some telemedicine solutions are disconnected from local providers, making care
isolated on a platform. Treatments can become incomplete or excessive owing
to the inability to participate with other providers for comprehensive care over
time. Such a dynamic could potentially lead to unforeseen consequences such as
overprescribing of antibiotics or redundant care with excessive referral patterns.

WAYS TO COMMUNICATE
Telemedicine is a broad term that captures a wide variety of communication
streams. Two forms or categories today are called synchronous and asynchro-
nous. Synchronous communication refers to real-​time, live conversations that take
place by phone or video. Asynchronous communication refers to information that
is batched together and pushed back and forth between patients and providers.
Asynchronous communication can take the form of texts, images, and emails or any
set of fixed information that can be reviewed at any given time.
Each modality has its benefits and its limitations. Synchronous communication
is great for diving into a detailed conversation, but it can often be challenging to get
the patients and providers interacting together at a specific time, which limits pa-
tient and provider engagement. On the other hand, asynchronous communication
allows for continuous interactions, but the nuances of a complicated issue could be
difficult to sort out without that live interaction component.
With the hundreds of telemedicine platforms available now, the formats of com-
munication differ between them as synchronous, asynchronous, or a combination
of both. Depending on the clinical problem being addressed and the care environ-
ment, each method of communication can be selectively deployed to allow for more
efficient communication. Currently, live video is a popular option in conjunction
with standard medical information being supplied asynchronously to the care pro-
vider. However, a number of combinations of the communication channels noted
previously can be displayed and presented at various points in a telemedicine care
encounter to make the communication flow a unique experience for the patient and
provider.

CONTINUING THE CONVERSATION

The biggest way telemedicine disrupts traditional medical care is by changing how
and when people access care. With telemedicine, there is less friction in trying to
communicate with a provider, thus allowing for patients to access care earlier in a
given illness and more continuously over time.
104

When telemedicine is put in the hands of the care providers most relevant to a
Patient and Family Interactions 104
person’s illness, it opens the opportunity for in-​depth communication with a care
team. With issues like lack of recollection of what the doctor said at time of dis-
charge, telemedicine can allow for reinforced care messaging to fill in the gaps in
communication and patient knowledge. There are several studies that have been
completed or are currently underway looking at the use of text messaging to im-
prove medication adherence, disease prevention, and patient outcomes.10–​13
Such a dynamic can better empower doctors to observe illnesses remotely,
opening the door for cost savings and better patient satisfaction. Furthermore,
patients often can feel more at ease communicating in their home environment
rather than in a busy emergency department after waiting for some time to talk to
the doctor. Although the care is often provided over a video screen, telemedicine
engages a means of talking to the doctor and feeling cared for when done correctly.

STAYING SAFE
One major benefit of telemedicine is the ability to help address and avoid medical
errors or communication disconnects that often happen in a busy health care envi-
ronment. Telemedicine can provide a safety net for providers who are in over their
heads with a clinical problem or for patients who are discharged and have a sudden
change in status. For providers, consults by phone can be considered a form of tel-
emedicine. For more complicated scenarios, there are now robots and live video
capabilities to allow a consultant to immediately assess a clinical situation with the
team at the bedside. For patients who are discharged and have a change in clinical
condition, a phone call, text, or video conference could help identify a major issue
before their follow-​up appointment or potentially prevent a visit to the emergency
department. In this way, the emergency department will likely develop into a virtual
emergency department for some clinical scenarios currently ending up on the door-
step of the emergency department.

RURAL AND REMOTE REACH

An area where telemedicine has been an obvious solution for access is for
populations with divergent geographies. Many parts of the United States lack pro-
vider coverage, owing to low population or lack of economic resources to support
a comprehensive medical provider community. Telemedicine becomes a perfect
way to bring providers into a community for specific medical care issues, alleviating
the problem of patients having to drive hours to get to a geographic location for an
in-​person care visit. Again, clinics can then be staffed by midlevel providers, with
specialist providers as backup, in order to expand the reach of care services while
utilizing limited workforce resources efficiently.
Local rural providers can also use telemedicine to stay connected with their
patients directly if their patient population is spread out over a large area. In-​person
visits can be critical for gathering nuanced details about a person’s condition and
health. However, for established patients with simple issues or even complex issues
not requiring a comprehensive physical exam, telemedicine can add a lot of value
for rural patients and providers. If a health system has reach in both urban and rural
environments, telemedicine can also allow for leveraging expertise for rural patients
who may not easily have the ability to talk with a specialist otherwise.
105

Other remote or impoverished areas will benefit from the dissemination of tel-

105
emedicine. Wilderness medicine techniques, disaster medicine, and international
medicine will allow a diverse population to gain access to expertise in new ways. In

Communication in the Era of Telemedicine

combination with new transport methods for medical equipment such as drones,
there will be less need for rapid extraction and the ability to apply more treatments
and emergency interventions on-​scene.

PREHOSPITAL EMERGENCY MEDICINE

Definitive expert assessment and interventions often do not take place until a crit-
ical patient is within the walls of a tertiary medical center. With telemedicine, an
expert specialist could get involved as a live consultant in the back of an ambulance.
For time-​sensitive decisions requiring physician specialist oversight, telemedicine
could move high-​risk care into the prehospital setting.
Precious, high-​risk interventions could be moved upstream, such as tPA in
stroke patients or prepping a STEMI (ST-​Elevation Myocardial Infarction) patient
for a heart catheter. Additionally, patients could be triaged to lower-​acuity settings
without even coming to the emergency department, helping acute care become
better stratified in areas with limited resources and reducing emergency department
overcrowding.

CROWDSOURCING PROVIDERS
Many health systems have expanded and merged over the past decade to create
huge provider networks. With frequent effort to expand the reach of a health ser-
vice, there can be brick-​and-​mortar facilities that require physician staffing regard-
less of intermittent patient demand.
In many health care local markets, health systems are building clinics and
hospitals in similar locations trying to gain valuable market share. They may even
open clinics that are not high volume simply to gain presence and patients long
term. This can often leave providers with downtime while providing coverage.
Telemedicine can become a tool for expanding the reach of that provider and allow
for more productivity for a group of providers to care for patient populations that
are in need of a physician on demand.

ENGAGING PATIENTS IN A NEW WAY

Many Americans spend hours in front of a screen every day. Digital health is still
early in its adoption curve, but over time, it is probable that effective user flows and
experiences will be captured on digital screens in ways that are easier for patients
and providers relative to traditional alternatives for accessing care and consultation.
Patient engagement is still relatively low on most telemedicine platforms that
are patient facing. Mass behavior can take years if not decades to change, even when
the behavior changes have massive benefits. With current platforms not being fully
integrated with local care communities and care teams with established, trusted
relationships with patients, engagement will likely continue to be low. At the end of
the day, people want to feel cared for, and getting that feeling from a total stranger
through telemedicine where you have no connection can be near impossible, even if
the doctor or provider has the best bedside manner in the world.
106

MENTAL HEALTH 2.0

Patient and Family Interactions 106 With the advent of smartphones directing so much of how we communicate, patients
with more interest in communicating by phone than by going to a doctor’s office in
person may favor expressing issues they are facing with mental health through the
use of telemedicine.
Clinically depressed or suicidal patients may not have the capacity to proactively
reach out to a physician or mental health provider in person during the early stage
of their illness. Smartphones allow for discrete outreach for care and screening for
at-​risk mental health issues.
Additionally, telemedicine allows for easy talk therapy and continuous
monitoring that may not happen in the traditional model of needing to see the
doctor in person every time for a mental health assessment. As artificial intelligence
and monitoring tools evolve, mental health and well-​being will likely be more readily
screened for outside the clinic. With mental health issues growing and a generation
of adolescents communicating by smartphones, telemedicine will likely start to im-
pact mental health and behavioral health communication flows.14–​16

BARRIERS TO CHANGE
There are several realities that need to be overcome for telemedicine to get more
traction in our profession. Some are cultural, whereas other issues are regulatory
and reimbursement based. Many Americans will always prefer to see a doctor in
person and shy away from a “virtual” doctor visit.
Trust must be established with consumers for this new channel of care to grow.
Similar to how many people told Jeff Bezos in the 1990s that they like to go to the
bookstore to buy books, there will be a period of time where telemedicine seems
like it lacks the experience people want when they go to the doctor.
Additionally, for any care model to get adopted beyond simple medical issues,
patients need to feel cared for and feel real human connection. The constrained dig-
ital domain of telemedicine can often leave patients feeling a lack of a relationship
with the provider on the other side of the screen. By integrating telemedicine with
established in-​person relationships, a stronger care relationship could be cultivated
while improving care costs and efficiencies. Additionally, there are ways to keep the
in-​person connection and human touch as an element of telemedicine through con-
tinuous communication and through care advocate or tele-​presenter telemedicine
models, where a care provider is there in person with the patient assisting with the
assessment and communication flow between the remote provider and the patient.
Beyond the need for people to get comfortable with the idea of telemedicine,
health care reimbursement and the practice of medicine is often regulated state by
state. It can often cost $1000 to be licensed in just one state. National telemedicine
companies are able to invest in those licensure requirements to cover all the states
for large populations, but there is then often a disconnect with local care, which is
critical to providing good care and having clear communication with relevant care
providers in a patient’s community.
Additionally, providers must be engaged by a telemedicine service properly for
a service to add real value. A number of compensation and partnership models are
being developed that best engage physicians. This issue can keep a telemedicine ser-
vice from integrating with a local care community effectively, once again limiting
clear, continuous communication for ensuring quality care.
107

THE FUTURE

107
So what does this new era of telemedicine mean for communication in emergency

Communication in the Era of Telemedicine

medicine? We have yet to see telemedicine dramatically impact the general commu-
nication flow and real-​time interaction inside the emergency department, but this
could significantly change in the next decade. Currently, there are major investments
being made in a number of arenas labeled as part of “digital health.” Telemedicine
is just one of these areas, but as we have seen with the impact of the internet and
mobile technology on other industries, separate digital technologies could start to
interconnect and create new value for patients and providers.
For instance, telemedicine by itself adds potential value to the health care value
chain by directly eliminating wasted time and resources, but what if you combine
telemedicine with genomics, big data, wearables, and population health? The value
could become exponential. Recent dollar amounts being invested by venture cap-
ital alone to transform these areas of digital health are similar to the amounts of
money being invested in the internet in the mid-​1990s. Although one cannot pre-
dict the impact of such investments, especially in the highly regulated industry of
health care, it is probable that we will see a digital revolution impacting every aspect
of health care.
With this potential phenomenon happening in real time coupled with the po-
tential for artificial intelligence (AI), acute care delivery, how we communicate, and
what we communicate about care could look very different in the future. With arti-
ficial intelligence and computer processing power continuing to improve, the cost
of major diagnostic and predictive analytics will improve, making previously una-
chievable computing affordable and accessible. Moore’s law is a principle reported
by one of the cofounders of Intel, Gordon Moore. He noticed that computing
power doubles every 2 years. This phenomenon has created an exponential effect
on a number of aspects of technology such as telemedicine.
What was unachievable or cost hundreds of thousands of dollars in technology
just 10 years ago is now accessible to the average consumer. A great example of this
is the human genome. In 2007, it could cost upward of $10 million to get one ge-
nome fully mapped. Today that cost is less than $1000. A lot of that change in cost
results from improved computing power. As AI, telemedicine, big data analytics,
and other big fields of digital health continue to drop in price point, there will be
a convergence of these technologies in ways that change the information a doctor
has to interpret and communicate. Can you imagine having comprehensive home-​
based clinical data from patients’ daily behavior patterns, their genome, and big data
for entire populations helping guide your decision making on telemedicine even
before the patient hits the door of your ED? It sounds like science fiction, but these
technologies are taking shape, and we need to think about what this will mean for
data analysis, decision making, and communication in emergency medicine.
With the rise of artificial intelligence, a number of manual functions in many
industries will become automated and pattern recognition will become more and
more accessible to robots. One of the biggest investors in digital health in the past
decade, Vinod Khosla, believes that the majority of tasks performed by physicians
today will be done by machines and machine-​learned algorithms more cheaply and
effectively than by human minds and hands.17
Things that we do 2 or 3 times a shift today would be considered repetitive tasks
in the AI world and thus pose an opportunity to eliminate unnecessary work by a
high-​cost care provider and be replaced by a piece of software or robot. Although
108

this sounds like a scary brave new world in some ways, the potential benefit will be
Patient and Family Interactions 108
that it frees up the emergency physician to focus on critical-​thinking decisions that
are beyond the world of algorithms. This could mean that in emergency medicine
communication becomes even more critical, as emergency physicians will be asked
to absorb, process, communicate, and act on increasingly large amounts of data.
Today, a doctor may click a mouse 4000 times in one shift, but AI could remove
many of those repetitious clicks, which would mean the doctor can go back to more
critical decision making and high-​level communicating.
With telemedicine and AI, new data will start to come to light about patients
before they hit the doors of the emergency department. If and when remote
monitoring sensors and other technologies improve in accuracy, the walls of the
emergency department and hospital will start to become less relevant. Prehospital
care and postdischarge care will become more continuous with the actual ED en-
counter. Communication and decision making will shift from an isolated care en-
counter to continuous care.
One luxury we do not have today for many moderate-​acuity issues is time. We
don’t always have the diagnostic of time as we work quickly to see multiple patients
an hour while meeting door-​to-​discharge metrics. Throughput times will go down
with telemedicine. Soon emergency physicians will be able to prescribe an app for
getting a patient home sooner and continuing the evaluation in a less resource-​
intense environment.

ISSUES SHAPING THE FUTURE

There are several trends that will likely continue over the next decade with health
care and emergency medicine. Each of these trends is likely to influence how we
value effective communication styles and tools in emergency medicine. These
trends include:

• More information: There will be more information for the emergency physician
to collect, manage, and communicate. With AI, remote sensing tools, and tele-
medicine, the data will get more complex and continuous.
• More costs: Based on historical trends, health care likely will continue to get
more expensive relative to the size of the US economy unless there is a major
change in the course of the traditional care system.
• More technology: Digital tools and systems will likely grow in scope, requiring
emergency physicians to understand multiple tools and methods for monitoring
health.

The pattern recognition required by an emergency physician will likely look some-
what different as we venture into the digital world of the “quantified self.” Clinical
decision making and clarity in communication will become more challenging un-
less there are standards developed between the numerous systems collecting health
information. Although early work is being done on establishing certain regulations
and standards, the clinical presentation of complex health data will likely become
accelerated as new digital health technologies take hold. It will be important for
emergency medicine as a specialty to be involved in how telemedicine and other
digital health technologies interface with our world. Academic research, work with
109

industry, and regulatory policy work will be critical for how these technologies help

109
or hurt our ability to communicate with our patients and with each other.
Communication in the era of telemedicine will be more and more interesting

Communication in the Era of Telemedicine

as our specialty starts to interface with patients demanding digital health care.
Although the technology can separate patients and providers at a distance, tele-
medicine can also keep the care conversation alive and interactive at critical clinical
moments when applied correctly.

REFERENCES
1. Breen GM, Matusitz J. An evolutionary examination of telemedicine: a health
and computer-​mediated communication perspective. Soc Work Public Health.
2010;25(1):59–​71.
2. Miller EA, Nelson EL. Modifying the Roter Interaction Analysis System to study
provider-​patient communication in telemedicine: promises, pitfalls, insights, and
recommendations. Telemed J E Health. 2005;11(1):44–​55.
3. Liu X, Sawada Y, Takizawa T, et al. Doctor-​patient communication: a comparison
between telemedicine consultation and face-​to-​face consultation. Intern Med.
2007;46(5):227–​232.
4. Christensen CM. The Innovator’s Dilemma: When New Technologies Cause Great Firms
to Fail. Boston, MA: Harvard Business School Press; 1997.
5. Kruse CS, Krowski N, Rodriguez B, et al. Telehealth and patient satisfaction: a
systematic review and narrative analysis. BMJ Open. 2017;7.
6. Polinski JM, Barker T, Gagliano N, et al. Patients’ satisfaction with and preference for
telehealth visits. J Gen Intern Med. 2016; 31(3):269–​275.
7. Weinick RM, Burns RM, Mehrotra A. How many emergency department visits
could be managed at urgent care centers and retail clinics? Health Aff (Millwood).
2010;29(9):1630–​1636.
8. Design, programming. “A Matter of Urgency: Reducing Emergency Department
Overuse.” NEHI Research Brief –​The Network For Excellence In Health Innovation,
30 March 2010, www.nehi.net/​.
9. Weinick R, Billings J, Thorpe J. Ambulatory care sensitive emergency department
visits: a national perspective. Abstr Academy Health Meet. 2003;20:abstract no. 8
10. Huo X, Spatz ES, Ding Q, et al. Design and rationale of the Cardiovascular Health
and Text Messaging (CHAT) Study and the CHAT-​Diabetes Mellitus (CHAT-​DM)
Study: two randomised controlled trials of text messaging to improve secondary
prevention for coronary heart disease and diabetes. BMJ Open. 2017;7(12):e018302.
11. Chow CK, Thiagalingam A, Santo K, et al. TEXT messages to improve MEDication
adherence and Secondary prevention (TEXTMEDS) after acute coronary
syndrome: a randomized clinical trial protocol. BMJ Open. 2018;8(1).
12. Yeates K, Campbell N, Maar MA, et al. The effectiveness of text messaging for
detection and management of hypertension in indigenous people in Canada:
protocol for a randomized controlled trial. JMIR Res Protoc. 2017;6(12).
13. Burner E, Lam CN, DeRoss R, et al. Using mobile health to improve social support
for low-​income Latino patients with diabetes: a mixed-​methods analysis of the
feasibility trial of TExT-​MED + FANS. Diabetes Technol Ther. 2018;20(1):39–​48.
14. Adams SM, Rice MJ, Jones SL, et al. TeleMental health: standards, reimbursement,
and interstate practice. J Am Psychiatr Nurses Assoc. 2018;24(4):295–​305.
15. Grist R, Porter J, Stallard P. Acceptability, use, and safety of a mobile phone app
(BlueIce) for young people who self-​harm: qualitative study of service users’
experience. JMIR Ment Health. 2018;5(1).
10

16. Banbury A, Nancarrow S, Dart J, et al. Telehealth interventions delivering home-​

Patient and Family Interactions 110
based support group videoconferencing: systematic review. J Med Internet Res.
2018;20(2):e25.
17. Farr C. Khosla explains his “robots replacing doctors” comment and goes on the hunt
for data scientists. http://​www.venturebeat.com. Published December 5, 2013.
1

SECTION III   
COMMUNICATION
WITH PROVIDERS,
STAFF, AND
PERSONNEL
WITHIN THE HEALTH
CARE SYSTEM
12
13

8 Provider-​ Nurse
Communication

Anna Engeln and Hillary Giorgio Lippke

INTRODUCTION
Provider-​nurse communication is the keystone to patient care and safety in the emer-
gency department. (We recognize that physicians, advanced practice providers, and
nurses all are considered providers, but for the purposes of this chapter provider
will refer to physicians, nurse practitioners, and physician assistants.) The emer-
gency department is a unique high-​risk patient care environment. In the emergency
department, physicians, advanced practice providers, and nurses are all essential
in coordinating the care for multiple patients with varying degrees of acuity in a
fast-​paced, high-​stress clinical setting complicated by frequent interruptions, noise,
overcrowding, high turnover, and varying patient influx.1,2 The ability of providers
and nurses to engage in effective communication improves patient care and safety
as well as provider and nurse satisfaction. Ineffective communication has been di-
rectly linked to negative health outcomes. In 2014, the Joint Commission identified
communication failure as one of the top 3 reasons for sentinel patient safety events
that result in medical errors.1,3,4 Unfortunately, poor communication has been a
consistent common contributor to errors in health care, resulting in serious injury
or death.3,5 In addition to having negative effects on patient safety, poor communi-
cation between providers and nurses can adversely affect patient satisfaction, nurse
and provider satisfaction, and department efficiency.2
Communication between emergency medicine providers is an essential non-
technical skill that promotes patient safety. Just like any skill, best practice in com-
munication must be identified, developed, taught, and practiced for successful
application.5,6 This chapter will provide emergency medicine physicians, advanced
14

practice providers, and nurses with the tools and skills to develop successful com-
Communication with Providers, Staff, and Personnel 114
munication techniques, recognize potential barriers to communication, and over-
come these barriers.

BARRIERS TO EFFECTIVE COMMUNICATION IN THE

EMERGENCY DEPARTMENT
The emergency department is a unique and challenging health care environment.
It has been found that the health care environment setting frames the communi-
cation processes that occur within it.7 The emergency department is a setting that
is often loud, chaotic, and stressful. The pace of patient care is significantly dif-
ferent than other health care settings. The risk of ineffective communication and its
consequences are heightened in the busy environment.8
Eisenberg et al.9 define several features of this unique environment and note
them to be universal to most emergency departments:

1. Emergency departments are unbounded,9 as clinicians are unable to control

workload in the same way that a provider in a different clinical setting can con-
trol the number of patients seen.
2. Emergency health care involves multiplicity9 and variability, simultaneously
caring for numerous patients with wide-​ranging complaints.
3. There is a high level of uncertainty regarding patients’ workup.9 There are pieces
of the diagnostic puzzle that are fragmented or missing either from patient
histories or from results that remain pending.
4. Time constraints related to demands on emergency systems from critically
ill patients,9 increasing high volumes of patients, and pressure to improve
throughput, productivity, and patient satisfaction are universal to emergency
medicine.

Environmental Barriers
There are features of the emergency department environment that create unique
difficulties in communication processes. By examining the characteristics that
are distinct, we enhance understanding of communication breakdown between
providers and nurses in the emergency department.
Unique communication difficulties in the emergency department setting
include:

1. Information overload
2. Frequent interruptions
3. Multitasking during communication events

Interruptions and information overload occur because of the unique factors of the
emergency department including the immense sense of urgency related to time
pressure and dynamic patient acuity. Research has found that a minimum of 19
complex communication events occur per patient in the emergency department.10
In any one of these communication events, information may be relayed unsuccess-
fully, hindering patient care. Interruptions and information overload are 2 main
causes of information exchange error in the emergency department. Frequent
15

communication events occur because providers are caring for multiple patients

115
in varying states of acuity and different stages of medical workup. This results in
receiving frequent updates related to the diagnostic findings and patient status

Provider-Nurse Communication
changes that must be communicated and acted upon.
It has also been shown that one-​third of all communications between clinical
teammates are viewed as interruptions.11 Furthermore, emergency caregivers expe-
rience 10 interruptions per hour as compared to only 4 interruptions per hour expe-
rienced in the primary care setting.8,12 Interruptions during direct patient care affect
the quality and reliability of communications, contribute to information overload,
and affect the quality of patient care. Face-​to-​face conversation accounts for be-
tween 80% and 90% of all communication events and was the cause of the majority
of interruptions.11 Interruptions are unavoidable in the emergency department, but
they are also the cause of communication failures and distraction of care.13 This
contributes to loss of information and wasted time.
Another example of a communication method that ultimately hinders pa-
tient care is communicating about more than one patient at a time. At least 10%
of all communications involved 2 or more concurrent conversations.14 When
conversations involve care decisions for more than one patient simultaneously, this
causes information overload. The multiplicity of emergency medicine and often fu-
tile efforts to save time creates a manner of multitasking that hinders effective com-
munication. Maximizing communication events and discussing multiple patients
are routine and can lead to confusion and errors. Coriera et al. state that “the com-
bination of interruptions and multiple concurrent tasks may produce clinical errors
by disrupting memory processes.”14

Interpersonal Barriers to Effective Communication

Efficient communication between providers and nurses can be achieved through
mutual respect, trust, and an environment of professional collegiality.6 Instead of a
hierarchical system, providers and nurses should strive to create an environment of
collaboration. The physician, advanced care provider, and nurse provide valuable in-
formation to each other that can improve efficiency, decrease duplicated efforts, and
promote education between all essential roles.6,15,16 Without this respectful collabo-
ration, there is risk for nurses to feel intimidated and hesitant to speak up, which can
lead to missed vital information, duplicated work, or loss of a valuable perspective.
Mickan and Rodger17 preformed a literature review in 2000 demonstrating the ef-
fective characteristics of teamwork. Their contribution suggests that effective team-
work and conflict resolution are hindered when all the team members’ opinions
are not equally valued or are dismissed.17 Dysfunctional hierarchical systems can
result in hesitancy in sharing pertinent information.7,18 Poor collaboration efforts
can result in delay of appropriate care and adversely affect patient outcomes when
changes in patient presentation or new pertinent results are not communicated in
a timely manner.19–​21 Dismissive attitudes and lack of approachability lead to a de-
crease in future information sharing and vital communication events. By removing
these barriers, it becomes possible to develop and nurture a formal and informal
organizational structure that supports open dialogue and discussion that supports a
collaborative clinical environment and enhances patient care.
Collaborative, trusting, and respectful professional relationships lead to
more successful communication behavior.22 The creation of a collaborative work
16

environment is motivated by the desire of providers and nurses to promote quality

Communication with Providers, Staff, and Personnel 116
patient care. Collaboration also improves the opportunity for positive negotiation
and conflict resolution and enhanced education, job satisfaction, staff retention, re-
cruitment, and professional development.20,23

Effects of Inadequate Communication

It is important to recognize potential barriers to promote effective communication
in the emergency department. The environmental barriers limit adequate commu-
nication between providers and nurses, and this is compounded by the historic
hierarchical authoritative structure of the physician-​nurse relationship.15 In the
complex setting of the emergency department, communication between providers
and nurses is challenging as caring for the same patient often occurs in parallel silos,
limiting effective information exchange.
Lack of high-​quality communication can result in patient harm when the fol-
lowing occurs:

1. Unrecognized dynamic clinical changes

2. Inadequately communicated diagnostic results
3. Inappropriate level of care
4. Premature discharge
5. Medication errors

Creating structured communication events for each of these potential situations

promotes effective communication between the provider and the nurse, resulting
in improved patient care.

Unrecognized Clinical Changes

Unrecognized dynamic clinical changes can be overcome by designing specific
prompts for required communication between providers and nurses that will facili-
tate the exchange of critical information to avoid missing a change in clinical status.
For example, abnormal vital signs from triage or a change in a patient’s clinical con-
dition should trigger a rapid and coordinated effort by all caregivers. Prompt recog-
nition of a clinical change and subsequent communication of this change decrease
time to escalation of care and therapeutic intervention.24

Inadequately Communicated Diagnostic Results

Diagnostic information resulting in changes to the patient care plan must be relayed
in a timely and accurate fashion between providers and nurses. Often, critical
findings are shared from other departments with one member of the team leaving
other members unaware. For example, a critically low glucose called to the nurse
needs to be reported to the provider for new appropriate orders. Another example
is a radiology result of acute appendicitis called to the provider, which must be
communicated to the bedside nurse in a timely manner as this changes diet status,
admit status, and need for additional orders such as consults, labs, medications, and
care plan.
17

Inappropriate Level of Care

117
Ensuring the appropriate level of care for patient admission can be achieved by

Provider-Nurse Communication
involving nurses in admission decisions. As nurses often spend more time at the
bedside than the provider, specific needs are often identified first by the nurse.6,24
The STOP mnemonic has been developed to identify any pending issues that could
adversely affect a patient’s smooth transfer from the emergency department to the
admission bed.
STOP stands for:

• Significant issues (Have there been any mental status changes? Does the patient
need a sitter on the floor?)
• Therapies (Have all ordered interventions been given? Is there a delay in a medi-
cation coming from the pharmacy?)
• Oxygen (Is the oxygen requirement available at the level of care the patient is
being admitted to? Is there an increased oxygen requirement that has not been
addressed?)
• Pending issues (Can the patient receive imaging en route to the inpatient bed, or
does he or she need to come back to the room? Or can those issues be addressed
at the patient’s next destination?)

This tool allows for appropriate pause in the admission process. With this tool,
complications such as triggered rapid response, falls, and timely continuity of care
are addressed.

Inappropriate Discharge
To avoid discharge before the patient is clinically ready, a discharge “timeout”
should be instituted to ensure all needs have been addressed, vital signs are stable,
and the patient is able to ambulate if applicable.24 Abnormal vital signs at discharge
may be one of the only signs that the patient may be at an increased risk for an ad-
verse event upon discharge. The discharge timeout provides an important opportu-
nity to recognize potential problems and avoid a missed diagnosis.24

Medication Errors
Medication errors are among the 10 most commonly reported sentinel events.4
Closed-​loop communication including read-​backs are recommended for medi-
cation orders as well as critical result reporting.25 Manojlovich et al.26 preformed
a descriptive study on nurse-​physician communication and patients’ outcomes.
The study demonstrated that a decrease in medication errors can be achieved with
improved provider-​nurse communication. Reducing medication errors is not the
only clinical benefit of clear, concise, and respectful communication. Improved
provider-​nurse communication promotes patient safety and efficiency of care by
effectively engaging nurses’ observational and intellectual skills. This positively
impacts job satisfaction, improves nurses’ ability to contribute to patient care, and
creates an environment of collegiality.27,28
18

SUCCESSFUL COMMUNICATION TECHNIQUES

Communication with Providers, Staff, and Personnel 118 When faced with the task of caring for patients in the complex and highly stressful
environment of the emergency department, strong communication skills and
behaviors are paramount to achieving patient care that is both safe and satisfactory.
Successful communication in an emergency department setting requires shifting
and resetting one’s cognitive frame and communicative approach.9 The following
proven tools and invaluable skills optimize communication between providers and
nursing staff without causing information overload:

1. Maximize teamwork and collaboration.

2. Develop effective communication skills.
3. Standardize communication.
4. Utilize technology appropriately.

Maximize Teamwork
Teamwork starts with clearly defining professional roles to avoid communication
conflict and redundancy. Just as role definition is paramount during a resuscita-
tion, it is also valuable during standard patient care. For example, establishing a
charge nurse to coordinate patient flow provides an essential source of communi-
cation between nursing staff and physicians as well as nondepartmental staff.24 It is
also important to understand who is responsible for patients and in what capacity.
How do nurses divide up patient care responsibilities? How do advanced practice
providers, resident doctors, and attending physicians divide responsibility and de-
cision making? Is there a chain of command to follow? Are there important scope-​
of-​practice issues to be aware of? To clearly define roles, all these questions must be
answered.

Effective Communication Skills

Effective communication is frequent, clear, and concise. It is important to under-
stand that communication styles vary by profession. Nurses tend to include more
detail, whereas physicians use briefer statements.29 Closed-​loop communication is
an effective communication strategy that has been shown to decrease communi-
cation errors and overcome the difficulty of varying communication styles.15 The
goal of closed-​loop communication is to accurately transfer information by verbally
ensuring that sent information was received and correctly interpreted.15,19,30,31
Hargestam et al.30 clearly define closed-​loop communication as a 3-​step process:

1. Sender sends a message.

2. Receiver acknowledges the receipt of the message.
3. Sender verifies that the message has been received and interpreted correctly.

This clear, concise, and confirming technique has been shown to improve com-
munication in trauma and emergent situations, decrease medication errors during
verbal orders, and improve collaborative communication among care teams.15,30 The
closed-​loop communication technique will be further illustrated in the problem-​
based scenarios later in this chapter.
19

Effective communication requires more than an exchange of information.7 It

119
also requires respectful dialogue and open body language as well as a collaborative
communication structure. Collaborative problem solving and interprofessional

Provider-Nurse Communication
teamwork involve presenting problems and data while working together to find
solutions.15 Research shows a link between nurse-​physician collaboration and pos-
itive patient outcomes.15,32

Standardize Communication
When working in a multidisciplinary team such as those typically found in emer-
gency departments, it is important to establish clear and consistent methods to
transfer knowledge.33,34 Standardized communication strategies have been found to
increase the amount and quality of communication as well as prevent adverse pa-
tient outcomes.34,35 One recommendation is to standardize the way in which infor-
mation is framed. The previously discussed STOP pneumonic to be used at the time
of admission is one form of structured communication; SBAR is another. SBAR
provides an evidence-​based communication framework.7 Using a format such
as SBAR (Situation, Background, Assessment, and Recommendation) provides
the structure for nurses who are uncertain or hesitant to approach physicians by
preparing them to update other team members in a clear, concise, and informed
manner.36 Another benefit of communication tools such as SBAR is that they can be
time saving, which is necessary in a busy emergency department.34 This tool helps
deliver information in a succinct and timely manner while presenting accurate and
relevant patient information.7 It also allows nurses to present their level of concern
and foster a collaborative structure by making recommendations.
Another example of a successful formal collaboration intervention includes
using a joint evaluation and structured huddle process. Martin and Ciurzynski34
found improved teamwork, communication, and nurse satisfaction scores when
the following processes were implemented: completing the patient evaluation to-
gether followed by a structured huddle. Standardization of communication events
is helpful. A structured huddle should be utilized during the following care events:
(1) formation of plan of care, (2) changes in condition, and (3) changes in dispo-
sition or management teams including admission or shift change. A shared under-
standing of the plan of care between nurses and providers can be the foundation of
an efficient and satisfying patient encounter.

Utilize Technology
One of the most significant barriers to effective communication is the time
constraints of the emergency department. Phones or other communication devices
have the potential to be a time-​saving tool, but efficacy varies. Phones have been
found to make communication error prone37 and have the potential to lead to
interruptions.7 However, in a large department, the handheld mobile phones
are the fastest way to locate and communicate quickly with other staff members.
Communication can consist of face-​to-​face and telephone communication, pa-
tient room white boards, or entry into the medical record. Emergency department
clinicians often choose face-​to-​face communication over the other modes.14 The use
of a telephone to bridge location gaps of a physically large department and sched-
uled structured huddles is an excellent way to minimize interruptions. Telephones
120

are also an excellent tool for a brief conversation such as to clarify an ambiguous
Communication with Providers, Staff, and Personnel 120
order. White boards in patient rooms can provide a generalized plan of care for pa-
tient and care team reference.
Another technological solution is implementing an electronic health record.
The electronic health record (EHR) can be an excellent tool for information ex-
change and an important medium of communication for physicians and nurses
when used correctly. The EHR is an efficient patient data management tool and
has been shown to reduce patient throughput times.38 However, it is not without
its limitations. When entering information into the EHR, it is important to stand-
ardize the information put into the system to avoid misleading or unclear orders.
Inappropriate reliance on the medical record can lead to decreased communication
events and poor outcomes. It is not appropriate for synchronous communication—​
when both parties need to be paying attention or for immediate feedback.11
However, utilizing the EHR for asynchronous communication reduces face-​to-​face
conversations and has the potential to reduce interruptions11 and information over-
load. EHRs should be used in conjunction with face-​to-​face communication, not as
a total replacement of it.

SIMULATION TRAINING
In the emergency department setting, the necessity of multitasking complicates
attempts at communication that is already plagued with interruptions. Given the de-
gree of challenge in the unique care environment, specific communication training
is beneficial for emergency medicine teams.24,28 Simulation scenarios highlighting
communication help to promote role clarity, leadership skills, closed-​loop commu-
nication, and delivery of coordinated care by the entire care team. Just as with any
technical skill that requires practice and repetition, communication and teamwork
can benefit from simulated clinical scenarios. In 2011, Maxson et al.39 demonstrated
that simulation team training enhanced provider and nurse awareness of potential
barriers to effective communication and improved collaboration in patient care
settings. Simulation provides an opportunity for providers and nurses to work to-
gether practicing skills in a realistic yet low-​risk environment and helps implement
these valuable skills into everyday practice. 19,24,30 Simulation promotes calm collab-
oration of care in a clinically chaotic process.19,20

ADVANCED PRACTICE PROVIDERS AND NURSES

Advanced practice providers (APPs) consist of both nurse practitioners (NPs)
and physician assistants (PAs) and are being incorporated into the care model of
emergency departments across the country. With a rapid expansion over the last
20 years, the number of patients seen by APPs now averages 13% of all emergency
department patients in the United States.40 APPs have a positive impact on quality
of care, patient satisfaction, and waiting times.41,42 One way they positively affect the
communication in the emergency department is by improving patient-​to-​provider
ratios, therefore relieving time pressures that cause communication errors.
Historically, the challenge has been to define the role of the APP—​from
“midlevels” to “physician extenders” to “advanced practice providers,” the difficulty
begins with the name. Culturally, conflicts between staff nurses and APPs often
stem from unclear role definitions. Role clarity can greatly improve staff nurse and
12

APP working relationships and communication. Without this definition in place,

121
communication issues arise. In the case of nurse practitioners, staff nurses find that
“taking orders” ’ from another nurse is an uncomfortable paradigm shift.43 APPs

Provider-Nurse Communication
can face difficulty with successful delegation and often receive pushback as their
authority is questioned.44 Likewise, doctors also struggle with understanding the
role of APPs45 and often have difficulty knowing how to incorporate them into their
teamwork model, which leads to missed opportunities for collaboration.
The benefit of working within an emerging model that includes APPs in the
emergency department setting is that there are no long-​held beliefs or attitudes
about behavior norms and communication expectations. APPs do not have a tra-
ditionally defined role; therefore, there is no implied hierarchical relationship.
This can be both positive and negative. The respect a physician might receive by
default is harder to obtain, but fostering a collaborative environment with more
open channels of communication is easier. This can affect their communication
patterns and those of other providers on their team. Studies have found that
nurses who work on a team with NPs and physicians reported a strong trend of
greater collaboration with NPs than with physicians.45 Also, physicians who work
on a team with NPs and nurses report higher collaboration with nurses than those
on teams without NPs.45 A wider range of training and communication styles
held by team members fosters increased opportunity for improved development
of flexible communication styles and collaboration. As their roles coalesce, APPs
prove themselves valuable to the uniquely demanding emergency department
environment.

PROBLEM-​B ASED SCENARIOS

The following clinical problem-​based scenarios highlight communication strategies.
These scenarios provide additional tools and demonstrate the application of pre-
viously discussed communication techniques to overcome barriers and to achieve
effective communication in the emergency department setting.

Communication in a Trauma
Case: A 33-​year-​old male arrives by ambulance to a level 1 trauma center with a
gunshot wound to the abdomen. Vital signs upon arrival to the emergency depart-
ment are blood pressure (BP): 70/​40, heart rate (HR): 122, respiratory rate (RR):
28 on Non-​Rebreather Mask (NRB).
On primary survey the airway is intact, bilateral symmetric breath sounds are
present, and a thready pulse is palpated with noted hypotension on the monitor.
Bilateral large-​bore IV access is obtained, blood transfusion is initiated with
non-​cross-​matched trauma blood, and the patient is taken emergently to the oper-
ating room with trauma surgery.

Discussion
Advanced Trauma Life Support (ATLS) training provides a systematic approach
to the trauma patient that supports rapid assessment and implementation of
appropriate care. Patient morbidity is directly related to time between injury
and definitive care.30,46,47 In the case described previously, clear, effective, and
12

efficient communication is paramount to excellent clinical management as well

Communication with Providers, Staff, and Personnel 122
as expedited definitive care, in this case, to the operating room. In this scenario,
there are many quickly moving necessary processes with multiple participants
from various teams. The initial assessment, vital signs, establishment of IV ac-
cess, recognition of hypotension in the setting of hemorrhagic shock, initiation
of blood transfusion, decision to admit to the operating room for definitive care,
and mobilization of the patient from the emergency department to the operating
room all have to be coordinated. All participants have the same goal of excellent
patient care. However, even with a shared goal, it is essential to clearly define
professional roles and establish a team leader to provide clear organization and
direction to efficiently achieve the common goal.19,20 Lack of an identified leader
results in confusion and can lead to information and communication overload
that results in errors or delay of care.19,30 An effective leader should use clear,
respectful, and concise communication to oversee, delegate tasks, anticipate
barriers, and direct the clinical plan to be implemented by a care team.15,19,30
Without a defined leader, the nurse is unclear which orders should take priority
and who is managing the resuscitation. Härgestam et al.30 noted that closed-​loop
communication initiated by an established leader decreased the time of making
a decision to go to surgery in trauma team simulations, whereas not establishing
closed-​ loop communication from a central source resulted in conflicting
commands and communication overload, resulting in a delay in definitive care.30
This can also happen with other orders for medications and fluids. If roles are
not defined and it is unclear who is leading and coordinating the patient care,
multiple orders called out by different people can lead to confusion and delay in
medication administration by the nurse.
This degree of coordination of communication and care is difficult to imple-
ment effectively without practice, and simulation has been shown to improve in-
tegration of these skills in real clinical situations.30 It is essential to practice the
techniques of establishing a leader, clearly defining roles and responsibilities, and
utilizing closed-​loop communication for more efficient management of trauma.
It is beneficial to have predefined protocols and guidelines that define roles that
providers and nurses can easily refer to and can be practiced in a simulation set-
ting. If the team is together for a few minutes prior to the patient’s arrival, make
sure that all members of the team are aware of their roles. For example, Dr. X as the
team lead can call out each member of the team and what role they will be playing
to make sure that everyone is on the same page. This will decrease confusion and
uncertainty when the patient arrives. Dr. X can also specify that all orders will be
called out by him so that the nurse is aware of who will be giving the orders to
be implemented. As another mechanism to prevent errors in this chaotic environ-
ment, the nurse will use closed-​loop communication. For example, when Dr. X
asks for 2U of blood, the nurse says “I am starting the infusion of 2 Units of Packed
Red Blood Cells (PRBCs),” and then Dr. X can reaffirm “2 Units of PRBCs are
infusing now.”

Tools Used
• Clearly defining roles and establishing a leader
• Closed-​loop communication
• Simulation training for development of skills
123

“Give 1mg epinephrine IV”

123
Code Leader Order Given Nurse

Provider-Nurse Communication
“1mg epinephrine IV given”

Nurse Order Acknowledged Code Leader

“Thank you for giving 1mg epinephrine”

Code Leader Verification of order interpretation Nurse

FIGURE 8.1. An example of closed-​loop communication utilized in ordering medication during a

medical code.

Communication in a Medical Code

Case: A 76-​year-​old male arrives by ambulance in cardiac arrest. Per paramedic re-
port he was found by family unresponsive in bed. On paramedic arrival, patient was
found to be pulseless and apneic and cardiopulmonary resuscitation (CPR) was
initiated. He was intubated by emergency medical services (EMS). The patient was
found to be in ventricular fibrillation on the monitor and he was defibrillated twice
prior to arrival. Two peripheral 18-​gauge IVs were established, and he received 2
doses of epinephrine 1 mg IV and 300 mg amiodarone IV and arrives to the emer-
gency department with CPR in progress now for 20 minutes.
Discussion: Interruptions in compressions should be minimized during car-
diac arrest, as interruptions have been shown to have a negative impact on mean-
ingful survival.48,49 Thus, before the patient arrives in the emergency department,
it is important to establish roles to minimize interruption of care during patient
handoff from the EMS team to the emergency department team. Establishing a
code leader is important for clear communication and guidance of care. Just as in
the trauma setting, it is also important to establish roles in the resuscitation, such
as who is giving medications, who is managing the airway, who is charting, who is
available to continue CPR, and so forth.19,20 Potential pitfalls in a code communica-
tion situation include:

1. Poor understanding of roles and responsibility

2. Information overload with too many uncoordinated orders from a noncentral
source that can lead to redundant or unnecessary orders
3. The use of verbal orders that can increase the risk for medication errors—​this
makes closed-​loop communication essential

Closed-​loop communication initiated by the code leader allows for clear and con-
cise orders and provides opportunity for immediate order clarification if needed
between the nurse and physician. Figure 8.1 provides an example of closed-​loop
communication in this resuscitation scenario.
124

Case continued: The patient is transferred to an emergency department bed

Communication with Providers, Staff, and Personnel 124
and CPR is continued and he is hooked up to the monitor. Intubation is confirmed,
and ACLS is continued using closed-​loop communication between the code leader
and nurse (Figure 8.1). An additional 1 mg epinephrine IV is administered and
pulse check reveals that the patient is in asystole. CPR is continued, and an addi-
tional 1 mg epinephrine is administered.
Discussion: It is helpful for the code leader to be clear in the summary and
plan of care, such as: “The patient has received 2 rounds of epinephrine so far in the
emergency department and 2 rounds of epinephrine and amiodarone from EMS
prior to arrival for a total of 4 mg epinephrine. His airway has been confirmed. We
will continue CPR for 2 more minutes and then preform a rhythm check. Who is
up next for CPR?”
An intrinsic difficulty in code situations is determining when to cease resuscita-
tion. It is important for the code leader to clearly and concisely communicate the
decision to cease resuscitation.
Case continued: On the third rhythm check, the patient is still pulseless and
apneic. He is still in asystole on the monitor. His pupils are fixed and dilated, and
bedside cardiac ultrasound reveals no cardiac activity. At this time, the physician
code leader reiterates these findings to the team and asks if there is any other clin-
ical input. There is none, and time of death is called, and time of death is acknowl-
edged. Additional responsibilities are delegated by the team leader, including who
is contacting family, who is contacting the coroner, and when a debriefing will
take place.
Discussion: This case demonstrates that despite our best medical manage-
ment, the patient may not survive. These high-​acuity situations that are asso-
ciated with high morbidity and mortality are taxing on health care providers.
Debriefing after such code situations improves provider and nurse morale,
provides valuable validation and education, and promotes the collaborative
environment of a successful emergency department.15 Arafeh et al. wrote:
“debriefing is the process whereby the healthcare team can reexamine the clin-
ical encounter to foster the development of clinical reasoning, critical thinking,
judgement skills, and communication through the reflective learning process.”50
Debriefing can improve teamwork and collaboration as the care team discusses
and reflects upon their clinical performance, providing an opportunity to learn
from the event, further refine effective communication skills between the care
providers, and improve future care in similar situations.51,52 During debriefings,
it is important to allow for focused, structured, open communication so that
all care providers have a voice and feel comfortable speaking up if they have
concerns or suggestions as to what could be improved upon or what was done
well. This provides greater insight into others’ perspectives, further enhancing
collaboration in the future.19,51

Tools Used
• Closed-​loop communication
• Clearly defining roles and establishing a code leader
• Establishing a collaborative environment through debriefing
125

Communication in a Changing Clinical Presentation

125
Case: An 86-​year-​old female arrives from the triage desk reporting general malaise,

Provider-Nurse Communication
fatigue, and intermittent shortness of breath (SOB) for 2 weeks. Vital signs from
triage are BP: 120/​62, HR: 90, RR: 22, SpO2: 92%. Initial assessment reveals a pa-
tient appropriately answering questions in no acute distress. Upon arrival, the pa-
tient is seen by the physician and nurse and general labs, electrocardiogram (ECG),
urinalysis, and chest x-​ray are ordered in the EHR. During nursing reassessment,
it is noted that there has been a change in mentation with abnormal vital signs.
Reassessment vital signs are BP: 82/​42, HR: 120, RR: 30, SpO2: 89%, temp: 40.
The patient is now only opening eyes to voice.
Discussion: The use of successful communication techniques is especially im-
portant when dealing with a complicated patient or a patient whose condition is
deteriorating. A patient who has an evolving level of care will require more communi-
cation and timely updates with appropriate levels of information. Sepsis training and
bundling techniques teach us that prompt recognition and intervention of the septic
patient are directly linked to morbidity and mortality.53 The nurse, noting these changes
upon reassessment, determines that the level of care planned for this patient needs to
be reevaluated. The nurse calls a structured huddle with the physician to present the
changes noted and to share her concerns within a structured format using SBAR.

Situation As patient X’s primary nurse I am concerned because

Mrs. Y has become hypotensive.
Background Mrs. Y presented with 2 weeks of fatigue and SOB. On
presentation her BP was 120/​62 and HR was 90. She
initially was talking in full sentences and answering
questions appropriately. We have sent the labs that were
ordered. ECG is in the room now. Chest x-​ray is pending.
On my reassessment, her BP is 82/​42 with an HR of 120
and now she is only opening her eyes to voice but not
answering questions. Additionally, her temperature is 40.
Assessment I am concerned this patient is septic.
Recommendation I need you to come reassess the patient. In the meantime
would you like me to go ahead and get blood cultures
and start some fluids?

The physician agrees that this is a significant change and reevaluates the patient
with the nurse. Findings are discussed, and new orders are added to the EHR in-
cluding lactate, blood cultures, weight-​based fluid resuscitation, oxygen, appro-
priate antibiotics, and medical intensive care unit (ICU) consults. It is agreed by all
staff that expediting care is paramount.

Tools Used
• Standardized communication event—​change in presentation, abnormal vitals
• Structured communication—​SBAR
• Teamwork—​closed-​loop communication, understanding of roles of care providers
126

Case continued: BP: 88/​50, HR: 115, RR: 25, SpO2: 92% on 2L Nasal Cannula
Communication with Providers, Staff, and Personnel 126
(NC). The patient’s vital signs have improved but she remains with a Glasgow Coma
Scale (GCS) score of 14.
Discussion continued: Upon reevaluation the nurse notes the improved
vital signs but no improvement of mentation. IV fluids have been given.
Assessment and findings are documented in the EHR and the provider is
updated. The admitting providers have seen the patient and reviewed the case in
the EHR noting the continued abnormal vitals with only minor improvement.
Based on the current data, ICU admission is appropriate. Another huddle is
called in which the provider and the nurse communicate these clinical findings
and the provider updates the nurse as to the revised plan of care with admission.
The STOP mnemonic is applied to the case to prevent any delays in admission
and the patient is admitted to the ICU.

Tools Used
• Standardized communication event—​admission
• Structured communication—​STOP
• Utilization of technology—​EHR

CONCLUSION
Communication between providers and nurses is essential for safe and efficient
patient care. The emergency department is a fast-​paced, high-​acuity environment
prone to distractions and interruptions. This complex care environment makes
clear, concise, and respectful communication hard but essential. Utilizing struc-
tured communication techniques such as SBAR, closed-​loop communication, and
STOP when making admission decisions as well as creating a respectful and collab-
orative care team with clearly defined roles helps navigate the challenges of commu-
nication between physicians and nurses in the emergency department.

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coordinating, and cooperating when lives depend on it: Tips for teamwork. The Joint
Commission Journal of Quality and Patient Safety. 2008;34(6): 333–​341.
32. Zwarenstein, M, and Reeves, S. Knowledge translation and interprofessional
collaboration: Where the rubber of evidence based care hits the road
of teamwork. Journal of Continuing Education in the Health Professions.
2006;26: 46–​54.
33. Pun J., Matthiessen, C, Murray, K, Slade, D. Factors affecting communication in
emergency departments: Doctors and nurses’ perceptions of communication in a
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online], 2015;8: 1–​12. Available from: Academic Search Complete, Ipswich, MA.
Accessed August 20, 2017.
34. Martin, HA, and Ciurzynski, SM. Practice improvement: Situation, background,
assessment, and recommendation–​guided huddles improve communication and
teamwork in the Emergency Department. Journal of Emergency Nursing. 2015;41(6):
484–​488. doi:10.1016/​j.jen.2015.05.017.
35. Bonds, RL. SBAR tool implementation to advance communication, teamwork, and
the perception of patient safety culture. Creative Nursing. 2018;24(2): 116–​123.
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nurse-​physician communication and reduces unexpected death: A pre and post
intervention study. Resuscitation. 2013;48: 1192–​1196.
37. Rabøl, LI, Andersen, ML, Østergaard, D, Bjørn, B, Lilja, B, and Mogensen, T et al.
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cause analysis-​reports from Danish hospitals. BMJ Quality & Safety. 2011;20(3):
268–​274. doi:10.1136/​bmjqs.2010.040238.
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on the trauma patient’s length of stay in an Emergency Department. JEN: Journal of
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39. Maxson, P, Dozois, E, Holubar, D, et al. Enhancing nurse and physician collaboration

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in clinical decision making through high-​fidelity interdisciplinary simulation training.
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40. Wiler, JL, Rooks, SP, and Ginde, AA. Update on midlevel provider utilization in U.S.
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41. Jennings, N, Clifford, S, Fox, A, O’Connel, J, and Gardner, GE et al. The impact of
nurse practitioner services on cost, quality of care, satisfaction and wait times in the
emergency department: A systematic review. International Journal of Nursing Studies.
2015;52(1): 421–​435.
42. Carter, AE, and Chochinov, AH. A systematic review of the impact of nurse
practitioners on cost, quality of care, satisfaction and wait times in the Emergency
Department. CJEM: Canadian Journal of Emergency Medicine. 2007;9(4): 286–​295.
43. Thrasher, C, Purc-​Stephenson, RJ. Integrating nurse practitioners into Canadian
emergency departments: A qualitative study of barriers and recommendations
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44. Bryson, C. How Emergency Department staff perceive acute nurse practitioners.
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chest compressions for rescue breathing during cardiopulmonary resuscitation for
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a reflective discussion. The Journal of Perinatal and Neonatal Nursing. 2010;24:
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Nursing. 2016;23(2): 58–​64.
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team communication skills. Hospital Pediatrics. 2012;2: 221–​227.
53. Doerfler, ME, D’Angelo, J, Jacobsen, D, et al. Innovation in patient safety and quality
at the local level: Methods for reducing sepsis mortality in Emergency Departments
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2015;41205: AP1–​211,AP4. doi:10.1016/​S1553-​7250(15)41027-​X .
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9 EMS Communication
Whitney Barrett and Benjamin Fisher

INTRODUCTION
Communications in the emergency department extend outside the hospital
through interactions with prehospital providers. Communication between pre-
hospital providers and the emergency department (ED) comes in the form of tel-
ephone communication, radio communication, face-​to-​face patient handoffs, and
written communication depending on the structure of each specific prehospital/​
hospital system. Additionally, the levels of providers (level of training, experience,
education, etc.) delivering the information and receiving the information vary. This
intersection where the outside world enters the ED creates a variety of communi-
cation challenges.
The title “EMS communications” in most emergency medical services (EMS)
books refers to the logistics and technology associated with exchanging informa-
tion in the prehospital setting. Typically, it involves dispatch, radio frequencies, and
access to 911. This chapter will focus on the nontechnical aspects of EMS commu-
nication and specifically the types of communication between the prehospital pro-
vider and the emergency department team. There are 3 primary goals in EMS-​ED
communications: (1) provide the information necessary for the emergency depart-
ment to prepare for an incoming patient; (2) allow collaboration between pre-
hospital providers and medical direction to manage medical situations that occur
outside the emergency department such as patient refusals of transport, termina-
tion of resuscitation, and destination decisions for large events (this is also referred
to as online medical control); and (3) transfer the care of the patient, including
the pertinent historical details, assessment, and interventions that have occurred,
to the new treatment team. Any broken link in the communication chain can cause
delays in care that these EMS communication systems are designed specifically to
13

avoid (e.g., not notifying the surgeons for a critical trauma patient who is coming

131
or transporting a patient who probably should have been pronounced on scene).
There is a lot of guidance on the technical aspects of EMS communication, such as

EMS Communication
types of radios, types of electronic patient care records (ePCRs), and reliable con-
tact with the emergency department; however, there is a paucity of research and
structured education regarding the actual communication itself.1

THE COMMUNICATORS
The communicators in the chain of communication include prehospital providers,
nurses in the ED (including charge nurses), and physicians or advanced practice
providers working in the ED. The prehospital providers can vary tremendously
depending on the EMS system in the area. They can include EMS providers, reg-
istered nurses (RNs), physicians, advanced practice providers (APPs), and others.
Emergency medical technicians (EMTs) and paramedics are by far the most com-
monly encountered EMS providers in the United States. EMTs provide Basic Life
Support (BLS) and paramedics provide Advanced Life Support (ALS). EMTs
typically receive less training (120 hours of didactics) and fewer clinical rotations.
Paramedics receive approximately 1500 clinical hours with specialty-​ specific
clinical rotations and a dedicated, 500-​hour clinical internship on an ambulance.
Depending on the practice location and needs of the community, there is some var-
iability between these 2 groups. Additionally, each individual provider will have a
range of experience, skill proficiency, and ongoing education. Because of this wide
variety, it is exceedingly important to understand the makeup of the EMS providers
in your area to maximize clarity of communication and minimize errors or conflict.
A misunderstanding because of an assumed scope of practice or of assumed medical
knowledge can quickly derail an already stressful scene in the ED. Throughout this
chapter, we will refer to both EMTs and paramedics as prehospital providers and
delineate between the 2 where necessary.
Nurses are the second type of provider involved in EMS communication. Nurses
can be delivering the patient to the ED with critical care transport teams or receiving
the patient in the hospital as the charge nurse or primary nurse. For the purposes
of this discussion, we will focus on the nurse role in receiving the patient in the ED.
As we will discuss later, nurses usually either receive prenotifications about patients
who are coming or receive face-​to-​face handoff of the EMS provider report. Both
are important links in EMS communications. Unlike prehospital providers, there is
less variability among nurses with respect to level of training, although amount of
experience is always a variable.
The final type of providers are physicians and APPs. Similar to nurses, these
providers can be part of the prehospital team or receive the transfer of care of
patients in the ED. The focus of this chapter will be on physicians and APPs in the
role of receiving providers. In most emergency departments, the physicians are
board certified in emergency medicine; however, it is important to note that in rural
areas or some smaller emergency departments/​clinics it is possible to have a non-​
emergency-​medicine-​trained provider. APPs are increasingly working as providers
in the emergency department and are physician assistants or nurse practitioners. It
is unusual for either of these groups to have extensive emergency medicine training
during school. Most of them are trained in emergency medicine once they have
graduated. Ideally, the physician or APP is also present with the nurse to receive
132

face-​to-​face handoff from the prehospital providers. If they are unable to receive a
Communication with Providers, Staff, and Personnel 132
face-​to-​face handoff from the prehospital providers, they become the final receiver
of a long game of telephone. The flow of EMS communication is from the patient or
others on scene to EMS/​prehospital providers to the nurse and finally to the physi-
cian/​APP—​it is not hard to see how communication might be challenging.
Though not a provider, it would be an error to not mention the role of the pa-
tient in EMS communications. A different chapter will provide a much more in-​
depth view of provider-​patient communications, but it is important to remember
the enormous impact a patient’s level of cooperation, alertness, and ability to com-
municate can play in the patient handoff to the emergency department.

CHALLENGES WITH DIVERSE PROVIDERS

With such a range of medical providers involved in EMS communication, one of the
first challenges is to manage educational gaps and priority differences between the
prehospital and hospital providers. Early identification and appreciation of these
differences can help frame communication in a productive manner. Physicians
have more education and training, which leads to gaps in knowledge between the
physician and the prehospital provider. Obviously, this can result in differences in
opinion about treatment that was, or should have been, rendered. Prior to assuming
negligence, it is exceedingly important to ascertain if the issue is actually one of
domain-​specific knowledge. To quote Hanlon’s razor: “Do not attribute to malice
that which can be explained by ignorance.”2
It is also important to recognize different priorities in patient care and the dy-
namic nature of patient status, particularly in emergency care. If the prehospital
provider is thankful to have gotten away from a scene simply without being injured
herself, obtaining information about the length of a knife or amount of blood on
scene is impractical information to even consider gathering. In the same way, be-
cause prehospital providers provide care over a short timeline, it is possible they
sometimes do not consider long-​term effects of interventions and their interactions
with possible ED treatments. Appreciation for prehospital scene dynamics as well
as hospital patient management is an important perspective to maintain for all
types of providers. These differences create a tremendous opportunity for educa-
tion and developing rapport among providers. They also are rife with opportunity
for miscommunication, misunderstanding, and difficult communications in the
future.

SCENARIO #1
A paramedic makes a phone call for a complicated refusal. The patient is a 3 year-​
old female who was the restrained rear-​seat passenger of a sedan involved in a low-​
speed motor vehicle collision. The patient was not in an age-​appropriate car seat
and is complaining of anterior neck pain from where the seatbelt crossed her neck.
Paramedics on scene have assessed the patient and do not feel the patient needs
to be transported by ambulance. The physician in the ED takes the call and is very
concerned about vascular injury—​which the paramedic had not mentioned as one
of her concerns. The physician describes the concerns to the patient’s mother, who
still refuses transport of her child by EMS.
13

This call highlights the following:

133
• Errors inherent to different levels of education/​knowledge. It may be apparent

EMS Communication
that this patient should be evaluated for vascular injury; however, without med-
ical knowledge of vascular injury patterns, this lack of concern could be a miss.
• Role of online medical direction, which can provide collaborative dispositions
for a high-​risk patient. Rather than berating the paramedic for her lack of know-
ledge or inadequate discussion with the patient about risks of refusal, the phy-
sician on the phone is able to identify the differences in training and is able to
ensure the patient’s mother understands the full spectrum of concerns and risks.
Ideally, this case is also communicated as a potential area for education of all pre-
hospital providers.

In this case, the right things happened for the care of this patient because of good
communication. The education gap was identified by the physician and was
addressed with the patient/​family directly. This was possible because the physician
paid attention to the details of the call and had an awareness of potential pitfalls. The
prehospital provider also learned from this interaction.

OBJECTIVES AND CHALLENGES INHERENT TO EMS

COMMUNICATION
Prearrival Notifications
Frequently the first communication between the prehospital providers and the
emergency department is the phone call to alert the ED of a patient who will be
arriving. This communication is usually brief, but the information relayed is crit-
ical because it allows the receiving hospital to prepare in advance for that patient.
The overwhelming majority of patients who arrive do not need any special prepara-
tion other than a bed to be transferred to. A small percentage of patients can benefit
greatly from this prearrival notification. In these cases, the EMS team must include
the necessary information that the provider answering the phone can take appro-
priate action on. This requires the provider answering the phone to actively listen
to EMS. Although jargon is discouraged, keywords or hooks are exceedingly impor-
tant to use to alert the listener to the nature of the case and ultimately impact patient
care.3 Even short-​notice notifications may allow the receiving ED team to activate
response systems that mobilize special resources, such as bringing blood to a trauma
room or notifying respiratory therapy personnel. Communication during a mass-​
casualty incident will be more difficult than routine communications. Developing
good habits during routine communication will help prevent miscommunications
during high-​stress, large incidents that are inherently prone to confusion and com-
munication problems.
Prenotification communication errors fall into 3 categories: passive listening,
inadequate system knowledge, and omitted critical information. All result in a single
outcome: the receiving facility and providers are not prepared for the type or acuity
of patient that is coming. Passive listening is failure on the part of the person re-
ceiving the call to engage in communication. The concept of listening and its im-
portance are described in many disciplines including sales, management, and direct
patient care. In EMS communication, similar principles of active listening can
be applied. The attributes of listening are attention to nonverbal cues, reflection,
134

summarizing, and feedback.3 Appropriate application of disciplined, active lis-

Communication with Providers, Staff, and Personnel 134
tening prevents downstream errors. Failure to ask clarifying questions or participate
in closed-​loop communication can result in lost information or misinformation. For
example, “40” and “14” sound very similar on the phone but obviously result in
significant differences in preparation. Although brief, it is exceedingly important to
“hear back and read back” critical information. Actively listening to the report and
reading back the information confirm that the physician has heard the content and
the shared information is correctly interpreted.4
Although we discussed earlier the differences in providers who participate in
EMS communication, it is very important that all providers share some standard
common vocabulary that is likely system specific. In other words, in critical situations,
everybody must speak the same language. Everybody involved in EMS communica-
tion, especially those giving and receiving prenotifications, need to understand this
common vocabulary. For example, hospitals often have established alert or other
treatment bundle criteria that activate predesignated events, such as a “cardiac alert,”
where the cardiology catheterization lab is activated for patients with ST elevation
myocardial infarctions identified in the field. Only people trained in identifying this
information and who can act on it should be in a position to receive prenotifications.
Finally, despite the potential chaos of a scene or case, the critical information
must be relayed to the receiving facility in a manner that is both concise and com-
plete. Formal patient handoffs will be discussed in the following section; how-
ever, inadequate or disorganized delivery of critical information as part of the
prenotification can directly impact hospital preparation.

Physician Consultation: Online Medical Direction

There are 2 types of communication from the medical director(s) to the prehos-
pital providers. The first type is offline medical direction. Offline medical direction
includes protocols, system guidelines, and any education or case review that happens
after the patient encounter. This type of communication is important to be aware of
because it directs the general care of most patients coming into the emergency depart-
ment by EMS. Specifics of protocols are subject to agency or individual provider in-
terpretation and may vary from agency to agency. Some written protocols may include
exigent, rare events such as surgical cricothyrotomy. Agencies that operate in rural or
mountainous areas that have inconsistent coverage for online medical control may re-
quire more extensive written protocols because they may not be able to call for online
medical control even when the prehospital provider would like to. Outside of partic-
ipation in protocol development, offline medical direction is 1-​way communication
from director to the EMS provider. Offline medical direction allows EMS providers
to function somewhat autonomously to provide patient care and establishes limita-
tions and restrictions to medications and other interventions. It is not important for
ED providers to know the details of EMS protocols or other aspects of offline medical
control, but it is very important to realize it exists. When questions about patient care
arise, it is important to establish first how the EMS provider was or was not operating
within the system protocols. EMTs and paramedics are first responsible for protocols
from their medical director and to their certification scope of practice. It serves no one
to argue agency policy/​protocol decisions made by a physician medical director with
a prehospital provider during a hectic ED handoff. These conversations regarding pro-
tocol itself are better had with the medical director.
135

The second type of medical direction is online medical direction and is equally

135
critical to the function of EMS systems. Online medical direction allows prehospital
providers to discuss with a physician real-​time issues involving patient care that fall

EMS Communication
outside of standard, written protocols or system guidelines. Online medical direc-
tion is very much a 2-​way communication. In some systems, a single or small group
of physicians share the “call” and provide access to a physician in that manner. In
many systems, whichever physician is working in the emergency department at the
time serves as online medical direction. As a physician or nurse in the ED who may
answer the phone call from EMS, it is imperative to know what level of certification
regional transporting providers generally have in order to frame your conversations.
It is unrealistic to know their entire scope of practice and protocols; however, it is
reasonable to know what to expect in terms of prehospital practice, education, and
interventions. It is equally important for prehospital providers to know the struc-
ture of online medical direction. Depending on the system, clarifying early to whom
they need to speak (physician, charge nurse, etc.) might be important.
Online medical direction communications frequently involve critical, high-​
risk, or complex patients or situations. This communication is made significantly
more difficult as usual nonverbal communication cues are limited. One of the
biggest challenges of communication by phone or radio is developing a common
picture. Visual cues from the scene and nuanced actions of the patient or the
prehospital provider—​all things we rely on in communication—​are missing.5
Similar to the parable of blind men touching an elephant and describing different
objects, it is imperative that all of the communicating parties both paint and see
the same picture. Judith Orasanu, as cited in Sydney Dekker’s text The Field Guide
to Understanding Human Error, describes this as a “shared mental model,” where
all parties understand the problem and intended solution.5 Once all the involved
parties are confident they understand the same situation similarly, both the pre-
hospital providers and online medical direction can more easily reach a consensus
for patient-​centered care.
Reaching a shared mental model requires effort on both ends of the phone.
Removing distractions, listening to the entire report, and practicing read-​back com-
munication are all good steps to accomplishing it. A good practice is to not answer
the phone or engage in the conversation until you are ready to be fully present in
the situation. This might mean delegating a task quickly to another provider or
excusing yourself from a conversation. Distracted communication applies equally
to the listener and speaker. Making a poorly thought-​out phone call or a call that
occurs while still trying to obtain vital signs on the patient frequently results in lost
information. Trying to multitask does not benefit the patient and usually is not ef-
ficient. Another key to establishing a shared picture of the scene includes avoiding
early closure. Listen to the entire EMS report. Early closure can result in critical
details that are missed or lack of understanding of nuanced situations. If a shared
mental model is not established, conflict quickly results from misunderstanding and
disparate goals. As you read the following scenario, see if you can identify some of
the errors that lead to the lack of a shared mental model in this case.

Scenario #2
Medic: I’m calling for a pronouncement.
Physician: Hold on. I have to call out a trauma. Hold on just a second.
136

Medic: Okay. No problem.

Communication with Providers, Staff, and Personnel 136
(60 seconds)
Physician: Okay go ahead.
Medic: I’m on scene with a 30-​year-​old male stab wound to the chest. We have slow
PEA [pulseless electrical activity] on the monitor; patient is pulseless and ap-
neic. There is a lot of blood around the patient and it is all coagulated.
Physician: You have a penetrating trauma and you are not transporting this pa-
tient? When did they lose pulses?
Medic: I don’t know, maybe like 10 minutes ago.
Physician: And you aren’t working him? You have a 30-​year-​old male with pen-
etrating trauma to the chest that had a rhythm and you aren’t doing anything?
Medic: He doesn’t have a pulse. All the blood is coagulated. I’m calling for a
pronouncement.
Physician: You have to transport this patient. He had a rhythm. This is a young pa-
tient with penetrating trauma to the chest. He has to be transported.
Medic: Okay. We will transport.

This phone call is an example of multiple errors that we have discussed previously
and ultimately a complete lack of a shared mental model in this case. These errors
occur on both ends of the communication. Some of the errors and challenges to
highlight are as follows:

• Distracted communication. It is obvious there is a lot going on in the emergency

department at this time because the physician asks the medic to hold after hearing
only, “I’m calling for a pronouncement.” This further delays care of what might be
a critical patient and sets the stage for the subsequent conversation.
• Distracted communication also leads to the physician making an error of equating
a rhythm on the monitor in some way with pulses and erroneously using that in-
formation in decision making.
• Lack of decision-​centered communication. There are important key details to
this scene that if shared with the physician paint a different picture of the neces-
sity for transport. Some of these details include a prolonged staging time before
the scene was cleared for medics to enter (up to 15 minutes of police ensuring
scene safety before EMS contact with the patient) and a location 10 miles from
the receiving hospital with the only access through rush-​hour traffic (20-​plus-​
minute transport).
• Education gap. To pronounce a penetrating trauma patient, the most critical
component to the physician is last signs of life or time of lost pulses. A pene-
trating trauma arrest patient can potentially be saved if the patient gets to the
hospital within 15 minutes of lost pulses. Without sufficient education, the pre-
hospital providers do not know this and instead focus on the amount of blood
and its coagulated status for not transporting. Blood loss or coagulation, though
impressive on scene, does not aid the physician in deciding the chance for
survival.

You can see how communication problems can be cumulative. Achieving a shared
mental model is critical to providing the best care possible, but it can be elusive.
Early identification of what you need to communicate as a prehospital provider or
what you need to know as a decision maker can help you lead the conversation.
137

Here are a couple examples of communication that quickly change this conversa-

137
tion. These are not always easy in the heat of the moment but if identified early can
change the direction of the conversation.

EMS Communication
Physician: In order to pronounce this patient, I really need to know how long this
patient has been down without pulses. Please describe the time course for me.

OR

Medic: We have had a really long scene time here; the police might have seen a
breath but it was 15 minutes before we even got in here. We don’t have pulses
now and we are 20 minutes from the hospital at best. Based on what I’m looking
at on scene I don’t think this is survivable at this point.

Transfer of Patient Care: Handoff Reports

The ED handoff serves as the final link in communicating the patient’s course be-
fore, or while, transferring care. This serves as the opportunity for EMS to provide
additional updates about the patient’s status and response to interventions or a po-
tentially lengthier version of events depending on the situation. It is also possible
that a severely abbreviated patient handoff is preferred, such as the case of a pene-
trating trauma arrest where the length of arrest will rapidly alter the ED course. This
face-​to-​face interaction is of most benefit to the patient when the entire care team
is present. This allows all of the relevant caregivers to hear directly from what may
be some of the only witnesses to events or symptoms and be able to ask pertinent
questions.
Of all the types of communication associated with EMS communication, pa-
tient handoff reports are the ones that have been studied and commented on most
frequently.7–​10 The transfer of patient care from the prehospital providers to the
ED team has the potential to help or hinder further patient care. The nature of the
interaction—​positive or negative—​has the potential to further develop trust or to
erode future relationships of the providers on the patient care team. Additionally,
patient handoffs have been identified as high-​risk events for medical error.6 The
goals of the patient handoff communication are 2-​fold. First is to communicate
the information that has been gathered by the EMS providers, including details
about the scene or social situations that directly impact patient care; relay the pre-
hospital vitals/​clinical status; and describe any interventions that were performed
and patient changes during transport (either by nature of disease or because of
interventions). Second, and equally important, is to listen to the information pro-
vided, incorporate it accurately into the patient care record and patient manage-
ment, and obtain any additional information from the EMS providers that might
not have initially been presented but might be pertinent.

Scenario #3
During a handoff report for a 12-​year-​old patient, the parent begins to yell at the
staff. There is only one nurse in the room who quickly starts trying to mobilize other
providers. The EMS crew—​who had obtained a thorough history from the patient
and mother—​does not get to finish their report owing to the flurry of activity. The
138

receiving care team begins to address the mother of the child instead. The advanced
Communication with Providers, Staff, and Personnel 138
practice provider enters the room hurriedly and starts asking everybody what is
going on. EMS hangs around for 5 minutes and eventually leaves.
Sometimes, everything about a particular case is distracting. Letting distraction
drive this communication instead of returning to standard practice as soon as pos-
sible leads to a number of errors:

• Departure from usual handoff routine. This level of distraction sometimes

demands an immediate response; however, it is particularly important in pa-
tient handoffs to return to the usual structure as soon as possible to make sure
important information is not completely lost. EMS providers might be the only
witnesses to changes in clinical presentation and are the only ones who can report
on prehospital interventions and responses to those interventions.
• Lack of the full team being present. Many distractions can be mitigated and com-
munication facilitated by the full team of providers being present for handoff.
• Failure of the links in communication to participate in a period of time where
questions can be answered about the case by the prehospital providers. Sometimes
this is brief, but the opportunity is very important.

Consistency in process is important. Addressing distractions and then having a dis-

ciplined return to standard process can promote improved handoffs. In an effort
to optimize patient handoff communication, the American College of Emergency
Physicians (ACEP) in conjunction with other national associations (Emergency
Nurses, National Association of EMS Physicians, etc.) developed a clinical policy
with recommendations for the transfer of the EMS patient to the ED. These
guidelines include a verbal as well as written patient care report, presence of all
members of the health care team for patient handoff (physician, nurse, etc.) with
dedicated opportunity for questions to be asked, handoff obtained from the EMS
providers in a timely manner, and prehospital documentation incorporated into the
patient’s permanent medical record in a timely manner.7 There are practical limita-
tions to meeting these recommendations that vary by system, but they set the bar
for the ideal state of EMS-​ED handoffs.
Interestingly, unlike the structured handoffs that have been developed in nursing
and physician transfers of care, the literature does not support a specific format for
patient care report from the EMS providers. A variety of qualitative studies have
looked at EMS and ED provider attitudes and perspectives about EMS communica-
tion and patient handoff.8–​10 Dynamic, complicated, and often critical patients make
standardizing handoffs very challenging. It is the responsibility of the EMS provider
to organize his or her handoff to convey all of the important pieces of the patient
presentation and care. Developing the skill of providing a complete and concise pa-
tient handoff is core to EMS care. Practicing and refining this skill is an important
part of training and provider self-​improvement.
It is always possible that there is a discrepancy between what the prehospital
and hospital team feel is most important. This may be because the prehospital pro-
vider index of suspicion is lower than the hospital care team’s, or vice versa. It is also
possible that the patient’s presentation by the time he or she arrives in the ED is
substantially different than what EMS encountered. At other times, a patient who
can speak may interject his or her own opinions into the middle of a handoff report,
providing an additional source of information. These information discrepancies are
139

usually unintentional. Follow-​up with the prehospital providers after the handoff to

139
ensure there is no information loss and there is a clear picture is important. In ex-
treme cases it may warrant following up with medical direction.

EMS Communication
Despite all the challenges, and beyond the ACEP policy guidelines, the ge-
neral communication principles we have previously mentioned remain essential
to avoiding obstacles in these phases of communication. Active listening, apprecia-
tion of education gaps, scope-​of-​practice limitations, general positive regard for the
other providers, and attention to nonverbal communication all are very important
to an excellent patient handoff.

Problems and Solutions

Scenario #4
Paramedics respond to a 30-​year-​old female who was found unresponsive in bed
at home early in the morning. The patient has a history of diabetes, and she told
family she was going to bed early the night before because she didn’t “feel well.”
BLS responders who were first on scene relay that they suspect an overdose because
of her unresponsiveness but do not have additional information beyond that sus-
picion. The family is unable to provide any additional history besides the history
of diabetes and not feeling well and that the patient was last seen normal last night
at 10 pm.
Paramedics find the patient profoundly tachypneic, tachycardic, hypotensive,
and hot to touch. She is altered but breathing on her own. She has a sugar >500 mg/​
dL and a 12-​lead electrocardiogram (ECG) that shows possible inferior ischemia.
During transport, the paramedic collects the aforementioned data, establishes
IV access, initiates fluid resuscitation, and calls the receiving hospital to let them
know about their emergent transportation of this patient.
The charge nurse who answers the phone listens to part of the prenotification
while evaluating the ambulance that just arrived at the ED. She assigns the incoming
ambulance a room with a chief complaint for the patient as “hyperglycemia.”
On arrival at the hospital, the paramedic crew is met by a single nurse in the
assigned room. The paramedic is irritated with the reception for this sick and com-
plex patient but launches into the handoff to the nurse. He is interrupted by the
physician, who comes in about halfway through his report. The now-​frustrated par-
amedic repeats a handoff report, this time forgetting to mention the ECG changes
he noticed, and leaves as the physician asks the nurse why this patient didn’t get a
resuscitation room because she is so sick. The concern for possible overdose was left
out of both reports.
Cases like this can result in each provider blaming others for perceived mistakes
in patient care that are the result of poor communication. The various providers’
frustration is understandable when viewed individually without a complete picture
of the case. Some of the errors to highlight in this scenario include:

• Distracted communication. The nurse taking the prehospital notification was

multitasking and obviously missed the concerning vitals reported by the medic
as well as the general concern for the patient he expressed.
• Lack of presence of the care team. As discussed, the presence of the whole care
team for the handoff report is important. It is even more important for complex
patients or patients who are unable to provide their own story.
140

• Interruptions. The physician arriving late to the report and requiring a repetition
Communication with Providers, Staff, and Personnel 140
of the story increases the risk for incomplete handoffs. Any interruption, even just
to repeat allergies or vitals, opens the window for information to be lost. When at
all possible, it is important to listen to a complete report and then ask questions.
• Standardization. A lack of a standardized patient handoff report from EMS
combined with a complicated patient course resulted in information loss after the
paramedic repeated the handoff.
• Attitude. Questions were not asked at the end of this report by either the phy-
sician or the nurse and the prehospital provider left quickly. Negative attitude
or interactions from any of the providers can lead to further communication
breakdown, whereas a positive interaction can actually help overcome many pre-
vious errors and establish rapport to prevent similar situations in the future. If the
providers involved can put their frustrations aside, lines of communication can be
reopened.

KEYS TO SUCCESS
1. Practice good communication habits.
a. Remove the distractions and interruptions. This is not always physically
possible in the back of an ambulance or in the emergency department, but
all providers must focus on actually hearing what the others are saying.
There may also be important implicit cues that can only be heard if you’re
focused, such as a disturbance in the background or a concerned prehospital
provider. Resist the temptation to interrupt.
b. Repeat back critical information. This is especially important for medication
orders, for destination decisions, and any time there is particular
information that is driving a decision (specific vital signs, age of the
patient, etc.).
c. Avoid jargon and abbreviations. The use of “10 codes” and system-​
specific phrases becomes meaningless to someone unfamiliar with them
and only causes confusion. Plain language is necessary to ensure clear
communication. “I’m coming emergently to [hospital name]” means the
same thing to everybody.
d. Be an active listener. As part of the receiving team, it is important to be
disciplined in listening to the whole report. Stress and the prehospital
setting are not conducive to well-​thought-​out reports or calls, especially for
infrequent, high-​stakes events. As members of the EMS-​ED team, help each
other obtain the important pieces of information.
2. Work with other providers to establish a shared mental model. This
requires work on the part of the EMS provider as well as the providers in
the hospital. If you are unsure of the situation or what is being described
or requested, it is important to ask for clarification early to help develop a
shared mental model so everyone “sees” the same thing.5 Keep in mind the
general differences in perspective and goals of patient care for the other
providers involved.
3. Be clear. If the call is for online medical direction, the report should lead
with “I am calling for . . .” to prepare your listeners for what you are saying.
An initial sentence that leads the listener down the wrong path frequently
14

141
Online Medical Pre arrival EMS – ED
Direction Notification Handoff

EMS Communication
Phone or Radio Phone or Radio In Person

• Limited non verbal cues • Passive listening • Absent care team

• Inadequate system members for report
• Different mental picture
knowledge • Lack of common
• Distracted communication structure for report
• Omitted critical
• Skill/education gaps
information
between pre hospital
and hospital providers

FIGURE 9.1. Phases of emergency medical services/​emergency department (EMS-​ED)

communication and their common pitfalls.

causes confusion. In the same way, if you are providing an order or approving
an intervention, make sure it is clearly communicated and always avoid
abbreviations.
4. Assume good intent on both sides. Seek first to understand what the other
party is thinking/​doing. Misunderstandings are frequently a key component to
communication problems and more than anything else can precipitate negative
interactions. These negative interactions usually only perpetuate problems.

CONCLUSION
EMS communications are simply an example of an interdisciplinary team with dif-
ferent skill sets working together along a continuum to accomplish a single common
goal: provide excellent patient care. The fundamental communication issues
discussed here are designed to demonstrate best practices and may not be universally
applicable to all prehospital systems because of the variation between EMS agencies,
training, and levels of certifications. That said, the nature of these patient handoffs
can lead to poor communication, with significant consequences if both prehospital
and hospital providers are not aware of potential pitfalls. The specific application of
these communications may vary from other instances of interdisciplinary commu-
nication, but the principles of communication are universal and their application
serves to strengthen the link between prehospital and hospital systems (Figure 9.1).

REFERENCES
1. Cone DC, Brice JH, Delbridge TR, Myers JB, eds. Emergency Medical Services:
Clinical Practice and Systems Oversight. 2nd ed. Chichester, UK; Hoboken: John
Wiley & Sons; 2015.
2. Bloch A. Murphy’s Law Book Two: More Reasons Why Things Go Wrong! London:
Magnum; 1981.
3. Camp-​Rogers T, Kurz MC, Brady WJ. Hospital-​based strategies contributing to
percutaneous coronary intervention time reduction in the patient with ST-​segment
142

elevation myocardial infarction: a review of the “ ‘system-​of-​care” approach. Am J

Communication with Providers, Staff, and Personnel 142
Emerg Med. 2012;30(3):491–​498. doi:10.1016/​j.ajem.2011.02.011.
4. Shipley SD. Listening: a concept analysis. Nurs Forum (Auckl). 2010;45.
doi:10.1111/​j.1744-​6198.2010.00174.x.
5. Engeström Y, Middleton D, eds. Cognition and Communication at Work. Cambridge,
UK: Cambridge University Press; 1998.
6. Frankel RM, Flanagan M, Ebright P, et al. Context, culture and (non-​verbal)
communication affect handover quality. BMJ Qual Saf. 2012;21(Suppl 1): i121–​128.
doi:10.1136/​bmjqs-​2012-​001482.
7. Dekker S. The Field Guide to Understanding Human Error. 3rd ed. Aldershot, UK;
Burlington, VT: Ashgate; 2006.
8. Catalano K. JCAHO’s National Patient Safety Goals 2006. J Perianesth Nurs.
2006;21(1):6–​11. doi:10.1016/​j.jopan.2005.11.005.
9. Transfer of patient care between EMS providers and receiving facilities. Ann Emerg
Med. 2014;63(4):503. doi:10.1016/​j.annemergmed.2013.12.023.
10. Meisel ZF, Shea JA, Peacock NJ, et al. Optimizing the patient handoff between
emergency medical services and the emergency department. Ann Emerg Med.
2015;65(3):310–​317.e1. doi:10.1016/​j.annemergmed.2014.07.003.
11. Harmsen AMK, Giannakopoulos G, Franschman G, et al. Limitations in prehospital
communication between trauma helicopter, ambulance services, and dispatch
centers. J Emerg Med. 2017;52(4):504–​512. doi:10.1016/​j.jemermed.2016.11.010.
12. Evans SM, Murray A, Patrick I, et al. Assessing clinical handover between
paramedics and the trauma team. Injury. 2010;41(5):460–​464. doi:10.1016/​
j.injury.2009.07.065.
143

10 Communication With
Hospital Administration

Christopher M. McStay

INTRODUCTION AND SCOPE

Effective communication with hospital administration is essential to ensure the
emergency department (ED) provides safe, appropriate, and timely care. Hospital
administration is an expansive term that will likely encompass multiple levels of lead-
ership including the board of directors, “C-​suite” leaders, medical staff leadership,
and midlevel managers. Similarly, ED leadership may have multiple tiers depending
on the organizational structure, incorporating such individuals as a departmental
chair, vice chair, operational leaders, and corresponding nursing and administra-
tive dyads/​triads. How the ED leadership team communicates internally and with
stakeholders externally may be complex given the ED’s central role in hospital
functions. ED leadership teams typically interact with most clinical service lines
within a hospital (e.g., medicine, surgery, radiology) and external agencies (public
health, emergency medical services [EMS], and media) and may be tasked during
times of crisis (mass-​casualty incidents and hospital boarding). The 24/​7 nature
of hospital operations and specifically the demands that this places on emergency
care can place stress on leadership teams as they communicate. The nature of com-
munication may vary depending on the circumstance, team members, and urgency.
Throughout this chapter we stress the importance of ED leaders seeing themselves
as hospital leaders and avoid an “us versus them” mentality. Effective communica-
tion doesn’t just happen; it is a product of a continually sustained effort by everyone
involved.
In this chapter, we’ll describe the often-​complex nature of hospital governance
and leaders and discuss internal communication strategies. With this foundation,
14

we’ll describe how ED leadership teams interface with key hospital leaders with
Communication with Providers, Staff, and Personnel 144
the aim of providing outstanding patient care. We’ll then describe, through the use
of case studies, how these communication strategies can be used to solve complex
problems.

HOSPITAL GOVERNANCE STRUCTURE

Hospital governance may take many forms depending on the nature and structure
of the organization. The Joint Commission has published standards and expecta-
tions for leaders and teams in hospitals.1 Governance refers to the structure through
which various operational leaders of the organization are responsible to their key
stakeholders. The hospital operational leaders are typically responsible for the day-​
to-​day operations and the setting of vision and strategy. Although structures vary,
hospitals and health care organizations have defined processes for how the med-
ical staff and operational leaders interface with their stakeholders, for example, the
board of directors.
Broadly and historically, health care organizations have been composed of 3
pillars that are responsible for operations: the medical staff, the hospital adminis-
tration, and the board of directors. The medical staff provides clinical services to
patients, hospital administration is responsible for operations, and the board of
directors provides overall oversight.2 Each of these 3 groups will typically have
its own leadership and administrative structure, some with overlapping roles and
responsibilities. For example, the chief medical officer (CMO) may be a member of
the medical staff and a key member of the hospital administration team.

Medical Staff
The medical staff may be organized in any number of ways depending on the orga-
nization. A typical structure would include a medical staff president and a medical
board composed of representative leaders across departments (often department
chairs) with some number of at-​large members. Advance practice providers in-
cluding nurse practitioners and physician assistants may be included in the med-
ical staff. Typically, the medical staff is bound by a set of bylaws that articulate a
committee structure that governs functions such as credentialing and disciplinary
action.

Hospital Administration
Hospital administration is typically composed of the group of leaders sometimes
referred to as the “C-​suite.” The chief executive officer (CEO), chief operating of-
ficer (COO), chief financial officer (CFO), chief nursing officer (CNO), and chief
medical officer (CMO) are common positions within hospitals that provide key
leadership over all operational domains. Additional roles may include the chief
information officer (CIO), chief medical information officer (CMIO), and roles
related to innovation, transformation, education, quality, disaster, and patient ex-
perience among others. Larger organizations may tend to have each of these roles
assigned to a single individual, whereas smaller organizations may have a single
individual responsible for more than one domain. Lower-​level management may
include senior/​vice presidents, managers, and directors in various capacities. ED
145

leadership teams would be expected to understand the leadership structure ger-

145
mane to their institution and likely serve in some of these capacities.

Communication With Hospital Administration

Board of Directors
Board members are often chosen based on their service to the organization and the
community and are typically selected to ensure a broad diversity in membership.
The board of directors (BOD) is charged with overseeing the operation and assets
of the entire facility or organization. Such functions include setting strategic direc-
tion, evaluating financial performance and capital expenditures, and providing for
the provision of excellent clinical care. The board has a fiduciary role to ensure that
the assets of the organization are used to further the mission of the institution.

DEFINING OTHER HOSPITAL LEADERSHIP

Hospital Committee Structure
Hospitals and health care organizations typically employ a number of committees
to perform essential functions of the hospital. Here we will limit our attention to
committees that typically interface with ED operations. As an overarching principle,
ED leadership should participate and lead to the maximal extent possible. Effective
communication with leadership depends on being present and having a voice.
Typical committees might include those pertaining to the

credentials committee;
quality, safety, peer review, and legal/​risk committees;
medical board; and
disaster and EMS committees.

Depending on the size and complexity of the organization, it may be necessary

for the ED to develop standing committees to address ongoing operational issues
between departments. For example, the ED may desire an ongoing meeting with
leadership from the department of medicine because that department ultimately
cares for the majority of inpatient admissions through the ED. Cardiac, stroke, and
trauma care might necessitate ongoing interdisciplinary meetings between several
services and the ED. Given the recent focus on sepsis care, an organization might
decide to convene a standing sepsis committee to place additional focus on the
topic. Depending on the organization, the CMO might be expected to participate,
lead, or be an executive sponsor of the group.
Other specific circumstances might alter one’s definition of “hospital leader-
ship” and are somewhat unique to problems that EDs might encounter. Given their
24/​7 nature, hospitals often have an administrator who represents administration
during off-​hours and weekends. Often known as a “hospital manager” or “admin-
istrator on duty,” ED leadership may often find themselves interacting with this in-
dividual. Additionally, during events where the emergency management plan may
need to be initiated, roles under the hospital incident command system (HICS)
may necessarily change.3 ED and hospital leadership should receive formal training
and be conversant in HICS organizational structure. Hospital emergency managers
or others with similar titles may take on key leadership positions in times of crisis,
146

and ED leadership team members may be tasked with taking on roles under HICS
Communication with Providers, Staff, and Personnel 146
that dramatically alter reporting structure and communication paradigms.
ED leadership may also be tasked to communicate externally, often to outside
agencies or news media. ED leadership should play an active role in the manage-
ment of EMS relationships, and often an ED physician would serve in some capacity
as an EMS medical director. Given the role that EMS plays in caring for the sur-
rounding community and the importance of EMS traffic to an institution, playing
a lead role in this relationship is essential. Media relations are also an important as-
pect of communication, and key members of the ED leadership team should receive
media training. Many organizations have a media relations specialist who typically
has a very close relationship with senior hospital leadership. Preferably any contact
with external media would be channeled through and approved by this individual.
ED leadership should work very closely with this individual and ensure external
messaging is consistent with the beliefs and values of the organization.

INTERNAL TEAMING AND COMMUNICATION

ED teaming and communication are critical for any successful ED leadership
team. Key to any successful team is how decisions are made internally and then
communicated to stakeholders external to the department. ED teams may at times
have internal conflict or disagreement. Depending on the environment, there may
be complexities in the governance. For example, in an academic environment, the
medical director might report up through the departmental chair, whereas nursing
leadership would report up through the CNO. With these differing reporting
structures comes the opportunity for competing priorities, mixed messaging, and
the appearance or reality of division among the leadership group. With appropriate
teaming, it is possible to manage the complexity and competing priorities and com-
municate with a single voice to the myriad stakeholders to which the ED leadership
team is accountable.
Internal departmental organization may vary greatly depending on the size
and complexity of the organization. In small EDs a single medical and nursing di-
rector may be entirely responsible for operations and communication with hospital
leadership. In large academic settings the departmental chair may be responsible
for communication with the board, academic dean, and C-​suite leadership. Larger
departments of emergency medicine may have a tiered structure and include
vice chairs of varying capacities such as academic affairs, operations, and quality.
Educational leadership involved in graduate medical education (GME) plays an
important role in departmental functions and would also likely have a separate
reporting structure. EDs may employ physicians as EMS medical directors and
directors of quality, each reporting to his or her designee. Nursing directors may
employ a similar cadre of individuals focusing on education and training.
Each individual department will need to determine the structure that best suits
its needs. Importantly, the leadership team will need to understand the appropriate
lines of communication and have some familiarity with all members of the senior
hospital administrative team. Given the 24/​7 nature of the work and the possibility
that members of all teams may be unavailable (e.g., vacation and medical leave), it
might be necessary for an assistant medical director to communicate to the CEO.
In such a circumstance, the hospital leadership team should feel comfortable that
the assistant medical director can appropriately represent the ED leadership team.
147

Internal departmental meetings and communication are key to the team’s ability

147
to speak with one voice across all disciplines. Smaller departments may find a single
monthly meeting appropriate, whereas larger departments may require multiple

Communication With Hospital Administration

meetings that may mirror hospital-​based meetings that work in the domains of
quality improvement, quality assurance, and operations. Wherever possible, senior
leadership should be invited to participate in ED-​based meetings. For example, a
senior vice president for hospital operations could participate in a monthly ED op-
erations team to ensure bidirectional communication.
Regardless of the internal structure, front-​line ED staff should have a clear un-
derstanding of how to communicate their concerns or issues. Depending on the cir-
cumstance, an ED nurse, staff member, or provider may have a concern that needs
to be handled in real time. In some circumstances, this may be escalated to the ap-
propriate ED administrator on call or handled through the hospital administrator
on call. Given the 24/​7 operation of the ED and our role as front-​line providers for
the community, most EDs should employ a system to provide around-​the-​clock ad-
ministrative support. This may take the shape of a physician and nursing dyad or a
single individual taking administrative calls at any one time. Front-​line staff should
also have a clear understanding of what types of issues need to be communicated,
to whom, and when. For example, an issue placing patient safety at risk (impaired
provider) would need immediate ED leadership attention and should result in an
in-​person response. An operational concern that needs addressing in the next days
to weeks could be communicated to an operational leader via email. Regardless of
the issue or circumstance, front-​line staff should understand the appropriate lines of
communication such that their voice feels valued and loop closure can occur.
ED leadership should make every effort to consistently round on ED staff on
a routine basis. For a variety of reasons, front-​line staff may be reluctant to report
or escalate issues that ED leadership would want to be made aware of. Routine
rounding with scripted questions is likely to elicit productive conversation and help
break down perceived barriers between leadership and staff. Leaders should make
every effort to be approachable and receptive to such conversations and take the
opportunity to listen. Leaders can help address problems in real time and better un-
derstand the ongoing issues that staff face on a day-​to-​day basis. Additionally, they
may use the opportunity to educate staff, for example, on the strategic direction set
by hospital and ED leadership. ED leaders should avoid an “us versus hospital lead-
ership” mentality but rather embrace a shared commitment to patient care as part
of an ongoing dialogue between various teams. Regardless of the issue raised by
staff, leadership should make every effort to catalog problems, communicate with
other leaders, and, most important, provide loop closure to the staff member who
initially raised the issue. Failure of loop closure is a very common pitfall and should
be avoided. Even if a staff member brings up an issue that cannot be solved, loop
closure should include a logical explanation of the barriers or issues preventing the
solution.

EFFECTIVE COMMUNICATION STRATEGIES

Communication between the ED and hospital leadership teams needs to be tai-
lored depending on the subject matter and circumstance. ED leadership must main-
tain effective relationships with all levels of governance across the institution and
with peers across other departments. The ED occupies a unique position in that it
148

interacts with most clinical services in hospitals and does so on a 24/​7 basis. Specific
Communication with Providers, Staff, and Personnel 148
communication strategies will depend highly on the organizational structure of the
various leadership teams. Regardless of the form, all communication must be re-
spectful and professional. During highly charged events, leaders should think care-
fully about their words and actions. Aggressive behavior or language that includes
profanity can quickly escalate situations and raise questions of professionalism.
Such unprofessional behavior should not be displayed or tolerated and is a very
quick way to negatively impact relationships and ultimately patient care. Keeping an
open mind and assuming positive intent are just 2 of many strategies well described
to avoid such circumstances.
Here we will address some general guidance for all forms and types of commu-
nication with hospital leadership.

Broad Strategies
An effective ED leadership team should speak with a consistent message to hospital
leadership. For example, the CEO speaking to the department chair should hear and
feel themes that would be consistent with a conversation between the CNO and the
ED nursing director. Although the nature and content of these conversations may
differ, wherever possible the overall messaging should be consistent.
Members of the ED and hospital leadership teams should participate in regu-
larly scheduled 1:1 or small group meetings. Again, depending on the structure of
the organization, this may take many forms. In general, there should be a desire to
remove silos of communication as much as possible and ensure all members of the
teams are speaking with a single voice and message. For example, the CEO may
participate with a small group with the department chair, vice chair, and nursing
director. The COO may meet with the operations chief or medical director of the
ED in conjunction with a nursing leader. Another strategy is to invite senior leaders
to ED operational or leadership meetings so that they may participate in discussion
and decision making. In general, leaders should favor transparency and an overall
inclusive approach to communication between leadership teams.

COMMUNICATION THROUGH GOVERNANCE

ED leadership team members should, wherever possible, strive to be included and
participate in hospital governance at the highest level possible. As a general rule,
a consistent and constant presence will benefit the ED and thus patient care. ED
leadership should make every effort to become familiar with board members and
interact with them whenever possible. Interfacing with the medical staff and the
corresponding leadership structure is also an important forum for engagement.4
Committee meetings and other similar forums also present an opportunity to
interact with hospital leadership on an ongoing basis. Ensuring adequate ED repre-
sentation at such meetings should be carefully coordinated with the ED leadership
team. It may be necessary and beneficial for multiple members of the ED team (e.g.,
physician and nursing leaders) to attend certain meetings. Being present and engaged
at such meetings is of great importance. Immediately after the meeting may be a good
time to engage in brief 1:1 conversations for other pressing matters as they arise.
149

Many health care organizations promote hospital leadership performing “walk

149
rounds” and interacting with front-​line staff.5 Some facilities have leadership from
different service lines round on each other; as such, ED leadership might have the

Communication With Hospital Administration

opportunity to round on an inpatient unit. Such “cross-​cultural” rounding can be
helpful in creating a shared understanding of each unit or service line’s pressing is-
sues and problems. Additionally, the sharing of solutions to complex problems can
be mutually beneficial. Inviting hospital leadership to round on front-​line staff can
be an essential form of communicating complex problems and personalizing them.
For example, a CEO walking through a busy department with multiple boarding
patients in the hallway might be incredibly meaningful. For many members of hos-
pital leadership, the ED can be an intimidating environment, and ensuring they feel
comfortable should be a top priority. Hospital leaders typically value the ability to
interact with front-​line staff, many of whom are also eager to interact with leadership
and feel valued as employees. Facilitating this type of interaction should be a part of
any ED leadership communication strategy.
Involving hospital leadership to participate in other ED-​based events can also
help to build relationships and good will. A leadership presence at a process im-
provement report out or other operations event could help the COO demonstrate
involvement and interest in the ED’s meaningful work. Front-​line staff will feel
appreciated and the 10 to 15 minutes of a C-​suite administrator’s time may be quite
valuable in terms of messaging. Similarly involving administration in front-​line staff
meetings, picnics, holiday parties, and tours with VIPs and community leaders can
be invaluable.
The role that the ED plays in caring for hospital staff and family members
deserves special mention. There are many appropriate caveats for the care of VIPs,
but ED leadership should not discount the importance of bidirectional communi-
cation in the care of patients who have a special connection to the facility. Board
members and leadership should feel especially comfortable reaching out to ED
leadership when they or others are seeking care in the ED. ED leadership in turn
should use the opportunity to demonstrate the excellent care that all ED patients
deserve. ED leadership presence at the bedside during such encounters is an excel-
lent way to build relationships and trust with hospital administration and should be
seen as an opportunity rather than a burden.

OTHER FORMS OF COMMUNICATION

In this day and age communication forms and platforms are ever evolving. It should
be noted that regardless of the platform, special attention should be paid to ensuring
Health Insurance and Portability Accountability Act of 1996 (HIPAA) compliance.
For example, the use of mobile phone texting of identifiable patient demographics
and medical information certainly would be in violation if not appropriately secured,
and likely occurs with far more regularity than commonly known. Regardless of the
platform, ED leaders should agree on a consistent set of guidelines and expectations
to guide the overall framework. There should be a general understanding of how
those outside of the ED leadership team expect to be communicated with, under-
standing that there will be some variability. As much as possible the use of various
platforms should look and feel consistent.
150

Ongoing Reporting
Communication with Providers, Staff, and Personnel 150 Many EDs are awash in data that streams from a variety of sources. Internal data
(ED length of stay), data from external vendors (patient satisfaction), and data
from compliance or quality (ST segment elevation myocardial infarction metrics)
are just a few of the relevant streams. This data should be validated by the ED to
create a single source of truth. Data should be freely shared internally in an or-
ganized fashion and sent to key stakeholders on an ongoing basis. Taking a pro-
active approach to data streams by owning and distributing the data ensures it is
communicated appropriately. A report showing poor performance from a hospital
leader that is surprising to the ED team represents a leadership and management
failure.
Data should be routinely distributed to key hospital leaders, and transparency
is of the utmost importance. Routine communication of data, which frankly may
include operational pain points or failures, is key to building a trusting relationship
between the ED operational team and hospital governance. Only through this com-
munication and trust can leaders begin to problem solve. The frequency of such
data communication as well as the level of detail should be discussed with the rel-
evant leaders. In the author’s own institution there are a variety of data reporting
mechanisms that will be outlined. This model represents total data transparency
and displays a deep level of ED leadership team involvement on a consistent and
ongoing basis.
Data reports that include key ED operational metrics are distributed to key ED
and hospital leadership daily including the C-​suite. These metrics include daily
census, standard ED length-​of-​stay metrics, left without being seen, radiology turn-
around times, and others. The report also shows rolling monthly medians for com-
parison. Three times a day the ED initiates an email update that shows volume and
flow in each ED zone, describes any pressure points (such as inpatient boarders),
and outlines what actions have been taken to address them. When the ED is per-
forming optimally, these communications may be brief; when specific actions need
to be taken, the communication may be lengthier. This communication is sent to
all ED leaders and key hospital administrators, many of whom are a bit lower in the
organizational structure but are required to act when necessary. Additionally, the
hospital sends out twice-​daily updates on inpatient bed capacity that includes cur-
rent ED census numbers.
By communicating consistently in this fashion, the ED leadership team sends
a strong message that it understands and manages operational challenges hour to
hour and day by day. When the ED is faced with internal issues, we are expected
to manage them and find appropriate solutions. When external forces are the root
cause (inpatient capacity issues), hospital leadership understands the need to act.
This team functions collectively not with an “us versus them” mentality but in lock-
step, supporting each other along the way.

The Smartphone and Electronic Communication

Multiple modalities of effective communication can be performed via the modern
smartphone. In general, in-​person communication is best, especially when there
may be disagreement or highly charged issues. Texting, emailing, and calling pre-
sent 3 very distinct forms of communication and, as mentioned previously, teams
need to agree to a general framework for how each is initiated and responded to. For
15

example, this author has seen a large increase in text traffic, which can quickly and

151
effectively inform multiple parties of acute issues.
The importance of an updated contact list that includes emails and mobile and

Communication With Hospital Administration

possibly home phone numbers cannot be overstated. ED teams should keep an
updated list to share with each other as well as have this information available to
front-​line staff. At 4 am the charge nurse should have no question who is on call
for the ED leadership team and how they can be reached. Hospital administra-
tion and key personnel should also make their contact information freely available
to ED leadership and feel comfortable communicating accordingly. Respecting
boundaries is important, but a hospital CEO should have no difficulty reaching the
appropriate ED leader in a time of need.
Although each health care organization will need to set its own ground rules for
communication style, the following may serve as a general road map for telephone
calls, texts, and email communication between leaders.
Unscheduled telephone calls are generally reserved for times where transfer
of complex and/​or important information needs to be relayed quickly. Although
telephone calls may be performed to discuss less urgent or complex matters, such
matters can typically be saved for times of in-​person meetings or email. Generally,
when phone calls occur between ED leadership and hospital leadership, those in-
volved should make every effort to answer or return the call as quickly as possible.
Voicemail inboxes should have succinct and professional greetings, and messages
should be similarly constructed. At times conference calls may be utilized when
more than one party needs to be included.
Text messaging is incredibly helpful in communicating information in a timely
fashion, often between multiple parties. Initiating a text message chain to 4 to 5
members of an ED leadership team regarding an acute issue in the ED is far faster
than calling and allows for discussion and information sharing in real time. As a
busy administrator, telephone calls typically require someone to step out of a
meeting. Text communication can be accomplished more discreetly with less inter-
ruption. The modern smartphone can cut and paste and include attachments such
as photographs that may assist in communication. This author finds text communi-
cation extremely helpful to keep an operations team (which includes senior-​level
hospital administrators) informed of current events in the ED when timely atten-
tion is needed.
Email may be used in a variety of ways as previously described in the distribu-
tion of data. There are many ways to deploy email and many “guides” as to how to
construct email and the proper etiquette in construction and replying. Although
an in-​depth discussion is beyond the scope of this chapter, we will suggest a few
guardrails.
Emails generally take the form of informational and those that need a reply or
action. The sender should be clear with intention of the email as to what action is
expected. If such an email is FYI only, it should be labeled as such in the subject line
or body of the email. Email should otherwise be constructed to be as succinct and
clear as possible with simply posed questions and needs for response. Large num-
bers of carbon copied recipients should be avoided unless the email is intended as
an FYI.
Receivers of email should attempt to address most communications the same
business day or within 24 hours. Communication from senior leaders (e.g., CEO)
may have an expectation of reply that is quicker than those from other leaders.
Each organization will need to set expectations especially around some more
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controversial areas such as sending/​replying on weekends and off-​hours. Some

Communication with Providers, Staff, and Personnel 152
senior leaders may be given leeway in terms of how they communicate, but in ge-
neral, as much as possible expectations should be clearly articulated.
It goes without saying that proper email etiquette dictates careful construction
for tone and content. Some topics are best addressed via phone call or in-​person
meetings. One oft-​quoted guideline is that one should never send an email that
one wouldn’t want posted on the front page of the New York Times. Other mes-
saging platforms do exist such as direct messaging with Twitter. Platforms may
be employed that allow secure messaging, and some are HIPAA compliant. Such
technology should be deployed and utilized in a consistent fashion if chosen. Every
member of the team should utilize these platforms if there is an expectation from
the team.

Communication During Emergency Management/​Disaster

Situations
Communication strategies may need to significantly change during situations that
require formal emergency management. In such situations, HICS would likely
be implemented necessitating dramatic alterations of the typical communication
schema between leaders. Although HICS structure may feel artificial to leaders who
have familiarity with communicating in certain ways, it should be appreciated and
observed. For example, a hospital CEO may find herself in a very different position
under HICS. All leaders should undergo appropriate training to be familiar with
and able to function under this paradigm.
Health care organizations and EDs should have communication strategies to
reach a targeted audience quickly. For example, if faced with a mass-​casualty in-
cident with multiple trauma victims, an onsite ED leader such as a charge nurse
should be able to rapidly initiate a conference call to loop in key emergency man-
agement, trauma, and ED leadership. A similar system could be scaled up to ini-
tiate a conference call with multiple key operational leaders in an event that requires
briefing a large number of individuals, such as preparation for a large weather event.
ED leaders, both on the ground and on call, need the ability to rapidly communicate
needs and effectively brief key leaders as to ongoing events.

PUTTING IT ALL TOGETHER: CASE STUDIES IN

COMMUNICATION WITH HOSPITAL LEADERSHIP
Hospital Capacity Crisis Scenario
Hospital X is suffering from a major inpatient bed capacity crisis. Over the last few
months a competing hospital in the same town has closed several inpatient units
and signaled to the community that they wish to downsize their facility. As such
there has been an increasing amount of ambulatory and EMS traffic to the hos-
pital, resulting in increasing door-​to-​provider times and percentages of patients
who have left without being seen. A board member recently came to the ED with
an acute medical condition and was unable to be roomed for over 2 hours. The
board member sent a note to the CEO, both of whom have communicated to the
ED leadership team that they expect a rapid change in ED process to accommodate
the increasing volume. EMS leadership is upset that their ambulance crews cannot
153

quickly offload patients and get their units back into service. Front-​line staff are frus-

153
trated that “nothing is being done.”

Communication With Hospital Administration

How Might the ED Leadership Team Effectively Communicate
to Hospital Leadership?
Many ED leadership teams and hospitals find themselves in similar circumstances
far too often. A skilled ED administrative team would recognize that the problem is
multifaceted and will require the cooperation of multiple parties to seek solutions
to this complex problem that places patient safety at risk. Although the specific
solutions to this common problem are beyond the scope of this text and outlined
elsewhere, let’s examine how the ED might effectively communicate to hospital
leadership.6–​8
At this point in the scenario there may be some damaged relationships and
ineffective communications paradigms that need to be addressed immediately.
However, let’s unpack some strategies that should have been employed previously.
Through whatever means any member of the governance structure came to under-
stand that the nearby hospital was downsizing in capacity, communication across
the structure should have occurred. ED leadership should also have a firm grasp on
the relevant operational metrics and should have recognized worsening operational
metrics. These 2 points, a stress on the system and meaningful data to prove that
stress has caused negative impact, should spur the teams to action.
Convening a meeting between the core ED and hospital operations stakeholders
should occur immediately to openly discuss the relevant issues. Senior leaders
across the governance structure should be briefed on the facts and begin to formu-
late solutions with the understanding that the entire hospital needs to participate
in solution finding. Finger pointing in such a circumstance will impede problem
solving.

Immediate Communication Interventions If Not Already

in Place
Daily capacity huddle
Twice-​daily bed capacity email updates
Twice-​daily ED status email updates
Daily ED operational metrics distribution

Setting up ongoing and structured communications across all relevant stakeholders

would be critical to begin managing the crisis. Reporting the data is a critical first
step; identifying the responsible leadership for managing the data elements is the
second step. It may be necessary for the ED leadership to set up additional working
groups or committees to assist in managing various aspects of the crisis.
Potential damaged relations with other aspects of hospital governance would
need to be managed. In this scenario, it will be important to manage the relation-
ship with the board of directors. It may be necessary for a senior ED leader to reach
out directly to the board member and apologize for the service rendered, but also
to engage that member and personalize the crisis. Additionally, the ED leader might
suggest a communication strategy to the board and other senior leaders to commu-
nicate to ED leadership if they or other members may require service in the ED.
154

Arranging for an ED tour with hospital leadership and board members, scheduled
Communication with Providers, Staff, and Personnel 154
during the busiest part of the day, may also personalize the issue and assist in en-
gagement and a broader understanding of the impact.
External stakeholders such as EMS and the surrounding community might also
need to be managed. Proactively meeting with EMS would be helpful to discuss
mitigating and addressing their potential concerns surrounding delayed turnaround
times for units and strategies to avoid EMS diversion. Creating open lines of com-
munication and setting expectations for how this communication should occur
would be an important outcome of such a meeting. Additionally, media relations
would need to be informed of the crisis in the event they are called to respond to
media stakeholders or address issues raised on various social media platforms.

EMERGENCY MANAGEMENT SCENARIO

Hospital Y is a large tertiary care hospital with level 1 trauma status. At 3 am a large
tour bus traveling at highway speeds with 40 passengers crashes with severe damage
to the vehicle. Approximately 30 passengers have severe injuries and several are
pronounced dead on scene. EMS notified the ED charge nurse, who immediately
informs all ED staff to prepare for a large influx of critically injured patients.
What attributes of ED communication to hospital administration and other
stakeholders would lead to success in managing this mass-​casualty incident (MCI)?
The successful management of such an event would require a well-​coordinated
effort across multiple service lines. In the immediate phase of the event resources
would need to be quickly deployed to the ED to handle the influx of patients. As
the event unfolds, one would expect that patients requiring surgical intervention
and intensive care could outstrip available resources. Media relations and security
would be important considerations and an after-​action debrief would need to be
accomplished.
Immediately upon learning of the event involving an MCI, the charge nurse
would recognize the need to implement the departmental and hospital disaster ac-
tivation plan. Although the details of such a plan would be specific to the hospital,
ideally this would trigger a notification and conference call to key hospital and de-
partmental leaders. Depending on the initial conference call and the details of the
emergency management plan, further conference calls and briefings may occur. In
the meantime, the mobilization of relevant staff including ED, trauma, and anesthe-
siology providers would be necessary as well as nursing and other ancillary staff as
needed.
Communication to senior hospital leadership should occur as a result of
initiating the relevant incident command system. By design, key leaders in opera-
tions, finance, and communication will be engaged and placed into roles commen-
surate with the emergency management plan. ED leadership should be prepared
to communicate needs through this structure as well as serve in various capacities
in the command structure as needed. As the event unfolds the focus will naturally
migrate to operating room and inpatient settings and likely involve media relations
and communication with families of victims. ED leadership will be responsible
for ensuring that ED staff involved in the event have the resources to take care of
patients, facilities for debriefing, and mental health professionals available for those
with specific needs related to the event. ED leadership should debrief with the en-
tire facility to learn from mistakes, celebrate successes, and plan for the next event.
15

CONCLUSION

155
Communication is a complex topic, and no single paradigm or organizational struc-

Communication With Hospital Administration

ture can be universally applied to any specific health care facility. Communication
with hospital leadership and ED administration requires a proactive and thoughtful
approach. Depending on the size of the organization, such communication might
be occurring on various levels with a large number of external stakeholders.
Effective internal ED organization is essential for the entire team to communicate
one message to hospital leadership. In general, we prefer transparency and frequent
communication of data. Developing general guidelines for phone and electronic
communication will help to set expectations for all team members. In times where
emergency management paradigms may be needed, leadership teams should be
skilled in operating under the HICS.

REFERENCES
1. Schyve P. Leadership in Healthcare Organizations, a Guide to Joint Commission
Leadership Standards. A Governance Institute White Paper, Winter 2009.
2. Mayer, T, Strauss R, Barnett C, et al. Emergency department interaction with
hospital governance. In: Strauss R, Mayer T, eds. Emergency Department Management.
New York, NY: McGraw-​Hill; 2014:29–​34.
3. Hospital Incident Command System, Guidebook. 5th ed. California Emergency
Medical Services Authority; 2014. https://​emsa.ca.gov/​w p-​content/​uploads/​sites/​
71/​2017/​09/​HICS_​Guidebook_​2014_​11.pdf
4. Mayer T, Strauss R. Leadership, medical director. In: Strauss R, Mayer T, eds.
Emergency Department Management. New York, NY: McGraw-​Hill; 2014:99–​117.
5. Studer Q. Hardwiring Excellence. Gulf Breeze, FL: Fire Starter Publishing; 2003.
6. Crane J, Noon C, eds. The Definitive Guide to Emergency Department Operational
Improvement. New York, NY: Productivity Press; 2011.
7. Soremekun O. Improving timeliness and access to acute and emergency care. The
science of improving emergency department crowding. In: Wiler J, Pines J, Ward
M, eds. Value and Quality Innovations in Acute and Emergency Care. Cambridge, UK:
Cambridge University Press; 2017:38–​45.
8. Rabin E, Kocher K, McClelland M, et al. Solutions to emergency department
“boarding” and crowding are underused and may need to be legislated. Health Affairs.
2012;31(8):1757–​1766.
156

11 Interactions
Consultants
With

Taylor Burkholder and Jennie Buchanan

INTRODUCTION
The emergency department (ED) serves as a critical access point and a central
hub to the health care system. Although the scope of practice and skill set of emer-
gency providers encompass the definitive treatment for a broad range of injuries
and illness, there remain times when patients require expertise from other health
care providers, admission for further treatment and evaluation, or coordination of
ongoing care in the outpatient setting. For these reasons and others, emergency
providers frequently engage other health care specialists through the process of
consultation. The emergency physician or advanced practitioner must be able to
effectively communicate with a multidisciplinary team to best coordinate patient
care, much like a conductor in the symphony.
Given that approximately 20% to 40% of all emergency department patients will
require a consultation, the art and science of communicating with consultants is a
vital skill set for emergency physicians and emergency advanced practice providers.1
Optimal communication with consultants is essential for safe and efficient coordi-
nation of patient care. However, there is very little formal teaching on the art of con-
sultation. Most emergency providers learn consultation-​specific communication
skills through experimentation and role modeling from teachers and peers.
Emergency providers often describe dissatisfaction with consultant interactions,
including the perception of incivility or disagreements with plans of care.2 Incivility
and interpersonal conflict in the workplace can have detrimental effects on both pa-
tient care and emergency provider well-​being.3 This interpersonal conflict or rude-
ness can directly impact quality of patient care and team performance.4 Additionally,
157

rudeness can contribute to job dissatisfaction among providers.5 Bullying, incivility,

157
and disruptive behaviors in the health care setting have been shown to increase
turnover, absenteeism, and mental health issues such as depression, anxiety, in-

Interactions With Consultants

somnia, and low self-​esteem. These behaviors are amplified by stress, changes in hi-
erarchy, and conflicting loyalties (i.e., quality patient care vs. ED patient throughput
metrics).6 By improving communication with consultants, one can achieve better
patient care and protect career longevity. This chapter will provide an overview of
the key components of emergency department consultation, introduce effective
communication tools for transfer of important information, and provide some
approaches to prevent or resolve difficult interactions with consultants.

ANATOMY OF THE ED CONSULTATION

Parties Involved in a Consult (Who)
To provide the most complete care to their patients, emergency providers may
need to consult a multitude of different services or specialties for their expert ad-
vice. Possible consultants can include other physicians, social work, mental health
professionals, utilization management, physical and occupational therapy, child
protective services, public health officials, advanced practice providers, nurses,
technicians, laboratory workers, and many others. For the purposes of this chapter
we will focus on the physician-​to-​physician consult. However, the same techniques
and recommendations can be employed in other forms of consultation as well.
As emergency providers, we work in a fish bowl. Everyone is aware of our work
environment and can constantly see what we do. We serve as the entry point to the
rest of the hospital. As such, it is imperative that we understand all the resources
available to us in the hospital including the services available for consultation and
the people providing those services. Having knowledge of the consultants available
at your institution will prevent the frustration that comes along with multiple calls
to various consulting services in search for the correct service that can best serve
your patient’s needs.
If your practice environment lacks the necessary consultative services required
for your patient, you will need to reach out to other institutions for those services.
They may either accept transfer of the patient or make recommendations for care
in the outpatient setting. In some cases, you will even be on the receiving end of
a consultation. Emergency physicians often accept transfers from clinics or other
emergency departments. Not infrequently, our specialist colleagues appeal to our
expertise when they are treating a patient with a concern outside of their scope and
comfort. Thus, emergency providers can serve as both the giver and the receiver of
a consult.

Method of Consult (How)

Most consultations are done by phone, but there is a portion that is done in person.
During a phone consultation, the provider has the luxury of having an electronic
medical record available for reference. In contrast, the in-​person consult requires
innate knowledge of the patient history, demographics, vitals, labs, and imaging.
Additionally, during in-​person consults, appearance and demeanor can play a sig-
nificant role in how the consult is received. Considerations for nonverbal cues and
body language become important for in-​person consultation. Body language that
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expresses interest, active listening, and engagement—​relaxed but upright posture,

Communication with Providers, Staff, and Personnel 158
sufficient eye contact, slightly leaning in, and nodding—​are encouraged. The emer-
gency provider should avoid defensive postures (e.g., crossed arms, frowning) or
body language that conveys disinterest (e.g., poor eye contact, fidgeting, looking at
a watch).7
Currently, telemedicine consults are becoming more common in order to bridge
regional specialist shortages. This type of consult merges components of the phone
and in-​person consult. To maximize communication over computerized telemedi-
cine platforms, be sure to adjust the camera and microphone so that you are visible
and audible, and be cognizant of your surroundings to avoid distractions and main-
tain a professional appearance.

Environment of Consult (Where)

The hospital practice environment can significantly affect the consult process. Are
you in a practice environment with a residency program where you are consulting
an exhausted resident that is already 3 consults behind? Or are you in a private hos-
pital environment and your consultant is a seasoned attending that gets reimbursed
generously for consultations? The consultation in these 2 scenarios may be received
very differently. The community doctor who is directly reimbursed for admission
and consultations may be happy to be asked for his or her expertise. On the other
hand, a trainee at an academic institution that feels overworked may be eager to
avoid further consults.
Working at an academic or community hospital can also have a negative or
positive effect on the consulting experience surrounding the process of admitting
privileges. As an example, in an academic teaching hospital, if a consultant is un-
willing to admit a patient that you think requires an admission, you may have the
ability to admit to another service. If you are in a community hospital with the same
situation, you may have to transfer the patient to another facility. On the other hand,
some community hospitals or health maintenance organizations may be able to ar-
range timely follow-​up appointments, which has the potential to sway the direction
of a consult from an admission to an outpatient appointment the next day.

Purpose of Consultation (Why)

Why do we consult? In general terms, consults are obtained to answer a question or
recruit additional resources. Emergency medicine providers primarily consult for 4
reasons: specialty opinion, admission, follow-​up planning, and disposition. These
consults differ in varying ways.
In general, specialty opinion consults are succinct, focused presentations with a
specific question to be answered. On the other hand, admission consults require an
increased transfer of information about history, evaluation, and ED course in order
for the consulting provider to fully assume care of the patient. Consultations that re-
quire the consultant to fully assume care or commonage the patient are often more
time consuming than consults for an opinion on a singular aspect of the patient’s
care. Follow-​up planning and disposition consultations usually require only verbal
interaction rather than bedside evaluation. Given decreased time requirements, this
type of consultation may be less stressful given that the consultant does not have to
come to the ED to perform an evaluation or complete a full consult documentation.
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PITFALLS FOR EMERGENCY PROVIDERS

159
To facilitate better communication with consultants, emergency providers should

Interactions With Consultants

be aware of several cognitive biases and disruptive cultural norms that may unfa-
vorably influence our interactions. An anthropological concept called tribalism in
medicine, the Dunning-​Kruger effect, imposter syndrome, and gender bias all have
particular relevance to providers in the ED.
Tribalism describes the concept of silos of clinicians who cluster by specialty,
share common behaviors and beliefs, and often have internalized hierarchies.8
Although sharing a common culture among tribes can create more productive
teams and a sense of security, tribalism may also create barriers to interdisciplinary
teamwork through conflicting values, ideas, or behaviors.9 Anecdotally, most emer-
gency providers have overheard unfair criticism or mocking of the emergency team
by a consulting service. We have been called glorified triage doctors, demeaned for
missing something that later became evident, or second-​guessed for our decisions
to admit. Conversely, many emergency providers also fall into the trap of demeaning
consultants who did not conform to expected roles or behaviors in the ED. For ex-
ample, an emergency provider may joke with a colleague about an orthopedics
resident who requested that the ED team call a medicine consult for an abnormal
electrocardiogram (ECG) prior to going to surgery. Of course, interpreting an ECG
comes as second nature to emergency providers, but this may be outside the scope
or comfort of our specialist consultants. This unfortunately serves to cause division
among disciplines in medicine. By remaining aware of this effect, avoiding speaking
ill of our colleagues, setting a good example for our peers and learners, and gently
encouraging others to avoid this pitfall, we can enhance the collaborative practice
of our consultations.
The Dunning-​Kruger effect describes a cognitive bias best characterized by mis-
placed overconfidence, where a person overestimates his or her cognitive or pro-
cedural abilities.10 Overestimating our own competence can produce conflicts
between emergency providers and consultants when our anticipated plan differs
from the plan proposed by the consultant, especially if our consultant is correct in
his or her recommendation. Through the metacognitive process of evaluating our
own limitations, we are less likely to commit the error of trusting our own opinion
over that of our consultant, which may lead to better care for our shared patient.
The antithesis to the Dunning-​Kruger Effect is imposter syndrome, where experts
feel they are a fraud and do not merit the recognition received for professional
accomplishments and abilities.11 Physicians sometimes attribute their successes to
luck rather than true skill and effort. They therefore fear that others will discover
that their successes have not been deserved.12 When providers lack confidence in
their judgments, they are prone to deferring to a consultant’s assessment and plan,
even if this plan is incorrect or harmful. By recognizing our own areas of expertise
and acknowledging that most of our peers have similar doubts, we may prevent this
type of error caused by lack of confidence.
Gender undoubtedly plays many roles within the house of medicine, and its po-
tential impact on consults is worth noting. Gender bias arises when perceptions and
attitudes toward gender influence thoughts and behaviors.13 A male surgeon who
gives firm orders may be perceived as direct and authoritative, whereas a female sur-
geon who engages in the same behavior may be perceived as bossy. We must recog-
nize this because it is clearly counterproductive to our interactions with consultants.
On our part, our unconscious biases regarding gender could cause us to find some
160

people more credible than others. On the part of our consultants, demeaning or
Communication with Providers, Staff, and Personnel 160
condescending behavior can be more common toward female emergency providers.
The best way to counteract gender bias is to encourage open dialogue and improve
gender-​based education with students, residents, and colleagues.
Other factors leading to conflict between emergency providers and consultants
include differences of opinion, unclear guidelines or best practices, or even unpro-
fessional behavior. Communication challenges can arise when the emergency team
and the consulting team have differing expectations or situational understanding. A
consultant may not be aware of the resources and expertise that are available in the
emergency department. If a consultant assumes that a process can be done in the
emergency department but that process requires resources that are not available at
that time, frustration commonly ensues. Additionally, some consultants will expect
an emergency provider to understand some aspect of their specialty that might not
be common knowledge among those who specialize in emergency medicine. This
disconnect influences the consultant’s perception of the emergency provider in an
unfavorable manner. It is therefore important to clearly communicate your reasons
for consultation and your limitations to achieve those in the emergency department
so that your consultant explicitly understands your rationale.

TOOLS FOR CONSULT COMMUNICATION

The process of consultation often requires a large transfer of information. There is
a paucity of validated tools to employ when describing the components of the con-
sult specific to emergency medicine; only Kessler’s 5 Cs are specific to the emer-
gency medicine consult; the ISBAR handoff tool is specific to transfer of care but
can be applicable to the consult.14–​17 Both the ISBAR (Identification, Situation,
Background, Assessment, and Requirements/​requests) handoff tool and Kessler’s 5
Cs are crucial for safe, efficient, and complete communication of care.
Realizing that lapses in good communication during provider-​to-​provider
handoffs has potential to cause adverse patient outcomes, the ISBAR handoff
tool stemmed from a quality improvement initiative supported by the Australian
Commission on Safety and Quality in Health Care (ACSQHC) and the Australian
College of Emergency Medicine (ACEM).16 This handoff tool is specific to bed-
side handover, but its components can be applicable to emergency medicine. The
simple and self-​explanatory ISBAR tool is easily applied and has been shown to im-
prove handoff communication, with some institutions also using the ISBAR format
to write transfer notes.
Kessler’s 5 Cs of consultation was developed from a detailed qualitative analysis of
emergency department consults and then further molded by a business model for the
consultative process.15 Kessler’s 5 Cs model of calling a consult include contact, com-
municate, core question, collaboration, and closing the loop (see Box 11.1).14 These
are then further subdivided into specific action items for efficacious consultation.15
The contact phase of the consult involves introduction of self, location and
confirmation that the correct consultant has been reached. Brevity is extremely im-
portant. A succinct report should include key history, labs, studies, and imaging.
Explicitly stating the core question or request that has prompted the consultation
alleviates your consultant of a cognitive burden while he or she listens and ensures
that your consultant efficiently responds to your request. For example: “Hi Dr. Jones,
this is Dr. Smith in the ED. I have a 35-​year-​old female with ultrasound-​confirmed
16

161
Box 11.1. Kessler’s 5 Cs of Consultation

Interactions With Consultants

1. Contact: Introduce the consulting and consultant physicians. Build a relationship.
2. Communicate: Give a concise story and ask focused questions.
3. Core question: Have a specific question or request of the consultant. Decide on
a reasonable time frame for consultation.
4. Collaboration: A result of the discussion between the emergency physician and
the consultant, including any alteration of management or testing of the patient’s
status.
5. Closing the loop: Ensure that both parties are on the same page regarding the plan,
and maintain proper communication about any changes in the patient’s status.

Reproduced with permission from: Kessler CS, Afshar Y, Sardar G, et al. A prospective,
randomized, controlled study demonstrating a novel, effective model of transfer of care
between physicians: the 5 Cs of consultation. Acad Emerg Med. 2012;19(8):968–​974.
doi:10.1111/​j.1553-​2712.2012.01412.x.

cholecystitis in room 5 that I would like for you to evaluate for the OR. She is previ-
ously healthy, no prior surgeries, has been having pain for 12 hours. Her labs show a
white blood cell count of 15 and normal liver function studies. Her last meal was 12
hours ago.” At this point, a timeline can be established to ensure prompt completion
of the consult that is safe for the patient and for the department flow. “I understand
you’re finishing up a case in the OR right now. Do you think you’ll be able to eval-
uate her in the next hour?”
The collaboration step involves arriving at a mutually agreeable plan for the pa-
tient. In the case of the 35-​year-​old female with cholecystitis, this might sound like,
“I agree that the patient needs surgery. Are you okay with giving antibiotics now?”
Depending on the purpose of the consult, this could be a simple plan for admission,
or it could involve treatments or disposition pending additional diagnostic studies
in the form of an if/​then statement. For example, if the lumbar puncture is negative,
the patient can be discharged home to follow up in the neurology clinic next week.
Closing the loop includes thanking the consultant for his or her assistance and re-
peating the plan briefly to ensure that your understanding of the plan is correct. “Thank
you for seeing this patient, Dr. Jones. We will make sure she gets antibiotics and arrange
for her transport to the OR in half an hour. I have already ordered her type and screen,
and she will remain NPO in the ED. Please let me know if anything changes.” Even
though it may seem redundant, this step is a critical failsafe to avoid miscommunications
that cause delays or medical errors. Only after both parties are confident they have a
shared understanding of the plan should they end the conversation.
Although not explicitly covered in either model, it is also important to con-
sider what your consultants typically need to make informed decisions prior to
initiating a consultation. For example, will the orthopedist need additional (com-
pletion) films to fully evaluate the extent of a fracture before deciding operative
versus nonoperative management? This courtesy respects the consultant’s time.
However, on occasion it is necessary to consult prior to completion of evaluation,
whether owing to patient acuity or expected clinical course. In the case where a
consult needs to be placed prior to complete information gathering, it is important
that the person placing the consultation is upfront and clear about the reason for the
162

immediacy of the consult. Having guidelines in place for requirements surrounding

Communication with Providers, Staff, and Personnel 162
consultations can be helpful.
Also not included in either tool is the preparatory phase prior to contacting a
consultant. Preparation is essential for clearly communicating key information to
your consultants and creating a confident image. Although taking the time to review
the chart, vitals, and labs before a consult during a chaotic shift may be difficult
to justify, your preparation will pay off with more efficient and effective consults,
which will ultimately save time. With experience and practice, advanced prepara-
tion takes minimal effort. Once an emergency provider understands the typical
needs of specific consultants, it is generally easy to review the chart rapidly to glean
the relevant information.
Both Kessler’s 5 Cs and the ISBAR tool are effective ways to model and in-
still effectual consultation skills that are imperative for providers practicing emer-
gency medicine and those in training. By practicing a regimented approach, much
like a checklist, emergency providers can standardize communication and avoid
miscommunications between consulting parties that can compromise patient care.
Understanding consultant needs and being prepared to provide the most important
information required to make decisions will help to ensure a positive consultative
experience.

TIMING, BREVITY, AND CLARITY

Consideration should be given to the timing of your consultation. Does this patient
require consultation in the middle of the night or can it wait until the morning?
Respecting our consultants’ time is important not only for building and maintaining
good relationships but also for protecting their wellness.
Be concise with your requests. Leading your conversation with a brief summary
of why you are consulting will convey the purpose to the consultant and allow the
conversation to be focused on the relevant points. Leave opportunities for your con-
sultant to inquire about further information as needed.
In summary: Tell them or ask them what you want upfront; be professional,
concise, and clear; and always prioritize what is right for the patient. In fact, re-
member you are not always going to be making the call but might occasionally be
on the receiving side as consultant or accepting physician. Consider how you would
want a consult presented if you were on the receiving end.

PRINCIPLES OF PERSUASION
Persuasive communication is essential to building a common understanding and
mutually agreeable plan among teams. A persuasive emergency provider can lev-
erage certain techniques to align the consultant with his or her own reasoning in
an efficient and effective manner. Of course, being persuasive is not the same as
being coercive, argumentative, or manipulative. The former implies a virtuous tactic
meant to expeditiously align the consultant with our own reasoning, whereas the
latter implies negative intent with often-​dubious ethical implications. Persuasion
should never involve lying to consultants or manipulating them into doing some-
thing that would otherwise not be good for them or for the patient.
A research psychologist named Robert Cialdini developed 6 principles of per-
suasion during a career spent observing persuasive individuals. The fundamental
163

idea behind persuasion is that people make many decisions based on heuristics

163
(whether or not those heuristic shortcuts are productive or misleading) and are
therefore suggestible to certain methods of redirecting our thought processes.18 Dr.

Interactions With Consultants

Cialdini’s 6 principles can be used in various ways to help align our interests with
our consultants’.
The first is the principle of reciprocity, which states that people are inclined to re-
turn favors.18 People feel a compulsive obligation to level debts. In this way, favors
paid to consultants not only help us build relationships but also allow us to ask for
favors in return when necessary. Going the extra mile to contact another specialty
for consultation on the patient who is being admitted to internal medicine regard-
less of the specialist’s recommendations helps build goodwill for future admissions
to internal medicine.
Commitment and consistency are another core principle of persuasion. People
derive a sense of identity from a public perception that they are consistent and de-
pendable. For this reason, a person who verbally commits to an action or ideal is far
more likely to follow through with it.18 By finding a common ground and getting
your consultant to commit to that ground, you are more likely to achieve a desirable
result for your patient. For example, if your consultant can commit to “doing what
is best for the patient,” then it will be easier to convince him or her that a patient is a
poor candidate for outpatient management of their pneumonia owing to homeless-
ness and poor medical literacy.
The concept of social proof describes the fact that people are more likely to do
things that they see others do.18 Evolutionarily, it makes sense that we should be
inclined to run when we see others run to avoid an unseen predator. In medicine,
this means that we often behave in patterns that are similar to those around us. This
highlights our ability to serve as role models of the types of behaviors we wish to see
among consultants. Speak to consultants in the way in which you want consultants
to speak back to you.
Because people tend to be persuaded more easily by people they like or see as
authority figures, emergency providers can leverage the principles of liking and au-
thority to our advantage. Conducting yourself in a friendly and caring way around
your consultant colleagues and building relationships in advance will ensure that
“liking” helps persuade them to at least consider your point of view. We can ap-
peal to authority by introducing ourselves and our roles, but caution is advised to
avoid using a “because I said so” argument ad hominem if you are in a position of
authority. Not only can this be damaging to the relationship, but also there is risk of
losing respect if your assertion turns out to be incorrect.
Finally, the principle of scarcity can be used to cultivate interest in our consultants.
People tend to want what they perceive as scarce because these things are often rare
and valuable.18 An interesting diagnosis, a procedure that a resident seldom gets to
perform, or even the chance of a cool story is an important selling point for your
consultants.
The feature that underpins all of these principles of persuasion is that of a
shared identity, which states that the more we identify ourselves with others, the
more influence we have on each other.18 Striving to create a culture of open com-
munication and collaboration with our consultants will serve to lower barriers to
developing a mutually agreeable plan for our patients. By creating a shared iden-
tity with consultants, we can combat tribalism and its potential barriers to effective
communication.
164

Communication with Providers, Staff, and Personnel 164

Box 11.2. Tips for Dealing With Difficult Consultants
• Refocus the conversation on what is best for the patient.
• Build relationships in advance. Show hospitality.
• Use applicable evidence-​based arguments when available.
• Never lie or make up information.
• Request that the consultant evaluate the patient at the bedside if you feel they are
not understanding the acuity of the consult.
• Seek explanations to understand the basis for your consultant’s rationale.
• Find common ground and then build your request upon your shared
understanding.
• If you anticipate a tough interaction, offer your hand as a shake prior to starting
the conversation.
• Use humor and kindness to diffuse aggressive behaviors.
• Never apologize for consulting, but do express your appreciation.
• Let go of your ego to maintain a level head.
• Have confidence, but avoid cockiness or competitiveness.
• Appeal to authority if needed. Escalate the conversation to leadership positions.
• Pick your battles. Some conflicts do not need to be resolved on the spot.

DECREASING POTENTIAL FOR CONFLICT

Although there is a paucity of evidence-​ based literature related to difficult
interactions between emergency providers and consultants, the tips in Box 11.2—​
collected from a group of experienced emergency medicine faculty—​are helpful
for preventing issues and resolving conflicts. Techniques to diffuse conflict in the
workplace take years to master, and not all techniques will fit with the emergency
provider’s personality and style. The key is to strive to maintain honesty, to diffuse
hostility without becoming angered or reciprocating bad behavior, and to center the
conversation on what is best for the patient. Sometimes this can be difficult over the
phone, so a request for an in-​person discussion can help. Consultants are dealing
with their own stressors and emotional triggers, so allowing them the benefit of the
doubt is gracious and may temper our own emotional responses. If a consultant is
behaving atypically, asking if he or she is doing okay is often enough to force self-​
reflection and diffuse the situation.
However, if a pattern of poor behavior is noted or there are concerns about
professionalism, consider involving your department leadership team to provide
feedback and mediate solutions with the consultant’s department. This can often
be done diplomatically so as to avoid pointing fingers or blaming individuals,
which often damages relationships that will be needed for future consults.
Appealing to authority is generally warranted in situations where conflicts are
repeatedly arising from something attributable to a systems flaw. The use of au-
thority may also be necessary in instances when consulting with trainees in an
academic setting, especially when a timely response is needed to avoid delays in
patient care.
165

CONCLUSION

165
Clear communication with consultants is essential for coordinating safe and effi-

Interactions With Consultants

cient care for our patients in the ED. By utilizing a regimented approach such as
Kessler’s 5 Cs or the ISBAR tool for the consultation process, we can convey com-
plete information to our consultants and minimize misunderstandings. When
conflicts do arise during consults, the use of diplomatic and persuasive techniques
to mediate an agreeable plan will ultimately improve career satisfaction and improve
our patients’ care.

REFERENCES
1. Lee RS, Woods R, Bullard M, et al. Consultations in the emergency department:
a systematic review of the literature. Emerg Med J. 2008;25(1):4–​9. doi:10.1136/​
emj.2007.051631.
2. Shetty AL, Vaghasiya M, Boddy R, et al. Perceived incivility during emergency
department phone consultations: emergency department Perceived Incivility. Emerg
Med Australas. 2016;28(3):256–​261. doi:10.1111/​1742-​6723.12564.
3. Behaviors that undermine a culture of safety. Sentin Event Alert. 2008;(40):1–​3.
4. Riskin A, Erez A, Foulk TA, et al. The impact of rudeness on medical team
performance: a randomized trial. Pediatrics. 2015;136(3):487–​495. doi:10.1542/​
peds.2015-​1385.
5. Rosenstein AH, O’Daniel M. A survey of the impact of disruptive behaviors
and communication defects on patient safety. Jt Comm J Qual Patient Saf.
2008;34(8):464–​471.
6. Felblinger DM. Bullying, incivility, and disruptive behaviors in the healthcare
setting: identification, impact, and intervention. Front Health Serv Manage.
2009;25(4):13–​23.
7. Kimberly Pendergrass. 10 positive body language techniques to help you succeed.
December 11, 2013 from https://​blog.udemy.com/​positive-​body-​language/​.
Accessed March 20, 2019
8. Braithwaite J, Clay-​Williams R, Vecellio E, et al. The basis of clinical tribalism,
hierarchy and stereotyping: a laboratory-​controlled teamwork experiment. BMJ
Open. 2016;6(7):e012467. doi:10.1136/​bmjopen-​2016-​012467.
9. Weller J. Shedding new light on tribalism in health care: commentaries. Med Educ.
2012;46(2):134–​136. doi:10.1111/​j.1365-​2923.2011.04178.x.
10. Hodges B, Regehr G, Martin D. Difficulties in recognizing one’s own incompetence:
novice physicians who are unskilled and unaware of it. Acad Med J Assoc Am Med
Coll. 2001;76(10 Suppl):S87–​S89.
11. de Vries MFRK. The impostor syndrome: developmental and societal issues. Hum
Relat. 1990;43(7):667–​686. doi:10.1177/​001872679004300704.
12. Broderick K, Breyer M. Confronting the imposter within. Emergency Physicians
Monthly. http://​epmonthly.com/​article/​confronting-​imposter-​within/​. Published
May 6, 2016. Accessed August 5, 2017.
13. Risberg G, Johansson EE, Hamberg K. A theoretical model for analysing gender bias
in medicine. Int J Equity Health. 2009;8(1):28. doi:10.1186/​1475-​9276-​8-​28.
14. Kessler CS, Afshar Y, Sardar G, et al. A prospective, randomized, controlled study
demonstrating a novel, effective model of transfer of care between physicians:
the 5 Cs of consultation. Acad Emerg Med. 2012;19(8):968–​974. doi:10.1111/​
j.1553-​2712.2012.01412.x.
16

15. Kessler C, Kutka BM, Badillo C. Consultation in the emergency department: a

Communication with Providers, Staff, and Personnel 166
qualitative analysis and review. J Emerg Med. 2012;42(6):704–​711. doi:10.1016/​
j.jemermed.2011.01.025.
16. Marmor GO, Li MY. Improving emergency department medical clinical handover:
barriers at the bedside: Medical Clinical Handover In The ED. Emerg Med Australas.
2017;29(3):297–​302. doi:10.1111/​1742-​6723.12768.
17. Bryant R. How to call a consult. Rebel EM. http://​rebelem.com/​how-​to-​call-​a-​
consult/​. Accessed August 1, 2017.
18. Cialdini RB. Influence: The Psychology of Persuasion. Rev. ed. New York, NY:
Collins; 2007.
167

12 Communication in
Medical Resuscitation
and the Post-​Code
Debrief

Sarah M. Perman

INTRODUCTION
Recent reports from the Joint Commission report that 2 out of every 3 in-​hospital
deaths are due to communication errors, resulting in the majority of sentinel
events.1 Communication in the emergency department is critical to providing ex-
cellent patient care. Effective teamwork and communication are directly associ-
ated with patient safety and outcomes.2 The art of the medical resuscitation is the
forte of the emergency medicine provider. Ensuring appropriate, evidence-​based,
time-​sensitive provision of emergency care to the medically unstable patient is par-
amount, but as important is the ability to communicate this resuscitation strategy
with the medical team in a highly stressful environment. As the emergency medicine
provider does not work in isolation, communication also encompasses interactions
with consultants and families.
In this chapter, the art of communication during a medical resuscitation will
be discussed. Medical resuscitations (including cardiac arrest/​code, cerebrovas-
cular accident, and respiratory distress, for example) are scenarios where a team
is convened and a leadership role is assumed by the senior physician. Teams in
these scenarios include nursing and respiratory therapy, in addition to pharmacy,
advanced practice providers, paramedics/​ technicians, and students in many
168

disciplines. As the resuscitation continues, often the organ-​specific expertise of

Communication with Providers, Staff, and Personnel 168
consultants will be requested to further aid in the care of the patient. The size and
varying practice of the team can raise challenges for the resuscitation team; how-
ever, this variability in expertise and clinical practice is required to ensure successful
outcomes from critical illness.
Communication is not complete during the resuscitation until one has
communicated the outcomes to family and friends who have convened at the
bedside of the critically ill patient. Communicating bad news is often the focus of
modules during medical school; however, the art of communicating uncertainty in
prognosis is often not explored during standard medical education. How providers
communicate information to family is important and can leave lasting impressions.
Setting inaccurate expectations or potentially being too pessimistic may undermine
the patient’s ability to recover. In addition, current literature has shown that family
presence during medical resuscitations can be beneficial to both families and med-
ical teams.3,4 Therefore, the art of communicating to patients’ families is often not
simple, and requires a significant amount of reflection, expertise, and practice.
At the conclusion of any resuscitation, health care teams are often physically and
emotionally exhausted. Yet the emergency department does not stop, and the return
to patient care as usual is a necessity. Despite this, it is very important to explore the
utility of the “debrief ” in discussing the patient scenario and identifying factors that
the team could improve upon in future similar patient encounters. The debrief is
also integral to allowing providers to communicate their emotions pertaining to the
patient’s encounter, which has been shown to assist providers in processing their
feelings, and is associated with provider retention and wellness.
This chapter will address communication during the resuscitation with team
members and consultants, the art of communicating with families, and finally the
importance of communication in debriefing after an acute event.

THE EMERGENCY DEPARTMENT

Unlike many other clinical settings, the emergency department (ED) is a unique clin-
ical setting where patient complaint and acuity range widely. Emergency providers
are well skilled at stabilization of critically ill and injured individuals, and they func-
tion within a team of like-​minded medical professionals. Emergency departments
are staffed with providers who have specialized training in emergency care. Unlike
the in-​patient setting, where code teams respond to all critically ill patients in all
arenas within the hospital, the encounter in the ED is somewhat contained. How
this becomes an advantage is very simple. For the most part, we know each other and
we work together frequently. This allows for a clear recognition of who the physician
and nursing teams are on shift that day, as well as the assigned ancillary providers
such as paramedics, respiratory therapists, and pharmacists. The ED benefits from
the sheer fact that this team convened for a medical resuscitation is not a unique
team, but is a group of medical professionals who function as a team for the resus-
citation but also for the care of the countless other patients who are being seen in
the ED during that shift. This familiarity is an added benefit but still requires a clear
delineation or identification of roles for the resuscitation.
Studies of critical incidents that explored errors in the emergency department
found that communication and teamwork were cited as frequent contributors to
error (documented in 22% to 32% of reports).5 In the report published by the
169

Institute of Medicine “To Err Is Human,” the authors state, “If there were one aspect

169
of health care delivery an organization could work on that would have the greatest
impact on patient safety, it would be improving the effectiveness of communication

Medical Resuscitation and Post-Code Debrief

on all levels-​written, oral, electronic.”6 This is only accentuated by the high-​stakes
environment of the emergency department when caring for a critically ill patient in
a resuscitation scenario.

TEAM DYNAMICS IN ACUTE RESUSCITATION

The team is integral to a successful resuscitation, as no single provider can resus-
citate a patient in isolation. Each member of the team brings a clear skill set to
the resuscitation and has a role in the care of the patient. Communication failures
are detrimental to this team dynamic and undoubtedly contribute to failed resus-
citation attempts or undesired outcomes. The American Heart Association has
explored the team dynamics necessary for a successful resuscitation in their training
guide “Advanced Cardiovascular Life Support Provider Manual.”7

Assigning Resuscitation Team Roles

Even prior to the patient’s arrival in the emergency department, the team leader is
actively communicating with the medical providers. The first step is to organize the
group and identify roles. Although many providers in the room might be capable
of completing a procedure, clearly stating who will be charged with that task in this
single situation is necessary. It is also important for the entire room to know who is
doing what, so that expectations are set clearly at the start. When roles are clearly
assigned, there is accountability for completing tasks and reduced redundancy so
that each team member can be effective in his or her role.
While organizing the team, the resuscitation leader, or “code leader,” can also set
the tone for the resuscitation. Organized and thoughtful conversations in anticipa-
tion of the patient’s needs can relay a level of confidence and preparation that makes
the team begin to function as a cohesive unit even prior to the patient’s arrival in
your resuscitation room. The team leader is directing the resuscitation; therefore,
his or her demeanor and engagement of the team as a whole will greatly affect the
overall team dynamic and success of the resuscitation.
Like all successful teams, it’s not just the starting quarterback who wins the
game. Being a team member requires tremendous skill and communication.
Understanding your role and keeping within that assigned job are necessary, as
resuscitations where team members deviate from their roles can be disorganized and
even dangerous. Team members must communicate with the team leader when they
have completed their tasks, what they have observed, or any further thoughts on the
resuscitation as their perspective is important and their observations might be crit-
ical to either informing the leader of a new finding or potentially troubleshooting an
error/​failure of the team.
Just as important to assigning roles as a team leader is ensuring that all members
of a resuscitation team are known. When new members join the resuscitation—​for
example, a medical intensivist or a specialty physician who has been caring for the
patient—​they should announce their presence and their specific role or title. Should
this occur, clear definitions of roles must be maintained, as the resuscitation leader
should continue the resuscitation unless a clear transition of leadership occurs and
170

the entire team is aware. Additionally, the team leader should be cognizant of the
Communication with Providers, Staff, and Personnel 170
crowd collecting in the room. The team leader must be proactive in limiting the
number of individuals who join the resuscitation effort who might not have a direct
role or task that is necessary to the team efforts. Overcrowding often contributes to
confusion over tasks and questions of leadership, contributes to the overall noise
level in the room, and can threaten the organization of the resuscitation team.
Failure to assign roles or remain within your assigned role leads to redundancy
in tasks completed, or worse, failure to complete tasks. These inefficiencies can be
frustrating and compromise the quality of the resuscitation. Without clear roles,
confusion ensues, and communication breaks down. Resuscitations become hectic
and loud and seem chaotic. This should be discouraged on all accords. In the ED,
where we have the luxury of knowing our teammates, the team leader must clearly
delineate roles prior to the initiation of a medical resuscitation.

Closed-​Loop Communication
To reduce communication breakdown during resuscitation, closed-​loop commu-
nication has been endorsed by the American Heart Association as a technique to
ensure active communication within the resuscitation team. Closed-​loop communi-
cation is defined by the following 3 tasks: (1) the team leader gives a message or di-
rection to a specific team member, (2) the team member confirms knowledge of the
message by giving a clear verbal response with eye contact, and (3) the team leader
listens for the team members’ confirmation of completion of the assigned task.

Example: 54-​year-​old male involved in a high-​speed motor vehicle accident

presenting with hypotension and tachycardia with concern for hemorrhagic
shock.
Doctor: Nurse Amy, infuse 1 unit of packed red blood cells/​
Nurse Amy: You would like me to start transfusion with 1 unit of packed red
blood cells.
Nurse Amy: One unit of packed red blood cells is infusing.
Example: 54-​year-​old male presenting unresponsive with an initial rhythm of
pulseless electrical activity on the monitor.
Dr Smith: Nurse Jones, please administer 1 amp of Epi.
Nurse Jones: You would like for me to administer 1 amp of Epi.
Nurse Jones: One amp of epi given.

Once the team leader is aware the task has been completed, the team member is
now ready and available for additional tasks. Closed-​loop communication does
not imply that only one task occurs at a time during a complex resuscitation, but
it does encourage the leader to identify one member to complete one task at one
time and ensures that all are clear on the leader’s direction and when the order has
been completed. Closed-​loop communication is also integral to ensuring an ade-
quate record of the event. When orders are clearly verbalized and confirmed when
completed, the individual who is recording the event can document the correct in-
tervention and time for accuracy in the medical record and in reviewing the resus-
citation with the providers.
Recently, closed-​loop communication was explored in the pediatric emergency
department where investigators found that closed-​loop communication resulted in
17

significant improvement in time to task completion in pediatric trauma activations.8

171
Closed-​loop communication has been shown to prevent medical error in resusci-
tation events, but this literature supports the idea that this form of communication

Medical Resuscitation and Post-Code Debrief

might actually encourage more efficient completion of tasks, which is crucial in
time-​critical illnesses encountered in the ED.
A framework detailing a 3-​pronged approach to teamwork was described that
focuses on communication, coordination, and cooperation. The authors suggest the
following guidelines to optimizing teamwork via efficient communication: (1) sup-
port precise and accurate communication through closed-​loop communication (2)
diagnose communication errors as you would any illness by examining the team
and looking for symptoms, and (3) then treat the symptoms through team learning
and self-​correction.9 These guidelines emphasize the importance of closed-​loop
communication, but also the need for continuous evaluation of how the team is
functioning. When a failure is appreciated, it is imperative to define the problem
and create an action plan for how to improve upon the performance. This will be-
come critical when we discuss the role of the debrief in resuscitation.

Mutual Respect
High-​performance teams attribute mutual respect as one of the factors that
contributes to their excellence. In any team dynamic, the ability to work together in
a collegial fashion is imperative. The team should communicate with each other in
a calm and controlled voice. Yelling, shouting, or aggressive behaviors can be detri-
mental to overall team dynamics. Acknowledging contributions during and at the
close of the resuscitation exhibits respect for the efforts and expertise of the team.

Knowledge Sharing and the Art of the “Recap”

Resuscitation teams are composed of members with different clinical expertise and
frequently variable levels of experience. Drawing upon the knowledge provided
from each team member strengthens the overall knowledge base of the resuscita-
tion team. As a team leader, by sharing your knowledge base, you create an oppor-
tunity for others to provide additional input that might emanate from their unique
clinical vantage point. Asking for suggestions or if a diagnosis or intervention has
been overlooked provides an opportunity for a broader resuscitation that reduces
the chance of anchoring bias by the resuscitation leader. It is often necessary, as a
team leader, to hear the suggestions of the team and potentially rule out a differ-
ential diagnosis or procedure as suggested, but again, doing this in a respectful and
thoughtful manner will further promote a cohesive team dynamic. Being dismissive
of others’ input is a pitfall that the team leader should avoid at all costs.
Providing frequent summaries of the resuscitation can be very useful as a way
of providing information to the team, engaging the team, and ensuring that there
are no oversights. By recapping the resuscitation, the team leader can reiterate to
the team the current status of the patient, interventions that have occurred, and a
reassessment of progress. This frequent recap maintains the attention of the team
and ensures that all are up to speed and engaged. Often, when resuscitations are
summarized in this fashion, team members will have further input and feel engaged
in the entire process.
172

Constructive Intervention
Communication with Providers, Staff, and Personnel 172 During a resuscitation event, there might come a time when the resuscitation
leader or a team member might disagree with a planned action or intervention.
This requires a communication skill that is necessary to ensure that the team dy-
namic is not hindered while patient safety and efficacy of the resuscitative efforts
are maintained. Team members should feel comfortable raising concerns or asking
questions; however, active confrontation should be minimized. In scenarios such
as these, possible approaches could include suggesting an alternative approach/​
strategy or inquiring for further detail as to the team members’ thought process.
These approaches will allow for discussion without alienating members of the team
or potentially disrupting the respect among team members. When patient safety is
at stake, team members must voice their thoughts in a constructive fashion so as to
minimize harm or error.

FAMILY PRESENCE IN EMERGENCY DEPARTMENT

RESUSCITATION
Family presence in emergency department resuscitations has been found to have
benefit not only to families who are coping with critical illness but also as a means
of improving team communication. Prior study focused within pediatric emergency
medicine found that family presence during resuscitations either had no impact or
improved upon team communication and medical decision making.3 Furthermore,
family presence was identified as being important to families and to caregivers, as
it allowed them to participate in the resuscitation, be there to support their family
member, and begin the grieving process.4 Finally, family presence did not impede
upon the timing of evidence-​based resuscitative procedures or protocols.10 Inviting
families to be present for resuscitations requires an additional level of commu-
nication expertise and often requires a team member to help explain the events
occurring, support them through critical decisions, and act as a liaison for the family
to the medical team.

TRANSITIONS OF CARE FOR THE

POST-​R ESUSCITATION PATIENT:
THE IMPORTANCE OF COMMUNICATION
The transition of care after resuscitation is an especially vulnerable time for a crit-
ically ill patient, where communication errors can greatly impact patient care and
safety. Critical patients who have been resuscitated in the emergency department
are often very complex and frequently have ongoing evaluations and incomplete
data at the time of admission. Poor handoff of information pertaining to the re-
suscitation events and outstanding tests can result in errors in patient care and
potentially bad outcomes.11 In one recent study exploring physician-​to-​physician
handoff of critically injured trauma patients, investigators determined that signifi-
cant patient information was lost during handover. In this small study of 50 patients,
48% had information discrepancies between the ED and intensive care unit (ICU)
notes, most often pertaining to extent or quantity of injury and past medical his-
tory. Notably, 32% of this cohort had changes in their clinical management as a re-
sult of the new information or clarified information obtained in the ICU. It is clear
173

that poor communication at the time of transfer results in missed information that

173
impacts patient care and safety. Suggestions to reduce this communication failure
include the introduction of a standardized communication tool and standardized

Medical Resuscitation and Post-Code Debrief

process for handoffs. Additionally, the authors note that local stressors in clinical
location may impede effective communication, as each provider has little apprecia-
tion for the stressors on the opposing provider, therefore reducing the effectiveness
of the communication. Encouraging better familiarization with the varying clinical
locations may enhance the ability of providers to relate to one another and improve
the effectiveness of the interaction.12
Frequently, handoffs of critically ill patients may occur among emergency medi-
cine providers, in the scenario where a patient’s care may span the shifts of multiple
teams of providers. Various methodologies have been trialed to ensure that among
emergency medicine providers transition of care for critically ill individuals is seam-
less and informative. The I-​PASS system was created to ensure that accurate infor-
mation is relayed. This system includes information regarding the illness severity,
patient summary, action list, situation awareness, and contingency plan, and ensures
synthesis by the receiver. By relaying the information detailed in the I-​PASS system,
providers will receive relevant information regarding the perceived acuity of the pa-
tient, a summary of the patient’s illness and resuscitation with anticipated disposi-
tion, results/​consults that are still outstanding, and a general to-​do list. I-​PASS ends
with an opportunity for the receiver to pose questions and then provide a summary
of his or her interpretation of the patient presentation. This system has been found
to be well suited to function in the emergency department; however, outcomes
data regarding its efficacy in ensuring adequate handoff and patient safety is still
pending,13 and specific outcomes data regarding the utility of this tool in the setting
of handoffs for critically ill patients are necessary before aggressively implementing
this strategy in the emergency department. Although several handoff tools have
been described,13–​16 the most important thing is for teams caring for critical patients
to pick a standardized reporting tool that will be utilized by all members, ensuring
accurate transfer of critical information.

THE DEBRIEF IN EMERGENCY MEDICINE

RESUSCITATION
The definition of debrief is to carefully review a critical event upon completion. In
emergency medicine, debriefing critical incidents after the event with the entire
treatment team has been gaining significant attention lately as the act of the debrief
is associated with improved processes and translates into better patient outcomes.
In this section we will review the evidence that supports the emergency department
debrief, practical approaches to completing a debrief, and the barriers/​facilitators to
implementing this useful practice in the emergency department.
The use of debriefing in medicine and resuscitation stems from performance of
debriefing in the military and aviation industry. In these scenarios, critical incidents
occur that require a systematic review of the event to ensure similar events do not
repeat themselves and that performance can be improved. It is this same notion
that encourages the use of debriefing in resuscitation events. Debriefing has been
commonly introduced as part of simulation training, where debriefing is defined as
“facilitated or guided reflection in the cycle of experimental learning.”17
174

In the 2015 American Heart Association (AHA) Cardiopulmonary

Communication with Providers, Staff, and Personnel 174
Resuscitation and Emergency Cardiovascular Care Guidelines, debriefing after
a medical resuscitation is recommended.18 The debrief is considered a “hot” de-
brief if it occurs immediately after the event, a “warm” debrief if it occurs within
hours after the resuscitation, or a “cold” debrief if it occurs at a later date and time
when participants have been able to process the event. There are advantages and
disadvantages to both strategies. Finding adequate time to debrief a medical resus-
citation immediately after the event can be challenging given the high-​stress/​fast-​
paced environments in which these events occur and the need to communicate with
families and other providers. However, this debrief allows for real-​time assessment
of events with better recall and ability to answer immediate questions and concerns.
A cold debrief allows for more time to prepare for the discussion, potentially en-
abling better communication and data gathering regarding the event (i.e., rhythm
strips, transcripts of the event, defibrillation data, etc.). A cold debrief, scheduled
at a later time and potentially in an outside location, might allow for participation
by a greater multidisciplinary team, including prehospital providers and consulting
specialists, for example.

How Do You Debrief After a Critical Incident?

Despite the body of evidence that supports debriefing as a quality improvement
strategy as well as a learning initiative, it has been challenging to implement in the
emergency department. Recent literature found that ED physicians debrief after re-
suscitation events less than 25% of the time.19,20 Reasons for poor implementation
of debriefing cited by emergency medicine physicians include a lack of sufficient
time, lack of trained facilitators, and inefficient space to conduct a debrief after the
event. Despite these previously mentioned barriers to implementation, a debriefing
program is very worthwhile in the ED, and the practical nature of establishing such
a program should be explored in emergency medicine.
First steps in establishing a debriefing program in the emergency department are
preparatory and should be completed so as to give direction to faculty and staff who
care for critically ill patients. A practical guide was described in the literature and
highlights major points that should be discussed prior to the initiation of a debrief
in the ED.21 Kessler and colleagues describe a structured approach to a hot debrief
that addresses “who, what, when, where, why, and how” to conduct a debriefing.
Who should debrief? Most debriefing events will require a facilitator to lead the
discussion. This can be a person who participated in the resuscitation or potentially
an individual who was not involved in the care of the patient. The leader can be ei-
ther the physician leader or the charge nurse; however, this can potentially hinder
the conversation if participants in the debrief do not feel as though they can be open
and honest in a debrief being conducted by clinical leadership. One suggested alter-
native is that the debrief be run by the recording registered nurse who observed the
entire event and can comment on the timeline of the resuscitation. Frequently the
role of the leader is best assigned to someone who has familiarity with the debriefing
process or has been provided a structured guide as to how to lead the discussion.
Who leads the debrief is really a conversation that must be initiated at each insti-
tution to ensure that the individuals tasked with this role are informed, educated,
and held accountable for ensuring that the debrief occurred; was honest; and has
training points that can be targeted for improvements. If at all possible, all members
175

of the resuscitation team should be included in the debriefing. The input from the

175
multidisciplinary team often yields great insight into facets of the resuscitation that
went well and where improvements could be made.

Medical Resuscitation and Post-Code Debrief

What should you debrief? Again, this is a topic that often needs to be discussed
among ED providers on an institutional level. Historically, cardiac arrest and trauma
resuscitations have been targeted as literature has shown that debriefing these crit-
ical incidents results in improved outcomes and team performance. Depending on
the needs of the institution with regard to areas that require further training or per-
formance enhancement, the patient scenarios that are debriefed may differ.
When should you debrief? Debriefings can occur immediately after the event, at
a specified time shortly after the event (hours), or days to weeks after the event.
Depending on the proximity to the actual resuscitation, individuals may have some
recall bias, but also may be more emotionally equipped to contribute to the con-
versation. The hot debrief that occurs immediately after the event can allow for
individuals to process the event collectively; however, this can be logistically chal-
lenging given how busy the ED can become. On the other hand, delaying the de-
brief until later risks the chance that members of the team will not be available or
will not participate. A cold debrief requires future planning but can be held offsite
and include facilitators. Additionally, the cold debrief can benefit from additional
information, for example, output from an automated external defibrillator or feed-
back from a cardiopulmonary resuscitation (CPR) quality device that can augment
the discussion. Most often, the warm debrief becomes the most practical approach
to debriefing in the emergency department. Allowing staff to check in on their ac-
tive patients and physician leadership to inform family and potentially discuss the
patient further with consultants or admitting physicians and then to reconvene once
the department has stabilized allows for attention to be focused on the conversation
without concern for the functioning of the department. The warm debrief should
occur while on shift, allowing participants from the resuscitation to participate.
Sometimes further information might become available at a later date, making a
cold debriefing necessary. This is described as a “hybrid” approach as it augments
the warm debrief with a cold debrief once further information is garnered by the re-
suscitation team. Of note, it is important to understand that a cold debriefing is very
different from root-​cause analysis. The latter event is often conducted to explore a
medical or systems error that must be addressed for safety concerns (high-​risk in-
jury or preventable death are 2 examples).
Where should the debriefing be conducted? Debriefing sessions can occur in almost
any location where the group can comfortably convene. On-​site debriefing allows
the team the opportunity to meet shortly after the event, potentially while the team
is still on shift. Off-​site debriefing allows the team the opportunity to meet in a lo-
cation that is separate from the ED to allow for further dialogue and comfortable
communication. The disadvantage to an off-​site debrief is that varying schedules
might result in a proportion of the team not attending. Most ED debriefs will occur
in a quiet area, within the hospital and near the emergency department to allow for
continued patient care. Examples include a conference room, break room, or vacant
family consultation room. A quiet area that allows for privacy will best support a
debriefing discussion.
Why should you debrief after a resuscitation? The goals for a debriefing should be
clearly defined prior to the debriefing event. Varying indications include resident
education, process improvement, quality assurance, and provider resiliency, just to
name a few. If the intention behind the debriefing is identified, the structure of the
176

debrief can be adapted to meet those goals. The reason that a debriefing is held might
Communication with Providers, Staff, and Personnel 176
vary from institution to institution, or even from resuscitation to resuscitation.
How should a debriefing be conducted? Aside from identifying who will run the
debriefing, when it will occur, and where it will be, there needs to be a format for the
debriefing. Often the person charged with leading the debriefing might use a struc-
tured guide to assist in leading the discussion. Debriefing guides are becoming more
commonly utilized to ensure that certain topics are addressed and participants are
identified. If there is a predetermined goal behind the debriefing, a guide can serve
as a structured method for ensuring that certain topics are discussed. Some guides
are also used as instruments for reporting back to educators, administration, or
quality officers about outcomes that might need further attention.
A new debriefing tool has been introduced given the concern that lack of clear
instructions on how to conduct a debriefing is a barrier to consistent implementa-
tion. The REFLECT framework structures debriefing as follows: Review the event,
Encourage team participation, Focus feedback, Listen to each other, Emphasize
key points, Communicate clearly, and Transform the future. REFLECT was shown
to be feasible in the ED setting, and on average, debriefings lasted less than 5
minutes, which is important in a busy emergency department where time allotted
to debriefing has been scarce.22
Overall, all resuscitation debriefings should be held in private locations. All
members of the debrief should be heard with respect and compassion. Debriefings
should never be punitive. If a member of the team expresses discomfort or distress,
mental health and support resources should be provided to assist that team member
as he or she processes the event. Ensuring the safety and well-​being of the resusci-
tation team is paramount, and administration within the emergency department
should be committed to provider and staff well-​being, especially in these emotion-
ally charged, life-​and-​death scenarios that are emotionally trying for emergency
medicine health care professionals.

DATA TO SUPPORT DEBRIEFING RESUSCITATIONS

Data from both adult and pediatric resuscitation debriefings have yielded impor-
tant information to secure the role of debriefing in emergency departments. Mullen
et al.23 found that the accuracy of what was reported in the debriefing correlated
well with what actually occurred during pediatric resuscitations. There was 87%
accuracy measured when participants were asked about resuscitation performance
measures.23 Based on these findings, the authors were able to conclude that teams
were able to recall resuscitative events in a hot debriefing with sufficient accuracy.
As an example of an effective cold debriefing program, Edelson et al.24
conducted weekly debriefings for medical housestaff and other members of the
code team. In these sessions, teams would review the prior week’s in-​hospital med-
ical resuscitations. During each session, CPR performance transcripts obtained
from CPR-​sensing and feedback-​enabled defibrillators were reviewed, the resusci-
tation event was discussed, and focused teaching was provided. The authors found
that implementation of this structured debrief resulted in improved provider know-
ledge, better CPR delivery, and a 14% increased rate of return of spontaneous circu-
lation for in-​hospital cardiac arrest within their center.24
17

Video recording has also been used to conduct cold debriefings of resusci-

177
tation events. Jiang et al. describe a weekly video review of recordings of medical
resuscitations in the emergency department. The authors found significant improve-

Medical Resuscitation and Post-Code Debrief

ment in CPR quality after these video debriefings.25 Other groups have replicated
this work applying video review to traumatic as well as pediatric resuscitations.
Although the previous studies have outlined weekly cold debriefings of the prior
week’s resuscitations, some hospitals have an insufficient number of resuscitations
to warrant this frequency of debrief. Zebuhr et al. 26 explore the use of the cold de-
brief in a pediatric ICU where cardiac arrests are infrequent events. The debriefings
occurred only 6 times in 1 year, and despite the reduced number of meetings,
participants found the debriefings to be helpful in reinforcing knowledge and pro-
viding performance confidence to providers.26

CHALLENGES TO EVALUATING THE EFFECTIVENESS

OF DEBRIEFING
Data to support debriefing with regard to patient outcomes has been challenging
to come by. Most research to date is composed of single-​center, before-​and-​after
trials that have yielded information regarding feasibility and acceptability, but
greater measurements like effectiveness and other measures of successful im-
plementation have not been documented. Multicenter implementation trials
will undoubtedly provide the rigorous evidence to support the implementa-
tion of debriefing programs in emergency departments. Such trials are currently
underway.

THE POST-​C ODE PAUSE

The need to attend to the psychological and spiritual needs of the resuscitation team
should not go underrecognized. To support the emotional well-​being of providers
who treat trauma and other acute life-​ending illnesses, a postcode pause has been
introduced into some teams’ debriefing strategies. This “pause” is a 10-​to 15-​second
moment of silence to honor the life of the patient or to reflect upon the team that so
actively cared for the patient. Early exploration of the utility of this postcode pause
has shown that providers find it helpful to allow them to honor patients and to return
to work with a sense of purpose. Participants also stated that they felt they were given
enough time to “regroup” after the event when the postcode pause was instituted.27

CONCLUSION
Effective, accurate, and timely communication among team members is of para-
mount importance during a resuscitation and in the transitions of care of the critical
patient. Identifying a team leader, defining roles, crowd control, use of closed-​
loop communication, frequent recap, and use of standardized tools for handoffs
are important to optimize communication in these chaotic, high-​stress situations.
Emergency departments should work on processes for debriefing to provide
opportunities for quality improvement, education, and support for provider resil-
ience and well-​being.
178

REFERENCES
Communication with Providers, Staff, and Personnel 178 1. The Joint Commission releases Improving America’s hospitals: The Joint
Commission’s annual report on quality and safety 2007. Jt Comm Perspect Jt Comm
Accreditation Healthc Organ. 2007;27(12):1, 3.
2. Baker DP, Day R, Salas E. Teamwork as an essential component of high-​reliability
organizations. Health Serv Res. 2006;41(4 Pt 2):1576–​1598. doi:10.1111/​
j.1475-​6773.2006.00566.x.
3. O’Connell KJ, Farah MM, Spandorfer P, Zorc JJ. Family presence during pediatric
trauma team activation: an assessment of a structured program. Pediatrics.
2007;120(3):e565–​e574.
4. O’Connell K, Fritzeen J, Guzzetta CE, et al. Family presence during trauma
resuscitation: family members’ attitudes, behaviors, and experiences. Am J Crit Care.
2017;26(3):229–​239.
5. Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review
of the literature. Acta Anaesthesiol Scand. 2009;53(2):143–​151. doi:10.1111/​
j.1399-​6576.2008.01717.x.
6. Institute of Medicine (US) Committee on Quality of Health Care in America. To Err
Is Human: Building a Safer Health System. (Kohn LT, Corrigan JM, Donaldson MS,
eds.). Washington, DC: National Academies Press; 2000. http://​www.ncbi.nlm.nih.
gov/​books/​NBK225182/​. Accessed November 17, 2017.
7. Advanced Cardiovascular Life Support Provider Manual eBook—​AHA. https://​
ebooks.heart.org/​product/​acls-​provider-​manual-​ebook-​collection. Accessed
November 17, 2017.
8. El-​Shafy IA, Delgado J, Akerman M, et al. Closed-​loop communication improves
task completion in pediatric trauma resuscitation. J Surg Educ. August 2017.
doi:10.1016/​j.jsurg.2017.06.025.
9. Salas E, Wilson KA, Murphy CE, et al. Communicating, coordinating, and
cooperating when lives depend on it: tips for teamwork. Jt Comm J Qual Patient Saf.
2008;34(6):333–​341.
10. Dudley NC, Hansen KW, Furnival RA, et al. The effect of family presence on the
efficiency of pediatric trauma resuscitations. Ann Emerg Med. 2009;53(6):777–​784.
11. Horwitz LI, Meredith T, Schuur JD, et al. Dropping the baton: a qualitative analysis
of failures during the transition from emergency department to inpatient care. Ann
Emerg Med. 2009;53(6):701–​710.e4. doi:10.1016/​j.annemergmed.2008.05.007.
12. Zakrison TL, Rosenbloom B, McFarlan A, et al. Lost information during the
handover of critically injured trauma patients: a mixed-​methods study. BMJ Qual Saf.
2016;25(12):929–​936. doi:10.1136/​bmjqs-​2014-​003903.
13. Heilman JA, Flanigan M, Nelson A, et al. Adapting the I-​PASS handoff program for
emergency department inter-​shift handoffs. West J Emerg Med. 2016;17(6):756–​761.
doi:10.5811/​westjem.2016.9.30574.
14. SBAR Tool Implementation to Advance Communication, Teamwork, and the
Perception of Patient Safety Culture. Creat Nurs. 2018;24(2):116–​123.
15. McCrory MC, Aboumatar H, Custer JW, et al. “ABC-​SBAR” training improves
simulated critical patient hand-​off by pediatric interns. Pediatr Emerg Care.
2012;28(6):538–​543.
16. Adams JM, Osborne-​McKenzie T. Advancing the evidence base for a standardized
provider handover structure: using staff nurse descriptions of information needed to
deliver competent care. J Contin Educ Nurs. 2012;43(6):261–​266.
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17. Fanning RM, Gaba DM. The role of debriefing in simulation-​based learning.

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SIH.0b013e3180315539.

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18. Bhanji F, Donoghue AJ, Wolff MS, et al. Part 14: Education: 2015 American Heart
Association guidelines update for cardiopulmonary resuscitation and emergency
cardiovascular care. Circulation. 2015;132(18 Suppl 2):S561–​573. doi:10.1161/​
CIR.0000000000000268.
19. Sandhu N, Eppich W, Mikrogianakis A, et al. Postresuscitation debriefing in
the pediatric emergency department: a national needs assessment. CJEM.
2014;16(5):383–​392.
20. Zinns LE, O’Connell KJ, Mullan PC, et al. National survey of pediatric emergency
medicine fellows on debriefing after medical resuscitations. Pediatr Emerg Care.
2015;31(8):551–​554. doi:10.1097/​PEC.0000000000000196.
21. Kessler DO, Cheng A, Mullan PC. Debriefing in the emergency department
after clinical events: a practical guide. Ann Emerg Med. 2015;65(6):690–​698.
doi:10.1016/​j.annemergmed.2014.10.019.
22. Zinns LE, Mullan PC, OʼConnell KJ, et al. An evaluation of a new debriefing
framework: REFLECT. Pediatr Emerg Care. April 2017. doi:10.1097/​
PEC.0000000000001111.
23. Mullan PC, Cochrane NH, Chamberlain JM, et al. Accuracy of postresuscitation
team debriefings in a pediatric emergency department. Ann Emerg Med.
2017;70(3):311–​319. doi:10.1016/​j.annemergmed.2017.01.034.
24. Edelson DP, Litzinger B, Arora V, et al. Improving in-​hospital cardiac arrest process
and outcomes with performance debriefing. Arch Intern Med. 2008;168(10):1063–​
1069. doi:10.1001/​archinte.168.10.1063.
25. Jiang C, Zhao Y, Chen Z, Chen S, Yang X. Improving cardiopulmonary
resuscitation in the emergency department by real-​time video recording and regular
feedback learning. Resuscitation. 2010 Dec;81(12):1664–​1669. doi:10.1016/​
j.resuscitation.2010.06.023. Epub 2010 Aug 19. PMID: 20727657.
26. Zebuhr C, Sutton RM, Morrison W, et al. Evaluation of quantitative debriefing
after pediatric cardiac arrest. Resuscitation. 2012;83(9):1124–​1128. doi:10.1016/​
j.resuscitation.2012.01.021.
27. Copeland D, Liska H. Implementation of a post-​code pause: extending post-​
event debriefing to include silence. J Trauma Nurs Off J Soc Trauma Nurses.
2016;23(2):58–​64. doi:10.1097/​JTN.0000000000000187.
180

13 The Art of
Communication in
Meetings

Melanie Jones

INTRODUCTION
Have you ever stepped out of a meeting confused, unclear of what the meeting
was about or what was even accomplished? You can start to feel like meetings are
a big waste of time and preventing you from doing your job. Studies have shown
meetings take up a large portion of employee time, and they are considered un-
productive and costly.1 However, meetings are necessary for exchanging ideas and
solving problems. The key is to make meetings efficient and productive.
Before delving into the formula for making meetings effective, we need to ex-
plore some other important concepts and talk about team dynamics. Your chances
of successfully facilitating effective meetings will skyrocket if you spend some time
on the ideas of repetition, messaging, and team building.

THE CRITICAL ROLE OF REPETITION

Have you ever found yourself shaking your head in frustration, thinking to yourself,
“What is wrong with people? I made the announcement in the department meeting
and it went out in our weekly email. Why are they saying they’ve never heard this
before?!”
Each of us is born with some sort of innate filter that subconsciously filters what
gets through to our conscious brain, an intrinsic wiring we can’t control. Personality
18

profiling like Myers-​Briggs or DISC can help us understand our internal filters and

181
how those filters compare to those of the people around us. We are big believers
in using tools like these to help us gain a common language and understanding

Communication in Meetings
of the communication preferences of those on our team. By the way, if you think
this type of tool is all a bunch of phooey, I would point you toward the incredible
work done by Dario Nardi in the Neuroscience of Personality and Our Brains in Color.
Nardi’s work focuses on the brain through the lens of Myers-​Briggs, but it’s appli-
cable enough to the point that each of us has different wiring.2,3 Pretending that
doesn’t exist is short-​sighted at best. Some brains filter toward sensory input, some
toward psychological inputs, some toward patterns or big picture. Some are wired
for observation; others are wired for action. Is it any wonder then that we have com-
munication problems?
Yet, if I asked you to tell me something a favorite teacher, mentor, or parent
taught you, something they cared strongly about, something they often said, I
would bet you could rattle off messages immediately and effortlessly. Why can we
remember something so clearly from so long ago?
The simple answer is repetition. How many times did your mother repeat that
adage? How many times did your coach tell you the same thing?
(Insert excerpts from http://​gretchenschmelzer.com/​blog-​1/​2015/​1/​11/​
understanding-​learning-​and-​memory-​the-​neuroscience-​of-​repetition)
Several years ago, my partner Brian Jones (Principal Consultant with the Table
Group and CEO of Brian Jones Consultants), was speaking at a conference in
Orlando. As he was perusing the conference lineup, he noticed that one of the other
speakers happened to be the executive vice president (EVP) of parking for Disney.
Brian decided to stick around and hear this guy speak because as he put it, “I’ve
parked as both an amateur and a professional, so I thought this seemed like a good
Disney executive job for me!” The EVP of parking shared with the group the exten-
sive research Disney has done around memory retention. As he stated, “My job is
done perfectly when you have no idea that I exist.”
When you think about your experience at a Disney park, the last thing Disney
executives want you to remember is the parking experience. Yet, with the largest
parking lots in the world, Disney has an incredible challenge in getting millions of
people in and out of Disney without losing their cars and ruining their entire per-
ception of a magical time at the park. Disney research revealed when people hear
something 7 times, 99.7% will retain short-​term memory. From the time you first
pay at the parking toll booth to the moment you exit the parking tram, you will have
been told a total of 7 times where you parked. And even after an entire day of Mickey
Mouse, princess encounters, and Avatar land, 99.7% of you will remember where
you parked without issue. Brian and I took a trip to Disney to test the “7 times”
theory. Though the trip took place 10 years ago, I can still tell you today we parked
in the Villains lot, Scar section, Row 109.
So, seven times does it for basic short-​term memory retention. But in our case,
we aren’t usually aiming for short-​term retention. We need long-​term memory inte-
gration with full commitment and implementation. How many more times do we
need to say the same thing over and over to get people to that stage? Our answer:
You will know you’ve got it right when mimicking you is the skit at the Christmas
party and when people roll their eyes when you open your mouth (“there he goes
again, talking about quality); when this happens, celebrate! You are getting it right!
Unfortunately, too many leaders and physicians push back on this: “But my
people are smart! I don’t need to tell them three times, let alone seven or more!”
182

To rebut this, I point you to the neuroscience. Intelligence is easily overridden by

Communication with Providers, Staff, and Personnel 182
distraction. Overcommunication is simply a tool to overcome those distractions.
Wield it with a vengeance!
In short, this means we have to get serious about overcommunicating the mes-
sage. Simple messages, repeated over and over, through various mediums, have the
best chance at “stickiness” in our overaddled brains.
Although this is not a technical treatise and people way smarter than me have
argued about the exact numbers, neuroscience tells us our brains are hit with
something like 11 million bits of information a second, of which our brain can
consciously process only a fraction, about 120 bits per second. Regardless of the
number, the point is our brains are flooded with everything from sensory inputs
(temperature of the room, shoes pinching, texture of clothes, the chair you are sit-
ting on, your glasses sliding down, colors of the environment, people around you,
your heartbeat, the way your stomach is growling, the headache hovering in the
back of your mind, smells) to emotional and psychological inputs (email tone, last
interaction with boss, feelings, spouse/​significant other, children, calendar juggling,
friendships, stress, communication with you and around you) to the inputs of pa-
tient care and all that entails.
Somehow, we have the arrogance to believe “because ‘I’ said it” immediately
overrides all those other inputs.

MISSTEPS IN THE MESSAGE

Early in my consulting and speaking career, a colleague gave me very good feedback:
“Write your message out, then cut out 10%. Leave it overnight, then pare another
10%. Better to leave them wanting more than to overload them.” This seems coun-
terintuitive, doesn’t it? We all want to be experts about something, and our com-
munications are the one place we get to be one! But the most memorable quotes
are not full of technical jargon. Think about the last speech you heard: Tell me (no
cheating by trying to find those notes!) what you remember from it. I daresay you
might remember one line or overall concept. Keep this in mind as you craft your
communication message: Keep it simple.
Building on this, simplicity must be married to clarity. Have you ever worked
somewhere with “flavor of the month” management directives? A year or so ago, I
was talking to the manager of our local office supply company. He shared his frustra-
tion with the last 20 memos of “top priority” received from headquarters:

• Immediately move all school supplies to the middle aisle.

• To prevent tripping, no school supplies should be displayed in the middle aisle.
• School supplies displayed in the middle aisle should be arranged in the following
manner (see diagram).

The stack of memos continued on in this manner. You could certainly say the
messages were simple: clear language, no jargon. But I don’t think you could call
them clear by any stretch.
You might be forgiven for thinking, “Melanie, you idiot. If someone doesn’t
understand, it’s their job to come ask me.” But what we’ve learned from cultures
full of confusion is that staff, when hearing or reading an unclear directive, shrug
their shoulders and say, “Oh well, it won’t last anyway. Next month it will be
183

something new. I’ll just wait this one out.” So I challenge you, make sure your

183
message is clear. Review past directives—​if this new communication will contra-
dict something in the past, be sure to acknowledge it. Always include the why in

Communication in Meetings
your messages.4

Practical Application
1. Do personality work with the team:

• Understand yourself first.

• Learn about each other’s innate filters.
• Tailor your communication style to meet the needs of those filters.
• If you need more help with this, reach out to us. We will be happy to send you
tools and help coach you through this part. (http://​www.tablegroup.com).

2. Keep the language simple:

• Now is not the time for impressing everyone with your technical expertise or
local jargon; simple is better.
• If you are wondering if it’s simple enough, find some kids and ask them what
they think.

3. Make the message clear and concise:

• Test your message out with a few key people from different groups (doctors,
nurses, administration): ask specific questions geared to root out any
ambiguity or questions about the intent of your message.
• Write it down—​don’t try to wing it.

4. Repeat your simple, concise message over and over. Hammer it home. Bring it
up in every meeting. Close every email with it. Work it into every conversation.
Be a broken record.

SMASHING THE BARRIERS TO GOOD COMMUNICATION

Be the Hammer
Several years ago, we worked with a well-​respected, kind, and gentle physician leader
who was having difficulty addressing disruptive behavior in meetings. The team had
created meeting behavioral norms about six months prior, and naturally they felt
angry and resentful that their esteemed leader seemed to have difficulty following
through on addressing disruptive behavior in the moment. When we discussed this
feedback with the leader, he talked about how hard it was for him to be confronta-
tional and bold, and he admitted he often let disruptive behaviors slide because of
the forcefulness of the personalities involved (can anyone relate to this story?). The
next morning, I presented him with a beautifully wrapped package; a bit surprised,
he opened it to find a bright yellow hammer. The message: Be the hammer! A few
months later, he emailed me to say he had the hammer framed in a display case as
a reminder that he has to ramp up the hammer in his personality and confront bad
behaviors.
184

Keepers of the Culture

Communication with Providers, Staff, and Personnel 184 According to Patient Safety & Quality Healthcare (PSQH), culture is the most fun-
damental intervention for improving nurse-​physician communication.5 I think we
can safely extrapolate this statement to cover other communication interactions,
whether provider to provider, provider to administration, and so forth. As leaders,
you are the keepers of the culture, and what you tolerate, you nurture; what you
nurture grows.
The key to a successful culture is an investment in the creation of a cohesive
team, with clear communication norms, behavioral expectations, and peer-​to-​peer
accountability. At first glance this might appear to be a bit overwhelming, but I
promise you, if you take one step at a time, you can get there.

Start With Your Team

The place to start is creating a strong, cohesive leadership team.
Physicians, I’m going to address you first, because, let’s face it, you set the lead-
ership tone. Let’s be honest: It’s all too easy to point fingers at sloppy nurse work or
the unprofessionalism of staff than to have a difficult look at ourselves. The Bible has
a parable about this (even if you aren’t religious, the parable has its own Wikipedia
page, so I hope you can overlook the source long enough to absorb the content):
Jesus is addressing a crowd of people and tells them they shouldn’t judge others. He
says it’s all too easy to point to the speck of dust in someone else’s eye while ignoring
the fact that you have a big old beam in your own. He goes on to say in fairly strong
language, “You hypocrite! First take the plank out of your own eye, then you will see
clearly to remove the speck from your brother’s eye.” Wow!
If you are a physician leader, start with building your team first. Who is your
second in command? Who are your deputies? Do you have every shift and weekend
covered with a deputy? (Being a deputy doesn’t always mean a paid, named posi-
tion. Think a little more informally. Who are your go-​to helpers, your trusted team
members?) Are your deputies on board with the direction you want to go? Are they
willing to respectfully disagree with you? Do they want to be right or do they want to
get it right? Are they willing to have difficult conversations to hold people (the trick-
iest part: other physicians) accountable? Are they willing to be part of the chain of
command to get things solved? Schedule an off-​site visit with them and take some
dedicated time to talk through their commitment level. If they aren’t committed, it
doesn’t make them bad people, but good people aren’t always going to be the best
fit to be your deputies. Building your team is the one single job a leader cannot del-
egate, and it will never thrive any more than the time and attention you lavish on it.
For more information on how to create a cohesive leadership team, refer to Patrick
Lencioni’s best-​selling book on teamwork, The Five Dysfunctions of a Team.6

Great Expectations
Now that your team is in place, work together with them to create clear behavioral
expectations. At this point, your focus is just on those under your purview. Yes,
it’s irritating that the nurses aren’t being held to this standard (yet), but don’t let
that derail your progress. You can control whether it’s acceptable that the urologist
yells at everyone who calls him and refuses to come in to see anyone until after
185

9 pm, no matter what time of day he’s been called. You can control the temper-​

185
tantrum-​throwing provider who is willing to work the holidays but has a bad habit
of screaming obscenities and throwing his stethoscope at the charge nurse when

Communication in Meetings
things don’t go his way (got a few personal scars from this guy). You can control
the long-​time staff doc who gets constant complaints for wearing his blinking
Bluetooth while talking to patients. You can control the provider who whips the
covers off the patient in the hallway with no regard for their privacy. These things
you can address.
If you aren’t sure what the issues are, use your eyes and ears. Come in on oppo-
site shifts. Read the patient satisfaction comments for the past six months to look for
trends (yes, I know, painful, painful, painful—​but enlightening, and I promise, well
worth the time!). Talk to the nursing staff, the lab, the pharmacy, and the x-​ray techs.
This isn’t intended to be a witch hunt—​but you cannot improve on what you don’t
know. It’s all too easy to surround ourselves with a bubble of confirmation bias,
thinking we know what’s going on; it’s only when we seek out ways to burst our own
bubble that we begin to truly learn. When you talk to staff, simply ask if there are
any ways physicians could do a better job interacting with patients, with staff, and
with each other. Ask the question(s), listen, and take notes. As you listen, don’t get
defensive or go into scorched-​earth-​offensive mode either (unless you hear some-
thing that would require immediate intervention such as patient safety). If you need
to ask a follow-​up question, acknowledge what you’ve heard, and then ask for help
understanding a particular point or clarifying a certain issue. Thank the person for
his or her time and then conclude the meeting.
Taking the data you’ve culled back to your team, together, create clear, written
behavioral expectations. These might be as simple as “No Bluetooths in the patient
room” Or “Calls will be returned within three hours.” If you have hallway patients,
address behaviors specifically around caring for them. The list should be some-
where around five to ten simple, clear items for which it will be easy to hold each
other accountable.

Having the Hard Conversations

Roll the behaviors out to the team. Sit down individually with as many as you can
one on one; take the difficult conversations on yourself—​do not pawn them off to
your team. This is the hard work of being a leader (and why you make the medium-​
sized bucks!). Be as specific as possible when sharing feedback you’ve gleaned during
your “data gathering” phase. Too often our own discomfort when having these types
of conversations leaves people feeling confused about the message and uncertain
what to do next.

The Importance of Overcommunication

Now comes the part everyone wants to skip: Overcommunicate, overcommunicate,
overcommunicate. Start every meeting with a reminder of the behaviors. Include
them in every email. Tie rewards and recognition back to them. When you see or
hear about someone acting in alignment with the behaviors, give immediate verbal
recognition and praise. Review your policies around rewards to make sure behav-
ioral considerations have as much priority as performance.
186

Table 13.1. Four Types of Employees

Communication with Providers, Staff, and Personnel 186 Gets Results Doesn’t Get Results

Lives Our Core Good-​Behaving High Performer Good-​Behaving Low

Values Hug ‘Em (Reward/​Promote/​ Performer
Recognize) Coach ‘Em (Train/​Reassign)
Doesn’t Live Bad-​Behaving High Performer Bad-​Behaving Low
Our Core Values Tough Call (What’s Your Plan?) Performer
Get Rid of ‘Em (Dismissal)

The Accountability Factor

By now, if you have created behavioral standards and overcommunicated them,
you can give your team permission to hold each other accountable, what we call
peer-​to-​peer accountability. It’s very difficult to hold each other accountable if there
aren’t clear guidelines in place. In good organizations, accountability runs through
the leader in what we call a “hub-​and-​spoke model”: Like a bike wheel, the leader
is in the middle with the team members around the outside of the wheel. For every
accountability issue, a team member goes to his or her leader and says, “Can you
please talk to Sid? He’s been missing deadlines, coming in late, being rude to staff,
etc.” The leader then goes to Sid with a message: “Sid, I can’t tell you who told me,
but someone on the team says you’ve been missing deadlines, coming in late, being
rude to staff, etc.” This is probably better than no accountability at all, although you
could argue Sid certainly doesn’t trust his teammates anymore. I’ve yet to meet an-
yone who thinks the best way to give them feedback about their behavior is to go
talk to someone else about them behind their back!
This is not to diminish the role the leader has to play in setting an example that
bad behavior will not be tolerated. We will talk more about that topic in the next
section.
On the best teams we work with, peers hold each other accountable. How pow-
erful is it for one peer to say to another, “Sid, I know you are going through a lot in
your personal life right now. But it’s no excuse for being rude to staff. You need to
apologize.”
Overcommunication will help drive these behavior standards so firmly into
memory that a new person coming into the department is going to hear on day one
from their peers, “You need to know this is how we behave around here . . .” And
your job just got a lot easier.

Four Types of Employees

Every organization/​department has four basic types of employees (Table 13.1).
When you roll out the behavioral expectations, keep these four groups in mind.
Some of your staff are going to be on board right from the beginning. The most dan-
gerous group to you right now is the bottom left quadrant: the providers who get
results, have great metrics, the patients love, but are absolutely toxic to work with.
They undermine you, run roughshod over your expectations, and tell everyone
“those don’t apply to me.” Every minute, every second you tolerate their behavior
without addressing it, you are losing credibility. Our diagram uses the words “Tough
187

Call” because you usually can’t afford to lose them all at once. But never fear. Your

187
trusty consultants are here to offer you some brilliant advice, advice that will make
the cost of this book worth every penny. Get your pencil ready to take notes.

Communication in Meetings
Here’s our advice: DO SOMETHING. Don’t ignore it.
A few practical tips for how to deal with these difficult types are provided in
Table 13.2.
If you are a nurse leader, you need to follow the same process as the physician
leader: Create your cohesive leadership team; mine for feedback; create behav-
ioral expectations; roll out the behaviors; overcommunicate, overcommunicate,
overcommunicate; and hold everyone accountable to the new behavioral expecta-
tions, firmly and fairly.
To achieve advanced levels (please note that the perquisite of addressing your
own area first is required), create a codisciplinary physician-​nurse leadership team.
These teams can be highly effective if done in the framework of a cohesive team,
working to do what’s best for the patient. Without some groundwork in place,
they tend to turn into highly political reporting-​out meetings where each faction
represents their personal “camp.” Bad, bad, bad. Avoid that committee like the
plague!

Table 13.2. Strategies for Bad-​Behaving High Performers

Recognition Coaching Feedback

Limit public recognition Set the expectation that Keep it private

attitude and behavior
are more important
than performance
Praise timely and privately Don’t let incidents slide Don’t give it when you
for any improvement in are upset
attitude and behavior
Keep recognition interactions Remind of previous Be sure the human
separate from coaching coaching resources (HR)
file matches your
assessment; keep HR
in the loop
Be consistent in rewarding Share the consequences Give constant quick
attitude and behavior over of their attitudes and feedback on behavioral
performance with all staff behaviors on their issues (2 minutes max)
career, the team, and the
organization
Praise specifically to the Limit the time frame to Require them to create
behavior you noticed weeks, not months; if an action plan—​today
it’s been six months,
that’s way too long
Tie recognition to collective What if they leave because Document, document,
team results of the coaching? Set up document!
a backup plan
18

Practical Application
Communication with Providers, Staff, and Personnel 188 1. Create a cohesive leadership team.
2. Burst your own confirmation bias by seeking feedback about the current state
of affairs.
3. With the help of your team, identify the desired state.
4. Create behavioral norms (expectations) that will move you toward the
desired state.
5. Roll them out to your department, individually, one on one with specific
feedback related to observed behaviors.
6. Overcommunicate, overcommunicate, overcommunicate.
7. Hold everyone accountable to the new expectations.
8. Prepare to be tested by the bad-​behaving high-​performer. DO SOMETHING.

MEETINGS
If your meetings are already great, you may want to skip this section. For the other 99%
of you, read on!
Meetings: What other word at work invokes so much dislike and dread?!
Dull, boring, monotonous, time-​wasting meetings. Necessary evils to grease the
cogwheels of administrative bureaucracy. We count ourselves lucky if the meeting is
scheduled during lunch or dinner—​at least then it’s useful time!
However, when conducted correctly, meetings are lively, energetic, purposeful,
and time saving in the long run. I hear you scoffing, but it’s being done in an emer-
gency department near you! And they don’t have any magic beans that you don’t
have. What they do have is a few tools that have helped them create clarity around
meetings.
You’ve already taken the first step—​building on the cohesive leadership team
and personality work you’ve done so far. The next step in the process is laying out a
few ground rules. These apply to all types of meetings, whether they’re conducted
in person or virtually by means of technology. We recommend that together you
create basic communication standards for the team. Here are some good examples:

1. We talk to each other, not about each other.

2. Silence equals disagreement.
3. What starts in a meeting ends in a meeting.
4. Close the back door (no meetings after the meeting).

Conflict Comfort Scale

When it comes to maximizing the potential of the dreaded meeting, clarity is key.
By clarity, I mean acquiring a clear picture of where everyone is on the conflict com-
fort scale. Don’t run! I promise, conflict in this context is positive. Substitute the
word debate if you prefer.
When engaging in intellectual debate around issues in pursuit of the best out-
come for our patients, there are two ends of the conflict scale: On one end is the red
zone, or the hot zone, where we get passionate and personal and sometimes even a
bit mean. In our experience, this is not most teams. Most teams err to the other ex-
treme, the blue zone, or the cold zone, where we don’t want to make waves, so we act
189

outwardly like we agree, but internally we can’t believe someone is such an idiot! We

189
call this the “artificial harmony” zone: It looks like everyone agrees with each other,
but later, you get the real story when you meet up with your teammate in the staff

Communication in Meetings
lounge or the parking lot. Both of these extremes are unproductive and can lead to
dysfunction within a team by destroying trust.
As a leader, it’s important to know who tends to get hotter first and who is
wired to stay quiet the longest. With a quick 1-​10 exercise (1 = conflict makes me
very uncomfortable, and I tend to withdraw; 10 = I bask in the heat, bring it on!),
have everyone quickly identify where they fall on the conflict comfort scale. This
information arms you as the leader with valuable information about how to run a
meeting, with the goal to move debate toward the middle zone of the comfort scale.
If you have a team that tends to run toward the red zone (hot), you will need to
cool things down. Here are a few facilitation techniques to accomplish this:

1. Cut off the verbal debate.

2. Use the Roman Council: thumbs up, thumbs down, thumbs sideways.
3. Fist to five: 1 = not ready to commit; 5 = ready to commit.
4. Yes—​no polling.
5. Remind team members the “back door” is closed (no meeting after the
meeting).
6. No personal attacks: Keep it about the topic and the data.

The far more frequent scenario is the team that tends toward the blue zone (arti-
ficial harmony). Your job as the leader is to draw debate out. A few tips for warming
up the blue zone by facilitating productive conflict (yes, there really is such a thing!):

1. Mine for it: bring it out.

2. Give real-​time permission when it’s happening: Pause the conversation to say,
“I know this is hard and some of you are very uncomfortable right now, but
we need to talk about this. What we are doing is important. Thank you for
engaging in this.”
3. Draw the quieter team members into the conversation: “John, I haven’t heard
from you yet. What do you think?”
4. Assume that silence = disagreement.
5. Remove the “back door”: Say what needs to be said in the meeting.

Now that you know how your team tends to respond to conflict, together you
can create a list of behavioral expectations/​norms for your meetings, drawing on
the previous lists, but also addressing the personality quirks of those in the room.
For example, one of our clients has a team member who tends to dominate the
conversation—​not intentionally, but it happens. One of the behaviors the team put
on their list was “Everyone will be heard.” Put these on a flip chart page and bring
them to every meeting—​place them in a prominent position and remind everyone
of the agreed upon behavioral norms at the beginning of every meeting.
These meeting norms now become the clear guidelines for conduct during
meetings. By creating clarity, you can now address disruptive meeting behaviors by
pointing out, “Mark, that’s not the way we behave around here.” If the disruptive
behavior is particularly egregious, immediately call a break and address the person
in private. Point out what they are doing, let them know it will not be tolerated, and
tell them you expect them to apologize to the team. Beyond that, empower the team
190

to hold each other accountable for behaviors. Your role as the leader is to go first, to
Communication with Providers, Staff, and Personnel 190
set the example—​take a gulp and do the hard work of being a leader.

Meeting Stew
The most pressing issue we are asked to address about meetings is something we
call “meeting stew.” Without clarity about the type of meeting you are having, it’s
all too easy to fall into the trap of circling around the real issue, getting sidetracked
by rabbit trails, trying to cram too many topics into one meeting, and talking and
talking (again! really, for the 10th time!) about what decision we should make.

Name That Meeting

Administrative Meeting
An administrative meeting is a quick check-​in. Some of our clients have it daily,
whereas others incorporate it into their weekly meetings. This is the time for status
reporting in the following context:

• Daily check-​in
• Standup meeting or dial-​in call
• 1 to 2 minutes per person
• 24-​hour horizon: behind and ahead
• Small wins, what you finished, what you are working on, what you need
help with
• Start on time; don’t wait for everyone to arrive
• Weekly check-​in
• First part of the weekly meeting
• 2 to 5 minutes per person
• 7-​day horizon: behind and ahead
• Small wins, what you finished, what you are working on, what you need
help with
• Start on time; don’t wait for everyone to arrive

Operational Meeting
An operational meeting is a weekly check-​in assessing progress toward goals and
should be about an hour long. No agenda is used, although I suppose you could say
the agenda is set and ongoing. Start the operational meeting by setting the ground
rules: Remind everyone of the purpose of the meeting and go over the meeting be-
havioral expectations (refer to your flip chart page):

• Take 1 to 2 minutes per person to share any small wins. Celebrate. Set a positive
tone.
• Hold a “lightning round” to identify critical tactical/​operational issues (1 minute
per person).
• Use a red/​yellow/​green scale to quickly evaluate progress on goals, work in prog-
ress, or objectives.
19

• Areas that are red become the agenda. If you deal with those and still have time,

191
work on the yellows.
• What are the roadblocks?

Communication in Meetings
• Whose help do we need?
• Create a quick action plan.
• Issues from the lightning round are addressed during the final quarter of the
meeting, unless they are big enough to require a separate meeting. This is where
meetings can get off track in a hurry—​valid issues can be brought up that tempt
us to address them without adequate time or preparation. Put them on a parking-​
lot list to address later.
• Create a “parking lot” list of topics that need to be addressed but can’t be addressed
today. Use time during a tactical meeting to prioritize the list prior to scheduling a
strategic meeting, but otherwise the list should be left alone.
• End the meeting with a cascading message plan:
• What was discussed?
• What was decided?
• What should not be shared with anyone outside the room?
• What should be shared? Is there anyone outside the room who should know
something specific? Who will take responsibility for doing it and by when?
• Start and end on time. It’s better to schedule a follow-​up meeting or assign a
couple of team members to work on an action plan than to drag the meeting on
for everyone.

Strategic Meeting
A strategic meeting is a monthly meeting (monthly is a relative term: anywhere
from four to eight weeks, depending on your needs) that allows you to deep dive
into issues requiring more research, debate, and time to decide and implement.
Outside presenters may be involved. This meeting should be scheduled to address
one to two topics at most, allowing at least one hour per topic. One tip here: It is
better to overestimate how much time you will need; if you will be using an outside
presenter, plan on two hours for one topic. Do not try to cram too many topics into
the allotted time frame.
About two to three weeks before the strategic meeting, select the topic(s) most
pressing to the team. Assign a subject matter expert (SME) to research the issue,
write a problem statement, and introduce a recommendation. The SME may also
line up an outside presenter to speak to the issue.
At least one week prior to the meeting, send a simple agenda to the team with
the topic and a clear delineation of what needs to be accomplished in the meeting.
Too many times, teams get hung up on where things are in the process and revisit
the discussion-​decision phases in an endless cycle. For every decision, there are
three distinct stages: debate, decision, and implementation. For every issue, iden-
tify clearly who has the authority and final say to make the decision (“D”). For
particularly thorny or complicated issues, separate the discussion phase and the de-
cision phase into separate meetings; this allows the team time to digest information
they’ve heard, seek further clarification, or explore additional options.
An example of what the strategic meeting agenda should look like is provided
in Table 13.3.
 192

Table 13.3. Strategic Meeting: Acme Hospital Emergence Department Leadership Team (June 1, 1–​3:30 pm, Palm Boardroom)
Topic SME Phase Outside Who Has the D? Time Allotment
Presenter?

1. Should we 1. Dr. John Roberts 1. Decision 1_​ No 1_​ Dr. Tom Smith 1. 60 minutes
treat patients
in the waiting
room when
the ED is
full?
Should we hire 2. Dr. Susan Lin 2. Discussion 1_​ Dr. Tammy 2. Dr. Winston 2. 90 minutes
scribes? Shell, Jones
general
hospital
ED
193

Begin your strategic meeting by once again setting the ground rules and

193
reminding everyone of the behavioral expectations (have that flip chart page prom-
inently displayed!). Almost immediately, ask the SME to state the topic, read his or

Communication in Meetings
her prepared problem statement, identify the decision needed, and provide a rec-
ommendation for action.
For topics that are in the discussion phase, remind everyone who has the
final “D,” then open the floor up to discussion following the recommendation.
Remember, the recommendation is simply intended to provoke conversation. The
person who has the final “D” should speak last; if that person is not the leader, the
leader should speak next to last. You will need to use your facilitation skills to draw
out those who tend to be quieter in meetings. Use a flip chart to capture the team’s
recommendations. Try to whittle the list down to three to five final options for con-
sideration. What could be combined? What needs further research? If you went
with _​_​_​, what could go wrong? Challenge each other’s thinking (in a kind way) to
get to the best options.
If you need to use outside presenters during the discussion phase, it’s critical
to have a plan for their participation. The SME is responsible for reviewing the
presenter’s materials prior to the meeting, coaching the presenter before and after
the meeting, and keeping his or her meeting participation present and on track.
Have the presenter wait outside the meeting until after the SME has introduced
the topic, introduced the presenter, and identified why having the presenter at this
meeting will be helpful. Once invited into the meeting, the presenter should be pre-
pared to efficiently and immediately state his or her point and share content. The
team should then be allowed time to ask questions related to content or presenter
expertise only. Thank the presenter for his or her time and dismiss him or her from
the meeting. Any debate around the option or information presented by the guest
should be held until after the person has left the room. The SME has responsibility
for following up with the presenter with any feedback or notes after the meeting.
When the discussion phase is closed, state clearly, “The discussion phase is now
closed. We are moving to the decision phase.”
For topics that are in the decision phase, team members should come prepared
to leave the meeting with a final decision in place, understanding that the appointed
“D” may disagree with their opinion, but they must be prepared to commit and im-
plement regardless. Begin the topic as earlier, asking the SME to state the issue, read
the prepared problem statement, and review the captured recommendations. For
any areas that needed additional research, have the SME review the new informa-
tion quickly. Open it up to the floor, allowing about 10 to 15 minutes for final dis-
cussion, and then move to the decision. The “D” may need to take a five-​minute
break to come to a final close. Once the decision is announced along with (most
critically) why this was the direction chosen, use fist-​to-​five or Roman Council to
ensure individual commitment to the decision. On a flip chart, record the final de-
cision and state, “The decision phase is closed. We are moving to implementation.”
Spend the remaining time identifying next steps for implementation and execu-
tion (you may need to create a small subcommittee to continue the work on this).
Use the RACI7 process to facilitate implementation:

Responsible: the owner of a particular deliverable/​action item. Each deliverable/​

objective must have an owner.
Accountable: the one person accountable for the entire project/​ decision. One
person only. Usually this is the person who had the “D.”
194

Team Decision-Making Process

Communication with Providers, Staff, and Personnel 194
Team Commitment:
When the team...
“Here’s why we decided...”
1. Is Heard & Understood “D”* makes and Leader is a Coach
2. Knows and Understands communicates the
the “Why” decision and the
3. Knows who has the “D”* “Why”

DISCUSS DECIDE IMPLEMENT

When the team... “D”* makes the Leader is a Cop

1. Has no chance to weigh-in decision in isolation
2. Does not know the Why and communicates
the ”What” without
3. Is unclear about who has At best: At worst:
the “Why”
the “D”*
Team Team Non-
Compliance compliance

FIGURE 13.1. Team Decision-​Making Process.

Consulted: a person who needs to give information or input necessary to do

the work.
Informed: a person who needs to be kept informed about the progress of the work.

Now that you have a decision and next steps, you can move this topic to your weekly
operational meetings to red/​yellow/​green check-​ins on implementation progress.
End your meeting with a cascading message plan, using the information from
the RACI process to fill out the questions:

• What was discussed?

• What was decided?
• What should not be shared with anyone outside the room (yet)?
• What should be shared? Is there anyone outside the room who should know
something specific? Who will take responsibility for doing it and by when?

(See Figure 13.1.)

Research on different aspects of meetings has provided input on how to make
meetings more productive and continue to engage participants. Table 13.4 provides
some suggestions for increasing meeting productivity.

MEETINGS AT A GLANCE
Practical Application
1. Understand the conflict comfort makeup of your team: Who runs hot? Who
runs cold?
2. Practice applicable facilitation skills that you can use to run a better meeting.
3. Create meeting behavioral norms together. Use them as ground rules for every
meeting.
4. Identify what type of meeting you are having. Avoid meeting stew.
195

Table 13.4. Methods to Promote Meeting Productivity8

195
Method Reasoning

Communication in Meetings
15-​minute meetings Attention span is 18 minutes
Set a timer Accountability for meeting length
Stand-​up meeting Leads to greater excitement about creative process9
No laptops Understand concepts better if notes taken by hand10
Coat-​check cell phones Frowned upon by coworkers11
2-​minute silence break Encourages deep thinking about ideas

5. Celebrate the small wins. Don’t wait for that big thing to happen. Maintain an
atmosphere of positivity.
6. Keep the three phases separate from each other: discussion, decision,
implementation.
7. For strategic meetings, send a simple but clear agenda at least one week in
advance to allow time to prepare. Assign a subject matter expert to do prework.
8. End every meeting with an action plan (next steps) and a cascading
message plan.

VIRTUAL TEAM MEETINGS: VIDEO OR

TELECONFERENCE
Brian’s grandfather turned 91 this year, frail in body, but sharp as a tack in mind.
When asked about the most interesting thing that has happened in his lifetime,
he immediately talks about the computer. During World War II, he worked on
radios, repairing and servicing those critical technological tools of the age. He often
mentions how different it would have been had they had access to the tools of our
modern military. And you get the feeling that just for a few minutes, he would love
to know what it feels like to be fully immersed in that world.
How easy it is for most of us to forget life before all these amazing tools existed!
Recently, I was explaining to my 15-​year-​old son what a library card catalog was
and how we used it to find information. Looking at me with pity in his eyes, he said,
“Mom, I really feel sorry for you, living in the olden days. It must have really been
terrible!” It’s true technology has enriched our lives in so many ways: Want to know
the current population of Malawi? The age of your favorite actress? The winner of
Super Bowl XIII? Siri or Google will tell you in an instant.
The downside of such technology, of course, is that we don’t always get to spend
as much time together in person as we used to. In fact, many of our clients’ teams are
spread not only nationwide but also worldwide. The good news is we gain access to
advice and expertise at a moment’s notice, and larger organizations can still main-
tain good communication and a tight leadership team despite the challenge of being
separated by time and distance.
The best virtual teams stay tight by fostering an environment of communication
not solely limited to the formal meeting times. Group text threads, Slack, or other
virtual tools can create an atmosphere of fun and camaraderie despite the distance.
One virtual group we work with came up with the idea of having an ongoing Slurpee
contest: They take selfies in front of Slurpee machines (the rule is it can’t be the
196

same one more than once) and text them to the group. At their annual in-​person
Communication with Providers, Staff, and Personnel 196
meeting, whoever has the most location pics wins a silly prize.
Another group has an ongoing Slack thread where they post articles or updates
that might be interesting for all—​a bit more serious than our Slurpee-​drinking
friends, but still a good way to communicate in an unstructured way. Other ideas
involve friendly sports rivalries (one of our clients has an ongoing emergency de-
partment patient satisfaction rivalry between campuses; the losing campus has to
wear scrubs from the other campus’s favorite rival sports team on a designated day
the following week), cheeseburger contests, and so forth. The “what” is really less
important than the concept—​I look forward to hearing your ideas!
If you are a leader of a virtual team, you will have to take an active role in
strengthening the bonds of the team. Many, many times we’ve heard the complaint,
“I never hear from my boss unless something is wrong or he needs something.” Ask
yourself, when is the last time you had a chat with every virtual team member that
did not include an agenda? You must go the extra mile to talk to everyone on a reg-
ular basis, with the intent to have a friendly, positive conversation. If you find the
whole idea a bit frightening, it’s fine to write out a list of questions to help you get
the conversation started. But please don’t use them as a checklist—​that would def-
initely defeat the purpose! Recently, I read something online referencing the work
of Matthew Kelly around the concept of carefree timelessness, meaning our strongest
bonds are formed when we spend unstructured time together. It’s why we can re-
member a conversational tidbit with a mentor but we really can’t remember our
high school graduation ceremony. It’s going to be more challenging to pursue care-
free timelessness with your virtual team, but the dividends it will pay to the team’s
strength will be well worth it.

Virtual Meeting Success

If you are part of a virtual team, we have a few tips to help you have good meetings.
Read the section on meetings first: Everything there applies to you, but on steroids.
In addition to the behavioral meeting expectations discussed earlier, together, you
must add very specific rules about behaviors during your virtual meetings. For in-
stance, is it OK to check email while you are on the call? Is it OK to show up to a
video call in your pajamas? Are you allowed to eat during the call? Are you going
to start on time, even if everyone isn’t on yet? How will you handle guests/​out-
side presenters—​should they even be invited to virtual meetings? How will you
ensure everyone speaks up? Is it OK to send text messages to one or two of the team
members during the meeting and leave everyone else off the group thread? If you
can’t make the meeting, how and to whom do you communicate that information?
I’m sure you can think of other things that should be on the list as you review your
own experiences with virtual meetings.
When you send the calendar invite for the virtual meeting, add the following
things in the notes section:

• Type of meeting (no meeting stew)

• List of behavioral meeting expectations including the virtual meeting behaviors
• Identify the facilitator (consider rotating responsibility)
• Identify the note-​taker: This is the person responsible for recording decisions,
action items, key messages/​takeaways
197

During the meeting, the facilitator will have to take a more active role in either

197
drawing people out or cutting someone off who is talking too much. Pay close atten-
tion to the balance of conversation.

Communication in Meetings
If you are holding a strategic meeting virtually, call a 10-​minute break every hour.
Keeping focus and attention in a virtual world is even harder than it is in person. Ask
everyone to take a quick walk (move) before resuming the meeting. Limit the stra-
tegic meeting to only one topic/​issue for the entire meeting.
Identify clearly the action items, responsible party, and due dates. There must
be no confusion. If you are worried about insulting someone’s intelligence, you can
use a favorite facilitator technique of making yourself the idiot: “I think I’m a little
confused. Sally, would you kindly recap for me what we’ve just decided?”
Finish out every meeting with a cascading plan, recorded by the note taker.
Finally, close the meeting with a poll: “John, are you clear on what you need to
do next?” (Yes/​No), “Alice, are you clear on what you need to do next?” (Yes/​No);
or “Alice, do you agree with this decision?” (Yes/​No), “John, do you agree with this
decision?” (Yes/​No). And so on, until everyone has spoken. If anyone says no, ask
him or her to stay on the line with you a little longer or schedule a quick follow-​
up call as quickly as possible. Alternatively, you could ask, “Can anyone help John
with this?”
Following the meeting, whether tactical or strategic, the note taker should follow
up within 30 minutes with a brief overview (note: This is not an English writing
exercise; keep it brief!) of the cascading plan, action items, and key messages/​
takeaways. Email is always an option, but Slack, Google docs, Evernote, and lots of
other tools are also out there to use.
Although there are challenges to holding meetings virtually (in person is always
better whenever possible), with some thoughtfulness and prework, you can create a
positive and productive meeting environment.

Practical Application
1. Create very specific virtual meeting behavioral expectations.
2. Go above and beyond to create meeting clarity from the moment you send the
calendar invitation.
3. Assign a note taker to keep track of decisions and key messages.
4. Take a movement break every hour.
5. Create a cascading message plan.
6. End virtual meetings with an individual verbal poll to make sure everyone is
clear on next steps and understands what their role is.
7. Within 30 minutes of the meeting ending, communicate a brief overview of the
decisions, key messages, action items, and cascading message plan to the team.

You’ve undoubtedly heard the adage “Plan your work, then work your plan.” By
building your team, establishing a few communication ground rules, holding each
other accountable to them, and determining where your team fits on the con-
flict comfort scale, you’re doing the important work of building a framework that
helps shape and measure expectations. By avoiding meeting stew and identifying
your meeting by type, you can further refine the framework and add the essen-
tial element of clarity to every meeting, whether it’s held in person or conducted
virtually.
198

Table 13.5. At-​A-​Glance: Recommended Reading

Communication with Providers, Staff, and Personnel 198 Topic Book and Author

Messaging Start With Why: How Great Leaders Inspire Everyone to Take Action,
by Simon Sinek
Teamwork The Five Dysfunctions of a Team: A Leadership Fable, by Patrick
Lencioni
Difficult Crucial Conversations: Tools for Talking When the Stakes Are High, by
conversations Kerry Patterson, Joseph Grenny, Ron McMillan and Al Switzler
How to Say Anything to Anyone: A Guide to Building Business
Relationships That Really Work, by Shari Harley
Decision making Decisive: How to Make Better Choices in Life and Work, by Chip Heath
and Dan Heath
Meetings Death by Meeting: A Leadership Fable . . . About Solving the Most
Painful Problem in Business, by Patrick Lencioni
The Advantage: Why Organizational Health Trumps Everything Else in
Business, by Patrick Lencioni

If you would like to have a more extensive reading list on any of these topics (see
Table 13.5), or any other help, I hope you reach out to us. More than that, tell me
your communication story—​I’d love to hear it (Figures 13.2–​13.5).

REFERENCES
1. Romano NC, Nunamaker JF. Meeting Analysis: Findings from Research and
Practice. In: Proceedings of the 34th Hawaii International Conference on System
Sciences; 2001.
2. Nardi D. Neuroscience of Personality: Brain Savvy Insights for All Types of People. Los
Angeles, CA: Radiance House; 2011.
3. Nardi D. Neuroscience of Personality: Our Brains in Color. Los Angeles, CA: Radiance
House; 2016.
4. Sinek S. Start With Why: How Great Leaders Inspire Everyone to Take Action. New
York, NY: Portfolio; 2009.
5. Shannon DW, Myers LA. Nurse-​to-​physician communications: connecting for safety.
Patient Safety & Quality Healthcare. http://​www.psqh.com. Published September/​
October 2012.
6. Lencioni PM, Okabayashi K. The Five Dysfunctions of a Team. Hoboken, NJ:
Wiley; 2012.
7. The RACI Model. Agreeing on Roles and Responsibilities: Summary of RACI.
http://​www.valuebasedmanagement.net.
8. Lee K. 9 Science-​Backed Methods for a Happier, More Productive Meeting. http://​
www.Open.buffer.com.
9. Knight AP, Baer M. Get up, stand up. The effects of a non-​sedentary workspace
on information elaboration and group performance. Social Psychol Person Sci.
2014;5(8):910–​917.
10. Mueller PA, Oppenheimer DM. The pen is mightier than the keyboard: advantages
of longhand over laptop note taking. Psychol Sci. 2014;25(6):1159–​1168.
11. Washington MC, Okoro EA, Cardon PW. Perceptions of civility for mobile phone
use in formal and informal meetings. Bus Prof Commun Qtly. 2013;77(1):52–​64.
19

14 Feedback and
Communication
With Learners in an
Emergency Department

Bonnie Kaplan

OVERVIEW
Feedback and effective communication are essential components of learner clin-
ical education, important for learner growth and development. Through feedback,
a learner is provided information on task performance to guide the improvement
process. In 1983, Ende wrote about feedback in the clinical environment, providing
a framework for delivery of feedback that continues to be part of many theories
(Ende, 1983). There have been numerous examples of techniques of how to give
feedback to learners. Hewson and Little proposed a model for feedback from a
general medicine perspective. In their model they talked about orientation and
climate, elicitation, diagnosis and feedback, improvement plan, application, and re-
view (Hewson & Little, 1998). They emphasized the same key themes expressed
in the medical education literature including being nonjudgmental and specific,
incorporating positive and constructive ideas, and incorporating the learner’s per-
spective (Hewson & Little, 1998). Yarris et al. (2009) summarized effective feed-
back as being “timely, specific, and respectful” (Yarris et al., 2009). However, even
with all the literature on this topic, learners still feel that feedback in the clinical
setting is inadequate (Isaacson & Posk, 1995). Twenty-​six years later, researchers
note that even with this understanding of the importance of feedback established
20

by Ende, we may be giving feedback, but it is unclear whether we are delivering ef-
Communication with Providers, Staff, and Personnel 200
fective feedback (Bing-​You & Trowbridge, 2009).

EMERGENCY-​D EPARTMENT-​S PECIFIC OVERVIEW

The chaotic emergency department (ED) environment poses unique challenges for
communication that can inhibit the supervising attending’s ability to provide effec-
tive feedback that will impact the learner’s development. Challenges encountered
in the ED environment include time constraints, physical space issues, variability
of learners, and limitations of exposure to individual learners. Additionally, the high
volume of patients and expectations for quick dispositions can also pose constraints
on communication with learners. This high-​intensity, high-​pressured environ-
ment not only impacts the capability of faculty to provide feedback but also creates
difficulties in finding time for formal teaching.
Given the constraints mentioned earlier, feedback often happens quickly and
with short “pearls” of wisdom while the clinicians are coordinating multiple urgent
patient care decisions. Yarris et al. (2009) found that this “informal” method of
delivering feedback in the ED was not perceived as effective by residents. This study
found a disconnect between faculty perception of quantity and quality of feedback
provided to residents in the ED compared to resident perception of that feedback.
When feedback is given in a formal way, it is often considered not “timely” or ef-
fective from the resident perspective. However, communication with learners and
effective feedback are essential for the learner’s education as well as for providing
excellent patient care. Understanding these barriers to communication allows us to
develop creative ways to address them.
Finding the right time and space to provide feedback in a busy environment can
be challenging, not just from the perspective of the person providing the feedback
but also from the perspective of the person receiving the feedback. It is best to pro-
vide feedback in a private space when the faculty member has time to dedicate to
the feedback process and the receiver is most likely to be receptive to that feedback.
For example, if a resident has 3 or more patients to go see, stopping that resident
at that moment for 10 minutes to provide feedback when he or she is stressed and
thinking about the patients he or she needs to still see may not be effective. The res-
ident is most likely not ready to listen to the feedback as he or she is just thinking
about the tasks that are accumulating. It would be best to let the resident catch up
and then take a few minutes to provide the feedback in a space where there will be
no interruptions. Perhaps there is an office within the department that can be used.
If an office is not available, an unoccupied room can serve the same purpose.
Multiple learners can be present in an emergency department, including med-
ical students, residents, and nursing students. How information is communicated,
and feedback is provided to learners will affect the learning process and reception of
information needed for improvement. Verbal, nonverbal, and written communica-
tion modalities are all used to interact with learners. Also, communication with each
learner may vary depending on the year of training.

LEARNER-​S PECIFIC OVERVIEW

It is important to understand a little about the variability in experience and expo-
sure that each year of medical school, as an example, provides that could contribute
201

to unique characteristics that might influence these generalities. Those unique

201
aspects should be considered when providing medical student feedback. Most first-​
and second-​year students spend most of their time learning outside of the clinical

Feedback and Communication With Learners

setting. Schools often pair these students up with mentors in clinical settings, but
the actual time they spend in those settings is minimal. The final 2 years of med-
ical school embrace education in more of a clinical setting through clerkships and
then electives. Although some medical students may be exposed to the ED in their
third year, there are others who will only rotate in the ED in their fourth year. These
learners are thrown into shifts with many different providers who themselves often
have different practice patterns and expectations. As one can imagine, communica-
tion with these students who only have a short time in the ED requires development
of quick rapport to create a safe educational space where learners will be open to
honest feedback that will help develop their skills.
Another complexity to communication with learners in the ED is the dura-
tion of the “learner relationship.” In the ED this could range from minutes to hours
to days. However, it is important to remember that each of these communication
experiences is an opportunity to engage the learner, develop a team mentality, and
establish rapport. Even with the briefest of exposures, establishing good communi-
cation early on can help build lasting relationships that will aid in future communi-
cation and interactions with learners.
It is important to consider all the challenges for effective communication
in the emergency department in order to address them. Even though there
are different types of learners in the emergency department, there are some
concepts that can aid in communicating and giving feedback to all the different
learner types.

PRINCIPLES OF EFFECTIVE COMMUNICATION WITH

LEARNERS IN THE ED SETTING
Setting the Stage
Clear expectations and guidelines for communication with learners in the emer-
gency department environment can lead to opportunities for improved learner
education and feedback. By starting the shift with an introduction of learners and
their level of education, the team sets the stage for open communication between all
learners and the rest of the team. Then it is important for the team to set the stage for
the rest of the factors impacting communication, deciding on where, how, and when
communication will occur on the shift.
There will most likely be different areas where communication will take place
during the shift. Specifically, communication can take place anywhere in the
department—​in a patient’s room, in a hallway, in the radiology department, in the
attending office, at a desk, and so forth. However, emergency departments may have
designated charting areas for different team members, which may also be used for
huddles to communicate important aspects of patient care. Sometimes these areas
are segregated by team member type (i.e., physician, nurse, technician). Other times
they can be joint spaces used by all members of a team. It is important for the learner
to understand the dynamics of the department as it pertains to these communica-
tion spaces. Additionally, the learner needs to know where to meet for intermittent
discussions of patients in the ED and for the shift-​to-​shift transition of care. This
gives the learner a plan for the shift.
20

Once learners know where communication will occur, there needs to be a dis-
Communication with Providers, Staff, and Personnel 202
cussion of how communication will occur. Drawing from research on interpersonal
care and business literature, there are many different variations on the types of
communicators that exist and their effectiveness (Suter et al., 2009). The most im-
portant piece is setting expectations around how the communication will go with
the learner. It helps to let the learner know what type of communicator you are and
ask them about their communication preferences. Are they very factual, do they
process through talking or thinking and how might that be similar or divergent from
your communication style. There are many factors that can affect communication
style and receptivity to communication; therefore, being clear when setting expecta-
tions is critical. Communication can be affected by gender and culture. Psychology
research notes that men more typically use communication to show dominance and
gain concrete information. Women, on the other hand, communicate as a means to
build relationships and create connections (Mason, 1994; Wood, 1996). For ex-
ample, Basow and Rubenfield (2003) noted that women tend to be more polite than
men in conflict situations. Similarly, differences based on gender seem to appear
in leadership styles. Communication preferences by gender appear to group men
as displaying a more task-​minded leadership approach, whereas women appear to
rely on an interpersonal relationship approach to leadership (Eagly & Karau, 2002).
Historically, more males were physicians and more females were nurses (Gjerberg
& Kjolsrod, 2001). Therefore, the historical relationship was seen as a male phy-
sician communicating with a female nurse. Over time, as the gender landscape in
medicine has changed, female physicians have developed different strategies to ef-
fectively communicate and interact with nurses, including befriending them and
taking on many tasks themselves (Gjerberg & Kjolsrod, 2001).
Giri (2006) described the relationship between culture and communication
and how “past experiences, perception, and cultural background greatly affect the
way people talk and behave.” Learners’ past experiences and cultural background
can also affect how they receive and perceive different communication styles. It is
important to remember that a learner’s initial impression of how we communicate
and the style in which we do it can impact how receptive he or she is to the commu-
nication. However, discussing how communication will happen during your time
with the learner and asking for feedback on the style that is chosen can help over-
come some of the barriers presented by different communication styles by setting
clear expectations.
It is important to reflect on the type of communicator you are and want to be to
clarify how you will communicate with your learners. Effective communication is a
2-​way street, where both parties come away with the same understanding of what
has been communicated. In a busy emergency department setting, where time is
of the essence, understanding your own communication style and then effectively
explaining it to learners is essential.
The other component of “the how” of communication is to understand that
there may be different mediums for communication in the emergency depart-
ment. Communication can occur through comments on the electronic medical re-
cord (EMR) system, announcements on the intercom system, and the phone. If
providers have phones, it is important to brief learners on when to call and who to
call depending on the situation and question.
The final piece is establishing when you will be communicating and giving feed-
back to learners. Communication and feedback happen in 2 general categories. The
first one is formal. This can happen right after one team hands off the patients in an
203

area to the new team or a preassigned time that is set aside for formal teaching and

203
feedback. The other general category, which happens more frequently, is on the fly
and often case based. The latter is more frequent and often takes some getting used

Feedback and Communication With Learners

to for the learner. This informal, frequent, case-​based communication and feedback
is short, to the point, and direct. However, it is important to set the stage for learners
so they are not taken by surprise by this type of communication and so they can be
prepared to be receptive to it.

Engagement and Rapport

After introductions and setting the stage for expectations for communication on
shift, it is important to cultivate learners’ engagement and your rapport with them.
This can be done in several ways. The first and often most effective way is to estab-
lish an environment where the learner feels comfortable bringing up questions and
points. By creating a safe environment for the learner to engage in, communication
becomes more open and a thoughtful discussion can ensue. This can happen by
having a simple discussion about how important it is to hear the learner’s thoughts
and perspectives, establishing that all questions are good questions and that the
learner is an important part of the team.
Once this has been established, it is important to continue to engage learners
and establish a rapport. In the emergency department, we often must develop a
rapport with patients, consultants, patients’ families, emergency medical services
(EMS), and ancillary staff in a quick and effective way in order to take better care
of the patients and the department as a whole. This also applies to establishing ef-
fective communication with learners. By bringing learners into the team early on,
introducing them and yourself, setting a clear expectation on how communication
will happen, and then making them feel like a welcome part of the team, learners
will be able to be more receptive and part of successful communication. Even when
delivering quick and timely pearls, helping the learner be a part of active communi-
cation is going to be key. By establishing this rapport and engagement early in the
learner communication relationship, one is able to move forward giving quick, effi-
cient, and timely feedback that is actually being heard and utilized and not quickly
forgotten.

Checking In
Another piece of communication that is very important to use throughout your
learner interaction is checking in with the learner along the way to see how things
need to be changed. After setting the stage, engaging the learner, and establishing
rapport, it is important to keep the momentum going throughout the whole learner
experience and interaction. Although some interactions will be very brief and some
will occur over days, checking in is very helpful to continue the engagement that has
been established. Checking in often entails asking for feedback, asking for any spe-
cific questions, and finding out if the communication style you are using is working
for the learner. As research has shown, educators often perceive the communication
as effective and clear, whereas learners do not. Therefore, it is important to check in,
figure out what has been working and what needs to be changed, and then be open
to adapting accordingly (Gil et al., 1984; Yarris et al., 2009; Jensen et al., 2012).
204

This checking in works well with all types of learners in the department and
Communication with Providers, Staff, and Personnel 204
is a very effective way of building up the team and therefore taking better care of
patients. The important part about this step is to do it in a timely fashion. Don’t
wait until the end of the interaction. Try to time a “check-​in” toward the middle of
the shift so that you can show learners that you can implement change if needed.
Again, when learners feel engaged and listened to, their ability to communicate and
be receptive to communication greatly improves and the whole interaction is seen
in a positive light.

Thank You
Giving thanks is one of the most important things you can do when closing out your
communication with learners. At the end of the shift, it is important to remember
that the whole team has worked hard toward the important goal of providing ex-
ceptional patient care. However, the ED can be chaotic, exhausting, stressful, and
thankless. Thanking learners for their time, hard work, and discussions throughout
the day acknowledges their contributions to the team and solidifies their position
on the team. In addition, by ending on this note, learners are often more receptive
to future communication and more engaged in the next interlude.

PRINCIPLES OF FEEDBACK WITH LEARNERS

Although you may have set the stage for communication, giving feedback to learners
in the ED can be fraught with difficulty and challenging in a very busy, chaotic en-
vironment. Additionally, as mentioned previously, attendings and residents have
different perceptions of satisfactory feedback, with attendings feeling they give ef-
fective, frequent, and timely feedback but residents disagreeing (Yarris et al., 2009).
As a result of this gap, it is important to break down what corresponds to effective
feedback in the clinical setting and especially in the ED clinical setting.
Several different approaches to feedback have been described. Some studies
have found that praise can lead to improvements in performance (Saraf et al.,
2014), but others have found that being able to point out deficiencies was im-
portant (Boehler et al., 2006). The feedback sandwich method incorporates a
discussion about deficiencies but places it right between compliments (positive-​
negative-​positive feedback). This method has not been shown to improve per-
formance (Parkes, 2013). A scoping review of the literature on feedback in
medical education published in 2017 points out the lack of evidence-​based
recommendations for feedback and the need for further research in this area
(Bing-​You et al., 2017).
Here we will provide one framework for feedback in the clinical setting. Let’s
start with an example of poor feedback and then build off of it to illustrate how the
feedback could be changed to be timely and effective for the learner. The setting is
the end of the shift. The attending physician is providing feedback to the resident in
a busy ED.

Feedback Example
Attending: John, how do you think it went today?
John: Ummm . . .
205

Attending (interrupts): I thought you did fine. Let’s touch base another time to

205
chat more about it. Why don’t you finish up your work and go home.
John: Ummm . . .

Feedback and Communication With Learners

What was wrong with this feedback session? How would you do it differently? Has
this ever happened to you? This example can be a frequent occurrence in a busy
emergency department. Although there was no malicious intent, there are many
ways that this feedback could be improved.
Feedback for medical learners is centered on the desire to narrow the gap be-
tween actual practice and aspired practice. Feedback can be extremely effective and
modify behavior. However, negative feedback can demoralize learners and cause
them to have worsening performance. Therefore, it is important to be thoughtful
about your communication style when delivering feedback and be strategic about
your delivery.
The first step is to be introspective about your perspective as the communicator
and determine if you have any biases or prior experiences with the learner that might
influence your reaction or creation of the feedback. The next step is engaging the
learner in his or her own feedback. Ask the learner how it went and what he or she
thinks went well and what could have been better. Not using negative language and
instead focusing on improvement can help build rapport and set the conversation
up for success. Also, giving specific instructions for the learner’s own self-​reflection
is helpful. For instance, “Tell me 3 things that you think went well today and 3 things
that you think could be better next time.” Then, as the feedback giver, you can build
off of what the learner stated and say what you think went well (3 bullet points) and
what could go better next time (3 bullet points). Professor Bernard Roth has made
a career of illustrating how language choices affect people’s receptiveness and can
positively change a person’s potential. Therefore, using the language of “what can go
better next time” instead of “what went poorly” gives the learner an opportunity to
reframe his or her way of looking at how to improve and be more receptive to con-
structive feedback.
The final piece to remember about feedback is that feedback should be concrete,
clear, and actionable. “I thought you did fine” doesn’t adhere to these principles and
the learner won’t be able to know how he or she can improve. Therefore, instead, the
attending could say the following:

John, I thought you did a nice job today. I was impressed with how you sat down when
talking to the patients, you followed up with your patients in a timely fashion once
the results were done, and you closed the loop with the nursing staff. A couple of
things you could do better next time is checking in on your patients in the middle of
their course to see if anything changes, loop me in as the attending sooner so I can
help support your clinical management, and remember to think about dissection
with chest pain.

Now the feedback provides John with the knowledge of 3 concrete things he does
well and 3 concrete areas where he can improve.
The final piece is about having enough time to give the feedback. This can be
challenging in the ED. That is why most will try to give formal feedback after the
new team comes on to take over and informal feedback happens more frequently
over the course of the shift. The key again with all of this is to set the stage and let
206

learners know at the very beginning how feedback will be given over the course of
Communication with Providers, Staff, and Personnel 206
your time working with them. This final piece will set you up for the most success.

Formal Feedback
In the education world there are generally 2 types of feedback given, formal and
informal. A popular medical student evaluation style falls into the RIME evalua-
tion framework (Pangaro, 1999). This framework places the medical student learner
into different buckets, which are reporter, interpreter, manager, and educator. This
formal feedback is usually placed into an electronic version that can be filled out by
educators to evaluate where medical student learners are in this progression.
Formal resident feedback in the ED usually consists of set evaluations filled
out by ED attendings after interactions or observations with resident learners. In
July 2015 the Accreditation Council for Graduate Medical Education collaborated
with the American Board of Emergency Medicine to develop the emergency med-
icine milestone project. Twenty-​three milestones were created to help evaluate
emergency medicine residents. Formal resident evaluations are tailored to pro-
vide data that allows faculty to rate residents on milestones that feed back into the
competencies necessary to be a practicing physician.
Although there are several ways to provide formal feedback, from a resident
standpoint the important components are that it is timely and actionable. Feedback
given 2 months after an event is a lost opportunity for improvement during that 2-​
month period. After 2 months the attending and the resident don’t remember the
incident as clearly as they would have remembered it the day it happened, making
the feedback less effective. Focusing on 1 or 2 actionable items for improvement
and making them specific to the resident and the shift ensure the feedback is more
meaningful and allow for better self-​reflection.

Informal Feedback
The much more common form of feedback that learners get is informal. This is the
feedback that is given casually as an aside after each patient encounter or a “tip”
when you overhear a learner with a consultant. This type of feedback can serve to
reinforce skills and thought processes and quickly steer learners in better manage-
ment directions. However, as emphasized earlier, it is important that this feedback
is timely within the context of a busy setting. If learners feel overwhelmed by the
amount of things they need to accomplish, it will be hard for them to hear and in-
ternalize feedback. Therefore, in the ED timely means taking into account how the
department is overall and picking times when the learner will be able to mentally
offload tasks enough to listen for a short (1-​to 2-​minute) period. Another way to
do this is to have a whiteboard in the department where topics can be written down
and referred to later but feedback and teaching opportunities are not lost as a result
of the business of the department.
The general communication principles discussed earlier apply to informal feed-
back as well. It needs to be constructive (Eraut, 2006). It needs to be timely and un-
derstandable and provide some sort of help (Reese-​Durham, 2005). It also needs to
make sense and be presented in a clear way that the learner can be receptive to, learn
from, and take action on (Helterbran, 2005). Conceptually understanding these
key components is part of what makes informal feedback effective.
207

However, there is often a divergence from what the educator perceives as feed-

207
back and what the learner interprets as actual feedback (Yarris et al., 2009). This can
happen a lot more frequently with informal feedback than with formal feedback.

Feedback and Communication With Learners

The learner needs to realize when something is merely a suggestion versus pointed
feedback. Many suggestions by academic faculty have been made on how to high-
light this kind of informal feedback to learners. Some recommend explicitly telling
a resident that something is feedback and then giving the feedback or writing down
tips on a piece of paper and then giving the whole list to the learner at the end of the
interaction. Another option that has been proposed is to sit down with the learner
after the end of a shift and put all the “informal” and “formal” feedback in the evalua-
tion together so that the learner gets the best of both worlds. The bottom line is that
informal feedback is a vital form of feedback; however, it needs to be emphasized so
that it isn’t lost in the chaos that is the ED.

CONCLUSION
Communication and feedback with learners is complicated and vital. There
are many different techniques on how to communicate with learners, and
there are many different types of learners that all respond differently to dif-
ferent techniques. Feedback is the same way, complicated and vital. However,
techniques can be used to ease the difficulty of communication and feedback and
therefore enrich the experience with each learner and ultimately take better care
of current and future patients. There will continue to be many views on the best
way to communicate and give feedback, but the most important piece is that we
have to engage learners in this discussion to better understand what they need
and how to continue to evolve to make it better.

REFERENCES
Basow SA, Rubenfeld K. “Troubles talk”: effects of gender and gender typing. 2003.
Bing-​You R, Hayes V, Varaklis K, et al. Feedback for learners in medical education: what is
known? A scoping review. Acad Med. 2017;92:1346–​1354.
Bing-​You RG, Trowbridge RL. Why medical educators may be failing at feedback. JAMA.
2009;302(12):1330–​1331.
Boehler ML, Rogers DA, Schwind CJ, et al. An investigation of medical student reactions to
feedback: a randomized controlled trial. Med Educ. 2006;40:746–​749.
Eagly AH, Karau SJ. Role congruity theory of prejudice toward female leaders. Psychol Rev.
2002;109:573–​598.
Ende J. Feedback in clinical medical education. JAMA. 1983;250(8):777–​781.
Eraut M. Feedback. Learn Health Social Care. July 28, 2006:111–​118. doi: http://​dx.doi.
org/​10.4135/​9781483326139
Gil DH, Heins M, Jones PB. Perceptions of medical school faculty members and students
on clinical clerkship feedback. J Med Educ. 1984;59(11 Pt 1):856–​864.
Giri VN. Culture and communication style. J Rev Commun. 2006;6(1–​2):124–​130.
Gjerberg E, Kjolsrod L. The doctor-​nurse relationship: how easy is it to be a female doctor
co-​operating with female nurses? Social Sci Med. 2001;52:189–​202.
Helterbran V. Lifelong or school long learning a daily choice. Clearing House.
2005;78(6):261–​263.
Hewson MG, Little ML. Giving feedback in medical education. J Gen Intern Med.
1998;13(2):111–​116.
208

Isaacson J, Posk L, Litaker DG, Halperin AK. Resident perceptions of the evaluation
Communication with Providers, Staff, and Personnel 208
process. J Gen Intern Med. 1995;10(supp):89.
Jensen AR, Wright AD, Kim S, et al. Educational feedback in the operating room: a gap
between resident and faculty perceptions. Am J Surg. 2012;204(2):248–​255.
Mason ES. Gender differences in job satisfaction. J Social Psychol. 1994;135:143–​151.
Pangaro L. Evaluating professional growth: a new vocabulary and other innovations
for improving the descriptive evaluation of students. Acad Med. 1999
Nov;74(11):1203–​1207.
Parkes J, Abercrombie S, McCarty T. Feedback sandwiches affect perceptions but not
performance. Adv Health Sci Educ Theory Pract. 2013;18:397–​407.
Reese-​Durham N. Peer evaluation as an active learning technique. J Instruct Psychol.
2005;32(4):338–​345.
Saraf S, Bayya J, Weedon J, et al. The relationship of praise/​criticism to learning during
obstetrical simulation: a randomized clinical trial. J Perinat Med. 2014;42:479–​486.
Suter E, Arndt J, Arthur N, et al. Role understanding and effective communication as
core competencies for collaborative practice. J Interprof Care. 2009;23(1):41–​51.
doi:10.1080/​13561820802338579.
Yarris L, Linden JA, Hern G, et al. Attending and resident satisfaction with feedback in the
emergency department. Acad Emerg Med. 2009;16(12):S76–​S81.
Wood JT. Gendered Lives: Communication, Gender and Culture. 2nd ed. Belmont, CA:
Wadsworth; 1996.
209

15 Electronic
Records
Health

Michael S. Victoroff

INTRODUCTION
Communication in emergency medicine (EM) involves high density, precision, and
tempo. It encompasses myriad channels, which are increasingly electronic and asyn-
chronous (with information stored and retrieved rather than transmitted in real time).
Avoidable failures in EM patient care can often be attributed to failures in com-
munication.1 This chapter explores a range of communication processes in emer-
gency medicine, focusing on patient safety and electronic media. Its goal is identifying
problems and solutions—​and the problems created by the solutions.
A good definition of patient safety is “the prevention of errors and adverse effects to
patients associated with health care.”2 Increasingly, this entails errors and adverse effects
caused by electronic information and communication technology.
Patient safety is different from public safety, which also has deep and impor-
tant interfaces with EM. Public safety is the domain associated with (usually gov-
ernment) agencies that respond to crimes, disasters, and public health hazards.
Emergency departments are typically connected to public safety communica-
tions networks but are less often responsible for maintaining or supporting them.
The chief technical challenge for public safety communications is improving in-
teroperability without compromising security. Despite efforts after events like 9/​
11 and Hurricane Katrina, emergency communications remain imperfect; it is
still commonplace in many jurisdictions for agencies like fire, police, emergency
210

medical services, and the National Guard to be unable to exchange information

Communication with Providers, Staff, and Personnel 210
seamlessly with each other’s systems for technical, organizational, or environ-
mental reasons.i
The broad ramifications of public safety communications are beyond the scope
of this chapter. However, their patient safety aspects largely reduce to a single
proposition:

Proposition 1—​Safety, effectiveness, and efficiency in health care increase in propor-

tion to relevant information at the point of care.

Simply delivering information is not so simple. It explodes into finer-​grained issues.

However, in reviewing the benefits and risks of communication technologies, the
theme of better information at the point of care surfaces repeatedly.
The better doctor is usually the one with better information. However, other
things being equal, having more information slows decisions and actions. Thus, the
better doctor is often the slower doctor. Greater cognitive load creates a dilemma in
EM, where rapid decision making is one measure of effectiveness.
Although diagnostic error is sometimes cited as the leading concern for EM
errors (and professional liability),3 a meaningful number of missed diagnoses and
delayed treatments are actually due to gaps in information rather than malfunctions
of cognition.4 The nature of EM is to be a transition hub for patients between
providers, sites, and episodes of care. One of the most important safety hazards to
EM patients is information loss between these nodes. This chapter is largely about
managing that problem.

DATA, INFORMATION, AND KNOWLEDGE

Communication is information in motion. In talking about communication, it is
useful to note—​and then set aside—​a technical distinction between data, informa-
tion, and knowledge.

• Data are symbols that represent the properties of objects and events.5 An example
of data is “2.9 mg/​dL.”
• Information is data with a context. For example, “At 0700 today, Mr. McFee had a
serum creatinine of 2.9 mg/​dL.”
• Knowledge is information with generalizable explanatory value. An example of
knowledge is, “A serum creatinine of 2.9 mg/​dL is abnormal in humans, and is
often associated with renal dysfunction.”

For the purposes of this chapter, data will mostly be used to refer to the streams of 1s
and 0s transmitted by electronic devices. Knowledge will be used in the sense of lore
of the kind that can be looked up in reference books, articles, and policy manuals.
Information will mean the content of messages exchanged in the course of commu-
nication. This isn’t strictly rigorous, but it won’t matter. When the context is ambig-
uous, the term information will be used for all.

i As recently as 2017, the author reviewed an active shooter event with staff of a Denver hospital, in
which police radios were not able to receive signals in certain areas of the facility.
21

COMPONENTS OF COMMUNICATION

211
Communication in the ED needs to be analyzed across many components,

Electronic Health Records

including:

Senders and receivers: These are humans, including medical and support
staff, patients and accompanying persons, and representatives of facilities
and organizations. They also include passive and active signaling and data
sources such as record repositories and information systems, as well as
devices that generate messages, reports, and results. There are important
functional differences between exchanges among intramural and extramural
parties.
Mode: The communication mode is either synchronous (real time) or
asynchronous (stored and forwarded or stored and retrieved).
Content: This is almost unlimited in format, scope, relevance, reliability,
legibility, value, and urgency. Accuracy, completeness, and timeliness are key
elements.
Channels: Oral communication (direct and electronic) still dominates with
respect to the value/​volume ratio. Electronic health record (EHR) systems
have proliferated since 2009 with the stimulus created by the Health
Information Technology for Economic and Clinical Health (HITECH)
Act6 and now compete with patients as the focus of the majority of
provider attention.7 EHRs can easily overwhelm any other channel in
terms of bandwidth. They offer the greatest promise and need the greatest
investment in planning and configuration for use as workflow management
and communication tools. Personal electronic devices (e.g., cell phones) are
the most rapidly growing vehicle for almost every kind of communication
(to the extent of replacing oral, in many settings). Paper forms will never
die. Radio (e.g., shortwave, cell/​satellite, GPS) remains important for
connections to external (and sometimes intramural) services. Other
electronic channels include wire/​cable/​optical. Direct, organic channels
such as sound, sight, and touch (e.g., Braille) remain critical. No one uses an
olfactory channel deliberately for clinical communication, but odors can be
signals with high informational value in many ways.
Formats: These include verbal language, auditory signals besides language,
nonverbal gestures and expressions, other visual displays, gestures, and
signals generated by beings and objects.
Media/​devices: Paper is a medium as well as a channel. Media include paper
and electronic charts, documents, forms, memos, reports, scratch sheets,
notes, checklists, and recording implements; passive and active signage and
displays; audiovisual equipment, loudspeakers, sirens, horns, and alarms;
telephones, switchboards, and answering machines; fax machines, scanners,
and copiers; computers and terminals used for general information
processing; diagnostic and monitoring instruments; radios, pagers, cell
phones, and tablets; voicemail, email, text messaging, and medical imaging
viewers; also security tools like cameras and infrared beams.

The exercise of cataloging these (which are obvious to most EM professionals, upon
reflection) is to build a mental matrix of interactions and combinations. This gives
practitioners, technologists, risk managers, and safety analysts a framework for
21

Table 15.1. Clinical Communication Versus Administrative Documentation

Communication with Providers, Staff, and Personnel 212 Primary User Secondary User

Care management (workflow) Payment (charge capture)

Provider communication Research
Recall, tracking, follow-​up Public health
Clinical quality management Legal defense
Archival record Health care operations
Patient and caregiver communication Process analytics
Regulatory compliance

thinking about any given set of components prospectively when designing systems,
or retrospectively when reviewing adverse events. Patient safety activities largely
revolve around foreseeing things that could go wrong and remembering things that
did go wrong.

Proposition 2—​Communication errors are analogous to statistical errors, either

type I (sending/​receiving false information) or type II (not sending/​receiving true
information).

In clinical care, each of these translates into a multitude of obvious—​and not so

obvious—​risks.

DOCUMENTATION VERSUS COMMUNICATION

The core organizing principle of modern medical information is the patient record,
which, broadly considered, has 2 functions. It is the central repository of enduring
information in patient care, and it is the central communication platform for clinical
messages (Table 15.1). Ideally, as electronic health records began to replace paper
charts, this would have been an opportunity to design them with communication
principally in mind. Unfortunately, clinical communication has lower priority in
EHR design than secondary purposes—​predominantly charge capture, which is
the one that pays for all the others. Providers are easily lulled into neglecting the
information needs of the next practitioner in line in favor of immediate pressure to
advance the workflow and capture a transactional record.
Secondary purposes are important and need to be integrated. But building
the needs of secondary users into the clinical workflow has demanded that pri-
mary users (the clinical experts) take on a large burden of data entry. This diverts
a significant amount of clinician attention and drains cognitive energy away from
patient care.

Proposition 3—​Clinical communication may suffer at the expense of clinical

documentation.

THE TEXAS EBOLA CASE

Flaws in provider communications were exposed in a widely reported case in 2014,
when a patient with Ebola virus was mistakenly sent home from a Texas hospital.
213

This event demonstrates so many instructive points that it is worth reviewing in a

213
bit of detail.
A 42-​year-​old male presented to the ED with a fever of 100.1°F, abdominal pain,

Electronic Health Records

dizziness, nausea, and a headache. The fact that he had recently arrived from Liberia
was not recorded in the EHR by the triage nurse, although this fact was noted and
entered in the EHR note by the nurse who performed his initial assessment. At that
time, the EHR did not flag “African travel” as a special risk factor. The physician who
next saw him did a number of tests and imaging procedures before discharging him
with a diagnosis of sinusitis. The patient returned by ambulance 3 days later in crit-
ical condition; he shortly died of Ebola virus. Two nurses who treated him became
infected with Ebola but survived.8
Initially, news articles reported the hospital’s claim that the history of African
travel was not visible to the ED physician in the EHR, and blamed sequestration of
nursing notes from physician notes for the error.
A hospital representative blamed the EHR vendor (Epic Systems Corporation)
for having a design flaw that failed to make the nurse’s note available to the physi-
cian. The hospital retracted this claim shortly after; it was not clear why this theory
was suggested or what made the hospital withdraw it. The vendor disputed that anal-
ysis and attributed any failure to propagate the information (if this occurred) to a
configuration decision by the hospital. Data logs revealed that the physician opened
the relevant portions of the EHR record but could not establish whether he saw or
appreciated the information. Some blamed the physician for overlooking the note,
which was apparently visible if the extensive nursing assessment had been carefully
reviewed. The significance of African travel did not register strongly enough with the
nurse to cause her to mention this to the physician directly. During the public furor
over the error, as conflicting statements were being issued by hospital and EHR rep-
resentatives, some experts questioned whether a “gag clause” in Epic’s license agree-
ment prevented an honest causal analysis. A year after the event, an expert panel with
full access to all records published a report that attributed the error to several causes;
however, it did not clarify whether the physician actually saw the nurse’s note.8
Amid intense discussion around the time of this event, numerous health in-
formation technology (HIT) experts cited EHR flaws in design, configuration,
workflow, interoperability, usability, and other factors as frequent sources of mis-
communication, misdiagnosis, and treatment errors, and speculated that such
factors could easily have caused such an incident (even though, in this case, it was not
clear that they did).9–13
This case is instructive, precisely because its facts are so unclear. Blaming the
EHR (rightly or wrongly) was the initial reflex of several parties. This demonstrates
a conspicuous sensitivity to EHR and workflow vulnerabilities among hospital staff.
The lessons learned from the event are not only about what actually caused the error
but also about how many alternate pathways might just as easily have produced the
same outcome.
For the purposes of this chapter, several lessons emerge from this event
(Box 15.1).

THE EHR AS A COMMUNICATIONS HUB

Health care workers colloquially refer to the global suite of electronic patient care
applications they interact with as “the EHR.” Although this is not always technically
214

Communication with Providers, Staff, and Personnel 214

Box 15.1. Texas Ebola Event
1. Diagnosis errors may originate as communication errors.
2. Overreliance on electronic, at the expense of verbal, communication can cause
critical information loss.
3. Workflow functions within electronic health records that can theoretically be val-
uable safety features must be designed and configured properly.
4. Simply entering data into an electronic system is no guarantee that it will be
noted, assimilated, or acted upon by intended recipients.
5. Information volume, user interface design, production pressure, institutional
custom, and professional culture work against the ability of practitioners to ap-
prehend critical facts, even when they are available to them.

accurate, it’s a good enough generalization. Safety issues of HIT (including EHRs
and everything else) are a matter of concern in all health care settings and are under
intense scrutiny from many perspectives. It is indisputable that HIT potentially
offers generous benefits and entails hazards and risks.14,15
Viewed through a communications lens, practically everything that happens in
an EHR involves transmitting information:

• Capturing, storing, retrieving, and transmitting archival (permanent) information

• Capturing transactions for financial and performance management
• Serving as temporary “working memory” for volatile information
• Capturing, displaying, reviewing, transmitting, and analyzing data
• Delivering alerts, prompts, alarms, reminders, and notifications
• Managing tasks (calendaring, reminders, etc.)
• Processing orders and tracking their status

In addition, many EHRs have messaging services that permit users to exchange vo-
latile or enduring information among local providers and export information to re-
mote (e.g., referring) providers and even directly to patients.
From this perspective, successes and failures related to communicating health
information depend on human and cultural systems, even more than technology.

FRAGMENTED INFORMATION
Ironically, although the multiuser, multiaccess capabilities of EHRs allow them to
be more coherent than paper charts, their contents are still often segregated into
local databases. This makes patient record availability subject to the capabilities and
whimsies of organizations.
One of the most fundamental of these is fragmentation, the physical storage
or limitation of access to records in multiple locations. Ironically, this hazard
may have lower impact in settings where paper charts are used, because providers
take for granted that their information is incomplete and have processes for
reconciling it. Missing information can be a more active hazard in delivery
systems where longitudinal data are electronically aggregated and there is an
expectation—​or illusion—​that a complete record is available. There is a bias
215

among users of electronic databases that retrievable information equals reliable

215
information.
The virtualization of patient records exerts a metaphorical Heisenberg ef-

Electronic Health Records

fect upon the concept of the “chart” as a discreet entity. Like atomic particles,
it is no longer possible to determine the precise location, boundaries, content,
and status of any piece of patient information as it moves and transmutes across
systems.
An example of this uncertainty would be the need to reconcile the patient’s
Medication List with the actual facts about the patient’s medication use. No one
concerned about patient safety blithely assumes that the stored record is ever accu-
rate in this respect.
Another example of uncertainty is seen when records are transmitted between
providers. Chart contents may be out of date or incompletely reflect recent activity.
Information in charts from different sources may conflict, even if they were created
on the same date.
One of the more insidious elements of the patient chart is the Problem List.
Originally intended as the principal, organizing signpost for navigating patient in-
formation,16 Problem Lists in most EHRs today are generated from codes submitted
for financial transactions (essentially representing a voluminous stream of “cash reg-
ister tape”). This causes a cascade of unfortunate effects:

1. Providers often don’t take Problem List management seriously in their own
systems.
2. Providers don’t attempt to reconcile or validate Problem Lists with their
patients.
3. Providers transmit unreliable Problem Lists to other providers, who often do
not take them seriously or attempt to reconcile them with their own.
4. Patients are unaware of the contents of their own Problem Lists and are rarely
called upon to verify and update them.

EM practitioners will sometimes find valuable information in a patient’s Problem

List, when the chart is readily available and there is time to review it. But they wisely
apply salt before taking the contents at face value.
Paradoxically, the availability of electronic information also reduces human-​
to-​human communication.17 It’s a sword that’s sharp on both edges: Electronic
channels give rapid, convenient access to provider work product. They also deper-
sonalize patient information by isolating it from its authors. They promote a habit of
looking for answers in computers about coworkers’ findings and judgments rather
than tracking them down and speaking in person. This is a legitimate efficiency
that can nevertheless result in misunderstandings. It mirrors a tendency in “mo-
bile device culture” whereby users prefer screens to physical interactions for social
information.
It is a truism of medical malpractice defense that a fair number of lawsuits
(implying patient injuries) could have been prevented if one provider had just
picked up a phone and spoken directly to another.ii

ii Many of the insights in this chapter are products of the author’s several decades of experience in the
medical malpractice insurance industry.
216

STRUCTURED VERSUS UNSTRUCTURED

Communication with Providers, Staff, and Personnel 216 INFORMATION
In a tradeoff for an enormous gain in legibility, EHRs have in many cases degraded
the quality, reliability, and nuanced meaning within provider documentation
by the use of data entry labor-​saving devices such as dropdown lists and check
boxes (“click-​tation”), auto-​populated fields, templates, paste-​forward, and voice
recognition.
Computers could only compute on structured data (as opposed to “free text”)
30 or 40 years ago. Rigidly structured data like dates, numbers, and defined codes
were needed for operations like counting, sorting, tabulating, graphing, and
so forth. This lead to numerous standardized coding systems and constrained
vocabularies (with the need for providers to memorize them). There is a legacy
of sentiment in the HIT world that disparages unstructured text and strongly
favors encoded information. (More recently, with the advent of more powerful
chips and programming, there are finally great expectations for “natural language
processing.”)
Unfortunately, content is always lost when narrative is reduced to codes. This
has powerfully shifted the emphasis in clinical information collection from un-
derstanding a patient’s story to rendering it into a structured format. This puts
narrative data on par with the lab and imaging reports that make up so much of
the input delivered to providers. Observing practitioner workflow in high-​data-​
flow settings, it is evident that interacting with electronic information not only
discourages consultation with colleagues but also far outweighs time spent on
patient history taking and physical examination. Furthermore, the structuring
of medical notes into stereotyped, highly templated, monotonous-​appearing
documentation—​which may contain gross inaccuracies—​induces a vicious cycle
in which practitioners have low expectations of the informational value of each
other’s notes, and hence don’t apply themselves diligently when creating their
own. The degradation of clinical documentation is worst in settings where narra-
tive notes are discouraged.
Another hazard of electronic documentation is the failure of practitioners to ap-
prehend information that is camouflaged in a large volume of irrelevant clutter that
is often displayed on screens. (This can reach the point of absurdity, when records
are physically printed.) User interface design has become recognized as an impor-
tant challenge for HIT developers and safety analysts.

INFLATION OF THE DIFFERENTIAL DIAGNOSIS

The dominance of documentation over communication in EHRs is seen in many
other ways. One practice prevalent in some EM settings is a mistaken attempt
to reduce liability by generating an excessive list of conditions “considered” on
the way to the diagnosis. It is valuable for practitioners to share their bona fide
thoughts about alternative diagnoses. But it is counterproductive to inflate this list
with conditions that are not reasonably likely—​especially if they have not effec-
tively been addressed. There can actually be increased liability when a condition
is listed in the differential but the steps that would need to be taken to rule it out
were not performed. Pro forma documentation looks different from conscientious
assessment.
217

PROLIFERATION OF DIAGNOSES FOR PERFORMANCE

217
MEASUREMENT

Electronic Health Records

Another distortion that health records are subject to is the padding of diagnostic
codes to raise patient acuity and complexity for billing purposes. When facility and
provider revenues depend on formulas that score the diagnosis count as a factor
in compensation, there is an understandable tendency to enumerate diagnoses as
completely as possible—​or even more than possible. This is another factor that
makes patient Problem Lists clinically dubious.

RELEGATION OF NURSE’S NOTES TO THE STATUS OF

METADATA
A serious, unintended effect of structured data entry in many EHRs has been to rel-
egate documentation by nurses, more than other practitioners, to the status of mere
metadata. Metadata refers to timestamps, signatures, and other information about
data that facilitates tracking of who created, edited, viewed, or transmitted it and
when events like these occurred. Aside from engineering and quality management
purposes, a growing use of EHR metadata is in the forensic examination of records
presented as evidence in legal claims (like malpractice suits).
Giving the right status and attention to nurses’ notes was a challenge for health
care before EHRs were invented. This is because the competing goals of documen-
tation (administrative vs. clinical) are formidable for nurses. Many EHRs depend
on nurse data entry to capture minutiae about the care process that has minimal
real-​time clinical value. Such material is more helpful in retrospective review of
events—​especially adverse events. This contrasts with nursing notation that is
critical to patient care, like vital signs, physical findings, and (sometimes) medica-
tion administration logs. Part of the increased data entry burden on nurses with
EHRs has been the duty to record what may amount to hundreds of data points on
checklists that have near-​zero value in patient care, such as “Bed rails up,” “Patient
in restroom,” “Patient watching TV.” These noncontributory data are often entered
and displayed on the same screens and with the same emphasis as truly vital infor-
mation, such as “Left leg is cold, numb, and blue.” Like the camouflage caused by
general EHR clutter, this tends to trivialize and monotonize nurses’ notes, makes
critical information easy to miss, and sabotages nurses’ primary functions of clin-
ically monitoring and emotionally supporting patients. Nurses who have actually
important messages to convey to their colleagues often still need to catch them in
“face time.” This workaround highlights the schism between documentation and
communication.

THE POTENTIAL OF EHRS AS COMMUNICATION TOOLS

Despite many flaws in the design and configuration of current EHRs, they are un-
doubtedly devices that support clinical communication. It is necessarily vague
which functions in EHRs should be labeled “communication.” It seems better to
use a broad definition. Many of the most useful functions EHRs provide help with
provider workflow. A recent time-​motion study of family physicians’ use of EHRs
identified 15 categories of electronic interactions (Table 15.2).18 These are similar
for EM providers.
218

Table 15.2. Classifying User-​Event Log Data Into 15 EHR Task Categories

Communication with Providers, Staff, and Personnel 218 EHR Task Category Examples

Clerical
Administrative Accessing patient demographics for telephone number
before calling patient
Billing and Coding Assigning CPT and ICD-​10 codes to encounter
diagnosis/​diagnoses
Documentation Typing into a progress note within any encounter type
Order Entry Placing an order for a medication, laboratory test,
consultation or referral, durable medical equipment,
others
System Security Logging in, logging out, secondary login to review
psychiatric records
Medical care
Chart Review-​Imaging Reviewing findings of a chest radiograph
Chart
Chart Reviewing cholesterol test results
Review-​Laboratories
Chart Reviewing medication list
Review-​Medications
Chart Review-​Notes Reviewing an encounter note from office visit, urgent
care, emergency department
EBM, Point of Care Accessing an evidence-​based resource available
through an EHR link, such as UpToDate
Problem List Reviewing or editing the active Problem List
Inbox
Refills and Results Refilling medications; interpreting new laboratory and
Management imaging results
Letter Generation Developing a letter to patient
MyChart Portal Responding to a patient’s question about a medication
through asynchronous email-​type dialogue
Telephone Call Addressing an incoming telephone call or generating an
outgoing telephone call encounter
CPT = Current Procedural Terminology; EBM = evidence-​based medicine; EHR = electronic health record:
ICD-​10 = International Classification of Diseases, 10th Revision.

Most of the activities enumerated in Table 15.2 would accurately be classified as

communication.
Despite the observation that electronic media are increasingly used by
clinicians for professional communication (somewhat inversely correlated with
user age), compared with face-​to-​face mode, there is some evidence that providers
find electronic channels less satisfying, efficient, and effective—​and they may even
be associated with worse outcomes.10 This possibility is important to investigate
further.
219

THE ALLURE AND RISK OF ASYNCHRONOUS

219
MESSAGING

Electronic Health Records

Since the first Neanderthal stuck a note on the refrigerator, the ability to “leave a
message” has immeasurably multiplied the power of human communication. It’s
not just persistence that makes written records potent; it’s the efficiency gained from
writers being able to leave to do other things.
The power of asynchronous communication is seductive. It continues to trans-
form human society.19 It is impossible to imagine EM practice without the capability
to hand off messages for succeeding practitioners and move on. However, “fire-​and-​
forget” messaging makes it more likely for content to be lost or neglected than in
face-​to-​face communication. This is increasingly true when messages are entrusted
to the chaotic and sometimes flawed medium of EHRs. Compared to, for example,
a voice message with exactly the same content, an EHR entry is more likely to be
diluted in a torrent of other information, overlooked, delayed, incomplete, stale, not
tailored for a specific recipient, and given less credibility on receipt. Synchronous
communication (face to face or microphone to earphone) is less efficient in terms of
time management but more effective in accuracy and relevance—​for many reasons,
including real-​time read-​back and clarification.

PHASES OF CARE WORKFLOW

To organize thinking about successes and failures in complex systems, it is useful to
segment processes into phases. This can be nearly arbitrary; it just makes analysis
easier. Here are some phases in the workflow in a typical ED. They overlap but are
sequentially dependent.

1. Prehospital care
2. Patient intake, identification, registration
3. Triage, interview, exam
4. Procedures, treatments, observation
5. Result review, consultation, decision making
6. Transition/​disposition
7. Education, instruction, follow-​up
8. Documentation
9. Retrospective analysis

Each of these phases benefits from communication technologies and is vulnerable

to their failings.

Prehospital Communication
Today’s communication technology offers a cornucopia of resources that can
transmit valuable information to emergency providers before the patient arrives.
Information comes from 3 typical sources (senders):

1. Professionals (health care, EMS, police, etc.) who usually have important infor-
mation about the patient and/​or the situation
20

2. Patients, families, and caregivers who usually have the most information about
Communication with Providers, Staff, and Personnel 220
the presenting concern as well as the patient’s history
3. Other interested parties (school teachers or witnesses) who may not have a great
deal of information but who may contribute critical facts

About 14% of the 114 million patients arriving at EDs in the United States come by
ambulance.20 This means that these patients, theoretically, will have at least some
basic information transmitted about their case to the ED before arrival. The channel
used for prehospital communication depends on local circumstances.
EMS professionals typically push information to the ED through devices they
have available in the field. Often, these are shortwave radio systems for voice com-
munication. Cell phones for voice and text are now supplementing, and in many
settings replacing, radio for communications from field workers to ED staff.
Increasingly, data content includes physiologic telemetry data as well as text
or verbal messaging. The availability of clinical data such as patient status, nature/​
mechanism of injury, vital signs, and electrocardiogram (ECG) strips before patient
arrival at the ED can be extremely valuable, and has to be ranked highly as a patient
safety measure. Simply having a few minutes’ advance notice that an obstetrician or
an operating room will be needed can be life-​saving.
Despite better prehospital communication, important or critical patient infor-
mation is unavailable to ED clinicians at least 32% of the time.21 The perennial gap
in prehospital information is the absence of patient records. This has generated great
interest in developing pull technology, which would permit EMS and ED staff to
query electronic databases about patient medical histories that are not obtainable
(or possibly not reliable) from oral history.
EM providers and hospitalists express true ambivalence about access to remote
records. On the one hand, rapidly usable records can save a tremendous amount of
time assessing a case. On the other hand, the work of navigating an unfamiliar or
cumbersome portal has to be weighed against proceeding with the data available.

EMS
A generation ago, notice of incoming casualties was by telephone or radio—​or
hearing commotion at the doorway. Today, a wide variety of applications make a
full spectrum of information available to receiving emergency practitioners from
the field many minutes or even hours before arrival. Moreover, communication
between external emergency medical services is now robust and bidirectional and
often generates documentation during the process.

Patient Intake, Identification, and Registration

A serious and complex problem for every component of the health care system is
definitively identifying patients. Misidentification occurs inadvertently and deliber-
ately. Emergency facilities are particularly vulnerable to

• patients who cannot be identified for various reasons;

• misidentification and impersonation (patients using credentials that are not
their own);
21

• chart duplication (creating new records for existing patients because the originals

221
were not located owing to spelling variations, incorrect birthdates, name changes,
etc.); and

Electronic Health Records

• data entry or retrieval errors, archived or purged records, system downtime, and
so forth.

Photo IDs, biometrics, and other authentication methods can reduce misidentifica-
tion but can’t eliminate it. Authenticity implies that there is somewhere a conclusive
identity with which to match. However, every person may not be registered in a
master database. Obvious consequences of failing to identify patients properly are
incomplete information or—​potentially worse—​linking them to the wrong infor-
mation. This is an environmental reality that produces innumerable downstream
risks to patient safety.
Although there is no comprehensive national solution to identity matching,
there are guidelines for administrative and technical measures facilities can adopt
to improve performance.22

Triage, Interview, Exam

Communication during initial patient assessment happens among providers per-
forming triage, the patient, and accompanying persons such as EMS personnel;
these rapidly propagate to other staff as needed. At this phase, much of it is verbal,
although sometimes relevant documents are available. Some communications
devices that are commonly applied to what might be viewed as “workflow manage-
ment” include

• annunciation/​public address systems;

• group paging;
• silent annunciators, whiteboards, and digital display boards; and
• room status indicators.

Group broadcast applications (group texting) on mobile devices have proven useful
when teams need to be mobilized for tasks like prepping for a cesarean delivery,
opening a catheter lab, or arranging a pediatric sexual assault examination. It is pos-
sible to program a set of communication rules into some applications that auto-
matically notify a designated set of individuals or roles (e.g., radiology tech on call)
about predefined circumstances. Some systems incorporate call-​back loops that
verify team member receipt of messages and have failover protocols that automati-
cally contact a backup provider if the primary contact does not respond.

Procedures, Treatments, Observation

During the patient treatment phase, communications in the ED occur over practi-
cally every channel and medium. The powerful workflow tools of computerized pro-
vider order entry (CPOE) and result reporting built into EHRs have their greatest
practical value in this phase—​indeed, it is primarily for these purposes that EHRs
are helpful to providers.
2

Patient safety issues related to these functions have been extensively documented
Communication with Providers, Staff, and Personnel 222
and are ongoing matters of high interest to clinical informaticians.23 One very
basic reporting form from the Agency for Healthcare Research and Quality partly
illustrates the breadth of the problem (Figure 15.1).24
However, a fine-​grained analysis is not necessary to conceptualize the highest
level of impacts of EHRs upon patient safety. Medical information and communica-
tion applications need to be viewed as “medical devices,” with indications and risks
analogous to other technology used in patient care.

Proposition 4—​For every function there is an equal and opposite malfunction.

In trying to understand safety aspects of HIT, a lot of ground can be covered by just
looking at the functions information systems perform when they are working right
and envisioning them working wrong.

Monitoring and Alarms

The earliest form of electronic patient monitoring was the nurse call button, which
in some hospitals has now evolved into a cell phone app. Today’s health care facilities
are heavily dependent on physiologic monitoring of patient parameters like vital
signs, ECG, and pulse oximetry. Monitoring is most effective when it incorporates
alarms triggered by critical events. Typically, device alarms operate completely in-
dependently from “alerts” (e.g., pharmacy warnings) that pop up in EHRs, although
increasingly EHRs may process data from peripheral devices. There are at least 3
troublesome problems associated with alarms embedded in monitoring devices:
1. Stand-​alone devices at some point require active human intervention upon sig-
nals of important events; after all, this is their purpose. Signals are almost al-
ways auditory or visual: horns, chimes, or lights. Unified monitoring stations
need devices to be technologically standardized and compatible. They also need
human attention when alarm signals are triggered. False alarms outnumber true
ones. The cumulative effect of multiple, independent devices sounding at once is
cacophony that can be uninformative or, worse, that becomes extinguished from
notice because of habituation.
2. Device data feeding into EHRs may be distorted, false, misdirected,
misinterpreted by algorithms, or not effectively delivered to caregivers.
3. In a bizarre legacy of poor engineering, there are still many devices in use today that
issue a regular auditory signal—​when conditions are normal! What designer thought
that quiet would be a good way to call attention to danger? This strategy is particu-
larly laughable in an environment where there are potentially dozens of chirping,
squawking, bleating, and cackling contraptions clamoring for provider attention.
A noisy environment not only induces alert neglect but also contributes to the phys-
iologic stress and attention deficit that lies at the root of many provider errors.

Result Review, Consultation, Decision Making

This phase in the ED workflow cumulatively inherits the patient safety issues from
the preceding phases, with the addition of hazards associated with decision support
tools, including alerts, alarms, and reminders.
 23

FIGURE 15.1. Agency for Healthcare Research and Quality screenshot.

24

Computer-​assisted clinical decision support is a high-​stakes area for informatics re-

Communication with Providers, Staff, and Personnel 224
search, with high promise of benefits—​and high risk of malfunction. For decades, the
applications generating the greatest excitement and probably the least return on invest-
ment have been artificial intelligence diagnostic suggestion systems (sometimes called
diagnostic decision support—​DDS). Given the potential for missed diagnoses or diag-
nostic error in the EM setting,25 such capabilities should be in high demand. Indeed, di-
agnostic and treatment algorithms have been built into software applications for many
specialized purposes, such as drug dose calculations in renal failure, cardiac risk assess-
ment, sepsis detection, and so forth. What have not been as successful are general-​purpose
diagnosis generators. In fact, there are only a few in existence and they are widely used.
There are 2 general approaches to differential diagnosis generators, which can
again be characterized as “push” or “pull.” In a “push” system, suggestions for pos-
sible diagnoses are presented to the user after a set of findings has been entered.
One of the few commercial systems of this type is the Isabel Differential Diagnosis
Generator.26 This application uses a search algorithm to retrieve a list of conditions
associated with a list of terms, such as “fever,” “petechial rash,” and “elevated white
count.” It is a learning system whose results improve continuously through user
feedback and active editorial review. Data entry is easy and response time is fast.
Output can be queried for references to evidence-​based literature. Costs of use are
modest compared to other HIT applications and anecdotal evidence suggests that
its output is felt to be useful by many users. Another currently available system is
SimulConsult, which uses a completely different technology to provide consulta-
tion on conditions found in pediatric neurology and medical genetics.27 One of the
oldest DDS systems in use today is DXplain, whose development began in 1964 by
the Laboratory of Computer Science at the Massachusetts General Hospital.28
“Pull-​type” diagnostic applications are essentially e-​textbooks; they are clin-
ical reference systems that deliver professionally summarized knowledge and
guidelines at a level appropriate for practitioners. They may include treatment
recommendations. In these systems, the clinician needs to have a basic idea of the
clinical problem and enter terms expected to locate a useful essay on the relevant
topic. The advantage of a clinical reference system is that it can give expert advice,
based on professional literature, about differential diagnosis, tests, treatments, and
pathophysiology once a category of interest is identified. One example of a popular
application of this sort is Up-​To-​Date.29
The puzzling question about this genre of relatively robust, clinical support
applications is why they aren’t more widely adopted. It’s not professional arrogance,
or resentment of memory aids.iii Rather, the answer probably lies in the most ma-
lignant feature of the US health care system: time pressure. This is a side effect of
reality, overlaid with cultural and psychological variables, inflamed in some cases by
perverse provider compensation systems.
Softer decision aids are in universal use throughout EM in the form of mne-
monics, prompters, guideline presentation systems, alerts, reminders, templates,
and forms. These can loosely be considered communication devices, in the sense
of knowledge delivery; they may also be embedded in the documentation process.
But even these can have unintended consequences. In one malpractice case, an in-
fant with a fever had a tragic outcome because the examining ED doctor relied on

iii Although the author remembers that, over 40 years ago in medical school, some senior faculty did
express sentiments of this sort, which should be held in the same esteem as bleeding as a treatment
for pneumonia.
25

an “abdominal pain” template rather than a “fever in an infant” template. The baby’s

225
meningitis would probably have been caught if a lumbar puncture had been done,
but that test did not appear on the “abdominal pain” template. The doctor—​who

Electronic Health Records

in other circumstances would have thought of it—​was blinkered by anchoring bias
and omitted what, in retrospect, he testified he would certainly have done.13

Documentation Versus Distraction

The negative aspects of documentation for the sake of secondary users, documenta-
tion to satisfy empty formalities, and documentation that is clinically defective have
been described. It should not be forgotten that the memorialization of an episode of
care is an essential aspect of the art and science of medicine and one of the primary
determinants of effectiveness and safety. Nevertheless, data entry burden presents
a serious distraction for provider attention, a diversion of cognitive effort, and, by
these means, a meaningful safety hazard.
The diabolical slogan “If it wasn’t documented, it wasn’t done” should be abjured
and forgotten by all responsible clinicians—​and particularly those of the managerial
class who perpetuate this delusion. No statement could be less true, or more absurd.
The burden of documentation has turned out to be a serious concern for every specialty,
and especially for nurses, on whom the chore of administrative data entry falls heaviest.
This drain on professional productivity is generating pushback toward administrators.
It is also a major source of burnout for providers. A 2013 study examining the produc-
tivity of ED physicians found that 43% of their time was spent on data entry, with an
average of 4000 mouse clicks needed for charting functions during a 10-​hour shift.30
This effort has not been offset by gains in quality, safety, or efficiency.

Retrospective Analysis of Care Processes

One kind of communication that receives short shrift in many health care settings is
the exercise of sharing feedback, collegial coaching, and clinical wisdom within care
teams. Because time away from patients does not generate revenue under US health
economics, providers and organizations need to budget carefully their activities in
quality assessment, team building, and interpersonal support. As a substitute for group
processes for maintaining morale and managing quality, high-​level managers (in gov-
ernment, payer, and delivery systems) have introjected thousands of “metrics” into
the documentation workflow to serve administrative goals. A major motive for this
intrusive surveillance of provider behavior has been the philosophy of “value-​based
payment” for services. It turns out that value requires enormous effort to quantify.
In exactly the way “management reports” are seen as crushing productivity in
some general business environments, ostensible quality measurements are now the
bane of medical practitioners, who only a generation ago enjoyed relative freedom
from this kind of intense oversight. There is currently no obvious way to balance
the needs for clinical and financial accountability against the safety and labor costs
of clerical work that contributes little—​and, in fact, is directly detrimental—​to the
patient experience of care.

DOCUMENTATION LAG TIME

There can sometimes be significant lag time between electronic data entry and
the appearance of records where they are needed. This is a major source of type
26

II errors (failing to receive necessary information). Delays can occur within a fa-
Communication with Providers, Staff, and Personnel 226
cility, for example, when an ED patient is admitted to the intensive care unit (ICU)
and orders, consults, and results aren’t yet visible in the system. Delays are even
more common on discharges and transfers, when external providers may become
responsible for patients on whom they do not have the necessary information to
manage the case.
In large part, documentation delay is a result of time pressure. Part of this is
just a natural hazard of the practice of medicine. Emergencies interrupt schedules;
sickness does not respect convenient hours. But some of the time the pressure
clinicians experience is self-​inflicted within organizations. Understaffing, resource
shortages, systemic inefficiencies, high-​acuity patients, fatigue, incentives, and
penalties related to turnaround and service goals all compete with the needs of
data entry. Some gaps in discharge documentation are also attributable to the in-
tense pressure to move patients out of facilities after their clinical needs (narrowly
defined) have been met—​which can mean that informational tasks may still be
incomplete.

THE INBOX PROBLEM

Information overload and data entry burden are the 2 nastiest monsters of HIT,
from users’ perspectives. Information overload has been discussed as a source of
error and safety hazards. The most direct form this takes in an electronic world is
the “inbox problem.” Examples of materials that fill providers’ inboxes (paper or
electronic) can be seen in Box 15.2.
In interviews with hundreds of health professionals, a qualitative tally by
the author suggests that as much as 25% of professional work (particularly for
nurses) can consist of shuttling “documents to be signed” between providers—​
an ironic job in an electronic environment. This exercise presents a bona fide di-
lemma. The vast majority of this material does not serve patient care and would
make no difference to anyone if it were simply ignored (better, purged—​better
still, never created). Whatever proportion of provider effort this nonproductive
work represents, it is a highly cited source of professional dissatisfaction and
burnout. Most professionals accept it with a shrug and graveyard humor. But alert
administrators realize that cynicism from workers about the value of what they
do is a strong signal of systemic mismanagement. The technology that is capable
of dumping nonproductive tasks on overstressed professionals should someday
be capable of reducing that burden. Yet, the current technology cycle threatens
to increase it.
Looming over this morass of unproductive work is the cloud of liability. Health
care is a highly regulated field, whose massive paper trail is used by armies of
managers, auditors, and analysts—​including plaintiffs’ attorneys—​to expose flaws
and faults. Buried in the rituals of ceremonial paper shuffling are rare, critical items
that actually need thoughtful attention, and when overlooked, create patient harm
or organizational disruption. Currently, there is no technological remedy for this
risk or relief from the labor of defending against it. Artificially intelligent agents
should be expected someday to help. For now, providers are in a breath-​holding
exercise.
27

227
Box 15.2. Materials That Fill Providers’ Inboxes

Electronic Health Records

Clinical

1. Results of tests the provider ordered

2. Results of tests the provider has already seen and signed off but are delivered
again in duplicate or amended form
3. Results of tests to be reviewed on behalf of partners and associates
4. Results of tests other providers have ordered on shared patients
5. Reports of studies, procedures, consultations, admission notes, and discharge
summaries on past, current, or future patients
6. Patient-​related messages from other providers
7. Email from patients

Administrative (May Require Clinical Input)

1. Phone messages to be returned

2. Meeting invitations
3. Pharmacy notices and requests
4. Payer notices and requests
5. Clinical and practice-​related documents to be ceremonially reviewed and/​or
signed, requiring no meaningful thought
6. Administrative and legal documents such as renewals of licenses and
subscriptions, maintenance of professional certification, forms related to em-
ployer or supervisor roles, contracts, regulatory compliance, etc.
7. Notices of professional meetings, seminars, educational opportunities, news
feeds, publications, and journals
8. Professional marketing and advertising material
9. Organizational correspondence, notices, and announcements

Personal

1. Leakage of every conceivable kind of email content from personal accounts into
professional ones, including personal messages, photos, videos, social media
posts, news articles, and advertisements

Spam

1. Items of no interest that drain attention and make up the hidden cognitive cost of
having email in the first place

PATIENT DIRECT COMMUNICATION

Patients and caregivers do not have access to dedicated communication systems
with services like police, fire, and ambulance. The usual channels for patients to
input information to the system are simply showing up in person or making con-
tact by phone. But civilian text messaging to emergency services—​sometimes in
the form of “Text-​to-​911” services—​are becoming more widely available.
28

Increasing also today are inputs in the form of direct data feeds from wear-
Communication with Providers, Staff, and Personnel 228
able (and implanted) devices attached to patients, which may be professionally
prescribed (e.g., pacemakers or glucose monitors) or obtained over the counter
(e.g., emergency alert systems or “smart” home apps). These may transmit GPS
location info, vital signs, and other device output (such as from pacemakers and
fetal monitors), and sometimes text messages or even audio and video. Many of
these data streams connect through independent applications on devices or mobile
phones; a few are beginning to connect directly to provider EHR systems.
Most direct patient communication with the ED is still by telephone. The phi-
losophy of EDs balances actively soliciting patient contact (such as through poison
control information services or suicide hotlines) against wariness about providing
medical advice telephonically because of staffing and liability concerns. Incoming
calls are typically routed to a triage nurse or specialist. In the near future, texting and
online chat applications will become more common. As is recommended for primary
care and specialty practices, EM providers who communicate electronically (apart
from telephone) with patients will need to develop and execute explicit policies,
terms of use, and consent agreements regarding ground rules for these technologies.
Some of the ever-​increasing information in the ED flows out to patients.
Bidirectional communication begins, of course, at the moment of first contact, but
patient-​facing information usually peaks at the time of discharge. Usually this is
verbal with written (hard copy) supplementation. Postdischarge phone calls are a
good practice for selected patients and may improve outcomes.31 Text messaging is
becoming more common. Discharge instructions usually contain several kinds of
content, for example:

1. Summary information about the ED diagnosis and course of treatment

2. Cautionary information about managing risks and complications
3. Recommendations for follow-​up care, with contact information
4. General education about the specific health condition that was addressed or ad-
ditional health issues that were identified

Unfortunately, for many reasons, the time of discharge is suboptimal for patients to
absorb and react to these inputs. Anxiety, pain, medications, data overload, multiple
distractions, and inherent barriers like literacy, education level, and language profi-
ciency limit patients’ and families’ capacity to process information effectively. Some
relevant skills that constitute an essential part of the art of medicine include:

• Anticipating difficulties and calibrating for them; slowing the pace of speech
(without being patronizing), making eye contact, and staying alert for signs of
drifting attention, hesitance, resistance or “automatic agreement”
• Using deliberate discipline to avoid medical jargon, acronyms, and terminology
• Structuring information so that it is reasonably complete and organized without
being overwhelming
• Taking time—​it cannot be emphasized enough that the better practitioner is
often the slower one; a slow but valuable process is using “teach-​back” techniques
to assess the receiver’s understanding

The “Ask Me 3” program (developed by the Institute for Healthcare Improvement)

is an example of a format for structuring health information for patients.32 Its elements
are:
29

1. What is my main problem?

229
2. What do I need to do?
3. Why is it important for me to do this?

Electronic Health Records

Steps can also be taken at the organizational level to improve provider commu-
nication in the direction of patients. Some of these include generating checklists,
practicing and role-​playing, and providing individual feedback and institutional
incentives.33
Because nothing can make real-​time communication perfectly effective, elec-
tronic media are increasingly being used to supplement discharge instructions and
materials. Channels like email, text messaging, and EHR portals (discussed later)
are useful for this purpose. A number of organizations have published guidelines
for electronic communication with patients.34,35 Typical concepts these address
include:

• Attention to professionalism
• Providing for confidentiality, privacy, security, and integrity of the content in
transit
• Providing for the retention of content exchanged within the medical record
• Disclosures about limitations and risks of electronic communication, such as
breach, misidentification of parties, delays in response times, contingencies
for alternate channels, and expectations about information handling at the
receiving end
• Consent for use and opportunity to opt out; obtaining agreement with terms of
use; maintenance and updating of patient email addresses
• Clarifying what kinds of information and transactions are appropriate for elec-
tronic exchange and which must be managed through other channels
• Professional oversight of outgoing content; receipt verification of critical out-
going messages; review and monitoring of incoming messages
• Compliance with legal and regulatory requirements

LANGUAGE, DISABILITY, AND LITERACY BARRIERS

Technology offers brilliant solutions for some of the most challenging situations for
EM providers, namely, barriers to direct patient communication presented by lan-
guage, communication disabilities, or low literacy.
Signage in hospitals is probably the “technology” with the greatest impact on
safety, efficiency, and workflow. Nevertheless, some patients and visitors are unable
to use it. Making facilities more usable by people with impairments to using infor-
mation systems that are taken for granted by the majority is an important challenge.
TDY services for deaf and hard-​of-​hearing patients have been available for
decades. Today, teleconferencing can be game-​changing for sign language inter-
pretation. Braille terminals are available for vision-​impaired patients with hearing
loss. Remote, live, certified foreign language specialists are widely available through
translation services by telephone or televideo.
Workable, consumer-​level real-​time language translation applications for cell
phones are in the “almost ready for prime time” stage of technology. Although these
are widely and successfully used by travelers (with numerous comical exceptions),
their fidelity is still nowhere near the quality required for acceptable medical use.
230

Except under extenuating circumstances, it would be highly inadvisable for a clini-

Communication with Providers, Staff, and Personnel 230
cian to rely on applications available today for automated translation.
Section 1557 of the Accountable Care Act prescribes standards for video re-
mote interpretation services36:
A covered entity that provides a qualified interpreter for an individual with lim-
ited English proficiency through video remote interpreting services in the covered
entity’s health programs and activities shall provide:

1. real-​time, full-​motion video and audio over a dedicated high-​speed, wide-​

bandwidth video connection or wireless connection that delivers high-​quality
video images that do not produce lags; choppy, blurry, or grainy images; or irreg-
ular pauses in communication;
2. a sharply delineated image that is large enough to display the interpreter’s
face and the participating individual’s face regardless of the individual’s body
position;
3. a clear, audible transmission of voices; and
4. adequate training to users of the technology and other involved individuals
so that they may quickly and efficiently set up and operate the video remote
interpreting.

PORTABLE PATIENT HEALTH INFORMATION

For decades, patients have carried analog information tokens (bracelets, necklaces)
and more recently digital devices (USB drives, smartphones) to provide selected
information in emergencies—​especially in case the patient is unable to commu-
nicate. Formerly, the amount of information that could be conveyed this way was
limited to a single serious allergy or diagnosis. But today’s technology has essen-
tially eliminated storage as a barrier (except for truly giant files, such as clinical
images.).
In many states, a special class of advance directives (known sometimes as cardi-
opulmonary resuscitation [CPR] directives) is legally recognized by EMS workers
as acceptable, legal evidence of a desire not to be resuscitated. These may also be
carried as wearable tokens. The American Medical Association has endorsed the use
of implantable electronic microchips such as those used in veterinary medicine.37
These can carry a modest amount of information on board or serve as access devices
to larger repositories through remote servers. Over the years, the idea of portable
health records has attracted investments in products ranging from microfiche (in
ancient times!) to optical cards and disks to magnetic cards and chips to other dedi-
cated devices that have almost all failed commercially. The main problem with most
of these was the difficulty in getting adequate adoption of dedicated readers for each
device. Another fatal flaw was managing updates.
These problems have been resolved today by 2 developments. First, cell phones
and tablets can store enormous quantities of information and also serve as their
own readers. Second, the internet now allows access to virtually infinite storage,
including such data formats as medical imaging, that would be impossible to put
on older chips. There is no longer any impediment to delivering any quantity of
raw medical information at the point of care as long as there is internet access.
(Unfortunately, for some rural facilities this remains a serious infrastructure gap and
hence a safety, effectiveness, and cost issue.)
231

Now the issues are:

231
1. The questionable utility of unfiltered information (which worsens with volume)

Electronic Health Records

2. The difficulty of acquiring and reconciling information from multiple sources

USB drives are another portable information vehicle. Again, modern flash drives
have more than adequate capacity to hold most patient records, and security with
encryption is also readily available. However, because of concerns about importing
malware, many IT departments forbid plugging unknown devices into data ports
connected to their networks. (Many institutions actually disable USB ports and CD
drives.) This sets up a standoff with patients who carry their health information this
way at facilities where a dedicated, air-​gapped computer (isolated from the working
network) is not maintained to read it.
The fundamental—​and inexplicably most difficult-​to-​solve—​gap in prehospital
information flow is the lack of medical records in the hands of patients. Few patients
possess copies of their own charts, let alone in a format that would be usable in
an urgent situation. Patient charts in the United States are almost exclusively kept
by providers and facilities. Rarely, records of patients who have been previously
seen can be made available to the ED in advance of arrival. More often, they can
be delivered after the patient arrives. A record request must usually be sent to each
individual source; but increasingly, information pooling within integrated delivery
systems (e.g., Kaiser Permanente, the Veteran’s Administration, and recently, users
of EPIC health records), allows charts from affiliated sites to be accessed. It is easy
to envision better data sharing across unaffiliated sites, which is actively happening
through a growing number of health information exchanges across the United
States. This trend broadens the scope of information available at the point of care
(not just for emergency purposes) and generates another proposition:

Proposition 5—​Access to reliable medical records is the single most powerful safety
measure in an advanced health care system.

There is currently intense effort by agencies including the Office of the National
Coordinator for Health Information Technology, regional health information ex-
change networks, health care providers, and technology developers to facilitate data
sharing between information systems. The Centers for Medicare & Medicaid Services
issued a set of Rules in 2019 that support “seamless and secure access, exchange, and
use of electronic health information.”38 Improved transitions, as well as emergency,
mass-​casualty, and epidemic care are among its principal, foreseeable benefits.39

THE DOUBLE-​E DGED SWORD OF INTEROPERABILITY

Information sharing is different from raw data “interoperability.” One burdensome
but unavoidable consequence of connecting health information systems is data over-
load. There is no technology for summarizing or curating EHR content. Although
it is possible to speculate about how this might be done with artificial intelligence
strategies, record distillation is currently exclusively a human, expert task that needs
to be performed by providers at the time of hospital admission, consultation, or
discharge—​and may be necessary at many ambulatory encounters. Facilities that
share identically configured EHRs enjoy the advantage of large quantities of data
23

aggregated into related sections (although it should be noted that this does not nec-
Communication with Providers, Staff, and Personnel 232
essarily apply to products from a single vendor that are not identically configured).
However, this is not the same as reconciliation and curation.
From both safety and liability standpoints, the chance of critical information
being missed by a provider grows when large quantities of information need to be
quickly reviewed. Reconciling conflicting data (e.g., medications, problems, adverse
reactions) also becomes a greater burden. Currently, there is no automated solution
for this mounting problem, as data sharing increases across networks. In fact, “inter-
operability” might be viewed as self-​limiting, like population growth. One remedy
for both data overload and reconciliation would be a curated, summarized record
set that is somehow attached to each patient. Technically, this could be accom-
plished by patients carrying offline copies of their information on portable devicesiv
or with cloud-​based storage systems that deliver access to professionally curated in-
formation as appropriate.
The simplistic idea of patients toting full copies of all their medical records is not
an effective solution, even though it could be technically feasible. Even presuming
a (not quite perfected) standardized format for displaying every type of record, this
would simply relocate the source of data overload and amplify it, without addressing
it. (It might help with the problem of fragmentation.) The fantasy of a single, unified
repository of everyone’s raw records in a standard format would undoubtedly be
appealing for patients with scant or straightforward information, but it is not clear
how that would be workable for those with extensive histories. It would also fully
confront patients and the health care system with the problem of sequestering ac-
cess to sensitive material.

TRANSITIONS AND DISPOSITIONS

The most defining characteristic of emergency medicine is transitions. There is nothing
unique in EM communication that doesn’t apply to other kinds of patient care. But the
variety, number, and pace of EM transitions make an emergency department the per-
fect laboratory for studying medical communications at high concentrations.

Proposition 6—​ Hoarding patient information in proprietary silos (facilities,

practices, organizations) creates serious barriers to care transitions.

An analysis done in 2015 by the Healthcare Information and Management Systems

Society (HIMSS) identified 16 elements that governed the success or failure of
transitions of care (Box 15.3).40
Not all these elements are relevant to every transition; however, in many
instances, medical errors—​usually manifesting as delays in completing actionable
tasks—​can be attributed to flaws in one or more of these components.

THE 800-​P OUND GORILLA OF FOLLOW-​U P

The most dangerous procedure in medicine is transferring a patient from one
site or provider or level of care to another. This includes admission, handoffs,

iv Such things might be referred to as “personal health records,” but that term more often applies to do-​
it-​yourself archives rather than professionally curated information.
23

233
Box 15.3. Healthcare Information and Management Systems Society
Transitions of Care Elements

Electronic Health Records

1. Initiator
2. Receiver
3. Person
4. Information payload
5. Physical payload
6. Scope
7. Authority
8. Transport carrier
9. Planning and preparation
10. Communication medium and mode
11. Latency
12. Complexity
13. Priority
14. Notices, acceptance, acknowledgment
15. Tracking
16. Patient experience
Victoroff MS, Mayers HL, Linares AP. A general framework for managing care
transitions. JHIM. 2015;29(4):26–​37.

referrals, consultations, discharge, transfer, and especially follow-​

up after
episodes of care.

Case: A 55-​year-​old obese smoker is seen for knee pain. Deep vein thrombosis
(DVT) is discounted as a probability because medical records show he is cur-
rently taking warfarin and has osteoarthritis. He dies of pulmonary embolus.
Retrospectively, the medication list is inaccurate; warfarin was actually dis-
continued 1 year before.
Case: A 45-​year-​old patient is discharged on antibiotics for pneumonia con-
firmed on x-​ray. The radiologist reading the film the next day raises a question
of a lung nodule; follow-​up films are recommended. The report is transmitted
to the ordering (EM) physician and primary care physician; however, nei-
ther registers the agenda for follow-​up. Late-​stage lung cancer is diagnosed
18 months later.
Case: A 32-​year-​old inmate is returned to the prison infirmary at midnight
after evaluation and treatment in the ED. No records accompany the transfer
and there is no provider-​to-​provider phone call. He has an IV labeled “van-
comycin” and there is a dressing on his thigh that covers a Penrose drain.
Despite several calls to the hospital, infirmary staff are unable to deter-
mine the diagnosis, treatment plan, or pharmacy orders until the following
morning.
Case: A 64-​year-​old patient with HIV, hepatitis C, Crohn’s disease, and rheuma-
toid arthritis is discharged from the ED after specialist consultation. A new
medication has been prescribed that costs $20,000/​month and is not covered
by the patient’s insurance.
234

These cases illustrate variations on a common theme. Loss of critical information

Communication with Providers, Staff, and Personnel 234
between points of care is a cause of patient harm at least as important as misdiag-
nosis or wrong-​side surgery. And it is far more common, because failure to transmit,
receive, track, and act upon serious case management tasks is normalized as an un-
fortunate but inevitable risk of the health care system. Although wrong-​side sur-
gery is viewed by patient safety advocates as an event that should theoretically be
almost 100% preventable,v losing track of important follow-​up tasks is seen by many
as “someone else’s problem.”
The “Three Monkeys Defense” (see no evil, etc.—​it’s not my problem) does not
work. Patients deserve, and recognize the need for, continuity of information be-
tween points of care. The transient nature of EM practice imposes a professional ob-
ligation to deliver the best possible “information payload” to treaters and caregivers
who are next in line. The practical problem is how to call attention to actionable
information amid the background noise.
Medical information comes in 2 basic flavors, volatile and enduring. The value
of volatile information decays with a half-​life that depends on many factors; en-
during information is permanent (or at least semipermanent—​even parameters
assumed to be fixed, like gender, may sometimes change or be recorded wrong).
It takes professional judgment to decide what information should be flagged for
special attention in the future. This problem reiterates the theme of “documenta-
tion versus communication” addressed earlier. If records are viewed only as pas-
sive instruments of “documentation,” opportunities to activate follow-​up systems
will be missed. Unfortunately, some practitioners and facilities operate in systems
where patient records are treated as little more than “notes in bottles” tossed into
a data ocean.
Artificial intelligence will eventually develop the talent for spotting missed
tasks and raising alerts about them. While awaiting that miracle, there are measures
EM services can take to strengthen the effectiveness of patient care transitions and
reduce information loss between nodes. A philosophy that could be called “task-​
oriented medicine” recognizes that most patient care today happens in teams and
adds a centrally curated “task list” (visible to the patient) to the classic “problem-​
oriented” medical record structure.

HANDOFFS
A special case of care transition is the handoff of management from one provider
to another. It has been estimated that 80% of serious medical errors involve mis-
communication between caregivers during the transfer of patients.41 Because of
rapid patient turnover, staffing patterns, and other systemic reasons, emergency
departments are susceptible to “high error rates with serious consequences.”42
EM providers probably execute more intramural patient handoffs (sign-​outs,
shift reports, handovers) than most specialties. This is certainly true if extramural
referrals (discharges for follow-​up care) are included. Faulty handoffs are implicated
in up to 24% of malpractice claims in the ED.43

v A few years ago, there was a movement to label certain adverse occurrences as “never events.” This
term is no longer felt to be useful by most patient safety professionals.
235

235
Box 15.4. Situational Briefing Model

Electronic Health Records

SBAR
Situation –​ Background –​ Assessment –​ Recommendation

VERBAL COMMUNICATION
Although this chapter is about electronic communication, it would be incomplete
without emphasizing the importance of verbal communication, which makes up, by
some enormous amount, the largest percentage of ED “messaging.”
In a study of closed malpractice claims against emergency medicine physicians
from 2007 to 2013, the Doctors Company, a professional liability insurer, found that
failed communication among providers was a factor in 17% of patient injuries, and
failed communication between patients and family was a factor in 14%.3 However,
as discussed in the introduction, these figures may understate the problem.
Verbal misunderstandings with patients can arise because of language barriers
or cognitive impairment (including transient impairment from drugs or trauma).
Mistakes can arise in team communication through garbled or incomplete mes-
saging due to carelessness, slips, disorientation, fatigue, distraction, or background
noise, among other causes. Each of these has mitigation strategies. For carelessness,
one important remedy is professionally disciplined speech.

STRUCTURED COMMUNICATION
Technology enables 2 paradigm shifts in human communications—​compressing
space and time. The limits of geography are overcome by connected devices. The
limits of time are mitigated by message storage and forwarding. But errors that
occur in face-​to-​face communication can be propagated electronically as well.
Institutional culture and staff experience are strongly influential on the ways
providers speak to each other. This has a great bearing on communication safety.
Much research has gone into improving the effectiveness of verbal communica-
tion in high-​stress settings, including aircraft cockpits and operating rooms. Most
of this is relevant to emergency departments. Two widely supported disciplines for
structuring verbal communications are SBAR44 (and cousins ISBARvi and AIDETvii)
and the SIGNOUT? Mnemonic (part of the I-​PASS Handoff Bundle) (Boxes 15.4
and 15.5).45,46
Verbal templates like these have their roots in military environments, where
verbal communications (and errors) have extreme consequences. The patient safety
community has adapted lessons learned in these settings (particularly aviation) to
its own purposes. A wide variety of forms (many developed into software tools and
mobile apps) are available for specialized types of transitions (Table 15.3).
Perhaps the simplest and most powerful habit for safety in verbal communica-
tion is performing a “read-​back,” which means repeating the statement just heard
during a critical information exchange. This procedure is mandated by the Federal

vi Introduction, Situation, Background, Assessment, Recommendation.

vii Acknowledge, Introduce, Duration, Explanation, Thank You.
236

Communication with Providers, Staff, and Personnel 236

Box 15.5. SIGNOUT? Mnemonic (Part of the I-​PASS Bundle)83

SIGNOUT? Mnemonic
S Sick or DNR? (highlight sick or unstable patients, identify DNR/​
DNI [do not resuscitate/​do not intubate] patients)
I Identifying data (name, age, gender, diagnosis)
G General hospital course
N New events of day
O Overall health status/​clinical condition
U Upcoming possibilities with plan, rationale
T Tasks to complete overnight with plan, rationale
? Any questions?

Aviation Administration for air traffic controllers.47 Inexperienced health care

workers sometimes initially feel awkward, stilted, or too assertive doing this, but
a strong patient safety culture in an institution normalizes this extremely valuable
practice, which should be universal even in low-​stress but high-​precision settings
(such as verbal orders to pharmacists).
It should be noted that the benefits of semistructured verbal communication
and read-​backs apply to both face-​to-​face exchanges and telephonic ones.

Table 15.3. Other Transition and Handoff Resources

A Transitions of Care Framework Healthcare Information Management and

Systems Society (HIMSS)74
Acute Care Toolkit 1: Handover Royal College of Physicians75
Computerized Sign-​Out and See Abraham J, Kannampallil T, Patel VL. A
Handoff Apps (numerous) systematic review of the literature on the
evaluation of handoff tools: implications for
research and practice. J Am Med Inform Assoc.
2014;21:154–​162.
EPOCH CLINIC SAFE Pocket Picker Institute, University of Chicago,
Card Engineering Patient Oriented Clinic
Handoffs76
HANDOFFS mnemonic University of Washington77,78
I PASS THE BATON TeamSTEPPS/​AHRQ79
Medications at Transitions and Agency for Healthcare Research and Quality
Clinical Handoffs (MATCH) (AHRQ)80
Toolkit for Medication
Reconciliation
Safer Sign-​Out Form Emergency Medicine Patient Safety Foundation81
Targeted Solutions Tool (TST) The Joint Commission Center for Transforming
Healthcare82
237

237
Box 15.6. Positive Exchange of Flight Controls

Electronic Health Records

1 “You have the flight controls”
2 “I have the flight controls”
3 “You have the flight controls”

A fine but critical gap in communication centers around the difference between
conveying information versus acknowledging (or negotiating) accountability and
responsibility.48 A cockpit ritual in aviation is the 3-​stage handoff demonstrated in
the guideline for “Positive Exchange of Flight Controls”49 (Box 15.6).

AUDIO AND VIDEO RECORDING

There are several good reasons to offer patients the opportunity to record
conversations with their health care providers. Not the least of these is to recognize
openly the possibility that visits may be recorded without providers’ knowledge.
The benefits of patients recording health care encounters can be significant. It
mitigates the “fog of the examining room,” which can make it difficult for patients
to recall instructions and advice. Caregivers who were not present at the visit may
appreciate having a clear understanding of what patients were told and advised
(and also not told for that matter). Understanding and adherence to preoperative
consents and instructions; postdischarge plans; activity, medication, equipment,
and dietary requirements; follow-​up needs; and warning signs may all be better
when available in the form of recordings. Comprehension of test results and answers
to questions often improve on a second hearing. Some patients may find it easier or
more natural to review verbal than written information.
Patients highly value recordings of their visits. They listen to them, share them
with caregivers, and report that they improve understanding and recall of medical
information. Some facilities routinely offer video recordings of patient visits. It has
been suggested that this practice may reduce professional liability costs.50
These benefits to patients are also good for providers, with 2 exceptions. First,
and quite obviously, if recordings document errors or misbehavior or they contradict
practitioner records, they become liability fodder. Second, surreptitious recording
by patients demonstrates a lack of trust in providers that may subtly—​or directly—​
impair the professional relationship or interfere with well-​intentioned care.
These concerns have prompted policies in some health care organizations that
discourage or attempt to prohibit some or all types of recordings, including audio,
photos, and videos taken with mobile phones.
Certainly, there are situations where audio or video recording is inappro-
priate. Covered entities (e.g., providers and facilities) under the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) are required to protect pa-
tient privacy. Allowing deliberate or even incidental recording of patients without
their consent (by other patients or visitors) may expose providers to civil or crim-
inal charges. Recordings made of patients in the course of treatment are clearly
protected health information and must be treated as such. But the universal avail-
ability of pocket-​sized devices that are widely used to document any conceivable
238

aspect of their users’ lives makes it increasingly probable that patients will expect the
Communication with Providers, Staff, and Personnel 238
freedom of using them and resist (or defy) restrictions they feel are unreasonable.
Wiretapping laws in 39 states permit “single party” consent to record
conversations.51 This means any party to a conversation can legally record it without
the consent of others. Eleven statesviii require consent from “all parties,” making it a
felony to record conversations without it. Providers and staff in “single party” states
would be best advised to assume they might be recorded at just about any time. This
implies that they must be on their best professional behavior whenever they’re on
the job—​which doesn’t seem too hard to ask. In other states, a decision needs to be
made whether it is really in the best interest of the health professions to prosecute
patients who make covert recordings even if they are, strictly speaking, illegal. The
general tide among health care organizations is flowing in the direction of “You can’t
beat them, so join them.” Many facilities may find that this offers more upside than
downside.
Emergency departments, specifically, might find it well received and potentially
beneficial to adopt policies that allow (or encourage) patients to record parts of
their encounters. This must be done in ways that do not risk violating the privacy
of other patients. Routinely making the recording a part of the patient record both
demonstrates good faith and helps ensure it is preserved unaltered.

TEXT MESSAGING AND THE WILDERNESS OF BYOD

Like fax machines, “dumb,” one-​way radio pagers are relics of a predigital era. This
is not to say they are not still widely used. However, health care organizations are
steadily replacing these with cell phones, which are “smarter” in the sense of having
numerous functions beyond the ability to make voice calls.
Cell phones use different communication frequencies and technical protocols
than pagers, have different security issues, and are much more often the personal
property of the individuals who carry them. The near universality of mobile, digital
communication devices purchased and maintained by individuals across the devel-
oped world has meant a windfall for organizations that used to budget for pagers.
“Bring Your Own Device” (BYOD) is now essentially taken for granted. This radi-
cally complicates the IT department’s job of securing and managing them.
The benefits of smartphones grow with every new application. A 2015 report
from the IMS Institute for Healthcare Informatics found over 165,000 apps in the
Apple iTunes and Android App Stores.52 (This is a nice, quotable, but meaningless
figure. The majority of these are aimed at consumer health and wellness, and only
a tiny fraction are even slightly popular or useful.) By far, the main uses of personal
mobile phones in health care are voice communications, voice messaging, text mes-
saging, email retrieval, and internet access.

BENEFITS AND VULNERABILITIES OF TEXT

MESSAGING
Off-​the-​shelf text messaging (TM) is included with every smartphone and is used
extensively by health care workers. Staff (especially residents) in many EDs readily

viii California, Florida, Illinois, Maryland, Massachusetts, Michigan, Montana, New Hampshire,
Oregon, Pennsylvania, Washington.
239

admit they could not get through a day without it. Apart from sparing the institu-

239
tion the cost of pagers, TM on personal devices has many benefits:

Electronic Health Records

• It requires no special training.
• The device is essentially inseparable from the individual.
• Messages are asynchronous—​they can be responded to immediately or later.
• Messages can be saved, copied, and forwarded.
• Messages can be sent to multiple recipients.
• There is universal connectivity across different manufacturers (in contrast
with EHRs).
• Messages allow media attachments.
• Messages are timestamped and sources are identified.
• Many TM apps automatically group messages with the same recipients in
“threads.”
• There is at least a modest degree of security if the device is protected.

There are also drawbacks, most of which can be mitigated by replacing the
device’s native, off-​the-​shelf application with one of many, inexpensive, “secure
messaging” apps:

• Misdialing. This can cause confidentiality breaches as well as message transmis-

sion failures. This risk is significantly reduced in apps that offer a restricted con-
tact list. Although there is a finite chance of misdialing with any device, limiting
errors to a list of authorized correspondents makes a serious HIPAA violation
much less likely.
• Lack of receipt verification. Type II errors (failure to receive/​transmit neces-
sary information) can occur if the phone is off or unavailable, if the device is in
a “dead” zone, if the recipient is not on call, and so forth. Off-​the-​shelf TM apps
do not have a way of notifying the sender when a message has been—​or has not
been—​received. Specialized messaging apps may have bounce-​back alerts when
messages are not acknowledged within a certain time interval. They may even
allow failover protocols to be programmed that specify secondary recipients ac-
cording to a “first on call,” “backup on call” list.
• The device may not be secure. Lost devices present a clear HIPAA breach
risk. They must be defended—​at a minimum—​with passwords. Many modern
cell phones are encrypted by default (which should be considered virtually
mandatory when used for protected health information). Text messages, even
unencrypted in transit, are moderately difficult to intercept, and the fear of unau-
thorized wiretapping is probably overblown as a HIPAA risk. However, all secure
messaging apps encrypt contents during transit, which reduces the risk of inter-
ception (by most adversaries) to infinitesimal. The much greater risk is loss or
theft of the device.
• Cell networks are not perfect. Although many urban users take cell connec-
tivity for granted, this is not necessarily true in some geographies, and is still
somewhat dependent on the service provider. Even in areas with dense coverage,
there are dead zones in many buildings, garages, and so forth.
• Vulnerability to phishing and spoofing. Unfortunately, error is not the only
source of risk. Bad actors may actively try to subvert or interfere with clinical mes-
saging. Like email, devices used for voice and TM are targets for fraud. Restricted
240

contact lists, encryption, and other technical measures are one line of defense.
Communication with Providers, Staff, and Personnel 240
User training remains the most important one.
• Does not integrate with EHR. Off-​the-​shelf TM apps have 2 integration problems,
both of which are typically solved with dedicated secure messaging apps. First, their
contact lists/​directories are not synchronized with those of the EHR. (They may
sync with personal email lists, but personal lists create breach hazards.) Second, and
more important, messages exchanged on standard TM apps are not automatically
brought into EHRs—​in fact, even copying and pasting them manually may involve
many steps. This creates a class of missing records that invites patient safety errors
and also makes liability defense problematic. Advanced mobile apps not only cap-
ture and archive clinical messages but also may even directly interface with EHR
functions such as order entry and result reporting.
• Commingling personal and professional messages. Dual-​use devices expose
users to misdialing errors when they do not separate contact lists. They also have
the subtler risk of interrupting medical workflow with personal messages or even
spam and junk calls. An increasing concern in health care settings is that mobile
devices tempt users to divert time from patient care and productivity onto social
agendas like shopping, chatting and following news feeds.

EXTRAMURAL COMMUNICATION
Typically, the most fluent and effective communications in a facility are in-
ternal, involving familiar participants, workflows, expectations, and technologies.
Communication habits tend to become more effective in teams that work to-
gether over time. Most EM practitioners are highly successful in delivering infor-
mation about the primary condition of concern to the receiving site when patient
transitions occur.
What sometimes become separated from the patient might be called “incidental
findings” (like a nonurgent but significantly abnormal x-​ray or lab report). When
patients become disconnected from the care system, the label often used is “lost to
follow-​up.” In a high-​performance safety culture, this phrase should have the same
implications as “wrong-​side surgery.”
In a lamentable symmetry, just as patient information available to EM
practitioners is often incomplete and sometimes unreliable on admission, likewise,
the information accompanying patients discharged from the ED can be frustratingly
unhelpful. Worse are the many cases in which it is simply not transmitted. This com-
ment is not meant to disparage the efforts of practitioners who take pains to pro-
vide good discharge documentation. Rather, it recognizes the enormous barriers to
achieving this goal.

Proposition 7—​Intramural communication within health care units is often

magnitudes more effective than extramural communication with outside parties.

Medicine does not embrace communication of health care information—​outside

the immediate workgroup—​as a core value. This is for a swarm of reasons, some
rooted in ancient models of doctoring, some arising from the way technologies are
deployed in institutions, some owing to a culture of professional autonomy. This
might seem to contradict the high level of activity in the United States (incentivized
241

by federal investment and mandated by regulations) promoting health information

241
exchange. But the need for public policy action on health information exchange
(HIE) comes in the face of disinterest, and sometimes active resistance, from health

Electronic Health Records

care organizations and providers.
The telephone (synchronous, direct, verbal) remains the single most effective
channel for providers to communicate actionable information about patients in
transition. But the 24/​7 nature and fast pace of EM and the disjunction between
the workflows of ED and non-​ED practitioners make real-​time conversation a chal-
lenge. When there is no pressing urgency, asynchronous communication is the
dominant and far-​preferred mode on both ends. Besides convenience, asynchro-
nous channels (like fax, texting, email, EHR portals, and postal mail) allow higher-​
density messages than can be conveyed in verbal reports. But both modes are
subject to information loss and task failures, through different mechanisms. Their
main failure mode is lack of a common path to enter critical tasks into a follow-​up
system.
Every impediment to direct provider-​to-​provider communication represents
a safety hazard. One reason hospital-​based providers (such as EM, radiology, and
pathology) sometimes dread calling outside colleagues is the barrier they often en-
counter in the form of the justifiably despised “automated call director.” In their best
form, these “Press 1 if you feel like pressing 1” systems can equal a human operator’s
efficiency in handling incoming calls. Unfortunately, in typical configurations, they
create agonizing inefficiency. Fighting automation with automation, health care
providers frustrated by the hassle factor involved in trying to reach colleagues di-
rectly fall back on asynchronous channels. This predicament contributes to defects
in information flow.

ELECTRONIC PORTALS
So-​called electronic portals deserve special mention. Almost every contemporary
EHR system offers some kind of access to medical records by external parties
(either patients or providers) who must register credentials in the system. A
few, rare systems grant full access to the unfiltered medical record—​although
the trend to completely open records (with exceptions) is spreading. The more
typical system publishes a limited set of highly filtered data (sometimes different
for patients and professionals), which may only appear after a lag time of hours
or days.
Portals offer the following advantages:

• Secure, asynchronous communication. “Fire and forget” publication of infor-

mation to a designated set of authorized recipients, on a secure platform.
• Attachments, links, resources. Capability of delivering downloadable files of
almost any size, or executable links to online services.
• Documentary record. Timestamping of transactions like uploads, downloads,
views, edits, responses—​or absence of responses.
• Engagement and follow-​up. A channel that allows patients and colleagues to
stay connected with the organization.
• Compliance. A tool that may help patients adhere to care plans.
• Translation. Information can be published in different languages.
24

• Bidirectional messaging. A portal may allow secure communication—​including

Communication with Providers, Staff, and Personnel 242
messages or uploads from physiologic devices—​from external parties.

However, portals introduce important issues that administrators must address:

• Data governance. There are administrative and technical requirements to super-

vise what is published for accuracy and appropriateness, manage “drift” between
versions of documents that may change after being initially viewed, manage
updates and corrections, control access (provision and de-​provision credentials),
monitor security, etc.
• Obligation to review. Both outgoing and incoming documents need to be
reviewed to ensure that critical information is addressed in a timely way.
• Assumptions. Paradoxically, the benefits of easy document exchange between
patients and providers can instill a false sense of confidence on both sides. It can
happen that one party or the other assumes, “They’ve seen it” or “They’ve got all
that” when it isn’t so.
• Minors. A large body of law and regulation (which varies by state) governs the
rights of parents and children to access, authorize access, and restrict access to
certain kinds of medical information on minors and dependents. Because no cur-
rent technology can automatically filter information at the level of granularity the
law demands, portal administrators are faced with the choice of manually (and
flawlessly) editing documents for consumption by different audiences, or simply
not publishing records on children of certain ages (e.g., 13 to 18). This problem
presents a dilemma for parents of children with serious conditions or develop-
mental delays, whose care depends on them to manage record exchanges.

Perhaps the most problematic aspect of portals is being tethered to EHRs. For
technical and economic reasons, data governance happens at the level of the re-
cord custodian who controls the source EHR, such as a hospital or medical group.
Access control—​passwords and permissions—​occurs separately for each institu-
tion. This means external users need credentials for every portal they wish to con-
nect to, even for a single patient. Imagine someone arriving in the ED from out of
state, who says, “Don’t worry, all my data is on the portal at Overthere University
Hospital. Just create a login and you’ll see everything.” For a department with 60
providers, this would mean registering 60 passwords (which can’t be shared for
security reasons) and potentially updating them at mandatory intervals, if the host
requires that. Multiplying this requirement by the number of potential external
data sources creates a logistic conundrum that is simply absurd. A universal data
repository, or a covenant for transparent, universal access as occurs in the credit
card industry, is a frequently invoked proposal. But a moment’s analysis of the
differences between bank balances and medical records exposes the fallacies of
this approach.
HIPAA does not require patient permission to transmit health information
between treating providers.53 And most institutions recognize certain authorized
recipients of medical information for a given patient (such as a referring physi-
cian) and deliver postdischarge information to them as part of a routine workflow.
However, lag times can be significant. In a far-​from-​unusual example, one large, aca-
demic health center ED often cannot deliver a handoff report to an external provider
calling on the phone about a just-​discharged patient, because “the dictation hasn’t
243

been transcribed yet.” Reports may be missing vital data or may be ludicrously in-

243
flated with irrelevant padding.
Many EHR systems publish printed versions of patient records that are dramat-

Electronic Health Records

ically different from the version seen by system users.ix In many cases, printed EHR
output is so badly formatted that it is virtually impossible for receivers to interpret,
or requires a demoralizing amount of effort to review. An exercise well worth its
time is for an organization to review its outgoing work product and evaluate it from
the perspective of outside users.

RECORD BLOCKING
For outside users to whom records are not automatically “pushed” by an information
system (including bona fide treating physicians, in many cases), the typical—​and
frustrating—​channel for medical record transmission is the dance of request and
release through a formal HIPAA ceremony. Most (but by no means all) providers
today understand that HIPAA waivers are not needed to transmit records to ex-
ternal practitioners who have bona fide relationships with patients. Nevertheless,
delays are standard in obtaining them. A commonly quoted myth in medical record
departments is, “We have 30 days to deliver requested records.” This is not, in fact,
how the Office for Civil Rights interprets the law:

The Privacy Rule is intended to set the outer time limit for providing access, not indicate
the desired or best result, and it is expected that many covered entities should be able
to respond to requests for access well before the 30-​day outer limit.54

There are valid reasons why some records may be hard to produce, for example,
when they are in paper form and have been archived, sometimes off-​site. However,
failing to deliver current, active records to treating providers occurs most often be-
cause of (1) willful hoarding for the purposes of monetization or (2) a culture that
does not take the information needs of colleagues seriously.
Regarding the first problem, in 2015, the national coordinator for HIT reported
to Congress that information blocking by EHR vendors and facilities impairs “the
safety, quality and effectiveness of care provided to patients.”55 Federal regulations
now impose significant penalties for this practice.56 These rules were strengthened
in 2019.
The second problem, like all cultural barriers to medical care, will take longer to
remedy. The simple approach being taken by growing numbers of facilities is auto-
matically to send documents from ED encounters (once prepared) to any provider
designated by the patient. This may not always be sufficient, but it is arguably better
than not communicating at all.

WEBSITES
Many hospitals, practices, and urgent care centers provide information about their
emergency services via websites. These may be purely “static,” in the sense of maps

ix This creates a problem in some professional liability and quality improvement settings, where the ac-
tual display that the user relied on may be essential to understand.
24

and directions, hours, and so forth. Or they may be interactive, offering registration
Communication with Providers, Staff, and Personnel 244
forms that can be filled out or even transmitted online. Real-​time information such
as ED waiting times may also be published, either via the internet or through elec-
tric signage visible from the street. As with other direct communication channels, it
is important for facilities that engage patients directly to have carefully considered
terms of use and disclosure statements.

DISTRACTED AND IMPAIRED PRACTITIONERS

A growing body of experience raises concern about the use of electronic devices in
health care environments (cell phones, tablets, and anything that can connect to the
internet—​including EHR workstations) for non-​work-​related purposes.57 Medical
professionals and staff have been observed in social media interactions, chatting,
online shopping, checking stock prices, viewing entertainment feeds (and pornog-
raphy), and doing every other conceivable activity that can be performed on a de-
vice, when they should have been engaged in patient care. This has created serious
questions about lost time and effort in the workplace and, much more importantly,
risk to patients.
Amplifying this concern is some early evidence that, at least for some users,
electronic devices may actually induce dependency and withdrawal syndromes
analogous (if not physiologically identical) to opioid or alcohol addiction.58
A widely discussed case was reported to the Food and Drug Administration
(FDA) involving a medical resident who was interrupted by a personal phone mes-
sage while writing an anticoagulant order. The order was not written and a patient
was critically harmed.59 Even work-​related distractions present a safety risk. In a
2013 study, researchers found that an interruption as short as 4 seconds tripled the
error rate of subjects performing a sequencing task.60
It is clear that it is impossible to drive safely while texting, and probably even
while verbally conversing on a handheld device.61 So, what makes a doctor or
nurse think that he or she can safely engage with a patient while typing notes
and checking lab results? What makes EHR vendors think this is possible? A
strong cultural bias supports “multitasking” as a normal aspect of medical prac-
tice. Actual evidence may demonstrate this to be a dangerous form of denial,
which fails to recognize the risk of “attentional blindness” induced by electronic
devices.

EDUCATION, INSTRUCTION, FOLLOW-​U P

Patient education and instruction are parts of the complex task of follow-​up. Many
software applications assist providers in publishing health education materials and
discharge instructions for patients in several languages. Some EHRs include this
function; some facilities use add-​on or external applications. As a matter of prac-
tice, simply handing patients a printout or leaflet may satisfy a formal, ceremonial
requirement for “education.” But this falls short of actually fulfilling the need for
communication.
It is in follow-​up, however, that EM faces one of its greatest ethical, technical,
and liability challenges. One factor that overshadows any simplistic solution to
postdischarge care planning is the fact that many patients treated in EDs are there
245

precisely because they have no other source of care. This shameful fact of life in US

245
healthcare can’t be solved by technology.
Thinking of the suicidal adolescent, the homeless schizophrenic, the undo-

Electronic Health Records

cumented trauma victim, the adult worker without insurance, the non-​English-​
speaking grandmother with diabetes—​the list is long and sad. Heroic efforts are
made in many EDs to secure postdischarge resources and treatment for complex
and high-​need patients. This chapter is not about that. Focusing strictly on ways
electronic information systems might help with follow-​up, a few ideas deserve
exploration.
The primary unmet need for the “informationally complex” patient is health in-
formation that is

• comprehensive (all dates, all sources),

• portable (accessible wherever the patient may be),
• summarized (filtered to eliminate volatile, stale, and irrelevant data),
• curated (professionally edited for coherence and intelligibility), and
• reconciled (verified for accuracy with providers and the patient).

Such high reliability information cannot currently be produced by EHRs and may
require the development of clinical information systems outside of them.
The second greatest unmet need is for a comprehensive task list that follows the
patient, rather than being tethered to any single source of care.
The third greatest need is for communication systems (including hardware,
applications, infrastructure, and processes) that can keep patients connected not
just to the health care system, but to other social support systems as well.
Implicit in these visions are policies, methods, and technologies for identify­
ing individual persons and efficiently paying for and tracking their necessary
expenses.

RADIOLOGY
The heaviest communications traffic in and out of the ED is with the lab, radiology,
and pharmacy. The American College of Radiology (ACR) has crafted guidelines
(“a practice parameter”) for the communication of diagnostic imaging findings, x
which present a thoughtful analysis with templates for critical workflow that could
profitably be studied by other specialties that render critical narrative reports to
colleagues.62
The ACR specifically recognizes a difference between routine and “nonroutine”
communication and advises that nonroutine communications “be handled in a
manner most likely to reach the attention of the treating or ordering physician/​
health care provider in time to provide the most benefit to the patient.” The ACR
favors direct, synchronous (“by telephone or in-​person”) communication over
asynchronous methods for these purposes.
The ACR also recognizes a category of communication it labels “informal.” It
uses the term curbside consult to refer to this category and points out that informal
communications between practitioners carry inherent risks. Some of these are:

x This is labeled as “an educational tool” for liability reasons.

246

1. The content may not become memorialized in the medical record.

Communication with Providers, Staff, and Personnel 246
2. Different providers may recall the content differently.
3. Tasks stemming from the communication may not be entered into task
management or reminder systems.
4. Amendments, corrections, retractions, or reconsiderations of the discussion
may not become disseminated.
5. Content is not available for later analysis.

This activity by the ACR is part of a general recognition of the hazard that has been
a running theme in this chapter: reducing the loss of information “signals” between
different nodes of care.

LAB AND PHARMACY COMMUNICATIONS

The founding principles of computerized provider order entry (CPOE) were aimed
at improving efficiency and reducing errors in medication orders. This has been
achieved, albeit with the predictable consequence of introducing new types of ad-
verse events arising from the design and use of electronic systems. These have been
extensively studied and reported.63,64 In fact, it is an artifact of the volume of CPOE
transactions, coupled with the ease with which data can be collected about them,
that has made “medication error” the largest single category of reported medical
mistakes. This statistic needs to be appreciated in light of availability bias. Order
processing encompasses millions of transactions per day in the United States.
Nevertheless, valuable lessons about how to create, transmit, and execute pharmacy
orders and exchange messages about them with a high degree of success continue to
be gleaned from this rich data source.
Vulnerabilities of CPOE are similar for pharmacy and laboratory commu-
nication. Both have been ideal problems and produced major successes for EHR
developers.

TELEMEDICINE AND TELECONSULTATION

No chapter on EM communication can omit mentioning telemedicine (used here
synonymously with “telehealth”).65 This technology is emerging as the great equal-
izer of EM capabilities and capacity. Telemedicine may be the most disruptive
sociotechnical practice to impact health care since the invention of the x-​ray. This
holds for both the developed world and the developing world, where adoption may
be progressing even faster. This is addressed more fully in Chapter 7.
The technical challenges of what might be called “Telemedicine 1.0” (real-​
time, audiovisual communication and data sharing among medical experts and
patients) have been solved, or are at least fully understood. Statutory, regulatory,
economic, cultural, and ethical issues are lagging behind user demand, not leading
it. “Telemedicine 2.0” (remote, robotically assisted services and procedures) are
more than imminent. Services that used to require an intimidating investment in
hardware and support are now cheap and as available as social media. It has been
speculated that virtual visits could outnumber traditional, face-​to-​face patient visits
by 2025.66
Professional-​to-​professional teleconsultation may even prove more quickly
disruptive to established care pathways—​ and effective in improving health
247

outcomes—​than remote physician-​to-​patient visits. The poster child for such

247
services is teleneurology, first introduced in 1999 in the form of a telestroke con-
sultation service, and now a mainstream practice.67 This model has exploded into

Electronic Health Records

services that provide expert clinical care for a wide spectrum of acute and chronic
conditions. Within the near future, EM providers will activate teleconsultation serv-
ices as regularly as they order advanced imaging procedures.
From an EM communications perspective, a few general points deserve
emphasis:

• The complex web of legal, regulatory, ethical, and liability issues surrounding tel-
emedicine practice is rapidly being addressed and resolved in favor of providing
access to these technologies for a broad population of patients.
• Many strategic, economic, workforce, and logistic calculations that have long
governed planning (especially by governments and large entities) in the health
care industry will need to be recalibrated as the constraint of geography is
replaced by the constraint of connectivity.
• Just as the “patient record stack” (either by its absence or its overwhelming
volume) presents problems for the EM practitioner, the same applies to
telemedical consultation. The need for portable, curated, interoperable patient
records becomes sharply apparent when care is virtualized across geographic and
organizational boundaries.
• The tremendous power of teleconsultation will become fully exploitable when
data channels (such as imaging, lab, telemetry, and curated records) run as easily
as video and audio.

METADATA
One issue lurking behind the visible benefits and hazards of HIT is the role played
by electronic metadata for administrative and forensic purposes. Metadata are es-
sentially electronic surveillance records of user and system behavior. They are files
and logs, typically hidden from users, that track and monitor user interactions with
computer applications. Some examples are:

1. Dates, times, and identities of users logging in and out; work duration and in-
tensity; pauses and interruptions; locations of terminals and devices used (in-
cluding in some cases GPS mapping)
2. Timestamped records of keystrokes and mouse clicks (including backspaces
and corrections) and data entered, changed, deleted, printed, or transmitted
3. Timestamped records of files, screens, and messages opened, viewed
(and for how long), closed, printed, saved, received, and sent (from and
to whom)
4. Timestamped records of applications used, including browser/​internet usage,
URLs of sites visited, and content viewed, uploaded, and downloaded
5. Timestamped records of cell phone usage, including numbers and duration of
calls and content of text messages

Electronic metadata are critical for IT staff who monitor security and privacy threats,
fraud detection, and user compliance. They are essential for software quality man-
agement and development. They are used in employee performance measurement,
248

quality improvement, and workflow analysis. And they are increasingly relied upon
Communication with Providers, Staff, and Personnel 248
by plaintiffs and defense to analyze adverse events in liability claims.
Health care workers essentially operate in a high-​surveillance environment, like
a convenience store with a video camera over the cash register. (For that matter,
video monitoring is also increasing in health care facilities.) It is essential that users
of HIT systems remain constantly aware that every interaction they have with an
electronic application is potentially being captured for future analysis.

Proposition 8—​Detailed data on user interactions with electronic systems are often
recorded and are discoverable for many legal and administrative purposes.

At the bottom of the Pandora’s box of all this previously unavailable data lies a
technology that might offer relief to providers overburdened by data entry tasks.
Teletranscription (telescribe) services that capture rich audio and video records
of physician-​patient encounters are being tested by a number of companies. In ad-
dition, real-​time, speech processing systems are being tested for hands-​free tran-
scription of both provider and patient dialog in the examining room. Some of these
use standard desktop or room-​based webcam equipment, some are testing wear-
able glasses or bodycams (like those being rapidly adopted by law enforcement
departments), and some are wiring the entire room with microphones and cameras.
The complex implications for medical culture, law, ethics, and privacy will be exhil-
arating to negotiate.

PRIVACY AND SECURITY

Long before the era of digital communications, there was a need to ensure confi-
dentiality, integrity, and access to patient information. But this familiar triad was not
clearly articulated until the 1990s, when electronic media beyond phone and fax
evolved to become the dominant channels for transmitting and storing medical in-
formation. Today, every US facility that uses electronic communication systems is
legally obliged to comply with the federal HIPAA Privacy and Security Rules, which
are meant to protect patient information from unauthorized access, corruption, and
loss.67
This chapter is not the place to delve into the important topics of physical, tech-
nical, and administrative safeguards for protecting electronic information. However,
a few bright points should be brought up regarding health care information systems
in general, and communication systems in particular.

• They are attractive targets for criminals, mischief makers, and disgruntled
employees. Health information systems at the time of this writing are the most
often hacked and breached databases in the United States.
• They are hard to secure because of the large number and variety of users who need
access to them, their wide variety of data types, the large number of applications
and databases in which they reside, and the multiplicity of channels through
which data need to be transmitted, among other factors.
• They are complicated and frequently updated; training, monitoring, and mainte-
nance are difficult.
• Health care culture and the needs of care management strongly depend on
sharing information.
249

• Medical professionals resist the discipline needed in highly secure information

249
environments.
• Computer applications that are built with security primarily in mind impose

Electronic Health Records

a high overhead of inefficiency, which is intolerable—​and unsafe—​in high-​
performance health care settings.

For these and more technical reasons, the communication capabilities of EHRs
and other HIT applications represent their weakest links with respect to threats to
protected health information. The best way to secure information is never to com-
municate it. But this is silly. So practitioners must consciously weigh and trade be-
tween the value and necessity of communication and the risk of breach and loss.
Two principles are easy to say and hard to implement:

1. Try to use the most secure channel that’s available, given the urgency of the
situation.
2. Try to transmit the minimal necessary information consistent with the clinical
need.

Again, looking at medical malpractice risk, there are only rare lawsuits against
providers who communicated too much. In contrast, many suits arise from
providers’ failure to communicate enough, or in a timely way. The default position
must be to communicate completely and promptly. HIPAA allows very broad lat-
itude in information sharing between clinicians for bona fide treatment purposes.
The electronic applications described in this chapter should be seen first as means
of promoting patient safety and care effectiveness, and only second as privacy risks.

DISASTER PREPAREDNESS AND DISASTER

RESPONSE
From the standpoint of the emergency department, disasters take 2 forms. The more
manageable type involves receiving casualties from an external event. The type with
the greatest impact on providers is when the ED itself falls victim to disruption.
External disaster preparedness is an entire subspecialty within EM, and
extending far beyond. From a communications standpoint, most of the previous
material is relevant, with an emphasis on coordinating resources and activities with
specialized external organizations. Technological interoperability between disaster
response services and emergency departments is a thread in a complex skein of
problems that have received intense scrutiny since 9/​11/​2001.68
Although the scale is smaller, a comparable effort needs to be put into prep-
aration for events within the facility itself. Risk assessment involves weighing the
nature of each potential threat, the pathway (vulnerability) through which it might
impact operations, the probability (risk) that it might occur, the impact if it did
occur, and the safeguards that are called for to prevent or mitigate it (Table 15.4).

COMMUNICATING WITH GROUPS

Whatever the disaster, messages usually need to be broadcast to multiple recipients.
In high-​performance systems, it is efficient to define groups to receive certain kinds
250

Table 15.4. Risk Assessment Examples

Communication with Providers, Staff, and Personnel 250 Nature Pathway Risk Impact Safeguards

Information Power outage, Moderate High; potentially Backups,

system hacking, short or antivirus,
downtime programming intermediate redundancy,
error, hardware duration training
failure
Staffing Epidemic, Low Very high; typically Redundancy,
shortage transportation short duration overtime,
failure temporary
staffing
services
Active Workplace Very low Catastrophic; very Access
shooter violence short duration controls,
visitor
screening
Flood Plumbing failure, Moderate From inconvenient Maintenance;
weather to catastrophic evacuation
plan
Infectious Patient, visitor, or High Typically low; Infection
exposure staff potentially high control
procedures

of communications. Some examples of messaging groups and communication

channels are listed in Table 15.5.
Programmable emergency communications systems (ECSs) can be set up with
sophisticated rules. For fires, power failures, or active shooter events, for example,
a variety of commercial products are available that will broadcast tailored text or
voice messages to selected recipients (e.g., administrators, chief of security, chief
medical and nursing officers, police) about the nature of the event in progress.
Some systems allow status reports from designated representatives and may even
poll users about their locations and the status of their surroundings (e.g., “all clear,”
“injured persons present”).
These systems can be used in departments that treat medical emergencies to
notify or summon on-​call teams for critical care, transport, psychiatric or surgical
needs, and so forth.

THE INTERSECTION OF MOBILE APPS, SOCIAL MEDIA,

AND EMERGENCY COMMUNICATIONS
In 2017, 50% of households had no landline telephone service; of the remaining
half, 39% had both a cell phone and a landline.69 In the decade from 2001 to 2010,
society transformed from one where 13% carried a mobile phone to one where 70%
carry one.70 The human impact of this revolution has not been upon voice commu-
nication, but on the prevalence of social media and mobile software applications.
Applications with both dubious and bona fide health care purposes appeared early
251

Table 15.5. Examples of Messaging Groups

251
Group Examples Channels

Electronic Health Records

Everyone in a given location Emergency Overhead page; audible or
department staff visual alarm system
People who need to see the Physician, nurse, Whiteboard; room status flag
status of something where radiology
they are physically present technician
People who need to be Administrator, Group phone/​voice; page;
notified about the status of pharmacy manager, text
something when they are plumber
not present
People who need to learn Public relations Group voice message, fax,
about something later manager, family email
members
Response team for Fire department, law Group phone/​voice, page,
emergency, disaster, crisis enforcement text, radio; with response
required

in this market, and now tally in the hundreds of thousands.71 This technology
presents enormous opportunities for potential benefits (as well as mischief) in the
field of EM:

• Welfare checks by family or professionals (e.g., Facebook Safety Check)72

• Real-​time disaster information and monitoring, family and friend connectivity,
public information from government and private organizations (e.g., National
Weather Service, Red Cross)73
• Suicide prevention, hotlines, crisis intervention, lost children or elderly
• Countless anecdotal reports of successes in connecting help to people in need,
from police to rescue services—​and yes, health care providers

Although some EHRs offer mobile connectivity like portal access, patient-​
generated physiologic monitoring data (e.g., blood sugar), health advice, and even
live chat, most traditional HIT systems do not welcome or accommodate most ex-
ternal data feeds, for very good reasons. These include obvious security concerns, as
well as daunting data governance issues like authenticating sources, filtering spam,
directing data into appropriate channels, logging responses, and perhaps the worst
practical problem, managing the already impossible provider “inbox.”

CONCLUSION
Analyzing technology today is like reporting on a tornado from inside it. During the
writing of this chapter, dozens of new applications, processes, systems, solutions,
failures, and disasters made themselves known that impacted its conclusions or de-
served more discussion. Ultimately, summarizing sociotechnological developments
arrives at a point of arbitrarily drawing a line and saying, “OK, we have to stop, now.”
Although new technology is rapidly producing improvements in delivery of care, we
25

need to be aware of the implications and pitfalls associated with both the transfer of
Communication with Providers, Staff, and Personnel 252
information and the infrastructure for doing it.

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257

SECTION IV   
COMMUNICATION
OUTSIDE OF
THE HEALTH
CARE SYSTEM
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259

16 Media Communication
Christopher B. Colwell

INTRODUCTION
Effective media communication doesn’t happen by accident or by chance. It is
often the result of using public relations tools and developing relationships with
the media. As the expertise of emergency physicians has become more recognized,
opportunities and responsibilities to interact and communicate with the media
have grown. Emergency physicians must be prepared to interact with the media
in response to situations they have been involved with and to communicate with
and educate the public on any number of health and safety issues. To be appropri-
ately prepared for these situations, you will need to know the laws and rules that
govern these communications as well as best approaches and potential pitfalls when
interacting with the media. This chapter will review both the laws and rules as well
as suggested approaches to handling these communications.

IMPORTANCE OF MEDIA COMMUNICATIONS

Although interacting with the media may be unappealing to some in health care and
downright unpleasant to others, these communications can be important to health
care providers for many reasons. If you are involved in an event that is of interest to
or potentially impacts the public, the media will be interested in speaking with you.
Avoidance may work in the short term, but it is not always the right approach and
may not be possible. When faced with situations that involve media interactions, it
is best to be prepared. In addition, media avenues such as television are a significant
source of health care information for the public. Medical content communicated
by the media affects public attitudes and behavior, and health care professionals
should participate more fully as sources and critics of that content if we are to have
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a positive impact on public health. Media can have a great influence on the attitudes
Communication Outside Health Care System 260
and actions of their audience, and communications with the media can represent
an important opportunity to influence public opinion and behavior. Although the
average person may only access health care several times a year, most will access
the media several times a week, and effective interaction and communication with
media sources can represent the best opportunity to impact the public or other
groups that may be of interest. Topics such as antibiotic-​prescribing practices could
fit well into a media communications effort that could educate the public, influence
patient behaviors, and even affect physician prescribing habits in a positive way. By
mastering the patterns and subtleties of media communications and appreciating
their impact on public attitudes and behaviors, health care professionals can make
media communications an important tool of medicine and increase their influence
on public health.

LEGAL ASPECTS OF MEDIA COMMUNICATIONS

Maintaining confidentiality is an essential component of media communications
as it is an essential element of the physician/​patient relationship. Federal standards
intended to protect the privacy and security of protected health information (PHI)
fall under the privacy and security provisions of the Health Insurance Portability
and Accountability Act of 1996 (HIPAA). To summarize HIPAA in an overly sim-
plistic way, a health care provider can get and give any information necessary to take
care of the patient. Because the media is very unlikely to play a role in taking care
of the patient, HIPAA significantly restricts what information can be given to the
media. Under the privacy rule of HIPAA, general information about a patient may
be released in response to an inquiry from a representative of the media or any other
individual who specifically asks for information about a patient by name, as long
as the patient or the patient’s representative has not objected to or restricted the
release of such information. If the inquirer does not ask for the patient by name or
if the patient has not approved the release, no individually identifiable information
about the patient may be disclosed.
Standard language describing the general condition of a specifically named pa-
tient should be used when responding to media inquiries. This language should be
defined departmentally in advance and used in all situations by all staff regardless
of the patient involved. The American Hospital Association (AHA) has developed
and defined one-​word patient condition descriptors for this purpose, as follows (see
“External Resources” later in the chapter to access the AHA document):

• Undetermined: Patient is awaiting physician and assessment.

• Good: Vital signs are stable and within normal limits. Patient is conscious and
comfortable. Indicators are excellent.
• Fair: Vital signs are stable and within normal limits. Patient is conscious but may
be uncomfortable. Indicators are favorable.
• Serious: Vital signs may be unstable and not within normal limits. Patient is
acutely ill. Indicators are questionable.
• Critical: Vital signs are unstable and not within normal limits. Patient may be un-
conscious. Indicators are unfavorable.
• Treated and released: Patient received treatment but was not admitted.
261

• Treated and transferred: Patient received treatment and was transferred to a dif-

261
ferent facility. (Although a hospital may disclose that a patient was treated and
released, it may not release information regarding the date of release or where the

Media Communication
patient went upon release without patient authorization.)

The American Medical Associations (AMA’s) Code of Medical Ethics (refer to

“External Resources” to access the document) provides specific tips for physicians
on media relations, including the following:

• Obtain consent from the patient or the patient’s authorized representative before
releasing information.
• Release only information that has been specifically authorized by the patient or
patient’s representative or that is part of the public record.
• Ensure that no statement regarding diagnosis or prognosis is made except by or
on behalf of the attending physician.
• Refer any questions regarding criminal activities or other police matters to the
proper authorities.

Some information such as certain drug and alcohol information, HIV information,
and mental health information is entitled to special restrictions related to its use and
disclosure that may be even more stringent than HIPAA. Each state may also have
privacy and confidentiality statutes that are in addition, not in place of, HIPAA. Ask
your hospital’s risk management office, attorney, privacy officer, or media liaison for
help in becoming familiar with them.

THE INTERVIEW
The first step is to ensure the interview has been properly vetted. The media com-
munications representative for your hospital or a communications professional can
do this for you. If you do not have one available, ask a few questions about the story
and the objectives. If the responses give you concern or if the reporter won’t give a
straight answer on what he or she is trying to accomplish with this story, these are
red flags and you should consider turning down the request. You should be comfort-
able that it is in your best interest to do this interview. Your patients, the public, your
organization, or you should benefit from this, and if you aren’t convinced a benefit
is there, don’t do it.
As in all situations, it is important to know your audience, and in the case of
media communications, your audience is the public and specifically the public au-
dience the reporter involved reaches. It can be easy to fall into a comfortable conver-
sation and forget the larger audience you are speaking to. Attempts at humor might
feel right in the moment but often fall flat or look flippant to an audience. Avoid
the temptation to become too casual and never let your guard down. Although
reporters are by no means always adversaries and often want to deliver important
messages to their audience just as you do, they are also in the process of doing their
job and their goals may or may not be exactly the same as yours. Nothing that you
say to or around a reporter is off the record, even when cameras or other recording
devices are off, so never let your guard down. The relationship does not need to be
adversarial and in most cases will have similar objectives, but it is a professional
26

relationship, not a friendship, and care should be taken with everything said in the
Communication Outside Health Care System 262
presence of the media.
Be prepared for the interview. Although some stories will be more urgent than
others, do not participate in an interview without taking adequate time to prepare.
Some interviews will certainly require more preparation than others, but be careful
of falling into the trap of believing you have everything you need in your head. A
quick review of a subject, even one you are very familiar with, can be very valuable.
If the topic crosses into other specialties or strays into legal or public relations issues,
consider consulting those specialists at your hospital before giving the interview.
Be careful with medical or technical language and be sure to explain any med-
ical terms and abbreviations when they are needed. You should be sure to answer
the question that is asked when you can, but there are many questions that offer the
opportunity to add additional information and educate the audience on important
public safety issues. Anticipate difficult questions or those you might not want to
answer ahead of time and consider how you will handle the situation when/​if you
are asked. Always remember when interacting with the media that nothing is off the
record and be prepared for anything you say to be published.
Sound bites are short statements, often 1 or 2 sentences that can be used as
either summary statements or teasers for an upcoming story. Sound bites are an
important tool that the media can use to promote a story and excite an audience.
Although they can be a great way to generate interest in a topic or story, they can
sometimes generate attention for the wrong reasons. What the media might think is
a good sound bite might not necessarily be the way you had intended it or wanted it
presented in that particular way. Reporters are often on the lookout for good sound
bites and if taken out of context these sound bites can sometimes suggest something
very different from what you intended. Although you may not be able to control
what is used as a sound bite, being aware of what sound bites are and how they
might be used is important for the person being interviewed, and efforts can be
made to avoid grandiose statements that can easily be taken out of context.
Another point to remember will seem very simple but can be challenging.
Always be honest. If you don’t know the answer to a question or are not at liberty
to answer a question, say that. It can sometimes feel that, as a subject expert, you
should be able to answer any question a reporter asks on that subject. It is very pos-
sible that at some point during the interview you will be asked something you don’t
know. Telling the truth in this situation may feel uncomfortable but is far better than
giving potentially incorrect or misleading information.
Box 16.1 provides a summary of tips to prevent potential pitfalls.

MEDIA INTERACTIONS IN DISASTERS AND MULTIPLE

CASUALTY INCIDENTS
Never is the interface between physicians and the media more important than
during a disaster or multiple casualty incident (MCI). If managed appropriately,
during these events, the media can be the most effective way of communicating
with the public. However, the media also has the potential to make a situation more
challenging. From a personal standpoint, I found the interactions with the media
during my experience with the Columbine and Aurora Theater shootings to be
more overwhelming than the medical management of those events, although the
experience at Columbine certainly helped prepare me for what would come after
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263
Box 16.1. Tips to Avoid Media Communication Pitfalls

Media Communication
Ensure the interview is properly vetted.
Remember your audience is the public.
Avoid humor.
Be prepared.
Anticipate difficult questions—​think about your answers.
Be aware of possible sound bites.
Be honest.
You are never off the record.
Never let your guard down.

the theater shootings. Getting information out to the public can be extremely im-
portant in these situations and the media may represent both the most timely and
most effective way of reaching the audience you need to reach. Whether it be poten-
tial victims, worried family members or friends, or the general public, news alerts
and media announcements can be efficient ways of getting information out and are
often a critical source the public turns to during major events.
The media takes this responsibility very seriously and considers it their job to
inform the public of issues that may affect them, so they will very likely be covering
any major event you are involved with. This represents an opportunity to work with
the media to get important information out that will benefit the public, and a good
working relationship with the media can go a long way toward effective manage-
ment of these situations. There needs to be designated personnel with experience
interacting with the media whose only responsibility will be to coordinate these
communications and be a conduit for information going out and coming in. The
media will often want to interact with physicians during these events and this can
represent a great opportunity for you, in terms of both distributing important in-
formation for the public to know and preventing unnecessary worry or even panic
where appropriate. It is also important to remember that because the media see it as
their job to inform the public, they will go about obtaining this information by what-
ever means they deem necessary. If you or your agency isn’t able to provide a means
for them to get important information about a big event, they will pursue other
means of getting this information, which may or may not be in line with your plans.
There are a number of things that can be arranged ahead of time in preparation
for these critical interactions with the media. A designated point person should be
identified in advance. All staff and physicians should refer any requests for informa-
tion or interviews to this point person to ensure the appropriate time and method
of releasing information and prevent the release of conflicting information. A place
should be identified where the media can be located that can’t be too close to where
the patients are being cared for, but can’t be too far away either. If the media don’t
trust that you will get them important information in a timely manner, they will
find other ways of obtaining that information. Putting them in a spot far away from
where things are happening will send them the message that they are not a priority.
Although the media can’t be the top priority and are never more important than
caring for the patients, careful attention will need to be focused on them if these
situations are going to be successfully managed.
264

Having a physician involved in caring for victims of a major event to interact

Communication Outside Health Care System 264
with the media is not always necessary but can be an important aspect of man-
aging a major event. Although our first duty as physicians will always be to our
patients, we also have a duty and responsibility to the public and specifically the
communities we serve. One part of that responsibility may be to inform the public
directly and immediately of any present dangers that may affect them or to alle-
viate unnecessary concern about ongoing threats. It won’t always be a physician
that is best for these communications, but there are times when it may be the
most effective way of delivering an important message, and making yourself avail-
able for these media communications can be an essential component of effective
event management. HIPAA and other privacy considerations will certainly be in
effect, but there is still almost always important information that can be released
or discussed that is of significant benefit. Having a strong relationship with your
local media and people in your organization who are trained and savvy in dealing
with the media will be an essential component of effective management of these
communications.
The onslaught of media attention that often occurs after a major event can
be overwhelming and is not something we are typically prepared for during our
training. Recognize the impact this can have on you and your colleagues and get the
help of your hospital media relations professional whenever available. Put limits on
the number of interviews and time you spend on these, and be sure you are both
physically and mentally prepared for these interviews. Be sure you take time to de-
brief from the event before getting in front of a camera, and always pay attention to
your own health and well-​being as you take care of others.

WHEN AND HOW TO SEEK MEDIA ATTENTION

What we have reviewed so far applies primarily to the situation where the media
is seeking you out to do something for them. There will also be situations where
it may be appropriate to seek the media out as well. News releases are tools for
communicating news, advocating, and educating journalists and the public on
health-​related issues. Press conferences and media events can generate significant
press attention and may also be appropriate in some circumstances. Both news
releases and press conferences can be very effective while also requiring some ef-
fort and coordination. Care should be taken not to overuse these tools, which can
reduce interest in future efforts. Developing relationships with the media is im-
portant for many reasons, and efforts in this area can generate credibility and trust
that will go a long way toward getting your message to your intended audience. The
American College of Emergency Physicians has published a media relations guide
that includes a number of tips for reaching out to and developing relationships with
the media that include:

• Keep it simple.
• It isn’t necessary to establish many contacts at once. Start with one and use
this experience to establish additional contacts later.
• Choose the right reporter for the topic you want to discuss. For example, if
you are planning on discussing health policy, a political reporter may be your
best option. Reading previous stories a reporter has done can be helpful in
picking the right one to reach out to.
265

265
Box 16.2. Tips When Using the Media to Educate

Media Communication
Have a limited amount of messages to deliver—​typically no more than 3.
Be repetitive—​repeat your messages at least once.
Keep it simple.
Be honest—​admit what you don’t know.
Avoid medical jargon.
Be very careful with humor. You can have fun with the topic but this is not the time
to be a comedian.

• Don’t underestimate local media.

• Local reporters can be very influential with the audience you are trying to
reach and valuable assets in getting information out.
• Know what reporters need.
• Reporters are looking for news that is timely, new, and/​or relevant to their
audience. Paying attention to what is currently in the news and finding a
connection can be a great way to generate attention for the topic you want to
discuss.

Disaster situations such as pandemics represent opportunities to reach out to the

press that may benefit the public. Without health professional involvement, the
press may amplify risks by emphasizing conflict and damage, presenting informa-
tion in a more dramatized way, and using risk-​amplifying frames to a greater extent
and risk-​attenuating frames to a lesser extent. Press releases that include input from
health authorities can help lessen an emphasis on drama and emotion in the way
information is presented.
When utilizing the media primarily for education on an important topic, some
of the same principles discussed previously still apply. Box 16.2 includes tips on
preparing for an educational interview with the media.

SOCIAL MEDIA
There are many social media tools that are available to emergency physicians in-
cluding social networking platforms (Facebook, MySpace, Twitter), blogs (Tumblr,
Blogger), professional networking (LinkedIn, Doximity), and media sharing sites
(YouTube). Benefits can include professional networking, professional and public
education, patient care, and organizational promotion. Dangers of social media in-
clude risks of poor-​quality information, damage to professional image, breaches
of patient privacy, and legal liability. It is important to be aware that even privacy
settings may not provide complete protection and anything posted on the internet
may be permanently available online. The AMA and the Federation of State Medical
Boards (FSMB) have guidelines on the ethical use of social media that emphasize
protection of patient privacy, the potential dangers of dispensing medical advice on-
line, and the importance of professionalism, collegiality, and maintaining separate
personal and professional profiles. Further information on communication through
the use of social media can be found in Chapter 17.
26

PHOTOGRAPHS/​D IGITAL IMAGES

Communication Outside Health Care System 266 Any photographs, video, or other digital images of patients that include any iden-
tifiable or potentially identifiably features should have the patient’s written author-
ization for use for anything other than direct patient care. There are occasional
exceptions made for educational purposes that will not be made public, although
even then identifying features should be removed whenever possible. A policy
should be written that specifies when and how photographs, video, or digital images
can be used at your institution.

A CAUTIONARY TALE
An example of how mistakes in communicating with the media can have a negative
impact occurred during the media interview frenzy that followed the shootings at
Columbine High School, which I had responded to. The large majority of the media
were simply trying to convey correct information from a source that was directly
involved in the event. Although many were looking for a new angle on the story that
had not been used before, a few appeared to be willing to create a story with the
purpose of getting a reaction rather than relaying the truth. When asked what I did
that night after getting home, I let my guard down and gave an answer that included
more information than necessary. Particularly, I revealed that I had a beer before
going to bed. The resulting headline from the interview, “Doc Had to Play God,”
seems more intended to get a reaction than to convey the truth. It served as an im-
portant reminder to stick to the facts that are necessary to answer the question, to
never let your guard down, and that not all media are interested in conveying the
same messages that you are.
Very few members of the media are actually trying to change reality as this one
was. They are, however, trying to depict reality in a way that will attract and hold
the interest of their audience. The way they do this may or may not be in line with
what you are trying to communicate. Keeping this in mind will be important as you
develop productive media communications that will meet their needs and yours.

CONCLUSION
Effective communication with the media can be an important part of your role as an
emergency physician. Although these communications can be very valuable for you,
they also represent potential risk as well. Understanding the important components
of media communication will help ensure these interactions are positive and pro-
ductive and go a long way toward helping to achieve your objectives.

RESOURCES
• ACEP Media Guide
• https://​www.acep.org/​advocacy/​media-​relations-​guide
• The HIPAA Privacy Rule
• https://​www.ecri.org/​components/​HRC/​LawReg19.aspx?tab=2
• Media Relations
• https://​www.ecri.org/​components/​HRC/​Pages/​AdSup1.aspx?tab=1
• American Hospital Associations HIPAA Privacy Regulations Overview
• http://​www.aha.org/​content/​00-​10/​overview0302.pdf
267

• American Medical Association’s Code of Ethics (chapter on privacy, confidentiality, and

267
medical records)
• https://​www.ama-​assn.org/​sites/​default/​files/​media-​browser/​

Media Communication
code-​of-​medical-​ethics-​chapter-​3.pdf
• American Osteopathic Association Code of Ethics
• http://​www.osteopathic.org/​inside-​aoa/​about/​leadership/​Pages/​aoa-​code-​of-​ethics.
aspx
• California Hospital Association’s guide on the release of patient information to the media
• http://​www.calhospital.org/​sites/​main/​files/​file-​attachments/​guide_​to_​release_​
2017_​web.pdf
• Professional Guidelines for Social Media Use—​AMA Journal of Ethics
• http://​www.Journalofethics.ama-​assn.org/​2015/​05/​nlit1-​1505.html
• Ventola CL. Social media and health care professionals: benefits, risks, and best
practices. Pharm Ther. 2014;39(7):491–​499,520. https://​www.ncbi.nlm.nih.gov/​
pmc/​articles/​PMC4103576/​.
• Rossmann C, Meyer L, Schulz PJ. The mediated amplification of a crisis:
communicating the A/​H1N1 Pandemic in Press Releases and Press Coverage in
Europe. Risk Anal. 2018;38(2):357–​75. doi:10.1111/​risa.12841.
• Sandman PM. Medicine and mass communication: an agenda for physicians. Ann
Intern Med. 1976;85:378–​383.
• LOcal Campaign on Antibiotics ALliance (LOCAAL) study group. Doctors and
local media: a synergy for public health information? A controlled trial to evaluate the
effects of a multifaceted campaign on antibiotic prescribing (protocol). BMC Public
Health. 2011;11:816.
• Brody M, Foehr U, Rideout V, et al. Communicating health information through the
entertainment media. Health Aff. 2001;20(1):192–​199.
268

17 Email and Social Media

Zach Jarou, Matt Zuckerman,
and Todd Taylor

WHAT IS SOCIAL MEDIA?

To many, the origins of social media are found in ARPANET, the predecessor to the
internet, or possibly when YouTube allowed everyone 5 minutes of fame, or when
2 billion people got Facebook accounts.1 Others dismiss social media as a passing
fad that has little to do with keeping up with medical advancements, novel research,
or professional advancement. Both groups are wrong: Social media predates the in-
ternet, and it is actually a reflection of our social nature. Earliest man told stories
around a glowing fire, and social media is the natural product of our need to com-
municate and connect with our community.

Origins of Social Media

Ancient Romans didn’t have Twitter accounts, but they frequently made copies of
their letters, sending them on to friends for additional commentary and further cir-
culation.2 Scribes would excerpt sections of the daily journal of Roman news, the
Acta, with special emphasis or commentary added. Nowadays we share excerpts
from online articles, adding our own commentary. Today on Facebook we write
similar messages continuing the tradition of ancient Rome graffiti artists who liter-
ally wrote their comments on each other’s walls.

Birth of the Internet

The relatively recent advent of printmaking in the 15th century, followed by broad-
cast media, has actually been an antisocial aberration, where the speaker was
269

separated in time and space from the audience. That changed with the development

269
of the internet. In the 1950s, Paul Baran described networks of “distributed adap-
tive message block switching” that would allow packets of information to be distrib-

Email and Social Media

uted among a large network of connected nodes. This work ultimately contributed
to the development in 1969 of the ARPANET, a nascent internet. Researchers
started messaging others on the same mainframe computer, and eventually wrote
to colleagues across the country.
The first online diaries or weblogs, shortened to blog, came about in the
1990s and rose in popularity as sites like OpenDiary and Blogger made it easy for
neophytes to write without knowing how to code HTML, the language many sites
are written in.3 In 1997, SixDegrees.com became the first site that would invite you
to create a network of online “friends” (and friends of friends) with whom you
share media and commentary. Succeeded by Friendster, MySpace, and ultimately
Facebook, each iteration brought innovation, transitioning online sharing from an
obscure nerdy activity to the ubiquitous presence it is today. Currently, 1 out of
every 7 minutes online is spent on Facebook, and we spend more time on social
media than we do eating, drinking, grooming, and (in-​person) socializing.4

Crowdsourcing Content
Just as the printing press drove down the cost of making books and democratized au-
thorship, advances in audio and video production have disrupted broadcast media.
Traditional media producers (television and movie studios, journal and textbook
publishers) have seen their industries disrupted by citizen journalists/​authors/​art-
ists, using free websites, cell phone cameras, USB microphones, and free software to
challenge the mass-​market paradigm.
YouTube went live in 2005 with an 18-​second video of a teenage boy at the zoo.
Initially conceived as a way for people to share home movies, users saw its poten-
tial as a communications platform. The simplicity of the site makes content gener-
ation and distribution free and easy, explaining why over 400 hours of content are
uploaded to YouTube every minute.5

Throwing Turnips
In 63 ad, Roman emperor Vespasian’s speech in a public forum was so unpop-
ular, people threw turnips at his head.6 Audience response, good or bad, is vital
to communication; audience response has long been suppressed by mass media
and resurrected in social media. YouTube gives viewers the ability to comment on
and rate content, to throw their own turnips. For many, the act of reading other
viewers’ comments is a vital part of watching YouTube videos, a shared audience
experience. Frustrated viewers may go further, contributing their own videos in
response.
How does this relate to communication for emergency medicine physicians?
Your goal is quick, clear communication that doesn’t allow technology to get in the
way of the patient encounter or student learning. Many providers are frustrated with
new technologies that seem to complicate rather than simplify. As described earlier,
social media is not a new technology. The teachings of Hippocrates live on in the
Hippocratic Corpus. This work is actually a collection of about 70 smaller works,
probably written and edited by many authors over many years.7 Some of the works
are aimed at physicians, others written for patients. The works themselves often
270

contradict each other, indicating a lack of unified editorial control. The oldest text in
Communication Outside Health Care System 270
medicine was crowdsourced via social media and produced in a fashion unfamiliar
to modern textbook and journal editors.

Old Media in Medicine

The most widespread emergency medicine journal, judged by impact factor, is
Annals of Emergency Medicine (at the time of this publication). Submitted articles
are reviewed by a select group of “peer reviewers.” Annals uses an online portal but is
largely an electronic version of the editorial review process implemented in the 18th
and 19th centuries by the editorial boards of science journals, such as Philosophical
Magazine. A lead expert and his or her professional group (essentially a social net-
work) review, evaluate, and comment on papers before publication. After a back and
forth, the paper hopefully is deemed worthy for publication, and only then does it
have an impact on the medical community. Ironically, as more people read articles
electronically and papers in press are released, the actual print publication date is
largely irrelevant. Many print publications have switched to online-​only dissemina-
tion, realizing the savings in cost without an impact on audience. Submissions that
are deemed unworthy of publication are lost. Many published articles have brief
periods of activity and impact; otherwise, their impact is noted by a lone entry in
PubMed. Ultimately, a selection of these articles are integrated into textbooks and
tertiary literature where the original authors are quickly forgotten.
As physicians grew frustrated with the limitations and slow speed of the journal-​
based “peer review process,” many turned to social networks to learn medicine and
teach others. YouTube, Facebook, and Blogger arose as a response to similar frus-
tration with mainstream producers of entertainment and news content. Consumers
with shared passions found that chatrooms, blogs, YouTube channels, and podcasts
allowed them to subvert mainstream peer review, instantly sharing content with
millions of true peers.
For years, Rick Bukata and Jerry Hoffman compiled their commentary and cri-
tique of emergency medicine literature into an entertaining and bite-​sized podcast.
Their insightful and entertaining podcast highlighted the shortcoming of tradi-
tional medical publication for dissemination of new ideas. Even those articles that
made it into print had deficiencies that needed to be addressed, and an article that
goes unread or undiscussed rarely makes changes. A growing group of inquisitive
emergency providers began curating online blogs and recorded podcasts, giving
rise to the movement that would become free, open-​access medical education (see
later).
Today, most journals have accompanying podcasts and social media accounts,
but these are largely a response to the home-​grown ones that demonstrated the need
to get in the game. New iterations of Advanced Cardiac Life Support (ACLS) and
sepsis guidelines are accompanied by a social media storm, as authors dialogue with
critics, increasing engagement and implementation. Indeed, if you find yourself
disagreeing with the authors of this book, you may have more impact responding
via social media than a letter to the editor. Such comments will be seen by others,
many of whom may agree or disagree and will join in the conversation. Whether
the editors agree or disagree with you, your opinions have influenced the conversa-
tion and your comments may have more impact than the chapter you’re currently
reading.
271

The invention of mass media made possible by the printing press and radio

271
transmitter has been superseded by the social media of the internet. Publishing
1000 copies of a manuscript means nothing if that manuscript has no audience.

Email and Social Media

CURRENT TRENDS IN HEALTH CARE SOCIAL MEDIA
#FOAMed and Residency Education
The Origins of #FOAMed
More than a Twitter hashtag, FOAM (free, open-​access medical education) is a
global, crowdsourced network of educational materials developed to augment tra-
ditional learning. The term FOAM was coined by Australian emergency physician
and cofounder of LifeInTheFastLane.com Dr. Mike Cadogan (@sandnsurf) over a
pint of Guinness in Dublin, Ireland, at the International Conference on Emergency
Medicine in 2012.8 Cadogan needed to describe the online medical education com-
munity that had been developing over the prior decade. Cadogan described with
blunt honesty the challenge: “The word social media turns people off. . . . [E]‌veryone
thinks that we’re a bunch of internet geeks who want to know what Snoop Dogg had
for breakfast.”8 The world had defined social media as the real-​time documentation
of inane personal details and celebrity gossip, a place most medical educators would
never go. Cadogan’s pub-​based revelation helped distill the movement that had al-
ready been occurring into its most basic parts. FOAM is free. FOAM is open access
without institutional barriers. FOAM is about medical education.

Be Cutting Edge Sooner

If you’ve used blogs to digest the latest literature or listened to podcasts to learn new
approaches to difficult clinical scenarios, you’re already using FOAM. Social media
platforms have exponentially increased the rate at which new information can be
disseminated, significantly shortening the time required for knowledge translation,
closing the gap between research and practice.

If you want to know how we practiced medicine 5 years ago, read a textbook.
If you want to know how we practiced medicine 2 years ago, read a journal.
If you want to know how we practice medicine now, go to a (good) conference.
If you want to know how we will practice medicine in the future, listen in the hallways
and use FOAM. (Joe Lex, MD)

Postpublication Peer Review

The traditional, prepublication peer review process used by scientific journals is not
perfect. Although it is carefully controlled, it is a closed process reliant upon the
opinions of a very small group of reviewers. In 1997, Dr. Richard Smith, former ed-
itor of the British Medical Journal, opined that traditional peer review is “expensive,
slow, prone to bias, open to abuse, possibly anti-​innovatory, and unable to detect
fraud.”9 He also argued that the future of review would be open, rather than closed,
and predicted that advances in electronic publishing would create an environment
where a structured account of the peer review process would be available to readers.9
Fourteen years later, in a British Medical Journal blog post, Dr. Smith said that the
27

Communication Outside Health Care System 272

FIGURE 17.1. #FOAMed bridges the gap between pre-​and postpublication peer review.
Traditionally, the peer review process for scientific publications has emphasized the prepublication
phase. Social media and #FOAMed facilitate an additional crowdsourced postpublication phase of
peer review.
This figure was inspired by Galbraith DW. Redrawing the frontiers in the age of post-​publication review.
Front Genet. 2005;6(198):1–​6, Figure 1.

“marketplace of ideas” should decide whether new literature is important and prac-
tice changing. “More important than formal types of peer review is the informal, the
thousands of comments, decisions, and actions from the many that lead to a sorting
of studies.”10 In many ways, Dr. Smith predicted and advocated for key components
of what is now known as #FOAMed. In 2013, Academic Life in Emergency Medicine
(ALiEM.com) implemented both prepublication and postpublication review, a trend
that has since been adopted by many other medical education blogs.11 See Figure
17.1 for an overview of the steps involved with traditional prepublication peer review
compared with the postpublication peer review process facilitated by #FOAMed.

The Landscape of FOAM

In the decade preceding Mike Cadogan giving the FOAM movement a name in 2012,
medical educators had already been hard at work over the previous decade, growing
from 2 to 165 blogs and podcasts in the areas of emergency medicine and critical care,
a number which has continued to grow year after year, as seen in Figure 17.2A and B.
There is no central repository or editorial authority for FOAM. Content is
contributed from individuals around the world in a variety of formats including
blogs, podcasts, videos, and ebooks disseminated over social networks using pop-
ular platforms such as Twitter, Facebook, iTunes, YouTube, and more. The number
of tweets posted with the #FOAMed hashtag increased from approximately 80 mil-
lion per year in 2012 to nearly 1.5 billion in 2016.
The disruptive force of social media innovation on traditional methods of com-
munication and education, coupled with its rapid rate of adoption, raises important
questions about the fate of textbooks, the peer review process, and the future of
teaching and learning. Much like with other sources of information, before clinicians
273

(a)

273
300

Email and Social Media

Number of EM-CC Blogs adn Podcasts

200

100

0
2002 2004 2006 2008 2010 2012 2014

FIGURE 17.2A. The growth of emergency medicine and critical care: blogs and podcasts by year.

change their practice they should do research, read from multiple sources, and fact
check articles. Clinicians should not make practice-​changing decisions based on
one article or on one blog post. As more learners turn to social media, educators
must emphasize that, similar to all potential sources of information, the quality of
each resource must be assessed.

A Replacement for Textbooks?

Caring for patients with a wide variety of undifferentiated chief complaints requires
a broad medical knowledge base. Emergency medicine physicians learn from a va-
riety of sources, with textbooks being an important resource. FOAM is more readily
accessible than textbooks. Critics state that FOAM is preoccupied with niche,

(b)
% of EM-CC Resources Using Social Media Platform

100%

75%

50%

25%

0%
Twitter Facebook iTunes/Soundcloud Google + YouTube/Vimeo

2012 2013 2016

FIGURE 17.2B. The growth of emergency medicine and critical care: blogs and podcasts by
platform. Mike Cadogan, the father of #FOAMed, has closely tracked the number of emergency
medicine and critical care (EM-​CC) blogs and podcasts over time, as well as the social media
platforms used to distribute these resources on his website LifeInTheFastLane.com.
Figures recreated with permission.
274

Table 17.1. Core Content Resources

Communication Outside Health Care System 274 Core Content Resource About This Resource

CRACKCast/​CanadiEM • An evolution of @Brent_​Thoma’s original BoringEM

www.CanadiEM.org blog that he started as a resident to force himself
@WeAreCanadiEM to cover “one digestible topic of intense disinterest
@CRACK_​cast each week”
• A series of podcasts with an episode covering each and
every chapter of Rosen’s Emergency Medicine
CORE EM • The official blog and podcast of the NYU/​Bellevue
www.CoreEM.net EM Residency, created by Anand Swaminathan
@Core_​EM (@EMSwami)
• Core content, procedure videos, podcast, and journal
article reviews
EM BASIC • Created by a former emergency medical technician,
www.EMBasic.org Dr. Steve Carroll (@embasic) while a resident at San
Antonio Military Medical Center
• A chief-​complaint-​based podcast designed for students
and EM interns to learn the important history/​exam
findings, workup, treatment, and disposition of each in
30 minutes
FOAMcast • “Don’t FOAM it alone”
www.FOAMcast.org • Join the dynamic duo of @jeremyfaust and @LWestafer
@FOAMpodcast as they tackle cutting-​edge topics in EM while creating
a mashup with everyone’s favorite imaginary core EM
text, Rosenalli’s (Rosen’s + Tintinalli’s)
EM, emergency medicine.

controversial topics while rarely mentioning the necessary core content. Although
these topics do compose a significant portion of FOAM, a number of resources have
been developed to specifically present core content, as shown in Table 17.1.
Chris Nickson and Mike Cadogan summarize a general feeling that textbooks
are dead but reborn:

So is the textbook dead? The monolithic tome of yore certainly should be. Bulky texts
that are out-​of-​date before they are published, with editor-​defined content, that are
non-​learner and non-​location centric and are unchallengeable in a public forum have a
dwindling role to play in medical education. A textbook of the future needs to integrate
many of the characteristics of FOAM resources: instantly updatable, continual post-​
publication review, user interactivity, multimedia integration, platform independent,
cloud based and adaptable to local needs.12

Meet Learners Where They Are

A 2014 survey of emergency medicine residents found that almost 98% reported
spending at least 1 hour per week learning outside of shifts or during weekly
conference. One-​third of residents reported spending 2 to 4 hours per week on
275

extracurricular learning, endorsing that podcasts were a more beneficial use of their

275
time compared to reading textbooks or journals.13

Email and Social Media

Augmenting Residency Education: Flipped Classrooms and
Asynchronous Learning
The majority of emergency medicine residency programs in the United States use
Twitter to curate content for their learners or to share content created by their resi-
dency program with others. Modalities such as blogs, podcasts, videocasts, Twitter,
and Google Hangouts have been used. Programs use Twitter to share pearls in
real time from weekly didactic sessions or on-​shift teaching to generate continued
feedback and discussion. #FOAMed can be integrated into residency education
asynchronously (to meet Accreditation Council for Graduate Medical Education
[ACGME] Individualized Interactive Instruction requirements to supplement up
to 20% of required weekly educational time) or in conjunction with didactic ses-
sions to create a flipped classroom experience, where learners come to the class-
room to apply the knowledge that they have already gained.14
The Council of Emergency Medicine Residency Directors supports the use of
social media as a valuable tool for graduate medical education and encourages each
residency program to create a social media presence and create content to enhance
the sharing of knowledge. They even have their own blog to disseminate know-
ledge. Social media can also be used to assess several of the ACGME Milestones
that trainees must be evaluated on, including medical knowledge, technology,
practice-​based performance improvement, professional values, and accountability.
Examples of integration beyond asynchronous learning and flipped classrooms
include facilitating journal clubs, developing emergency medicine (EM)-​focused
materials for off-​service residents or to encourage peer-​to-​peer teaching between
services, creating blogs to highlight pearls learned from patient follow-​ups, and de-
veloping alumni networks.15 See Table 17.2 for #FOAMed resources that can be
used to supplement a residency program’s curriculum.

Assessment of “FOAM Quality”

The explosion of #FOAMed resources presents a dilemma for learners with limited
time as well as program directors who want to ensure that their learners are using
appropriate resources. Physicians should not change their medical practice based
on a tweet or a blog post alone, but they can use FOAM to locate, read, and discuss
new literature. Unfortunately, one study showed that more than half of residents do
not routinely assess the quality of #FOAMed resources or review the references.13
To address this issue, a number of quality assessment tools have been developed.
The ALiEM Social Media Index (SMi) was developed to rank the overall impact
of each emergency medicine #FOAMed website. Analogous to the impact factors
used to rank academic journals, the SMi incorporates a site’s Alexa Rank, Twitter
Followers, and Facebook Likes.16
Decision tools have also been built to determine the quality of individual
blog posts, including the ALiEM AIR17 (Approved Instructional Resource) and
METRIQ11 scores. For example, the ALiEM AIR Score is composed of 5 components
each scored on a 7-​point Likert scale: (1) the previously developed “Best Evidence
in Emergency Medicine” (BEEM) score,18 (2) assessment of content accuracy, (3)
276

Table 17.2. Residency Education Resources

Communication Outside Health Care System 276 Residency Education Resource About This Resource

ALiEMU • An online learning management system that allows

www.ALiEMU.com residents to obtain asynchronous learning credit
• 3 types of courses, including the AIR (Approved
Instruction Resources) and AIR Pro (for advanced
learners) series, as well as Capsules (practical
pharmacology)
EMFundamentals • Created by medical education fellow @ericshappell
EMFundamentals. from @UChicagoEM in the spring of 2014 as an online
blogspot.com curriculum for EM interns
@EMFundamentals • A series of chief-​complaint-​based modules with curated
#FOAMed resources, plus 17 pre-​prepared small group
sessions and evaluation forms

educational utility (pearls), (4) practice of evidence-​based medicine, and (5) cita-
tion of authors and literature. ALiEM AIR Scores of ≥30 out of 35 are considered
“AIR Approved.” There are posts that AIR board members identify as worthwhile to
highlight regardless of the point score received. These posts receive a designation of
“Honorable Mention.” Although more research remains to be done, for now, quality
is most likely going to be determined by the end use. See Table 17.3 for a list of the
top 3 #FOAMed resources according to their ALiEM AIR scores.

Personal Learning Networks

Many providers find themselves inundated with journals, newsletters, lectures,
and more information than they can currently process. Adding social media re-
sources seems like an impossible task. However, one of the beautiful things about
#FOAMed is that you can use tools like Twitter or RSS feed aggregators to filter and
refine the information that you are exposed to by choosing which content sources
to follow or unfollow. Instead of combing through a table of content to determine
which 2 articles you might read from a journal, allow these resources to curate the
best, relevant, timely resources.
By building this network of resources and experts, people create a personal
learning network (PLN). A PLN is a group of people that make connections in
order to learn ideas and share information. Social media gives you access to subject
matter experts who might otherwise be inaccessible to you. Whether you practice
in a tertiary center with a full set of specialists or you are a sole provider in a crit-
ical access hospital, you have access to thousands of online colleagues. Being a con-
sumer of #FOAMed gives you an opportunity to have a front-​row seat to expert
debate you might not otherwise witness, but you’ll gain even more by engaging.

Building Communities
The practice of emergency medicine is filled with emotional highs and lows, victory
and defeat, joy and sorrow, fulfillment and frustration. Having a professional home
27

Table 17.3. Top 3 #FOAMed Resources

277
Top 3 #FOAMed Resources per About This Resource

Email and Social Media

ALiEM’s Social Media Index (SMi)

Life in the Fast Lane • Cofounded by Drs. Mike Cadogan (@sandnsurf)

www.LifeInTheFastLane.com and Chris Nickson (@precordialthump) in 2007
• Collections of blog posts on electrocardiograms,
toxicology, critical care, and ultrasound, as well as
of Global FOAM and critical appraisals of recent
literature
EMCrit Podcast • A blog and podcast created by ED intensivist
www.EMCrit.org Dr. Scott Weingart in 2009 with the goal of
@emcrit “bringing upstairs care downstairs” so patients
www.facebook.com/​emcrit can receive ICU-​level care from the moment
they arrive in the ED
• Scott has recently expanded the EMCrit team
to include the previously independent blogs of
Drs. Josh Farkas (@PulmCrit) and Rory Spiegel
(@EMNerd_​), as well as posts on human
performance under stress by combat physician
Mike Lauria
Academic Life in Emergency • Founded by Dr. Michelle Lin in 2009 to store
Medicine “Tricks of the Trade,” ALiEM has since evolved into
www.ALiEM.com an organization that boasts virtual communities of
@ALiEMteam practice, an online teaching management platform,
and a searchable set of point-​of-​care reference cards,
and boasts an expansive team of authors and editors
producing engaging series of articles on clinical and
lifestyle topics
ED, emergency department; ICU, intensive care unit.

where you can engage with your peers can be protective against burnout by pro-
viding a sense of community, belonging, and unified purpose.19
For years, many physicians have found this professional home within their
training programs, departments, and institutions; for others their home has been
with local, state, or national medical societies. The advent of social media has enabled
a paradigm shift in the way that communities develop and communicate with one
another. The following are a few examples of successful online communities.

EM Docs
Created by emergency physician Dr. K. Kay Moody (@KKayMoodyDOMPH) in
April 2013, “EM Docs” has grown from a small group of EM physician friends to
a community of nearly 15,000 members (as of August 2017, more than double the
number of members boasted a year prior when the Facebook group was featured in
ACEPNow). “EM Docs” provides a forum for colleagues to share interesting and
difficult cases with one another, obtain virtual crowdsourced consults, navigate
278

career and contract issues, and discuss the unique challenges of being an EM doctor
Communication Outside Health Care System 278
(complete with the occasional dark humor). To join the conversation, search for the
“EM Docs” group on Facebook; only physicians are allowed to join as members,
so your request to join will require approval by a moderator who can confirm your
identity as an EM doctor.20

Physician Moms Group

The Physician Moms Group (MyPMG.com) was founded in November 2014
by emergency physician Dr. Hala Sabry to provide a global platform for female
physicians across all specialties to bond with and learn from a community of physi-
cian mothers who have faced similar struggles while juggling career and family. Now
more than 65,000 strong, the Physician Moms Group is a bustling community for
physician moms to seek and share information, advice, and expertise.

FemInEM
In September 2015, Dr. Dara Kass (@darakass), associate professor of emergency
medicine at NYU/​Bellevue Hospital, launched FemInEM.org (@feminemtweets)
with a goal of facilitating deliberate conversations to address gender disparities
and support the development and advancement of women in EM. Kass has since
found a coeditor-​in-​chief in former resident Jenny Beck-​Esmay (@jbeckesmay) and
together the 2 have grown FemInEM beyond the blog with new features like the
FemInEM Speakers Bureau, a database of female EM physician lecturers that can
be filtered by topic and geographic location, and their inaugural FemInEM Idea
Exchange (FIX) Conference hosted in October 2017.

ALiEM Incubators and Wellness Think Tank

In 2015, more than 200 chief residents from more than 71 emergency medicine
residency programs joined the ALiEM Chief Resident Incubator (@ALiEMCRInc
#CRincubator), a virtual community of practice designed to allow chief residents to
think beyond their day-​to-​day challenges of making schedules, fielding complaints,
and reinventing weekly conferences and to instead take part in a longitudinal
leadership and career development curriculum with mentorship by educational
leaders from around the globe and to have the opportunity to cocreate new know-
ledge with their peers. Facilitated by Slack, a digital communication platform that
enables teams to efficiently collaborate in ways never before possible, in its first year
alone the #CRincubator cocreated a number of blog posts and Google Hangouts,
launched ALiEM’s AIR Series, and started a Chief Resident Visiting Grand Rounds
program. The success of the Chief Resident Incubator has led ALiEM to also
create virtual communities of practice for fellows and faculty (#Fincubator and
#Facubator, respectively).
ALiEM moved beyond virtual communities of practice and in 2016 created a
Wellness Think Tank of more than 125 resident members to develop innovative
solutions to wellness issues for themselves and their training programs. Topics
included shift-​work scheduling, resident impairment, suicide awareness and pre-
vention, second-​victim syndrome, litigation stress, imposter syndrome, resilience
strategies, meditation and mindfulness, financial smarts, performance psychology,
279

humanities in medicine, and creating a residency wellness committee and cur-

279
riculum. Members of the Think Tank were able to meet at the 2017 Essentials of
Emergency Resident Wellness Consensus Summit, the proceeds of which will be

Email and Social Media

published in the Western Journal of Emergency Medicine.21

Personal Branding, Professional Advancement

In December 2006, Time Magazine famously announced that the 2006 “Person of the
Year” was YOU—​in recognition of the millions of internet users who contributed
user-​generated content to the web. The cover featured an image of a computer
desktop whose screen was a reflective Mylar pane so that readers peering at the
cover would see themselves reflected as the star of their very own YouTube video.
There is no doubt that the internet has given individuals a wide variety of
platforms to promote themselves. From the early days of AOL Member Profiles and
MySpace accounts to the rise of Facebook, LinkedIn, and Doximity, it is clear that
there is high demand for services that allow individuals to tell their stories, stand out
from the crowd, celebrate their accomplishments, develop a niche, and communi-
cate their value.
It’s estimated that 80% of employers Google job applicants prior to sending in-
terview invitations. Whereas past discussions on the impact of social media on one’s
professional life were preoccupied with risk mitigation, some academicians are now
focusing on ways to incorporate digital and social media scholarship criteria for ac-
ademic advancement through the creation of social media portfolios that can be
reviewed by promotion and tenure committees.22

Augmented (or Virtually Attended) Medical Conferences

Medical conferences are a great way for physicians to connect with their colleagues
and stay up to date on the latest information in their fields. Today, most national and
international emergency medicine conferences publicize unique Twitter hashtags
to help advertise the event, facilitate attendee interaction, broadcast new and inter-
esting findings with those not in attendance, spark debate among content experts,
and more. See Table 17.4 for a list of popular emergency medicine conferences and
their hashtags.

HIPAA Dos and Don’ts

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) created
standards to maintain the security and privacy of health care data. HIPAA states
what information can be shared with whom and for what purposes. Many physicians
may be reluctant to engage in #FOAMed for fear of HIPAA violations for uninten-
tionally sharing protected health information (PHI), landing them in a world of
trouble with their employers and the law.
In general, if you use common sense and focus on scenarios and general man-
agement principles, rather than posting timestamped, geo-​tagged photos and iden-
tifiable data about your patients, you should be compliant.
For those who are especially worried about violating HIPAA, there is a “Safe
Harbor Method” for de-​identifying PHI by removing 18 types of identifiers, in-
cluding names, account numbers, dates, addresses, phone numbers, identifiable
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Table 17.4. Emergency Medicine Conferences and Their Hashtags

Communication Outside Health Care System 280 Conference Hashtags

American College of Emergency Physicians (ACEP) Scientific #ACEP18

Assembly
Council of Emergency Medicine Residency Directors (CORD) #CORDAA18
Academic Assembly
Society for Academic Emergency Medicine (SAEM) Annual #SAEM18
Meeting
ACEP Leadership and Advocacy Conference #LAC18
American Academy of Emergency Medicine Scientific Assembly #AAEM18
Rocky Mountain Winter Conference on Emergency Medicine #RMWC18

images, specific location (more than state), and pretty much anything that is a
unique identifier.23
Aside from being mindful to not violate HIPAA, you will also want to verify
your institution’s specific policies regarding social media use to ensure compliance.
See Box 17.1 for a list of general best practices for physicians on social media.

ELECTRONIC COMMUNICATION BETWEEN PATIENTS

AND PROVIDERS
Providers regularly share private patient information via email and text messaging.
Though not considered social media, these technologies have best practices to en-
sure clear communication and minimize risk to patients.

Text Messaging
There are 20 billion text messages sent daily worldwide. In the United states, 91% of
adults own cell phones and 81% use their phones to text, making it the most com-
monly used mobile app. In the clinical world, more than half of physicians report
using text messaging to communicate with their teams regarding patient care.

Box 17.1. 8 Best Practices for Physicians on Social Media

1. Always look at photos carefully for personal health information (especially what’s
in the background).
2. Do not “friend” patients on social media.
3. Change or remove all identifiers (age, sex, main complaint) and location.
4. Get written permission from patient, if possible.
5. Delay discussion of cases for a period of time (months to years).
6. Write a post as if it’s impossible to delete it, because it is.
7. If in doubt, don’t post it.
8. Don’t forget that the Health Insurance Portability and Accountability Act of
1996 (HIPAA) applies to social media.
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Many physicians incorrectly assume that HIPAA prevents the use of text mes-

281
saging. The Department of Health and Human Services Office for Civil Rights,
which is responsible for enforcing HIPAA compliance, does not specify any ad-

Email and Social Media

ditional requirements for text messaging beyond the requirements of the Security
Rule. All systems are vulnerable to breach, including text messaging, and in the
absence of meaningful compliance standards, so long as covered entities have
considered “reasonably anticipated risks” and have created mitigation strategies,
there is nothing specifically prohibiting the use of text messaging. For instance, an
encrypted Apple iMessage sent to a device with message preview disabled could
be considered compliant if both devices have strong passwords and are capable of
remote deactivation.
For many people, text messaging has replaced the telephone call. It is inevitable
that this technology will play an increasingly important role in communication be-
tween physicians and patients in the future. Finally, although HIPAA may not pre-
vent the use of text messaging, physicians should follow (or advocate changing) the
policies of the institutions at which they work.

Email
Email has been used for many types of communication between patients and
providers, including health promotion and disease prevention, communicating test
results, communication between health care professionals, to assist in the care co-
ordination and scheduling of appointments, requesting medication refills, and for
clinical advice. Many studies have shown that both patients and providers prefer
email over telephone consults for nonurgent consultations.
Advantages include low-​cost, quick, asynchronous, written, archivable means
of communication, which aids in recall and documentation of the information
exchanged. Potential disadvantages of using email for clinical communication in-
clude concerns about privacy and confidentiality, physician wariness of increased
workload and expectations regarding the timeliness of responses by patients,
and the dangers of patients inappropriately seeking advice for urgent/​emergent
conditions by email.24
A major challenge in email is avoiding inflaming conflict and clearly
communicating tone. Avoid profanity, all capital letters, and excessive exclamation
points or question marks.25 Although emojis are generally discouraged by managers,
studies suggest their use can improve communication.26 Additionally, although bad
news is hard to give, studies suggest bad news received via email is more accurate
with less distortion than delivered via telephone or in person.27 Research suggests
that perceptions of formality and timeliness in email can vary by culture.28 See Box
17.2 for a list of best email practices.

Patient Portals
Many electronic health records systems include patient portals that can be used as
an alternative to conventional email and offer encryption and access control, as well
as allow triaging of certain types of messages to the most appropriate staff member.
As with other types of electronic communication, follow your institution’s specific
guidelines for emailing PHI between patients and providers.29
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Communication Outside Health Care System 282

Box 17.2. 8 Best Practices for Email
1. Never send email while angry. When in doubt, write and reread in the morning.
2. Respond in a timely fashion.
3. Beware of reply all.
4. Avoid using slang, jargon, or emoji.
5. If you’re worried about tone or privacy, consider phone or face-​ to-​
face
communication.
6. Use appropriate greetings and signatures.
7. The subject line should be well thought out and searchable and convey the main
point of the email.
8. Never assume privacy. Emails are easy to save, easy to forward.

SOCIAL MEDIA PLATFORMS AND TIPS FOR SUCCESS

Twitter
Twitter is the juggernaut of health care social media (at the time of writing this
chapter). It has become one of the top social media platforms in the last several
years and is the first place to go when starting to use social media. Twitter was
founded in 2006 and now has approximately 310 million monthly users.30 It is a
microblogging platform. Microblogging is using instant messaging, images, and
video links (i.e., microposts) to post a variety of content to subscribers. All tweets
are open to the public unless the user designates that the message is to be sent to
his or her followers. A tweet is limited to 280 characters. Tweets can include links
to articles or videos. Tweets can have pictures embedded in them. Including @han-
dles sends notifications to specific users. Including #hashtags (placed at the begin-
ning of a word/​phrase) highlights a topic of discussion or event. Therefore, if the
user wanted to search a particular topic, he or she could do so through a hashtag.
This is used often at conferences. The user searches by the hashtag and sees posts
from a variety of users that relate to that particular topic. For example, at the 2016
American College of Emergency Physicians (ACEP) Scientific Assembly con-
ference, attendees could search for topics related to the conference by entering
#ACEP16 into the Twitter search bar.

Twitter Use in Education

Twitter (and indeed all of social media) can be used in a variety of ways in edu-
cation. Many scholars use it to share information, request assistance, and build
collaborations. Scholars can use Twitter to help with branding. Branding is the
intention to get their online persona linked with a particular educational topic or
idea. Twitter can also extend the scholar’s impact and engagement on a national and
international level by increasing communication opportunities with others in the
field. See Box 17.3 for a list of best practices for using Twitter.
Most large conferences use Twitter for promotion. Typically, the conference
identifies a shared hashtag to promote social media exposure. The hashtag functions
as a search feature. This allows people to see all of the tweets about a particular con-
ference by searching the hashtag. Therefore, this builds connection opportunities.
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Box 17.3. Twitter Best Practices

Email and Social Media

• Double check grammar and spelling.
• Share information that adds value to your followers.
• Retweet others and interact with them as this will increase engagement.
• Use appropriate #hashtags and @handles.
• Use pictures and videos.
• Do not boast or post negative comments about others.
• Include a call to action.

People begin replying to one another starting conversations. The goal of these
interactions and conversations is to network. Unfortunately, these conference
connections typically end when the conference is over. A key theme to building
lasting connections is to engage in backchannel conversations.31 A backchannel con-
versation is one that starts with discussing a topic by tweeting and replying with
others and then the conversation continues as the subject matter shifts to other
conference topics. As the tweeting continues it solidifies those contacts, therefore
increasing the chance that those connections remain after the conference is over.
The more personal followers one gains during the conference, the higher likelihood
the person will retain these followers after the conference has ended.

Creating a Twitter Profile

The initial step with Twitter is to create a profile. This profile should be well thought
out. The goal is to make connections in a few seconds with people. A great profile
includes a picture. Typically this is a headshot. If this is a business or professional
Twitter account, then consider having a picture that is professional. Avoid having
pictures of being out at a party on your business account as it sends the wrong mes-
sage. Be thoughtful when filling out the bio. The bio is the 1 or 2 sentences that
people are going to read when reviewing a profile. The goal is to find and make
connections with people who have similar interests or professions in the 10 to 20
seconds they are going to spend reading the bio. There should be no grammar errors
or misspellings. Make sure that it encapsulates who you are, what you do, and your
interests. Include a background picture. This is an opportunity to brand yourself.
For example, if you identify yourself as an expert in ultrasound education, then
include an interesting ultrasound picture. If you have a website or blog, consider
using the header picture of your blog. Consistency will drive people to your site. See
Figure 17.3 for examples of the authors’ Twitter profiles.

Writing a Great Tweet

There are several components to a great tweet. A great tweet is defined by the
number of interactions, likes, and retweets that it receives. Interesting tweets in-
troduce your audience to a useful resource, represent a point of view that elicits
a reaction, and/​or is entertaining. The goal is to improve the chances of engage-
ment. Including links helps build engagement and improves the odds that your
tweet will be liked or retweeted by others. Including pictures also is an easy way
284

Communication Outside Health Care System 284

FIGURE 17.3. Example Twitter profiles. Your Twitter profile should feature a headshot and header
image as well as a short bio that is less than 160 characters. Including the handles of organizations
you are affiliated with and hashtags of topics you are interested in can increase the likelihood of
gaining new followers.

to build engagements. A tweet with a picture is 34% more likely to be retweeted

than one without.32 Although 280 characters seems short, ideal tweets are actu-
ally shorter. Also, consider including a hashtag. Tweets that include a hashtag are
33% more likely to be retweeted than tweets without a hashtag. Include only one
hashtag per tweet as with more than one your engagement can drop. You can re-
tweet someone else’s tweet. This is a great way to increase engagement and con-
nect with others. The easiest way to retweet someone is to just hit the retweet
button. A smarter way to do it is to “retweet with comment.” This will not only
allow your viewers to know your thoughts on the tweet but also allow the orig-
inal author to interact with you as well. Check out Figure 17.4 for 2 ways to tweet
about the same topic.

LinkedIn
LinkedIn’s niche in social media is making professional connections. LinkedIn is
very similar to Facebook in its architecture but focuses more on careers and the
professional side of its users rather than personal interactions. It has been dubbed
“Facebook with a suit.” LinkedIn was founded in 2003. Although initially constructed
similar to Facebook, it has grown to purposefully exclude its customers’ personal
lives. In focusing on being a professional matchmaker, the platform discourages
forms of self-​expression or emotional attachments as these might hinder profes-
sional growth.33 Instead of chronicling the person’s life story, LinkedIn focuses on
promoting the user’s specific skills and expertise.
A vast majority of recruiters are using LinkedIn to screen, interview, and hire
potential job candidates. Whether it is fair or not, recruiters are positively and neg-
atively affected by what the candidate posts on social media. People with family-​
or professionally oriented social network sites are rated higher by recruiters.
Conversely, candidates who post about drugs and alcohol are rated not only as less
qualified and less conscientious but also as less likely to be interviewed.34 Lastly,
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285
Email and Social Media

FIGURE 17.4. Good Tweet, bad Tweet. Compare the tone, identifiable information, and linked
resources in these two tweets about the same patient.

almost 70% of employers have declined to offer a position to a candidate based

solely on unflattering social media posts.33
One of the major ideas behind what recruiters are looking for in evaluating a
person’s social media site is the concept fit. Fit is related to person-​job fit or person-​
organization fit. Person-​job fit is related to the applicant’s knowledge, skills, and
abilities for the particular job in question. This fit is strongly related to overall
job satisfaction. Person-​organization fit refers to the similarity of the applicant’s
values to the company’s values. Person-​organization fit has a strong correlation to
286

job turnover and absenteeism.35 Keeping these ideas in mind when filling out the
Communication Outside Health Care System 286
LinkedIn profile can ensure that candidates are viewed as desirable.

How to Use LinkedIn Effectively

As with all social media sites, be intentional when filling out the profile. Start by
using a professional picture. Because this is functionally going to be an online CV,
make the picture professional. Also use a background photo as this helps the pro-
file stand out. The headline should be well thought out. The default headline is the
job title, which is not memorable and lumps the person in with the thousands of
others with a similar title. Successful headlines focus on the individual’s particular
interest, job focus, and how the person’s expertise can benefit the reader. Ensure
that the contact information is filled out completely and that it remains up to date.
Customize the URL address to include the person’s name. This makes searching
and finding easier. The summary is a vital component of a complete profile. Attempt
to create a story with a summary that incorporates passions, interests, and career
direction. It may be beneficial to attempt this a few times to get the wording down
correctly. Request recommendations from others in the same field. Think about
who would make a solid recommendation before spamming out requests. Lastly,
make sure to add things to the publications section. This can be especially useful in
displaying content expertise. A list of best practices for using LinkedIn can be found
in Box 17.4.

Facebook
In 2004, students at Harvard started using Facebook as an electronic student direc-
tory. Initially restricted to Harvard, it soon spread to other college campuses across
the nation. Currently there are over 2 billion users of Facebook with over 1 billion
daily users. The most common age group is 25 to 34.36 Although primarily used as
a social networking site, there are a lot of different ways to utilize Facebook. Many
businesses, politicians, marketers, and schools use Facebook.
Facebook is used in a variety of ways in education. Internationally, it is used in
all levels of education. As schools look to enhance student engagement, they are
turning to using a variety of media to deliver content. It has the benefit of many
students already being comfortable with the interface as they use Facebook for so-
cial purposes. Multiple studies have been done on Facebook’s use in education, and
it has been shown to increase student motivation, increase active learning, and im-
prove teacher credibility.37 Students use Facebook to share resources, participate
actively, increase discussions and communication, share content, and expose other
students to external resources.38 Teachers benefit from Facebook by increasing ac-
tive learning opportunities, increasing avenues to translate knowledge, enhancing
teacher credibility, interconnecting learning experiences, and comparing different
ways of student learning.39
There are 2 Facebook functions commonly used by educators. These are pages
or groups. Each has its pros and cons, with a complete overview being out of the
scope of this text. Pages are easy to use as they are very similar to people’s Facebook
profile. The instructor can post notifications for course material, reminders, and
links to relevant websites. The drawback to pages is that there is less interaction and
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287
Box 17.4. LinkedIn Dos and Don’ts

Email and Social Media

The following are considered best practices:
• Make your profile public and fill it out completely.
• The headline should be well thought out with keywords (so it is easily searchable).
• Use a professional photo.
• Ensure all contact information is filled out and up to date.
• Use keywords when filling out experience section.
• Join groups that are in your industry.
• Write a summary that tells something about you personally and why your work
matters.
• Customize your URL.
• Get professional recommendations from others.
Users should avoid the following:
• Posting inappropriate photos
• Using poor grammar or communication skills
• Posting information on drug or alcohol use
• Falsifying information (especially data that is easily verifiable, i.e., educational
background)
• Posting disparaging comments about work associates or job

engagement between students. Also, educators cannot create group documents

using pages (they can in groups). Many educators opt to use Facebook groups in-
stead. Groups can be used similarly to pages but create an environment for richer
engagement between students as well as greater faculty-​student interactions. A
helpful feature of groups is that they can be set to a closed or secret setting, ensuring
that there is some privacy. This helps as some students have been concerned that
with open groups others might find out their academic performance. If the setting
is closed other people can still search and find the group but cannot see any of the
group’s activity. Secret groups cannot be searched for; therefore, students must be
invited. In groups students can post questions and answer each other. They can also
easily comment on others’ posts or use the chat function for real-​time discussions.
Group documents can be used to collaborate in real time with other members of the
group. Lastly, groups have a search option that allows users to search for terms in the
groups, whereas this does not exist in pages.40
An interesting way to use Facebook in education is as a replacement learning
management system. These learning management systems (LMSs) can be very ex-
pensive to use, and Facebook provides the educator a tool to have a low-​cost and
easy-​to-​use alternative for their class. Educators can leverage the Facebook group
function as an LMS. The wall is used to distribute materials and information. Here
important dates, links to articles, and other resources can be stored for easy access.
Students can work on group documents. Peer-​to-​peer discussions occur in real time
or asynchronously, leading to students teaching each other. This increases engage-
ment and connections within the class. Reminders can be made for important dates.
Facebook has many of the same abilities of a formal LMS while being a platform
that students are already using daily.
28

Communication Outside Health Care System 288

Box 17.5. 5 Tips for Using Periscope
1. Make sure that the camera and mic are turned on and the ringer is turned off.
2. Tweet out ahead of time to increase followers and use hashtags.
3. Acknowledge comments and respond to questions (increases interactivity).
4. Have a compelling title.
5. Make the broadcast public.

Periscope
Periscope is a live video streaming app developed in 2015 and first released by
Twitter. Twitter integrated Periscope into it’s platform, thereby negating the need
to have a Periscope app. Periscope is often used at conferences or live events but
interestingly can be used to record lectures. One study looked at pathology lectures
and noted that one of the lectures was viewed by 279 people worldwide using the
Periscope app.41 The 2 features of Periscope that make it so successful are the ease
of use and interactivity.
Periscope allows for easy broadcasting of videos. The startup cost is low as the
equipment needed is a smartphone and maybe a tripod. Getting started is easy as it
only requires downloading an app. Also, the software is simple and intuitive. Lastly,
broadcast is free for viewers and can be archived for later use.
The major feature that drives the success of Periscope is that it is interactive.
With Periscope, the stream is in real time, with the ability to allow viewers to interact
with broadcasters. This allows for a more active form of viewing. When watching a
remote live stream, the viewers oftentimes want to interact with the broadcasters,
which increases the sense of engagement and immersion in the stream.42 Many
features of Periscope have been integrated into other platforms, such as Facebook
Live. See Box 17.5 for a list of best practices for using Periscope.

Podcasts
The term podcast was first used by journalist Ben Hammersley in 2004 to describe
the audio weblogs that were recorded in garages and living rooms and disseminated
via the internet to people’s MP3 players and computers. In 2005, Apple added
podcasts to its popular iTunes store, allowing millions of people without technical
skills to browse and download new episodes to their iPod. As MP3s replaced phys-
ical tapes and CDs, downloadable audio programs replaced mass-​market radio sta-
tions. Today, approximately 67 million Americans listen monthly to podcasts, most
of them on their phones.
Podcasts are increasingly used in education. Initially, educators were reluctant
to use podcasts, citing concerns for decreased classroom attendance and that it
mandates a particular style of teaching.43 For instance, it works well for lecturers
who stand behind the podium but not for lecturers who use other teaching
modalities (small group, team teaching, etc.). However, students prefer classes that
offer podcast/​lecture recordings, and many universities are offering these online re-
sources. Universities can increase their student numbers while decreasing cost by
289

using online resources. Also, smaller universities can band together to increase the

289
number of classes they offer.
In the field of medicine there are a variety of podcasts dedicated to particular

Email and Social Media

specialties. Popular emergency medicine podcasts such as EM RAP involve a mix
of recorded didactics and discussions of current issues in emergency medicine.
Podcast consumers are more likely to be active on social media platforms (e.g.,
Facebook, Twitter) and have a higher educational background. EM RAP is only 1
of over 30 different podcasts that focus on emergency medicine topics. Figure 17.5
highlights the many emergency medicine podcasts available in the iTunes store.
To get started with listening to podcasts, download a podcast app (if you don’t
already have one). Most apps will have an option to explore new podcasts and sub-
scribe to them. Similar to channel surfing, you may find shows you like or dislike.
Unlike radio, if you enjoy a particular show, you can use the app to listen to old
episodes and subscribe to automatically receive updates about new episodes. Life
in the Fast Lane is a website that has a running list of all major emergency medicine
podcasts and blogs and is a great way to get started listening.
Contributing your own podcast is easier than ever. Apps such as Anchor and
Soundcloud allow you to record, edit, syndicate, and release episodes from your
smartphone. For a more professional approach, online resources such as “The
Podcast Host” have detailed information about equipment, software, and techniques
for creating a high-​quality podcast. Be aware, though, that starting a podcast means
engaging in a never-​ending production cycle of record, edit, release, and the vast
majority of podcast consumers are not producers.

Snapchat
Similar to Facebook, Snapchat began as a social media messaging platform pop-
ular with teens. Its use of short multimedia videos and timed destruction of con-
tent is engaging, especially for a generation of digital natives. These users have never
known a world without smartphones and 30-​second YouTube videos. Major con-
tent producers, such as the Economist and Washington Post, have begun curating
Snapchat stories on major news events. It is conceivable that medical educators will
harness this for medical education very soon.

THE END, BUT NOT FOR LONG

Communication is the transmission of information. Each new iteration of com-
munication technology has been driven to remove the barriers of the last. Roman
scribes allowed for conversation at a distance, printing presses allowed one person
to lecture millions, and broadcasting made this communication instantaneous. As
technology advances, so will communication. Inventions like the telephone, in-
ternet, Facebook, and Snapchat are all built around the human need to communi-
cate easily with others. Similarly, the foundation of education is the transmission
of knowledge. As we improve our communication tools, education will harness
them. The most recent innovations in social media further break down the barriers
of communication, and gifted educators will inevitably use these technologies to
improve their educational product.
 290

FIGURE 17.5. Emergency medicine podcasts. iTunes is one place to find a variety of emergency medicine podcasts.
291

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294

Communication Scenarios

Maria E. Moreira and Andrew J. French

CASE 1: MEDICATION ERROR

A 12-​month-​old male is brought in by parents with difficulty breathing and hives
after eating a peanut butter milkshake. The patient looks ill. When placed on the
monitor he is tachycardic and hypotensive. This is appropriately recognized as an-
aphylaxis and the physician calls for 0.01 mg/​kg dose of epinephrine to be given
IM of a 1:1000 solution. The patient is 20 lbs. The nurse administers 0.9 mL to this
child, which is 10 times the appropriate dose. The patient becomes tachycardic and
hypertensive and is admitted to the hospital for monitoring as the error is identified.
What communication technique should have been used that could have
prevented this error? Once the error has happened, what could improve team func-
tion for future interactions?

CASE 2: JOINT COMMISSION RULES

(ADMINISTRATORS VS. PROVIDERS)
At a departmental meeting, findings of a recent mock Joint Commission survey
were presented that cited concerns around various items of personal protective
equipment (PPE) being worn outside of a patient room. Although the items were
not soiled or contaminated, this violated Joint Commission standards and is put-
ting the hospital at risk. While the hospital administrator was relaying the findings
of the mock survey to the department faculty, multiple physicians commented ag-
gressively with voices raised that these guidelines are not evidence based and began
to push back at the request to adhere to the standards. The administrator, feeling
attacked, became defensive and mirrored this aggression by demanding they follow
the Joint Commission guidelines without any further dialogue.
295

How could the physicians have responded more appropriately?

295
What could the administrator have done to handle the situation more effectively?

Communication Scenarios
CASE 3: THE IRRITATED PATIENT
A 35-​year-​old male presents to the emergency department complaining of 1 day
of abdominal pain and vomiting. On exam, the patient has tenderness to palpation
at the epigastrium. The rest of his exam is normal and his vital signs are all within
normal limits. The patient receives IV fluids and labs are sent including a complete
blood count (CBC), basic metabolic panel, liver function tests, and lipase, which all
come back normal. As the department is busy, the physician asks the nurse to dis-
charge the patient with a diagnosis of gastroenteritis. The patient has only spoken
to the physician once during his emergency department (ED) encounter. Over the
course of several days the patient continues to have abdominal pain and develops
anorexia and a fever. He comes back to the ED 5 days later. Now he is febrile and
tachycardic and has tenderness to palpation in the right lower quadrant with
guarding. The physician sees the patient and orders labs and a computed tomog-
raphy (CT) scan. The department is very busy. Three hours later, the patient is irri-
tated and doesn’t understand why he is waiting. He tells the nurse he has not spoken
to the physician in 3 hours and has no idea what is going on. The physician gets the
CT scan results back showing that the patient has a ruptured appendix. The patient
is so irritated that he asks to be transferred to another hospital for further care.
What could have been done differently at the first visit to potentially prevent a
delay in diagnosis?
What could have the physician utilized in the second visit to help with commu-
nication and prevent the patient’s dissatisfaction?

CASE 4: THE ANGRY PATIENT

A 48-​year-​old female presents to the ED by ambulance with police. The patient was
involved in a domestic violence incident. She is yelling and is upset about being in
handcuffs, stating that this doesn’t make sense because she was the one who was hit.
The physician starts raising his voice to get the patient’s attention, which leads to
further escalation and the need for Haldol.
How could this situation have been diffused?

CASE 5: THE UNEXPECTED DEATH

A 17-​year-​old male presents to the ED by ambulance with multiple gunshot wounds.
The patient loses pulses in the ambulance bay. The patient is placed in a critical care
room with cardiopulmonary resuscitation (CPR) in progress. Despite the trauma
team’s best efforts, including performing a thoracotomy and administering blood
and intracardiac epinephrine, the patient is pronounced in the ED. The social
worker says she was able to contact the patient’s family, who are all waiting in the
family room. You are informed that at this time the family cannot see the patient as
this is considered a homicide.
How do you approach this situation? How will you deliver the news to the
family?
296

CASE 6: THE SHY CHILD

Communication Scenarios 296 A 3-​year-​old female is brought in by her mother for abdominal pain with associ-
ated vomiting and diarrhea. When you enter the room, the child is sitting on her
mother’s lap. The patient’s 5-​year-​old sister and 7-​year-​old brother are in the room
as well. You introduce yourself to the mother and as soon as you try to get close to
the patient to examine her, she begins to cry and hold on to her mother without
allowing you to examine her abdomen. You are able to get part of the exam done
and decide that because her vital signs are normal and she is well appearing overall,
nothing acute is going on. You will give the patient some time to calm down and
then try again.
How could you have created a better rapport with the patient that would have
allowed for a better examination and less frustration?

CASE 7: THE REPORT MISHAP

The paramedic calls to the emergency department about an emergent ambulance
coming to your hospital. The paramedic tells the physician they are bringing a 50-​
year-​old male with a stab wound to the neck. Vital signs are stable and the patient’s
airway is intact. The paramedic reports the patient will be at your facility in 5
minutes. The physician heard “a 15-​year-​old male” and lets the pediatric side of the
ED know this patient is coming. The provider assumes this is a small stab wound to
the neck and the patient is stable. When the patient arrives it is noted that this is an
almost circumferential laceration to the neck. Additionally, the patient is brought
to the wrong bed in the ED because of the confusion in ages. The patient is quickly
moved to the appropriate room along with the rest of the trauma team and the as-
sessment of the patient and resuscitation begins.
How could these errors in communication have been avoided?

CASE 8: THE IRRITATED CONSULTANT

You are only 4 hours into your shift and already consulted orthopedics 3 times. The
next person you see has a fracture dislocation of his ankle. You quickly relocate the
joint but know that given his ankle films he will need surgery and you consult or-
thopedics. The orthopedic resident answers the phone and angrily responds that he
will not see this patient until you get a knee film. You answer back that the knee film
is unnecessary and will not change this patient’s management. After a heated discus-
sion back and forth you say, “Fine, I will order the film” and hang up the phone. This
has now changed your attitude for the rest of your shift.
How could this interaction have gone differently?

CASE 9: THE CONFUSING RESUSCITATION

A 20-​year-​old patient stabbed in the abdomen is brought in by ambulance. The
surgery resident and emergency medicine resident are at the bedside. The emer-
gency medicine resident calls out for IV fluids. The surgery resident calls out for 2
U of blood cells and says no IV fluids should be given. The nurse hears the orders
from the ED resident and starts the IV fluids. The surgery resident sees the fluids
running and yells at the nurse for starting the fluids, telling her to start the blood
297

immediately, which hadn’t been started yet. The patient’s blood pressure drops right

297
before the blood is started. Once the blood transfusion is started the blood pressure
improves. The decision is made to take the patient to the operating room.

Communication Scenarios
What went wrong in this scenario and what could have been done to improve
the care of the patient?
What should the next steps be for the team?

CASE 10: THE ELECTRONIC MEDICAL RECORD ABYSS

A 48-​year-​old female presents with 3 days of fever, cough, runny nose, and short-
ness of breath. You obtain a chest x-​ray to evaluate for pneumonia. The chest x-​ray
is normal except for a nodule, which was noted on an overread after the patient was
discharged. The recommendation on the radiology read is for a repeat chest x-​ray 6
weeks later. The overread is not noted by the physician evaluating the patient in the
ED. The patient does not follow up until a year later, when she is diagnosed with
lung cancer.
What could have been done to expedite the diagnosis?

CASE 11: MEDIA BLUNDER

You are being interviewed by the media for a piece on the importance of
vaccinations during flu season. During the interview the journalist begins asking
you questions on the role of emergency medicine as a “major contributor” to
rising health care costs and asks if you think it is fair that emergency departments
charge patients so much money and if they should even be allowed to be “out of
network.” Feeling a bit defensive, you begin debating emergency medicine costs
and health care economics. It quickly becomes clear that the journalist has done
his research on this topic and within minutes you realize you are not prepared for
the level of detail the journalist has brought to the interview. With every passing
second, the journalist seems to be making you look more and more ignorant to
the facts.
What could have been done to avoid this?
Can anything be done to save the interview?

CASE 12: PHYSICIAN/​N URSE INTERACTION

On a busy night in the department, the nurse becomes concerned about a patient
with chronic obstructive pulmonary disorder (COPD) who has been in the depart-
ment for less than an hour. He calls the physician and tells the doctor that he thinks
the patient requires positive pressure ventilation even though he is not done with
his nebulizer. The nurse states the patient “doesn’t look good.” The physician, who
knows the patient well from many prior visits and having just fully evaluated the
patient less than 20 minutes prior, asks for the oxygen saturation. The nurse reports
it as normal, and with multiple patients still to see and historical knowledge of the
patient, and somewhat frustrated with the interruption, the physician states to con-
tinue the nebulizer and reevaluate. Subsequently, the conversation ends. Twenty
minutes later there is an emergent overhead page to the patient’s room. The physi-
cian arrives to find the patient no longer breathing.
298

What simple questions and interventions could have been asked and taken
Communication Scenarios 298
during the brief physician-​to-​nurse conversation that could have avoided this
outcome?

SOLUTIONS
Case 1: Medication Error
In this case, closed-​loop communication could have caught the error potentially
before the medication was given. In pediatrics, if the nurse has to do multiple
calculations during a high-​stress situation, simple math becomes complicated. In
this situation a miscalculation was made because there are multiple solutions of
epinephrine.
Example of closed-​loop communication:

Physician: Give 0.01 mg/​kg of a 1/​1000 solution of epinephrine IM.

Nurse: I am giving 0.9 mL of epinephrine IM.
The physician recognizes this is too big of a dose for this child and looks at the
dosing with the nurse and they both recognize the error and catch that it should
be 0.09 mL.
Nurse: I am now giving 0.09 mL of epinephrine IM.
Physician: 0.09 mL of epinephrine has been administered.

If an error in dosing is made, the patient or patient’s family needs to be notified and
the team should have a debrief. In the debrief, the team can discuss systems issues
and how to prevent the same error in the future.

Case 2: Joint Commission Rules (Administrators vs.

Providers)
From the physician perspective, it is important to recognize that many regulatory
standards and guidelines (such as the case with the Joint Commission) are outside
of the control of not only physicians but also hospital administrators. Additionally,
as much as physicians often do not like to have items outside of their control en-
forced upon them, administrators equally dislike having to enforce these standards,
rules, and guidelines.
Administrators must understand that physicians are typically very data driven
and evidence based. Furthermore, part of what drove many individuals to become
physicians is the ability to have a significant amount of control. Having to comply
with guidelines they did not help create, especially when not clear that they are ev-
idence based, can add to the growing frustration and burnout in the medical field.
In this case, focusing on the concept of mutual understanding is of the utmost
importance. Both sides understanding that neither may be happy about these (or
similar) regulations but that they are necessary to have an accredited and successful
hospital is key. When possible, administrators should seek data and evidence be-
hind best-​practice changes or regulatory guidelines and present these to physicians
with any requests. Physicians must understand that administrators would much
rather work with the providers than against them. Lastly, to minimize the need for
rule enforcement, administrators could seek ways to make compliance easier for
the physicians, such as increasing ease of access and disposal of PPE. Seeking to
29

understand each other’s views and situation can minimize conflict, open dialogue,

299
and facilitate open communication.

Communication Scenarios
Case 3: The Irritated Patient
The provider only spoke to the patient at the beginning of the encounter to obtain
the history needed in order to obtain labs and start the treatment. The provider
never went back into the room to discuss the diagnosis given. Additionally, this pa-
tient with abdominal pain and vomiting still has an unclear diagnosis. It would have
been better for the provider to give the patient a diagnosis of abdominal pain of
unclear etiology and explain that it is unclear what is causing his pain but give him
return precautions, which may have led the patient to return to the emergency de-
partment sooner.
On the second visit there are several things that the physician could have
done to improve communication with the patient. The physician could have
used AIDET in his communication with the patient, letting the patient know the
tests and treatment to be performed, including an expected duration for the visit.
Additionally, the physician could have written this information on a communi-
cation board that the patient and the rest of the care team could refer to. If there
is an unexpected delay in obtaining studies, the patient should be informed of
the delay. Going in to tell the patient that you are awaiting a CT scan to evaluate
for potential perforated appendix and that he is next to go to CT helps keep the
patient informed. Additionally, that is an opportunity to ask about the patient’s
comfort and to reassess the patient.
When the patient asks to be transferred to another hospital, the physician has an
opportunity to reengage the patient and try to build rapport if it hasn’t been done
prior to this moment. At this time the physician should seek to understand why the
patient is frustrated, apologize for not keeping the patient informed, and explain
what the next steps will be.

Case 4: The Angry Patient

This patient is upset and angry at the situation she is in. It is also possible that she
is scared. The physician should try to not raise his voice and speak in a calming
tone. Body language is also a key element with all communication but especially
in scenarios like these. While you should also focus on your own safety by staying
close to the door and not allowing any aggressive individuals to stand between you
and a point of exit, it does help to sit with an open and relaxed posture when dealing
with these situations. Also, try to show empathy by saying, “I see how upsetting this
is for you.” Ask the patient what she is most worried about. Additionally, explain the
current situation. Let the patient know that the first priority is to make sure that an
acute medical condition is not present and that she needs to be assessed to deter-
mine if she has any injuries from the assault. Ask her what is bothering her the most.
If she is complaining about the handcuffs, you can let her know that you will ask
about making her more comfortable. You can give her a choice about her workup
as she can still make her own health care decisions. In this way you are returning
some decision-​making capacity to her as she has no control over the fact that she is
currently in handcuffs.
30

Case 5: The Unexpected Death

Communication Scenarios 300 Death notification is anxiety provoking. In the emergency department, we have
to give bad news on our first encounter with the family before we have been able
to establish rapport. Additionally, this is a traumatic unexpected death in a young
person. Each family member may react differently to the news and you need to be
ready. Make sure you have a private room for the death notification. Prepare what
you are going to say. Give your pager or phone to someone else so that you are
uninterrupted. Obtain all information you need to talk with the family and make
sure the patient is appropriately identified so that you are making the appropriate
notification. It is important to have the social worker or chaplain with you to help
support the family.
Start by identifying yourself and your role in the care of the patient. Confirm
that you are talking to the correct family. Start by asking what the family knows
about the situation. Provide a warning shot—​“I have some bad news.” Deliver the
news—​“John died a few minutes ago.” Allow time for the family to process. Answer
any questions. You may need to tell the family that they are unable to see the patient
given the circumstances but that you will keep them informed of when they may be
able to do so.

Case 6: The Shy Child

First, you need to recognize that the patient is anxious and you need to alleviate
that anxiety to be able to evaluate the patient. Try to first build rapport with the
patient by asking some age-​appropriate questions that will engage her. For this
patient you can ask her to introduce you to her family in the room. Ask her about
her favorite toy. You can also compliment her on her pretty shoes. If possible
have toys available as they serve as a good distraction. With this patient, you can
also demonstrate the physical exam on the older sibling first in order to show
that you can be trusted. Once you have introduced yourself to the patient, talked
about some age-​appropriate topics, and demonstrated the abdominal exam on
the older brother, the patient allows you to perform an abdominal exam on her.
She is not crying for this exam and you note that she has a very benign exam and
are able to assure yourself and the mom that this is a viral illness and requires
symptomatic care. You tell the patient that she did a great job and give her a
popsicle.

Case 7: The Report Mishap

There were 2 errors in this communication. The first is the error in age—​the age was
heard improperly. The second error is in the failure to create a shared mental model.
The first error could be prevented by a read-​back; the physician could have clarified
the age through read-​back. Additionally, for numbers that can potentially sound
similar on the phone, the paramedic can say the number and then give each number
individually—​the patient is 50—​5, 0. The second error requires a little more work
on the part of both the paramedic and provider. The paramedic is the eyes for the
physician in this case. If the injury is described as a stab wound, the physician on the
other end may be thinking of a 2 cm laceration on the neck ,which is very different
than an almost circumferential laceration of the neck with significant bleeding at the
301

scene. Sometimes the physician may need to ask a couple of quick questions to be

301
able to get a better understanding of the patient’s presentation.

Communication Scenarios
Case 8: The Irritated Consultant
In this situation, as the consulting physician, start by using Kessler’s 5 Cs of con-
sultation. You have already spoken to this physician a couple of times, so this inter-
action may start a little differently. You already may have established a relationship
with this consultant. Perhaps recognizing that you have kept the consultant busy
and thanking him for his time will start the conversation on a good note. Start with,
“This has been a busy night with many orthopedic injuries. Thank you for partnering
with me to provide our patients with the best care possible. I have a young man with
an ankle fracture dislocation that has been relocated and is neurovascularly intact.
We have an x-​ray of the ankle. This patient most likely will need surgery. Would this
be a patient you would want us to admit today to go straight to surgery or place the
ankle in a splint and have him come back for follow-​up? If there is anything else that
you need to make that decision, please let me know and I will make it happen.” The
orthopedic resident, though tired, appreciates your concise presentation and spe-
cific question. He asks you to get knee x-​rays and says that he will check the ankle
films and give you an answer in the next 15 minutes about the disposition. You order
the knee films and the orthopedic resident calls you back to let you know that he
would like to admit the patient to have surgery in the morning. You ask if there is
anything else you can do to help. The resident asks if you can help make sure that all
supplies are available for splinting the patient.

Case 9: The Confusing Resuscitation

There are several problems that can be identified in this scenario: lack of defined
roles, lack of a clear resuscitation leader, and lack of the use of closed-​loop com-
munication. For recurrent events, it is beneficial to have guidelines for resuscita-
tion roles. Having predefined roles avoids any confusion during the resuscitation. A
team leader also needs to be identified. In the case where there are different learners,
on even days the emergency medicine resident can be team leader and on odd days
the surgery resident can be the team leader. If these roles are not a part of guidelines,
then they should be assigned prior to the patient arriving in the department. The
use of closed-​loop communication can be used for important verbal orders. In this
scenario, when IV fluids are ordered, the nurse could say, “I am about to give 1 L of
normal saline.” If that is not the order that is wanted, then the physician can redirect.
If it is the order that is wanted, then the physician would reaffirm, “Yes, please give
1 L of normal saline.”
After each resuscitation, it is good to have a debrief as a whole team. The debrief
gives all members an opportunity to review what happened in the resuscitation and
to discuss what went well and what things can be done in the future to improve how
the team works together.

Case 10: The Electronic Medical Record Abyss

This case highlights the dangers and overreliance on electronic communication in
the era of the electronic health record (EHR). There are several different solutions
302

that can be applied to this problem. The first solution would require a call from the
Communication Scenarios 302
radiologist to the emergency physician for any overread on a film. Once the emer-
gency physician is aware of the overread, he can try to contact the patient either
through a phone call or a message through the EHR. Additionally, the emergency
physician can send a message to the patient’s primary physician through the EHR.
As technology evolves there are additional opportunities to potentially flag changes
in reads to alert all the physicians involved in the patient’s care as well as the patient
him-​or herself.

Case 11: Media Blunder

In this situation, which can occur with any discussion (and not just with the media),
the journalist has redirected the conversation to a completely different topic. Worse
yet, it is a topic you were not prepared to discuss. The solution to this is straightfor-
ward, but the situation is not always easy to recognize in the moment. Once you
feel that the primary topic has changed, you should reframe the conversation to the
primary subject that you planned to discuss. Although it sometimes feels awkward
and rude to avoid direct questioning, simply say something such as “That is an im-
portant topic, but I would prefer to discuss the extremely important public health
issue surrounding flu vaccines. I would be happy to discuss this complex topic at
a different time.” If you have already engaged on the newly introduced topic, it is
never too late to reframe. Again, use a simple statement such as “I can see you would
like to discuss this in greater detail. In order to give you the time and information
you need, I would ask that we revisit this soon in a separate interview.”

Case 12: Physician/​Nurse Interaction

Many complicating factors contributed to the poor communication in this scenario
on both the physician’s and the nurse’s part. For the physician, taking the moment
to understand the concerns of the nurse is key. Simply asking, “What makes you
concerned?” or “Why are you worried?” would allow the nurse to better explain her
concerns. Likewise, on the nursing side, being much more explicit about things like
a respiratory rate or work of breathing may have helped the physician understand
the concerns much more quickly. The use of SBAR to express nursing concerns to
the physician may have been helpful in this situation.
Another key item that may have improved the communication in this setting is
engaging in face-​to-​face conversation. Not only can concerns be lost in translation
over the phone compared to in-​person discussions, but also it is just simply harder
to decline a request when discussing something face to face. The combination of
language, tone of voice, and body language that accompany in-​person dialogue
maximizes the effectiveness of sending and receiving any message.
30

Resources

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305

Index

Tables, figures, and boxes are indicated by an italic t, f, or b following the page number.
For the benefit of digital users, indexed terms that span two pages (e.g., 52–​53) may,
on occasion, appear on only one of those pages.

abbreviations, 140–​41, 262 Agency for Healthcare Research and

Academic Life in Emergency Medicine Quality, 222, 223f
(ALiEM) aggressive communication style
AIR Score, 275–​76 comparison with other styles, 5
Incubators and Wellness Think example of, 5
Tank, 278–​79 perception as, 13
pre-​and post-​publication peer AHA (American Heart Association),
review, 271–​72 169, 174
Social Media Index, 275 AHA (American Hospital Association),
Accreditation Council for Graduate Medical 260, 266
Education (ACGME), xi–​xii, AI. See artificial intelligence
206, 275 AIDET (Acknowledge, Introduce,
ACEM (Australian College of Emergency Duration, Explanation, Thank You),
Medicine), 160 4, 58, 65–​66
ACEP (American College of Emergency AMA (American Medical Association), 46,
Physicians), 53, 138, 266, 282 230, 260–​61, 265, 267
ACR (American College of ambient noise, 46–​47
Radiology), 245–​46 American Board of Emergency Medicine, 206
ACSQHC (Australian Commission on American College of Emergency Physicians
Safety and Quality in Health (ACEP), 53, 138, 266, 282
Care), 160 American College of Radiology
active listening, 67–​68, 81, 133–​34, 139, (ACR), 245–​46
140, 157–​58 American Heart Association (AHA),
adaption to circumstances, 28–​29 169, 174
administration. See hospital administration American Hospital Association (AHA),
administrative meetings, 190. 260, 266
See also meetings American Medical Association (AMA), 46,
“Advanced Cardiovascular Life Support 230, 260–​61, 265, 267
Provider Manual” (AHA), 169 American Osteopathic Association, 267
advanced practice providers (APPs) American Sign Language (ASL), 54
consultants and consultations, 156, 157 Annals of Emergency Medicine, 270
EMS communication, 131–​32, 137–​38 appearance
provider-​nurse communication, consultants and consultations, 157–​58
118, 120–​21 pediatric patient communication, 83, 84
resuscitation, 167–​68 provider-​patient relationship, 57
306

APPs. See advanced practice providers brief-​huddle-​debrief actions, 32

Index 306
Arafeh, J., 124 briefing, 32
artificial intelligence (AI) debriefing, 32
diagnostic decision support, 224 huddles, 32
electronic health records, 231–​32 British Medical Journal, 271–​72
telemedicine, 98, 106, 107–​8 Buchner, Carol, 55
transitions of care, 234 Bukata, Rick, 270
“Ask Me 3” program, 228
Ask-​Tell-​Ask, 34t, 66 Cadogan, Mike, 271, 274
ASL (American Sign Language), 54 California Hospital Association, 267
assertive communication style Canopy Speak, 59
comparison with other styles, 5 Cardiopulmonary Resuscitation and
example of, 5 Emergency Cardiovascular Care
asynchronous communication, 103, 209, Guidelines (AHA), 174
211, 241 carefree timelessness, 196
allure and risk of, 219 CCLSs (child life specialists), 87
asynchronous learning via FOAM, 275 Center of Excellence for Transgender
electronic health records, 120 Health, 50
audio recording, 237–​38 Centers for Disease Control and
Australian College of Emergency Medicine Prevention, 51
(ACEM), 160 Centers for Medicare and
Australian Commission on Safety Medicaid Services
and Quality in Health Care (CMS), 45, 98, 231
(ACSQHC), 160 child life specialists (CCLSs), 87
children. See pediatric patients
bad news, delivering, 55–​56 Chisholm, C.D., xi, 47
communication strategies, 55–​56 Christensen, Clayton, 100–​1
pediatric patients, 92b, 92–​94 Churchill, Winston, 53
scope of issue, 55 Cialdini, Robert, 162–​63
SPIKES protocol, 70–​72 Cicero, 45
emotion/​empathy, 71–​72 Ciurzynski, S.M., 119
invitation, 71 clarity, 39
knowledge, 71 consultants and consultations, 162
perception, 71 EMS communication, 140–​41
setting, 70–​71 family communication, 67–​68
summarize, 72 meetings, 182–​83
via email, 281 closed-​loop communication
Baran, Paul, 268–​69 avoiding medication errors, 298
Basow, S.A., 202 EMS communication, 133–​34
Beck-​Esmay, Jenny, 278 provider-​nurse communication,
Beckhard, Richard, 19 117, 118, 120, 121–​22, 123f,
Bezos, Jeff, 106 123–​24, 125
blogs, 269, 270, 272, 273f, 275, 282, 283 resuscitation teams, 170–​71, 301
boards of directors (BODs), 144, 145, closing the loop, 68–​69, 147, 160, 161b,
153–​54. See also hospital 161, 205
administration CMS (Centers for Medicare and Medicaid
body language. See nonverbal Services), 45, 98, 231
communication and body College of Emergency Physicians, 264
language Columbine shootings, 262–​63, 266
307

communication, xi–​xii, 27–​40. communication guidelines, 29, 30b

307
See also names of specific all communication is purposeful, 30b
communication senders and body doesn’t lie and it always leaks, 30b

Index
receivers; names of specific types of everyone has agency, 30b
communication interactions are built between two
case examples, 294–​302 or more people and spiral in
angry patient, 295, 299 trajectory, 30b
confusing resuscitation, 296–​97, 301 listening for repetitions, 30b
electronic medical record abyss, much conflict is born from challenges to
297, 301–​2 face, 30b
irritated consultant, 296, 301 one size does not fit all, 30b
irritated patient, 295, 299 two eyes, two ears, one mouth, 30b
Joint Commission rules, communication styles, 3–​14
294–​95, 298–​99 adjusting and adapting, 4
media blunder, 297, 302 aggressive, 5
medication error, 294, 298 assertive, 5
physician/​nurse interaction, awareness of, 3–​4
297–​98, 302 communication tools versus, 4
report mishap, 296, 300–​1 defined, 4
shy child, 296, 300 direct versus reserved (indirect)
unexpected death, 295, 300 communication, 11–​12
components of, 211–​12 direct communication, 12
channels, 211 indirect communication, 12
content, 211 DISC assessment, 9–​10, 10t
formats, 211 innate, 4
media and devices, 211 Myers-​Briggs Type Indicator, 5–​6
mode, 211 S-​N (Sensing-​iNtuitive)
senders and receivers, 211 dichotomy, 6–​7
defined, 3, 28–​29 T-​F (Thinking-​Feeling)
documentation versus, 212 dichotomy, 7–​8
external contributors to, xii using to improve communication, 8–​9
importance of effective, xi–​xii, 3, 45–​46 neuro-​linguistic programming
interpreting and adapting to evolving (NLP), 12–​13
circumstances, 28–​33 passive, 5
communication goals, 29–​33 passive-​aggressive, 5
communication guidelines, 29, 30b perception and, 13–​14
interaction design skills, 33–​40, 34t Thomas-​Kilmann Conflict Mode
scripted, routinized , and habituated Instrument, 10–​11
communication versus, 28, 29 computerized provider order entry
interruptions and, 28, 46–​47 (CPOE), 221, 246
nonverbal elements of, 3 confidentiality, 53
patient safety and, 45–​46 electronic communication, 229, 239,
vocal elements of, 3 248–​49, 281
communication boards (wipe boards), family communication, 65
59, 119–​20 media communication, 260, 261
communication goals, 29–​31 pediatric and adolescent patients, 87–​88
respect for context, 32–​33 conflict and conflict management, 15–​26
respect for others, 31–​32 assertive communication style, 5
respect for self, 31 case examples, 20–​26
308

conflict and conflict management (cont.) consultants and consultations, 156–​65

Index 308
myopic standoff example, 24–​26 anatomy of consultations, 157–​58
non-​flict example, 20–​21 environment, 158
overworked servant example, 23–​24 method, 157–​58
passive observer example, 21–​22 parties involved, 157
Conflict Between People model, 25t purpose, 158
conflict management training, 22 brevity, 162
conflict scale (red and blue clarity, 162
zones), 188–​90 communication tools, 160–​62
consultations and, 164 ISBAR handoff tool, 160
Courageous Conversations model, 25t Kessler’s 5 Cs, 160–​61, 161b
defined, 15 decreasing potential for conflict, 164b, 164
family communication, 64 irritated consultants, 296, 301
functional or constructive persuasion, 162–​63
conflicts, 15–​16 commitment and consistency, 163
GRPI model, 19–​20 liking and authority, 163
goals, 19 reciprocity, 163
interactions, 19 scarcity, 163
process, 19 shared identity, 163
roles, 19 social proof, 163
harm caused by conflict, 15 pitfalls for emergency providers, 159–​60
Other People’s Shoes model, 25t Dunning-​Kruger effect, 159
STATE model, 25t, 25 gender bias, 159–​60
Thomas-​Kilmann Conflict Mode imposter syndrome, 159
Instrument, 10–​11, 17, 18t tribalism, 159
accommodating style, 17, 18t timing, 162
advantages of some conflict Coriera, E.W., 115
management styles, 19 coroners, 56
assertiveness dimension, 17 Council of Emergency Medicine Residency
avoiding style, 17, 18t, 19 Directors, 275
collaborating style, 17, 18t CPOE (computerized provider order
competing style, 17, 18t entry), 221, 246
compromising style, 17, 18t CPP Inc., 15
cooperativeness dimension, 17 cross-​cultural issues
dominating style, 19 cultural barriers to communication, 47
flexibility of conflict management direct and indirect communication, 12
style, 17–​19 family communication, 69–​70
integrative style, 19 learners, 202
obliging style, 19 pediatric patients, 84, 86
types of conflict, 16–​17 Crucial Conversations (Patterson &
mistaking one type for another, 16–​17 McMillan), 25
relationship-​based conflict, 16 “C-​suite” leaders, 144–​45, 148, 149. See also
task-​based conflict, 16 hospital administration
consent
electronic communication, 228, data, defined, 210
229, 237–​38 death and dying notifications, 56, 72–​74, 295,
media communication, 261 300. See also bad news, delivering
pediatric patients, 86, 88 case example, 295, 300
VIPs, 53 in-​person notifications, 73
309

responding to emotions and grief, 73–​74 documentation

309
telephone notifications, 72–​73 distraction versus, 225
debriefing electronic communication versus, 212t, 212

Index
brief-​huddle-​debrief actions, 32 lag time, 225–​26
conflict management, 22 relegation of documentation by nurses to
family communication, 76 metadata status, 217
provider-​nurse communication, 124 Dostoyevsky, Fyodor, 53
resuscitation, 168, 173–​76 Dunning-​Kruger effect, 159
challenges to evaluating effectiveness
of, 177 ED. See emergency department
data supporting, 176–​77 Edelson, D.P., 176
REFLECT framework, 176 education/​knowledge gap, 47, 132, 133,
decision-​centered communication, 136 136, 139, 171, 228
developmental stages and EHRs. See electronic health records
communication, 85–​87 Eisenberg, E.M., 114
adolescence, 87 electronic communication, 209–​52, 280
infancy, 85 asynchronous messaging, 219
school-​aged children, 86–​87 audio and video recording, 237–​38
toddlers and preschoolers, 86 case examples, 212–​13
differential diagnosis generators, 224 Texas Ebola case, 212–​13, 214b, 214
direct communication, 11, 12 components of communication, 211–​12
culture and, 12 channels, 211
defined, 11 content, 211
example of, 11 formats, 211
perception as, 13 media and devices, 211
pros and cons of, 12 mode, 211
disaster preparedness and response senders and receivers, 211
electronic communication, 249 definitions, 210
media communication, 262–​64 data, 210
risk assessment examples, 250t information, 210
DISC (Dominance, Influence, Steadiness, knowledge, 210
and Conscientiousness) assessment, disaster preparedness and disaster
9–​10, 10t, 180–​81 response, 249, 250t
conscientious-​type people, 9–​10, 10t distracted and impaired practitioners, 244
dominant-​type people, 9, 10t documentation lag time, 225–​26
influential-​type people, 9, 10t documentation versus, 212t, 212
steady-​type people, 9, 10t electronic health records, 213–​14
discharge against medical advice (AMA), categories of electronic
50–​51, 117 interactions, 218t
communication strategies, 50–​51 fragmentation, 214–​15
predictors of, 50 inflation of differential diagnosis, 216
distractions potential of as communication
consultants and consultations, 158 tools, 217–​18
documentation versus, 225 proliferation of diagnoses for
electronic communication, 244 performance measurement, 217
EMS communication, 136, 138, 139, 140 relegation of documentation by nurses
meetings, 181–​82 to metadata status, 217
pediatric patients, 90 structured versus unstructured
Doctors Company, 235 information, 216
310

electronic communication (cont.) Periscope, 288b, 288

Index 310
electronic patient portals, 241–​43, 281 personal branding, 279
email, 281, 282b, 282 podcasts, 273f, 288–​89, 290f
extramural communication, 240–​41 Snapchat, 289
with groups, 249–​50, 251t traditional media and, 270–​71
hospital administration Twitter, 282–​84, 283b, 284–​85f
communication, 150–​52 structured communication, 235–​37
email, 151–​52, 153 telemedicine, 97–​109, 246–​47
telephone calls, 151 barriers to, 106
text messages, 151 breaking down barriers, 102–​3
“inbox problem,” 226, 227b, 227 communication streams, 103
interoperability, 231–​32 consultations, 158
lab and pharmacy communication, 246 crowdsourcing providers, 105
language, disability, and literacy current state of, 101–​2
barriers, 229–​30 disruptive innovation, 100–​1
metadata, 247–​48 empathy, 100
mobile apps, social media, future of, 107–​8
and, 250–​51 mental health, 106
needs of “informationally complex” overview of, 98–​99
patients, 244–​45 patient engagement, 105
patient direct communication, 227–​29 patient safety, 104
phases of care workflow, 219 pitfalls of, 99
documentation versus distraction, 225 prehospital emergency medicine, 105
patient intake, identification, and promotion of conversation, 103–​4
registration, 220–​21 reasons for considering, 99
prehospital communication, 219–​20 rural and remote access, 104–​5
procedures, treatments, and trends in, 108–​9
observation, 221–​22 text messaging, 238–​40, 280–​81
result review, consultation, and benefits and vulnerabilities
decision making, 222–​25 of, 238–​40
retrospective analysis of care “Bring Your Own Device”
processes, 225 (BYOD), 238
triage, interview, and exam, 221 transitions of care, 232
portable patient health elements of, 233b, 233
information, 230–​31 follow-​up, 232–​34
privacy and security, 248–​49 handoffs, 234
radiology communication, 245–​46 tools for, 236t
record blocking, 243 verbal communication, 235
social media, 268–​80, 282–​89 websites, 243–​44
augmented (or virtually attended) electronic health records (EHRs), 97–​98,
medical conferences, 279 99, 120, 126
commenting, 269–​70 case example, 297, 301–​2
community development, 276–​79 categories of electronic interactions, 218t
current trends in, 270–​71 as communication channel, 211
Facebook, 286–​87 as communication hub, 213–​14
FOAM, 271–​74 consultations, 157–​58
HIPAA and, 279–​80 design of, 212
LinkedIn, 284–​86, 287b, 287 electronic portals, 241–​43
origins and development of, 268–​69 fragmentation, 214–​15
31

inflation of differential diagnosis, 216 goals of, 130–​31

311
lack of integration with text handoff reports, 137
messaging, 240 objectives and challenges inherent

Index
potential of as communication to, 132–​33
tools, 217–​18 online medical direction, 134–​35
privacy and security, 248–​49 prearrival notifications, 133–​34
Problem Lists, 215 successful techniques, 140–​41
proliferation of diagnoses emergency medical technicians (EMTs).
for performance See emergency medical services
measurement, 217 communication
record blocking, 243 Emergency Nurses association, 138
relegation of documentation by nurses to empathy, 58
metadata status, 217 AIDET acronym, 58
structured versus unstructured defined, 58
information, 216 delivering bad news, 71–​72
Texas Ebola case, 212–​13, 214b, 214 improving empathetic
electronic patient care records communication, 58
(ePCRs), 130–​31 pediatric patients, 82
electronic patient portals, 241–​43, 281 RELATE acronym, 58
email, 281 telemedicine and, 100
best practices, 282b, 282 EM RAP podcast, 289
hospital administration communication, EMS. See emergency medical services
151–​52, 153 communication
EM Docs, 277–​78 EMTs (emergency medical technicians).
emergency department (ED). See also names See emergency medical services
of specific communication senders and communication
receivers Ende, J., 199–​200
as challenging communication “Enforcement of Title VI of the Civil Rights
environment, 27–​28 Act of 1964—​National Origin
environmental barriers to Discrimination Against Persons
communication, 46–​47, 114 With Limited English Proficiency”
importance of effective communication (DOJ), 59
in, xi–​xii, 3 ePCRs (electronic patient care
interactions per hour, xi, 3 records), 130–​31
internal teaming and “Evolutionary Examination of
communication, 146–​47 Telemedicine, An” (Breen &
interruptions, 28, 46–​47 Matusitz), 98
time spent communicating, 27 existential pain and suffering, 76
emergency medical services (EMS) extramural communication, 211,
communication, 130–​41 234, 240–​41
case examples
complicated refusal, 132–​33 Facebook, 269, 286–​87
handoff reports, 137–​39 face-​to-​face communication, 3, 100, 218,
multiple error scenarios, 219, 246, 282, 302
135–​37, 139–​40 EMS communication, 130, 131–​32,
challenges with diverse 137
providers, 132 provider-​nurse communication,
communicators, 131–​32 115, 119–​20
defined, 130–​31 structured communication, 235, 236
312

family communication, 63–​78 origins of, 271

Index 312
bad news, delivering, 70–​72 personal learning networks, 276
emotion/​empathy, 71–​72 postpublication peer review, 271–​72
invitation, 71 quality of, 275–​76
knowledge, 71 rapid dissemination, 271
perception, 71 textbooks versus, 273–​74
setting, 70–​71 Food and Drug Administration (FDA), 244
summarize, 72 fragmentation of information, 214–​15
cross-​cultural care, 69–​70 FSMB (Federation of State Medical
crying family members, managing, 74–​75 Boards), 265
death and dying notifications, 72–​74
in-​person or via telephone, 73 gender
responding to emotions and cross-​cultural issues, 69–​70
grief, 73–​74 gender bias, 159–​60
ethical and legal considerations, 63 gender differences in
conflict, 64 communication, 202
family, defined, 64 Giri, V.N., 202
family visit management, 64 good intent, assuming, 141
neglect or abuse, 64–​65 Google Translate, 59
nondisclosure requests, 65 graduate medical education (GME), 146
existential pain, 76 GRPI (goals, roles, process, and
family meeting management, 67 interactions) model, 19–​20
family presence in resuscitations, 172 goals, 19
importance of, 63 interactions, 19
models for effective, 65–​66 non-​flict example, 20–​21
AIDET acronym, 65–​66 process, 19
Ask-​Tell-​Ask, 66 roles, 19
nonverbal communication, 67–​68, 68t Guzman, J.A., 52
supportive counseling, 75–​76
team member communication, 68–​69 Hall, J.A., 57
therapeutic suggestion, 76–​78 handoffs. See also transitions of care
FDA (Food and Drug Administration), 244 handoff reports, 137–​39
Federation of State Medical Boards “Positive Exchange of Flight Controls,”
(FSMB), 265 237b, 237
feedback. See learners post-​resuscitation patients, 172–​73
FemInEM, 278 Hanlon’s razor, 132
Fenway Institute, 50 Härgestam, M., 118
Field Guide to Understanding Human Error, HCAHPS (Hospital Consumer Assessment
The (Dekker), 135 of Healthcare Providers and
fish bowl concept, 157 Services), 45
Five Dysfunctions of a Team, The Healthcare Information and Management
(Lencioni), 184 Systems Society (HIMSS), 232,
flipped classroom experience, 275 233b, 233
FOAM (free, open-​access medical Health Information Technology for
education), 271–​74 Economic and Clinical Health
augmenting residency education, 275 (HITECH) Act, 211
core content, 273–​74, 274t Health Insurance Portability and
landscape of, 272–​73 Accountability Act (HIPAA), 98,
learners’ use of time, 274–​75 149, 237–​38
31

electronic portals, 242–​43 structure of, 144–​45

313
media communication, 260, 261, boards of directors, 145
264, 266 hospital administration, 144–​45

Index
privacy and security, 248 medical staff, 144
record blocking, 243 hospital incident command system (HICS),
social media, 280b, 280 145–​46, 152
social media and, 279–​80 hostile and angry patients, 48–​49
text messaging, 281 angry parents, 94b, 94–​95
Hewson, M.G., 199–​200 angry patients, 295, 299
HICS (hospital incident command system), death and dying notifications, 74
145–​46, 152 irritated patients, 295, 299
HIMSS (Healthcare Information and management strategies, 49
Management Systems Society), scope of issue, 48–​49
232, 233b, 233 “hub-​and-​spoke model” of
HIPAA. See Health Insurance Portability accountability, 186
and Accountability Act huddles, 32, 119, 153
Hippocrates, 269–​70 hypnotic techniques, 77–​78
HITECH (Health Information Technology
for Economic and Clinical Health) imposter syndrome, 159
Act, 211 IMS Institute for Healthcare
Hoffman, Jerry, 270 Informatics, 238
honesty, 55 “inbox problem,” 226, 227b, 227
consultants and consultations, 164 incarcerated patients. See prisoners
media communication, 262 “Increasing Clinical Presence of Mobile
pediatric patients, 82, 91–​92, 93 Communication Technology,” 99
hospital administration, 143–​55 indirect communication, 12
case examples, 152–​54 culture and, 12
emergency management scenario, 154 example of, 11
hospital capacity crisis perception as, 13
scenario, 152–​54 pros and cons of, 12
defined, 143 information, defined, 210
ED teaming and communication, 146–​47 information overload, 114–​15, 120,
electronic communication, 150–​52 123, 226
email, 151–​52, 153 Innovator’s Dilemma, The
telephone calls, 151 (Christensen), 100–​1
text messages, 151 Institute for Healthcare Improvement, 228
during emergency management/​disaster Institute of Medicine, 168
situations, 152 interaction design skills, 33–​40, 34t
hospital committee structure, 145–​46 application of, 33–​40
ongoing reporting, 150 handoff for admission, 37–​38
strategies for effective patient care and team
communication, 147–​48 dynamics, 38–​39
hospital committee structure, 145–​46 patient triage, 39–​40
Hospital Consumer Assessment of chasing concordance, 34t, 37–​38
Healthcare Providers and Services context-​appropriate relationships, 34t,
(HCAHPS), 45 37–​38, 40
hospital governance countering chaos, 34t, 38–​39
communication through, 148–​49 managing the interaction floor,
defined, 144 34t, 38–​39
314

interaction design skills (cont.) American Sign Language, 54

Index 314
pursuing clarity, 34t, 39 apps, 59
setting clear expectations, 34t, 39, 40 family communication, 70
setting the frame, 34t, 37, 38, 40 language translation applications, 229–​30
staying on the same page, 34t, 39, 40 Limited English Proficiency, 59
sustaining continuity, 34t, 37–​38 signage, 229
International Conference on Emergency TDY services, 229
Medicine, 271 video remote interpretation, 230
interoperability, 231–​32 lawsuits and communication problems, 46,
interruptions, 27–​28, 46–​47 215, 249
electronic communication, 244 leadership skills and styles
EMS communication, 140 gender differences, 202
pediatric patients, 81 models of leadership development, 4–​12
provider-​nurse communication, 114–​15, simulation training, 120
119–​20, 123 learners, 199–​207, 274–​75. See also FOAM
interviews, 261–​62, 263b, 263 ED environment and feedback, 200
intramural communication, 211, 234, 240 effective communication principles, 201
introductions checking in, 203–​4
bad news, delivering, 55 engagement and rapport, 203
family meetings, 67 giving thanks, 204
pediatric patients, 83–​84, 90 setting the stage, 201–​3
I-​PASS system, 173 feedback principles, 204–​6
SIGNOUT? mnemonic, 235, 236b feedback sandwich method, 204
ISBAR (Identification, Situation, formal feedback, 206
Background, Assessment, and informal feedback, 206–​7
Requirements/​requests) handoff variability in experience and
tool, 160 exposure, 200–​1
Lencioni, Patrick, 184
jargon Limited English Proficiency (LEP)
electronic communication, 228 Executive Order, 59
EMS communication, 133, 140 LinkedIn, 284
family communication, 66, 70, 71, 72 best practices, 287b, 287
media communication, 262 using effectively, 286
meetings, 182, 183 listening and listening skills, 9, 12, 30b, 48
pediatric patients, 82, 93 active listening, 67–​68, 81, 133–​34, 139,
Jiang, C., 177 140, 157–​58
Joint Commission, 45–​46, 50, 113, 167, adolescent patients, 87
294–​95, 298–​99 listening for repetitions, 30b
Jones, Brian, 181 nonverbal communication, 67–​68
pediatric patients, 81
Kass, Dara, 278 reflective listening, 58
Kelly, Matthew, 196 RELATE acronym, 58
Kessler, D.O., 174 RESPECT acronym, 57
Kessler’s 5 Cs, 160–​61, 161b supportive counseling, 75
knowledge, defined, 210 Little, M.L., 199–​200

lab communication, 246

labeling, 13, 54, 74 Manojlovich, M., 117
language barriers, 47, 229 Mariano, E.C., 52
315

Martin, H.A., 119 repetition, 180–​82, 183

315
“mature minor” status, 88 simplicity, 182–​83
Maxson, P., 120 team building, 184

Index
MBTI. See Myers-​Briggs Type Indicator types of employees, 186–​87t,
MCIs (multiple casualty incidents), 262–​64 186–​87
McLeod, J.A., 52 types of meetings, 190
media communication, 259–​66 administrative meetings, 190
case example operational meetings, 190–​91
Columbine shootings, 266 strategic meetings, 191–​94, 192t
media blunder, 297, 302 Mehrabian, A., 3
in disasters and multiple casualty metadata, 247–​48
incidents, 262–​64 examples of, 247
importance of, 259–​60 relegation of documentation by nurses to
interviews, 261–​62, 263b, 263 status of, 217
legal aspects of, 260–​61 Meyers-​Briggs Type Indicator
online resources, 266–​67 (MBTI), 15
patient condition descriptors, 260–​61 Mickan, S., 115
photographs and digital minors. See pediatric patients
images, 266 mobile apps, 238, 250–​51. See also
seeking media attention, 264–​65, 265b electronic communication;
social media, 265 social media
sound bites, 262 language barriers, 59
MediBabble Translator, 59 patient monitoring, 222
medical students. See learners Moody, K. Kay, 277–​78
medication errors, 117, 118, 123, 246, Mullen, P.C., 176
294, 298 multiple casualty incidents (MCIs), 262–​64
medicine. See emergency department; multiplicity of emergency medicine,
names of specific communication 114, 115
senders and receivers; names of Myers-​Briggs Type Indicator (MBTI),
specific types of communication; 5–​6, 180–​81
telemedicine, telehealth, and S-​N (Sensing-​iNtuitive) dichotomy, 6–​7
teleconsultation T-​F (Thinking-​Feeling) dichotomy, 7–​8
meditation, 77 using to improve communication, 8–​9
meetings, 180–​98
accountability, 186 naming behaviors and emotions, 64
augmented (or virtually attended) crying family members, 74–​75
medical conferences, 195–​97, nonverbal communication, 67
279, 280t responding to emotions and grief, 74
behavioral expectations, 184–​85 Nardi, Dario, 180–​81
clarity, 182–​83, 188 National Association of EMS
conflict comfort scale, 188–​90 Physicians, 138
confronting bad behavior, 183 neuro-​linguistic programming
culture and, 184 (NLP), 12–​13
decision-​making process, 193–​94 Neuroscience of Personality (Nardi), 180–​81
ground rules, 188 Nickson, Chris, 274
increasing productivity, 195t nondisclosure requests, 65
“meeting stew,” 190 non-​flict, 20–​21
overcommunication, 185 applying GRPI model, 20–​21
recommended reading, 198t example of, 20
316

nonverbal communication and body communication boards (wipe

Index 316
language, 3, 31, 57 boards), 59
consultants and consultations, 157–​58 communication-​related skills, 48
consultations, 157–​58 discharge against medical advice, 50–​51
family communication, 64, 67–​68, electronic communication, 227–​29
68t, 69 future tools, 59
hostile and angry patients, 49, 299 hostile patients, 48–​49
nonverbal patients, 54 management strategies, 49
pediatric patients, 82, 84 scope of issue, 48–​49
provider-​nurse communication, 119 improving the provider-​patient
telemedicine, 100 relationship, 57–​58
nurses. See provider-​nurse communication communication pitfalls, 57–​58
communication strategies, 57
Occupational Safety and Health empathy, 58
Administration (OSHA), 48 nonverbal patients, 54
Office for Civil Rights, 243 patients with psychiatric
omitted critical information, 133–​34 disorders, 51–​52
online medical direction, 133, communication strategies, 51–​52
134–​35, 140–​41 scope of issue, 51
open posture, 57 prisoners, 53–​54
operational meetings, 190–​91, 194. See also communication strategies, 53–​54
meetings scope of issue, 53
Orasanu, Judith, 135 transgender patients, 50
OSHA (Occupational Safety and Health uncertainty, 54–​55
Administration), 48 VIPs, 52–​53
other monitoring, 31–​32 communication strategies, 52–​53
Our Brains in Color (Nardi), 180–​81 scope of issue, 52
overcommunication, 181–​82, 185, 186 patient safety, 45–​46, 209–​10, 211–​12, 222.
See also electronic communication
parents. See also family communication; defined, 209
pediatric patients provider-​nurse communication,
angry, 94b, 94–​95 113–​14, 117
overtalkative, 95b, 95 public safety versus, 209–​10
passive-​aggressive communication style, 23 resuscitation, 167, 168–​69, 172
comparison with other styles, 5 verbal templates, 235
example of, 5 Patient Safety & Quality Healthcare
passive communication style (PSQH), 184
comparison with other styles, 5 pausing, acknowledging, empathizing,
example of, 5 redirecting, and delayed
perception as, 13 readdressing approach, 23–​24, 25
passive listening, 133–​34 pediatric patients, 80–​95
patient communication, 45–​59 body language, 84
bad news, delivering, 55–​56 case examples
communication strategies, 55–​56 angry parents, 94b, 94–​95
scope of issue, 55 bad news, 92–​94, 94–​92b
barriers to, 46–​47 overtalkative parents, 95b, 95
environmental, 46–​47 painful procedures, 91b, 91–​92
patient-​related, 47 reticent child, 89b, 89–​91
provider-​related, 47 child life specialists, 87
317

versus communicating with adults, 81–​82 post-​code pause, 177

317
avoiding medical jargon, 82 prearrival notifications, 133–​34
body language, 82 prehospital providers, 105, 130–​32

Index
empathy, 82 online medical direction, 134–​35
goals of communication, 81 prearrival notifications, 133–​34
honesty, 82 prehospital communication, 219–​20
listening, 81 prisoners, 53–​54
confidentiality, 87–​88 communication strategies, 53–​54
consent, 88 scope of issue, 53
developmental stages, 85–​87 privacy and security issues
adolescence, 87 electronic communication, 237–​38,
infancy, 85 248–​49, 279
school-​aged children, 86–​87 email, 281
toddlers and preschoolers, 86 environmental barriers to
introductions, 83–​84 communication, 46–​47
involvement in health care decisions, 89 family communication, 65
pearls and pitfalls in, 95 media communication, 260, 261
provider appearance, 83 record blocking, 243
shy children, 296, 300 social media, 265, 279–​80
triadic discussion, 83 text messaging, 281
perception, communication styles and, 13–​14 problem setting, 32
Pérez-​Cárceles, M.D., 65 progressive muscle relaxation (PMR)
Periscope, 288b, 288 practices, 77
personal learning networks (PLNs), 276 provider-​nurse communication, 113–​26
pharmacy communication, 246 advanced practice providers, 120–​21
phases of care workflow, 219 barriers to, 114–​16
documentation versus distraction, 225 environmental barriers, 114–​15
patient intake, identification, and interpersonal barriers, 115–​16
registration, 220–​21 case example, 297–​98, 302
prehospital communication, 219–​20 effects of inadequate
procedures, treatments, and communication, 116–​17
observation, 221–​22 inadequately communicated
monitoring and alarms, 222 diagnostic results, 116
result review, consultation, and decision inappropriate discharge, 117
making, 222–​25 inappropriate level of care, 117
retrospective analysis of care processes, 225 medication errors, 117
triage, interview, and exam, 221 unrecognized dynamic clinical
PHE (positive healthcare environment), 48 changes, 116
Philosophical Magazine, 270 problem-​based case examples, 121–​26
Physician Moms Group, 278 changing clinical presentation, 125–​26
PLNs (personal learning networks), 276 medical code, 123–​24
PMR (progressive muscle relaxation) trauma, 121–​22
practices, 77 successful techniques, 118–​20
podcasts, 273f, 288–​89, 290f effective communication
Polinski, J.M., 101 skills, 118–​19
portable patient health information, 230–​31 maximizing teamwork, 118
“Positive Exchange of Flight Controls,” simulation training, 120
237b, 237 standardizing communication, 119
positive healthcare environment (PHE), 48 utilizing technology, 119–​20
318

provider-​patient relationship, 57–​58. assigning resuscitation team

Index 318
See also patient communication roles, 169–​70
communication pitfalls, 57–​58 closed-​loop communication, 170–​71
communication strategies, 57 constructive intervention, 172
empathy, 58 knowledge sharing and
psychiatric disorders, patients with, 51–​52 summaries, 171
communication strategies, 51–​52 mutual respect, 171
scope of issue, 51 transitions of care for post-​resuscitation
PubMed, 270 patients, 172–​73
RIME evaluation framework, 206
RACI (Responsible, Accountable, Rodger, S., 115
Consulted, Informed) role definition and clarity
process, 193–​94 conflict management, 19–​20
radiology communication, 245–​46 provider-​nurse communication, 118,
“read-​backs,” 235–​36 120–​22, 123
record blocking, 243 resuscitation, 169–​70, 301
REFLECT (Review, Encourage, Focus, simulation training, 120
Listen, Emphasize, Communicate, Roth, Bernard, 205
Transform) framework, 176 rounding, 147, 149
reflection in action, 31 Rubenfield, K., 202
reflective listening, 58
RELATE (Reassure, Explain, Listen, Sabry, Hala, 278
Answer, Take action, Express “Safe Harbor Method,” 279–​80
appreciation), 58 SBAR (Situation, Background, Assessment,
relationship-​based conflict, 23 and Recommendation) mnemonic,
defined, 16 119, 125
task-​based conflict escalating to, 16–​17 SBAR (Situation, Background, Assessment,
relaxation approaches, 76–​77 Recommendation), 68–​69,
repetition 235b, 235
listening for, 140 Schon, D., 31, 32
meetings, 180–​82, 183 security. See privacy and security issues
repeating critical information, 140 self-​regulatory techniques, 77
residents. See learners Sensing-​iNtuitive (S-​N) dichotomy, 6–​7
resilience, 23, 28, 76 Separate-​Educate-​Negotiate, 34t
RESPECT (Rapport, Explain, Show, separation anxiety, 85
Practice, Empathy, Collaboration, shared mental model, 135, 140
Technology), 57 Shaw, George Bernard, xi
respect for context, 32–​33 Shepherd, S.M., 69
respect for others, 31–​32, 33 signage, 229
respect for self, 31, 33 SIGNOUT? mnemonic, 235, 236b
resuscitation, 167–​77 simulation training, 120, 121–​22
case example, 296–​97, 301 situational awareness, 27–​28, 32
debriefing, 173–​76 Slack, 278
challenges to evaluating effectiveness SMEs (subject matter experts), 191, 193
of, 177 Smith, Richard, 271–​72
data supporting, 176–​77 S-​N (Sensing-​iNtuitive) dichotomy, 6–​7
emergency department, 168–​69 Snapchat, 289
family presence in resuscitations, 172 social media, 250–​51, 265, 268–​80, 282–​89
post-​code pause, 177 augmented (or virtually attended)
team dynamics, 169 medical conferences, 279, 280t
319

commenting, 269–​70 stranger anxiety, 85

319
community development, 276–​79 strategic meetings, 191–​94, 192t.
ALiEM Incubators and Wellness See also meetings

Index
Think Tank, 278–​79 “Strategies for Leadership: Improving
EM Docs, 277–​78 Communications With Patients
FemInEM, 278 and Families” (AMA), 46
Physician Moms Group, 278 Street, R., 28–​29
current trends in, 270–​71 structured communication, 216, 235–​37
Facebook, 286–​87 Studer Group, 58
FOAM, 271–​74 subject matter experts (SMEs), 191, 193
augmenting residency education, 275, Sydney Dekker, 135
276t, 276 synchronous communication, 103, 120,
landscape of, 272–​73 211, 219
learners’ use of time, 274–​75 system knowledge, 133–​34
origins of, 271
personal learning networks, 276 task-​based conflict
postpublication peer review, defined, 16
271–​72, 272f escalating to relationship-​based
quality of, 275–​76, 277t, 277 conflict, 16–​17
rapid dissemination, 271 TDY services, 229
textbooks versus, 273–​74, 274t TeamSTEPPs, 32
HIPAA and, 279–​80, 280b telemedicine, telehealth, and
LinkedIn, 284 teleconsultation, 97–​109
best practices, 287b, 287 barriers to, 98–​99, 106
using effectively, 286 breaking down barriers, 102–​3
origins and development of, 268–​69 communication streams, 103
Periscope, 288b, 288 consultations, 158
personal branding, 279 consumer-​facing telemedicine, 101–​2
podcasts, 273f, 288–​89, 290f creating roadblocks, 103
Snapchat, 289 crowdsourcing providers, 105
traditional media and, 270–​71 current state of, 98, 101–​2
Twitter, 282 disruptive innovation, 100–​1
best practices, 283b, 283 economics and, 99, 106, 107, 108
creating profiles, 283, 284f empathy, 100
in education, 282–​83 future of, 98, 107–​8
writing tweets, 283–​84, 285f mental health, 106
sound bites, 262 overview of, 98–​99
SPIKES protocol, 70–​72 patient engagement, 105
emotion/​empathy, 71–​72 patient safety, 104
invitation, 71 physician-​facing telemedicine, 101–​2
knowledge, 71 pitfalls of, 98–​99
perception, 71 prehospital emergency medicine, 105
setting, 70–​71 promotion of conversation, 103–​4
summarize, 72 reasons for considering, 99
standardized communication, 97, 119, 120, rural and remote access, 104–​5
125, 126, 140, 162, 172–​73, 216 trends in, 108–​9
STATE for conflict management, 25t, 25 virtual team-​based assessments, 102
STOP (Significant issues, Therapies, telephone calls, 228, 241
Oxygen, Pending issues) bad news, delivering, 56
mnemonic, 117, 119, 126 death and dying notifications, 72–​73
320

telephone calls (cont.) follow-​up, 232–​34

Index 320
hospital administration handoffs, 234
communication, 151 post-​resuscitation patients, 172–​73
text messaging, 238–​40, 280–​81 tools for, 236t
benefits of, 238–​39 triadic discussion, 83
“Bring Your Own Device” tribalism, 159
(BYOD), 238 Twitter, 275, 282
hospital administration best practices, 283b, 283
communication, 151 creating profiles, 283, 284f
vulnerabilities of, 239–​40 in education, 282–​83
T-​F (Thinking-​Feeling) dichotomy, 7–​8 writing tweets, 283–​84, 285f
therapeutic suggestion, 76–​78
Thomas-​Kilmann Conflict Mode uncertainty, communicating, 54–​55
Instrument (TKI), 10–​11, 17, 18t US Department of Health and Human
accommodating style, 11, 17, 18t Services, 97, 281
advantages of some conflict management US Department of Justice, 59
styles, 19
assertiveness dimension, 17 validating statements, 49, 76
avoiding style, 10–​11, 17, 18t, 19, 22 Vespasian, 269
collaborating style, 11, 17, 18t video recording, 237–​38
competing style, 10, 11, 17, 18t VIPs, 52–​53, 149
compromising style, 11, 17, 18t communication strategies, 52–​53
cooperativeness dimension, 17 scope of issue, 52
dominating style, 19 virtual care. See telemedicine, telehealth,
flexibility of conflict management and teleconsultation
style, 17–​19 virtual meetings, 195–​97, 279, 280t
integrative style, 19 Visual Anatomy Lite, 59
obliging style, 19 VisualDX, 59
“Three Monkeys Defense,” 234
Time Magazine, 278 websites, 243–​44
TKI. See Thomas-​Kilmann Conflict Mode Williams Institute, 50
Instrument wipe boards (communication boards),
“To Err Is Human” (Institute of 59, 119–​20
Medicine), 168–​69
transgender patients, 50 Yarris, L., 199–​200
transitions of care YouTube, 269
electronic communication, 232–​34
elements of, 233b, 233 Zebuhr, C., 177