Medicine is full of communication. We must communicate effectively with our patients and with other professionals on the care team. Duty-hour limits have also increased the number of shift-to-shift handoffs among residents and trainees, making communication even more critical. In addition, emergency medicine is perhaps the specialty that engages in the most inter- and intra-professional communication. On any given shift, we are not only communicating with an active care team of nurses, pharmacists, and others, but we also take reports from pre-hospital paramedics, consult with inpatient services, and coordinate with primary care physicians for follow up. As individuals, we tend to think we are good communicators, but that may not necessarily be the case.
We generally do not follow up with patients after they leave the ED, and that means we likely do not always hear about the outcomes of our patients and how poor communication may have played a role. Consider, however, the last time you got a poor sign-out from a colleague going off shift or incomplete information on an inter-hospital transfer. The information you get then can drastically change the patient's course. Whether or not the patient was actually harmed, the potential for harm was clearly there.
It should be no surprise, then, that a breakdown of communication between physicians is one of the most commonly cited reasons for medical errors, which contributes to a significant number of deaths each year. The landmark 1999 report, To Err is Human, estimated preventable medical errors caused between 44,000 and 98,000 deaths per year, with EDs cited as one of the areas with significant risk for patients.1 The Joint Commission also estimated that in 2014, more than two-thirds of serious preventable adverse events were due to communication errors.2
Communication is also one of the most valuable characteristics that program directors look for during interviews. Handoff communication is one of 12 entrustable professional activities (EPAs) that a residency director should expect an intern to be able to complete independently on day one of residency. Interns, however, overestimate their communication skills, and many medical schools are still lacking a formal handoff curriculum.
It is no wonder that poor communication is such a common problem. Residency programs don't often emphasize the teaching of communication because house staff are supposed to learn it as medical students; yet, interns did not learn it well in medical school. We know that our poor communication can affect our patients negatively and that we can do better. It is time to find a home for communication skills across the spectrum of medical education. Currently, it is expected that interns can conduct a safe, effective handoff on the first day of residency. That is a reasonable expectation for a physician who is managing a patient's care. Standardization of communication training, therefore, needs to be a part of all medical curricula, and really should begin as an undergraduate.
Residency programs don't often emphasize the teaching of communication because house staff are supposed to learn it as medical students.
The Accreditation Council for Graduate Medical Education (ACGME) also requires all residency programs to “monitor effective, structured handover processes to facilitate both continuity of care and patient safety.”3 Also, programs must ensure that residents are competent in communicating with all team members.3 However, there is little guidance from the ACGME or consensus among programs on how to do this, or whether a residency program is responsible for merely assessing communication skills, or for a formal curriculum. There are also very few tools validated for evaluating resident competency in communication skills.
Communication is clearly a vital component of emergency care, yet research in this area is lacking.4 Some would argue that communication is a skill and cannot be taught. However, curricula do exist for various aspects of emergency medicine communication and there is research from other specialties showing that handoff communication training can prevent errors.5 The I-PASS curriculum from inpatient pediatrics is one of the newest curricula, and it has shown positive results in a large, multi-center study.5
One of the major issues with developing a successful curriculum in emergency medicine is that there are many different types of communication in the ED that are unique to emergency medicine. There are mnemonics and checklists for communication from other specialties, and some within emergency medicine; yet these are very context-specific and cannot adequately address all areas of communication an emergency physician sees on a daily basis.
An ideal curriculum needs to focus on communication during shift-to-shift handoffs; with paramedics and out-of-hospital staff; during trauma and resuscitation; for consults and admitting patients; and with staff during a shift. Simulation has been suggested as a way to adequately train residents in communication skills, but there is limited patient outcome data to show that this has been effective. A didactic lecture can be an adjunct in a comprehensive curriculum but has been suggested as a poor way to teach communication skills. Retention of communication skills is also important, as it may wane as physicians progress through training and their careers. Periodic reinforcement and the use of continuous feedback may help long-term retention of communication skills.
Emergency physicians frequently shy away from the more nebulous areas of research like communication for more “emergent” issues like cardiac arrest, airway management, and neurologic emergencies. Think, though, of the number of patients you saw on your last shift with a stroke or an MI and compare it to how many patients were brought in by EMS, admitted to the hospital, or signed out to another physician at the end of your shift. With the sheer number of handoffs we do per shift, and the number of adverse events and deaths tied to poor communication, this really is a topic in which quality research could significantly improve patient outcomes. Emergency medicine should become a research leader in this field. Research should focus on developing an effective emergency medicine curriculum in communication training, validating assessment tools, and evaluating effectiveness of resident training using patient outcomes.
Whether you're thinking about it or not, some of the most critical aspects of your patient care come not from your thoughtful analysis or actions, but from the simple words you speak and the way you communicate with those around you. As a specialty, we are in a prime position to make a world of difference through how we interact and communicate. With more effort on our part, we can greatly increase patient safety and become excellent examples of communicators in medicine.
REFERENCES
- Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, DC: National Academy Press, Institute of Medicine; 1999.
- Sentinel event data: root causes by event type. Chicago: The Joint Commission, March 19, 2014.
- Accreditation Council for Graduate Medical Education (ACGME). Common Program Requirements. www.acgme.org/acWebsite/home/Common_Program_Requirements_07012011.pdf. Accessed November 13, 2014.
- Gordon M, Findley R. Educational interventions to improve handover in health care: a systematic review. Med Educ. 2011;45(11):1081-1089.
- Starmer AJ, Spector ND, Srivastiva R, et al. Changes in Medical Errors after Implementation of a Handoff Program. NEJM. 2014;371(19);1803-1812.