The CORD Remediation Task Force has developed materials related to resident interpersonal and communication skills (ICS). These skills sit at the heart of Emergency Medicine, and deficiencies here are grave and can be career threatening for residents and attending physicians alike. This page catalogs important information related to ICS.
Milestone 22 - Patient Centered Communication
Milestone 23 - Team Management
What follows is a listing of some advice based on experience by taskforce members of when dealing with residents with ICS issues.
This FAQ lists commonly encountered ICS issues and remedation tips for each issue.
Examples: “ Patient has no idea what he is waiting for, what tests have been ordered, what his results are, or was not informed he was being admitted.”
Remediation tips: Have resident check in as a “patient” or alternatively have him follow an actual patient in the waiting room throughout their ED course to experience the frustration of delays and importance of updates, information, results first hand Have resident evaluate another resident or student to become more aware of specific behaviors and impact of effective communication or lack thereof Shadow attending with specific emphasis on communication with patients Provide resident with patient communication checklist (ie anticipated wait time, plan for work-up, medications to be administered, patient re-evaluation, updates on lab and imaging results, review of diagnosis and treatment plan, discharge instructions) and review after several patient encounters
“Does not communicate with nurses.”
Examples: “Resident ignores nurse’s request to re-evaluate a patient”
Remediation tips: Resident performs a nursing shift where he/she shadows nurse, understands what they do, how they prioritize tasks, and how vital their interactions and frequent reevaluations of pain, vitals, and overall assessment provide important feedback to MDs Address ICS if issue is frequent dismissal of RN concerns
Examples: “Resident decided he wanted blood cultures after RN drew the blood and patient was an impossible stick. Antibiotics were ordered late, but not verbally discussed with RN, and there was a significant delay to administration of meds.”
Remediation tips: Emphasize direct communication with RN for time sensitive orders. Round every couple of hours or during change of shift with either the nursing team leader or the nurses in general. It really helps flow, communication and patient care. Surprising how many things you realize that only you knew when you round frequently!
Examples: “Resident evaluates a patient and initiates work-up, but does not present to attending until work-up is “complete” and has to start over again when plan is changed and different labs or imaging is required.
Remediation tips: Peform chart reviews to evaluate time to disposition and ED course. Discuss how early communication with attending may improve efficiency. Review specific medical errors that were made as a result of poor communication with attending and impact on patient care and time to disposition Encourage more frequent presentations to attending after each encounter rather than “batching” patients if knowledge base or judgment is poor or below anticipated level of training
Examples: “Resident froze when he had to inform family of the death of a loved one. He did not introduce himself, did not make eye contacts and was uncompassionate.”
Remediation tips: Standardized patients with different scenarios involving death notification Videotaped simulated encounters of death notification. Have resident watch himself or herself to evaluate specific wording, body language, and perception by grieving family members Shadowing attendings and/or chaplain during death notification GRIEVING curriculum on death notification
Examples: “Resident speaks very quickly when he is stressed and everyone has a hard time understanding him. Resident appears frustrated when asked to repeat himself.”
Remediation tips: Record or videotape stressful standardized patient encounter and have resident listen to himself or herself for clarity Request that patient repeats discharge instructions back to resident to see how much patient was able to understand Instruct resident to make conscious effort to slow down, take a deep breath, speak clearly. Consider typing notes if handwriting is illegible. Consider toast master’s class or forum for public speaking to make resident more aware of annunciation, speed, volume, pitch, and articulation.
Examples: “ Resident has a hard time collecting his thoughts, succinctly presenting information, and tends to get frustrated on the phone with his consultants.”
Remediation tips: Have the resident write out, almost in script fashion, the proposed conversation with the consultant, thus being able to weed out the unnecessary information and craft a concise presentation. After a few of these written out conversations, it should become easier to put it together in his/her head SAEM workshop on communication with consultants and hand-offs ACEP webinar on effective communication and specific examples of good and poor communication with consultants. Some residents may benefit from a checklist (Resident introduces him/herself and obtains name of person he/she is speaking with, succinctly provides relevant patient information, specifically states what they are consulting for, repeats plan and time frame (if applicable) back to consultant, documents time and name of consult in chart)
Example: “Resident is quiet, reserved, and can’t be heard well during a code. Chaos ensues as it is unclear who is running the resuscitation.”
Remediation tips: Perform mock codes, oral board cases, and scenarios in simulation lab Have resident run as many actual resuscitations as possible and give specific feedback on volume of voice, teamwork and assuming leadership, and delegation of tasks to improve confidence. Consider “ED critical care” elective where resident is on call at specific times and is expected to run resuscitations and perform critical procedures in ED as they occur. Checklist of important tasks running a code or resuscitation to raise awareness of critical actions. Have the resident teach resuscitation, either in simulation format or didactic and practice format, to medical students. Teaching a skill is one of the best ways to become good at it.
Example: “ Resident asks a 10 year old boy to translate for his mother with a chief complaint of vaginal bleeding”
Remediation tips: Familiarize resident with language line and how to use it. Discuss what situations are acceptable to have family translate and when it is not. Encourage use of translator or phone as patient may not feel comfortable or honest with family member present. Review specific cases where language barrier may have caused adverse outcome or missed diagnosis Consider cultural sensitivity training and education regarding cultural differences in communication, perception, and approach to illness.