Simple Tips to Improve Physician
Communication with ED Patients

Loren Crown, MD, FAAEP and Robert Grober, MD

Abstract

A physician’s ability to communicate effectively and efficiently may be the single most important tool in gaining the trust and cooperation of a sick patient. Without question, good communication represents the “art of medicine” and helps foster the building of a healthy alliance between the patient and physician. Certainly communication is very important in the emergency department or acute care setting where physician and patient usually meet for the first time, occasionally under crisis circumstances and where rapport is difficult to establish.

The purpose of this article is to present simple tips designed to refine the communication skills of emergency physicians or other acute care providers with the ultimate goal of improved patient outcome and satisfaction. At the conclusion of this article, a typical emergency department case scenario will be presented to reinforce important concepts.

Introduction

Historically, many wise physicians have lived by the adage “treat your patients the way you would want to be treated if you were sick.” In addition, they suggest you communicate with your patients in an empathetic caring manner utilizing simple concepts and concise, understandable terminology. Not only will meaningful communication elicit the trust and cooperation of the patient, numerous studies have shown that physicians with good communication skills are less likely to be sued.¹ On a more fundamental level, meaningful communication helps build healthy physician-patient relationships resulting in enhanced physician job satisfaction and fulfillment while deterring premature burnout from burdensome paperwork and inherent work stress.

Effective communication is more than just “common sense.” It derives from a solid foundation in psychosocial medical research, emotional insight, life experience and operator wisdom. It must be flexible and adaptable. It must not be condescending or complicated. It is expressed in a variety of modalities including language, vision, touch and empathy. Communication is the bridge that connects the patient to the science and ministry of medicine. With proper physician motivation, new communication techniques can be learned and old ones refined.

To further illustrate, physicians should remember that every medical encounter follows a logical sequence consisting of (1) physician introduction, (2) historical data collection, (3) problem oriented physical examination, (4) ancillary testing, (5) assessment and treatment plan, and (6) disposition. Inadequate communication with respect to any one of these components is likely to impede chances for a successful medical outcome and lead to patient frustration and dissatisfaction with the medical system.

Presented below are important communication tips relating to each component of the patient encounter. We hope you find them simple, understandable and logical. Surprisingly, though many of these techniques have been taught and reinforced over the years, they may still be overlooked or discarded, even by the most dedicated physicians.

Greetings

First impressions can “make or break” a medical encounter. Effective communication begins with a proper introduction to the patient. The introduction should be initiated with a gentle knock on the exam room door or a brief verbal announcement before entering a curtained examination bay. This allows patients and family to mentally and physically prepare for the medical interview and also protects patients, particularly door hugging children from being knocked to the ground by an hastily opened exam room door.

A more important issue that influences a patient’s first impression is the physician’s appearance. The physician should “look the part.”² A 1998 Stanford study confirmed the importance of the physician’s appearance and stated “A carefully dressed physician might convey the image that he or she is meticulous and careful. Alternatively, an unkempt appearance might convey the impression of uncaring or disorganized behavior. Physicians are best served by wearing a name badge, white coat and dress shoes and by not wearing scrubs, blue jeans, clogs or sandals while on duty. Most male physicians should probably avoid heavy cologne, open shirts, long hair and earrings. Female physicians are most appropriate with a skirt, dress or dress pants.”³ We appreciate there are alternative strategies for achieving this goal, but at minimum suggest patients in need be able to distinguish the physician from the other health care providers and at least from the maintenance and housekeeping staff.

The actual verbal introduction should be directed to the patient and should begin with a simple salutation such as, “Hello, Mrs. Smith, I’m Dr. Jones and I will be evaluating you today.” Avoid calling patients by their first name or other adjectives such as “honey,” “sweety pie” or “dear” unless given permission or requested by the patient. It is, however, acceptable to ask the parents of a pediatric
patient what first name or nickname the child prefers. It is wise to acknowledge all family members and “significant others” with a simple nod or glance and then saying, “its nice to meet all of you” or “thank you for being here.” Another useful phrase is to ask “who do you have with you today?”⁴ As always, do not forget about HIPAA considerations when family or friends are present.

A firm handshake to the patient (and spouse) or touch on the shoulder or elbow, is not only polite but endearing. Handshakes are an expression of friendliness and warmth and are helpful in building rapport. The worry of transmission of a deadly germ from the patient’s hand to the physician is unwarranted in an environment where contagions routinely reside on equipment and staff. Feel free to use the hand cleaners ad lib. If necessary, apologize for any significant waiting time but avoid routinely
placing blame on insufficient staffing, excessive patient volume or inadequate facilities; this will often be viewed as grounds for formal complaint and argument. Just say you are “sorry for the wait.” Finally, it is unacceptable to forego some form of introduction in all but the most emergent situations.

The History

Obtaining a reliable history from a sick patient in the ED can be laborious and time consuming. Several communication techniques will enhance the process. Begin the interview process by sitting, not standing at the patient’s bedside. This gesture imparts a sense of complete attention to the patient’s problem and also facilitates hand-written charting. Do not distract the interview with cell phones or conversation with the nurse or medical student. Periodic eye contact will help.

Very importantly, use simple terminology, usually at a fourth grade level, when asking questions or
conveying information.⁵ Use of complex, confusing, medical “phraseology” may be the single biggest
complaint made by patients about their health care provider. Undoubtedly, medical terminology is a
language unto itself and many physicians experience great difficulty in transforming medical concepts into understandable patient dialogue. To improve upon this frequently encountered problem, physicians might try to role play and critique their medical terminology skills on an ongoing basis.

While obtaining the history, try to avoid interrupting the patient during the initial dialogue, if possible. A published report reveals the average patient to be interrupted after only 18 seconds.⁶ If time is critical, simply apologize for the interruption and then tell the patient you will return to the issue at a later time, when possible. To assist patient recall and comprehension, ask broad, simple questions such as “have you ever had any problems with your heart, lung, stomach or kidneys” rather than “give me your medical and surgical history.” More detailed questioning can then evolve, if necessary. Finally, thank the patient and family for the information provided and reassure them that the data will be very useful in solving the patient’s medical difficulty. For vague or forgotten medical history, politely encourage the retrieval of that information and never show frustration or disdain by its lack of availability.

The Physical Exam

As an important communication tool, many physicians underestimate the power of touch. Patients expect the “laying on of hands” and many medical experts believe that patients should not leave the ED without some form of physical examination.⁴ Irrespective of the skill of the physician or the sophistication of the ancillary testing, most patients do not believe that an accurate diagnosis can be secured without some form of direct physician/ patient contact.

When performing any physical examination, pay careful attention to patient privacy and comfort. Use sheets, gowns or drapes liberally, even with children, and do not leave a body part exposed once the examination is completed. Warm your stethoscope and consider heated vaginal speculums if possible; warm hands are appreciated as well. Wash hands in front of the patient and use gloves liberally. Very importantly, be gentle. Never hastily “mash on” a tender body part and warn the patient of any potential discomfort that may be incurred during the exam. A reckless, rough examination will be perceived as careless and uncaring.

Finally, withhold ill considered remarks such as, “I don’t like the sound of that” or “that’s not good” or “I have no idea what that is.” The physician should remain stoic and methodical throughout the examination and refrain from communication of abnormal findings until the evaluation is complete. Remember, a carefully performed physical examination will convey respect for the patient’s privacy, dignity and intellect.

Ancillary Testing

Most patients understand that medical testing can be frightening, time consuming and painful. To allay patient concerns, clearly communicate the diagnostic plan before leaving the patient’s bedside. Too often, busy ED physicians take the history, do a quick physical exam and then walk out of the room only to order testing at the nursing station without ever telling the patient what tests are to be performed. Fear of the unknown propagates unnecessary patient anxiety. An informed patient is much more likely to cooperate with aggressive and uncomfortable evaluation protocols.

As previously mentioned, use simple concepts and terminology when conveying the testing “game plan.” Educate patients about tests which may require special steps such as drinking contrast, insertion of catheters, confinement in small, enclosed spaces (i.e. MRI and CT scans). Outline a general time frame for the completion of testing and remember it is better to overestimate rather than underestimate the time necessary to complete any portion of the medical evaluation. For example, if blood testing typically takes one hour until results are returned, tell the patient it may be two hours or more until results are available. Patient expectations are then met or even exceeded on a more consistent basis.

It is imperative to inform the patient of any potential discomfort or pain associated with testing. Once again, overestimate rather than underestimate the amount of pain in a gentle, tactful manner. Never tell the patient “it will only be a little pinch or bee sting” only to have the patient cry out in severe pain and then become angry and distrustful of everything else the physician does. Also, consider procedural analgesia and inform the patient that reasonable attempts to decrease pain will be made on their behalf.

Finally, inform the patient of completed test results as soon as available. Patients expect and deserve some explanation even when results are negative and prefer it come directly from the physician rather than the nurse or other ancillary personnel. If time permits, letting the patient know that a test result is normal, even before completion of other testing, is particularly reassuring and the appearance of the physician on more than one occasion conveys a sense of diligence and concern. Avoid ordering further testing without forewarning the patient. An unannounced procedure only heightens patient concern. And always attempt explanation for any testing delays due to technical difficulties or other unforeseen circumstances.

Assessment and Treatment Plan

Once the initial medical evaluation is completed, the diagnosis should be appropriately communicated to the patient. To set the stage, maintain privacy and consider asking to have the patient’s family in the room. Often patients are challenged with pain, weakness or lethargy and may hear only bits and pieces of important information. Allowing the family to be present minimizes the need for repetitive explanation and helps unify the family. Remember HIPAA and ask the patient if this is alright. Articulate physical examination abnormalities, lab results, and x-ray findings in very simple terms, once again utilizing lay terminology. Sometimes it helps to correlate a finding or diagnosis to the patient’s lifestyle or occupation. For example, if a patient is a plumber, explain that a “heart attack is similar to a clogged drain pipe” and future treatment will be directed at “unclogging or repairing the pipe.” Patient education diagrams are excellent adjuncts and in the complex medical arena “a picture is truly worth a thousand words.”

If the patient requires aggressive emergency department management or inpatient therapy, describe the general treatment protocols and possible major side effects. Always address the issue of pain control as this is often the patient’s greatest priority. And do not forget to explain the rationale for such seemingly simple monitoring and treatment modalities as BP and cardiac monitors, oxygen, IV fluids and urinary catheters.

If a consultant is needed, get the approval of the patient before the call is placed except in the most urgent, life threatening circumstances. Patients often have a preference for consultants. Sometimes, insurance dictates consultant selection.

At the end of the discussion, ask the patient and family to verbalize their understanding of the findings. Show enthusiasm when further explanation or clarification is requested rather than disdain, suspicion, or frustration. Finally, ask the patient and family if the treatment plan is agreeable or acceptable as this helps to empower them in the decision making process. It is only on the rare occasion that a patient or family disagrees with an appropriately communicated plan and usually an acceptable alternative can be negotiated if the physician shows patience and understanding.

Disposition

When the patient is discharged from the ED to outpatient follow-up, the discharge instructions assume monumental importance. Discharge instructions, in general, are poorly communicated and fraught with handwriting illegibility, confusing medical terminology and logistical inconsistencies. Inappropriately communicated discharge instructions are also a great source of potential medical liability. The patient must be given a thoughtfully constructed discharge plan and, ideally, this plan should be communicated by the physician rather than support staff. The instructions should be verbalized and followed with a legibly written or typed instruction sheet reinforcing the plan.⁷ Use simple terminology and refrain from the use of medical abbreviations such as “F/U, PRN, PCP, SOB” and so forth.

Every discharge plan should address certain basic issues. First, explain the usual therapeutic modalities such as medications, pain control, wound care and fever control. Caution the patient about potential adverse medication reactions such as nausea, vomiting, rash, sun sensitivity, etc. Mention medication pricing if the medication is particularly expensive or known to have challenging formulary coverage. Unanticipated medication reactions and high cost are a major reason for noncompliance and patient dissatisfaction. Inability to obtain needed medication after a lengthy and costly visit is a terrible waste of time and resources.

Next, arrange appropriate follow-up and be very specific with times and dates. Accurate communication of this data is vital, particularly for serious medical problems requiring close monitoring. For example, “call Dr. Jones at 622-4567 on Monday, September 10th at 9 a.m., for an appointment that day” is far superior to “see family doctor in three days.” If urgent outpatient follow-up is known to be difficult with certain physicians, place a call to that physician’s office or to the “on call” physician to make specific arrangements before the patient is discharged from the emergency department. Learn as much about local outpatient referral patterns as possible.

Advise patients about worsening symptoms or other potentially significant complications making it clear that return to the ED for revaluation is always an appropriate option and not to delay. Conversely, make certain that patients understand that certain problems require followup even if the problem resolves. For instance, an elderly patient with only one episode of presumed hemorroidal bleeding may require further investigation for occult malignancy or other serious conditions. Lastly, check for comprehension of the discharge instructions by having the patient also verbalize their understanding of the information presented. Also, asking the patient to read back written or printed discharge instructions helps reinforce important concepts and may allow the physician to better gauge the patient’s level of education and understanding. Once again, a word about medication cost can help prepare a patient for “pharmacy shock” and is usually appreciated. Finalize the encounter by asking the patient if there are any unanswered questions about “this particular illness or injury.” Refrain from using the abbreviated “do you have any questions?” as this often invites numerous concerns about other unrelated maladies. The patient often appreciates a sincere physician who leaves the encounter with, “I hope you feel better soon.”

Children

A special note should be made about children. Children demand special attention and sometime require unorthodox or specialized communication techniques. A few particularly helpful pointers can pave the way for a more fruitful encounter.

Before allowing children to enter the examination room, hide or dispose of frightening equipment such as needles, syringes or scissors. It is appropriate to “dress down” as children are more fearful of traditional, white coated medical attire than their adult counterparts. Utilize dolls, toys or other non-threatening objects liberally.

Upon entering the examination room, many physicians find the following technique useful: immediately stoop down or sit at the level of the patient and introduce yourself as “Dr. Jim” or “Dr. Susan.” With children, the physician’s last name is of little importance for the initial introduction. Say “hello” to the patient with a smile and address the patient by first name or nickname depending upon patient or parent preference. A simple “give me five” is an excellent way to make initial physical contact with most children. For toddlers, offering a toy or other safe familiar object can be an effective icebreaker.

To enlist better cooperation for the physical exam, keep the younger child in the secure confines of the parent’s lap or arms for as much of the exam as possible. Avoid attempts to examine a child without a loved one close by and explain and consider demonstrating problematic portions of the exam by utilizing older siblings or parents as physical exam surrogates. If a frightened child sees a family member comfortably survive an ear exam or chest auscultation, he or she is less likely to resist that exam. Also, remember that older children enjoy the opportunity to look through the otoscope or listen to their own heart with a stethoscope, making future cooperation more likely.

Be particularly gentle during the examination of children. Children and parents remember rough or hurried treatment and will immediately assume an adversarial position. Even in young patients, pay attention to privacy and avoid unnecessary exposure. Once completed, thank the child for allowing the examination and compliment the parents if the child was reasonably cooperative or well mannered.

Summary

A physician’s ability to relate effectively and efficiently is vital to every aspect of the patient encounter from the initial introduction to the final disposition. Effective communication is multifaceted and more than just “common sense” and can be improved and refined with proper education and practice. Children are particularly challenging but several techniques can improve the chances of a successful encounter. Hopefully, by incorporating the suggestions in this article, you will experience a greater degree of patient cooperation and satisfaction as well as more professional fulfillment. A well studied secondary benefit of effective communication is reduced exposure to malpractice litigation.¹ Remember, most patients, at least initially, are unable to evaluate a physician’s diagnostic and therapeutic prowess but are usually “expert” in evaluating a medical provider’s communication skills and whether the physician cares about the patient. Wise physicians understand and embrace the concept that effective communication represents the highest in medicine and never tire in their quest to improve their communication skills.

Analyze the following case presentation and decide whether physician A or physician B is more likely to be successful in his mission.

Case Presentation

A 75-year-old female, Mrs. Smith, presents to your ED with a two day history of mild, intermittent retrosternal chest pain. She has received the standard regimen of nasal oxygen, ASA and intravenous live placement and has had oxygen saturation, BP and cardiac rhythm monitors placed. She is accompanied by her husband, a grown daughter and her three-year-old grandson. She is appears comfortable and has been pain free for several hours.

Scenario by Dr. A

Dr. A is a 45-year-old male emergency department physician who is dressed in wrinkled, mismatched scrubs with no white coat and no name badge. Dr. A wears clogs, has an earring and wears his hair long with a ponytail. He is partially unshaven. His cologne is noticeable and some of his fingernails are dirty. His stellar reputation in the medical community (for excellent medical decision making) is unknown to the patient.

Dr. A. begins the medical encounter by hastily opening the exam room door and knocking over the three-yearold grandchild who immediately begins to cry. Dr. A says, in a nonchalant tone, “I’m sorry” and then hurriedly walks up to the end of the bed and says to the patient “hello, what are you here for today ?” After describing her chest pain for less than ten seconds, Dr. A interrupts the patient and says, “give me your past medical history.” Exhibiting frustration with the patient’s inability to rapidly recall her past medical history, Dr. A announces (after not touching the patient in any way), “we’ll get you fixed up dear” and then walks out of the room.

Dr. A then goes to the nursing station and orders nitroglycerin “prn,” blood work, an EKG and a chest x-ray. Two hours later, after reviewing test results, Dr. A advances to the patient’s room only to find the patient’s daughter standing in the doorway and appearing agitated. The patient’s daughter complains that her mother “does not know what’s going on!”

Dr. A sheepishly disregards the daughter, marches to the foot of the bed and proclaims “sweety pie, it’s a long shot but you probably have CAD with angina. Well need to put you in!” Dr. A then walks out of the room back to the nursing station, calls a cardiology consultant and tells the nurse to admit the patient. The physician-patient encounter was finished at this point as far as Dr. A was concerned. There was no further direct communication between Dr. A and the patient or her family. Dr. A was certain that he had “covered all the bases.” Three weeks later Dr. A sees the cardiologist on the golf course and is told that the 75-year-old female he admitted was cathed and had two vessel CAD with successful angioplasty; “good call, Dr. A,” said the cardiologist. “Great,” Dr. A replied proudly. Two months later, Dr. A announces to the ED staff that he is taking a leave of absence because of “burnout.”

Scenario 2 - Dr. B

(same case presentation as above, different doctor)
Dr. B is a 38-year-old male emergency department physician who is wearing a clean white labcoat with name badge, dress shirt with tie, dress pants and polished dress shoes. His hair is conservative in length and nicely trimmed. He has a mustache but is very clean shaven. His fingernails are short and he has no noticeable aroma. His stellar reputation in the medical community is unknown to the patient.

Dr. B first reviews Mrs. Smith’s chart and then gently knocks on the exam room door which was wise because the patient’s grandson was leaning up against the door. Dr. B enters the room and politely says, “hello, Mrs. Smith, I am Dr. B and I will be evaluating you today.” Dr. B firmly shakes her hand and introduces himself to the patient’s spouse, shaking the spouses hand. Dr. B then looks toward the patient’s daughter and her son and says, “hello, its nice to meet all of you” and “thank you for being here.”

Dr. B then sits at the patient’s bedside and begins to obtain the history. After allowing the patient to explain her symptoms, Dr. B asks about her past medical history in the following manner: “Mrs. Smith, I would like to know more about any previous illnesses or operations you have had at any point in your life.” To help jostle the patient’s failing memory, Dr. B asks the patient if she has ever had any problems with her “lungs, kidneys, stomach, female organs, blood, brain,” etc.

After obtaining the history, Dr. B explains that he would like to perform a physical examination and would like to know if the patient prefers to have the family in the room during the examination. Dr. B then washes and warms his hands, warms the stethoscope and explains each part of the physical exam as it is in progress. When completed, Dr. B pulls the bed sheet to its original position, adjusts the head of the bed and returns the bed safety rails to their original position.

Dr. B then summons the family to the patient’s room and verbalizes his findings and concerns (after obtaining permission from the patient to speak with the family present). “Mrs. Smith, I am concerned that the pain you are experiencing could be coming from your heart. I would like to do more testing. With your permission, I will ask our staff to get some blood work, an x-ray picture of your heart and lungs and a tracing of your heartbeat. The x-ray picture and heart tracing should not cause any significant discomfort but, as you might know, the blood specimen, which can usually be taken from your arm, may cause some pain although the pain is not usually severe.”

Dr. B then informs the patient and family that the testing may take several hours to complete but that when testing is complete and the results are available, “I will discuss the results with you and your family.”

Also Dr. B informs the patient that nitroglycerin has been ordered to be taken if the chest pain returns and this medicine could cause a headache, dizziness or nausea. Dr. B also tells the patient that the oxygen is to “help the heart work better” and that the attached monitors are there to measure the blood oxygen level, the blood pressure and the heartbeat.”

The patient and her family are surprised when Dr. B returns in 45 minutes, sooner than originally anticipated, to report that the blood work and heart tracings are normal but that the x-ray picture results are not yet available. The family feels that Dr. B is “right on top of things” and greatly appreciates Dr. B’s subsequent inquiry as to how the patient is feeling.

Once all test results are available, Dr. B gathers the family with attention to privacy and then communicates his findings. “Mrs. Smith, I am concerned that your heart is not getting enough blood and oxygen, which is causing you to have chest pain. This can be a serious condition and for that reason, I would like to admit you into the hospital for further testing and treatment. I would like to have a heart doctor see you–do you have a preference? If not, I will contact a qualified heart doctor and then arrange for your admission to the hospital. It is possible that it make take several hours before you are transferred from the emergency department to your hospital room. In the meantime, we will closely monitor your condition. Once admitted, the nurses and doctors will likely repeat some of the testing done in the emergency department and decide if further testing or treatment is necessary. Also, it is unclear as to how long you will be in the hospital.”

Dr. B then asks the patient to verbalize her understanding of the findings and if she, or her family, has any questions regarding her chest pain evaluation. After questions are answered, the family is further impressed when Dr. B asks the patient and her family if there is anything else he can do to make all of them more comfortable. Two months later, Dr. B receives a letter from the patient’s daughter complimenting his outstanding care and that Mrs. Smith did indeed have a heart problem and the entire family is grateful for Dr. B “saving our mother’s life.” Dr. B feels invigorated by the letter and looks forward to his next shift.

Which doctor, A or B, would you prefer for your family?

Which doctor would you rather be?

References

1. Levinson, W. Physician-patient communication: A key to malpractice prevention. JAMA 1994; 272:1619.
2. Kelly G. Physicians must look the part. Physicians’s Money Digest. May 15, 2002.
3. Kanzler M, Gorsulowsky D., et al. Patient’s attitudes regarding physical characteristics of medical care providers in dermatologic practices. Archives of Dermatology. 2002 April; 138(4):518.
4. Emergency Practice Associates. Making the Most of a Clinical Encounter. EMERGENCY: An Emergency Medicine Newsletter, 2003, Vol. 8, No. 1.
5. Davis TC, Wolf MS. Health Literacy: Implications for Family Medicine. Family Medicine. 2004; 36(8):595-598.
6. BelzerE. Improving Patient Communication in No Time. Family Practice Management. May 1999.
7. Taylor DM, Cameron PA. Discharge instructions for emergency department patient: what we should provide. J Accid Emerg Med. 2000 March;17(2):86-90.

© 2005 American Association of Physician Specialists, Inc.

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