As emergency physicians we need to speak a lot to different
people in the ED and the fact that people are so different from each other
makes the task very challenging. Communication plays an important role in the
smooth running of the ED. Since ED is an emotionally charged area, where
patient’s attenders constantly look up to the doctor for his next words about
the condition of the patient and next course of action, conflicts sprout up
very easily when we lack effective communication skills. The words we speak, thus makes a (huge)
difference! We are what we speak!
General rules:
1. Recognize there’s something called ‘Transference
and countertransference’: Some patients
don’t like you without any seemingly obvious explanations or reasons and the
vice versa also sometimes holds good. Have you thought why?
“Transference is the phenomenon whereby we
unconsciously transfer feelings and attitudes from a person or situation in the
past on to a person or situation in the present. The process is at least partly
inappropriate to the present” (patient might think ‘this doc seems to be an
idiot’)
“Countertransference is the response that
is elicited in the recipient (therapist) by the other's (patient's) unconscious
transference communications” (Might make you think ‘this guys is such a pain in
the a**)
Awareness of the transference–countertransference
allows reflection and thoughtful response rather than unproductive reaction
from the doctor.
2. Introduce
yourself: Does that require more introductions? May be yes! Often we
have seen doctors who just jump in and start checking for abdominal tenderness
without even uttering a word while the patient stares at the doctor thinking
“Who the heck is this guy?”
Often we think this isn’t important
(especially in India!) . This often is
the first step towards building a good rapport. Say who you are. How do you expect the patient
to know that you are the emergency physician who’s gonna treat him now?!
3. When there’s a crowd/mob of relatives, try to
keep only 1-2 attenders inside the ED.
Make them understand that crowding will
hinder the progress of treatment in the ED and will add to unnecessary
confusion. Tell this in a convincing way rather than a paternalistic manner.
4. Find out to whom you are speaking to? How’s he
related to the patient? When asking history,
LISTEN before you speak
(Interrupt
only when you think he’s describing how USA captured Osama when asked about
chest pain of the patient)
5. Don’t
be Judgmental: Never ever judge a person before you get to know the
complete story. Don’t get carried away by your biases (Yes, each one of us is
biased). Put yourself in other person’s shoes (‘Chappals’?! Ok that will also
do) before you judge someone!
6. Use Please, Thank you and Sorry SOS
7. Be confident
about what you speak. Most of the scuttle in the ED starts when we are not
confident of what we are speaking.
It’s always good
to mentally prepare ourselves before we speak to the relatives about the
patient. Be clear about the present condition and next plan of action. Brief
them if you have any concerns. One of the most common questions we encounter is
“Is he out of danger?” Be very (you
can add few more VERYs) cautious when you answer this question. The answer
usually cannot be a mere YES or NO. Explain that to the relatives and make sure
they understand the gravity of the situation.
Before we look at how to speak to the attenders, let’s try
to classify different types of attenders we see in the ED commonly followed by
Dos and DONTs in communication wrt each groups.
1. Parents
of a sick child:
These are a special population and would
require special care as they are genuinely concerned about the health of the
child (No, we aren’t talking about Munchausen’s) and most of the times very
anxious.
DO'S
- Reassure them: Say everything has been in
place for the wellbeing of the child. Update them about the general condition
of the child. Quickly give an overview of differential diagnoses after the
initial assessment and the next plan of action.
- Make sure you address the primary ‘cause of concern’ – It’s not uncommon
to hear ‘’Head of the child becomes
hotter than the rest of the body’’ being the primary concern of the parents
while you are more worried about the pneumonia and low SpO2. Make sure you
address the primary concern by suitable explanation as you discus your
concerns.
- When parents say something is abnormal about
child’s behavior, BELIEVE! (Yes,
they know better)
- ANALGESIA IN KIDS IS AS IMPORTANT AS IN ADULTS.
Discuss regarding analgesia in detail with parents. Provide good analgesia.
Involve senior on the shift, ED consultant, Pediatrics/Pediatric EM consultants
when in doubt about dosages. (It’s not always half tablet Paracetamol)
- Try non-pharmacological modalities for relieving
pain/anxiety. Distraction often really works as an adjunct to the medicines for
pain.
- Read this article about pediatric specific
techniques that can be adopted in the ED on REBEL EM: http://rebelem.com/7-pediatric-hacks-for-your-ed/
DON’T
- Don’t be judgmental about the parents or the
child (Not all kids complaining pain abdomen are malingering)
- Don’t be rude / cruel to the kid or parents. If
the kid is not cooperating that shows your inability to deal with the kid and
not kid’s issues with coping.
2. Angry
attender: Angry people are a common finding in EDs. The reason for anger
could be multiple; ranging from waiting time in the ED to grief reaction upon
the death of a patient. (Sometimes even the non-functional Air conditioner)
DOs
and DONTs
- Find out the reason for the anger and offer him
help.
- Be gentle in your approach. Taking him to a room
and offering him some water would help. Put possible practical solutions before
him if the reason for the anger is genuine.
- Be safe when speaking to such attenders. Involve
senior on the shift or keep him informed. Don’t
put yourself at risk of physical harm.
Keep the security informed about the situation if you sense that the
person is a ‘trouble maker’.
- Never raise your voice or be angry. Don’t lose
your cool.
3. Overtly
anxious attender
This problem is commonly encountered when dealing with kids. But a good conversation with the parents would solve the problem.
When there’s anxiousness ‘out of proportion’ to
the existing problem despite being explained about the condition would say two
things: 1) The person is generally over anxious (Type A personalities) 2) Case
of abuse, troubled relationships, harassment, etc. Always keep the later in
mind and offer help to the patient in every possible way.
4. Unruly Crowd
/ Mob
This is a serious problem especially if you
are working in India. Even though there are tough laws dealing with violence
against healthcare providers, there are serious lapses when it comes to
implementation of these laws. So it has become a regular menace to the doctors
and emergency physicians are undoubtedly the most susceptible group when
compared to other specialties. Some hospitals have even gone to the extent of
hiring private bodyguards (bouncers) as a safety measure. (Read: http://www.ndtv.com/india-news/indian-hospitals-hire-bouncers-to-deter-attacks-498923)
Your safety is of prime importance when you
work in the ED. Most of these incidences occur when there is presumed
negligence by the doctor / hospital staff.
- All the general rules apply in this situation as
well.
- Keep the security informed.
- Keep the local police informed about the
situation
- Let the ED Head and the hospital administration
know about the situation.
- Try to calm down the situation by whatever means
you can. (If you can’t do this, at least don’t add fuel to the fire)
5. ‘Obsessive compulsive googler with internet
based diagnosing skills’.
Ah! You know what I’m talking about!
‘I know everything-I have diagnosed myself
with ABC variant of XYZ disease-Just came here to check how good doctor’s
knowledge of the condition is-I already self-medicated with PQR drug-Would like
to undergo 123 test-I will never be happy if the test results are negative or
if you tell me I’m wrong-I will find problems with all your advices and
prescriptions-Your Paracetamol will damage my liver and you are still giving it
to me-I don’t need solutions at all’ types.
Dealing with this kind of people is indeed
a very tough job.
-
Be PATIENT while they check your patience.
-
Like the great men said – “Use individualized
approach”
6. Attenders
with ‘VIP-syndrome’
Again this seems more to be an
India-specific problem.
An unknown person wearing white
shirt and white pant enters the ED from nowhere and almost inserts his mobile
phone into doctor’s mouth saying “Baat karo…Baat karo..Saab se baat karo”
(Speak…Speak…Speak to the master) before you even take a glimpse at the
patient.
Keep your calm. Make them understand that you
would speak to whoever it is on the
phone once you see and assess the patient.
Involve senior on shift and administrative staff
early in case you sense some trouble.
These are some of the tips that are helpful for an effective
communication in the ED. I hope this would have helped you just like a revision tool for
the communication course (Your ED rotations) you have undergone all through
these years.
Thank you!
References:
- “Transference and countertransference in
communication between doctor and patient”
- Patricia Hughes, Ian Kerr Advances in
Psychiatric Treatment Jan 2000, 6 (1) 57-64; DOI: 10.1192/apt.6.1.57
- Oxford handbook of emergency medicine: General
approach.
- Emergency department violence http://www.acep.org/workarea/DownloadAsset.aspx?id=81782
- “Doctor-Patient Communication: A Review” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096184/ PMCID: PMC3096184
- “Effective physician-patient communication and
health outcomes: a review.” http://www.ncbi.nlm.nih.gov/pubmed/7728691
Author
Dr. Apoorva Chandra
Resident, Emergency medicine
Apollo health city, Hyderabad
Twitter: @apoorvamagic
apoorvamagic@gmail.com
