Communicate, communicate, communicate

Author: Charlotte Davies / Editor: Liz Herrieven / Codes:  / Published: 23/11/2020

Whenever you ask for tips around care in the Emergency Department (ED), you’re more than likely to be told “communication”. Communication. Communication. We become (mostly) emergency practitioners to reduce suffering of patients – not all suffering is pain, and both suffering and pain can be reduced by compassionate communication.

But what does communication mean?

And who do you have to communicate with?

We’re going to focus here on communication with your patient. We’re not going to mention communicating “bad news” as we’ve covered that elsewhere, but do remember, for a self employed roofer, telling them they’ve broken their leg probably counts as bad news. We’re not going to mention communicating with your extended team, although there will be a lot of overlap. We’re also not going to mention communicating with special groups, like those in whom English is not their first language, including deaf people, and those with learning difficulties.

  1. Patient communication in the ED serves several purposes. You want to get information from the patient, which needs rapport and skill, but you also want to give the patient information whilst maybe using your words to treat. “AIDET” is one framework that might help. Many of you will complete components of this subconsciously and intuitively:

Acknowledge the patient. Confirm their name, and the names of others in the room. This saves you assuming that their wife is their daughter, or breaking confidentiality when you assume their sports coach is the father of their unborn child.

Introduce yourself, and everyone in your team using #hellomynameis – simple, but really effective. By introducing everyone and acknowledging their contribution, you imply that you are a well oiled and highly functioning team – as evidenced by this short example from If Disney Ran your Hospital.

Duration – give an estimate of time to be taken. It’s probably best to round up, rather than down, but do be realistic.
“Blood results normally take about an hour and a half to come back”.

When we’re stressed, as let’s face it, most patients in the ED are, we tend to interpret things negatively. A patient who has been waiting 65 minutes for their results is more likely to think “that’s a long time, something really must be wrong” than “I’m sure they’ll be back soon”. Giving a time duration can also help to focus patients:
“In the short time we have together, what is the most important thing for us to cover?”
“In the five minutes we have left, let’s complete the examination.”

Explanation is easily forgotten. Remember to explain to the patient what’s been done, what it means, and what to do next. We’ll explore this a bit more.

“Thank you” is probably an over simplified term, but it’s nice to end your interaction with some degree of politeness. “Have a nice evening” is difficult if the patient is unwell. “Thank you for explaining so clearly” might be appropriate. Use your judgement.

Compassion Counts

The most important top tip when communicating, is to communicate with compassion and care. Realise that every word you say, on what might be the worst day of your patient’s life, is important, and carefully considered. There’s lots of evidence that compassionate clinicians have better outcomes, and hear and know more things. If we asked our patients “what worries you most” instead of “what’s the problem” or similar statements, the answers, and therefore the treatment might be very different. High physician compassion was associated with enhanced immune response, a one day decrease in duration of cold symptoms and a 15% decrease in cold symptom severity. Patients of high compassion physicians had 41% lower odds of serious diabetes complications. Coming from a different angle, patients also perceive compassionate physicians to be more competent, but being compassionate doesnt encourage the patients to keep coming back either – a study looking at homelessness patients randomised to be treated compassionately or not, showed compassion reduced subsequent visits by 33%. So really, being compassionate is a win win.

If you’ve been very compassionate, maybe your patient will start to cry. How you “cope” with this will depend on your patient, but have a think about what to say, instead of “stop crying”.

Compassion doesn’t need to take lots of time: 40 seconds in one study. 38 seconds in another. A simple phrase like: “what ever we do, and however that develops, we will continue to take good care of you” is all that is needed. The precise words will vary. If you like a framework, have a look at the GRACE frame work for compassionate communication. I think the most important part of “GRACE” is to remind yourself of your intentions. Sometimes when the shift is busy, it’s difficult to remember that your intention is not to make patients feel stupid for attending ED, but to make them feel “heard” and better. Checking your intention is similar to checking your energy.

Time Tricks

You’ve always got time to communicate well. If you sit down it makes patients think you’ve spent longer with them. If you let the patient tell you their story, they’ll tell you what is worrying them, and the diagnosis. If you’re listening, you’ll hear what’s wrong. Arguably, you don’t have time NOT to communicate well.

Naughty Nocebo

We’ve talked before about nocebo. Good communication is both the avoidance of nocebo, and potentially, the introduction of placebo – positive benefits from your words. At times of stress, where two meanings can be inferred, we normally believe the negative one. So “he might pull through” becomes he might he might not therefore he won’t. These negative thoughts often block other thoughts, but can be prevented with careful communication.

Lovely Listening

Listen to what the patient has to say and confirm it, or pursue it – ask a follow up question. As well as demonstrating listening, this demonstrates compassion. There’s 2.5 compassion opportunities per visit if you listen hard enough. Don’t just listen to the words used, listen to the way those words are said. We all know “I’m OK” could mean a million things depending on how it is said. Have a listen to the “State Farm Commercial Jacked Up” video to highlight the importance of tone.

There’s “levels of listening“, summarised wonderfully by @impactWales below. I’m not sure in healthcare we can honestly say we meet level one, let alone level 5 or 6 – but we can certainly strive to understand, observe non verbal cues, understand feelings, and clarify assumptions.

So, how do we listen well? We’ve all heard of “active listening” and try to practice it. “LISTEN” is one set of suggestions, but I prefer the 5Ss because it reminds us that listening is a two way process, and as much as we need to “shut up”, its good to also “sum up”.

A lot of our listening approach has come to us from handover research, but some of it is common sense. Try a little exercise: Ask someone you know to spend two minutes telling you something brilliant about a really exciting and enthusiastic experience they’ve had recently. Something they’re really passionate about. Listen intently. When they’re about thirty seconds in, physically turn your back to them. If they falter, say “oh, I’m still listening, do continue”. Then talk about how they knew you were listening, and how they felt when faced with your back.
This is an extreme example – but think about how we do similar things in medicine. A patient is talking, and then we get given an ECG to sign, or the bleep goes off, or we’re face down in our notes. I’m sure you’ve got lots of your own examples.

Listening requires all of your senses.

If your patient speaks to you with a lot of emotion, dont answer those feelings with facts. If a patient says they’re scared about their manipulation, don’t just say “it’ll be fine, and over in a few minutes”, but take a few moments to use the GIVE framework to acknowledge their feelings:
“I hear that youre scared. What is worrying you the most”.

Some of our patients are proactive, some are reactive. Proactive patients will tend to speak as though they are in control, in short sentences, and may have signs of impatience in their body language. Reactive patients may speak in incomplete sentences with lots of passive verbs, long convoluted sentences, and their body language will tell you they are willing to sit still for long periods of time. Matching proactive and reactive preferences will influence them more strongly. If I asked some of you to write an RCEMLearning blog, and your trusted advisor said “run with it; right now. What are you waiting for”, that would motivate and spur some of you on. Some of you would respond better to “let’s think about it, the time could be right”. Think about the difference between these two:

Let’s get your asthma in control straight away. What you need to do right away, is start using a spacer to take your inhalers. Let’s hurry to get a prescription to pharmacy before it closes.

and

Let’s think about how to get your asthma in control. You might consider using a spacer, as I think then, more of the active medicine will enter your lungs where it needs to be. While you consider this, I’m going to write a prescription, that you could take to pharmacy.

Most people demonstrate “toward” (focussed on moving towards a goal eg. good asthma control) or “away from” patterns (no more exacerbations). Listen to their words – toward people prefer things like have, get, include where as away from prefer solve, prevent, avoid, get rid of.

Talk through your Thinking

We’re always encouraged to “show our workings” at school, and actually it’s no different in medicine. PEMMorsels talks through this, and it’s useful to think about layering the information you give parents – “baby Zain looks really well today look how well he’s wriggling” etc. The ladder of inference is a useful framework that explains how we “jump to conclusions” – by talking through our data and decisions as we climb each rung of the ladder, we prevent ourselves from having to descend the ladder to understand the patient’s viewpoint.

Giving Information

As communication isn’t all verbal, we need to be good at writing information and explaining it to patients. This “best case/ worst case” structure where you join a potential timeline with each treatment, and each treatments best and worst case might be a useful technique.

Patients won’t remember everything we say. They’ll remember the first and the last things you say. Think about what the message you want them to remember is. Safety net information is covered well by St Emlyns, and is a skill worth thinking about. How do you tell a patient to return if they get symptom XYZ, without introducing a nocebo. Tricky isnt it!

The Passive Aggressive Patient

We’ve all been there. You think one thing, and your patient disagrees. They tell you they disagree firmly, politely, and repeatedly. What do you do? Well, develop credibility and rapport before you even enter the room. After that, be persistent? Put your suggestions in the comments!

Rapport development with your patient begins as soon as you enter the workplace. The FBI is reported to have conducted a study on people who shot police officers. Before doing so, the prisoners evaluated how easy it would be to take down the officers by their dress (were they sloppy or smart) and their deportment (slouching or straight). This is a good reminder that people, including our patients, are judging us all the time. If we are dressed smartly, and appear confident from the moment we arrive in the room, the passive aggressive cycle is less likely to even begin.

We need to develop our “command presence”. If you need to power pose before you go into the room to remind yourself how awesome you are, thats OK. If you havent already, listen to Amy Cuddys TED talk.

Children probably sometimes fall into the passive aggressive group. There are special techniques for dealing with children – but both children and adults respond to the double bind. “Do you want to go home with hospital transport, or in a taxi?”

The Difficult Patient

Theres normally a reason for a patient being “difficult” – try to find it out early on what the problem is. Non-violent communication might be a useful technique here:

OBSERVATION: When I hear you swearing loudly
FEELINGS: I feel uneasy.
NEEDS: Because I value polite, calm communication.
REQUESTS: Would you be willing to adjust your language so we can begin to get to the bottom of your presentation?


Image from Wikipedia. For more information on this, visit the centre for non violent communication.
After a difficult consultation, maybe consider a debrief?

Sometimes patients just don’t like you, and another Clinician with another approach may be needed. If this isn’t an option, solving this can be difficult but is sometimes solved by addressing the elephant in the room:

“You don’t seem confident in the plan I’ve suggested. What do you think I’ve missed?”

“Thank you for waiting so long to see a Clinician”

Shared Decision Making

Well, that’s the subject of another blog if anyone is interested! If you can’t wait, there’s some e-learning here.

Every little will count – great communication can save lives. If all else fails, go for the ABC of communication:

We’d also like to draw your attention to this fabulous podcast on hostage negotiation from Risky Business and this post blog twitter thread:

If your communication challenge is more around asking questions, check out this post from Tessa Davis with a video here.

References

  1. Words that Change Minds: Mastering the language of influence
  2. Compassionomics
  3. EM Didactic
  4. Talk Like TED
  5. https://emdidactic.blogspot.com/2015/06/for-people-who-think-ed-is-cocoon-think.html
  6. https://happinessishereblog.com/10-things-say-instead-stop-crying/
  7. https://blogs.bmj.com/bmj/2020/04/13/laura-k-rock-dont-answer-feelings-with-facts/
  8. https://www.upaya.org/2012/09/practicing-g-r-a-c-e-how-to-bring-compassion-into-yourinteractions-with-others/
  9. https://emj.bmj.com/content/32/1/15
  10. https://www.studergroup.com/aidet
  11. https://www.stemlynsblog.org/strengthening-communication-st-emlyns/?utm_source=ReviveOldPost&utm_medium=social&utm_campaign=ReviveOldPost
  12. https://www.stemlynsblog.org/its-not-ok/
  13. https://www.stemlynsblog.org/communicated-discharge-safety-netting/
  14. https://litfl.com/mastering-intensive-care-048-with-laura-rock/

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