Communication during residency

Congratulations on moving on to the next stage in your professional career! This article is part of a series called "Transitioning to residency," which is designed to help new interns and subinterns adjust to their new responsibilities. The other articles in this series include:

• “Logistics of US health care and hospitals”
• “Daily life of the intern”
• “Navigating stressful situations in residency”
• “Life outside of the hospital”

This article discusses the importance of communicating well with the various groups you will interact with as a resident (including medical students, nonphysician members of the health care team, and patients). It also offers strategies for improving communication in a range of specific scenarios, from providing feedback to medical students at the end of a rotation, to handling frustrating pages from nurses, to addressing goals of care with patients and family.

Communication with both patients and colleagues should involve active listening and the use of language that is clear, respectful, nonjudgmental, and empathetic.

• Why does communication matter?
  • Establishing a pattern of good communication with team members:
    • Makes people feel comfortable approaching you with questions or concerns
    • Improves team-building and makes your daily life in the hospital more pleasant
    • Helps a lot when you need to ask a team member for a favor
  • Applying communication skills to patient encounters:
    • Impacts health care quality and safety by improving patient-centered care and preventing errors
    • Allows you to identify information that could otherwise have been missed
    • Helps reduce stress during potentially difficult communication scenarios, such as discussing goals of care and code status
  • You are evaluated on professionalism throughout residency.
• The basics
  • Introduce yourself.
    • Learn and use people’s names.
    • Ask about pronunciation if you are unsure.
    • Ask how people prefer to be identified; some nurses may prefer not to be called by their first name.
  • Never make assumptions about someone's clinical role based on their gender or appearance.
  • Say please and thank you, even when you're asking someone to “do their job.” People like to feel appreciated!
  • Acknowledge and apologize for mistakes.
  • Avoid interrupting; apologize if it is necessary due to time constraints.
• Ask-tell-ask ^[1]
  • Ask: Ask an open ended question that avoids making assumptions.
  • Tell: Provide information relevant to the response to the open ended question, with your rationale.
  • Ask: Ask again to check for understanding and see if the issue or concern was resolved (ideally with another open ended question).

Working in healthcare was not easy even before the COVID-19 pandemic. Try to remember that many people are dealing with overwhelming feelings, distress, and burnout; try to relate with compassion and empathy as much as possible.

Be aware of what your nonverbal communication (e.g., eye contact, facial expressions, and head nodding) may be conveying about your level of concern regarding, interest in, and understanding of what the other person is saying.

Setting expectations

• Do this from the beginning, based on objective standards appropriate to the student's level, and not personal beliefs or opinions.
• Set clear expectations regarding:
  • Seeing patients
  • Writing notes
  • Presenting to the team

Teaching effectively

• Sit down with the student briefly at the beginning of the rotation to ask if they have a particular learning goal.
• Remember teaching does not have to take extra time; it can be as simple as thinking out loud as you place an order or write a note, or talking through the steps as you do a procedure.
• Use the 5 microskills approach when possible.

Giving feedback effectively ^[3][4][5]

• Definitions
  • Formative feedback: feedback given in real time, which allows the student to make changes before the end of the rotation
  • Summative feedback: feedback given at the end of the rotation as a final assessment of performance, which is often accompanied by a grade or standardized evaluation
• Some basics
  • Tell the student to ask you for formative feedback intermittently throughout the rotation so that it is not only your obligation to remember.
  • When giving summative feedback:
    • Make sure you are seated in a private, quiet environment, with at least some amount of uninterrupted time.
    • Start by asking the student for their own self-assessment; they may already be aware of issues you were going to raise.
• Effective feedback is:
  • Objective: Understand what objective standards the learner is measured against; don't give a subjective evaluation based on your personal impressions.
  • Timely: Give formative feedback throughout the rotation (on a daily or weekly basis), as soon as it is relevant.
  • Specific: Give specific examples; avoid generalizations.
  • Appropriate in amount: Don't overwhelm students with a large amount of feedback at once (this is another reason to provide more frequent formative feedback).
  • Constructive: Normalize making mistakes and growing from them (this is how learning works!). Offer specific recommendations for improvement.
  • Actionable: Focus on modifiable behaviors, not personality.
  • Positive: Always acknowledge strengths, and aim for positives to outweigh negatives.

Summative feedback should never be the first time a student hears about a concern or deficiency! Constructive feedback should be given as formative feedback throughout the rotation to allow the student time to course correct.

Nurses

• Collaboration and teamwork
  • Keep nurses informed of the team plan for the patient (e.g., planned tests or procedures, new orders, planned discharges).
  • If they raise a concern or question about patient’s care:
    • Take it seriously.
    • Ask if they would like you to see the patient (newer nurses may feel less comfortable asking you directly). Regardless of their response, always see the patient if the nurse reports a new or worsening symptom, or a potentially concerning change in the patient's vitals, exam, or labs.
    • Use the ask-tell-ask strategy.
    • If you feel you are getting inappropriate pushback, avoid getting into an argument. Instead, offer to have your senior resident or attending check in with them about the issue.
  • Avoid disagreeing with or criticizing a nurse in front of a patient (unless it is a matter of immediate patient safety).
• When making a request
  • Choose the right moment. Don't interrupt while they're with a patient if it's not an emergency.
  • Introduce yourself; don't assume they know who you are.
  • Ask if they have a moment. If they say no, but the issue is urgent, apologize and explain why it's urgent.
  • Remember to say please and thank you!
• Tips to avoid frustrating pages
  • If you anticipate being unavailable for some amount of time (e.g., while admitting a patient or doing a procedure), check in beforehand with the nurse(s) to let them know and ask if they have any pending issues.
  • Pay attention to the way your orders are written. Pages that may seem unnecessary and irritating (such as mild elevations in blood pressure or blood glucose) can often be avoided by adding specific parameters to your orders.

Other team members

• Pharmacists
  • They are an excellent resource for information about dosing, interactions, side effects, etc. Feel free to reach out to them with questions!
  • They can help catch and prevent potentially significant medication errors.
  • Expect to hear from them with questions about orders you place (especially early on as an intern), and consider their input carefully.
• Social workers and case managers
  • They are often understaffed and covering multiple teams at a time; they have a difficult job, too!
  • They appreciate when you can provide basic information about your patients (e.g., whether they live alone or if they have a health aide) to help them do their job more efficiently.
  • Delayed discharges can be a huge source of frustration, but recognize that these delays are often due to insurance issues that are beyond their control.
• Clinical documentation improvement (CDI) specialists
  • You may receive messages asking you to make a certain revision in your clinical notes.
    • Often, the request is to make a general diagnosis (e.g., diabetes) more specific (e.g., type 2 diabetes with neuropathy).
    • Sometimes, you may disagree with their request based on your clinical assessment (e.g., you do not believe the patient actually has sepsis).
      • This can be frustrating, but remain pleasant and explain your reasoning.
      • If they are insistent, just escalate it to your senior resident or attending.

See also ”Key principles of communication and counseling.”

Techniques for communication at the bedside

• Include the patient in your presentation; avoid talking only to your attending or senior resident.
  • Invite the patient to interrupt and correct you if you get something wrong.
  • Ask for clarification: e.g., “Let me make sure I have this right,” or “So it sounds like what you're saying is...”
• If using medical terms and jargon to discuss management with the team, warn the patient beforehand, and let the patient know you'll explain the final diagnosis and plan to them as soon as you're done.
• Use patient-centered, nonstigmatizing language (e.g., “uses drugs” instead of “addict,” “currently not using drugs” instead of “clean”).

Working with medical interpreters

• Know that you are not alone if you find this to be stressful. It can be!
  • In-person interpreter services may not be available at your institution, so you may need to use a phone or video interpretation service, which can be cumbersome, feel awkward, and can be difficult for patients who are hard of hearing.
  • It can take much longer to obtain information, since everything is being said twice. This is tough when you're already pressed for time.
• It's important to remember the following:
  • You have a legal obligation to provide this service to patients when needed.
  • A family member or noncertified interpreter should not be used to interpret unless it is an emergency.
  • Always speak directly to the patient. Make eye contact with them, and use the pronoun “you”; the interpreter will translate exactly what you're saying to the patient.
  • Patients of some ethnicities who are members of a particularly small and close-knit community may be concerned about disclosing personal information to the interpreter because of who they may know. Be aware of this possibility and, if this is the case, reassure the patient that what they say is strictly confidential.

To avoid using the sometimes cumbersome landline phones for interpretation, program the interpreter hotline and access code into your cell phone and use speakerphone (if appropriate, given who else may be in the room at the time). If you set the phone on the patient's tray table, you can perform exam maneuvers while talking.

Family members of patients you are cross-covering

• One of the pages most dreaded by overnight interns: “Mr. X has 5 family members here, and they have some questions for you! Can you come talk to them?”
• Don't panic! Although it can feel frustrating to be in this position, appreciate that:
  • Many family members are unable to visit during daytime hours. They may have to work or may not have transportation until the evening.
  • Family members may not be aware of how coverage schedules work. They may not realize that the doctor available at night is not a member of the primary care team.
• Use this approach:
  • Check your signout sheet to see if it includes updates about test results or planned interventions.
  • If possible, briefly review the assessment and plan portion of the daily progress note in the chart.
  • Introduce yourself to the family members, and manage their expectations by explaining your role.
    • Don't use phrases like “I'm just the covering doctor.”
  • Obtain consent from the patient to speak with the family.
  • Use the ask-tell-ask strategy to explore what the family would like to know.
  • Ask the family members to leave any specific questions with you, along with their contact information, and explain that you will pass this on to the primary team.
    • Have them choose one preferred person to be updated by the primary team (if the patient consents).
    • Record this information on your signout sheet or as an event note in the chart, and sign it out to the day team, letting them know the family would like updates by phone.
  • Let them know the approximate time that rounds occur, in case they do happen to be available during the day.

Breaking bad news and discussing goals of care

It's normal to feel overwhelmed by these tasks! It's stressful to be asked to do these things, often without ever having been specifically trained in doing them. The following basic approach is not comprehensive but should help you get started. See “Tips & links” for more useful articles and resources.

• Set up appropriately.
  • Who: Make sure the right people are present.
    • If the patient does not have capacity, who is the surrogate decision-maker?
    • Some patients may not want to receive medical information about themselves and would prefer that a family member be told about their diagnosis instead.
  • When: Give yourself enough time for the conversation.
  • Where: Sit down, in a space that is as quiet and private as possible. Ask a coresident or senior resident to hold your pager during the conversation, if possible.
• Breaking bad news: Consider using the SPIKES protocol.
• Goals of care
  • May require an assessment of decision-making capacity and/or discussion with surrogate decision-makers
  • Can include discussions about code status, withdrawal of care, futile treatment, no escalation of treatment (NEOT) designation, and end-of-life directives (e.g., advance directives, Medical Orders for Life-Sustaining Treatment)
• Consider using repeated cycles of ask-tell-ask.
  • Ask: Find out what the patient or family member's baseline understanding of the current clinical situation is.
  • Tell: Give information in small “chunks,” with pauses in between to allow for processing and questions.
  • Ask: Periodically check for understanding.
• In some situations, it may be best to return to have a follow-up discussion; offer this option to patients and families when possible.

Think about these conversations as a procedure like any other. Setup is essential, there is a recommended approach to follow, and you will improve with practice!

Don't use phrases like “stop the machines” or “withdraw care.” Focus on what additional comfort-focused interventions you will be providing for the patient, not what will be discontinued.