Published in the May 2008 issue of Today’s Hospitalist
IN THEIR INTERACTIONS with emergency department (ED) physicians, hospitalists complain that ED doctors often pressure them to admit patients, even before test results are available and a diagnosis is made.
ED doctors, on the other hand, grumble that it can take the hospitalist service hours to send a physician down to admit a patient. By then, the ED physician who first treated that patient is long gone.
Sound familiar? According to a recent study that examines communication problems between hospitalists and ED physicians, this exchange can lead to frustrating tug-of-wars and less-than-stellar patient handoffs.
Julie Apker, PhD, co-author of a study that appeared in the October 2007 issue of Journal for Academic Emergency Medicine, says that hospitalists feel “boxed in” to agree to admissions when they think patients should spend more time being observed in the ED. Physicians in the ED, however, say they’re tired of having to “sell an admission” to hospitalists.
What’s really at play, says Dr. Apker, an associate professor of communication at Western Michigan University in Kalamazoo, is the clash of differing goals and work environments. While hospitalists are looking at patients’ long-term placement, from admission to discharge, ED physicians take a much more short-term view: how to get the patient out of the ED to the next stage of care.
“Both services want quality patient care,” Dr. Apker says. “But the short-term vs. long-term perspective can create conflicts.”
Getting beyond “headlines”
Despite the tension between their different medical approaches, both groups of physicians interviewed for the study said they felt their relationship was collegial.
According to Dr. Apker, that might reflect the nature of those who volunteered for the study: six ED physicians and six hospitalists who are all attendings at Kalamazoo’s 348-bed Bronson Methodist Hospital. Researchers interviewed the 12 physicians about their recall of handoffs, a process that produced a number of common themes and frustrations.
Dr. Apker says that perhaps the biggest challenge is that, other than in the case of a “slam dunk” admission, hospitalists and ED physicians cope with a great deal of uncertainty when it comes to diagnosis and patient disposition. Physician participants dubbed this the “gray zone,” an area of tension that researchers say is a “consistent obstacle in physicians’ handoff communication.”
A key problem is that each group’s perspective plays out in a different communication style. Because ED physicians want to move the patient along, for example, they want hospitalists to agree to not only admit the patient, but to follow up on all pending tests and lab studies.
Hospitalists, on the other hand, feel that ED physicians focus only on case “headlines,” forcing them to make admission decisions without all the necessary information.
Safety and boarding issues
Sometimes miscommunication comes down to a matter of words. When, for example, hospitalists tell an ED doctor that they’ll come see a patient, the ED physician may interpret that to mean that the patient will be admitted.
In reality, however, hospitalists probably mean that they plan to assess the patient, whether or not that patient is admitted. “The two physicians walk away with different perspectives on how the situation is to be resolved,” Dr. Apker explains.
And even when the decision is made to admit, the question of who is responsible for a boarded patient who’s still in the ED can become a source of frustration. While that responsibility technically rests with the hospitalist, ED staff find that it’s not always practical to page that physician. As a result, ED nurses take problems to the ED physicians “who are busy with their own emergent patients.
As Dr. Apker notes, patient boarding can lead to potential quality of care issues. That’s because patients may experience treatment delays, which may ultimately result in longer hospital stays.
Botched communication can exacerbate system failures in other ways, she notes. Patient boarding has the ripple effect of draining precious hospital resources, from nursing staff to beds.
Solutions that can work now
How can physicians improve gray zone communication? While the most obvious solution is for residency programs to focus on handoffs during physician training, Dr. Apker says there are steps that physicians can take now.
A good place to start, she explains, is trying to understand the other side’s point of view. Talking to your ED colleagues about your expectations for handoff communication may be particularly effective.
“Empathy is an important component,” Dr. Apker says. “Understanding what my colleagues expect from me and why they expect that information could go a long way to reducing frustration.”
Hospitalists, for instance, could let ED physicians know what pressures they’re under. “They could say, ‘I have three admissions and this is the information I need to make my decision about those admissions,’ ” she says. That dialogue “is not asking for huge changes in existing handoff communication behaviors.”
She also urges hospitalists and ED physicians to discuss handoff issues outside of the high-pressure environment of the ED. Based on the findings of her study, Dr. Apker suggests focusing on what it means when someone says, “I’ll come and see that patient.”
Finally, Dr. Apker recommends that hospitals use a survey or other research tool to assess physician communication. Results of that survey could not only lead to in-service CME on improving handoffs, but it could identify those who do well as handoff “leaders."
An even closer look
As for changing the actual conversations between physicians, that’s next on Dr. Apker’s research agenda. She just finished a pilot study that analyzes handoffs between hospitalists and ER, and offers more detail to explain “and improve “communication.
A preliminary review of pilot data reveals, for instance, that both sets of physicians should use more read back “paraphrasing what the other has already said “and open-ended questions. Both techniques provide opportunities to share more information.
Pilot data also suggest that little rapport-building is done during handoff conversations, and that there is relatively little back and forth dialogue in the discussions, which typically last less than three minutes.
“From a safety perspective, the Joint Commission would like more of a dialogue to ask and answer questions,” Dr. Apker points out. “But the reality is that physicians are really busy.” One relatively simple solution might be to just repeat back what the other physician has said.
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.