Published in the February 2006 issue of Today’s Hospitalist
After studying the problem of patient handoffs in the hospital, one of the nation’s leading researchers on medical communication has proposed a solution that not only calls for more face-to-face communication between physicians, but a uniform terminology to standardize how doctors discuss handoffs.
Recent research by Richard Frankel, PhD, and his colleagues Darrell Solet, MD, and Gale Rutan MD, found that handoffs in the hospital often don’t give physicians the information they need to manage patients. The study concluded that handoffs could be greatly improved if physicians actually talked to each other, instead of relying on electronic forms of communication.
“Oftentimes when handoffs take place,” says Dr. Frankel, professor of medicine and geriatrics at Indiana University School of Medicine, and a researcher at the center for implementing evidence-based practice at the Richard L. Roudebush Veteran’s Administration Medical Center, “it is mechanical and you don’t get the whole picture.”
But increasing the amount of physician-to-physician communication is only the beginning. Even when physicians talk to each other face-to-face about handoffs, Dr. Frankel says, they often don’t speak the same language.
As a result, he is calling for an overhaul in the way that physicians discuss handoffs, one that could begin with medical students.
Stepping back from the fray
The study, which appeared in the December 2005 issue of Academic Medicine, examined communication among residents as they handed patients off to each other in the hospital.
Dr. Frankel acknowledges that a certain degree of patient information can be passed on to subsequent caregivers via written notes or electronically. He argues, however, that for a patient handoff to be truly successful, physicians need a face-to-face conversation that allows them to ask questions, explain or even rethink care plans, and confirm content and instructions.
In his mind, the best handoffs give physicians a chance to step back from the fray and at least temporarily stop focusing on the myriad details of a patient’s case. He says that physicians simply need a little extra time to regroup “and possibly reconsider their plan of action.
“It’s adding a dimension of what has been called reflection in- action and mindfulness,” Dr. Frankel explains. A handoff, he adds, should be more than “a mechanical transfer of a list of things that need to be done or not be done. You need to ask yourself, ‘Who is this patient, why am I doing this and how can I do it best, and what does another person who is unfamiliar with my care plan need to know to assume care from me?’ ”
Without time for this kind of reflection or mindfulness, he explains, “You may miss out on some important dimensions of the care of the patient. At 4 o’clock in the morning, when it comes back to haunt you, you are caught between a rock and a hard place.”
The best method to hand off patient information, Dr. Frankel adds, includes a combination of written and verbal information delivered face-to-face. The written component should contain the basic information regarding each patient, while the verbal conversation should ensure that physicians on both ends of the handoff understand the situation, any instructions and the rationale.
Uniform handoff language
The study also concludes that physicians could benefit from a standardized set of communication tools to talk to each other. He says that physicians need a consistent and uniform language to talk to each other when handing off patients.
Dr. Frankel suggests teaching medical students and residents a common handoff language to “optimize precision and anticipate errors.” The idea is similar to techniques used by air traffic controllers or relay racers, he says, where success ultimately depends on consistently smooth handoffs.
Standardizing the way verbal handoffs occur could also counter another barrier to optimal handoffs: colloquialisms, abbreviations or short-hand terminology that is understood differently by physicians from diverse backgrounds, or by physicians who are not used to working together.
And because what constitutes an effective patient handoff “let alone how to do one “is rarely taught in medical school, Dr. Frankel and his colleagues would like to see it added to the curriculum. Their study found that only 8 percent of medical schools talk about handoffs in a formal didactic session.
Because of this educational gap, he explains, there is huge variation in how physicians exchange information, even within single institutions. Residents in training at Indiana University who were part of the study, for example, used four different methods to hand off patients, in part because they rotated through four different hospitals. Some used forms on their computers; others used PDAs; others passed handwritten forms back and forth.
This is particularly important in teaching hospitals, Dr. Frankel adds, because the inherent flaws in indirect communication ” the inability to ask questions and confirm understanding, for example “are exacerbated when communication is taking place between people “who are unequal in status.”
Errors have been shown to occur when physicians don’t feel comfortable discussing treatment options with their superiors or their junior colleagues, he adds. That’s why young physicians need to be taught how to talk to people who may have more or less power than them.
The good news is that there are skills that can be taught and practiced. Dr. Frankel says that one popular method known as teach back or read back may be particularly well-suited for the handoff process.
Here’s how it works: After a physician presents a patient, the receiving physician says something like, “What I’ve heard you say so far is that this person is an 87-year-old women with metastatic liver disease, and she is on a dose of 500 mg of morphine.” At that point, the first physician can correct a misunderstanding and say, “No, it’s 50 mg of morphine.”
In the case of air traffic controllers, Dr. Frankel says, where even a small misunderstanding can result in catastrophe, this interaction is taken one step further, and the “teach back” has to be acknowledged as correct. No one assumes that information was heard, let alone understood, without actively confirming it.
The problem in medicine, he explains, is that doctors all too often assume that “there is a one-to-one relationship between the information I have to give you and the information that you walk away with. There really is no tradition within the delivery of medical care to ensure that patients or doctors have heard and understood what is being asked of them.”
Dr. Frankel says that another skill that can be taught, especially to interns and residents, is “exposing your thinking and rationale for the care plan.” Instead of training physicians to say, “We’re doing this, this and this,” Dr. Frankel would like them to say, “We are doing this, this and this because we believe the patient has X, Y and Z.”
Help from a form
The Indianapolis VA is creating a standardized handoff process that incorporates a form based on the SOAP note. During face-to-face meetings, physicians give the completed form to the subsequent physician or team.
The form, Dr. Frankel says, functions as “a decision aid that prompts you to think about aspects of the patient’s care that might not come up in either a written or verbal handoff.” He plans to study how well these changes are working.
The Indianapolis VA is also developing a curriculum for residents that will include learning and practicing communication skills. Initially, however, the curriculum has a more simple goal: raising physicians’ awareness of communication issues in handoffs.
This program is focusing on what Dr. Frankel considers the crux of the handoff problem: attitude. The most important part of the discussion, he says, is to change physicians’ traditional views about handoffs and sign-outs. All too often, he says, physicians think that sign-outs mean the patient is no longer their responsibility, or that accepting a handoff means they’re babysitting the patient until the “real” doctor returns.
Lessons for hospitalists
While this study focused on interactions between physicians caring for patients in the hospital “typically residents and interns “its conclusions offer some interesting lessons for hospitalists handing off patients to their colleagues both in and outside of the hospital.
Improving handoff communication, Dr. Frankel says, is especially critical for hospitalists, who sometimes “lose some of the human dimension of medical care” because they often have not had any previous relationship with the patient they are now caring for. The handoff, he says, is a perfect time “to step back and think about the patient again and realize that this is not just a set of processes.”
Actually talking to referring physicians certainly takes more time than simply filling in a written form or computerized template, but Dr. Frankel argues that it saves time and money down the line. Caregivers on the receiving end “both primary care physicians and inpatient colleagues “do not have to waste time tracking down information or repeating tests that may either have already been done or already had been ruled out.
“Time pressure is the greatest enemy of this process,” he explains. “It does take some time. But when you consider the potential cost, it really is a small amount of time.”
“Medicine is rediscovering the necessity of face-to-face interaction,” Dr. Frankel adds. “We know that medicine, as high-tech as it has become, is still practiced one conversation at a time. Anything we can do to underscore the importance of this interaction is critical.”
Deborah Gesensway is a freelance writer who reports on U.S. health care from Toronto, Canada.