The Nine Hand-Offs And What They Say About You

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Most of us can’t articulate what makes a great handoff, but we know one when we see it. But did you know how much your post-shift rituals say about your personality? Which type are you?

Everyone’s stable. There’s nothing to do

1. The Minimizer
The minimizer underestimates patient acuity and thinks everyone can go home. His sign-out takes less than a minute, everyone is stable, and “there’s nothing to do”. He doesn’t report admitted patients still in the department, or those being discharged. You find yourself hoping none of his “flyovers” come back to bite you before they leave— and you wish he didn’t put your name on his charts. By the way, he likes to leave right on time, so don’t be late! After he leaves you peek at his patients to make sure they’re able to walk (or still breathing). Happily, the nurses know the game and usually alert you as to who needs your attention.

 Could this be exotic zoonotic colonization?

2. The Specialist
Her extensive sub-specialization has given her an impressive vocabulary and a license to weigh down her sign-out with a plethora of high-brow words. She weaves esoteric terms throughout her discussion and references obscure journals like others name pop stars. With nary a pause she poses rhetorical questions about the likelihood of an exotic zoonotic colonization and peculiar effects of some rare toxic element… then closes with an “in” joke that only another specialist would appreciate. You feel stunned and when she asks if you have any questions you utter a quiet “no”.

. . . so then the nurse manager said . . .

3. The Lonely Guy
He works mostly small, rural EDs. With no peer to talk to for the past day, he’s been looking forward to sign-out. He whips through the first few patients and then starts expounding on an “interesting case”. You skillfully get him back on track, but soon he’s comparing the neck pain he saw to his mother-in-law. He spills all sorts of unsolicited details about his eccentric patients, and even the staff. First he complains about the nurse manager, and next he’s telling you about his cousin’s destination wedding—it turns out the cousin married the nurse manager! By the time he’s finished, your seat is numb and you’re aching to see the new patients.

Just one more CT before I go . . .

4. The Last Minute Adder
This guy’s report always includes patients with major tests pending—because they were added on to the work-up just before signing out. These patients have been in the department for hours, yet the CT scan, MRI, or surgical consult was just ordered minutes ago. While nodding quietly, you really want to ask about the medical decision-making process that accelerated into overdrive just before you arrived. But instead you tell yourself that your fresh eyes will be helpful to discern the patient’s problem.

I’ll just be over here, finishing up charts . . .

5. The Lingerer
This physician seems to always stay late after his shift, ostensibly wrapping up work-ups and finishing charts. He never signs out on time. In fact, he routinely stays around for hours, chatting to the nurses and making phone calls. You good-naturedly assure him that you can be trusted to follow-up on his patients, but he seems in no hurry to leave. You rationalize this behavior by speculating his documentation must be impressive… and that you shouldn’t feel guilty about not taking report. And you recall Lingerer’s close relative, the Muddler, who sticks around after signing out and continues to manage and disposition his patients—leaving you thoroughly confused.

What is it with all of these anxious wimps?

6. The Curmudgeon
He’s a real sourpuss. He’s sarcastic and rarely smiles, except when telling one of his inappropriate jokes—about patients. He’s a real grouch. He complains about the nurses and grumbles about hospital administration. He believes the patients come to the ED simply to torment him. His low patient satisfaction scores are tolerated because he moves the room. He’s jaded and moody, and nothing impresses him. This guy probably burned out a few years ago but doesn’t know what else to do with himself. (The Lonely Guy shares the rumor: his wife wouldn’t let him retire)

Hand off complete. We’re done here.

7. The Dragon Lady
She’s an excellent clinician, smart and efficient. She’s also demanding and opinionated, and doesn’t suffer fools gladly. To the nurses she’s imperious, and woe to anyone who gets in her way: she takes no prisoners! She’s impatient with hospitalists who block her admissions, with consultants who ask for too many studies, and with patients who ask too many questions. At sign-out she gives you a hard time if you ask about details. Who are you, to ask for clarification about the plan for these patients? She brushes off your concerns, or makes you feel incompetent.

What do you think? What would you do?

8. The Milquetoast
He’s meek and apologetic, and works hard to please everyone. He spends a great deal of time with patients, works up every symptom, and seems to live in fear of being sued. Even social issues become his dilemma. He couldn’t hurt a flea, and an angry patient can cause him to decompensate. He presents every patient as a question, and his summary is open-ended and vague. He seems to be asking if you approve of his diagnosis and treatment, peppering his sign-out with questions like “what do you think?” and “if you’re okay with this”.

Anything that I might have missed?

9. Old Reliable
He doesn’t sign-out immediately, but within half an hour, after he’s dispositioned the difficult ones and tidied up his area. Although he’s seen more than his share of patients, he’s admitted or discharged all but 4, and the plan he relates for those remaining is simple and clear. He spends most of the time describing his ICU-patient, then walks you to the bedside to introduce him. Back at the computer, he briefly summarizes his patients that are about to be discharged, and surprises you by asking, “Can you see anything I might have missed?” After you confirm a few details, he jots his cell phone on the top of the sign-out sheet, saying “You can reach me here if you have any questions in the next few hours.” His sign-out took 12 minutes, and left you with a spring in your step.


So What?
The care and diligence with which we approach each patient should be evident in our handoffs. A thorough and well-crafted handoff reflects clinical skill, and also reflects our regard for colleagues who assume responsibility. One of the most important and overlooked components in a handoff is the opportunity for the fresh physician to ask questions, and to shed light on potential diagnostic or treatment issues. When handoffs are at their best, the incoming physician may actually uncover a problem that was not immediately apparent to the initial clinician. For this, everyone can be grateful.

So the next time you hand over responsibility for the department to your colleague, have the insight and the co fidence to let them ask questions about your diagnoses and disposition, and give them your best signout ever!

REFERENCES

  1. Cheung DS, Kelly JJ, Beach C,et al; Improving Handoffs in the Emergency Department, Ann Emerg Med
  2. Communicating in the “Gray Zone”: Perceptions about Emergency Physician–hospitalist Handoffs and Patient Safety, Julie Apker PhD1,*, Larry A. Mallak PhD2 and Scott C. Gibson MD3 Article first published online: 28 JUN 2008 DOI: 10.1197/j.aem.2007.06.037
  3. Personal communications

ABOUT THE AUTHOR

John Williams, MD is the ED Director of Operations at the University of Illinois Hospital, and has been involved with a number of handoff and consultant initiatives.

2 Comments

  1. Myra Buttreeks on

    Long overdue – it’s a wonder this isn’t a required competency in residencies…probably because career academics are terrible at sign out and couldn’t teach it if their job depended on it.

  2. Kudos to Dr. John Williams this was brilliant. The sign off is such a hassle to so many clinicians that we really do need to educate them on it rather then allowing them to develop their own style. Residents should have a full blown course on how to do it so it “lands correctly” and yet doesn’t get in the way. We all know the need to effectively transfer care between providers yet this transfer was the issue in the infamous JAMA article on error rates in healthcare and the beginning of the actual realization that the biggest errors are created at the very moment that one professional takes over the mindset of the previous provider. In fact that is what is happening it is a transidental mind exchange that if done well is seamless and if not can lead to absolute chaos and even mortality. Dr D

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