Signouts and handoffs, whether they’re from an outgoing doctor, mid-level provider or transferring hospital, are ripe for consternation, anger and medico-legal risk. Here’s a real case of a PA-physician conflict and how it could be peacefully resolved.
A PA staffing an urgent care clinic calls the nearby emergency department to tell the physician on duty that she is sending over a patient with pelvic pain for IV fluids and further evaluation. The labs and vital signs are normal, so the doctor suggests that the patient would be best served by Tylenol and a follow-up appointment in GYN the next day. The patient shows up at the emergency department anyway, at which point the doctor instructs her to return to the clinic for further discharge instructions.
The PA Says
“I see a new patient every 15-20 minutes for 10 hours in a row and I only transfer, on average, 1 of those a day to your ED. I call as a courtesy, wait several minutes on hold to speak to you, only to have you speak to me in a condescending way about what I should do when I have already determined that I need your help to further evaluate the patient that I feel is outside the scope of my training. And sending the patient back — how is that not an EMTALA violation?”
The EP Says
“I just took time from my busy day to explain to you what this patient needs and why. I have saved the ED from seeing a patient who does not have an emergency and I am saving the patient hours of her time as well as money for a visit she doesn’t need. I said everything nicely. It wasn’t that I delivered the message poorly, you just didn’t like the message.”
The Patient Says
“I was so confused. The PA told me that I needed more evaluation at the emergency department, then the ER doc told me that I had to go back to clinic. It took me several days to feel better again and it would have been well worth my time and money to be seen in the emergency department if I could have been back on my feet sooner.”
Common ground: Everyone in this story wants the patient to receive the right diagnosis and treatment plan at the minimum expense to the patient (time and money).
Divergence: The PA and physician differ in how to reach the right diagnostic and therapeutic conclusion.
Path to resolution: Emotional intelligence (EQ) is defined as “the ability to sense, understand, and effectively apply the power and acumen of emotions as a source of human energy, information, connection, and influence”. As the emergency physician, you have the most authority, and thus the burden of power, in this interaction. Therefore, the onus is on you to use EQ to recognize that:
The PA only reluctantly calls you to transfer a patient, in the same way that you may be sorry to bother internal medicine for an admission. Recognize your own irritation at the transfer/sign out, and keep it out of your voice, tone, and word choice or you will degrade the interaction instantly.
If you strongly believe that the patient does not need an ED visit, check in with the transferring provider by asking if agreement has been reached. This must be done delicately, because you want to reach a genuine agreement, especially if you turn out to be wrong. Your communication style must be spot-on to ensure that you are not forcing your opinion on the transferring provider. Communication expectations vary from person to person, men to women, provider to provider.
Consciously try to meet the other person on their own ground. This may require what seems to be an excessive amount of kindness or patience, but will also be the difference between a great sign out and a shot to the foot.
Your exact world view is unique to you, and almost nobody else will share it. When patients come to the ED, they have concluded that they need your care. We don’t want radiology to demean us for ordering yet another CT pulmonary angiogram. In the same way we should not think less of patients who present to our ED, no matter how many times they have done so.
It is natural to dislike transfers like the one in this story, but they are an important part of our job. Accept that they will happen. Recognize that you’ll have negative thoughts about transfers and purge those thoughts when they occur. Do not allow your mind to engage in negative inner dialogue because it will wire you that way and make you miserable. Be the doc that earns the reputation of being evenkeeled. This will allow you to ask intelligent questions and make requests that will be well-received.
Plus, you’ll be a happier human being.