Getting started on the right path with the patient.
Dear Director,
Our department has received a variety of complaints from patients where it just seems like the docs didn’t get off to a good start with the patients. Do you have any tricks to help establish a bond with the patient?
Fortunately, providers generally get the medicine right and we’re not regularly dealing with complaints based on medical errors. However, communication blunders do account for a large amount of the complaints. This may be a failure to provide information or just having a provider put their foot in their mouth by saying something inappropriate.
Five to 10 percent of our patients are critically ill. Including that group, 15-30% of our patients will require admission. That means 70-85% of our patients will be discharged. So why are they coming to the ED? People often seek care in the ED because they’re in pain or afraid.
One of my mentors used to refer to our job as being in the reassurance business. Fairly quickly you can tell who your admitted patients are so that means for your discharged patients, it’s important to understand why they came to the ED and whether or not you need to reset their expectations.
In our business, it’s very important to quickly form a good patient-physician relationship so the patient immediately trusts you with what they may perceive to be a life-threatening condition. Additionally, I’ve had patients come with suitcases who clearly weren’t going to be admitted and others present with chest pain that tell me they just want to get checked out before they get on a flight in a few hours. Without understanding their expectations from the get go and then resetting them fairly quickly, neither type of patient will be satisfied.
AIDET
Starting the visit off on the right foot is critical. As I greet the patient, I generally have a standardized approach. One strategy is the AIDET method, developed by the Studer Group. The simple mnemonic stands for Acknowledge—Introduce—Duration—Explanation—Thank you. The entire AIDET process can be accomplished during the initial encounter, but I find that the final explanation and thank you is best done at the end of the visit.
When you walk into the room, you should Acknowledge your patient, greeting them by name, making eye contact and smiling. Introduce yourself to everyone in the room and learn their relationship to the patient. We’ve all been burned by jumping right into obtaining the history and asking personal questions only to find out the other person in the room isn’t a spouse, but a co-worker. Embarrassing for all. Given that almost all ED patients wait prior to seeing a provider, outside the AIDET mnemonic, I almost always apologize for the wait at this point. I can’t tell you how many times a day I apologize for “the wait,” but even if the patient has only waited a few minutes, they appreciate you acknowledging it.
Then, Introduce yourself by name and role, and your scribe or other members of the ED team if you’re with a group. This is a great opportunity to “manage up” your team. For instance, this is Maggie, she’s a great nurse. Or this is Nelson, he’s the best we have at drawing blood. I then go into the history and physical. Once you have a game plan in mind, you should tell the patient the Duration of how long you expect their ED encounter to take, accounting for ancillary studies, possible consults, etc.
I include explanations as to what I found on their physical exam, what I’m concerned about from a diagnosis point of view and why I’m ordering these tests (or no tests). This Explanation is different than explaining all of the results and conclusions at the end of the visit. You should provide the patient with your business card either after you introduce yourself or after discussing the duration of the visit and explaining the next steps, before leaving the room.
Not everyone uses business cards, but I think they’re a good idea. I have a fairly simple name yet I find people staring at my coat or badge to see what it is or how it’s spelled. I’ve tried writing my name on white boards, but my handwriting looks like a second grader and I forgot more often than not. And while I may buy some credibility having chair as my title, you’ll buy credibility with “board-certified emergency physician.”
Here’s my usual phrasing for explaining the process to a hypothetical patient being evaluated for appendicitis: “The nurse will be in shortly to draw blood, give you an IV and medications so you feel better. I’m going to order a CT scan on you to help evaluate your pain as I’m concerned about appendicitis.” And then a choice of, “I expect I’ll have an answer for you in about three hours” or “labs should be back an hour after the nurse draws them and I’ll be back then to update you on results and see how the pain meds did for you. It’s typically about two to three hours from now until I have the results of the CT scan. At that point, I’ll generally know whether you have appendicitis and you’ll need surgery, but sometimes I’ll need to have our surgeons evaluate you.”
This is also the time to address any potential expectations, such as the patient who wants to be admitted for a few days of rest! Or the patient who needs a repeat troponin, but insists they’re leaving in an hour. My wording for this varies, but usually comes back to how I can help as an emergency physician.
We’ve all seen patients who have been to numerous specialists, but come to the ED for another opinion. I’ll ask them how they think I can help them after they’ve seen the specialist already. I reassure them I can evaluate them from an emergency perspective to make sure they don’t have a life-threatening problem and that I can likely help them to feel better, but ultimately they’ll need to follow back up with their specialist.
All of my jobs have been near airports, so I frequently see people who “want to get checked out before they catch a flight.” The explanation and duration are critical for these patients. We have to be up front with them regarding our limitations and why we want certain tests or why procedures take so long. On the other hand, it’s their decision as to how concerned they are about the issue. At the end of the day, maintaining a professional, compassionate and caring voice is critical to helping reset the patient’s expectations.
I’m always amazed when I see patient feedback that says, “The doctor never came back in to go over my results. I was just handed prescriptions by the nurse.” As I alluded to, E is for Explanation and it’s critical to provide the explanation for their symptoms after the data are back, review what was done, what the tests mean, and the final treatment plan. This is our chance to shine, let them know what we accomplished behind the scenes over the last few hours, and provide any additional reassurance that the patient needs so they know they’re okay.
This is also where I go through my thought process with the differential diagnosis, which may include saying, “I’ve considered numerous life-threatening causes, but I don’t see evidence of any of them. It’s very common for people to have chest/abdominal/etc pain without receiving a definitive diagnosis in the ER. I can still help you to feel better and I want to make sure that you get the follow up that you need.”
As I explain the discharge plan, I remind the patient (and their family) that they have my business card with my contact information on it. I’ll explain their home care and prescriptions and then reassure them that I’ll put it all on their discharge instructions.
Finally, Thank the patient for coming to the ED and trusting you to care for them. Ask if they have any questions or if there’s anything else you can do for them. You can thank the family members for coming to support the patient as well. This is usually where I thank the wife for getting their husband to the ED when he didn’t want to come.
For patients that I’m going to do a follow up phone call on, this is the time I tell them I’m going to call them in a day (I give them a specific time frame) to check on them and I ask them for their best phone number. I’ll usually confirm that it’s a cell. I find that a lot of times patients feel guilty for coming to the ED and “taking up our time.” If I hear this, I’ll validate their need to be in the ED either at the beginning or at the end of the visit, reminding them why the ED was the right place for them.
Don’t’ Trip Over Your Own Feet
As emergency physicians, we’re generally really good at reading and talking to people. Yet, at least once a year, I get a complaint where it seemed the doctor got too comfortable with the patient. I’ve had doctor’s put their feet up on beds (too unprofessional and painful for the patient with migraines or abdominal pain), sit on the counters to talk to patients, and sit on the bed besides patients.
While you can imagine the scenario where any of these may be appropriate (okay, probably not sitting on the counter), the possibility of all of them backfiring on you are pretty high. While it’s important to sit down with the patient since they perceive your time in the room to be longer than when you stand, it’s also important not to appear so comfortable that the patient thinks you’re tired, lazy or disinterested. At the end of the day, we’re professionals and patients notice our actions and our word choice.
Follow Up Phone Calls
I’ve written about these before and I remain a huge fan of the follow up phone call. The calls represent a final chance to help guide the patient, do service recovery or just reinforce the patient’s positive experience. A well-timed follow up phone call may prevent a complaint from being filed or may be the key factor when the patient has to decide if they’ll send in the patient experience survey or not. I also get a lot of personal satisfaction knowing the patient is feeling better and has follow-up in place.
Conclusions
Many of the complaints that we get are legitimate and often involve issues with communication. We should try to establish what the patient’s expectations are, reset them when necessary and do our best to explain to patients the rationale when we can’t accommodate their needs. Tools like AIDET help to get the conversation off to the right start, but ultimately it’s about making all of these behaviors habits and doing them with every patient. We should always try to communicate clearly to our patients while being compassionate and empathetic.
