When emergency physicians use ER-Speak, they can leave patients confused. While nurses will later come in and translate, let’s get on the same page to reinforce important discharge instructions.
A 30-year-old banker comes into the ER with chest pain. He’s overweight, a smoker, and has a family history of hypertension, mild heart disease, and high cholesterol. The physician comes in, evaluates him, makes his assessment, and orders tests. After a proper workup, he is not having any acute issues, his labs are negative, his pain resolved, and his visit ends with instructions from the physician, “You’re going to need to follow up with your primary care doctor and a cardiologist.”
Three months later, the patient is admitted for acute coronary syndrome. He never saw his primary care doctor, or the cardiologist.
“I honestly didn’t think it was that big of a deal,” he said to me. “You guys were discharging me so I thought I couldn’t have been that sick.”
Sound familiar? This problem is twofold. Of course, it is the patient’s responsibility to make the appointment and follow through with medications and instructions. However, on the other hand, maybe there’s something being lost in translation, something that points to deeper communication issues between physicians and patients.
In my experience, emergency physicians are usually great about explaining discharge instructions and asking patients whether they have any questions or concerns. But what many might not appreciate is that oftentimes, patients don’t want to speak up when they don’t understand “ER talk.” They’re confused. They’re embarrassed that they don’t understand, and likely they’re still scared or nervous about being in the ER to begin with.
Once I get to them, patients are often left wondering what terms like “CT”, “PE Study”, “Stroke Protocol” or “troponin” mean. In the banker’s case, he came back to the ER because he simply didn’t understand the severity behind the words “you need to follow up with a cardiologist.”
Let’s backtrack. The banker had never been to the ER a day in his life. He had never taken any medications or had any surgery. After his initial assessment during his first visit, he didn’t understand what “possible outcomes” or “possible consequences” were. On top of that, he was not comfortable enough to ask questions because he felt like he was rushed through his visit. Upon his admission the second time, he stressed to me, “they just told me I needed to see someone. I mean, I guess I just didn’t get it.”
My advice? Break down and spell out discharge instructions and ask more questions. “Do you understand why we want you to follow up with this specific specialist? Do you have support at home? If you don’t understand something, it’s okay to ask. Do you have any questions?” Here’s what the physician could have said:
“Alright, your tests were negative and you don’t have an acute issue today. However, after reviewing some of your family history and lifestyle issues, you have a lot of risk factors. It would be best for your health if you see a cardiologist and monitor your heart on an outpatient basis. This is why I want you to see a cardiologist: you smoke, you’re overweight, and you have a family history of heart disease and high cholesterol. These are all risk factors that can lead to a heart attack.”
Go further in-depth and ask the following: “Do you have any questions about seeing a cardiologist?” “Do you know a cardiologist?” Explain how a cardiologist can help the patient outside of the emergency room and what can potentially happen if they don’t follow up.
“ER talk” is our common language, but the patient won’t know what a “CTAP” or a “troponin” is. It’s easy to forget to speak in laymen’s terms.
Take Patient No. 2. Mr. Smith came in having a shortness of breath and the physician said, “Alright, Mr. Smith, we’re going to get a chest X-ray, then we’re going to get a CBC, a troponin, and a chem panel, and then we will give you a nebulizer.”
Based on the blank look that then registered on Mr. Smith’s face, here’s how I might suggest the physician start instead:
“Hi, Mr. Smith, since you’re having some shortness of breath, I would like to run some tests to make sure that you don’t have any damage to your heart or your lungs. This is how we’re going to do this: We’re going to get an EKG, which is a picture of the hearts electrical activity, and an X-ray, or a picture of your chest. It’s not going to hurt, it’s going to help us make sure that you don’t have any signs of infection or broken bones that could be causing your symptoms. After that, we’re going to take some blood from you, one of those tests is going to be a troponin, and that is an enzyme in your heart that, when elevated, can tell us if you’re having any cardiac issues…”
These explanations only take a minute or two longer, but they can mean so much more for the patient, and also the provider. I know that ‘speaking in laymen’s terms’ is something we all try to do as providers, and physicians work diligently to consistently provide this. But as the shift gets busier and the waiting room fills up, and the ED turns into standing room only, it’s easy to forget to speak to people like a human being. This is a real problem that won’t be solved by core measures or quality initiatives, reimbursement pushback or an administrative agenda. It is strictly a grassroots effort that we can contribute to every day, with every patient – that is, addressing the epidemic of healthcare illiteracy. Physicians and nurses have long been a very collaborative team, and we work hard to deliver information to patients in an efficient and concise manner. Sure, as a nurse, I’m going to come in and explain what’s happening in clear terms. But if the physician clears out the jargon during the first pass, I can come in to reinforce the information, which will help it stick.