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The CORD Remediation Task Force has developed materials related to resident interpersonal and communication skills (ICS). These skills sit at the heart of Emergency Medicine, and deficiencies here are grave and can be career threatening for residents and attending physicians alike. This page catalogs important information related to ICS.
Remediation Plans by Milestone
http://cordrtf.wikidot.com/local--files/interpersonal-and-communication-skills/Milestone%2022%20Patient%20Centered%20Communication
http://cordrtf.wikidot.com/local--files/interpersonal-and-communication-skills/Milestone%2023%20Team%20Management
ICS Words of Wisdom
What follows is a listing of some advice based on experience by taskforce members of when dealing with residents with ICS issues.
General comments
1. ICS is at the core of all patient encounters.
2. In contrast to other competencies (e.g. MK, SBP), ICS does not reliably improve from experience alone.
3. Deficiencies in this competency are common and as a result, lead to misdiagnoses, malpractice, and patient dissatisfaction.
4. ICS is traditionally not taught or is ineffectively taught in medical education/residency.
5. ICS is not the equivalent to professionalism. One can be professional in their practice but yet have significant deficiency in their ability to communicate effectively with patients and peers.
The Remediation Plan
1. Know your hospital, institution, GME ICS policies and procedures
2. Develop a residency policy that outlines consequences for non-compliance with residency requirements or poor evaluations
3. Make sure you have an Education Committee in place (with resident representation) that can help with policies and reviewing resident remediation issues
4. Document, document, document. Keep a file about issues, particularly when relevant to ICS.
5. Be proactive in identifying the potential problem. This cannot be emphasized enough! Particularly regarding ICS issues. Residents requiring remediation in ICS will often show signs of struggle early in training. Addressing issues early will pay significant dividends as training progresses.
6. During the process of remediation, provide formative, tangible, and positive feedback.
7. Residents must be given instruction and experiences to learn the nature and varieties of communication: • didactic and experiential teaching that addresses verbal and nonverbal communication;
• topical areas that address communication with the patient and their family (e.g., delivering bad news, educating patients about their disease, behavior change, end of life issues); • topical areas that address communication with colleagues (e.g., hand-off, presenting lectures, leadership); and • topical areas that address communication about medicine (e.g., the presentation of scholarly work).
8. Residents must be able to combine knowledge and skills needed to: • communicate effectively with patients and families; • use effective listening, question, non-verbal, and written skills; • communicate effectively with physicians and other health care professionals; • work effectively in a consultative role; and • maintain comprehensive, timely, and legible medical records.
Communication with Patients and Families - (Clinical teaching, role modeling, case based teaching, interactive workshops or seminars using role-plays)
• Encourage faculty to discuss communication with the patient during clinical teaching. Examples might include: • effective strategies for delivering bad news; • effective strategies for holding a family meeting; or • effective strategies for educating patient and their families. • Encourage faculty to use cases to demonstrate effective and ineffective communication via role-modeling. • Use cases that illustrate examples of effective and ineffective communication strategies to stimulate discussion with residents. • Multiple examples of effective workshops on these topics are present in the literature. Models for giving bad news, holding family meetings, resolving conflict, helping patients make life-style change are useful. Encouraging residents to roleplay how they might accomplish a particular skill is also helpful.
Communication with Colleagues – (Standardized communication around handoff, clinical teaching, role modeling, interactive workshops or seminars)
• Determining a standardized method for hand-off in your program or institution is helpful in reducing medical errors, and it aligns well with JCAHO initiatives. • During clinical teaching, discuss how to establish and maintain effective consultative relationships with colleagues of other specialties. Review a series of consultative notes that residents have written, and provide feedback • Be aware how role-modeling affects consultative relationships, and discuss techniques you use to resolve conflict, manage consultations, or provide communication to other specialties.
• Interactive workshops that center on developing leadership skills are useful to residents, particularly as they reach their senior year.
ICS FAQ
This FAQ lists commonly encountered ICS issues and remedation tips for each issue.
“Does not keep patients informed of work-up or plan.”
Examples: “ Patient has no idea what he is waiting for, what tests have been ordered, what his results are, or was not informed he was being admitted.”
Remediation tips: Have resident check in as a “patient” or alternatively have him follow an actual patient in the waiting room throughout their ED course to experience the frustration of delays and importance of updates, information, results first hand Have resident evaluate another resident or student to become more aware of specific behaviors and impact of effective communication or lack thereof Shadow attending with specific emphasis on communication with patients Provide resident with patient communication checklist (ie anticipated wait time, plan for work-up, medications to be administered, patient re-evaluation, updates on lab and imaging results, review of diagnosis and treatment plan, discharge instructions) and review after several patient encounters
“Does not communicate with nurses.”
Examples: “Resident ignores nurse’s request to re-evaluate a patient”
Remediation tips: Resident performs a nursing shift where he/she shadows nurse, understands what they do, how they prioritize tasks, and how vital their interactions and frequent reevaluations of pain, vitals, and overall assessment provide important feedback to MDs Address ICS if issue is frequent dismissal of RN concerns
“Does not coordinate plan with RN or address time sensitive orders with RN.”
Examples: “Resident decided he wanted blood cultures after RN drew the blood and patient was an impossible stick. Antibiotics were ordered late, but not verbally discussed with RN, and there was a significant delay to administration of meds.”
Remediation tips: Emphasize direct communication with RN for time sensitive orders. Round every couple of hours or during change of shift with either the nursing team leader or the nurses in general. It really helps flow, communication and patient care. Surprising how many things you realize that only you knew when you round frequently!
“Does not communicate in a timely manner with attending.”
Examples: “Resident evaluates a patient and initiates work-up, but does not present to attending until work-up is “complete” and has to start over again when plan is changed and different labs or imaging is required.
Remediation tips: Peform chart reviews to evaluate time to disposition and ED course. Discuss how early communication with attending may improve efficiency. Review specific medical errors that were made as a result of poor communication with attending and impact on patient care and time to disposition Encourage more frequent presentations to attending after each encounter rather than “batching” patients if knowledge base or judgment is poor or below anticipated level of training
“Does not communicate death notification well with family.”
Examples: “Resident froze when he had to inform family of the death of a loved one. He did not introduce himself, did not make eye contacts and was uncompassionate.”
Remediation tips: Standardized patients with different scenarios involving death notification Videotaped simulated encounters of death notification. Have resident watch himself or herself to evaluate specific wording, body language, and perception by grieving family members Shadowing attendings and/or chaplain during death notification GRIEVING curriculum on death notification
“Does not communicate well…in general. (e.g., English is not first language, heavy accent or difficulty with articulation, handwriting is illegible).”
Examples: “Resident speaks very quickly when he is stressed and everyone has a hard time understanding him. Resident appears frustrated when asked to repeat himself.”
Remediation tips: Record or videotape stressful standardized patient encounter and have resident listen to himself or herself for clarity Request that patient repeats discharge instructions back to resident to see how much patient was able to understand Instruct resident to make conscious effort to slow down, take a deep breath, speak clearly. Consider typing notes if handwriting is illegible. Consider toast master’s class or forum for public speaking to make resident more aware of annunciation, speed, volume, pitch, and articulation.
“Does not communicate well with consultants.”
Examples: “ Resident has a hard time collecting his thoughts, succinctly presenting information, and tends to get frustrated on the phone with his consultants.”
Remediation tips: Have the resident write out, almost in script fashion, the proposed conversation with the consultant, thus being able to weed out the unnecessary information and craft a concise presentation. After a few of these written out conversations, it should become easier to put it together in his/her head SAEM workshop on communication with consultants and hand-offs ACEP webinar on effective communication and specific examples of good and poor communication with consultants. Some residents may benefit from a checklist (Resident introduces him/herself and obtains name of person he/she is speaking with, succinctly provides relevant patient information, specifically states what they are consulting for, repeats plan and time frame (if applicable) back to consultant, documents time and name of consult in chart)
“Resident is timid leading a resuscitation and does not manage team.”
Example: “Resident is quiet, reserved, and can’t be heard well during a code. Chaos ensues as it is unclear who is running the resuscitation.”
Remediation tips: Perform mock codes, oral board cases, and scenarios in simulation lab Have resident run as many actual resuscitations as possible and give specific feedback on volume of voice, teamwork and assuming leadership, and delegation of tasks to improve confidence. Consider “ED critical care” elective where resident is on call at specific times and is expected to run resuscitations and perform critical procedures in ED as they occur. Checklist of important tasks running a code or resuscitation to raise awareness of critical actions. Have the resident teach resuscitation, either in simulation format or didactic and practice format, to medical students. Teaching a skill is one of the best ways to become good at it.
“Resident doesn’t utilize translator or language line.”
Example: “ Resident asks a 10 year old boy to translate for his mother with a chief complaint of vaginal bleeding”
Remediation tips: Familiarize resident with language line and how to use it. Discuss what situations are acceptable to have family translate and when it is not. Encourage use of translator or phone as patient may not feel comfortable or honest with family member present. Review specific cases where language barrier may have caused adverse outcome or missed diagnosis Consider cultural sensitivity training and education regarding cultural differences in communication, perception, and approach to illness.
JGME Article on ICS Remediation by RTF Members
http://cordrtf.wikidot.com/local--files/professionalism/ICS%20and%20Professionalism%20Milestones.pdf