While today’s doctors-in-training learn the most advanced clinical treatments and diagnostic methods, they may be missing out on something equally important: communication skills.
“Care delivery is moving towards a team-oriented model,” says Theodore Sectish, MD, director of education for the Boston Combined Residency Program (BRCP, a joint pediatric training program of Boston Children’s Hospital and Boston Medical Center). “We need to do a better job of training doctors to work with other clinicians and use standardized language.”
Poor communication can have a significant impact on patient outcomes. As Sectish points out, “Communication errors are the number one cause for sentinel events.” (A sentinel event is a death or serious injury in a health care setting that is unrelated to the natural course of the patient’s illness.)
And it’s not just discussions among clinicians that are important. Physicians must also be trained to translate complex medical information into a clear, comprehensible message for patients and families.
Recognizing that the era of maverick physicians working alone is over, hospital residency programs are developing initiatives to better prepare young doctors for the collaborative, patient-centered model of modern health care.
In 2011, the Accreditation Council for Graduate Medical Education drastically reduced the maximum number of hours residents were allowed to work per shift from 30 to 16. This increased the number of hand-offs, or changes in command, because residents had to leave the hospital and transfer the care of their patients more often.
The transition of care is a particularly sensitive time for communication. Accuracy and scope are of the utmost importance when handing a patient’s care over to someone unfamiliar with the case. Poorly facilitated hand-offs are notorious for causing medical errors.
Still, “in medicine, the hand-off is commonly viewed as a chore, not as a critical safety event,” says Christopher Landrigan, MD, research director of Boston Children’s Inpatient Pediatric Service. “But think about the change of command on a ship; that’s a very structured, standardized system. It should be this way in medicine too. It’s vital communication in either case.”
Landrigran knew there had to be a way to improve hand-offs. He teamed up with Amy Starmer, MD, and a dedicated team of colleagues to create I-PASS, a set of hand-off procedures and training tools that guide physicians through the most important aspects of transitioning care. In a nine-institution research study, I-PASS was associated with an approximately 30 percent reduction in rates of preventable adverse events.
Holly Hodges, MD, a chief resident with the BCRP who trained in I-PASS at the start of her residency, says the system was incredibly helpful. “When you’re a resident, everything is new,” she says. “It can feel like drinking from a fire hydrant! I-PASS gives you a place to start and the organization to stay on track and not miss anything.”
Like hand-offs, the time-honored tradition of morning rounds at hospitals could also use some improvement when it comes to clinical communication. In recent years, a growing number of pediatric hospitals across the country have adopted “family-centered rounds.” The “family-centered” model is designed to engage patients and family members in clinical discussions about a patient’s condition and modifications to the plan of care.
However, the system is not perfect. In 2013, hospitalist and researcher Alisa Khan, MD, surveyed parents and physicians of hospitalized children at Boston Children’s to assess whether or not they were “on the same page” when it came to understanding reasons for hospitalization and care plan decisions. In nearly half of all cases, there was a substantial discrepancy between what doctors and parents understood. Even worse, both groups often significantly overestimated the extent to which they had a shared comprehension.
Khan’s survey inspired the I-PASS team to adapt its toolkit for family-centered rounds. “By expanding the communication principles of prior I-PASS work and truly bringing the family to the center of the care team, we may be able to improve shared understanding between families and providers,” says Khan. “Our hope is that this will allow us to partner with families and provide better, safer care for all children.”
The new model will incorporate the perspectives of families (including those with limited health literacy and limited English proficiency) as well as physician specialists, nurses and other clinicians who are working more collaboratively with physicians to care for hospital patients in an integrated manner.
Communication-based milestones for residents
But when a novice physician isn’t rounding or handing off care, how does she know if she is communicating effectively? Sectish advocates a dynamic “feedback loop” to help residents identify areas of their practice that could use some improvement. In other words: communication about communication is critical.
Ariel Winn, MD, associate program director for the BCRP, explains that the program has recently adopted a new method of resident evaluation based on milestones, spearheaded by her counterpart at Boston Medical Center, Daniel Schumacher, MD.
“Our previous method for rating resident competency was essentially meaningless,” says Winn. “Grades corresponded to your year, or the amount of time you’d spent in the program. This wasn’t helpful at all for residents who are wondering where they fall on the developmental continuum.”
The new milestones are not just numbers on a scale, but descriptors of behaviors. Different scales apply to different aspects of clinical practice, two of which center on communication:
- Communicate effectively with patients, families and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds.
- Work in inter-professional teams to improve patient safety and patient care quality.
Residents who score a 1 on the first scale “may feel intimidated asking personal questions,” while their peers who score a 5 “intuitively handle the gamut of difficult communication scenarios with grace and humility.”
Winn says the milestones are more transparent for everyone, “not just for the residents, but also for the evaluators, who can provide more specific feedback and background for their scores.”
While the initiatives above address some problem areas in communication, there is still much room for improvement.
Alex Hirsch, MD, another chief resident with the BCRP with a strong career interest in medical education, observes that more medical schools are adopting team-based learning models. “It would be a natural step for residency programs to have educational sessions and simulations with nurses, doctors and pharmacists working together,” he says. “I think we need to see more of that.”