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How we Communicate with Our Peers

When the American Academy of Communications in Health Care was founded 30 years ago, its primary concern was improving communication between health care providers and patients. In recent years, as the concept of teamwork in health care has become more widely accepted, the emphasis has shifted to improving communication among the members of health care teams. The relational aspects of our work have become more important as the evidence about their effect on patient care has mounted. Research has shown that good communication among health care providers decreases patient mortality,1-3 improves functional health outcomes,4,5 shortens the length of hospital stays,4,6,7 improves workplace morale,8 and decreases staff turnover.1,5,9,10

When teams care for patients, multiple experts must work together to solve complex problems. That requires extensive communication. Physicians, who are trained to be content and technical experts, have often focused more on other skills and competencies than on how they communicate with their staff members and colleagues. As a result, we can inadvertently express things in ways that stifle rather than promote open communication among the people we work with and diminish the effectiveness of the care our teams provide.

Although many physicians graciously and gracefully interact with their colleagues, there are times when we physicians get it wrong. I share the following examples in hopes that they illustrate why communication is so fundamental to health care.

Common Communication Missteps ■ Coming Off as Condescending A dialysis patient comes into the ER where you are providing coverage. She is seizing and vomiting. Concerned that there could be a metabolic abnormality and remembering that the usual paralytic was contraindicated if the patient was hyperkalemic, you call an anesthesiologist for help. After describing the situation over the phone, she says, “You know, if you paralyze him and can’t intubate, he will die.”

As an emergency physician, you know that. You were asking for help because you had two patients to attend to at the same time.

The problem with this interaction is that the anesthesiologist never allowed you to explain the reason for the call. The anesthesiologist came off as patronizing (although she may not have intended to do so), and you feel demeaned. In the future, you will avoid that physician. You may even hesitate to ask for help from others as well. Who wants to risk being insulted?

People naturally avoid interacting with someone whom they feel may be condescending. This can have a direct impact on patient care. When we are reluctant to call or seek advice from a colleague, patient care can be delayed or the patient may not get the most appropriate care. In this case, it would have been better if the anesthesiologist had simply asked, “How can I help you?”

■ Taking Too Much Credit A colleague is making a presentation about a performance-improvement project that nurses and other clinic staff have worked on. She fails to mention that others were involved in the effort. In fact, even as she is being congratulated on the success of the project, she still doesn’t mention the work the others did.

Obviously, when group members aren’t given credit for their efforts, they feel discounted. This leads people to disengage from the group. They become less willing to participate in future projects and less passionate about their work.

Physicians often lead teams. As team leaders, we need to be mindful about sharing credit with our staff for good patient outcomes and for successful process-improvement efforts. I recommend setting a goal of thanking three people a day and celebrating collaboration every chance you can. In our everyday clinical work, there are many opportunities to express gratitude toward our team members. Saying “Thank you” is a powerful way of building trust and engaging people.

■ Killing the Messenger You have a critically ill patient in the ICU. You’ve managed to restore his blood pressure but have just discovered he needs surgery that your facility can’t provide. The patient needs to be transferred to a tertiary care center to have the procedure. You have spoken with the patient’s wife, received her consent to send the patient to a hospital in the Twin Cities, and completed all the discussions and paperwork needed to set the process in motion. Then a nurse approaches you with news: The patient’s daughter has just arrived, and she wants her father to go elsewhere. Frustrated, you angrily tell the nurse, “That’s the last thing I need to hear right now.” The nurse backs away silently.

Many of us fail to appreciate the effect that our expressions of frustration can have on those we work with. Although we don’t intend to shoot the messenger, we inadvertently do so by losing our cool in the moment. The effect in this case is that this nurse might hesitate to share information in the future, fearing that it might incite an outburst.

The trick to reacting differently in such stressful situations is to anticipate them. Think through the scenarios that might happen and how you can respond. Ask yourself, What are some possible situations in which you might have a reaction that could negatively affect team members? Then think of responses and rehearse the ones that are more positive. The more times you practice those kinds of responses, the more likely you are to use them when you again find yourself in a stressful situation.

Assume that your staff members are bringing you information that you need to know. And remind yourself that such situations are merely problems to solve and that the best thing you can bring to your team as you try to solve problems is positive energy.

■ When Physicians Get it Right Of course, physicians can be wonderful communicators. I used to watch with admiration as a colleague would lead meetings. He would present all sides of an issue and then remind the group of the goal they were trying to achieve. Once the members reflected on the purpose and heard all of the arguments, they would then freely discuss them and decide on a strategy.

This colleague did not do what many of us do—advocate for one strategy. When you advocate hard for your position, someone is likely to push back. And then, everyone can start to lose sight of the purpose of the meeting. Pushing too hard for a position stifles communication, blocking ideas that might arise in a more open discussion. This can have an effect on decisions about patient care. When people feel their voices have been heard and that they aren’t being pushed toward a particular position, they are more likely to buy into the decisions a leader or team makes.

As physicians, we need to recognize there is much we can do to encourage the kind of open communication that builds trust among team members and leads to better patient care. Without intending to, we can do much to stymie it. As leaders of patient-care teams, we set a tone for communication. As experts, we are respected not only by our patients but by our co-workers. If we fail to show our colleagues the respect they deserve, they will hesitate to speak up when situations demand it, they will avoid us, and patients may suffer. Physicians need to recognize that every interaction matters and that good communication is essential to providing high-quality patient care.MM

Dawn Ellison is an emergency medicine physician and president of Influencing Healthcare, LLC. Published in Minnesota Medicine 2012.

References 1. Aiken LH, Smith HL, Lake ET. Lower Medicare mortality among a set of hospitals known for good nursing care. Med Care. 1994;32:771–87. 2. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. An evaluation of outcome from intensive care in major medical centers. Ann Intern Med. 1986;104:410–8. 3. Baggs JG, Ryan SA, Phelps CE, Richeson JF, Johnson JE. The association between interdisciplinary collaboration and patient outcomes in a medical intensive care unit. Heart Lung.1992;21:18–24. 4. Gittell JH, Fairfield KM, Bierbaum B. Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay. Med Care. 2000;38:807–19. 5. Shortell SM, Jones RH, Rademaker AW. Assessing the impact of total quality management and organizational culture on multiple outcomes of care for coronary artery bypass graft surgery patients.Med Care. 2000;38:207–17. 6. Shortell SM, Zimmerman JE, Rousseau DM. The performance of intensive care units does good management make a difference? Med Care. 1994;32:508–25. 7. Argote L. Input uncertainty and organizational coordination in hospital emergency units. Adm Sci Q. 1982;27:420–34. 8. Uhlig PN, Brown J, Nason AK, Camelio A, Kendall E, John M. Eisenberg patient safety awards. System innovation Concord Hospital. Joint Comm J Qual Improv. 2002;28:666–72. 9. Aiken LH, Sloane DM. Effects of organizational innovations in AIDS care on burnout among urban hospital nurses. Work Occup. 1997;24:453–7. 10. Vahey DC, Aiken LH, Sloane DM, Clarke SP, Vargas D. Nurse burnout and patient satisfaction. Med Care. 2004;42:II57–66.

Monday, June 9, 2014

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