Long neglected entity in Medical Field is Communication Skills, which needs to be addressed to. This presentation covers the main aspects of Communication skills needed for an Emergency Physician.

1. Communication
skills: A vital yet
neglected Entity
- DR VARUN PATEL

2. Why is communication so important?

3. General Tips for communication-
 Always ask for Permission – Knock the door, ask if you can talk to them
(especially when you are not the first one visiting the patient)
 Always greet and Introduce – Form templates to make conversation
smoother (Hello, I am Dr. X a doctor in Emergency Dept, may I know your
name please?). If possible Always shake hands.
 Be calm and confident – But not overconfident
 If speaking is silver, listening is gold. Average interruption time for a doctor
in an initial conversation as per study was 21 seconds. Don’t just hear what
patient says, try to actually listen to them.
 Give them your undivided attention. Do not use phone or computer while
speaking to them.

4.  Smile whenever appropriate. Be careful as to not smile in a high stress
situation.
 Remember the name of the patient during all times and call them with
their name. It helps building rapport.
 Start conversations with things that might not be related to their condition,
it makes them more comfortable to speak about the issue.
 Whenever possible, sit down and converse. Sitting down makes patient
more comfortable rather than doctors hovering above them.
 At all time, maintain eye contact with the patient.
General Tips for communication-

5.  Always start with open ended questions- Let patients describe you in form
of a story. Give them a perception that you have time for them, even if you
don’t actually do give much time. Open ended questions can be – What
brought you here today? I have been told you have headache, tell me
more about it. Can you narrate the events that led to the fainting spell?
 Continue to closed ended questions only after you are done with open
ended questions,
 Never use JARGONS- eg: Your HstropI is very high, which indicates you
have Non ST elevation Myocardial infarction
 Always keep family in the loop. It will be easy to keep family at bedside
when you are talking to patient.
General Tips for communication-

6.  Always say things that encourages patient. Eg- Tell an elderly patient who
is 83yr old, that he or she is still very young and looks so fit. There are
many more years before they reach old age.
 End your conversation with a positive note – eg: You will get through this,
We will make sure you are as fit as an athlete.
 Always summarize – About what is your impression of the condition, what
are your further plans, how long will you keep them in the department
 Always ask if they have any questions before leaving.
 Always show Empathy- Acknowledge that you understand they are in pain,
address to patient concerns even if they sound stupid.
General Tips for communication-

7. What you should never do-
 Keep turning around to look at your PC or mobile while talking to the
patient or relative.
 Giving subtle cues that you are in a hurry – eg- talking too fast, gesturing
to move towards the door, looking at your watch
 Neglecting problems told by patients. Even if the concern is small like
chronic backache, do not neglect it. Tell them you will return back to the
problem a little later, but acknowledge it.

8. Patients rely on you-
 That patient might be one of many for you, but for him you are the only
one they can rely on.

9. Let’s see a good and bad
communication video
 click for video

10. How bad can communication be?
 Communication gone bad
 Communication gone bad 2

11. Breaking bad news
 Ensure you are in a quiet place before beginning.
 If possible ask one of the staff nurses to come with you. Both as a
continuing link and as a witness.
 Start with introduction. Ensure you are speaking to correct person. Do not
break bad news to distant relatives if close relatives are present.
 Before explaining things, ask how much the person already knows.
 Depending on how much they know, provide information of the events
that have taken place. This may include explaining CT scan report, ECG
findings etc.
 Do not delay too much before actually delivering the news.

12.  Always give a warning before actually telling them the news. Eg- I am sorry I
have some bad news.
 Now give an abrupt sentence saying their loved one has died.
 Use the word ‘Died’, do not use euphemisms.
 If needed repeat that the loved is dead.
 After delivering the news, give adequate time to let the news sink in. Do not
interrupt. Let them express. Silence is the key.
 Once enough time is given to take the news in, ask them if they want to call
anyone else and inform them about this. ( Like family, friends, religious
ministers)
 Now offer for relatives to see the patient. Before taking them to the
patient,make sure you warn them about current state of patient. What they
might expect.
Breaking bad news

13.  When they are near the patient, always give them privacy. Let them
express themselves for a while. Give them enough time.
 Encourage them to touch the patient and let them speak to the patient.
 After enough time was given to bereave, you can now discuss practical
aspects of Death certificate or Post Mortem. Be empathic when discussing
these topics. (Eg- I know it’s a difficult time for you, but I need to discuss
about Death Certificate formalities with you,if that is okay with you,
 Also, if your hospital policy allows, discuss about organ donation with
relatives.
 At the end ask if they have any questions.
Breaking bad news

14.  Explanatory video with example
Breaking bad news

15. Breaking bad news - Practice
 A 34 yr old female Neha Pawar came to Emergency Dept after she
suddenly collapsed while walking on the road. On arrival patient had poor
GCS and was desaturating. You intubated the patient and did a CT scan
which showed a large intraparenchymal bleed. CT images are available
with you. You have given a reference to Neurosurgery team and they are
of opinion that nothing can be done, patient was declared moribund. Your
plan is to wait till the events ultimately lead to her death.
 Mr Varun Pawar, her husband is waiting for you in the lobby in triage area
pacing around. You need to break bad news to Mr. Varun. You have CT
images available with you to aid the explanation.

16. Neha’s CT image-

17. Breaking bad news- Practice
 A 10 yr old boy Prem Choubey was brought to emergency Dept after
multiple episodes of seizures in an unconscious and unresponsive state.
You started CPR as per PALS protocol, but could not achieve ROSC. You
have called Prem as dead on arrival. You do not know the cause of death
yet.
 Prem’s father Mr. Bholakumar Choubey is standing outside your Resus
room and is in panic. Bholakumar’s wife, Mrs. Nandini Choubey is also
standing besides him. You need to break the bad news to both of them.
Also, discuss about need for post mortem investigations to be carried out,
and the need to involve police.

18. Dealing with a complaint- Angry
patient or relative
 The key here is to not escalate the issue.
 Remember, they are upset and not thinking straight, but you are!
 Do expect logic in conversation.
 Always move away from crowded area and go to a more quiet place. Have
them seated and sit down at eye to eye level
 Start with introduction. Confirm identity.
 Let them know that you are here to talk to them and help them solve their
problem.
 Start with open ended question – Let them narrate the incidence.
 Do not interrupt when they are narrating.

19.  You should have all the facts ready before beginning the conversation. You
should review all reports or xrays if needed before you begin conversing
with the person.
 As soon as they finish narrating the incidence, always ‘Apologize’. Apology
should be about how they feel, and not about departmental fault. It simply
acknowledges other parties dissatisfaction and makes them mellow down
a little,
 Do not tolerate offensive or derogatory comments, and make it clear that
you want to help but not if they will speak bad to you.
 A balance should be maintained between listening to their complaints and
supporting your staff appropriately,
Dealing with a complaint- Angry
patient or relative

20.  Always empathise with the person. If it is a complaint about improper
treatment provided to a relative, ask them about there’ll being of the relative.
Promise them that relative will be treated appropriately and will be cared for.
Assurance is important.
 If diagnosis was missed, explain why it could happen. Also, explain the system
in place for which missed diagnosis can be picked up. Eg- Review by
radiologist of all xrays.
 Do not blame the personnel involved. And be honest about everything.
 Next step would be to discuss on how you will deal with this complaint.
 Tell them that you will personally speak to the staff involved. If needed, explain
them that this will be taken up in MMM meetings.
 If person is still unhappy, take a formal complaint written from them on paper
and promise them, that it will be submitted to appropriate authority.
Dealing with a complaint- Angry
patient or relative

21.  Explanation video on Complaint scenario
Dealing with a complaint- Angry
patient or relative

22. Dealing with complaint - Practice
 A 6yr old child Ricky D’souza was brought to Emergency Dept with history
of fall while playing with injury to right forearm. Your colleague Dr Arpit
had seen the patient 2 days back. Patient is brought by his father Ryan
D’souza, and is complaining about ongoing pain not relieved by pain
killers given to Ricky. You have a look at the X-ray and notice that there is
a fracture which was missed by Dr Arpit. Now you need to deal with Mr
Ryan as he wants to complaint about how his child was not treated
properly by Dr Arpit. Also, explain Ryan about further plan of action for
Ricky.
 X-ray is available to aid for explanation.

23. Dealing with complaint - Practice

24. Dealing with a colleague- Difficult
referral
 Start with introduction and confirm colleague’s identity.
 Explain that you need to discuss a patient for referral.
 If colleague is not accepting the referral, try to find out the reason. It may
be because colleague is extremely busy, he genuinely feels that it’s not an
appropriate referral, he has misunderstood the case, or may be having a
bad day.
 Always be non-confrontational.
 Keep your facts ready before you call for referral
 Colleague may pass derogatory comments and might become abusive. It is
important not to let the situation escalate

25.  Keep repeating that patient’s safety is the main priority.
 Out of professional courtesy it may be appropriate to acknowledge the
fact that colleague might be busy and that you understand that.
 If needed, come up with some plan of action. You can help colleague to
come and smoothly evaluate the patient by keeping things ready.
 Bargaining is the key
 Note- If colleague does not accept the referral even after all efforts, it is
perfectly reasonable to tell them that you will escalate the complaint to
their seniors.
Dealing with a colleague- Difficult
referral

26.  Video showing difficult referral scenario
Dealing with a colleague- Difficult
referral

27.  A 33yr old male Mr Qazi has come to your emergency department with
history of retrosternal chest pain and sweating since 30min. His ECG shows
no significant abnormalities and HstropI at admission and after 3hrs is 2.0
and 2.1 respectively. In spite of giving Morphine, patient’s pain has not yet
subsided and you are worried about pain being cardiac in origin.
 Your colleague had given a cardiology reference to Dr Ravindra and who
denied to take the reference as it did not seem like a cardiac cause of chest
pain. Speak to Dr Ravindra and give him the reference as you believe this
pain is cardiac in origin in spite of normal investigations.
 ECG is given for referral.
Dealing with a colleague- Practice

28. Dealing with a colleague- pratice

29. Conflict resolution
 In Emergency Dept, very often you will find yourself resolving conflicts with
patients in terms of their management.
 Common examples- Patient demands or refuses for Tetanus injection,
patient demands for antibiotics in a viral infection, diabetic patient refuses
for insulin, etc
 Start with introduction and confirming the identity.
 Ask about patient’s concerns and allow them to speak. Do not interrupt.
 Explain rationale on the topic involved
 Allow them to ask you questions and answer them politely.

30.  Never be dismissive of their concerns
 Maintain non-confrontational manner
 Do not use Medical Jargon
 Give scientific evidence on why they are wrong.
 Give a safety net advice prior to disposition
Conflict resolution

31.  A 32yr old male, Mr Simarpreet Singh has come to your Emergency
department with complaints of sore throat, dry cough, low grade fever
(<39C) and runny nose. On examination he does not have cervical
lymphadenopathy or tonsillar exudates. He demands for antibiotics as one
of his GP Has told him that he needs it. You do not believe that he needs
the antibiotics. Respond to his demand for antibiotics.
 His CENTOR score is 0
Conflict resolution- Practice

32. Patients be crazy
 Click for video

33. Doctors are beaten up
 Why do doctors get beaten up?

34. Let us revise what we have learnt so far

35. Something to remember-
 People will forget what you say, people will forget what you did, but they
will always remember how you made them feel.