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Avoid common ED communication errors by recognizing – and redirecting – outsized patient expectations.

Dear Director,
I received a complaint from a patient who was sent by their physician for an ED evaluation and possible admission. I saw the patient, did an appropriate workup, and discharged them with a treatment plan. But the patient complained that I was supposed to have arranged for their PMD to see them in the ED. How am I supposed to respond?


After eliminating billing and pain management complaints, the most common and often preventable type of complaints that I deal with are issues with communication. As a subset of communication, many complaints are related to a failure to identify the patient’s expectations and, if necessary, reset their expectations to something more appropriate. I think you fell into this category.

Most of our patients may not know who Marcus Welby, MD was (some of my readers may not either), but that image of a caring, compassionate and warm physician who saves the day continues to form the basis for today’s physician role model. I think as soon as we put on our white coats, we have the responsibility to be compassionate and caring. This means listening to our patients and addressing their needs, particularly their pain. But we also must be able to communicate with them the “what” and “why” of their evaluation, care and treatment plan.

There are some absolute basics to patient communication that will make your patient interactions smoother, will minimize complaints, and may have the added benefit of improving patient satisfaction scores. One strategy is the AIDET method, which stands for Acknowledge - Introduce - Duration - Explanation - Thank You.” This simple yet effective mnemonic was developed by the Studor Group, a healthcare consulting firm, and has been used in many international corporations. To start your patient encounter, Acknowledge your patient by using their name, smiling at them, and offering a handshake. Then Introduce yourself by name and your role. You can even include the reason they’re in the ED that you read off the triage note. Then tell the patient the Duration of time that you expect their ED visit to take, including your evaluation and then estimates for ancillary studies if appropriate. Be sure to provide an Explanation after your initial visit, and then, after the data are back, review all that was done, what the tests mean and what their treatment plan will be. Finally, Thank the patient for coming to your ED and trusting you to care for them and ask them if they have any questions for you or if there is anything else you could do for them today.

Whether it’s the patient who has a positive suitcase sign but the diagnosis of the flu who you are about to discharge or the chronic kidney stone patient who may or may not really need Dilaudid, figuring out what the patient expects is part of our job. Sometimes, this can be as easy as directly asking the patient what you can do for them – for the flu patient, the answer might be

“I’m too sick to take care of myself and need admission.” Or you might ask what the patient is hoping to accomplish with you. The answer might be “nothing since my doctor sent me here and I want to see him.” Sometimes the answer will be obvious, other times it may require more effective questioning, and sometimes their answers will force you to reset expectations. Although we try to be all things to all patients, in today’s busy ED, it often isn’t realistic to order the ultrasound for the asymptomatic pregnant patient, the spine MRI for the chronic back pain patient, or the ENT consult for the patient with recurrent strep throat. Over the years I have learned some useful phrases that I use with the AIDET tool to reset the expectations of the patient or their family. I’ve included a few in the sidebar at left.

Many complaints from patients are legitimate and often preventable. While we can’t be all things to all patients, we should try to establish what the patient’s expectations are, meet them if we can, and reset them if we can’t, explaining to the patient how and where they can get there needs cared for. Using a tool such as AIDET can keep us on track with all of the information we need to communicate to the patients in an effective, compassionate, and caring format.

 

Classic Cases of Mistaken Expectations
...and a few helpful responses to keep in your back pocket

The surgeon who operated on me last week wants to see me here and I only want him to examine me.

Response:
I appreciate the relationship you have with your surgeon and am happy to respect your wishes, but I have spoken with him on the phone [and yes, you really have to do this before you tell the patient that]. He is tied up right now and asked for my help. After I examine you, I will discuss my findings with him and we will formulate a care plan. He told me he’ll see you as soon as possible.

I have 2 days of back pain and think I need an MRI.

Response:
Back pain can be very painful and concerning, but based on your history and exam, I don’t think an MRI will be of medical benefit to you right now. It’s typically an outpatient test that your doctor can order for you down the line if your symptoms continue or worsen. But based on my findings now, fortunately, it does not appear that you need immediate surgery but rather you do need immediate pain relief and I can help with that.

My throat hurts. I frequently get strep and I think I need to get my tonsils out today.

Response:
It can be frustrating to get repeat infections. I am happy to examine you and start you on a treatment plan. You will need to see an ENT in their office to determine if you need surgery. Unfortunately, that type of visit isn’t done through the emergency department. The good news is that I can give you medicine and recommendations to make you feel better and the phone number of an ENT to schedule a follow up appointment with.

My kidney stone is killing me.  Can’t you make all the pain go away?

Response:
Kidney stones can be really painful and I have plenty of pain medicine to make you feel better.  Unfortunately, without making you unconscious, you probably will continue to have some pain.  What I’ve found is that most people who start with a 10 on the pain scale, are pretty comfortable and able to function once we get that pain down to a 5 and then the medications that I prescribe for you will help to keep you comfortable and functional.



Michael Silverman, MD, is a member of  Emergency Medicine Associates and is chairman of emergency medicine at the Virginia Hospital Center in Arlington, Virginia.

 

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