If you were a patient, would you want your case to be subject to a game of telephone between doctors? Probably not. But what if I asked the question this way: Would you like two doctors to think about your case or four?

In real life these pluses and minuses go together. Transitioning care from one team of doctors to another is an important part of our jobs as emergency medicine physicians. We all know this experience: Your shift is winding down. You are hurrying to dispo your long list of patients before time runs out. You don’t want to leave a mess behind for the fresh team of doctors coming to relieve you. The “network rules” fill your mind. ABC and CBS. “Always Be Closing” and “Close Before Signout.” As you rush to discharge a couple of patients, admit a few others, you come to the inescapable conclusion that you are going to have to sign out several of your patients to the next shift.

Oh, the shame! In baseball terms, this is akin to batting into the third out of the ninth inning and leaving runners on base. You had wanted to be the hero, ending the game with a base-clearing home run, just like that Hall of Fame legend Babe Ruth, the Sultan of Swat.

A good signout can also be a good consult – fresh eyes and ears from new doctors, often with different areas of expertise. A poor signout can be dangerous, more hole than cheese.

Now you’ve got a new goal: to get everything together and organize a smooth transition of care from one doctor to the next. You’re going to be the Sultan of Signout.

Most residents work on the active skill of signing out a patient to the oncoming team. But we don’t think about receiving sign out as a skill of its own. Instead we devote energy learning to better focus the presentations we give to others, providing the most important information and trying to leave out less important details.

Many use mnemonic devices such as SBAR (Situation, Background, Assessment, Recommendations) to guide this. A good signout leaves the new team knowing who the patient is, why he or she came in, what has occurred so far, the current thinking, and the plan going forward.

Most of the time, the new doctor is scribbling down as much information as possible. Not me. When possible, I type a signout note as a progress note as the presenter is talking. I use an incomplete macro (which I wrote about previously in ACEP News) to organize my notes in real time. But other than good progress notes, are there other ways we can improve on the skill of taking signout when starting a new shift? Yes.

Signout is actually a special moment that goes unnoticed by many of my fellow residents. It is the singular time that junior residents are on the receiving end of patient presentations from other doctors. Signout is a time we may have the opportunity to feel, momentarily, like an attending. I don’t mean this with respect to the power or responsibility, but rather the markedly different feeling of analyzing someone else’s work. Studies show that attendings actually think differently than residents. A lot of this is experience, learning to hone in on what matters. But some of it is a difference in role, requiring different cognitive skills. Analyzing someone else’s work is an entirely separate cognitive process from presenting your own.

How can we get better at receiving signout? First, we should change our disposition when receiving a patient from the previous team (pardon the pun). Currently, the atmosphere of signout is friendly, professional, collegial, and I think, just a little too polite. After all, we don’t want to keep our colleagues from leaving on time and we don’t want to be seen as pushy or overly second guessing. But this is prioritizing manners over patient care. What I’m advocating is a less friendly, even skeptical tenor during signout, if only for a moment: one of questioning. The null hypothesis ought to be: “The previous team missed something huge.” I’m not saying to wheel every abdominal pain patient who is about to pass an oral intake trial of Jell-O and water to the CT scanner. Rather, I’m saying to ask “what about” and “what if” questions. Ask “Did you think of … ?” and “How do you know it’s not … ?” questions. After signout, go meet and actually examine the patient. (Admit it: You’ve met patients for the very first time only when handing them their discharge papers!)

It’s not that your colleagues are so often wrong. It’s that we don’t always follow up on intentions to do important tasks, including serial abdominal exams. So the first to-do item on any signout plan should be to personally examine the patient. To avoid forgetting, I ask Siri to remind me 30 minutes later: “Did you examine the patient in bed 3A?” My incomplete macro for signout includes a stock line: “I will personally examine the patient.” If I don’t do this, the responsibility is mine. On the other hand, if signouts are well presented and well received, they can feel less like a dangerous transfers of care and more like consults.

Transfer of care from one doctor to another has been a topic bandied about in the mainstream media in the years since Libby Zion, the college student whose death from serotonin syndrome led to the Bell Commission and eventually resident work hour restrictions. Dr. Darshak Sanghavi, a pediatric cardiologist, wrote about this in the New York Times in 2011, noting that the British psychologist James Reason likened transfer of care to Swiss cheese: overlapping holes in medical care that usually – hopefully – do not line up. I agree in part. But a good signout can also be a good consult – fresh eyes and ears from new doctors, often with different areas of expertise. Meanwhile, a poor signout can be dangerous, more hole than cheese. And once in a while we do receive particularly poor transfers, especially when censuses are large. The natural reaction to receiving bad signout is alienation. Often, we put less thought into these cases, when in fact we should do the opposite. If you suspect that you’ve received bad signout, invite the following thought: Start over.

Finally, don’t just give and receive signout from your fellow doctors – include your patients in the process. Inform your patients that your shift is ending and a new doctor will meet them soon. Ask them, “Is there something that I need to communicate to the doctor coming on duty?” You’d be surprised what they will remind you.

It is the rare shift in which you can tie up all of the loose ends before quitting time. If you infrequently have to sign out a few patients, you probably aren’t seeing enough of them. You can’t always hit those base-clearing, game-ending home runs. Don’t feel badly about that. Many Hall of Fame ball players hit for average, not only power.

So take pride in hitting a few singles and doubles and getting a pinch hitter to drive in the runs. And when it is your turn to come to the plate to pinch hit, take an active role in the process. Be a Sultan of Signout.

Dr. Faust is an Emergency Medicine Resident at Mount Sinai Hospital and Elmhurst Hospital in New York City. He tweets about classical music and #FOAMed @jeremyfaust.