When considering an optimized environment for compassionate patient communication, the chaotic emergency department (ED) probably gives some clinicians pause. EDs, filled with alarms, frequent interruptions, hurried paramedics and consultants, hallway beds, and the looming sense that clinicians are out of time, is rarely thought of as a place for empathetic communication. Indeed, the evidence would suggest that the environment is challenging. On average, physicians only allow patients to speak for about 18 to 23 seconds before an interruption.¹ Yet, empathetic communication is paramount to the patient-physician relationship.² Empathy is not feeling sorry for your patient or mere sympathy. Empathetic communication means listening to the total communication (words, gestures, or feelings) of your patient and letting them know you are really listening.³ Communication with patients is the most common task we do as clinicians. It is estimated that physicians each conduct about 150,000 patient interviews throughout their careers.² Hurried and fragmented histories can lead to diagnostic uncertainty and error.⁴ Algorithmic histories lacking empathy can leave patients feeling unheard and anxious.⁴ Worse, they won’t disclose critical information that would unlock the diagnostic puzzle. Depending on the clinical setting, patients typically share their story multiple times with nurses, advanced practice providers, residents, and attending physicians, creating an environment ripe for dropped information and fragmented relationships.

As challenging as soliciting information is, so is sharing it back with patients. Studies show that less than half of hospitalized patients could identify their diagnosis or name their medications at discharge.⁵ Despite how critical communication is, structured training on communication remains muted.⁶ If we approached patient interviews and communication the same way we approached any other procedure, the rates of error and patient frustration may decrease. There are, however, ways that we can optimize our communication with patients. Here, we share a framework of our Top 10 communication skills aiding in empathetic communication in the chaos:

1) Ask Permission

It is often difficult for a patient to feel any sense of control in a health care setting, let alone the emergency department. Asking permission allows the patient to feel a sense of control and prepare emotionally for the interview.

Example: “Would it be okay for me to share some of my concerns?” Or, “Is this a good time to discuss what brought you in?”

2) Name Any Dilemmas

Inevitably, problems arise when communicating with patients. To ensure clinician-patient alignment, any dilemmas need to be identified and discussed. This will help you as a clinician get a better sense of the patient’s perspective and provide goal-concordant care.

Example: “On the one hand, I can hear this is hard to talk about and that you would rather have this conversation another time. On the other hand, I am worried that your dad’s body is very sick and that decisions need to be made now.”

3) Reflect and Affirm

Another fundamental skill in communication that will add to any therapeutic alliance is reflecting and affirming. This concept assures the patient that you are listening to their story and understanding their experience.

Example: “You’ve done so much to try to stay out of the hospital, and it’s just so disappointing to be back here again.”

4) Establish Urgency

As emergency medicine clinicians, we are under the impression that we are best at this skill. However, it can be difficult to relay a sense of urgency in many situations. Ending phrases with the statement, “We have to make a decision quickly,” can set the stage.

Example: “I expect your breathing only to get worse, we have to make a decision quickly.”

5) Responding to Hopes of Miracles

When patients respond with “trusting in a miracle,” or “my spirituality will bring me a miracle,” clinicians are often left speechless. Leading with affirmations such as “I can see your faith brings you strength,” followed by, “If a miracle was not possible, what would be most important?” may empower some clinicians to respond more appropriately.

6) Responding to Emotion (Imagining)

This step allows the clinician to respond to any emotions that arise during the interview. Often, patients are going through physical, emotional, or spiritual discomfort and this step allows for us to recognize their discomfort.

Example: “I can imagine this comes as a shock” or “I can hear how upset you are.”

7) Focus on What We Can Do

Many patients and family members arrive in the ED with expectations set from television dramas or third-party experiences that may not correlate to their current situation. Often, we need to reiterate the reality of their clinical presentation and focus on what is possible.

Example: “I think we should focus on treatments that would be helpful.”

8) Use “Yes and…” Statements

It is vital that your patient feels empowered through collaboration in their workup and treatment plan. Using “Yes and…” statements allows the patient to express their wishes while allowing the clinician to add on their concerns.

Example: “You want to go home, and I’m worried you could fall again, and I think you need to work with physical therapy to make sure it’s safe.”

9) Tell Me More, or What Else, Statements

Admittedly, this proficiency can be difficult in the busy emergency department. Yet, this phrase can be crucial in eliciting a history from a stoic or minimizing patient. It allows you to get to root of the visitation reason.

Example: “My spouse said I should come in.”

“Tell me more.”

“For some chest pain I had last night.”

10) Pair Hope with Worry

This final skill allows for the clinician to remain emotionally connected but candid with their patient. Often, the outcome of an ED visit is not what the patient wants, but this skill prepares the patient for the reality.

Example: “I hope we can find you a bed in the hospital quickly, and I’m worried it may not be until tomorrow.”

Despite the inevitable time constraints, interruptions, and chaos of the emergency department, every patient should leave feeling heard and empowered. Using these fundamental communication skills, we hope the clinician is enabled to have an empathetic, goal-oriented conversation with each patient.

Dr. Zirulnik is a third-year resident of the Harvard Affiliated Emergency Medicine Residency of Massachusetts General Hospital and Brigham and Women’s Hospital.

Dr. Aaronson is the associate chief quality officer at Massachusetts General Hospital, and an emergency physician. Emily has an interest in the intersection of emergency medicine and palliative care and leads research and implementation efforts aimed at improving the quality of palliative care in the ED.

References

1. Phillips KA, Ospina NS. Physicians interrupting patients. JAMA. 2017;318(1):93–94.
2. Strategies for acing the fundamentals and mitigating legal and ethical consequences of poor physician-patient communication. AMA Journal of Ethics. 2017;19(3),289–295.
3. Platt FW, Platt CM. Empathy: A miracle or nothing at all? JCOM. 1998;18(1):27-33
4. King A, Hoppe RB. “best practice” for patient-centered communication: A narrative review. J Grad Med Educ. 2013;5(3):385–393.
5. Makaryus AN, Friedman EA. Patients‘‘ understanding of their treatment plans and diagnosis at Discharge. Mayo Clin Proc. 2005;80(8),991–4.
6. Visser M, et al. Physician-related barriers to communication and patient- and family-centred decision-making towards the end of life in intensive care: a systematic review. Crit Care. 2014;18:604.