By Kristi Tucker, MD
Trainees are taught how to communicate with patients and how to behave professionally during patient interactions, but sadly there is much less emphasis placed on effective communication with medical colleagues. In residency programs, there is little, if any, formal instruction and most of the learning comes from observation. However, mastery of these skills is an important part of providing consultation services. Also, notably, two of the six Accreditation Council for Graduate Medical Education (ACGME) core competencies for residents are 1) professionalism and 2) interpersonal and communication skills.
Rooted in the key ethical principles of beneficence and nonmaleficence, we as providers have a duty to serve our patients and to represent our profession respectably. The increasing subspecialization in medicine and the demands of the electronic medical record (EMR) are potential barriers to professional communication in the ICU. Our technologies keep patients alive today who would have died 10 years ago. As a result, today’s patients have more complex illnesses and comorbid issues with more providers and teams involved in their care.
Residents need guidance to navigate these challenges to become adept at providing consultations in the ICU. As such, I created a list of expectations for residents based on review of relevant literature and my experience providing and requesting consultations. One of the best references on this topic is “Ten Commandments for Effective Consultations” by L. Goldman and others (Arch Int Med 1983; 143: 1753-55). Another excellent resource is “Elements of a High-Quality Inpatient Consultation in the Intensive Care Unit” by J. Stevens and others (Ann Am Thorac Soc 2013; 10(3): 220-7).
With respect to communication, residents are taught to elicit a specific question or concern from the requesting team and be sure to effectively respond to that. Consultants should primarily address issues specific to their requested expertise. Any general ICU care recommendations (like suggesting a sepsis workup) are typically given verbally, while written recommendations should be focused on the neurologic question. Other than urgent recommendations (like a stat head CT), all resident recommendations should be discussed with the consult attending prior to communicating them verbally or in written form to the requesting team. Consult team members should exhibit a positive professional attitude in verbal communication and EMR documentation. Even if there is a disagreement among teams or our recommendations are not followed, the language in the chart should be neutral and non-inflammatory.
One of the greatest strengths of neurointensivists performing consults in other ICUs is our critical care expertise. Residents learn to view the neurologic problem within the context of ongoing medical issues, to make recommendations that are specific and doable for that patient, and to avoid testing that is unlikely to impact the care plan. We teach residents to go beyond the information in the history and physical and to seek additional data from available sources. We convey the importance of talking to nurses and family members, and sometimes outpatient physicians, if needed. We teach tips and tricks to access collateral information from other care facilities via the EMR. We prioritize and model in-person communication with the requesting team, especially for more complex or nuanced issues. I find that medical and surgical intensivist colleagues are happy to have us working collaboratively to enhance the care plan for their patients. At the same time, our residents are gaining communication skills that will serve them well in any career they pursue.
As the consultant, it is critically important to avoid giving any confusing or conflicting information to families. While our care is patient-centered, most of our communication happens with the primary team and surrogate decision-makers at bedside. Multiple studies have demonstrated that ICU families often have a poor understanding of the diagnoses and care plan for their loved one, and often disagree with medical teams on prognosis.
Families benefit from seeing the teamwork between consultants and the primary team and from hearing a single unified message. Any differences in medical opinion should be clarified among the involved care teams prior to conversations with families. Anchoring is a form of cognitive bias where individuals focus on the initial information to primarily inform their decision-making. I have seen many families struggle with decisions in the ICU because of misleading or incorrect information that was given too early and without consideration of the overall picture. It can be extremely difficult to regain trust if the initial communication is suboptimal. In working with us, residents experience these challenges firsthand and learn strategies to enhance and repair communication moving forward.
I view ethics and professionalism as inexorably linked concepts, and to be successful at either requires incorporating the ideals of both. Residents gain a tremendous amount by rotating with neurointensivists on an ICU consult service.
When people ask me about my job, I tell them that the most important thing I do each day is communication. As neurointensivists, there are many things we do to help our patients, but I believe our greatest professional duty and impact is with intensive communication. Teaching this important skill to our residents gives them invaluable capability to positively impact many lives in the future.