Saturday, July 13, 2013

Communication Breakdown: Get 'em booked

One of the most intimidating tasks for a student in the ED is getting patients admitted.  You want the responsibility.  You want the sense of ownership.  You want to prove that you can be persuasive and get things done.  Successfully booking an admission accomplishes all of these things. I am more impressed with a student who can complete a tough admission than if they can close a complex laceration.  

Conversely, should the admitting conversation not go well, you may feel embarrassed or inadequate.  If your supervisor has to take over, their evaluation of your performance may go down.  

There is no surefire, guaranteed, approach that will sell even the obstructionist medicine resident.  But there are some things you can do to keep your admission call from going down in flames.

Walk a mile in their clogs
Understand the perspective of the person on the other end of the phone.  This may be easier as a student, having recently been on these other services,  than a couple years from now when you are firmly entrenched in the ways of the ED.  

Dig up those detailed IM presentation skills and give them a deluge of data.  Often times they do not want you to tell them what you think is wrong with the patient, they want you to give them the information so that they arrive at the same conclusion you did.  This is, of course, the exact opposite of what we are looking for in the ED - for you to make an assessment and come up with a plan.  

But if you are talking to a surgeon, you need to give them a very specific reason for why the patient should be admitted to them.  Not, “because they have belly pain”, instead, “we believe they have appendicitis”.  

Use the hammer
The hammer is the point that cannot be argued, that no physician behaving in a remotely professional manner can ignore:  “the best interest of the patient”.  This is a powerful tool.  You will encounter many objections from people you have contacted asking them to do work.  You have added to their task list.  They may be thinking in terms of what your request means for their day/night/weekend.  By judiciously using “the best interest of the patient” you can wear down almost anyone.  

In the same vein, you will often encounter pushback on “social admits”.  These are patients who cannot go home, but not for a strictly medical reason.  These patients are very frustrating for in-patient doctors and so they will often work hard to convince you that they do not need to take them in the first place.  But if a patient is unsafe, or can’t walk, or can’t control their pain at home, going back to “the best interest of the patient” is a hard thing to argue effectively.  

Practice makes perfect
If possible, run your admitting presentation by one of your supervisors.  If that is not time practical, at least make sure that the reasons for the admission are clear.  Make sure that you understand why the patient will benefit from being in the hospital.  If you do not know or if you are struggling to put the rationale into words, this is probably not a good admit for you to attempt because you are likely to fail.  

It is important to remember that even if you do everything right, sometimes you will have to call in your supervisor because the person on the other end of the phone is not being reasonable.  This has happened to everyone.  Making your calls within earshot of your supervisor helps them realize when it is not you that is the problem.  

If you want additional tools for getting others in medicine to do what you want, have a listen to an EMRAP Educators Edition podcast with Dr. Chad Kessler on communicating with consultants.  

Good luck!

No comments:

Post a Comment