Be a HOT Interventionalist With Honest, Open, Two-Way Communication
Fellows are perhaps in the best position to learn optimal communication practices for their future patients.
Over a year ago, my diabetic aunt presented with acute chest pain to the emergency department of a small hospital located in central California. She was diagnosed with NSTEMI and was transferred to a hospital with cath lab capabilities. Because my aunt and my cousins did not have any medical background—and were all very anxious and fearful about the next steps—they wanted the interventional cardiologist to talk to me about his plan, so that I could then help them understand what medical care my aunt would be undergoing. To my disbelief, not only did this interventionalist refuse to speak with me even after my family pleaded with him, but he had his assistant call me to tell me not to call him. The reason being that he had already spoken “clearly” with my family and he felt it was not his problem if they did not understand everything. This experience shocked me and solidified my already conscious decision to never leave anyone, especially my patients, in the dark when it comes to patient care.
Clear communication is a necessity in patient care. Making our patients feel at ease with full understanding of the procedures to be performed and their expected results is an integral aspect that all physicians must execute well. This characteristic is a learned behavior initiated from direct observation of our attendings. For fellows beginning their interventional cardiology career, this is the time when you will learn the best approach to patients, their families, and referring physicians.
First, it is important to review each case to gather as much information as possible before you even interact with the patient or his/her family. While this may sound intuitive, it’s surprising how many physicians do not know the patients on whom they’ll be intervening. So please start this good habit early! Talking to the patient is essential, whether before or after speaking with the physician or team in charge. However, it is often helpful to also interview the patient beforehand in order to have a robust discussion with the team on what the appropriate steps of care are. Sometimes the patient would like for you to speak with his or her family members, especially if one of the family members has been appointed as the durable power of attorney.
Having open dialogue with the patient and those important to the patient is essential to building rapport and is a professional aspect of medicine. As the interventionalist performing the procedure, you should help the patients feel reassured with their care in your hands. While keeping within HIPAA rules, speaking to the family members at a patient’s request not only builds trust and provides comfort to their apprehension of upcoming intervention, but also serves a vital purpose when time comes to obtain informed consent.
Even when it’s unclear whether an invasive approach is required, you should not be afraid to professionally talk this out with the team. Then, if after reevaluation and discussion it is determined that the best option is an invasive procedure, such as PCI or TAVR, then not only are the patient and their family fully informed, but so are you as their interventionalist. If it is not a straightforward case, take a pause and page/call the referring physician or team to review the new findings with them. This is a collegial and trustworthy move to keep the lines of communication open in complex situations.
After the procedure is complete, finish the appropriate documentation in a timely manner. It is equally vital to disclose the results including any complications that have occurred with those who will be subsequently caring for the patient—the referring physician, the primary team, or often both. Calling, text paging, and texting from a secure phone are all possible avenues of communication. Remember how much you appreciated getting a concise yet information-filled sign-out from your colleague? Likewise, you should also provide this to your colleagues. Continuity of care will be established, and if there is ever a fear that the patient will accidentally miss a crucial medication after stent delivery, communicating with everyone involved will decrease that anxiety.
Lastly, one of the most important conversations is the postprocedural talk with the patient and his or her family. It is important to be honest about the results, including complications. Be empathetic if the results are not ideal or the patient ends up remaining critical. I have witnessed some interventionalists who are only interested in the procedure and suddenly become shy or conveniently forget to speak with the patient and their family after, sometimes leaving the fellow or staff to communicate the outcomes. Being ‘shy’ in medicine is a quality that must be rectified. Therefore, as a fellow, try to perfect your professional and patient communication skills. Mastering the art of effective communication begins in and should be refined during your fellowship through observation of those attendings who do it perfectly. But also observe those attendings who do it poorly, and learn from their mistakes.
Here is a handy checklist for maintaining HOT (honest, open, two-way) communication:
1) Always read about the patient and know as much as you can before meeting him or her.
2) After any case, but especially complex ones, directly discuss the patient with the primary team/attending or referring physician. Patient care is teamwork.
3) Speak with the patient and his or her family at several time points. Make sure everyone is on the same page and understands your role in their care. If the patient wants you to talk with someone else about their medical issues and management, do so. Trustworthiness starts from the beginning.
4) Don’t forget to keep everyone in the circle of care informed. If a timeout is needed in the middle of a case to discuss with the other parties involved in the case or to get an emergent/immediate consult, then do not hesitate to take the time-out. Remember to communicate with the team at the end of the case as well.
5) Close the loop by telling the patient about his or her procedural results. Be sincere and honest. If the patient is not fully awake, go back after they’ve recovered to speak with them. Also, do not forget to speak with their family members present in the waiting room and also potentially those who were not able to travel.