Communication in health care

This article highlights the importance of effective communication across health care settings and offers practical strategies for interacting with patients, families, and interprofessional team members.

Related articles include:

• “Logistics of US health care and hospitals”
• “Daily life of the intern”
• “Navigating stressful situations in residency”
• “Life outside of the hospital”

Communicate clearly and respectfully. Use active listening and language that is empathetic, nonjudgmental, and easy to understand.

• Why communication matters
  • With colleagues
    • Builds trust and encourages open dialogue
    • Reduces missed information that could impact patient safety
    • Strengthens teamwork and improves the work environment
    • Makes it easier to ask for help when needed
  • With patients
    • Improves care quality and safety
    • Helps uncover key information
    • Supports difficult conversations (e.g., code status, goals of care)
  • Reflects professionalism, an expectation throughout your career
• Communication basics
  • Introduce yourself.
  • Learn and use people’s names; ask about pronunciation.
  • Ask how others prefer to be addressed.
  • Don’t assume professional roles based on gender or appearance.
  • Say please and thank you.
  • Acknowledge and apologize for mistakes.
  • Avoid interrupting unless necessary; explain when you must.
• Ask-tell-ask
  • Ask: Start with an open-ended, nonjudgmental question, e.g., “Could you walk me through your thinking on X?”
  • Tell: Share your perspective with rationale, e.g., “We didn’t order X due to the patient’s history of Y.”
  • Ask again: Check for understanding and resolution, e.g., “Does that make sense?” or “How does that sound to you?”

Try to remember that your colleagues, patients, and their caregivers may be dealing with overwhelming feelings, distress, and/or burnout; try to relate with compassion and empathy as much as possible.

Be aware of what your nonverbal communication (e.g., eye contact, facial expressions, and head nodding) may be conveying about your level of concern, interest in, and understanding of what the other person is saying.

General principles

• Set clear expectations regarding:
  • Seeing patients
  • Writing notes
  • Presenting to the team
  • How and when they should be in touch with you
• Base expectations on objective standards appropriate to the learner's level.
• Take time to teach.
• Give effective feedback.

Teaching effectively

• Sit down with the learner briefly at the beginning of the rotation to ask if they have a particular learning goal.
• Remember teaching does not have to take extra time; it can be as simple as thinking out loud as you place an order or write a note, or talking through the steps as you do a procedure.
• Use the 5 microskills approach when possible.

Giving feedback effectively ^[2][3][4]

• Definitions
  • Formative feedback: feedback given in real time, which allows the learner to make changes before the end of the rotation
  • Summative feedback: feedback given at the end of the rotation as a final assessment of performance, which is often accompanied by a grade or standardized evaluation
• Some basics
  • Tell the learner to ask you for formative feedback intermittently throughout the rotation so that it is not only your obligation to remember.
  • When giving summative feedback:
    • Make sure you are seated in a private, quiet environment, with at least some amount of uninterrupted time.
    • Start by asking the learner for their own self-assessment; they may already be aware of issues you were going to raise.
• Effective feedback is:
  • Objective: Understand what objective standards the learner is measured against; don't give a subjective evaluation based on your personal impressions.
  • Timely: Give formative feedback throughout the rotation (on a daily or weekly basis), as soon as it is relevant.
  • Specific: Give specific examples; avoid generalizations.
  • Appropriate in amount: Don't overwhelm learners with a large amount of feedback at once (this is another reason to provide more frequent formative feedback).
  • Constructive: Normalize making mistakes and growing from them (this is how learning works!). Offer specific recommendations for improvement.
  • Actionable: Focus on modifiable behaviors, not personality.
  • Positive: Always acknowledge strengths, and aim for positives to outweigh negatives.

Summative feedback should never be the first time a learner hears about a concern or deficiency! Constructive feedback should be given as formative feedback throughout the rotation to allow the learner time to course correct.

Nurses

• Collaboration and teamwork
  • Keep nurses informed of key plans (e.g., tests, procedures, new orders, anticipated discharges).
  • When a nurse raises a concern, take it seriously.
  • When in doubt, see the patient, especially if there’s a new symptom, vital sign change, or worsening clinical status.
  • Use the ask-tell-ask approach: solicit input, explain your reasoning, and invite feedback.
  • If a concern feels inappropriate or unclear, avoid argument; suggest escalating to an attending.
  • Prioritize in-person conversations when feasible.
  • Avoid disagreements in front of patients unless urgent for safety.
• When making a request
  • Choose the right time; avoid interrupting patient care unless emergent.
  • Introduce yourself; don’t assume familiarity.
  • Ask if now is a good time. If not, and it’s urgent, acknowledge that and explain.
  • Always say please and thank you.
• Tips to reduce avoidable pages
  • If you'll be unavailable (e.g., during admissions or procedures), check in with the team beforehand to address open issues (especially helpful on night shifts).
  • Communicate clearly about when you will be available again, and how you will follow up on any deferred issues.
  • For nonurgent requests, ask that notes be left in the EHR or on paper for review.
  • Anticipate routine concerns by writing proactive orders

Other team members

• Pharmacists
  • Valuable resource for dosing, interactions, and side effects
  • In some settings, they may independently adjust certain medications (e.g., vancomycin).
  • They help prevent medication errors and will contact you with questions about your orders.
  • Always consider their input; their expertise is complementary, not subordinate.
• Social workers and case managers
  • Often covering multiple teams; concise, relevant information (e.g., living situation, home support) helps them work more efficiently.
  • Include key details in EMR consults when placing referrals.
  • Disposition planning is typically discussed during multidisciplinary rounds; participation may vary by role or program.
• Clinical documentation improvement specialists
  • Ensure diagnoses and treatments are documented and coded accurately.
  • You may receive requests to clarify or revise documentation (e.g., specifying “type 2 diabetes with neuropathy” instead of just “diabetes”).
  • If you disagree, respond professionally and explain your reasoning.
  • If unresolved, escalate to your senior or attending.

See also ”Key principles of communication and counseling.”

Techniques for communication at the bedside

• Include the patient in your presentation; don’t speak only to your senior or attending.
  • Invite the patient to clarify or correct you if needed.
  • Use reflective listening (e.g., “Let me make sure I have this right…”).
• If using medical jargon, let the patient know and reassure them you’ll explain clearly afterward (e.g., “We’ll talk briefly among ourselves, then I’ll summarize and answer any questions.”).
• Use patient-centered, nonstigmatizing language (e.g., “uses drugs” vs. “addict”).

Working with medical interpreters

• Know that you are not alone if you find this to be stressful. It can be!
  • In-person interpreter services may not be available at your institution, so you may need to use a phone or video interpretation service, which can be cumbersome, feel awkward, and can be difficult for patients who are hard of hearing.
  • It can take much longer to obtain information, since everything is being said twice. This is tough when you're already pressed for time.
• It's important to remember the following:
  • You have a legal obligation to provide this service to patients when needed.
  • A family member or noncertified interpreter should not be used to interpret unless it is an emergency.
  • Always speak directly to the patient. Make eye contact with them, and use the pronoun “you”; the interpreter will translate exactly what you're saying to the patient.
  • Patients of some ethnicities who are members of a particularly small and close-knit community may be concerned about disclosing personal information to the interpreter because of who they may know. Be aware of this possibility and, if this is the case, reassure the patient that what they say is strictly confidential.

To avoid using the sometimes cumbersome landline phones for interpretation, program the interpreter hotline and access code into your cell phone and use speakerphone (if appropriate, given who else may be in the room at the time). If you set the phone on the patient's tray table, you can perform exam maneuvers while talking.

Family members of patients you are cross-covering

• One of the pages most dreaded by overnight interns: “Mr. X has 5 family members here, and they have some questions for you! Can you come talk to them?”
• Don't panic! Although it can feel frustrating to be in this position, appreciate that:
  • Many family members are unable to visit during daytime hours. They may have to work or may not have transportation until the evening.
  • Family members may not be aware of how coverage schedules work. They may not realize that the doctor available at night is not a member of the primary care team.
• Use this approach:
  • Check your signout sheet to see if it includes updates about test results or planned interventions.
  • If possible, briefly review the assessment and plan portion of the daily progress note in the chart.
  • Introduce yourself to the family members, and manage their expectations by explaining your role.
    • Don't use phrases like “I'm just the covering doctor.”
  • Obtain consent from the patient to speak with the family.
  • Use the ask-tell-ask strategy to explore what the family would like to know.
  • Ask the family members to leave any specific questions with you, along with their contact information, and explain that you will pass this on to the primary team.
    • Have them choose one preferred person to be updated by the primary team (if the patient consents).
    • Record this information on your signout sheet or as an event note in the chart, and sign it out to the day team, letting them know the family would like updates by phone.
  • Let them know the approximate time that rounds occur, in case they do happen to be available during the day.

Breaking bad news

It's normal to feel overwhelmed by these tasks! It's stressful to be asked to do these things, often without ever having been specifically trained in doing them. The following basic approach is not comprehensive but should help you get started. See “Tips & links” for more useful articles and resources.

• Set up appropriately.
  • Who: Make sure the right people are present.
    • If the patient does not have capacity, who is the surrogate decision-maker?
    • Some patients may not want to receive medical information about themselves and would prefer that a family member be told about their diagnosis instead.
  • When: Give yourself enough time for the conversation.
  • Where: Sit down, in a space that is as quiet and private as possible. Ask a coresident or senior resident to hold your pager during the conversation, if possible.
• Breaking bad news: Consider using the SPIKES protocol.
• Consider using repeated cycles of ask-tell-ask.
  • Ask: Find out what the patient or family member's baseline understanding of the current clinical situation is.
  • Tell: Give information in small “chunks,” with pauses in between to allow for processing and questions.
  • Ask: Periodically check for understanding.
• In some situations, it may be best to return to have a follow-up discussion; offer this option to patients and families when possible.
• See also “Discussing goals of care.”

Think about these conversations as a procedure like any other. Setup is essential, there is a recommended approach to follow, and you will improve with practice!