In Reply to Chou et al
Year: 2021
Type: letter
Abstract: We thank the authors for raising attention to the importance of incorporating opportunities for empathy when communicating about uncertainty. Aligning with the majority of existing communication checklists, we intentionally did not “script” providers in how to achieve checklist items, with the exception of item 3: “Clearly state that either ‘life-threatening’ or ‘dangerous’ conditions have not been found.” Rather, the checklist is meant to provide an outline of key elements to include in discharge discussions where there is diagnostic uncertainty, regardless of the patient’s “persona” or the specific clinical scenario. We agree that bidirectional “dialogic” communication when discussing diagnostic uncertainty is valuable; however, as you noted, patients’ reactions to uncertainty vary widely and are just as often acceptance as they are confusion or anger. Rather than build a specific checklist item inquiring about the patient’s emotional response, we opted to write several checklist items that would achieve the same end goal of creating an empathy opportunity while simultaneously not assuming the need for that opportunity universally. For example, the visibly upset patient may be better approached with a statement of “You seem upset…,” whereas required scripting of an empathy opportunity for the “accepting” patient may be unnecessary. This decision was directly informed by our expert panel and patient focus groups: while our initial checklist included the item “Ask how the patient is feeling about what was discussed,” feedback from these groups resulted in removal of that item. In addition to checklist items 10 and 12 (“Validate the patient symptoms” and “Normalize leaving the [emergency department] with uncertainty”), 5 of our 21 checklist items are focused on asking the patient for questions. Our intentional focus on engaging the patient through questions supports building empathic, bidirectional communication. Item 7 (“Ask patient if they were expecting anything else to be done during their encounter”) is the item (in addition to 10 and 12) that most often resulted in an empathy opportunity, as patients voiced frustration (at not having a specific test completed) or made statements such as “Well, I was expecting a diagnosis!” In addition, while our article in Academic Medicine focuses solely on creation of a checklist and these concrete action items, our larger curriculum (see https://rise.articulate.com/share/7HtSck8Gw2zbg56yeO356oV0VrN17LWZ#/; password: Uncertainty) delves more deeply into the patient’s emotional experience of uncertainty in the emergency department through the use of patient quotes and graphic portrayals of the emotional response. Finally, although beyond the scope of that article, our simulation case design for testing and training participants on the checklist was created to cover a range of patient “personas” with a variety of patient reactions to uncertainty (e.g., acceptance, confusion, anger) to broaden the applicability of the training. We hope that this work will encourage increased attention to the importance of the discharge conversation as a key component of a care encounter for patients who do not have a clear diagnosis and that achieving competence on this checklist will empower physicians to lead bidirectional empathic conversations with this vulnerable patient population.
Source: Academic Medicine
Authors: Kristin L Rising, Danielle M. McCarthy
Institutions: Thomas Jefferson University, Northwestern University
Language: English
Subfield: General Health Professions
Field: Health Professions
Domain: Health Sciences
Open Access status: green
Award: G540173577
OpenAlex ID: W3173779252