Organizers and Facilitators: Sonia Dalal, Blair Golden, James Harrison, Karnjit Johl, Angela Keniston, Monish Sheth, Lucy Shi, Andrew White

Background

Effective clinician communication with patients is associated with positive patient outcomes (including improved comprehension and satisfaction) and is identified as a high priority by hospitalized patients and their caregivers. However, hospitalizations introduce unique challenges to effectively communicating with patients, such frequent clinician hand-offs and complex team structures. This summary highlights some of our discussion regarding current initiatives to improve patient-clinician communication across hospital medicine groups, as well as barriers to these efforts.

Initiatives to Improve Hospital Medicine Clinician Communication with Patients

Participants described diverse initiatives geared at improving patient communication and patient experience more broadly. Whereas some initiatives were homegrown within hospital medicine, others were driven by broader institutional priorities. However, some participants reported being aware of few (if any) initiatives at their institution.

Participants described programs falling into several common areas of focus, although specifics of programs varied within these focus areas. Examples included:

• Interdisciplinary rounding and care coordination: Several initiatives focused on improving communication among members of the clinical team. Some were geared at promoting interdisciplinary bedside rounds, whereas others described non-patient facing initiatives (e.g., structured check-ins between hospitalists and nursing via Epic chat) with the goal of improving patients' perception of clinician collaboration.
• Patient comprehension of their care plan and hospital care team: Tools used to implement such programs were varied and extended beyond whiteboards; for example, some leveraged EHR portals (MyChart) whereas another provided patients with a daily printout highlighting care plans (e.g., planned imaging, medication changes, and consultants). Multiple groups used "face cards" to facilitate recognition of clinicians and understanding of team roles.
• Care transitions: Multiple programs focused on discharge care coordination and education, including implementation of a standard multidisciplinary discharge "huddle", optimizing discharge instructions, and providing pharmacist medication counseling.
• Serious illness conversations: Some described initiatives (including clinician training) to promote discussion and clarification of patient care preferences and goals. Many of these programs were based on existing frameworks or best practices (e.g., Vital Talk, "What Matters Most" as part of 4Ms Age Friendly care).
• Other tools and trainings to increase communication skills: Participants also described initiatives and training to improve communication skills beyond serious illness conversations. Examples of such programs included AIDET (Acknowledge, Introduce, Duration, Explanation, and Thank) training, "Commit to Sit" initiatives, and a curriculum to build skills with trauma-informed care.

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores were the most commonly mentioned metric used to motivate and assess efforts. Nonetheless, participants also acknowledged the limitations of HCAHPS.

There was also variation in how patient perspectives have been incorporated into initiative development. For example, some participants described having limited or no access to Patient Family and Advisory Councils (PFACs) locally, whereas others have successfully developed hospital medicine-specific PFAC groups.

"I feel like HCAHPS is a very imperfect measure, but that's the only measure that we currently have and is widely used. Most providers don't enjoy having to discuss or review HCAHPS scores. Especially for hospital settings, there are so many providers that patients encounter, you never know who that score is supposed to be for, so the attribution is imperfect."

Initiatives to Improve Communication Skills Among Trainees

Participants described diverse educational initiatives with regard to content and learner level, spanning from pre-clinical medical students to senior residents. Many of the described educational initiatives were workshop-based and/or incorporated simulation experiences with standardized patients. For example, some institutions have developed simulation curricula for learners focused on breaking bad news or communicating diagnostic uncertainty. 

Other educational initiatives focused on providing direct observations of communication skills and reflection opportunities for learners. For example, one institution developed curriculum for third-year medical clerkships promoting standardized observations and reflections of patient encounters. At another institution, residents are shadowed by a designated faculty member and receive targeted feedback and coaching on communication skills. Finally, some participants described opportunities to integrate communication training into other educational initiatives, such as residency training pathways or narrative medicine curricula.

Participants also reflected on challenges in communication-focused curricula for trainees. The emphasis on communication skills in pre-clinical medical training may not optimally prepare learners for "real world" experiences within clerkships. Residency programs may prioritize other outcomes over communication skills. In addition, there was a perceived siloing between hospital efforts to improve communication and those directed toward learners. Trainees may be excluded from hospital-based initiatives to improve patient communication, and hospital medicine clinicians may not be integrated into communication-based initiatives for trainees.

"I feel like I don't really know about medical school communication initiatives, which highlights the siloing within academic medicine."

Barriers to Implementing These Initiatives

In addition to challenges above, participants described other barriers in developing, evaluating, and sustaining patient-clinician communication initiatives, including:

• Structural limitations within the hospital care environment: There are hospital factors that are not easily modifiable and make it difficult to develop agile, tailored communication interventions. The physical environment (e.g., double rooms, boarding areas, a lack of chairs) may undermine efforts to promote optimal communication. It can be difficult or impractical to modify the electronic health record for interventions.
• Competing demands for hospitalist time and EHR burden: Documentation requirements, secure chat, and other time pressures make it difficult for hospitalists to spend time at the bedside or communicate in person with nursing.
• Measurement and assessment challenges: Participants recognized the limitations of HCAHPS scores and reflected that rigorous assessment of communication initiatives is limited by the scarcity of robust outcome measurements. The need for IRB approval for some projects is a deterrent to obtaining patient-reported outcomes data.
• Social determinants of health: Participants recognized the need for effective communication interventions for highly vulnerable patients, yet reflected on the challenges of addressing mistrust stemming from patients' experiences with discrimination. Many patients may prefer a language other than English or experience low health literacy, and communication interventions should account for these needs and preferences.
• Sustainability: Programs may struggle to sustain initiative momentum, especially given multiple concurrent initiatives. Furthermore, there may be misalignment between divisional and institutional priorities and investments.
• Hospital medicine cultural norms: Participants reflected that some hospitalists may prefer text or virtual communication over in-person dialogue with nursing. Hospitalists may also be self-conscious about receiving feedback on their communication. Finally, it may be difficult for experienced clinicians to readily modify their care practices.

"Getting experienced physicians to change their workflows and practice patterns is really, really hard. It's much easier to teach students and residents because they are open to that, and experienced physicians aren't."

Conclusion

Hospital medicine groups are engaged in diverse efforts to improve patient communication, ranging from interdisciplinary rounding and care transition support to communication training for clinicians and trainees. Despite these efforts, barriers such as structural limitations, time constraints, and institutional silos hinder the development, implementation, and sustainability of these programs. Efforts to address these broader systemic factors may also benefit initiatives improve patient-clinician communication.

Our next HOMERuN meeting will be on July 11, 2025.

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