The ED provider will inevitably encounter situations in which sensitive communication skills are important. These situations include such events as fetal death, sexually transmitted diseases, domestic violence, rape, and potentially serious diseases (10,13,15,16). These issues are discussed herein. First, however, thought should be given to the more general aspects of provider-patient communication: process, content, and personality.

Men and women communicate differently. Men tend to be more focused on factual issues and tend to be action oriented. (What are the facts, and what needs to be done?) Women tend to focus more on emotional issues and work out solutions through dealing with the emotional aspects (2). Although these statements are generalizations and there is certainly a significant overlap in communication styles between the genders, the stereotypes are, nonetheless, well supported by research (1,2,3,4,5,6). To optimize communication with female patients, it may be helpful to consciously identify a communication style that is more emotionally oriented than one might embrace with male patients.

The process by which sensitive information is communicated is important and goes more smoothly if the physician considers some basic issues to be addressed (7,8,11,12,13,15,17,18,19). The first important issue to decide is who does the telling. Oftentimes in the ED, the physician does not have an ongoing relationship with the patient and, in fact, may have never seen her before. However, if
sensitive information has to be communicated, it is usually better that it originally come from the physician rather than a nurse or a technician. This demonstrates respect for the patient, and for the seriousness of the situation, and bypasses the “I want to speak to the doctor” scenario. Many physicians consciously or unconsciously opt out of difficult or sensitive communication scenarios because they may be time-consuming or because the providers recognize their own inadequacies as communicators. Ultimately, both the provider and the patient are better served by the provider’s making a deliberate effort to learn satisfactory communication skills than simply abdicating communication responsibilities.

It is also helpful, if possible, to have some support personnel in the room with the physician. One study indicates that team-based/family communication is preferable to physician-patient dyad communication (20). A social worker or nurse may be the one to provide support once the physician has left, and it may be helpful to make the connection while the unwanted news is being given. It also helps the patient understand that the support personnel have a relationship with the physician. This person may also be able to give the provider helpful insight that will allow further communication skills refinement. At times, it is impossible or impractical for the physician to be the communicator of sensitive news, but this should be the ideal.

After deciding who does the telling, attention needs to be paid to the setting (21). Standing in the middle of the hallway to inform a woman that she has a sexually transmitted disease is not optimal. The preferred setting would be a room (not a curtained cubicle) that is not a high-traffic area and where there is a place to sit. The physician needs to be at eye level with the patient, preferably sitting. Eye contact is important when talking with a patient. (This is a skill that can be formally rehearsed to improve performance.) The physician also needs to communicate to the staff that he or she needs uninterrupted time with the patient or family. Attempting to discuss sensitive information while being interrupted by staff or by a pager going off may increase the patient’s anxiety, as well as inspire anger. Uninterrupted time in an appropriate setting is more likely to transmit a sense of care and concern on the part of the physician (22,23). The physician also needs to be conscious of his or her own communication style, including such issues as speed of delivery. Speaking at a slower speed and in a lower tone helps to reduce anxiety. Even though the physician may be feeling enormous pressure to complete the conversation and move on to other tasks, very little time is lost by techniques such as sitting down, pacing the delivery of news, and maintaining appropriate tone and speed of speech. Indeed, time may be saved if patients comprehend information more clearly on the first transmission.

Timing is also important. There is never a good time to present bad news. However, there are bad times to present bad news, such as when the patient or family members have been up all night with no sleep and are fatigued or when a large family group has just arrived and emotions are intense. One cannot always wait for the optimal time, but it is important that this issue be considered. Less urgent tasks such as acquiring consent for autopsy may be deferred until the family has had a chance to recover from the initial emotional blow.

Providing the patient with an opportunity for follow-up questions and clarification of issues is also important. If the physician cannot provide this opportunity, it is imperative that the patient or family members have contact with someone who can answer their questions. This allows closure to the current event and allows the patient or family members to know that someone will be there to help when they have dealt with some of the emotional issues of the situation. Many support groups exist to provide patients with information and assistance beyond what the ED can provide. Contact information for national
agencies are listed in Table 30.1. It is helpful to have a similar list of local resources available (preferably in a pocket-card format) to all ED physicians.