Today I’m going to pull the curtain back and show you how I trained myself to have successful verbal communications with physicians and get my interventions accepted. I’ll go over:

Expected acceptance rates First impressions of your conversation Planning out your conversation What to do when the physician comes to you with a question

Having the right idea on how to care for a patient is only half of the equation.

The way the hospital system is set up, there is one person with the absolute authority to make a decision for the patient: The physician.

As a pharmacist you have unique and expert knowledge in areas that the physician may not.

You may have the best idea in the world for the patient, but in order to make it happen you must convince the physician that it is the best idea. If you don’t communicate your idea well, it may not be accepted.

Recommendation acceptance rate

What should your acceptance rate be? Published data suggests it should be 90% or higher.

92-97%

90%

92%

99%

First impressions are everything

But how do you start off on the right foot when presenting a recommendation?

Get inside the mind of the physician and pay attention to how they think about patients.

Physicians approach patients in a problem-based manner

They are used to case studies and history & physicals.

They may or may not know a patient by name yet – especially if they haven’t seen them yet.

They see many patients (over 20) in a day and may have been in the middle of thinking about a different patient when you talk to them.

The first thing you must do to successfully communicate an idea about a patient to a physician is get the physician to remember/think about the patient!

Here are two different examples:

Incorrect:

I want to talk to you about Jane Doe’s dose of lovenox.

Correct:

I want to talk to you about Jane Doe, the 55 year old female you just admitted with a pulmonary embolism and are treating with lovenox.

Planning out the conversation

Have you ever found yourself stumbling through a conversation with a physician?

You know you are right but are having trouble phrasing to the physician the problem. You get the sinking feeling that they are losing interest and not really paying attention to you…

You went into the conversation without a plan!

To prevent this from happening, I use a tool called ISBAR to collect my thoughts and train myself how to talk like a physician and get the physician to listen like a pharmacist.

Introduction (if they don’t know you already)

Situation

Background

Assessment

Recommendation

Early on I would literally sketch out the conversation using this tool. After doing that for a while it has become 2nd nature.

The ISBAR tool helps you collect your thoughts and present them to a physician in a logical manner that allows them to follow your decision-making process.

Example 1:

Introduction

Hello Dr. Smith, I am Joe a pharmacist.

Situation

I would like to talk to you about your patient Jane Doe, the 55 year old female you just admitted with a pulmonary embolism and are treating with Lovenox 1mg/kg subcut bid. I am concerned that her dose of lovenox is too high given her kidney function.

Background

I was looking at her labs and saw her serum creatinine is 1.9. She is 5’ tall and weighs 45kg. She has a history of chronic renal insufficiency from her diabetes.

Assessment

I estimate her creatinine clearance to be 24 mL/min.

Recommendation

I would like you to consider reducing her lovenox dose to 1mg/kg once daily, as this is the recommended dose for her level of renal function.

Example 2:

Introduction

Dr. Jones, it’s Pharmacy Joe.

Situation

I would like to talk to you about your patient John Doe, the 55 year old male you just admitted with a community acquired pneumonia and are treating with Levaquin 750 mg IV daily. I am concerned about a potential drug interaction with the patient’s sotalol.

Background

The patient has been taking sotalol 160 mg po bid for his atrial fibrillation. Both sotalol and levaquin may prolong the QTc interval and this risk is greater when the two are used together.

Assessment

The 12-lead EKG done in the emergency department shows the patient’s QTc is already above normal from the sotalol – it is 490 msec.

Recommendation

Since the patient has no allergies, I would like you to consider stopping the levofloxacin and using ceftriaxone 1g IV daily and doxycycline 100 mg IV twice daily instead to treat the patient’s pneumonia. This combination will cover the likely pathogens just as well as the levofloxacin would have.

I’ve made a free pdf tool for you to practice scripting your conversations using the ISBAR method, just like I did when I first learned this. You can download it inside my free critical care download area.

When the physician comes to you with a question

I’ve found that physicians seldom start out by asking me the “real” question.

Instead they tend to start off with a narrow question where they think “If I only knew this one tiny piece of information then I can answer the real question.”

But we as pharmacists know and do much more than recite obscure pieces of information from reference texts.

But to do so, we need to know the whole picture, not just the tiny bit in the initial question.

Let’s go over some real examples of initial, narrow questions that have been posed to me and the real questions that were underneath.

Example 1:

You are sitting on a patient care area reviewing a patient’s chart when an intensive care physician asks you “Is there an SSRI of choice?”

The Real Question:

Today on multidisciplinary rounds we have been discussing patient X, a 54 year old female here for a severe GI bleed. She doesn’t want to participate in her care and we think she may be depressed. Her sister died suddenly a few weeks ago. She is on an esomeprazole drip and she takes carbamazepine for a seizure disorder. We would like to start her on an SSRI – which one should we choose?

Example 2:

A Family Practice resident calls you and asks you “How much zinc is in the multivit w/minerals on formulary?”

The Real Question:

I am taking care of a 90 year old woman who fell and developed rhabdomyolysis. She is 4’9” and 37 kg. She has been in the hospital now for 8 days. She is severely malnourished. She has a rash on her chest and upper arms that is consistent with a zinc deficiency. We have ordered a zinc level but it will not be back for several days because it must be sent out to another laboratory. We would like to treat this patient empirically for zinc deficiency. What dose of zinc should we use?

Example 3:

An emergency physician calls you on the phone and asks “What is the half-life of methadone?”

The Real Question:

I am taking care of a 23 year old male over in room R2. He was found in the parking lot in respiratory arrest. His friend says he took too much methadone. We gave him 4 mg IV of naloxone and he is now breathing normally. I am worried that the naloxone might wear off before the methadone is eliminated and the patient may go back into respiratory arrest. When should I re-dose the naloxone? Does the patient need a continuous infusion?

How to uncover the real question

Slow the physician down and ask several questions back before knee-jerk answering.

Who is the patient?

Why are they here?

What does the rash look like?

Are they making urine?

Are you planning to I&D the wound?

What is in your differential diagnosis?

I’ve never had a negative response when I have used any of these techniques.

Most physicians just answer my questions without flinching, allowing me to uncover the real question they need help with.

Some are surprised, but none are insulted so…

ASK ASK ASK ASK!

Not doing so sells yourself short. You are a clinician that needs time and information to properly answer a question.

No physician ever expects a peer to give them a quick answer without knowing the whole picture.

Some physicians may not be used to pharmacists asking for time and the whole picture, but they can be trained. ☺

IHI SBAR Page

If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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