Handoffs between physicians are a crucial part of high-quality patient care, but learning how to effectively manage this critical process in residency training requires a special skill all its own.
“If you think about it [the handoff] as a procedure, it's a very common one. We spend a lot of time thinking about how to train doctors, medical students and residents to communicate with patients, but it's equally important to communicate with your colleagues,” said Vineet Arora, MD, MAPP, a prominent voice in U.S. medical education and an AMA member. “Particularly now—in an era where overnight call has really become very much less likely due to widespread use of night float models and shift work—having a good handoff is really important.”
While there are parts of the process that you, as a resident, cannot control—such as whether you will be handing off to someone familiar with the patient—there are ways to deliver a high-quality handoff that will reduce the risk of error.
Here are seven strategies for improving your patient handoffs in residency training.
Use a proven mnemonic
Mnemonic devices can be highly effective in creating a standardized format for handoffs. While the I-PASS mnemonic has a great deal of evidence supporting its efficacy, some specialties and programs will require or prefer a different mnemonic.
“The mnemonic is an important piece of it, but what is it really doing? It's basically a mental model to try to remind people what constitutes a good handoff,” said Dr. Arora, who is dean for medical education and vice dean of education in the biological sciences division at the University of Chicago. “But you can still have outdated information because your electronic medical record didn't prompt you to update your information. It still could say the wrong code status. So, just because you're using the mnemonic does not mean the information is accurate or being delivered in a way that actually promotes retention and learning.”
Additionally, physicians need to be willing to pivot when required.
“There needs to be room for customization and innovation,” Dr. Arora added.
Focus on the most important issues
When conducting or receiving a handoff, ask yourself, “What information do I really need to effectively care for this patient right now?” Instead of offering unnecessary biographic details about your patient or running through every review system in their physical exam, Dr. Arora urges physicians in training to focus on the major “if-then” and “to-do” items about the patient.
“Don’t worry about [explaining] that Mrs. Smith is from Michigan, and this is what her CT showed,” she said. “If it doesn’t relate to the anticipatory guidance, it’s probably OK to leave it on the written information and move on.”
Minimize interruptions, if possible
The I-PASS mnemonic can be an effective one, Dr. Arora said, while noting that its use can be impeded in noisy, busy emergency departments or intensive care units where having a focused, interruption-free handoff conversation can be difficult.
If possible, pull the other physician aside to a less busy environment for the handoff, Dr. Arora advised. Try to focus your mental energy on the task at hand for the time required. But, she noted, there is only so much a resident can do to control the situation in which they are required to give verbal handoffs.
“Most of our work is very interruption-driven,” she said.
Know the limitations of the handoff method
The best practice for handoffs is face to face with an oral update, Dr. Arora said.
While physicians have multiple channels for communication, “the highest level of communication still occurs when we are face to face with someone,” she said.
In written handoffs, she suggested employing a technology-enabled solution. And while handoff technologies using AI (augmented intelligence)—often called “artificial intelligence”—do exist, Dr. Arora said more research is needed to determine their accuracy and efficiency.
Customize for high-risk patients
Different circumstances require different strategies, Dr. Arora said. She mentioned as one example patients with limited English proficiency, saying that research shows they are placed at particularly high risk during handoffs.
Be aware of more complex situations and be prepared to change handoffs in ways that can be helpful.
“There's now a lot of literature that shows that, for some patients—where appropriate—doing a handoff at the bedside with the family and the patient involved is actually very helpful and can reduce calls and help improve family satisfaction,” she said.
Have specific strategies for high-risk patients, she advised further, and assess any potential bias during handoffs.
Clarify written sign-outs
Most handoffs still are conducted using low-tech solutions, Dr. Arora said, but resident physicians should use technology whenever possible to make sure written handoffs are up to date and accurate.
She noted that keeping the patients’ information updated is an intrinsic but pertinent challenge for trainees, who often act as the “masters of information” for patients.
“The nice thing about using technology is that technology can often auto-update, and so it can actually change the date, change the meds, change other things,” Dr. Arora said. “But you still need to pass along the newest clinical judgment. And if the electronic medical record that's being used is just copy-pasted with old information, then your handoff is going to be privy to that same problem.”
Check for receiver understanding
The give-and-take nature of a handoff requires not just an effective delivery of information, but synthesis by the listener, as well.
Problems with “back channeling” often occur in “data dump” situations. That is when one physician quickly runs through their notes about a patient while the person receiving the handoff nods or uses filler phrases such as “uh-huh” during the conversation to passively express that they understand the information that’s being communicated, Dr. Arora said.
“That is not an active display of understanding,” she said. “Handoffs are meant to be a conversation, so the next time you are in a handoff [ask yourself], ‘How can I, as the receiver, take a more active role and assure the sender that I really understand everything?’”
Learn more about the AMA Resident and Fellow Section, which gives voice to—and advocates on—issues that affect resident and fellow physicians.
