As a medical professional, we often need to communicate with our colleagues, allied health professionals, and others. This can include discussing our own patients with our registrar or consultant seeking advice, publishing about a case in a journal, or discussing with the multi-disciplinary team for management of the patient. In this article, we will be looking at one of the recommended models for discussion within the healthcare system.
I feel that understanding the structured communication model recommended in healthcare can help in many situations, whether that is discussing a situation in a business or talking to someone at a networking event. Understanding ISBAR could even help you to be more clear and structured in your general conversations. As a member of Toastmasters with a passion for developing my public speaking ability, and as someone who has always been very interested in following a strong structure, I feel it is also a useful tool for thinking about when conveying information or discussing stories with others.
In fact, I intend to in future (as an experiment) attempt to discuss with a business owner or business development manager their business using a model such as a modified NILDOCAAFIAT (which I will discuss at a later date), assess it medically (such as my Think Like A Medical Student series explores), and then describe their business using ISBAR. This would likely occur at a situation similar to a chamber of commerce event during a speaking engagement on the very topic of thinking about, analysing and discussing a business like a medical professional
Why bother with this? Can’t you just have a quick conversation, say what’s needed, without all this fluff? After all, we’re all busy, you can probably communicate your point however you decide to. And you’ll remember everything important, and say it clearly. Right?
Imagine that you are an authority, in this case, a consultant, and one of your juniors comes up to you asking for advice on a particular situation/case without some form of structure. They’ve interrupted you in the middle of you performing other work: “Hi, should we start 100 mcg fentanyl for severe acute back pain?” It would be immediately disorientating and confusing, and besides doesn’t give you enough information to know the specifics of the relevant situation, and even doesn’t provide enough to answer purely objectively (even if this wasn’t about a specific patient and was just an exam true or false question). Your response would likely be something like, “Err, who are we talking about? What is their situation? What are their indications for starting? What is their past history? Do they have a background of opioid dependence or opioid-seeking behaviour? What do you mean by back pain? Etc.”
Alternatively, a fault of new medical students or interns is often to list off the complete patient history like an information dump to their consultant, colleagues or other’s involved in care. This would be particularly frustrating when they’re just asking about whether, for example, changing the dosage of their medications is liable to have a very irritable consultant by the end of it. It can even make the information too hard to follow and determine what’s going on when the information is all just lumped together, not building on itself. This is where signposting the situation early can be very helpful, as it allows the latter information to be slotted into the stated situation (and any discrepancies noticed).
Besides, even if you do cover everything that is important without following a structure, by following a structure that the other party is familiar with you make things easier for them to follow and understand what you are describing. This particularly applies for something which quickly becomes complex to follow such as medical cases or detail-oriented presentations. It’s the difference between using normal English grammar and sentence structure and just randomly throwing words at the listener. Even if you use all the same words, most people won’t be able to decipher what you tried to say.
As can be seen, it makes sense to follow a structure where all parties can follow along, and which highlights important points at the start. This also helps in keeping things fluid and concise, with a complete (relevant) patient presentation being discussable in person or over the phone within a couple of minutes, even in complex cases.
The structure that has been recommended for us to normally follow is known as ISBAR. This structure starts by discussing the identity of those involved, then the situation, the background, assessment, and
ISBAR is derived from the military structure known as SBAR, which is the same but leaves out the identity step. Additionally, as far as I can tell, only Australia has formalised the use of ISBAR with the Identity separated out as an individual step. That said, even people using only SBAR in the healthcare setting still have to identify who they are talking about (even when deidentified) at a minimum, and as such, they are still unintentionally following the ISBAR model. Therefore, I will discuss ISBAR in full and it will apply equally whether in Australia or elsewhere that SBAR is used in its place.
The first thing that belongs in the description under the ISBAR model is who is being talked about, and, particularly if you’re talking to someone unfamiliar, a mention of who you are and potentially who you are talking to. This gets any ambiguity out of the way, makes sure that everyone is on the same page.
An example could be, when talking to radiology, “Hi, my name is Adrian Pavone, a second year medical student. I am here to
An even more condensed version might be: “Hi, my name is Dr Adrian Pavone, a resident at ED. We have a patient John Smith who we need your respiratory consult on.” Alternatively, if required, it could go longer, but the Identity should normally fit within a few lines like the original example.
Talking to someone familiar to you, particularly in person, can remove the identification of self. “John Samuel Bloggs, a 69-year-old male, was admitted three days ago for investigation of dizziness.” The same sort of description (likely with no patient name) also commonly shows up in journal articles, where the patient may have an acronym (J.S.B. for example) or just be identified as “a 46-year-old male.”
We will follow John through for the remainder of this article, but please note that John is fictional and similarity to real cases is purely coincidental.
Next, a brief description of the situation is appropriate. This isn’t a complete history but is more like a primer as to why you are discussing this patient with that person and the major highlights. Most commonly, this will involve the patients presenting complaint or current issues.
An example could be “John has presented to the emergency department with shortness of breath, hypoxaemia (low oxygen levels in the blood), and wheezing, consistent with obstructive lung disease.” Often, the situation can be short and sweet, such as this case. Another example is “J.S.B. was referred from Royal Brisbane Hospital for neurosurgeon consult, following profound intermittent dizziness during his recent archery practice and an occasion of syncope (loss of consciousness) when checking his blind spot while driving.”
The situation, as can be seen from those simple sentences, give you a frame of mind to then hear the background and further information with some sort of idea about what is going on. In a way, it is like building a scaffolding that you are then going to fill in in the next step.
Speaking of filling in the scaffold, that is the purpose of the background. The background should provide further details that have been discovered, and includes the patient history, the results of your examination, and any investigations that have already been completed (including their results where available). Pertinent negatives (things that were negative which are relevant to excluding differential diagnoses for this presentation) should also be described. It is also recommended to structure this history to include the most relevant details first, and depending on the situation the brevity or verbosity can be adjusted. For example, reporting for the first time to your consultant on a new patient would include a thorough explanation. Speaking to a team you are referring to though may only include the specific relevant details.
“John described an 18-month history of worsening dizziness, pre-syncope (light-headedness, dizziness, blurry vision, feeling faint) with occasional syncope (loss of consciousness). At least one occasion has involved emesis (vomiting) following his return of consciousness.
“John presents with evidence of orthostatic hypotension (significant changes in blood pressure when from lying to standing, a common cause of pre-syncope). He was previously assessed by the neurology team with balance tests, was found to be negative for balance related vertigo on their assessment. He also describes chronic posterior neck pain, however, without headaches or shoulder involvement (i.e., no shoulder pain or difficulty).
“John has a background of one instance of myocardial infarction two years prior. A confirmation of occlusion (blockage) of the left anterior descending coronary artery was confirmed by angiography (a scan of the blood vessels) at the time.
“Prescriptions include antithrombotics, ACE inhibitors (angiotensin-converting enzyme inhibitors, a blood pressure medication), statins (cholesterol medication), diuretics (increase urine volume, generally to decrease fluid overload or overcome renal compromise), and beta-blockers (blood pressure medication).” (Of note, most of these (and many more) are fairly standard medications in a 79-year-old male, particularly one with a past history of MI, but are reported as their mechanisms of action could potentially suggest differentials)
This is a reasonably complete background for the patient. However, it doesn’t include absolutely everything that has been discussed with the patient, it removes irrelevant details, while still being as thorough as possible. Description of other previous conditions and prescriptions can be particularly helpful when discussing with a superior as they may allow the superior to think of something that you will have overlooked, and allows the superior to review the medications and make sure they are all appropriate for the patient’s current state (and aren’t contributing to the patient’s current condition).
The next step is to provide your assessment. This can vary depending on the situation and the protocols of your environment. For example, NSW Health guidelines are to include the A-G physical assessment at this point. This includes describing airways, breathing, circulation, disability (altered level of consciousness, stroke, cognitive signs), exposure (checking for hidden bleeding, checking bowel sounds), fluids (fluid input and output, amount and colour of urine, patient thirst), and glucose (blood glucose level). These findings can identify patients that are deteriorating.
Briefly, this could look like: “Airway was clear, breathing 16 breaths per minute, pulse was 72 beats per minute, regular and strong. No altered level of conciousness or other disability, no evidence of skin abnormalities identified, bowel sounds present, moist mucous membranes (tongue mucous membranes are commonly assessed for this, commonly why the doctor says to stick out your tongue), and BSL was within normal limits.”
Further assessment includes your own input and opinion (finally). Primarily, the key point is to state what you think is the likely problem or your provisional diagnoses. A recommended guideline, particularly in imaging, is that when you are coming up with differentials you should always come up with or list the top three differentials. Even if something appears to you very obviously to be one condition, this forces you to think about potential other conditions that could also present the same.
“John seems to have a vertigo-like process that is consistent with reduced blood flow to the brain during movement of his neck. However, the syncope and limiting to only during neck movement is not consistent with a pure vertigo finding (i.e., this doesn’t appear to be paroxysmal benign postural vertigo, the most common cause of vertigo-like symptoms). As such, these findings appear to be most in keeping with mechanical occlusion of the vertebral artery. Other possibilities for his presentation that may warrant investigation could include vasovagal syndrome (a cardiogenic (heart + blood vessels) cause) or Meniere’s disease (abnormal fluid in the inner ear labyrinth).”
As can be seen from this, this is primarily a discussion of what I believe the likely diagnosis is for this patient and the potential differential diagnoses. It even includes a brief explanation for why the most likely diagnosis for vertigo doesn’t apply in this case. It can also includes things such as what the patient is at risk for, or other concerns you have identified. Additionally, it doesn’t include mention of other conditions that can cause muscle weakness and pre-syncope, such as stroke, because those conditions don’t correlate very well with the syncope finding. They need to be thought about originally and have been investigated, but once ruled out they no longer exist in the assessment.
Finally, we’re at the recommendation. The thing you’ve been building to this whole time. What is the next step? What do you think should happen next with the patient. Where do they need to be transferred? What consults are required? What further investigations are required? What medications or surgery is required? Can the patient potentially even be discharged?
This section more than any previously depends on your own experience and knowledge, and can definitely be the hardest part to be certain about. That said, in medicine, there are numerous articles that can guide you in this area based on your assessment. Therefore, your assessment needed to be correct for them to be valuable. However, assuming that isn’t an issue, sites such as Medscape, the eTG complete Therapeutic Guidelines (in Australia, although equivalents exist elsewhere), and UpToDate are great examples of sites that can guide the clinical next step.
“Recommendation for confirmation of the diagnosis is a CT or MRI of the neck, likely with angiography, to assess for structural causes (However, in this case, the clinical diagnosis is likely sufficient (see below paragraph)). If negative, an ECG or Halter monitor, plus potentially a stress test, could be used to assess for vasovagal syndrome causes. Finally, hearing assessment and keeping a logbook of his events could be a consideration if Meniere’s disease becomes most likely.”
The recommendation though should be considered in the clinical setting as well. If it is reasonably clear that the suspected cause is actually in play, and if alternate findings aren’t overly dangerous to miss, costly investigations should be avoided unless required. CT or MRI is a costly investigation. CT/MRI with or without angiography is diagnostic for this condition. However, just because something is diagnostic doesn’t mean that you will always perform it in 100% of cases. Other considerations have to be included.
One piece of advice I heard was to consider “If this was the only patient that you could send for a CT today, would you still recommend sending them?” This can allow you to put in context the requirement of sharing resources between all available patients (the ethical concept of justice), and so may adjust the recommendations.
Congratulations on making it through that discussion with me. I hope that you have gotten some value out of it, regardless of whether you are looking to go into medicine or not. Even just thinking about our communication, and looking at the structure used (and the reasons for it) can make us better and clearer communicators.
I look forward to publishing again next week. My next post published on New Years Day will resume my Think Like a Medical Student series. At this point, I’m planning my Friday post for next week to be on how patients notes are written.
As always, I would appreciate any comments and discussion below. Remember to subscribe to this blog in the sidebar if you’re interested in future updates. And, as always, stay healthy and keep learning.