Poor communication is a well-established cause of ED malpractice claims.1 However, “there’s a lack of validated methods to assess these important skills in resident physicians,” says Nicole Dubosh, MD, assistant professor of emergency medicine at Harvard Medical School.

Faculty or attending physicians assess communication skills, which are a core competency for medical students and residents.

“Patients don’t get the opportunity to do that, even though the patient is actually the recipient of the communication,” notes Dubosh, director of undergraduate medical education at Beth Israel Deaconess Medical Center.

Dubosh and colleagues wanted to know if attending physicians and patients would rate communication skills of emergency medicine residents differently. During ED shifts at an academic medical center in 2017-2018, researchers asked 1,097 attending physicians and 952 patients to rate the communication skills of 26 residents.2

Participants were asked to rate how well the resident communicated with colleagues, patients, and nursing/ancillary staff. Ratings of attending physicians and patients varied significantly. The researchers were not surprised by this finding. “This is a starting point for further study on how to assess this domain,” Dubosh says. “We are always looking at the best way to assess our learners. We don’t have a gold standard tool to assess communication.”

EDs use various methods to do this. “The questions arise: How valid are these tools that we are using? How good are we at assessing?” Dubosh asks.

For ED visits, many factors come into play with how patients perceive the provider’s communication skills. Patients’ emotions and perhaps unrealistic expectations can cloud their perception. “It’s possible the resident conveyed all information perfectly well, yet the patient left confused,” Dubosh offers.

An attending physician may note the resident conveyed everything the patient needed to know, but what is really important is whether the patient actually understood the information and retained it. The discrepancy in ratings showed the importance of gathering feedback not only from attendings but also patients. “As we’ve found, they do differ,” Dubosh says. “With what we call ‘360’ evaluations, you are getting input from multiple people — the attending, the nurses, the patient.”

With better communication, ED patients are more likely to follow recommendations and experience better outcomes.3 “Furthermore, there is decreased chance of litigation if the patient perceives their doctor to be a strong communicator,” Dubosh adds.

There are many studies on communication assessment tools, but none are statistically significantly different enough to be considered a best practice, according to Jay M. Brenner, MD, FACEP, medical director of the community ED at SUNY Upstate University Medical Campus.

“Ultimately, I think that the best practice is for an ED medical director to pay attention to their direct observation of their ED clinicians’ communication behavior,” he says.

Some ED clinicians will be able to self-correct if they receive feedback from a patient. “Some, however, will require more intensive coaching and mentoring. All may benefit from emotional intelligence training,” Brenner suggests. “Alternatively, observation of simulation behavior can be informative.”

For example, communication skills demonstrated during resuscitation drills may be a good indication of how EPs behave with actual patients and give an opportunity for brief feedback. “Patient surveys have become an industry standard; however, they can be ripe with issues, such as bias and discrimination,” Brenner cautions.

For instance, patients might give terrible scores because the EP adhered to strict opiate prescribing guidelines. “Nevertheless, surveys are an easy and available indicator of how your ED clinicians are perceived,” Brenner says.


  1. Ferguson B, Geralds J, Petrey J, Huecker M. Malpractice in emergency medicine — A review of risk and mitigation practices for the emergency medicine provider. J Emerg Med 2018;55:659-665.
  2. Lewis JJ, Balaji L, Grossestreuer AV, et al. Correlation of attending and patient assessment of resident communication skills in the emergency department. AEM Educ Train 2021;5:e10629.
  3. Anhang Prince R, Elliott MN, Zaslavsky AM, et al. Examining the role of patient experience surveys in measuring health care quality. Med Care Res Rev 2014;71:522-554.