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Phone a Friend


As supervisor for the latest batch of interns that come through our emergency department I get to nurture them straight out of medical school, before the cynicism of the ward service sets in. It’s never the medicine that is a challenge, but the hidden curriculum that they are not taught in medical school. This time I’m going to focus on a piece of technology that I use every day at work but have never once been taught how to use – the telephone.

Let’s play a game

Why do we do so badly at telephone consultations and requests for help? If you have time in your busy schedules, I’d like you to indulge me and play a little game. The set-up is simple. You need two chairs, placed back to back, with one of them facing the screen/projection area/whiteboard. You also need two players, one to be the referrer and one to be the specialist. The referrer can see the screen, but the specialist can’t.

Scenario one

Scenario two

Scenario three

They have two minutes to make a referral. At the end of the two minutes the specialist gets to present the referral to the audience.  What information got missed?

Pick up the phone

Like a lot of introverts I have a thing about telephones. I know I am not the only one (though I won’t out them here) who hates calling people. I think it is partly the fear that I am going to be be interrupting them when they are doing something much more interesting instead. I’ve spent the last four or five years in a graded exposure programme whilst working for the state retrieval service.  I’ve called registrars, consultants and GPs in the middle of the night without a second of hesitation. That phone phobia is something that can be unlearned.

“We’re talking away, I don’t know what I’m to say, I’ll say it anyway..”

Mags Furuholmen, Morten Harket, Pål Waaktaar (1984)*

Rather than bluster straight into a referral it is worth while using a structured approach to make sure all the pertinent information gets across.  I’m used to the SBAR/ISBAR approach.

How does the SBAR/ISBAR approach work?

SBAR was originally developed by the US Navy as a communication tool in nuclear submarines. If you think clear communication is important in healthcare then consider the problems that may occur at 20 fathoms carrying 24 Trident II ballistic missiles and Donald Trump controlling the launch codes.

I think the I is one of the most important yet overlooked parts of the consultation process. You need to identify not only yourself and your place of work but confirm that you are talking to the correct person. Woe betide you if you wake up the urologist at 3 am to talk about a stroke call that should have gone to the neurologist (though tamsulosin may be as effective as TPA).

My institution uses specially printed ISBAR forms for the handover of patient to the ward staff. Whilst the nursing staff are excellent at this it has been poorly adopted by medical staff.  I have also seen printed consultation pads with ISBAR on them.  The specialist can then keep the referring doctor on track. This interesting paper from St Vincent’s in Melbourne found that a brief teaching session on the application of SBAR didn’t seem to make much of a difference to the amount of critical information transferred but did seem to improve the impact of the call, with better calls including a diagnosis (or stating a lack of diagnosis) and making specific requests.

I also like Kessler’s 5C method of consultation. 

Whilst this doesn’t have the specifics of ISBAR, and is a little harder to remember, it really reinforces the core concepts. Once you’ve introduced yourself you need to tell a story, one that is not going to bore the pants off the person on the other end. Simon Carley and Iain Beardsell over at  St Emlyn’s would call this the James Bond opening. What does that mean? Well, it means you start with the most exciting, most important bit before moving on to exposition. I was once referred a case that was sold as a non-STEMI until the referrer casually dropped into the conversation that the patient arrested during their episode of chest pain and needed two minutes of CPR. This sort of stuff needs to be mentioned at the get go. For those of you coming up to specialist exams, think of it as signposting the problem.

This is a critically unwell child with sepsis who is profoundly hypotensive despite two 20ml/kg fluid boluses

This is a four-year-old girl with a limb-threatening Gartland III supracondylar fracture“.

Hopefully, phrases like this will make them sit up and pay attention. I am all for being polite but opening a consultation at three in the morning with a wishy-washy “I wonder if you can help me” does nobody any favours.

This approach also emphasises that you are calling for a reason, be it clinical advice, a bedside consultation or an admission. Again I have been involved in a number of conversations where this has not been made clear and the in-patient unit had thought they were only consulting. With the burden of 4-hour targets patients should be admitted in a timely fashion. If the ED consultant thinks they need to come in then they are probably right. Arguing about which unit they come under is semantic (as is asking for blood tests that will not change their ED management one iota).

I also like the way the 5C model ends with Closing the Loop. I’m a big fan of this in any critical conversation, in resus, during retrieval or just on a phone consultation. It’s too easy for someone to mumble their way through a phone call and be unclear on what the outcome is unless you take the time to clarify who is doing what.

What’s the worst that can happen?

You could get sworn at, abused, laughed at or belittled. Remember, though, that this is bullying. Call it out for what it is. You are not calling to be annoying. You shouldn’t apologise for making a referral (if they didn’t want to be on call then they shouldn’t have chosen their speciality). You are calling because you want to help the patient. Fundamentally it is all about the patient. Over many years I have become better at not rising to phone abuse. I am more likely to say, “I am not prepared to listen to your verbal bullying; I’ll just call your consultant.” Of course, it is easy for me to say that, as I am a consultant, but if you are getting bullied, you need to involve a senior.

* You know this one… no clues this time.


Kessler CS, Afshar Y, Sardar G, Yudkowsky R, Ankel F, Schwartz A. A prospective, randomized, controlled study demonstrating a novel, effective model of transfer of care between physicians: the 5 Cs of consultation. Acad Emerg Med. 2012 Aug;19(8):968-74. doi: 10.1111/j.1553-2712.2012.01412.x. PubMed PMID: 22905961.

Making a referral with Iain Beardsell @ St Emylns

Thompson JE, Collett LW, Langbart MJ, Purcell NJ, Boyd SM, Yuminaga Y, Ossolinski G, Susanto C, McCormack A. Using the ISBAR handover tool in junior medical officer handover: a study in an Australian tertiary hospital. Postgraduate medical journal. 2011 May 1;87(1027):340-4.

Marshall S, Harrison J, Flanagan B. The teaching of a structured tool improves the clarity and content of interprofessional clinical communication. Quality and Safety in Health Care. 2009 Apr 1;18(2):137-40.

Solevåg AL, Karlgren K. Competences for enhancing interprofessional collaboration in a paediatrics setting: Enabling and hindering factors. Journal of interprofessional care. 2016 Jan 2;30(1):129-31.

Mannix T, Parry Y, Roderick A. Improving clinical handover in a paediatric ward: implications for nursing management. Journal of Nursing Management. 2017 Jan 1.

Cunningham NJ, Weiland TJ, van Dijk J, Paddle P, Shilkofski N, Cunningham NY. Telephone referrals by junior doctors: a randomised controlled trial assessing the impact of SBAR in a simulated setting. Postgraduate medical journal. 2012 Nov 1;88(1045):619-26.

Forrest CB, Glade GB, Baker AE, Bocian AB, Kang M, Starfield B. The pediatric primary-specialty care interface: how pediatricians refer children and adolescents to specialty care. Archives of pediatrics & adolescent medicine. 1999 Jul 1;153(7):705-14.

Nugus P, McCarthy S, Holdgate A, Braithwaite J, Schoenmakers A, Wagner C. Packaging Patients and Handing Them Over: Communication Context and Persuasion in the Emergency Department. Annals of Emergency Medicine. 2016 Dec 10.<



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3 thoughts on “Phone a Friend”

  1. Great post Andy, it brings up a lot of points around structured communication – another one of those things we’re told we should adopt from the aviation industry, but of course, like transposing any intervention from aviation it’s not quite that straightforward.
    Another advantage to structured communication that we often forget is the expectation on behalf of the recipient. Our experience was that it was only when we started teaching ISBAR to consultants and senior nurses that it gained traction in the hospitals in Melbourne.

    I’ll own up to being involved in ISBAR from a long time ago – in fact it was a conversation about an orthropod seeing a patient in the wrong ED in Melbourne that prompted us to add the ‘I’ for Identify before teaching it to medical students about 12 years ago now.
    Since then there’s been some good work both positive and negative about its effectiveness. Like any intervention, it’s often how it’s taught and implemented that makes a difference to its acceptance and effective use.

    A really important leap forward for me, came with Liz Pryor’s work looking at telephone communications by doctors where English is not their first language. Even though it’s a small subgroup of the population, I think the lessons are still applicable generally to all clinicians.
    Liz performed linguistic analyses of effective and non-effective telephone calls to work out the elements of good calls and found 9 stages in the call. These fit broadly with the ISBAR structure but there are two important lessons from this:

    1) The Assessment is a vital stage of the call. Unlike what most people think, it isn’t the examination or investigations, it’s a diagnosis, differential and level of certainty.
    Without this stage the conversation becomes extended turn-taking (often for several minutes). The receiver of the call doesn’t have a clear idea of what’s going on and can’t provide help / advice / (and crucially) determine urgency without it. Even a “I have no idea what’s going on” helps the receiver infinitely more than nothing.

    2) Is perhaps more obvious – that communication is not a monologue. In particular the Request / Recommendation stage* becomes a negotiation. Importantly, they also need specific strategies for managing this stage – readback of information, formulating specific questions ahead of time etc.

    My teaching strategies have now gone beyond ISBAR – I challenge the Anaesthetic registrars to construct a ‘Handover Haiku’ that gives the ‘Punchline’ or ‘James Bond opening’ in a clear concise way!


    Pryor, L. Woodward-Kron, R. (2014) International medical graduate doctor to doctor telephone communication: A genre perspective English for Specific Purposes 35: 41-53
    Marshall, S.D., Harrison, J.C., Flanagan, B. The teaching of a structured tool improves the clarity and content of inter-professional clinical communication. Quality & Safety in Health Care 2009; 18: 137-40.

  2. I hate using the telephone too ! When I started out as an NP I used to really stress out when needing to refer patients to the tertiary hospital. A learned colleague of mine advised me to use SBAR.

    Stupidly I’d used it as a nurse calling the doctor when I needed a patient reviewed but hadn’t thought of using it as an NP referring my patient ! I use it every time I refer now. Definitely gives me more confidence.

  3. I always say that the telephone is the most sensitive instrument in the department. How it is used of course can be everything from delicate negotiation to blunderbuss diplomacy and that’s alway a two way thing.

    As someone on the receiving end of referrals can I make a few pleas?

    1. Tell me straight off what you need from me, especially at 3 am. I know it comes at the end of (I)SBAR but, “I need you to come and see this patient now, I’ve very concerned” will focus me differently from “I just wanted to let you know.” Even if it is about the same patient. It helps me recognise where you are with respect to the patient and their management. If everything is completely under control, the thought processes are different than if the faecal fan interface has been maximised.

    2. Never* make a referral if you haven’t physically managed the patient. I know shifts end and priorities change and things get in the way but if the answer to more than one question is “I’m sorry I haven’t seen the patient,” it just makes everything more difficult. Please don’t hand off a referral.

    *exception being if those managing the patient are currently the only thing keeping the patient alive

    3. Whilst the impression sometimes is that someone on the phone if not physically in your department is basically being lazy and drinking coffee, try to remember that there are other pressures that may keep folks elsewhere. Their workload of 40 patients compared to this referral all needs balanced.

    4. Don’t be a dick. As Iain Beardsell says. Whatever happens. You don’t know what battles they are fighting. Sometimes that knowing smile, the offer of a coffee later or just camaraderie can make ALL the difference.