Field notes: Passing the baton in the ER.

What happens when your doctor leaves in the middle of your visit?

You go to the ER. You see a doctor and tell them your entire story. You feel like the doctor really understands your situation, despite having just met you.

Some tests are ordered, and maybe some treatments provided. Then, at some point, your doctor/new bestie seems to vanish, only to be replaced by some random stranger you’ve never met before.

What happened?! Does this new person even know what’s going on?

My friends, you just got “signed out.” Or, your care was “passed off,” “handed over,” or “transitioned.” There are many ways to describe the process by which one doctor assumes the care of the patients of a colleague whose shift has ended.

Are ER signouts safe? Yes, most of the time. But there’s an art to this process. Overall, I see signouts as an opportunity to get a second opinion from a fresh team of clinicians. But these interactions have to be handled delicately, as they can lead to complicated feelings between coworkers, especially when even small points of disagreement arise. Indeed, simultaneously maintaining patient safety while preserving collegiality can be tricky. But it’s part of the job and we do it every day so that you get the best possible care. Here’s how…

How the baton is passed.

What happens to your care when your ER doctor leaves in the middle of your visit? How do we do transition your care?

We sit down (face-to-face) and talk about each patient. We boil everything down to a few sentences. Your age, sex, relevant medical history, what conditions we are ruling out. The most important piece of information is what we call “dispo,” which is short for “disposition,” which is lingo for “where is this person going after the ER?” Are you being hospitalized no matter what? Are you being sent home no matter what? Or does it depend on the findings of the tests that are in process?

The easy part is knowing what to do if we make a diagnosis. Treat it! We all know the treatments for every emergency condition of any relevance, so unless there is some finer point, treatment would not even be discussed.

Where treatment should occur is another story. For example, if a young healthy person has bacterial pneumonia but is not extremely ill, oral antibiotics suffice. Dispo: home. But if a person with many medical problems has that very same pneumonia, they might be getting IV antibiotics and fluids. Dispo: inpatient ward of the hospital.

To transfer care efficiently, we have a lingo, full of buzzwords. If I say “Bed 32 is a 50-year-old man, no past medical, low speed, MVC, neurovascularly intact, dc after head CT", that means that the motor vehicle collision he was in was minor, and that the CT scan of the brain is more or less pro forma, as there are no signs of any damage to the brain, major nerves, or blood vessels. So, after the CT scan is completed (and found to be negative, as we suspect it will be), this healthy guy can go home.

The harder cases are when something might be going on, we do not know what, and we do not actually expect to be able to make a definitive diagnosis in the ER. What to do with patients with a bunch of negative tests (i.e., no abnormal results) in the ER? It depends on the situation. Some can safely go home and seek answers in outpatient clinics. Others need hospital admission for further testing or treatment.

Signouts/passoffs are safe.

For any of this to work, ER doctors have to trust one another. If I didn’t trust my colleagues’ judgment, I’d have to start over with all of their patients whose tests are already underway, rather than seeing all of the new patients who just arrived. That said, I see signouts as an opportunity to catch mistakes, or to remind the outgoing doctor to tie up a loose end. So, I see signout as a built-in second opinion for my patients. Still, this process has its dangers and pitfalls.

There is a whole body of literature about ER hand offs—how to do them well, how to avoid making mistakes, and even how to limit the constant interruptions we face while we are trying to make these transitions.

Mistakes are caught during signout. That is part of the process.

Some signouts are clean and there is very little for the oncoming doctor to do. This tends to happen when things are less busy (or when we aren’t too understaffed in comparison to demand). This also depends somewhat on local culture. For example, here in Boston, I’ve found that the culture is to leave less work on patients whose care was initiated by the outgoing doctor, even if that means there are more new patients who have not yet been seen by a doctor at all. In New York, the culture was quite different. There were so many patients at all times that it was preferred that we get the ball rolling on new patients and sign out a bunch of unfinished business, rather than leave more patients for the new doc to start on from scratch.

Still, there are times when signout is a bit of an…adventure. I’ve given suboptimal signouts. I’ve received suboptimal signouts. It happens all the time. I sometimes know that many things have been left incomplete; so I’ll half-jokingly tell the oncoming doctor that I’d like to do a “trial of signout.” What I mean is that in the process of transitioning the care of my patients to the next doctor, I fully expect to discover loose ends that I need to tie up before leaving. The residents sometimes jokingly refer to this as “discovery rounds.” As in, “let’s discover together what has happened, and what has fallen through the cracks!” If this sounds scary, I assure you that it isn’t. If I forget 5% of things I am supposed to have done (usually nothing major, mind you), it’s very likely that either I, my newly arrived colleague, or both of us will notice that thing during signout.

I’ll admit feeling a sense of guilt when a colleague points out something I’ve forgotten about or missed, even though that’s just how the process works. One day I am the safety net for an outgoing doctor; the next day, my colleague returns the favor.

Etiquette on “subpar” signouts.

Despite the fact that discovering loose ends during signout is an expected part of the process, there is still an etiquette to this. Occasionally, I find myself feeling a little, let us say, judged by one of my colleagues, even though I know this is part of the deal. (And I’m sure I’ve unintentionally done the same.)

How do we handle awkward moments when the incoming doctor feels like the outgoing team didn’t do as well as they could have? Disagreeing with a plan is called “pushback.”

Pushback is its own art. For one thing, I always try to soften things by saying something like, “Wow, you clearly all saw a ton of challenging patients today. It’s only natural that not everything got done. That’s what signout is for!” (Sidebar: on this I disagree with my brilliant friend Adam Grant, who recently wrote a Substack about why he thinks “compliment sandwiches” are counterproductive. I think they’re great.)

I’d say there are four levels of pushback.

Level 1 pushback: Saying nothing, or softly asking why something was/was not done. Now, unless I think there’s good reason to tell the outgoing doctor that I disagree with something they’ve done, I may not even mention it. Sometimes, I find myself thinking there’s another test that should be done that had not been. So, I just add it on a few minutes later. Minimal conflict.

By the way, while in general I think we all overtest, it is exceedingly rare for me to de-escalate a plan I am receiving during signout. That’s because the outgoing team saw the patient and spent much more time with them than I likely ever will. So, I assume that they saw something that I did not see (i.e., the patient initially looked worse than they sound now). So, when receiving signout, I almost always leave plans in place, or add to them, rather than canceling any tests. If I say anything at all, it might be, “Would you be opposed to me adding a CT scan?” The reason I might ask is that I’m looking for them to say why they haven’t so far. They might say something like, “We thought about a CT” and tell me why the patient does not need one. If that rationale computes, I’ll abide by it. If not, I may just add it anyway after they leave.

Level 2 pushback: Specifically asking for more to be done before the transfer of care is complete. Sometimes a loose end that needs to be tied up is best done by the outgoing doctor. For example, if a patient is going to the ICU, I should be the one to speak to the ICU doctor, rather than leaving it for the incoming doctor who does not know the patient as well. Asking for a task like that makes good sense. Usually Level 2 pushback centers around incomplete tasks, rather than the questioning of medical judgment. But occasionally you find that you need to go back and re-evaluate the situation before officially handing over the patient’s care.

Level 3 pushback: Sometimes during Level 1 or Level 2 pushback, it becomes clear that a case is more complicated than initially billed by the outgoing doctor. After a little back-and-forth, the incoming doctor may say four words which, honestly, are a not-so-subtle burn. “We’ll figure it out.”

That’s code for, “Okay this case is actually a hot mess but rather than sit here and itemize your unique incompetence, we’ll just start over and get it right this time.” Alright, alright, the connotation is not really that bad, but if someone says “we’ll figure it out,” to me during signout rounds, I die inside, just a little bit.

Level 4 pushback. “Let’s go see the patient.” This is like Level 3 pushback, except in some ways worse. It’s like saying, “This is a mess, and I need you to help me clean it up, since it is your fault.” Again, the connotation is not really that harsh. Recently, I had a very tough case. We’d handled it well, but there were complexities and loose ends that my colleague picked up on during signout. My colleague said those words to me and we walked over to that patient’s bed to discuss the case while we re-examined him. Because my colleague’s delivery was compassionate, I felt supported, not judged. It was more like “Wow, this patient is really complicated and I appreciate everything you’ve done to keep them alive. But I think it would be a safer handoff if we all work on this together for a few minutes before you leave.” I genuinely appreciated it, rather than feeling insulted in any way. That’s probably because that colleague is generous and genuine in giving authentic praise and positive feedback. He puts money in the bank so that when he needs to engage in Level 4 pushback, I’m grateful rather than defensive. (Again, I really believe that compliment sandwiches are a good thing. Or maybe a “money in the bank” analogy is best. If you let someone know that you respect their work, they won’t be as offended when you critique it.)

If all of this sounds like a recipe for mistakes, I assure you that the system works. Signouts are like having an additional safety net. There’s me, the nurses, the techs, the physician assistants, the residents. If we all somehow missed something important and obvious, when the next team comes in with fresh eyes, they’ll see it.

What can you do?

It’s always possible for something to have been forgotten, either before or after a signout. Here are some things that you or family can do to help avoid that:

1. Know what tests are being done and why. If you were told you were getting an X-ray, but you haven’t gotten one several hours later, ask about it. Sometimes the delay is because things are backed up. That’s frustrating but reasonable. Our priority is safety, not speed. But once in awhile, a delay really is because someone like me forgot to sign some order in the computer. So, it’s okay (and good) to ask for updates.

2. Know when your doctor is leaving. I don’t mind being asked when my shift ends. If a patient says, “Will you drop by before you leave?” I almost always will. It’s hard to do that for all of my patients—or else I’d never leave—but if you specifically ask, it’s likely I’ll find a way to do that. That last interaction may last just a minute or so, but it may just jog my memory about something I’d meant to do, or tell the incoming team.

3. Trust but verify. It might feel shoddy to have your care “passed off” to some other doctor. But I am proud to say that emergency medicine training makes these transitions safe for you. I trust the incoming doctor and so can you. So, don’t see handoffs as a bad thing. But, as above, don’t be afraid to ask the incoming doctor for an update.

Now, outside of the ER (in clinics or hospital wards), handoffs are a different beast. But I still think that when done well, they serve as a type of second opinion. While each doctor would like to believe that they are irreplaceable, the fact is that we are often quite interchangeable. I’ve come to believe that this is a good thing.

I’m sure you’re all going to tell me about terrible signouts you were a part of, as either a patient or a clinician. That’s okay. Let’s hear about them and learn together. Please add your comments and questions!