Patient perspectives on communication with the medical team: Pilot study using
the communication assessment tool-team (CAT-T)
Laura Min Mercera, Paula Tanabea, Peter S. Panga,*, Michael A. Gisondia, D. Mark Courtneya,
Kirsten G. Engela, Sarah M. Donlana, James G. Adamsa, Gregory Makoulb
aDepartment of Emergency Medicine, Northwestern University Feinberg School of Medicine, United States
bCenter for Communication and Medicine and Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, United States
There is international recognition that effective communica-
tion is fundamental to high-quality patient care [1–7]. In the U.S.,
the Accreditation Council for Graduate Medical Education
(ACGME), American Board of Medical Specialties (ABMS), and
the Joint Commission (JCAHO) have all established communica-
tion as a core competency for physicians [4,8,9]. Despite the
acknowledged importance of communication, assessment of
communication skills in team-based care settings has not been
well established. Traditionally, communication assessment has
focused on communication processes [10,11] and individual
caregivers, despite evidence that effective teams improve both
safety and quality .
Improving communication is particularly important in the
emergency department (ED), where patients experience care in a
seemingly chaotic but well orchestrated team environment.
Communication challenges include multiple hand-offs (informa-
tion exchange to the next shift/person responsible), transitions in
patient care between medical team members, frequent team-
member substitution, 24/7 operations, frequent interruptions,
overcrowding, high-risk diagnoses, time compression, and lack of
previously established provider–patient relationships. We con-
ducted a pilot study to test the feasibility of collecting patient
perspectives of communication with the medical team in the ED.
Our approach was to tailor a psychometrically validated instru-
ment, the Communication Assessment Tool, for use in Team
Patient Education and Counseling 73 (2008) 220–223
A R T I C L EI N F O
Received 13 February 2008
Received in revised form 20 June 2008
Accepted 1 July 2008
Medical team communication
A B S T R A C T
Objective: Effective communication is an essential aspect of high-quality patient care and a core
competency for physicians. To date, assessment of communication skills in team-based settings has not
been well established. We sought to tailor a psychometrically validated instrument, the Communication
Assessment Tool, for use in Team settings (CAT-T), and test the feasibility of collecting patient
perspectives of communication with medical teams in the emergency department (ED).
Methods: Aprospective,cross-sectionalstudyinan academic, tertiary, urban,Level 1traumacenterusing
the CAT-T, a 15-item instrument. Items were answered via a 5-point scale, with 5 = excellent. All adult ED
patients (?18 y/o) were eligible if the following exclusion criteria did not apply: primary psychiatric
issues, critically ill, physiologically unstable, non-English speaking, or under arrest.
Results: 81 patients were enrolled (mean age: 44, S.D. = 17; 44% male). Highest ratings were for treating
the patient with respect(69% excellent), paying attention tothepatient(69%excellent), and showingcare
and concern (69% excellent). Lowest ratings were for greeting the patient appropriately (54%),
encouraging the patient to ask questions (54%), showing interest in the patient’s ideas about his or her
health(53%excellent), andinvolvingthepatientindecisionsasmuch ashe orshewanted(53% excellent).
Conclusion: Although this pilot study has several methodological limitations, it demonstrates a signal
that patient assessment of communication with the medical team is feasible and offers important
feedback. Results indicate the need to improve communication in the ED.
Practice implications: In the ED, focusing on the medical team rather then individual caregivers may more
accurately reflect patients’ experience.
? 2008 Elsevier Ireland Ltd. All rights reserved.
* Corresponding author at: Department of Emergency Medicine, Northwestern
University Feinberg School of Medicine, 259 East Erie, Suite 100, Chicago, IL 60611,
United States. Tel.: +1 312 694 7000; fax: +1 312 926 6274.
E-mail address: firstname.lastname@example.org (P.S. Pang).
Contents lists available at ScienceDirect
Patient Education and Counseling
journal homepage: www.elsevier.com/locate/pateducou
0738-3991/$ – see front matter ? 2008 Elsevier Ireland Ltd. All rights reserved.
2.1. Study design
We conducted a prospective, cross-sectional study during a one
week period in July 2007 and 3 days in October 2007. This study
was processed through the University’s IRB and considered
exempt. However, patients were asked to participate only after
hearing a description of the project and providing verbal consent
[see textbox 1 for background considerations to study design].
2.2. Study setting and population
The study was conducted in an academic, tertiary, urban, Level
1 trauma center with over 75,000 ED patient visits/year, an
approximate 20% hospital admission rate, with 40% of ED patients
evaluated in the ‘‘fast-track’’ (urgent care) area. All adult ED
patients (>18 y/o) were eligible if the following exclusion criteria
did not apply: primary psychiatric issues, critically ill, physiolo-
gically unstable, non-English speaking, or under arrest. Interviews
were conducted in the ED either in an exam room or a secluded
private area within the ED.
2.3. Study protocol
Data collected represents a convenience sample of patients
based on research assistant availability. Enrollment occurred
during eight (4 day, 3 evening, and 1 overnight), 10-h shifts,
mirroring residents’ shifts schedules. These shifts were chosen as
senior residents guide patient care through extensive contact
with the patient, nurses, other medical team members, and the
attending physician. The research assistant conducted structured
interviews with individual patients immediately following
discharge or upon assignment of a hospital bed. Interviews took
place in the ED either within the patient’s room or in a secluded
ED hall area. The structured interview consisted of informing the
patient that questions pertained to the medical team and
defining the medical team as ‘‘all those who have taken care of
you in the ED today’’, the CAT-T, with additional items designed
to collect demographic information (age, race, gender), self-
reported ratings of wait times, identity of residents and staff
physicians, ED disposition (admit, discharge), treatment area
(main area, urgent care), and frequency of ED use (never, once,
more than once).
2.4. Key outcome measure
Patient perception of communication with the medical team
was gauged via an adaptation of the Communication Assessment
Tool (CAT), a previously validated instrument developed to assess
The CAT includes 15 items and a 5-point response scale (1 = poor,
2 = fair, 3 = good, 4 = very good, 5 = excellent). It was originally
designed to assess patient perceptions of an individual physician’s
communication effectiveness. The CAT was field tested with 950
patients and 38 physicians across multiple specialties (dermatol-
ogy, family medicine, neurosurgery, ophthalmology, orthopaedic
surgery, physical medicine and rehabilitation) .
The CAT was adapted for Team environments (CAT-T) by
making minor changes in the instructions and item-stems to
broaden the focus of assessment from a single doctor to the
medical team. First, references in the original CAT to ‘‘your doctor’’
or ‘‘the doctor’’ were changed to ‘‘your medical team’’ or ‘‘the
medical team’’. Second, the stem of item 15 focused on ‘‘The
doctor’s staff’’ in the original CAT and was changed to ‘‘The front
desk staff’’ in the CAT-T. The wording of the 15 items was identical
in both the CAT and the CAT-T (see Appendix). Consistent with
previous research on the CAT, results are reported as percentages
of ‘‘excellent’’ responses . This scoring is based on the original
CAT where patients’ percent excellent (scores of 5) correspond to a
‘‘yes’’ answer while percents non-excellent (scores of 1–4)
correspond to a ‘‘no’’ answer .
We screened 105 patients: 81 were enrolled, 12 refused, and 9
were missed because they were occupied (e.g. sleeping, talking on
phone). Patients refused to participate for multiple reasons
including public transportation issues, in a hurry to leave, or
apparently dissatisfied with care. The81 participants rangedin age
from 18 to 90 (mean = 44, S.D. = 17); 44% were male. Approxi-
mately three-quarters of the participants (74%) were discharged
home, with the remainder either admitted to the hospital or to the
the main care areas vs. 43% in urgent care.
In general, the CAT-T was administered in 5 min or less per
patient; this includes time for explanation, verbal consent,
administration of the survey instrument, and thanking the patient.
Pilot-test results are presented in Table 1. Highest ratings were for
Pilot study results for communication assessment tool-team (N = 81)
CAT-T item % Excellent scoresConfidence interval (%)
The medical team:
1. Greeted me in a way that made me feel comfortable
2. Treated me with respect
3. Showed interest in my ideas about my health
4. Understood my main health concerns
5. Paid attention to me
6. Let me talk without interruptions
7. Gave me as much information as I wanted
8. Talked in terms I could understand
9. Checked to be sure I understood everything
10. Encouraged me to ask questions
11. Involved me in decisions as much as I wanted
12. Discussed next steps, including any follow-up plans
13. Showed care and concern
14. Spent the right amount of time with me
The front desk staff:a
15. Treated me with respect 67 54–79
aThis question was only asked in the July 2007 enrollment period (N = 52).
L.M. Mercer et al./Patient Education and Counseling 73 (2008) 220–223
treating the patient with respect (69% excellent), paying attention
to the patient (69% excellent), and showing care and concern (69%
excellent). Lowest ratings were for greeting the patient appro-
priately (54%), encouraging the patient to ask questions (54%),
showing interest in the patient’s ideas about his or her health (53%
excellent), and involving the patient in decisions as much as he or
she wanted (53% excellent).
4. Discussion and conclusion
This ED pilot study is the first to utilize the CAT-T within the ED
and to explore patient perspectives on communication with the
medical team. Items in the CAT and CAT-T correspond to specific,
relevant communication tasks (e.g. ‘‘talked in terms I could
understand’’). Accordingly, results target actionable areas for
improvement. Additionally, this study demonstrated feasibility of
CAT-T administration in the ED suggesting a method that similar
team-based programs can use to assess the communication core
competency established by the ACGME, ABMS, and JCAHO.
Scores were lower overall than those reported in the original
CAT study, which was not performed in an ED setting . By
focusing on the medical team, CAT-T results may better reflect the
patients’ overall ED experience. Unlike traditional outpatient
settings, where a physician–patient encounter typically has a clear
beginning and conclusion, the nature of acute emergencies, lack of
previously established relationships, and operational processes of
emergency care delivery adds other dimensions to this interaction.
care assistants, laboratory or radiology technicians, transport
personnel, volunteers, consultants, and others. This environment
presents challenges for effective communication. While larger
studies are needed, it is clear that measuring team performance
emphasizes both the importance of individual interactions and the
need for a coordinated, well-led team. All team members must
ensure that respect, information, and involvement are offered to
each patient. Ideally, team members would encourage each other
as individual performance is necessary, but insufficient. Measuring
team performance and being accountable for the results implies a
higher level of responsibility; it requires leadership.
This pilot study had several limitations [see textbox 1].
Convenience sampling and limited sample size may have
introduced bias. The weekend population was not interviewed
and only two overnight shift patients were captured after multiple
screening failures, which may reflect a unique population subset.
Our findings cannot be generalized to these or other populations.
Future studies should enroll subjects from a more varied and
representative time frame. While the original CAT was psychome-
trically validated, this is the first time the CAT-T has been used and
this modification itself has not been validated. At present, there is
no established benchmark to determine whether particular
percentages of excellent scores have clinical meaning or compara-
will inform future educational initiatives, followed by post-testing
for comparison. In addition, surveys were administered face to
face, thus social desirability may have influenced scores. However,
research staff as opposed to clinical staff conducted the interviews
and overall, scores in the ED were lower compared to other CAT
administrations. This might reflect the reality of care in the hectic
To the best of our knowledge, this is the first study to assess
communication skills of ED teams from the patients’ perspective.
Focusing on the medical team is consistent with daily ED clinical
practice. Data from this study suggest that the CAT-T is feasible for
use in a busy team-based care environment. Moreover, the CAT-T
identified specific target areas for development of educational
programs for ED team members.
4.3. Practice implications
While focusing on the medical team rather then individual
caregivers may more accurately reflect patients’ experience, further
and suggests multiple areas for further education and research.
This project was supported by the Ken M. Davee Foundation.
Also supported [PSP], in part, by the Augusta Webster Grants for
Innovation in Medical Education and the Chester B. Tripp
Endowments, Office of the Dean, Northwestern University Fein-
berg School of Medicine. The Davee Communication Group would
like to thank research assistants Jordan Duval-Arnould, Nicole
Klekowski, Jennifer McCormick, Justin Steinberg, and Elena
Department nurses and staff.
Textbox 1—Underlying considerations for use of the CAT-T in
1. Assessment tools are needed, especially as medical educa-
tion move towards competency based learning/assessment.
2. Individual assessments would best capture one-to-one
interactions. However, feasibility (for example, asking
emergency medicine programs to have resources available
to capture the exact moment after one provider concluded
vs. the entrance of another) was also considered. In addition,
patients receive and provide information to multiple
caregivers in different ways, reflecting clinical reality.
3. An informal validation process of the CAT-T, with our ED
advisory group made up of former patients and volunteers,
was conducted to ensure face validity of this method to
capture caregiver’s communication from the patient’s per-
4. Although individuals would have varying levels of impact on
responses, we wanted to emphasize the importance of team
the limitations of this method by attempting to best reflect
daily clinical practice, it reflects the patients experience and
perception of communication from caregivers.
5. Our goal, and current ongoingeducational initiative, has been
RNs, MDs, residents, techs, unit secretaries, registration
personnel, and volunteers), to emphasize teamwork, the
importance of every individual role in communication, and
how individual interactions culminate in a patients overall
experience. Through focus groups, adult-education learning,
and participatory research, we are currently designing
solutions to improve.
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Appendix A. Communication assessment tool-team (CAT-T)
Communication with patients is a very important part of quality medical care. We would like to know how you feel about the way your
medical team communicated with you. Your answers are completely confidential, so please be as open and honest as you can. Thank you very
PoorFair Good Very goodExcellent
Please use this scale to rate communication during this visit. Circle your answer for each item below.
The medical teamPoor Excellent
1. Greeted me in a way that made me feel comfortable12345
2. Treated me with respect12345
3. Showed interest in my ideas about my health12345
4. Understood my main health concerns12345
5. Paid attention to me (looked at me, listened carefully)12345
6. Let me talk without interruptions12345
7. Gave me as much information as I wanted12345
8. Talked in terms I could understand12345
9. Checked to be sure I understood everything12345
10. Encouraged me to ask questions12345
11. Involved me in decisions as much as I wanted12345
12. Discussed next steps, including any follow-up plans12345
13. Showed care and concern12345
14. Spent the right amount of time with me12345
The front-desk staff PoorExcellent
15. Treated me with respect12345
L.M. Mercer et al./Patient Education and Counseling 73 (2008) 220–223