CHPPC Module 23, Section 3: When to Speak & What to Say
MODULE 23: CLINICAL PHARMACY ON THE FLOORS: MASTERING PATIENT CARE ROUNDS

Section 23.3: When to Speak & What to Say: Timing, Brevity, and Impact

Transforming your clinical knowledge from a passive library into an active, influential force through the art of strategic communication.

SECTION 23.3

When to Speak & What to Say: A Deep Dive

This is where preparation meets performance. Mastering the soft skills of communication is what elevates a good pharmacist to a great one.

23.3.1 The “Why”: The Currency of Clinical Influence

You have performed a masterful pre-rounds workup. Your cheat sheet is a model of systematic data collection. You have identified three significant, evidence-based medication optimization opportunities for your first patient. You possess the correct answer, the superior therapeutic plan. But on rounds, this knowledge, in and of itself, is worthless. Its value is only unlocked at the moment of successful transmission—when you are able to transfer that knowledge from your notes into the mind of the decision-maker in a way that is heard, understood, respected, and, ultimately, acted upon. Communication is the currency of clinical influence.

As a retail pharmacist, you have honed specific communication skills, often centered on patient counseling and prescriber clarification calls. You are an expert at translating complex concepts into patient-friendly language and at performing concise, direct-to-the-point calls to busy outpatient offices. These skills are a phenomenal foundation. However, the communication dynamic on multidisciplinary rounds is an entirely different beast. It is a complex interplay of hierarchy, group dynamics, time pressure, and unwritten social rules.

Learning when to speak and what to say is not about changing who you are or developing a new personality. It is about learning the rules of a new game. It’s about developing situational awareness—the ability to “read the room”—and building a toolkit of communication strategies that you can deploy to fit any clinical scenario. An ill-timed or poorly worded intervention, no matter how clinically brilliant, will be ignored at best and may damage your credibility at worst. Conversely, a well-timed, concise, and confidently delivered recommendation can change the entire course of a patient’s therapy, prevent a catastrophic error, and solidify your role as an indispensable member of the team. This section is dedicated to mastering the art and science of that delivery.

Retail Pharmacist Analogy: The High-Stakes Warfarin Counseling

Think about the first time you had to counsel a nervous, elderly patient starting warfarin. You have a mountain of critical information to convey: the complex dosing schedule, the need for consistent Vitamin K intake, the endless list of drug interactions, the signs of bleeding and clotting, and the absolute necessity of regular INR monitoring.

How do you succeed? It’s not by simply reciting the entire drug monograph at them. That would be overwhelming and ineffective. Instead, you use a sophisticated set of communication skills:

  • You establish rapport first. You make eye contact, introduce yourself, and create a safe space.
  • You assess their current understanding. (“Has anyone ever talked to you about blood thinners before?”) This is you reading the room.
  • You prioritize your points. You focus on the most critical, life-threatening information first (signs of bleeding) before moving on to less urgent details. This is you understanding impact.
  • You use clear, simple language. You avoid jargon. This is brevity and clarity.
  • You check for understanding as you go. (“Does that make sense so far?”) This is ensuring your message has been received.
  • You know when to stop. You sense when the patient is becoming overwhelmed and know to schedule a follow-up call rather than pushing more information. This is mastering timing.

The skills you use in that high-stakes counseling session are the exact same skills required to succeed on rounds. You are simply adapting them for a different audience (a medical team) in a different setting (a fast-paced clinical discussion). You already have the tools; this section will teach you how to use them in this new environment.

23.3.2 Mastering the “When”: The Art of Surgical Interjection

Timing is arguably the most critical and most difficult communication skill to master on rounds. An intervention’s success is often determined less by its content and more by the moment it is delivered. Speaking at the wrong time can disrupt the team’s flow, appear disrespectful, and cause your message to be lost. The goal is to become a master of the “surgical interjection”—a comment that is so well-timed and relevant that it feels like a natural and essential part of the conversation, not an interruption.

The Foundational Skill: The Power of the Deliberate Pause

We introduced this concept in a previous section, but it is so fundamental that it warrants a deeper dive. The single biggest mistake new learners on rounds make is speaking too soon. They hear a piece of information, immediately identify a problem, and feel an urgent need to correct it at that very moment. This is almost always the wrong instinct.

The presentation of a patient, especially on teaching rounds, is a structured performance. The intern or medical student is following a mental script. Interrupting this script to correct a minor detail is like shouting a correction at an actor in the middle of a monologue. It’s jarring and counterproductive.

You must train yourself to listen to the entire presentation, particularly the “Assessment and Plan” portion. Let the presenter finish their thought. Let them lay out their entire proposed plan for the problem you’ve identified. Inevitably, there will be a moment of silence after they finish. It might only be a second or two, but it is a palpable shift in the conversation. In that pause, the floor is implicitly opened for discussion. That is your moment. It feels natural, respectful, and signals to the team that you have listened to their entire thought process before offering your own.

Identifying High-Yield vs. Low-Yield Moments

Not all moments on rounds are created equal. Part of your developing situational awareness is learning to distinguish between a discussion that is ripe for a pharmacotherapy intervention and one that is not. Your time and the team’s time are finite resources; you must invest your communication capital where it will have the greatest return.

Scenario Type Analysis & Pharmacist’s Strategy
The team is discussing the patient’s antibiotic plan after the intern has presented the latest culture data. High-Yield This is your prime time. The conversation is squarely in your area of expertise. The team is actively making a decision about drug therapy. Your input here is expected, relevant, and highly valuable.
The attending is explaining the nuances of interpreting a complex EKG to the medical student. Low-Yield This is a diagnostic teaching moment. Unless the EKG finding has a direct, immediate, and urgent pharmacologic consequence that the team is missing (e.g., QTc prolongation in a patient about to be started on ondansetron), your role is to listen and learn. Interjecting here would be a significant disruption.
The team is discussing the patient’s discharge plan and placement needs with the case manager. High-Yield This is a critical moment for a pharmacist. The conversation is about transitions of care. This is your opportunity to bring up issues like medication cost and access, the complexity of a new regimen, or the need for special adherence aids.
The patient’s family is in the room asking the senior resident detailed questions about the patient’s prognosis. Low-Yield This is a sensitive, physician-led conversation. Your role is to be a silent, supportive presence. Do not offer medication information unless you are directly invited into the conversation by the physician. After the team leaves the room is a better time to address any medication questions that arose.

The High Bar for Interruption

Are there times when it is appropriate to interrupt? Yes, but the bar must be exceptionally high. Interrupting the flow of rounds is reserved for situations where there is a risk of imminent, significant patient harm if you remain silent.

When to Break the Rules: The “Stop the Line” Scenarios

You should only interrupt a presentation for a true “stop the line” patient safety issue. Think of it as pulling the fire alarm. You only do it for a real fire.

  • The Wrong Patient: The team pulls up a chart and begins discussing a plan, but you realize from your notes that they have the wrong patient’s information displayed. You must speak up immediately and politely: “Excuse me, Dr. Smith, I apologize for interrupting, but I believe we’re looking at the chart for John Smith in room 201, not 210.”
  • A Critical, Missed Allergy: The team is discussing starting a carbapenem for a patient, and you know from your detailed pre-work that the patient had a severe, anaphylactic reaction to a carbapenem at an outside hospital that isn’t properly documented in your EHR. You must interrupt: “I’m so sorry to interrupt, but I have a critical safety concern. This patient has a history of anaphylaxis to meropenem. We cannot use this drug.”
  • A Life-Threatening Lab Value: The team is planning to give a dose of IV potassium, but you just saw a new lab value pop up showing severe hyperkalemia (e.g., K+ of 6.8). You must interrupt: “STOP. Pardon the interruption, but a critical lab just came back. The potassium is 6.8. We must hold all potassium.”

In these rare but critical scenarios, the potential for catastrophic harm outweighs the social convention of waiting for a pause. The key is to be firm, clear, and professional.

The Art of “Taking It Offline”

A crucial skill for maintaining the pace of rounds and demonstrating respect for the team’s time is knowing when a discussion is too complex or nuanced for the group setting. These are perfect opportunities to “take it offline.” This is the act of acknowledging an issue, taking ownership of it, and promising to resolve it outside of the rounds format.

Prime Scenarios for an Offline Discussion:

  • Complex Medication Histories: “The patient’s home anticoagulant regimen is unclear from the records. I’ll take that offline, call their spouse and their retail pharmacy, and I’ll get back to the team with a confirmed history and a restart plan this afternoon.”
  • Cost/Access Issues: “The apixaban you’re planning for discharge is an excellent choice clinically, but it may be very expensive for the patient. Let me take that offline to investigate their insurance coverage and see if a prior authorization is needed. I’ll coordinate with the case manager.”
  • Nuanced Therapeutic Debates: “There are a couple of different guideline recommendations for this patient’s secondary stroke prevention. It’s a bit of a complex decision. Let me pull the most recent trials, and I can discuss the pros and cons with you after rounds.”

This technique is incredibly effective. It signals to the team that you are a proactive problem-solver, that you are working on their behalf, and that you respect their time. It allows you to do a proper deep dive into an issue without derailing the momentum of rounds for the other 14 patients.

23.3.3 Masterclass on “What” to Say: The Anatomy of a Powerful Intervention

Once you have found the perfect moment to speak, the content of your message becomes paramount. A powerful intervention is not just clinically correct; it is also structured, concise, and persuasive. It provides the team with a clear problem, a clear solution, and a clear rationale. Mastering this requires moving beyond just stating facts and learning how to frame your knowledge in the most impactful way possible.

The Core Framework: Problem, Solution, Rationale

Every effective intervention, whether it takes 10 seconds or 60, should contain three core components. We introduced this as the “30-Second Intervention,” but let’s break it down further. This is your mental template for every contribution you make.

  1. State the PROBLEM Clearly: Begin by identifying the specific, objective issue you’ve uncovered. This grounds the conversation in data. Avoid vague statements.
    • Weak: “We should be careful with the diltiazem.”
    • Strong: “I’m concerned about the diltiazem dose. The patient’s heart rate has been trending down into the 50s overnight.”
  2. Propose a specific SOLUTION: Don’t just identify a problem; solve it. The most valuable pharmacists provide actionable recommendations. Tell the team exactly what you think they should do.
    • Weak: “We should do something about the diltiazem.”
    • Strong: “I recommend we decrease the diltiazem dose from 120mg BID to 60mg BID.”
  3. Provide a concise RATIONALE: Briefly explain the “why” behind your recommendation. This builds credibility and serves as a teaching point. On a fast-paced non-teaching service, this can sometimes be omitted unless asked, but on a teaching service, it’s essential.
    • Weak: “…because the heart rate is low.”
    • Strong: “…this should keep his atrial fibrillation controlled while preventing his heart rate from dropping further.”

The Full Intervention: “I’m concerned about the diltiazem dose. The patient’s heart rate has been trending down into the 50s overnight. I recommend we decrease the diltiazem dose from 120mg BID to 60mg BID. This should keep his atrial fibrillation controlled while preventing his heart rate from dropping further.”

Using Graded Assertiveness: A Tool for High-Stakes Communication

Sometimes, you will encounter resistance, or you may be in a situation with a steep authority gradient where a direct recommendation feels confrontational. In these moments, a technique called “graded assertiveness” is invaluable. It provides a structured, escalating framework for voicing a concern in a way that is respectful but firm. One popular model is the PACE mnemonic.

The PACE Mnemonic for Graded Assertiveness

PACE provides a four-step escalation ladder for voicing a concern. You always start at the lowest, most collaborative level and only escalate if your concern is not being heard.

  • P – Probe: Start by asking a clarifying, non-judgmental question to open a discussion. This is collaborative and assumes the other person may have information you don’t.

    “I see we’re planning to start enoxaparin for VTE prophylaxis. Can you help me understand the thinking on that, given the patient’s platelets are down to 45?”

  • A – Alert: If your initial probe is dismissed, you can escalate by stating your concern in a more direct, alerting manner, but still framed as your own perception.

    “I am becoming concerned that starting enoxaparin with a platelet count this low could put the patient at a high risk for bleeding.”

  • C – Challenge: If you are still meeting resistance on a critical issue, you must challenge the plan directly and state the problem clearly. The “we” language is still collaborative.

    “We need to find a different solution. It would be unsafe to give a chemical anticoagulant to a patient with a platelet count of 45. The guidelines would recommend we use mechanical prophylaxis instead.”

  • E – Emergency: This is the final step and is reserved for true “stop the line” situations where you must take emergency action if the team is not listening.

    “STOP. I cannot agree with this course of action. For the safety of the patient, we must not give this enoxaparin. If we are proceeding, I will need to call the pharmacy director and the chief medical officer.”

In 99% of your interactions, you will live in the “Probe” and “Alert” stages. The simple act of asking a well-framed question is often enough to make the team reconsider. The higher levels are reserved for rare but critical safety situations.

Framing Recommendations as Questions

A powerful, non-confrontational way to offer a suggestion, particularly on teaching rounds or with a sensitive attending, is to frame your recommendation as a question. This Socratic method invites discussion rather than dictating a plan, and it allows the team to “own” the final decision, which can increase buy-in.

Direct Recommendation Recommendation Framed as a Question Why It’s Effective
“We should switch this patient from IV to PO levofloxacin.” “The patient has been afebrile for 48 hours and is tolerating a diet. Do we think she might be a candidate for switching to oral levofloxacin today?” It presents the clinical data and invites the team to apply the established criteria for IV to PO conversion, making it a collaborative decision.
“This patient needs VTE prophylaxis.” “I noticed we don’t have VTE prophylaxis ordered yet. What would be our preferred agent for this patient?” It points out the omission in a non-accusatory way and immediately moves the conversation to the solution, positioning you as a helpful collaborator.
“The dose of piperacillin-tazobactam is too high for his renal function.” “I calculated this patient’s creatinine clearance to be about 25 mL/min. Should we consider a renal dose adjustment for the piperacillin-tazobactam?” It provides the key piece of data (the CrCl) and then prompts the team to apply their own knowledge of renal dosing, reinforcing a teaching point rather than just giving a command.
Bringing It All Together: From Data-Gatherer to Trusted Advisor

Your journey to becoming an exceptional clinical pharmacist on rounds rests on the integration of the concepts from the last three sections. It’s a three-legged stool, and all legs must be strong:

  • Masterful Preparation: Your pre-rounds workup is the foundation of your credibility. Without a deep and systematic understanding of your patients’ data, your voice has no power.
  • Strategic Timing: Knowing when to speak, when to listen, when to interrupt, and when to take a conversation offline is what makes your contributions feel seamless and respectful.
  • Impactful Delivery: Structuring your interventions with clarity (Problem, Solution, Rationale) and emotional intelligence (Graded Assertiveness, Framing) is what ensures your knowledge is successfully translated into action.

When these three pillars work in harmony, you transition from being seen as a source of drug information to being a source of drug therapy wisdom. You move from being the “pharmacy person” to being an integral, respected, and indispensable member of the patient care team.