Section 23.7: Avoiding Pitfalls: Over-speaking, Hedging, and Appeals to Authority

23.7.1 The “Why”: The Unspoken Rules of Clinical Credibility

Throughout this module, we have built a comprehensive system for success on rounds. You have learned how to prepare meticulously with the 5-Box system, how to structure your recommendations with SBAR, and how to deliver them using the specific dialect of inpatient medicine. This final section addresses the most subtle, yet perhaps most critical, layer of communication: the psychological aspect. It’s about avoiding the common conversational traps that even the most knowledgeable clinicians can fall into—traps that can inadvertently signal a lack of confidence, create confusion, or undermine the very expertise you are trying to demonstrate.

Your clinical knowledge is the price of admission to rounds. But your long-term effectiveness and your reputation as a trusted colleague are built on how you communicate that knowledge. The medical team is constantly, and often subconsciously, assessing your credibility. They are listening not just to *what* you say, but *how* you say it. Do you sound confident? Are you efficient with your words? Do you demonstrate true understanding, or are you just reciting facts from a guideline? The pitfalls of over-speaking, hedging, and relying solely on appeals to authority are critical to avoid because they directly attack these unspoken pillars of credibility.

Mastering this final layer is the difference between being a good clinical pharmacist and being a great one. It is how you ensure that your brilliant, well-researched interventions are not just heard, but are embraced and acted upon. It’s the final polish that makes your contributions shine, solidifying your role as an equal, indispensable member of the patient care team.

23.7.2 Pitfall 1: Over-speaking – The Enemy of Impact

Over-speaking is the tendency to provide too much information, burying your key message in a sea of irrelevant details, long narratives, or disorganized thoughts. It is the natural enemy of effective communication on rounds. In an environment where time is the most precious commodity, your ability to be concise is a direct reflection of your ability to think clearly. When you over-speak, you are inadvertently telling the team that you haven’t been able to distill the complex patient data into a clear, actionable point. This dilutes the impact of your message and, over time, can cause the team to tune you out.

This pitfall is particularly tempting for new practitioners or those transitioning to a new environment. It often stems from a desire to prove that you’ve done your homework and to share all the interesting facts you’ve uncovered. But you must resist this urge. Your value is not in reciting the patient’s chart; it is in interpreting it. The 5-Box prep system is designed to help you gather all the data, but the SBAR framework is the filter you must use to present only the most critical pieces.

Masterclass: Recognizing and Curing Over-speaking

The Symptom (What it sounds like)	The Root Cause	The Cure (How to fix it)
The Rambling Narrative “So this is a 72-year-old gentleman who came in last Tuesday, I believe, from the nursing home with a cough. They started him on Levaquin in the ED, and then his creatinine started to go up on day two, it went from 1.1 to 1.5, and then yesterday it hit 2.0, so we stopped the Levaquin and started Zosyn, but his white count is still up a little bit today at 12.5…”	Failure to synthesize. You are re-telling the story from the chart instead of presenting your conclusion.	Trust your SBAR. The entire narrative can be condensed. Try this instead: “(S) For Mr. Jones, I have a recommendation on his antibiotic therapy. (B) He is on day 3 of Zosyn for HCAP and has a new AKI with a CrCl of 30. (A) My assessment is that his current Zosyn dose is too high for his renal function. (R) I recommend we reduce the dose to 3.375g q8h.”
The Irrelevant Detail “I’m recommending we switch from IV to oral metronidazole. He’s afebrile, his white count is down from 15 to 11.2, his diet was advanced from clear liquids to soft yesterday afternoon, and the nurse said he ate 75% of his dinner. He also has a history of GERD and his daughter is visiting from out of town…”	A desire to show you know *everything* about the patient. You haven’t filtered the “need to know” from the “nice to know.”	Stick to the critical criteria. The daughter’s visit and the exact percentage of dinner eaten are not relevant to the clinical decision. Try this instead: “I’m recommending we switch from IV to oral metronidazole. He’s clinically improving, afebrile, and is now tolerating a diet.”
The Unfocused “Data Dump” “Okay, for this patient, labs are: sodium 138, potassium 4.2, chloride 101, bicarb 25, BUN 40, creatinine 2.1, white count 14, hemoglobin 10.1, platelets 190. Vitals are stable.”	Reading your cheat sheet aloud without interpretation. This is data reporting, not clinical analysis.	Only mention the data points that are abnormal and directly relevant to your recommendation. Try this instead: “The key overnight event for this patient is the development of an AKI, with his BUN and creatinine rising to 40 and 2.1, respectively. This has implications for his anticoagulation…”

23.7.3 Pitfall 2: Hedging – The Credibility Killer

Hedging is the use of tentative, uncertain, or weak language when making a clinical recommendation. It is the verbal equivalent of shrugging your shoulders. Phrases like “maybe,” “I think,” “perhaps we could,” or “I was just wondering if…” are classic examples of hedging. While these phrases may feel safer or more polite, they have a devastating effect on your perceived credibility. They signal to the team that you are not confident in your own assessment or recommendation. If you don’t sound sure, why should they be?

This is arguably the most common pitfall for pharmacists transitioning into a clinical role. It often stems from “imposter syndrome”—the feeling that you are not as experienced or knowledgeable as the physicians on the team. It can also be a misguided attempt to be overly deferential or polite. However, the medical team is not looking for you to be tentative. They are looking for you to be the confident medication expert. Your job is to have a strong, evidence-based opinion. When you hedge, you are abdicating that responsibility and forcing the team to guess at the strength of your conviction.

Masterclass: Translating Hedged Language into Confident Recommendations

Hedged, Uncertain Phrase	Confident, Professional Translation	Analysis of the Change
“I was just wondering if maybe we should think about changing the antibiotic?”	“I recommend we change the antibiotic.”	This is the most fundamental shift. Replace weak, questioning phrases with a direct statement of recommendation. You have done the work; you have the evidence. State your conclusion.
“I think his creatinine is up, so the dose might be a little too high.”	“His creatinine is up to 2.8, which requires a dose reduction. The current dose is too high.”	Replace “I think” with a statement of fact. Replace “might be” with “is.” You are not guessing; you are interpreting objective data. State the facts confidently.
“Perhaps we could consider discontinuing the pantoprazole?”	“I recommend we discontinue the pantoprazole because the patient no longer has an indication for SUP.”	“Perhaps” and “could we consider” make the recommendation sound like a casual, optional idea. A direct recommendation linked to a clear rationale is far more powerful.
“Sorry to interrupt, but I have a quick thought.”	(Wait for a pause) “I have a safety concern regarding the new warfarin order.”	Never apologize for contributing to patient care. Apologizing diminishes your status. Wait for the appropriate moment to interject and state your purpose clearly and professionally.

23.7.4 Pitfall 3: The Appeal to Authority – Citing “What” Without Knowing “Why”

The appeal to authority is a logical fallacy where one claims something is true simply because a person or source of authority said it is true, without providing any supporting evidence or rationale. In the context of rounds, this often manifests as a pharmacist making a recommendation by citing a guideline, a protocol, or a famous study without being able to explain the underlying clinical reasoning. While referencing evidence is good, relying on it as a substitute for your own clinical explanation is a critical pitfall.

When you say, “We should switch to ceftriaxone because the guidelines say so,” you are essentially asking the team to trust the guideline. When you say, “We should switch to ceftriaxone because the culture grew *E. coli* that is sensitive to it, allowing us to use a narrower-spectrum agent to reduce the risk of C. diff,” you are asking the team to trust *you* and your clinical reasoning. The latter is infinitely more powerful for building credibility. It demonstrates that you are not just a fact-retriever; you are a clinical thinker who understands the “why” behind the recommendation. The team needs to know that you can apply the evidence to the specific patient in front of them.

Masterclass: From Authority Appeal to Evidence-Based Rationale

Weak Appeal to Authority	Strong Evidence-Based Rationale	Analysis of the Change
“We should only continue antibiotics for 5 days. That’s what the CAP guidelines say.”	“Since the patient has been afebrile for 48 hours and is clinically stable, she has met the criteria for a 5-day course of therapy per the CAP guidelines. Studies have shown that longer durations in this scenario do not improve outcomes but do increase side effects.”	The strong response demonstrates that you know *why* the guideline recommends 5 days—it’s based on specific clinical stability criteria and supported by outcomes data.
“The renal dosing guide says we have to cut the dose in half.”	“With a creatinine clearance of 25, the patient’s ability to eliminate the drug is significantly reduced. To avoid accumulation and potential neurotoxicity, we need to reduce the dose by 50%, which is in line with our hospital’s protocol.”	The strong response explains the pharmacokinetic principle (reduced elimination), the specific risk (neurotoxicity), and then uses the protocol as a supporting piece of evidence, not the sole justification.
“The ACCP guidelines recommend against using sliding scale insulin alone.”	“The patient’s blood sugars continue to be elevated, and he’s required the sliding scale three times overnight. My assessment is that this reactive approach isn’t providing adequate glycemic control. I recommend we add a scheduled basal insulin, like glargine, to provide a foundation of control, which is the standard of care.”	The strong response uses patient-specific data (the BG trends) to illustrate the problem and then presents the recommendation as the logical, evidence-based solution.

The takeaway: Use guidelines and protocols to *support* your argument, not to *be* your argument. Your primary role is to apply the evidence to the patient. Always be prepared to explain the “why” behind the guideline. This demonstrates a depth of understanding that builds immense credibility.