Dr. Manners, I presume?

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Dr Val posted last week about doctors needing to go “finishing school” (original article in the NEJM and “mass marketed” via the New York Times) and said that at a minimum, physicians needed to do basic things that should be automatic, especially with common sense applied to a patient (read: vulnerable) situation. The automatic part would be taught as part of the medical school curriculum, with true compassion and sensitivity coming later. In other words, teach the rote mechanics as one would a physical exam, so a bare minimum of [manufactured] rapport can be established.

Dr. Val said

I don’t think that’s related to their medical school curriculae – it’s the sad result of a broken healthcare system that wears thin our common human decency. Doctors are exhausted by clinical volume, henpecked by bureaucracy, delirious from lack of sleep, and stressed out by the daily grind of bad news, disease progression, and death. When well-groomed adults of sound mind require a checklist in order to smile appropriately, you know something’s terribly wrong.

Let’s remember that this is written by a psychiatrist (this will come up again later). The freedom to think, meta-think, and think again is a luxury (and necessity) that is part and parcel with the specialty. A psychiatrist being “overworked” is quite a different thing than, say, a surgeon, physically and time-wise. It’s no wonder that the more “harried” doctors like surgeons and way over-stretched IM-based specialists would most likely fit a “bad doctor” stereotype needing the bullet list given in the article.

Let’s re-look at the list and find out where, if any, each bullet point can get just a tad unreasonable:

• Ask permission to enter the room; wait for an answer.
The physician is not housekeeping at a hotel, and many patients can’t answer. I am guessing the spirit here is to give the patient some privacy and autonomy, but it’s not always appropriate or practical. You think physicians–multiple ones in the same hall at that–are going to yell through a closed door, “Mr. Sanders? Mr. Sanders? May I come in? Are you decent? *wait* *wait* Mr. Sanders? I just want to talk to you, can I do that?” If you stop to think about how it would play out, it’s just comical.

• Introduce yourself; show your ID badge.
Introducing oneself is a must, I agree. But more important than the name is their specialty or purpose. Doctors, nurses, techs, etc. flow in and out as a matter of course; any one person’s name will NOT be remembered on first meeting usually. “The surgeon” or “the heart doctor” means something to the patient, however.  Showing the ID badge is a bit much, but I agree it should be reasonably visible (not hanging all “cool-like” off the scrub bottom’s cargo pocket) should there be a concern, its absence being the true red flag.

• Shake hands.
In normal conversational etiquitte this goes without saying, but not every patient is in a position to shake hands. Patients might have IVs on the dorsum of one or both hands, or be weak where a handshake (particularly coming up from a bed in a supine position) might be taxing. At the doctor’s discretion, perhaps a small pat on the shoulder from above or the like establishes a “connection.” Some patients may be standoffish or even hostile, and with so much to do and accomplish besides some physical token of greeting on top of the verbal one, just skip it already, it’s not worth the trouble. Psychiatrists live for dancing this dance, reading volumes in the smallest gestures and pondering the meanings; most everyone else uses their time on more practical matters.

• Sit down. Smile if appropriate.
This is where the author really jumped the shark. Sit down?! Where, exactly? Most hospital rooms have ONE chair apart from the bed, and a family member is often sitting in it. A doctor is going to sit in the patient’s bed during the interview? This psychiatrist-centered view is starting to really show its limitations and other-worldly approach. After all, psychiatrists are used to being in rooms where there are more chairs than people, so of course, why not sit down?  And what exactly is considered appropriate to smile or not smile?  I smile naturally almost all the time when meeting someone, like a reflex. Some don’t. I’m not going to second guess all of this now.

• Explain your role on the health care team.
Of all the bullet points so far, this is by far the most useful. If there is one thing that confuses the hell out of the poor patient in today’s overly-specialized/referred environment. No arguments here, solid advice.

• Ask how the patient feels about being in the hospital.
After the previous useful directive, we just had to go back to shrink world–it couldn’t last forever. Asking something like this is fine, if it’s worked into the general conversation and there’s oodles of time on everyone’s hands, but asking directly as written is awkward at best. (“It sucks, what do you think!?”) A far better and more reasonable approach would be “Is there anything else you need, any concerns that we haven’t addressed?” — in other words, be practical. Time is of the essence, and one can make a patient feel listened to and respected beyond their disease without falling into an open-ended, potentially never-ending pit of feelings.

I know that some of what I’ve written above sounds insensitive, but it’s done intentionally and not without a little bit of sardonic wit to balance out the candyland view of the author. It’s ironic that the author’s original purpose was to establish a practical workflow to make patients feel more “listened to,” I suppose, but offered a sample checklist that is, in my opinion, beyond impractical. Perhaps this would have been better tackled by someone in another field who sees [non-psychiatric] inpatients on far greater volume. The author himself wrote about being “good enough,” and I think the smallest common-sense steps can get us there.

I know I kind of beat this to death a little bit, but I do feel strongly about not only good physician-patient interaction having been on both sides of the bed, but also I’ve seen quite a bit of “doctor bashing” in the media lately, and it’s unfair. There are definitely bad doctors who need a serious attitude adjustment to be sure, but there are far more good doctors with good hearts and intentions, twisted into an impossible struggle in a no-win environment.  Knocking before entering a room and waiting outside for a patient to get off the phone to receive an answer like “Come in” shouldn’t even be part of the discussion.  Let me know your thoughts.

  • By Dr. Val, December 17, 2008 @ 10:05 pm

    I liked that you made the connection between the odd advice and the perspective of a psychiatrist who doesn’t work in inpatient medicine. Makes perfect sense. I don’t think you were insensitive.

  • By Strong One, December 19, 2008 @ 11:41 am

    I’m agreeing with the message: increasing good patient-physician relationships.
    I think we both agree that there are far more good than bad out there. And I guess that’s the take home message. Most physicians do not fall into this category, but the mere fact that it exists and it’s being tolerated should be enough for all of us physician and patients to do a better job at maintaining a positive environment.
    I also don’t think you were insensitive.
    Great thoughts.

  • By bongi, December 21, 2008 @ 2:14 pm

    if that psychiatrist graded me i’d fail dismally.

    not that this is necessarily my take on it, but i know of a cape town surgeon who told a social worker; “i’ll learn to take a social history when you learn to do an a-p resection.”

  • By Jon Slater, December 21, 2008 @ 6:00 pm

    I’d probably fail on many counts but fwiw…
    - I do knock on the door *as I enter*, introducing myself as the patient sees me – this does give a patient time to get modest or to warn me that (s)he needs time to get dressed.
    - sometimes I knock on the curtain by saying “knock-knock” – not everyone has a private room
    - I *do* sit. If there is no chair, I squat, stand, lean or do whatever I have to to give the impression I have all the time in the world. Paradoxically, I get out faster that way.
    - The rest of it – well, my name tag is often missing, I assume that no one is happy about being in hospital, and I try to treat the patient/parent like a human being. Enjoy your posts

  • By bongi, December 22, 2008 @ 1:07 pm

    let’s face it. each to his own. a psychiatrist needs to speak and appease. i don’t quite understand a paediatrician knocking before entering. an acute abdomen is usually not checking to see if my name tag is straight. the gunshot wounds don’t usually appreciate a ‘how are you doing? and how do you feel about being in the hospital?’

    i’m a surgeon. end up with me and i’m going to hurt you, but it hopefully will be good for you. i’m not there to make you feel better about life. for that go to the shrink that wrote the manners article.

  • By Jon Slater, December 22, 2008 @ 2:30 pm

    Having had the privilege of being a patient, I think a caring attitude is as important as a caring thought. That is what is meant by bedside manner, and for me, it’s part of the medicine. It’s possible to be efficient, and even to hurt a patient in a therapeutic way without humiliating them. My two cents

  • By enrico, December 22, 2008 @ 2:41 pm

    Hmm…the exchange between Drs. Bongi and Slater just inspired my Christmas post! Thanks guys! :)

    (FWIW, as a patient, I do appreciate a quick knock before entering a *closed* door, just because I may be “indecent” going to or from bathroom/shower/etc. I do expect to potentially lose all modesty to healthcare personnel in the line of duty as per my treatment–this isn’t about forgetting I am in a hospital and not a Hilton–but the yokels playing “looksie” in the hallway aren’t part of that deal.) More later…

  • By Laika (Jacqueline), December 23, 2008 @ 6:01 pm

    Mmmm, does this difference in opinion reflect the discrepancy between psychiatrists and doctors, surgeons and other doctors, new world and old world doctors or doctors and patients??

    To me it is unfair and unnecessary to put the shrink with his *odd* advice in one corner and the practicing doctor in the other. It is not a match, not one against the other.

    All Dr. Khan suggests is that medical education and postgraduate training should place more emphasis on “etiquette-based medicine”. The list as he shows it is not rigid: Citation:
    I would propose a similar approach to tackling the problem of patient satisfaction: that we develop checklists of physician etiquette for the clinical encounter. Here, for instance, is a possible checklist for the first meeting with a hospitalized patient..

    The idea of etiquette training was based on complaints of his patients regarding their doctor’s attitude and his own positive experiences with good mannered old world doctors.

    Of course in some situations the list is impractical, it is only meant as a guidance for the first approach of hospitalized patients (no urgency), and for some (like me) it is just common sense.

    The idea of etiquette-based medicine is not unique, i.e. in our hospital the integration of knowledge, skills and attitude are now central to the new curricula. According to the one who teaches it : “What good are doctors who have great knowledge but behave badly? Or vice versa”?!
    (o.k. some surgeons may be pardoned, but only if they are extremely good – they can’t be taught anyway ;) ).

    I’ve wrote about this paper a half year ago, see:
    and the related: http://laikaspoetnik.wordpress.com/2008/05/14/appropriate-bedside-manners/

  • By John, December 23, 2008 @ 11:16 pm

    It truly is amazing that even within the few posts here the surgeons have to go out of their way to puff their virtual chests up…
    Despite the bloggers continuation of the myth that only surgeons and IM residents are overworked, I can see how this list would make physicians uncomfortable.
    As a psych resident, I would like to sit and write down the vital elements of the history, but this is only because my feet are aching from seeing the consults the “overworked” surgeons and IM residents call me with at 4 am when Mrs. Jones is waxing and waning.
    As in life and as in each patient we see, your manners are dictated by the situation. It’s really that simple. I believe our behavior is examined and blown out of proportion by researchers/reporters whom needs a good article.
    And honestly, I wouldn’t want my surgeon to ask me how my day was.. just take out my damn gallbladder and get me out of the MRSA swamp.

  • By bongi, December 27, 2008 @ 12:57 am

    i think i look good with a virtually puffed up chest, john. but thanks for the comment. sweet of you.

  • By me, January 18, 2009 @ 8:14 am

    I agree with you on the shrink writing the article isnt a good authority on this.

    Rather than asking for permission you might ANNOUNCE yourself as you enter the room (might not work as well in a multi-patient room ) esp if your the doc doing rounds with a herd in tow.

    But given that a major cause of death in a hospital is complications from infection esp drug resistant bugs I as your patient would try to avoid the handshaking esp if I cant get up and wash my hands.

  • By Dr. Vikram, August 5, 2009 @ 2:06 pm

    Good article i will rewrite it on my blog as soon as i get time…
    dr. vikram

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