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.