The lost art of common courtesy in medicine

27 Dec

by Carolyn Thomas  @HeartSisters

So I showed up for a scheduled medical test at the hospital the other day. It was one of those particularly distasteful tests that involve a full day’s prep at home choking down a range of hideous chemical cocktails, consumption of which is designed to induce explosive liquid diarrhea that requires staying very, very close to a toilet all day long. The procedure itself  on the following morning was right up there on the Creepy Disgusting Embarrassing Cringe Scale of medical experiences.

Hospital procedures like this feel invasive, uncomfortable, distressing, and revoltingly undignified for most patients. All the more reason that medical staff who administer such procedures need to start treating us like we’re more than just the nameless, faceless 10 o’clock patient in Bed 8, what I’ve previously described here as “the obstacle between them and their next coffee break, just a piece of meat on a slab – but worse, an invisible piece of meat.”

Call me crazy, but I might even go so far as to insist that patients deserve to be treated with common courtesy, and let’s start with the simple basics of saying something like:

Hello. My name is _____ and I’ll be doing your ______  today.”

Consider, for example, the young male who greeted me in the hospital’s Medical Imaging Department.

Well, perhaps “greeted” is not quite the right word. Rather, he walked up to my gurney where I lay dressed only in my drafty hospital gown, my I.V. already poked into place in my right arm.  “So you must be Carolyn?” he said aloud, reading from my chart without actually looking up or making any eye contact whatsoever. I replied:

“Yes, I am. And who are YOU? “

He actually seemed surprised that I would have the temerity to engage him like this.  Apparently, he must have missed the “Hello. My name is . . .” basic training on his first-day orientation at Medical Imaging.

But since surviving my heart attack in 2008, I have decided to stop meekly tolerating bad manners from health care providers.

My responses now range from simply stopping them in mid-sentence in order to force them to make eye contact or to introduce themselves or to explain an upcoming procedure, to complaining directly to their department heads (as I detailed in An Open Letter To All Hospital Staff). 

1. My first basic rule of interpersonal health care communication: Do not under any circumstances let a man who hasn’t bothered with the simple human courtesy of introducing himself to you start sticking objects up your bum.

2. My second basic rule of interpersonal health care communication (of particular interest to female heart patients whose cardiac diagnostics/procedures  seem to require more than their fair share of above-the-waist nudity):  Next time you’re ordered to strip to the waist in front of a strange man, he’d better buy you dinner first.

Last year, I wrote about a study reported in the journal, Archives of Internal Medicine, that had examined patients’ preferences of exam room etiquette vs. the actual reality as captured on videotape during the study.  Researchers from Northwest University’s school of medicine interviewed patients and found that:

  • Just over 78% of patients wanted doctors to shake their hands, while about 18% did not (this study was done prior to the H1N1 flu pandemic scare and subsequent warnings to limit public handshakes).
  • Slightly more than half of patients preferred that their first names be used during interactions.
  • About 17% preferred  that the doctor use the patient’s last name.

But when researchers videotaped new patient visits with doctors, they found that:

  • In over half of visits, doctors did not mention patients’ names at all.
  • Doctors did not introduce themselves at all in about 11% of the visits. (This number, by the way, should be ZERO unless the doctor has a bona fide personality disorder, in which case, he/she should not be allowed to practice medicine).

My own experience with medical rudeness is not uncommon, according to Dr. Lyle Fettig, who conducted a survey of patients at a teaching hospital affiliated with Yale University School of Medicine. His study included hospitalized patients as well as physicians of various levels of training (intern, resident, and attending).  Patients were interviewed on the day of hospital discharge, and the physicians were interviewed towards the end of their inpatient month.

His key findings:

  • Only 18% of patients knew the name of the physician in charge of their care (but most physicians assumed the patient knew).
  • 43% of patients could not state their reason for their admission (but most physicians assumed the patient understood diagnosis “at least somewhat well“),
  • 90% of patients reported not being told about adverse side effects of new medications,
  • Physicians were more likely to report that they occasionally spoke in front of patients without including them in the conversation.
  • 58% of patients described physician explanations as “incomprehensible”.
  • Over half of patients reported having anxiety or fears while hospitalized, and of those, 54% indicated that a physician never discussed these fears (but only 2% of physicians reported never discussing patient fears).

Dr. Michael W. Kahn wrote about the need for doctors to smarten up their interpersonal skills for The New England Journal of Medicine*.

“Patients ideally deserve to have a compassionate doctor, but might they be satisfied with one who is simply well-behaved?

“When I hear patients complain about doctors, their criticism often has nothing to do with not feeling understood or empathized with. Instead, they object that ‘he just stared at his computer screen’ or ‘she never smiles’ or ‘I had no idea who I was talking to’.

“I believe that medical education and postgraduate training should place more emphasis on this aspect of the doctor–patient relationship — what I would call ‘etiquette-based medicine.’

“There have been many attempts to foster empathy, curiosity, and compassion in clinicians, but none that I know of to systematically teach good manners. The very notion of good manners may seem quaint or anachronistic, but it is at the heart of the mission of other service-related professions. The goals of a doctor differ in obviously important ways from those of a Nordstrom’s employee, but why shouldn’t the clinical encounter similarly emphasize the provision of customer satisfaction through explicit actions? “

Here, for instance, is Dr. Kahn’s staff checklist for the first meeting with a hospitalized patient:

1.  Ask permission to enter the room – then wait for an answer.

2.  Introduce yourself, showing ID badge.

3.  Shake hands (wear glove if needed).

4.  Sit down. Smile if appropriate.

5.  Briefly explain your role on the team.

6.  Ask the patient how he or she is feeling.

He added:

“Such a checklist has the advantages of being clear, efficient to teach and evaluate, and easy for trainees to practice. It does not address the way the health care provider feels, only how he or she behaves; it provides guidance for trainees whose bedside skills need the most improvement.

“The list can be modified to address a variety of clinical situations: explaining an ongoing workup, delivering bad news, preparing for discharge, etc.”

.

For more on exam room etiquette, see also:

* Etiquette-Based Medicine, Dr. Michael W. Kahn, M.D. N Engl J Med 2008; 358:1988-1989

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15 Responses to “The lost art of common courtesy in medicine”

  1. Dr. Kate Granger March 29, 2014 at 8:38 pm #

    Hi Carolyn,
    I’m a UK Physician in training but also a sarcoma patient. I have very similar experiences so last year launched my #hellomynameis campaign to encourage all healthcare staff to introduce themselves to their patients.

    I believe it is more than a simple common courtesy; I think it is the beginning of a therapeutic relationship, building trust and a human connection in which you as the patient feel comfortable to share your fears and anxieties or to let intimidate examinations happen.

    Kate x

    Liked by 1 person

    • Carolyn Thomas March 30, 2014 at 7:37 am #

      Thank you so much, Dr. Kate, for taking the time to share your amazing campaign with us. I love what you’ve done – and in fact I marvel that no other physician has tackled such an important issue until now. You’re so right – it is far more than simple common courtesy, yet the fact that simple courtesy can be so often ignored in health care relationships is a telling indictment of our system. All the best of luck to you in your own journey.

      Like

  2. Elle M., RN January 27, 2013 at 8:41 pm #

    I have been in the health care field for 30 years; 23 of them as an Intensive Care Registered Nurse with lots of initials after my name that really impress no one ;)

    I may have that “old school” etiquette, as the newbies run around with training that seems to have focused more on data than humanity, but I am a firm believer in giving every patient, family member and medical team member my eye contact and attention early in the interaction.

    This is critically valuable in establishing the relationship.

    There are no words that can replace “I will be your nurse tonight. My name is Elle” (saying my name secondly rarely requires a repeat).

    You can literally see and feel some tension relax when the patient/client is assured of who you are and what your role is in the plan of care without them having to ask.

    And a gentle touch goes far beyond words.

    Like

    • Carolyn Thomas January 28, 2013 at 6:51 am #

      Thanks so much, Elle, for sharing your unique perspective. There are indeed health care professionals who don’t need lessons in common courtesy – I only wish there were more like you.

      Like

  3. Ashleigh Folks March 12, 2012 at 11:40 am #

    Don’t trust people. They’re able to greatness. There isn’t any tips for success. It does not take response to preparation, efforts, and gaining knowledge from failure.

    Like

  4. Dev January 10, 2012 at 5:55 pm #

    Here in the UK, the NHS is notorious for this. People just have no respect anymore, no politeness. Oh well . . .

    Like

    • Carolyn Thomas January 11, 2012 at 8:26 am #

      Hello Dev – there may be many excuses for this lack of politeness, but no good reason for it.

      Like

  5. SUZANNE O'MALLEY December 29, 2011 at 7:24 pm #

    Just btw, re a previous wonderful post of yours ROYALTY NOT IMMUNE TO CHRISTMAS CORONARY: Prince Philip, Queen Elizabeth II’s 90-year-old husband, underwent a successful coronary stent procedure after complaining of chest pains on Dec. 23. For the first time in years, Prince Philip was forced to miss the royal family’s traditional Christmas festivities, spending four days in the Papworth heart specialty hospital near Cambridge. YALE HEART STUDY reminds heart attack survivors to help others get treatment faster by sharing their experiences at https://heartstudy.yale.edu/hacs/

    Like

    • Carolyn Thomas December 29, 2011 at 7:38 pm #

      Thanks for the reminder to participate in the Yale Heart Study during this holiday season, Suzanne! :-)

      Like

  6. MIsurvivorX6 December 28, 2011 at 1:06 pm #

    Carolyn~
    Aren’t you glad you have THAT procedure over with? :) Sorry you had medical staff that matched the unpleasantness of the procedure . . .

    While hospitalized for my last heart attack, I had a rounding cardiologist suddenly appear in the doorway of my darkened room where I lay in bed without wearing contacts or glasses. I was staring at a blurry, dark shadowy form, who made three quick statements and vanished.

    The next day I asked the nurse if she could please give me a heads up when the rounding cardiologist got on the floor and she did. Even though I’d had a heart attack, I pushed a light desk chair across the room next to my bed. Fortunately, the doctor (a different one) came all the way into my room, introduced himself, took a look at the chair, and parked his butt on it!

    He spent a good half hour listening and talking with me, and together got some things worked out with my meds and angina relief. I’ve had numerous hospitalizations, and thanks to the doctor who warmed that chair, I have to say that after this particular discharge I left the hospital with a good head start on recovery and feeling of hope.

    Like

    • Carolyn Thomas December 28, 2011 at 2:49 pm #

      And that is EXACTLY what I’m talking about! In one single hospital stay, you were able to describe both the worst and the best in bedside manner – and just plain kindness. My hunch is that even if the second doc had not been able to spend “a good half hour” with you, just the courtesy of introducing himself, making eye contact and sitting down at your level (not standing above you looking down – a clearly vulnerable position for patients) would have made this interaction far more positive for you. Thanks for telling us this story.
      Cheers,
      C.

      Like

  7. Dr. Anne Stohrer December 27, 2011 at 1:55 pm #

    I absolutely agree with you Carolyn. I am a physician and have recently been a patient (quadruple bypass in October) and met many physicians and staff members who did not identify themselves to me. Many did not wear an ID that could be seen or read. I asked each person I met what their name was and what they did within the system, and sometimes had to explain basic things to them like why they should remove their long white coats and wash their hands before examining me. I was also appalled that most of the clinicians (PAs and fellows) never examined me – we had thirty seconds of brief interaction and they were gone like the wind.

    I would also add to your checklist the use of please and thank you, and asking permission before doing an examination. As an OBGYN I have found this a very powerful tool to build a sense of partnership instead of a power dynamic.

    Thank you for raising this all important issue.

    Like

    • Carolyn Thomas December 27, 2011 at 7:23 pm #

      I hope you continue to feel better following your CABGx4, Dr. Anne. As traumatic as that experience likely was for you, I believe that when doctors become patients, it can be a real shocker to see firsthand how patients are routinely treated (or even mistreated). Welcome to the very exclusive club that none of us ever wanted to join . . .

      Thanks so much for your two extra important checklist tips here.
      Cheers,
      C.

      Like

  8. readytochangenow December 27, 2011 at 5:23 am #

    I spent years being intimidated by doctors until I finally realized they worked for me – thank you for such a great post!

    Like

    • Carolyn Thomas December 27, 2011 at 5:35 am #

      Yes, it’s a relationship not a dictatorship! I prefer to view this relationship as working WITH my doctors.

      Like

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