standardized patient acting class response paper

EtiquetteBasedMedicine.pdf

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P E R S P E C T I V E

n engl j med 358;19 www.nejm.org may 8, 20081988

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,” “she never smiles,” or “I had no idea who I was talking to.” Dur- ing my own recent hospitaliza- tion, I found the Old World man- ners of my European-born surgeon — and my reaction to them — revealing in this regard. What- ever he might actually have been feeling, his behavior — dress, manners, body language, eye con- tact — was impeccable. I wasn’t left thinking, “What compassion.” Instead, I found myself thinking, “What a professional,” and even (unexpectedly), “What a gentle- man.” The impression he made was remarkably calming, and it helped to confirm my suspicion that patients may care less about whether their doctors are ref lec- tive and empathic than whether they are respectful and attentive.

I believe that medical educa- tion 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 fos- ter empathy, curiosity, and com- passion in clinicians, but none that I know of to systematically teach good manners. The very no- tion of good manners may seem

quaint or anachronistic, but it is at the heart of the mission of oth- er service-related professions. The goals of a doctor differ in obvi- ously important ways from those of a Nordstrom’s employee, but why shouldn’t the clinical encoun- ter similarly emphasize the pro- vision of customer satisfaction through explicit actions? A doc- tor who has trouble feeling com- passion for or even recognizing a patient’s suffering can neverthe- less behave in certain specified ways that will result in the pa- tient’s feeling well treated. How could we implement an etiquette- based approach to patient care?

The success achieved by Peter Pronovost and colleagues in solv- ing a different kind of complex problem — reducing the likeli- hood of central-line infections in critical care patients1 — provides a thought-provoking suggestion. Instead of taking an elaborate, “sophisticated” approach — say, tackling infections by developing more advanced antibiotics or clar- ifying the genetic basis for drug resistance — Pronovost et al. in- troduced a checklist to enforce the use of hand washing, thorough draping of the patient, and other tasks that could be easily per- formed. The results of this sim- ple intervention were swift and dramatically effective. I would pro- pose a similar approach to tack- ling the problem of patient satis- faction: that we develop checklists of physician etiquette for the clin- ical encounter. Here, for instance, is a possible checklist for the first

meeting with a hospitalized pa- tient:

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

2. Introduce yourself, showing ID badge.

3. Shake hands (wear glove if needed).

4. Sit down. Smile if appropri- ate.

5. Brief ly explain your role on the team.

6. Ask the patient how he or she is feeling about being in the hospital.

Such a checklist has the ad- vantages of being clear, efficient to teach and evaluate, and easy for trainees to practice. It does not address the way the doctor 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, and so forth.

Training for an etiquette-based approach to patient care would complement, rather than replace, efforts to train physicians to be more humane. Pedagogically, an argument could be made for eti- quette-based medicine to take pri- ority over compassion-based med- icine. The finer points of patient care should be built on a base of good manners. Beginning pianists don’t take courses in musicianship and artistic sensibility; they learn

Etiquet te-Based Medicine

Etiquette-Based Medicine Michael W. Kahn, M.D.

The New England Journal of Medicine Downloaded from nejm.org on August 13, 2016. For personal use only. No other uses without permission.

n engl j med 358;19 www.nejm.org may 8, 2008

P E R S P E C T I V E

1989

how to have proper posture at the piano and how to play scales and are expected to develop those higher-level skills through a life- time of study and practice. I may or may not be able to teach stu- dents or residents to be curious about the world, to see things through the patient’s eyes, or to tolerate suffering. I think I can, however, train them to shake a patient’s hand, sit down during a conversation, and pay attention. Such behavior provides the nec- essary — if not always sufficient — foundation for the patient to have a satisfying experience.

Furthermore, it’s simpler to change behavior than attitudes. Although reading medically rel- evant literary classics and writing ref lection pieces (as is now done in many medical schools) may make some students more mature

and humane, I wonder whether these exercises are most helpful for those students who arrive at medical school already in posses- sion of those qualities to some degree. For many students, I sus- pect that these exercises may have a more limited effect, if only be- cause they are too brief to allow the student to comprehend, prac- tice, and master the intended val- ues. It isn’t easy to modify a per- son’s character or outlook in a classroom; besides, clinical train- ing is more effective when it re- sembles apprenticeship rather than graduate school. Trainees are likely to learn more from watching col- leagues act with compassion than from hearing them discuss it.

Etiquette-based medicine would prioritize behavior over feeling. It would stress practice and mas- tery over character development.

It would put professionalism and patient satisfaction at the center of the clinical encounter and bring back some of the elements of rit- ual that have always been an im- portant part of the healing pro- fessions. We should continue our efforts to develop compassionate physicians, but let’s not overlook the possibly more immediate ben- efits of emphasizing good be- havior.

No potential conf lict of interest relevant to this article was reported.

Dr. Kahn is a psychiatrist at Beth Israel Dea- coness Medical Center and an assistant professor of psychiatry at Harvard Medical School — both in Boston.

Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter- related bloodstream infections in the ICU. N Engl J Med 2006;355:2725-32. [Erratum, N Engl J Med 2007;356:2660.] Copyright © 2008 Massachusetts Medical Society.

Etiquet te-Based Medicine

The New England Journal of Medicine Downloaded from nejm.org on August 13, 2016. For personal use only. No other uses without permission.