In the last post we examined the solutions to the problem of disruptive physician behaviour. In this post, the focus is on the standards of physician behaviour when engaging with patients. The subject of professional etiquette has become a cornerstone of medical practice with the realisation that impeccable behaviour is critical to satisfactory and safe patient-doctor relationships.
Physician Barry Silverman took the long view of medical professional etiquette in an article titled Physician behavior and bedside manners: the influence of William Osler and The Johns Hopkins School of Medicine. Pointing out that ‘the accomplished doctor has a bedside manner that is humane and compassionate, empathetic and supportive‘, he criticised the Oslerian approach to bedside manner and drew his lessons on professional etiquette from the historical traditions of medicine. He particularly pointed to the Hippocratic oath which outlines several principles of physician etiquette as it relates to the patient. These recommend that the physician should:
- Have an ‘appearance and approach that is distinguished‘
- Be ‘solicitous‘ in approaching the patient, ‘with head inclined slightly as the art demands’
- ‘Hold his head humbly and evenly’
- ‘Approach the patient with moderate steps, not noisily’
- Gaze ‘calmly at the sick bed’
- ‘Endure peacefully the insults of the patients since those suffering from melancholic or frenetic ailments are likely to hurl evil words at physicians’
Professional etiquette starts the very first time the physician meets the patient, and this first contact was explored by physician Lloyd Kitchens in an article titled Viewpoint: Medical etiquette. After emphasising the importance of appropriate dressing and demeanour, he said ‘it is proper to introduce yourself to the patient, remembering that even in private settings the patient may not know who you are’. He then discussed how the physician should address the patient stressing that ‘how one addresses a patient is critically important and can either make or break the doctor-patient relationship at its very inception‘. He recommended that ‘patients should invariably be addressed by the doctor as “sir” or “ma’am,” or “Mr.” or “Ms.”, cautioning that ‘early use of first names prior to being asked…is highly inappropriate’. He went on to add that the physician should ‘keep the interaction formal, unless and until the ground rules are changed by the patient’.
In a broader view of professional etiquette, etiquette consultants Marisa Torrieri and Aubrey Westgate viewed medical etiquette through the universal principles of old-fashioned good manners. In this regard, Torrieri and Westgate made the following helpful recommendations:
- ‘Ask patients how they would like to be addressed, and address them in that same manner at each visit’
- ‘Apologize for delays and thank patients for waiting’
- ‘Be genuine and smile often’
- ‘Really listen to patients and take action based on what you learn’
- ‘Use words patients can understand’
Many lessons of professional etiquette come from nursing – a profession that also places a high premium on the dignity of patients. Nurse Kathleen Pagana captured the essence of nursing decorum in an article titled 7 tips to improve your professional etiquette. These contained several lessons applicable to medicine which can be classified into 16 do’s and don’ts:
- Dress appropriately and professionally
- ‘Present a positive, professional image‘
- Introduce yourself and be ‘always ready to introduce yourself’.
- Have a confident and firm handshake if this is culturally appropriate
- Address all patients with their titles unless they have given permission to be addressed by their first names.
- Avoid derogatory nicknames such as ‘honey’ or ‘sweetie’.
- Speak softly
- ‘Wait for permission before approaching the patient’s bedside’.
- Ask what more you could do before leaving the patient
- Don’t slouch
- Don’t send the wrong signals with your body language
- Don’t put your hands in the pocket, across the chest, or on the hips
- Don’t use disrespectful language
- Don’t display demeaning behaviours such as outbursts of anger
- Don’t discuss controversial topics or personal problems with a patient
- Don’t criticise other caregivers in front of others
With the increasing recognition of the importance of respectful patient-doctor interactions, the field of etiquette-based medicine has taken root and blossomed over the years. The most frequently cited reference for this is the article by psychiatrist Michael Kahn aptly titled Etiquette based medicine. From the perspective of his time as a patient, he arrived at the view that ‘patients may care less about whether their doctors are reflective and empathic than whether they are respectful and attentive‘. It is from his experience that he conceived the concept of etiquette-based medicine and compiled a simple checklist of its six behaviours for the first meeting with a patient and these are:
- ‘Ask permission to enter the room; wait for an answer’
- ‘Introduce yourself, showing ID badge
- ‘Shake hands (wear glove if needed)
- ‘Sit down. Smile if appropriate’
- ‘Briefly explain your role on the team’
- ‘Ask the patient how he or she is feeling about being in the hospital’
Kahn pointed out that it is far easier to change the behaviour of doctors than to alter their attitudes, and in this regard he thought etiquette-based medicine should ‘take priority over compassion-based medicine‘. He therefore argued that behaviour should take priority over feeling‘, practice and mastery should take priority over character development. In his view, etiquette-based medicine would ‘put professionalism and patient satisfaction at the center of the clinical encounter and bring back some of the elements of ritual that have always been an important part of the healing professions‘.
How well do doctors conform to the principles of professional etiquette listed by Kahn? Sean Tackett and colleagues investigated this when they studied doctors during their daily ward rounds and documented how often they executed Kahn’s six key behaviours. Publishing their findings in a 2013 paper titled Appraising the practice of etiquette-based medicine in the inpatient setting, the authors discovered that the doctors overlooked all six behaviours a third of the time, and ‘not one of the behaviors was performed with a majority of patients’. This indicates that there is a yawning gap in physician etiquette that is yearning to be filled.
We have now completed our review of physician behaviour and etiquette, and in the next post we will look at the effect of doctors’ emotions on patient safety.