My wife pointed out this CNN article about how resident doctors are just plain rude. The writer cites a media report on a Johns Hopkins study which comments on the study findings, which point to medical interns not doing basic things like introducing themselves to patients, sitting down to talk them eye-to-eye despite research showing that using these interpersonal skills improves medical outcomes .
It turns out that this problem is not isolated to trainees. Hospitalist physicians also don’t practice etiquette-based communication.
As the authors point out in the discussion section of this paper, about two-thirds of patients find a comforting touch from doctors reduces anxiety (and well over half find it healing), yet most young doctors didn’t do that in this study. A randomized trial found that most patients preferred a doctor sit down to talk with them, which was thought to be an indicator of more compassion. But most interns didn’t do that.
The authors speculated that interns don’t engage in these simple behaviors because they don’t see their teachers modeling them.
Now these were medicine interns, provoking the question of whether psychiatry interns might pay closer attention to these etiquette-based behaviors. I can tell you I don’t see it very often.
I think I should point out that chairs are not readily available in many patient rooms. And in the intensive care units, the beds are often elevated to facilitate nursing cares and certain types of invasive procedures.
Residents are used to leaving the room to hunt for a chair for me because I make it a point to try to sit down.
Role modeling is not enough. I need to provide specific feedback and don’t often do it.
I made a point of providing it on the day I read this article and gave them copies. Will that be enough? Probably not. Because of the Hawthorne effect, trainees may behave in the way they think I want them to behave. Then again, there will be those incredibly busy days on the psychiatry consultation service in which we typically do more flying than sitting.
One thing I know. Most resident physicians care deeply about their patients and they tell me that. I also witness their caring behaviors, etiquette-based or not.
The CNN article has a provocative title which probably overgeneralizes about resident physicians. By and large I think most doctors are not rude, at least not intentionally. Hospitals and clinics expect a lot from them and our systems of care are often ill-designed to accommodate the kinds of humanistic behaviors so important to patients and their families.
Most us think, “If only we had the time…”
1. Block, L., et al. (2013). “Do internal medicine interns practice etiquette-based communication? A critical look at the inpatient encounter.” Journal of Hospital Medicine: n/a-n/a.
Etiquette-based communication may improve the inpatient experience but is not universally practiced. We sought to determine the extent to which internal medicine interns practice behaviors that characterize etiquette-based medicine. Trained observers evaluated the use of 5 key communication strategies by internal medicine interns during inpatient clinical encounters: introducing one’s self, explaining one’s role in the patient’s care, touching the patient, asking open-ended questions, and sitting down with the patient. Participants at 1 site then completed a survey estimating how frequently they performed each of the observed behaviors. A convenience sample of 29 interns was observed on a total of 732 patient encounters. Overall, interns introduced themselves 40% of the time and explained their role 37% of the time. Interns touched patients on 65% of visits, asked open-ended questions on 75% of visits, and sat down with patients during 9% of visits. Interns at 1 site estimated introducing themselves and their role and sitting with patients significantly more frequently than was observed (80% vs 40%, P < 0.01; 80% vs 37%, P < 0.01; and 58% vs 9%, P < 0.01, respectively). Resident physicians introduced themselves to patients, explained their role, and sat down with patients infrequently during observed inpatient encounters. Residents surveyed tended to overestimate their own practice of etiquette-based medicine. Journal of Hospital Medicine 2013. © 2013 Society of Hospital Medicine