Are Doctors Just Rude?

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 [1].

It turns out that this problem is not isolated to trainees. Hospitalist physicians also don’t practice etiquette-based communication.

A simple chairAs 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…”

Reference:

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

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Comments

  1. Great post and great point. I truly believe that most health care practitioners are caring…..and are not intentionally rude. I just feel that the economies of scale brought about by the insurance companies reimbursement policies leave LITTLE TIME for the healers to take the TIME to remember to do the LITTLE things that humanize the patient experience and reduce patient anxiety. After sitting in a waiting room for an hour or more….. waiting to be seen…..a genuine smile….a reassuring touch on the shoulder….or a seat in a chair could go a LONG way to improving patient satisfaction.KUDOS to all the health care professionals out there giving the personal touch a real effort.

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  2. George Dawson, MD, DFAPA says:

    A good reason to continue the oral boards. I recall that not introducing yourself and orienting the patient was grounds for immediate failure.

    Another dimension is an attitude problem that is prevalent in some areas and types of medical training and that is that the people with difficult problems are being sent your way in order to make somebody else’s life easier. The terms “dumping” and “turfing” were popularized in a book back in the days when I was an intern. That type of approach to patient care can become quite malignant especially if it’s adopted by senior house staff. Rudeness would be one aspect. Back in the day it was also associated with extreme overwork by house staff and I wonder if the atmosphere is more enlightened now that residency hours are more humane.

    Even back then, the best antidote was an attending physician who could point out that complex problems are not only academically interesting but also professionally satisfying. Not everyone can provide complex care. That same attending can model the appropriate interaction with patients who have problems that demand our closest attention.

    Neutrality is valuable even outside of psychoanalysis and every doctor needs to have it in their toolbox. If you can’t be nice to the patient – don’t even walk into their room.

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