Interns observed interacting with hospitalized patients exhibited five basic behaviors associated with etiquette-based medicine during only 4% of all encounters.
Medical interns rarely bother with common acts of courtesy when they meet their patients in the hospital, but are often unaware of it.
That's according to a study of how 29 interns interacted with 732 patients hospitalized at Johns Hopkins Hospital and the University of Maryland Medical Center during one month, January, 2012.
"I don't think the interns are actively trying to be rude or mean," says Leonard Feldman, MD, principal author of the paper published in this month's Journal of Hospital Medicine. "I just don't think they're thinking about the fact that they should be courteous and polite, especially when they're worried about their patients' issues of morbidity and mortality, like a possible heart attack or pneumonia."
In the study, interns failed to introduce themselves at the start of 60% of their patient encounters, failed to explain what role they play in their care with 63%, and failed to touch 35% of their patients either with a handshake or other reassuring gesture or with a physical exam. They failed to sit down to talk with 91% of their patients, and failed to ask 25% standard open-ended questions to elicit conversation that reveals more about the patients' problems and makes them feel more comfortable.
The five actions are components of what is termed "etiquette-based medicine" by Michael Kahn, MD, in a 2008 article in the New England Journal of Medicine.
Interns performed all five of these behaviors during only 4% of all encounters.
Feldman and his co-authors studied encounters between 29 interns and 732 patients with the use of 22 undergraduate pre-med student observers, most of whom were paid about $10 an hour to watch those encounters and document the five behaviors.
Interns at Johns Hopkins were then asked to estimate how frequently they performed those same five behaviors. And for three of the five, the interns overestimated the percentage of times they complied by more than 50%. For example, interns said they introduced themselves to their patients 80% of the time but student observers saw them doing it during only 40% of their patient encounters. Interns said they explained their role 80% of the time, but observers found they did so in only 37%.
Feldman, an associate program director of the Johns Hopkins internal medicine residency program, says that apart from perhaps helping the hospital score better on patient experience surveys, how well interns engage with their patients may very well be a quality of care issue that might be linked to better patient outcomes.
"With internal medicine in particular, especially these days, it's all about chronic medical problems and chronic care, where much of what we need to do is motivate the patient to provide self-care and self-management to improve their health over the long term," he says. "You can't do that if you're not connecting with the patient very well."
These courteous steps might be alright if all the doctor is doing is giving a patient with pneumonia a prescription for antibiotics. "But if you want to figure out why the patient has pneumonia, perhaps an occupational exposure or some underlying issue," he says, "then having a good doctor-patient relationship probably matters."
Without that connection and encouragement, Feldman says, the hospitalist physician or intern is merely treating the acute illness, which may lead to a readmission, or worse. "We should be trying to treat them and send them on a road to a healthier lifestyle."
So who's fault is it that these new doctors in training aren't extending common courtesies to their patients? The problem, Feldman says, is generally the fault of the attending physicians, or what he calls "role modeling."
"Often, we as attending physicians role model behavior that I would consider —if you want to call it rude, I think that would probably be reasonable. We're not being polite, not showing common courtesy."
He adds, "when I'm the attending physician, I walk in on rounds with the whole team, introduce myself and put out my hand to shake the patient's hand, and then make the intern who is going to present the case sit down with the patient in a chair next to the bed. I'm showing them how I think it should be done. And they go, 'You know, that's how Dr. Feldman does it, so I should be doing it that way.'
"We teach this in medical school, but then we don't do a good job following up with that in residency education."
Feldman emphasizes that interns should introduce themselves and engage in all four other behaviors during every patient encounter, even if they have seen the patient before. That's because for any patient hospitalized, the experience "has got to be daunting. They've met several emergency room physicians, the intern that's going to take care of them, the whole Hopkins team that rounds the next morning, possibly a pharmacist, a case manager, social worker, a head floor nurse, senior residents, attendings, and maybe a specialty consultant or surgeon.
"So it shouldn't be a lot for us to take 10 seconds to say who we are. If I introduce myself again and the patient says, 'Of course I know who you are Dr. Feldman,' then I know I've done my job."
One project that has been tried at Johns Hopkins Hospital's pediatric department is called "face sheets." Patients and their families are given a page with photos of every physician on the patient's care team with their titles, and a description of their role in that patient's care. "You hand that out when you meet the patient for the first time as if to say, 'Here I am on this piece of paper, and you can look at the back and see what I do."
Feldman says that something so simple as placement of a chair by the bed that the intern can sit on to be at eye-level with the patient can help enormously.
That's done so infrequently now that when Feldman finds a chair and sits with a patient, they often ask if something's wrong, "Am I going to die?"
"They shouldn't think something terrible is going on because someone is taking the time to just sit with the patient," he says. "That's some of the culture we need to change. Patients should expect us to sit with them.