Examining common courtesy among medical residents

Researchers at Hopkins and the University of Maryland learn that medical residents could be better about showing respect

  • Dr. Leonard S. Feldman is a Johns Hopkins Medicine assistant professor and residency program director.
Dr. Leonard S. Feldman is a Johns Hopkins Medicine assistant… (Kim Hairston, Baltimore…)
December 22, 2013|By Jonathan Pitts, The Baltimore Sun

When physician Lenny Feldman visits a hospitalized patient, he said, he does what he can to infuse the encounter with a personal touch.

One favorite technique: sitting at the edge of the bed so he can address his client eye-to-eye.

Their reaction often takes him aback.

"It's not uncommon for a patient to get this panicked look and ask, 'What's wrong, Doc? Is it bad news?'" said Feldman, an internist who also directs the training of medical residents at Johns Hopkins Hospital.

To Feldman, it's troubling that a simple act of respect might be so rare in a hospital that patients don't know how to deal with it. That's one reason he helped lead a study on how courteous doctors are when dealing with inpatients.

If the project's findings are to be believed, the doctors are being downright brusque — a problem doctors agree can affect health outcomes.

Working with researchers from Johns Hopkins and University of Maryland Medical Center, Feldman and fellow lead investigator Dr. Lauren Block, a former colleague at Hopkins, found that internal medicine residents practiced specific acts associated with courtesy even less frequently than either had anticipated, sometimes less than 10 percent of the time.

"Effective communication and good relationships are essential to good medicine, especially when we're dealing with chronic illnesses over time," Feldman said. "Somewhere along the line, on the inpatient side, we stopped being courteous."

Observers measured how often 29 medical residents used five techniques meant to convey respect for patients. Among the findings: the residents only sat down while speaking with patients 9 percent of the time, and they practiced all the respectful actions in a mere 4 percent of encounters.

"This reveals some pretty big deficits in the physician-patient relationship," said Dr. Robert J. Habicht of the University of Maryland School of Medicine, a co-author of the study. "It gives us a chance to focus on finding ways to improve."

An article on the results appeared in the Journal of Hospital Medicine last month.

Feldman and Block decided to explore the matter last year as part of a larger study of how residents are doing under new guidelines instituted by the Accreditation Council for Graduate Medical Education in 2011 that limited the hours in a work shift.

Feldman and company hired undergraduates from Hopkins and Maryland to follow medical residents at those two institutions and study how they were spending those hours. As a smaller slice of that project, Feldman decided to figure out how frequently the residents were exhibiting respect toward patients.

The researchers decided to focus on five physician behaviors a Harvard psychiatrist, Michael W. Kahn, used as criteria for a study he did five years ago on what he called "etiquette-based medicine."

Five ways doctors can convey respect, according to Kahn, include sitting down with the patient, introducing themselves, taking the time to explain his or her role in the treatment plan, touching the patient (offering a handshake or pat on the shoulder) and asking open-ended questions such as "How are you feeling?"

Sitting down, Feldman said, eases the power imbalance that can exist between doctor and patient, introducing oneself and explaining one's role personalizes the hospital experience, touch communicates a sense of well-being, and asking open-ended questions gives patients a chance to be heard.

Research backs him up. A comforting touch has been shown to reduce anxiety levels and improve compliance, and randomized trials have demonstrated that patients believe physicians who sit down are more caring.

Such actions communicate a sense of respect over and above what the physician might or might not say, Feldman said, and create a framework within which doctor and patient can establish an emotional link.

Without that bond, the investigators say, many patients will lack the motivation to follow through on what needs to be done to recover and stay healthy.

"If patients feel you are respecting their opinion, that you're fully invested, there's better potential for them to take part in the [treatment] program," Habicht said.

Feldman and Block made the study a two-institution enterprise so it wouldn't appear that the results were limited to a single residency program. The observers followed 20 residents from Hopkins and nine from the University of Maryland Medical Center, observing more than 700 doctor-patient encounters last January.

The doctors fared best in asking open-ended questions (they did so 70 percent of the time), worst in sitting down with patients. They touched patients 65 percent of the time, introduced themselves 40 percent of the time and explained their role 37 percent of the time.

It was beyond the study's scope to investigate causes, but the researchers have some guesses. Urban hospitals are bustling places, which can divide attention, Feldman and Habicht said. Both cite new federal laws requiring doctors to spend more time doing electronic record-keeping. And though modern medical schools do offer instruction in bedside manner, both say the teaching physicians in hospitals display the behaviors so rarely that residents forget their importance.

If improving things seems a daunting prospect, Feldman believes starting small can help. If hospitals could provide more chairs in patient rooms, for instance, it could make a big difference. And he already has residents posting photographs of the doctors, nurses, therapists and medical students who work on each ward.

"For an internist to be technically good, he or she must communicate well," he said. "It helps if patients know who they are."

jonathan.pitts@baltsun.com

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