Wednesday, May 14, 2008

When Good Manners Go A Long Way: In Support of Etiquette-Based Medicine

I was reading the Grand Rounds today, when I came across this post written by, “In Sickness and in Health.” This blogger wrote a post in response to an article she read in the May 8, 2008 New England Journal of Medicine titled, Etiquette-Based Medicine by Michael W. Kahn, M.D.

“The article opens with the question: "Patients ideally deserve to have a compassionate doctor, but might they be satisfied with one who is simply well-behaved?" The author goes on to say, "A doctor who has trouble feeling compassion for or even recognizing a patient's suffering can nevertheless behave in certain specified ways that will result in the patient's feeling well treated.”

The author goes on and outlines a checklist of physician etiquette for the clinical encounter and gives a possible checklist for the first meeting with a hospitalized patient.

"The basic manners include:

1. Ask permission to enter the room; wait for an answer.
2. Introduce yourself, showing ID badge.
3. Shake hands (wear glove if needed).
4. Sit down. Smile if appropriate.
5. Briefly explain your role on the team.
6. Ask the patient how he or she is feeling about being in the hospital.”

The blogger, “In Sickness and in Health” argues that etiquette is not quite enough. I am not going to argue with that, but rather, I’d like to offer a different perspective in support of the article. In the article, the author states that perhaps “patients may care less about whether their doctors are reflective and empathic than whether they are respectful and attentive.”


Dear Son has had over fifty hospitalizations since he was born. Most have occurred at Big Academic Medical Center, a large teaching hospital twenty five miles from our home. Over the years, we have had a few hospitalizations that have spanned over thirty days. One in particular was quite stressful and happened a few years back. At that time, Dear Son was vomiting severely and they couldn’t determine what was causing his issues. He had a new g-tube installed in May of that year and had hospitalizations for vomiting in September, October, November and finally December/January of that year.

During that time, several specialties were called into see Dear Son, many of whom I had never met. In addition to the attending physicians, I might have other physician specialties consulted and see them along with the residents and fellows as well for each of them. I stayed with Dear Son twenty four hours a day and the number of hospital personnel that entered my room on a daily basis was over fifty. During that time, I spoke with the Pediatric Attending Physician and told him that each of the residents/fellows needed to identify themselves and their specialty when they came into the room. He agreed and said that he had the conversation with them on several occasions however they still didn’t comply. They didn’t seem to grasp the importance of it. More often than not, they also incorrectly assumed that if they identified themselves once, that I would remember each of them and their specialty no matter what time of the day it was. As the days wore on, and the lack of a definitive diagnosis went on, I became weary. I soon began asking each and every person, their name and their specialty and asked for them to identify themselves when they came into the room. Only then would I answer their questions. (The reason is that once I knew what their specialty was, I could frame my response and better answer their questions.) It would have been an easier hospitalization for me if they had done that.

It’s amazing how those small acts would have had a positive effect on that hospitalization. In addition, I think it’s just good manners for any hospital personnel to do that. During this hospitalization, I was “on” twenty four hours a day. It was hard. Two of the things that were particularly hard for me were: 1) having to talk to someone the minute I woke up and 2) not having fifteen minutes to eat uninterrupted. On one occasion in particular, prior to building the new hospital, they had showers in the room that had a curtain that went around you. I was taking a shower when a nurse came in and asked me several questions regarding Dear Son. I was “in” the shower for goodness sakes! I also remember one day, asking for fifteen minutes to be by myself to eat. Normally, it’s not a big deal when I am there to talk to physicians or anyone, even if I am eating. However, when you are there for weeks at a time, it can be very challenging to be “on” twenty four hours a day. I remember asking a nurse for just fifteen minutes by myself “once” in thirty days. I think the reason it was so hard was because I am not an extroverted person. If I would tell most people that, especially those that know me, they would laugh however it’s true. I am friendly and speak to people however on a scale of 1 to 10, with 10 being extroverted and 1 being introverted, I am about a 6. I need some time to myself every day without anyone around. I crave it. Not having any for weeks, well, that was very uncomfortable.

That hospitalization cost $172,000 and the total for all of them that year exceeded $250,000. The hospitalizations were a result of a medical error by a surgical nurse placing a too large feeding tube in him that not only blocked the stomach opening (hence the vomiting) but caused a ton of abrasions. He had a Vagus Nerve Stimulator implanted at that time and the surgical risk was increased due to the risk of vomiting during the operation. He lost over 10% of his bodyweight and became comatose. On top of that, there was confusion over the hospitalization and our normal doc thought he had been released and I couldn’t get nutrition to authorize a feeding over the Christmas holidays. It was a disaster and the worst hospitalization to date. The repeated hospitalizations weakened Dear Son. He was not able to go to school for nine months following that hospitalization and the tenth month could only attend part time. I could not work during this time since I needed to care for him. He slept almost twenty four hours a day. He lost his ability to weight bear and never was able to weight bear again. He walked on his knees prior to that hospitalization and never walked again after that. I lost a lot of him during that year and never regained it. Today, people assume that since he isn’t hospitalized a lot, that he’s doing well. I remind them that he’s lost a lot of skills over the last few years. If they had asked me how I felt about the hospitalizations, I could have told them.

Etiquette isn’t only nice, sometimes it means a lot. I have learned a lot from Dear Son and over the years, when the lifestyle of caring for disabled individual has worn me down, simple acts of kindness mean a lot. Somehow, stating your name and your specialty and title doesn’t seem like a lot to ask. And that hospitalization, it happened in 2004; I still remember the fact that they didn’t introduce themselves and how I was treated. That’s four years after the hospitalization occurred. Maybe Dr. Kahn is on to something. Thank you Dr.Kahn, for thinking of me.

Note: Time to celebrate-this is my 250th post as Dream Mom!
The picture is of Dear Son at the playhouse last month when we saw the children's play, "The Wizard of Oz" hosted by the local Lions club.


Shannon said...

Happy 250th post!!

I couldn't agree more. Gage has also been in the hospital a lot and as a result we've come across both the best and the worst when it comes to good bedside manner. I've never wanted to overstep my bounds so I haven't directly asked the dr.'s or nurses to identify themselves and their speciality but after reading this I realize that I need to ask them. For myself and for my child.
Thank You for writing this.

Daisy said...

Congratulations on your 250th post!

I think everyone deserves to be treated with courtesy and respect at all times. I wonder what it is about the hospital environment that makes the physicians and other staff forget this?

RunAwayImagination said...

I couldn't agree more.

I lived in the hospital room with my wife Nancy during three 30-day rounds of chemotherapy for Acute Myelogenous Leukemia in 2002. It was impossible to get a decent night's sleep with the incessant sound of the PA system ("WILL DOCTOR SO-AND-SO CALL EXTENSION XXX"), the alarms for her IV pump continually going off and medical personnel constantly entering the room. I also had an embarassing moment when a nurse barged into the room just as I had stepped out of the shower. The disease eventually took her life in the spring of 2003. It became quite obvious to me that the hospital's processes are designed to benefit the hospital, but not the patient.

Very few patients have a 24/7 caregiver. But being in such a role does provide one with a unique perspective on hospital life.

Jaime said...

Congratulations on your 250th post! ;)

Anonymous said...

Happy 250th! Congrats on being published through Reuters!

Sarabeth said...

So many doctors have not been a hospital patient themselves that they don't know how confusing it can get as specialist after specialist enters the room while phlebotomists, nurses, and assistants enter the room.

In fact, your post has gotten me thinking that I should write my own patient story. May I link to you?

Dream Mom said...

Thanks, everyone.

Sarabeth-That would be fine. said...

Dear Dream Mom,

Thank you for your blog, and for this post in particular. I'm in the process of applying to medical schools, and I'm hoping to absorb as many of these kinds of lessons as possible before I'm indoctrinated by the substandard status quo of healthcare etiquette.

I would love to read more posts like this. I know it's a long shot... but do you happen to know of any resources (other blogs, perhaps?) where I could read about the things that doctors do that drive their patients up the wall? (I know this should be intuitive... but sometimes doctors can be a little socially dim, no?)

Thank you again; I wish you and your son the best!

Dream Mom said...

freudchild-Thank you for your comments. I don't have a list of resources however I did write a post that you may find helpful; it's called the, "Top Ten Qualities of a Great Physician". You can find that link here:

The only other thing that I've noticed is that many of the young residents seem to think in terms of straight problem solving and not in terms of what that solution might do to the patient. Two examples that come to mind in our lives are 1) a trach and 2)Ashley Treatment.

Regarding the trach, when my son was in the ICU on a vent, some suggested that he get a trach. While a trach might solve the issue, it wasn't a good solution for my son for many reasons: he couldn't hold his head up so it would always be popping out but the main reason was that it would have broken his spirit. He has so many mental and physical disabiities but that would have done his in, to cut into his body to put that in. It would have been horribly stressful for me as well and would have made our lives horrible. My son was around 18 at the time. Many of the residents and attending ICU docs thought this was a good solution. When I spoke with the Director of Pediatric Pulmonary, she agreed it wasn't the right answer for my son.
It is a viable option for much younger patients.

In terms of the Ashley Treatment (it's a treatment where the parents opted for surgical intervention to prevent a disabled child from growing and keep her small so they could lift her), it's a horrific alternative and something you'd never do to a normal person let alone one with a disability.

Bottom line is to put yourself in your patient's shoes and to treat all patients with disabilities the same as regular ones and not perform treatments that you would not like done on yourself.

Good luck.

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