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Manners for MDs

Does your doctor have good manners? And how much does that matter to you?

We depend on physicians to analyze our symptoms, make diagnoses and spell out treatment plans. It's nice when they can do all that with a well-developed bedside manner. At the very least, we expect them to be civil.

But Michael Kahn, a psychiatrist at Beth Israel Deaconess Medical Center in Boston and assistant professor of psychiatry at Harvard Medical School, detects a deficit in doctors' manners. In the current issue of the New England Journal of Medicine, Kahn reports, "When I hear patients complain about doctors, their criticism often has nothing to do with not feeling understood or empathized with. Instead, they object that 'he just stared at his computer screen,' 'she never smiles,' or 'I had no idea who I was talking to.'"

Kahn goes on to say that when he himself was recently hospitalized, he was treated by a European-born surgeon whose presence and demeanor he found "impeccable."

"I wasn't left thinking, 'What compassion,'" Kahn notes. "Instead, I found myself thinking, 'What a professional,' and even (unexpectedly), 'What a gentleman.'"

Kahn suggests that patients "may care less about whether their doctors are reflective and empathic than whether they are respectful and attentive."

Medical schools already try to teach doctors to be compassionate and humane. But, Kahn argues, that may be easier said than done; some people are more naturally compassionate than others, and it might not be possible to teach compassion to those who aren't inclined that way.

That's where Kahn's notion of "etiquette-based medicine" comes in. He proposes a manners checklist, a simple document that spells out the basic things a physician should say and do when meeting with a patient. Kahn's model 6-point checklist includes such items as "Ask permission to enter the room; wait for an answer," "Shake hands (wear glove if needed), " and "Sit down. Smile if appropriate."

Kahn's checklist is inspired by the work of Johns Hopkins University School of Medicine professor Peter Pronovost, who designed a checklist that has drastically reduced the number of infections in critical-care hospital patients. (Like Provonost's, Kahn's list is aimed at doctors treating patients in hospital, but he says it could be used in clinics and private offices, too.)

"It's not like doctors are bad people," Kahn told me on the phone. "It's just that these courtesies get overlooked."

So, let's hear some stories. How polite are the doctors you deal with? How much does it matter to you? And do you think it affects your care and recovery?


By Jennifer LaRue Huget  |  May 13, 2008; 7:00 AM ET
Categories:  Hospitals  
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Comments

If I eventually get in to see a doctor, I have no problems. My primary care provider is only in his office two days a week. If I want to see him, I have to schedule for those days. Otherwise, another doctor in his group will see me. THen appointments are scheduled in 10-minute increments. You only have ten minutes with your doctor if they aren't dashing between exam rooms. Then there's the dermatologist -- I a year or so ago I had spots on my forehead that look suspicious. The local dermatologist was booked FOUR MONTHS in advance! I called a doctor in Annapolis (47 miles away) and only had to wait TWO MONTHS to see a doctor there. (I understand they prefer botox patients and see them first because that treatment is paid for up front and no insurance paperwork.)

On the other hand, my ob/gyn (a female) is great. Very friendly, explaining what's going on, answering questions. I've never had a problem with an ob/gyn.

Posted by: Southern Maryland | May 13, 2008 9:15 AM | Report abuse

In 1976-77, going through divorce, I had a "melt-down," was diagnosed as in clinical depression which, with help from an amazing behavioral psychologist, I came out of whole, sane, and a better person. Thirty years later, during a routine check-up, my new ob/gyn asked, out of the blue and with a smirk, "Had any nervous breakdowns lately?" He seemed to think this was funny. If it isn't on the list, I propose another "rule": do not denigrate a patient's past difficulties, whatever they may have been. This fellow, I believe, was using his question as a way to let me know he'd done his homework i.e. had read my "jacket," but it certainly was a bad way to do it!

Posted by: Senior in Boise | May 13, 2008 9:40 AM | Report abuse

Keep in mind, as you whine about the lack of "courtesy", that the doctor is probably working a 60-70 hour week, and doesn't have a lot of time to spend on you because the crappy reimbursement he gets for any given patient means he has to see a patient every 10 or 15 minutes just to break even.

Posted by: Lugo | May 13, 2008 9:50 AM | Report abuse

The doctor finally showed in the examining room and I was in the middle of my explanation of the problem. Cell phone rings. Doctor stops our conversation and takes the call. It was his wife trying to finalize DINNER plans with another couple and the plans on what to do about a babysitter. Somehow I felt that call could have waited. If it had been the hospital calling to let him know the OR shedule had been set, that would have been different. Never went back.

Posted by: InVirginia | May 13, 2008 9:54 AM | Report abuse

OH, and then there's the time I was having heart palpitations and was on a Holter monitor. The 10-minute doctor ordered an echocardiogram. When I showed up for that appointment (taking time off from work) the technician who was to do the procedure had to leave work and go home to referee a fight between her teenaged daughters. I had to reschedule because nobody else in the office knew how to operate the echocardiogram equipment. More time off from work because this woman had kids who were fighting.

Another thing that bugs me -- why do doctors' offices 'close down' during their lunch hour? About the only time we can call for test results is at lunch and then we get a recorded message that they are closed for lunch. Can't they stagger their lunch so somebody covers the phone? DUH!

Posted by: Southern Maryland again.... | May 13, 2008 10:10 AM | Report abuse

I think we all let our manners slide a little sometimes. I know I've been catching myself with my elbows on the table at meals, and I'm certainly old enough to know better! Medical folks are humans just like the rest of us -- so I'm sure a little manners refreshment is probably in order.

Posted by: RoseG | May 13, 2008 10:38 AM | Report abuse

The experiences I've had have ranged from the sublime (the oncologist who generously and patiently fielded many questions from my family and boyfriend) to the ridiculous (the senior resident who, after examining me following a severe back injury, breezed our of the room and left me standing with my pants around my ankles, saying, "The nurse will have to help you.") Some people get it, some don't, and that applies to men and women in all professions. I agree with Lugo that doctors work very hard and, because of the reimbursement policies of the insurance companies, are on a constant treadmill. However, courtesy and kindness are free and add positive energy to everyone's day.

Posted by: Volnole | May 13, 2008 10:50 AM | Report abuse

Following a startling diagnosis of cancer, my husband's soon-to-be ex-urologist just blurted out scheduling and surgical info - without making eye contact even once. He sat at his desk staring into my husband's brand-new file. I sat up straight, pointed my finger at him and said, "I ask a lot of questions. Do you have a problem with that?" Apparently that woke him up - but his brusqueness and absent caring manner have led us to seek another urologist for his continued care.

Posted by: formerdc girl | May 13, 2008 11:00 AM | Report abuse

Lugo, no doctor I know works 60-70 hours a week unless he's attached to a hospital and is 'on call.' Mine only works 3-4 days a week. Any other time another doctor in his practice sees his patients. That's why they join a group and 'cluster up' so they can cover for each other and golf or go boating the rest of the time.

Posted by: Anonymous | May 13, 2008 11:31 AM | Report abuse

When I am given a nurse practitioner to see, passed off as an MD, and she dismisses low blood sugar issues by saying "I don't believe in hypoglycemia", then we have something REALLY wrong with our health care system, because these pseudo-docs are handling more of the general practice load. Following difficult retina repair, my mother reported to her eye doctor that she had a partiular problem remain months after surgery. It was breezily blown off as 'not an issue'. Upon seeing another specialist a few months later, it was determined that a repair reported as 'fixed' in patient record was in fact, not repaired at all. This is blatant malpractice and worse, dismissal of valid patient concerns. I find many practitioners quasi-competent as diagnosticians, probably because they allocate so little time per patient. This is NOT valued service worth the stiff cost of health care premiums. I am more concerned over quality of service, rather than the manors that accompany that service.

Posted by: Credo | May 13, 2008 12:01 PM | Report abuse

An ex-orthodonitist used to have such godawful beside manner, making sarcastic comments or saying "you should know that" instead of actually answering our questions, and then claiming he had not said something he had said the appointment prior (he'd said I could stop wearing my bottom retainer, and then rescinded this at the next appointment). When he told the patient next to me (well within my earshot since the office was set up so he could dash between multiple chairs at once) that he was going to have to "clean out [their] mouth with a toilet brush" if they didn't learn to clean their brackets better, I decided that I was not going back to that doc. There are times when humorous sarcasm and glib answers can be just fine -- but those fall under *social* situations with friends/family circles in which that's accepted, not doctor-patient appointments involving patient care.

Worst part? This guy still practices, I passed his new office on the way to an errand the other day. UGH.

Brusque I can deal with. Downright insulting I can't and won't. You may be a perfectly competent doctor, but if you cannot communicate effectively *and respectfully* to your patients, they will not be able to participate fully in their own home-care and thus the quality of the overall care received declines rapidly.

Posted by: Anonymous | May 13, 2008 12:07 PM | Report abuse

I'm relieved when a psychiatrist can reassure that "It's not like doctors are bad people", because there WAS a part of me that wondered if physicians spend between 10-15 years their elemental youth working an unreasonable number of hours for absolute peanuts, helping the poor, uninsured and marginalized, all so that they can get to that "paycheck point" when they no longer have to care, and can sit in their cush lairs, twist their moustaches and hatch plans to deprive their clients of their money and physical well-being.

This column and the responses it has engendered, is a reflection of our society's convoluted view of medicine. Americans have a love-hate relationship with their doctors, and this is rather unique in the industrialized world.

Here's an update for you: it is extremely likely that your doctor has worked much harder in his/her life than you have in yours. Furthermore, that hard work was not in the pursuit of riches (which would've been far more easily obtained in other markets), but rather in the interest of his fellow man. It is probable, though not certain, that you have not done as much for the human condition as your physician has.

So what's my point? Don't treat your doctor like the cashier at Burger King, not that the latter deserves the sort of casual abuse that they get. If your doctor doesn't seem to be wearing his Burger crown today with a super-chipper smile, and isn't gazing presciently into your soul, this very minute, entertain the possibility that they have had a hard day. Because this individual has a tough job, makes decisions that alter people's lives, and USUALLY does not get thanks for it.

If the tone of my response strikes you, interpret it not as indignation, but as profound irony at a column extolling the need for physician manners and compassion, in a culture that is so pervasively devoid of such principles, in return.

Posted by: Ken Naciamento | May 13, 2008 2:14 PM | Report abuse

Went to a fancy DC dermatologist's office. I had to wait 45 minutes after my appt time to be brought back to an exam room, then another 10 minutes for the doctor, who then berated me for asking for a cancer screening as well as a face check up (cancer screening had always been part of the standard exam at my other derm) and then spent exactly 2 minutes doing BOTH the screening and diagnosing my facial blemishes without ever coming within 2 feet me. He prescribed the most popular acne treatment and charged my insurance a fortune. He never asked me a single question about my skin and did not smile at all.

Posted by: DC Derm | May 13, 2008 2:44 PM | Report abuse

Moderator: I suggest you delete poster at 2:00. Sounds like a nutjob to me.

Posted by: Anonymous | May 13, 2008 2:46 PM | Report abuse

While we're teaching doctors some manners, how about we teach their front office people some, too? I have never met ruder, more ignorant people than the women at my PCPs front desk. They bark orders, never greet anyone, never recognize me (I've been going there for 18 years), loudly ask people "what are you here for" (uh, whatever happened to HIPAA laws?) and give nasty answers to every question. On the other hand, the women in my dentist's front office are the friendliest, nicest, most helpful people in the world. When I complimented my dentist on them, he replied that he wouldn't tolerate anyone on his staff who was rude or unfriendly. Waht a shame doctors can't have the same standards as dentists.

Posted by: Nan M | May 13, 2008 3:07 PM | Report abuse

Moderator... Leave 2:00 post be I just
e-mailed investigateninds@yahoo.com
that person is telling the truth and
has the documents from NIH and showed me.
No one in this country should have medical records like this from the National Institute of Health. Those doctors should be ashamed.

Posted by: Anonymous | May 13, 2008 3:10 PM | Report abuse

Mr. Naciemento: Just because a person is a doctor, it doesn't mean they are a saint. Look at the sneaky ones committing Medicare and insurance fraud every day. Look at that sperm doctor who used his own sperm to impregnate women seeking fertility help. Of course there are good and bad people in every profession and those with the initials M.D. after their names should be held to a higher standard when it comes to interacting with other people. And don't think they are the only people who have sacrificed and worked hard to get where they are.

Posted by: Anonymous | May 13, 2008 3:20 PM | Report abuse

The general sports medicine doctors I went were good about listening to, and checking symptoms (once I got an appointment) and explained all relevant information. They gave me my options, and explained the ramifications of each one.

I had to train my orthopedist to answer questions and explain everything to me (preferably with diagrams), but after a few appointments, he began assuming that I wanted to know everything and worked accordingly. He explained once that most people don't want to know the details - they just want the do's and don'ts.

I understand that doctors are over-scheduled, but I don't care - I need the information, because the doctor will be more reliable than the internet. I expect them to answer my questions.

Posted by: Susie | May 13, 2008 3:21 PM | Report abuse

Here's my complaint - every single woman I know, no matter if they were seeing the doctor for a a sprained ankle or a sinus infection or something more serious - has been told at least once in her lifetime by a doctor that her problem is entirely psychological. I know of only one man who has ever had this happen to him. This is why I only go to female doctors now. No preconceptions.

Posted by: Anonymous | May 13, 2008 3:48 PM | Report abuse

"Here's an update for you: it is extremely likely that your doctor has worked much harder in his/her life than you have in yours."

How could you possibly know how hard I, or anyone else in this discussion, have worked during the span of our respective lives? I am not going to dispute the difficulty of medical school, but there are other opportunities in life for "hard work." Imagine an individual who has grown up in a single parent household, gone to substandard public school, and put themselves through a two year community college. Have they worked half as hard as a doctor? Three-quarters as hard as a doctor?

"Furthermore, that hard work was not in the pursuit of riches, but rather in the interest of his fellow man. It is probable, though not certain, that you have not done as much for the human condition as your physician has."

Yikes. OK first of all, my sister-in-law is currently in medical school and I can assure you that there are plenty of people entering the program for reasons other than altruism. Some are eagerly anticipating their big paychecks, some are hoping to finally impress their parents, and some are doing it because they are overachievers and med school is perceived as the ultimate achievement. And regarding the "probability" that your typical doctor has provided more valuable community service than your typical non-doctor...is medical community service so much more valuable than a person who teaches? Or someone who helps the homeless? Or a clergyman? And if medical services are indeed worth more than all of these other services, than have nurses contributed as much to society as doctors?

Look, I appreciate that doctors have knowledge and abilities far exceeding mine, and I don't expect "Burger King" service. I think you're right, America has a love-hate relationship with doctors, and I think there are probably more rude patients than rude doctors, and MOST people could use a review in basic courtesy. But the tone of your post is an example of the attitude that pushes a wedge between doctors and Everybody Else: "You couldn't possibly understand the work I've had to go through or the sacrifices I've made, give me your symptoms quickly because I have Other Things To Do."

Posted by: Omaha | May 13, 2008 4:00 PM | Report abuse

Right on, 3:48!!!! My sister has hemochromatosis (iron overload) which can play havoc with your body. Her doctor told her 'It's all in your head. Take more Prozac.' She finally went to another doc and found her blood iron levels were 4 times the safe level (he called her at home on Saturday evening to tell her) and got her into treatment right away.

Posted by: Anonymous | May 13, 2008 4:01 PM | Report abuse

My graduate thesis in behavioral psychology had to do with communication issues in patient/doctor relationships. There is some research that suggests that the admissions and selection process in many medical schools distorts the student population towards personality types that are actually less empathetic, and poorer in communication skills, than the general public. In addition, the one way teaching mode that med school professors often use--which discourages student challenges--establishes a mode of communication that the med student emulates when he or she comes to clinical practice.

Posted by: Patrick McGuire | May 13, 2008 4:38 PM | Report abuse

I guess I am lucky because I find all the doctors with whom I am dealing nowadays respectful and attentive.
However, the staff is another story. In some cases nurses and office personnel could
use a course in proper conduct.

Posted by: csavargo | May 13, 2008 6:24 PM | Report abuse

Some MDs are wonderful, others are awful. This makes them like most everyone. However, since they are dealing with folks who may be stressed, emotional, or in some general abnormal state, the MDs with bad people skills REALLY stand out. Case in point: some years ago my wife had a lump in her breast. She asked me to go to the pre-op appt with the surgeon with her. While waiting for him, she was sitting on the table in paper gown while I sat on a chair in the corner. When the doctor entered, he was headed toward her until he saw me. He then reversed course and came to shake my hand and talk to me. I took his hand and nicely said "She is the one you are here to see." My wife certainly took it as a snub.

Posted by: John | May 22, 2008 3:15 PM | Report abuse

Just yesterday I took my nine year old to see the Physicians assistant at the family clinic we attend. My daughter is deathly afraid of having her throat swabbed and when she refused to comply, the P.A became very nasty and snapped at my daughter and began yelling at me! I asked him at least 3 times over our discourse if he would please adjust his tone and he never apologized or admitted losing his temper. I understand his point as well as his frustration however he did not handle it in a very professional or respectful manner. I plan to find a new pediatrician and write a complaint to the doctor who owns the coinic.

Posted by: tg in nc | May 25, 2008 9:07 PM | Report abuse

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