The New York Times
1.12.2008.
Kahn MW.
Recently, I asked a colleague about the quality of care her hospitalized mother was getting. “Well, you can at least have a conversation with her doctor,” she replied. Clearly this was a big relief.
High-level skills like reflectiveness and empathy are an important part of medical education these days. That is all to the good, of course. But as I noted last May in an article in The New England Journal of Medicine, medical schools may be underemphasizing a much simpler virtue: good manners.
In the article, I described a common-sense method for spreading clinical courtesy that I call “etiquette-based medicine,” and I proposed a simple six-step checklist for doctors to follow when meeting a hospitalized patient for the first time:
• Ask permission to enter the room; wait for an answer.
• Introduce yourself; show your ID badge.
• Shake hands.
• Sit down. Smile if appropriate.
• Explain your role on the health care team.
• Ask how the patient feels about being in the hospital.
Do doctors really need to be told to do such obvious things? Unfortunately, anyone who has spent time in the hospital as a patient or a physician knows how haphazardly such actions are performed, and as Samuel Johnson wrote, “Man needs more to be reminded than instructed.”
There is a useful analogy here to raising children. The British physician D. W. Winnicott coined the term “good enough mother” in part to help mothers who were overly anxious about their parenting skills. Rather than worry about trying to be perfect (whatever that meant), he urged them to relax, trust their intuition and realize that their children needed a mother who was caring, alert and reliable — in other words, good enough.
Similarly, when medical schools try to turn out ideal doctors, they can miss the opportunity to help them be good enough: perhaps not perfectly attuned to the patient, but at least respectful and professional. An etiquette-based approach can promote such behavior.
Etiquette-based medicine rests on the fact that patients derive comfort from specific actions — as opposed to attitudes or feelings — that are independent of the doctor’s emotional investment in the patient. My doctor may be tired, preoccupied or not that interested in me as a person; but I should still expect him or her to treat me with the kind of attentiveness and respect I recently received from a “genius” at the local Apple store.
The “genius” was skillful, efficient and professional, and solved my problem quickly without feeling my pain (which had been considerable). I don’t necessarily want or need to have an exceptional healer, but I would like to have good service. Patients should command at least the same regard from their doctors.
Does this mean surrendering medicine’s nobler values in the service of mere client satisfaction? Not at all. Consider one more analogy: A developing country may make a major investment in M.R.I. machines, an essential element of up-to-date medicine. But that money will be misspent if the country lacks enough antibiotics and doctors to prescribe them.
By the same token, trying to cultivate deeper human sensibility in doctors will be an inefficient use of scarce educational resources if those doctors cannot make the time to sit down, introduce themselves and make eye contact with their patients. Training good enough doctors should be like fluoridating the water supply or vaccinating children: uncomplicated, routine, relatively inexpensive — but with widespread and long-lasting benefits.
Michael W. Kahn is a psychiatrist in Boston.
http://www.nytimes.com/2008/12/02/health/02etiq.html?_r=1
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