'Common courtesy' lacking among doctors-in-training

Johns Hopkins investigators have found that doctors-in-training are unlikely to introduce themselves fully to hospitalized patients or sit down to talk to them eye-to-eye, despite research suggesting that courteous bedside manners improve medical recovery along with patient satisfaction.

A report on the research, published online this month in the Journal of Hospital Medicine, calls for some simple adjustments to intern communications to make the whole experience of a hospital stay better.

"Basic things make a difference in patient outcomes and they're not being done to the extent they should be," says study leader Leonard S. Feldman, M.D., an assistant professor of medicine at the Johns Hopkins University School of Medicine and one of the associate program directors of the internal medicine residency program at The Johns Hopkins Hospital. "These are things that matter to and are relatively easy to do."

For the study, trained observers followed 29 internal medicine —physicians in their first year out of medical school—at The Johns Hopkins Hospital and the University of Maryland Medical Center for three weeks during January 2012. They witnessed 732 inpatient "encounters" during 118 intern work shifts. The observers used an iPod Touch app to record whether the interns employed five key strategies known as etiquette-based communication: introducing oneself, explaining one's role in the patient's care, touching the patient, asking open-ended questions such as "How are you feeling today?" and sitting down with the patient.

Interns touched their patients (which could be either a physical exam or just a handshake or a gentle, caring touch) during 65 percent of visits and asked open-ended questions 75 percent of the time. But they introduced themselves only 40 percent of the time, explained their role only 37 percent of the time and sat down during only 9 percent of visits.

Worse, interns performed all five of the recommended behaviors during just 4 percent of all patient encounters, and were only slightly more likely to introduce themselves to patients during their first encounter than a later one, the researchers say.

"Many times when I sit down," Feldman says, "patients say 'Oh my God, is something wrong?' because I actually bothered to take a seat. People should expect their physicians to sit down with them, to introduce themselves. They shouldn't be taken aback when they actually do. It's part of being a doctor."

Feldman and co-author Lauren Block, M.D., M.P.H., a former general internal medicine fellow at Johns Hopkins, say one of the reasons internal medicine trainees may not be following such basic social protocols is that hospitalists, the senior doctors they often learn from, fail to use them. Previous studies have shown that to be the case.

In a follow-up study six months after the observational research was completed, the Johns Hopkins researchers surveyed nine of the 10 Johns Hopkins interns, asking how often they believe they used the five communication strategies. The interns estimated they introduced themselves to their patients and explained their role 80 percent of the time and that they sat down with patients 58 percent of the time—far more often than they actually did.

"Our perception of ourselves is off a lot of the time and that's why it is so important to have data," Block noted.

Block says follow-up care also suffers because of the lack of good doctor-patient communications. "It's no wonder patients don't feel connected to what we are telling them because many times we are not doing as much as we could to make that connection," she says. Other research, she says, has shown that only 10 percent of patients can name a doctor who cared for them in the hospital.

The researchers say hospitals and training program officials can take simple steps to improve things, such as providing chairs and photos of the care team in patient rooms and adding lessons on etiquette-based communication to the curriculum.

Feldman says that when he brings trainees into a patient room on rounds, he has everyone introduce themselves. Even if it's unlikely the patient will remember everyone, it creates a better relationship, he says, adding that modeling appropriate behavior for interns is a good place to start.

"The hospital is a dizzying place," he says. "It's a new crew all the time—in the emergency room, on the unit, the day team, the night team, the nurses, the respiratory therapist, the pharmacist. By introducing ourselves, we can go a long way toward making the entire hospital experience a little less daunting."

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