Thursday, May 8, 2008

Medical Ethics, Etiquette, and Checklists

Here's what Dr. Michael Kahn learned from his recent hospitalization - "patients may care less about about whether their doctors are reflective and empathic than whether they are respectful and attentive." (His engaging article is in this week's New England Journal of Medicine.)

Dr. Kahn makes a good point. Manners matter! Many of his comments ring true:

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."

Dr. Kahn goes on to apply the Pronovost checklist concept to first meetings with a hospitalized patient:

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.

I think Dr. Kahn is half-way correct.

In the 1980s, in what was then the Harvard Community Health Plan HMO, the leadership introduced what was ultimately called the "smile memo" for support staff: when the patient is within 6 feet of the desk, make eye contact and smile.

But when the directive, taken from service industries like retail stores, arrived at the front desks, the support staff said - "this is an OK idea - but why doesn't it apply to how the doctors and supervisors treat us?" (They didn't mention the nurses, most of whom apparently had good manners!)

They were right. Of course they should be expected to show good manners in dealing with patients. But asking them to do this focused their attention on the fact that they were not consistently treated with comparable respect. That led to a shift in the project - from putting the spotlight on the support staff as the starting point to focusing on how well the higher status folks supported the support staff in their difficult work.

I guarantee that the same thing will happen with Dr. Kahn's proposal. Of course he is right that a physician's behavior counts. As an teen-ager I fought against my mother's constant reminders about manners, but over the years I have been grateful that she knocked many good habits into my resistant adolescent self. Considerate behavior and good manners should be on automatic pilot for everyone who deals with patients.

Pronovost's checklists were about washing hands and draping patients. No one asked why the hospital didn't wash its hands or cover itself. But a checklist of mannerly interactions with patients will - and should - focus on whether the hospital or clinic walks the talk in dealing with its own staff.

A checklist of etiquette alone won't improve the experience of patients. But trying to implement one could trigger useful scrutiny of the ethics and manners of the organization itself.

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