I was disappointed to read of a recent study that found that medical interns have trouble with basic courtesy in their interactions with patients.
The study, published in the Journal of Hospital Medicine, is a small one, looking at how 29 interns interacted with 732 patients hospitalized at Johns Hopkins Hospital and the University of Maryland Medical Center during January 2012. And yet it is troubling.
The study looked at whether interns used five key communications strategies, including introducing themselves, explaining their 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. The five actions are components of what is termed "etiquette-based medicine," as described in a 2008 New England Journal of Medicine article by Michael W. Kahn, MD. 
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. They asked open-ended questions 75 percent of the time. However, they introduced themselves only 40 percent of the time, explained their role only 37 percent of the time and sat down during just 9 percent of visits.
Worse, the researchers found that the interns performed all five of the recommended behaviors during just 4 percent of all patient encounters, and were only a little more likely to introduce themselves to patients during their first encounter than a later one.
Now here is the kicker: The interns who were studied were later asked to estimate how frequently they performed the five behaviors. They overestimated their performance by more than half. For instance, interns said that they introduced themselves to their patients 80 percent of the time and explained their role 80 percent of the time.
This isn't just about being nice. Research shows that courteous bedside manners are associated with improved patient recovery and satisfaction. These findings show the need to improve interns’communication with patients, according to the researchers.
"With internal medicine in particular, especially these days, it's about chronic medical problems and chronic care, where much of what we need to do is motivate the patient to provide self-care and self-management to improve their health over the long term," says study leader Leonard Feldman, MD, 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. "You can't do that if you're not connecting with the patient very well."
Dr. Feldman says that without establishing a personal rapport with a patient, the physician may be risking a readmission, as the patient fails to follow treatment advice. "Basic things make a difference in patient outcomes and they're not being done to the extent they should be. These are things that matter to patients and are relatively easy to do."
However, Dr. Feldman gives the interns an excuse when he says, "I just don't think they're thinking about the fact that they should be courteous and polite, especially when they're worried about their patients' morbidity and mortality, like a possible heart attack or pneumonia."
Dr. Feldman blames attending physicians for failing to be better role models in extending common courtesies to patients. "When I'm the attending physician I walk rounds with the whole team, introduce myself and put out my hand to shake the patient's hand, and then make the intern who is going to present the case sit down with the patient in a chair next to the bed. I'm showing them how I think it should be done. And you know they go, 'That's how Dr. Feldman does it, so I should be doing it that way.'"
Many aspects of health reform effectively mandate better communication with patients. The Hospital Consumer Assessment of Healthcare Providers and Systems — better known as HCAHPS — is all about measuring the quality of caregiver-patient interactions, and payment is based in part on scores. The same goes for the Hospital Inpatient Readmissions Reduction Program and for accountable care organizations, where keeping patients emotionally connected to the provider is essential to success. Also, in a time when patients are on the hook for paying for far more of the cost of care, the patient experience is a way of building loyalty and repeat business.
More importantly, it’s just the right thing to do. Patients have feelings. They are interacting with physicians in moments of vulnerability and anxiety. They deserve all the common courtesy the medical provider can muster. Instead, they are often left wondering how such an educated and skilled professional can be so callous in their time of need.
I think that all medical schools should offer a mandatory course on customer service. I have been told there is only one school in the U.S. that does so — Duke University. With the advent of HCAHPS and population health management, medical schools would do well to teach their students the art of making patients feel valued.
We are in a turbulent time of change in our industry. Margins and census are down significantly. Competition is rising fast. Regulations are proliferating. Healthcare organizations that want to survive need to build a new kind of patient relationship, one based on mutual trust and respect. So physicians, please sit down, reach out and introduce yourself as another human being, one who wants to be the patient’s trusted partner in improving their well-being.
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