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The Healing Touch
Keeping the Doctor-Patient Relationship Alive Under Managed Care
By David L. Cram
Addicus Books, Inc.Copyright © 1997 David L. Cram, MD
All rights reserved.
The Influence of Bedside Manner
The concept of bedside manner dates back 2,500 years, when Plato wrote the earliest known description of the doctor-patient relationship in The Laws. Plato writes that the best clinical medicine is practiced when the doctor and the patient have concluded a fully human relationship in which the technical aspects of care are placed in the human context (Siegler 1993). However, throughout much of history, doctors would not always fully inform patients of their conditions. This "code of silence" still exists today in some cultures. For example, a physician might not inform a cancer patient of his or her condition, believing that not knowing will enhance the patient's immunity, decrease anxiety and therefore extend life.
Fortunately, in the United States today, medical professionals recognize patients' need to know and understand their conditions. We realize that, especially with a serious or chronic disease, patients are vulnerable. What doctors say and how they act toward these patients can have a major effect on both the patients and their diseases. The will to get better and to remain upbeat irrespective of the illness can be a direct result of a sympathetic physician playing a significant role in the patient's life. S.H. Kaplan (1989) states, "The physician-patient relationship is a primary bond that may act as a social support to influence the patient's health status."
Good physicians realize that patients expect answers from their doctors. The manner in which a physician talks to the patient can affect the long-range outlook of the disease. Incorrectly done, it can result in such undesirable effects as noncompliance with therapy, more complicated testing, the need for higher doses of medication, more frequent office visits, longer hospital stays, or an increase in medical lawsuits. The patient may also decide to seek another doctor. If the goal of our society is to achieve better health care at reduced costs, a good bedside manner from health care providers obviously will play a significant role in reducing these costs.
Qualities of a good doctor
I believe the following are the qualities of a good doctor and the foundation of a good bedside manner:
* Inquisitive mind
* Sense of humor
* Good memory
* Genuine concern for the welfare of others
How is bedside manner best applied?
To have medical knowledge and skill alone is not enough. To be truly effective in treating the sick, doctors and nurses must have good communication skills. In one sense, they are educators. Education helps patients make decisions. Doctors should allow patients to make shared decisions and be willing to walk the road to recovery with them (Herman 1985).
Many times when I was treating a patient with a difficult problem, I asked myself: "If this were a member of my own family, what would I do?" I wanted every patient to have the best care available. These thoughts often helped guide my decisions. When treating a chronic, recalcitrant skin disease like psoriasis, I knew I could not cure the disease since there is no cure. But I was confident that I could relieve the discomfort and often free the patient from significant disease for long periods of time. I believe the keys to my success were good communication, empathy, sharing decisions about therapy with the patient, and, perhaps most importantly, believing in my abilities and offering the patient encouragement every step of the way. I found that successfully treating this difficult skin disease was a challenge that brought me great satisfaction.
Evidence shows that encouraging patients to take an active role in their care can enhance therapeutic outcomes (Speedling 1985). Decisions concerning therapy should, whenever possible, attempt to incorporate the patient's preferences. This may not be possible in emergency situations, for patients with high dependency needs, or when the patient's psychological state clouds his or her judgment. In these situations, discussions with family members become very important in helping the physician decide how best to proceed with treatment.
Why do some doctors neglect bedside manner?
Some doctors regard a good bedside manner as simply irrelevant to the practice of medicine. It is not surprising that this attitude exists since interpersonal skills receive only token attention in the curricula of many of our medical schools. Studies indicate that interpersonal skills may even decline as medical education progresses (Helfer 1990).
Some new doctors, after years of exposure to illness and dying, become numb and indifferent as a means of self-protection. Unfortunately, such self-protective measures may render them unable to empathize. As these doctors either mask their feelings or deny them, they often regard patients as diseased bodies to be treated or as teaching case studies.
An American Medical Association survey conducted in 1993 reveals that public esteem for physicians has diminished during the last decade. The survey further shows that fewer than a third of patients think doctors spend enough time with them. Forty-four percent agree that "doctors act like they are better than other people" (American Medical News 1993). To many physicians these statistics may be troubling, but they may be the direct result of negative behavior, interpreted by patients as a lack of concern and caring. A positive outcome depends on behavior that is facilitating rather than dominating (Stewart 1984).CHAPTER 2
Learning Bedside Manner
Webster's dictionary defines bedside manner as "the attitude, approach and deportment of a doctor toward patients" (Webster 1992). However, it is much more complex. Bedside manner is actually a special skill that must be learned, practiced, and never taken for granted. There are few formal lectures given directly on the subject in many of our medical schools. Some doctors fail to properly apply it, and some even scoff at its importance.
The importance of role models
My experience has been that in the absence of formal lectures, a good bedside manner can be learned in two ways. The first is by observation — watching clinical instructors in medical training talk with patients and noticing their reactions. The second is by reflection — referring to one's own life experiences. By observing the interplay of words between the instructor and the patient, the alert medical student soon comes to recognize what effect certain words and demeanor have on patients. Hopefully the exchange will be a positive one. Unfortunately, if the instructor's pattern of communication with patients is dehumanizing, the medical student may also imitate this pattern (Roter and Hall 1992).
I came to recognize the importance of a good bedside manner early in my medical training. However, it was during my residency training in dermatology at the Mayo Clinic when I finally mastered my technique. I learned my bedside manner by observing the excellent physicians who were my teachers. Each had his own style; some had a quiet, gentle approach while others were more forceful and commanding. But, they all showed warmth and concern for patients. Perhaps what made the greatest impression on me was that all patients were treated with equal dignity and respect. And bear in mind that we saw patients from all walks of life — some rich and famous to those with meager means. From this excellent exposure, I borrowed what I considered the best traits from each of these physicians and developed my own style of bedside manner that I would use for the rest of my career.
The influence of life experiences and books
Added to this learning process were my previous life experiences. I had wanted to be a doctor all of my life, and I very early sought ways to learn how to better interact with people. I sought out jobs as a camp counselor and hospital orderly. During my high school years I discovered a book in my father's library that changed my life. That book is Dale Carnegie's How to Win Friends and Influence People. In short, the book stresses developing your personality, showing an interest in others, being sympathetic and respectful and remembering the benefit of a smile. After reading the book and applying the recommendations, I went from an average, little-noticed student to vice president of my senior class and president of the Junior Red Cross. That book would play a definite role in my future success as a physician as would other books in the humanities.
As I grew more confident, I developed a better and more outgoing personality. I wanted to help people, and I was confident that nothing would prevent me from becoming a doctor. I would soon learn that it would take more than a friendly, personal style to be perceived as competent by my patients. It takes proficient medical skills as well as a better understanding of the patient's concerns to achieve that goal.
The importance of empathy
An integral part of a good bedside manner is empathy. Freud (1955) describes empathy as "a means by which we are enabled to take up any attitude at all toward another's mental health." To put it in the simplest terms, put yourself in somebody else's shoes. Empathy, compassion, and communication are really the essence of a good bedside manner. By listening to the patient and being empathetic, a doctor can not only gain the patient's trust but can also arrive at a diagnosis more quickly and accurately (Bellet 1991).
The best way to teach empathy and a good bedside manner is to have good medical teachers as role models. In addition, medical students would benefit to see firsthand what patients have to experience. A good example is an intensive program called "hospitalization week," an idea developed at the Ben-Gurion University Medical School in Israel (Carmel 1986). Medical students there are not only given courses in basic communication skills and medical ethics but some are also hospitalized, after which they discuss with their classmates their reactions to this experience. Furthermore, they take courses on families in crisis, conduct interviews with dying patients and their families, and observe patients in intensive care. The goal is to enhance empathetic feelings in these medical students and to help them develop a good bedside manner. This should be the goal of all medical schools in this country. We need to better prepare our doctors to deal with the emotional aspects of a patient's illness and to understand how they affect other family members.CHAPTER 3
The Cardinal Rules of a Good Bedside Manner
One does not need specialized psychological training to learn and apply what I consider some of the most important rules of a good bedside manner. The seven principles I have chosen are straightforward and based on common sense.
* Put the patient at ease
* Be kind and courteous in your approach
* Convey a sense of confidence
* Make the patient and the problem important
* Be a good listener
* Answer the patient's questions and anticipate his or her concerns
* Be positive and reassuring whenever possible
Put the patient at ease
A smile after introducing yourself, a warm handshake, and a "How can I help you?" are often all that is necessary to put a patient at ease. When a warm greeting pleases the patient, the same warm behavior is often returned to the doctor (DiMatteo 1979; DiMatteo et al. 1986). "Sorry if I kept you waiting" goes a long way to reduce any tension resulting from the patient having to wait for what may at times seem like an eternity. Everyone hates to wait. For the patient, their time is just as important as the doctor's. Doctors should try to schedule their appointments so that patients seldom have to wait. Long periods of waiting lead to frustration among patients and sometimes to hostility toward the doctor and staff. Always inform patients of any delays and give them reasons for the wait. They should also be made to feel as comfortable as possible during the wait.
If patients seem deeply troubled, touching a hand or shoulder will help reassure them that you are sensitive to their emotional concerns. Sitting down with a patient, rather than standing, and maintaining eye contact reduce authoritarian posture and help convey a sense of individual attention. This approach also suggests, whether true or not, that you are not in a hurry. With today's concern over inappropriate sexual behavior, touching a patient — no matter how brief or confined to the hand or shoulder — can carry a risk with certain patients. But doctors should trust their instincts and not be afraid to exercise this touch that has for centuries been recognized as a component of compassionate patient care.
Talking with patients involves both verbal and nonverbal communication (Blondis 1982). Nonverbal communication, better known as body language, includes gestures like a smile, a frown, a warm handshake, and the way one stands when addressing another person. Body language is something we often use to help express our inner emotions. The patient's interpretation of these gestures can influence the doctor-patient relationship as much as spoken words. A frown, a look of disgust, or frequently looking at your watch are types of nonverbal communication that the patient may interpret as negative. On the other hand, a smile, paying close attention to the patient's words, maintaining good eye contact, and appearing genuine in the interview will usually be interpreted positively and will help put the patient at ease. Paying attention to the patient's nonverbal behavior is also important in assessing both the patient's physical and emotional state. The information given and received must be clear. If the verbal and nonverbal information provided by the patient seems incomplete, careful questioning can often fill in the gaps.
You may set the stage for a positive doctor-patient relationship well before your first encounter. The patient's choice of the doctor, when that is possible, may come from prior knowledge of your reputation and skill, especially from the reports of satisfied patients. In the American Medical Association's 1993 survey of patients on the subject of choosing a physician, respondents ranked the quality of care their highest priority, the cost and personal recommendations lowest. This, however, was not my experience. My patients who stated in their initial visit "you come highly recommended" or "you have a wonderful reputation" for the most part were immediately at ease. Perhaps their preconceived trust was the reason for their comfort.
A patient's first impression of a doctor can also be the result of conversation with a receptionist or other staff member. A friendly, well-informed, and professional support team, expressing an interest in helping the patient, is often the start of a good doctor -patient relationship. People at all levels of the health care team should convey warmth, sympathy, and understanding so that a patient feels important from the very beginning, not just a number or a collection of complaints. No one likes to be treated as a number.
A doctor's personal appearance may also influence a patient's first impression. Patients like their doctors to be well-groomed. In my interviews with patients, most prefer their doctors wear a white coat, perhaps because it conveys cleanliness. A white coat is also perceived as professional. Patients often "dress up" for their medical appointments, a sign of respect deserving reciprocity.
Be kind and courteous in your approach
People often come to doctors because they fear illness. Some worry that a doctor may misunderstand their concerns. A kind and courteous approach with an awareness of the patient's dignity and possible lack of any medical knowledge can help allay that fear and form the beginning of a strong doctor-patient bond. Conversations with patients should use terms the patient can understand, not medical jargon.
Excerpted from The Healing Touch by David L. Cram. Copyright © 1997 David L. Cram, MD. Excerpted by permission of Addicus Books, Inc..
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents
1 The Influence of Bedside Manner,
2 Learning Bedside Manner,
3 The Cardinal Rules of a Good Bedside Manner,
4 Bedside Manner and Patient's Expectations,
5 The Dying Patient,
6 The Changing Role of Nurses Under Managed Care,
7 The Good, the Bad, and the Ugly: Real-Life Experiences,
8 Other Consequences of Managed Care,
About The Author,