Patient-centered communication can impact several aspects of the patient-doctor relationship, including disclosure of illness-related information and compliance with medical recommendations. Etiquette-based medicine involves simple patient-centered communication strategies that convey professionalism and respect to patients. “Research has shown that patients prefer physicians who practice etiquette-based medicine behaviors, most notably those who sit down and introduce themselves,” says Leonard S. Feldman, MD. Little is known, however, about  whether physicians in training are actually performing these easy-to-practice behaviors.

An In-Depth Look

In a study published in the Journal of Hospital Medicine, Dr. Feldman and colleagues sought to understand whether etiquette-based communication behaviors were practiced by trainees on inpatient medicine rotations. Trained observers followed 29 internal medicine interns in their first year out of medical school at Johns Hopkins Hospital and the University of Maryland Medical Center for 3 weeks. They witnessed 732 inpatient encounters and used an iPod Touch application to record whether the interns employed five key strategies in etiquette-based communication: 1) introducing oneself, 2) explaining one’s role in the patient’s care, 3) touching the patient, 4) asking open-ended questions, and 5) sitting down with the patient.

 

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According to the findings, interns touched their patients—defined as either a physical exam or simply a handshake or a gentle, caring touch—during 65% of visits and asked open-ended questions 75% of the time. However, they introduced themselves only 40% of the time, explained their role in just 37% of cases, and sat down during only 9% of visits (Table). The study subjects performed all five of the recom-mended etiquette-based communication behaviors during just 4% of all patient encounters. Interns were only slightly more likely to introduce themselves to patients during their first encounter than a later one.

In a follow-up study conducted 6 months after the observational research was completed, the researchers surveyed nine of the 10 Johns Hopkins interns. They were asked how often they believe they used the five communication strategies. The interns estimated that they introduced themselves to their patients and explained their role 80% of the time and that they sat down with patients 58% of the time, but these percentages were significantly higher than what they actually did when the trained observers logged their observations (Figure).

Important Implications

One of the reasons that etiquette-based communication behaviors are not being performed regularly may be that hospitalists and other clinicians who train interns fail to use them. Previous studies have shown that many physicians who train others are not introducing themselves to patients, explaining their role, or sitting down to speak with patients, according to Dr. Feldman. “Basic etiquette-based communication makes a difference in patient outcomes, but it doesn’t appear that these strategies are being used to the extent that they should be,” he says. “These communication strategies matter to patients and are relatively easy to do. Patients shouldn’t be shocked when their physician sits down with them and introduces themselves. It’s an important part of being a doctor.”

Data from Dr. Feldman’s study indicate that many trainees have perceptions of their patient encounters that do not match what is actually occurring. “Efforts are needed to improve how we connect with patients,” Dr. Feldman says. Other research has shown that as few as 10% of patients can name a physician who cared for them in a hospital. Follow-up care can suffer when doctor–patient communication is lacking.

Simple Measures

Several adjustments to intern communications can improve the entire patient experience during a hospital stay, says Dr. Feldman. “Hospitals and training program leaders can take simple steps to make noticeable improvements. For example, they can provide chairs and photos of the care team in patient rooms and add lessons on etiquette-based communication to the curriculum. When I bring trainees into a patient room on rounds, I have everyone introduce themselves to the patient. Even if it’s unlikely the patient will remember everyone, it creates a better relationship. The clinicians who train interns need to view themselves as role models for appropriate communication behaviors.”

Hospital admissions are a time of vulnerability for patients, but Dr. Feldman says that taking a basic etiquette-based communication approach can comfort patients and help them feel more secure. “Even though interns often believe they are practicing etiquette-based communication behaviors, the reality is that few actually do these things,” he says. “We need to reinforce the use of basic etiquette-based communication strategies in order to make the hospital experience less daunting for patients.”

References

Block L, Hutzler L, Habicht R, et al. Do internal medicine interns practice etiquette-based communication? A critical look at the inpatient encounter. J Hosp Med. 2013 Oct 12 [Epub ahead of print]. Available at: http://onlinelibrary.wiley.com/doi/10.1002/jhm.2092/abstract.

Tackett S, Tad-y D, Rios R, Kisuule F, Wright S. Appraising the practice of etiquette-based medicine in the inpatient setting. J Gen Intern Med. 2013; 28:908-913.

Wilson BE. Performance-based assessment of internal medicine interns: evaluation of baseline clinical and communication skills. Acad Med. 2002; 77:1158.

Kahn MW. Etiquette-based medicine. N Engl J Med. 2008;358:1988-1989.