In 2008 a Dr Michael Kahn published an article in the Prestigious New England Journal (which I abbreviate to PNEJM, for any new readers). It was entitled ‘etiquette-based medicine’. He made the introductory comment that although patients deserve compassionate doctors, maybe they would be satisfied with well-behaved ones. That might sound rather critical, but he went on to suggest a checklist of 6 items of common courtesy that he believed were often lacking in medical interactions, but which he thought were important for patients.
I could criticize the article for not being evidence based, but I won’t, because he was right; he also wasn’t in the least dogmatic about the list which he suggested should include these items.
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.
That might all sound like simple politeness, but writing from his own experience he knew these steps were often ignored. A more recent research project (free full text) has confirmed his suspicions. In 226 observed patient encounters the investigators found that none of the individual items were performed with a majority of patients, and, in about 1 third of the encounters, not a single one of the items were performed. Of course the physicians had given their consent to be in the study, and new that they were being observed, nevertheless, they still couldn’t manage the basics.
This is all a long preamble to our new publication. Over the years since Violette was hospitalised we have got to know a lot of physicians and nurses and ethicists who have had sick babies in the NICU, either as their parents or grandparents. In our discussions with them we found that many had had individual or recurrent occurrences of poor communication, rudeness, or thoughtlessness of the medical (and sometimes the nursing) staff. We (particularly Annie Janvier and John Lantos who were the motivators and primary authors for this article, which was a real group effort for POST, Parents on the Other Side of Treatment) thought that the particular circumstances of the NICU are different enough that we should write a new checklist, of behaviours that should be routine and automatic, but are all-too-often lacking.
I reproduce the list here:
1. Say my baby’s name, regardless of how odd or misspelled it may be to you. Know my baby’s sex.
2. Don’t label my baby. My baby is not a diagnosis. She is not the “T-18,” the “23-weeker,” the “tiny critter,” or the “horrible BPDer in room 8.”
3. Say your name. Tell us who you are, what your profession is, and why you are here. Don’t assume we know and don’t assume we remember.
4. Listen to me. When you enter my baby’s bedside, acknowledge my presence. Sit down if you can. Ask me how I think my baby is doing. Embrace silence. Expect us to be upset. Don’t take it personally.
5. Speak my language. Every parent is different. Some of us want numbers, predictions, and statistics. Others don’t. We generally want to know whether our baby’s course is comparable with other babies with similar conditions or gestational age. Adapt your language to fit our needs.
6. Speak with one voice. We are overwhelmed with health care team members—nurses, students, residents, advanced practice nurses, respiratory therapists, and more. Limit the number of providers attending deliveries, difficult conversations, and code situations. Limit the number of people who examine my baby. Communicate with us in a consistent way.
7. Know my baby. We expect you to know everything about our baby.Take ownership and be responsible. Give us the results that are important to us the same day. Know the facts. Never tell us, “I’m just covering for today.”
8. Acknowledge my role. I contribute to my baby’s care too. I spend hours at the bedside; I pump my breast milk. I may be juggling a job or other children, operating on little sleep, and exercising continuous worry. Please understand and acknowledge this. Your acknowledgment of me in the role of a caring parent strengthens my resolve to be that good parent.
9. Don’t label me. Remember you are meeting me under the worst of circumstances. What is routine to you may be the greatest stress I’ve encountered in my life. Avoid the expression “difficult parents.” Instead, talk about “parents in a difficult situation.” If you feel the need to complain about a family, do so in privacy.
10. Know how important you are to me. I am placing my child’s life in your hands. Do not underestimate how important you are to our family.
We all know there are other issues in our interactions with parents that are important. We have already received one thoughtful and stimulating email that I will ask permission to quote in a future post. Our intention was to create a list of behaviours that should be as universal and automatic as knowing which end of a stethoscope to use. (I was going to say ‘as washing your hands’ but we are pretty pathetic at that!).
I think these kinds of behaviours should be taught as being essential in doctor-patient relationships. When I was being trained in medicine, modelling of good ‘bedside manner’ and general prinicples of doctor-patient relationships were certainly in the curriculum, but putting those general principles into action is clearly beyond some of our colleagues, senior and junior. I think we also need simple specific rules, and, yes, a checklist. If each time we interact with a family we keep these items in mind, families will be more content, we will be more satisfied and I am sure that our patients will be improved.
I am sure that most doctors and other health care professionals want to be good communicators, we should be teaching them how, and sometimes the simple basics will be all that is needed to make a big difference to parents.