Etiquette-Based Medicine

This has nothing to do with couples and illness, but I was so surprised when I read this article, I had to blog about it.

One of the most prestigious medical journals in the world, the New England Journal of Medicine, just published an article on Etiquette-Based Medicine, by Michael W. Kahn.M.D.

Now you'd think this article would be about some cutting edge approach to medical care, along the lines of narrative medicine (a practice at the College of Physicians and Surgeons at Columbia University) or about some of the terrific scientific and social innovations that come from the The Cleveland Clinic, which is ranked among the four leading hospitals in America (US News & World Report, 2007).

But this NEJM article is really about etiquette. The article opens with the question:
"Patients ideally deserve to have a compassionate doctor, but might they be satisfied with one who is simply well-behaved?" The author goes on to say, "A doctor who has trouble feeling compassion for or even recognizing a patient's suffering can nevertheless behave in certain specified ways that will result in the patient's feeling well treated."

First of all, a doctor who is unable to feel compassion and can't see suffering when it's under his/her nose is, imho, not practicing excellent medicine and should probably be re-trained or re-positioned into a role that has less to do with direct patient care.

Second of all, do we really need to bring Miss Manners into the consulting room? Isn't that a bit insulting to doctors. Do they really need to be reminded to say hello and introduce themselves to the patient? Apparently so, according to the author. The basic manners include:

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 may or may not be able to teach students or residents to be curious about the world, to see things through the patient's eyes, or to tolerate suffering. I think I can, however, train them to shake a patient's hand, sit down during a conversation, and pay attention. Such behavior provides the necessary — if not always sufficient — foundation for the patient to have a satisfying experience," writes the author.

I find this terribly sad. I am not my medical condition. And for my doctor to learn about my condition he/she has to go through me. If my doctor can't recognize suffering or have empathy (not sympathy), he/she is only getting a portion of the data, that which can be conveyed in simple answers to questions asked. The story I have to tell about my pain condition, for example, is bigger than answers to, "When did it start?" "How would you rate it on a 1-10 scale?"

I welcome doctors who are scientifically brilliant. I want to hear what they have to say about their area of expertise. And if they have good manners and can "smile if appropriate," I would even have a cup of tea with them. But I would never equate that with a "satisfying experience."

I don't need or want my doctor to weep with me. I don't want him/her to look deeply in my eyes, hold my hand and say, "I feel for your pain." But I do want my doctor to be able to make a genuine human connection with me - one that makes it possible for him/her to ask deeper questions and for me to give deeper answers. And who knows, that connection, that relationship may actually play a serious part in the healing process.