Bedside manner and the Christian Clinician.

12 MINUTE READ

from Luke’s Journal 2020 | Breath of Life | Vol.25 No.2

“Doctor, would you mind taking me on as a patient? I don’t think I can go back to my previous doctor. He was so rude to me.”

Edith (pseudonym) was a gentle lady in her mid-70s and had attended my GP practice with the company of her friend for moral support. I am always wary when a new patient begins a consultation by criticising another doctor. Her friend chimed in, perhaps sensing my guardedness, saying “Edith has been with her previous doctor for years, but he has become increasingly rude to her. At the last visit, he told her that if he wrote a book about being stupid, he would write the first chapter about her. She does not want to go back to see him after that experience.”

Most readers will immediately react to the appalling bedside manner displayed by the doctor towards Edith. This is an extreme case and, thankfully, not particularly common. I have concerns for colleagues who think that it is fine to talk to patients (or anyone!) in this manner. In addition, I have a suspicion that Edith’s previous doctor was impaired and close to burnout.

Mosby’s Medical dictionary defines bedside manner as “the behaviours of a nurse or doctor as perceived by a patient or peers.” The excuse of “they are a good doctor even though their bedside manner is terrible” no longer carries validity with many patients. As a doctor, it is insufficient to be knowledgeable alone, without also possessing important qualities of good bedside manner with patients. In fact, medical knowledge is only one of the six core values which are defined by the Accreditation Council for Graduate Medical Education (ACGME) as essential for practising medicine.¹ The other five core values are: Professionalism, Patient Care, Practicebased learning and improvement, Interpersonal and communication and skills, and Systems-based practice (i.e. practising within the wider healthcare systems and teams). However, teaching and assessing competence in these other five core areas remains a challenge.

“The excuse of ‘they are a good doctor even though their bedside manner is terrible’ no longer carries validity with many patients.”

Hence, many medical students graduate and commence working as doctors, but lack the skills and experience for effective bedside manner with patients. This may be due to factors including personality traits and preferences, lack of experience, or unawareness of an issue or its importance. It is vital to address these concerns and issues within medical education and healthcare delivery.

As Christians, the prime motivation to strive for an excellent bedside manner is that, first and foremost, our goal is to follow in the footsteps of Jesus, whose treatment of others was exemplary. Even those who do not believe his claim to be God usually recognise that Jesus was an exceptional human who set a new standard for the treatment of others. His compassionate treatment of people who were vulnerable or rejected was so shockingly countercultural that the religious leaders of the time could not understand or perceive his actions. Jesus threatened to undermine the carefully planned social structure of the time. Had Jesus been an employee in the present healthcare setting, he would likely have been fired for becoming distracted, being tardy or late often, and treating patients who were not ‘on his list’. He certainly would not have climbed the ranks within the system because he spent too much time with the ‘wrong people’ and was critical of those in power or authority.

Yet, Jesus was approachable to those who recognised their need for him, including children, women, lepers, prostitutes and many other marginalised or minority populations. His ‘bedside manner’ was so enticing that crowds began to follow him, at times by the thousands. Jesus showed us how to love and continues to challenge us personally to live out of love for others every day.

Beside the Christian call and the desire to imitate Christ, three further propositions for the importance of prioritising bedside manner are:

1. for the sake of our patients,

2. for the sake of ourselves,

3. for the sake of Christ.

For The Sake Of Our Patients

Patients deserve to feel that they have been listened to and treated with respect, regardless of what we are able to offer them.

I clearly recall watching a Consultant Physician spend 40 minutes listening to a patient with chronic pain in the outpatient department. The patient spoke of all the different tests and treatments that he had endured over the years and how he was not getting any better. The Physician barely spoke, beyond simple encouraging statements to show they were listening (“go on…” “that must have been difficult…” etc). At the end of the consultation, the Physician simply said, “I am so sorry you have endured all this. I cannot think of anything else that we can offer you to treat your pain. You have tried everything I know about. We need to focus now on how to help you live with where things are at.”

Unbelievably, the patient broke into a huge smile and thanked the Physician profusely. He acted as if he had just been offered a cure for his pain. He stood up and shook the Physician’s hand and then left, still smiling. He had been heard and this brought him more satisfaction and peace than being offered yet another intervention. This example is consistent with recent findings that the practice of simple ‘etiquette-based medicine’ may improve patient satisfaction.²

Improving patient satisfaction is not the only benefit of good bedside manner. In fact, research has shown that doctors who treat their teams or their patients poorly result in measurably poorer patient outcomes. For example, one study found that surgeons who had a higher number of co-worker reports regarding unprofessional behaviour in the 36 months prior to an operation or procedure, were at increased risk of surgical and medical complications.³ In a different study, researchers found that rudeness reduced communication and the sharing of information between physicians and nurses which was, in turn, detrimental to diagnostic performance. Similarly, rudeness reduced teamwork and collaboration amongst team members which had a negative impact on procedural performance.⁴

“Research has shown that doctors who treat their teams or their patients poorly result in measurably poorer patient outcomes.”

Possessing good bedside manner is not only applicable in Western societies, as there is mounting evidence that patients in other cultures believe that an essential component of being a good doctor includes the skills of good bedside manner.⁵ This is a human issue and not simply an issue affecting Western medicine.

For The Sake Of Ourselves

In the opening vignette, I described the true story of a doctor whose rudeness towards his patients elicited my concern about his own mental health. Such rudeness toward others can be a sign of burnout, and perhaps no one had the courage to point it out to him. One of the difficult things about burnout is that it is very difficult to recognise in oneself.

Having an excellent bedside manner may not protect us from burnout, but it will certainly make it more obvious to detect if, or when, it occurs. A doctor who has always been moody and rude may practise in an impaired condition for a long time because everyone puts their behaviour down to their modus operandi. However, if a kind, gentle, and compassionate doctor suddenly starts snapping at their team, it will be recognised much earlier.

On a more positive note, I believe that practising medicine with a good bedside manner enhances practitioner self-satisfaction, as it improves our relationship with patients, colleagues, and team members. When we treat others with dignity and respect, we are treating them as Christ would have us do and, therefore, we are carrying out our assigned purpose on earth. Our work is therefore understood in the context of God’s kingdom, rather than our own individual efforts.

For The Sake Of Christ

What if our patient is in a coma, from which they are not expected to recover? What if they are unaware of what is going on around them, such as due to dementia or delirium? What if they are mentally unstable and do not want us to help them? In these cases, does our meticulous personal treatment towards them matter? They may not know or care whether we are empathetic and kind. In these instances, listening to our patients may make little difference to their overall healthcare delivery and not provide essential professional assistance towards their treatment. In these situations, it may be tempting to treat them with less patience and kindness than we would if we could build rapport. I have certainly seen colleagues behave with impatience and even unkindness towards such patients.

As Christians, we need to remember that every human being is made in the image of God, regardless of how disfigured, incapacitated or disgruntled they are. Even if they will never know or understand how much we are doing for them, we know that our actions toward them are, in fact, our actions toward Christ. When I am struggling to be compassionate towards someone, I find it helpful to remember the words that Jesus spoke in Matthew 25:34 – 45. Even seemingly small and insignificant acts toward others are, in fact, acts of service to Christ. It does not matter whether that person knows or understands; Christ does.

List For Good Bedside Manner

Below is a very brief list of practices that I have found helpful when striving for good bedside manner:

1. Communicating with excellence

Nowadays, students need to demonstrate at an early stage in their training that they can communicate with patients. However, just because you “passed” communication at university, it does not mean you are a good communicator. I believe it is something that we will never truly master and every encounter with a patient is a chance to improve.

Some basic communication skills that we all need, and in which I still remind myself after 20 years of clinical practice, include:

• Avoiding jargon

• Checking that my patient understands me

• Checking that I have understood my patient

• Being careful with my body language

2. Listening and hearing

Active listening is a skill that most of us need to continually cultivate, especially in an era where screens constantly demand our attention and we spend a lot of our lives torn between a virtual and real world. Making sure that we are ‘truly present’ with patients is vital to truly hearing them.

This can be achieved by not interrupting patients unless it is essential to do so, as well as being careful to take notes in a way that does not interrupt the flow of conversation. It also includes validating the concerns and emotions of the patient, even if we do not agree with their perspective.

3. Taking time

In our fast-paced and demanding jobs, taking time with our patients may be the most difficult aspect of good bedside manner that we aspire to achieve. However, in my opinion, it is also one of the most important and critical aspects. A few things that I have learnt over the years include:

• Sitting down next to someone makes them feel that we are spending more time with them.

• It is very helpful to acknowledge that their time is important and to thank them for their patience in waiting, especially if we are running late.

• Realising that time heals and is therapeutic; spending a bit longer with someone may save time, as well as costly interventions, in the long term.

“Good bedside manner… is essential to cultivating a life lived in the footsteps of Jesus.”

4. Being compassionate

Compassionate care is about care “with” a patient, not simply “of” a patient. In other words, they need to know that we are there with them through their struggles and not aloofly evaluating and trying to “fix” things. Of course, the way we provide care towards our patients is through accurate and timely diagnosis, investigation and treatment, but patients should never feel that they are just another sausage on the healthcare conveyor belt.

5. Being respectful

Every patient that we see is precious to God, regardless of how they may present to us on the surface. Starting a consultation by asking what name they would like us to use when we speak to them is one way of showing courtesy. Acknowledging other people that are present in the room or accompanying the patient, including children, is also helpful. Different cultures show respect in different ways, so learning about specific features of the various cultures that you are working with is crucial. However, in my own experience, I have found that patients forgive our ignorance even if we make significant cultural mistakes, if they can sense that we are trying to be kind and respectful towards them.

Good bedside manner encompasses more than just being “nice”. It forms the core to providing good medical practice and, for Christians, it is essential to cultivating a life lived in the footsteps of Jesus. The benefits of good bedside manner will flow to our patients, colleagues, and even ourselves. When we treat our patients, we are treating Christ in them – this alone should challenge us, as Christians, to behave in an exemplary way towards each and every patient no matter how ‘insignificant’ or ‘unaware’ they may seem.

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References

1. Lauer AK, Lauer DA. The good doctor: more than medical knowledge & surgical skill. Ann Eye Sci. 2017;2:36.
2. 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(7):908-13.
3. Cooper WO, Spain DA, Guillamondegui O, Kelz RR, Domenico HJ, Hopkins J, et al. Association of Coworker Reports About Unprofessional Behavior by Surgeons With Surgical Complications in Their PatientsCoworker Reports of Unprofessional Behavior by Surgeons and Surgical Complications in Their PatientsCoworker Reports of Unprofessional Behavior by Surgeons and Surgical Complications in Their Patients. JAMA Surgery. 2019.
4. Limb M. Rudeness in medical teams harms clinical performance, study finds. BMJ. 2015;351:h4821.
5. Hao H, Zhang K, Wang W, Gao G. A tale of two countries: International comparison of online doctor reviews between China and the United States. International Journal of Medical Informatics. 2017;99:37-44.