Saturday, January 28, 2006

Whatever became of bedside manner?

The New York Times ran a series of letters to the editor last month under the heading: “What ever became of bedside manner?” [1]

The nine letters were mostly from doctors, who offered their own advice for improving doctor-patient communications. The doctors recommended good manners, such as making eye contact, remaining seated while a patient recounts symptoms, washing hands in the presence of a patient, returning phones calls and accepting appointments promptly for established patients. [2]

Some letters also pointed out a patient’s responsibility for effective communications. “So often patients come to us without organized information or prior records,” one wrote. [3] Another physician noted that patients can waste time by speaking of irrelevant things. He wrote about a recent example where a patient recounted a lengthy medical experience from the Korean War. The physician said,
I listened patiently as the minutes ticked by, wondering what the story had to do with his eye condition or general medical history. It eventually became evident that it was simply an interesting anecdote that the patient felt like sharing…[4]
Several weeks after the first set of letters, the Times printed more letters on bedside manners. Several suggested that better communications training is (or should be) available for health care professionals. One writer suggested that health care workers “ask themselves, ‘Is this how I would want my family member to be cared for? Is this how I would want a family member to be addressed?’” [5]

I have been in the hospital field for over 30 years, and I am still amazed at how much we sometimes talk past each other. We must all have examples of people misunderstanding one another – not because they were not listening, but because they applied different frames of reference to what was being said.

Messages we think we are sending may not be the same messages the other is receiving. We have different training, different experiences. We cannot automatically assume that our own perspective is shared by another. Sometimes our different frame of reference may cause us to make assumptions about another’s motivation. We may not even know we’re making an assumption, but what we think about the other fellow can affect the way we listen to – and accept or dismiss – what is being said.

I can imagine, for example, that the gentleman who rambled on about his Korean War experience (in the example above) may have done so because he was nervous at seeing a doctor – and his nervousness prompted too much talking. Or perhaps his long-winded story was an attempt to establish a relationship with the doctor before he brought up an embarrassing problem or a scary health complaint.

The point is, we may not know what motivates the other party, but our communications can improve if we imagine reasons why the other party might say or do something that is otherwise inexplicable. Keeping an open mind about the other person can help get past distracting or annoying communications. How might the caregiver’s communication with the Korean veteran have changed if he had considered reasons for the patient’s story other than mindless prattle?

When communications prompt an emotional reaction in the caregiver or the patient the focus can move away from what is being done or what has to be learned. If we’re thinking “How rude!” or “Who knows what she meant by that!” we’ve already changed the focus of our attention. When the focus moves away from the communication process, we risk not hearing something, forgetting to say something, not paying attention to something.

Good manners in health care communications are not just the “extra” that we bring to the bedside. They are an important part of the caring that we do, facilitating unambiguous understanding and reducing the chance for a mistake.

[1] “What’s Become of Bedside Manner? (Nine Letters),” New York Times, December 4, 2005.
[2] “Some Simple Guidelines for (seeing) Patients,”, Sharon Lewin, MD, New York Times, December 4, 2005
[3] Allan B. Ettinger, MD & Deborah M. Wesibot, MD, New York Times, December 4, 2005
[4] Mark Melamed, MD, New York Times, December 4, 2005
[5] Judith A. Erlen, New York Times, January 17, 2006

Saturday, January 7, 2006

"A classic example”

Earlier this week an employee raised a concern about patient privacy after she saw a provider interviewing a patient about her health history in a way that could be overheard by others.

Yesterday John Conner, our HIPAA[1] Privacy Officer, sent an all-department e-mail to remind us how important it is to use only the minimum necessary information when communicating about patients.

He wrote about a situation involving a department that produces a list of patients to be treated each day. The list is used to check-off names as patients arrive for their appointments. Last week a patient reported being able to see information on the list, such as the diagnoses or treatments associated with other names.

John called the situation “a classic example” of not following the minimum necessary standard.[2] In other words, more information was included on the patient list than was necessary. A second problem was that the list was visible to others. Patient information must be protected from unauthorized access, including casual access by others.

“The event provides a valuable learning opportunity for us,” John wrote, and he asked employees to bring similar situations to the attention of their supervisors right away.

I responded to John with an e-mail, saying that his message reminded me of another situation that dates from pre-HIPAA days. The mother of a patient called me to complain about a lack of information privacy. Her son, who had been a patient the prior week, had left his blue jeans in the room when he was discharged. She called Security, which promptly contacted the nursing unit, and the lost jeans were found.

When the mother stopped at Security to pick up the clothing, she saw that they were stored in a clear plastic bag, marked “patient belongings.” The bag also contained the printed half-sheet with the patient’s name, address, age – and diagnosis.

“Why, Mr. Quinn,” the mother asked me, “did the security officer have to know that my son is HIV positive?” It was a good question, and as a result, CGH changed its then-policy of including the half-sheet to identify patient belongings.

I’d like to thank the employees who showed their interest in (and sensitivity to) patient privacy this week. Confidentiality is a subject we take very seriously, and – as is apparent – one we need to remind ourselves about constantly.[3]


[1] HIPAA refers to the Health Insurance Portability and Accountability Act of 1996, a federal law that limits how hospitals and other health care providers may use health information that identifies an individual patient. The rule does not restrict the ability of doctors, nurses and other providers to share the information necessary to treat patients.

[2] HIPAA requires providers to use or share only the minimum amount of protected information necessary for a particular purpose. Information on HIPAA is available on this federal website:

[3] For CGH policies on patient confidentiality, go to “Public Folders” on the CGH intranet, find “Manuals” and select “Hospital Policies.” “Hospital Policies” will take you to a number of headings. Select “09 Management of Information” and go to the subsection on “Confidentiality & Security.”