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PERSPE C T I V E Etiquette-Based Medicine

Etiquette-Based Medicine
Michael W. Kahn, M.D.

P atients ideally deserve to have

a compassionate doctor, but
might they be satisfied with one
quaint or anachronistic, but it is
at the heart of the mission of oth-
er service-related professions. The
meeting with a hospitalized pa-

who is simply well-behaved? When goals of a doctor differ in obvi- 1. Ask permission to enter the
I hear patients complain about ously important ways from those room; wait for an answer.
doctors, their criticism often has of a Nordstroms employee, but 2. Introduce yourself, showing
nothing to do with not feeling why shouldnt the clinical encoun- ID badge.
understood or empathized with. ter similarly emphasize the pro- 3. Shake hands (wear glove if
Instead, they object that he just vision of customer satisfaction needed).
stared at his computer screen, through explicit actions? A doc- 4. Sit down. Smile if appropri-
she never smiles, or I had no tor who has trouble feeling com- ate.
idea who I was talking to. Dur- passion for or even recognizing a 5. Briefly explain your role on
ing my own recent hospitaliza- patients suffering can neverthe- the team.
tion, I found the Old World man- less behave in certain specified 6. Ask the patient how he or she
ners of my European-born surgeon ways that will result in the pa- is feeling about being in the
and my reaction to them tients feeling well treated. How hospital.
revealing in this regard. What- could we implement an etiquette-
ever he might actually have been based approach to patient care? Such a checklist has the ad-
feeling, his behavior dress, The success achieved by Peter vantages of being clear, efficient
manners, body language, eye con- Pronovost and colleagues in solv- to teach and evaluate, and easy for
tact was impeccable. I wasnt ing a different kind of complex trainees to practice. It does not
left thinking, What compassion. problem reducing the likeli- address the way the doctor feels,
Instead, I found myself thinking, hood of central-line infections in only how he or she behaves; it
What a professional, and even critical care patients1 provides provides guidance for trainees
(unexpectedly), What a gentle- a thought-provoking suggestion. whose bedside skills need the
man. The impression he made Instead of taking an elaborate, most improvement. The list can
was remarkably calming, and it sophisticated approach say, be modified to address a variety
helped to confirm my suspicion tackling infections by developing of clinical situations: explaining
that patients may care less about more advanced antibiotics or clar- an ongoing workup, delivering bad
whether their doctors are reflec- ifying the genetic basis for drug news, preparing for discharge,
tive and empathic than whether resistance Pronovost et al. in- and so forth.
they are respectful and attentive. troduced a checklist to enforce the Training for an etiquette-based
I believe that medical educa- use of hand washing, thorough approach to patient care would
tion and postgraduate training draping of the patient, and other complement, rather than replace,
should place more emphasis on tasks that could be easily per- efforts to train physicians to be
this aspect of the doctorpatient formed. The results of this sim- more humane. Pedagogically, an
relationship what I would call ple intervention were swift and argument could be made for eti-
etiquette-based medicine. There dramatically effective. I would pro- quette-based medicine to take pri-
have been many attempts to fos- pose a similar approach to tack- ority over compassion-based med-
ter empathy, curiosity, and com- ling the problem of patient satis- icine. The finer points of patient
passion in clinicians, but none faction: that we develop checklists care should be built on a base of
that I know of to systematically of physician etiquette for the clin- good manners. Beginning pianists
teach good manners. The very no- ical encounter. Here, for instance, dont take courses in musicianship
tion of good manners may seem is a possible checklist for the first and artistic sensibility; they learn

1988 n engl j med 358;19 may 8, 2008

The New England Journal of Medicine

Downloaded from by EDUARDO CARRILLO-MARAVILLA on February 26, 2016. For personal use only. No other uses without permission.
Copyright 2008 Massachusetts Medical Society. All rights reserved.
PERSPECTIVE Etiquette-Based Medicine

how to have proper posture at the and humane, I wonder whether It would put professionalism and
piano and how to play scales and these exercises are most helpful patient satisfaction at the center
are expected to develop those for those students who arrive at of the clinical encounter and bring
higher-level skills through a life- medical school already in posses- back some of the elements of rit-
time of study and practice. I may sion of those qualities to some ual that have always been an im-
or may not be able to teach stu- degree. For many students, I sus- portant part of the healing pro-
dents or residents to be curious pect that these exercises may have fessions. We should continue our
about the world, to see things a more limited effect, if only be- efforts to develop compassionate
through the patients eyes, or to cause they are too brief to allow physicians, but lets not overlook
tolerate suffering. I think I can, the student to comprehend, prac- the possibly more immediate ben-
however, train them to shake a tice, and master the intended val- efits of emphasizing good be-
patients hand, sit down during a ues. It isnt easy to modify a per- havior.
conversation, and pay attention. sons character or outlook in a No potential conflict of interest relevant
Such behavior provides the nec- classroom; besides, clinical train- to this article was reported.
essary if not always sufficient ing is more effective when it re-
Dr. Kahn is a psychiatrist at Beth Israel Dea-
foundation for the patient to sembles apprenticeship rather than coness Medical Center and an assistant
have a satisfying experience. graduate school. Trainees are likely professor of psychiatry at Harvard Medical
Furthermore, its simpler to to learn more from watching col- School both in Boston.

change behavior than attitudes. leagues act with compassion than 1. Pronovost P, Needham D, Berenholtz S,
Although reading medically rel- from hearing them discuss it. et al. An intervention to decrease catheter-
evant literary classics and writing Etiquette-based medicine would related bloodstream infections in the ICU.
N Engl J Med 2006;355:2725-32. [Erratum,
reflection pieces (as is now done prioritize behavior over feeling. N Engl J Med 2007;356:2660.]
in many medical schools) may It would stress practice and mas- Copyright 2008 Massachusetts Medical Society.

make some students more mature tery over character development.

n engl j med 358;19 may 8, 2008 1989

The New England Journal of Medicine
Downloaded from by EDUARDO CARRILLO-MARAVILLA on February 26, 2016. For personal use only. No other uses without permission.
Copyright 2008 Massachusetts Medical Society. All rights reserved.