Journal of General Internal Medicine

, Volume 28, Issue 7, pp 908–913 | Cite as

Appraising the Practice of Etiquette-Based Medicine in the Inpatient Setting

  • Sean Tackett
  • Darlene Tad-y
  • Rebeca Rios
  • Flora Kisuule
  • Scott Wright
Original Research

ABSTRACT

BACKGROUND

The physician–patient relationship is at the heart of patient care. Dr. Michael Kahn proposed a checklist of six behaviors, defining “etiquette-based medicine”, as a strategy to start each encounter respectfully and improve patient–physician rapport.

OBJECTIVE

To assess performance of “etiquette-based medicine” in the inpatient setting.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional observational study using time-motion techniques between May and July, 2009. Eight hospitalists were randomly selected at each of three hospitals in the Greater Baltimore area. Each time the physician entered a patient’s room, a single observer recorded whether the “etiquette-based medicine” behaviors were performed: (1) knocking or asking to enter the patient’s room, (2) introducing oneself, (3) shaking the patient’s hand, (4) sitting down in the patient’s room, (5) explaining one’s role in the patient’s care, and (6) asking about the patient’s feelings regarding his or her hospitalization or illness.

MEASUREMENTS

The frequency with which physicians performed the six behaviors, predictors of behavior performance, and Press-Ganey performance scores. The etiquette-based medicine (EtBM) score was defined and calculated by dividing the number of observed behaviors by the number expected.

RESULTS

The 24 observed hospitalists collectively saw 226 unique patients. No individual behavior was performed with a majority of patients, and, with 30 % of the patients, none of the behaviors were performed. The average EtBM score for the physicians was 22.3 % (SD 10.9 %). Physicians who spent more time with patients were more likely to perform behaviors. Sitting down (p = 0.026) and EtBM scores (p = 0.019) were associated with physician-specific Press-Ganey ratings.

LIMITATIONS

Cross-sectional design does not allow for determination of causality.

CONCLUSIONS

“Etiquette-based medicine” was infrequently practiced by this sample of hospitalist physicians. Improving performance of etiquette-based medicine may improve patient satisfaction.

KEY WORDS

etiquette-based medicine professionalism hospitalists 

Notes

Acknowledgements

Dr. Wright is a Miller-Coulson Family Scholar and this work is supported by the Miller-Coulson family through the Johns Hopkins Center for Innovative Medicine. We are grateful to Supriya Munshaw for her statistical expertise. This work was presented as a poster at the two national conferences: Society of Hospital Medicine’s Annual Meeting in Dallas, TX, May 11, 2011, and the Society of General Internal Medicine Annual Meeting in Phoenix, AZ, May 4, 2011.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

REFERENCES

  1. 1.
    Inui TS. (Association of American Medical Colleges). Flag in the Wind: Educating for Professionalism in Medicine. 2003.Google Scholar
  2. 2.
    Arora V, Gangireddy S, Mehrotra A, Ginde R, Tormey M, Meltzer D. Ability of hospitalized patients to identify their in-hospital physicians. Arch Intern Med. 2009;169(2):199–201.PubMedCrossRefGoogle Scholar
  3. 3.
    Maniaci MJ, Heckman MG, Dawson NL. Increasing a patient’s ability to identify his or her attending physician using a patient room display. Arch Intern Med. 2010;170(12):1084–1085.PubMedGoogle Scholar
  4. 4.
    O’Leary KJ, Kulkarni N, Landler MP, et al. Hospitalized patients’ understanding of their plan of care. Mayo Clin Proc. 2010;85(1):47–52.PubMedCrossRefGoogle Scholar
  5. 5.
    Levinson W, Lesser CS, Epstein RM. Developing physician communication skills for patient-centered care. Health Aff (Project Hope). 2010;29(7):1310–1318.CrossRefGoogle Scholar
  6. 6.
    Auerbach S. The impact on patient health outcomes of interventions targeting the patient–physician relationship. Patient. 2009;2(2):77–84.PubMedCrossRefGoogle Scholar
  7. 7.
    Griffin SJ, Kinmonth AL, Veltman MW, Gillard S, Grant J, Stewart M. Effect on health-related outcomes of interventions to alter the interaction between patients and practitioners: a systematic review of trials. Ann Fam Med. 2004;2(6):595–608.PubMedCrossRefGoogle Scholar
  8. 8.
    Street RL Jr, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician–patient communication to health outcomes. Patient Educ Couns. 2009;74(3):295–301.PubMedCrossRefGoogle Scholar
  9. 9.
    U.S. Department of Health and Human Services. Medicare Hospital Compare Quality of Care. Available at http://www.hospitalcompare.hhs.gov/ Last accessed on December 20, 2012.
  10. 10.
    Center for Medicare and Medicaid Services. Hospital Value Based Purchasing. Available at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based-purchasing. Last accessed on December 20, 2012.
  11. 11.
    Kahn MW. Etiquette-based medicine. N Engl J Med. 2008;358(19):1988–1989.PubMedCrossRefGoogle Scholar
  12. 12.
    Press Ganey. Creating High-Performance Healthcare Organizations. Available at http://www.pressganey.com/aboutUs.aspx. Last accessed on December 20, 2012.
  13. 13.
    Fulton BR, Drevs KE, Ayala LJ, Malott DL Jr. Patient satisfaction with hospitalists: facility-level analyses. Am J Med Qual. 2011;26(2):95–102.PubMedCrossRefGoogle Scholar
  14. 14.
    Aiken LS, West SG. Multiple Regression: Testing and Interpreting Interactions. Thousand Oaks, CA: Sage Publications; 1991.Google Scholar
  15. 15.
    Cohen JC, West P, Aiken SG. Applied Multiple Regression/Correlation Analysis for the Behavioral Sciences. 3rd ed. Mahwah, NJ: Erlbaum; 2003.Google Scholar
  16. 16.
    Makoul G, Zick A, Green M. An evidence-based perspective on greetings in medical encounters. Arch Intern Med. 2007;167(11):1172–1176.PubMedCrossRefGoogle Scholar
  17. 17.
    Santen SA, Rotter TS, Hemphill RR. Patients do not know the level of training of their doctors because doctors do not tell them. J Gen Intern Med. 2008;23(5):607–610.PubMedCrossRefGoogle Scholar
  18. 18.
    Arora VM, Schaninger C, D’Arcy M, et al. Improving inpatients’ identification of their doctors: use of FACE cards. Jt Comm J Qual Patient Saf / Jt Comm Resour. 2009;35(12):613–619.Google Scholar
  19. 19.
    Francis JJ, Pankratz VS, Huddleston JM. Patient satisfaction associated with correct identification of physician’s photographs. Mayo Clin Proc. 2001;76(6):604–608.PubMedGoogle Scholar
  20. 20.
    Johnson RL, Sadosty AT, Weaver AL, Goyal DG. To sit or not to sit? Ann Emerg Med. 2008;51(2):188–193. 193 e1–2.PubMedCrossRefGoogle Scholar
  21. 21.
    Radosh L, Keller B, Spicer J. Effects upon patient satisfaction during inpatient rounding of physician sitting vs. standing. Society of Teachers of Family Medicine Annual National Conference. Vancouver, Canada; 2010.Google Scholar
  22. 22.
    Strasser F, Palmer JL, Willey J, et al. Impact of physician sitting versus standing during inpatient oncology consultations: patients’ preference and perception of compassion and duration. A randomized controlled trial. J Pain Symptom Manag. 2005;29(5):489–497.CrossRefGoogle Scholar
  23. 23.
    Swayden KJ, Anderson KK, Connelly LM, Moran JS, McMahon JK, Arnold PM. Effect of sitting vs. standing on perception of provider time at bedside: a pilot study. Patient Educ Couns. 2012;86(2):166–71.Google Scholar
  24. 24.
    Day L, Benner P. Ethics, ethical comportment, and etiquette. Am J Crit Care: Off Publ Am Assoc Crit Care Nurses. 2002;11(1):76–79.Google Scholar
  25. 25.
    Maio G. Is etiquette relevant to medical ethics? Ethics and aesthetics in the works of John Gregory (1724–1773). Med Health Care Philos. 1999;2(2):181–187.PubMedCrossRefGoogle Scholar
  26. 26.
    Rao JK, Anderson LA, Inui TS, Frankel RM. Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence. Med Care. 2007;45(4):340–349.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2013

Authors and Affiliations

  • Sean Tackett
    • 1
  • Darlene Tad-y
    • 2
  • Rebeca Rios
    • 1
  • Flora Kisuule
    • 1
  • Scott Wright
    • 1
  1. 1.Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University, School of MedicineBaltimoreUSA
  2. 2.University of Colorado Anschutz Medical CampusAuroraUSA

Personalised recommendations