DDS Perspective: Etiquette in Medicine

Introduction

I believe the field of Medicine is extremely noble. I take pride in knowing that I am at least a partial conduit for patients to feel better and potentially live longer. It is humbling to acknowledge that everyday patients put their lives in our hands.

Unfortunately, our field has been changing and, arguably in some aspects, to a less personal system. We are rewarded not on the quality of care, but on the number of patients we see. The utilization of computers in patients examination rooms may be helpful for charting or quickly searching for collaborating medical advice but may alienate the patient from us. Because we are “on the clock,” we are more likely to type than to look or examine a patient during their clinic visit.

In this evolving environment, what has not changed with this great responsibility is the critical requisite to treat everyone with respect, compassion, and empathy. We should follow a level of etiquette that resonates these values.

My Rules of Etiquette

• 1. Dress sharply. Avoid wearing scrubs to clinic. Do not look worse than your patient. What defines professional appearance will depend on your type of and where you practice. Guayaberas may be appropriate in some parts of the world, Hawaiian shirts in others, and collared shirts with ties still in others. Consider comfortable shoes, a clean white lab coat, and nice slacks. No shorts.

• 2. Always knock on the exam room door before entering. A patient may be engaged in a private conversation on the telephone or in the room. They may be getting dressed. You do not want to barge in or appear intrusive.

• 3. Address patients by their last name—at least at the first encounter. This may be old fashioned, but I always refer to patients as mister/miss/missus and their last name. Then, I immediately ask how they would like to be addressed. Do not make assumptions. Document the response so you will not forget how they want to be addressed. Most physicians want to be addressed as “Doctor.” Patients deserve the same respect.

• 4. Shake hands and look the patient in the eye. Smile.

• 5. Avoid interrupting patients when they are explaining. Never minimize what the patient is feeling. Even though you may not think what they say is pertinent, it is important to them. Patients can drive far to see us, have a substantial copayment, take time off from work, pay for parking, and struggle to identify a parking space. Patients sacrifice a lot to see us. They do not want to be rushed; they want to feel listened to. We need to make sure their time spent is worthwhile.

• 6. Ask permission before examining a patient. When I was resident, one of my patients said I was the only male physician she ever allowed to examine her because I had asked her permission first. Patients are not mannequins, and as a courtesy we should ask for permission. An examination should not be considered a physical attack.

• 7. Ask permission before talking to a patient’s caregivers. Do not just assume we can ask caregivers questions. Remember there may be sensitive issues and a desire for confidentiality. I remember a patient sternly reminding me that he was the patient and all questions regarding his health should only be directed to him.

• 8. Talk with the patient not at the patient. Avoid medical jargon. We speak a different language. Draw pictures. Utilize images from the internet. Ask the patient’s opinion. This is the essence of health care literacy. Be careful in using some medical terms like “obesity.” We define “obesity” as a BMI greater than 30. However, patients find the term extremely stigmatizing.

• 9. Consider giving best- and worst-case scenarios, and likely scenarios. We do not have crystal balls. Predicting natural history and outcomes can be difficult. I am by nature a cup-half-full person. I try to find the positive in our situations but am cognizant of not trying to oversell anything. I do not want to mislead patients or their caregivers.

• 10. If writing notes in the office, engage the patient by showing lab results and/or image reports. Modern medicine encourages us to write notes during a patient visit. However, this often means that our back is turned to the patient. I like to ask permission to stand up and move closer to the computer so I can show the trend of liver-associated tests. Can you imagine talking to your business partner or therapist while they are looking elsewhere?

• 11. Ask where the clinic note should be sent. Patients want to know that their doctors are communicating. They likely have a long-standing and trustworthy relationship with their primary providers or other specialists. It is also a courtesy to forward your notes.

• 12. Be sensitive when writing notes. Nothing is confidential. Do not describe patients by their medical conditions. Say patients with cirrhosis instead of cirrhotic patients. It is ironic that we are so concerned with the term fatty liver yet neglect the stigmatization of the medical term obese.

• 13. Identify what is important to the patient. Is it to be pain free? Understand what to expect from the diagnosis. Understand if the patient has a heritable condition that can affect their kids.

• 14. Contact the patient after results are known. This is difficult. I tend to contact patients only with serious results. However, I do encourage all patients to message me for the results so they do not need to wait six months for the good results.

• 15. Use professional interpreters and not family members to translate.

• 16. Don’t be judgmental. Our job is not to judge a patient’s beliefs or their behaviors; it is to provide the best medical care possible in a noble way.

• 17. Never lose your cool. Although we are all human and losing your temper can be natural, I have learned that when patients are upset it often is not personal but anger because of their diagnosis or prognosis. Sometimes, it is reflection of no longer being in control. Some of my dearest patients have started our relationship in a state of annoyance.

Conclusion

I feel lucky to be a physician. As a student of karma, I appreciate the importance of treating everyone with the utmost respect and care. For by the grace of God, we will all eventually be on the other side of the desk there but for the grace of God go I.