{"id":10822,"date":"2023-11-16T15:16:02","date_gmt":"2023-11-16T20:16:02","guid":{"rendered":"https:\/\/blogs.nejm.org\/hiv-id-observations\/?p=10822"},"modified":"2023-11-21T09:09:44","modified_gmt":"2023-11-21T14:09:44","slug":"being-a-good-doctor-why-are-the-simple-things-so-hard","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/being-a-good-doctor-why-are-the-simple-things-so-hard\/2023\/11\/16\/","title":{"rendered":"Being a Good Doctor — Why Are the Simple Things So Hard?"},"content":{"rendered":"

The simple things that make someone not just a doctor — but a good<\/em> doctor — can slip away from us when we’re too busy, or tired, or preoccupied, or hungry. That’s why it’s wise periodically to be reminded of the “soft skills” that, while individually not tricky, together make a huge difference in how patients perceive us.<\/p>\n

“Soft skills,” by the way, is the term coined recently by Dr. Robert Oubre, a hospitalist from Louisiana who specializes in Clinical Documentation Improvement, or CDI. Periodically imparting his wisdom on social media and in his newsletter, he recently posted something entitled, “Preventing and Protecting Against Lawsuits.”<\/a> Here’s what one lawyer told him was a critical part of avoiding legal trouble during patient care:<\/p>\n

You should practice in a way that causes your patients, and everyone you work with, to like you.<\/p><\/blockquote>\n

Be likable! How sensible. Because beyond lawsuit protection, I’d argue these soft skill make up critical components of patient care, and legal risk-reduction is just a corollary benefit.<\/p>\n

Here are some of those skills he cites, in bold, followed by my comments — it’s a great list. He writes from the perspective of hospital care, but a lot of them transfer over to the clinic.<\/p>\n

Sit.<\/strong> In the hospital, patients are often in bed, sometimes in a chair, but hardly ever standing. Get on their level. This small physical act greatly increases their sense that you care about them and that you’re giving them time. Logistically, it’s not always easy — family might be visiting, chairs might be occupied or have stuff on them, the room might be architecturally challenging. But try to make it happen when you can.<\/p>\n

Call.<\/strong> Find out who they’ve listed as their designated family member or friend to help out, and keep that person updated. We had the importance of this action driven home to us during the dark days of the pandemic, when families couldn’t visit. One time-saving strategy is to have the patient call while you’re rounding in the room or during the office visit, and put their family member on speaker phone.<\/p>\n

Ask, \u201cWhat questions do you have?\u201d rather than \u201cDo you have any questions?”<\/strong> The former invites questions, the latter subtly discourages them.<\/p>\n

Introduce yourself.<\/strong> Patients meet a ton of clinicians during their hospitalization, especially if it’s a long and complex one. Coverage changes, weekends and holidays happen, specialists aplenty get called in. For many services, the era of working extended blocks of time of consecutive days is long gone. So it never hurts to remind patients who you are — and do it repeatedly, as with rare exceptions, we are terrible with names. (You lucky few out there who are good with names are fortunate indeed!) During his wife’s recent care, Dr. Oubre posted the following<\/a> — that empty, confused feeling when people fail to introduce themselves:<\/p>\n

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Use the patient\u2019s name.<\/strong> There’s really no excuse for not greeting the patient by their name — after all, we all know it, it’s right at the top of the medical record. So use it — “Good morning, Mr. Smith”, “Hello again, Ms. Lopez”, “Hi, Mr. Gupta, how was your night?”, etc. (Then introduce yourself — again. See above.) If the name is unfamiliar or hard to pronounce, ask them how to pronounce it, and do your best to get it right. Plus, on those occasions when a patient changes rooms, this action provides another check that you’re not about to take a history, do a physical exam, or worst of all, do a procedure on the wrong person. (Yes, it happens<\/a>.)<\/p>\n

Acknowledge others in the room — and find out who they are.<\/strong> I added that last bit. Both are crucial. Let’s imagine you walk in the room, and your patient (a man) is accompanied by a woman. Try this script: “Hello Mr. White, I’m Dr. Schwartz, nice to meet you.” Turn now to the woman, and say, “And who do we have with us today?” Not — “… and is this your wife?” Most<\/em> of the time it will be the spouse or partner — but not always. Everyone has made the mistake of assuming<\/em> it’s a spouse, only to find out it’s the patient’s friend, or sibling, or parole officer, or daughter (ugh), or mother (ugh again). If you haven’t yet made this embarrassing generational error, learn from our mistakes and don’t do it yourself.<\/p>\n

Corollary to this point: On rare occasions, your patient doesn’t want the extra person there, but has been forced (or even bullied) into it. Give them an opportunity to be alone with you, by asking if they’d like the person to be there during the history or during the physical exam. For young adults (ages 18-25, give or take), I typically allow the parents in the room during the initial history, then ask them to leave during the physical at which time I can ask more delicate and private questions.<\/p>\n

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American Theater Poster, 1899<\/p><\/div>\n

Mention the NAME of other doctors that are caring for them.<\/strong> While you may not be able to do this for all<\/em> the doctors, try at least to name the primary attending physician, or in the outpatient setting, the referring clinician. And don’t just mention their name — tell them you’ve been communicating. “I heard from Dr. Li, your primary care doctor, that you had a positive TB blood test and had some questions”, or “I know from reviewing your chart that Dr. Aslam thinks you might need a change in antibiotics.” With so many people involved in a patient’s care, it’s critical to inform them that everyone is working as a team to help them get better — “Establish a team-work mentality” is another one of Dr. Oubre’s soft skills, and this strategy affirms this team work.<\/p>\n

Smile. Listen. Affirm their experiences.<\/strong> One patient I saw with severe asthma told me how grateful she felt when one of our gifted pulmonologists said something like, “That must be very scary for you” when she described the sensation of having an asthma attack. Remarkably, in all the years of seeing various clinicians, no one had ever mentioned that before. Having this doctor acknowledge her fear went a long way to establishing their very successful long-term care plan.<\/p>\n

For our new HIV diagnoses, we make sure to acknowledge the feelings they have when they find out their HIV test returned positive — something along the lines of, “It can be hard to hear that the test is positive.” Then pause, and let them speak. We can then quickly move on to reassure them that the diagnosis is no longer a death sentence, that treatment can lead to a long and normal life, and that we’ll help them adjust to this new reality of having a chronic (but treatable!) condition.<\/p>\n

Follow up on promises.<\/strong> My wonderful (and still dearly missed) late colleague Paul Farmer took this to heart more than anyone I’ve met. No matter how busy or crazy his schedule, if he told a patient he’d be back to hear more of their story, or to give them boots, he’d do it. (Here’s the boots story<\/a>, #2 in the list.) I’m not saying we need to buy everyone boots — but his actions stand out as a good model for what we should aim for.<\/p>\n

Be approachable to nurses.<\/strong> This statement, of course, applies to all the members of the care team. There’s no room in good patient care for outdated hierarchies or authoritarian actions. The nurses, social workers, pharmacists, front desk staff, the person delivering the food tray, transport personnel — we’re all there to accomplish the same thing, which is to get our patients better. The more we acknowledge and validate the others we work with, the better we’ll do.<\/p>\n

Remember to look at them — not just the computer.<\/strong> Sure, we can consult the electronic medical record during the visit — just tell them that’s what you’re doing, and even apologize if you need to go on a lengthy search. Or invite them over to do it with you! But staring exclusively at the computer screen and typing while seeing a patient is a surefire way to create distance between “us” and “them.” And yes, I added this one to the list, as it’s long been a pet peeve of mine.<\/a><\/p>\n

A non-medical person reading the above might think this stuff is easy. What’s the big deal? But trust me, the fact they seem so obvious stands in sharp contrast to just how difficult they are to do consistently, in particular when external demands weigh in as distractions.<\/p>\n

But try we must — not only to avoid lawsuits (the original purpose of Dr. Oubre’s excellent list), but just to be a kind and caring doctor.<\/p>\n

Anything left out you want to mention?<\/p>\n

It certainly never hurts to ask about pets — people love<\/em> talking about their pets, especially if they have a special talent.<\/p>\n