On this side of the surgical suite you have the doctor known throughout the hospital as "the Raptor." He's earned his vulturine sobriquet not only because he's arrogant and disdainful — a terror to colleagues, nurses, residents and anyone who has to work with him — but also because he's famously rude and insulting to patients and families. Nobody actually likes him. And yet his surgical results are outstanding. His technical skill is the envy of associates; he's quick and precise, and he has the lowest complication rate in the hospital.
Over in the other corner you have the doctor known as "Dr. Hodad." He's cheerful, friendly, a good listener, brimming with compassion. Everyone adores him. Unfortunately he's terrible in the operating room. He's known for performing procedures on people who don't need them. His error and complication rates are among the worst in the facility — yet patients extol him, even when they've been harmed. He's so lovable. They don't know that the staff's fond-sounding nickname for him is an acronym: "hands of death and destruction."
Which of these two doctors — described by Johns Hopkins surgeon Martin Makary, M.D., in his 2012 book Unaccountable — would you want operating on you? Which one would you want on staff at your hospital?
The answer to the first question is probably a slam dunk. Who wouldn't want the better surgeon? To the second … maybe not so much.
In fact, there might be reasons to choose Dr. Hodad over the Raptor. Some research, for example, suggests that patients who perceive their surgeons as empathetic have better outcomes in general than patients who regard their surgeons as cold and unfeeling. So, perhaps that offsets in part the harms caused by the affable Hodad's lack of skill. And at least one study has found that a surgeon's ability to project compassion translates, not surprisingly, to higher patient satisfaction.
So, in a health care environment in which hospitals have serious money riding on patient satisfaction scores, maybe it would make sense to hire the clumsier but more emotionally reassuring surgeon. Fully 30 percent of a hospital's reimbursement for in-patient services to Medicare patients is now based on how pleased the patients are with their experience, as recorded on a standardized survey (called the HCAHPS — or Hospital Consumer Assessment of Healthcare Providers and Systems). Three of its 21 questions address how the doctors behaved: Did they always, usually, sometimes or never show courtesy and respect to you? Listen carefully to you? Explain what was happening clearly?
Having the Raptor around pretty much assures an HCAHPS ding. A surgeon like Hodad can be depended on to help bring up the score. Assuming he doesn't kill people right and left, or cause too many costly complications (they're part of the quality measures that determine value-based hospital payment as well), maybe hiring him would be the smarter (if not the more cynical and less ethical) choice.
Born Not Made
Most people who go into medicine do it because they want to help people. They may not particularly like people (in which case they may gravitate to back-room specialties like radiology, pathology or surgery) but they have at least a rudimentary sense of compassion.
Until medical school drains it out of them.
"Hundreds of articles about empathy have appeared in medical journals in the past few years," notes internist Suzanne Koven, M.D., writing in the Los Angeles Review of Books. "Researchers find that patients of empathic doctors are more likely to take their medications as prescribed and achieve better control of conditions like diabetes and asthma, and are less likely to initiate malpractice suits. But several studies show that during medical school, internship, and residency, young doctors actually become less empathic, that in the process of learning how to care for sick people, they unlearn how to care about them. [That's why] today's doctors-to-be are encouraged, often required, to participate in activities meant to boost empathy."
Not everyone is convinced such efforts are worth the candle. When she missed a mandatory ethics lecture in med school, recalled UCLA surgeon Pauline Chen, M.D., in a New York Times column "The Hidden Curriculum of Medical School" (Jan. 29, 2009), her professor told her not to worry. "You can't learn ethics or compassion," she was reassured. "You either have it or you don't."
Michael Kahn, M.D., a psychiatrist at Boston's Beth Israel Deaconess Medical Center and an assistant professor at Harvard Medical School, thinks there may be something to that. "Teaching compassion is extremely difficult," he says. "More people are born that way than are made that way."
Indeed, Kahn found empathy to be in short supply when he was himself a patient in an emergency room several years ago. The diagnosis was complicated, and each doctor who popped in on him — to report increasingly dire hypotheses, ineptly expressed — only made him more nervous. Finally a surgeon knocked on his door, shook his hand, introduced himself and admitted that it wasn't clear yet exactly what was wrong. This clinician's "behavior — dress, manners, body language, eye contact — was impeccable," Kahn reported. But "I wasn't left thinking, ‘What compassion.' Instead, I found myself thinking, ‘What a professional,' and even (unexpectedly), ‘What a gentleman.' The impression he made was remarkably calming, and it helped to confirm my suspicion that patients may care less about whether their doctors are reflective and empathic than whether they are respectful and attentive."
Old-Fashioned Good Manners
Kahn elaborated on that experience in the New England Journal of Medicine in 2008 (May 8). It had started him thinking.
"There have been many attempts to foster empathy, curiosity, and compassion in clinicians," he wrote, "but none that I know of to systematically teach good manners. The very notion of good manners may seem quaint or anachronistic, but it is at the heart of the mission of other service-related professions … . A doctor who has trouble feeling compassion for or even recognizing a patient's suffering can nevertheless behave in certain specified ways that will result in the patient's feeling well treated."
Kahn gave his piece the catchy title "Etiquette-Based Medicine." He proposed six rudimentary things a doctor always ought to do to practice it. When meeting with a hospitalized patient, he counseled, you should:
- Ask permission to enter the room; wait for an answer.
- Introduce yourself, showing ID badge.
- Shake hands (wear glove if needed).
- Sit down. Smile if appropriate.
- Briefly explain your role on the team.
- Ask the patient how he or she is feeling about being in the hospital. [Emphasis added.]
Interestingly, two observational studies conducted at Johns Hopkins institutions in Baltimore in 2012 and 2013 found that not one of a group of 29 interns and 24 hospitalists ever did all of those six things during some 1,000 collective patient encounters. What's more, in almost a third of their visits the doctors failed to do a single one of them.
Although it was only afterward that they were told what the observers were watching for, the interns invariably overestimated how often they had tagged each etiquette base. Sean Tackett, M.D., who as a resident led the hospitalist study, admits that his own adherence is hit or miss.
"I introduce myself to patients pretty much every day," he says. (Studies have shown that less than a quarter of hospital patients know whom their doctor is. See Archives of Internal Medicine, 2009; 169(2):199–201.) "I tell them what my role is in their care. I knock probably most of the time [unless there are two beds in the room and no door]. Sitting down, I don't do as much. Often there isn't a chair, and I don't feel comfortable sitting on a patient's bed or crouching. Shaking hands? Studies show men prefer it, women less. But there's a commentary that just came out in JAMA that says don't shake hands. (Two-thirds of patients in a Canadian study, however, considered a physician's touch comforting, and 58 percent believed it to be healing, especially women.) Do I ask how they feel about their hospitalization? Not so often. One barrier is the time crunch."
Learn to Make Nice
That's the usual excuse given by doctors for brushing aside the niceties of human interaction, Kahn notes. But only the sixth item on his list adds more than a second or two to the encounter. "Most patients don't want to alienate the doctor," he explains, "so they'll just say, ‘Fine'" if asked how they feel, unless the question probes deeper.
"They may be angry, scared, frustrated, but they don't want to say it." Inviting them to express how they feel about being in the hospital "is a simple thing to do, and it has a very high payoff," Kahn maintains. "The answer is often very, very helpful. But the reason we don't ask is that we really don't want to hear the answer. With a lot of patients you see a visual expression of relief when they're given a chance to vent a little."
Kahn suggested that doctors ought to carry around a checklist of the six essentials of etiquette-based medicine just as they tick off checklists in operating rooms and intensive care units. That may be impractical, he admits. (Tackett still thinks it's "a great idea.") "It's more a metaphorical checklist, a way of teaching trainees."
In fact, Kahn says, "an argument could be made for etiquette-based medicine to take priority over compassion-based medicine … . I may or may not be able to teach students or residents to be curious about the world, to see things through the patient's eyes, or to tolerate suffering. I think I can, however, train them to shake a patient's hand, sit down during a conversation and pay attention. Such behavior provides the necessary — if not always sufficient — foundation for the patient to have a satisfying experience."
Who cares if raptors are sincere? It's enough if they've learned to make nice.
David Ollier Weber is a principal of The Kila Springs Group in Placerville, Calif., and a regular contributor to H&HN Daily.