History of professional etiquette
Hospitals as we know them didn’t exist until the first Muslim-built “bimaristan” was established in Baghdad in 9th AD. Till late 19th century AD, doctors occupied a fairly low status in the society. From Roman times and throughout the European middle ages, doctors were subjected to and endured any indignity (even tasting the urine of their patients as a means of diagnosis – earning them the nickname ‘piss prophet’). It was only after late 19th century that the doctor’s status transited in society from a low to a high one. Interestingly, two changes mirrored (or perhaps as a result of these changes) this shift in the status happened and they generally started enjoying better working conditions. These changes were:
Doctors replaced the somber black dress to white lab coat (white apron)
Started valuing professional etiquette
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These basic rules guiding their etiquette, style, clothes, and decorum have remained surprisingly static since then.
Why are ‘office’ manners important?
It is now realised that technical solutions are only half of the cure because the real cure is of illness and not merely disease. Now, there is a growing body of evidence that the patient’s perception of the doctor’s character influences health outcomes:
Patients are more likely to be honest and satisfied with physicians when they’re viewed as compassionate; not just capable and competent
Displays of empathy improve outcomes in patients struggling with conditions such as obesity, DM, HT COAD, pulmonary infections, OA and other chronic diseases
Doctor-patient relationship, which is in turn, governed by the doctor’s professional etiquette correlates with-
patients, compliance, treatment outcomes, and satisfaction
perception of doctor’s competence
From the doctor’s point of view, it helps in retaining and attracting more patients.
10 tips to increase OPD volume
Healthcare is actually more of a social science than a physical one. The best way to increase OPD volumes (a type of social interaction) is through appropriate professional etiquette because more than most careers, medicine is characterised by professional relationships, among different people, in numerous settings. Etiquette is more than mere good manners; it is a tool for cultivating good relationships.
Here are 10 valuable tips in improving professional etiquettes:
1 Maintain a professional appearance
2 Use a welcome greeting
3 Practice good communication
4 Keep patients in the loop, stay focused on issues
5 Build rapport with the patients
6 Be present with the patients
7 Don’t rush patients
8 Cultivate a positive work environment at the clinic
9 Make arrangements for subsequent follow-up
10 Get expert help when needed
Maintain a professional appearance
Physicians’ appearance has been most closely monitored of any professional class in history. Dress code is a physical structure and those professions which deal with uncertainties particularly in the context of life and death; healthcare professionals (HCPs), police and military professionals; an ordered structure places the victim in a “comfort zone.” Thus, an appropriate attire (a physical structure) of HCPs provides great psychological comfort to the patient. For doctors, the dress code should be such that it should appear neat, without much adornment and as such a nicely, starched and pressed white lab coat fits the bill. As a matter of fact, not only doctors but all staff members should be clean, tidy and approachable-looking. For doctors the ideal appearance is:
The uniform (which is a white lab coat), scrubs and shoes, which should be clean and professional looking
Name tag should be visible and readable
If hair is long, it should be pulled up and back, away from the face
Why white lab coat?
The first thing that distinguishes a doctor from a patient in a clinical (social) encounter is appearance. Psychologically, it gives a marked contrast; while the doctors appearance is characterised by neatness, professionalism abd vitality, the patient appears weak and in supplicant state. Several studies have revealed that patients feel that physicians who wear white coats are more knowledgeable, truthful abd competent than those not wearing them.
Use a welcome greeting
Introduce yourself and greet the patient by name. Gesture Namaste or shake hands (as per appropriate social norm) and say your name in a confident voice. Introduce colleagues, if present to the patient/care-givers as well.
Desk staff should greet patients as soon as they walk in the door. Other staff members should greet patients by name, introduce themselves by name and position, and inform patients as to what steps and procedures they’ll be going through. Staff should do this even if they are wearing a name tag (which they should be doing at all times).
Practice good communication
1 Remember body language- Office etiquette is all about impressions; smile and make eye contact when first greeting the patient and continue to make eye contact throughout the appointment to assure the patient that they have their doctor’s full attention. Make it clear to patients with body language and cues before you touch them. Body language is an essential component of communication. When making conversation, remember, care invested in words can be undone by non-verbal communication. Tune in and be aware of what image your body language is creating.
Stand tall with shoulders back and chin up; avoid slouching
Keep your hands out of your pockets
Use a sincere smile to denote warmth and friendliness
Make eye contact with your patient when you’re talking to show interest
Move with confidence and purpose
Be sensitive to the fact that body language could unknowingly offend someone. The mistake may be made obvious from someone’s comments, expressions/body language. Apologise immediately. If you don’t know what you did, adopt a humble and respectful attitude and ask. Some things you should avoid:
Don’t slouch/fidget or move suddenly
Don’t wring your hands or make a fist
Don’t put hands on your hips or cross them over your chest
Don’t drag or shuffle your feet
Some gestures may be misunderstood and considered offensive to people in different cultures. To play it safe, try to avoid these in a conversation:
the ‘okay’ sign
the ‘thumbs-up’ sign
the “V” for victory sign, especially with palm facing inward
waving hands with arms raised
2 Perfect your opening statement
Give broad openings to provide clues on what to explore with this particular patient.
Example: “Hello I’m Dr…, what do you want to talk about today?”
Don’t talk rapidly or ask multiple sets of questions or change subjects rapidly.
Why? Patients can get easily confused. They might not be able to communicate effectively.
Example: “What is your name? I see you like books. How do you feel?”
3 Make observations, not judgment
State to the patients what has been observed so patients can validate that you have understood their statements. Summarise by reviewing the main points of the discussion
Example: “You look worried. At the beginning, you stated that you doubt your decisions and that includes…”
Never give self judgments, opinion/beliefs. Using words like “great, nice, wrong, bad, good, should, ought, etc.” implies judgment.
Why? This is a common source of misunderstanding between HCPs and patients. They may fear communicating personal thoughts with a doctor who is openly vocal about opinions/judgments
Example: “This is wrong. You shouldn’t think about this. As a Hindu, we should not be initiators of such thoughts.”
4 Practice active listening and feedback
Practice active listening. Observe both verbal and non-verbal cues from the patient. Throughout, maintain eye contact and make verbal remarks to encourage the progression of communication.
Example: “Yes I understood you. You were prescribed low-fat, low carbohydrate diet. You can have some fish and eggs along with vegetable for your meals. Are you having trouble in sleeping?”
Don’t fail to give feedback, be inappropriately unresponsive
Why? Patients’ statements should not be taken for granted. They need to be acknowledged as they might contain important cues that may reflect their condition.
Example: Patient asked the HCP about diet but the HCP walked away
5 Set realistic expectations
Set realistic expectations. Give information that will help the patient better understand the situation.
Example: “You are diagnosed with Acute Lymphoblastic Leukemia. There are treatments for it like chemotherapy and radiotherapy.”
Don’t give false reassurance or set unrealistic expectations like using clichés to allay patients’ worries/fears.
Why? Patients may lose their trust on their healthcare team if false reassurance is given and later on turns out untrue.
Example: “Don’t worry about anything. You Everything’s going to be completely alright.”
6 Frame questions very carefully
Explore the patient’s statement and be objective in asking follow-up questions. It is always possible to ascertain the reason behind a patient’s statement by changing the approach.
Example: “You said you thought I made a wrong diagnosis. Is there other information or symptoms you want to share?”
Don’t ask “why” directly rather ask if patient wants to provide any other information.
Why? Asking “why” may result in a negative impact and It will make the patient feel confronted and judged which may lead to defensive answers.
Example: “You think I made a wrong diagnosis. Why?”
7 Keep conversations focused and keep patients in the loop- Patients want to know what is going on during their treatment, especially if they become anxious because of medical appointments. If they have to wait for a while, check in with them to ensure that they’re comfortable and update them on when they’ll be seen. During the visit, let the patient know what you’re doing before you do it, whether it’s taking vital signs, administering injection or taking a sample for a test.
When talking with patients, keep in mind that the conversation should be kept around the patient at all times. This way, they feel that the doctor is a good listener and will help him/her gain their trust.
Example: “I see that you are wearing a coat. Are you feeling cold in here?”
Don’t express your feelings or reveal any personal details.
Why? When establishing rapport, revealing feelings or any personal details are irrelevant to the patient. Talking more about yourself will spoil a budding rapport from being established with the patient.
Example: “Do you like artwork in your home? I like it; in fact, I have many paintings in my home.”
8 Don’t steer the subject away from the patient
Acknowledge the patient’s statements. When the patient becomes emotional, stay silent and let them express their emotions.
Example: The patient is crying on hearing they need surgery, and the doctor says “I see that it has been hard on you. I can stay here a bit longer if that helps.”
Don’t change subject during conversations
Why? Suddenly changing the subject of a conversation will negatively affect rapport established with the patient. They might feel enough attention is not being paid to what they say.
Example: Patient is crying on hearing they need for surgery, and doctor says “What time did you start from home today?”
9 Keep conversation focused on the topic- The ability to connect with patients by making conversation is essential for success. To avoid inadvertently offending someone, stay away from controversial topics. Topics that should be generally avoided include religion, politics, and salary, jokes of questionable taste, medical problems and gossip. Topics that are usually safe to talk about include weather, traffic, sports, travel, books, and TV programs but ask them in reference to the patient and not others. When talking with patients don’t discuss personal problems. In case you face trouble getting a conversation started, try using the acronym OAR to help:
Observe. Make an observation. (“It looks like you’re ready for your operation.”)
Ask questions. (“Is this the first time you’ve visited this hospital?”)
Reveal something about yourself, but avoid getting too personal and in context with patient. (“I like a neat tidy dress, like yourself.”)
Build a rapport with the patient
Help put the patient at ease by opening interaction with some small talk, such as about the weather, the patient’s recent holiday, a major event in your community etc. It helps patients relax and ease them into an interaction which encourages them to open up about medical problems that they are dealing with (which for some patients can be potentially awkward /embarrassing).
Be present with patients
Doctors need to be truly mentally present as well, truly listening to the patient which makes them feel more comfortable about the quality of their care and can also make a difference between correct and incorrect diagnosis. Thus always be with the patient and not on the screen of a device or be mentally elsewhere.
Don’t rush patients
Never cut patients short in their communication. Take time to allow patients to:
Fully explain the reason for their visit
Ask any question
Voice any concerns they have about their treatment
This may extend appointments a bit longer but in the long run it can also save time and improve quality of medical care by preventing follow ups/problems due to misunderstanding about how the patient should be taking medication or caring for their health issue.
Cultivate a positive work environment
Kindness, consideration and common sense that characterise etiquette are also essential for HCP-HCP interaction. Be polite and courteous to colleagues, irrespective of stress; respect shown makes others feel valued contributing to effective communication and team building. Offer to help others and and thank others for helping. Use good manners and polite language, and avoid listening to gossip or complaints about other colleagues. Participate in department events to show team spirit. The key is to keep your work environment positive.
Keep disagreements with staff under wraps
Disagreements between staff is totally normal and disagreements should be handled in a mature and respectful way. Patients should never be able to detect strained relationships between staff members because when patients see that the staff aren’t on the same page, it makes them feel uncomfortable.
Make arrangements for follow up
If patients need follow-up appointments or consultations, ensure your staff helps them book that appointment before they leave office (if patients have to schedule these appointments on their own, they often won’t). Patients that have significant problems (but don’t need a follow-up appointment) will benefit from and appreciate a follow-up call. Put this on the calendar and have your staff call to ensure that the patient is feeling better and getting the care they need.
Get expert help when you need it
1 While office etiquette is important, it’s not the only thing a medical practice needs. When moving medical practices, opening a new location, or needing new medical equipment get the help of an expert.
2 All matters may not be handled by the doctor. Be ready to refer when additional help is needed.
3 Seek help of additional staff to streamline patient care and communication: physician attendant, nurse, dietician, pharmacist, IT professional, health counselor etc.
Disclaimer- The views and opinions expressed in this article are those of the author’s and do not necessarily reflect the official policy or position of M3 India.
The author, Dr. Sundeep Mishra is a Professor of Cardiology.