How Exemplary Teaching Physicians Interact with Hospitalized Patients
BACKGROUND: Effectively interacting with patients defines the consummate clinician.
OBJECTIVE: As part of a broader study, we examined how 12 carefully selected attending physicians interacted with patients during inpatient teaching rounds.
DESIGN: A multisite study using an exploratory, qualitative approach.
PARTICIPANTS: Exemplary teaching physicians were identified using modified snowball sampling. Of 59 potential participants, 16 were contacted, and 12 agreed to participate. Current and former learners of the participants were also interviewed. Participants were from hospitals located throughout the United States.
INTERVENTION: Two researchers—a physician and a medical anthropologist—conducted 1-day site visits, during which they observed teaching rounds and patient-physician interactions and interviewed learners and attendings.
MEASUREMENTS: Field notes were taken during teaching rounds. Interviews were recorded and transcribed, and code reports were generated.
RESULTS: The attendings generally exhibited the following 3 thematic behaviors when interacting with patients: (1) care for the patient’s well-being by being a patient advocate and forming a bond with the patient; (2) consideration of the “big picture” of the patient’s medical and social situation by anticipating what the patient may need upon discharge and inquiring about the patient’s social situation; and (3) respect for the patient through behaviors such as shaking hands with the patient and speaking with the patient at eye level by sitting or kneeling.
CONCLUSIONS: The key findings of our study (care for the patient’s well-being, consideration of the “big picture,” and respect for the patient) can be adopted and honed by physicians to improve their own interactions with hospitalized patients.
© 2017 Society of Hospital Medicine
Our findings are largely consistent with other key studies in this field. Not surprisingly, the attendings we observed adhered to the major suggestions that Branch and colleagues2 put forth more than 15 years ago to improve the teaching of the humanistic dimension of the patient-physician relationship. Examples include greeting the patient, introducing team members and explaining each person’s role, asking open-ended questions, providing patient education, placing oneself at the same level as the patient, using appropriate touch, and being respectful. Weissmann et al.22 also found similar themes in their study of teaching physicians at 4 universities from 2003 to 2004. In that study, role-modeling was the primary method used by physician educators to teach the humanistic aspects of medical care, including nonverbal communication (eg, touch and eye contact), demonstration of respect, and building a personal connection with the patients.22In a focus group-based study performed at a teaching hospital in Boston, Ramani and Orlander23 concluded that both participating teachers and learners considered the patient’s bedside as a valuable venue to learn humanistic skills. Unfortunately, they also noted that there has been a decline in bedside teaching related to various factors, including documentation requirements and electronic medical records.23 Our attendings all demonstrated the value of teaching at a patient’s bedside. Not only could physical examination skills be demonstrated but role-modeling of interpersonal skills could be observed by learners.
Block and colleagues24 observed 29 interns in 732 patient encounters in 2 Baltimore training programs using Kahn’s “etiquette-based medicine” behaviors as a guide.12 They found that interns introduced themselves 40% of the time, explained their role 37% of the time, touched patients on 65% of visits (including as part of the physical examination), asked open-ended questions 75% of the time, and sat down with patients during only 9% of visits.24 Tackett et al.7 observed 24 hospitalists who collectively cared for 226 unique patients in 3 Baltimore-area hospitals. They found that each of the following behaviors was performed less than 30% of the time: explains role in care, shakes hand, and sits down.7 However, our attendings appeared to adhere to these behaviors to a much higher extent, though we did not quantify the interactions. This lends support to the notion that effective patient-physician interactions are the foundation of great teaching.
The attendings we observed (most of whom are inpatient based) tended to the contextual issues of the patients, such as their home environments and social support. Our exemplary physicians did what they could to ensure that patients received the appropriate follow-up care upon discharge.
Our study has important limitations. First, it was conducted in a limited number of US hospitals. The institutions represented were generally large, research-intensive, academic medical centers. Therefore, our findings may not apply to settings that are different from the hospitals studied. Second, our study included only 12 attendings and their learners, which may also limit the study’s generalizability. Third, we focused exclusively on teaching within general medicine rounds. Thus, our findings may not be generalizable to other subspecialties. Fourth, attendings were selected through a nonexhaustive method, increasing the potential for selection bias. However, the multisite design, the modified snowball sampling, and the inclusion of several types of institutions in the final participant pool introduced diversity to the final list. Former-learner responses were subject to recall bias. Finally, the study design is susceptible to observer bias. Attempts to reduce this included the diversity of the observers (ie, both a clinician and a nonclinician, the latter of whom was unfamiliar with medical education) and review of the data and coding by multiple research team members to ensure validity. Although we cannot discount the potential role of a Hawthorne effect on our data collection, the research team attempted to mitigate this by standing apart from the care teams and remaining unobtrusive during observations.
Limitations notwithstanding, we believe that our multisite study is important given the longstanding imperative to improve patient-physician interactions. We found empirical support for behaviors proposed by Branch and colleagues2 and Kahn12 in order to enhance these relationships. While others have studied attendings and their current learners,22 we add to the literature by also examining former learners’ perspectives on how the attendings’ teaching and role-modeling have created and sustained a lasting impact. The key findings of our national, qualitative study (care for the patient’s well-being, consideration of the “big picture,” and respect for the patient) can be readily adopted and honed by physicians to improve their interactions with hospitalized patients.
A cknowledgments
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the US Department of Veterans Affairs.
