Bedside Manner 2020: An Inventory of Best Practices

Sami Abuqayyas, MD; Christopher Yurosko, DO; Ambreen Ali, MD; Christopher Rymer, MD; James K. Stoller, MD, MS

Disclosures

South Med J. 2021;114(3):156-160. 

In This Article

The Inventory

Engage the Patient With Humility at Eye Level

Sitting down at the bedside to talk with the patient "levels the topography."[7] Many have commented that standing over the patient can compromise communication by setting "the stage for intimidation, poor communication, and quick exits,"[7] the very things that undermine a patient's feeling of being cared for. Furthermore, engaging the patient at eye level is an act of humility. As Don Berwick reminds us in his commencement address to the 2010 Yale Medical School graduating class,[8] a physician's humility is essential to being a healer: "Those who suffer need you to be something more than a doctor; they need you to be a healer. And, to become a healer, you must do something even more difficult than putting your white coat on. You must take your white coat off. You must recover, embrace, and treasure the memory of your shared, frail humanity—of the dignity of each and every soul."

Clearly, engaging the patient with humility at eye level is a critical element of an effective bedside manner. That said, sitting at the bedside carries logistical challenges; it could be perceived as an infringement on the patient's personal space or there may be objects on the bed that preclude sitting.

Given the importance of "leveling the topography," Wolpaw[7] suggested carrying a portable chair on rounds. The chair, often a cane-like apparatus with a seat (Figure), allows the clinician to sit and then engage the patient eye-to-eye. The portable chair-cane can also serve as a "talking stick" on rounds, which can be passed from team member to team member as each engages the patient. This confers the additional benefit of fostering a culture in which every member can engage the patient directly in the conversation on rounds and can do so in an organized way to enhance understanding.

Figure.

Drs Ali Mehdi and Aaron Hamilton demonstrating their chair-canes, which they use to engage their patients at eye level.

Engage the Patient Based on Observing his or her Personal Artifacts

Being hospitalized quickly extracts the patient from his or her environment and can be dehumanizing. Activities that patients enjoy and people who know them and who know what brings them joy often are absent. As patients try to restore their personhood, they may decorate their rooms with family pictures and the visible artifacts of their joys (eg, pictures of pets, sports team logos, religious icons).

Scanning the patient's environment for clues about the patient's health status (eg, noticing a cane that may indicate instability) can provide a fuller assessment of the whole patient.[1,9] Looking for clues about the patient's life in his or her room can help forge connections.

A recent experience highlights the impact of such environmental scanning. In entering the room of an inpatient whom the team was meeting for the first time, a Pittsburgh Steelers logo on the patient's blanket caught our attention. "So, you're a Steelers fan! Have a Terrible Towel?" the attending asked, and the patient lit up in affirmation. As it happened, the attending's son had actually played for the Steelers and sharing his picture brought delight to the patient.

An expected response to the stress of hospitalization is to display things that bring calm and solace—for example, pictures of family, friends, and pets, and reminders of activities that bring a sense of normality to the hospital room. Noticing these objects validates the fullness of the patient's life and provides an opportunity, where appropriate, to reassure the patient that the opportunity to enjoy these things is coming, a lifeline to hope.

Use Intentional Indirect Communication With the Patient

A powerful practice with a great deal of impact that was observed during one of the coauthors' training could be called "intentional indirect communication with the patient." Dr Bernie Lown, Nobel Laureate for Physicians for Social Responsibility, and a venerated clinician at the Peter Bent Brigham Hospital, routinely rounded with an entourage of fellows, residents, and medical students. On entering a patient's room, Dr Lown would first directly engage the patient by eliciting a history, examining the patient, reviewing results, and so forth. Lown would share his assessment with the patient and, when encouraging, would add another comment. As the visit began to wind down and as Dr Lown turned to leave the room, again followed by the entourage, he would reach the door jamb of the patient's room, turn to his fellow and mutter, "God, the patient is doing so well." This "mutter" was pure bedside manner. Although putatively directed to a physician colleague while leaving the room, the mutter was actually purposely stated loud enough for the patient to hear and was, in fact, meant to be heard by the patient as a sign of reassurance. This "indirect" encouragement only served to underscore the words of direct encouragement that Dr Lown shared with the patient directly earlier, thereby ensuring congruence of the patient's understanding.

As one of the entourage of trainees who witnessed this practice, one of the current authors personally witnessed many patients' nonverbal expressions of relief and comfort at "overhearing" Dr Lown's muttered reassurance to a colleague.

Use Metaphors (With Full Appreciation of Their Strengths and Potential Shortcomings)

At the core of every successful relationship is open communication. To help facilitate the understanding of complex medical conditions and their equally complex treatments, physicians commonly use metaphors. The example of insulin being a "key that opens up a door to the cell," allowing the uptake of glucose intracellularly, has been heard often on endocrinology rounds. The simile that "the lung is like a balloon that pops with a pneumothorax" is often used by pulmonologists. Metaphors clearly have the capability of enhancing a patient's understanding,[10–12] and patients themselves often use metaphors to understand their illness. Extending this concept further, Arroliga et al[11] both surveyed pulmonologists regarding their use of metaphors in communicating with patients and classified metaphors into four categories of analogies or similes based on the type of image that the metaphor created—for example, as a container, an object from nature, a mechanical object (like a key opening a door or a balloon popping), or a somatic object.

As helpful as metaphors may be in enhancing communication, they do have limitations, especially regarding causing unintended meanings. Metaphors are always developed in specific cultural contexts and when they are applied in different contexts, their use can cause inadvertent miscommunication. For example, the concept of moving in an "upward" direction indicates improvement and optimism in American culture. In other cultures (eg, the Hmong in Cambodia), the connotation of direction is reversed: "up" has a dire connotation and "down" is a sign of improvement. Because miscommunication runs the risk of causing inadvertent harm to the patient relationship, metaphors must be used judiciously.

Listen Actively

Active listening is another critical bedside technique. Active listening affirms the patient's personhood and promotes healing through enhancing the physician–patient relationship.[12–14] As articulated by Fassaert et al,[15] several behaviors comprise active listening, including using inviting body language, listening attentively (eg, not interrupting the patient, asking open-ended questions, summarizing by paraphrasing the patient's words, and confirming understanding by repeating perceived understanding), and expressing understanding nonverbally (eg, nodding the head). Active listening also includes validating the patient's perception of his or her illness and the associated feelings and expectations. Naming the emotion and normalizing the patient's response can be so helpful, as in "I can imagine you are very anxious about this situation. Anybody would be."

Active listening can be taught[14,16] through simulation, role plays, and video training and can enhance the patient's experience of care. For example, Boissy et al[16] showed that a formal communication course was associated with improvements in CAHPS Clinician and Group Survey (CG-CAHPS) and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Respect Domain scores and significant increases in empathy scores that were sustained for at least 3 months.

Show Respect

To counteract the dehumanizing effect of being hospitalized, the astute clinician can first recognize the effect by naming it. Specifically, acknowledging on meeting the patient that "I recognize that this experience can be depersonalizing; we will do everything we can to acknowledge your personhood and special individuality," or, more simply, "Being in the hospital would make anybody feel as though they were stripped of who they are. We know you are a special person and want to do everything we can to preserve and celebrate that." A respected clinician colleague offered his approach to ensuring patient-centered care;[17] he focuses on establishing personhood before inquiring about medical issues. He begins an encounter with, "Before we discuss your medical problem, tell me about yourself," or "What would you like me to know about you?" Actions to acknowledge the patient's personhood are needed as well—could the patient wear some part of his own clothes instead of a hospital gown and slippers (eg, homemade slippers) without compromising care? Bring her dog to visit?

An important aspect of recognizing personhood is demonstrating respect for the patient. The process of making rounds represents many opportunities to show respect but equally, because rounds often are so ritualized, an opportunity to inadvertently demonstrate disrespect. Consider the scenario of entering a patient's room with a team on rounds. Knocking to ask permission to enter and actually waiting for an answer from the patient before entering demonstrates respect. Similarly, introducing each team member and his or her role to the patient demonstrates respect. Failure to do so, which all authors have regrettably witnessed at times, inadvertently reinforces depersonalization. Asking a patient's permission to turn off the television, to pull down the bedsheets for an examination, or to shift the gown to auscultate the heart and lungs represent respectful gestures that can be overlooked in the haste and routinization of rounds. When there are multiple examiners on rounds, seeking a patient's preference as to whether one member of the team may listen at a time or whether all members may listen simultaneously embodies respect.[2]

Use Humor Judiciously

Finding humor in the face of illness is hard to do and yet, when done well, can be associated with healing.[18–20] Consider the experience that Norman Cousins described.[18] Wracked with pain from a spinal inflammatory illness (ascribed to ankylosing spondylitis), he retreated to a hotel and surrounded himself with humor (eg, he binge watched Marx Brothers movies) and invited only positive interactions with visitors.

The experience of Stephen Gould, famed paleontologist, provides another example of the healing power of humor. Faced with an abdominal mesothelioma and a dire prognosis (ie, 8-month median survival), he committed to humor. In his article "The Median Isn't the Message,"[19] he recounted his unexpectedly prolonged 20-year postdiagnosis survival and noted that "the swords of battle are numerous, and none more effective than humor."

Just as humor is described as healing by patients, so too can the physician judiciously bring jocularity to the patient encounter. One of the authors recalls rounding on an inpatient who was pouring over a puzzle (ie, the anagram puzzle "Jumble") in the local newspaper. As an avid reader of the Jumble, the attending asked the patient if he wanted help. Hearing an affirmative response from the patient, he worked with the patient to unscramble the letters. Illness was banished for the moment with a salutary effect. Of course, humor must be deployed judiciously. To avoid the unintended perverse consequence of using humor, the clinician must follow the patient's lead and deploy humor only when the patient has demonstrated openness or avidity for humor as a coping strategy.

Write a Condolence Letter or Call Bereaved People

A patient's death is a broadly harrowing experience. In caring for a dying inpatient, the physician's care is directed not only to the patient but, as important, to the patient's family, especially when the gravity of the patient's condition and the inevitability of death become evident. In such an instance, the physician's bedside manner is directed to the family, both during the illness and afterward. A personal condolence letter written by the physician to the close relatives (eg, spouse, siblings) soon after the patient's death can be a powerful way to mitigate grief. As described by Bedell et al,[21] "the physician's responsibility to the patient does not end when the patient dies. There is one final responsibility—to help the bereaved family members." In their suggestions about how to write a condolence letter, they advise against superficial attempts to lessen grief, such as "It was meant to be." Rather, they suggest beginning with a direct expression of sorrow, such as "I am sending my heartfelt condolences on the passing of your … ." Much like the importance of acknowledging personal artifacts of the patient during life, an expression of a personal memory of the patient's life in a condolence letter can be powerful—for example, recognizing the patient's impact on his or her family or community or calling out an aspect of the patient's character. Acknowledging having observed the family's support for the patient and the privilege of having cared for the patient also are important elements of a condolence letter. Finally, expressing sympathy and the physician's availability to help during this time of bereavement are important (eg, "I hope it comes as some solace to you to know that all of us who had the privilege of caring for _________ share in your deep sense of loss. If we can help in any way during this time of bereavement, we are absolutely available to do so."). As an alternative to a condolence letter, clinicians may make condolence telephone calls to the family or attend funeral services.

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