Teaching bedside manner

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Category : Medical Rants

 

The Hidden Curriculum of Medical School

While most of medical education and training is about the nuts and bolts of clinical care — how to treat hypertension, how to manage a ventilator, how to take out a gallbladder — the process also involves learning how to be “a doctor.” As opposed to lessons covered in textbooks and classrooms, this kind of learning is done through modeling, or what medical sociologist F. W. Hafferty has called the “informal” or “hidden curriculum.”

Medical students and residents copy the lingo, manners and expressions of more established senior residents and attending physicians. The lessons from these role models, who are often tired and stressed out themselves, can be sobering. They are also often cynical, rooted in large part in the belief that a doctor’s level of compassion is fixed.

“See one, do one, teach one.”

“Trust no one.”

“Keep ’em alive until 6:05.”

Or as I once was told: “You either have ’it’ or you don’t.”

So, I remember thinking, why make any effort to change?

Obviously, one cannot teach bedside manner unless one wants to teach bedside manner.  I believe that attending physicians have a responsibility to demonstrate and discuss bedside manner each and every day.  Of course this statement implies that attending physicians have a clue and care.

The first step in teaching bedside manner is in acknowledging its importance.  When you start talking about bedside manner, then students and residents pay attention.  When you start considering your own bedside manner, you quickly realize your importance as a role model.  When you do all these things, bedside manner is no longer part of the hidden curriculum.

Too many teaching attending physicians never think about bedside manner.  Too many residents have seen too few positive role models, and too many weak role models.

We (the universe of medical educators) have a responsibility to make bedside manner part of our everyday concerns.  If we do not, then we are failing.

 

Comments (5)

Teaching anything takes time. Teaching bedside manner requires time, actual patients, and that the learners and the instructors be int he same place simultaneously.

That’s really hard to accomplish in this era of hour restrictions, numerous demands on faculty(and residents and students) and the intense focus on discharge planning that comes with being on the wards in 2009.

The only time I ever got feedback about bedside manner in medical school was with a “standardized patient” – an actor who had no medical needs. Medical education seems to use these “standardized patients” more than real patients.

In this economy, it will hard to convince medical schools to pay for teaching bediside manner – it generates no revenue, has no RVUs attacked to it, and really does not seem to impress the people who sit on the promotions boards.

Culture change takes time, of course, but it has to start with more than “lip service” to how important bedside manner is. Students and residents see plenty of examples of poor bedside manner that have no negative consequences.

Great post. I hate med school for many reasons but high up there is that most of what matters most to patients is not really taught at all. Case in point – I realize I’m preaching to the choir – I’m better off spending as little time in the actual room with the patient and instead sitting in front of my computer with medline or uptodate priming myself to look smart for the attending. The point is that attendings (at least at my med school) never evaluate your bedside manners. They can’t because they never see you in the room with the patients and the patients have 0 say in your evaluations.

Some of the rudest human beings I ever met in my life were attendings at a large tertiary care hospital. The medical staff becomes “institutionalized” in their thinking and become very demeaning to house-staff, students, and patients. In private practice bedside manner goes a long way. Patients will vote with their feet. Academic attendings should attempt to emulate the manners of their private practice colleagues.

I totally agree with the comments made above. Unfortunately, things haven’t changed much since I went to medical school in the 70’s. There was no formal training in bedside manner and our mentors were downright caustic and very berating at times. This is probably why there have been so many complaints about my generation of physicians having poor bedside manner. Furthermore, this has eroded public confidence and trust in physicians. We definitely need more formal training in med schools and better role models. You can be the smartest doc in the world, but if you don’t have decent bedside manner, your patients won’t get good care, because they won’t want to follow your directions and won’t want to come in for follow up.

I am an academic attending at a tertiary care facility….and I agree that bedside manner is not taught nor appreciated in medical education the way it should be. This is precisely what I spend a large part of MY time teaching but it is not appreciated by academia at large nor…in fact….surprisingly also by many of the residents and students who are just there to get by and get on to fellowship and making money. It is sad that people care more about getting patients out of their clinic or ER or floor bed than staying that extra five minutes to talk to a family and actually meet their needs. Now this is by no means everyone….there are those bright and shining stars who are dedicated and really do care and have that caring style….the problem is…they already KNOW bedside manner so how do we teach those who don’t? And who sometimes don’t care?
I’ve seen medicine change from a field full of self sacrifice and caring for the patient….where we’d stay that extra few minutes to talk to a mother, where we’d pick up the phone in the evening to call a parent with lab results….to one in which admissions are passed off as soon as the clock hits twelve without so much as any curiosity the next day as to what befell the patient….where no one every really follows up on “whatever happened to that patient in the ER anyway??”…and where residents actually give me attitude for suggesting they take a family’s number down and call them with results…..I get a blank stare and a look like “aren’t YOU going to do it for me????”….well yes of course I can do it…but in doing so you rob yourself of the chance to bond with the parent, to hear the appreciation in their voice, and to know of the reward of going the extra mile for your fellow man.
I wish I knew how to impart enthusiasm on all doctors….my experience is it is one of the most difficult things to teach and in this age of evidence based medicine….all that seems to matter anymore is numbers and RCT’s and QI projects that have little to do with building the human element back into medical care. Patients pale by comparison. Sad times indeed. Great article!

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