Saturday, October 31, 2009

Where Have All the Bedside Manners Gone?

St. Anthony plagued by demons. 15th century work.

I read a thoughtful post at See First entitled, What Really Matters. The blog’s name, See First, is taken from a quote from Sir William Osler, one of medicine’s greatest luminaries who emphasized the importance of learning medicine at the beside. The post is a plea for physicians to strive to achieve caring and compassionate bedside manners. It emphasizes the importance of attentiveness, communication and empathy with patients. Though it is not stated, the author clearly understands that the doctor-patient relationship is the essential element of the healing art. While every physician knows this, we still need to be reminded of this truth, from time to time.

I commented on his blog that the piece was spot on. I agree unreservedly that patients deserve compassion and caring from their physicians. They deserve appointments without bleating pagers and phone calls. They deserve eye contact. They deserve an opportunity to say 3 or 4 sentences without interruption. They deserve enough time to get their point across. They deserve to be heard. They deserve a doctor who is focused solely on their medical interests, without extraneous distractions.

Although patients deserve all of this, they don’t always get it. Why are today’s bedside manners often less robust than they should be? I offer no excuses, but there are explanations for patients to be aware of.

There are many forces swirling in physicians’ minds today that distract us and threaten our doctor-patient relationships. We try to muffle these demons that are whispering in our ears. We try to compartmentalize them and stifle their interference, but we are members of the human species. Sometimes, they win and we fail. When you visit your physician, here are a few distractions that he won’t mention or record in your medical chart.

  • Physicians are working harder each year for less money.

  • Physicians battle insurance companies every day to receive money we have already earned.

  • Physicians are demoralized by an unfair medical malpractice system.

  • Private practice physicians are being driven out by corporate medicine.

  • Employed physicians have limited professional autonomy and must genuflect to administrators and bean-counting bureaucrats.

  • Medical practices in private medicine have all the stresses and challenges of running a business - payroll, inventory, staffing, overhead and unexpected crises.

  • Physicians must plow through mounds of ridiculous paperwork every day.

  • Physicians are required to participate in government and insurance company quality programs that have no effect on medical quality, but cost us money and time.

  • Health care reform may proceed at the expense of the medical profession.

Despite these distractions, physicians should provide patients with the care and attention they deserve, even though this task is harder than ever. Ironically, we physicians increasingly feel that no one is giving us care and attention. We’re not getting it from the government. We’re not getting it from the insurance companies. We're not getting it from the press. We're certainly not getting it from the legal community. Our patients may be our last best hope for showing us some understanding. This gesture would revitalize us and shake off the demons. Then, we could try a little harder to give you Marcus Welby, M.D. instead of Dr. Gregory House.


  1. It's interesting that some of the problems you cite (battling insurance companies to get payment and mounds of paperwork, for example) are absent in countries that use a single-payer-based national healthcare system: no insurance companies enter the picture, and no billing and thus an enormous reduction in paperwork.

    And, of course, from a consumer view, the medical malpractice system doesn't seem all that unfair when you look at the specifics of the cases that go to outcome. The most comprehensive solution to that problem is to reduce the instances of malpractice, and a lot of that can clearly be done by removing from the system the doctors who are most frequently guilty of malpractice. Other steps---using checklists, designing more informative packaging that clearly signal the meds they contain, and so on---could take care of most of the rest.

  2. Like your blog that was on kevinmd - can I use it with you permission and name on my blog (your authorship for complete credit is what I mean)?

    Robert Sadaty MD

  3. LG
    "It's interesting that some of the problems you cite (battling insurance companies to get payment and mounds of paperwork, for example) are absent in countries that use a single-payer-based national healthcare system: no insurance companies enter the picture, and no billing and thus an enormous reduction in paperwork."

    On the surface, this makes no sense. Govt is known for its confusing regulations and paperwork. Have you ever completed a tax return?
    Have you read some regulations in the Federal Register?
    Have you read even part of the 1990 page House bill soon to be voted on?
    If you want to advocate for single payer, fine - but at least be straight-forward about it.

  4. I am being straightforward, and I suggest some reading for you on how single-payer healthcare systems work in France, Germany, and other advanced countries. There is no billing, for one thing, and there are no insurance companies to deal with. Can you get your head around that?

    And so far as tort "reform" is concerned, I highly recommend this article:

  5. Agree with LeisureGuy. Doctors have too much discretion to decide what they will and won't do. That leaves patients with difficult diagnoses "pretty much nowhere," without even a referral, as my family doctor put it.

    Malpractice "unfairness" becomes just a cover for doctors' cherry-picking. "You look fine" just doesn't cut it in terms of diagnostics. Why can't we strive for Marcus Welby with House's skills?

  6. LG

    The article you cited is all anecdotal.

    You are ignoring policy implications. BTW, I have read about the French + Swiss + UK system. One problem with single payor is it is a political system - every special interest group lobbies to have their procedures included in the base coverage. That is why the Swiss system + the French (forget about the UK system) are starting to break apart at the seams.

    Did you know that prayer is now included in the newest House bill just passed this past weekend? READ just parts of the bill - I am sure you will not be able to comprehend huge parts of it. READ some of the Federal Register. It is gobbledegook - and I am a post graduate from one of the more prestigious unversities in the country.

    Single Payor is a simplistic approach but ultimately, there are no free lunches. Somebody has to pay - and bureaucratic committees do the ratioing. If you do not allow a price mechanism to allocate goods and services, you then subscribe to bureaucrats - who do it via directives in the Federal Register or legislation.

    And if you do not like the govt rationing, where do you go? In the UK, if you want to pay for some test or procedure on your own, you have to forgo ALL other govt paid medical services forever. So you cannot.

    The current system is far from perfect but at least you have options. With S/P, you're lucky if they answer the phone.Try calling Medicare (as I have) just to ask about billing. Or call the IRS about tax questions. Did you know 43% of the answers IRS personnel give are WRONG? And even with wrong advice from the IRS, you still are responsible. Is that what you are advocating for?

  7. It is easy to complain about all the problems we get when we call government "help lines." BUT while trashing one system, let's not overlook the EXACT same problems in the other. I have had the "thrill" of trying to talk to my insurance company, back when I had insurance, and the experience was exactly the same as you complain of. There's nothing more infuriating than having your doctor finally find a medication that addresses a problem you're having and then having the insurance company denying your access to it. Let's not pretend that all the scary things that are being put out there against a government option plan don't already exist in plentiful quantities in the private health care "system" that SOME of us have access to now.

    Some of us do not have access to health care because we need insurance, and all the yammering about the harmful maybes that might come to everybody else is leaving many of those in need with NOTHING! It's easy for those with health care insurance to cast stones at a system that appears to be all the rest of us have any hope of getting.

    It must be nice, indeed, not to have the problems that nearly 40% of all Americans are having to live with every day.

    How about a little generosity of spirit?

  8. Left Eyed Jack
    I agree - there is lots imperfect with our current system. However, that does not mean a single payer system would be any better. That was my argument. In fact, imo, it will be far, far worse. Since when have Americans thought monopoly/monopsony power is a good thing?

    We need more options - not fewer. We need more flexibility - not fewer. I used to live in NY where my policy was over $1200/mo. Simply by moving, my premium was able to go to $279/mo. There are lots of state mandates that raise the cost of insurance. There are states with community rating which greatly increases premiums. There are lots of restrictions on the interstate sale of health insurance which limits our options and raises premiums.

    The single payer solution is not increasing options + not allowing for more flexibility. The devil is in the details.

  9. Nice article. This goes right along with a book I'm reading called "Time to Care" by Norman Makous, M.D. The book advocates that the doctor-patient relationship has deteriorated over the decades as the growth of technology has skyrocketed. He believes the relationship is a critical part of understanding the patient’s medical situation, making a diagnosis, and applying effective treatment. I learned the difference between individualized medicine and truly personal medicine.

  10. @Evinx: The idea of single-payer, as you know, is that the government functions as the insurance company. In the public option proposal there would be premiums paid, but the government would write the checks.

    In my reading, the single-payer systems are doing well and patients get better care than in the US at half the per-capita cost. Moreover, patients in those countries LIKE the system. And, on the whole, they live longer and experience lower infant mortality than in the US.

    You need to do more study of the issue and the possible solutions.

  11. Thanks for a fine essay, especially your compassion for your long-suffering colleagues.

    Jeff Kane MD

  12. Thanks Jeff. I don't think that bedside manner issues are part of health care reform (HCR). As I noted in the post, I fear that HCR may further threaten the doctor-patient relationship.

  13. I think that bedside manner went out the door when patients began to be forced to have amnesia drugs. I mean, what's the point if the patient is going to be a zonked out zombie? They won't remember it anyway (many do) so who cares? I hope that "cost effectiveness" will get an iron grip on frivolous sedation.

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