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
Approximately a century ago, Francis Peabody taught that “the secret of the care of the patient is in caring for the patient.”1 His advice remains true today. Despite the advent of novel diagnostic tests, technologically sophisticated interventional procedures, and life-saving medications, perhaps the most important skill a bedside clinician can use is the ability to connect with patients.
The literature on patient-physician interaction is vast2-11 and generally indicates that exemplary bedside clinicians are able to interact well with patients by being competent, trustworthy, personable, empathetic, and effective communicators. “Etiquette-based medicine,” first proposed by Kahn,12 emphasizes the importance of certain behaviors from physicians, such as introducing yourself and
Yet, improving patient-physician interactions remains necessary. A recent systematic review reported that almost half of the reviewed studies on the patient-physician relationship published between 2000 and 2014 conveyed the idea that the patient-physician relationship is deteriorating.13
As part of a broader study to understand the behaviors and approaches of exemplary inpatient attending physicians,14-16 we examined how 12 carefully selected physicians interacted with their patients during inpatient teaching rounds.
METHODS
Overview
We conducted a multisite study using an exploratory, qualitative approach to inquiry, which has been described previously.14-16 Our primary purpose was to study the attributes and behaviors of outstanding general medicine attendings in the setting of inpatient rounds. The focus of this article is on the attendings’ interactions with patients.
We used a modified snowball sampling approach17 to identify 12 exemplary physicians. First, we contacted individuals throughout the United States who were known to the principal investigator (S.S.) and asked for suggestions of excellent clinician educators (also referred to as attendings) for potential inclusion in the study. In addition to these personal contacts, other individuals unknown to the investigative team were contacted and asked to provide suggestions for attendings to include in the study. Specifically, the US News & World Report 2015 Top Medical Schools: Research Rankings,18 which are widely used to represent the best U.S. hospitals, were reviewed in an effort to identify attendings from a broad range of medical schools. Using this list, we identified other medical schools that were in the top 25 and were not already represented. We contacted the division chiefs of general internal (or hospital) medicine, chairs and chiefs of departments of internal medicine, and internal medicine residency program directors from these medical schools and asked for recommendations of attendings from both within and outside their institutions whom they considered to be great inpatient teachers.
This sampling method resulted in 59 potential participants. An internet search was conducted on each potential participant to obtain further information about the individuals and their institutions. Both personal characteristics (medical education, training, and educational awards) and organizational characteristics (geographic location, hospital size and affiliation, and patient population) were considered so that a variety of organizations and backgrounds were represented. Through this process, the list was narrowed to 16 attendings who were contacted to participate in the study, of which 12 agreed. The number of attendings examined was appropriate because saturation of metathemes can occur in as little as 6 interviews, and data saturation occurs at 12 interviews.19 The participants were asked to provide a list of their current learners (ie, residents and medical students) and 6 to 10 former learners to contact for interviews and focus groups.
Data Collection
Observations
Two researchers conducted the one-day site visits. One was a physician (S.S.) and the other a medical anthropologist (M.H.), and both have extensive experience in qualitative methods. The only exception was the site visit at the principal investigator’s own institution, which was conducted by the medical anthropologist and a nonpracticing physician who was unknown to the participants. The team structure varied slightly among different institutions but in general was composed of 1 attending, 1 senior medical resident, 1 to 2 interns, and approximately 2 medical students. Each site visit began with observing the attendings (n = 12) and current learners (n = 57) on morning rounds, which included their interactions with patients. These observations lasted approximately 2 to 3 hours. The observers took handwritten field notes, paying particular attention to group interactions, teaching approaches, and patient interactions. The observers stood outside the medical team circle and remained silent during rounds so as to be unobtrusive to the teams’ discussions. The observers discussed and compared their notes after each site visit.
