Good Doctor Etiquette

Sometimes etiquette seems to fall by the wayside

Sometimes etiquette seems to fall by the wayside

Is there such a thing as a doctor who is too happy or too smiley?  I have been told that one of my endearing features is my happy, smiling personality, and I try to keep this up in the workplace and my consulting room, even if I feel stressed.  I have noticed mostly that patients tend to respond positively to a smile and a friendly greeting by mirroring this with a smile.  I have however been caught out before when I have greeted someone in a really positive way with a big smile, and it then turns out that the reason they are visiting the doctor is quite a sad and difficult one, making my smile seem cruel and inappropriate.  The appropriateness of a smile and a positive greeting ultimately depends on the context, and as long as the smile and greeting do not seem forced or over-the-top, then I believe that it ismiles better than being downcast and speaking in a monotonous voice when calling in your patients!

               

               “Smile, and the world smiles with you”     

So just how happy should a GP be when calling in a patient?  I usually have a quick read of the patient’s notes prior to calling them in to the consulting room, as quite often the appointment is a review of results, or the person may have several medical problems and a long list of medications.  It is nice to refresh one’s memory of these things and what medications the patient is currently taking, so that you feel up to speed before calling them in.  I often try to guess what the patient may be attending the doctor for on that particular day, and sometimes I am right – other times however, I am very wrong!  If I can clearly see that the patient’s reason for attending the doctor is not such a happy one, I tend to ‘tone down’ the happy greeting a little so that it doesn’t come across as mocking or inappropriate.

The next point that I find a little awkward at times is the timing of the initial social niceties, like asking how a person is.  At what point should the GP ask the “how are you” question?  It will depend on the set up of the practice, but most GPs exit their consulting room and walk down some sort of corridor to get to a waiting room before calling a patient’s name.  At this time, I normally smile and say hello to the patient as they follow me from the waiting room, after which, as social norms dictate, there is the impetus for each to ask a polite “how are you today?”  This question however, is rather inappropriate for the GP to be asking in the public arena of the corridor of the medical practice, as most of the time, a person attending the doctor is in fact not well!  (And confidentiality is unfortunately not guaranteed in this setting!)  If the “how are you” question automatically slips out from the GP’s lips, it usually becomes a little joke where the patient responds, “well I wouldn’t be here if I was well, would I?”, making the GP (including myself at times) realize how silly it was to ask this question at that point in time!

After the initial smile and greeting, I close the consulting room door and motion for the patient to take a seat.  The next step is usually a brief chat to help build rapport and show interest in things other than the issue bringing the patient to see the doctor on that day.  Topics may include the current weather pattern, how their work is going, or a recent holiday they have had.

bedside-manner

Toward the end of the consult, depending on how talkative the patient is, it can be helpful to indicate that the consult is ending by summarizing the plan and checking this with the patient.  Usually this is followed by making arrangements for follow-up.  It is sometimes necessary to motion to the door and actually start to stand up before the patient does!

I learnt the great importance of arranging follow up appointments (on the day) from my first GP supervisor – even if this is for an appointment in 3 months time, or placing a reminder in the software for review in 6-12 months, particularly for people with a chronic illness.  Doing this limits the risk of patients being lost to follow up and falling through the cracks.  There was a case of this only recently where a lady had been diagnosed with type 2 diabetes, which was at the time, stable enough to be controlled with dietary intervention alone.  She, for whatever reason, had not returned for follow-up in 18 months and had presented dramatically to the local hospital after being found unconscious in a pool of blood in her bed.  As it turned out, this lady had a severe urinary tract infection with haematuria, acute renal failure and a hyperosmolar non-ketotic diabetic coma, with a blood sugar level of 70 and a HbA1c of 16%!  Her vision after discharge from the tertiary hospital was still 6/60 due to her severe  untreated hyperglycaemia.  Thankfully in this case she recovered, but this could have been fatal for her, all because follow-up was neglected.

I love a good backronym, and on my drive to Snowtown for an outreach clinic today,  thinking about all of these things, I came up with a backronym for ‘CHARM’, which describes in a nutshell, a few ways to display the etiquette of a ‘good doctor’, in my humble opinion.

"They're always after me lucky charms!"

“They’re always after me lucky charms!”

  • Charming smile (or Cheesy smile if appropriate!)

As long a this isn’t over-the-top or forced, it shows that you are a friendly person and willing to help where you can.

  • How are you?

This question is preferably asked within the closed consulting room!

  • Allow a seat

Motion for the patient to take a seat and ensure that there is not a barrier like a desk between the two of you.

  • Rapport-building

Spend some time at the beginning of the consult getting to know the patient, if you don’t already.  A short period of ‘chit chat’ can help to break the ice and shows that you are interested in their life and wellbeing as a person with a problem, not a problem on its own.  Then allow the patient to tell their story in their own words, with one or two initial open questions before honing in with more closed questions.

  • Make arrangements for follow up.

This usually shows the patient that you care, and are interested in ensuring that results are followed up or that treatments trialled are effective.

CHARMing!

Now go forth and be a good doctor with good etiquette!

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4 thoughts on “Good Doctor Etiquette

  1. Thanks Mel

    It’s good to reflect on the seemingly minor aspects of consulting skills, and the way we greet patients and the intensity of a smile is actually pretty relevant to how the consultation progresses. I found as a junior GP reg that it was really hard to keep to time with appointments, so I used to try and rush through the initial niceties. However, it dawned on me that when I took time to build rapport through small talk at the start of the consultation, it was much easier to stick to time. It was as if a small investment of rapport building at the start made the whole consultation feel more like the patient and I were on the same team.

  2. CHARM – I like it! Well done.

    My mum, bless her, who loved creating catchy acronyms almost as much as do companies running drug trials, used to say “BANG BANG” when I wasn’t exhibiting model behaviour in public. “BANG“ stood for “Be A Nice Girl”. Alternatively, she got the “BANG BANG” message across by miming the shooting of a gun. I’m not sure whether pretending to fire at your misbehaving child with a firearm will ever get into the Positive Parenting Program but I found the approach surprisingly effective.

    In answer to your “Is there such a thing as a doctor who is too happy or too smiley?”, I would have to say “yes, occasionally”.
    Smiling is great and being happy at work is wonderful – but unrestrained ebullience can be a tad annoying. Or so I’ve been told – by the odd grumpy colleague or patient. Hasn’t stopped me smiling! 🙂

  3. Handshake. Every single patient, whatever age, gender. Been doing this for almost 10 years now.

    Nev used to. Oddly it was a habit I picked up in ED, particularly with psych or ‘difficult’ patients. It seems to break down the barriers, implies I am ‘here to help you’ – not just a hand shake, but also here to give the patient a hand up.

    I am probably very much in the minority…and again, it could be a country thing…

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