Are Good Bedside Manners Still Important to Patients?

Clinical Scenario

Mrs. Clark is a 45-year-old female presenting to Dr. Davis to learn the results of a fine-needle biopsy previously performed on a 4-centimeter mass located in the posterior triangle of her neck. She and her husband have been very worried about the biopsy results and what they would mean for her health. The Clarks have one child in high school and one just starting college. They both work at a clothing manufacturing plant and depend on their salaries to support the family, including saving for college expenses for both children.

When Dr. Davis enters the room in a rush, looking a bit disheveled, the Clarks both look up at him abruptly, scanning his face and demeanor for a clue to the biopsy news. Without any preface, Dr. Davis begins to give the news to Mr. and Mrs. Clark. He states that the biopsy report strongly indicates an “undifferentiated carcinoma” (his term) and that further imaging studies will be needed to provide a better understanding of what might be the primary site for this “nodal metastasis” (also his term). He stands above the Clarks, who are seated, and continues to look at the report, rather than at them. Without giving time for questions, Dr. Davis indicates that he will arrange for the imaging studies and will see Mrs. Clark in a return visit after they are performed.

Finally, he shakes their hands, turns, and quickly exits the room. The Clarks are stunned and look at each other for support. Mrs. Clark begins to cry softly as the clinic nurse enters the room to arrange for the imaging studies. She inquires as to why Mrs. Clark is crying, and learns that the Clarks are feeling lost, not understanding the meaning or implications of the diagnosis and what the cancer might mean to their family’s life. The nurse nods and explains that Dr. Davis is very busy, and that he was late for a surgery today—perhaps he will have more time to explain everything during the next visit. Mr. Clark angrily states that Dr. Davis has “no more bedside manner than a log.”

Discussion

A “great bedside manner” is a difficult entity to quantify or define—it is akin to the old saw of “I will know it when I see it”; however, we can identify many elements of what patients have indicated are part of its fabric and presentation. The bedside manner, as viewed over the centuries, is a changing construct, with generational considerations, and is subject to new environments in medical diagnoses and treatments. “Traditional bedside manner” (as I grew to know it) 50-60 years ago was noted by the compassionate, respectful, and calm behavior of clinicians during patient encounters. Time constraints were not as onerous, and patients appreciated active listening, thoughtful consideration of their complaints, reassuring presence, and appropriate confidence. Physicians’ dress and decorum were more formal to convey professional seriousness and to honor the patients with a respectful appearance.

More contemporary, or “modern,” concepts of bedside manner have added the dimensions of empathy, transparency, cultural sensitivity, digital communication skills, and shared decision making. Recently, good bedside manners have been linked to better patient satisfaction, trust, and clinical outcomes. Patients may now value a more approachable, less formal appearance, particularly with surgical and pediatric specialists, given the different practice settings and procedural needs for scrubs. Pediatric otolaryngologists are particularly sensitive to making their patients feel comfortable with their appearance and decorum.

In the 1960s and 1970s, the strong paternalistic ethos in medicine meant that physicians were seen as authoritative experts in a field that was quite foreign to most patients. No patient-oriented/friendly books on otolaryngology existed, nor did patients have access to a cloud of information as they do currently. The otolaryngologist held the medical information, and the patients sought care based on their knowledge. Physicians’ appearance and conduct were felt to be of primary importance for good patient care, and rarely would physicians wear their surgical attire to the clinic. Hospital bedside rounds were part and parcel of otolaryngology practice, and the physician was often accompanied by a nurse who wrote the orders and composed the notes for the physician’s signature. Emotional expression was limited, often due to the otolaryngologist setting the “tone” of the interaction with the patient, based on the concept that “emotion must be set aside when caring for the patient in the best manner.”

In contrast, contemporary bedside medicine from the patient’s perspective has the expectation of the otolaryngologist as a “partner” in the relationship, not an authority figure. Patients seek active involvement in acquiring knowledge so they will be able to make an informed decision regarding their care. Most patients value honesty, accessibility, and competence in their otolaryngologist these days, and need clear explanations of complicated medical terminology and conditions. Otolaryngologists are expected to acknowledge each patient’s lived experiences and their desired quality of life, and to engage their patients as individuals, not just medical cases. Professionalism and good bedside manner are essential to the patient–physician relationship, but should be defined by appropriate and empathetic interactions, with the patient’s interest at the center.

As a medical student in the 1960s, I was taught to respect not only the patient but also the profession, and part of that was to consider how my actions would reflect on the House of Medicine. In fact, the 1847 American Medical Association Code of Medical Ethics was composed of various admonitions as to how patients should treat their physicians, not vice versa (that came later). One medical student entered my medical school with long hair, down to his shoulders. An inquiry was quickly set up, and he was given the option of cutting his hair or leaving the school. He cut his hair. The first two years of my undergraduate medical education were noteworthy because students had to wear a shirt and tie to every class and were expected to stand up when quizzed by the faculty. I never thought to question that, as it was an early inculcation of respect into my professional personhood.

The role of dress and decorum in evaluating bedside manners appears to be generational in good part. Appearance—good hygiene, clean clothing, and appropriate attire for the setting—is still considered important, but more so to the older generations than to current generations. Effective communication, active listening, and empathy now seem to be more appreciated. Some otolaryngologists, like me, still consider appearance and decorum to be an outward expression of respect for the patient, and a foundational concept in good bedside manner. Generational differences in patient perspectives are now emerging. Younger otolaryngologists may be more comfortable in casual attire or functional scrubs, particularly in the outpatient clinic setting. Although fewer otolaryngologists now have large numbers of patients hospitalized for periods of time, some patients still feel comfortable with their physician making rounds in a white coat. We just have to make certain that the white coat is worn by a physician who also exhibits the best in empathy and compassion. Respect for the patient is perhaps the most important element in bedside manner, as it is closely linked to good communication skills, empathy, and ethical care, all fundamentals of our obligations to patients.

The digital revolution and the emergence of artificial intelligence in medical practices constitute challenges to the patient–physician relationship. Bedside (clinic-side) manners must now be delivered in a setting of telehealth, patient portals, physician reviews online by patients, television portrayals of medicine (“E.R.,” “The Pitt”), and so on. Evidence-based medicine is challenging some of the classic judgments by experienced physicians, requiring practice pathways to be followed that are population-based, not necessarily individual patient-based. Patient visit times are slowly being reduced to a short encounter for the main complaint. Burnout and compassion fatigue are weighing heavily on physicians and impacting the patient care experience. Efficiency is considered more important than empathy. Medical ethics may slip into “relativity,” rather than providing foundational guidance for appropriate care. Business ethics and medical ethics are not the same.

Bedside manners must remain a cornerstone of effective professional and compassionate healthcare delivery, ensuring the patient–physician relationship remains intact, sanctified, and rewarding to all. The human desire for connection, as well as the duty of physicians to hold patient care above all, must be part and parcel of good bedside manners.

In the case of the Clarks and Dr. Davis, there is an obvious lack of empathy and understanding of the patient’s needs. Good bedside manners would require that Dr. Davis address the Clarks’ need for more understanding, understandable information, and compassion. Being busy is no excuse for failure to consider the patient and their needs. No matter what the composition of the otolaryngologist’s personality or capability for compassion and empathy might be, Mrs. Clark deserves both. We have a duty as both physicians and human beings to care for others with kindness and competence. Evidence-based practice and good bedside manners can exist together—and should.

Dr. Holt is professor emeritus and clinical professor in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.