The 25 Rules of Considerate Conduct for Healers

Patients want their health care providers to be polite and civil as well as competent. In the first part of this guest commentary,¹ published in the March 2016 issue, I offered tips on how to practice etiquette-based medicine, as advanced by Michael W. Kahn, MD,² and excerpted from my book, Advice to the Healer: On the Art of Caring.³ Here in the second part of the this commentary, I expand on this concept with a look at 25 rules of civil conduct,⁴ authored by P. M. Forni, PhD, and how these rules may be incorporated into our clinical practice.

Etiquette-based medicine is not uniformly practiced today. This lack of civility is not unique to medicine, but an insidious social problem that has escalated over time according to Dr P. M. Forni, a professor at Johns Hopkins University and cofounder of the Johns Hopkins Civility Project. In Dr Forni’s book Choosing Civility he makes the suggestion that “we agree on one principle: that a crucial measure of our success in life is the way we treat one another every day of our lives.”⁴ Dr Forni cites 25 behaviors which the civil person exemplifies. Most of these “rules” are important considerations for all members of society and are applicable to clinicians as we strive to become the most effective civil healers possible. Those who wish to improve their healing skills may adapt some of these rules in the care of the patient. The 25 “rules” are included below with examples of how they may relate to patient care.

The 25 Rules of Considerate Conduct Abridged for the Healer

1. Pay attention. This is understood as a variation of Hippocrates urging that we observe all and of Osler’s admonition to use all of our senses when caring for the patient.

2. Acknowledge others. Introducing ourselves to others in the room and understanding how they may be familiar with our patient is an example of acknowledging others.

3. Think the best. It is easy to assume that a patient requesting narcotics is drug seeking, when in fact the patient likely wants relief from a physical or emotional pain. Our challenge is to begin each encounter with a hopeful attitude and optimistic expectations. We must be careful not to prejudge patients, even though it is known that some patients may be drug seeking.

4. Listen. We have already learned that if you listen to the patients, they will tell you the diagnosis, and that much can be inferred from nonverbal communications. I observed a great example of a clinician who showed a keen sense of listening. Recently, in explaining an unpleasant event to a colleague and several third-year medical students, the attending took a long deep breath, followed by a long audible exhalation. In observing this, the astute medical student acknowledged a “deep sigh” gaining information on the attending’s mood, opinions, and emotional state that may have not otherwise been obvious from words alone. I was impressed because she showed astute listening skills—not only to the spoken word but to other sounds around her.

5. Be inclusive. Certainly the best way we can be inclusive in the medical profession is by honoring cultural diversity through considerate and thoughtful medical practice. An example of this would be asking our patients who are having sex if that is with men, women, or both.

6. Speak kindly. Beginning your interview with something like, “How may I help?” and ending with a simple, “Is there anything else I can do for you?” denotes kindness.

7. Do not speak ill. Healers are at their best when they do not criticize the care rendered by others. Doing so sabotages our common mission of helping the patient.

8. Accept and give praise. One of the best ways to promote well-being in our patients is to go out of our way to find something positive in what they have done to positively affect their health and then compliment them for doing so. Encouraging our patients, and having what the American psychologist Carl Rogers calls “unconditional positive regard” is something we can easily do to improve our patient’s health care experience.

9. Respect even a subtle “no.” Of course we must respect our patient’s wishes when they do not agree with our recommendations; however, we still have an obligation to obtain proper informed consent with respect to what may happen if a patient does not follow our advice. It is our duty to provide the patient with all the information necessary to make an educated decision about his or her health. Even in dire circumstances—such as disregarding advice to visit the emergency department when experiencing anginal chest pain—the patient must understand the consequences. Although difficult, it is our obligation to lay down the facts, especially when disregarding professional medical advice may result in the patient’s death; after which, if the answer is still “no,” we must respect and honor that person’s wishes.

10. Respect others’ opinions. This works in all directions in every relationship in health care. A primary care provider must value the opinions of a consultant, just as a consultant must value the opinions of his or her primary care colleague. We must value the opinions of our patients, with the hope that they will value ours. Understanding these dynamic relationships and being aware of their implications for health care delivery will serve our patients well.

11. Mind your body. We cannot take good care of our patients if we do not take good care of ourselves. Often the physician puts his or her health to the wayside to accomplish his or her professional duties.

12. Be agreeable. Even though we may disagree with our patient’s decision, we must strive to be agreeable and continue to help in the most effective way possible in the context of that disagreement. As with the example in No. 9, although we may not agree with the decision to forego emergency room care, we can still be agreeable. We can agree to disagree in a civil manner.

13. Keep it down (and rediscover silence). Psychiatrists seem to have cornered the market on appreciating the value of silence. This is a skill which, when appropriate, we can emulate. Much can be gained from silence. Often, giving the anxious patient an extended period of time to think before they respond to a question will result in information that may have been missed. Be patient, do not assume, and listen. Allowing our patients their time to tell us what is concerning to them is civility at its best.

14. Respect other people’s time. “Running late” is at the top of most patients’ lists of what frustrates them during visits to their doctor’s office. Often this is the reality of health care delivery, as unexpected situations arise and simply take longer than expected. However, we can try to prevent dissatisfaction through our actions such as being on time to the office, not overbooking inordinately, and—when all else fails—simply apologizing when we are late. This occurred to me recently when I assumed the role of the patient. I had an appointment with a highly respected and very busy physician and still had not been called back to the room 45 minutes after my appointed time. I had another meeting to attend, so I informed his front desk staff that I needed to reschedule. Although I realized he must have had an urgent situation arise, I was displeased that I had wasted 2 hours of my time. I was surprised to answer a call from this physician at 5:30 that night, apologizing for keeping me waiting. This simple gesture showed class and respect.

15. Respect other people’s space. It is proper to ask for permission to sit down or start an exam when visiting a hospitalized patient.

16. Apologize earnestly. We are going to make mistakes in the course of our job. When we do, it is appropriate and necessary to apologize. Gallagher and colleagues reported in a 2003 JAMA article on patients’ and physicians’ attitudes regarding the disclosure of medical errors that “Physicians should strive to meet patients’ desires for an apology and for information on the nature, cause, and prevention of errors.”⁵

17. Assert yourself. Our duty is to assert ourselves for our patients, especially when doing so will result in more comprehensive care. This is not always easy or glamorous and often is the source of conflict—such as appealing for a previously denied authorization for medical care by an insurance company or going to extra lengths to make sure proper information about your patient reaches a consultant. We should all strive to be the physician that “goes the extra mile” for his or her patients.

18. Avoid (unnecessary) personal questions. Our job description entails asking personal questions as part of a true physician-patient interaction. The medical consultation room is sometimes referred to as “the confessional,” because it is behind these closed doors in which our patients will tell us things they may never tell anyone else. It is a privilege to be in a position to gather this information; furthermore, to possess such trust and patient confidence. Personal questions are needed to gather pertinent information for patient diagnosis, treatment, and follow-up care. The patient’s personal history often has important medical implications. However, this does not give us license to ask personal questions beyond medical necessity to satisfy our own curiosity. While it may be important to ascertain if a patient is receiving Social Security disability income, medical assistance, Food Stamps, or the like, it would likely not be necessary to ask someone who by all appearances is not financially depressed about how much money they make. It is our professional duty to use personal information where appropriate and not overstep our privilege by asking inappropriate or irrelevant questions.

19. Care for your guests. It is important to have an office that is accommodating to our elderly and disabled patients; moreover, when extra assistance is provided, it should be done so with respect and thoughtfulness.

20. Be a considerate guest. When conducting a home visit, we should schedule our appointment at a time that is amenable to both the care provider and the patient. In the course of the home visit, we must be respectful of their environment. For example, asking for permission to sit in a certain chair, using a certain area for the exam, or washing your hands on the way out shows great consideration.

21. Think twice before asking for favors. The physician-patient relationship represents a complex distribution of power. We are a profession of power—gatekeepers to medical information and health services—and help those who are vulnerable. It can be safely argued that we should not, in the course of our caring for patients, ask for favors from them.

22. Refrain from idle complaints. There is no room in our practice for complaints. Common ones such as, “The office has overbooked me again,” or “The insurance companies keep wringing me dry,” or “I am not paid enough for what I do” are known frustrations associated with providing medical care. However, it does no good to practice with such negative attitudes. We must always realize that as bad as we think things may be for us, they are typically much, much worse for those whom we serve.

23. Accept and give constructive criticism. Some of the most valuable lessons we can learn come from our patients as they offer criticism of our care. We should remember that neither the overly flattering nor the overly critical patient is likely accurate in assessing our overall care. But we can learn from frank comments from our patients. Likewise, we can and should learn from constructive criticism from our colleagues and teachers. However, it is important to be objective when doing so and not make personal attacks or take criticism personally. Many young physicians may feel disheartened when they receive criticism, but it is important to realize this is because your mentor believes in you and wants to help you be the best you can be. We all will make mistakes and are expected to learn from them. …

24. Respect the environment and be gentle to animals. Schweitzer might use this rule to advocate for reverence for life—all life.

25. Don’t shift responsibility and blame. When I became the medical director of the Family Medicine Department, I took over responsibilities for an academic health center that serves close to 40,000 patients per year. I learned a terrific lesson from the practice manager, called the “Triple A approach.” The Triple A approach is useful in dealing with a patient who is angry because of a perceived wrong inflicted upon him or her by you or your organization. If appropriate, you can often quickly diffuse a volatile situation by (1) Acknowledging that the person is upset, (2) Accepting responsibility (if and when it is yours to own), and (3) Amending the situation as best you can. 

The works of Drs Kahn and Forni are critical in understanding how best to practice the art of caring for others. While it is important to be competent, altruistic, virtuous, well-meaning, and all of the other character traits that constitute a clinician successful in practicing the art of caring, these authors highlight the need to translate good training, intentions, and medical practice into behaviors that are perceived by the patient as being proper, civil, respectful, and professional. You might consider taking an inventory of how you are going to be respectful before you visit your next patient as impractical or obvious, but, from my experience, I do not think our patients feel this way. If anything, patients are impressed by such attention to detail regarding their satisfaction of care.

If each of us were competent in practicing etiquette-based medicine and did so at all times, we would not need to be reminded of this. But if we are honest with ourselves, we may admit that there are times when fatigue, inattentiveness, and maybe just being rushed have led to patient interactions that are less civil than our personal ideals. Be aware of yourself, your patients, and how your behaviors, actions, and mannerisms affect their health care experiences.

Richard Colgan, MD, is a professor and the vice chair for medical student education and clinical operations in the Department of Family and Community Medicine at the University of Maryland School of Medicine in Baltimore. For more, visit www.advicetotheyoungphysician.com.

References:

1. Colgan R. Civility in medicine: 6 habits of highly respectful physicians. Consultant. 2016; 56(3):212.
2. Kahn MW. Etiquette-based medicine. N Engl J Med. 2008;358(19):1988-1989.
3. Colgan R. Civility. In: Colgan R. Advice to the Healer: On the Art of Caring. 2nd ed. New York, NY: Springer; 2013:chap 7.
4. Forni PM. Choosing Civility: The Twenty-Five Rules of Considerate Conduct. New York, NY: St Martin’s Press; 2002.
5. Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001-1007.

For part 1 of Dr Colgan’s essay here, along with additional “Guest Commentary” articles, click here.