For internist Nayan K. Kothari, MD, a good bedside manner involves three crucial steps: taking a patient’s history, performing a proper physical examination, and arriving at a proper diagnosis.
“Studies have shown that if you do that, you will get 85% to 90% of your diagnosis on almost anyone,” said Dr. Kothari during a recent episode of “AMA Update.”
Dr. Kothari is chief academic officer and directs the internal medicine residency program at Saint Peter’s Healthcare System. Based in New Brunswick, New Jersey, Saint Peter’s is a AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Dr. Kothari inspired the creation of the Saint Peter’s Simulation Center for Interprofessional Learning, which houses the Institute for Bedside Medicine. Dr. Kothari discussed the role of simulation in training doctors on effective bedside manner—and why it’s important to use the right language to deliver unsettling news to patients.
Bedside skills on the decline
The crux of medicine is to interact directly with the patient at the bedside or in the clinic. Such skills have declined significantly over the last 50 years, said Dr. Kothari.
“There's a lot of literature on this. This is not my opinion,” he said. Many reasons exist, but the bottom line is patient care suffers because physicians miss the diagnosis.
The leads to a “nocebo effect,” in which therapeutic value diminishes or disappears when a physician is rude or abrupt with a patient.
Personal interaction, however, plays a small role in good bedside manner, he continued. “There is nothing worse than having excellent personal manners but making mistakes in doing the proper history and physical examination,” contributing to a misdiagnosis.
Learning through simulation
Recruiting patients and actors from the community, the Institute for Bedside Medicine uses fully furnished exam rooms to teach residents and students about the technique of proper bedside manner.
Patients may have real conditions they want to talk about, such as severe arthritis. Actors do scripts of real-world scenarios.
In one script, two actors played a husband who was dying and a wife who wanted all these procedures to save his life. This included an unrealistic request to do a lung transplant.
“The doctor had to go in and explain why that was not the right choice. It's a very difficult situation to tell [that to] a wife who is desperate that her husband is going to die in two days,” said Dr. Kothari.
Residents and students who attend this training learn these skills in a didactic manner, he continued. “Before we start the teaching exercise, for 20 minutes we will go over the basics—why we are doing this, what is the science behind it.”
The resident then engages the patient on the script. Several faculty members observe this interaction, interrupting from time to time to offer feedback on what went right or wrong.
“It’s a very interactive, sometimes highly charged environment,” said Dr. Kothari.
Predicting patient responses
Delivering bad news is one of the more challenging aspects of bedside manner. Dr. Kothari believes that every hospital should have a “quiet room” to address these situations. Small gestures, such having water or a box of tissues available to the patients, matter a great deal.
The institute has a station on breast cancer to act out these scenarios.
A woman learns she has an adenocarcinoma of the breast. “Now the doctor is calling and something must be wrong,” said Dr. Kothari. The script goes through the process of breaking the news to the patient. What kind of cancer does the patient have? What drugs are available? Will the patient need radiation or chemotherapy?
Relating this information in a very controlled environment is key, he emphasized. Attending physicians and faculty are there to guide residents and students, ensuring that they don’t use jargon that might be harmful.
A resident may tell a patient, “We’re going to give you radiation.” For some people, that conjures up images of Hiroshima. The goal is to predict the patient response and modify the tone and language of the message to reduce anxiety.
“It works. I can tell you that,” said Dr. Kothari.