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What is good bedside manner—and how can you teach it? Today we discuss innovative ways to train physicians on bedside manner and the art of compassion with Nayan Kothari, MD, chief academic officer at Saint Peter’s University Hospital in New Brunswick, N.J. AMA Chief Experience Officer Todd Unger hosts.

Learn more about Saint Peter's Simulation Center for Interprofessional Learning and The Institute for Bedside Medicine.

 

Speaker

  • Nayan Kothari, MD, chief academic officer, Saint Peter’s University Hospital

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Unger: Hello and welcome to the AMA Update video and podcast. Today we're talking about innovative ways to teach physicians bedside manner and the art of compassion. I'm joined today by Dr. Nayan Kothari, chief academic officer at Saint Peter's University Hospital in New Brunswick, New Jersey. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Kothari, welcome.

Dr. Kothari: Thank you. Glad to be here.

Unger: Why don't we just start off talking a little bit about bedside manner? Unlike many science-based issues within medicine, good bedside manner can mean a lot of different things to a lot of different people. Let's start off by talking about what's your definition of a good bedside manner.

Dr. Kothari: A good bedside manner is an ability to take a proper history and perform a proper physical examination and then arrive at a proper diagnosis. Studies have shown that if you do that, you will get 85% to 90% of your diagnosis on almost anyone.

Unger: So I think, though, a lot of people, when they talk about bedside manner, they have more of the personal interaction part of that. Is that part of your definition or no?

Dr. Kothari: It is but a small part of the definition. Because there is nothing worse than having excellent personal manners but making mistakes in doing the proper history and physical examination and miss a diagnosis. So you really—yes, it would be very nice to have good manners—and essential. But not at the cost of science.

Unger: Interesting. I think that's probably an interesting way for people to recast the whole idea of what bedside manner is. Before we talk about the how, let's start by talking about the why. Why is bedside manner training so important and what can happen when physicians—they don't have that skill?

Dr. Kothari: Well, it is important because that is the crux of medicine, to interact with the patient at the bedside or in the clinic but with the patient directly. And unfortunately, over the last 50 plus years, those skills have declined significantly. There's a lot of literature on this. This is not my opinion. There is a decline. And there are a number of reasons. And that affects the patient care. That hurts the patient. You miss the diagnosis.

There is a—I think all of us know what a placebo effect is, which means you will please the person by good manners and good thoughts but there's an opposite called a nocebo effect. And that is when you are rude to a patient, when you are abrupt with a patient, the therapeutic value goes away or diminishes. And bedside manners would incorporate all those elements into conversation. So bedside manner—I'm sorry.

Unger: So how do you teach something like this?

Dr. Kothari: Well, the only way to teach properly is at the bedside. You cannot teach any other way. But like anything else, simulation now has entered in medicine. We are late in medicine. The Air Force, perhaps, was the only one 50 years ago, and the Navy started simulation techniques. They have these ships which are massive and they are to maneuver them in war. So they created simulation.

And eventually, but late—and then the airline industry picked it up. You have a billion dollar jumbo. You don't want an intern to fly it and crash it. That's why the Air Force created simulations all across Air Force. And then, finally, maybe a few years ago, medicine picked it up. It's not there yet. It's very rare. Our simulation center is probably one of the two in the whole state.

Unger: I want to talk—let's talk more about your simulation center. This is really interesting because you've established an Institute for Bedside Medicine, and it's within your Simulation Center for Interprofessional Learning. Take us—what does that look like physically? I think people think about—you mentioned an airline, for instance, what a simulator would look like there. Describe this process of using simulation to teach good bedside manner.

Dr. Kothari: Yeah. If you came to look at it, you will see something like a hospital, like an emergency ward. It's regular rooms, lighted, with oxygen aspiration tubes. It looks just like a regular ICU, with stretchers. Instead of people, there are wearing mannequins there. These mannequins—people call them dummies but they are not dummies. They cost $120,000 each and they are sophisticated.

For example, they would react to pain. They would cry. They would shout, scream. And they would communicate with the doctor. We can pretend to create a cardiac arrest. We did a simulation last year where we had a pregnant mother deliver a baby and she delivered a baby. But during the delivery, she hemorrhaged to death. She died and the baby died.

We had several residents in OB watch that. And they were taught at the bedside what to do if something like this happens. And miraculously, next week, same scenario happened in real life. And I'm glad to tell you that the mother and the baby went home alive. And we all believe that it was due to the simulation because they went through the exercises.

And I can give you a dozen examples of that success. I do not think the old habit of learning on patients is valid anymore. I think if I tell my residents that if I come with meningitis and you're going to do a lumbar puncture, you better find somebody who has done it on simulation first, not just see one, do one and teach one. That method is gone.

So if you came to our simulation center, you will see almost like a hospital ward, operating room kind, with glass doors and stretchers and equipment laying around. And then we use mannequins. We have a sim man who can develop cardiac arrest, anything, arrhythmias, various things.

And we intervene, for example, if he develops a pneumothorax when the lungs are punctured, you can insert a tube to salvage him. We can do that on this sim man. We have a sim mom who can deliver a baby, can hemorrhage, can develop eclampsia, pre-eclampsia, all those things. We have seen sim junior, a 12-year-old boy, who—it is different in pediatrics.

Unger: Mm-hmm.

Dr. Kothari: And we have sim baby. Sim baby is, I think, six months old. And they can work around that baby and program the baby for a variety of diseases and conditions, and then the students and the residents practice.

Unger: Now, you mentioned that there were only two of these—I think, two of these centers. So this is not something that is necessarily commonplace.

Dr. Kothari: No, medical schools are building them now but it should be in every hospital. If you are having your staff do procedures, I don't think they should go directly to procedures. They should learn on the sim. But the second part of the sim center is—I'm most proud of—is the Institute for Bedside Medicine. And that doesn't exist anywhere in New Jersey. We are the only one.

What we do—we have eight or ten exam rooms, just like a doctor's office. They're fully furnished with exam tables, blood pressure cuff, all that. And we have a patient bank. We have created a patient bank on the—we basically copied what they do in Edinburgh, Scotland. So some of us went to Edinburgh and learned how they do it.

It's very simple. You recruit patients from the community who have physical findings. So for example, somebody has severe arthritis, and we know that that is going to last forever, those deformities. So we talk to them. Many of them are our patients. We tell them why we need them. And they register with our list of patients and when we perform the exercise to teach about arthritis.

We bring that person in. We give them a small stipend. But they all come for the love of it. They don't come because of the money. That money is not much. And we do these exercises along with our colleagues in Scotland—Edinburgh, Scotland. Because we couldn't find a good partner here in the United States. We do work with Stanford and Hopkins. They are doing these very similar things. So there's a good partnership.

But the Institute of Better Medicine brings real patients and also actors who can do a script. For example, last week, we had externalized patients—they are not real patients—who play the script of a wife of a husband who is dying and she wanted everything done, including transplant of the lung—unrealistic. So the doctor had to go in and explain why that was not the right choice. It's a very difficult situation to tell a wife who is desperate that your mother—your husband is going to die in two days. So we do this.

Unger: OK, well, that brings me to my other question, then, which I—back to bedside manner and the way that you've defined it here but the flip side of that is around issues around communication and empathy. When you're in simulation world, is that hard to teach that part of this? Or kind of more to the story you just told, is that also part of the lesson?

Dr. Kothari: It's not hard to teach but you have to teach it properly by experts who know these things and you have to do it repeatedly. Like any skill, you have to do what we call deliberate practice. So you are taught in a didactic manner first. So 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.

Then we bring in a standardized patient and the resident engages that patient on the script. And two or three faculty members watch it and call timeout now and then and interrupt and say, "OK, what was right here, what was wrong here." And there are about 17 or 18 residents, students, sitting there. So it's very interactive, sometimes highly charged environment.

Unger: Mm-hmm.

Dr. Kothari: So we can practice, not when we do it real. And then they practice in the different levels with different patients. We also ask the opinion of the patient. How did you feel about it? They fill out a form, an evaluation form. And one question we ask is, "Do you wish that this doctor takes care of you?" And that feedback is powerful, very powerful. The resident may have done everything right but the answer to the last question is no, then we know there's a problem.

Unger: Mm-hmm. What's the most difficult thing or situation in terms of bedside manner communication that you have to teach students?

Dr. Kothari: To be patient and to be thorough. They are always in a hurry because the way in which hospitals work, everybody is in a hurry. You cannot just go on a round, and "Oh, by the way, I'm going to talk to your father." Appointment has to be made. A quiet room has to be—try to obtain a quiet room in a hospital. It's impossible.

Unger: Mm-hmm.

Dr. Kothari: A quiet room has to be obtained. We recommend that you bring some water or something—the normal things which you and I would do if we went to each other's home, just plain simple manners. You want to have a box of tissues because somebody is going to cry, so we make it available. But these are small things but they're important things in aggregate.

Unger: Mm-hmm. Is that really part of that delivery of bad—I'll call it "bad news," I guess, is that?

Dr. Kothari: Yeah. So we go with it. We have a station on breast cancer. The lady goes through a biopsy of the breast because of the abnormal mammogram and she has a adenocarcinoma of the breast. She's here now to hear the news. And that's a powerful station. Because there's one thing which freaks out a women, is the mammogram. They worry about it. Now the doctor is calling and something must be wrong.

How do you break the news that you have cancer? So there is a whole script for that. What kind of cancer? And what does it mean? What about these new fancy drugs? What are you going to do? Do we—do I need a mastectomy? Do I need radiation? Do I need chemotherapy?

All that is discussed in a very controlled environment. That is the key. And the attending physicians, faculty, are there to guide them if they use the jargon. They immediately stop. Don't use this. For example, a simple example of a jargon that's almost a comedy—resident will say, we are going to give you radiation. Now, radiation to many people means Hiroshima or something of that sort.

But they have to modify the term so that they don't get panicky about, "Oh my god, they are going to cut my breast out, they're going to burn it," and all that kind of thing. So we predict the responses of the patients, real patients and then accordingly modify. It works. I can tell you that.

Unger: Any final thoughts about the importance of getting folks to adopt better bedside manner training and communication?

Dr. Kothari: I think it is going to spread slowly. In the last few years, I've been doing this, I already have about five—three major universities and two residency programs like ours—doing it. We are collaborating it. But this is a vast country. You cannot just change that. Something has to come from center, like AMA, ACB.

Whichever way—it doesn't matter to me. But that needs to be. And I'm glad that this year AMA has started certain programming for bedside medicine. So does the ACGME. They have started Joy of Medicine. Because joy of medicine is gone. And what little was there, the COVID destroyed it. Because of COVID, it is now OK not to examine your patient.

Unger: Mm-hmm.

Dr. Kothari: It should never be OK.

Unger: Well, thank you so much, Dr. Kothari, for being here today and for sharing that very important and interesting perspective. We'll be back soon with another AMA Update. You can find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.


Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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