Secrets of Bedside Manner in Medicine

Good Medicine Is Directly Proportionate to Patient Expectation

I was fired from my job as an emergency room physician assistant only after working there for a year. It was my first job after I graduated from physician assistant school. I was called into the office by the emergency department director and nurse manager and told to find a new job. It was explained, that if I leave quietly, they would give me a good reference. However, if I make it difficult, they would fire me and not give a good reference. That was absolutely devastating; it was one of the worse things that had ever happened in my life. I thought my professional life was over.

My problem wasn’t medically. It was socially. I had brought a military attitude, full of ego and ambition, into a civilian emergency room. I upset key people in the hospital; doctors, consultants and nurses. That spilled over into patients. I always thought if I worked hard, stayed late, came in early and studied, my work ethic would make up for my lack in emotional intelligence. Well, it got me fired. I blamed a lot of people for this, the doctor that I upset because I called him out for being lazy, or the charge nurse that was “out to get me,” or even the head physician assistant that enjoyed providing the criticism. It took a few years to get over, until I realized it wasn’t anybody else fault but was my own.

I created these problems. I am responsible for my behavior. I own this. So, I must fix this.

When I made that understanding, I became a student of human interaction. I began studying leadership, human interaction and emotional intelligence. I read books and went to classes. I took seminars. I became a life long student of human interaction.

What solidified for me that this needed to be put into a lecture was from the executive MBA program at the University of Buffalo. There was one mandatory course that spanned all four semesters. It wasn’t accounting, organization business or economics. It was emotional intelligence. This MBA program found how critical it was to teach executives how to interact with people at a very high level. There is good science behind this; enhanced human interaction skills are needed to succeed in today’s business culture. I have taken the principles learned through my years of study, and the material learned in the MBA program that I had attended, and put that information into a format designed for medical professionals.

You need two key components to be an expert in your field of medicine and to provide excellent care.

1.    Medical knowledge

2.    Likability and effectiveness

 They are equally important and they balance out. We will start with medical knowledge, but first I need to ask you a question. What makes an expert? When I say that, I mean, what makes one person an extraordinary provider when the people around them are only average? What factors decides who is an excellent physician, physician assistant or nurse practitioner?

I will give you three options for you to choose from:

1.    Education, such as, where they went to school?

2.    Experience as where they worked or how long worked?

3.    Domain Specific Training, which reflects classes that they attended or courses taken?

Which one of the three is most important: education, experience or domain specific training? The answer is: all of those contribute but that isn’t the deciding factor. The deciding factor is the provider that practices “meta- cognition” or a learning philosophy known as “deliberate practice.”

Meta-cognition was studied by evaluating four different groups of people; chess players, musicians, professional athletics and physicians. It looked at who obtained knowledge the quickest and most effectively. It wasn’t education, experience or domain specific training. It was the person that learned through “meta-cognition;” the provider that evaluates their own thinking. They ponder about weakness in their own practice and how to fix it. They constantly reflect on their practice. They goal set and are courageous in taking on new challenges. But, most importantly, they identify the areas in their practice and makes correction.

Where are you weak? What patients do you avoid because you are uncomfortable with them? Those are the people you need to focus on.

Why are you uncomfortable with them? What clinical skill set do you need to feel more comfortable with them? Those are the areas of your knowledge your need to focus on. When I started working for a regional stroke center, I had a difficult time making clinical sense out of the neurological exam. It really motivated me to learn neurology. Meta- cognition is the key to your professional growth. I challenge you to research this concept independently.

Now we will move on to the other side of the balance, equally as important as medical knowledge; human interaction and effectiveness. You can be a very bright provider, but if you have a lousy bedside manor, you won’t do well, especially if you are a mid-level provider. You can be a brilliant clinician, but if you upset your patients they won’t listen to you or respect you. If you upset the consultants, they won’t want to help you.

Who ultimately suffers? It is your patients that suffer. You will have a very difficult time if you upset a consultant, and then have to interact with them again. I am speaking from experience. I call this the “intelligence to ego” ratio, or “I:E” ratio.

If you are very smart and you have a very big ego; you will do fine in medicine. If you are an orthopedic surgeon or a radiologist, and you are very good at what you do, but you are cocky about it; that’s ok too. You’ll be fine. If you have a low I:E ratio, meaning you are not very smart medically (or not very experienced) but if your ego is low, you will also be fine. You will frequently not know the answer, but you are humble enough to ask for help. If the opposite happens, and your ego is high and your intelligence (or experience) is low, that is when you make very bad decisions and people can die. How is your I:E ratio?

 The Beauty of Medicine - Don’t Miss the Forest from the Trees

What prevents you from seeing the forest from the trees? The “forest” is the healthcare field. The “forest” is the beauty of taking care of patients. There is no more noble or honorable calling. We are taking care of patients when they are most desperate, scared, sick, ill, or worried. We are preventing disease.

The “trees” are the problems that prevent us from providing the care to patients that is needed. On a scale from 1-10, how much do you enjoy your job? What are the trees that stand in front of you preventing you from seeing the beauty in your job? Is it that you work with a doctor that you don’t relate to, or that you don’t feel appreciated? Is it the manage care model or formularies? Is it a difficult patient population, or complicated staff interactions? What prevents you from seeing the beauty in what we do? When we clear away the trees, at the most fundamental level, we are caring for these people’s lives and there is not a more noble profession.

What percentage of patients do you truly, deeply affect? Out of a hundred patients, how many do you truly make a difference to? Whether it is kindness, a particular diagnoses or therapy? What percent of patients do you truly and deeply affect their lives? When I first started developing this lecture, out of 100 people in the emergency room, I believe I made a difference in about two percent of patients. Out of 100 patients I may see in a weeks time, I believe 2% would cross the mall to come shake my hand and say thank you, and really appreciate my interaction with them. Let’s explore what “2%” really means.

If I see four patients per hour in a normal eight-hour shift, I would have seen about thirty-two patients. I work approximately 200 shifts per year, therefore I see about 6,400 patients per year. I have been a physician assistant for thirteen years; that means I have see over 83,000 patients!

And if I only made a difference to 2% of my patients, then I would have made a difference to over 1,600 families! Have you ever been somebody’s miracle? Have you ever made really made a difference?

When my son Matthew was born, I was excited. I knew it was going to be a boy. I was happy – things were good. When my wife’s water broke, we took her to the hospital and we were being taking care of by two experienced labor and delivery nurses. You could tell they were seasoned veterans of the labor and delivery wing. They were confidence and friendly and they knew their stuff. The doctor came in and told me that everything looks good and I was going to have another son today. Life was good.

Then everything changed….

 All of a sudden there was de-celerations on the fetal heart monitor.

The nurses whipped my wife on her side and did a quick exam as they called the doctor stat. I don’t read fetal heart monitors, but I read nurses. I knew that they were scared and I know enough about medicine that I was aware, that at that moment, my son is dying. The cord was either prolapsed or wrapped around his neck. His brain was not getting enough oxygen. I knew there was nothing I could do. I never felt so helpless, so hopeless… there was nothing I could do.

Then in walked my wife’s OB-GYN. He assesses the circumstances and saw me hanging by a string. He finally said, “John look at me.” I snapped out of my daze. He said, “I am going to take your wife in for a c- section. There is risk of bleeding and infection, but that is not going to happen and you are going to have a baby today.”

Then he was gone, along with the nursing staff and my wife. I was a blubbering mess at this point, praying, please save my baby. Next thing I know, I am helped into scrubs and hustled into the OR. I saw our doctor working like a sushi-chef, and the next think I see, is Matthew –crying–pink and healthy. I asked for a miracle and got my wife’s doctor. My question is have you been somebody’s miracle?

But wait, we don’t do c-sections! We don’t do surgery like this! I want you to change your perspective on what a miracle really is. Picture five years down the road and you are looking down into an ICU room – you see a patient that you know well, who is now on a ventilator. You watch as an intensivist walks into the room and presents the news to the family. The family all huddles together as the doctor states there is nothing more he can do, and he states, “your father is going to die tonight.” They all start to cry. The doctor then leaves, and you stay with the family through out the night. You are still watching as you see a the patient’s nine year old son drop to his knees and pray for his father to not die, asking for a miracle. “Please save my Dad, send me a miracle.”

Now lets rewind back to today. Same patient, but you are the provider that got their diabetes under control so he didn’t have a heart attach. You are the provider that controlled his blood pressure so he didn’t have his stroke. You are the provider that ordered the colonoscopy that found the polyp that did not turn into metastatic cancer. You are the provider that got him to quit smoking are prevented his lung cancer. So my question again is have you ever been somebody’s miracle? The answer is, more than you will ever know. You don’t know how far out you affect patients. Every single patient interaction is like dropping a pebble into water. You don’t know the ripple effect it may have. How far the ripples go, with every kindness – with courtesy – with every time you go that extra mile for your patients. So, if you are wondering if you were ever a miracle to someone the answer is more than you will ever know.

You as a Provider

How do you see yourself as a provider? When you look in the mirror, honestly, how do you see yourself? Where are your strengths and where are your flaws? Are you doing your patients a tremendous service? Are you being selfish and not caring for your patients the way you know you should? When are you pretending to be an excellent provider and not being an excellent provider? Are you the kind of provider that you would want your child to go to when they are sick? If not, then how do you need to change? How do you want to be remembered as a provider?

 My Massive Mistakes:

Let me introduce you to “John the Jester.” “John the Jester” is the guy who did not understand human interactions and that made critical mistakes in human effectiveness. I don’t want you to make those same mistakes I have made. I want you to understand the four main principles of human interaction. These principles are time tested and true. This will help you become more in tune to your patients, staff, coworkers and consultants.

Principles of Human Interaction

Principle one – Wear glasses of sincere appreciation Principle two - Don’t be a negative work force influence Principle three – Preserve someone’s ego at all costs.

Principle four – Don’t give orders

Wear “Glasses of Appreciation”

I try to wear these glasses all the time. I try to see sincere appreciation from everyone I interact with. What do the people around you do that you truly appreciate? Do you express that appreciation? That is currency that feeds peoples soul more then anything. People want to be acknowledged and appreciated more than anything.

Appreciation cannot be generalized. People won’t respond effectively that way. If you say to a co-worker – “Hey, you did a really good job today. It is nice, but it does not affect people’s behavior. If you say something more specific, like how you really appreciated the care you gave that patient in room 8 when you went out of your way to give a blanket, because she was cold. You just made someone’s day in a small and simple way.

Flattery is counterfeit. Flattery is when you want to fluff their ego, so they like you better; to tell someone something they already want to hear. It is universally despised. It is a gimmick. Sincere appreciation is something beautiful and specific. If you want to affect those around you positively, more then anything else you can do, show someone sincere appreciation.

 Don’t Bitch, Whine, Piss or Moan

 Do you know somebody at work that only does four things; bitch whine, piss or moan? They are the big complainer where mostly every word out of their mouth is negative. Has it ever been you? You see, it is easy to go to work at times with a neutral mind; not in a good mood but not in a bad mood either. When you hear someone constantly complaining, it pulls you into their’ mindset. Your mood begins to change. I call it the malignancy of negativity and it is cancerous to an organization. You have to fight it every chance you can. Don’t be negative and don’t let the people around you be negative. If someone is being negative you might want to mention it to that person. It might chance their perception.

People Rationalize: Preserve One’s Ego at All Costs

 Criminals try to justify their behavior. “I did not kill that guy it was self defense.” “Sure I sold drugs but I needed money to feed my family.” We all rationalize our decision we make. It is only human nature and you just have to understand that. It does not matter who you are or how high or low you are on the hierarchy of working in medicine. You cannot criticize someone because they will rationalize their behavior and have resentment towards you for taking away their the self respect. It tells me a lot about a person in a position of authority that bets up on somebody else in s sub- servant position, such as a nurse’s aid, secretary or a waitress.

If you have to give someone fee back there are some tools you can use to do in constructively. First, make the issue a little matter and easy to correct. Another technique is talking about your self-making the same or similar mistake in the past. By doing that, you do not seem as if you a directly picking on the person, but using this as an opportunity to learn and grow.

You Aren’t in the Marines Anymore

Do not give orders. This is something I thought I could do because I was the Physician Assistant. That does not work in a civilian emergency room. It also does not work for team building. I use to tell someone, like a nurse to go and get me orthostatic vitals. People do not work or respond that way. Medicine is a team environment. I am much more aware of this as a provider now then I have been in the past. I now ask for someone to do something instead of giving orders. It’s a simple mindset. We are a team in medical field. You cannot give orders because it breaks all the principles we have spoken about. People want to feel involved, invested and appreciated. These principles of human interactions are important in a work environment and need to be followed.

 Who Would Make a Better Lover:

 To understand how patients perceive us, you must be familiar with the principles of Apollo and Dionysus. Apollo was the god of numbers, logic and science. He applied statics, formulas and numbers to what he did and how he saw the world. We practice medicine this way. Why do we prescribe Amoxicillin for otitis media? The answer is because the numbers tell us to do it. Why do we use aspirin with acute coronary syndrome? It comes down to statics. Statistics tells us it is the standard of care.

However, only about ten percent of our brain and societies brain works this way. We are much more like the god Dionysus; the god of drink, song, emotion and merriment. When you go into a room and exam a patient, applying all the statics perfectly, are you are providing the highest standard of care? Are you going to be judged that way? The answer is, you are going to be judged based on the rules of Dionysus – by emotion. People want to feel that you care about them. In a court setting, juries want to see that you cared for your patients. You can apply all the studies perfectly, provide medicine to the highest standard of care, but if you didn’t care about the patient, or the patient feels you didn’t care, you have done a tremendous disservice to your patient. Juries readily admit that they will dismiss medical fact if they feel sympathy for the plaintiff.

To prove this point, let me ask you a question. Why did you vote for the last President that you voted for? Was it based on statics and numbers? Was it based on his platforms and policies? Was it based on emotion? “Hey, I liked that guy.” “I like how he speaks.” “I like his message.” How do you think society votes? (Why do you think smear campaigns work?) Understand, in the words of Gregory L Henry, MD, “we are Apollonian practicing in a Dionysian world”. We are practicing an Apollonian science that will be judged by Dionysian.

How can we better care for the Dionysian side of patients? How can you affect emotion? How can you get your patient to feel that you care for them?

1.          Shake hands.

Shake hands and greet people when you walk into the room. You greet everyone in the room whether it is grandma or grandpa, little kids.

2.          Listen with your eyes.

Patients feel that you are not be paying attention to them if you are not looking at them as they are telling you their problems. When a patient is talking to you, you should be looking directly at them and responding to them with your eyes. Patients feel that they are connecting to you when are focused with your eyes. Use your eyes to convey emotions.

This was really big in old silent films. People would move around in the screens and it was impressive how people communicated emotion with only their eyes.

3.          Sit.

As often as you can, sit down to take your history. It alters their perspective of time. People feel that you spend more time with them if you sit down. Sitting makes it a more relaxed atmosphere and people think that you listen more in depth.

4.          Find Something You Have in Common.

If you can find something in common with your patients, that is great. This is a universal need that we have. We all want to bond somehow so we try to find something that we have in common.

5)          Time is on YOUR Side.

 Time is illusion to patients. You can ultimately sway that perception. Time is an illusion that YOU can control.

Never tell the patient the doctor will be in “in a minute.” That is something that you cannot control. You need to always over estimate time. Instead of saying the doctor will be in “in a minute,” tell the patient the doctor is backed up with some critical patients, but he knows your are here and will be in as soon as he can.”

 I have to let you know that there are a lot of times as a Physician Assistant that I feel like Rodney Dangerfield. No respect. This can be very frustrating. I remember working an emergency room shift one night and had to juggle several sick patients throughout the night. I had a patient in cardiac arrest and also had to intubate a different patient. I even had to shock another out of a lethal arrthymia. I was exhausted from that long shift, but I needed to catch a plane to California the next day. The person that was sitting next to me asked what I did for a living. When I told them I was a physician assistant, he asked if that was similar to being a nursing assistant.

There are times as a midlevel that you will feel that you have no respect. This is can happen like mine when a person is not educated about our profession or by patients who at your work place states, “I want to see a real doctor.” There are even times when consultants will give you a hard time strictly because of your midlevel status, even if you did everything perfectly. My best advice is that you have to accept that for your patients. I use to pick a lot of fights because of feeling disrespected. I would not back down from consultants that gave me a hard time. I would “show him.”

This would create unhealthy relationships with a consultant that would be resistant to assist me in the future. Ultimately, my patient would suffer.

Understand that there are times as a Physician Assistant /Nurse Practitioner that you are going to be disrespected. It’s life so deal with it.

What are you doing when your best ideas come to you? How do you relax and regroup. For me, it’s either when I am going for a long run, fishing by myself, or at church. What is it for you?

Take the time to see the natural beauty in what we do. We have a front row, VIP ticket, into people’s lives. There is no more noble, honorable and trusting position to be in then to care for someone’s health. I understand at times, it’s easy to get caught up in the routine but if you keep your mind and eyes open, you can see the most awesome natural beauty in your patients.

Be yourself. It is ok to bring your unique passions and insights to your patients. Even though we are taught a structured approach to patient care, it is ok to express your inner beauty as you provide medical care. It’s ok to care and use your unique skills to make a patient well.

In conclusion, one day a man was walking along a beach. The sun was shining and it was a beautiful day. Off in the distance he could see a young native going back and forth between the surf's edge and the beach. Back and forth the native went. As the man approached, he could see that there were hundreds of sea horses stranded on the sand as the result of the natural action of the tide. The man was stuck by the apparent futility of the task. There were far too many sea horses. Many of them were sure to die. As he approached, the native continued the task of picking up sea horses, one by one and throwing them back into the sea. As he came up to the boy he said, "You must be crazy! There are thousands of miles of beach covered with sea horses. You can't possibly make a difference.” The native looked at the man. He then bent down and picked up one more sea horse, and threw it back into the sea. He turned back to the man and replied, "But it made a difference to that one".

 You see, there are a lot of things we do because it’s right, not because we really thing we are going to change the world. Every time I evaluate a patient that smokes, I have a conversation with them about quitting. Do I really think I am going to make a difference? Is that an efficient use of my time? I do what I do not because I feel I am going to change the world, but, I truly believe that my job is to strive to help people. Even though I may not get every patient to quit smoking, I am not going to stop trying. I reflect on a Garth Brooks’ song, “ I do this so the world will know that it will not change me.”

It is a pleasure and an honor that you would take the time and read through this eBook on bedside manner and excellent patient care. I value your feedback. Please send me comments or suggestions, or stories on how you have affected your patients in a positive way, or how you make your patients feel more cared for.

 Be well, and always CYA!

John Bielinski is a physician assistant, working emergency medicine and critical care in Buffalo, NY.

John is the founder and president of CME4Life, LLC, owner of American Medical Seminars, Inc and the Emergency Medicine Institute and lectures internationally on medical topics.

He has taught for multiple physician assistant programs, including PANCE/PANRE board review courses and countless ACLS and ACLS-Experienced Provider courses, as well as lecturing at numerous state conferences. John was invited to lecture at the first civilian PA program in Canada, at McMaster’s University. YouTube Videos Here.

If you would like to discuss retaining CME4Life or John Bielinski as a speaker, please email [email protected].