Sunday, September 25, 2011

Better Bedside Manners? What's It's Worth To You?

How much are good bedside manners worth? Would you double your copay if you could be guaranteed an extra measure of TLC from your physician? Can we put price on a physician’s warm smile, an understanding nod or a reassuring hand on your shoulder? Do patients have to contract with a concierge medical practice to receive this treatment?

I agree that our bedside manners with patients need some rejuvenation. It’s not fair, however, to isolate this issue out of context. Physicians today are facing crunching pressures from various sources that we cannot always compartmentalize when we are facing our patients – even though we should. Most folks believe that the bedside manners of the prior generation of physicians were superior to ours. Were our predecessors simply more compassionate and caring human beings than we are? I don’t think so. I think the medical profession was a different beast then. I hypothesize that if these wizened physicians entered the profession today, that they would behave differently.

Context is so critical when examining any issue. Many physicians find today’s patients to be demanding and entitled. Again, before pronouncing a verdict here, there are reasons and explanations behind this that need to be aired. Patients and physicians are both different today because the culture and nature of the profession has changed. How would Marcus Welby behave if he weren’t making house calls with a black bag 40 years ago, but were now an employed physician in a large clinic who was sued every few years and whose medical ‘quality’ was monitored by bureaucrats who determined his reimbursement?

Again, I’m not excusing deficient bedside manners, but the issue has nuance and complexity.

A Chicago couple, Matthew and Carolyn Bucksbaum, believe that bedside manners are worth a lot. These philanthropists are donating $42 million to the University of Chicago which will create an institute under their names which will be devoted to teaching medical students good bedside manners. The hope is to ingrain values of compassion and empathy deeply enough into medical students that they will not be contaminated when they enter the medical arena later. The training would function like a suit of armor to protect young physicians from bedside manner decay and attack.

This is a fantastic initiative and I hope that other donors and medical institutions emulate the Chicago program. While medical schools do teach bedside manners and the importance of the doctor-patient relationship, it was undervalued, at least in my day. Younger physician readers can comment if times have changed.

Can you really teach compassion or do you have to be born with it? A Chicago couple has wagered in a big way that it’s nurture, not nature.

19 comments:

A. Bailey said...

Frank Davidoff addresses this general topic in his wonderful little essay: "Music lessons". I would link it but it is a members only page at the AIM.

I'm still trying to sort my opinion of "boutique" medicine. I have trouble moving beyond the "pay me extra and I'll be nice to you" aspect of it.

tired resident said...

I totally agree with you that times have changed and physicians 50 years ago are practicing in a totally different environment than now. Bedside manners and compassion are 2 different things though. I think my bedside manners are pretty good, but I admit that I struggle to have compassion for many patients. As I've mentioned in previous comments, more and more patients these days have illness that are due to their own lifestyle, that is, self-inflicted. How do you have compassion for someone who has lived a lifetime of poor decisions and is now having medical problems directly related to those decisions? I don't know how many times I've seen patients with 40+ pack year smoking histories now with end stage COPD or lung cancer, and continue to smoke!

I'm not saying that these people shouldn't receive treatment; they definitely should. but for me, compassion is much easier to have when dealing with a patient that didn't have a hand in causing their own health problems

Elaine Schattner, MD said...

Hi Michael,
I like this post and its ambivalence on "teaching" bedside manner. Some doctors "get it right" by nature. But instruction can up their skills further, or identify interpersonal lapses that aren't self-recognized. As for those for whom professional, warm and respectful dialogue with patients doesn't come easily, instruction can help.

Anonymous said...

tired resident,

How many of us don't have problems of our own making (and not just in the physical sense). The human condition is imperfect. To expect otherwise is to limit yourself and your capacity to give as a physician and human being. Compassion comes from understanding our own limitations as well as others.

Michael Kirsch, M.D. said...

Great comments appreciated. While it seems to me that compassion and empathy originate from an individual, I realize that it is shaped by external forces. Physicians today and tomorrow have many more pressures and forces that can frustrate our ability to provide caring bedside manners consistently. It's a battle we can win, I think, but it's not a downhill coast.

GlassHospital said...

It was once said about a certain doctor that "he invented concierge medicine before there was concierge medicine."

Instead of retainer fees, he was rewarded with donations to his center.

ClinicalPosters said...

Doctors with no patience for e-patients may soon have no patients.

Healthcare reform is shortening office visits. Most patients are forced to research online prior to or following exams. These e-Patients range from passive to confrontational. Today's physicians need training in how to work with them and display policies so e-patients understand the boundaries.

Anonymous said...

From Duluth News Tribune
By Mark Stodghill, April 28, 2011


A judge threw out a lawsuit today filed by a Duluth physician who said he was defamed by a man who publicly criticized his bedside manner.


Dr. David McKee, a neurologist with Northland Neurology and Myology, alleged that Dennis Laurion of Duluth defamed him and interfered with his business by making false statements to the American Academy of Neurology, the American Neurological Association, two physicians in Duluth, the St. Louis County Public Health and Human Services Advisory Committee and St. Luke’s hospital, among others.


Laurion was critical of the treatment his father, Kenneth, received from McKee after suffering a hemorrhagic stroke and spending four days at St. Luke’s hospital from April 17-21 last year. Kenneth Laurion recovered from his condition.


In his 18-page order dismissing the suit, Sixth Judicial District Judge Eric Hylden wrote that looking at Laurion’s “statements as a whole, the court does not find defamatory meaning, but rather a sometimes emotional discussion of the issues.”


Hylden addressed the fact that Laurion posted some of his criticisms of McKee on websites. “In modern society, there needs to be some give and take, some ability for parties to air their differences,” the judge wrote. “Today, those disagreements may take place on various Internet sources. Because the medium has changed, however, does not make statements of this sort any more or less defamatory.”


Hylden concluded his order by stating that there wasn’t enough objective information provided to justify asking a jury to decide the matter.


Laurion was relieved by the court’s ruling.
“My parents, who are now 86, my wife and I have found this process very stressful for the past year, since my father’s stroke. There was never just one defendant,” he said. “We’re grateful that Judge Hylden found no need for a trial.”


In his suit, McKee alleged that Laurion made false statements including that McKee “seemed upset” that Kenneth Laurion had been transferred from the Intensive Care Unit to a ward room; that McKee told the Laurion family that he had to “spend time finding out if [the patient] had been transferred or died;” that McKee told the Laurions that 44 percent of hemorrhagic stroke victims die within 30 days; that McKee told the patient that he didn’t need therapy; that McKee said it didn’t matter that the patient’s gown was hanging from his neck with his backside exposed; that McKee blamed the patient for the loss of his time; and that McKee didn’t treat his patient with dignity.


According to the Minnesota Board of Medical Practice website, McKee has had no disciplinary actions brought against him.


“I’m very disappointed by this court’s decision because as far as I can see the only avenue that I can see that I had to respond to this overwhelming attack was through the courts, and for the time being it appears that avenue has been closed without me ever getting a chance to present my evidence,” McKee said.


McKee said he hadn’t had a chance to confer with Marshall Tanick, his Minneapolis attorney. He said he will do so before he decides whether to appeal the decision. Tanick told the News Tribune he had not yet seen the decision and couldn’t comment on it.


“Dennis Laurion is a liar and a bully and a coward,” McKee said. “He knowingly made false and malicious statements about me to a total of 19 different professional and medical organizations, regulatory agencies and websites. He often used false names and attributed his statements to fictitious third parties. I’ll make the observation that every one of those organizations that was required to make an official decision or take an official action either determined that the statement that he made was so ludicrous that it required no response from me at all or decided that his complaint had no merit.”


Summary Judgment:
http://www.onpointnews.com/docs/Mckee-v-Laurion.pdf

Anonymous said...

I have had the unfortunate opportunity to deal with many physicians in my life-time. I say unfortunate meaning having to be ill, and for the actual experiences with certain MD's. I had an amazing family doctor for many years, but unfortunately he had the audacity to pass away at a far too young age. (;) That man was extremely intelligent, intuitive, caring, nurturing and empathetic. Then I've had a surgeon, who came bursting into my hospital room, this was my first time seeing him ever, he yelled at the phlebotomist who was just getting ready to draw blood to get out of my room and come back later. He then proceeded to act like the most arrogant a hole on the planet while going over my rather complicated health history. He literally at one point made the implication that I was lieing about how many bowel movements I have in a week! Absurd. He literally had me in tears when he left. I told the nurse, who said he has that reputation, I then told the head of nursing about him and that I never wanted to see him again. The next day he came in when my husband and father were in the room, and had a completely different demeanor. Jerk. I know doctors work hard. I know they have crazy schedules. I know its stressful. I know there are difficult patients, who think they themselves know as much about medicine as the doctors do nowadays with webmd and whatnot. But, I also know, that we are all human beings, and doctors and nurses went into their professions knowing they would be dealing with people...all types of people...sick people...people who need care and compassion. What I don't get is, it seems so many people who are so obviously not "people persons" get into these professions...why? The money? The prestige? All I know is, being a disabled person myself, I am very appreciative when a medical person takes that extra sixty seconds to make me feel like they see me as a person and care about my condition. That's all it takes. And if it takes a dang class to make another human being show another human being who is obviously ill some compassion, then so be it, but what a sad and disappointing picture of our world that shows. I was a nurse. I've been on both sides. I took the time to show my patients I cared. It's not hard.

Christianna Capra said...

Thank you for this post and for your work on the front of better providers... we are doing something that I think is pretty interesting on the forefront of teaching better bedside manner - instantly!

See:

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Have you ever herd of EAP/L? (Equine Assisted Psychotherapy/Learning) where HORSES can help us solve problems and live fuller lives?
*Spring 2012 Open House Live Demonstration – Free and Open to the General Public – Sat, June 2nd at SROH in Pittstown, NJ:
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Anonymous said...

Thank you for this article. I too was subjected to a doctor that was rude and cruel then left me crying hysterically. You came into the room and immediately asked what was wrong and the bedside manner you showed was a breath of fresh air. Doctors like the other need a talking too. When he came into the room the next day I gave him an earful on his behavior and maybe he should go take a hike. I don't care if he was the best of his field in the city. He was surprised with what I said. He actually said he was sorry and has treated me well ever since.

Anonymous said...

The David McKee MD vs Dennis Laurion case described above was appealed to the Minnesota Court of Appeals and, now, to the Minnesota Supreme Court.

http://www.mncourts.gov/Documents/0/Public/Calendars/September_2012.pdf
Oral hearings for David McKee MD vs Dennis Laurion to be held 9/4/12 at Minnesota Supreme Court, Second Floor, State Capitol, St. Paul MN

http://www.mncourts.gov/Documents/0/Public/Calendars/September_2012_Summary.htm#a111154
Summary Of Issues prepared by the Supreme Court Commissioner’s Office

http://herald-review.com/news/national/doctor-s-suit-tests-limits-of-online-criticism/article_972968c4-78f2-11e1-8852-0019bb2963f4.html
Latest case history from Minnesota "Star Tribune"

Anonymous said...

Supreme Court to decide whether Duluth doctor gets jury trial
By: Mark Stodghill, Duluth News Tribune


The Minnesota Supreme Court heard the case of a Duluth neurologist Tuesday who sued a patient’s son after being criticized on rate-your-doctor websites for his bedside manner.


Dr. David McKee, a neurologist with Northland Neurology and Myology, in 2010 filed the defamation lawsuit against Dennis Laurion of Duluth. McKee alleged that Laurion defamed him and interfered with his business by posting false statements on the internet and to various third parties, including the American Academy of Neurology, the American Neurological Association, the St. Louis County Public Health and Human Services Advisory Committee and St. Luke’s hospital, among others.


Defendant Laurion claimed that any statements he made about the doctor were true and that he is immune from any liability to the plaintiff. McKee is asking for more than $50,000 in damages.


State District Judge Eric Hylden last year ruled that McKee was not defamed by the criticism and dismissed the doctor’s lawsuit. McKee appealed to the Minnesota Court of Appeals and in January that court sent the case back to the district court for a jury to decide if six statements Laurion posted about McKee on rate-your-doctor websites and distributed elsewhere were defamatory.


Laurion appealed the Court of Appeals decision to the state Supreme Court and the case was heard in St. Paul on Tuesday. Duluth attorney John Kelly presented Laurion’s position to the high court. “I argued that the posting to a website is part of the context that colors or shapes what Mr. Laurion was trying to do, and the essential nature of one of these websites is to provide subjective feedback and people get lots of subjective feedback from different perspectives and from different experiences,” Kelly said.


“I believe that people going to these websites don’t expect any one recitation or report to be definitive. They’re looking for a range. So seen in that light, what Mr. Laurion was doing was offering his view of an encounter and his overall impression was that the doctor hadn’t responded as well, or wasn’t as respectful, toward his father as he would have hoped.”


Read more:
http://www.duluthnewstribune.com/event/article/id/242154/group/homepage/


Watch more:
http://www.tpt.org/courts/MNJudicialBranchvideo_NEW.php?number=A111154#

Michael Kirsch, M.D. said...

Please keep us posted on the Duluth Supreme Court trial! Interesting stuff. Thanks for posting.

Anonymous said...

In David McKee MD vs Dennis Laurion, the plaintiff’s attorney told the Minnesota Supreme Court the correct way to critique a doctor at a rating site.

Taken from Marshall Tanick’s comments to Minnesota Supreme Court:
http://www.tpt.org/courts/MNJudicialBranchvideo_NEW.php?number=A111154#

He may have been upset at how Dr. McKee treated his father. Apparently he was, and he’s entitled to say that. He can say that “I’m upset. Doctor McKee did not treat my father well. He was insensitive.” He can make statements like that: “He didn’t spend enough time in my opinion.” He can make factual (sic) statements, he can make them on the Internet, he can make them in letters, he can write a letter to the editor, he can stand in front of St. Luke’s Hospital with a placard saying those things if they are opinions . . .

Court Watch said...

[ MINNEAPOLIS -- A man's online post calling a doctor "a real tool" is protected speech, the Minnesota Supreme Court ruled Wednesday. The state's highest court dismissed a case by Duluth neurologist David McKee, who took offense when a patient's son posted critical remarks about him on rate-your-doctor websites. Those remarks included a claim that a nurse called the doctor "a real tool," slang for stupid or foolish. ]

See also:

http://hosted.ap.org/dynamic/stories/U/US_ONLINE_RATING_RISKS?SITE=AP&SECTION=HOME&TEMPLATE=DEFAULT
Minnesota high court says online post legally protected
By STEVE KARNOWSKI, January 30, 5:34 PM EST, 2013

http://www.duluthnewstribune.com/event/article/id/257287/
Court protects Duluth doctor's online critic
By: STEVE KUCHERA, Duluth News Tribune, January 30, 2013

http://www.startribune.com/local/189028521.html
Duluth doctor's lawsuit against patient's son over online criticism dismissed
Article by: ABBY SIMONS , Star Tribune, January 30, 2013

http://comments.startribune.com/comments.php?d=content_comments&asset_id=189028521&section=/local&comments=true
Star Tribune comments

http://www.mncourts.gov/opinions/sc/current/OPA111154-0130.pdf.
Unanimous ruling of the Supreme Court of Minnesota

http://learningboosters.blogspot.com/search/label/.%20McKee%20v%20Laurion
Laurion answers questions

Dennis said...

Although the Minnesota Supreme Court dismissed David McKee MD vs Dennis Laurion, the entire experience has been distressing to my family. We were initially shocked and blindsided by “jocular” comments made so soon after my father’s stroke by somebody who didn’t know us. We were overwhelmed by my being sued after posting a consumer opinion, and we were shocked by the rapidity with which it happened. My parents would be 88-year-old witnesses. My mother and wife prefer no discussion, because they don’t want to think about it. Conversation with my father only reminds him of his anger over this situation. My siblings and children don’t often bring it up, because they don’t know how to say anything helpful. I have been demoralized by three years of being called “Defendant Laurion” in public documents. While being sued for defamation, I have been called a passive aggressive, an oddball, a liar, a coward, a bully, a malicious person, and a zealot family member. I’ve been said to have run a cottage industry vendetta, posting 108 adverse Internet postings in person or through proxies. That’s not correct. In reality, I posted ratings at three consumer rating sites, deleted them, and never rewrote them again.

The plaintiff’s first contact with me was a letter that said in part that he had the means and motivation to pursue me. The financial impact of being sued three years to date has been burdensome, a game of financial attrition that I haven’t wanted to play. The suit cost me the equivalent of two year’s net income - the same as 48 of my car payments plus 48 of my house payments. My family members had to dip into retirement funds to help me.

After receipt of a threat letter, I deleted my rate-your-doctor site postings and sent confirmation emails to opposing counsel. Since May of 2010, postings on the Internet by others include newspaper accounts of the lawsuit; readers’ remarks about the newspaper accounts; and blog opinion pieces written by doctors, lawyers, public relations professionals, patient advocates, and information technology experts. Dozens of websites by doctors, lawyers, patient advocates, medical students, law schools, consumer advocates, and free speech monitors posted opinions that a doctor or plumber shouldn’t sue the family of a customer for a bad rating. These authors never said they saw my deleted ratings – only the news coverage.

I’ve learned that laws about slander and libel do not conform to one’s expectations. I’ve read that online complaints are safe "if you stick to the facts." That’s exactly the wrong advice. I did not want to merely post my conclusions. I wanted to stick to my recollection of what I’d heard. I don’t like to read generalities like “I’m upset. He did not treat my father well. He was insensitive. He didn’t spend enough time in my opinion.” However, such generalities are excused as opinion, hyperbole, or angry utterances. If one purports to say what happened, factual recitations can be litigated. The plaintiff must prove the facts are willfully misstated, but the defendant can go broke while waiting through the effort.

Chicago Brick said...

This lawsuit, McKee v Laurion, was named among "The top lawsuits of 2013" by "Twin Cities Business Magazine” on December 20, 2013:

If hamburgers could sue, the courts (like the eater’s arteries) would be clogged. Scroll down any of the dozens of websites that rate restaurants and you’ll see food described in the vilest terms: hog slop, garbage-dump-ready, rat -meat. The proliferation of rating sites shows both that these sites are providing an appreciated service and that people love to give their opinion. But when you move from hamburgers and hotel rooms to rating people, quite often the fun ends.

Dr. David McKee, a Duluth neurologist, was not laughing when he saw what one former client wrote about him on a doctor-rating website. The reviewer, Dennis Laurion, complained that McKee made statements that he interpreted as rude and quoted a nurse who had called the doctor “a real tool.” As these statements echoed through the Internet, McKee felt his reputation was being tarnished. He sued, and so began a four-year journey that ended this year in the Minnesota Supreme Court.

Laurion was unhappy with the way McKee treated his father, who was brought to the doctor after he had a stroke. Laurion went to several rate-your-doctor sites to give his opinion. That’s just free speech, isn’t it?

It sure is, says Laurion’s attorney, John D. Kelly of the Duluth firm Hanft Fride. “The court held that what my client was quoted as saying was not defamatory,” he says. “I do think the Internet makes it much easier for persons exercising poor judgment to broadcast defamatory statements, however… a medium… doesn’t change the quality of a statement from non-defamatory to defamatory.”

But McKee’s lawyer, Marshall Tanick, of Hellmuth & Johnson, says no matter where it was said, defamation is defamation. “The thing that’s often misunderstood is that this was not just about free speech, but about making actual false statements,” Tanick says. “The problem is today’s unfettered opportunity to express opinion, whether or not the substance of what’s said is true or not. We need some boundaries.”

But boundaries were not on the minds of the Minnesota Supreme Court. Free speech was. Chief Justice Lorie Gildea wrote, “The point of the post is, ‘This doctor did not treat my father well.’ I can’t grasp why that wouldn’t be protected opinion.”

As to referring to the doctor as “a real tool,” Justice Alan Page wrote that the insult “falls into the category of pure opinion because the term … cannot be reasonably interpreted as a fact and it cannot be proven true or false.”

The takeaway from this case might be the knowledge that behind any rating service lie real people with real feelings. McKee spent more than $60,000 in the effort to clear his name, as he saw it.

Dennis Laurion told the Star Tribune he spent the equivalent of two years’ income, some of which he had to borrow from relatives who supplied the money by raiding their retirement funds.

Dennis said...

Marshall Tanick is STILL saying "The thing that’s often misunderstood is that this was not just about free speech, but about making actual false statements. The problem is today’s unfettered opportunity to express opinion, whether or not the substance of what’s said is true or not. We need some boundaries."

From the American Health Lawyers Association: In this case, the court found the six allegedly defamatory statements were not actionable because the “substance, the gist, the sting” of plaintiff’s version for each of the statements as provided in deposition and defendant’s version essentially carried the same meaning, satisfied the standard for substantial truth, did not show a tendency to harm the plaintiff’s reputation and lower his estimation in the community, or were incapable of conveying a defamatory meaning (e.g., when a nurse told defendant that plaintiff was “a real tool”) based on “how an ordinary person understands the language used in the light of surrounding circumstances.”

From the Business Insurance Blog: The Minnesota high court said, for instance, that Dr. McKee’s version of his comment about the intensive care unit was substantially similar to Mr. Laurion’s. “In other words, Dr. McKee’s account of what he said would produce the same effect on the mind of the reader,” the court said. “The minor inaccuracies of expression (in the statement) as compared to Dr. McKee’s version of what he said do not give rise to a genuine issue as to falsity.”

From the Duane Morris Media Blog: The doctor said in his deposition that with regard to finding out if Mr. Laurion was alive or dead, “I made a jocular comment… to the effect of I had looked for [Kenneth Laurion] up there in the intensive care unit and was glad to find that, when he wasn’t there, that he had been moved to a regular hospital bed, because you only go one of two ways when you leave the intensive care unit; you either have improved to the point where you’re someplace like this or you leave because you’ve died.” The court said the differences between the two versions of the statements about death or transfer by both plaintiff and defendant were so minor that there was no falsity in the website postings. In other words, the court indicated that the allegation about the statement was true.

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