Manners in medicine
Authors: Tessa Richards
Journal: BMJ (2008)

Is Britain the rudest nation on earth? The results of a recent poll reported in The Week suggest as much, and as night follows day the idea that schools should teach “good manners” has been floated. Nothing new here then. In 1898 George Bernard Shaw observed, “We don’t bother much about dress and manners in England, because as a nation we don’t dress well, and we’ve no manners.” Centuries before him William of Wykeham enshrined the motto “Manners makyth man” to steer the schoolboys of Winchester College.

When our daily exchange with others is courteous and pleasant, life is enhanced. On days when we are worried, vulnerable, or sick our interaction with others assumes added importance. Shaw was no lover of doctors, but in his day the value of good “bedside” manners (and professional attire) was acknowledged. Sitting by the bed, listening and observing, reassuring where possible, showing empathy where not, were often all a doctor or nurse could offer. Now the black bags contain effective medicines, and the outcomes achieved by multidisciplinary teams are a great deal better. The down side has been an attenuation of the relationship between patients and health professionals, and sometimes it shows.

In February a hereditary peer, Lord Mancroft, made an incendiary speech in the House of Lords. In it he criticised the attitude and professional conduct of the nurses who had looked after him in hospital. He accused them of being not only “grubby, slipshod, and lazy” but also “drunken and promiscuous.” His words provoked uproar. “Peer attacks angels” screamed the tabloids, and Mancroft was castigated by the health minister and the public services union. The reasons for his outburst were explored in more detail in an article in the Evening Standard magazine (25 April). The attitude of his nurses apart, there seems little doubt that the quality of medical care he received was less than optimal and that his experience of being a patient had been harrowing. Pilloried in public, in private he received many letters of support expressing gratitude to him for speaking out.

Reading his description of “dirt and despair” on the ward and the dying man “ignored by staff” rekindled memories of my own. A large operation and a week in intensive care had taken its toll. I could do very little without help; mostly, I just watched. Nurses and other ward staff came and went and clustered round the central station. The faces changed frequently. Observations were taken, drugs dispensed, meals set down, boxes ticked on a mixed ward that was less than clean. Sometimes the sight and sound of fellow patients was distressing, especially at night when piteous cries of “Nurse, nurse” went unanswered. I frequently longed for simple human contact: someone to hold my hand, wash my face, note when I had dirtied my sheets, and pass me my glass of water, which always seemed to be just out of reach. When my (non-medical) sister visited she saw at a glance what I needed. Her empathy and sensitive personal care made a big difference. So did a visit from two cheery medical students who sat on my bed and engaged with me as a person, as well as a patient.

Lord Mancroft put his eventual recovery from his long illness down to the excellent all round care and kindness he received at a second hospital. Excellent well describes my mother’s recent care, too. Facing surgery at 85 is challenging. She wondered if she would survive it. The warm welcome, impeccably clean ward, efficient staff, and clear explanations from a medical team honed by an impressive consultant allayed her anxiety and inspired confidence.

Arguably, the quality of a patient’s journey matters as much as where it takes them. How care is delivered is not less important than the content of the medical package. We know that good basic nursing care and the quality of the relationship between patients and health professionals improves outcomes (BMJ 2008;336:967-8; doi: 10.1136/bmj.39535.344201.BE).

Boorish as a nation we may be, aggressive and violent too, not least towards health professionals. Perhaps we get the service we deserve, or better. The latest report from the Healthcare Commission shows a rise in the proportion of patients rating their care in NHS hospitals as good to excellent. But it also points to striking variations between trusts—variation that can scarcely be explained by a clustering of difficult patients or substandard health professionals. Poor leadership and a culture that fails to acknowledge the importance of basic care and respect to patients seems a more likely cause.

Seeking or undergoing medical care is a stressful business. Worry may precipitate or exacerbate ungracious behaviour. If front line staff can muster the good manners that we as patients cannot, it helps. To my mind, simple explanations and apologies for delay are preferable to (usually inaccurate) notice boards in outpatients stating that “Dr A, B, and C are running X hours late.” These are redolent of our airports, as is the unsettling notice that reads: “We will not tolerate any form of threatening or aggressive behaviour towards our staff.” Is this really more effective than the “soft answer” which “turneth away wrath”? Health has many dimensions. Few are not improved by a sensitive, caring, and observant presence at the bedside or in the clinic.