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Dr. Keller:
Welcome to DermConsult on ReachMD. I’m Dr. Matthew Keller, and joining me in this two-part episode is my fellow ReachMD host, Dr. Michael Greenberg, to discuss bedside manner, a topic that affects all of us health care professionals. Michael, thanks so much for being here today. Care to tell our audience a little bit about yourself?

Dr. Greenberg:
Sure, Matthew. I’m a dermatologist in Elk Grove Village, Illinois and I’ve actually been in clinical practice for 43 years, but of those 43 years, I would say 25-30 of them have been dedicated to communication, education, compassion, trying to live out a vision of having a health care system based on health and care, and not focused primarily on money.

Dr. Keller:
That’s great, Michael, thank you. Now there’s obviously a lot to cover on this topic, so let’s dive right in. To start us off, can you tell us what quality bedside manner looks like to you as a clinician?

Dr. Greenberg:
First of all, I think it needs to be said that it is a privilege to be a physician. You’ve got to come in with the right attitude. This is not a job. This is not a business. When people ask me, “How’s my business going?” I look at them and go, “I’m not in business.” It’s, to me, such a wonderful thing to be a doctor. This week I had one patient who drove a hundred miles to see me for his regular annual checkup, and another patient who reminded me that 34 years ago, I saved her life with a melanoma. So that’s what it’s about. But, when you walk into a patient’s room, I think what you have to do is bring that sense of privilege with you, but also sit yourself down on that chair and become present. Let your patient know that you’re actually in that room. Your head is not someplace else, it’s not thinking about the last patient, it’s not thinking about your stock portfolio, it’s not thinking about what you just saw on the news. You’re there totally to listen.

Dr. Keller:
Yeah, I completely agree with that. I think sitting down I think is a very good thing you mentioned. Patients really appreciate that, and there’s actually a lot of studies to show that not only do you get more out of the visit, but they actually appreciate that you spent more time with them, just by simply sitting down. I think the other thing for me that’s really important as far as bedside manner goes is learning to read the room, to understand what’s going on within the room and the fact that the patients come in, as you mentioned, sometimes with other things going on. It’s very common that patients will sometimes seem a little anger or, a little bitterness during the visit, and it’s unlike them. And I always find that when I ask them, “What’s going on?” it’s because a loved one’s in the hospital or they’re dealing with something tough in their life, and they’re not really meaning to come across that way, but things are really tough for them. So I think part of bedside manner is really kind of reading that room, and understanding how that visit’s going to kind of go. So I think that’s a spectacular point.

So how do you define “presence” when speaking with your patients?

Dr. Greenberg:
Well, one of my spiritual teachers said to me a long time ago that the greatest gift we give to each other is the quality of our presence. And you just said it. First thing is to walk in that room and take an emotional snapshot of what’s happening. And I do this by looking right in my patient’s eyes, and the first thing I do, Matthew, is I sit down and take like a little breath, like “Hi.” I’ve stopped; in other words, they see that I’ve stopped. I look in their eyes, and you can read a patient through their eyes. Part of classical acting training, which I’ve taken Meisner training, is to be able to look in your scene partner’s eyes and read what’s there. Read the emotion. So, that’s the first thing. It really is very simple. Presence is exactly what it means. You’re literally there, and the patient feels that. I know it sounds like such a simple concept, but for some of us it’s difficult to do, because we’re in our head, worrying or thinking about something else.

Dr. Keller:
I completely agree, and I’m in academic practice and frequently, like many of us, I run far behind. My residents are often, sort of trying to push me along through the visits to make sure that we sort of try to stay on time and finish clinic on time. One of the things I often stop and talk to them about is that it’s not my patients’ responsibility if I’m behind. I’m there to give them their due, one way or the other, and if that makes me further behind, all my patients know that I’m going to spend the time it takes to get them taken care of. With that in mind, how do you manage patient fears that may prevent them from listening to you?

Dr. Greenberg:
Well, before I answer that, let me go back for a second about the idea of being late. My patients know the same thing. They’re never going to be rushed, but they’ll get all the time we need, and I think sometimes it’s really important to just sit down and tell the truth, like, “I know I’m running late. I’m terribly sorry. I’ve had patients with lots of complications today,” And I’ll tell them the truth. Maybe two patients ago, somebody lost someone in their family and I was talking to them about that. And then assure them, “But don’t worry, you’re not going to be rushed.” So that’s key on that.

Dr. Keller:
With that in mind, how do you manage patient fears that may prevent them from listening to you?

Dr. Greenberg:
Going into your next question. How do I manage patient fears? Well, this is a big issue to me. I believe that patients walk in the room with a bunch of sentences that start, “I’m scared that…” That’s why they’re coming to see us, you know? As dermatologists, I think I can teach anybody to do a punch biopsy or a shave biopsy, in a couple weeks. But what’s really important, what we’re really there is peace of mind. And so when I see a patient looking anxious or upset, I stop to ask them what they’re scared of. First of all, I don’t ever ask a patient to tell me what’s wrong.  I think that’s a mistake. I say, “Tell me your story.” Because patients want to tell you their story, and they will. And along the story, if I have to stop them for a second, and ask them a question, and if I see they’re not listening, I’ll specifically say, “Look, before we go any further, tell me what you’re scared of because unless you get that fear out of your head, it’s blocking your ears.” And that’s when the patient says, “Here, this lesion on my arm, I think it’s a melanoma. At least Dr. Google said it was a melanoma.” And I laugh, and I go, “No, that’s a seborrheic keratosis. You’ll be the next pope before that becomes cancer.” You get that fear out of their head, and then they can listen. Fear blocks patients’ ears.

Dr. Keller:
Yeah. I completely agree with that, and I think asking the patient those questions is really, really important, because one, it invites them into that conversation. It lets them know you actually want to hear what they’re scared about. You actually want to hear their concerns. I always kid with my patients, there’s no stupid questions, just stupid people, right? So I want you to ask me those questions because you can’t know the answers to them. That’s what they pay me to do. And I think that frees them up, and you’re exactly right, it’s amazing the types of questions they ask you.

Dr. Greenberg:
Right. It’s all about connection. Connecting to the patient.

Dr. Keller:
That’s great. So for those just tuning in, you’re listening to DermConsult on ReachMD. I’m Dr. Matthew Keller, and today I’m speaking with my fellow ReachMD host Dr. Michael Greenberg about bedside manner. So Michael, picking back up on our conversation, where does patient peace of mind come into the communication between doctors and patients? And how do you help them find that peace of mind?

Dr. Greenberg:
That’s a great question, Matthew, and I think it takes getting ourselves off the pedestal and becoming human just like our patients. When I teach this to residents or medical students, what I say is basically I want you to put yourself across the room in that patient’s chair and listen to the questions they’re not asking. What would you ask if you were sitting over there, knowing what you know? And if that patient were a member of your family, what questions would you ask? So for instance, when a patient shows me a nevus that’s probably dysplastic and it’s going to come off, and they don’t really ask questions about it, I would say, “Listen, if I was sitting over there, this is what I’d be asking. Is this going to hurt? What’s the procedure like? What’s the follow-up going to be like? Am I going to be able to go swimming, or what.” I answer all these questions, even if they’re not asked. And patients just brighten up, because these are things they didn’t even think of, and they’re so appreciative because these are the questions that give them peace of mind, the things that they won’t think about until they get out in the hallway or out of your office. When patients do brighten up and you see that they have peace of mind, they love you as a doctor. That’s why we get people that drive a hundred miles for their annual checkup.

Dr. Keller:
You’re exactly right. I mean, there’s no greater a compliment than when someone goes out of their way to see you, even when they don’t actually have to.  That’s a great point. So managing patient expectations is also very important. So how do you help ensure patients don’t create unrealistic expectations?

Dr. Greenberg:
I think you need spend time talking to the patient and making it very clear that they hear what you’re saying about expectations, and they repeat it back to you. I’m sure you’ve had the same experience. I’ve had patients over the years who will come to my office and say, “I went to Dr. so-and-so, and he was no good.” Why was he no good? “Well, he didn’t help me.” What do you mean he didn’t help you? “Well, I have eczema.” Yeah, I can see that. “He gave me a cream.” Yeah…and what happened? “Well, when I stopped the cream, it came back.” And I go, “Oh, didn’t Dr. X tell you that this would come back?” Well, the answer is always no, which means either the patient wasn’t listening, or the physician didn’t say that. Most of the things that we see are chronic, and I think it’s really important to explain to patients, “Hey, this is not a cure. I’m only looking for control. I’m looking to make this better. Do you understand that?” And they go, “Uh, what do you mean?” I go, “Well, would you go ask your dentist for a toothpaste that you could brush your teeth for a week and never brush your teeth again?” They go, “Of course not.” I go, “Well, it’s the same thing here. I’m going to give a steroid cream. It’s going to calm this down. You’re going to think it went away, but it will come back.” I think that is so important. And ask patients what they expect too. Say, “What do you think’s going to happen here? What would you like to have happen?” Ask all those questions, and then tell them the truth, and make sure they’ve heard you by making them repeat it.

Dr. Keller:
Yeah, I completely agree. I have a couple of funny lines I use. “I’m a physician, not a magician.” I think setting that expectation, like you mentioned, about answering the questions the patients maybe haven’t even thought to ask, I try to set those expectations. I tell a lot of psoriasis patients up front of what I can do and what I can’t do, and I tell them, “Think about it like high blood pressure. You know, you would never expect to take your pill once and never have high blood pressure again.” These are chronic conditions and that doesn’t mean they can’t be controlled. It doesn’t mean they have to have a huge impact on your life. But what it does mean is it’s going to need a certain amount of treatment.

That’ll be different for everybody in order to keep it that way. So we’re almost out of time for today, but before we wrap up, Michael, let me ask you one last question that will probably resonate with a lot of our listeners. If you’re in a system that only allows so much time with a patient, how can you make sure that that visit is fulfilling for both you and your patient?

Dr. Greenberg:
Yeah, well first of all, I’m lucky because I’m in a partnership that nobody cares about time. We don’t deal with metrics, but I know a lot of people are. They’re –owned by a university system and they get like nine minutes a patient, whatever it is.  I had a bunch of nurses who came to me years ago, because they knew about the books I had written, that this was a subject I cared about. And they said, “Look, Michael. We get about five minutes at the patient’s bedside these days. We used to get a half an hour. We’re really upset. What do we do?” And my answer to them was, “Make it the best damn five minutes that patient ever had in their life.” It always goes back to presence. If you’re in your head upset because you’ve only got five or nine or ten or fifteen – however much time you have, you’re not really present. I’m telling you, Matthew, a minute can seem like an hour of presence if you’re really there. So don’t worry about the time, and I don’t have a time limit, but sometimes I am running behind and I’m busy, and I have to say, “Hey, listen, I can’t get into your personal stories today. I can’t go there, but I want to make sure that I’m really listening to what your problem is today.” You just have to tell the truth and adjust with the situation.

Dr. Keller:
Well, I couldn’t think of a better way to wrap up the first half of our two-part discussion on bedside manner. And I want to thank my guest and ReachMD host Dr. Michael Greenberg for sharing his insights. Michael, it was great speaking with you today.

Dr. Greenberg:
Hey, it’s always good to be here, especially with you, Matthew, and it’s kind of fun to be the guest instead of the host.

Dr. Keller:
For ReachMD, I’m Dr. Matthew Keller. To access this episode and to hear Part Two of our discussion on bedside manner,

visit ReachMD.com/DermConsult where you can Be Part of the Knowledge. Thanks for listening.