Walking the line between candor and cruelty

What is appropriate for a physician to say to a patient in the clinical encounter? When do those comments cross the line of good taste?

Consider these exchanges: A Mississippi physician overhears a surgeon treating an emergency department patient who shot himself in the shoulder in a failed suicide attempt. The surgeon shapes the mentally unstable patient's hand into a gun and tells him to point it in his mouth to get the job done next time.

In New Hampshire, a woman complains to the state medical board that her doctor said she needed to lose weight and was so obese that, if her husband died, she might only be desirable to black men. That report prompted the board to re-examine a previous complaint against the doctor from a woman who claimed he told her to kill herself to end her suffering.

While the first example comes from an alleged incident 20 years ago, the second is the subject of recent litigation. Physician leaders and medical ethicists say the case brings attention to the bedside manner of physicians and how they communicate.

Even if a patient considers the physician to be offensive or bad-mannered, and complains to the state medical board, words alone usually won't lead to discipline, physician leaders said. But doctors need to be concerned about more than just sanctions.

"Patients may have different tolerances for someone who is being candid and someone who is being unkind. Being candid can be a very good thing, but you have to think about the spirit of your candor," said Denise M. Dudzinski, PhD, assistant professor of medical ethics at the University of Washington School of Medicine. "Physicians have a special kind of power and influence with patients."

In the New Hampshire case, the patient filed a complaint with the state medical board against Rochester, N.H., family physician Terry Bennett, MD. He denied making the obesity remark and the comment about the woman killing herself. The New Hampshire Board of Medicine planned a hearing on both complaints, but Dr. Bennett sought and won a court injunction.

Merrimack County (N.H.) Superior Court Judge Edward Fitzgerald III halted the board's disciplinary proceedings, saying he did not condone such comments but that a physician is is allowed to speak his or her mind. At press time, medical board officials had not decided whether to appeal.

Dr. Bennett said some doctors resist talking truthfully because they are employees and fear their employers might retaliate. Sometimes, he said, he speaks frankly to patients for their own good, pressing an obese patient to lose weight or telling a smoker to stop. "I have to crack open that whole armor of denial and get through it," he said.

Physician leaders agree doctors have freedom of speech in the exam room, but professional ethics suggest they should not verbally run roughshod over patients.

Frank Boehm, MD, a professor of obstetrics and gynecology at Tennessee's Vanderbilt University School of Medicine who has written about building patient trust, is among those who say doctors step over the line when they come across to patients as cruel or mean-spirited.

"Strong-arm tactics just do not work. They have just the opposite effect: 'The hell with my doctor, I'm going to smoke,' " said Dr. Boehm, a former chair of the ethics committee at Vanderbilt.

Arkansas internist William Golden, MD, chair of the Board of Regents of the American College of Physicians, said, "There's a difference between freedom of speech and expected professional behavior. You're there to be supportive. The patient is coming to you in a privileged environment."

Sometimes, a patient takes a unique approach to reach rude doctors. Ruth Hillebrand (now deceased) said her doctor called her one night and told her she had mesothelioma. He said there was no cure, then hung up. Through her estate, Ohio native Hillebrand left an endowment to train physicians in bedside manners.

Her $1.9 million gift to the Medical College of Ohio, now part of the University of Toledo, is the school's largest individual gift. In March 2005 the school dedicated the Ruth M. Hillebrand Clinical Skills Center.

Patients want empathy, respect

Hillebrand's actions may speak to how other patients feel. A review of 25 surveys on doctor-patient relationships in the March 10, 2001, The Lancet found that physicians with good bedside manners had a better impact on patients than did doctors who were less personal. Mayo Clinic patients wanted their physicians to be empathetic, humane, personal and respectful, according to a survey in the March 2006 Mayo Clinic Proceedings.

"Doctors used to be able to get away with a lot more than they do now because patients put up with it. Patients used to think doctors were gods," said family physician Dwalia South, MD, president-elect of the Mississippi State Medical Assn.

Dr. South is the one who witnessed the ED incident with the irritated surgeon who showed the patient how to point a gun to kill himself. "Then they won't have to call me out again," Dr. South recalled the doctor saying.

She was equally stunned during her residency when an ob-gyn put two operating tables together to deliver an obese patient's twins via cesarean section. "He said, 'Woman, you are so fat, I never thought we'd ever get through all that fat,' " Dr. South said.

"One thing that's different now with patients is they're more well-read than before. People have too many choices; they'll go someplace else," Dr. South said.

Physician leaders and ethicists said doctors should be open and honest in speaking with patients. How direct they are depends on how long they've known the patient and the nature of his or her condition.

"At some point and time, you may have to get frank about smoking. How far to go comes with knowing your patient," said Ashland, Ky., family physician Larry S. Fields, MD, president of the American Academy of Family Physicians.

Say the wrong thing and you could end up in court. Or lose business.

"If a patient is pleased [with a doctor], they'll tell one person," Dr. South said. "If they're displeased, they'll go out and tell 20 people."