Manners maketh the doctor

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Politeness is a much under-rated virtue in medicine. This is surprising, as so many complaints about clinicians concern a lack of politeness. “The doctor was terribly rude,” the disgruntled patient recounts, “he didn’t seem at all interested.” At school the motto was “manners maketh man.” For many patients, especially those unfamiliar with medicine, the measure of a doctor’s worth may well rest on his or her manner. In the eyes of the patient, “manners maketh the physician.”

The importance of politeness extends to all professions dealing with clients. The Code of Conduct for Barristers, for example, states that a barrister “must in all his professional activities be courteous.” The General Medical Council’s Good Medical Practice also instructs doctors to “treat patients politely and considerately.” In writing such injunctions sound trite; of course doctors should be polite. Yet in the surgery or the hospital, when time is short, the art difficult, and the patient trying, even the naturally courteous are pushed to the limit.

In the early 18th century Sir John Floyer in his Advice to a Young Physician laments the rudeness and accusations of patients: “How easily are the sick disgusted . . . All this happens because the patients cannot judge of the physician’s ability and his method.”1

“Such injuries,” Floyer notes, “the physician must expect and bear patiently.” The duty to be polite is most demanding, but perhaps most essential, when patients fail in their own duty to be courteous. In fairness to some patients the experience of illness, pain, and fear is not always conducive to civility.2

Time, pervasive enemy of good medicine, is often blamed for the curt treatment of patients. Polite interaction with patients is deemed a luxury, affordable only in times of relative calm. In an unpublished address Osler said: “The motto of each of you as you undertake the examination and treatment of a case should be ‘put yourself in his place,’” listing three simple actions that can make all the difference: “The kindly word, the cheerful greeting, the sympathetic look.”3 Even the busiest practitioner cannot say that time precludes these virtually instant acts.

By all accounts Osler acted on his own advice. He was once called to visit a severely disabled boy for whom he could do nothing. When the boy’s mother, 30 years later, recalled her encounter with Osler, she said that “he looked at me so kindly.” That sympathetic look was her most vivid memory.4

Osler’s views on adopting the patient’s perspective were not new. On the subject of surgeons, Thomas Percival wrote in Medical Ethics (published in 1803): “This branch of the profession has been charged with hardness of heart: And some of its members have formerly justified the stigma, by ridiculing all softness of manners.” Percival advised surgeons: “Make their [the patients’] cases, in a reasonable degree, your own; and whatsoever ye would that men should do unto you, do ye even so unto them.”5 Politeness, kindness, and respect for others go hand in glove.

Politeness is but one aspect of the good doctor, and a courteous doctor can be an awful one in other respects. But it would be a mistake to dismiss the duty to be polite as superficial, a quaint vestige of the days when medical ethics was, in essence, etiquette. It is central to the currently fashionable concept of professionalism. A rude doctor, however knowledgeable and technically proficient, is an unprofessional one.

The duty to be polite also forms part of a doctor’s broader moral obligations to act in the patient’s best interests (the principle of beneficence) and the obligation to avoid causing net harm (the principle of non-maleficence). Since the earliest days of medicine, doctors have known that soothing words and manners can raise spirits and alleviate distress, while ill placed ones can induce fear and anxiety. More pragmatically, courtesy encourages cooperation. Being polite, in the long run, may save time and lead to healthier patients.

The GMC’s guidance concerns the politeness of doctors towards patients, but it is also important to be courteous with colleagues. I am regularly surprised by the rudeness of some hospital doctors towards referring GPs, accusing them behind their backs of incompetence. Sweeping diatribes against surgeons are also common, as if surgeons were one homogeneous group. For reasons both empirical and diplomatic, criticism should be qualified. Percival does not attack all surgeons but “some members of the profession.” I wonder if the fragmentation of the medical profession, through super-specialisation and the expansion of doctors (approximately 218 000 doctors have a licence to practise in the UK),6 has led to a dilution of the medical esprit de corps and an increase in mudslinging.

In this age of multidisciplinary teams, where new members come and go every few months, the duty to be polite and respectful towards other clinicians, and indeed all staff from ward clerks to cleaners, is more important than ever. Politeness is not an optional bonus but a moral imperative.