With the rise of hospital medicine in the United States, the lion’s share of inpatient care is delivered by hospitalists. Both hospitals and hospitalist providers are committed to delivering excellent patient care, but to accomplish this goal, specific feedback is essential.

Patient satisfaction surveys that assess provider performance, such as Press Ganey (PG)1 and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS),2 do not truly provide feedback at the encounter level with valid attribution, and these data are not sent to providers in a timely manner.

Our team developed the hospital medicine comportment and communication observation tool (HMCCOT) as a way to assess a hospitalist’s performance at the bedside while they saw patients.3 The tool was iteratively revised and validated using multiple methods. An observer watches a hospitalist care for a patient and notes whether or not desirable behaviors are executed. A score is calculated using the HMCCOT variables, and places where the provider does not score highly can be used as a coaching tool to give immediate feedback related to comportment and communication with patients.

In the analyses, the HMCCOT scores were moderately correlated with the hospitalists’ PG scores. Higher scores on the HMCCOT took an average of 13 minutes per patient encounter, giving further credence to the fact that excellent communication and comportment can be rapidly established at the bedside.

Patients’ complaints about doctors often relate to comportment and communication; the grievances are most commonly about feeling rushed, not being heard, and that information was not conveyed in a clear manner.4 Patient-centeredness has been shown to improve patient satisfaction as well as clinical outcomes, in part because they feel like partners in the mutually agreed upon treatment plans.5 Many of the components of the HMCCOT are at the heart of patient-centered care. While comportment may not be a frequently used term in patient care, respectful behaviors performed at the opening of any encounter [etiquette-based medicine which includes introducing oneself to patients and smiling] set the tone for the doctor-patient interaction.

Demonstrating genuine interest in the patient as a person is a core component of excellent patient care. Sir William Osler famously observed “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”6 A common method of “demonstrating interest in the patient as a person” recorded by the HMCCOT was physicians asking about patient’s personal history and of their interests. It is not difficult to fathom how knowing about patients’ personal interests and perspectives can help to most effectively engage them in establishing their goals of care and with therapeutic decisions.

Because hospitalists spend only a small proportion of their clinical time in direct patient care at the bedside, they need to make every moment count. HMCCOT allows for the identification of providers who are excellent in communication and comportment. Once identified, these exemplars can watch their peers and become the trainers to establish a culture of excellence.

Larger studies will be needed in the future to assess whether interventions that translate into improved comportment and communication among hospitalists will definitively augment patient satisfaction and ameliorate clinical outcomes.

1. Press Ganey . Accessed Dec. 15, 2015.

2. HCAHPS . Accessed Feb. 2, 2016.

3. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine. J Hosp Med. 2016 Aug 13. doi: 10.1002/jhm.2647 .

4. Hickson GB, Clayton EW, Entman SS, Miller CS, Githens PB, Whetten-Goldstein K, Sloan FA. Obstetricians’ prior malpractice experience and patients’ satisfaction with care. JAMA. 1994 Nov 23-30;272(20):1583-7 .

5. Epstein RM, Street RL. Patient-centered communication in cancer care: promoting healing and reducing suffering. National Cancer Institute, NIH Publication No. 07-6225 . Bethesda, MD, 2007.

6. Taylor RB. White Coat Tales: Medicine’s Heroes, Heritage, and Misadventure. New York: Springer; 2007:126.

Susrutha Kotwal, MD, and Scott Wright, MD, are based in the department of medicine, division of hospital medicine, Johns Hopkins Bayview Medical Center and Johns Hopkins University, Baltimore.


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