Greetings: You had me at ‘Hello’

Bronislaw  Malinowski and Drake – “Yo”

THE GREETING – a social custom triggered when first approaching others in typical encounters and gatherings.

The simplicity of the basic greeting can deceive us into believing this action is of little value. Branislaw Malinowski disagrees [1]. As the founder of social anthropology, he developed the ethnographic theory of language, studied the “mentality, culture, and language” of the Melanesian tribes of Eastern New Guinea, and is acclaimed for introducing the ethnographic technique of the participant observer. He is also credited for coining the phrase phatic communion, a phenomenon that occurs when people first encounter or depart from each another. ‘Hi, how are you?’ and “Nice weather today.” are examples. Malinowski maintained that these informal conversation starters served many purposes, including

• acting as a social function to open channels of communication,
• acting as a means to break initial silences,
• to establish rapport, and
• to follow decorum (i.e., observe social customs).

So for example, instead of approaching a friend or colleague and saying “Dear colleague, I would like now to engage in a conversation with you by following the appropriate social rules and traditions of our culture” – we just say “Hey” or “Tsup.” Based on this premise, I like to imagine Dr. Malinowski observing our culture today, taking his ethnographic talents to the west coast. There, after listening and observing a rap concert, he meets up with his friend Drake backstage. Bron strolls up to the rapper and casually asks “Watup Dog?” Drake responds “Yo, namaste.” They then share a fist bump (and a moment). . .

I digress.

Although important, Malinowski asserted that greetings were not necessarily intended to convey meaning. However later, scholars compellingly argued that these expressions can and do convey meaning, often more than one (e.g., encourage participation, highlight or downplay social status, etc.), as well as perform expected social conventions [2,3,4].

The clinical “hello”: Meanings, expectations, and effects

Greetings within a medical context are particularly meaningful. For example, ‘Hi, how are you?’ from a clinician can

• act as a courteous greeting (i.e., phatic communion) that initiates an invitation to begin a conversation,
• immediately launch an inquiry about the patient’s general condition and wellbeing, and/or
• confuse a patient about the intention of the question (i.e., Is this a greeting or the beginning of the problem presentation phase of my appointment? – more about this later).

Patient expectations about greetings during medical visits reveal that

• appropriate greetings are necessary and expected,
• they begin the process of establishing rapport between the clinician and patient, and
• they affect patients’ first impressions, expectations, and the communication exchanges of the visit.

The quality of the relationships initiated during greetings influences patients’ subsequent levels of

• participation,
• disclosure, and
• willingness to cooperate with medical professionals.

Greetings can affect patients’ perceptions of health care providers, which can

•  influence the content of medical discussions provided by patients that can range from personal, sensitive, and clear to remote, cryptic, and vague,
•  influence whether patients sense their clinicians like, believe, and understand them,
•  determine patients’ ratings of satisfaction with their clinical experiences,
•  alter patients’ willingness to adhere to medical recommendations and treatment regimes and/or
•  strengthen patients’ resolve to remain or switch practitioners

Also see FIRST IMPRESSIONS

Giving patients what they want: Testing your phatic communion

So we know relationships happen and relationship development that incorporates credibility, trust, and initial patient satisfaction can be activated or discouraged within the first moments of medical encounters (see First Impressions). Patients want and expect to be treated with respect and kindness. As in most alliances, we prefer to work with nice people, we want to like them, and we want them to like us. In this section, we identify behaviors that patients desire from their clinicians. The following suggestions provide you with a variety of actions to consider when greeting patients. As always, electing to adopt some of these behaviors is contingent on your circumstances, abilities, and levels of comfort in performing them.

“Mr. Charles Benet? Good morning. I’m Dr. Anita Rodríguez. Do you like being called Charles or is there another name you prefer?”

During medical encounters, research indicates the following patient preferences for initial greetings by their health care professionals. Additional explanation and detail are provided in the When-in-Doubt Training Tutorial (WID) provided next.

1. When possible, knock before entering an exam room and enter after receiving your patient’s permission. (WID 1)
2. Smile and make early eye contact with your patient. (WID 2)
3. Offer to shake hands with your patient. (WID 3)
4. Address your patient by name. (WID 4)
5. Introduce yourself by including your formal title, first, and last name. (WID 5)
6. Ask your patient what name he/she prefers to be called and be sure to note the preferred name and pronunciation into your records as a reference for future appointments. (WID 4)
7. Acknowledge and introduce yourself to those accompanying your patient (e.g., relative, significant other, or companion). (WID 5)

WHEN-IN-DOUBT Training Tutorial

WID 1. Avoid bursting into the examination room without warning. Remember Kramer’s entrances on Seinfeld? Don’t do that.

WID 2. Don’t be weird. Because inappropriate eye contact and other behaviors can creep us out, avoid glaring, staring, or standing too close to your patient during greetings. Eye contact in Western cultures is important. We often gauge the credibility, honesty, abilities, trust, and confidence of our medical professionals by their willingness to make eye contact and nonverbally express themselves. Research indicates delaying eye contact in clinical settings can reduce clinician credibility & patient satisfaction. If you want to find out how disturbing it can feel to experience inappropriate eye contact and expression, perform or think about the following behaviors.

Eye contact – Greet and hold a conversation with someone using the following approaches:

• No eye contact (look out of a window, observe a clock/your watch, a computer monitor, chart, etc.) while speaking
• Very brief, infrequent, or indirect eye contact (e.g., look at someone’s forehead)
• Gazing/staring too long
• Gazing/staring while standing too close

Expression – Greet someone with

• an exaggerated serious expression
• a smirk
• an exaggerated happy expression

What if Dr. Perry Cox from the television show “Scrubs” was your clinician? In his white coat, strolling in with his mandatory smirk and acid tongue, imagine Dr. Cox greeting you with a wisecrack about your condition. How would you respond? Would you be encouraged to provide him with details about your illness or share very personal medical or psychological concerns?

WID 3. Many studies report that patients like to shake hands with their practitioners. However, handshaking customs can differ based on a variety of cultural and religious practices as well as personal preferences (yours too). If you are comfortable with the custom, a good practice is to be prepared but not determined to shake your patients’ hands. Because research indicates that many patients desire to shake hands with their medical professionals, offering an extended hand to patients and allowing them to choose to accept your gesture can be a meaningful activity toward a positive connection to your patients. Most patients happily accept, but be aware and responsive to the nonverbal cues of a patient’s acceptance or hesitation to your gesture.

The technique for an appropriate handshake is also important. Handshakes should be relatively brief, firm, and avoid too much of anything (e.g., too aggressive, wimpy, long, or short). One strategy is to match the performance of the individual you are shaking hands with. This can be problematic however, if you are shaking hands with a competitive or aggressive person. A good action word to use as a guide for proper handshakes is to be “unremarkable.” If you are comfortable with the custom and it fits within the constraints of you practice, sample the following behaviors that clarify why the following approaches should be avoided.

Handshake – Greet a partner by shaking hands . . .

• too long
• too quick
• too firm
• feeble (ewww, dead fish – see video)

WID 4. Research clearly indicates that patients want to be identified by name. Findings regarding how physicians should address their patients are mixed based on patient’s gender, age, and culture, and range from patients preferring first-name-only to those favoring titles and surnames. So initially greeting patients by their first and last names and then asking them how they prefer to be addressed exhibits caring and consideration early in the relationship-building process. Also, if you go through the trouble of asking for your patients’ preferences, be sure to record and refer to your notes before greeting them in future visits.

WID 5. Patients report their desire for physicians to formally introduce themselves, either using their title, first and last names or title and last name. Patients also indicate their desire for physicians to greet and acknowledge family members and/or caregivers participating in appointments.

References

1. Malinowski, B. (1989). The problem of meaning in primitive languages. In C. K. Ogden & I. A., Richards [1923], The Meaning of Meaning (pp. 296-336). New York, NY: Harcourt Brace Jonvanovich.
2. Coulmas, F. (1981). Poison to your soul. In F. Coulmas (Ed.), Conversational routine (pp. 69-91). New York, NY: Mouton.
3. Laver, J. (1981). Linguistic routines and politeness in greeting and parting. In F. Coulmas (Ed.), Conversational routine (pp. 289-304). New York, NY: Mouton.
4. Senft, G. (2009). Phatic communion. In G. Senft, J. Ostman & J. Verschueren (Eds.), Culture and language use.

Bibliography

Amer, A. & Fischer, H. (2009). “Don’t call me ‘Mom’”: How parents want to be greeted by their pediatrician. Clinical Pediatrics, 48, 720-722.

Bergman, J. J., Eggertsen, S. C., Phillips, W. R., Cherkin, D. C., & Schultz, J. K. (1988). How patients and physicians address each other in the office. The Journal of Family Practice, 27, 399-402. Davis, R. L.,

Wiggins, M. N., Mercado, C. C., & O’Sullivan, P. (2007). Defining the core competency of professionalism based on the patient’s perception. Clinical and Experimental Ophthalmology, 35,51-54. doi:10.1111/j.14429071.2006.01383.x

Gillette, R. D., Filak, A., & Thorne, C. (1992). First name or last name: Which do patients prefer? Journal of the American Board of Family Practice, 5, 517-522.

Lill, M. M. , & Wilkinson, T. J. (2005). Judging a book by its cover: Descriptive survey of patients’ preference for doctors’ appearance and mode of address. BMJ: British Medical Journal (International Edition), 331,1526-1527.

Makoul, G., Zick, A., & Green, M. (2007). An evidence-based perspective on greetings in medical encounters. Archives of Internal Medicine, 167, 1172-1176.

Mckinstry, B. (1990). Should general practitioners call patients by their first names? British Medical Journal, 301, 795-796.

Wallace, L. S., Cassada, D. C., Ergen, W. F., & Goldman, M. H. (2009). Setting the stage: Surgery patients’ expectations for greetings during routine office visits. Journal of Surgical Research,157,91-95. doi: 10.1016/j.jss.2009.03.065