TY - JOUR
AU - USN, Cynthia Gray, MC
AB - ABSTRACT Using the proper greeting may be important to help establish rapport between health care providers and their patients. It may be particularly useful for family medicine physicians working in a military medical facility, where military rank and traditions are important. A total of 259 anonymous surveys were collected from patients treated at a military family medicine clinic. Most of the patients who completed the survey preferred to shake hands with their provider, be greeted using only their first name, and preferred that the provider introduce themselves using their last name only. Active duty patients were more likely than civilians to prefer a handshake (odds ratio [OR] 3.05, 95% confidence interval [CI] 1.46–6.39) and officers were more likely to prefer a handshake compared to enlisted service members (OR 3.29; 95% CI 1.18–9.20). Respondents who were older were more likely to prefer a formal introduction by their provider compared to respondents under 35 years old (OR 2.92, 95% CI 1.35–6.31). Although most patients in this facility expressed a preference for how they would like to be greeted, providers are still encouraged to ask their patients how they would prefer to be addressed. INTRODUCTION Physicians are regularly taught during their medical training the proper way to address patients at the initial meeting. Guidance on how to properly conduct the initial introduction is important because rapport is established within the first few minutes of the medical encounter.1 Communication skills and empathy, critical to rapport, are strongly influenced by initial provider–patient interactions.2,3 Studies in various medical settings and patient populations have shown that patients have preferences for how the physician should greet the patient and introduce themselves4,–11; however, there have been no studies conducted in a military medical setting, where military ranks and traditions may influence patients' preferences for how they are greeted. Family medicine clinics located in military treatment facilities include a combination of active duty military residents and active duty and civilian faculty members with varying degrees of military experience. Family medicine interns, who are relatively new to the military, and civilian staff members may have little understanding of the military culture and could potentially benefit from some recommendation or guidance on how to greet patients in a military setting. The purpose of this study is to describe patients' expectations during the greeting stage of medical visits in a military setting and to possibly provide some guidance for medical residents and physicians in this unique medical setting. METHODS Naval Hospital Camp Pendleton is a military treatment facility with a Family Medicine Department located on Marine Corps Base Camp Pendleton, California. The family medicine clinic serves a large Marine Corps population as well as a smaller Navy population that is assigned to Camp Pendleton in support of the Marine Corps and their family members. Self-completed, anonymous surveys were distributed at the family medicine clinic between July and November 2010. All patients over the age of 18 years presenting for care at the clinic were asked to complete the surveys before seeing their family medicine physician. Surveys were left in the waiting area with boxes available to deposit completed forms. The survey collected demographic information, and included questions adopted from a previously published survey.9 The instrument was based on prior assessments of communication skills with established psychometric properties of validity and reliability.12 The response choices for questions that asked preference for patient name and physician name were modified to include two additional options specific to military rank: “Rank only (e.g., “Lieutenant”)” and “Rank and last name (e.g., “Lieutenant Smith”).” Returning the survey constituted agreement to participate in the study. The protocol was granted approval by the Uniformed Services University and the Navy Medicine West Institutional Review Boards and was conducted in compliance with all applicable federal regulations governing the protection of human subjects in research (NHCP.2009.0110). Statistical analysis was performed using STATA Data Analysis and Statistical Software (StataCorp LP, College Station, Texas). Descriptive statistics and frequencies were computed to describe patient characteristics and expectations for greetings in a family medicine setting. Multiple regression analysis was used to determine the relationship between select demographic variables (age, gender, education, race, military affiliation, enlisted vs. officer, and military service) and patient preference for a formal or informal greeting. RESULTS There were 259 completed surveys available for analysis. Although more than 2,000 patients were seen in the clinic during the time the surveys were available, it was impossible to determine which patients noticed their availability and had the opportunity to complete a survey; therefore, it was impossible to determine a true response rate. The characteristics of the survey respondents are presented in Table I. Survey respondents tended to be under the age of 35 years, reported that either they or their sponsor were enlisted, and in the Marine Corps. Approximately half of respondents were active duty and the remainder were either family members or retired members. For the purpose of logistic regression analysis, age was dichotomized (under 35 years old vs. 35 years and older); education was categorized as college graduate vs. noncollege graduate; race/ethnicity was categorized as Caucasian vs. non-Caucasian; current military affiliation was categorized as active duty vs. family members and retirees; and branch was split into Marines vs. Navy and Air Force. TABLE I. Characteristics of Survey Respondents Characteristic  n = 259  %  Age   Under 35 Years  174  −67   35 or Over  85  −33  Sex   Female  151  −58   Male  108  −42  Education   Less Than a College Degree  201  −78   College or Advanced Degree  58  −22  Race/Ethnicity   Caucasian  162  −63   Non-Caucasian  97  −37  Military Status   Family Member OR Retiree  152  −59   Active Duty  107  −41  Rank of Self or Sponsor   Enlisted  228  −88   Officer  31  −12  Service Branch   Marine Corps  222  −86   Navy or Air Force  37  −14  Characteristic  n = 259  %  Age   Under 35 Years  174  −67   35 or Over  85  −33  Sex   Female  151  −58   Male  108  −42  Education   Less Than a College Degree  201  −78   College or Advanced Degree  58  −22  Race/Ethnicity   Caucasian  162  −63   Non-Caucasian  97  −37  Military Status   Family Member OR Retiree  152  −59   Active Duty  107  −41  Rank of Self or Sponsor   Enlisted  228  −88   Officer  31  −12  Service Branch   Marine Corps  222  −86   Navy or Air Force  37  −14  View Large TABLE I. Characteristics of Survey Respondents Characteristic  n = 259  %  Age   Under 35 Years  174  −67   35 or Over  85  −33  Sex   Female  151  −58   Male  108  −42  Education   Less Than a College Degree  201  −78   College or Advanced Degree  58  −22  Race/Ethnicity   Caucasian  162  −63   Non-Caucasian  97  −37  Military Status   Family Member OR Retiree  152  −59   Active Duty  107  −41  Rank of Self or Sponsor   Enlisted  228  −88   Officer  31  −12  Service Branch   Marine Corps  222  −86   Navy or Air Force  37  −14  Characteristic  n = 259  %  Age   Under 35 Years  174  −67   35 or Over  85  −33  Sex   Female  151  −58   Male  108  −42  Education   Less Than a College Degree  201  −78   College or Advanced Degree  58  −22  Race/Ethnicity   Caucasian  162  −63   Non-Caucasian  97  −37  Military Status   Family Member OR Retiree  152  −59   Active Duty  107  −41  Rank of Self or Sponsor   Enlisted  228  −88   Officer  31  −12  Service Branch   Marine Corps  222  −86   Navy or Air Force  37  −14  View Large At the initial visit, most patients reported that they wanted their provider to shake their hand (n = 159, 61%), greet them by their first name only (n = 129, 49%), and have the physician introduce themselves using their last name only (n = 80, 31%) (Table II). Multivariable logistic regression analyses, as shown in Table III, revealed that active duty respondents were three times more likely to prefer to shake hands with their providers (odds ratio (OR) 3.05, 95% confidence interval (CI) 1.46–6.39), and officers were three times more likely to prefer to shake hands compared to enlisted respondents (OR 3.29, 95% CI 1.18–9.21). No respondent characteristics were significantly associated with a preference for being greeted by first name at the initial visit. Only older respondents were more likely to express a preference for providers to use their last names in their introductions (Table III). TABLE II. Respondents' Preferences for Greeting at the Initial Family Medicine Encounter Greeting Preference  n = 259  %  Handshake   Yes  159  −61   No  43  −17   No Preference or Unsure  57  −22  Patient Name   First Name Only  126  −49   Last Name Only  36  −14   First and Last Name  17  −7   Rank Only  3  −1   Rank and Last Name  32  −12   No Preference or Unsure  45  −17  Provider Name   First Name Only  25  −10   Last Name Only  80  −31   First and Last Name  57  −22   Rank Only  0  0   Rank and Last Name  47  −18   No Preference or Unsure  50  −19  Greeting Preference  n = 259  %  Handshake   Yes  159  −61   No  43  −17   No Preference or Unsure  57  −22  Patient Name   First Name Only  126  −49   Last Name Only  36  −14   First and Last Name  17  −7   Rank Only  3  −1   Rank and Last Name  32  −12   No Preference or Unsure  45  −17  Provider Name   First Name Only  25  −10   Last Name Only  80  −31   First and Last Name  57  −22   Rank Only  0  0   Rank and Last Name  47  −18   No Preference or Unsure  50  −19  View Large TABLE II. Respondents' Preferences for Greeting at the Initial Family Medicine Encounter Greeting Preference  n = 259  %  Handshake   Yes  159  −61   No  43  −17   No Preference or Unsure  57  −22  Patient Name   First Name Only  126  −49   Last Name Only  36  −14   First and Last Name  17  −7   Rank Only  3  −1   Rank and Last Name  32  −12   No Preference or Unsure  45  −17  Provider Name   First Name Only  25  −10   Last Name Only  80  −31   First and Last Name  57  −22   Rank Only  0  0   Rank and Last Name  47  −18   No Preference or Unsure  50  −19  Greeting Preference  n = 259  %  Handshake   Yes  159  −61   No  43  −17   No Preference or Unsure  57  −22  Patient Name   First Name Only  126  −49   Last Name Only  36  −14   First and Last Name  17  −7   Rank Only  3  −1   Rank and Last Name  32  −12   No Preference or Unsure  45  −17  Provider Name   First Name Only  25  −10   Last Name Only  80  −31   First and Last Name  57  −22   Rank Only  0  0   Rank and Last Name  47  −18   No Preference or Unsure  50  −19  View Large TABLE III. Adjusted Odds of Preferences for Greetings at the Initial Family Medicine Encounter    Prefer Handshake  Prefer Greeting by Patient First Name  Prefer Introduction by Provider Last Name  OR  (95% CI)  OR  (95% CI)  OR  (95% CI)  Age   Under 35 Years  Reference  —    —     35 or Over  1.11  (0.56–2.19)  0.86  (0.45–1.66)  2.92  (1.35–5.31)  Sex   Female  Reference  —    —     Male  1.45  (0.70–3.01)  0.66  (0.34–1.32)  0.66  (0.30–1.41)  Education   Less Than a College Degree  Reference  —    —     College or Advanced Degree  0.83  (0.41–1.72)  0.67  (0.33–1.37)  1.28  (0.58–2.85)  Race/Ethnicity   Caucasian  Reference  —    —     Non-Caucasian  0.82  (0.46–1.45)  0.62  (0.36–1.09)  1.59  (0.87–2.94)  Military Status   Family Member or Retiree  Reference  —    —     Active Duty  3.05  (1.46–6.39)  0.58  (0.29–1.17)  1.25  (0.57–2.72)  Rank of Self or Sponsor   Enlisted  Reference  —    —     Officer  3.29  (1.18–9.21)  1.16  (0.45–3.03)  0.55  (0.21–1.50)  Service Branch   Marine Corps  Reference  —    —     Navy or Air Force  0.51  (0.23–1.11)  0.98  (0.45–2.13)  0.93  (0.40–2.22)     Prefer Handshake  Prefer Greeting by Patient First Name  Prefer Introduction by Provider Last Name  OR  (95% CI)  OR  (95% CI)  OR  (95% CI)  Age   Under 35 Years  Reference  —    —     35 or Over  1.11  (0.56–2.19)  0.86  (0.45–1.66)  2.92  (1.35–5.31)  Sex   Female  Reference  —    —     Male  1.45  (0.70–3.01)  0.66  (0.34–1.32)  0.66  (0.30–1.41)  Education   Less Than a College Degree  Reference  —    —     College or Advanced Degree  0.83  (0.41–1.72)  0.67  (0.33–1.37)  1.28  (0.58–2.85)  Race/Ethnicity   Caucasian  Reference  —    —     Non-Caucasian  0.82  (0.46–1.45)  0.62  (0.36–1.09)  1.59  (0.87–2.94)  Military Status   Family Member or Retiree  Reference  —    —     Active Duty  3.05  (1.46–6.39)  0.58  (0.29–1.17)  1.25  (0.57–2.72)  Rank of Self or Sponsor   Enlisted  Reference  —    —     Officer  3.29  (1.18–9.21)  1.16  (0.45–3.03)  0.55  (0.21–1.50)  Service Branch   Marine Corps  Reference  —    —     Navy or Air Force  0.51  (0.23–1.11)  0.98  (0.45–2.13)  0.93  (0.40–2.22)  Significance of bolded values is p < 0.05. View Large TABLE III. Adjusted Odds of Preferences for Greetings at the Initial Family Medicine Encounter    Prefer Handshake  Prefer Greeting by Patient First Name  Prefer Introduction by Provider Last Name  OR  (95% CI)  OR  (95% CI)  OR  (95% CI)  Age   Under 35 Years  Reference  —    —     35 or Over  1.11  (0.56–2.19)  0.86  (0.45–1.66)  2.92  (1.35–5.31)  Sex   Female  Reference  —    —     Male  1.45  (0.70–3.01)  0.66  (0.34–1.32)  0.66  (0.30–1.41)  Education   Less Than a College Degree  Reference  —    —     College or Advanced Degree  0.83  (0.41–1.72)  0.67  (0.33–1.37)  1.28  (0.58–2.85)  Race/Ethnicity   Caucasian  Reference  —    —     Non-Caucasian  0.82  (0.46–1.45)  0.62  (0.36–1.09)  1.59  (0.87–2.94)  Military Status   Family Member or Retiree  Reference  —    —     Active Duty  3.05  (1.46–6.39)  0.58  (0.29–1.17)  1.25  (0.57–2.72)  Rank of Self or Sponsor   Enlisted  Reference  —    —     Officer  3.29  (1.18–9.21)  1.16  (0.45–3.03)  0.55  (0.21–1.50)  Service Branch   Marine Corps  Reference  —    —     Navy or Air Force  0.51  (0.23–1.11)  0.98  (0.45–2.13)  0.93  (0.40–2.22)     Prefer Handshake  Prefer Greeting by Patient First Name  Prefer Introduction by Provider Last Name  OR  (95% CI)  OR  (95% CI)  OR  (95% CI)  Age   Under 35 Years  Reference  —    —     35 or Over  1.11  (0.56–2.19)  0.86  (0.45–1.66)  2.92  (1.35–5.31)  Sex   Female  Reference  —    —     Male  1.45  (0.70–3.01)  0.66  (0.34–1.32)  0.66  (0.30–1.41)  Education   Less Than a College Degree  Reference  —    —     College or Advanced Degree  0.83  (0.41–1.72)  0.67  (0.33–1.37)  1.28  (0.58–2.85)  Race/Ethnicity   Caucasian  Reference  —    —     Non-Caucasian  0.82  (0.46–1.45)  0.62  (0.36–1.09)  1.59  (0.87–2.94)  Military Status   Family Member or Retiree  Reference  —    —     Active Duty  3.05  (1.46–6.39)  0.58  (0.29–1.17)  1.25  (0.57–2.72)  Rank of Self or Sponsor   Enlisted  Reference  —    —     Officer  3.29  (1.18–9.21)  1.16  (0.45–3.03)  0.55  (0.21–1.50)  Service Branch   Marine Corps  Reference  —    —     Navy or Air Force  0.51  (0.23–1.11)  0.98  (0.45–2.13)  0.93  (0.40–2.22)  Significance of bolded values is p < 0.05. View Large Qualitative analyses of the open-ended question regarding additional preferences at first visit included these most frequent responses: smiling, being attentive and listening, and reviewing the medical record before the visit. DISCUSSION This is the first study to look at patient medical greeting preferences in a military medical facility. The results suggest that patients in a military treatment facility have some preferences for how they would like to be greeted. A majority of the patients prefer to be greeted with a handshake, nearly half of this population preferred to be greeted by their first name, and most patients preferred their providers introduce themselves in a more formal way, using the provider's last name. These data are similar to results from research conducted in civilian medical settings.4,–11 Previous research found that between 78.1% and 86.6% of respondents prefer to shake hands with their physicians and our study reports comparable numbers.4,11 Although most studies did not find a significant difference with respect to age, sex, education, and race/ethnicity, one study found that older patients are less likely to prefer a handshake compared to younger patients.11 In our patient population, we found that active duty military patients are more likely to prefer a handshake compared to family members or retirees. We also found that officers were more likely to prefer a handshake compared to enlisted respondents. Although our findings are consistent with other clinical studies, a recent survey found increasing hesitation among Americans to shake hands because of the infection concerns.13 Although providers may be cognizant of this concern and hesitate to greet their patients with a handshake, it may be useful to know that a handshake may still be preferred, especially by military officers. The introductory handshake can be a powerful tool for establishing rapport,14 and infection concerns may be mitigated by visible hand hygiene during other parts of a clinical encounter. Studies have found that the number of patients who prefer to be addressed solely by their first name ranges widely, from 45% to 96%,4,–11 with some differences noted by the race/ethnicity of patients. Our results were fairly consistent with past findings, although we identified no demographic characteristics, such as military status, sex, age, or race/ethnicity, associated with this preference. Our finding that nearly half of patients prefer that providers use patients' first names should not imply that such practice can be appropriately applied in all encounters. In contrast to patients' possible preference to be addressed informally by their provider, our study found that most patients treated in a military medical facility prefer to have their providers introduce themselves using a formal name (e.g., “Dr. John Smith” or “Dr. Smith”). The preference for a formal introduction of the providers' name is consistent with 2 studies that report that over half of respondents preferred that physicians introduce themselves using their first and last name or last name only.9,11 Although prior studies did not observe this preference varying across age and education strata, one study found that women and African Americans were more likely to prefer providers' first and last name.9 In our study, we found that older patients were more likely to prefer the formal introduction, when compared to respondents under 35 years old. It is possible that older patients are more accustomed to the formal introductions. The variability in these results suggests that patient preferences may be specific to the type of medical practice and the patient population. Other studies have found that cultural and language issues are critical to address when establishing provider–patient rapport.15,–17 Military health care providers must be cognizant of all such cultural and language differences, including the potentially unique culture of the military itself. Although this study did not find surprising differences in greeting preference, it may be useful for providers to be aware that between 10% and 20% of patients in this population prefer greetings that incorporate military rank. Identifying patients with such preferences can only be accomplished by respectful inquiry at the start of an encounter. Providers should also take into consideration other changes to their practice that could improve the overall experience of the initial medical meeting. Responses to the open-ended question in our study may provide insight into what is important to patients at the initial meeting. In our population, the most frequent answers to this question included requests to smile, be attentive and listen to the patient, and be knowledgeable of the patient's medical history before the visit. Other studies echo these findings, advising that providers adjust their vocabulary when explaining medical information to patients, be upfront and straightforward, be respectful, and make eye contact with their patients.9,11 The results of our study should be interpreted in light of several limitations. The study population was small and limited to a single military treatment facility providing care for Marine Corps and Navy service members and their families. Future studies may include primary care providers in military treatment facilities across all services. Our surveys were anonymous, therefore we do not know if those who completed the surveys are a representative sample of our population. Like all surveys, response bias may limit generalizability. Finally, while our survey asked patients to indicate a preference, we did not ask the intensity of their preference nor did we assess how provider greetings affected other measures of rapport. Despite these limitations, our study was novel in evaluating greeting preferences in the unique environment of a military treatment facility. This medical setting is an understudied population where strong traditions may influence preference for how patients would like to be greeted by their primary care providers at the initial visit. In addition, our methods used a slightly modified standard instrument used by previous studies, which allowed us to easily compare our findings to past studies. Future research will be valuable in continuing to address patient communication in the military and other settings. Such evaluations may be especially important as the range of primary care providers expands in Patient Centered Medical Home models of care, and as technology changes compel provider–patient rapport to be established and maintained through telephone, email, and text contact.18,19 CONCLUSIONS We conclude that many patients seen in a military treatment facility have a preference for how they would like to be greeted, and knowing these preferences may help primary care providers to establish rapport with their patients. Although some of the findings of this study, such as military officers' preference for handshakes, may be helpful to bear in mind, providers should still recognize that each patient is unique. It will always be good practice to respectfully ask each patient their preference for how they would like to be greeted. ACKNOWLEDGMENTS We thank Dr. Margaret Ryan from the Clinical Investigation Program at Naval Hospital Camp Pendleton for her invaluable guidance and advice in the preparation of this article. We appreciate the engagement of all the patients who completed questionnaires and all of the staff at Naval Hospital Camp Pendleton who collected these clinical data. REFERENCES 1. Barnett PB Rapport and the hospitalist. Dis.-Mon  2002; 48: 250– 9. Google Scholar CrossRef Search ADS PubMed  2. Anderson WG, Winters K, Arnold RM, Puntillo KA, White DB, Auerbach AD Studying physician-patient communication in the acute care setting: the hospitalist rapport study. Patient Educ Couns  2011; 82( 2): 275– 9. Google Scholar CrossRef Search ADS PubMed  3. Norfolk T, Birdi K, Walsh D The role of empathy in establishing rapport in the consultation: a new model. Med Educ  2007; 41( 7): 690– 7. Google Scholar CrossRef Search ADS PubMed  4. 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Mancuso JM, Manchester E, Zamborini L, et al.   Veteran satisfaction with RN voice-mail greeting. J Nurs Care Qual  2012; 27( 4): 325– 32. Google Scholar CrossRef Search ADS PubMed  Reprint & Copyright © Association of Military Surgeons of the U.S.
TI - Patient Greeting Preferences for Themselves and Their Providers in a Military Family Medicine Clinic
JF - Military Medicine
DO - 10.7205/MILMED-D-12-00360
DA - 2013-10-01
UR - https://www.deepdyve.com/lp/oxford-university-press/patient-greeting-preferences-for-themselves-and-their-providers-in-a-OznmcxycA0
SP - 1111
EP - 1114
VL - 178
IS - 10
DP - DeepDyve
ER -