Getting to know you

I ASKED my children what they thought I should choose as the subject for a new addition to my task list: this column. They were curious. Why was I asking the advice of those who have little interest in healthcare ethics and prefer to spend their time skateboarding and singing musical theatre songs? It was a legitimate question.

On reflection, the explanation was the significance of first impressions. The impression left by my debut mattered to me. Why do first impressions matter? I had found the subject for my first column.

Each initial encounter has an ethical dimension. Trust, sincerity, competence and commitment to service are inferred. Is this a doctor who can be relied upon? Does this dentist value shared decision-making? Will this consultant take the time to listen to patient concerns? Is this GP likely to make informed use of guidelines?

It is not just people who make a swift and often lasting impression. The state of the surgery, the clinic’s administrative systems, the types of written information available and the tone of notices on the wall all contribute to the patient’s perception of the environment. The new patient is making judgements from the moment he or she arrives. Those judgements are not insignificant. Indeed first impressions reflect the fundamentals of ethical practice.

Some readers by now will be protesting that first impressions are just that: impressions and perceptions. To infer that a clinician is trustworthy, competent and dedicated is not the same as it being indubitably proven. That may be so, but therapeutic relationships depend on fostering trust, confidence and rapport quickly. Without careful attention to those first impressions, patients will not confide in their doctors and dentists. First impressions are the gate to an effective therapeutic alliance.

When we think about a ‘good’ first impression and why it matters, we mirror different approaches to ethics. The person who believes that professionals should always present themselves in a particular way, irrespective of context or possible outcome, would make Immanuel Kant proud. A belief in universal principles or even rules reflects a deontological approach. In contrast, those who cite the effects of making a positive first impression are grounded in the consequentialist approach. There will be others who believe in the importance of character and emotion in professional practice and would take their place on the virtue ethics team.

Whilst locating the routine business of first impressions in the philosophical language of moral theory might, for some readers, be a novel way to pass a coffee break, it probably doesn’t matter why you believe that first impressions are important. The priority is simpler: it is to recognise and remember that first impressions are redolent with ethical meaning and opportunity.

Is it possible to describe what makes a ‘good’ first impression? Probably not definitively, although there may be consensus about core features and non-negotiable standards of behaviour at initial meetings. As someone who tends to line up in the virtue ethics queue, my vote goes to particular traits which will, when enacted, create an environment in which both professional and patient can flourish. Those traits include authenticity, openness, humility, compassion, respect and kindness. Others will have their own lists which may reference rules or focus on outcomes rather than characteristics.

What are yours? At the risk of leaving an impression of bossiness, take a minute to think about the first impressions you have left and made this week. What worked? What puzzled you? What felt uncomfortable or even wrong? Your answers reveal your ethical priorities and go to the heart of what it means to be a doctor or a dentist.

Medical ethics is often concerned with the grand, cutting edge moral dilemmas – euthanasia, cloning, abortion and gene therapy jostle for space in journals, on the news and at conferences. Yet, the most routine and unremarkable work of clinical practice is imbued with moral significance – nowhere more so than in the daily business of first impressions.

Deborah Bowman is a senior lecturer in medical ethics and law at St George’s, University of London