Teaching medicine as a human experience: a patient-doctor relationship course for faculty and first-year medical students.

ACADEMIA

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Teaching Medicine as a Human Experience: A Patient-Doctor Relationship Course for Faculty and First-Year Medical Students William T. Branch, MD; Ronald A. Arky, MD; Beverly Woo, MD; John D. Stoeckle, MD; Donald B. Levy, MD; and William C. Taylor, MD

We developed a required, longitudinal course for first-year medical students that addressed the patient-doctor relationship. Our course linked understanding patients' experiences and perspectives on illness with listening to, talking with, and establishing a rapport with patients while obtaining their medical histories. Learning was enhanced by use of an interdisciplinary faculty and by small-group continuity and faculty mentoring. Our curriculum adapted problem-based, self-directed educational methods to convey medical humanism. We focused on bedside interviewing as the means for exploring patients' social, emotional, and ethical concerns. Annals of Internal Medicine. 1991;114:482-489. From Brigham and Women's Hospital, Massachusetts General Hospital, Beth Israel Hospital, and Harvard Medical School, Boston, Massachusetts; and Mt. Auburn Hospital, Cambridge, Massachusetts. For current author addresses, see end of text.

1 he patient-doctor relationship is an important aspect of patient care. A good relationship is essential for effective diagnosis and treatment (1, 2). It pledges the doctor to act for the welfare of the patient, which is the moral code of the profession. Practitioners and medical educators agree that medical students must acquire humanistic and interpersonal skills applicable to this relationship (3-13). However, uncertainty has persisted for decades about how to achieve this educational goal (4). In fact, as medicine becomes more specialized and medical care more driven by demands for accounting and efficiency (14-17), medical students devote more of their education to technical skills and patients complain that they are being treated impersonally (10). Difficulties reflecting these changes in the direction and organization of health care are growing and appear to be symptomatic of the weakening of the patientdoctor relationship (15-25). There is considerable concern within medicine about increased numbers of malpractice suits, fewer medical students entering primary care specialties, and discouragement among practicing physicians (23-31). If these trends are to be reversed, the most rewarding aspect of medicine, the humanistic aspect, needs to be strengthened (12, 13, 19). We address the issue of what can be done in medical education to enhance the humanistic and interpersonal skills of future physicians. We believe that strongly positive educational efforts that begin early and extend through medical school are needed. We describe an 482

initiative taken at Harvard Medical School that addressed this problem by instituting a 3-year, required, longitudinal course in the patient-doctor relationship. We describe in detail the crucial first year of this course, its goals and teaching strategies, its curriculum, and the development of its faculty. Evolution and Background In 1985, a pilot project—the New Pathway—introduced problem-based learning to Harvard Medical School (32). Before implementing the project, faculty committees examined all aspects of medical education, and one committee proposed a patient-doctor relationship course. Although several medical schools had instituted problem-based curricula, some of which emphasized the integration of psychological and social material into basic science tutorials (33-40), no medical school had developed a required course that solely addressed the patient-doctor relationship and began in and extended beyond the first year. Such a course became an integral component of the pilot New Pathway Project in Medical Education. In 1988, when elements of the New Pathway were adopted generally by the medical school, our course became required for all first-year students. Changes were needed to accommodate 130 medical students and more than 70 faculty members, but we preserved two important educational strategies. Patient-student contact begins early in medical school in our course, and we use small groups of faculty and students working together over time as the centerpiece of our educational efforts. Goals and Objectives Producing a more humanistic physician is the major goal of the patient-doctor course. We define a humanistic physician as one who understands patients as people and considers their psychological and social features in his or her assessments and treatments, who is compassionate and ethically sensitive, and who communicates compassion and sensitivity warmly and effectively to patients. A curriculum for achieving these goals must develop students' values, social perspectives, and interpersonal skills (32, 40, 41). As our efforts evolved, the faculty identified the underlying values that characterize the course. Students at times questioned whether there was a course "ideology." Did the faculty intend to make all students behave a certain way or adopt certain beliefs? Struggling with this issue, the faculty identified tolerance for others'

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beliefs as one basic value that they could espouse. An additional quality valued by the faculty is the ability to respectfully and compassionately understand patients' perspectives and their experiences with illness (3, 5, 11, 12, 18, 19). Consistent with these underlying values is an additional premise: Not only the content but also the process by which students learn is fundamentally important. We assume that learning about human relationships is closely tied to working with others, including one's peers in the course, the faculty, and the patients. Therefore, examining the process of learning in the course includes examining how students discuss content, how they talk to patients, and how they work with others. We build discussions of these processes into the curriculum of our course. The learning objectives of the course reflect its values and educational approach, as well as our choices of subjects best taught to first-year medical students. In the first-year curriculum, educational objectives (Table 1) link understanding the patient-doctor relationship to patient interviewing. Additional learning objectives of our first-year curriculum address health promotion and disease prevention, aspects of ethical and social sciences central to the patient-doctor relationship, and the ability to form a respectful working alliance with a group of peers and faculty. Educational Structure of the Course Planners assumed that mastering the humanistic aspects of medicine differs in important ways from traditional medical educational endeavors. Hence, our firstyear patient-doctor course includes educational elements that are traditionally not part of medical school courses.

Table 1. Educational Objectives for Students First-Year Patient-Doctor Course

in the

To be able to describe the types of relationships that develop between patients and physicians and to demonstrate understanding of the patient's perspective on illness and an understanding of how such perspectives affect patient care To be able to take a complete medical history, demonstrating skills in listening, establishing rapport, and collecting accurate data and to give an oral and written presentation of the information obtained To demonstrate understanding of principles of health promotion and disease prevention, with specific application to cigarette smoking, alcohol and substance abuse, and sexually transmitted diseases To demonstrate understanding of aspects of medical ethics and of the social sciences that are central to the patient-doctor relationship To form a respectful working alliance with a small group of peers and faculty as the basis for succeeding patient-doctor courses and future professional relationships

the group for the year. The process of learning about humanistic medicine occurs under faculty guidance in these groups; thus, students can continually examine and refine their beliefs, attitudes, and values in conjunction with other students and faculty. They learn to be supportive and to give honest, specific feedback to each other (42). They learn to resolve disagreements, and they learn from each other's experience. They become comfortable talking about deeply held values and beliefs (43). Experiential learning methods, using bedside interviews with patients and role plays with each other (13, 44), lead to close working relationships between students and faculty in the groups. Mentoring

The course is conducted by the medical school and is not within the domain of a single department. It has a director and four "fellows," each of whom coordinates educational activities for about 35 students and 18 faculty. Faculty currently come from the departments of medicine (50%), psychiatry (22%), pediatrics (19.5%), social medicine (6.1%), and surgery (2.4%). Basing the course centrally and drawing on an interdisciplinary faculty allows the use of ideas and expertise from multiple departments. This is appropriate because the patient-doctor relationship is not the exclusive domain of a single discipline or department. Neither the course director nor the fellows are required to be from any single department, although at present all are internists.

In the small groups, six to eight students relate to three faculty members. Each student, therefore, may find a mentor among these faculty, someone who will work closely with the student throughout the year, will guide the student's learning, and will be an advocate and advisor, as well as an example, to the student. The course thereby fosters a more collegial, personal working relationship than traditionally exists between students and teachers. The student, however, is not limited to relating to one faculty person, because there are several in the group. In addition to representing multiple departments, our faculty mentors range in age from about 30 to 60 years and in rank from instructor to full professor. Thirty-five percent of our faculty are women and 10% are minority faculty members. We consider personal, interpersonal, and professional qualities in selecting our faculty, who will strongly influence our students early in their medical careers.

Small-Group Continuity

Learning Medical Interviewing

In the course, students work in groups of six to eight. Each group meets for a two-hour session each week during the academic year, and each has three faculty, generally two clinicians (internists, pediatricians, or surgeons, or a combination thereof) and a behavioral scientist (social scientist or psychiatrist) who remain with

We find that making medical interviewing the focus of patient contact for first-year students is an effective educational strategy. We purposely introduce our students to patients in exercises in which talking with patients and understanding them as people experiencing illness are the initial learning objectives (18, 19). For the

Interdisciplinary Faculty

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first time in our curriculum, the medical interview—the chief activity of most caregivers (45) and the major medium for communication between patients and their physicians (46-48)—receives top priority in the learning process. Linking Tutorial Discussions with Interviewing Exercises Our strategy for teaching the course alternates clinical exercises involving bedside interviews of patients by students with tutorial sessions in which students and faculty discuss cases or selected readings from the literature. Thus, students can relate their discussions to the real patient contact that occurs in the interviews. In the interviewing exercise, students explore with patients a theme from the curriculum, for example, understanding the patients' explanatory models of illness (49, 50). This is one goal of the clinical exercise; other goals include gaining practice in taking the patient's history and learning interviewing techniques for establishing a rapport with patients (51). The following week, when the group meets for its tutorial discussion of the assigned theme (patients' explanatory models in this example), students can reflect on their actual experiences with patients (52). This format produces synergism between our curricular topics and the clinical skills being mastered by the students. As students master interviewing skills, they can simultaneously explore patients' relationships with their doctors (53), their adaptability to illness and treatment (54), and their life experiences of illness (18, 55, 56). Learning Methods Problem-based Learning in Tutorials Our tutorials use the problem-based approach pioneered by several medical schools as the most effective method for adult learners (33, 34, 57-60). Faculty using this method facilitate discussions in which students and faculty learn from each other by analyzing problems (61-65). Educational materials prepared for the course state the educational objectives of each exercise, suggest the format for the exercise, and include carefully selected published papers designed to require approximately 1 hour of reading per week from the students. Each session's material includes guiding questions that challenge students to discuss and analyze disparate viewpoints related to the goals of the session. The material supplies some factual information but chiefly seeks to stimulate independent thinking. Usually, students are allowed to set the agenda for discussion. Learning is fostered by defining terms and clarifying issues at the outset, by elaborating on important points in discussion, and by applying the learning to the practical task of interviewing (34, 59, 65). The written description of a clinical case designed to illustrate major points is the focus of most discussions, but, when advantageous, students are encouraged to substitute discussions of patients they have interviewed for the 4 'paper" case. Our faculty report that problem-based methods work 484

particularly well for learning about patient-doctor relationships. Students can explore and debate the thinking of others. Faculty contributions to discussions are based on their experience in caring for patients. In discussion, students can refine their values and become aware of their underlying attitudes toward patients. Learner-centered Interviewing Exercises Subgroups of one to four students with a faculty person interview patients. Within the format and overall educational goals of each exercise, students are asked to identify their personal goals and to explore with faculty ways for achieving these goals (13, 44). Students then receive concrete, usable feedback from faculty and other students about the extent to which their goals were met or need further work (42). As in problembased learning, the teacher is a guide or facilitator; the learner does the active work and expands his or her skills, knowledge, and understanding. Faculty Development Before teaching in the course, most of our faculty used didactic teaching methods, received little formal training in medical interviewing, and had not extensively examined the psychological and social dimensions of patients' illness experiences. Faculty development is essential to train these teachers to work with students in small groups that interview patients and examine these issues. Our faculty-development process includes two intensive day-long sessions, one in September before the course begins and the other in January or February; there are also three to five 2-hour sessions during the academic year. Faculty-development exercises group six to eight faculty with an experienced facilitator, someone familiar with the content of the course and with our educational methods. During a day-long session, this group stays together and addresses a series of exercises taken from the curriculum. Faculty learn topics in the curriculum and interviewing skills by doing the same tutorials and clinical exercises that they will later lead for the students. The facilitator creates a problem-based or learner-centered environment in which faculty can discover the nature of these teaching methods by experiencing and then analyzing them. In the small-group sessions with faculty, facilitators model the techniques for leading problem-based tutorials and then make explicit what these techniques are and how they work. Participants often negotiate a learning agenda for the session. Tutorial discussions begin open-ended, with questions that encourage participants' responses. Vigorous discussion with collaborative problem solving ensues (64). At critical times, the facilitator summarizes or asks for a consensus. By respectfully and attentively listening to each participant, the facilitator models the kinds of interactions between faculty and students that our course espouses (61). Facilitators also discuss group process and ask for feedback on their own work. Finally, we ask that facilitators critique each other and plan how to conduct future sessions, an essential strategy for conducting the course.



In interviewing exercises at faculty-development sessions, one member of the group usually interviews a consenting patient in the hospital for about 20 minutes (13). The facilitator and other group members observe the interview. Each participant may be assigned to give feedback on a particular goal identified before the interview as important to the interviewer. Such an approach involves everyone in the exercise. Sometimes more than one participant or a participant plus the facilitator may interview the patient. However, details such as these are negotiated by the group. Some general principles of this exercise include sticking to the negotiated plan to which everyone has agreed and treating the patient in a respectful, understanding way that models patient-physician interactions for our students (13). We believe that it is more important to maintain these principles for interactions than it is to complete an interview. After the interview exercise, participants give feedback to one another. The exercise includes a final phase for examining the learning process. The facilitator asks, How did the session go? What did you learn? Why? What made it work? Faculty-development sessions also influence personal interactions among faculty. Participants frequently comment that teaching in the patient-doctor course provides a rare opportunity for them to work with faculty from other departments or institutions. Many also comment that only in the patient-doctor course are their teaching and interviewing skills actually observed and do they receive first-hand feedback on teaching and interviewing that is given honestly and respectfully. Thus, faculty take home important lessons from both the facultydevelopment sessions and the course. The Curriculum The curriculum planners, who include the course director, the fellows, and faculty members with special expertise in the curriculum, choose the topics pertaining to patient-doctor relationships that are included in the first-year course and relate each topic to the structure and underlying themes of the course. Planners also endeavor to link our curriculum to the curriculum in basic sciences. The underlying themes of our curriculum are the patient's experience of illness, the doctor's experience of working with patients, and the use of the medical interview as a medium for understanding these themes. Revisions are made from year to year, but our overall curriculum, leaving out several sessions that address topics of special interest to the groups each year, can be outlined as follows. Relationships between Patients and Doctors The course begins with ''shared autobiographies," a session in which students and faculty in each group talk about themselves, their backgrounds, why they are in medical school, and the experiences that have influenced them. Students then '"shadow" their preceptors in the next session, giving them an opportunity to see what it is like to be a doctor and to get to know their preceptors. This "shadowing" is discussed by the group in their third session; and bedside interviewing is

introduced in the fourth session. The students' first interviewing assignment is simply to listen to the patient's "story" of illness. Our introduction to patient interviewing purposely avoids technical jargon and encourages students to relate to patients as people. Students discuss their feelings and concerns about beginning to talk with patients. The group addresses each step of the interview (how to introduce yourself, where to sit, how to begin) and afterwards the group shares experiences. This model for learning to interview continues throughout the course. Interviews are carefully planned, usually observed, and are followed by discussion and feedback sessions. In the discussion after the interviews, students share with each other problems encountered, solutions discovered, and questions about how to relate to patients. For example, a student may ask, Do you ever reveal your own feelings to your patients? Is it okay to ask about sensitive issues like sexuality? What do you do when a patient becomes upset or cries? Our first interview (obtaining the patient's "story") is paired with a tutorial discussion on the following week of the case of a medical student who describes what it was like to have a complicated fracture of the femur in adolescence, (Table 2) (66). The case is an example of how our curriculum correlates with that of basic sciences; when the discussion of this patient's experience occurs, students are studying the anatomy of the lower extremity. After this pair of sessions, the students, guided by the faculty in their small groups, next "invent the interview" by logically discovering the principles of historytaking and of forming relationships with patients. Subsequent exercises are patient interviews paired on the following weeks with tutorial discussions. In one pair of sessions, the interview explores the explanatory models of illness developed by patients and the tutorial discussion focuses on the relevance of patients' explanatory models to medical care (49, 50). In another pair, the interview explores the medical and social history in the context of the biopsychosocial model (67, 68) and the tutorial discussion focuses on home visits that students have made to patients on the recommendation of their preceptors. In this initial series of tutorials and exercises, students gradually add components of formal medical history-taking to their interviews. Although they lack knowledge of pathophysiology, they can explore a patient's illness history by asking open-ended questions, clarifying and checking a patient's statements, and learning to ask specific questions about a patient's problem such as, What makes your symptom worse? and What relieves it? After 10 weeks, students can complete the history of the present illness, as well as the past medical and social history of their patients (69). Enabling students to see illness from the different perspectives of patient and doctor sometimes hinges on discussing the students' experiences with illness. For example, students' personal experiences often come up in relation to the tutorial case of the young man with the fractured femur, someone with whom they can readily identify. As they talk about this case, students often naturally bring up their own, their friends', or



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Table 2. Examples of Cases Used in the Curriculum Case

Learning Objectives

Fractured femur A 16-year-old boy accidentally fractures his femur. His warm, caring family physician manages the case for months, but the fracture fails to heal. Surgery by a chief orthopedist is successful. This "small, fastidious man" talks tersely with the patient for 15 minutes on the day of his transfer. It is the single longest interaction that boy has with this physician during the time under his care* Chronic illness Afiercelyindependent 46-year-old woman with juvenile-onset diabetes mellitus complicated by retinopathy, angina, and severe peripheral vascular disease contemplates amputation of her left foot. Her doctor explores her dealing with repeated losses as a consequence of her disease. She asks the doctor to give her the courage to carry on.t Bereavement A mother comes for psychotherapy 3 months after her 19-year-old daughter, a bright college sophomore and a talented athlete, has died from acute leukemia. She speaks about her relationship with her daughter, the ordeal of the illness, its impact on her marriage, and her own profound grief.

To understand the patient's experience of illness To understand the patient-doctor relationship; to compare it with other relationships To apply these insights to student-patient interactions; to suggest approaches to make student interactions with patients comfortable and ethically justifiable

To understand how patients cope psychologically and physically with chronic illness To explore ways for physicians to provide support for their patients with chronic illness To examine attitudes toward terminal illness and death To consider the physician's role in caring for the dying patient To develop an understanding of bereavement—its stages, features, and recovery process^

* See Emond (66). t See Kleinman (18). $ See Gonda and Ruark (77) and Raphael (78).

their families' experiences with illness. The natural empathy that beginning medical students have for the sick is thereby encouraged. This occurs within a setting that also encourages some self-exploration and the sharing of feelings and concerns with fellow students.

like to be a patient. This is especially useful when the educational objectives of the exercise include dealing with sensitive topics in ways that respect a person's dignity and autonomy. Students can build on this background later in medical school when they address prevention through clinical epidemiology (70).

Introduction to Health Promotion and Disease Prevention Health-promotion topics that develop interviewing skills were chosen for our first-year course (70) and include helping smokers to quit (71), recognizing problem-drinking and alcoholism (72), and sexual historytaking and sexual counseling (69, 73). Each topic is covered by a tutorial discussion paired with an interviewing exercise. For example, the group discusses the videotape of a man with advanced chronic obstructive lung disease who talks about his efforts to quit smoking. This is paired with role plays for helping smokers to quit. Discussion of alcoholism developing in a nurse is paired with interviews with patients to determine their drinking patterns. Role plays of sexual history-taking and counseling are paired with interviews of patients to obtain their sexual histories. These exercises are planned so that students can put their interviewing skills into practice in concrete ways that may help patients. For example, the role plays of helping smokers to quit explore patients' personal motivations and barriers to quitting. The interviews with patients about alcohol use questions that confront patients' denial (72). Sexuality role plays include counseling an adolescent girl about ways to avoid unwanted pregnancy and uncovering the fears of a homosexual man about a sexually transmitted disease. The role plays allow students to feel what it may be 486

Chronic Illness, the Acquired Immunodeficiency Syndrome (AIDS), Death, and Dying Topics covered in the second semester of the course include chronic illness, AIDS, death, and dying. By this time, students have a background in interviewing, understanding illness, and exploring sensitive topics. We provide the opportunity for them to discuss in tutorials what it is like to be chronically ill, to have AIDS, or to be dying or bereaved (Table 2) (18, 74-78). Interviewing patients in these situations challenges students to observe respectfully and empathically what such patients go through. Interviews may be conducted in small groups of two to four students with a member of the faculty. It is not unusual for the patients to confide in the students. Many patients state that these interviews help them "to get things off [their] chest." In this way, we give students their first opportunity to listen to a patient with a serious or fatal illness under warmly humanistic conditions. Experienced faculty are present. There is sufficient time for the students to listen to the patients and, afterwards, to discuss their feelings about their patients. Students may learn from the exercise how much support they can give by listening empathically to patients who have a serious illness or are dying.



Additional Topics In the first year, we introduce two other topics that are covered in more depth in later years of the patientdoctor course, medical ethics (79) and health care financing (80-82). For ethics, we choose cases pertaining to students. For example, what if a student were asked to practice intubating a recently deceased patient, but the student realized that the patient or patient's family never gave permission for this procedure. Students are asked first how they might feel in the situation, and then how they might analyze the situation using ethical principles of beneficence, justice, and patient autonomy. For health financing, the patient-interviewing assignment is the detailed exploration with a patient of the costs of illness, including doctor and hospital bills, third-party payers, employment difficulties, and related issues. Assessment of Students' Performance Throughout the year our students are observed by faculty. They receive written feedback from faculty on case write-ups, which include psychosocial assessments of their patients. Regular attendance and participation in the discussions and patient interviews are required. In the final assessment exercise, students interview a simulated patient while they are observed by two faculty members. The faculty evaluate the content of the interview, the student's interviewing skills, and the exploration of topics deemed important in the curriculum (the patient's explanatory model of illness; cigarette smoking; alcohol abuse; sexuality; and the ethical, social, and financial issues that are built into the case). This assessment exercise models the type of patientstudent interactions that we aspire for students to achieve. The assessment thereby reinforces our goals while also ensuring that every student attains competency as a medical interviewer before the second year of medical school. The last tutorial held after the assessment exercise gives the group an opportunity to reflect on its experiences, to define future learning goals, and to say goodbye until the group works together again, as is planned in future years of the patient-doctor course. Discussion We seek to foster the humanistic qualities and interpersonal skills of future physicians by beginning medical education with a required longitudinal course that addresses the patient-doctor relationship. Our students learn to talk with patients in the context of exploring the patients' explanatory models, ethical dilemmas, financial difficulties, and ways of coping with illness. Understanding of the whole patient gained through the patient interviews and group discussions of key concepts becomes the cornerstone of clinical education for first-year students. Later, we envisage that students will build on this cornerstone as they progressively incorporate pathophysiology, more advanced skills, and clinical acumen into their approach to patients. The small-group process, in which students and fac-

ulty work together longitudinally, is the major vehicle for learning. The group process shapes the attitudes of the students toward patients and toward doctoring. We find that trust and limited self-disclosure develop in the groups. We believe that these foster the students' capacity for empathy and their understanding of both themselves and their patients. This introduces students to patient care in a context that explores and nourishes their sense of purpose and personal values. It has been said that perhaps only physicians who have been sick themselves can understand a sick person (22). We explore an alternative: By reflecting on and understanding our collective experiences, we may become more compassionate toward ourselves and our patients. Fostering humanistic values in our students requires humanizing the educational process itself (86-88). The relationships between students and faculty in our small groups, their discussions of values and attitudes, their opportunities to explore patients' experiences of illness, and the opportunities for the students to chart their own educational courses to some extent and to work with others in doing so are humanizing experiences for our students. Medical faculties seeking to implement our model may be daunted by the large number of teachers used in our course. Several points may alleviate their concerns. Group size could be somewhat larger than ours, although we think eight is an optimal number of students per group. A lower faculty-to-student ratio than we use, perhaps one to four, should be satisfactory. The course itself need not be excessively time-consuming for faculty. Indeed, many participating physicians comment that the course has revitalized their commitment to medicine and to teaching—a wonderful "side effect" of this project. Attesting to this, almost all of the faculty, who are paid little for teaching in the course, volunteer to continue. Students value the course. The annual survey in 19891990 conducted by the Committee on Educational Evaluation at Harvard Medical School revealed that the students believed their interviewing exercises and tutorial discussions were effective learning experiences (rated 1.5 and 1.7, respectively, on a scale of 1 being "very effective" and 5 being "ineffective" [average rating, all first-year courses: 1.9]). Some reported data suggest that medical graduates of innovative programs communicate better with patients and are better prepared to deal with patients' social and emotional problems than are graduates from traditional programs (89, 90). Investigators at Harvard Medical School are assessing the impact of our course on students; others are comparing graduates from the New Pathway Project with similar persons who were enrolled in the traditional curriculum from 1985 to 1988. Multiple studies at many institutions are desirable to assess the ways that courses like ours may influence students' attitudes, learning styles, and professional development (91). At present, we conclude that our students are studying important new topics in innovative ways and are learning to do many new things; most topics listed above previously received short shrift in our curriculum. Our course changes students' experiences in medical



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school and thus changes the medical educational process. We hope that some or all of its methods will help others to teach humanistic medicine in innovative ways at their institutions. Our experience in the patient-doctor course has been highly positive. We and the faculty get to know our students better, and we perceive some differences in these students when we compare them with those we previously taught. Our students appear to know themselves better, to be more purposeful, and, perhaps, to enjoy themselves more. We do not know if such apparent changes are transient or long-term. The same educational methods that we use for first-year students may be needed throughout medical school and beyond if medical education is going to be made more humanistic.

20. 21. 22. 23. 24.

25. 26. 27. 28.

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Acknowledgments: The authors thank those who helped organize and administer the course, especially Peg Hinrichs, Patricia McArdle, EdD, Luann Wilkerson, EdD, and Eleanor McLaughlin; and those persons who contributed to the New Pathway Project at Harvard Medical School that preceded the implementation of our course, especially J. Andrew Billings, MD, Susan Block, MD, Leon Eisenberg, MD, Allan Goroll, MD, Robert Lawrence, MD, and Gordon Moore, MD.

32.

Grant Support: In part by the Kaiser Family Foundation.

33.

Requests for Reprints: William T. Branch, Jr., MD, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.

34.

Current Author Addresses: Drs. Branch and Woo: Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115. Dr. Arky: Department of Medicine, Mt. Auburn Hospital, 300 Mt. Auburn Street, Cambridge, MA 02238. Dr. Stoeckle: Department of Medicine, Massachusetts General Hospital, Fruit Street, Boston, MA 02114. Dr. Levy: Department of Medicine, Mt. Auburn Hospital, Doctors Building, Suite 310, 300 Mt. Auburn Street, Cambridge, MA 02238. Dr. Taylor: Department of Medicine, Beth Israel Hospital, 330 Brookline Avenue, Boston, MA 02215.

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56. Reiser DE, Schroder AK. Patient Interviewing: the Human Dimension. Baltimore: Williams & Wilkins Co.; 1980:3-20. 57. Knowles MS. The Modern Practice of Adult Education: From Pedagogy to Androgogy. New York: The Adult Educational Company; 1980. 58. Barrows HS, Tamblyn RM. Problem-based Learning: An Approach to Medical Education. New York: Springer Publishing; 1980. 59. Barrows HS. Problem-based, self-directed learning. JAMA. 1983; 250:3077-80. 60. Lambie AT, McLean CM, McGuire RJ. The introduction of problem-based learning projects into a clinical correlation course in the first year of the Edinburgh medical curriculum. Med Education. 1981;15:209-15. 61. Brookfield SD. Understanding and Facilitating Adult Learning. San Francisco: Jossey-Bass; 1987. 62. Cross KP. Adults as Learners. San Francisco: Jossey-Bass; 1981. 63. Neufield VR, Barrows HS. Preparing medical students for lifelong learning. In: Andragogy in Action. Applying Modern Principles of Adult Learning. Knowles MS, et al., eds. San Francisco: JosseyBass; 1984:207-26. 64. McCormick D, Kahn M. Barnraising: Collaborative Group Process and Seminars. Cambridge, Massachusetts: Harvard Business School; 1985. Harvard Business School publication number 8-38625. 65. Schmidt HG. The rationale behind problem-based learning. In: New Directions for Medical Education. Schmidt HG, Lipkin M Jr., deVries MW, Greep JM, eds. New York: Springer-Verlag; 1989: 105-11. 66. Emond S. The case of the boy with the bad leg. In: Woo B, Levy D, Branch WT, et al. Patient/Doctor: A Guide. Boston: Harvard Medical School; 1989. 67. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196:129-36. 68. Engel GL. Care of the patient: art or science? In: Reiser DE, Rosen DH, eds. Medicine as a Human Experience. Rockville, Maryland: Aspen Publications; 1985:61-72. 69. Billings JA, Stoeckle JD. The Clinical Encounter: A Guide to the Medical Interview and Case Presentation. Chicago: Year Book Medical Publishers, Inc.; 1989:117-24. 70. Taylor WC, Pels RJ, Lawrence RS. A first-year problem-based curriculum in health promotion and disease prevention. Acad Med. 1989;64:673-7. 71. Stokes J 3d, Rigotti NA. The health consequences of cigarette smoking and the internist's role in smoking cessation. Adv Int Med. 1988;33:431-60. 72. Barnes HN, Aronson MD, Delbanco TL, eds. Alcoholism: A Guide for the Primary Care Physician. New York: Springer-Verlag; 1987: 3-25. 73. Kolodny RC. The medical and psychiatric perspectives on a

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15 M a r c h 1991 • Annals

of Internal

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489

Nursing faculty teaching a module in clinical skills to medical students: a Lebanese experience.

Evaluation of a Biomedical Informatics course for medical students: a pre-posttest study at UNAM Faculty of Medicine in Mexico.

A faculty-facilitated near-peer teaching programme: an effective way of teaching undergraduate medical students.

Effective Communication Barriers in Clinical Teaching among Malaysian Medical Students in Zagazig Faculty of Medicine (Egypt).

A group dynamics course for medical students.

Using feature films as a teaching aid with medical students.

Teaching psychosomatic medicine to medical students, residents and postgraduate fellows.

teaching in a physiology course for medical students: acceptance by students and subjective effect on learning.

Changing the culture of a medical school by orienting students and faculty toward community medicine.

Teaching ethics in family medicine: introducing a faculty handbook.

The Conversion of a Peer Teaching Course in the Puncture of Peripheral Veins for Medical Students into an Interprofessional Course.

Teaching Communication Skills to Medical and Pharmacy Students Through a Blended Learning Course.

Faculty development for learning and teaching of medical professionalism.

A clinical course on death and dying for medical students.

A learning skills course for the 1st year medical students: an experience at a Saudi medical school.

Influence of clinical experience and productivity on emergency medicine faculty teaching scores.

A review of teaching skills development programmes for medical students.

A new approach to teaching normal human growth and development. The role of clinical simulations as a teaching and evaluation device for preclinical medical students.

A mandatory course in scientific writing for undergraduate medical students.

Implementation of a comprehensive MR safety course for medical students.

Stress and adaptation in learning and practicing medicine : an elective course for medical students.

Team-based learning as a teaching strategy for first-year medical students.

Effectiveness of Revised Pharmacology Record Books as a Teaching-Learning Method for Second Year Medical Students.

Chest ultrasound integrated teaching of respiratory system physiology to medical students: a first experience.