CONCEPTS, COMPONENTS & CONFIGURATIONS emergency medicine, education; interpersonal skills, education
Teaching the Art of Emergency Medicine The devaluation of interpersonal skills in medical education and practice has contributed to the current breakdown of the patient-physician relationship. The proliferation of medical technologies and the rise of the medical-industrial complex require even greater competency in these skills. No guidelines exist for teaching and~or evaluating interpersonal skills within emergency medicine residency programs. A written survey sent to all directors of allopathic emergency medicine residencies revealed large differences among programs in terms of quantity of formal teaching and specific formats used. A literature review demonstrates the direct impact of interpersonal skills on patient care and suggests methods for measuring proficiency in these skills. Elements of a core curriculum are proposed. [Rosenzweig S: Teaching the art of emergency medicine. Ann Emerg Med January 1991;20:71-76.] "Medicine is not only a science, but also the art of letting our own individuality interact with the individuality of the patient. '']
Steven Rosenzweig, MD Philadelphia, Pennsylvania From the Division of Emergency Medicine, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania. Received for publication February 9, 1990. Revisions received May 22, and July 25, 1990. Accepted for publication August 14, 1990. Address for reprints: Steven Rosenzweig, MD, Department of Emergency Medicine, Thomas Jefferson University Hospital, 11th and Walnut Streets, Philadelphia, Pennsylvania 19107.
INTRODUCTION The current growing crisis involving the relationship between patient and physician undermines our health care system. Public opinion polls reflect increasing dissatisfaction and distrust directed at physicians despite gains in technical ability.2, 3 The roots of this crisis are complex; they include forces beyond the control of the medical profession. However, they also include factors for which only physicians are responsible. For example, both professional and lay observers often cite the physician's own failure to communicate and empathize with patients. 4-6 Medicine in the United States has undergone enormous change during this past century. Two trends emerge as essential to the breakdown of the patient-physician relationship. The first is a combination of social forces that served to dehumanize the encounter between physician and patient. The second is the devaluation by institutionalized medicine of exactly those values and skills necessary to "rehumanize" the interaction between ill persons and their physicians. REVOLUTIONS IN MEDICAL CARE This century has witnessed two revolutions in medicine, each representing a strong, depersonalizing force.7, s The explosive proliferation of medical technologies drastically changed the content of the patient-physician encounter. Time previously devoted to speaking with and touching the patient is now spent interpreting test data and performing procedures. Furthermore, many of these routine procedures are in themselves humiliating to patients as they "expose their bodies, place themselves in undignified postures, and accept handling of their bodies including intrusions into orifices."9 The second revolution was the rise of the medical-industrial complex. The patient was forced out of the personal and secure atmosphere of the neighborhood practitioner's office and into an anonymous marketplace. Patient care was distributed among several unfamiliar, overscheduled primary providers and specialists. The ill person was transformed into a con-
102/71
Annals of Emergency Medicine
20:1 January 1991
TEACHING Rosenzweig
Physician Interpersonal Skills Presentations and considerations Acute grief reactions Financial and social impediments to care Problematic patients Repeaters Victims of violence Skills Communication Empathic listening Objectivity Pain management Problem resolution Self-control Self-resolution 1
~ J J J 3o J J
~
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45 40 35 to
J J
20 15
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4'0 FIGURE 1. Section 19 of the Emer-
'/J°OrOel Olljb~
gency Medicine Core Content of the American College of Emergency Physicians and American Board of Emergency Medicine.
%tieOteo%~, eOee4~
FIGURE 2. Distribution for frequen-
cies of formats used in teaching the art of emergency medicine.
sumer and the physician into a supplier, lo fostering an impersonal and litigious milieu. Nowhere are these impersonal elements as readily apparent as in the emergency department. The patientphysician encounter takes place between strangers and is dominated by tests and procedures that are invasive and often painful. The patient lies physically and emotionally exposed to a frightening and confusing environment in which insurance information and vital signs are often obtained simultaneously. Traditionally, the "art of medicine" addressed the necessary skills for surmounting obstacles to an effective patient-physician relationship. However, this period of transformation and depersonalization witnessed a devaluation of our art as the profession embraced more "scientific" standards. 11
MEDICINE: ART VERSUS SCIENCE We have come to view the science and the art of m e d i c i n e as com-
20:1 January 1991
prising two distinct sets of tasks. The former includes mastery of facts and technology necessary for diagnosing and treating the diseased body. Alternatively, the art of medicine is concerned with diseased persons. It has been said to include "taking histories, establishing rapport, achieving compliance with even the most unpleasant regimens, being sensitive to unspoken needs, providing empathic support, communicating effectively, and even getting paid after the illness.Ill2 The joining of scientific research to clinical practice emerged as the ideal of medical education reform at the turn of the century. 13,14 A new standard was set for practicing the science of medicine. The physician took on the role of "medical scientist" by mastering the rapid advances of the laboratory and applying "scientific method in the wards. The Flexner report provided the impetus to regulate and standardize curricula toward this goal. is Medical educators such as Shattuck recognized that the new, scientific curriculum neglected the pat i e n t - p h y s i c i a n r e l a t i o n s h i p . 16 Francis Peabody wrote in 1927 that "young graduates are too 'scientific' Annals of Emergency Medicine
and do not know how to take care of patients. 'q7 This was clearly not the intent of education reform. Flexner wrote that the sciences are an "inadequate" basis for medical practice, which also requires "specific preparation" in cultivating "insight" and "sympathy."15 Yet, in the ensuing decades, the art of medicine became virtually excluded from the canon of medical c u r r i c u l a , l e a v i n g to i n d i v i d u a l teachers the dispensation of occasional "pearls" and "intuitions" to the neophyte. CALL FOR E D U C A T I O N
REVISION The recognition of underdeveloped humanistic values and skills prompted educators to seek reforms in the way physicians are trained. The Association of American Medical Colleges called for special enhancement of students' "kindness, empathy, integrity, intellectual curiosity, and humaneness. ''18 Efforts were also made to effect change on the postgraduate level. The American Board of Internal Medicine mandated that verbal and nonverbal c o m m u n i c a t i o n skills of its candidates be evaluated directly. 19
72/103
TEACHING Rosenzweig
FIGURE 3. Distribution for direct
observation of residents while taking clinical histories or giving discharge instructions.
18 16
~ 14 ~ 12 £ 10 13.. "5 8 6
4
3 Educators among other primary specialty boards have called for the same.2O The recent recognition of emergency medicine as a primary board specialty c o n f i r m s the t e c h n i c a l competence of residency graduates. Yet, there has been a growing awareness of deficiencies in their interpersonal skills,~l, 2~ I N T E R P E R S O N A L SKILLS IN EMERGENCY MEDICINE The "Emergency Medicine Core Content" was developed in 1979 by the E d u c a t i o n C o m m i t t e e of the American College of Emergency Physicians, approved by the Society of Teachers of Emergency Medicine, and endorsed by the University Association for Emergency Medicine and the Emergency Medicine Residents Association. ~3 This document outlines the "central body of knowledge of emergency medicine" and delineates the "educational scope of postgraduate training and c o n t i n u i n g medical education." Section 19 of the revised Core Content 24 enumerates essential physician interpersonal skills as communication, empathic listening, objectivity, pain management, problem 104/73
resolution, self-control, self-resolution, understanding of acute grief reactions, alertness to financial and social impediments to care, managem e n t of problematic patients and repeaters, and special care for victims of violence (Figure 1). However, there are no published guidelines for teaching these skills within an emergency medicine residency. Furthermore, there are no standards for monitoring the success with which these skills are taught to residents. SURVEY OF EMERGENCY MEDICINE RESIDENCIES To assess the integration of this goal for competence in interpersonal skills into emergency medicine residency programs, a national survey was conducted. Methods A written survey (available on request) was sent to the 76 directors of allopathic emergency medicine residencies listed in the 1988-1989 Di-
rectory of Graduate Medical Education Programs. The first mailing was in January 1989, with a follow-up mailing four weeks later. The survey was sensitive to the Annals of Emergency Medicine
fact that i n t e r p e r s o n a l skills are taught in a variety of ways. The first part assessed the amount of formal instruction in these skills offered by each program. Information was requested regarding lectures, workshops, journal clubs, case conferences, research projects, incorporation of audiovisual aids, and use of role-playing techniques. Respondents also were asked to estimate the amount of direct observation and feedback offered by attendings to residents when taking a clinical h i s t o r y and w h e n g i v i n g discharge instructions. Recognizing the impact of the directors' own convictions on their respective programs, their beliefs were solicited regarding the impact of patient-physician c o m m u n i c a t i o n on treatment compliance, patient education, therapeutic outcome, and malpractice risk to the physician. Their opinions were explored regarding the uniqueness of communication in the ED and as to whether communication skills can or should be studied or taught. The final part of the survey requested general identifying information. All data were entered into a microcomputer, and frequencies were determined using Systat software. Results A total of 54 of 76 program directors or designated faculty members (71%) responded. Respondents had practiced emergency medicine for 9 _+ 4 (mean _+ SD) years and had been involved in academic medicine for 8 _+ 4 years. Classroom instruction per program per year was quantified (Figure 2). There was a mean number of three lectures (range, none to 50); 65% of programs offered at least one lecture. There was a mean number of 0.5 workshops (range, 0 to 12); 24% of programs offered at least one workshop. The mean number of journal club articles was 2.7 (range, 0 to 56); 57% of programs reviewed at least one article. A mean of 11.8 problempatient case conferences was given (range, 0 to 100); 72% of programs made use of this format. 20:1 January1991
TEACHING Rosenzweig
One program offered no classroom instruction. Four programs used a lecture format exclusively, ranging between two and six per year. Six programs used only problem-patient case conferences, giving between one and 52 per year. Regarding bedside instruction, estimates were obtained of the percentage of cases in which residents were directly observed and critiqued when taking a clinical history or giving discharge instructions (Figure 3). There were m e a n s u p e r v i s i o n rates of 15.4% for history taking (range, 0% to 75%) and 14.7% (range, 0% to 100%) for giving discharge instructions. Two programs reported no supervision of history taking or instruction giving. Forty-three percent of programs reported supervision rates of 5% or less. Fifteen percent of programs used audiovisual aids; 26% used role-playing techniques. Seventeen percent reported completed or ongoing research projects relevant to the physicianpatient interpersonal dynamics. Respondents expressed their beliefs regarding the impact of patientphysician communication on a variety of factors. N i n e t y - s i x percent agreed (41% strongly agreed) that the success or failure of this communication determines patient compliance. N i n e t y - t h r e e p e r c e n t agreed (7% strongly agreed) that it determines therapeutic outcome. N i n e t y - f o u r percent agreed (63% strongly agreed, and 5% strongly disagreed) that it determines malpractice risk for the physician. Ninety-eight percent agreed (37% strongly agreed) that it determines patient education. Eighty-nine percent believed that patients and physicians communicate in a unique way in the ED. Of this last group, 92% believed that these unique features could be studied and taught. In general, 98% agreed (35% strongly agreed) that c o m m u n i c a t i o n skills s h o u l d be studied and taught.
THE SCIENCE OF O U R ART: MEASURING OUTCOMES Bridging the gap between patient and physician means bridging the gap between the art of emergency medicine and the science of emergency medicine. The first step is a clearheaded philosophy that recognizes the interdependence of art and science. The second step is the applica20:1 January 1991
tion of scientific method to further elucidate that interdependence. The impact of our art on health care can be demonstrated objectively by measuring specific outcomes. The skillfulness of its practitioners can be directly observed and evaluated. Educational principles can be established empirically. Although few studies have actually been conducted within an ED, data can be tentatively generalized from other settings. Patients are seen more efficiently and more effectively when the art of emergency medicine is applied. Increased patient satisfaction and compliance can be clearly shown. Korsch and Francis prospectively studied 800 patient-physician interactions in a pediatric ED.ZS,26 They showed that s a t i s f a c t i o n and c o m p l i a n c e correlated with the physician's friendly attitude, capacity to communicate, and ability to meet the parent's expectation for information about the illness. These outcomes were independent of social class or educational background. The art of emergency medicine is time efficient. Both satisfaction and compliance were independent of actual time spent by the physician with the patient (range, less than three minutes to more than 15 minutes). This challenges the erroneous assumption that the pace of a busy ED does not allow for a satisfactory interaction between physician and patient. Waggoner et al offered a fiveminute exit interview to cystitis patients in their ED and observed a significant increase in compliance. 27 Bertakis demonstrated that a fiveminute exit interview in a primary care setting significantly increased patient i n f o r m a t i o n r e t e n t i o n and satisfaction. 28 A direct impact on therapeutic outcome has been shown. Egbert et al studied 97 patients undergoing elective laparotomy. 29 The experimental group received nonroutine information concerning the severity of postoperative pain they were to expect, reassurance as to what was "normal" pain, and encouragement to relax w h e n having pain. They showed a reduction in narcotics use and an earlier discharge rate (mean time to discharge, 2.7 days) compared with controls. Inui et al achieved significant medication compliance and blood pressure control among clinic hypertensives when physicians adAnnals of Emergency Medicine
dressed patients' beliefs about their illness.30 Malpractice liability is another important outcome. Poor communication between physician and patient may be the one most important risk factor for being sued. 31-34 EVALUATING PROFICIENCY The skills with which we practice our art can be objectively critiqued and rigorously taught. The clinical interview is a complex process involving strategy, negotiation, 3s and psychodynamic intervention. 36-38 The structure and conditions of the interview in the ED require special skills.39, 4° Studies of the interview process have revealed i m p o r t a n t information. Platt and M c M a t h observed 300 interviews and found a high frequency of physician deficiencies. 37 Duffy et al found an inability among house officers to address psychosocial issues during the interview. 41 Beckman and Frankel showed that physicians interrupted patients' opening statements after an average of only 18 seconds, taking the earliest pieces of information to be the most important; 42 yet others have shown marked discrepancies between the initial complaint and the principal problem. 43-4s* Because patients tend not to spontaneously offer additional information once interrupted, a high control style can undermine the interview.37,42 We tend to u n d e r e s t i m a t e the amount of information that patients want from physicians during the interviews.ZS, 46 Although lower-class, more poorly educated patients are hesitant in asking questions, they desire the same information as upperclass, better-educated patients.47, 4s Often this diffidence is misconstrued as indifference. We also misjudge the amount and quality of information actually conveyed to the patient. Waitzkin found that doctors o v e r e s t i m a t e the amount of time devoted to giving information by a factor of nine. 48 The informing process is often muddled by unnecessary medical jargon and
*R Snyder, S Rosenzweig, unpublished data. We studied 100 ED encounters and found a 20% discordance between patient and physician formulations of the chief complaint. 74/105
TEACHING Rosenzweig
confounded by divergent cultural beliefs.25,4s-so
T E A C H I N G THE A R T T e a c h i n g the art of e m e r g e n c y m e d i c i n e is essential to t r a i n i n g " r e a l " physicians. A l t h o u g h the Emergency Medicine Core Content delineates key interpersonal skills, it does not define the "experiential and e d u c a t i o n a l m e a n s " n e c e s s a r y to teach these skills. Teaching these skills only by example is ineffectual. Kramer et al showed that a workshop approach to teaching interpersonal skills was superior to teaching these skills by preceptorship. 51 The survey results reveal the absence of any s t a n d a r d a p p r o a c h among allopathic emergency medicine residencies in either classroom or bedside teaching of these skills. They vary greatly in the share of the curriculum devoted to this subject; they also differ in the various formats that are used. Although there was a greater reliance on problem-patient case conferences, this may not be an effective means for teaching these skills. The survey was limited by certain factors. First, some use was made of subjective estimates. Second, 29% of programs failed to respond; it is unclear how the additional data would have affected the results. Third, some of the responses may have been open to interpretation. For example, one program reported 50 lectures per year devoted to interpersonal skills. It remains unclear whether these lectures addressed the topic exclusively. A follow-up study could analyze the content of lectures, workshops, journal discussions, and conferences. Insufficient data are available from which to derive the most effective curriculum, s2 However, several components seem essential. Role modeling. C o m m i t m e n t to the d e v e l o p m e n t of interpersonal skills must be exemplified and vocalized b y the director and f a c u l t y members. 53 The present survey reflects a general acceptance of the importance of these skills among the respondents. T h e s e skills m u s t be brought to the bedside as well as integrated into hallway case presentations. Formalized instruction. Instruction by precept alone is insufficient. This instruction may use lectures, workshops, or case conferences. 106/75
Observation and immediate feedback in the ED. Review and analysis of relevant data available in the literature. This is coupled with support for new investigations into patient-physician interactions specific to the ED. Attention to physicians' emotional responses to their interactions with patients. Our personal reactions have enormous impact on our ability to care for patients. 53-ss Opportunity must be provided for the resident to investigate and test the validity of these responses. We are exploring the impact of such a core curriculum in our residency program this year. It consists of an hour-long lecture introducing the philosophy of the patient-physician relationship as well as a literature review, a four-hour workshop in c o m m u n i c a t i o n skills, 56 an hourlong conference on the psychosocial issues of pain management in the ED, and a conference to review actual cases in which physician deficiency in interpersonal skills led to a poor outcome for the patient. There are informal, evening sessions each month that are facilitated by a professor of psychiatry; these sessions are devoted to exploring the residents' personal responses to clinical situations. We plan in the future to measure the impact of this curriculum on our residents' skills. SUMMARY Skillfulness in the art of emergency medicine enables us to treat patients more efficiently and effectively. It gains patient satisfaction and c o m p l i a n c e and thus reduces spurious malpractice claims. This "art" encompasses a set of interpersonal skills that can be defined, observed, measured, and taught. Emergency medicine residency programs are charged with the task of teaching these skills. The results of this survey reflect the absence of any standard approach; we conclude that we need one. REFERENCES i. AIbert Schweitzer. 2. Gibbs N: Doctors and patients: Image vs reality. Time July 31, 1989. 3. Shubat SC, Harvey LK: Public opinion on health care issues, 1989. A M A Surveys of Physician and Public Opiniorl on Health Care Issues 1989. Chicago, AMA, 1989. 4. Nelson AR: Humanism and the art of medicine: Our commitments to care. JAMA 1989;262:1228-1230.
Annals of Emergency Medicine
5. Krupat E: A delicate imbalance: Has modern medicine lost sight of the human element in healing? Psychology Today, November 1986. 6. Wallace A: Teaching the humane touch. The New York Times Magazine, December 21, 1986. 7. Eisenberg L: The search for care. Daedalus, Winter 1977, p 235-246. 8. Easterbrook G: The revolution in medicine. News week, January 26, 1987. 9. Lazare A: Shame and humiliation in the medical encounter. Arch Intern Med 1987;147:1653 1658. 10. Kleinman A: The Illness Narratives, ed 1. New York, Basic Books, 1988, p 218-219. 11. Stoeckle JD: Introductory comments, in Stoeckle JD led): Encounters Between Doctors and Patients, ed 1. Cambridge, Massachusetts, The MIT Press, 1987, p 91. 12. Cassell EJ: Talking with Patients, ed 1. Cambridge, Massachusetts, The MIT Press, vol 1, 1985, p 4. 13. Starr P: The Social Transformation of American Medicine, ed 1. New York~ Basic Books, 1982, p 115-116. 14. Ludmerer KM: Leanizlg to Heal: The Development of American Medical Education, ed 1. New York, Basic Books, 1985, p 102-108. 15. Flexner A: Medical education in the United States and Canada. Bull Carnegie Fmmd Adv Teach 1910; 4. Reprint: Buffalo, NY, The Heritage Press, 1973. 16. Shattuck GS: The science and art of medicine in some of their aspects. Boston Med Snrg J 1907;157: 63-6?. 17. Peabody FP: The care of the p a t i e n t . JAMA 1927;88:877-882. Reprinted in reference 11, p 387-401. 18. Association of American Medical Colleges: Physicians for the 21st century. J Med Eddic 1984;59(suppI). 19. American Board of Internal Medicine: Clinical corn petence in internal medicine. Ann Intern Med 1979; 90:402-411. 20. Numann PJ: Out greatest failure. A m J Surg 1988; 155:212-214. 21. Frumkin K: Residency training: The missing curricuium. Ann Emerg Med 1990;19:153-154. 22. McCann J: After residency training, what next? Emerg Med News September 9, 1989; XI:32. 23. Graduate/Undergraduate Education Committee of the American College of Emergency Physicians: Emergency medicine core content. JACEP 1979;8:58-65. 24. Special Committee on the Core Content Revision: Emergency medicine core content. Ann Emerg Med 1986;15:853-863. 25. Korsch BM, Gozzi EK, Francis V: Gaps in doctorpatient communication: Doctor-patient interaction and patient satisfaction. Pediatrics 1968;42:855-871. 26. Francis V, Korsch BM, Morris MJ: Gaps in doctorpatient communication: Patients' response to medical advice. N Engl J Med 1969;280:535-540. 27. Waggoner DM, Jackson EB, Kern DE: Physician influence on patient compliance: A clinical trial. Ann Emerg Med 1981;10:348-352. 28. Bertakis KD: The communication of information from physician to patient: A method for increasing patient retention and satisfaction. J Faro Pract 1977; 5:217-222. 29. Egbert LD, Battit GE, Welch CE, et al: Reduction of postoperative pain by encouragement and instruction of patients. N ErlgI J Med 1964;270:825-827. 30. Inui TS, Yourtee EL, Williamson JW: Improved outcomes in hypertension after physician tutorials. Ann Intern Med 1976;84:646-651. 31. Valente CM, Antlitz AM, Boyd MD, et al: The importance of physician-patient communication in reducing medical liability. Md Med J 1988;37:75-78. 32. Rogers JT, Blair PJ: Physician-patient communication. foresight January 1989. 33. Vaccarino JM: Malpractice: The problem in perspective. JAMA i977;238:861-863.
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34. Winslow R: Sometimes talk is the best medicine. Wall Street Journal, October 6, 1989. 35. Bernarde MA, Mayerson EW: Patient-physician ne gotiation. JAMA 1978;239:1413-1415. 36. Buchsbaum DG: Reassurance reconsidered. Sac Sci Med 1986;23:423-427. 37. Platt FW, McMath JC: Clinical hypocompetenee: The interview. Ann Intern Med 1979;91:898-902. 38. Cousins'N: The physician as communicator. JAMA 1982;248:587-589. 39. Flomenbaum N, Goldfrank L: Emergency department medical history: Principles and techniques. Hasp Phys June 1981;17. 40. Gordon GS~ Silverstien S: Ischemic heart disease, in Rosen P, Baker FJ, Barkin RM, et al (eds): Emergency Medicine: Concepts and Clinical Practice, ed 2. St Louis, CV Mosby Co, vol 2, 1988, p 1325-1327. 41. Duffy DL, Hammerman D, Cohen MA: Communication s k i l l s of house officers. A n n Intern Med 1980;93:354-357.
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42. Beckman HB, l~rankel RM: The effect of physician behavior on the collection of data. Ann Intern Med 1984;10i:692 696. 43. Burack RC, Carpenter RR: The predictive value of the presenting complaint. ] Faro Pract 1983;i6:749-754.
munication. Prim Care 1976;3:365-386. 50. Kleiuman A, Eisenberg L, Good B: Culture, illness, and care: Clinical lessons from anthropologic and crosscultural research. Ann Intern Med 1978~88:251-258.
44. Barsky AJ: Hidden reasons some patients visit doctors. Ann Intern Med 1981;94:492-498.
51. Kramer D, Bet R, Moore M: Impact of workshop on students ~ and physicians' rejecting behaviors in patient interviews. [ Med Educ 1987;62:904-910.
45. Cassell EJ: Talking with Patients, ed 1. Cambridge, Massachusetts, The MIT Press, vol 1, 1985, p 94-102.
52. Platt FW: Research in medical interviewing. Ann Intern Med 1981;94:405-407.
46. Waitzkin H: Doctor-patient communication: Clinical implications of social scientific research, lAMA 1984;252:2441-2446.
53. Gorlin R, Zucker HD: Physicians' reactions to patients. N EngI J Med 1983;308:1059-1063.
47. Cartwright A: Humazl Relations and Hospital Care, ed 1. London, Routledge and Kegan Paul, Ltd, 1964, p 192-194. 48. Waitzkin H, Stoeekle JD, Belier E, et aI: The infor~ mative process in medical care: A preliminary report with implications for instructional communication. Instruct Sci 1978;7:409-411. 49. Shuy R: The medical interview: Problems in cam-
Annals of Emergency Medicine
54. Talasferro E: Too stressed out to care? Ann Emerg Med 1989;18:1248-1249. 55. Osier W: Aequanimitas. Valedictory address, University of Pennsylvania, 1889. 56. The Miles Council for Physician-Patient Communication: The Miles Workshop on Physician-Patient Communication. This multi-media package is geared primarily for the office practitioner. Selected portions were found to be applicable to emergency medicine.
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Teaching the Art of Emergency Medicine The devaluation of interpersonal skills in medical education and practice has contributed to the current breakdown of the patient-physician relationship. The proliferation of medical technologies and the rise of the medical-industrial complex require even greater competency in these skills. No guidelines exist for teaching and~or evaluating interpersonal skills within emergency medicine residency programs. A written survey sent to all directors of allopathic emergency medicine residencies revealed large differences among programs in terms of quantity of formal teaching and specific formats used. A literature review demonstrates the direct impact of interpersonal skills on patient care and suggests methods for measuring proficiency in these skills. Elements of a core curriculum are proposed. [Rosenzweig S: Teaching the art of emergency medicine. Ann Emerg Med January 1991;20:71-76.] "Medicine is not only a science, but also the art of letting our own individuality interact with the individuality of the patient. '']
Steven Rosenzweig, MD Philadelphia, Pennsylvania From the Division of Emergency Medicine, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania. Received for publication February 9, 1990. Revisions received May 22, and July 25, 1990. Accepted for publication August 14, 1990. Address for reprints: Steven Rosenzweig, MD, Department of Emergency Medicine, Thomas Jefferson University Hospital, 11th and Walnut Streets, Philadelphia, Pennsylvania 19107.
INTRODUCTION The current growing crisis involving the relationship between patient and physician undermines our health care system. Public opinion polls reflect increasing dissatisfaction and distrust directed at physicians despite gains in technical ability.2, 3 The roots of this crisis are complex; they include forces beyond the control of the medical profession. However, they also include factors for which only physicians are responsible. For example, both professional and lay observers often cite the physician's own failure to communicate and empathize with patients. 4-6 Medicine in the United States has undergone enormous change during this past century. Two trends emerge as essential to the breakdown of the patient-physician relationship. The first is a combination of social forces that served to dehumanize the encounter between physician and patient. The second is the devaluation by institutionalized medicine of exactly those values and skills necessary to "rehumanize" the interaction between ill persons and their physicians. REVOLUTIONS IN MEDICAL CARE This century has witnessed two revolutions in medicine, each representing a strong, depersonalizing force.7, s The explosive proliferation of medical technologies drastically changed the content of the patient-physician encounter. Time previously devoted to speaking with and touching the patient is now spent interpreting test data and performing procedures. Furthermore, many of these routine procedures are in themselves humiliating to patients as they "expose their bodies, place themselves in undignified postures, and accept handling of their bodies including intrusions into orifices."9 The second revolution was the rise of the medical-industrial complex. The patient was forced out of the personal and secure atmosphere of the neighborhood practitioner's office and into an anonymous marketplace. Patient care was distributed among several unfamiliar, overscheduled primary providers and specialists. The ill person was transformed into a con-
102/71
Annals of Emergency Medicine
20:1 January 1991
TEACHING Rosenzweig
Physician Interpersonal Skills Presentations and considerations Acute grief reactions Financial and social impediments to care Problematic patients Repeaters Victims of violence Skills Communication Empathic listening Objectivity Pain management Problem resolution Self-control Self-resolution 1
~ J J J 3o J J
~
J
~iiii
45 40 35 to
J J
20 15
/'eeturoa' Io
4'0 FIGURE 1. Section 19 of the Emer-
'/J°OrOel Olljb~
gency Medicine Core Content of the American College of Emergency Physicians and American Board of Emergency Medicine.
%tieOteo%~, eOee4~
FIGURE 2. Distribution for frequen-
cies of formats used in teaching the art of emergency medicine.
sumer and the physician into a supplier, lo fostering an impersonal and litigious milieu. Nowhere are these impersonal elements as readily apparent as in the emergency department. The patientphysician encounter takes place between strangers and is dominated by tests and procedures that are invasive and often painful. The patient lies physically and emotionally exposed to a frightening and confusing environment in which insurance information and vital signs are often obtained simultaneously. Traditionally, the "art of medicine" addressed the necessary skills for surmounting obstacles to an effective patient-physician relationship. However, this period of transformation and depersonalization witnessed a devaluation of our art as the profession embraced more "scientific" standards. 11
MEDICINE: ART VERSUS SCIENCE We have come to view the science and the art of m e d i c i n e as com-
20:1 January 1991
prising two distinct sets of tasks. The former includes mastery of facts and technology necessary for diagnosing and treating the diseased body. Alternatively, the art of medicine is concerned with diseased persons. It has been said to include "taking histories, establishing rapport, achieving compliance with even the most unpleasant regimens, being sensitive to unspoken needs, providing empathic support, communicating effectively, and even getting paid after the illness.Ill2 The joining of scientific research to clinical practice emerged as the ideal of medical education reform at the turn of the century. 13,14 A new standard was set for practicing the science of medicine. The physician took on the role of "medical scientist" by mastering the rapid advances of the laboratory and applying "scientific method in the wards. The Flexner report provided the impetus to regulate and standardize curricula toward this goal. is Medical educators such as Shattuck recognized that the new, scientific curriculum neglected the pat i e n t - p h y s i c i a n r e l a t i o n s h i p . 16 Francis Peabody wrote in 1927 that "young graduates are too 'scientific' Annals of Emergency Medicine
and do not know how to take care of patients. 'q7 This was clearly not the intent of education reform. Flexner wrote that the sciences are an "inadequate" basis for medical practice, which also requires "specific preparation" in cultivating "insight" and "sympathy."15 Yet, in the ensuing decades, the art of medicine became virtually excluded from the canon of medical c u r r i c u l a , l e a v i n g to i n d i v i d u a l teachers the dispensation of occasional "pearls" and "intuitions" to the neophyte. CALL FOR E D U C A T I O N
REVISION The recognition of underdeveloped humanistic values and skills prompted educators to seek reforms in the way physicians are trained. The Association of American Medical Colleges called for special enhancement of students' "kindness, empathy, integrity, intellectual curiosity, and humaneness. ''18 Efforts were also made to effect change on the postgraduate level. The American Board of Internal Medicine mandated that verbal and nonverbal c o m m u n i c a t i o n skills of its candidates be evaluated directly. 19
72/103
TEACHING Rosenzweig
FIGURE 3. Distribution for direct
observation of residents while taking clinical histories or giving discharge instructions.
18 16
~ 14 ~ 12 £ 10 13.. "5 8 6
4
3 Educators among other primary specialty boards have called for the same.2O The recent recognition of emergency medicine as a primary board specialty c o n f i r m s the t e c h n i c a l competence of residency graduates. Yet, there has been a growing awareness of deficiencies in their interpersonal skills,~l, 2~ I N T E R P E R S O N A L SKILLS IN EMERGENCY MEDICINE The "Emergency Medicine Core Content" was developed in 1979 by the E d u c a t i o n C o m m i t t e e of the American College of Emergency Physicians, approved by the Society of Teachers of Emergency Medicine, and endorsed by the University Association for Emergency Medicine and the Emergency Medicine Residents Association. ~3 This document outlines the "central body of knowledge of emergency medicine" and delineates the "educational scope of postgraduate training and c o n t i n u i n g medical education." Section 19 of the revised Core Content 24 enumerates essential physician interpersonal skills as communication, empathic listening, objectivity, pain management, problem 104/73
resolution, self-control, self-resolution, understanding of acute grief reactions, alertness to financial and social impediments to care, managem e n t of problematic patients and repeaters, and special care for victims of violence (Figure 1). However, there are no published guidelines for teaching these skills within an emergency medicine residency. Furthermore, there are no standards for monitoring the success with which these skills are taught to residents. SURVEY OF EMERGENCY MEDICINE RESIDENCIES To assess the integration of this goal for competence in interpersonal skills into emergency medicine residency programs, a national survey was conducted. Methods A written survey (available on request) was sent to the 76 directors of allopathic emergency medicine residencies listed in the 1988-1989 Di-
rectory of Graduate Medical Education Programs. The first mailing was in January 1989, with a follow-up mailing four weeks later. The survey was sensitive to the Annals of Emergency Medicine
fact that i n t e r p e r s o n a l skills are taught in a variety of ways. The first part assessed the amount of formal instruction in these skills offered by each program. Information was requested regarding lectures, workshops, journal clubs, case conferences, research projects, incorporation of audiovisual aids, and use of role-playing techniques. Respondents also were asked to estimate the amount of direct observation and feedback offered by attendings to residents when taking a clinical h i s t o r y and w h e n g i v i n g discharge instructions. Recognizing the impact of the directors' own convictions on their respective programs, their beliefs were solicited regarding the impact of patient-physician c o m m u n i c a t i o n on treatment compliance, patient education, therapeutic outcome, and malpractice risk to the physician. Their opinions were explored regarding the uniqueness of communication in the ED and as to whether communication skills can or should be studied or taught. The final part of the survey requested general identifying information. All data were entered into a microcomputer, and frequencies were determined using Systat software. Results A total of 54 of 76 program directors or designated faculty members (71%) responded. Respondents had practiced emergency medicine for 9 _+ 4 (mean _+ SD) years and had been involved in academic medicine for 8 _+ 4 years. Classroom instruction per program per year was quantified (Figure 2). There was a mean number of three lectures (range, none to 50); 65% of programs offered at least one lecture. There was a mean number of 0.5 workshops (range, 0 to 12); 24% of programs offered at least one workshop. The mean number of journal club articles was 2.7 (range, 0 to 56); 57% of programs reviewed at least one article. A mean of 11.8 problempatient case conferences was given (range, 0 to 100); 72% of programs made use of this format. 20:1 January1991
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One program offered no classroom instruction. Four programs used a lecture format exclusively, ranging between two and six per year. Six programs used only problem-patient case conferences, giving between one and 52 per year. Regarding bedside instruction, estimates were obtained of the percentage of cases in which residents were directly observed and critiqued when taking a clinical history or giving discharge instructions (Figure 3). There were m e a n s u p e r v i s i o n rates of 15.4% for history taking (range, 0% to 75%) and 14.7% (range, 0% to 100%) for giving discharge instructions. Two programs reported no supervision of history taking or instruction giving. Forty-three percent of programs reported supervision rates of 5% or less. Fifteen percent of programs used audiovisual aids; 26% used role-playing techniques. Seventeen percent reported completed or ongoing research projects relevant to the physicianpatient interpersonal dynamics. Respondents expressed their beliefs regarding the impact of patientphysician communication on a variety of factors. N i n e t y - s i x percent agreed (41% strongly agreed) that the success or failure of this communication determines patient compliance. N i n e t y - t h r e e p e r c e n t agreed (7% strongly agreed) that it determines therapeutic outcome. N i n e t y - f o u r percent agreed (63% strongly agreed, and 5% strongly disagreed) that it determines malpractice risk for the physician. Ninety-eight percent agreed (37% strongly agreed) that it determines patient education. Eighty-nine percent believed that patients and physicians communicate in a unique way in the ED. Of this last group, 92% believed that these unique features could be studied and taught. In general, 98% agreed (35% strongly agreed) that c o m m u n i c a t i o n skills s h o u l d be studied and taught.
THE SCIENCE OF O U R ART: MEASURING OUTCOMES Bridging the gap between patient and physician means bridging the gap between the art of emergency medicine and the science of emergency medicine. The first step is a clearheaded philosophy that recognizes the interdependence of art and science. The second step is the applica20:1 January 1991
tion of scientific method to further elucidate that interdependence. The impact of our art on health care can be demonstrated objectively by measuring specific outcomes. The skillfulness of its practitioners can be directly observed and evaluated. Educational principles can be established empirically. Although few studies have actually been conducted within an ED, data can be tentatively generalized from other settings. Patients are seen more efficiently and more effectively when the art of emergency medicine is applied. Increased patient satisfaction and compliance can be clearly shown. Korsch and Francis prospectively studied 800 patient-physician interactions in a pediatric ED.ZS,26 They showed that s a t i s f a c t i o n and c o m p l i a n c e correlated with the physician's friendly attitude, capacity to communicate, and ability to meet the parent's expectation for information about the illness. These outcomes were independent of social class or educational background. The art of emergency medicine is time efficient. Both satisfaction and compliance were independent of actual time spent by the physician with the patient (range, less than three minutes to more than 15 minutes). This challenges the erroneous assumption that the pace of a busy ED does not allow for a satisfactory interaction between physician and patient. Waggoner et al offered a fiveminute exit interview to cystitis patients in their ED and observed a significant increase in compliance. 27 Bertakis demonstrated that a fiveminute exit interview in a primary care setting significantly increased patient i n f o r m a t i o n r e t e n t i o n and satisfaction. 28 A direct impact on therapeutic outcome has been shown. Egbert et al studied 97 patients undergoing elective laparotomy. 29 The experimental group received nonroutine information concerning the severity of postoperative pain they were to expect, reassurance as to what was "normal" pain, and encouragement to relax w h e n having pain. They showed a reduction in narcotics use and an earlier discharge rate (mean time to discharge, 2.7 days) compared with controls. Inui et al achieved significant medication compliance and blood pressure control among clinic hypertensives when physicians adAnnals of Emergency Medicine
dressed patients' beliefs about their illness.30 Malpractice liability is another important outcome. Poor communication between physician and patient may be the one most important risk factor for being sued. 31-34 EVALUATING PROFICIENCY The skills with which we practice our art can be objectively critiqued and rigorously taught. The clinical interview is a complex process involving strategy, negotiation, 3s and psychodynamic intervention. 36-38 The structure and conditions of the interview in the ED require special skills.39, 4° Studies of the interview process have revealed i m p o r t a n t information. Platt and M c M a t h observed 300 interviews and found a high frequency of physician deficiencies. 37 Duffy et al found an inability among house officers to address psychosocial issues during the interview. 41 Beckman and Frankel showed that physicians interrupted patients' opening statements after an average of only 18 seconds, taking the earliest pieces of information to be the most important; 42 yet others have shown marked discrepancies between the initial complaint and the principal problem. 43-4s* Because patients tend not to spontaneously offer additional information once interrupted, a high control style can undermine the interview.37,42 We tend to u n d e r e s t i m a t e the amount of information that patients want from physicians during the interviews.ZS, 46 Although lower-class, more poorly educated patients are hesitant in asking questions, they desire the same information as upperclass, better-educated patients.47, 4s Often this diffidence is misconstrued as indifference. We also misjudge the amount and quality of information actually conveyed to the patient. Waitzkin found that doctors o v e r e s t i m a t e the amount of time devoted to giving information by a factor of nine. 48 The informing process is often muddled by unnecessary medical jargon and
*R Snyder, S Rosenzweig, unpublished data. We studied 100 ED encounters and found a 20% discordance between patient and physician formulations of the chief complaint. 74/105
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confounded by divergent cultural beliefs.25,4s-so
T E A C H I N G THE A R T T e a c h i n g the art of e m e r g e n c y m e d i c i n e is essential to t r a i n i n g " r e a l " physicians. A l t h o u g h the Emergency Medicine Core Content delineates key interpersonal skills, it does not define the "experiential and e d u c a t i o n a l m e a n s " n e c e s s a r y to teach these skills. Teaching these skills only by example is ineffectual. Kramer et al showed that a workshop approach to teaching interpersonal skills was superior to teaching these skills by preceptorship. 51 The survey results reveal the absence of any s t a n d a r d a p p r o a c h among allopathic emergency medicine residencies in either classroom or bedside teaching of these skills. They vary greatly in the share of the curriculum devoted to this subject; they also differ in the various formats that are used. Although there was a greater reliance on problem-patient case conferences, this may not be an effective means for teaching these skills. The survey was limited by certain factors. First, some use was made of subjective estimates. Second, 29% of programs failed to respond; it is unclear how the additional data would have affected the results. Third, some of the responses may have been open to interpretation. For example, one program reported 50 lectures per year devoted to interpersonal skills. It remains unclear whether these lectures addressed the topic exclusively. A follow-up study could analyze the content of lectures, workshops, journal discussions, and conferences. Insufficient data are available from which to derive the most effective curriculum, s2 However, several components seem essential. Role modeling. C o m m i t m e n t to the d e v e l o p m e n t of interpersonal skills must be exemplified and vocalized b y the director and f a c u l t y members. 53 The present survey reflects a general acceptance of the importance of these skills among the respondents. T h e s e skills m u s t be brought to the bedside as well as integrated into hallway case presentations. Formalized instruction. Instruction by precept alone is insufficient. This instruction may use lectures, workshops, or case conferences. 106/75
Observation and immediate feedback in the ED. Review and analysis of relevant data available in the literature. This is coupled with support for new investigations into patient-physician interactions specific to the ED. Attention to physicians' emotional responses to their interactions with patients. Our personal reactions have enormous impact on our ability to care for patients. 53-ss Opportunity must be provided for the resident to investigate and test the validity of these responses. We are exploring the impact of such a core curriculum in our residency program this year. It consists of an hour-long lecture introducing the philosophy of the patient-physician relationship as well as a literature review, a four-hour workshop in c o m m u n i c a t i o n skills, 56 an hourlong conference on the psychosocial issues of pain management in the ED, and a conference to review actual cases in which physician deficiency in interpersonal skills led to a poor outcome for the patient. There are informal, evening sessions each month that are facilitated by a professor of psychiatry; these sessions are devoted to exploring the residents' personal responses to clinical situations. We plan in the future to measure the impact of this curriculum on our residents' skills. SUMMARY Skillfulness in the art of emergency medicine enables us to treat patients more efficiently and effectively. It gains patient satisfaction and c o m p l i a n c e and thus reduces spurious malpractice claims. This "art" encompasses a set of interpersonal skills that can be defined, observed, measured, and taught. Emergency medicine residency programs are charged with the task of teaching these skills. The results of this survey reflect the absence of any standard approach; we conclude that we need one. REFERENCES i. AIbert Schweitzer. 2. Gibbs N: Doctors and patients: Image vs reality. Time July 31, 1989. 3. Shubat SC, Harvey LK: Public opinion on health care issues, 1989. A M A Surveys of Physician and Public Opiniorl on Health Care Issues 1989. Chicago, AMA, 1989. 4. Nelson AR: Humanism and the art of medicine: Our commitments to care. JAMA 1989;262:1228-1230.
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5. Krupat E: A delicate imbalance: Has modern medicine lost sight of the human element in healing? Psychology Today, November 1986. 6. Wallace A: Teaching the humane touch. The New York Times Magazine, December 21, 1986. 7. Eisenberg L: The search for care. Daedalus, Winter 1977, p 235-246. 8. Easterbrook G: The revolution in medicine. News week, January 26, 1987. 9. Lazare A: Shame and humiliation in the medical encounter. Arch Intern Med 1987;147:1653 1658. 10. Kleinman A: The Illness Narratives, ed 1. New York, Basic Books, 1988, p 218-219. 11. Stoeckle JD: Introductory comments, in Stoeckle JD led): Encounters Between Doctors and Patients, ed 1. Cambridge, Massachusetts, The MIT Press, 1987, p 91. 12. Cassell EJ: Talking with Patients, ed 1. Cambridge, Massachusetts, The MIT Press, vol 1, 1985, p 4. 13. Starr P: The Social Transformation of American Medicine, ed 1. New York~ Basic Books, 1982, p 115-116. 14. Ludmerer KM: Leanizlg to Heal: The Development of American Medical Education, ed 1. New York, Basic Books, 1985, p 102-108. 15. Flexner A: Medical education in the United States and Canada. Bull Carnegie Fmmd Adv Teach 1910; 4. Reprint: Buffalo, NY, The Heritage Press, 1973. 16. Shattuck GS: The science and art of medicine in some of their aspects. Boston Med Snrg J 1907;157: 63-6?. 17. Peabody FP: The care of the p a t i e n t . JAMA 1927;88:877-882. Reprinted in reference 11, p 387-401. 18. Association of American Medical Colleges: Physicians for the 21st century. J Med Eddic 1984;59(suppI). 19. American Board of Internal Medicine: Clinical corn petence in internal medicine. Ann Intern Med 1979; 90:402-411. 20. Numann PJ: Out greatest failure. A m J Surg 1988; 155:212-214. 21. Frumkin K: Residency training: The missing curricuium. Ann Emerg Med 1990;19:153-154. 22. McCann J: After residency training, what next? Emerg Med News September 9, 1989; XI:32. 23. Graduate/Undergraduate Education Committee of the American College of Emergency Physicians: Emergency medicine core content. JACEP 1979;8:58-65. 24. Special Committee on the Core Content Revision: Emergency medicine core content. Ann Emerg Med 1986;15:853-863. 25. Korsch BM, Gozzi EK, Francis V: Gaps in doctorpatient communication: Doctor-patient interaction and patient satisfaction. Pediatrics 1968;42:855-871. 26. Francis V, Korsch BM, Morris MJ: Gaps in doctorpatient communication: Patients' response to medical advice. N Engl J Med 1969;280:535-540. 27. Waggoner DM, Jackson EB, Kern DE: Physician influence on patient compliance: A clinical trial. Ann Emerg Med 1981;10:348-352. 28. Bertakis KD: The communication of information from physician to patient: A method for increasing patient retention and satisfaction. J Faro Pract 1977; 5:217-222. 29. Egbert LD, Battit GE, Welch CE, et al: Reduction of postoperative pain by encouragement and instruction of patients. N ErlgI J Med 1964;270:825-827. 30. Inui TS, Yourtee EL, Williamson JW: Improved outcomes in hypertension after physician tutorials. Ann Intern Med 1976;84:646-651. 31. Valente CM, Antlitz AM, Boyd MD, et al: The importance of physician-patient communication in reducing medical liability. Md Med J 1988;37:75-78. 32. Rogers JT, Blair PJ: Physician-patient communication. foresight January 1989. 33. Vaccarino JM: Malpractice: The problem in perspective. JAMA i977;238:861-863.
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42. Beckman HB, l~rankel RM: The effect of physician behavior on the collection of data. Ann Intern Med 1984;10i:692 696. 43. Burack RC, Carpenter RR: The predictive value of the presenting complaint. ] Faro Pract 1983;i6:749-754.
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47. Cartwright A: Humazl Relations and Hospital Care, ed 1. London, Routledge and Kegan Paul, Ltd, 1964, p 192-194. 48. Waitzkin H, Stoeekle JD, Belier E, et aI: The infor~ mative process in medical care: A preliminary report with implications for instructional communication. Instruct Sci 1978;7:409-411. 49. Shuy R: The medical interview: Problems in cam-
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54. Talasferro E: Too stressed out to care? Ann Emerg Med 1989;18:1248-1249. 55. Osier W: Aequanimitas. Valedictory address, University of Pennsylvania, 1889. 56. The Miles Council for Physician-Patient Communication: The Miles Workshop on Physician-Patient Communication. This multi-media package is geared primarily for the office practitioner. Selected portions were found to be applicable to emergency medicine.
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