THE’,WAY WE TEACH ...
Students to Care for Patients L. M. COMSTOCK and R. C.WILLIAMS
Med Teach Downloaded from informahealthcare.com by Queen's University on 01/03/15 For personal use only.
L. M . Comstock, M A , is Instructor and Chief Medical Social Worker, and R . C . Williams,Jr, MD, is Professor and Chairman, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA 871 3 1 .
T h i s article describes several techniques used at the University of New Mexico School of Medicine i n a n attempt to overcome the problem of dehumanization of young physicians i n training. Finding the use of questionnaires, interview evaluators and simulated patients insufficient, the authors developed a caring skills curriculum. Practical skills i n communication, understanding, listening a n d awareness are developed through a study programme utilizing videotapes, work-books, interrupted audiotapes and simulated patients. Fifty-two years ago Dr Francis Peabody maintained that “One of the essential qualities of the clinician is interest in humanity, for the secret of care for the patient is caring for the patient” (Peabody 1927). It is interesting that, even then - before the advent of respiratory machines, artificial kidneys and complicated diagnostic procedures -impersonalization and detachment had already a p parently crept into medical practice. During the medical school curriculum and, in particular, during the clinical years students undergo a subtle process of dehumanization: patients are treated as lists of problems (as in the Weed system) or regarded as diagnoses rather than as people.
How Does Dehumanization Occur? In discussing this general problem with medical students and housestaff, a number of factors have been alluded to as reasons for the dehumanization of young physicians in training. The first factor most frequently mentioned is the constraint allegedly imposed by time and schedule: the workup must be done, the chart updated, and the orders written in time for the morning report rounds by the attending physician or the surgical schedule. In fact, impersonalization would not disappear if more time were available for these activities, the problem being one of quality rather than quantity of care. Rapport with the patient can be established more effectively with a “Hello, how are you?” than with 20 minutes of impersonal discussion about a patient’s disease with the medical team 168
in the patient’s room. A second factor is the necessity some physicians feel to insulate themselves from the unpleasant realities of many human conditions. Nowhere is the physician’s detach ment as a means of self-protection or self-preservation better described than in Caroline Driver’s account of an attending physician’s withdrawal while her husband was dying of cancer (Driver 1973). Avoidance is protection, and one means of avoidance for the physician is to remain in his specialized role leaving the caring and concern for patients to other health professionals, such as social workers, aides or nurses. In this approach human responsibility is dispersed and no one really assumes direct care for the patient as a person. A third factor contributing to the depersonalization process is the societal pressure on physicians to ‘cure’. The young physician’s clumsiness and discomfort when faced with patients he cannot cure often causes him to intellectualize and detach himself from a patient. If a patient involves a doctor by confiding in him about his personal concerns or psychosocial needs, the doctor feels threatened because the ‘cure’ becomes more difficult. Approaches to Dehumanization At the University of New Mexico School of Medicine we have tried to overcome this malady in a number of ways and most recently by means of a caring skills curriculum designed to teach medical students and young physicians the rudiments of a positive approach to patients. The various approaches we used are described below.
The Questionnaire Approach that Failed Groups of students were evaluated before and after participation in the caring skills curriculum described below, in an attempt to rate their performance from the viewpoint of the patient. This was done either by means of a written questionnaire or by a trained interview evaluator. We ran into some unexpected difficulties. First, when patients were interviewed at our affiliated veterans’ teaching hospital, many were loath to criticize
Medical Teacher V o l 2 N o 4 1980
their doctors or their health care for fear that they would lose their veterans’ benefits. Second, patients were not afwa? able to separate their feelings about the student from those about the rest of the medical team. T h i r d , and most important, we discovered that patients were $aiically reluctant to say anything derogatory about their a m d i n g students. Reasons given were that such corn. w t s were inappropriate so early in a student’s training, Q that they would prefer to f i l l in such evaluations at -e and to mail them to us at a later date. We, have, &erefore. learned that objective, reliable evaluations of -dents by patients are hard to come by a n d , therefore, i-om a practical standpoint cannot be utilized as a 3rimar-y data base for effective or meaningful student e\.aIua tions.
Med Teach Downloaded from informahealthcare.com by Queen's University on 01/03/15 For personal use only.
Trained Interview Evaluators and Simulated Patients
Another approach we have used is to train interview evaluators or faculty members to observe medical studentlpatient encounters and to evaluate directly the learner’s skill in communicating with t h e patient. (Evaluators were trained by observing the caring skills videotapes described below, studying the teaching booklets and discussing the material and concepts with the programme director .) This method probably comes closest to providing a measured degree of insight and useful feedback for the student or house officer. However, i t requires a tremendous commitment of faculty time and effort. I t also suffers from the nuances affecting any third -party evaluation process. What sometimes appears to a young student as an appropriate level of communication may seem awkward or off-base to a critical attending physician. An additional option we have explored at our institution is the use of simulated patients usually drawn from the ranks of secretaries, clerks. or ancillary support personnel within t h e medical centre. Such individuals can be trained to hide or unconsciously cloud their symptoms. They can also pick o u t specific difficulties which inexperienced students manifest in relating to their patients as human beings. Again, the faults of any such implicitly subjective system become readily apparent. Finally, the use of simulated patients can be expensive unless the institution is well supplied with highly motivated indi viduals willing 10 donate their services presumably for a good cause.
The Caring Curriculum Dissatisfied with the use of questionnaires, trained o b servers, or even simulated patients, we have developed a caring skills curriculum -caring skill being defined as the ability to communicate to the patient that he is being treated as a feeling human being. Aimed at medical students just entering their clinical years, the curriculum attempts to identify the positive features of good doctor/ patient interaction rather than penalizing the learners for blunders or awkwardness. So far, 4 8 third-year students have participated in the programme. Medical Teacher V o l 2 No 4 1980
This approach is structured around a series of four two-hour training sessions. T h e programme emphasizes verbal and non-verbal behaviours that manifest empathy with another person. Practical skills in communication. understanding, listening. and awareness are developed through a study programme utilizing videotapes, workbooks, interrupted audiotapes and simulated patients. At our institution a social worker teaches the course, though faculty staff and counsellors can also serve as course leaders. Specially trained personnel are not necessary because the course is self-instructional. Each session begins with a 10-minute film to demonstrate the caring skill in question. For example, one videocassette depicts an empathetic physician attending to his patient verbally and non-verbally . Workbooks are prepared to allow students to answer questions about the skill which had been demonstrated directly on the film. After general discussion, students participate in role playing with a simulated patient and receive immediate feedback on their caring skills. This feedback is supplemented by discussion and checklists (Figure I ) . At the end of the course students complete an evaluation sheet (Figure 2). To date, they have been uniformly enthusiastic about the curriculum. T h e effectiveness of the course is evaluated by administration of a patient -satisfaction questionnaire (as described above) to patients of students participating in the course, as well as to those from students in a control group. However, ab mentioned, the problem here was that patients were reluctant to say anything critical of their student physicians. In emphasizing the basic caring skills for non verbal and verbal behaviour. the student is reminded to knock before entering a patient’s room, look at the patient, maintain eye contact and shake hands at the beginning of every visit. In this way the student humanizes the interaction and allows the patient to feel that he is a central part of the relationship. In an article by Werner ct al (1976) one student reported how on his first day on the wards tagging along on rounds, he noticed that all the patients were looking at him and asking him questions rather than their doctors. He realized i t was because he was the only one looking at them rather than at the charts! Small-talk, such as: “You are looking better today”, “How was your night?”. “Was your family able to visit?” shows an interest in the patient as a person. This approach is emphasized as the caring skills are presented systematically to the students. Learners are also taught to listen effectively, using taped exchanges between physicians and patients. Developing the skill of listening is stressed as important in understanding the patient and relating to him. Students are taught to hear the meaning as well as t h e content of what the patient is saying. For example, o n videotape an inpatient recuperating from a myocardial infarction tells his physician “I’m bored here, I want to go home.” The patient may also be expressing anxiety about the many psychosocial pressures and concerns precipitated by his illness that can. in fact, hinder his recovery process. Acknowledging the patient’s concerns can enlist the patient’s support in dealing with problems that arise. We teach our learners that the skill of communicating 160
Med Teach Downloaded from informahealthcare.com by Queen's University on 01/03/15 For personal use only.
Figure 2 . Evaluation of the caring skills cumculum: part of the checkltjt completed by students.
and why, gives a patient an opportunity to take more responsibility for hidher own medical problems. In this way the patient becomes involved in the process and feels he can trust his physician. Good and bad examples of communication are shown to medical students on videotape. The caring skills curriculum may be given without specially trained personnel and it provides a high degree of teaching proficiency in a relatively short amount of time. The programme does not attempt to teach someone to care, but rather to acquire a skill that reflects caring behaviour. There is a tendency to assume that acquisition of a caring skill may be a complicated task that involves much time and energy. As a result, the caring function is often postponed for a more ‘appropriate’ time and place. In fact, the caring process should be examined, defined and taught at the beginning, and throughout, the medical experience.
Figure 1. Checklist used to rate student performance. References
honestly and openly with a confused, worried or angry patient can equalize the Letting a patient knowthe plans for his care, describing tests which are to be done, informing him when someone else is to see him 170
Peabody, F. W . , Thc care of the patient, Journal of the American Medical Association, 1927,88,877-882. Driver, C, What a dying man taught doctors about caring, Medzcal Econom2cs,1973, 81-86, Werner, E, R. and Karsch, B. M.,The vulnerability of the medical student: Dosthurnous oresentation of L. L. SteDhens’ ideas. Pedtatncs. 1976,57,’321.327. ‘
Medical Teacher V o l 2 N o 4 I980
Students to Care for Patients L. M. COMSTOCK and R. C.WILLIAMS
Med Teach Downloaded from informahealthcare.com by Queen's University on 01/03/15 For personal use only.
L. M . Comstock, M A , is Instructor and Chief Medical Social Worker, and R . C . Williams,Jr, MD, is Professor and Chairman, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA 871 3 1 .
T h i s article describes several techniques used at the University of New Mexico School of Medicine i n a n attempt to overcome the problem of dehumanization of young physicians i n training. Finding the use of questionnaires, interview evaluators and simulated patients insufficient, the authors developed a caring skills curriculum. Practical skills i n communication, understanding, listening a n d awareness are developed through a study programme utilizing videotapes, work-books, interrupted audiotapes and simulated patients. Fifty-two years ago Dr Francis Peabody maintained that “One of the essential qualities of the clinician is interest in humanity, for the secret of care for the patient is caring for the patient” (Peabody 1927). It is interesting that, even then - before the advent of respiratory machines, artificial kidneys and complicated diagnostic procedures -impersonalization and detachment had already a p parently crept into medical practice. During the medical school curriculum and, in particular, during the clinical years students undergo a subtle process of dehumanization: patients are treated as lists of problems (as in the Weed system) or regarded as diagnoses rather than as people.
How Does Dehumanization Occur? In discussing this general problem with medical students and housestaff, a number of factors have been alluded to as reasons for the dehumanization of young physicians in training. The first factor most frequently mentioned is the constraint allegedly imposed by time and schedule: the workup must be done, the chart updated, and the orders written in time for the morning report rounds by the attending physician or the surgical schedule. In fact, impersonalization would not disappear if more time were available for these activities, the problem being one of quality rather than quantity of care. Rapport with the patient can be established more effectively with a “Hello, how are you?” than with 20 minutes of impersonal discussion about a patient’s disease with the medical team 168
in the patient’s room. A second factor is the necessity some physicians feel to insulate themselves from the unpleasant realities of many human conditions. Nowhere is the physician’s detach ment as a means of self-protection or self-preservation better described than in Caroline Driver’s account of an attending physician’s withdrawal while her husband was dying of cancer (Driver 1973). Avoidance is protection, and one means of avoidance for the physician is to remain in his specialized role leaving the caring and concern for patients to other health professionals, such as social workers, aides or nurses. In this approach human responsibility is dispersed and no one really assumes direct care for the patient as a person. A third factor contributing to the depersonalization process is the societal pressure on physicians to ‘cure’. The young physician’s clumsiness and discomfort when faced with patients he cannot cure often causes him to intellectualize and detach himself from a patient. If a patient involves a doctor by confiding in him about his personal concerns or psychosocial needs, the doctor feels threatened because the ‘cure’ becomes more difficult. Approaches to Dehumanization At the University of New Mexico School of Medicine we have tried to overcome this malady in a number of ways and most recently by means of a caring skills curriculum designed to teach medical students and young physicians the rudiments of a positive approach to patients. The various approaches we used are described below.
The Questionnaire Approach that Failed Groups of students were evaluated before and after participation in the caring skills curriculum described below, in an attempt to rate their performance from the viewpoint of the patient. This was done either by means of a written questionnaire or by a trained interview evaluator. We ran into some unexpected difficulties. First, when patients were interviewed at our affiliated veterans’ teaching hospital, many were loath to criticize
Medical Teacher V o l 2 N o 4 1980
their doctors or their health care for fear that they would lose their veterans’ benefits. Second, patients were not afwa? able to separate their feelings about the student from those about the rest of the medical team. T h i r d , and most important, we discovered that patients were $aiically reluctant to say anything derogatory about their a m d i n g students. Reasons given were that such corn. w t s were inappropriate so early in a student’s training, Q that they would prefer to f i l l in such evaluations at -e and to mail them to us at a later date. We, have, &erefore. learned that objective, reliable evaluations of -dents by patients are hard to come by a n d , therefore, i-om a practical standpoint cannot be utilized as a 3rimar-y data base for effective or meaningful student e\.aIua tions.
Med Teach Downloaded from informahealthcare.com by Queen's University on 01/03/15 For personal use only.
Trained Interview Evaluators and Simulated Patients
Another approach we have used is to train interview evaluators or faculty members to observe medical studentlpatient encounters and to evaluate directly the learner’s skill in communicating with t h e patient. (Evaluators were trained by observing the caring skills videotapes described below, studying the teaching booklets and discussing the material and concepts with the programme director .) This method probably comes closest to providing a measured degree of insight and useful feedback for the student or house officer. However, i t requires a tremendous commitment of faculty time and effort. I t also suffers from the nuances affecting any third -party evaluation process. What sometimes appears to a young student as an appropriate level of communication may seem awkward or off-base to a critical attending physician. An additional option we have explored at our institution is the use of simulated patients usually drawn from the ranks of secretaries, clerks. or ancillary support personnel within t h e medical centre. Such individuals can be trained to hide or unconsciously cloud their symptoms. They can also pick o u t specific difficulties which inexperienced students manifest in relating to their patients as human beings. Again, the faults of any such implicitly subjective system become readily apparent. Finally, the use of simulated patients can be expensive unless the institution is well supplied with highly motivated indi viduals willing 10 donate their services presumably for a good cause.
The Caring Curriculum Dissatisfied with the use of questionnaires, trained o b servers, or even simulated patients, we have developed a caring skills curriculum -caring skill being defined as the ability to communicate to the patient that he is being treated as a feeling human being. Aimed at medical students just entering their clinical years, the curriculum attempts to identify the positive features of good doctor/ patient interaction rather than penalizing the learners for blunders or awkwardness. So far, 4 8 third-year students have participated in the programme. Medical Teacher V o l 2 No 4 1980
This approach is structured around a series of four two-hour training sessions. T h e programme emphasizes verbal and non-verbal behaviours that manifest empathy with another person. Practical skills in communication. understanding, listening. and awareness are developed through a study programme utilizing videotapes, workbooks, interrupted audiotapes and simulated patients. At our institution a social worker teaches the course, though faculty staff and counsellors can also serve as course leaders. Specially trained personnel are not necessary because the course is self-instructional. Each session begins with a 10-minute film to demonstrate the caring skill in question. For example, one videocassette depicts an empathetic physician attending to his patient verbally and non-verbally . Workbooks are prepared to allow students to answer questions about the skill which had been demonstrated directly on the film. After general discussion, students participate in role playing with a simulated patient and receive immediate feedback on their caring skills. This feedback is supplemented by discussion and checklists (Figure I ) . At the end of the course students complete an evaluation sheet (Figure 2). To date, they have been uniformly enthusiastic about the curriculum. T h e effectiveness of the course is evaluated by administration of a patient -satisfaction questionnaire (as described above) to patients of students participating in the course, as well as to those from students in a control group. However, ab mentioned, the problem here was that patients were reluctant to say anything critical of their student physicians. In emphasizing the basic caring skills for non verbal and verbal behaviour. the student is reminded to knock before entering a patient’s room, look at the patient, maintain eye contact and shake hands at the beginning of every visit. In this way the student humanizes the interaction and allows the patient to feel that he is a central part of the relationship. In an article by Werner ct al (1976) one student reported how on his first day on the wards tagging along on rounds, he noticed that all the patients were looking at him and asking him questions rather than their doctors. He realized i t was because he was the only one looking at them rather than at the charts! Small-talk, such as: “You are looking better today”, “How was your night?”. “Was your family able to visit?” shows an interest in the patient as a person. This approach is emphasized as the caring skills are presented systematically to the students. Learners are also taught to listen effectively, using taped exchanges between physicians and patients. Developing the skill of listening is stressed as important in understanding the patient and relating to him. Students are taught to hear the meaning as well as t h e content of what the patient is saying. For example, o n videotape an inpatient recuperating from a myocardial infarction tells his physician “I’m bored here, I want to go home.” The patient may also be expressing anxiety about the many psychosocial pressures and concerns precipitated by his illness that can. in fact, hinder his recovery process. Acknowledging the patient’s concerns can enlist the patient’s support in dealing with problems that arise. We teach our learners that the skill of communicating 160
Med Teach Downloaded from informahealthcare.com by Queen's University on 01/03/15 For personal use only.
Figure 2 . Evaluation of the caring skills cumculum: part of the checkltjt completed by students.
and why, gives a patient an opportunity to take more responsibility for hidher own medical problems. In this way the patient becomes involved in the process and feels he can trust his physician. Good and bad examples of communication are shown to medical students on videotape. The caring skills curriculum may be given without specially trained personnel and it provides a high degree of teaching proficiency in a relatively short amount of time. The programme does not attempt to teach someone to care, but rather to acquire a skill that reflects caring behaviour. There is a tendency to assume that acquisition of a caring skill may be a complicated task that involves much time and energy. As a result, the caring function is often postponed for a more ‘appropriate’ time and place. In fact, the caring process should be examined, defined and taught at the beginning, and throughout, the medical experience.
Figure 1. Checklist used to rate student performance. References
honestly and openly with a confused, worried or angry patient can equalize the Letting a patient knowthe plans for his care, describing tests which are to be done, informing him when someone else is to see him 170
Peabody, F. W . , Thc care of the patient, Journal of the American Medical Association, 1927,88,877-882. Driver, C, What a dying man taught doctors about caring, Medzcal Econom2cs,1973, 81-86, Werner, E, R. and Karsch, B. M.,The vulnerability of the medical student: Dosthurnous oresentation of L. L. SteDhens’ ideas. Pedtatncs. 1976,57,’321.327. ‘
Medical Teacher V o l 2 N o 4 I980
