The year 2000 will likely be remembered in medical history for the mapping of the first draft of the human genome. But for many medical educators teaching tomorrow’s doctors, the focus today is not on new technologies, drugs and discoveries. Instead, they say, the emphasis is on empathy.
Teaching empathy, effective communication and caring is not new to medical schools, but those topics are getting more attention and more space in medical school curriculums in the 21st Century.
In fact, the National Board of Medical Educators plans to add a doctor-patient communication component to what is now a computer-only licensing test sometime next year. Add an increasingly diverse population, combined with a rise in medical malpractice suits and a growing sensitivity to patients’ needs, and schools have seen enough signals to know it’s time to teach doctors to talk — and to listen.
“Twenty years ago only 35 percent of medical schools had explicit communications skills classes,” says Dr. Mack Lipkin, professor of medicine and director of the division of primary care at the New York University School of Medicine in Manhattan.
Today, the Association of American Medical Colleges, a nonprofit association that sets the agenda for medical education for the 141 accredited U.S. and Canadian medical schools and more than 400 major teaching hospitals and health systems, says all schools do. According to AAMC public opinion research, patients rate communication as the most important factor in choosing a new doctor at 85 percent, ahead of board certification, number of years of practice and where a doctor attended medical school.
Learning to Listen
“All too often medical students and physicians do not listen to their patients. But the history a patient tells is more important than the physical examination,” says Dr. Mark Schwartz, founder and director of The Morchand Center for Clinical Competence at Mount Sinai Medical School in Manhattan, a center created in 1991 to train medical students to become compassionate physicians.
But teaching students how to talk and listen is not as simple as it may sound.
“It’s a more complex, richer environment medicine is being practiced in today,” explains Dr. Deborah Danoff, assistant vice president of the division of medical education at AAMC. “It’s not just one White Anglo-Saxon Protestant explaining things to another White Anglo-Saxon Protestant anymore.”
Emotionally-laden issues like religion, or value-laden ones, like recreational drug use, sexuality and sexual behavior, and even smoking, can be hard for young doctors to deal with, Danoff points out. The topics become even more difficult to discuss when a patient either does not speak English or has a different belief system.
A person’s medical history is important because it offers clues about lifestyle and habits that directly impact the way a patient ought to be treated, Schwartz says. Knowing how to hear the clues — and follow them up — is critical to the patient’s care, he says.
Many communication classes at medical schools break down doctor-patient communication into five basic skills — establishing a relationship, gathering information, giving information, negotiating a treatment and closing a session. These programs also put students in a simulated clinical setting with a standardized patient, or trained actor, to work on these different aptitudes.
Simulated Clinical Settings Educate
Standardized patients describe symptoms and feelings and students practice their interviewing skills during role-play sessions. Like coaches and athletes, teachers and students then observe and review the taped interview to discuss what was effective and what should be done differently. Then they practice again. “We break down [communication] skills into discrete skills people can practice and monitor on their own,” says NYU’s Lipkin.
The AAMC’s Danoff, gives an example of an observed student interview she taught several years ago in which the patient mentioned that he had quit drinking. The student failed to follow up on the comment, thinking it would be indiscreet. After pointing this out and discussing with the student how to delicately handle such an admission, Danoff says, she watched the student evolve into a deft and compassionate questioner.
The Talking Test
Soon, these communication skills will be put to the test. The National Board of Medical Examiners plans to use actor/patients for the communication component of its licensing exam. The Board currently requires all physicians who wish to practice in the United States to take a three-part computerized test that measures competency in medical facts. The results are sent to state licensing boards.
“To label someone competent for practice involves more than being able to answer multiple choice questions,” says Daniel Klass, the director of the Standardized Patient Project at the National Board. Plans are in place to implement the communication test, but when exactly that will happen, Klass cannot say.
Other methods used for grooming empathic doctors include having medical school students stay overnight as patients in emergency rooms, foreign study programs, and offering classes in which students read essays and poems by doctors and patients and write about their own experiences in the hope that a more self-aware human will become a more sensitive doctor.
But not everyone believes sensitivity is smart for a doctor. In his essay, Least of These is Empathy, included in Empathy and the Practice of Medicine: Beyond Pills and the Scalpel, published in 1996 by Yale University Press, Dr. Richard Landau is among those who say too much empathy could contaminate medical practice, turning it soft. Landau’s concern is that too much focus on patients’ feelings could detract from a physician’s ability to objectively assess their physical state.
Art vs. Science
Not so, says Khama Ennis, a student of Lipkin’s at New York University’s medical school. “It’s one thing to come in after the first two years of medical school with a lot of textbook knowledge of what’s wrong with people and different conditions that can afflict them, but to be able to talk with them about it and get the information you need to make clinical decisions is a very different thing and it takes a lot of practice,” Ennis says. “I think it’s been very valuable.”
“People can easily think this is soft and touchy-feely, but there is research to back it up,” says Kathy Cole-Kelly, co-director of the Introduction to Clinical Medicine Program at Case Western Reserve University in Cleveland. Mount Sinai’s Schwartz agrees, calling it a battle between the science of medicine vs. the art of medicine, adding that ineffective communication accounts for 80 percent of all medical malpractice suits.
American Medical Association spokesperson Robert Mills also sees the value to effective empathy and communication training. “[Communication] is extremely important in order to empower patients to make the right decisions.” He points out, though, that with demands of managed care, doctors today have even less time to communicate. Mills says the Web is now an important avenue for conveying information.
But the Web requires a certain level of literacy and technical proficiency, and that’s exactly the sort of assumption of which Cole-Kelly says she and her peers are trying to make students aware. Physicians often fail to recognize the gap between their level of education and that of their patients. Overwhelmed by all the information they have to assimilate in medical school, she claims even the best-intentioned students can forget how to talk to their fellow humans. With the grueling hours they then put in as interns, notions of niceness can fade even further.
“Standard medical practice decreases interpersonal skills,” NYU’s Lipkin concedes. He believes students are sincere when they start medical school and they really do want to help people. His job is to remind them of their intentions when the science of medicine overwhelms the art of it.
“This [communication] is what good physicians have always done. We are just trying to make it more conscious and more rational, rather than just intuitive,” says Dr. Gregory Plotnikoff, medical director of the Center for Spirituality and Healing in Minneapolis, Minn.