Apr 27, 2009

Humanism for Patients

On April 23rd, Dr. Don Berwick gave a lecture at Yale School of Medicine for the Humanities in Medicine series. Each lecture in the series is named after someone special. This particular lecture was named after Dr. Morris Dillard, who was actually my interviewer when I was applying to Yale medical school. Dr. Dillard, who I guess is about 80 years old, is still very sharp and active in the Yale clinical community. In fact, he was the one who stood at the door to the lecture room, and personally greeted everyone. When he saw me, I worried that he would not remember or recognize me. Immediately, however, he smiled at me, and made bowing motions with his arms as if he was playing a violin. He had remembered me after all, recalling our interview when we had talked about me playing the violin during medical school and afterwards. He still remembered this aspect of me, over a year later.

Don Berwick’s lecture was about many things. As a first-year medical student, what I took away from the talk was the importance of humanism, a concept that is repeatedly thrown at us in our pre-clinical clerkship course, but which rarely sinks in unless delivered with inspiration and precision. At this early stage, when we are beginning to develop our habits, routines, and attitudes regarding helping the patient, learning about humanism is critically important.

We were told about being a humanistic doctor. Dr. Berwick’s personal experience of learning about humanism came, in part, from one of his patients at Children’s Hospital in Boston, where he was an attending. He described a young 14-year old boy, with a chronic illness, who had been admitted to the hospital over 80 times. This boy told him three ways to be a better doctor. First, he said, please, please, tell me what you are going to do to me, before you do it. Second, talk to each other more (and this point was directly related to a larger topic of the talk, the fragmentation of the health care system). Third, ask me (the patient) for help. Patients often know more about their condition than their doctors can ever hope to know. So, it is our responsibility to ask. In a very moving manner, Dr. Berwick shared with us something very personal about his own health and what his health means to him, something that none of his own doctors know about, which allowed us—future, current, and retired physicians—to experience first-hand how incomplete our ability to care for our patients is if we never ask, what do you want? What does your health mean to you?

Finally, always thank your patient. Thank them for coming in, thank them for sharing their secrets with you, thank them for placing their trust in you. Dr. Berwick made these points in reference to Dr. Dillard, who continues to exemplify the best humanism a doctor can have. If Dr. Dillard is able to remember that I play the violin, over a year later, I have no doubt how grateful his patients must be for his strong sense of genuine care and appreciation for others.

-Adam Sang
1st year med student

Tell me...

As a first year medical student, I spend most of my time in lecture halls dimly lit by computer projectors learning the basic sciences of medicine. Once every week I get the chance to escape from the lecture halls and spend time in the clinic with patients through a yearlong course where we learn and practice different elements of the patient interview. This course is a welcome reminder of a core reason we are drawn to this profession. However, these experiences are not without challenges.

One of the first concepts we are introduced to is building rapport with a patient and getting to know them as people. Upon this foundation, we add layers of information regarding the patient’s current illness and medical history, social support and family history. Our preceptors also incorporate in these lessons introductions to how to discuss tough issues such as alcohol and drug use, sexual history, and domestic violence. For myself and many of my classmates, it has been difficult to become comfortable with assessing when these questions are appropriate and how to discuss them in a nonjudgmental manner. Even when the patient is actually one of our preceptors role-playing, these patients are strangers and establishing mutual trust is difficult.

Whether asking about possible domestic violence or gathering all the details of the present illness, an overarching challenge that I have encountered as an interviewer is to avoid jumping to conclusions based on a patient’s initial responses. Sometimes, the excitement of remembering a detail in class that might apply to the patient (“It’s the positive pleural pressure!”) inadvertently directs me to jump to specific, closed questions that may miss an important component of the patient’s health. I have to constantly remind myself to go back to the broad, open questions, and I imagine that this balance will be easier with more clinical knowledge and experience.

A challenge from a different perspective is a patient’s reluctance to reveal all the facts or not knowing what information is pertinent to his or her health. The issue is not as simple as the stereotype of patients who lie because they think it will please their physicians, and I did not begin to appreciate this complexity until the first time I was a patient since starting medical school.

My recent visit to the university clinic was for a routine annual physical. As my physician began to ask the same questions that I had been learning throughout the year, I had a feeling of being a detached observer of the interview. I thought to myself, “Well, this is how I would expect a patient to answer,” and then I realized that it was I who was the patient.

For a few questions, I experienced a split second of hesitation to wonder if what I was about to say would be an important detail or if it was just medical school-induced hypochondria. Small things like past tobacco use or an unusual mole. Feeling compelled to be a “model” patient, I did report this information to my physician. She smiled and told me that the occasional cigars in college did not constitute being a past smoker. However, my physician also examined my skin and referred me to a dermatologist. Reflecting on these minimal internal debates, I can only begin to understand what it would be like to be wary of discussing much more serious and personal issues with a physician.

I do not think addressing these issues of communication between patient and physician are as easy as reaffirming confidentiality of the interview. In my observations, the physician does set the stage by expressing empathy and trying to build a connection. I have been surprised that silence can be as effective in interviews as follow up questions. A purposeful pause following a patient response can lead to the patient reframing a more complete response and revealing a significant detail. Yet, I worry if there will be the ability to conduct full interviews as time becomes compressed through medical school and during residency. I hope that my classmates (and future colleagues) and I do not forget the skill of maintaining a full dialogue with our patients.

-Michael Jaung
1st year med student
Harvard Medical School

What do you wish you were learning?

If you're like most students, you probably don't have much of a say over what you're learning in school. You may just be focused on making it through in one piece.

But are you learning the things you'll need to know after graduation?

During today's On Call teleconference, Dr. David B. Nash* listed five crucial skills that most health professions students aren't learning in school. These abilities included the following:

  • Working effectively in teams
  • Understanding work as a process
  • Collecting, analyzing, and displaying data on the outcomes of care
  • Working collaboratively with managers and patients
  • Being able and willing to learn from mistakes

All these skills, Nash argued, are necessary if students are to improve care and patient safety.

Continue or join the conversation. What do you wish you were learning in school? Do you think the skills listed above are really crucial? What will it take to change what's routinely taught to students of medicine, nursing, pharmacy, and other health professions?

If you're a faculty member, what are the obstacles you face in changing the curriculum? What successes have you had?

You can post your thoughts by clicking the "Comment" button below this post. David Nash will be checking this site and will respond occasionally. Also, check back here in a week or so for a link to the audio recording of the call.

*Nash, MD, MBA, is a professor of health policy and dean of the Jefferson School of Population Health in Philadelphia, Pennsylvania.