New Doctors Develop an Old Skill
Tuesday, May 15, 2007
In a pistachio-colored classroom in downtown Richmond, a dozen neophyte doctors gathered recently to learn the old-fashioned skill known as bedside manner, now rechristened with a more contemporary moniker: clinical empathy.
Instead of their usual frenetic routine -- ordering lab tests, juggling patients and boning up on the details of "interesting cases" that are the staples of the ordeal known as internship -- these first-year residents at the Medical College of Virginia, part of Virginia Commonwealth University, are honing softer skills. Much as acting students do, they are learning to read body language, modulate the quality and pitch of their voices and scrutinize their interpersonal styles.
The pilot program underway at Virginia's largest academic medical center represents an unusual collaboration between theater and medicine, two departments that have traditionally gone separate ways. The four-week course, designed by theater department chairman David S. Leong, associate professor of theater Aaron Anderson and internist Alan Dow, the associate director of residency training, is an effort to adapt the bedrock techniques taught to actors to create better and more humane doctors.
"The reason we're taking about clinical empathy is that it's a very important skill," akin to listening to a patient's heart, Dow told the residents, their concentration intermittently punctured by the insistent bleat of their pagers.
Empathy, Anderson reminded them, does not consist of simply parroting back what a patient has said ("What I hear you saying is . . .") or reflexively sympathizing ("That must be hard . . ."). It is grounded in nonverbal cues, such as facial expression and stance, as well as in pitch and tone of voice.
For these interns, that means paying attention to their own body language -- Are their arms crossed? Do they stand too far away? Is their manner warm or chilly? -- in addition to reading cues from their patients. The hope is that these techniques will be incorporated into the styles of still-malleable physicians and result in improved outcomes for patients.
"Doctors don't know how to listen to, or talk to, patients," Leong said, describing a recent visit with his own doctor, who focused intently on Leong's chart while barely glancing at him. "They know how to diagnose."
As medicine has become increasingly technical, Dow said, the personal relationship between physician and patient has suffered, to the detriment of both. "Much of the empathy role has been delegated to nurses, who call it 'caring for the patient,' " he noted.
Medical educators agree that the relentless demands imposed by technology and the explosion of knowledge have crowded out the humanistic qualities that are the hallmark of good doctoring.
In 1994, the Accreditation Council for Graduate Medical Education, which oversees residency training programs in the United States, singled out "interpersonal and communication skills" as one of six "core competencies" newly minted physicians must possess.
But as Dow and his VCU colleagues note in an article expected to appear in the Journal of General Internal Medicine, there is little consensus about how to develop and measure these skills: "No widespread or well-studied curricula exist to teach clinical empathy."
Some programs designed to train doctors to be empathic appear promising. One of the best known is called "Oncotalk," a four-day workshop developed by an oncologist at the University of Washington and funded by the National Cancer Institute. A study published in March in the Archives of Internal Medicine found that the program dramatically improved the ability of 115 physicians to talk to their patients about the recurrence of cancer as well as about palliative care.
Dow said his team expects to publish the results of a study, now underway, of the impact of the VCU program. It will rely on blinded observations of 30 residents, half of whom were randomly assigned to take the course.
Some older faculty members, Dow acknowledged, have grumbled that the course is unnecessary fluff and has no place in medical training.
That was the view of internist Jeff Kushinka, who was required to take the course two years ago when it was first offered while he was a resident.
"I spent the whole time with my arms folded and legs crossed, thinking I didn't need someone to tell me how to express myself," said Kushinka, now an attending physician at VCU.
Kushinka's opposition softened as he found himself using some of the techniques with patients. "It made me cognizant of how my body language can reflect what I'm thinking and of nonverbal interactions that patients can definitely pick up on," he said. "But I'm still not sure this course should be mandatory."
"Actor training is authentic behavior in a fictitious world -- it's not lying," Anderson told the residents, some of whom looked dubious.
"If you don't show patients you're engaged, they don't think you're engaged, and if they don't think you're engaged, they don't think you're a good doctor," he said. Anderson cited his small survey of 20 randomly selected patients from VCU's ambulatory clinic: "Competence" was rarely cited in their description of what constitutes a "good doctor." Nearly everyone mentioned qualities such as approachability, caring and the time a doctor spent with them as important.
"It's a time-saving device to develop rapport with patients upfront," Anderson added. Not only are they more likely to open up and tell you what's wrong, "their perception of how long you spend" is based on their assessment of how empathic a doctor seems.
Dow uses a recent example from his own practice: a diabetic patient who comes in with a severely elevated blood sugar reading of 300. The patient says he had cake for dessert the night before. The best approach is not to fold your arms across your chest and remind the patient he needs to lay off sweets, Dow advised, but to say, "Well, I like cake, too, but you really shouldn't eat it, and here's why."
To assess the residents' awareness of the image they project, Dow divided them into two groups for a role-playing exercise intended to mimic a clinical interview. Residents interviewed each other on innocuous topics such as home decor, cars and vacations.
The goal, explained Dow, who observed and critiqued the interactions along with the acting faculty, was to demonstrate how a skilled and perceptive interviewer can tease out deeper meaning from answers to seemingly superficial questions.
Intern Amanda Leicht, who quizzed her reserved classmate Brian Lingerfelt about cars, learned that he and his wife are close to their families and plan to settle in the South after he finishes residency.
"You have a very effective and engaging smile," Leong told Leicht, pointing out that she uncrossed her arms as she began speaking to Lingerfelt and seemed relaxed during the five-minute interview. "Your tone of voice is very pleasant, and you did a good job drawing him out."
A second pair was not so successful.
The interviewer failed to pick up on her classmate's abrupt change in demeanor when he told her his family was still in Lebanon; she continued to ask questions without a follow-up or acknowledgment of his obviously emotional reaction.
"His whole body locked up," Anderson said later. "It was pretty dramatic."
"If you miss a significant empathy moment," Anderson warned as the session drew to a close, "patients feel you don't understand them."
Leicht, who learned some basic communication techniques during medical school in Philadelphia, said the class has helped her "read" patients and become more aware of how she is perceived.
"The more you get into medicine, the more you realize how much of an art there is to it," she said. "It's not just about science." ·