How hard is it for doctors to listen and to care?
Dr. Calvin Chou, a professor at University of California, San Francisco and a member of the American Academy for Communication in Healthcare (AACH), agreed. He cited approvingly a patient-centered “medical home” model. That model is team-based and “provides continuous and coordinated care throughout a patient’s lifetime,” he said.
The model essentially keeps patients within a specific practice and attended to by a specific team, rather than shuttling them around to different physicians all the time. Chou said there were several benefits to this model. There are “more people who are on the team, more eyes to catch things that an individual might not be able to catch,” he said.
But this approach is not the reality in most hospitals across the country, Chou said. On the contrary, “teams mainly function to support the hectic routines of the physicians rather than accommodating the diverse needs of patients.”
Movement towards change
Among the medical schools that have implemented programs designed to help medical students learn to communicate effectively with future patients, the Stanford University School of Medicine has adopted a program called Educators-4-Care. That program matches every medical student with a faculty mentor who, according to the program’s web site, is charged with helping students “acquire and refine patient communication skills, physical examination skills, clinical reasoning, and professionalism.” The mentor meets with his or her mentees once a week during the first two years, and then during the clerkship years, “continues to provide guidance for students’ bedside clinical skills and professionalism” through semi-monthly meetings.
Dr. Lars Osterberg, director of the program, emphasized that these faculty mentors are given “20 percent paid, protected time to teach doctor-patient communication. Traditional medical school faculty members usually do not [get compensated] for teaching core values.”
Osterberg spoke frankly about the difficulties of maintaining a focus on good communication skills. “The clinical years are where we struggle,” he said, adding that, “In many ways, students are treated as a third wheel on a rotation, and are seen as getting in the way of productivity.” The rotation system “doesn’t lend itself particularly well to teaching effective communication,” he observed.
Osterberg’s concerns echo those of a study done by the AACH. That study found that “a hostile clinical learning climate [in medical schools] and a lack of importance attributed to teaching caring attitudes [in clinics] were significant barriers” to medical students’ ability to learn effective communication skills.
The Stanford program attempts to overcome these challenges by incorporating a “360 degree evaluation” in which “nurses, peers, residents, doctors and patients” are all asked to fill out evaluations on their interactions with students, and then using those evaluations to assess and grade students.
At the University of Pittsburgh, the Doctor-Patient Institute has implemented mandatory courses on effective communication for first- and second-year students, and has attempted to remedy the loss of control of the student experience during the clinical years by instituting several day-long assessments of students’ communication skills during the third and fourth years.
Robert Arnold, the Institute’s director, said, “While most schools have courses in first year or second year, we’ve tried to build our courses on each other so that there’s teaching of communication in each of the rotations that students are in. We’ve also extended the program beyond medical school and have spent a lot of energy making sure our residents practice communication skills as well, giving them several days when they’re just supposed to be learning about how to communicate.”
UCSF: following the patient, not the specialty
An innovative program at the University of California, San Francisco, attempts to remedy the fact that students have little long-term exposure to patient care in a course entitled “Foundations of Patient Care.”
In this course, patients are assigned to a specific clinic, rather rotating through different specialties. While at the clinic, students interact with the patients who attend that clinic on a regular basis and learn to communicate with those patients on a long-term basis.
The idea behind the program is that longitudinal experience with patients, rather than short-term exposure to different specialties, allows medical students to understand what it means to work within a team to provide care to patients over a long period of time.
Dr. Anna Chang, director of the Foundations of Patient Care course, described the course as “complex,” stating that it runs over 18 months, starting the first week of medical school and running through the end of the second year. The program, according to Chang, “focuses on getting students in touch with patients, practicing clinical skills, learning how to communicate with patients. They are out in the community with real practicing physicians interacting with real patients.”
“The idea, she said, “is that under supervision they have a real setting to put everything else that they’re learning together.” This program avoids the problem of the medical student being seen as the “third wheel” — the person in the way — because the student is integrated into the long-term life of the clinic.
For patients, the medical student often becomes a familiar face, one whose main focus is on communicating with them.