How hard is it for doctors to listen and to care?

Original Reporting | By Margaret Moslander |

Varied levels of commitment

In 2007, the Association of American Medical Colleges identified significant gaps in physician preparation, among them “a loss of altruism and qualities of caring as [students] proceed through training and enter the practice environment,” an inability to “communicate with patients about difficult issues,” and a lack of skills in “cultural competence and awareness and [inability] to recognize that some patients may have health literacy issues.” The AACH found “inconsistent implementation of [communication] values in admissions, teaching, assessment and faculty development processes”; medical students reported that “professionalism and compassion” were “role modeled” less than 12 percent of the time by the doctors who served as their mentors during their clinical years.

The Multiple Mini Interview

A report of the 2011 annual meeting of the AMA’s Council on Medical Education found that “tools to assess personal qualities are limited,” and “the tools now used by many admissions committees to assess applicants’ personal qualities…are insufficient with regard to validity and reliability.”

Medical schools seem unable, or unwilling, to inject the application process with something other than numbers; while students’ grades and MCAT scores are under the microscope, other personal characteristics that are important to becoming a good doctor are left untested.

At Stanford, the medical school has started to experiment with the “Multiple Mini Interview” (MMI) in the hope that it will help schools better gauge students’ interpersonal and communication skills. Osterberg explained that the MMI replaces the traditional one-hour medical school interview with several eight- to ten-minute interviews with various members of the medical community, including former patients, nurses, and medical school faculty.

According to one published report, at least eight U.S. medical schools are employing the MMI as part of the admissions process.

Since 2004, communications skills have been among those tested by the National Board of Medical Examiners during the exam that doctors take to be licensed to practice. As a result, Jeffrey Gold of the AMA’s Council on Higher Education believes that just about every medical school in the country has instituted some sort of communication training.

The rigor of the training varies, however. “For some schools, it’s very important,” he said. “For others, it’s less so.” A report by the AACH found that while “most [respondents] believed that their medical schools’ curricula strongly emphasized caring attitudes, one third disagreed that they were emphasized as much as scientific knowledge.”

While the report found that “patients define quality of care in terms of the quality of communication with members of their health care team, ” Chou of UCSF and the AACH said that, “The penetration of the message is variable. Some people have gotten it, others haven’t.”

One factor that contributes to stymieing progress, Chou said, is the “myth that doctors know how to communicate.”

There also remains a problem that admissions procedures for most medical schools do not have effective means of evaluating applicants’ ability to foster “caring attitudes” or effective communication skills. This gap in medical school admissions procedures is particularly significant when, as discovered by the AACH, “most [medical school deans] expressed pessimism about fostering caring attitudes in students who do not already possess them.” Furthermore, while “three quarters of medical schools ask admissions interviewers to assess caring attitudes in medical school applicants,” only “25 percent of those schools train them to do so.” (See sidebar on a different way to assess medical school applicants.)


The key structural obstacle: there’s just no time

Every doctor Remapping Debate spoke with identified a lack of time to spend with patients as a significant obstacle.

An AACH 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.

“There has been a push to see more patients in a quicker period of time,” Sorrentino said. “The 10 minute patient visit in an outpatient clinic has become common, but it’s hard to have good communication, an opportunity to educate your patient, and a good rapport with your patient in 10 minutes. It takes a fair amount of time to educate a patient about their disease in words they understand.”

Osterberg noted that “in a traditional doctor-patient relationship, you had time to spend with the patient. Now we’re pushed and pushed to see more patients, in less time, and we haven’t thought about the consequences of that. The actual communication part gets pushed by the wayside.”

Gold reiterated this concern, noting the importance of doctors learning what it means to be in the position of a patient.

“What doctors learn when they are in the patient role is that when you’re under stress or delivering or receiving bad news, your ability to focus and concentrate on hearing full story sometimes gets lost,” he stated. “Doctors need time with patients to make sure they understand, to be sure that they’re getting 100 percent of the story. That doesn’t always happen the first time you give someone news. You need time to repeat yourself, and doctors don’t have that.”

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