Tuesday, June 12, 2007

A Letter to Medical School Administrators

To Whom It May Concern:

Every time I speak to a group of med students I get the same question; “How are we supposed to be able to care for patients with respect and compassion when the system is continually pushing us for results, not quality of time spent?” It’s a good question and one I have come to dislike.

Yes, there is no doubt that our medical system is not set up for doctors to be personal therapists. Yes, they are under great pressure to do the job and do it quickly. I also think we have missed the point.

When it comes to patient care, one option is to sit down and have a heart to heart with great depth and emotion. Another option is to fake it. I don’t mean to fake the emotion, but I do think good patient care does not have to be the result of a bleeding heart. It also doesn’t have to mean canceling all of your afternoon appointments. Let me explain…

I don’t believe that the aspect of patient care that revolves around psychological wellness needs to be in depth or sincere. It can be as rehearsed as all the other doctor-speak taught in med school. It requires observation and practice, two skills that all doctors need no matter what. Here is my formula for “bedside manner”:

Step One: see the patient.

When I am upset about something, I don’t usually announce it. That doesn’t mean it’s not obvious, however! When doctors come and go and pretend as though life was a bunch of honey lollipops, it makes me more upset. I feel like I am invisible. That is a desperate feeling.

Step Two: acknowledge what you see.

If someone were to acknowledge that they recognize my emotional state would calm me down immediately. I would feel recognized and respected as a human being. Sometimes, this might be all I need.

Step Three: ask if there is anything that you, as the doctor, can do to help

Often there won’t be but simply asking is a sign of understanding and compassion (even if you’re faking it).

Step Four: set boundaries

This would be about the time that many patients would take up the rest of your afternoon spilling their guts (that’s because you’ve reached out to them and they trust you enough to let some things off their chest). Let them know you care (even if you don’t) but that you have an obligation to the other patients waiting.

Step Five: mirror

Paraphrase what you heard them say and let them know you understand how they could feel that way (even if you don’t).

Step Six: food for thought

Let them know you will mull over the things they have said and will get back with them if you think of anything helpful (even if you won’t). This is also a good time to give them names of organizations or individuals that specialize in this part of illness work. Giving them therapists or other support resources can allow them to feel they have left with something that might give some relief from the current emotional state.

Will this take longer than a normal visit? Perhaps, but not much.

Will this take an emotional toll on the doctor? Not if they learn this as part of a routine visit and can remain emotionally objective and calm.

Will this help patients feel as though they were being treated with respect and kindness? Most certainly.

Will this increase patient compliance? No doubt.

“Bedside Manner” training is quite in vogue. Medical Schools all around the country are implementing classes to teach doctors how to have more empathy for their patients. I believe this is an unrealistic goal. You can not teach a person how to feel anything. This will vary from personality to personality. With one individual it will vary from day to day. To attempt to reach this goal is to attempt to hit a moving target; it will happen on occasion but will usually be a miss.

When you are teaching scientific minds, wouldn’t it be best to teach a kind of compassion that can be consistent and logical? The truth is, a compassion that is genuine and a compassion that is manufactured are indistinguishable. As a patient, I would welcome either one.

Your med students do not have to graduate as Masters of Sympathy, as I once preached. However, I won’t give up on the fight for them to treat me like a whole being and not just a car that needs a tune up. Give them the skills, please, I beg you.

Thanks so much,



Femail doc said...

I feel bad that at times the best we as doctors can offer is what we learned in Compassion 101, but I agree Tiffany that a little goes a long way.

I often find myself running late. Patients then enter the exam room tensed to not get what they need. When I sit down, I set down my pen my glasses, my stethoscope, etc. and ask "So how's your day going?" like I have all the time in the world. The atmosphere in the room almost instantly relaxes, for both of us.

I wish you'd send your letter off. I've got just the person to send it to at Univ. of Colo. Med. School. May I?


Tiffany said...

Thanks Denver Doc...
I'm curious to know if you (and the other docs that read my blog) find the concept of "faking it" offensive.
I hope I have made my case and explained it well enough that my point is understood...If the real emotion is not there, I'd prefer you fake it and use your doctor skill set rather than ignore the elephant in the room...
As for actually sending my letter, where would you send it? I'm fine with that, certainly, but very very curious about the story behind it! Do tell!
Thanks so much for all of your insightful and supportive comments. I hope you are doing ok in light of all the things going on with your mom. It must be so hard for you but I'm sure you realize how lucky she is to have such a kind doc for a daughter! Take care of yourself...

OB Doctor said...

Your piece touches on so many issues relevant to the state of medicine. One answer to the question that the medical students are commonly asking is the idea of a micropractice: some physicians have started "micropractices", small practices in which they have minimal overhead in order that they still may make a decent income while spending as much time as they want with patients.

My gut reaction is that patients will be able to spot manufactured compassion pretty easily and be turned off by it--I would. Off the cuff, I think it might be better to attempt to increase physicians' empathy for patients (i.e. through talking with patients/reading about the patient perspective/walking in the patients' shoes for a day, etc.).

Interestingly, my hunch is that the most empathetic physicians are going to get burned out in many of today's practice settings because the goals of the practice administrators are almost antithetical to physicians who want to provide compassionate care to patients.

Lastly, I think addressing the issues raised in both posts (reducing medical errors and improving physicians' ability to provide compassionate care) is key to mitigating the current malpractice crisis. My hunch is that patients will be much more understanding when adverse complications occur if the complication would not have been easily avoidable, and the physician explains to them what went wrong, why it went wrong, and what will be necessary to address the problem.

Thank you for your encouragement, by the way!

Femail doc said...

CU medical school has a program called 'Foundations in Doctoring.' This is a mentoring practicum that students participate in from year one of their training. They go one half day weekly to the offices of practicing physicians and learn in an apprentice style fashion.

I have done this for years now, and have been impressed with the efforts of the course director to include both the art and the science of hands-on medicine as part of the training. This truly does include 'Compassion 101.' I would like to send your letter to the coordinators of the Foundations program; I know they would share it with students in a positive way.

I think learning the basics of active listening etc. provides even the best of students and physicians with a fallback position. When I'm impatient, frantic with lateness or distractions, I find pulling up the behaviors of compassion centers me back with the encounter at hand in a positive way.

I have provided students in the past with copies of "How Can I Help" by Ram Dass, a wonderful book about mindful service to others. I'm glad that your musings reminded me to pull that book out again and put it in service.