Teaching Doctors to Care

These programs focus on relationships

By inculcating "people skills" and self-awareness, educators aim to produce a generation of more-humane physicians.

By Deborah A. Grandinetti
Senior Editor

Every year, about an hour before sunset on the eve of the summer solstice, FP William L. Miller puts the six new members of his residency program on a bus to Manhattan. Miller, who chairs Lehigh Valley Hospital's Department of Family Practice and its residency program in Allentown, PA, knows this means the new doctors will emerge from the Lincoln Tunnel after dark.

After the bus arrives in Manhattan, the residents are spirited to someplace outrageous. The particulars change every year, but the chosen outing is always something so far out of the young doctors' typical experience—like a punked-out leather bar in Greenwich Village—that it disorients them.

After midnight, Miller, faculty members, and older residents catch up with the neophytes at an all-night diner in lower Manhattan. Miller tells them they've glimpsed what's ahead: Residency often will leave them feeling out of their element and uncertain of themselves.

At 4 am, the group heads to the Cathedral of St. John the Divine to hear Paul Winter and friends perform the annual Summer Solstice Celebration concert. "The concert begins in the dark and ends as the morning light shines in, leaving the cathedral in the magnificent brightness of the day," says Miller.

This is his way of assuring the residents that the long, dark period of exile—otherwise known as residency training—will ultimately come to a satisfying close. They will emerge as capable family physicians, ready to assume their place in society.

This is medical training? It is to Miller and a growing number of medical educators, who say they're trying to replace the traditional Marine boot-camp break-'em-down style of initiation with approaches that emphasize personal empowerment, self-development, and relationship skills.

These concepts have taken root mainly in family practice education because of its focus on relationship-oriented primary care, but they're driving innovations in some internal medicine residencies, too. In time, this new take on medical training could spread to other specialties, as patients become more vocal in their demand for physicians who are sympathetic guides, rather than coolly detached dictators.

The result may well be a rash of physicians who emerge from training with wholly different attitudes, values, and approaches to patient care than their predecessors had. Proponents of relationship-oriented training methods predict that these new physicians will outscore older colleagues on patient satisfaction surveys and, over time, prove to be healthier role models for patients because of their own self-care skills. Proponents also say these physicians will be better equipped to take on leadership roles, because the training hones decision-making and interpersonal skills. It builds confidence, rather than undermines it.

No doubt some physicians would retch over this. "There are plenty of doctors, residents, and medical educators who think we already spend far too much time beating people about the head with personal development and relationship skills," says FP Stephen Lurie, who edits JAMA's annual medical education issue. Although Lurie doesn't hold this view himself, he acknowledges those who consider medical training "such serious business, there's no place for this kind of navel-gazing."

Many residents might agree. "Although we have this lovely notion about wanting to be more sensitive to patients' needs and in touch with our feelings, that's not the reality of internship and residency," says Concord, MA, psychiatrist Kernan T. Manion, who specializes in burnout prevention. "Residents are under immense pressure to care for a multitude of patients whose diseases they only touched on in medical school. They're just trying to survive."

But emergency physician Bill Benda, director of medical and public affairs for the National Integrative Medicine Council in Tucson, argues that looking at these new areas as an "add-on" is wrong-headed. "The whole system needs to be re-evaluated, from the minute students walk into medical school on up."

Trying to give patients what they want

What's driving the move to reconfigure medical training? There is a growing belief among physicians and others in medical educational circles that medical school and residency don't turn out the kind of doctor today's patient wants.

Thanks largely to the Internet, some patients know more about their disease and current treatments than their doctors. "This has created an atmosphere in which a more equal partnership is necessary, and the equality will only become more pronounced as time goes on," says Lurie. Such a patient is as attentive to the quality of the relationship with her physician as she is to the physician's clinical competence.

To satisfy her, proponents of change argue, medical training must foster a fundamental shift in how faculty members and chief residents treat their charges. They must learn collaborative, respectful ways of relating to the house staff, instead of transmitting knowledge in a top-down, often demeaning way. That will teach young doctors to do the same with patients, goes the theory.

"There's a constant belittling of students in medical schools and residency programs," says Reid B. Blackwelder, program director of Kingsport Family Practice Residency Program at the James H. Quillen College of Medicine at East Tennessee State University. "Essentially, we're teaching bright, capable people to lose confidence and self-esteem by constantly telling them they're wrong. By the time they graduate, they hate themselves and they hate their patients."

Some believe that if new physicians don't learn to share their expertise without imposing their view, or to communicate in ways that take the patient's autonomy into account, conventional medicine will continue to forfeit patients to alternative medicine.

"Huge numbers of people go to alternative practitioners because someone is willing to talk with them for 30 minutes," says Bill Benda. "They're sick, afraid, and need to make contact."

Others say that teaching physicians these new skills improves not only the quality of the physician-patient relationship, but health outcomes as well. That was the conclusion of a 1996 study of more than 6,000 patients conducted at The Health Institute at the New England Medical Center.

The study found that patient satisfaction, adherence to medical therapy, and improvements in patient health were most closely correlated with patients' trust in their physicians and physicians' knowledge of their patients' home life, health beliefs, and personal values. The University of California-Davis, School of Medicine reported similar conclusions in a study published in 1998.

The rise of "relationship-centered care"

One of the pioneers in the patient-physician relationship movement in medical education is The Arnold P. Gold Foundation, founded in 1988 by pediatric neurologist Arnold P. Gold and his wife Sandra. The Golds started the first "white coat ceremony" for medical students, to help "create an environment that fosters establishing a psychological contract for professionalism and empathy in the profession," according to Arnold Gold. More than 100 institutions have adopted the ceremony.

The Gold Foundation has provided financial and other support for the design of a curriculum emphasizing humanistic values for residents. It's being piloted at Columbia University College of Physicians & Surgeons, the University of Chicago Pritzker School of Medicine, and Harvard Medical School.

The foundation funds 26 different programs that promote humanism and makes awards to students and faculty. It also has run home visit programs for pediatric, geriatric, and internal medicine residents, to encourage them to get to know patients as people. "At least one of our programs is in place at 85 percent of all American schools of medicine and osteopathy," says Sandra Gold.

The other major player in the education reform movement is the Relationship-Centered Care Network of the Fetzer Institute of Kalamazoo, MI. The network grew out of efforts by the Fetzer Institute and the Pew Health Professions Commission to examine psychosocial issues in health education. In 1994, the group produced a monograph that introduced several nontraditional ideas. Among them:

• The greatest benefits and the highest quality of care can emerge only from a health care system that is based on caring, respectful relationships, and a health care education system that helps students, faculty, and practitioners learn how to form such relationships with patients and their communities.

• Physicians don't stand outside the patient's experience as detached observers/scientists. They influence both the patient's (and his family's) experience of illness and the course of healing. Therefore, the physician's character is as much an instrument of healing as drugs and procedures.

• Professional education must support the clinician's self-development: "Who practitioners are as persons is most relevant to the quality of care that they give and to the quality of relationships they form," the Pew-Fetzer report said. "Without self-knowledge, a practitioner's own emotional responses to patient needs may act as a barrier to effective care and can result in harm to the patient."

Even innovative programs see limits

Those ideas have already inspired change in residency programs throughout the country. Reid Blackwelder's program for FPs at East Tennessee State University, for instance, focuses on building self-esteem and leadership skills. One way to accomplish that goal, says Blackwelder, is through shared decision-making.

"Instead of maintaining a system where students are the 'children' and faculty are the 'parents,' we give residents say in all aspects of the practice and in their own curriculum," he says. "It's not a democracy, but we try to make joint decisions as much as possible." This better prepares residents for the responsibilities they will assume in private practice, says Blackwelder.

Residents must also set professional and personal goals. "We check in with them halfway through the month to see how they're doing with their personal goals," which may be to spend more time with their newborn or read a good book. "Merely talking about these things may be a way to change behaviors, but we're trying to measure actual progress."

In New York, internist Zeev Neuwirth, who is active in Fetzer's relationship-centered care network, takes his residents on "interpersonal rounds" to show them how to engage with patients in a healing way. Typically, he and residents discuss the patient first, pay a brief visit to the person, and then adjourn to discuss the interaction.

One memorable visit, says Neuwirth, was prompted by a resident's frustration with a patient he considered noncompliant. The patient, a man in his 40s who had been hospitalized for a second heart attack, couldn't give the resident any details about his first heart attack. Neuwirth's other residents took that to mean that the man didn't care about his health.

But Neuwirth questioned that assumption. He brought the residents into the patient's room and asked the man about himself. During the conversation, they discovered that the man was illiterate and had never learned the alphabet. So when the resident asked him about his last "MI," he didn't know the resident was referring to his prior myocardial infarction, says Neuwirth.

The point of interpersonal rounds, says Neuwirth, "is to help residents understand that they're here to take care of other people. I don't even like to use the word 'patient' because it sets up an unequal, hierarchical relationship."

With the possible exception of Neuwirth's, which applies the principles of relationship-centered care to every facet of teaching, no residency program has embraced this approach as much as Lehigh Valley, which has restyled its entire program. Lehigh eschews rotations for a curriculum that allows for longer-term observation and study. Throughout a student's residency, faculty place "a powerful emphasis on self-reflection, along with evidence-based knowledge and relationship skills"—three components that are accorded equal weight, says program director William Miller. "We have residents probe deeply into their own family issues, since these are the issues where they'll be most vulnerable in conflicts with patients," says Miller. "We make that explicit."

Miller also takes residents on camping retreats to explore the interpersonal dimensions of the physician-patient relationship. He draws on storytelling and journal-writing exercises meant to foster self-reflection and develop the "healer" in the physician. Residents also share with each other in informal support group sessions.

Yet even Miller acknowledges limits to how much residency programs should change. "For years I worked to eliminate the stress of training," says Miller. "But it suddenly hit me that this was counterproductive." Other cultures he studied also subject their healers-in-training to intense pressure, which he believes is necessary to transform an ordinary individual into a healer. In the West, for instance, it's the pressure—of having to digest and be able to recall enormous amounts of information, of being responsible for life/death decisions, of having to behave like a clear-thinking professional despite one's own exhaustion or terror—that transforms a person into a physician.

While that stress is necessary for the initiation, educators don't have to make it worse by tyrannizing their apprentices. "I realized that this was not about eliminating stress," Miller says, "but about setting boundaries around it, and providing residents with a deep reservoir of empathy.

"The residency process is parallel to the patient's experience and what it means to be sick," Miller continues. "You lose control, you begin to lose hope, you are sleep-deprived, you're not eating well, your relationships are at risk because you're not able to meet social obligations. You lose your identity, you come apart, you're dismembered and no longer whole. Our role as faculty is to be there for residents as they come apart, just as we expect them to be there for patients when they come apart."

 

Deborah Grandinetti. Teaching Doctors to Care: These programs focus on relationships. Medical Economics 2001;9:99.