Patients as Teachers

I’ve often been asked if our programs to improve doctor-patient communication have been incorporated into medical education. I can tell you that over the years we presented the Center for Communication in Medicine’s medical humanism work at Brown Medical School, New York University Medical School, University of Vermont College of Medicine, MD Anderson Cancer Center and Stanford Medical Center. It was certainly flattering to receive these invitations but we also learned something that helped shape our organization’s thinking in developing programs to bridge the communication divide between doctors and patients. Time and again we heard faculty and students talk about the challenges of incorporating communication skills training in curriculums that were already saturated with medical science courses and clinical training. I’d like to share some of what we learned.

My first presentation at a medical education institution occurred in 1999 when several staff at the cancer center in Bennington introduced our medical humanism model to 1^st and 3^rd year students at Brown Medical School. We offered the perspectives of an oncologist, psychologist, patient and myself, a medical humanist. In a discussion with the 1^st year students, we heard their excitement about our inter-disciplinary approach to patient care. Later, we met with 3^rd year students who has just begun their clinical rotations. One of the students was quite candid. He acknowledged that communication had a role in patient care but new technology was most important to him. He wanted to be the first doctor at the bedside to make a correct diagnosis. Another student was demonstrably upset as she spoke about the absence of training in communication skills, something she valued. She was told that it was up to her to find mentors who could help her become proficient in talking with patients, especially about delivering bad news. I’m all for cutting edge diagnostic tools. However, I couldn’t help think about what happens when patients may not understand the meaning of test results.

On another occasion, a well-respected professor of medicine at NYU Medical School extended an invitation to present our medical humanist communication model. He was a pioneer in the field of humanistic medicine and for many years led a seminar on this subject to 3^rd year students who, for the first time, were meeting patients on clinical rotations. After our presentation, he expressed concern that a humanistic approach to care could be lost when they became doctors. To emphasize this point he talked about how some of his former students who, when they became attending physicians at the hospital, showed little interest in mentoring interns and residents about listening to and communicating with patients and their loved ones.

Then, there was the time we were invited to MD Anderson Cancer Center in Houston, TX to introduce SpeakSooner: A Patient’s Guide to Difficult Conversations, a tool we developed to help patients identify and communicate questions and concerns. After a presentation to oncology fellows, one of the participants declared that he was being trained to treat cancer and had no time for lengthy discussions with patients about the issues identified in the guide. He added, “Maybe you have time for these conversations in Vermont.” That blunt statement caught me by surprise. In response, I told him that he needed to “get ready for these conversations” because I might be his patient someday. There was laughter among the fellows but a look of shock on the doctor’s face. Perhaps, I shouldn’t have made it personal but the importance of making time for open and honest conversations needed to get through.

In sharing these teaching moments, it is not my intent to criticize medical education. I do recognize the reasons for not incorporating communication skills training into a medical science curriculum. However, although communication may not be hard science, it is a vital component of patients making informed healthcare decisions. And, these decisions have consequences.

So, what does the absence of communication skills training mean for patients?

For one, it certainly places greater responsibility on patients to open channels of communication. With time at a premium at medical office visits, this can be a daunting task. I can tell you that in my role of medical humanist, I not only documented a patient’s perspective of illness but encouraged them to voice their questions and concerns to the cancer care team. For those who were fearful of offending doctors, I shared my observation that doctors appreciated patients who expressed concerns and took an active role in treatment decisions, especially when quality of life or end of life care decisions were a consideration.

So, with medical schools challenged to offer courses in communication skills training, I have come to the conclusion that patients need to be teachers. That is, patients need to remind doctors that they understand the time pressures and demands they face while letting it be known that open and honest communication about healthcare issues is their priority. I’m not saying this is easy but it is well documented that effective communication can lead to informed healthcare decisions and greater satisfaction with care. For sure, we don’t want to have regrets about what we should have asked.