YOU ARE A SEASONED PHYSICIAN. A NEW PATIENT WAITS IN your office. After you shake hands and say hello, how will you figure out what is wrong with this person and determine the best treatment? a Although the problem is the essence of the practice of medicine, the subtle detective work required by such an encounter is not something you were born knowing how to do. Instead, the relevant techniques had to be learned gradually, by close observation and through the example of your instructors. In this special double feature, we look at how our medical school is teaching students to be more effective doctors, one patient at a time. The first story gives the perspective of a veteran instructor of the basic first-year course; the second examines the use of patient actors during third year to help students refine their skills.
A Veteran Instructor In Patient Interviewing Relates What She Has Learned
By Lisa Y. LIivshin, Ed.D.
I AM SQUEEZED INTO A PATIENT room at Tufts-New England Medical Center with my six students. We are on North 4, the general surgery unit. The student begins the interview with a nice open-ended question: “Can you tell me what brings you to the hospital?”
The patient, a 54-year-old woman lying in bed, responds by saying that four years ago, she was diagnosed with ovarian cancer, at which time she had surgery, radiation and chemotherapy. She was in remission for three years. The patient tells us she is back in the hospital because the cancer is back. My class appears tense. When she finishes speaking, my student pauses a moment. Then, straining for .something to fill the void, he stammers, “Do you have any hobbies?”
Welcome to the medical school’s “Patient Interviewing” course, a mandatory firstyear, first-semester class for all students. It is almost impossible to believe that I have been teaching this course for 20 years, but I began subbing as a doctoral psychology intern in child psychiatry in 1986. I was 25 years old and merely a hair older than most of my students.
Psychologists in training do a lot of intakes—it is our rite of passage. Having worked in hospitals, clinics and mental health agencies for five years, I was an experienced patient interviewer. I had a knack for interviewing and enjoyed the challenge of learning as much as possible in the scarce amount of time allotted. Also, my personal history had its share of “bad-doctor experiences;’ so I was eager to teach future doctors their lessons in treating patients with kindness and respect. The year after my internship, I became a full-fledged psychiatry staff member and signed on for another year of teaching the Patient Interviewing class.
This is a course, simply put, on bedside manner. Students learn how to treat the patient as a person, not a disease. They learn about how an illness may impact a patient’s life—such as the patient with irritable bowel syndrome (IBS) who works on a construction site and has limited access to a near-by bathroom. Students learn that being an effective doctor necessitates knowledge of their patients’ home—lives for example, the elderly woman with rheumatoid arthritis who lives alone, has no support system and can no longer take care of herself. They learn how to talk to the patient like a doctor, which is not all that different from the way they would talk to a relative or friend. Most important, they learn how to ask questions that will lead them to an understanding of how the patient experiences his or her illness.
STAYING WITH THE SILENCE
The weekly class convenes at 1 p.m. on Thursdays for a lecture by the course leader, Dr. Jody Schindelheim, clinical professor of psychiatry. The lectures include guest speakers and exposure to new and difficult topics such as death and dying, domestic and substance abuse, and talking to patients about sex. From 2 to 4 p.m., the students accompany their instructors to classrooms in small groups of six. Not all instructors take their students onto the unit to interview a patient’ on the first day, but I always do.
I always ask for a volunteer for the first interview and reassure the students that I will do the interview if they prefer. It is a fascinating exercise. The students immediately break all eye contact with me, and many begin searching the syllabus. Every few years a student offers to go first—one who usually has interviewing experience from working in a medical setting. Occasionally, someone volunteers who simply wants to get the interview out of the way and figures I can’t judge him or her too harshly on Day One. Ninety percent of the time, the class asks me to conduct
the first interview.
And so, on this particular day, I do. I begin interviewing a middle-aged woman who has been hospitalized for a minor procedure on her foot. As the interview proceeds, the woman strikes me as clinically depressed. I ask about her home life (lives alone) and her work (she hates it) and about what she does for enjoyment.
Then there is silence. I stay with the silence. The class looks tense. I see them looking at me, willing me to speak. More silence. In a moment the patient is crying. The new medical students are noticeably uncomfortable with the tears, and several of them reach for tissues at the same time. I let her cry a bit and then say, “You’re sad.” Soon the patient is volunteering information about her depression. We talk about her extensive family history of mood disorders as well as her current symptoms.
The class is in awe of what has transpired. Back in the classroom, we discuss the importance of learning to feel comfortable with a patient’s emotions and how doctors can communicate that ease. However, somehow the students walk away with the notion they need,to make a patient cry in order to get a good grade. This is a rumor that has persisted throughout all my years at Tufts.
A BADGE OF COURAGE
My group interviews one or two patients per class. Every week I designate one primary interviewer and one back-up interviewer per patient. The back-up person takes over when her classmate hits a wall and runs out of questions. I assure my students that I am there to rescue them should they get into a difficult spot. I usually wrap up each interview by asking questions that have been missed entirely or pursuing areas that have not been fully explored. Sometimes I model how to talk to family members who may be in the room.
Often I am using this end-of-class time to demonstrate how to ask a question about the two toughies: sex and death. At these moments I am reminded of the students’ relatively young ages and mixed cultural backgrounds. Many grew up in homes where it was considered rude to ask intimate questions. Or they came from cultures where it is inappropriate to make personal inquiries of an elderly person or someone of the opposite gender. Simply asking a patient’s age can be difficult for some students.
But my students sell themselves short. Although they have been in medical school for only a short while, their white coats and their presence on the unit legitimize them in the eyes of the patient. I think about all the patients who had no modesty with the class—the ones who didn’t care about which body parts were exposed as they lifted their gowns to show an incision or bruise.
For many patients, that incision is a badge of courage to be shown with pride. Or its display can be an attempt to work through the trauma of having been cut, open—of bodily intrusion. Students often encounter more graphic detail than they expected. Three of my students have fainted over the years, and two have vomited, all claiming to be overcome by the heat in the patient’s room.
Not all patients are willing to be interviewed. Many of them have had enough of the teaching hospital environment and its endless stream of students and interns. However, my experience has been that most patients do agree to be interviewed. They want to help teach. They have· a story to tell about their illnesses, and frankly, they are eager to break the monotony of their long days with our visit.
Often, it is the patient who primarily teaches the students. One patient in her 30s had a wheelchair by her bed. The student interviewer astutely picked up on this (students are taught to observe the patient’s personal belongings to glean information) and asked, “How long have you been in a wheelchair?” The patient gently corrected the interviewer’s question and told us that she had “used the chair for six years:’ She made sure we understood the distinction between being in a chair—the dependency that this implied—and using a chair as an aid.
Another instructive case concerned an 86-year-old man lying in bed in a silk robe and monogrammed slippers; he had a Wall Street Journal, briefcase and laptop by his bed. The student began an excellent interview, learning a great deal about the course of the man’s heart condition. Then, missing all the clues, she asked, “How long have you been retired?” to which the patient replied that he still headed up a large law firm.
WHEN TO BE QUIET
The lessons I impart to my students haven’t changed over the past 20 years. First, listen and make no assumptions. One day you may be treating your 27th heart attack, but it’s usually the patient’s first. Be compassionate. Patients are vulnerable—lying in bed without the dignity of their clothes, feeling sick and uncertain about their health, stripped of the appearance they usually make when meeting someone new. There are many factors that influence how a patient experiences illness—ask questions to find out.
Don’t be afraid to ask about age, sex and death. If the patient is 50 and looks 70, that’s important information. If the patient is practicing unsafe sex, you need to know. The scariest part of being sick is getting a little closer to the possibility of death. You can help make all of it less frightening for the patient to talk about,simply by being comfortable asking. Then keep listening.
My favorite moments over the years have been when I see students “get it.” At these times, they are totally present during their interviews. Their eyes aren’t looking off in search of the next question. They are listening and responding to what the patient has said. They’re not thinking about me or their peers standing behind them. They know when to be quiet, wait a beat, and let the patient show the way; they also know when to steer. They let the patients know they are listening by paraphrasing what has been said and asking the next question that begs to be asked. The interviews flow, the patients open up, and we learn what we need to know.