Medical students examine doctor/patient communication

Angel Platas, left, and Kim O’Connor worked with a professor to create an independent elective in doctor/patient communications. Photo by Leila Gray.

Public opinion research, recently conducted in Boston and Seattle by the Association of American Medical Colleges, asked, “What makes a good doctor?” In all cases, respondents assumed that anyone with an M.D. after his or her name must have sufficient scientific and clinical expertise to practice medicine.

What distinguished a good doctor, in their minds, was the physician’s attentiveness and compassion. Patients wanted to be treated like a person, not just another case. People of all educational levels, from those with less than a high school diploma to those with graduate degrees, wanted a doctor who listened to them and who could explain medical procedures in an understandable fashion.

Long recognizing that doctor/patient communication skills were essential to good practice, two fourth-year UW medical students, Angel Platas and Kim O’Connor, helped create an elective course on patient interviewing skills in an actual clinical setting. Their instructor was Larry Mauksch, UW clinical associate professor of family medicine and a behavioral scientist for the UW Medical Center Family Practice Residency. Their training site was the Marillac Clinic in Grand Junction, Colo. where Mauksch is a visiting faculty member.

“Larry taught us how to learn about illness from a patient’s perspective, how to bring out the issues a patient wants to discuss, ways to respond to the patient’s concerns and other aspects of patient-centered care,” Platas said.

O’Connor also has a professional interest in learning more about psychosocial counseling, skills she hopes to include in her primary-care practice in general adult medicine.

“I’d like to help patients deal with common issues, such as lack of motivation for behavioral change, difficulties in their relationships, alcoholism, depression, substance abuse, and domestic violence,” O’Connor said. While the clinic in which she and Platas trained serves low-income patients who frequently had such concerns, O’Connor stressed that these problems also exist among people from other socio-economic strata.

Both students said that one of the important ideas they learned from Mauksch is that the subject that troubles the patient the most, whether it’s a medical or a psychological worry, is unlikely to be the first topic the patient will bring up in the doctor’s office. This reticence is made worse when a physician immediately interrupts a patient after a few seconds into the interview, before the patient has had a chance to finish expressing a list of concerns.

Platas gave as an example a man who might tell the doctor, “Well, I have this rash....” and immediately the doctor will begin to ask about the rash, examine the skin and prescribe treatment. When the doctor is done, the patient might say, “And, by the way, I also have this chest pain.”

A better approach, and wiser time-management, O’Connor said, would be to encourage the patient to briefly list his or her reasons for coming to the doctor, then help the patient determine which issues to address at that visit. The doctor can then do a good job for the patient without necessarily taking more time.

A second key insight from Mauksch is that patients who can’t be open about their worries will often drop clues. A young man with vague, recurrent abdominal pains for which no cause can be found may be unable to express the fear he feels because an older relative had stomach cancer. In this case, Platas said, it might help to have the physician discuss the actual health risks with the patient. Or, when a patient has puzzling symptoms, it might be useful to ask what the patient thinks, “What does this seem like to you? How is it affecting your daily life?”

The two students also discussed how to work better with patients who have difficulty adhering to treatment plans. The students would often ask for their patient’s thoughts about the proposed treatment and whether it would be feasible for the patient to follow-through.

“Overall, we tried to be better listeners by making the concerns of the patient No. 1,” O’Connor said. Mauksch added that, when patients feel they have participated more fully in their treatment decisions, when they feel as though they’ve been heard and their questions answered, their satisfaction with their care is higher and the outcome of the care is likely better, as well.

Other approaches the students used to improve their bedside manners were to pay attention to varied, yet effective, communication styles, among health-care providers. They also used a checklist Mauksch designed of patient-centered medicine skills they could emulate.

“Several research studies,” Mauksch explained, “have documented the effectiveness of these skills in the provision of patient care.”

After observing each other interviewing patients, the students privately critiqued each other’s strengths and weaknesses, assessed the overall flow of the interaction and suggested what could have been done differently. They also videotaped many patient interviews. They later played back the tape to reflect on what went well and what could be improved.

“Larry suggested that we videotape, which we discovered was much more reliable than relying exclusively on our memories of, ‘Remember when you kind of said this and she kind of said that,’” Platas said. “At first it was hard to watch ourselves on videotape and easy for us to make fun of ourselves. It’s like criticizing a central part of yourself. But we realized that being a good communicator isn’t something you either are or aren’t. There are many specific skills that all of us can acquire.”

The students’ elective clerkship followed the traditional learning aphorism, “Watch, Practice, Teach.” The checklist Mauksch provided, segments of the students’ videotapes, and the observational techniques became part of the materials for a seminar they participated in with Mauksch for the family practice residents at the Fort Collins Family Practice Residency in Colorado. The students hope that these materials on patient-centered interviewing techniques might also become part of the elective training offered to UW fourth-year medical students.

“The students were forthright in revealing their initial struggles in their videotapes, and then their successes,” Mauksch said. “They showed the progress that can be made when students or physicians dedicate themselves to communicating better with patients. The residents and faculty at the Fort Collins residency program found the medical student consultations with them on patient communications to be a valuable and enriching opportunity.”

This summer Platas and O’Connor will enter the UW’s primary-care internal medicine residency program. They plan to incorporate their training from this clerkship into their daily interactions with patients.

Leila Gray