Program Helps Medical Students Relate : Health: Working with the terminally ill, future doctors see themselves through patients’ eyes and experience the importance of bedside manners.

In the chemotherapy room at Yale-New Haven Hospital, medical student May Chen and patient Sister Claire Dubuc meet several times a month to talk about dying.

Chen is enrolled in a seminar on seriously ill patients. For a semester, the 22-year-old and other first-year medical students are paired with cancer and AIDS patients who volunteer to teach them about terminal illness.

Soon enough, Chen will be overwhelmed by the technical demands of patient care. This may be her last chance to get to know a patient as a person first, a medical problem second. “It’s important to reach them before they put on the white coat,” said Dr. Alan C. Mermann, Yale Medical School’s chaplain, who created the course three years ago.

About 40% of the freshman class have enrolled in the seminar this year. Most are in their early 20s and have had no previous exposure to serious illness or death. Peter Bernstein, a second-year student who took the course as a freshman, recalled his first meeting with his patient-teacher: “I had no idea what to say. I thought I would have to be profound, or cry.”

Kathy Ryder, also a second-year student, said she had “expected to be sitting by someone’s bed, holding their hand and talking to them abstractly about Kubler-Ross’ stages of death.” Instead, her patient, who had colon cancer, preferred discussing his children. She said she had learned from this “that people don’t necessarily collapse when they have a serious disease. They can go on enjoying life.”

Dubuc is 50 and has metastatic breast cancer. She has confessed to her students that she mistakenly thought that losing a breast would be less devastating for her than for other women since she has no husband to please. Chemotherapy frightened her at first, she said, and years of wearing a habit failed to mitigate the trauma of losing her hair. She has spoken about her anger, depression and her bargaining with God.

Mostly, though, she has tried to explain what, from her perspective, makes a good physician. She told Chen: “A good physician listens very carefully to the patient and respects the patient’s knowledge of her body.” When Dubuc first went to her physician with back pain--a symptom of her cancer--he dismissed it as stress and advised her to take a vacation.

The nun has complained about the indignity of being ordered to strip before a group of physicians on rounds. A good physician respects the patient’s modesty, she told Chen, and also takes a moment to put the patient at ease. “A touch on the shoulder can make the difference between improvement and not,” she said.

Few patients asked to participate in the seminar have refused. The patients are eager to share their horror stories and to help future physicians do better, Mermann said. He recalled a hospitalized leukemia patient who told of hearing a group of physicians approach. From the hall, he heard the word “cancer,” then laughter. The group entered, and one of the physicians spoke to him from behind a chart. To the patient, it was an everyday example of astonishing insensitivity. “It doesn’t take any longer to sit on the edge of the bed and touch my shoulder or knee and say, ‘How are you?’ ” he said.

In a small library that is part of Mermann’s suite of offices, first-year student Evan Fischer met recently with his patient-teacher, a 62-year-old man with cancer of the bone marrow. The patient told Fischer that he regularly attends a cancer-support group emphasizing a positive attitude, meditation and visualization of cancer cells being destroyed. “I pray, not on a regular, steady basis, but I do,” he said. “It’s good to think about a force other than yourself or medicine--God, nature, energy--that might be able to help.”

He added that he drew strength from his two grandchildren. “You think about their growth, their healthy cells, their energy,” he said.

Then he paused, seeming embarrassed. “I hope you’re getting something out of all this conversation.”

“Oh, you don’t know!” Fischer replied. He said he had never interacted with a patient before. “Everyone comes to medical school with the idea of becoming a hot-shot surgeon, but I realized all I want is to be liked by my patients and to help them. That’s why I ask you questions that I hope aren’t too personal.”

Another first-year student, Ross Zbar, has been paired with a pediatric resident who has Hodgkin’s disease. Said Zbar: “He’s only five years older than I am.”

At first, the resident assumed a teaching role with Zbar. One day, he slapped an X-ray up on the light board.

“What’s wrong with this chest?” he asked the student.

Zbar identified a cloudy mass.

Suddenly, tears sprang into the resident’s eyes. “I can’t believe that’s mine,” he said.

Mermann conceived the idea for the seminar after students mentioned their awkwardness around dying patients. With no instruction, the students found themselves mimicking the cool, distant demeanors of the interns and residents.

Mermann understood the dilemma. As a pediatrician for 30 years, he was never comfortable with terminally ill patients. When his own mother was dying, he had trouble broaching her illness with her. “I could have been taught those things like I was taught other things,” he said. “My God, if you can teach people Sanskrit, you ought to be able to teach them empathy and compassion.” His dismay led him to pursue a divinity degree.

The seminar’s students are learning how much the patients value their emotional support.

Steven Care, a second-year student, was paired last year with an AIDS patient. One day, the patient was rushed to the emergency room, where Care found him frightened and withdrawn. “You could almost see him curled up in a fetal position,” Care said. “I reached out and touched him, and he stopped shaking; he wasn’t so scared any more. It was as if I’d given him a cup of water and a pill. I don’t think you can get much more graphic than that.”

Peter Bernstein’s patient-teacher died in October. Bernstein had stayed in touch with him after the seminar ended, striving to walk what Mermann calls the delicate line between friendship and professionalism. “I was surprised at how much his death hit me,” Bernstein said. “But it wasn’t traumatic. I was still able to go to class that day and perform.”

A few days before his death, the patient had asked to see Bernstein. Mermann was present at the meeting, where Bernstein told the patient that he had written a paper based on their discussions. Mermann recalled: “They shook hands and thanked each other for what they had done for each other. Bob said to Peter, ‘You allowed me to do something with the last days of my life--to offer a gift out of my hopelessness.’ ”