COLUMN ONE : Learning Bedside Manners : Medical groups and educators are paying more attention to how doctors communicate with their patients. Some physicians are even finding out what it’s like to be hospitalized.
Her skin itched. She felt exhausted. She was hyperventilating. And from her fingers to her toes, she complained, “everything hurts.”
The housewife, in her 30s with two small children, was running through this litany of pain when her doctor, a specialist in internal medicine, cut her off in mid-sentence.
With only a few questions, and without a physical exam, he diagnosed a recurrence of depression--”suburban syndrome,” he called it--and prescribed a tranquilizer.
Such conversations--so truncated they can hardly be called that--are common when doctors and patients meet, said UC Irvine professor of medicine Dr. Howard Waitzkin, who tape-recorded this exchange along with 335 other doctor-patient interviews.
Physicians typically interrupt their patients 15 to 30 seconds after they start talking and spend just 90 seconds of a 20-minute meeting imparting medical information, he reports. Further, many doctors use a “high-control style” that ignores social problems such as job loss, or, in the housewife’s case, possible stress from a recent Dallas-to-Boston move.
But cutting off dialogue and ignoring non-medical issues can have serious consequences, Waitzkin and others argue--at worst, leading to the wrong diagnosis.
The way doctors communicate is now getting some extra attention. Do they really listen to patients? Can they explain medical information clearly? Do they blend sophisticated medical skills with a large dose of compassion? Do cool and clinical “bedside manners” come across as rude?
Even Hollywood has taken up the cause. In the movie “The Doctor,” a hotshot surgeon played by William Hurt is a whiz with the scalpel but is also an arrogant snob. Only after a bout with throat cancer does he learn to mix medicine with tender loving care.
In the real world, medical educators, doctors and hospitals have sought to find the proper blend themselves:
* At Long Beach Memorial Medical Center, young doctors in the family practice residency program spend their first day as patients. Wearing backless gowns and hooked to IVs, they learn firsthand the indignities and sense of helplessness endured by patients.
“In the hospital, I felt absolutely out of control. It’s a whole different world, literally stripped of all your clothes,” said Dr. Jose de Souza, now a third-year resident from Irvine. Now, he said, “I’m a little more comfortable with how a patient feels. . . . And I’m more apt to sit on his side of the bed, to be at eye level with him.”
* Since 1989, Miles Inc.’s pharmaceutical division in West Haven, Conn., has offered free workshops on communications skills to 2,000 physicians around the nation. Some insurance companies offer attendees discounts of up to 20% a year on malpractice insurance.
* This January, the American Medical Assn. published a malpractice textbook for students and physicians that urges them to talk with patients. “Frankly, we’re dealing with a population that hasn’t been taught communication skills,” one AMA official explained. “Most doctors have a highly scientific education all the way through to their residency--without having anyone telling them how to sit down and interact with patients.”
* At the FHP health maintenance organization based in Fountain Valley, all 625 staff doctors must take a class that stresses eye contact, positive body language and empathy with patients. Veteran physicians are videotaped and critiqued as they take turns playing doctor and patient. FHP says the 3-year-old program has increased patient satisfaction and reduced turnover among the medical staff, who report more enjoyment from their work.
* Many medical schools are revising curricula to develop greater awareness and compassion for patients. In January, the UCLA School of Medicine will begin a new “doctoring” curriculum that will require students to work at a homeless shelter and to meet regularly with someone chronically ill.
Beyond the obvious need for proper diagnosis and treatment, there is good reason to improve communication skills.
A 1990 survey by the Miles pharmaceutical division found that one in four Americans had switched physicians at least once because the doctor made them feel uncomfortable, did not relieve their anxiety or failed to answer questions. A 1991 AMA survey reported that only 42% of respondents thought doctors explained things well to their patients.
Some studies show that 70% of malpractice claims resulted at least in part from a doctor communicating poorly and making his patient upset.
“In some specialties like family practice, it’s improving, but I think patients don’t always feel welcome to express their feelings,” said Ellen Severoni, president of California Health Decisions, a nonprofit education group in Orange.
Cancer patient Vicki Goldish said she frequently has to “train” her physicians “to be sensitive, listening doctors.”
“I have asked them to look me in the eye. I have asked them not to race through their comments,” said Goldish, who often brings a yellow legal pad to appointments and takes notes.
Four years ago, when a surgeon informed her she had cancer, he then abruptly left the room, Goldish said. On his return, she demanded that he close the door, sit down, and give her a full explanation. He complied.
But Goldish--executive director of the Wellness Community-Orange County, a cancer support group--is not shy. “All we teach is: ‘Doctors may be busy. They may be rude. They may be insensitive. But you have a right as a patient to ask as many questions as you like,’ ” Goldish said.
Some doctors argue that there is little time for compassion. They say the sensitive physician, depicted in 1950s Norman Rockwell paintings or the 1970s TV show “Marcus Welby, M.D.,” has been driven into extinction.
“As much as you would like to practice the kind of medicine that your grandfather practiced, you can’t,” said Anaheim plastic surgeon Robert Miner, past president of the Orange County Medical Assn.
“The patient is antagonistic because he’s going in for treatment that’s at best outrageously expensive,” Miner said. Meanwhile, a doctor’s time--and often the treatments he would like to offer--are sharply limited by Medicare or private insurance.
“Try and bill someone for talking to grandma,” Miner said. “Doctors would really like to have that good bedside manner, but they can’t afford the time. You don’t get paid for being caring.”
Many other doctors, however, believe they have a duty to hear their patients out--not just listen to their medical problems but spend part of the doctor-patient interview learning about job stress, a pending divorce or whatever comes up.
UC Irvine’s Waitzkin, author of a recent book, “The Politics of Medical Encounters,” argues that a system of national health insurance would make it easier for doctors to listen to patients--and to refer them to social services.
But national health insurance may be a long time coming. For now, programs at medical schools and elsewhere will affect a new generation of physicians.
When the UCLA School of Medicine launches its “doctoring” curriculum, students will meet patients during their first week of classes--not, as in years past, in their third year of medical school. Working in small groups, the students will meet regularly with a chronically ill person and a new mother for at least two years.
After taking courses in ethics, communication skills, and the health-care system, third-year students will be required to work in nursing homes and drug rehabilitation programs as well as jails and homeless shelters.
“What I’m trying to create are physicians that care about people and feel a social obligation to care about people,” said Dr. Michael Wilkes, an assistant professor of medicine who directs the program.
At UC Irvine, medical students must take the traditional class in interviewing and examining patients, but for the last three years, they have also had to take a medical ethics course that stresses each patient’s “humanity.” And in a novel effort to make sure that they do not consider aging a synonym for disease, first-year students are now paired with healthy, active senior citizens who attend some classes with them and discuss what it is like to grow old.
“We have our powerful scientific tools, our MRIs, our DNA-based testing, our methods of studying the heart and brain no one dreamed of 10 years ago,” said Dr. Robert Chilcote, a pediatric oncologist at UC Irvine School of Medicine and past curriculum committee chair. “But we can’t order those expensive tests in lieu of talking to the patient.”
At Harvard University Medical School, the curriculum was rewritten four years ago to emphasize communication skills as well as scientific knowledge. Groups of six medical students meet weekly with faculty to learn to talk to patients, discuss medical ethics, and talk about recent cases.
Harvard’s curriculum was revised because medical students had become “so technologically focused,” said Dr. Richard J. Pels, a primary care physician and Harvard instructor. “Society clearly wants people who are technically competent,” Pels said. “But society also wants people as their doctors who are caring and who stop to listen.”
The new emphasis is popular with students. “Unlike the traditional first year (of medical school) where you learn the basic science but have no idea how this relates to patient care, we do this from the beginning,” said Harvard second-year student Lauren Solanko, 24.
In a recent class, Solanko and her colleagues reviewed the case of a man with Parkinson’s disease but quickly decided that they had “two patients: the man with Parkinson’s--and his wife.” They discussed how the disease might affect the couple’s marriage, their savings and his wife’s emotions as she assumed the burden of caretaker.
As the second year of Harvard Medical School began for Richard Krasuski, he had already talked with patients about bereavement, teen sexuality and the impact of a disfiguring disease. The latter patient was an elderly woman with neurofibromatosis--”elephant man’s disease”--who described how she felt when strangers stared at her.
“Certainly, I learned a greater appreciation for what these people go through--her physical and mental pain,” said Krasuski, 22.
“You have to take a caring attitude,” he added. “But you don’t want to approach the patient in a way that says you’re feeling sorry for her.”
Harvard students initially worried that the new curriculum might be too “laid back,” and that their scores on national medical exams might fall. So far, those fears have proved groundless. Students have recorded higher scores each year and last spring’s exams marked the highest pass rate ever for second-year students--with 99% passing the exam.
Despite the emphasis on communication, medical school professors are divided over whether a doctor--or anybody--can be taught to be caring.
“A lot of it is in the genes,” said Dr. Jules Cohen, senior associate dean for medical education at University of Rochester Medical School, which has long trained students in “psychosocial” medicine.
Still, Cohen said, Rochester’s medical students are expected to learn “professional intimacy.” They must “get close enough to care about patients,” he said, “but whether you’re a surgeon or a cardiologist or a psychiatrist, not so close that your judgment is impaired, so that if things don’t go quite right, you’re devastated.”
At Long Beach Memorial, family medicine director Dr. Stephen Brunton drew on his experience in starting the resident-as-patient program five years ago.
As a medical student, Brunton was hospitalized with an eye injury and quickly “realized there was more to be learned from the other side of the sheet.”
Each year, his six residents are admitted to the hospital overnight with a false diagnosis, a handicap (perhaps a full leg cast or patches over both eyes), a special hospital diet, and, to make sure they feel “a sense of discomfort,” an IV line.
Brunton calls the experience “very humbling and enlightening. . . . These are people spending their lives in health care, and some of them have never been in a hospital before.”
