Blog | Tuesday, October 13, 2015

I know what you did last summer


“You've always had the power, my dear. You just had to learn it for yourself.”
—Glenda the Good Witch

I acquired a new small group of medical student learners in July. First-year students fresh out of the layperson's world and still in those bumpy stages of trying to make sense of this new culture. My group is a mixture of students just months outside of 4-year universities and others who'd worked for a few years before coming to medical school. Either way, I'm fortunate to have 8 earnest, insightful and seemingly emotionally mature students in this new crew.

Yep.

For the last couple of weeks, we've been on the part of the curriculum where we introduce our students to the patient interview. They've been taught all of the elements of how to take a medical history and determine the narrative of a patient's present illness. Readings outlining nonverbal cues and ways to facilitate a conversation have been assigned and handouts posted on their electronic blackboard site explaining the right and wrong ways to build rapport with patients. And while all of it is good and true and well-meaning, any person studying these materials would probably discern quickly that it doesn't seem like rocket science. Then again, maybe it does sound a little too much like rocket science (even though it isn't) which is why the students get so tripped up about these early patient encounters.

At least that's what I think.

So yeah. I guess whenever I look at literature about how to talk to patients, I almost always instinctively wrinkle my nose and squint one eye. “Why are we making this so academic?” I always mumble to myself. And again, I am taking nothing from the experts who've devoted their medical career to this. Instead, I'm just thinking that, just maybe, all of this would be much, much easier for our students if they could just remember one thing and one thing only: Patients are people.

Simple, right?

I mean, actually? Yeah. Right. Patients are people. And people are not something that should be foreign to a high achieving college-educated person beyond the age of 21. What makes it even easier is that our students are people, too. So they already have a point of reference.

Does this sound confusing? I'm sorry. Let me be more clear.

So check it. I was tasked a few weeks back with helping my students take a medical history. They'd learned the elements and I was supposed to have them interview each other in pairs with a mock chief complaint that had been provided in the assignment. And yes, those simulated complaints were good ones that, I'm sure, would offer great practice to these budding young student doctors.

But.

The focus was supposed to be fluidity and asking open ended questions. Fighting the urge to do what 100% of doctors in nearly every patient-doctor communication study I've ever read does to their patients--interrupt. Yeah. So the point was that and not so much those complaints. And the students knew what they were supposed to be doing and were ready to give it a try.

Yup.

So the truth is that I've been doing this long enough to know that somehow, some way all of the academicism of the exercise causes even the best communicators to forget simple tenants of interpersonal skills. Being told that you're “in a clinic” instead of “in Starbucks” creates this weirdness that more often than not morphs into these staccato yes-no questions that fly out of mouths without rhyme or reason.

And so. This year, I decided to try something different for that first session. Since I knew that we'd have enough time, I started the session off by going over all of the assigned material. We talked about ways to have a good interview and tips for encouraging the patient to speak. I told them that we were going to do the mock chief complaints but first we'd do something else. Something very different yet pretty much the same.

I paired them up and then gave these instructions instead:

“You are in a coffee shop. Your task is to find out about the very best thing the person did this summer. Get as much detail as possible because you'll have to tell us about it. Why was it the best thing? Who was there? What did they do? What experiences did they have?”

You know what happened? They relaxed. They listened. They didn't interrupt or interject with their opinions. They nodded their heads in the places one would nod a head and asked the kinds of questions that convey genuine interest. And, of course, the person being interviewed opened right up and gave even more information.

Yep.

It was so awesome, man. They were laughing and enjoying one another. Reacting to the remarkable parts of the stories and gaining clarity on the aspects that didn't make sense. And, because those conversations were light and the “patients” felt heard, it was easy. No one had to explain to anyone “how to be”--it came natural.

Sure did.

I had them swap interviewer and interviewee but changed the instructions a bit. This time they had to find out about the most frustrating or disappointing thing to happen to them in the last year. Similar to the last one, it was the job of the person asking to find out what happened and why this particular incident was identified as the one so significant that it got this label.

You know what happened? The empathy came right on out. Facial expressions conveying regret and automatic shifting of intonation. Softer voices, gentler eyes. And all of it happened naturally.

Yep.

Immediately after, we moved into those medical complaints and did the same exercise. And you know what? It went great. It really did.

You know what else about this was so cool? After each of those first interviews, I asked the interviewer to tell the group what they'd learned. Without fail, every single one of them broke out into these elaborate story lines chronicling summers in Barcelona, rides on very, very big roller coasters, and long summer days in New York City. No one took a single note. Yet, somehow, they got all of the most important parts. Just from listening and not jumping ahead. And conveying through body language and voice that they were there precisely for one reason--to get that person's story.

I guess what I loved so much about that part was that I believe that when one person is allowed to speak while the other carefully listens, it's usually easy to remember most of it. I think getting too many rules thrown at you on how to do this takes away from our ability to listen. Any time a person is trying to remember the steps to something, hearing gets interrupted. Like, totally.

Honestly, I wish someone had told me all of this when I was a medical student or an intern. Like, I wish they'd simply reminded me that patients are people and that I'd already gotten quite far with the communication skills that I have. It would have been great to have it explained to me that I wouldn't need to overhaul my complete personality to be a doctor. I'd just need to acquire some knowledge to help guide my questions.

Yep.

Somewhere around my third or fourth year of residency, I started realizing all of this. It dawned on me that having only 1 version of myself that adjusted only slightly depending upon the patient and the setting required less memory. And it felt more authentic. On top of that, I got far more from my patients when I just told myself, “This is a person who needs to be heard. And I am a person who is here to listen so that they can.”

I still tell myself that to this day.

So, I guess my approach now is simpler. I come out of the gates telling them that any person who cares about other humans is already qualified and able to take a kick ass, non-awkward, and completely thorough history. I spend more time discussing the art of listening, which is an art indeed, and try as hard as I can to model that for them.

You know what? Every day I'm realizing more and more that being tasked with guiding brand new medical students into what is arguably the most critical aspects of who they will be professionally is huge. More than huge, it's ginormous, man. But the more I do this, the more I am seeing my role as more like Glenda the Good Witch than the Wizard of Oz. That is, my job is to simply shine a light on the person that is already there and give them the courage to click their heels and trust who they are.

And the best part? Every lesson for them is a lesson for me.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.