American College of Physicians: Internal Medicine — Doctors for Adults ®

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.


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.


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.


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.


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.


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.


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.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

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PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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