The other side of the exam table
By Kay Torrance
In the late 1960s, William Branch arrived at a Boston hospital as a new resident. Bright-eyed and energetic, he walked through the front door, eagerly anticipating the challenging medical cases he would be asked to solve. He expected to work with an older, more experienced doctor—someone resembling Marcus Welby, the fictional TV doctor who was steady as a rock and loyal to his patients.
What Branch got instead was a rude awakening. Shifts that lasted 24 hours with little, if any, time to sleep. Being left overnight with a hospital ward of patients to tend on his own. And impatient doctors who were often indifferent to residents as well as patients.
Marcus Welby was nowhere in sight.
“The system back then was inhumane,” Branch says. “Compassion was stamped out. The egregious stuff that happened in the 1960s—like people making comments about patients or calling them names—rarely happens today.”
At times during his residency, his ability to be compassionate to patients sometimes took a hit, concedes Branch, now an Emory internist. To his dismay, he saw residents soaking up the bad behavior of some of the doctors and unconsciously replicating it.
Armed with a steely will not to repeat those behaviors, Branch entered academic medicine and spent the next 30 years teaching experienced and future doctors how to maintain compassion. His research has helped dispel the long-held myth that compassion and empathy are character traits—either a doctor has them or not. In fact, behavior that reflects compassion and empathy can be learned, and Emory’s new medical curriculum reflects that fact.
For decades medical schools and teaching hospitals focused on turning out superb technicians. Students and residents were expected to be well versed in the latest medical advances and knowledge about disease, but the advice they usually received on how to communicate with patients was to maintain emotional distance. As patients found out, good technicians didn’t necessarily make compassionate clinicians.
Teaching compassion begins on the first day of medical school at Emory.
Students are assigned to small groups of no more than nine led by a faculty adviser, who will remain with them throughout their four years of school. The groups cover topics not frequently found in textbooks, such as doctor-patient communications. These interactions are key starting points to learn how to develop the behavior of compassion and empathize with patients’ experiences.
Since then medicine has learned that compassion and communication skills should—and need to—matter. Studies have shown that compassionate care can lead to better patient outcomes and adherence to treatment regimens. And how doctors communicate to the rest of the care team also can affect patient outcomes, as well as work relationships and the culture of a health care system.
The behavior of established doctors also has a profound effect on another group—medical students. Medical students model themselves after the doctors they see in action and internalize the behaviors they witness. Medicine has long wrestled with ways to abolish what is referred to as “the hidden curriculum.”
“A great deal of what gets transmitted to students is from being around someone for those four years and what that person conveys,” Branch says. “A lot rubs off. Most students come in full of idealism and want to be compassionate. Whether it’s pressure to memorize or pressure on the wards to get the job done, the compassion gets left behind. Our job is to keep that from happening. We want to help students develop compassion and empathy to their fullest extent.”
When Emory’s medical school began revising its curriculum eight years ago, Branch and other faculty worked hard to better incorporate long-term mentoring into the student experience.
“In our minds, the most important thing was to incorporate mentoring into the curriculum—not just a hit or miss thing where students would have to schedule an appointment with an adviser,” says Monica Farley, an Emory infectious disease specialist who co-chaired a faculty committee that looked at ways to incorporate mentoring into the curriculum. “We wanted students to have much longer and higher-quality exposures to faculty and physicians so they could really model themselves after someone with whom they had worked for a long time. I think it’s one of the biggest achievements of this curriculum.”
The day students enter the school, they are assigned to a small group of no more than nine students called a society. Each group spends all four years with the same faculty adviser, mirroring the longtime relationship that ideally a patient has with his or her doctor. The groups often function as a mini version of class, covering topics not usually found in a textbook, such as doctor-patient communication (for example, using open body language, breaking bad news, discussing the results of genetics tests, or talking about adherence to a medication regimen).
“These days patients are far more likely to be cared for by a doctor who doesn’t have a longtime relationship with them,” says Emory internist Nathan Spell. “So more than ever, we need a new skill set to be able to quickly step inside a role and form a trusting relationship with a patient.”
Do unto others
Tim Buchman, director of critical care at Emory Healthcare, calls himself a “recovering trauma surgeon.” He practiced that high-pressure specialty for more than 20 years and knows that surgeons have a reputation for being insensitive. After all, they often find themselves in situations where “command and control” communications are necessary to save a life. “Resuscitating a bleeding gunshot victim requires split-second decision making, along with the confidence that the team can and will follow orders,” he says.
Like many practicing doctors today, Buchman received no instruction during medical school and residency on the different styles of communication that are needed to be effective with patients and co-workers. Trainees mimicked their attending physicians, whose ineffective, even hurtful, communication styles passed from one generation of doctors to the next. “Task completion trumped civility in medicine, right up until the moment that it became necessary for health care to make a quantum leap toward delivery of consistent, high quality, high reliability service,” Buchman says.
A few years ago, when Emory’s surgery department wanted to improve the flow of surgical patients, employees came back to the department chair and reported that they couldn’t agree on how to improve any process because they didn’t get along. The department then developed a covenant—an agreement among the professionals as to how they would communicate with, and treat, one another. The document proved so popular that other areas began using it, and last year, Emory Healthcare rebranded it as “The Pledge” and incorporated it into their operational plan.
Hundreds of Emory Healthcare employees—from doctors to nurses to financial analysts to housekeeping staff—have taken the pledge, which is optional, to treat others the way they would want to be treated.
“These are things we learned at age three,” says Doug Morris, director of the Emory Clinic and J. Willis Hurst Chair of Medicine. “But it’s helpful to be reminded. This is about how you want to be treated and how you remind someone when they slip.”
When someone does slip, the health care system encourages a “cup-of-coffee” conversation, and it even offers workshops on the pledge to give employees examples of language to use to start such a conversation. I’d like to talk to you about the interaction we had yesterday…
“The more people who take the steps to have these conversations, the sooner this will become a part of our culture,” says Hal Jones, who leads the workshops as part of Emory’s care transformation team. “The pledge is not enough—it needs people to practice and reinforce it.”
Breaking through the culture of medicine may be the biggest challenge in spreading the pledge, says Emory University Hospital’s Chief Quality Officer Nathan Spell. Health care professionals tend to hold themselves up to the level of perfection. “We have to get doctors and nurses to admit they are human,” he says, “and then they can be more compassionate with themselves, each other, and patients.”
Compassion and communication
Emory oncologist Mary Jo Lechowicz walked into a classroom where her small society group was waiting for her on an early afternoon in mid-September. These brand new students were eager to get started. They had begun medical school less than two months earlier, and already they were learning the ins and outs of giving a physical exam.
This day the lesson focused on pelvic and breast exams, but the session’s goal involved much more than learning how to insert a speculum or use proper technique to detect lumps in the breast. It also concerned how to talk to a patient. Always ask the patient about the experience of her last exam. Is there anything you’d like to discuss? Such an opening can elicit important information, like past sexual trauma, explained Lechowicz.
This is the back of my hand on your inner thigh. Now you’ll feel my hand. Explaining any procedure in detail, regardless of the patient’s prior experience, helps build rapport and trust, Lechowicz told the class.
What may not be obvious at first to these students is that the communication lessons are designed to foster compassion. Emory’s medical faculty want students to see that compassion is much more than sympathizing with a patient’s medical issue or “being nice.” It’s about body language, allowing a patient to process difficult news, not just hearing what a patient says but really listening.
Expressing compassion is not something a medical student can learn overnight, says Lechowicz, but with practice, students can become more at ease with difficult conversations. Communication lessons are repeated throughout the four years of Emory’s medical school to help students internalize this ability.
“The mistake in medicine in the past is that people thought you either had compassion or empathy or you didn’t,” she says. “I think there are tools that can be taught and used that can help enhance a physician’s natural wish to do the best for their patients.”
On this day, the male medical students got special attention in Lechowicz’s class. She had them put on a gown (pants remain on, of course), put their feet in stirrups, and slide all the way down the exam table, as she went over how to communicate with a patient during the exam.
“It’s a really vulnerable position, unpleasant,” student Michael LaRiviere says after his turn. “Even though I knew she wasn’t going to do an exam, I still felt I needed to trust her.”
The male students also realized the need for warm instruments, why the exam table should not face the door, and that the curtain should always be pulled in case someone accidentally walks in. Murphy’s Law, Lechowicz told the students, dictates that the door seems to fly open only during a testicular, rectal, or pelvic exam.
A student’s first patient
In many medical schools, a student’s first patient is, well, deceased. Human anatomy taught with the use of cadavers is often one of the earliest classes for a first-year student. Contact with living patients typically is confined to the second half of medical school.
When Emory’s medical school turned the old curriculum on its head five years ago, anatomy was delayed seven months. Now Emory students interact with real patients within several weeks of starting medical school. (As one faculty member says, “Emory believes your first patient should be a living one.”) Modules throughout the four years of medical school usually incorporate real patients so that students can experience what it’s like on the other side of the exam table.
For example, in a weeklong module on aging and geriatrics, students watch an actor age from 50, as she enters menopause, to 80, when she is dying of cancer. They hear from caregivers, who talk about their changing relationships with their loved ones and their struggles to manage a dizzying array of doctors and medications. They also hear from patients in palliative care who are coping with their own mortality. Not only are the lessons of how to talk and listen to a patient repeated, but students also learn how to process their own feelings about death and dying so that they are able to open a similarly difficult conversation with a patient.
Practice and reflect
Fast-forward to 2015, and those students who are now in their first year of medical school have graduated and are in the throes of residencies. Long hours, the demands of patients, and impatient senior doctors take a toll on many residents. The eagerness and compassion with which they entered medical school have begun to drain away.
Humanistic training beginning in medical school and continuing into residency can help stop the erosion of compassion, say Emory faculty who teach the techniques. One Emory internist has seen a difference in recent graduates compared with those of years past. Kimberly Manning, who supervises residents at Grady Hospital and serves as an adviser to medical students, says the emails she received from the 2011 class are encouraging and suggestive of an evolution toward more humanistic behaviors in up and coming physicians.
One of her former students, who graduated last May, is an anesthesiology resident at a military hospital in Washington, D.C. Her recent email to Manning detailed how little she had previously thought about the sacrifices soldiers made during their service in the Middle East, and how now every day she sees men and women younger than her who are missing limbs. Her email barely mentioned her long hours or the other trials and tribulations of being a first-year resident, a significant change from what Manning herself would have even thought to share as an intern.
“We’re talking about things that we didn’t talk about before,” Manning says. “When I was a resident if I saw something happen that troubled me, I would talk to my classmates about it. It wasn’t the culture in medicine to talk about it up the chain. Now the culture is different. Things like dealing with difficult patients, noticing when someone is impaired—all the things that are humanistic have a found a place at the table in the new curriculum. We humanize people now. We spend time talking about our experiences with patients.”
Manning asks her residents to write about an experience—good or bad—that made a lasting impression on them. By examining the experiences, they can become better doctors. She calls the practice “habitual reflection” and believes it is vital to developing compassionate doctors. She also writes regularly herself in a blog, Reflections of a Grady Doctor (gradydoctor.com).
“One of my goals when I’m working with residents or students is for them to develop what is referred to in the literature as a habit of humanism,” she says, “to habitually think about the other side of the story. In some of my most difficult situations as a doctor, falling back on humanism has helped me. When it becomes your default, you do it without thinking.
“I don’t try to teach morals or values. I just want people to think about what they are doing. We are not football players reviewing plays. We are dealing with humans. This will always be a profession that’s different from others because it’s about people.”
When Manning gives talks around the country to other doctors about humanistic behaviors and the teaching techniques that Emory’s medical school is using, she often sees them have an “a-ha” moment. She is glad to see medical schools and health care systems embracing this approach and placing more importance on humanism in medicine.