Weissmann, Peter F. MD; Branch, William T. MD, MACP; Gracey, Catherine F. MD; Haidet, Paul MD, MPH; Frankel, Richard M. PhD
When I ask an educated person, “What is the most significant experience in your education?” I almost never get back an idea, but almost always a person. - —Daniel C. Tosteson, 1979
As suggested above, humanism is an essential skill for medical practice.1–3 When physicians are perceived as humanistic, their patients are more satisfied and achieve better health outcomes.4,5 The Accreditation Council for Graduate Medical Education and several other certification and specialty boards seem to agree with this observation, requiring that medical residents learn attitudes and demonstrate behaviors consistent with humanistic care.6
Although the medical literature amply describes these attitudes and behaviors and residents can identify faculty physicians who are exemplary humanistic role models, neither indicate how these skills should be taught.6–16
Possibly, the real question for medical educators may be not so much what, but who, can best model professional values and humanistic attitudes. In our attempt to answer this question, we audiotaped teaching encounters with 12 faculty physicians from four medical schools who were voted by their learners (i.e., residents and medical students) as outstanding teachers of humanism. In addition we conducted postencounter interviews with patients, learners, and teachers. We wanted to learn the techniques these faculty employed for imparting such values and attitudes.
From our analysis of the transcribed tapes, a common theme appeared—the faculty we observed taught professional values by modeling them. We noted that each clinical teacher had a unique style as a role model and surmised that each had learned the role modeling skills on his or her own. They were, perhaps, influenced by important teachers who they, themselves, had previously encountered. We also noted an interrelated, important second theme: Most of the clinical faculty were highly aware of their status as role models. They reflected on the effectiveness of this component of their teaching and eloquently described their personal approaches to role modeling. They assigned a high degree of importance to imparting humanistic values to their learners. Our report describes how these superb teachers went about this task.
We collaboratively designed a survey instrument for residents to use in identifying outstanding humanistic clinical faculty at each participating institution (University of Minnesota Medical School—Twin Cities, University of Rochester School of Medicine and Dentistry, Emory University School of Medicine, and Baylor College of Medicine). In 2003, we asked residents in the departments of medicine to respond to the following survey question:
We are conducting a multicenter study to identify practices by which physicians learn to incorporate humanistic behavior into clinical practice. For the purposes of this question, humanistic medical care is defined as: “Medical care that combines the appropriate application of scientific knowledge and technical skills with acknowledgment of and respect for the emotional, social, and cultural needs and preferences of individual patients and their families.” Please name two attending physicians who have served you as excellent role models or teachers in the provision of humanistic medical care to patients. Your nominees should embody humanism in patient care, teaching, and relationships with colleagues.
We approached the top three to seven faculty members at each site and invited them to participate in the study. Of the 18 faculty physicians approached, 12 agreed to participate. All 12 were included in the study and directly observed during inpatient rounds in the years 2003 to 2004.
Institutional review board approval was obtained at each of the four participating institutions. Study participants signed an informed consent form.
For our data collection strategy, we observed each participating faculty member with specific patients during routine inpatient teaching rounds. We selected these patients based on their consent to an audiotaped encounter. While observing the clinical teachers, we audiotaped encounters with their patients and kept structured field notes. All audiotapes were transcribed verbatim and checked for accuracy. After each encounter, one of us conducted separate semistructured interviews with the clinical teacher, learners, and patients. Interview questions for each group appear in List 1.
As a means of calibrating our recording and interpretation of field notes, each of us received and highlighted sections of an index videotaped encounter that best illustrated teaching humanism. The index tape was not part of the current study. We then met by conference call to compare notes and reconcile differences. We reached agreement on 100% of the cases.
To identify best practices for teaching humanism at the bedside, each of us reviewed data from all sources, including the field notes, semistructured interviews, and transcripts. This information was synthesized into a structured abstract that consisted of the section of transcript containing the exemplary teaching behavior, supporting field notes, additional analysis, and description of the concepts involved. An example of a structured abstract appears in List 2.
In the final step of the analysis, each of us reviewed all of the structured abstracts. In total, we reviewed 25 teaching encounters from which we identified best practices for teaching humanistic care based on observed behavior. The following best practices, supported by data from the postencounter interviews, reflect our consensus.
The clinical teachers we studied taught humanism and professional values almost exclusively by role modeling. Generally, they assumed that learners would recognize, learn, and emulate their behaviors without added comment or direction. Occasionally, the teachers would hold reflective discussions followed by role modeling. We were most impressed by the wide spectrum of role modeling behaviors we observed. Below, we describe this rich array of role modeling on clinical inpatient rounds, not only as we observed but also as patients and medical trainees corroborated.
Teachers frequently demonstrated personal interest in their patients by nonverbal cues. Listening closely to patients characterized many clinical teachers. Sometimes asking permission and sitting on the side of the bed at eye level with the patient conveyed the teacher’s interest. One teacher carefully arranged chairs for his residents and students in the patient’s room. A student commented that another teacher “crouched and was eye level with the patient and was paying attention to what [the patient was] saying, not only verbally but also physically.” Occasionally, the clinical faculty held a patient’s hand or used another form of brief, appropriate touching.
Learners and patients also identified their teacher’s/doctor’s tone of voice and pace of speech as important communication components. As one patient described it, “[the doctor] wasn’t forcing me.” Another patient described his teaching physician as “not coming on too strong.”
Demonstrations of respect
All of the teachers we observed had overtly and frequently demonstrated respect for their patients in ways that were obvious to both learners and patients. Demonstrations were as simple as making proper introductions or asking the patient’s permission before turning down the volume of the television.
The clinical teachers we studied made certain that patients participated in discussions of medical decision making. One faculty physician primed his learners by asking them to consider whether aggressive inpatient diuresis would be preferable to slower outpatient treatment. After the team of residents and students had deliberated outside the patient’s room for a few minutes without coming to any consensus, the teacher suggested, “Let’s ask the patient. Maybe she has a preference.” The team then proceeded to discuss the treatment options with her and follow her lead.
In another particularly poignant encounter, a young woman suffering from leukemia had posted a sign on her hospital door stating specific preferences and visitation limits. The teacher honored her request by carefully negotiating a plan for pain control. He frequently asked the patient if she felt comfortable with the discussion. In the postencounter interview with the site investigator, the patient stated that this doctor differed from most of those she had dealt with because “he looks at you, he listens, he’s nice, he takes what you have to say, and he makes sure it’s OK with you, the patient.”
Building a personal connection
One highly experienced and revered faculty physician powerfully influenced residents by using his extensive shared cultural heritage to establish common ground with his patients. This physician later reflected that he purposely bonded with patients in front of the residents. He did this by bringing up features of small-town life, especially acquaintances and doctors both he and his patients knew. This doctor felt he was showing the residents how “medicine should be practiced.”
Several of the teachers demonstrated interest by observing and specifically commenting on their patients’ personal effects, such as a pair of unusual slippers or a book on the bedside table. One faculty physician simply commented that he had seen the patient being taken to the radiology department the evening before, indicating that he recognized the patient even without seeing his chart or room designation.
Eliciting and addressing patients’ emotional responses to illness
Almost every encounter included some affective component introduced by the patient. Expressions of fear, worry, grief, or anger commonly pertained to illness or medical care. In many situations, the faculty physician responded empathically.
In one case, a patient was transferred to a different floor because she needed cardiac monitoring. When the faculty physician saw her, she began weeping.
Doctor: You’re a little upset today.
Patient: I’m very upset.
Doctor: Are you just upset in terms of pain?
Patient: No. No. Not knowing whether [my daughters] will find me.
Naming the emotion is a standard medical interviewing technique for expressing empathy. Here the technique seemed to take on added power when demonstrated by a senior faculty physician in front of the residents. He encouraged the patient to respond by naming the emotion and providing space for her reaction. Later, one of the residents offered to call her family to let them know her location in the hospital.
Another faculty physician, a palliative care consultant, recognized that a patient’s husband was experiencing strong emotions. Immediately introducing himself, he focused quickly on the likely emotional issues: “Mr. X, I’m Dr. Y from the palliative care service. I’m very sorry about your wife. This must be a very hard week for you.” The patient and family commented about this doctor afterwards, “[He was] talking to us directly, at our level, not in a medical way. . . . He was sympathetic in the way he was informing us. He was nurturing and showed a loving touch. We understood him.” When this patient died, the family asked that memorials be donated to the palliative care service even though this physician had met with them only once.
Clinical teachers’ self-awareness
The clinical faculty consciously recognized their influence on students and residents. An example is this faculty physician conversing with his team after an encounter:
Teacher: Any countertransference stuff with [the patient]? Does she elicit anything in you? It’s good to have an awareness. She has a powerful presence in a certain way.
Resident 1: I think, listening to her, I immediately sympathize with her more than I normally do. She’s so young. She’s such an unfortunate thing. I think knowing all that [before] walking in there helps me.
Student: She looks so good, even though she has ten out of ten pain.
Resident 2: I find her intimidating. From the sign on the door where she sets up the rules, you feel like if you cross some of those boundaries, I thought she might get upset.
Nurse: She said that it bothers her when someone comes in and she doesn’t know who they are. She was trying to establish some limits. I like her. I like that she can give me some limits and tell me how things are going. . . . Even before I said my name, she said, “Do not touch me,” and I respected that.
In other ways, the teacher consciously changed the environment to facilitate compassionate care. One teacher arranged chairs in the team room before rounds. Another attending, when the patient’s husband entered the room, said, “We’ll widen the circle because I would like for you to be included.”
Almost all of our participants described self-reflection as a means of improving their teaching. From an interview with one of the faculty, we learned:
Formation of residents is a main part of what we do, and residents are influenced by staff behavior. Each encounter with a patient or family or staff is important. We have to be very careful about how we speak to a patient and about a patient. My own communication style—regardless of whether residents are present—is somewhat informal and tries to put the patient’s problem in the broader context of their life. For example, my first questions in clinic are almost always, “Where do you live?” … or “What do (or did) you do for work?” Then when the interview moves to chief complaint … the problem is already somewhat framed. The formal H and P process (patient interview and physical examination) fills out many details, mainly through social history, family history, and review of systems.
Discussion and Conclusions
Transmission of humanistic qualities to our learners is important. First, compelling evidence indicates that patients want and expect this kind of care from their doctors.17 Second, care delivered in a humanistic way is associated with better health care outcomes.5,18–23 The medical literature is rich in recommended teaching practices, the majority of which are anecdotal and do not include the perspectives of learners or patients.2,20,24–29 As far as we can determine, our study is the first to observe how humanistic care is actually taught in clinical settings. Triangulating the results (using more than one methodology to study the same phenomenon) of our own observations of faculty, learners, and patients lends validity to our findings. We found that each faculty physician we observed exhibited unique qualities as a teacher. We identified common elements in their teaching (see “Results” and List 3), but each faculty physician also exhibited unique qualities as a teacher. In essence, there are many ways to excel in teaching humanism at the bedside.
To impart humanistic care to their learners, the clinical teachers we studied used role modeling. Learners directly observed the desired behaviors. In postencounter interviews, teachers were acutely aware of their influence as role models for residents and students. In terms of methods, these master teachers neither primed the learners by drawing attention to behaviors to be modeled nor did they involve them in the learning activity. The learners simply watched and listened. Implicitly, teachers assumed that learners would recognize, accept, and ultimately embody desirable behaviors. We were surprised that some of the teachers consciously withheld overt statements of humanistic learning goals. Apparently, they felt this would sound “preachy” or might be experienced as “overkill.” Generally they did not actively involve the residents or students, aside from the learners’ passive observation, in the humanistic interactions demonstrated during clinical rounds as is illustrated in the following reflection by one of the teachers:
I never make any deliberate attempt to exhibit specific teaching items, although I am sure there are recurring themes that are emphasized or modeled to each group of residents.
Because we identified our faculty physicians by surveying residents who were asked to identify outstanding role models, we were not surprised that our participants proved to be excellent examples of the attributes we sought to study. We presumed that we would find faculty physicians who not only excelled at role modeling but who also employed a number of other educational methods. We have described elsewhere30 a number of educational strategies by which clinical teachers can help learners become more humanistic clinicians. Our hope had been to identify still more teaching methods that could be used on clinical rounds. Unfortunately, we were disappointed in this regard.
In addition to describing role modeling, we described the use of seminal events, or educationally meaningful and poignant occurrences in practice. Clinical teachers can use these occurrences as points of departure for reflection by a group of learners, thereby deepening the learners’ awareness of human dimensions that suffuse their cases. We also described active learning exercises in which faculty physicians use a clinical problem, such as a patient who declines treatment. In such situations, faculty could propose a way of working with such a patient, then demonstrate (or ask a resident to demonstrate) the particular behavior, and finally convene with the team afterwards to debrief and reflect on the exercise. In no cases did we see such examples of more active teaching. Possibly clinical teachers could enhance their educational effectiveness on clinical rounds by using multiple teaching methods although such teaching could be more time intensive.31
One could also imagine having identified a different cohort of clinical faculty had we asked residents to identify other attributes such as providing outstanding feedback to learners about humanistic practices. We doubt, however, that learners would distinguish among teachers on the basis of educational styles. Good teachers are good teachers, regardless of teaching style, and we believe we sampled the best overall teachers of humanistic medical care in our respective departments.
Interestingly, in our postencounter interviews, learners expressed the hope that they would find role models, although they did not explicitly say they had sought them out. Learners waited for role models to appear as dictated by clinical assignments. Anecdotally, we observed instances in which the faculty physician demonstrated humanistic behavior that was quickly emulated by one of the residents in the patient’s room, as described in the case of the woman who was moved to the cardiac care unit and feared her family would not find her (see “Results”). The literature on role modeling indicates that role modeling is the most common form of teaching values, ethics, and the human dimensions of care.1,2,14–16,32–34
Unfortunately, the demonstration of undesirable behaviors and attitudes is also effective. Such “negative role modeling” has been documented to produce unprofessional behavior and even ethical erosion during clinical training.35–39 Sometimes referred to as a “hidden curriculum,” such negative role modeling can be understood as a pattern of behaviors prevalent in a group that runs contrary to the desired and explicitly stated attitudes and behavior of humanistic care. Further, this hidden curriculum undermines the curricular objectives of courses on professionalism, ethics, and “the art of medicine” that are usually taught during the first two years of medical school. Given the pervasiveness of negative attitudes and nonhumanistic behavior, we believe proper role modeling is an important teaching method by which to counter the hidden curriculum modeled by others.37,38
How do master clinical teachers develop their teaching skills with respect to the human dimensions of care? In postencounter interviews, the faculty indicated that they use personal self-reflection to develop their teaching skills. Reflective practice has been recognized as an important element of professional development.24,40–43 For the faculty in our study, self-reflection was an iterative process that continued throughout their teaching careers.
Given the importance of addressing the human dimensions of care, we asked ourselves why some clinical faculty would excel at humanistic teaching and others would not. In informal discussions, many faculty members have cited lack of time for addressing anything but biomedical aspects of care. In our study, the faculty demonstrated a seamless, tightly integrated approach to addressing both the biomedical and psychosocial dimensions of care. The clinical teachers we observed demonstrated their care for patients effectively, yet very efficiently. Patients identified these behaviors as caring and were grateful for them. Using a calm tone, sitting at eye level, and talking directly to the patient all tend to amplify the communication of caring and respect.
Role modeling practices developed by individual faculty physicians through iterative self-reflection is one effective method of teaching the human dimensions of care. However, in prior work, we proposed a broad palette of educational options.2,26 Educators believe multiple instructional modes are more effective than a single mode of teaching,44 and active learning methods are more effective than passive ones.22,45,46 In previous articles, we have described active methods that apply to clinical settings.2,26 Possibly our faculty participants, although identified as master teachers, would enhance their effectiveness by learning to use these active modalities of instruction.
Our study is limited by its focus on inpatient, hospital-based teaching on internal medicine services. One should not assume that the skills we describe are equally effective in outpatient settings. In the clinic, the teaching is often more fast-paced and occurs between a single resident and faculty physician. As a result there may be fewer opportunities for faculty to see a patient together with a resident or student. Our findings also may not generalize to specialties outside of internal medicine. Since our project was conceived as a qualitative, hypothesis-generating study to seek best practices, we did not include a control group of teachers who were not identified as exemplary. It is possible that more unique qualities of our faculty participants could be determined by comparison with average or below-average clinical teachers.
On the other hand, our findings are based on rigorous qualitative methods that were consistently applied across four geographically distinct teaching hospitals with a range of clinical faculty. Having used a variety of tools, including direct observation and postencounter interviews with the principal parties involved, we believe our results are well triangulated and represent effective practices in this domain. Given the absence of a gold standard for humanistic teaching, we believe that identifying best practices of effective teachers is a good first step toward developing evidence-based curricula and pedagogy.
In summary, across the four institutions we studied, the participating faculty exhibited a variety of individual role modeling behaviors that they used consciously and deliberately. In addition to individual variation in approach, we also found common elements among the behaviors we observed as summarized in List 3. We conclude that there are many different ways that clinical teachers demonstrate humanistic behavior at the bedside. Apparently, one size does not fit all in this area, an important finding for faculty development. It is possible our findings could assist future clinicians with their efforts to include the human dimensions of health care in their encounters with patients.
This study was supported by a grant from The Kenneth B. Schwartz Center.
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