Humanistic medical care is an important element of quality health care, and teaching humanism is increasingly recognized as an integral component of medi-cal education. In this article, we develop and illustrate a series of tools that are effective in fostering both the provision and teaching of humanistic medical care in the ambulatory setting.
We begin with two contrasting encounters concerning the same outpatient between a resident, Dr. Jones, and two preceptors, Dr. Morgan and Dr. Juarez, that illustrate a way of teaching and providing humanistic care.
Precepting Encounter 1
- Dr. Morgan: Good morning, Dr. Jones. Do you have a patient to discuss this morning?
- Dr. Jones: Yes, I do, Dr. Morgan. You remember Mrs. Smith, my lady with hypertension from last month?
- Dr. Morgan: Yes.
- Dr. Jones: She still isn't taking her medicine. I just don't understand. Every month I tell her how important it is to take the pills. She always seems to understand but never takes more than a few of them. I just don't think she cares.
- Dr. Morgan: What's your plan to make her more compliant?
- Dr. Jones: I don't know; I'm at the end of my rope with her.
- Dr. Morgan: It's frustrating to take care of patients who don't follow our recommendations. But, after all, we can't make a patient do what they don't want to do. I think all you can do is continue to try to educate her about the risks of her behavior—you know, the SHEP trial showed that folks like her are at increased risk for stroke if their systolic hypertension goes uncontrolled. Make sure she understands this fact. The other thing you can try is have her see the clinical pharmacist to also talk to her and give her a pill box and things to increase her compliance.
- Dr. Jones: Do I have to continue to see her if she doesn't get serious about this?
- Dr. Morgan: I think so, for now. You wouldn't want to abandon her if there's the chance she might become compliant. When patients come to see us we are obligated to give them the best care we can, and it's their responsibility to follow our recommendations. Let's see how another lecture works and talk again next month.
Precepting Encounter 2
- Dr. Juarez: Good morning, Dr. Jones. Do you have a patient to discuss this morning?
- Dr. Jones: Yes, I do, Dr. Juarez. You remember Mrs. Smith, my lady with hypertension from last month?
- Dr. Juarez: Yes.
- Dr. Jones: She still isn't taking her medicine. I just don't understand. Every month I tell her how important it is to take the pills. She always seems to understand but never takes more than a few of them. I just don't think she cares.
- Dr. Juarez: You seem frustrated by her behavior.
- Dr. Jones: I really am. She should understand how important her medicine is.
- Dr. Juarez: Why do you think she isn't taking the medicine?
- Dr. Jones: What do you mean?
- Dr. Juarez: Well, nonadherence is often a symptom of a deeper underlying problem. Oftentimes patients have reasons for not doing what we think they should that they find difficult or embarrassing to share.
- Dr. Jones: I'm not sure I understand.
- Dr. Juarez: For example, why don't you ease off on the facts and try to just get to know her a bit better. From her perspective, she might have some very good reasons for not taking her medicine.
- Dr. Jones: She could have told me about them.
- Dr. Juarez: Maybe she doesn't think you would understand. Maybe it has to do with something she doesn't feel comfortable opening up to you about.
- Dr. Jones: Like maybe she needs her money for something else or someone at home doesn't approve of her taking the medicine.
- Dr. Juarez: That's the idea. Why don't we take a few minutes and talk with her. Let's think about how you might explore this with her and we'll give it a try. We can debrief for a minute afterwards.
In both of the above dialogues, the preceptor and the resident struggle with the issue of a patient's adherence to a prescribed treatment regimen. However, the “lens” through which Drs. Juarez and Jones view this issue in the second dialogue is a more contextualized and humanistic one. As an outpatient preceptor, Dr. Juarez makes a series of implicit and explicit teaching decisions in order to foster this view.
Teaching about the human dimensions of care has become a priority in medical education.1 The Accreditation Council for Graduate Medical Education has identified “patient care that is compassionate, appropriate, and effective” and “interpersonal and communication skills that result in effective information exchange and teaming with patients and their families”2 as core competencies in residency education. The American Board of Internal Medicine includes a communication portion in its clinical skills module for recertification.3 Similarly, in a 1996 editorial marking the inauguration of a new section of JAMA entitled “The Physician–Patient Relationship,” Richard Glass, an associate editor of the journal, pointed to a lack of empathy and compassion that often accompany an uncritical reliance on technology, and pressing economic considerations as major failures of the current medical system.4 Despite these initiatives, however, educators and program directors struggle with competing priorities and limits on space and time for teaching.
The outpatient setting presents some unique opportunities and challenges. There are opportunities for longitudinal doctor–patient and preceptor–learner relationships to develop, for doctors to get to know their patients and preceptors their learners as persons, for trust to build, and for patients and learners to reveal relevant emotional and psychosocial issues. On the other hand, outpatient preceptors’ desire to teach and promote humanistic care may be challenged by time and productivity pressures, the desire to meet other legitimate patient and learner needs (e.g., check the patient's history, provide biomedical content), the demand of other learners who are simultaneously being precepted, learner resistance, a competing informal, or “hidden,” curriculum that undervalues a humanistic approach to care, and lack of teaching proficiency in this area.5 As learners develop increasing autonomy, opportunities to observe learner–patient interactions may become limited.
In our previous work,6 we outlined general principles that underlie high-quality teaching of the human dimensions of patient care. We define humanism in medicine as physician attitudes and actions that demonstrate interest in and respect for the patient and that address the patient's concerns and values. Issues of humanism are generally related to patients’ psychological, social, and spiritual concerns, and encompass a number of problems commonly encountered in the outpatient setting (List 1). Teaching practices that foster the human dimensions of care in the outpatient setting are the focus of this article.
We have formulated our strategies for outpatient humanistic teaching in light of four general principles:
- Successful teaching begins by establishing a humanistic learning climate.
- Skillful teachers, who master complex tools for humanistic teaching, can use them selectively and efficiently in the outpatient setting.
- “Diagnosing” the learner is particularly important in outpatient humanistic teaching, as learner resistance is frequently an obstacle and the correct teaching tool often depends on the readiness of the learner to learn.
- Brief learning interactions focused on achieving specific goals and used repeatedly over time are most effective for teaching humanistic care in the outpatient setting.
The critical elements in the teaching of humanism we have identified and will discuss below include establishing a humanistic learning climate, creating clear individualized learning goals within a framework of humanism, developing an educational diagnosis of the learner, integrating psychosocial issues into the teaching intervention, reflection, providing feedback, and planning follow-up with the learner.
Developing the Recommendations
We began a project on teaching humanism at a meeting on physician –patient communication sponsored by the American Academy on Physician and Patient in June 1999. We surveyed more than 50 faculty members at that meeting about their ideas and practices for teaching humanism in various patient-care settings. Subsequently, we conducted workshops at the national meetings of the Society of General Internal Medicine (2000 and 2001), the American College of Physicians/American Society of Internal Medicine (2001), and the General Internal Medicine Faculty Development Project*, as well as numerous regional workshops and presentations at or near our home institutions. Many of these workshops were specifically devoted to teaching humanism in outpatient settings. During these workshops and presentations, we discussed teaching humanism in outpatient settings with over 300 faculty at medical schools, residencies, and outpatient clinics. In addition, we reviewed existing literature on learning principles and precepting.7–14 In a series of conference calls, we sought consensus on effective teaching strategies that preceptors use in outpatient settings. The results of at least 30 iterations of this process have led us to a consensus about specific teaching strategies for fostering the human dimensions of care in the outpatient setting (List 2).
Educational Strategies Before the Precepting Encounter
Establishing a humanistic learning climate
To optimize learning, learners must be cared for by providing a safe place for them to acknowledge their own attitudes and beliefs, knowledge gaps, uncertainty, and mistakes.7,9,12,15–17 Creating a safe, supportive learning climate is especially important in outpatient settings, where awareness and appropriate management of one's own attitudes, emotions, and behaviors are critical,18–20 but time pressures and, to some degree, cynicism tend to discourage humanism.
In outpatient settings with multiple learners, conferences can be used to promote a safe learning climate conducive to humanistic care. Social learning theory suggests that peer support makes learning more effective.21 Teachers in group settings can model humanistic behaviors and thereby create a culture of learning that is passed from one generation to another. Clinic conference discussions about communication-related topics or patients perceived to be “difficult” demonstrate that these topics are educationally important. Having a small, safe cohort of peers who are faced with the same challenges and difficulties encourages debriefing and reflection about patient care experiences. Fostering faculty and peer-support in conferences may encourage innovative learning methods, such as discussion emphasizing personal awareness, learning by role play, and review of audiotapes and videotapes.
Orientation and establishing learning goals
Setting the stage by orienting the learner22 is the next step in establishing a humanistic learning climate in outpatient settings. Orientation may introduce the expectation that care will be provided within a framework of humanism. Orientation provides an opportunity for the learner and teacher to mutually agree on learning goals that place humanistic care “on the map” of patient care. Then, in a given clinical encounter, the preceptor may choose a particular teaching method based on the clinical scenario, the individual learner, his or her experience, the relationship with the patient, and learning goals. As an example, this conversation between Drs. Juarez and Jones might occur early in the year:
- Dr. Juarez: Good morning, Dr. Jones. I see we'll be working together in Tuesday afternoon clinic this year.
- Dr. Jones: That's right. Now that I'm a second-year resident I hope to be able to give more of my attention to my clinic patients.
- Dr. Juarez: Great. Do you have any specific areas that you'd like to work on?
- Dr. Jones: Well, I'm pretty weak on my cardiac examination and I'm not always clear on the treatment of lipid disorders.
- Dr. Juarez: Those are definitely important areas for us to work on, and I can help. In addition to your cardiac exam and knowledge of lipid disorders, I'm wondering how you feel about your patient communication skills.
- Dr. Jones: What do you mean? I think I can take a good history. I always seem to get along with my patients.
- Dr. Juarez: I'm thinking more about the kinds of challenging patient encounters we all face in our practices. You know there are topics I have trouble discussing with my patients.
- Dr. Jones: You mean like giving bad news?
- Dr. Juarez: Sure. That and other difficult conversations on sensitive areas.
- Dr. Jones: I guess I haven't had much experience here. I always seemed to be in such a hurry last year.
- Dr. Juarez: Why don't you come next week with a few thoughts on communication issues you would like to work on. You can also think about other issues you find difficult or challenging in your clinic experience.
- Dr. Jones: OK, I'll do that.
Educational Strategies During the Precepting Encounter
We emphasize five well-established teaching strategies to help bring humanism into the precepting encounter (List 2). These are diagnosing the learner, integrating psychosocial issues, debriefing and reflection, feedback, and planning follow-up. In outpatient settings, mastery of these strategies is especially important, as most preceptors rarely include all of the strategies in a single encounter; they usually pick and choose the best strategy for the moment. Mastery has particular relevance in implementing the second strategy (integrating relevant psychosocial issues) because here one must pick from several recommended specific teaching methods (the “preceptor's toolbox,” List 3). Like a carpenter's tools, specific teaching tools in the preceptor's toolbox may be more useful in some situations and less so in others. Below, we discuss these five teaching strategies for fostering humanism and the selective use of the teaching methods in the preceptor's toolbox to achieve these aims.
Diagnosing the learner
While you precept in a residents’ continuity clinic, a resident presents a patient who comes in for follow-up of her diabetes and hypertension. The resident has uncovered no new problems needing evaluation. Although the patient's blood pressure and glycemic control are not adequate, the resident does not include any plan to improve control of either in his presentation. When asked about trying to improve control, he concludes: “She just doesn't want to take her meds.” You suggest going into the room and briefly discussing adherence to prescribed medications with the patient, and the resident agrees. In the examination room, you notice that the resident sits off to the side and appears disengaged. While you interview the patient for five minutes, the resident completes the paperwork for the encounter.
It is often useful to consider performance issues of residents and students like symptoms needing diagnosis. In the vignette above, the preceptor must construct a list of potential “differential learning diagnoses” for the resident's performance deficit. The preceptor knows, for example, that this resident has performed adequately in inpatient settings. It is possible, however, that the resident is not confident of his skills in assessing medication adherence or in negotiating treatment plans with patients. It is also plausible that this resident may have a negative attitude toward nonadherent patients or cynicism toward outpatient primary care in general. The “learning symptom” suggesting this possibility is the resident's apparent disinterest in participating in the discussion of medical adherence. Other potential considerations could include personal issues, such as fatigue, depression, or substance abuse, competing demands of concurrent inpatient duties, or lack of interest in the particular clinical problem presented by the patient. As with any differential diagnosis, the list of possible etiologies could be extended at great length. Compared to the above scenario, consider the following alternative approach that acknowledges the resident's and the patient's feelings, attitudes, and beliefs, and actively engages the resident:
- Dr. Juarez: What can you suggest to improve her glucose control?
- Dr. Jones: She just doesn't want to take her meds.
- Dr. Juarez: That must be frustrating for you.
- Dr. Jones: Every time I see her I feel like I'm just beating my head against the wall.
- Dr. Juarez (concluding that the resident feels negatively about nonadherent patients and has limited knowledge and skills for addressing nonadherence): It sounds like you get frustrated and feel like you're wasting your time and hers. I know that when I feel useless about something, I have a hard time getting engaged in it.
- Dr. Jones: It's true, I just feel like getting out of the room fast.
- Dr. Juarez: Have you ever discussed with her that you feel that you're not really helping her?
- Dr. Jones: No.
- Dr. Juarez: That can sometimes be helpful. Why don't we see her together for a few minutes. You can talk to her about how you feel and get her perspective, too. We might be surprised to hear what she gets out of her visits with you.
It is useful to employ the “stages of change” model23 when diagnosing learners in the area of humanism. Learners may be “precontemplative” (i.e., not aware of or interested in issues concerning humanism), “contemplative” (thinking about, but not yet acting in a humanistic manner), in “preparation” (preparing to integrate a humanistic approach to patient care), in “action” (experimenting with ways of providing humanistic care), in “maintenance/integration” (consistently incorporating a humanistic approach to patient care), or in “relapse” (when episodes of nonhumanistic care recur for a resident who otherwise consistently provides humanistic care). The type and level of teaching intervention will depend on the stage of change. For example, an intervention aimed at raising consciousness may be required in the precontemplative stage, one aimed at skill building in the action phase, or simply recognition and support in the maintenance/integration stage. In the above example, Dr. Juarez determined that Dr. Jones was in a precontemplative stage, and directed her intervention toward raising the resident's consciousness.
An accurate diagnosis of the learner, therefore, contains two types of information: (1) an assessment of the learner's attitudes, knowledge, and skills; and (2) an assessment of the learner's stage of change. In outpatient settings, longitudinal contact and repeated interactions between preceptor and resident assist in making an accurate diagnosis.
Integrating psychosocial issues
Using psychosocial issues commonly encountered in outpatient care (List 1), preceptors can choose among a variety of brief but long-term interventions aimed at fostering a shift toward more humanistic care by residents. Brief interventions are more useful in outpatient settings. Behaviors are more likely to change when reinforced through repeated, varied, but focused efforts that stress the underlying message that high-quality care attends to human dimensions.24–26 A primary source of resistance to dealing with psychosocial aspects of care is the idea that it will increase visit length and the number of tasks a resident is required to do but is not “really” part of a doctor's job.24 Integrating psychosocial issues into the total care of the patient may lead residents to appreciate the efficiency of this approach and the relevance of psychosocial issues to the patient's overall care.25–28
Determining the relative usefulness of any given teaching method depends on the resident's learning need (see “Toolbox,” List 3). For attitudinal issues, useful methods include facilitation of openness, introspection, and reflection; exposure through discussion, experience, and reading; role modeling with active debriefing; judicious use of seminal events; and facilitating a successful active learning experience. For knowledge deficits, useful methods include mini-lectures, discussion, readings, and subsequent observation and feedback. For skills and behaviors, methods that allow observation and practice with feedback and reflection are most useful; these include role modeling with active learner involvement, and observing and providing feedback to the learner. Some methods in the toolbox can accomplish more than one goal, but how they are used varies depending on the goal. For example, a successful interaction with a patient (either by the preceptor or the resident) could be used both to influence attitudes and to teach skills. However, in the attitudinal change scenario, the focus during reflection may be on what happened and what it means in terms of clinical effectiveness, while for skills development, the focus may be on the actual behaviors that produced the successful interaction.
In teaching humanism in the context of psychosocial issues, we make a distinction between role modeling to passive observers and actively engaging learners. Our survey about teaching humanism6 revealed that role modeling to passive observers (e.g., the teacher performs a particular humanistic action with the resident in attendance, and it is assumed that the resident learns valued behaviors through observation) was the most frequently employed method of instruction. While role modeling can effectively promote learning, its power may be lost if the trainee is unaware of what is being role modeled,11,29,30 as is often the case with a resident who is precontemplative. Role modeling is more effective when framed explicitly so that it is clear to the learner what actions and behaviors to observe.31 Role modeled behaviors can be powerful learning tools even if the learner is a passive observer (List 3) if the stage is set before the encounter and debriefing of the encounter occurs afterward. Ideally, role modeling is an active process, and mutual agreement is reached with the resident on educational and observational goals. Debriefing on what went well, what needs improvement, and what alternative actions might have been taken consolidates and reinforces the learning.
Preceptors who choose an observer role should be similarly active. Clarifying what the resident will practice before the encounter and facilitating reflection and self-assessment afterward should be incorporated into these interactions as well. Observing and providing feedback is generally most effective with residents who are prepared and motivated to learn specific humanistic skills, such as those who are in an “action” stage.
Debriefing and reflecting on the learning experience
Debriefing and reflecting on the experience of an encounter permit learning goals to be reassessed and also provide the foundation for future precepting encounters.
Debriefing and reflection increase the impact of what we have termed “seminal events”6 (List 3), which we define as an occurrence that will have lasting impact on the learner. Many physicians can recall an experience during their training (either good or bad) that changed the way that they approached their practice of medicine. A common feature of such events is a strong emotional context in which the learning occurred. This is a sign that attitudes and values may have come into play in a meaningful way. Reflecting on the event, even briefly, enhances self-awareness of why the event was important and may link the event's influence to a resident's future practice. We suggest that preceptors can create “mini” seminal events through recognition and reinforcement of commonplace but potentially important interactions, such as delivering bad news, discussing a new diagnosis, exploring emotional aspects of a patient's illness, or discussing end-of-life care with a patient or family.
Feedback is used for learners at all stages and can help develop and maintain humanistic attitudes and behaviors. Consider the informal use of feedback to raise awareness in the following example:
- Dr. Juarez: Do you have a patient to present?
- Dr. Jones: Yes, though she's a real crock, always has symptoms but nothing's ever wrong.
- Dr. Juarez: Do you think she might meet criteria for somatization? Sometimes if things don't make sense we need to step back and take a broader look at what we might be missing rather than label the patient.
The feedback in this example is informal because it is in response to the resident's casual assessment of the patient as “a real crock” without providing any specific clinical information. Brief informal feedback, delivered in a respectful manner, can occur anywhere in the precepting encounter. To be effective, informal feedback needs to be nonjudgmental and based on observed affect and behaviors. Often reframing an offhanded remark in clinical terms can produce a seminal or mini-seminal event. Feedback can also be combined with reflection by using appropriate focusing questions, such as:
- How did you go about doing _____?
- Why did you choose that way of doing it?
- If you could do it again, what would you do differently?
It is rare to hear anyone assess their actions without room for improvement, so even if a resident's answers to these questions do not display particular depth of thought, the answers frequently leave room for feedback and suggestions.
An advantage of the outpatient clinic setting is that the longitudinal nature of many preceptor–resident relationships permits building on previous experiences. Later follow-up of a teaching interaction is a reinforcing tool and may be especially useful for residents who are contemplative or in an action phase. By being able to follow-up later, the preceptor can keep teaching interventions brief and not feel that he or she has to accomplish everything when additional work is required to effect desired learning.
Before and during the outpatient teaching encounter it is important to keep some overarching principles in mind to be effective at fostering humanistic care by residents. These principles are outlined in List 4. We have suggested ways to compensate for the limited educational time available for most precepting interactions. Making judicious choices about when to bring up the topic of humanism and which teaching method will work for a particular resident in a particular context will maximize the chances of success and efficiency. Like any outpatient skill, humanistic care is one facet of a whole package that is oriented toward clinical effectiveness and optimal outcomes; the preceptor who conveys a balanced and integrated view to residents will be most likely to promote humanistic behaviors by the residents.
Opportunities and Challenges
The ambulatory clinic as an environment for teaching presents unique opportunities as well as challenges for conveying humanism. The longitudinal relationships that develop between many preceptors and residents in outpatient settings are an important facilitator of teaching humanism. Longitudinal relationships allow for creation of a learning climate that enhances the effectiveness of multiple brief interventions. The literature on behavior change suggests that multiple “booster” interventions are more effective than a single intervention without follow-up.32 The longitudinal relationships with learners and patients help with the issue of time. One can choose to focus on a psychosocial issue preferentially, knowing that addressing it will likely save time in the long term and lead to improved communication and trust even if more time is expended up front. One can also pick and choose when to focus on a humanistic issue and when to use a more biomedical focus.
We have suggested specific teaching strategies, as have others,9,11,13,16,31,33–36 that require complex teaching skills. Once the skills are mastered, they may be applied selectively and efficiently to learning interactions that foster humanism. Such skills include creating the learning environment, diagnosing learners, and applying specific teaching methods from the toolbox (List 3) at appropriate times. Preceptors who have mastered the educational toolbox can seamlessly use mini seminal events, active role modeling, active observation, feedback, reflection, and other techniques tailored to individual residents and patient interactions. Like the “one-minute preceptor” model33,37 often used for teaching in outpatient settings, our model includes the steps of “diagnosing” the learner's educational needs and willingness to change, intervening in a manner consistent with the learner's diagnosis, and providing feedback and encouragement. Our model, however, is targeted to teaching a specific content area, and is more comprehensive in its educational methodology. Unlike the one-minute preceptor, our model explicitly identifies particular teaching issues, including noncognitive aspects of learning, role modeling, experiential learning, reflection, and learning climate. It also covers teaching during practitioner–patient as well as preceptor–learner interactions.
Furthering the teaching of humanism requires that the teachers are amenable to guiding learners. It may be that some teachers do not find the issue compelling or do not feel confident in their own abilities. In these situations the stages-of-change model can be applied to faculty. For faculty unconvinced of the importance of the subject (precontemplative stage), the preferred intervention may be raising awareness. This can be approached affectively through reflection on personal experiences, sharing in the experiences of others, small-group discussions, and observing successes. It can be approached cognitively by sharing evidence that effective communication improves patients’ trust and outcomes and that addressing, rather than missing, psychosocial cues reduces visit length.25,26 Teachers in the contemplative, preparation, and action stages can learn, practice, reflect, and receive feedback on their skills in faculty development programs, such as those offered by the American Academy on Physician and Patient or Bayer Institute. Another way for faculty to improve skills is to work in learning groups using a continuous improvement method. In this strategy, an innovator works with a small group of like-minded colleagues to identify incremental steps, practice them, then report back to the group and repeat the cycle.
Our recommendations are informed by and grounded in the collective experiences of outpatient preceptors across the United States, as well as the literature on adult learning. However, they are limited by a lack of empiric data on the effectiveness of various teaching practices in fostering humanistic care. In our ongoing work, we are collecting systematic field observations of attending physicians who have been identified as humanistic role models by their residents. We suggest that accreditation bodies and funding agencies devote resources to determining best practices in teaching humanism through empiric research, and that such resources should be in addition to those that are devoted to developing accreditation guidelines and strategies for evaluating progress of programs in meeting those guidelines.
Dr. Haidet is supported by a career development award from the Office of Research and Development, Health Services Research and Development Service, U.S. Department of Veterans Affairs.
The authors would like to thank all of the dedicated faculty that have provided their thoughts and interest in this topic over the past three years.
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*A national effort supported by the Health Resources and Services Administration of the U.S. Public Health Service, involving collaboration among the major internal medicine organizations in the United States.