Professionalism and humanistic communication skills are core competencies for physicians.1–3 Increasingly, residency programs will be required to document that their graduates attain these competencies.1 Effective methods have been developed for teaching humanistic communication skills and approaches to patient care4–8 and are used in many medical schools and residency programs.4,7,9 However, the knowledge, skills and attitudes taught in targeted curricula are often neither modeled nor reinforced in clinical settings,10–12 and humanistic attitudes and behaviors may become attenuated or extinguished.12–15 As part of this problem, well-meaning clinical preceptors may fail to recognize opportunities for teaching the psychosocial aspects of patient care,16 and may inadvertently model12,17,18 or fail to address19 negative attitudes and behaviors.
With these issues in mind, we developed the recommendations proposed in this article, after refining them with other experts and with generalist teachers. The recommendations are designed to help preceptors teach, reinforce, and promote the application of humanistic approaches in the care of patients in busy clinical settings. We use the shorthand term “TIPS” for these recommendations; we use it both in the normal sense of the word tips, as items of advice, and as an acronym to connote the context for that advice, teaching in the patient setting. Humanistic care is defined as being patient-centered and integrating the psychosocial with the biomedical aspects of care. Those who practice humanistic care demonstrate interest in and respect for individual patients and address their values, concerns, and emotional, social, cultural and spiritual needs. Such care improves information-gathering and promotes accurate diagnoses,4,20–23 increases patients,4,24–26 and physicians,27–29 satisfaction, decreases the likelihood of malpractice litigation,30 and improves important clinical outcomes such as adherence with medication.24,31–33 It addresses psychosocial problems, which are common in medical patients, frequently go unrecognized, are associated with increased medical utilization, and affect the management and outcomes of patients’ medical problems.4,34
Developing the Recommendations
We developed these psychosocial TIPS from 2001 to 2004 as part of the National Faculty Development Program for General Internal Medicine, sponsored by the U.S. Public Health Service Health Resources and Services Administration.35 The planning group for this collaborative effort, termed GIMGEL (the General Internal Medicine Generalist Educational Leadership Group), included representatives from several major organizations representing internal medicine.* TIPS were designed to provide practical guidance for generalist outpatient preceptors to teach trainees (both medical students and residents) and reinforce previous learning in key content areas in which the preceptors may not be expert: cost–effectiveness, end-of-life care, evidence-based medicine (EBM), geriatrics, prevention, and psychosocial aspects of care. Development teams consisted of one to two GIMGEL members plus one or more outside experts in the content area. Each TIPS recommendation was presented as a work-in-progress workshop (held twice) at the program's final national conference, and subsequently revised based upon feedback from workshop participants. The psychosocial TIPS we present here underwent additional revisions based upon input from participants at workshops that were subsequently presented at national meetings of the Society of General Internal Medicine and the American College of Physicians–American Society of Internal Medicine. Final revisions were made during conference calls of the authors, which include two expert GIMGEL members (WB, DK), two outside experts (ML, WL), and three expert participants (DB, MF, JJ) from the initial workshops held at the program's final national conference. The final recommendations represent the consensus of the authors and include input from content experts, educational experts, and practicing preceptors.
Challenges, Barriers to Teaching Humanistic Care
Preceptors in a busy clinical setting face a number of challenges and barriers to helping trainees use appropriate communication skills and address the psychosocial needs of patients. Some barriers reside within patients, others within the preceptors or residents, yet others within the medical care system.
- Patients may reduce the recognition of psychosocial issues by presenting with somatic rather than emotional complaints36–38 or resist psychosocial diagnoses by attributing symptoms to physical causes.39
- Preceptors and residents may be concerned about potential patient stigma,36,40 fear they are opening a Pandora's box the contents of which they cannot adequately address,40,41 believe that psychosocial management is burdensome,42 have inadequate knowledge about diagnostic criteria or treatment options,43–45 lack psychosocial orientation,46 have practice styles not conducive to psychosocial talk,47,48 or lack insight into patients’ different cultural presentations of psychosocial issues.49
- As for the systems barriers, the average ambulatory teaching encounter is short, between four to 15 minutes in length,50 and physicians face an ever-expanding slate of topics to cover with patients. Other systems barriers include productivity pressures, limitations of third-party coverage, restrictions on specialist, drug, and psychotherapeutic care,36,40 lack of a systematic method for detecting and managing patients with psychosocial problems,51 and inadequate continuity.36,40
TIPS: The Preceptor's Toolbox
In this section, we present psychosocial TIPS—recommendations for teaching a humanistic approach while precepting patient care—and also outline uses of TIPS for specific situations.
TIPS for teaching a humanistic approach
Because of the challenges to teaching a humanistic approach while precepting, the preceptor needs to use a variety of teaching methods. Some of these methods are designed to raise awareness and change attitudes (asking, promoting reflection, role modeling), some to teach skills (supervised practice, observation and feedback, role play), some to reinforce behaviors (observation, feedback), and others to fill in knowledge gaps (brief didactics, discussion, mini-assignments, readings).52 Accordingly, the TIPS may be viewed as a toolbox, the contents of which should be used selectively depending on patient and trainee needs. Table 1 lists the TIPS; each of them is bolded, followed by clarifications and examples, with comments in the right-hand column. The TIPS are shown in a sequence that produces a mnemonic, CAARE MORE, for ease of recall.
The psychosocial aspects of care can be taught both during the time a trainee presents and discusses a patient with a preceptor outside of the patient's room and also in the room with the patient and trainee. As can be seen in the table, many of the teaching skills recommended in interacting with the trainee are paralleled by the communications skills that are desired in interacting with the patient. The TIPS focus on establishing learner–centered and patient–centered safe, and helpful preceptor–trainee–patient relationships. They are directed to raising awareness of and attention to the humanistic needs of both trainees and patients. Because trainee–patient interactions can mirror supervisor–trainee interactions, addressing this “parallel process” is a recognized component of psychotherapy supervision.53 It has been also been described in precepting family medicine residents.54,55
Because the human dimensions of care are part of every doctor–patient interaction, some of these TIPS are applicable to almost every encounter. One or more teaching methods may be used in a given teaching encounter, such as picking up on a patient cue or asking the trainee about the patient's concerns, as shown in the following example. (The applicable TIPS are italicized within parentheses in this example and the one that follows.)
With the Patient
After the resident explains to the patient that he will need to be on Coumadin for anticoagulation, the patient hesitates, then says, “I guess that will be OK.” (TIP: Observe patient's affect or other nonverbal or verbal clues.)
The resident goes on to explain other aspects of the management plan and write the new prescription for Coumadin.
Preceptor to patient, at an appropriate time in the three-way interaction. “I wonder if you have some reservations or questions about taking Coumadin?” (TIP: Role model asking psychosocial questions: What are the patient concerns? What are the patient feelings regarding the management plan?)
In the Conference Room
After leaving the exam room, the preceptor asks the resident, “Why do you think I asked the patient the question about whether he had reservations or questions? (TIP: Reflect, discuss, and provide feedback on doctor–patient–attending interaction, summarize main learning points.)
If the trainee had picked up on the patient's hesitation and asked the same question as the preceptor, the preceptor could have provided positive feedback, such as by saying to the trainee, “I was impressed the way you picked up on the patient's hesitation, and asked him about any reservations or concerns. By addressing his concerns you probably increased his chances of taking the Coumadin. (TIP: Acknowledge positive humanistic behaviors.)
Not infrequently, patient concerns or psychosocial issues assume a dominant role in a patient-physician interaction. When this is the case, the TIPS may be used more extensively, as illustrated in the following example.
In the Conference Room
- Resident: This is a quick case. She's a 43-year-old women who comes in for some GI complaints. She had the same problems a month ago. There are several complaints, no particular pattern: some stomach gas and acid, some rumbling, a little distention, some constipation, but no blood in the stool and negative hemoccult. Really no past history or anything on review of systems. Exam was normal. I gave her some Zantac and some Colace. Basically she just needs reassurance.
- Preceptor: So, what do you think is going on with the patient? (TIP: Assess trainee's knowledge and thinking, be learner centered.)
- Resident: Probably nothing (said a little disdainfully). Most likely irritable bowel syndrome. She has had no weight loss, bleeding, fever, night sweats, nor steady pain. I think she has had some episodes of loose bowels in the past, but most of the symptoms now seem related to dyspepsia. So I gave her Zantac. (TIP: Observe trainee's affect or other nonverbal or verbal clues.)
- Preceptor (Sensing something more is going on with the patient): She has been in twice with these complaints. What does she think she has? (TIP: Ask psychosocial questions, e.g., What are the patient's concerns?)
- Resident: Actually, I am not sure. She seems a little overly anxious for someone with just these symptoms. I didn't think to ask her what she thought it might be.
- Preceptor: Sometimes asking the patient about their thoughts and concerns is a good way to start when you're not sure what may be worrying a patient. (TIP: Be practical: focus on psychosocial issues that are likely to affect health outcomes; help trainee deal with time issues.)
- Preceptor: You seem to have a pretty good history of the patient's symptoms, and a negative physical examination, so when we go in let's concentrate on trying to find out what she is concerned about. Would you like me to demonstrate or would you like to try yourself? (TIPS: Provide feedback. Interview patient jointly, being patient-centered. Clarify in advance goals/process/roles when seeing patient together, including who will take the lead in talking to the patient.)
- Resident: Why don't you demonstrate?
With the Patient
- Preceptor: So, Mrs. Smith, Dr. Jones just filled me in on your symptoms and findings. He tells me you have some acid burning sensations in your stomach for about a month, along with rumbling noises, fullness, and constipation. But importantly, he did not find any abnormalities on physical examination or any history of loss of weight or blood in the bowel movements that might be of concern to us. Have I gotten that right?
- Patient: Yes, that's pretty much what I have been experiencing. I was wondering about having further tests, though.
- Preceptor: It would help me to know what concerns you have about these symptoms? (TIP: Assess patient jointly. Role model or have trainee practice asking psychosocial questions to ascertain what are the patient concerns.)
- Patient: Well, doctor, the truth is, I have had these symptoms for more than just a month. I've had some loose bowel moments and some constipation, and I read that a change in bowel movements might be a sign of cancer. My father died of colon cancer ten years ago and so it's been a concern of mine.
- Preceptor: Your concern seems very understandable to me in light of that history, although I do not think that the symptoms you describe are particularly suggestive of colon cancer. (TIP: Role model the addressing of psychosocial issues and patient concerns.) We often call these symptoms irritable bowel, a type of symptom that occurs when the bowel itself is normal, but is experiencing spasm related to changes in the diet, or even stress. Are you under any stress? (TIP: Role model or have trainee practice psychosocial questioning skills: What stressors are present in the patient's life?)
- Patient: Well, I have been worried about my job. There have been a lot of layoffs at the plant, and I haven't been sleeping well. But I still wonder about the change in bowel movements.
- Preceptor: The types of changes you are experiencing are more typical of irritable bowel, and the stress you are currently under would explain why it is worse at present. Nevertheless, you are understandably concerned about your family history. There are criteria for screening for colon cancer in folks with family histories of colon cancer. (TIP: Role model empathy and respect. Role model or practice patient education, negotiate management plan with patient and resident together.) How old was your father when he developed colon cancer?
- Patient: He was 72.
- Preceptor: Well, that means that we would normally not start colonoscopy, without any evidence of blood in the stool, until you are 50. Let me get Dr. Jones back into the conversation, because he may have an opinion on this as well, and now that we know your concern about colon cancer, we want to set up a screening program that we can all agree upon and that will detect any abnormalities before they progress to cancer. (TIP: Demonstrate partnership with the trainee and/or patient, respect for trainee's role as care provider. TIP: Involve patient in decision and management plan. TIP: Integrate communication skills and the management of psychosocial issues into management plan.)
In the Conference Room after Leaving the Exam Room
- Preceptor to Trainee: So, what did we learn from that interaction? (The preceptor and trainee discuss the need to find out patients’ hidden concerns, the need to integrate psychosocial issues into the management plan.) (TIPS: Reflect on the doctor–patient interaction, summarize main learning points.)
In both examples, the preceptor focused on psychosocial issues relevant to health outcomes and used the toolbox selectively. Even though teaching the psychosocial aspects of patient care may have taken more time in the second than in the first example, both interactions occurred within the time frame of a precepting encounter, provided meaningful learning, and probably improved the outcomes of the visit.
TIPS for specific situations
To meet the psychosocial needs of their patients, physicians must be aware of these needs. Preceptors can teach and reinforce data gathering skills that identify psychosocial needs. Tables 2 and 3 list specific psychosocial questions, relevant to implementing TIPS, that are helpful in eliciting sensitive information (sexual history, literacy, health-related behaviors) and pursuing diagnoses of suspected, commonly encountered psychosocial conditions. Where available, the evidence base is summarized and cited.
Management of a psychosocial condition will depend on the specific diagnosis. In addition to treatment directed to the specific disorder, patients often benefit, regardless of the diagnosis, from emotional support and counseling related to psychosocial stresses.57 Treatment, support, and counseling may be provided by the primary care provider or by referring the patient to a mental health professional or religious advisor, depending on the patient's condition and preferences, the provider's expertise, and the level of rapport, trust and respect in the provider–patient relationship. By role modeling or facilitating the trainee's recognition and management of specific psychosocial conditions, the preceptor is promoting an integrated, humanistic approach to patient care.
Patient education and promoting behavioral change are parts of most doctor–patient interactions, and are discussed in detail in other publications.58 These activities involve assessing the patient's needs (including literacy level59,60), health-related behaviors, and adherence to prescribed regimens; targeting the educational intervention to the patient's needs and interests; prioritizing and limiting the educational objectives and material to be covered at each visit; negotiating with the patient; and checking for the patient's comprehension and agreement. A useful model for counseling behavioral change is based on “readiness for change” theory.58,61,62 The task of a physician is to assess which stage (precontemplation, contemplation, determination, action, maintenance, or relapse) best describes the patient's readiness to change, and then to target the educational intervention based on the stage. For example, for a patient who is not even contemplating a change, assessing his or her understanding and concerns, promoting reflection, or just giving brief general advice is appropriate. For a patient who is ready for action, it is appropriate to discuss specific strategies. There are frequently opportunities for preceptors to role model and teach the complicated skill sets related to patient education and behavior change.
Sometimes the preceptor may encounter a resistant learner. In this situation, connecting with the learner, creating an individual-specific safe and supportive learning environment, understanding the resistance, assessing the trainee's needs, and tailoring an intervention to meet those needs become especially important. The preceptor can also apply patient education and behavior change strategies58 and the “readiness for change model”58,61,62 to the trainee and use them to guide and supplement the preceptor's use of TIPS. As with resistant patients, it is important that the preceptor maintain empathy for resistant learners and flexibility in teaching method. Attention to “parallel process,” as discussed above, may be particularly important in interacting with resistant learners. The preceptor can help prevent trainee resistance by using TIPS selectively, within available time frames and when such an approach is clearly relevant to the problem at hand and likely to improve patient (or trainee) outcome.
While the TIPS listed in Table 1 are focused on single preceptor interactions, in longitudinal precepting situations learning will build from one interaction to the next, as the preceptor's relationship with and understanding of the trainee, the trainee's trust in the preceptor, the trainee's attitudes, and the trainee's skills develop. Initially, methods may focus on raising awareness and basic communication skills, whereas, as the trainee matures, more attention may be given to differential diagnosis, clinical decision making, advanced communication skills, and reinforcement of attitudes and skills related to the psychosocial aspects of care. Over time and multiple interactions, most tools in the toolbox can be used, and the learning (or reinforcement of previous learning) can be comprehensive.
Finally, it should be acknowledged that the TIPS presented in Table 1 and demonstrated in the examples are cognitive descriptions of teaching skills. To be mastered, skills need to be learned by repeated cycles of practice, accompanied by feedback and/or reflection on performance.63–65 By applying these teaching methods in the context of one's own precepting or in simulated situations, eliciting feedback from trainees and colleagues, reviewing audio or videotapes of one's performance, and taking time to reflect and learn from experiences and feedback, preceptors can develop expertise in the use of these tools. Textbooks66–67 and faculty development resources68–71 are also available, as are workshops at professional meetings.
While numerous programs, workshops, and publications address general teaching skills,72–76 and some have addressed teaching skills in specific content areas such as preventive medicine,77 EBM,78 communication skills, and psychosocial medicine,68–71,79 TIPS are distinguished by focusing on the teaching and reinforcement of important content areas by generalist outpatient preceptors who may not have expertise in the content areas. Unfortunately, content that is taught in isolated medical school curricula and residency rotations may not be reinforced by medical school and hospital systems or in the subsequent clinical experience of trainees, i.e., in the “hidden” and “informal” curriculum of medical training institutions.80,81 In fact, humanistic attitudes and behaviors have been shown to erode during medical training,12–15 despite our ability to teach them effectively.4–8 Hopefully, the TIPS provided in this paper, which have undergone numerous cycles of feedback and revision, are formatted in a way that will promote their adoption by generalist preceptors.
Because psychosocial TIPS involve teaching attitudes and doctor –patient interaction skills, they include educational methods that are more sophisticated than previous models for precepting such as the “one-minute preceptor.”82,83 Like the “one-minute preceptor,” psychosocial TIPS includes assessing the trainee's clinical reasoning, giving feedback, providing focused teaching points, and being practical and efficient. Unlike the “one-minute preceptor,” psychosocial TIPS includes methods designed to influence attitudes and teach doctor–patient skills, such as role-modeling, experiential learning, reflection on performance, and creating a safe, supportive learning environment. Psychosocial TIPS also includes teaching in the presence of the patient and recognizes the “parallel” process between preceptor–trainee and trainee–patient interactions.53–55
In developing these TIPS, we focused on several principles of effective adult learning:
- Being-learner centered (assessing the trainee, and tailoring teaching interventions to the trainee's needs)
- Engaging the trainee (by being practical and trainee-centered)
- Focusing and limiting the teaching to what can be accomplished within the available time
- Addressing needs in whatever domain is required–cognitive (knowledge and higher-order clinical reasoning and judgment), affective (attitudes), or psychomotor (skills, behavior)
- Using multiple methods to address different learning preferences and the need for reinforcement.52
While designed for outpatient preceptors, many of the TIPS are also applicable to teaching in the inpatient setting.
There are some limitations to these TIPS that should be kept in mind. While based, wherever possible, on educational research and theory, they are the product of experts’ and consensus opinions. The degree to which they can be adopted and applied by generalist and specialist preceptors, and the degree to which their application influences the knowledge, attitudes, and behaviors of trainees, remains to be tested.
Just as doctor–patient interaction skills can be difficult to master for trainees and require enlightened precepting, it must be acknowledged that sophisticated teaching skills may not readily be learned by preceptors from an article or a textbook. We have tried to include here teaching methods that are a natural extension of the approach of many generalist preceptors and that can be tried and practiced on one's own. That said, learning to teach these issues will likely be fostered by attending workshops that include practice, reflection, feedback from other participants and skilled preceptors, and help with handling resistant learners and failed attempts.68–71 Such workshops are provided by the American Academy on Physician and Patient and the Bayer Institute in the U.S. and the Medical Interview Teaching Association in the United Kingdom.68–71 We anticipate that psychosocial TIPS will provide a cognitive structure that will be useful to participants in and facilitators for such workshops.
The TIPS presented here are confined to teaching in the context of precepting patient care. They do not address practice operations. Ideally, the preceptor's practice should articulate and communicate a mission that includes humanistic care. The receptionist and the clerical, administrative, and nursing staff can model humanistic interactions with patients. Systems can be present that provide important services for the patient, such as patient education, notification of test results, accessible appointment systems, telephone or e-mail access etc. Patients and trainees can be directed to resources related to specific psychosocial problems.84–87 To the extent that the preceptor controls the practice operations, the preceptor can help establish a practice culture that demonstrates sensitivity to patient needs.
TIPS do not address nondyadic methods of teaching and learning, which can supplement and reinforce humanistic care. Home visits can be incorporated into the trainee's schedule when appropriate. Trainees can be given reflective writing assignments or be assigned projects that promote learning in this area. In clinic settings where there are several trainees, didactic and small-group approaches to teaching can be integrated into the total educational milieu. For example, humanistic approaches to patient care and humanistic topics can be included in pre- or postclinic conferences. Patients can be included in some teaching conferences. Representatives from different ethnic groups can be invited to conferences in order to increase awareness of the groups’ needs and problems, and to draw attention to cross-cultural issues. In small-group settings, preceptors can skillfully expose nonpsychosocially to psychosocially oriented trainees, to promote exchanges of perspectives and experiences and promote humanistic attitudes.
Although precepting has some limitations, it is a very important teaching method. When skillfully implemented, it incorporates several teaching approaches: the application of knowledge to real patients and their problems, role modeling, practice, feedback, reflection, and discussion. Perhaps more than any other educational methodology used to teach humanistic care, it has the potential to influence practice patterns. While additional study is required to determine which precepting strategies are most effective in promoting humanistic approaches to care by trainees, we hope that the TIPS presented in this paper will serve as an interval model by which both generalist and specialist preceptors can teach and reinforce learning in this area.
This work was supported in part by funding from HRSA Contract #240-97-0044, Faculty Development for General Internal Medicine: Generalist Faculty Teaching in Community-Based Ambulatory Settings.
The authors appreciate the feedback and suggestions from the many participants in their workshops, both those who teach this content area and those generalist clinicians who precept trainees but were less experienced in teaching this content area. These participants contributed substantively to the final content of the authors’ recommendations.
Note: References 88–110 are citations to information in Tables 2 and 3.
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*The American College of Physicians–American Society of Internal Medicine (ACP–ASIM), the Association of Program Directors in Internal Medicine (APDIM), the Association of Professors of Medicine (APM), the Association of Subspecialty Professors (ASP), the Clerkship Directors in Internal Medicine (CDIM), and the Society of General Internal Medicine (SGIM).
†Adapted from Brady D, Schultz L, Spell N, Branch WT Jr. Iterative method for learning skills as an efficient outpatient teacher. Am J Med Sci. 2002;323:124-9. Used with permission.