The semistructured interview script was developed in consultation with the McGill Centre for Medical Education. The script opened with a dialogue seeking personal accounts of illness and experiences with physicians, moved on to an exploration of patient expectations of physicians and targeted questioning on the physician as a professional and healer, and closed with related issues such as the context of health care. It was tested in four pilot interviews; these resulted in reflexive alteration to the script. For example, to listen respectfully to complaints about health care while ensuring an opportunity to discuss a full range of experiences, it was decided that the interviewers could gently redirect conversations with statements such as “This research on curricular change is a project of hope.” The interview script was translated into French using a translation service. An outline of the original interview script is presented in the Appendix.
The script was modified after 19 interviews to respond to emerging themes. Subsequent participants were invited to provide specific recommendations for educators and were asked to identify “must-dos” and “must never-dos” of doctoring. A tension was identified between permitting concepts to emerge organically versus presenting constructs previously defined by the medical community. Our preference was for indigenous language as opposed to predetermined constructs.
Data collection included semistructured interviews and field notes; the latter included the reflections of the interviewers as well as contextual information.18 Moving back and forth between the research field and data analysis helped the interviewers refine the interview script, test developing conceptualizations and theorization, and challenge the abstractions that were emerging.
A number of measures were taken to ensure patients’ comfort during data collection. Participants were given their choice for the time, date, and location of the interview. Interviews lasted from 15 minutes to one hour, with the majority lasting approximately 40 minutes in length. With one exception, an employee of the MUHC, all participants agreed to having the interview recorded. The recorded interviews were then transcribed verbatim by an individual not associated with the project. For the exception, the interviewer took extensive notes instead. The names of patients, physicians, and other health care workers were removed from the interview transcripts, and code numbers were used to identify participants. The recordings and transcripts were stored on two computers protected by security access codes. All confidential materials were kept in locked filing cabinets. Research ethics approval was granted by the MUHC Research Ethics Board.
The preliminary analysis of transcripts and their accompanying field notes of reflections was process oriented, giving direction to the way in which data interpretation could most effectively produce theoretically relevant findings. Following the observations of Thorne and colleagues19 that complex coding systems can overwhelm inductive interpretation, we read and reread the data before coding, classifying, and forming linkages. A qualitative software program (NUD*IST, version 6, qualitative Solutions & Research Pty Ltd, Latrobe University, Australia) was used to facilitate systematic organization of coding categories by multiple team members.
Analysis was directed with probing and open-ended questions such as “What is happening here?” For example, as the capacity of physicians to listen emerged as a recurring issue, each of the authors reflected recursively on this phenomenon and posed questions such as “What is identified as being listened to?” and “What did listening do to/for patients?” The two interviewers did the majority of coding, meeting on numerous occasions to discuss emergent themes and to further integrate their analyses using the constant comparative method. Other members of the research team read a subset of transcripts to corroborate these themes and participated in the analytic discussions. Final interpretations were agreed to by team consensus.
Methodological rigor was ensured using standard methods for ID. A multidisciplinary research team with a breadth of experience in medical education, pedagogy, and qualitative research provided investigator triangulation from design through to analysis. The team met on a regular basis. Field notes were also used to ensure that biases were kept in check, to record the context of data gathering, and to speculate on linkages between these contexts and the phenomenon being studied. An audit trail was maintained throughout the study, mapping the development of linkages and conceptualizations and ensuring that the analytic reasoning was grounded in the data.
Although we specifically sought to understand patients’ perspectives on curricular concepts, we also were successful in eliciting perspectives on physicianship more broadly. We have thus organized the findings in two sections. The first section will present the participants’ views on the two a priori curricular concepts that were explored explicitly: (1) the physician as healer, and (2) the physician as professional. The second section will describe two emergent themes: (1) listening is the “essentia” of good doctoring, and (2) being treated as a number represents a threat to personal identity. We chose to present the findings in this particular sequence because it respects the original motivation for embarking on this study (i.e., to elucidate patients’ opinions and understandings of specific curricular constructs). However, this sequence should not be understood to represent the relative importance of the themes. We provide examples of quotations for both sections (those from French-speaking participants have been translated into English).
Patients’ views on the concepts of healer and professional
Few participants made spontaneous use of the terms healer or professional when speaking of their health care experiences. The interviewers were obliged to introduce these words themselves to elucidate patients’ understanding of these concepts.
The physician as a healer.
Although many of the attributes that the McGill Faculty of Medicine uses to describe physicianship were meaningful to patients, the term healer was problematic. It was often regarded in a negative light; examples of pejorative descriptions included “gobbledygook,” “folklore,” “smoke and mirror,” “primitive societies,” “charlatan,” and “African wizard.” On the other hand, one patient seemed to have a positive concept of healer but saw some physicians as being the opposite of healers:
I don’t see some of the doctors I’ve met as healers. In fact, I see them as sort of, unfortunately, just having to be very destructive, like the opposite of healers, I mean warriors. And I remember saying over and over again in my head … wait, I’m a pacifist, I don’t want to start a war with this thing.
Contrary to the word healer, the concept of healing elicited comments of a more positive nature. The most frequently used expressions to define healing referred to emotional or psychological dimensions:
Healing a person is seeing to the whole of that person … mentally [and] physically.
Participants were prompted to think of healing by the question, “Is there a distinction between healing and curing?” Addressing the mental or emotional component of sickness was seen as being more closely associated with healing than with curing. The words used in describing healing (“soothing,” “peaceful,” “comforting”) contrasted with those accompanying curing (“definitive,” “absolute,” “absence of something”).
Additional features of healing, such as prevention and achieving a more profound understanding of root causes of personal sickness, were presented:
Healing is more about a deepening, a transformation, the kind of change that involves the symptom going away but also involves the awareness of what caused that symptom to be there, how that symptom changed the person’s life … and how such things can be prevented in the future.
The physician as professional.
Participants were asked specifically to identify the attributes of a physician they would consider to be “very professional.” The most common responses dealt with behaviors—behaviors that can be categorized broadly as interpersonal skills or good bedside manners. These included “be encouraging,” “care,” “treat me with respect,” “be honest,” “be compassionate,” “communicate well,” “maintain your composure … even in the face of annoyances,” “have good attire,” “identify yourself,” “avoid interruptions,” and “be on time.”
It is interesting to note that although the terms professionalism and professional were generally accompanied by a positive value judgment, some participants suggested otherwise. The expression “professional distance” was used on several occasions. Other examples of comments having a negative valence included
Very professional means stuffy-nosed … not my favorite kind of person.
Professional men … They can’t be bothered doing the menial things, so they put things off on other people.
Medical knowledge and/or diagnostic and procedural skills were seldom cited explicitly by patients. When the issue of competence was explored further, it became clear that patients considered those characteristics of their physicians to be a given. In one striking example, a particularly articulate participant was revisited after the initial interview. In the subsequent meeting, the participant was asked, “Sir, when we met yesterday, in your responses to the question, ‘What do you consider are the most important features of a good doctor?’ you did not suggest anything relating to knowledge, skills, know-how, expertise, or competence; do you consider these to be important?” The participant’s response was “Of course it’s important … it’s tops! But I would imagine that this institution would not have incompetent physicians on staff.” For several participants, the process of a physician arriving at the correct diagnosis and starting appropriate treatment is equivalent to having achieved a “passing grade.” It describes a “pass” rather than a superior performance.
Teamwork was rarely invoked by patients as a requirement of a good doctor. Although it was often mentioned, the concept seemed to be linked to the broader health care system rather than to physicians per se. Several participants commented on the key role played by liaison nurses in coordinating care. They also expressed concerns that the health care team might be threatened by administrative decisions such as the fusion of hospitals. The physician was usually described as the “core” of the team.
Listening is the “essentia” of good doctoring.
All participants, without prompting, talked about the physician’s listening skills. It was generally broached early on in the interview, often in response to the question, “What do you think makes a doctor a good doctor?” It was a dominant issue and often was expressed as a priority requirement. One participant described it as the “number one” expectation. Another, a patient in the palliative care unit, referred to its “essentialism” for doctoring.
Listening was understood to be an important phase in the encounter, setting the scene or, as one participant alluded to it, “starting the engine,” so that the doctor would know how to proceed next and would understand which questions to ask. Listening was considered necessary to the fulfillment of many goals of the encounter including understanding, explaining, believing the patient, answering questions, and giving information. It was also considered an ingredient in therapy
because sometimes listening to a person will cure half of [one’s] problems.
Listening was closely allied to time, the two words often appearing together in the same phrase. Time was seen as a necessary ingredient for some; however, most participants suggested that a lack of time need not be an absolute limiting factor to effective listening:
I know a physician in [name of town] who was superbusy and so he never gave you more than two minutes, but in those two minutes he listened to you. You have the impression that you had spent an hour with him, but it was only two minutes.
Participants generally implied that the object of the physician’s listening was the patient. However, this was not universal. One individual recounted an episode where a physician seemed to have listened to, and believed, another medical doctor more so than herself. Furthermore, the object that was “heard” could be a “what” rather than a “who”; for example, some envisaged doctors as listening to the medical chart rather than the person to whom the chart referred. One participant, a young woman on long-term hemodialysis who had consulted many different physicians during her illness, suggested that some listen to the disease:
I called them “by the book.” If something doesn’t coincide with something that they read in the book of [inaudible] disease, it doesn’t exist. Myself as a human being, I am different than other people, we all are different…. They listen to the disease, not the person, so they separate the two.
When confronted with poor listeners, participants described strategies they adopt in response; for example, they may exaggerate their symptoms, even though they might feel guilty about it, to create a sense of urgency, hoping to compel the physician to listen. One middle-aged woman, admitted on a surgical ward with recurrent bowel obstruction, expressed exasperation at encounters with what she perceived as a series of nonlisteners; she stated that
If they close their ears to you, then what are they understanding? Only what they’re seeing, right? And seeing is not everything.
When listening was discussed with Anglophone participants, it was often interpretable as an action. Those interviewed in French often used the term “être à l’écoute”; this phrase can be translated as “a state of listening.” In English, listening seems to be a process, whereas in French it is more akin to a state of being—that is, being in a “listening mode.” Listening was an aspect of doctoring that was of great value, with a rich array of meaning, to all participants.
Being treated as a number represents a threat to personal identity—to ipseity.
The Oxford English Dictionary defines ipseity as “personal identity and individuality.”20 It seems like an ideal word to encapsulate the following observations. In addition to wanting to be heard, participants poignantly expressed a need to be recognized as unique persons. This was articulated in a variety of ways. Some were concerned about being treated as something other than a whole person—for example, as the problematic body part:
To show you that they know you have a wife or you have children, and, you know, not only concentrate on the medical aspect of a person … just seeing a liver walking in, or a kidney.
They have a relationship with you. They know your thoughts. They just don’t have a relationship with your ankle.
In addition to body parts, they also used descriptions such as “a research project” or “a case.” The most frequently cited criticism, however, related to being made to feel or being treated like a number. It seemed to be a potent phenomenon whereby patients experienced loss of personhood:
I don’t want to be abandoned, like you brand an animal with a number and you then send it off in the field and never see it again. I’d say that a patient is not a chart number. Not a hospital number. He’s a human being. I do request [the doctor’s] help but I do so as a human being, not as a number.
Patients want to be seen as unique, to be recognized and remembered as distinct beings, even while acknowledging that their physicians generally have responsibility for numerous patients. They described several techniques that are able to affirm individuality. A source of praise was an approach to history taking focusing not only on the biological elements of sickness but also on the everyday aspects of a lived life, aspects often bordering on the mundane:
The best doctor here is Dr. [X]. When you walk into his office, he will never say, “Hi, how has your breathing been? How are your lungs? Are you coughing?” Nothing like that. He says instead, “How’s your work? Are you still driving? What’s going on in your life?”
Doctor [Y] asks me often, “How is your little girl? What is she doing? How is Sammy?” … Not an intimate relationship, because that would not be correct, but one of an almost-friendship. A “good-day,” just a little “good-day,” without necessarily going into my family’s pedigree.
In addition to showing an interest in a person’s life, physicians can demonstrate their shared humanity, thereby protecting against depersonalization, by other means. Participants described such approaches—empathic gestures or statements implying a partnership:
You can’t imagine the power of someone just doing that [placing a hand on the interviewer’s shoulder], just that, which is what Doctor [Z] did when he told me,“Okay, I’m going to be your doctor, I’m going to do the operation.” And he looked into my eyes and he just did that and I felt his empathy … you think, okay, this is a human being who feels, who understands and who knows how tough this is. And to me it seems that it’s so easy to make those little gestures.
Eye contact to me is always important. It’s like anything else, it’s like a business deal, you shake someone’s hand, you look at them in the eye and say hello.
The goal of this study was to elucidate patients’ perspectives in order to inform the ongoing development and deployment of teaching modules in a new curriculum. With this in mind, and with the expectation that products of ID design should have application potential, we highlight pragmatic implications below.
A significant finding was that healer and professional, words integral to the conceptual armature of the curriculum, were largely absent from the patients’ lexicon. Although there was considerable overlap between the expectations of patients and faculty with respect to ideal physician behaviors, there was incongruence between the expressions and terms used to encapsulate these. It is as if each were speaking with a unique voice. This mirrors the recognition that different voices are operational in physician–patient encounters. Mishler et al,21 for example, have described the “the voice of the lifeworld” in contrast to the “voice of medicine.”
It is beyond the scope of this study to engage in discourse analysis or to describe, in detail, the textual architecture of the unique “voices” that may be manifest in these transcripts. Nevertheless, it is noteworthy that patients speak in active terms (e.g., “knows his/her limits;” “is straightforward;” “stays with, encourages and inspires me”)—phrases that describe specific behaviors—whereas faculty use passive terms or labels (e.g., “insight;” “openness;” “presence”). The patients’ voices may, therefore, suggest codified practices or provide “behavioral markers” that have potential applicability for the role modeling of specific physicianship attributes. Despite these distinct linguistic features, it is, nevertheless, important to emphasize that the detailed descriptions provided by faculty for physicianship attributes overlap significantly with patient concerns. For example, McGill’s Faculty of Medicine defines openness as “willingness to hear and accept and respond with sensitivity to the views and experiences of others.”11 “Willingness to hear” may simply be a different formulation of the same phenomenon—active and attentive listening. Although the faculty have a predilection for a language centered on personal attributes and patients’ focus on behaviors, these remain ineluctably linked. For example, listening may well be a behavior through which compassion is expressed.
Another interesting observation, illustrative of differences between faculty-centered and patient-centered vocabulary, is the potentially negative overtone attributed to the word professional. This is of particular interest, given the intense level of discourse on professionalism in the current medical education literature. It may be theorized that the intensity and spontaneity with which patients apprehend the interpersonal abilities of physicians may not be adequately evoked by the word professional. One can readily imagine a person emphatically recommending a physician using a statement such as, “You must consult Dr. X; she’ll take the time to listen and explain. She’s got a great bedside manner!” Enthusiasm may be muted if one were to be confined to a standard list of professional attributes focused preferentially on physicians’ obligations to society and/or professional institutions; these professional roles are likely to be rather tacitly understood by patients. Our purpose is not to diminish the importance of physicians’ societal obligations but, rather, to speculate on why the word professional was rarely used by participants in this study. We posit other explanations. Widespread use of the word professional in other contexts (e.g., professional gardeners, professional wrestling, and professional Formula 1 drivers) may be confusing and result in a blurring of ties to the world of professional education in fields such as medicine, law, and the clergy. Also, patients may simply expect that doctors’ comportment will not be marred by behaviors that are clearly unprofessional. In other words, professionalism may be linked conceptually to a baseline behavior—a minimal competence—(the presence of which is assumed) rather than to a set of ideal behaviors. Hence, a transgression of the former (i.e., the expected minimum) may be more salient than the failure to achieve the latter (i.e., the ideals).
A similar perplexing situation exists regarding the words healer and healing. A search for an understanding of the denotative and/or connotative asymmetry would be intriguing. One hypothesis may be that the word healing has a primary intent that is focused inward or emanating from within—it speaks to a process that is inherent to the person and is, thus, “owned” by the person qua patient. On the other hand, the word healer may imply a locus of control external to the patient, as in “being done to.” If these conjectures reflect patients’ conceptual framework, the intransitive use of the verb—“the patient heals [on her own]”—may be less evocative of a power differential than the transitive form—“the doctor heals [the patient].” Such interpretations point to potential implications beyond the community in which this particular study was conducted. These tentative claims suggest avenues for future research; use of the semantic differential survey technique or approaches such as narrative inquiry may succeed in creating new understandings of these descriptive findings.
Our findings show that many patients in our hospital setting attribute high value to the physician’s ability to listen, thereby corroborating results from commentary in other venues.22,23 The tasks comprising effective communication in medical encounters and the crucial links between interpersonal skills and communication skills have been described previously and have resulted in the dissemination of well-validated instruments useful in teaching and evaluation.24,25 As noted previously, such instruments have been constructed with patient input. The salutary effects of good communication skills are widely recognized.26 Listening has also been singled out as a defining characteristic of the role modeling of ideal physician behavior.27 That it seemed to be more visible than expertise—a factor the Faculty of Medicine assumed would be critical to patients—was unexpected. A recent survey conducted in the United Kingdom and published in 2006 has yielded similar results.28 In updating its standards, the Standards and Ethics Committee of Good Medical Practice (a committee of the General Medical Council of the United Kingdom) decided to incorporate lay perspectives. Members of the public were asked to rate the relative importance of various duties of a doctor. They selected the duties “make the care of your patient your first concern” and “listen to patients” as the two most important. These ranked ahead of “keep your professional skills and knowledge up to date.” Other research has been explicit in exploring the tension that patients feel when asked to select physicians according to either high technical expertise or high interpersonal qualities. When forced to make such trade-offs, many favor the technical aspect.29 This is compatible with our findings; when one is prompted to discriminate the minimally competent from the ideal, the “given-ness” of the former seems to require a shift of attention to interpersonal qualities.
Findings from this study will result in modifications to the faculty’s description of physicianship. The original list, which dates to 2002, is presented in Table 1. It will be revised to incorporate listening within the ambit of core physicianship attributes.
Interpersonal interactions that suggest the physician fails to recognize the patient as a unique individual was an additional aspect of doctoring deemed important by our participants. Similar concerns have been expressed elsewhere. In 2001 and 2002, a telephone survey of approximately 200 patients in the Mayo Clinic system revealed seven ideal physician behaviors; one was described as “personal behavior.” Its essence was captured with the following statement: “The doctor is interested in me more than just as a patient, interacts with me, and remembers me as an individual.”30 A further example illustrating the phenomenon of depersonalization is apparent in an innovative curricular exercise aimed at fostering empathy. In that study, medical students were invited to participate in a standardized hospitalization and subsequently prompted to reflect on their experience as mock patients. A typical comment was “No doctor ever asked me how I felt; rather they asked me about this body part or that.”31 Although medical students are attuned to the risk of depersonalization, there is increasing evidence to suggest that they, too, suffer an erosion in empathy and a decline in the valuing of whole-person care during the educational experience.32–34 A medical training process that emphasizes technology and science may very well be a contributor to the objectification of sick and suffering persons. Our finding of objectification as experienced through “numbering” may also be a phenomenon that is (arguably) more relevant to Canada and other jurisdictions with similar, “socialized” health care systems. Given that the MUHC operates within a publicly funded environment, queues, waiting lists, and triaging are constant features. Each participant would have possessed either a health insurance card number or, in the case of recent immigrants, a temporary health services number from the federal government. Also, it may be pertinent to underline that most participants were interviewed while in-hospital, a context where a hospital card number would be a frequent companion.
The study was marked by certain methodological limitations. Although the participants recruited were culturally diverse, it was common for them to have had a university education. This prevalence is not reflective of the patient population receiving care at the MUHC, an institution that provides care to significant numbers of urban inner-city poor and disadvantaged refugee populations. The reason for this overrepresentation may lie with the referring clinicians’ assumptions about which patients could speak articulately to our research topic. Whereas the number of well-educated individuals may have facilitated the interview process and, thus, been beneficial to our study, their perspectives may have been overrepresented.
We consider this study to have illuminated several avenues by which patients can make important contributions to curricular reform. Our findings have had important practical ramifications locally. They have helped to put into operation the idea of physicianship, moving from Platonic ideas to educational directives, and they have resulted in modifications to aspects of the curriculum. For example, the admission process as well as the assessment protocol of medical students’ performance in clinical rotations have been redesigned to include listening as a specific evaluation criterion. Additional examples of changes to program administration are provided in Table 4. We also anticipate patients’ perspectives to have implications for program evaluation. We expect that listening skills—the degree to which patients feel heard—will be a major focus of outcome measures. In short, we have been stimulated to consider the specificity of patient-defined attributes of good doctoring and to find words that map onto patients’ unique modes of expression.
We suggest that our experience is relevant to the medical education community at large. Conversing with patients on our curricular initiative was both grounding and directive. Now that it has been obtained, it seems self-evident that soliciting patients’ points of view would be invaluable in designing any curriculum that is responsive and accountable to patient needs. It is surprising that such an approach has only recently appeared on the medical education research agenda.
This project was supported by grants from the Montréal General Hospital Foundation and the Max Bell Foundation.
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