Art of medicine

Schools keying on writing, verbal skills to deepen students’ clinical acumen

Along with teaching bedside skills, medical schools recognize the value of writing to spur reflection and understanding in students.

Becoming adept at the multiple aspects of medical communication requires career-long perseverance, observes Arnold Melnick, DO, the founding dean of the Nova Southeastern University College of Osteopathic Medicine (NSU-COM) in Fort Lauderdale, Fla. “Just as medical schools cannot teach students all of medicine, we cannot possibly instruct students in all facets of medical communication. But we need to give them enough of the basic material that they can build on what they’ve learned, and we need to stimulate their interest so they will want to learn more,” says Dr. Melnick, the author of the newly published book Effective Medical Communication, a compilation of the columns he wrote for The DO.

Medical schools must stress that communication skills are just as important to a physician’s success as clinical knowledge, Dr. Melnick contends. Citing a Wall Street Journal and Harris Interactive poll conducted in 2004, he states in his book, “Patients place more emphasis on the interpersonal skills of their physicians than they do on the knowledge, judgment and experience of their doctors.”

Medical writing and oral presentation skills are also essential to physicians and should be introduced in medical school, says Dr. Melnick, a former president of both the American Medical Writers Association and the American College of Osteopathic Pediatricians. In his book, he explains how clear and succinct writing without ambiguous abbreviations—in patient charts, prescriptions and letters to consulting physicians and insurance companies—can help reduce medical errors, minimize a physician’s medical liability and improve patient care. “Medical speaking,” as Dr. Melnick terms it, includes not just presentations at medical conferences but also interactions with colleagues in other specialties, broadcast media interviews, and testimonies on medical and health-policy matters before legal and governmental entities.

In 1982, Dr. Melnick established at NSU-COM what he believes was the first course dedicated to medical communication at a medical school. A required course for second-year students until 1990, Medical Communications focused primarily on medical writing and medical speaking.

“For several years, I introduced the course with the question ‘How many of you expect to do medical writing when you graduate?’ And each time I would see only a scattering of raised hands,” Dr. Melnick recounts. “Then I would ask students a brief series of questions: ‘How many of you expect to write progress notes?’ Several hands would go up. ‘How many of you expect to give consultation reports to other doctors?’ After a few such questions, almost all of the students had raised their hands. Medical writing is far more encompassing than students expect it to be.”

Osteopathic medical schools today place much more emphasis on physician-patient communication than on formal writing. Courses on scientific medical writing, when offered, are generally electives. But increasingly, both osteopathic and allopathic medical schools have come to recognize the value of writing as a tool to spur deeper reflection and clinical understanding in students.

Physician-patient communication

Interpersonal and communication skills constitute one of the AOA’s seven core competencies for osteopathic undergraduate and graduate medical education. Osteopathic medical schools use a variety of approaches to hone these skills in students, such as small-group learning and simulated patient encounters.

“We consider communication to be a very important aspect of medical education,” says Thomas A. Cavalieri, DO, the dean of the University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine (UMDNJ-SOM) in Stratford, noting that physician-patient communication is integrated throughout the curriculum as well as addressed in a specific course. In their second year, students take Interpersonal Communication, which is designed to foster cultural competency. The students learn how to communicate with patients who speak other languages, who are hearing impaired or have other special needs, who are indigent, who are gay, lesbian or transgender.

As is becoming increasingly common in osteopathic medical colleges, UMDNJ-SOM assesses students’ communication skills in the school’s standardized patient laboratory, in which actors play the role of patients and caregivers. The students are asked to interact with an elderly patient accompanied by a son or daughter, as well as with a patient who doesn’t speak English, among other scenarios. “We look at whether the students shake hands when approached, make eye contact and allow the patient to speak,” Dr. Cavalieri says. These encounters are recorded on video, so students and faculty can review them closely and discuss what the students should have done differently.

The standardized patient encounters help prepare students for the performance evaluation portion of the Comprehensive Osteopathic Medical Licensing Examination—USA, Dr. Cavalieri notes. As students serve their clinical rotations in their third year, they receive additional training in cultural competency and evaluations at the bedside.

As at UMDNJ-SOM and many other osteopathic medical schools, students at the Michigan State University College of Osteopathic Medicine (MSUCOM) in East Lansing can begin to develop their patient communication skills in their first and second years by volunteering at health fairs and clinics that serve the underserved. Students can also acquire insights into effective communication from mentors they are paired with.

Emphasizing the need to be sensitive to cultural diversity, MSUCOM’s Doctor-Patient Relationship course uses small-group work and standardized patient assessments so students can practice the three basic types of clinical interviews: gathering information from patients, giving information to patients, and motivating patients to adopt more healthful behavior. “We have students who’ve had previous careers and already have professional quality communication skills alongside of students who recently received their bachelor’s degrees,” points out course coordinator Deborah B. Wagenaar, DO, an associate professor of psychiatry. “Students from various backgrounds learn from one another. Our course helps equalize their skills.”

Dr. Melnick offers insights into nonverbal communication with patients in Effective Medical Communication. “Your position in relation to the patient is important,” he writes. “To sit behind a desk may suggest to the patient that you have created a block between the two of you. Physicians should not stand above the patient and look down on him or her—except where part of the examination might require it. This puts you in a perceived position of superiority, the so-called ‘power position’ resented by most people. It is always better to maintain your eye contact on as even a level as possible.”

Reflective writing

The director of the Program in Narrative Medicine at the Columbia University College of Physicians and Surgeons in New York City, Rita Charon, MD, PhD, is the pioneer of a movement to have medical students read literature and write reflectively about the texts and their experiences so that they develop more empathy for patients.

Dr. Charon, who has a doctorate in English literature, explained how she developed narrative medicine in an essay for LitSite Alaska. “I realized that the narrative skills I was learning in my English studies made me a better doctor,” she writes. “I could listen to what my patients tell me with a greater ability to follow the narrative thread of their story, to recognize the governing images and metaphors, to adopt the patients’ or the family members’ points of view, to identify the subtexts present in all stories, to interpret one story in the light of others told by the same teller. The better I was as a ‘reader’ of what my patients told me, the more deeply moved I myself was by their predicament, making more of myself available as I tried to help.”

Narrative medicine has significantly influenced instruction at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, says Leonard H. Calabrese, DO, a professor of medicine and the vice chairman of the Department of Rheumatic and Immunologic Diseases. “At Lerner College, we put great stress on reflective narrative as a way to build empathy in our students,” Dr. Calabrese says. In one class, for example, students are presented with scenarios, such as breaking bad news to patients and understanding the financial troubles patients may face as they cope with illness. The students are asked to write their reflections on the scenario, which they read to the class.

At the end of the term, “bits and pieces” from the Lerner students’ writings are put together into a script that is performed by professional actors. Besides being fun, the dramatization reinforces and gives weight to the insights students gleaned during the class, according to Dr. Calabrese. “Narrative writing adds greatly to reflective practice and is an important part of the curriculum for all of our students,” he stresses.

Gary C. Hoff, DO, also has students write reflectively in the classes he teaches at the Des Moines (Iowa) University College of Osteopathic Medicine (DMU-COM). In the elective course “Medicine in the Arts,” students read short stories and poetry, watch movies, and look at many examples of the visual arts. “I ask students to keep a journal in which they reflect on what they are learning in class. They turn their journals in, so I have an idea of their thought processes, but I do not grade their writing or correct their spelling and punctuation,” says Dr. Hoff, who chairs DMU-COM’s Department of Medical Humanities and Bioethics.

An artist and a fiction writer, Dr. Hoff encourages students to contribute to DMU-COM’s literary arts journal, Abaton, which publishes nonfiction narratives by students and alumni, short stories, poetry, photography and images of paintings and other art forms.

Many DMU-COM students have served rotations with Des Moines psychiatrist David E. Drake, DO, who also believes that reflective writing helps students and physicians better understand themselves and their patients. “At the beginning of a student’s rotation with me, I have him or her write an autobiography to give me a sense of what I’m up against in working with that student. More important, this gives students a chance to reflect on where they are in their lives and their medical studies,” Dr. Drake explains. At the end of the rotation, which includes many opportunities to observe and work with patients, students write about what they’ve learned. Being able to plumb the depths of human experience is an important trait for all physicians, not just psychiatrists, Dr. Drake says.

A social activist who serves as the vice chairman of the Des Moines Human Rights Commission, Dr. Drake frequently writes opinion pieces for The Des Moines Register. He encourages students to leverage the knowledge and respect they will have as physicians, as well their passion and communication skills, to try to make the world a better place.

Narrative medicine has also affected how Felix J. Rogers, DO, of Trenton, Mich., practices cardiology and guides trainees and young colleagues. “We need to know how to establish a context for the person we’re treating,” says Dr. Rogers, a senior section editor for JAOA—The Journal of the American Osteopathic Association. “We need to ask ourselves, ‘What is this patient’s story?’ ”

But rather than writing reflective narratives on their patients, “cardiologists need to learn how to express a patient’s story in one sentence,” Dr. Rogers says, explaining that progress notes often have extraneous information. “That means they have to listen to the patient carefully and discern what is important.”

Distinguishing what is crucial from what is irrelevant or ancillary is a hallmark of both effective communication and effective clinical care, Dr. Rogers observes.

Continuing education

Medical communication, in Dr. Melnick’s view, extends well beyond physicians’ interpersonal, writing and speaking skills and ability to interpret patients’ and their own emotional states. Physicians’ attire and promptness, office cleanliness, the friendliness and helpfulness of staff, telephone answering procedures, and the quality of office handouts, for example, are all facets of communication, he notes. What’s more, how physicians conduct themselves in the community, online, and even in their private lives communicates volumes about their professionalism, he says.

“Effective medical communication,” notes Dr. Melnick, “cannot just be left to the classroom. Becoming a skilled communicator demands years of study, reflection and practice.”

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