Minding your bedside manner
An unexpected collaboration between VCU’s theatre and internal medicine departments aims to revive the fading art of doctor-patient rapport
by Katherine Schutt
We’ve all experienced it before: the doctor who spends a mere five minutes in the patient room, rarely lifting his head from his scribbling as he fires staccato questions at you, tucks a prescription in your hand and shoots back into the hallway, leaving you wide-eyed and bewildered on the exam table. For those on a routine visit, the experience can be frustrating. For situations more serious, it’s downright scary.
Though the science of medicine seems to have eclipsed the art of doctor-patient rapport, some faculty members at Virginia Commonwealth University hope to re-emphasize the importance of communication in health care. The solution comes from an unlikely source: the VCU Department of Theatre. Since 2004, the departments of Internal Medicine and Theatre have collaborated on a communication curriculum in which faculty use a theatre-based approach to teach empathy to medical students and health care professionals.
“There is a crisis in the health care field in doctor-patient relationships to the point that it is actually affecting patient outcomes,” says Aaron Anderson, Ph.D., associate professor and vice chair in the Department of Theatre. “Essentially, medical schools have crammed so much into four years of study that science has squeezed out the humanistic aspects of medicine. In theatre, we teach how to be authentically present in inauthentic moments. We thought we would see if we could take some of those skills and teach them to physicians.”
The collaboration continued in 2007 with a widely publicized pilot study in the Journal of General Internal Medicine. Anderson and co-authors David Leong, chair of the Department of Theatre; Richard P. Wenzel, M.D., M.Sc., then-chair of the Department of Internal Medicine; and Alan Dow, M.D., M.S.H.A., assistant dean of the School of Medicine, evaluated 14 internal medicine residents on their patient interactions before and after six hours of communication workshops with theatre faculty. A control group of six residents received no training.
“What we found was the group that we trained was, in fact, better at communicating with patients,” Dow says. Following the initial study, Dow and Anderson expanded their curriculum for use with third- and fourth-year medical students, nursing students, general and orthopaedic surgery residents, and geriatric and palliative care fellows — all of whom showed marked improvement in communication skills after the training.
Their most recent study, made possible through a VCU Presidential Research Incentive Program award, assessed the effects of the curriculum on patient perceptions of medical students’ communication abilities to determine if patients also noted an improvement in rapport after training.
Seven fourth-year medical students opted to take Advanced Clinical Communication, a springtime elective course that included four workshops and multiple interactions with standardized patients. Standardized patients, also called simulated patients, are carefully coached to simulate an actual patient so accurately that the simulation cannot be detected by a skilled clinician. The patients used in this study also were coached to evaluate the students’ communication skills, both before and after the training workshops.
Dow and Anderson are analyzing the results and plan to publish the study later in the year. As for the participating students, they embarked on their residencies with an enhanced understanding of how to best communicate with patients.
“I think the training will be really important going forward because it’s really easy to get caught up in medical facts and minutiae and forget the personal aspect of medicine,” says class participant Ashley Talbott, M.D. (M.D. ’11/M), currently an anesthesiology resident at Wake Forest Baptist Health in North Carolina. “As a young doctor trying so hard to understand the medical aspects of a situation, you also really need to think about how you’re communicating with a patient.”
The art of communication
While VCU isn’t the first university to use unorthodox techniques to improve doctor-patient relationships — Northwestern University notably offers a class called Magic and Medicine for the same purpose — Dow says it could be the first in the country to call on its theatre faculty to teach communication skills to medical students. To Anderson, the partnership makes perfect sense.
“The misconception is that theatre trains people to ‘perform,’” he says. “In fact, theatre trains people on how to be ‘present’ — that is, how to be fully involved in the current moment and how to communicate that personal involvement to other people.”
In the context of medicine, that translates to a doctor putting aside her other concerns, whether about another, sicker patient or her daughter’s soccer game, and focusing fully on the patient in front of her.
“We spend years and years of medical training focusing on the diagnostic aspect of doctor-patient communication and practically no time on the rapport-building component,” Dow says. “I think they’re equally important because they’re so interwoven. Through this curriculum, we teach residents how to be good listeners, how to be more human, how to understand how the elements of a person affect the specific clinical situation that they find themselves in.”
The training workshops address the basics of interpersonal communication, focusing on the importance of nonverbal cues, how body language and tone of voice can reveal more about a patient’s state of being than the words he or she says. Students also learn to recognize their own subconscious behaviors by participating in extensive role-play with a “parent” or “patient” played by Anderson.
“The workshops were designed to challenge the residents to think about what they do and how it can be interpreted to others,” says Brian J. Kaplan, M.D., vice chair of surgery education and program director of the general surgery residency program. “I think that one thing our residents gain from the training is a greater self-awareness in terms of what they communicate with their body language and other nonverbal components of communication.”
Trainees also walk through difficult conversations with patients, such as delivering bad news and admitting mistakes — experiences that otherwise would not have arisen until their medical practice. Through the acting exercises, the residents learn to make small adjustments that can make a big difference to a patient.
“Throughout medical school, they tell you things that seem like common sense — that you need to approach a patient personally, not go in spouting facts,” says VCU Medical Center resident Katie Miller, M.D. (M.D. ’11/M), who participated in the spring 2011 elective class. “In one of the scenarios, I found that I was automatically giving the patient more medical information than he needed. I realized that you need to step back and gauge the situation individually to find out what the patient can understand and take in at that moment.”
Workshop graduates like Talbott and Miller routinely say they feel more confident in their communication skills after training, a boost Anderson and Dow believe will pay off for patients down the road.
“The average length of a medical visit is eight minutes,” Anderson explains. “If a doctor spends the first two minutes building rapport — asking how you are, inquiring about your kids and getting you comfortable — he or she can do much more with those eight minutes than if they just ask medical questions but don’t have your trust. There are plenty of medical studies that show a clear correlation between positive health outcomes and patients saying they had a good rapport with their doctor.”
Now that Dow and Anderson have demonstrated repeated success with their approach to improving doctor-patient rapport, they plan to expand the program. This year, the School of Medicine’s Center for Human Simulation and Patient Safety partnered with the Department of Theatre to start a standardized patient program at VCU.
“The standardized patient program is the first-ever full partnership between humanities and medicine in the country,” Anderson says. “Right now, interactions at VCU and across the country are happenstance. Individuals like Dr. Dow and I are collaborating with one another on a one-to-one basis, but once those individuals leave, the program ends. This new program provides a systemic structure through which collaboration will be easily done.”
For their past studies on empathy training, Dow and Anderson hired standardized patients from outside the university to interact with VCU residents. Now, they’re training their own. This summer, Anderson coached 23 actors of various ages and demographics on specific medical cases. Each standardized patient learns and presents the entire gestalt of the patient: the history, body language, physical findings and emotional and personal characteristics. A 67-year-old man, for example, might be trained for a diagnosis of colon cancer, so he would be versed fully on his symptoms, past health issues and how he would react, physically and emotionally, to his diagnosis.
The actors made their debut in June during new intern orientation. Within a year, Anderson hopes to increase the pool of standardized patients to 100 to 150, as well as to establish a bank of common cases to use for classes and workshops. The program also will allow for customization of cases according to the needs of different departments and specialties — a logical task for the theatre faculty to undertake.
“The steps involved in creating standardized patient cases — writing a case, casting and training the patients, establishing the logistics and running the exercises — exactly parallel how you make theatre,” Anderson explains.
The new James W. and Frances G. McGlothlin Medical Education Center, set to open in spring 2013, will feature a standardized patient environment with two-way mirrors, video recordings and observation rooms, providing a high-tech home for the program.
Making the grade
For the communication curriculum and standardized patient program to succeed on a broad scale, the results must be measured. Here, both Dow and Anderson say the field of medicine lacks an effective assessment tool.
“One of the core competencies in medical education is interpersonal communication,” Anderson says, “but measuring ability in this area is challenging. We are trying to establish ground rules on how you measure what someone says and how he or she says it. The long-term goal of the simulated patient program is to create and validate an assessment tool for rapport.”
Currently, communication assessments often allow a simple yes/no answer to the question of whether a student is being empathetic.
“We can be much more granular than that,” Dow says. “Did they reflect your body language? Did they recognize what your tone of voice was trying to convey? Was their body language consistent with the message they were trying to convey?”
Ultimately, Dow and Anderson hope to disseminate VCU’s own rapport-assessment scale so that it becomes the mainstream model for evaluating doctor-patient communication. It’s a lofty goal, but one that is achievable primarily because of the uncommon collaboration between the School of Medicine and Department of Theatre.
“We have a pretty specific expertise here because of our ability to bring in the theatre concepts,” Dow admits. “It’s very unique.”
Should they succeed, it will be the patient who ultimately benefits.
“Communicating with patients is fundamental to everything we do, whether you’re going to be in general practice or very specialized,” Dow says. “The ability of our students to become doctors who their patients trust and whose advice their patients will listen to and whose patients will give complete information to, is only going to increase the health of our communities.”
Katherine Schutt is a contributing writer for Shafer Court Connections.