To become excellent physicians, medical students must master the science of medicine. But they also must learn the art of healing, which is a much more subtle skill.
The patient presented with vague symptoms of fatigue.
“I was running three miles, three times a week,” the soft-spoken man explained. “Now after about a mile, I’m ready to cash it in. I just don’t have the stamina, I guess.”
The young doctor probed further, asking him if there was any associated pain or difficulty breathing and whether he had experienced anything like this before. He took a detailed medical history and asked about the man’s family. He asked about possible sources of stress and about his work life, carefully jotting down the answers in his notes. He listened to the patient’s heart and lungs, taking care to place the stethoscope directly on the man’s skin rather than listening through his hospital gown. He palpated his neck, checking his thyroid.
He learned that the man was a divorced teacher who loved his job. He was happy with his life, but was experiencing unexplained fatigue. Further questioning revealed the patient woke up several times in the night to urinate and that his mother had a “sugar issue,” although he was unclear what it was and whether she took medication for it.
When the interview was complete, the patient delivered the diagnosis.
“I thought it went well,” he explained. “These are my suggestions…”
The patient was a standardized patient, carefully trained to help teach medical students how to conduct a medical interview and physical exam and—more importantly—how to interact with patients. The doctor was second-year medical student Arvind Suguness.
To become excellent physicians, medical students must master the science of medicine. They must learn the biological, physical, genetic, molecular, and mathematical foundations of medicine. But they also must learn the art of healing, which is a much more subtle skill.
At the Boonshoft School of Medicine, that process starts early
“Our students start from day 10,” said Bruce Binder, M.D., associate professor, Department of Family Medicine and director of the Skills Assessment and Training Center. All first-year medical students take Introduction to Clinical Medicine, where they learn the fundamentals of building a relationship with a patient, how to gather relevant information, and how conduct a physical examination.
“We model it to build an interview—not just take down information,” Binder said. “We want to teach them to treat people, not diseases.”
Two first-year exams called OSCEs, (Objective Structured Clinical Exams) use standardized patients, trained professionals following a script prepared by the professor.
“Part of their evaluation is whether they get the appropriate information,” said Binder. “But a large part of their evaluation is interpersonal skills, how are you interacting, how are you doing with that piece of it?”
During the second year the focus is on differential diagnosis, how to determine what’s wrong with a patient, taking a focused history, and the physical, taught through 14 different standardized patient encounters in sets of three.
Students are again evaluated on their interpersonal skills. “Did they show concern for the patient as a person?” said Binder. “Patients will interpret that a little differently at times, but really getting at the issue of were they just there to diagnose a disease, or were they really there to be concerned about a person. The thrust here is to learn to have a good conversation, learn how to care for your patient.”
Second-year student Arvind Suguness was participating in his second set of interviews. Although uncomfortable at first, Suguness has found talking to patients easier than he expected.
“It’s definitely intimidating at first, to go into a room with someone you’ve never met before and ask them a whole bunch of questions about their life,” he said. “That can be kind of invasive. It’s a very nerve wracking thing, but you find that with some experience, it starts to come pretty naturally. When you start, you never think you’re going to be that person, a doctor who goes in the room and can just talk to someone. But then, by the end of it, I learned that I could do it.”
The ability to listen carefully and empathize with others doesn’t come easily to everyone
Some people are more in tune with others. And for the ones who aren’t?
“If they’re not a people person, it’s a tough sell,” said Binder. “You keep it out there as a value. You let them know that this is the expectation and continue to evaluate them based on that expectation.
“Honestly, the ones who want to and don’t have the inherent skill are trainable,” he explained. “The bigger problem—and we really don’t encounter it a whole lot—are the ones who just don’t see the value there at all.”
Binder credits the admissions process at the medical school for recruiting caring students. “I think they do a nice job of recruiting people with those good interpersonal skills and people values,” he said. “That’s always been kind of our trademark.”
Learning the art of healing will now start before students enter medical school
The Association of American Medical Colleges (AAMC) also recognizes the need to recruit medical students who not only have a broad understanding of the scientific underpinnings of medicine but are also well versed in the social and behavioral sciences.
Recent AAMC research found that although the public believes physicians have a strong medical background, they often lack bedside manner.
In an effort to ensure a broader range of skills for incoming medical students, in February of this year the AAMC announced it has revamped its Medical College Admission Test (MCAT), required for admission to virtually all U.S. and Canadian medical schools, to include testing in the behavioral and social sciences and in critical analysis and reasoning, in addition to the current sections on the natural sciences. The new MCAT will launch in 2015 and is expected to remain in place until 2030. This is only the fifth revision of the MCAT exam in its 84-year history.
“Being a good doctor is about more than scientific knowledge,” said Darrell G. Kirch, M.D., AAMC president and CEO. “It also requires an understanding of people. By balancing the MCAT exam’s focus on the natural sciences with a new section on the psychological, social, and biological foundations of behavior, the new exam will better prepare students to build strong knowledge of the socio-cultural and behavioral determinants of health.”
The revised MCAT exam will include a new section that will test students’ understanding of how these disciplines influence behavior, cultural and social differences that affect well-being, and the relationship among socioeconomic status, access to resources, and well-being.
Putting the pieces together
Sister Mary Diana Dreger, O.P., M.D., has seen these complex interactions first-hand, working on the frontlines of medicine providing health care for the underserved at the St. Thomas Family Health Center South Clinic in Nashville, Tenn. Dreger, a Dominican nun and practicing physician, visited Wright State in March to speak on the practice of virtue in the practice of medicine.
“I’m in primary care because I love that piece of taking care of the whole person and thinking of all the pieces that go together,” she said. “I think that we find that understanding the psychosocial situations of our patients is extremely important. Because without that piece, you don’t really know what’s going on with that patient.”
She recounted the story of a new patient she had seen recently. The young woman was 22 and had many vague complaints that had been going on for a while, but she had been without medical insurance so they hadn’t been addressed.
“As we talked, she revealed to me that five years ago she was shot and so was her boyfriend, and he died,” Dreger said. “And it’s changed her life in many, many ways—really not to the good of her health. And yet she doesn’t have a way of dealing with those issues. “I didn’t get to that in the first 10 or even 15 minutes of the conversation,” she said. “Yet that was the part I needed to know, and I couldn’t have known any other way except for spending some time and finally getting there.”
For Dreger, providing medical care for a patient has a deeper meaning.
“I think it’s a very true statement that the real heart of medicine, not art, but heart, is about love for the patient, love for the person,” she explained.
As medicine has become more subspecialized, that sense of caring for the person can become more difficult to maintain.
“We can run the risk of being subspecialists who only take care of parts of a person and not the whole person,” she said. “And so perhaps the subspecialists are called in a more real way to think about that and to not lose out on the fact that they are truly taking care of the person and not just the person’s parts.”
Sometimes caring for the patient means doing less
There are times when interventions can be more burdensome on a patient than helpful, Dreger believes.
She recently treated a 59-year-old patient with a host of medical issues. Dreger listed his many problems, “End-stage liver disease due to hepatitis C and alcohol, and he’s still drinking. End-stage lung disease because of smoking, and he’s still smoking. Untreatable coronary artery disease— untreatable mostly because his liver disease is so bad that his platelet count is so low that nobody is willing to do a cardiac catheterization because you’re afraid he’s actually going to bleed out. Now on top of the fact that his kidney function is actually pretty low, and you could basically put him on dialysis if you actually gave him the contrast that you would do with cardiac cath.
“He was just a good honest fellow who doesn’t really want to give up his beer from time to time and really doesn’t want to give up his cigarettes,” she said. “And for anybody standing on the outside, you would say poor quality of life. But he’s able to enjoy his friends and enjoy his family and to know that he has very serious disease,” she said. “The last six months of his life, he actually flew down to Florida with his family. He had never been on an airplane before… had never been to Florida before, and he had a great time.”
Near the end of his life they were able to get a palliative care team on board to visit him at home. “Initially he and his family had made it very clear to me that they didn’t want to go the hospice route,” she said. “They still wanted the opportunity that if he was feeling very bad to go to the hospital.
“But once the palliative care people went out and talked to him, he was able to understand it in a different way and actually did end up very quickly on hospice and got the care that he needed,” she said.
Healing can be much more than just curing the disease
According to the Center to Advance Palliative Care, palliative care growth in hospitals has been exponential. The number of teams has doubled over the last six years. To date, there are more than 1,500 hospitals with a palliative care team. Approximately 63 percent of all hospitals with more than 50 beds have a palliative care team today.
The Boonshoft School of Medicine has been at the forefront of this wave with its Palliative and Hospice Care Fellowship program, created in 2008.
Boonshoft School of Medicine graduate Howard Edwards, M.D., (’08) was attracted to the fellowship program following a year-long rotation at the Hospice of Western Reserve in Cleveland.
“I had an amazing year, I loved what I was doing,” he said. “I thought I was actually helping people.”
Palliative care focuses on decreasing pain and suffering by providing treatments for relief of symptoms, along with comfort and support for patients and their families. Palliative care uses a team approach that involves the treating doctor, the family, and other health care professionals and social services. Palliative care relieves symptoms without curing the disease and can be offered at any stage of a disease.
Hospice care is provided at the end of life and always includes palliative care. The goal is to make the patient comfortable and improve his or her quality of life.
“Instead of fighting against a disease, I wanted to fight for patients,” said Edwards. “Instead of fighting against a disease or against a condition, you start fighting for someone and their quality of life.
“It’s a team-based approach to not only looking at the patient medically, but taking care of all of their needs— including the family’s needs,” he said.
A palliative and hospice care team can include physicians, pharmacists, nurses, chaplains, social workers, psychologists, and other allied health professionals as necessary. They work together with the patient and his or her family to develop a plan for care that focuses on treating symptoms and ensuring quality of life for the patient.
Perhaps the purest form of the art of healing is palliative and hospice care
Palliative care begins with a goals-of-care consult to get the family involved, said Edwards. The purpose is to meet with the family to ensure that they are informed about the patient’s condition and the options for care, so that they can make informed decisions as a family.
“A lot of times, rightfully so, we don’t know what’s going to happen,” he said. “As physicians it’s kind of the art of what’s going to happen. And it’s really dependent on the man upstairs and how well the patient’s body responds to the medical therapy we’re trying to provide.”
Since physicians don’t always know exactly what’s going to happen with an individual patient, the situation can be very stressful for families. “They can’t get clear answers simply because there aren’t clear answers,” he said. “A lot of what we do, then, through goals-of-care, is we hope for the best, plan for the worst. We put in perspective what they would want to happen, what their expectations are, and if that doesn’t happen, what we are going to do.
“We always make what they want to happen be the goal—that’s the goal and that’s what everybody’s striving for—but if we can never get there, what happens then?” he said. “A lot of times it’s a personal choice; it’s the family’s own choice. We make sure that they’re fully informed of the big picture, and then we bring in the patient’s ideas and what they believe quality of life is, so they can make these hard decisions at the end of life. We’re there for them to know that we’re looking out for whatever they believe is the patient’s best interest.”
Hospice care is a refocus of energies
Many times there’s a misperception that switching from aggressive medical care to hospice is giving up. “It’s not giving up, it’s just a refocus of what your goals are,” said Edwards. “Sometimes it’s okay to say, ‘instead of living my life in the ICU, it’s okay to have a better quality of life while I’m here, and be at home with family.’ It’s never giving up. It’s just a refocus of your energies.”
Edwards cites the example of those needing organ transplants as patients who often graduate from hospice care. “So that’s the extreme example where you get the transplant and then you graduate hospice, and we discharge you,” he said.
“Our mindset and our treatment is always to have them graduate—to get out,” he said. “I would hope all my patients would graduate. But with this severe disease process that we work with, we know that a lot won’t.”
Sometimes learning the art of healing comes down to answering the question: what are you trying to heal? “When you say the “art of healing,” what are you healing?” he asks. “Are you healing the numbers? Are you healing the body? Are you healing the soul? Are you healing the family? And that’s kind of the focus of hospice: what are you trying to heal?”
— Cindy Young