Four Habits of Highly Effective Clinicians: A Practical Guide. Frankel RM and Stein TS

Much of our learning about basic clinical skills centers around the doctor-patient relationship. As such, we have begun to learn and practice a number of techniques for ensuring that our interactions with patients remain patient-centered.

 

After each lecture, we divide into groups of ten and practice interviews with professional standardized patients. We take turns and after each scenario, we ask the patient how we did, and then each of nine classmates for constructive criticism. There is also a senior faculty member present to facilitate or fill in with wisdom gained in practice that may concern each situation.

 

The first week (last week) we learned and practiced:

1. initiating the session (introductions, titles, putting the patient at ease, ensuring comfort, establishing rapport, naming the patients main concerns, and setting a common agenda).

 

2. patient-centered interviewing --> amazing how efficient my information gathering can be if I let the patient answer open ended questions about herself. The main concerns and worries and surrounding circumstances, disease timeline, and much more can come out of a natural conversation rather than the typical closed ended questions that we used in EMS. It is very tricky to direct these conversations and there are many cues that I fail to recognise.

 

This week we learned and practiced:

3. Clarifying the patient's concerns. This task was more familiar to me after my year as an EMT. It is important to give the patient a "sign post" so that she knows that we are moving into more specific questioning. We practiced using the idea of "coning" where we take something that started out as an open ended question, and work it down to a specific detail.

["What did it feel like?" --> "Tell me more about that sensation" --> "Was it a burning pain?".]

The difficult part for me was climbing back out of the cone and using other things that were mentioned in the earlier narrative to repeat the coning process with other useful data.

 

4. How to build the patient-doctor relationship.

This is cool. Empathic listening skills drawn from the principles of nonviolent communication.

It's been proven, using actual data, that empathy is "highly associated with patient satisfaction" (Wasserman et al 1984). Thus our task yesterday was to demonstrate empathy using the full range of human communication. I found the empathy part natural, but to combine this with an interview that must accomplish certain clinical aims will take years to master. The most striking part of the demonstration in lecture was how reassurance and encouragement do not help a patient feel connected to her doctor. Only empathy makes people feel that they are being listened to and truly understood.

First you have to recognize verbal or nonverbal statements that give insight into an underlying feeling (potential empathic opportunities). This comes pretty easily from active listening, where I verify my understanding of what the patient said. Then it gets tricky as you have to identify the specific emotion and its strength. Again I'll ask the patient if I've understood correctly and readily accept any corrections. Then I'll reflect on her situation portraying my empathy without searching for solutions or reassurance (this is really tough). From this heavy moment, I need to learn how to focus on

a. legitimation "I can understand how that must be incredibly difficult"

b. support "I want to help"

c. partnership "how can we begin to address these issues?"

d. respect "you're doing great"

 

I did fairly well with legitimation, but I need more practice with the last three.

 

More practice tomorrow.

Now I'm off to run a local 5k...

Class Schedule and Nonviolent Communication by Marshall Rosenberg

I should explain that I'm in two classes.
1 epidemiology/biostatistics
2 basic clinical skills
Both have lecture and small group components.
The small groups are especially useful.
In the small groups for #2, we've been practicing patient centered interview techniques.
Awesome concepts centered around the ideas that Marshall Rosenberg put forth in his life works, especially a  book called Nonviolent Communication.
I wonder where Rosenberg got these ideas from?
The Center for Nonviolent Communication is in Albuquerque.

Let this be a reminder to myself to read something by Rosenberg before I graduate.

First Standardized Patient

On Wednesday, in small groups, I was the first to try out our new "patient centered" interviewing skills on a real, live, standardized patient. It was very realistic, all the way down to what you'd find in a doctor's office and my white coat. Tough with 9 classmates + real doctor watching.

I forgot to make her comfortable during the introductions (she wanted to put her leg up on something), and failed to fully explore her worries concerning her injury (other than that, I did okay). Got to work on these open ended questions, using the patient's ideas to direct the flow of conversation. It's so strange after a year of asking very specific questions in the choppy manner of an EMT. Turns out you can actually get most of the same information more quickly and then additional helpful information as well if you just let the patient direct the flow. It won't always work, but it is pretty successful.

What I learned in biostatistics today: "The average human has one breast and one testicle." Des McHale

On average, physicians interrupt their patients after only 18 seconds. Source forthcoming

Class of 2015 Code of Conduct URSM&D

We, the URSM&D Class of 2015, gratefully embrace our diversity of backgrounds, personalities and ambitions. We gather united for the purpose of serving humanity, arriving at this moment not simply through our own work, but indebted to innumerable others.


Excellence in this endeavor requires our adherence to certain principles. As students and physicians, we recognize our role as ambassadors for our institution and the field of medicine. We accept responsibility to adhere to a moral and ethical code in our words and actions. We believe that this life of service must be rooted first in compassion and empathy: for our patients, for our peers, and for our community. In the framework of the biopsychosocial model, we acknowledge that our patients, and all people, are more than their ailments.


We share a belief that challenges are better faced together than alone. We trust that our curiosity, patience, and humor willhelp us in our journey. Maintaining balance and strength in our personal lives and relationships is crucial to the optimal care of our patients. As we are at our best, so we give our best.


The value of our beliefs lies in our commitment to live them out through our actions. Recalling the privileged contract we have made with society, we dedicate ourselves as physicians to be advocates for our patients and agents of social justice. We will maximize our potential through continued introspection, embracing our limitations as opportunities for growth. As we mature in our understanding of medicine, we will strive to be innovative leaders and teachers of the next generation.


In the spirit of Meliora, we will remember this pledge in the hope that we may find renewed energy and commitment to our beliefs and purpose.




We pledged the above in unison after we received our white coats yesterday. It was written by sending one representative from each small group to a threshing session where the details were worked out. While not every word was unanimously agreed on, this pledge captures the spirit of our class and what we hope to achieve.  

Reservation Blues by Sherman Alexie

I am

homesick for the west

inspired to seek employment on a reservation

angered by our continued mistakes with the first nations

saddened in solidarity

daunted by the height of the obstacles facing American Indians