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...
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