Patient Communication on Med Schools' Agenda

OB/GYN News, Nov 1, 2000 by Doug Brunk

Most students encounter a cadaver on their first day of medical school. At the University of Pittsburgh, students' first exposure to medicine comes by observing physicians as they meet and interview real, breathing patients.

The complex world of physician-patient communication is emerging as a priority. Earlier this year, the Task Force on Competence of the American Council on Graduate Medical Education and the American Board of Medical Specialties identified interpersonal and communication skills as one of six areas in which physicians need to demonstrate competence. The other five are medical knowledge, patient care, professionalism, practice-based learning and improvement, and systems-based practice. The task now becomes developing techniques for assessing competence in each of these six areas.

According to Dr. Norman Cant, executive director of the American Board of Obstetrics and Gynecology, there is no specific assessment of patient-physician communication skills included in certification or recertification tests for obstetrics and gynecology "We have an extensive oral examination, but we have no plans at the present time to find out how good [a patient] interviewer candidates are," Dr. Cant said. "There is not a specific part of the oral exam isolated to this."

The American Board of Internal Medicine, however, has already taken up the gauntlet and is mandating that interviewing techniques and other physician communication skills be part of certification. Beginning in July of 2001, communication skills will be included as an elective component of ABIM's self-evaluation test for recertification. Beginning in 2004, all candidates for ABIM recertification will be required to be tested on their communications skills.

According to ABIM's executive vice president, Dr. Daniel Duffy, physician-candidates will respond to a videotaped patient-physician scenario, which includes questions about nonverbal communication.

"Doctor-patient communication is the most critical element of day-in, day-out medical care, yet it's been seriously neglected in medical education," said Dr. Mack Lipkin Jr., an internist who directs the division of primary care at New York University.

That skill is important, he said, because over the past 3 decades studies in the medical literature have shown that patient-physician communication skills affect important health outcomes, including adherence, symptom relief, and physiologic status.

Dr. Geoffrey Gordon noted that many physicians don't use skills that are known to be effective, such as letting patients finish an opening statement and eliciting an agenda with the patient.

"We used to think that these kinds of skills were bedside manner, something you learn as you go along," said Dr. Gordon, associate director of clinical education at the West Haven, Conn.-based Bayer Institute for Health Care Communication, which works with more than 20 medical schools to improve and expand physician-patient communication curricula. "We now know that you can teach and learn these skills."

Dr. Lipkin said that solid research on patient-physician communication started around 1969. Ten years later he became the founding president of the American Academy on Physician and Patient, one of the first organizations to seriously address the topic.

Today, he said, the field of physician-patient communication has grown from "a period in which this skill was taught charismatically, meaning 'do what I do, and you'll be great,' to a period in which people are taught empirically, using methods that have been tested and shown to be of value."

Dr. Lipkin is a principal investigator for the Macy Initiative in Health Communication, a 4-year effort launched in 1999 to strengthen the communication skills of physicians through enhancement of curricula for medical students and residents, and through faculty development. Participating medical schools include NYU. the University of Massachusetts, and Case Western Reserve.

The goal of the project is to set a standard for communication curriculum that other medical schools will emulate, Dr. Lipkin said. "We're creating something that curriculum committees can look at--something that's coherent and will be accompanied by curriculum materials that they can adapt and modify. [The program] will be accompanied by an evaluation method that's objective and about which we'll have a lot of data."

Some schools will be ahead of the curve once standards are established. At the University of Pittsburgh, students spend the first day of medical school watching physicians interview real patients. This is followed by a full-time course in which students are exposed to five different physician-patient scenarios over a 2-week period.

For example, one case may have to do with a patient who has a complicated case of breast cancer, said Dr. Steven Kanter, senior associate dean of the University of Pittsburgh School of Medicine. "The goal is to understand the very complicated events that occur and the very complicated relationship that develops between a patient and a physician when you're dealing with a patient like that."