Looking in the rearview mirror

Kimberly Manning, Lisa Bernstein, and William Branch
Kimberly Manning, Lisa Bernstein, and William Branch

Reflecting on clinical experiences can yield important insight into compassion

By Kay Torrance

The Emory resident was on call on Thanksgiving Day, and sure enough, he was paged to come to the hospital. Irritated that he was missing the rest of his holiday with family and friends, the resident walked into the hospital with less pep in his step than he usually had. Little did he realize that that day would mark a defining moment in his training.

He ended up spending his dinner break with his patient. He sat down in a chair beside the patient's bed, with reheated leftovers from the Thanksgiving meal he had missed. The patient took his dinner through a feeding tube. The two ending up talking for quite some time, and the resident began to see things through the eyes of his patient. Yes, he had to spend Thanksgiving working, but the patient missed the holiday altogether.

The resident recounted this day in a written piece for Kimberly Manning, an internist at Grady Hospital who directs Emory's Transitional Year Residency Program. Manning asked her residents to write about an experience—good or bad—that made a lasting impression on them. Thinking about the experience later, the resident wrote that he would not have changed that day for anything.


Reflective essays written by students: Student 12M

l always imagined a physician's duty to inform a patient he or she has cancer a most difficult and unenviable one. I had the chance to be present when an Emory doctor did just that. I was incredibly surprised at how the interaction proceeded. The doctor did not waste any time getting the bad news out. He sat down, looked the patient in the eye, and told him what the pathology report revealed. What astonished me was the lack of surprise in the patient and his family. The disbelief and demands for further testing that I always had assumed would happen, simply did not. And the physician, instead of having to defend his diagnosis, got the opportunity to do something amazing: offer some hope to his patient.

Although there were tears shed by the patient and his family, the doctor skillfully moved beyond the dark horizon of cancer to the promise of brighter skies in the future with a little luck and a little work. The doctor's professional, but supportive and understanding, disposition that he assumed with the patient probably did wonders for everyone in the room. The doctor has the terrible responsibility to deliver such news to his patients, but he also has the awesome privilege to help them move past the diagnosis to action and hope for the future.


Becoming a habitual reflector

Manning herself regularly writes about her experiences as a doctor. She calls it "habitual reflection" and believes that the practice is vital to developing good doctors. She regularly asks herself about interactions with patients and imagines herself in their place. What was the patient feeling? How would I feel in the same situation? Did the patient process everything I said?

These are the kinds of questions she wants medical students and residents to ask themselves regularly. By examining experiences that were rewarding, saddening, or even frustrating, they can become better doctors, she says.

Previously, doctors were encouraged to be compassionate but to keep emotional distance from their patients. Today, some medical schools, like Emory's, are stepping beyond teaching traditional doctor-patient communication and putting students more in touch with the feelings and experiences of patients.

With the help of their faculty advisers, Emory medical students learn how to break bad news in a caring manner, to listen effectively, and to perceive and acknowledge the patient's feelings. They learn to read patients' body language and to be aware of how their own body language influences patients' perceptions.

Traditionally, such abilities were thought of as character traits—a doctor either had them or not. A doctor was either caring or not, for example. A recent study, however, shows that these attributes can be improved by education. Practicing doctors who had little or no training in communicating to patients could still learn to be a more caring humanistic doctor.

The study showed that medical school faculty who learned how to provide constructive feedback and teach caring attitudes were perceived to be more effective teachers. And there's another big payoff: Faculty who've gone through such training feel that doctoring is more rewarding.


Reflective essays written by students: Student 11M

R was a 35-year-old construction worker who presented to the neurology clinic with progressive weakness in his upper extremities and extensive fasciculations of his upper arms. His primary care physician had referred him to Dr. X for evaluation of ALS. For anyone who has worked with Dr. X, he comes across as a bit gruff to his trainees.

Dr. X draped his hands over his knees, clasped his hands together, looked Mr. R right in the eye, and said, "Has [your primary care physician] spoken to you about ALS? Because I believe very strongly that this is what is going on here." Mr. R didn't say anything; he just broke down right in front of us. Dr. X let him cry for a few minutes before touching him gently on the knee and saying, "There are probably questions you don't even know you have yet, and I will be happy to help with those when they arise. In the meantime, there is a specific protocol we take with patients when they are first diagnosed with ALS. Would you like us to take care of that on this visit or schedule for another time?"

While all this was something Dr. X had said many times, that didn't make it any less effective or less professional. The message still retained the necessary empathy, and it still felt genuine. It would take many pages to convey the inflection in his voice or the small mannerisms conveying only the deepest sympathy, but please believe that it was there. I learned that the specifics of the bad news that I am delivering to a patient are not as important as making sure they understand that my deepest feelings of sympathy and empathy are being conveyed in the nonverbal communication.

"The result was a radical change in my practice," says William Branch, chief of general internal medicine at Emory. Branch was trained in the techniques when he worked at Harvard in the 1980s and was so impressed that he quickly signed up to teach them to other faculty and residents. "My patients appreciated my interest in them more so than the medical details I was telling them. They were soon telling me how much they appreciated what I was doing for them."

Branch recently led a study at five medical schools, including Emory's, which showed an 8% to 13% improvement in how students and residents rated faculty who had undergone special training to learn humanistic techniques versus those who had not. The trainees completed a questionnaire on which they rated faculty on "listening carefully to connect with others" and being known as a "caring person."

Faculty in the study were coached on using role playing, writing reflective assignments, and giving feedback. Participating in the study forced Emory internist Lisa Bernstein to take more time to reflect on her actions, she says.

"I became more aware of my interaction with students and patients," she says. "As a mentor, I have to be aware of how I talk to people. Reflection does that. Humanism should permeate everything we do."

The medical school's new curriculum allows for more time to spend on such topics, Bernstein says. At the center of the curriculum are society groups, in which every medical student is assigned to a faculty adviser. (Each class is broken into four societies, and then each society is broken into groups of 8-9 students.) Each group stays with the same adviser for all four years of medical school.

At one such group meeting in June, students met to talk about how to break bad news to patients. They role-played, critiquing each other on demeanor and body language, reading the patient's expression, and responding to patient concerns and questions.

"The hardest thing we have to do is sit there and be quiet while the patient processes bad news," Bernstein told the students. "But that's what we need to do. We all have a tendency to keep talking when we are uncomfortable."

"Are we just to sit there and not say anything?" asked a student, who said that, too, seemed uncomfortable.

"Yes, because that's what the patient needs," she replied.

Teaching humanistic behavior to students before they enter their residencies is especially important to engrain the practice, Branch says. Studies have shown residents usually are burned out and build coping mechanisms, such as displaying sardonic humor.

"Residents are deeply engaged in mastering the profession," Branch says. "It doesn't leave much room for reflecting on the patient."

Manning, though, doesn't think it's too late for residents who come to Emory from other medical schools to pick up humanistic behaviors. She'll take whatever time is available to teach them reflection.


Reflective essays written by students: Student 11M

The patient was a 50-year-old man who had worked as an airline baggage handler and had begun to trip over his feet and show other signs of muscle weakness. He was referred to the neuromuscular disease clinic to confirm a diagnosis of ALS. Dr. X examined the patient and explained to him and his wife that his findings were consistent with ALS. The patient reacted pretty soberly to the news; I distinctly remember he did not show any outward signs of being upset. His wife was trying very hard to stay composed while they were in the office.

The patient and his wife asked Dr. X a number of questions, but they seemed to be most interested to know over what period of time the patient's muscle strength would deteriorate, eventually leading to his death. Dr. X was very forthcoming about the fact that for now that wasn't something he could answer.

This experience was, not surprisingly, somewhat depressing. A disease like ALS is difficult for everyone involved; the patient has to come to terms with the fact that he will slowly (or quickly) lose all voluntary muscle control, his wife has to resign herself to losing her partner, and the doctor can do essentially nothing to alter the course of the disease. Despite the fact that they can't always do a lot to treat ALS, the physicians and staff made it a priority to comfort patients and alleviate their suffering to the extent that they can. I can't remember where I heard this, but I agree that healing and curing a patient aren't necessarily the same thing, and we can still heal even if we can't treat.

It's never too late

Manning, though, doesn't think it's too late for residents who come to Emory from other medical schools to pick up humanistic behaviors. She'll take whatever time is available to teach them reflection.

Manning, who also participated in the study, says true reflection wasn't a skill she picked up in medical school when she attended in the mid-1990s. Later, as a dual pediatrics/internal medicine resident in the neonatal intensive care unit, she felt conflicted and upset about taking great measures to save very premature babies. But she had no outlet for her feelings, except a good cry in the stairwell.

"I was so conflicted—what would these fragile babies' lives be like," she says. "If I had been in this mode of habitual reflection, my experience would have been completely different. Talking about your feelings will make a big difference later."

Since then, she has learned to funnel her feelings into writing and reflecting. Each year, Manning asks her 24 residents to do two written essays, called "Appreciative Inquiries," on a positive experience. She purposely assigns the first one in December, when the residents' long hours are catching up with them, and they are homesick. She wants to remind them why they became doctors.

"They write incredible pieces," she says. "If they become habitual reflectors at this age, it will be something they do easily for the rest of their lives."

Learning and teaching humanistic behavior has been immensely rewarding, she says. "I thought I was caring before, but the training made everyday experiences richer," Manning says. "It makes you better at everything."


Reflective essays written by students: Student 10M

After a long morning of pediatric neurology rounds, my team went to see one last patient for a consult with his parents. He was a 3-month-old boy with congenital herpes simplex virus. I watched my attending speak to his parents. In a calm voice she told them, "It is hard to know at 12 weeks what he will and will not be able to do as he grows. He will be dependent on you for the rest of his life." As the mother's face grew ashen, the attending said to her, "I know this is a lot to take in and that you must have questions. Do you have any questions for me?" The mother responded, "No." "Well here's my card," the attending said. "You can call me anytime, even if you just want to talk." The parents said, "Thank you."

I felt very sad and sorry for the parents. I wished there was something I could do to help them, and I felt naturally inclined to give the mother a hug, although I did not. This was their first child and to have something debilitating like this happen was awful. I thought that the doctor handled the situation well; she was calm and relatively diplomatic. I would have tried to explain it a little better, but I think it's difficult to really get a patient to understand what's happening when they are still in shock themselves.

Although having a breadth of medical knowledge and ability to apply it are vital hallmarks of a physician, I believe the ability to communicate and show compassion to a patient in light of any bad news is truly the hallmark of a physician's greatness.


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winter cover 2010