The Teachable Moment
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Education: A Six-Step Approach. Baltimore, Md: Johns Hopkins University Press; 1998. 4 Bordage G. Elaborated knowledge: a key to successful diagnostic thinking. Acad Med. 1994;69:883–885. 5 Fraenkel JR, Wallen NF. How to Design and Evaluate Research in Education. 5th ed. Boston, Mass: McGraw Hill; 2003. 6 Robinson AG, Metten S, Guiton G, Berek J. Using fresh tissue dissection to teach human anatomy in the clinical years. Acad Med. 2004; 79:711–716. 7 Sommers PS, Muller JH, Ozer EM. The faculty self-efficacy scale: a tool for evaluating faculty development interventions. Acad Med. 2000; 75:559–560. Teaching and Learning Moments The Teachable Moment Two students, Stephen and Peggy, were ready to do their videotaped interviews to demonstrate the fundamental skills and tasks of a medical interview with a standardized patient. Stephen, appearing shy, reluctantly agreed to go first while Peggy and I watched through the video monitor. Stephen’s interview went smoothly until the patient said emphatically, “Well, certainly when I started having so much trouble breathing, I was really very scared!” Although Stephen asked some good clarifying questions, he never responded to the patient’s repeated statements of anxiety. He continued being extremely professional and thorough, but never showed a scintilla of compassion or empathy, verbally or nonverbally, to the patient’s repeated statements of fear. After the interview, I knew we needed to pursue this empathic black hole. I had an exasperated muffled scream in my head—but didn’t you see my lectures and videos on relationship building and empathy? Or observe your peers demonstrating this? WHAT HAPPENED? But, instead I went with an analogy, often a useful strategy when covering more directive assaults. I asked Stephen: “When you are really nervous about an upcoming test, how would you respond if I simply asked you more details about the test?” Stephen responded “Oh, I’d feel much better than if you said: ‘Yeah, I can see how you’d be nervous.’ I would never want someone to acknowledge my fears. I would think that means there truly is something to be fearful of. It would only confirm to me that I should be scared.” LIGHT BULB! Now I understood. We had totally different frames for making empathic statements. I could lecture all I wanted, demonstrate examples galore, include patient testimonials, but until I understood Stephen’s perspective, it was useless. Students arrive with their own experiences of communicating in their families of origin, which often dictate their inclinations towards exploring emotions, dealing with conflict, etc. But, there is little time to really dig and understand the student’s map of communicating. Without exploring these maps and comparing them to the “official” communication map of the school’s communication model, we are often missing a rich opportunity for more authentic integration of skillful medical interviewing. Stephen, Peggy, and I discussed the different ways people respond to emotion, to anxiety, to conflict. Stephen offered his personal preference for avoiding acknowledgement of difficulties, thinking acknowledgement only amplifies or legitimizes the fear. We didn’t disavow Stephen of his way of dealing with these situations for him. We posed the possibility of many patients hoping for some empathic comment, some witnessing of their fear or suffering. This discussion was full of personal discovery. Stephen went back into the room. We “rewound” the patient to where she first said her fears. This time Stephen tried the alternative way of responding—still not sure it was the best approach, but willing to give it a try. This time Stephen responded to her concern. Despite the awkwardness he felt inside, it appeared natural and well integrated. Stephen came back into our room and was more animated than I had ever seen him. Every time I see Stephen in the hall since this experience, we have a knowing exchange. He is a caring, kind, and compassionate student. I am now confident he will convey that to patients in a way that feels more and more genuine. He’ll still be doing it in a self-conscious manner, knowing it’s not how he would necessarily want it done to him, but he had the unforgettable experience of “clicking” with a patient who did benefit from the empathic approach. I asked Stephen soon after that experience how he would feel if I wrote up what I had learned from this experience. He encouraged me to do so. I still am wrestling with the best ways to tap into the student’s own map. I’ll continue to think more about that. Acknowledgments The names have been changed to protect the confidentiality of these individuals. Kathy Cole-Kelly, MS, MSW Ms. Cole-Kelly is a professor of family medicine and director of Communication in Medicine Program, Case School of Medicine, Cleveland, Ohio. Teaching and Learning Moments Academic Medicine, Vol. 81, No. 11 / November 2006 958
description
Advice for medical student interviews of patients.
Transcript of The Teachable Moment
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Education: A Six-Step Approach. Baltimore,Md: Johns Hopkins University Press; 1998.
4 Bordage G. Elaborated knowledge: a key tosuccessful diagnostic thinking. Acad Med.1994;69:883885.
5 Fraenkel JR, Wallen NF. How to Design andEvaluate Research in Education. 5th ed.Boston, Mass: McGraw Hill; 2003.
6 Robinson AG, Metten S, Guiton G, Berek J.Using fresh tissue dissection to teach human
anatomy in the clinical years. Acad Med. 2004;79:711716.
7 Sommers PS, Muller JH, Ozer EM. The facultyself-efficacy scale: a tool for evaluating facultydevelopment interventions. Acad Med. 2000;75:559560.
Teaching and Learning MomentsThe Teachable Moment
Two students, Stephen and Peggy,were ready to do their videotapedinterviews to demonstrate thefundamental skills and tasks of amedical interview with a standardizedpatient. Stephen, appearing shy,reluctantly agreed to go first whilePeggy and I watched through thevideo monitor.
Stephens interview went smoothlyuntil the patient said emphatically,Well, certainly when I started havingso much trouble breathing, I was reallyvery scared! Although Stephen askedsome good clarifying questions, henever responded to the patientsrepeated statements of anxiety. Hecontinued being extremely professionaland thorough, but never showed ascintilla of compassion or empathy,verbally or nonverbally, to the patientsrepeated statements of fear.
After the interview, I knew we neededto pursue this empathic black hole. Ihad an exasperated muffled scream inmy headbut didnt you see mylectures and videos on relationshipbuilding and empathy? Or observeyour peers demonstrating this? WHATHAPPENED? But, instead I went withan analogy, often a useful strategywhen covering more directive assaults.I asked Stephen: When you are reallynervous about an upcoming test, howwould you respond if I simply askedyou more details about the test?
Stephen responded Oh, Id feel muchbetter than if you said: Yeah, I can seehow youd be nervous. I would neverwant someone to acknowledge my
fears. I would think that means theretruly is something to be fearful of. Itwould only confirm to me that I shouldbe scared.
LIGHT BULB! Now I understood. Wehad totally different frames for makingempathic statements. I could lecture allI wanted, demonstrate examplesgalore, include patient testimonials,but until I understood Stephensperspective, it was useless. Studentsarrive with their own experiences ofcommunicating in their families oforigin, which often dictate theirinclinations towards exploringemotions, dealing with conflict, etc.But, there is little time to really dig andunderstand the students map ofcommunicating. Without exploringthese maps and comparing them tothe official communication map ofthe schools communication model, weare often missing a rich opportunity formore authentic integration of skillfulmedical interviewing. Stephen, Peggy,and I discussed the different wayspeople respond to emotion, to anxiety,to conflict. Stephen offered hispersonal preference for avoidingacknowledgement of difficulties,thinking acknowledgement onlyamplifies or legitimizes the fear. Wedidnt disavow Stephen of his way ofdealing with these situations for him.We posed the possibility of manypatients hoping for some empathiccomment, some witnessing of theirfear or suffering. This discussion wasfull of personal discovery.
Stephen went back into the room. Werewound the patient to where she
first said her fears. This time Stephentried the alternative way ofrespondingstill not sure it was thebest approach, but willing to give it atry. This time Stephen responded toher concern. Despite the awkwardnesshe felt inside, it appeared natural andwell integrated. Stephen came backinto our room and was more animatedthan I had ever seen him.
Every time I see Stephen in the hallsince this experience, we have aknowing exchange. He is a caring,kind, and compassionate student. I amnow confident he will convey that topatients in a way that feels more andmore genuine. Hell still be doing it ina self-conscious manner, knowing itsnot how he would necessarily want itdone to him, but he had theunforgettable experience of clickingwith a patient who did benefit fromthe empathic approach.
I asked Stephen soon after thatexperience how he would feel if Iwrote up what I had learned from thisexperience. He encouraged me to doso. I still am wrestling with the bestways to tap into the students ownmap. Ill continue to think more aboutthat.
AcknowledgmentsThe names have been changed to protect theconfidentiality of these individuals.
Kathy Cole-Kelly, MS, MSW
Ms. Cole-Kelly is a professor of family medicineand director of Communication in MedicineProgram, Case School of Medicine, Cleveland, Ohio.
Teaching and Learning Moments
Academic Medicine, Vol. 81, No. 11 / November 2006958
