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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