Medical Lesson: Learning to Relate to Patients Medical schools and residency programs are under increasing pressure to turn out doctors who are good communicators and compassionate in their interactions with patients. It's a huge challenge, but one program is addressing the issue with monthly lunch for first-year doctors.
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Medical Lesson: Learning to Relate to Patients

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Medical Lesson: Learning to Relate to Patients

Medical Lesson: Learning to Relate to Patients

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MICHELE NORRIS, host:

From NPR News, this is ALL THINGS CONSIDERED. I'm Michele Norris.

MELISSA BLOCK, host:

And I'm Melissa Block.

I bet you've had this experience. You go for a doctor's appointment and your doctor doesn't look you in the eye. He or she pecks away at a computer as you talk and interrupts you before you've even finished describing why you're there.

Well, medical schools have been trying to change that, trying to turn out doctors who are better communicators. And hospitals try to keep that training going. More and more, they're being pressed to emphasize effective listening skills and compassion as they train residents.

Unidentified Man: You guys may as well grab some food now.

BLOCK: Last month, I sat in on an interns' lunch at the Columbia campus of New York Presbyterian Hospital in Manhattan. The interns are in their first year as doctors, overworked and often overwhelmed. They work 80-hour weeks that can creep up to 90 and every third or fourth night they're on call, so they work at least 24 hours straight. It's a year of incredible pressure and burnout, a time when compassionate patient care can get blown away by the demands of the job.

So, once a month, Dr. Barron Lerner meets with the interns over lunch. He wants to help them think about the doctor-patient relationship and ways of humanizing the hospital experience.

Dr. BARRON LERNER (New York Presbyterian Hospital): Sometimes there is things we can do. You know, you forget like to bring the person outside. You know, they're not going to get infected if you put them in a wheelchair and bring them outside and stuff like that. Are there other things that you guys have remembered doing for patients, maybe a little thing here and there that may have improved their day?

BLOCK: Intern John Dodson thinks of one example.

Dr. JOHN DODSON (New York Presbyterian Hospital): I had one patient in particular who wasn't eating and he was complaining about the coffee in the hospital and that the coffee was too weak. And so, I brought him coffee. One morning, on my way to work, I just picked him up coffee with my coffee and I brought it to him. And he said, you didn't get any milk.

BLOCK: So much for good intentions. Dr. Lerner steers the discussion to the frustrations of being a new doctor and intern Sarah Russell picks up on that with something that's surprised her.

Dr. SARAH RUSSELL (New York Presbyterian Hospital): How quickly I've transitioned from a med student who was so keenly interested in the whole person to now only interested in a set of numbers. I mean, it happened, it feels like, overnight, which is the hardest thing. And I've talked to older physicians who say that your interest in the patient will come back.

But in the meantime, all you're thinking is, I have a list with all these boxes I have to check off and will you please just step aside so I can get this done, you know, praying for the patient who showed up half asleep, can sit up and give me a good lung exam and then go back to bed so I can report it on rounds and just get through.

I mean, it's a terrible feeling and it happens more often than not. And what's sad is the gratification comes when in fact you do actually stop and then you have this weird feeling of like, oh, that's so great. It's just you doing your job.

Dr. LERNER: You know, when I started internship 20 years ago, I had a list with little boxes on it, too. And it sure was great to check those off at the end of the day. Maybe, you know, you need to put little boxes there saying, okay, now I'm done. It's time to go back and talk to my patients and their families. And I think that by acknowledging that, that's the first step toward remembering what you also need to do.

BLOCK: The lunch series was started by two women doctors at New York Presbyterian who had cancer. They realized their experience as patients would be a valuable teaching tool. There are perennial topics that come up in these lunches, breaking bad news, dealing with difficult patients, medical mistakes and what Dr. Lerner calls bad outcomes.

Dr. LERNER: Let's talk a little bit about how if someone gets very sick unexpectedly and even dies, how do you deal with that, both with interacting with the family but also going home at the end of the day? How do you become the sort of doctor who can deal with bad outcomes and then come to the hospital the next day? Any cases that you remember?

BLOCK: Sarah Russell thinks of one.

Dr. RUSSELL: Sometimes in the drama of a particularly hard outcome, I think, it's hard to find space to get your own needs met in the sense that like you need to process and find closure for yourself in your own way. And I remember that happened, I was, did a pediatric rotation for three months and I had an inpatient who was very ill, a young boy who had a terribly catastrophic event that no one counted on. And he - it was just an absolutely nightmarish series of events.

And I was sort of there in the morning, the morning he turned. And remembered, you know, my job was sort of to explain what was happening to his mother. And, you know, everyone said, oh, you're post-call, go home, go home, go home. And so I remember I went home and I slept and maybe two days later I was running and I remember just bursting into tears in the middle of my run. And I was so overwhelmed by it.

I mean, I didn't think of myself as somebody who's not - well, I never had that happen before. So I was trying to figure out where was I - what was I sad about? Was it about, you know, his mother's pain? Was it about just the tragedy, you know, of a 7-year-old dying? It was very complicated, but I remember feeling very, I guess sort of helpless. Like you're not - you think you're on top of everything and then it sort of escapes from you. And you thought, oh, I thought I was keeping that in check.

Dr. DODSON: I think one of the hardest parts is that -

BLOCK: This is John Dodson again.

Dr. DODSON: - the pace is so fast and there's so little time to stop in the middle of work and kind of think about what has happened. And I remember I had a particular patient who had a cardiac arrest and she was very sick to begin with. But I was kind of paged up from the ER and had to run upstairs. And she had already, I think for 10 minutes, not had a heartbeat. And after 20 minutes, we called the arrest and she had died.

And I was sitting at the nurse's station and my resident just went over to me, and she said, okay, let's talk about the other patients. And I found that that situation in particular was very difficult, but you know, the way things work, it kind of just continues with the other patients and all of the other responsibilities.

Dr. LERNER: You know, I love the anecdote about crying two days later. You know, it's probably not a great thing to cry in front of all your patients all the time because you're a nice person and you feel bad for them. At some point, the patients and the families are going to lose confidence in you, I'd guess. But a real display of human emotion - either, you know, at the bedside, you know, I think it's okay to cry a little bit and certainly afterwards, is only human. I mean, a little boy died tragically. It's almost wrong if you don't cry, I think. We talked about a lot of sort of sad cases. Want to finish with some great saves or something?

Dr. JONATHAN NEWMAN (New York Presbyterian Hospital): I don't really call it a save, but I had sort of a redemptive experience at the end of one day. You know, I came back from clinic and had just a horrendous back to back schedule of patients who had lost their medications and just came in with worsening of these chronic conditions. And I'd left clinic and I was so frustrated. I wanted to just, you know, bang my head against the wall.

And walking back into the hospital, I bumped into this patient who we had diagnosed with this bizarre renal disease, who had been in the hospital for six weeks and, you know, was just miserable. And she was walking out of the hospital and I saw her and she saw me and she came up to me and just gave me this huge hug and started crying. And that day and the rest of the week and probably the weeks following were just fine. So that was one of the best experiences of this year.

BLOCK: That's Jonathan Newman. After the lunch, I sat down with him and a few of the other interns to talk about listening. We'll hear first from Joseph Luca, then from Sarah Russell, Beth Harre and last, from Jonathan Newman.

Dr. JOSEPH LUCA (New York Presbyterian Hospital): Somewhere in medical school, someone warned me that when they first meet and sit down with a patient, the average doctor starts talking after some obscenely short amount of time, like 17 seconds or something like that. And I just force myself to shut up for 60 seconds. It sounds silly, but you just enforce a rule and things come out better.

BLOCK: Do you find yourself looking at your watch in the minute?

Dr. LUCA: No, no, it's not -

Unidentified Woman: I don't bring a watch...

Dr. LUCA: I don't wear a watch and I don't look at the clock when I talk to a patient.

BLOCK: So you think it's a minute.

Dr. LUCA: I think it's a minute. I think, what I do - in truth, what I do is I let the patient talk until they stop talking. And then, maybe I'll ask them another, once or twice I'll ask them another open-ended question until they stop talking again. And then, later on, I'll beat them over the head with my yes or no questions. But, you know, for what I perceive to be a minute or two, I'll just let them talk, you know. And you just have to force yourself.

BLOCK: Sarah, you were talking during the lunch about something that I thought was very brave, which is feeling, even at this early point, that you've lost something in how you empathize with patients.

Dr. RUSSELL: Thank you for calling it brave. It mostly just feels like - I don't know if you guys feel the same way. I kind of - I rarely have those moments, actually where I'm not aware that it's happening. You know, when I go in and I just say, please make this easy for me, and then I think, you are so selfish. Like, look at this person.

You know, and the other thing to make the point too, which we think forget, is do you make it into the hospital these days, you have to be sick. I mean, you really have to "fail on the outside," you know? So we have reason in the world to have empathy and compassion for these people who are so fragile.

That, I think, also adds to my disappointment in myself when I find myself completely blanking on that. I mean, I guess talking about it is, you know, saying it out loud, I'm less likely to do it in the next few days. I don't know.

BLOCK: Can any of the rest of you relate to what Sarah was talking about? In fact, you were nodding your head.

Dr. BETH HARRE (New York Presbyterian): Yeah. I have long lapses of empathy and frustration and negative feelings towards patients and their families. But I assume that that's because - I mean, I hope that this is a function of being overwhelmed a lot of the time. How could you not have a failure of empathy? I mean you can't even find time to go to the bathroom, literally, at times, to meet you own fundamental needs.

And so I assume and I hope that there's a time later in my practicing life -because that's why I went in - I mean I went into medicine because I like patients. Period. And there've been lots of times this year where I haven't been in touch with that.

BLOCK: Jonathan, what about you?

Dr. NEWMAN: I totally agree with that. I just finished, I think, the worst two weeks of internship, which were two weeks of cross coverage, where you don't have your own patients. And as a result you make no decisions really. You sort of implement plans that are already made. And you really have no meaningful contact with any of your patients, because you don't know them. And I was miserable.

And since I have gone back on "service," and I have actually my own 12 patients, it's a completely different world because these people identify me as their doctor. They are ostensibly my patients. And the interactions that I have with them, albeit brief at 6:30 in the morning, make all the difference for me. I have to hold onto those because all the other idiosyncrasies of this hallowed institution can drive you crazy. Sorry.

BLOCK: I think the other people here knew what you were talking about.

Jonathan Newman. Later he tells me he feels troubled that he's become a party to what can be a dehumanizing process in the hospital. He says you watch people get stripped of their dignity. One of the things that makes it tolerable, he says, is that there are these moments of care. For Dr. Newman, one of those moments came when he took a leukemia patient out to the park in her wheelchair to talk about anything but her illness - to cross briefly the line between doctor and friend.

Barron Lerner hopes the discussions he leads may help these young doctors take those steps outside. And in a medical world whose economy demands a fast pace, help them remember how to listen.

Dr. LERNER: He really would like them to finish these lunches and say, you know what? When I approach a patient who has cancer and I'm the one that has to tell them they have cancer, hey, I remember I what we talked about in that lunch and there's some important things to do.

I'm going to turn my beeper off. I'm going to sit down and be at eye level with the patient. I'm going to make sure I don't get interrupted and I'm going to spend enough time and I'm going to bring tissues if they cry.

And those sorts of things, I think, are wonderful ways to teach, wonderful little pearls, as it were, for doctors who are busy and have important and very sensitive things to do.

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