Education: Student Programs: Human Context in Health Care
Human Context in Health Care- Course Description
An Approach to Teaching "The Clinical Approach"- Human Context in Health Care
This required course has been included in the first year curriculum at the Uniformed Services University School of Medicine since the school opened in 1976. Its purpose, according to founding Dean Jay Sanford, was to establish at the beginning of the student's education the principle that physicians treat people, not collections of diseases, and to teach a method of observation and analytic thinking that students should know as people, if not as physicians. The course was intended to be complementary to Introduction to Clinical Medicine-I, where through practice, students are expected to develop basic skills in obtaining a medical history and performing a physical examination; "Human Context" would provide both an orienting perspective and a conceptual foundation for the development of the "clinical approach" to patients. It has been offered in its present form, as developed by the current course director, since 1982. As presently formulated, the goal of the course is to prepare the student to effectively deal with the human elements in patient and physician that transcend diagnosis and medical specialty.
Since what you see when you look depends on where you're standing when you're looking, essential to achieving this goal is the student's ability to be clear about where they are standing, to recognize their personal perspective on the human aspects of the clinical issues in the particular patient encounter. That perspective, a manifestation of the attitude the student brings to the encounter, is revealed by the student's affective reactions to the patient or the situation. Those reactions, the non-cognitive element of the clinical encounter, determine how the student sees and responds to what they may be looking at, and exert their influence on the clinical encounter out of the awareness of most practitioners. Enabling the student to become aware of the influence of those reactions on their ultimate response to the patient entails directly addressing the non-cognitive element of the clinical encounter. Ordinarily not addressed in the curriculum, until recently, this element was typically not even recognized as an appropriate focus of attention in the medical school educational experience.
Several factors contribute to this widespread unawareness: Emotional reactions to clinical situations have traditionally been perceived as reflecting a lack of professionalism and consequently were suppressed, often even before the student became fully aware of them. At best, usually when such reactions were strongly positive, they were sequestered and excluded from consideration of the clinical problem that elicited them. But when, as not uncommonly occurs, the affects involved carried negative overtones that until relatively recently, were considered incompatible with the role of the physician, this suppression was reinforced. These reactions thus became taboos that could not be openly discussed; often enough, they were not even identified for what they were. The taboo was reinforced by concepts of objectivity derived from the classical sciences that deem emotion inappropriate to scientific study. These concepts were unthinkingly extended to the clinical situation; rather than recognizing the potential of an emotional reaction to a clinical situation for enhancing clinical judgment, that reaction was presumed to impair judgment-ignoring the reality that some of the most egregious inhumanities to which patients have been subjected have arguably been a consequence of the absence of emotion in the decision making equation. Further contributing to the failure to consider these issues in the curriculum is the synthetic, integrative approach that addressing these issues requires, radically different from the analytic, dissociative approach of the classical sciences with which most physicians are familiar (and for which, they often have a personal predilection).
In systematic approaches to curriculum design, the components of professional responsibility have been identified as knowledge, skills and attitudes. Medical education has traditionally approached curriculum design only in terms of the first two of those components, knowledge and skills, both readily testable. Attitudes, when considered at all, were assumed to be appropriate from the outset; it was the task of the Admissions Committee to assure, to the extent humanly possible, that this was the case. Should it occur that a student lacked the attitudes necessary to make a good physician, it was assumed that these would be adequately conveyed by teachers in the course of the student's education. Evidence for the failure of medical education in this dimension is manifest in the sources of the disaffection of patients with their medical care.
When attitude was identified as a significant, independent dimension in professional competence, and methods for developing attitudes that would facilitate care were studied, it was recognized that all such methods required active engagement with the student; unlike the situation with knowledge and skills, self-directed learning is generally ineffective in this dimension. As Segall, et al, in their seminal presentation of course design point out, self-directed learning, if anything, is likely to reinforce existing attitudes; given a choice, people almost invariably seek information confirming their established views.
Attitudes are determined by a diversity of elements rooted in personal experience and integral to the perspective and thinking the individual brings to a situation. These factors include not only the physician's views on the appropriate approach to patients generally, but also the physician's perceptions of the individual patient and of the particular circumstances of the situation. With such deeply rooted determinants of attitude, self-directed learning, however effective it may be for the acquisition of technical information and for the development of technical skills, is unlikely to result in modification of attitudes for two reasons. First, because these are elements that the individual does not customarily consider, and second, because as Segall implies, even when considered, none of them are readily questioned.
The basic premise of the Human Context in Health Care course is that these non-cognitive elements can be subject to open examination and analysis in the formal curriculum, and it is to the benefit of the student (and their future patients) to do this. These elements are most readily accessible to examination in attitudes expressed by the student-recognizing that attitudes articulated may be quite different from attitudes manifest in behavior. The actual-as compared to professed-attitudes of the student (or physician), in a clinical situation are revealed by their emotional reactions to that situation, whether it be to the patient personally, or to the particular circumstances of the patient, and tt is these reactions that determine the attitude that physician brings to that patient, and in turn, how that physician thinks about that patient.
The physician's attitude forms the lens through which cognitive knowledge is focused on the individual patient. If the lens is clear and free of distortion-if the physician is comfortable with their emotional reaction to a clinical situation, whatever it is, and appreciates and can correct for the possible effects of idiosyncratic personal experience-the physician's attitude will enable an analysis that is caring in the clarity of its focus on the individual patient's situation. If the lens is cloudy and replete with astigmatic distortions-if the physician cannot acknowledge that emotional reaction, whether because it is frightening or otherwise unacceptable, and fails to recognize the existence or the possible consequences of idiosyncratic personal experience-by obscuring relevant issues or introducing issues irrelevant to the particular patient, however precise the analysis may be in the abstract, the physician's attitude will preclude a clear focus on the needs of the particular patient. It is the synchronous functioning of affect and cognition that enables the physician to provide the most effective care.
As noted above, however, the affective elements underlying attitudes are not customarily considered, and even when considered, not readily questioned, making it particularly difficult to reach them. Influencing attitudes thus requires first, that the student be exposed to a situation likely to elicit an affective response, and second, the creation of an educational environment that both validates and encourages the active examination of that response and the attitudes it reveals, an environment where the student feels safe in undertaking this unfamiliar activity.
The course is structured to facilitate this process. It provides the student first, with an opportunity to identify and examine the implications of their responses to those human elements. This enables them to recognize when and how attitudes of which they may not be aware can seriously impede patient care; simultaneously, it presents methods of alleviating potential problems of that nature. Over the course of the academic year, 14 topics, known to be sources of concern to medical students and physicians, are examined; these include aspects of both the patient's experience and the physician's experience. Students are provided with background reading addressing the distinctive characteristics of each topic.
Classes consist of panel presentations; four or five panelists address each topic from a personal perspective. Panelists are selected on the basis of direct experience with the topic, whether as physician or patient, and willingness to be entirely open in their presentation and in responding to student questions; the affective component of the experience (as physician, no less than as patient), is not concealed. To blur the boundary between student and speaker, speakers are physicians, generally faculty members, or fellow medical students, minimizing the opportunity for students to distance themselves from the immediacy of the experience through creating a "we physicians-those patients", or "we youthful and healthy-those older and becoming ill" dichotomy. Students are advised to regard the presentations as primary data, asking questions as they arise. It is noteworthy that despite the degree of self-disclosure the panel presentations entail, invitations to participate have rarely been declined, and as the course has become better known, faculty and students have volunteered to speak.
Prior to the panel presentation, students are given a sequence of steps through which they can analyze their reactions to the topic and the presentation. Following the presentation, they discuss this analysis in a brief paper, identifying the attitudes they bring to the topic, as revealed by their reactions, the sources of those attitudes, and their implications for their future encounters with patients. These are discussed the following week in groups of nine or ten with a faculty facilitator.
Addressing the "human context" in the care of patients-and through that process developing the attitudes that facilitate care-thus begins with the student identifying and accepting their own emotional reactions to clinical situations, a reflection of the attitudes they bring to those situations. Since these reactions are determined by life experience, each student must learn for themselves what elements in a situation elicit a reaction, and the nature of that reaction-which can and does differ widely among individuals. In the step that is unique to medical education-and for the reasons noted earlier, most difficult to achieve-the student begins to recognize how these reactions and the attitudes they bespeak, influence the student's perspective and hence their thinking, in specific clinical situations. It is the inculcation of the habit of translating the non-cognitive experiences that are a part of the clinical encounter into cognitive terms, and identifying their implications for patient care that is the ultimate goal of the course.
Recognizing that student attitudes are reflected in their emotional reactions to clinical situations, the panel presentations are specifically designed to both elicit such reactions and to make them acceptable in a clinical situation, first steps in the development of attitudes that will facilitate care. Respected panelists who, as a matter of course, discusses their emotional reactions and the roles they played in a clinical situation, both legitimate those reactions as appropriate subjects for professional consideration and demonstrate that such reactions, however intense, need not overwhelm, and in fact, often play a valid and significant role in clinical decisions. And in the very process of conveying those concepts, panelists are also demonstrating that however awkward, "inappropriate", even embarrassing these reactions may be, they can be talked about without harm, the anticipated negative judgments rarely, if at all, being passed, and even if passed, not to be feared.
But insofar as the legitimation of affect is essentially a cognitive phenomenon, it is only a part of the educational process. By providing a panelist with whom, as nascent physicians, the students likely will identify, one who will address in personal terms an emotionally charged topic and with whom the students interact, we have established the optimal conditions in a classroom for engendering an emotional response in students. (Our success in eliciting such a response is suggested by student comments about not wanting to attend particular classes because of the emotions stirred up.)
With the students in this state of heightened emotionality, we are in a position to demonstrate how that emotional reaction that they have characteristically dissociated from their cognitive activities (and typically experience as more than a little threatening), structures their thinking; we can provide the necessary encouragement for the individual student to examine that emotional reaction to determine its roots in personal experience, values, and expectations and to identify its implications for patient care; where the reaction carries a potential for impeding care we can support the student in exploring means of reversing that potential, in identifying mitigating factors in the situation; and finally, we can furnish the students with a mechanism for juxtaposing those emotional reactions with available cognitive knowledge, for using those emotional reactions as a clear lens through which they can focus their cognitive knowledge to most effectively apply it to a particular patient.
Several features of the course warrant specific mention:
There are no examinations in the course. Customary letter grades are awarded, based on faculty evaluation of the rigor of the analysis demonstrated in the student papers prepared for each topic, and of the quality of participation in the discussion. The initial distribution of final grades parallels the grade distribution of the clinical years. Students who feel their grade does not accurately reflect their grasp of the goals of the course are encouraged to meet with the course director to discuss ways in which they might demonstrate their ability to apply the "clinical approach" in a manner better than their initial grade would suggest.
Student assessment of the course is conducted at each panel session through 15 questionnaires, randomly distributed at the beginning of each class, and by a more general questionnaire to which all students respond at the end of the course. Objections have been raised primarily to the volume of assigned reading and to the biweekly papers, but even those objecting have generally acknowledged that if it were not for the papers, they likely would not spend any time thinking about the issues.
Time demands on faculty discussion leaders are not insubstantial. To enable faculty to know what occurred during the panel presentation, yet minimize demands on their schedules, discussion leaders are provided audiotapes of the panel presentation for listening at their convenience; many do so while commuting. Between that, reading the handout, and evaluating student papers before the discussion group, as much as 3-4 hours may be spent every 2 weeks for each of the 14 topics covered through the year; "core" faculty are generally able to participate in 10-11 discussions each year.
While the quality of the analysis in the student papers on which grades are based hopefully reflects the student's ability to think clinically, it is not a true assessment of the effectiveness of the course. That can occur only in the clinical context, and with the multiple variables an evaluation in that situation would entail-not least of which is the one year interval between the ending of the course and starting on the wards-such an assessment has not been possible. While anecdotal, my experience suggests a lasting effect. It is not uncommon for graduates, some of whom I never even knew when they were students, or for students in their clinical years, to come by my office when they happen to be on campus, or to stop me on casual encounters in the halls of the hospital, to tell me how they are applying in their work, experiences they had in the course (Not atypical was the student who described being angry when leaving a patient after a difficult encounter and catching himself, thinking, "Wait a minute. Simon says it's OK to get mad at patients as long as you figure out what made you mad and do something about it", then thinking about what had happened and going back and resolving the situation in a very positive way with the patient. But probably the most satisfying-to me-of such encounters was reported to me indirectly. A student told me of meeting a classmate who had just left a patient's room, mumbling, "The son-of-a-bitch was right." Hoping to be supportive, my informant asked his classmate who he was talking about. The response came as a snarl: "Simon!")
Finally, we must address the question, "Is it worth the time investment by both students and faculty?" Obviously, there is no absolute answer to such a value question. Participating faculty from all medical specialties seem to think so, volunteering annually without tangible rewards, often commenting on how helpful they have found the course; about half the core faculty each year, primarily senior clinicians, have been with the course for at least five years, several having participated from its inception in its present form. The student perspective on this question-negative, as well as positive-was expressed by one student in his observation, "You talk about things we don't want to hear about, and you challenge us to be honest about things that we've lied to ourselves about all our lives."
An affirmative answer to the question is implied as well by an entirely unforeseen development among the students. With increasing frequency over the years, in discussing the basis for their reactions to a topic in their response papers, students have been describing intense, personal traumatic experiences which many indicated they had never revealed until that time. Whether they were doing so because they were discovering through the panel presentations that it was safe to reveal such experiences, or whether it was because they have learned that it will elicit a concerned response, more than a few subsequently reported that classmate and faculty reactions to their revelations had a therapeutic effect (These are often the students who volunteer to speak on class panels). Given the widespread concern about burnout and disability in the profession, this phenomenon would also suggest the effort to be worthwhile.
Simon L. Auster, M.D., J.D.
Highlights
Department of Family Medicine (FAP)
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, Maryland 20814
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