Tagged: medicine
Things they didn’t teach in Medical School: Part 5 The 21st Century Skills
In thinking about my question – about what I wasn’t taught (or maybe didn’t learn) in medical school – I’ve been trying to come up with a way of summarising the themes and chanced upon a book about life skills needed for the 21st Century. I thought it encapsulated the needs of the modern doctor in training nicely. Whilst modern curricula do address some of these issues they certainly don’t give them enough prominence.
Trilling and Fadel describe in their book 21st Century Skills: Learning for Life in Our Times, 7 C’s that constitute the 21st Century skill-set when combined with the tradiational 3 R’s (reading, writing & arithmetic). The 7 C’s are:
Critical thinking and problem solving
Communications, information, and media literacy
Collaboration, teamwork, and leadership
Creativity and innovation
Computing and ICT literacy
Career and learning self-reliance
Cross-cultural understanding
Looking through the 7 C’s one can see the importance of each of these skills for a doctor working in a health system dominated by team-based healthcare, electronic connectivity, mHealth, social media, and patient empowerment. These skills also subserve the doctors of the future as more and more digital natives or Millennials pursue non-traditional, portfolio-style careers. Practising doctors and medical students can evaluate themselves against these 7 C’s.
Things they didn’t teach in Medical School: Part 4 Theatre Sports & Improv
As I was going though medical school and especially when I was doing speciality training as a medical oncologist there was a growing trend to teaching communication skills. Generally this focused on communicating with patients and in particular this focused on breaking bad news. Although this was useful and now it is something that I pride myself on doing well it wasn’t really enough to address my communication needs.
Doctors need to be able to communicate with patients but also with their colleagues including other doctors, nursing and allied health professionals, junior staff and students. Although rough frameworks are taught in communication skills training what isn’t taught is how any of these interactions requires dramatic skill and the ability to improvise.
An example I use is from a tutorial I run with medical students about malignant spinal cord compression. As we work through the case I get the students to pretend that they are the doctor in the emergency department in the middle of the night who has to call the radiologist, the neurosurgical fellow and the radiation oncologist about the patient. Any doctor who has worked in an ED on an overtime shift can tell you of the joys of having to make these calls and ‘sell’ the case to another doctor. The job of the junior doctor is to do stuff for other peope and to get people to do stuff for you. This process continues on through one’s career as you move from making your case to one other doctor to groups of doctors in multi-disciplinary meetings.
When dealing with patients the communication skills we are dealth with at medical school really only covers the basics. I like to think of it as jazz. There are a set of chords and melodic themes to work with but then you have to adapt to the occasion. In any given clinic the doctor might move from needing to break bad news to the patient he or she has known for years and whom there is an established rapport to the totally new patient whom one has to assess in a matter of minutes and then play one’s spiel to the tempo of the occasion. Discussing end-of-life with somebody who you met 15 minutes earlier requires a lot of improvisation and a great deal of practice: one size doesn’t fit all.
Now I guess you can argue it is hard to teach these skills and that some are more naturally gifted than others. Well that it true but I think one can learn. The first step is to realise that you can’t simply say the same things in the same way to every person. The worst communicators I’ve met follow the same pattern every time.
For me the most important components of learning to improv in medical communication are:
– actually know what you are talking about – it is hard to be an expert if you aren’t actually an expert
– if you don’t know what you are talking about then admit it openly
– establish what the patient and their family expect from the consultation
– find out what people know first – sometimes I ask if they just want to ask questions or would they like me to do the talking
– start with the most simple explanations and then make them more complex as needed
– use non-medical analogies to help people understand
– compare and contrast – for example – when I explain chemotherapy I explain what happens with and what happens without treatment
– practice a lot and remember what works
– be repetititive so you are thorough but don’t follow a strict script
– when there are treatment options offer clear choices that are genuinely different and don’t offer too many
– recap and check understanding
One particular way to improve communication improv skills is to explain the same concept to different audiences, expert and non-expert, – this way you learn to move the explanations along the complexity spectrum. With the experts you have to use the right jargon – with the non-experts you can’t.
It seems, as time goes on, there is less time for junior doctors to watch senior doctors explain things to patients and also less time for senior doctors to watch junior doctors make explanations. In the era of mHealth this needs to change. Medical schools need to move beyond the limited communication skills currently taught and train star performers.
Population Health or Personalised Health in Preventive Medicine
One of the common comments about modern healthcare is that we would do a lot better to focus on prevention of disease rather than treatment of disease. The argument goes that we could reduce the cost of healthcare by preventing diseases in the first place and through promotion of ‘wellness’. In principle this sounds like a fair approach but are we sure that this will be the case?
Many effective prevention strategies are already in place: clean water and food sources, fluoridation of water, vaccination against childhood illness, and screening for some forms of cancer. Many of these activities are also cost-effective. These are population level strategies.
But many for many other conditions the role for prevention is less clear. Populations turn out to be heterogeneous and many conditions, whilst common, are actually not likely to occur for any given individual. The way around this is to identify who should receive a preventive intervention by risk stratification. The simplest example is smoking. Smokers are approximately 25 times more likely to develop lung cancer than non-smokers. Lung cancer and other smoking related diseases contribute substantially to the economic burden of disease. So it makes sense to promote smoking prevention.
On the other hand – not every smoker develops lung cancer (‘uncle Eddy lived to 90 and wasn’t sick a day in his life’) and 10-15% of lung cancer patients are non-smokers. So as an intervention smoking prevention will not necessarily eliminate the development of new cases (like universal polio vaccination) but it will have a substantive impact.
One way to increase the chances of correctly identifying ‘at risk’ individuals for any given disease is to obtain more in-depth information about risk factors. For many diseases this will involve genotyping or knowing the genetic make-up of a person. It is now possible to sequence the whole genome of individuals and commercial ventures undertaking genetic screening for predisposition to common conditions such as Alzheimer’s disease already exist.
With the possible exception of public policy around obesity prevention is possible that most of the population health measures to prevent disease are already in place. The way to move forwards is to gather more information on genetic predisposition to disease in order to target efforts at prevention. Some of the genetic factors will provide targets for intervention. Some genetic factors will cluster together – e.g. a cardiac risk profile – and will help direct prevention. Whilst this is the is the logical approach it may not be as cost-effective as the population health approach, but then the population approach isn’t necessarily applicable to the problems not yet tackled.
What they didn’t teach in medical school Part 2: how the health system works
One of the things that wasn’t taught well when I went to medical school was actually how the health system works: in my case I’m referring to the Australian health care system but I’m sure the sentiment applies in other countries. Knowing how the health system works overlaps with how to run a business, which I’ll cover in a later post.
When you are studying medicine and even once you’ve graduated and working in the hospital you don’t really pay attention to how the health system works. The patients come and go and you do your best to look after them. It’s perhaps only once you actually have to go out and get a job, either in the hospital system or in private practice, that you start to care. When I refer to ‘how the health system works’ what I really mean is ‘how is health care paid for’. Once you get a job you are concerned with how you are paid and/or will pay other people. If you work in hospitals then you spend a lot of time listening to other people tell you you can’t do stuff because there is no money – even if what you want to do will result in real improvements and maybe even save money at the end of the day.
In Australia it is becoming even more important for medical students and junior medical officers to be taught how the health system works. As a result of the last round of health care reform the Federal government is phasing-in activity-based funding. So hospitals will be based on what they do according to a National efficient price. This sounds straight forward but in practice it is much more complicated. Hospitals won’t necessarily be getting paid on the basis of the activity they undertake. Governments must allocate budgets from finite coffers so the money local hospitals receives is based on projections, somewhat spuriously called targets. If the hospital undertakes more activity than predicted then unless it operates very efficiently it may end up over budget.
Medical students, junior and senior medical officers need to know about how activity-based funding works as they are the source of the the documentation about how much activity is being undertaken. Unless the doctor records not only the cholecystectomy but the co-morbidities of the patient and complications incurred during the hospital stay then ultimately the coding of the data to obtain funding will be inaccurate and inadequate. This in turn leads to inadequate models upon which the hospital activity targets are set.
These processes and in evolution and being rolled-out over the coming years. Doctors and their students need to become more familiar with how the system works so they can influence how their hospitals or practices are run and how the money is spent. Knowing how the system works will change how doctors work. Health care practitioners also need to be aware developments in primary care, such as the development of Medicare Locals. They will also need to keep up to date and the system is likely to change again. This is the decade of activity-based funding in Australia. The next decade might see a shift to process and outcomes-based funding and further changes to the way doctors practice.
I’ve only touched one major aspect of how the health system works. In Australia it is very complicated due to Federal, State and Local considerations. Medical schools will need to teach according to their local health care environment.
For more information see Activity Based Funding and the Independent Hospital Pricing Authority
The Curator Unplugged – Training Future Doctors in the Era of Electronic Decision Support
One of the key problems facing educators in medicine today is how to train future doctors in medical decision making in an emerging era of electronic decisions support in EHR (electronic health record).
Harvey Chochinov’s Interview with Geraldine Doogue
http://www.abc.net.au/rn/saturdayextra/stories/2009/2728604.htm
Geraldine Doogue: Now a change of pace from childhood memories of Anne Manne, to the other inevitable end-of-life spectrum: illness and death and the quite rapid strides being taken by the relatively new discipline of palliative care, and the challenges it’s throwing out to broader accepted medical practice.
Over the years there’s been quite a lot of lay writing about how people feel and react when death is near, but my next guest has been gathering notice internationally for his systematic reflection on the role of medical professionals at the core of this time of people’s lives.
Professor Harvey Chochinov holds many posts, chief among them, professor of psychiatry and community health sciences at the University of Manitoba, and director of the Manitoba Palliative Care Research Unit at Cancer Care Manitoba, and he’s known as the founder of the relatively new intervention, Dignity Therapy. He’s speaking today at the Inaugural Whole Person Care National Symposium in Sydney, and it’s my pleasure to welcome him. Professor Chochinov, welcome to Saturday Extra.
Harvey Chochinov: Glad to be here.
Geraldine Doogue: Now in one of your papers, Professor Chochinov, you quote the late Anatole Broyard, the former editor of The New York Times Book Review, and it’s a great quote: ‘To the typical physician, my illness, metastatic prostate cancer, is a routine incident in his rounds, while for me it’s the crisis of my life. I’d feel better if I had a doctor who at least perceived this incongruity. I just wish he would.’ A very heartfelt appeal, I would have thought, but a common one?
Harvey Chochinov: Absolutely. Broyard, by the way was a wonderful writer; the remainder of that quote I believe he says something to the effect ‘I want a physician who will not only grope for my prostate but for my soul.’ Patients want to look towards healthcare providers, and know that we are seeing something more than the lump or more than the aberrant blood test, that somehow we are seeing them.
We’ve done some research on the issue of dignity, and in fact found that the thing that’s most predictive of whether someone’s dignity is intact or not, really depends on how they perceive others to experience them, which is extraordinary when you think about it. And very much implicates the position of the healthcare provider. In fact I was so taken by the data that I wrote an article called ‘Dignity in the Eye of the Beholder’, and we the health care providers, behold patient and patient experience; and the message of the paper is that the reflection that patients see of themselves in the eye of the beholder needs to be one that’s affirming of their sense of dignity.
Geraldine Doogue: Look, it just prompts so many thoughts, because maybe the orthodox expectation — and I have to say maybe I would have thought this myself — is that above all what you want when you are terribly ill, is the competence, the practical competence of the specialist, or the doctor that you’re dealing with. You’re really challenging that notion, you’re saying that it’s not one or t’other, it’s not pragmatic competence versus a sense of compassion, the two absolutely can go in the one form.
Harvey Chochinov: Patients absolutely do want competence but isn’t it interesting that we’ve parsed out competence to be exclusive of the humanities of care. So we can say we can have somebody who was profoundly technically competent, but they have absolutely no people skills. And the truth is, there have been studies that have been done looking at why is it that patients receive complaints at the level of the Royal College of Physicians and Surgeons, and in 80% of instances the reason that physicians get into trouble is not because of competence issues, it’s because of tone issues, and tone of care. It is because of lack of communication abilities. So we know that of course patients want competence, they want the best of care, but the best of care should include the humanities of care.
Geraldine Doogue: In a way, it just sounds like very good bedside manner. You might say well of course.
Harvey Chochinov: What we say to health care providers oftentimes to simplify this, is you know, just be a good person, you know. I don’t know if it translates well in Australian parlance but in Canadian terms, trust your gut. We know, and what the data shows is that physicians get into trouble. So I don’t think it’s that anybody has bad intention necessarily, I think the reality is that we tend to think of this as somehow being outside of the realm of delivering healthcare. This is something we can refer to the social worker, to the pastoral care provider, somebody will look after the ‘niceties of care’, while I will do medicine. Well, pardon me, but medicine should include those core values of medical professionalism, like kindness and respect.
Geraldine Doogue: And compassion, which you put a lot of emphasis on. Can compassion be learned? Let’s say we have a specialist who’s a very good diagnostician, which I would actually like if I’m very ill. But they just don’t think of these things as important. Can they learn it?
Harvey Chochinov: I think the difficulty with compassion and trying to teach it, when I look at various different programs around the world that have attempted to do this, is they’re — I’ll just use an analogy — a bit like a shoe store that only sells size 9. You know, it fits some people, but not everyone. I think to make care providers more compassionate, you need to have them find what puts them in touch with their own sense of vulnerability, mortality, and for some people, I was at a…
Geraldine Doogue: Might that not, dare I say, might that not undermine their sense of competence? Isn’t it possible that that’s the very thing you would least want in someone who’s going to have to go through lots and lots of decision-making in a day?
Harvey Chochinov: Physicians need to make decisions, and they need to be able to compartmentalise. The truth is that when your surgeon is about to make the first incision, what you want him thinking about the appropriate anatomical landmarks; not the fact that this is a young mother with two children and single, and so on and so forth. But unless he or she is planning on only dealing with anaesthetised patients, patients deserve to have somebody who can at least acknowledge that there is something more to them, than their illness. I was saying that I was at Harvard in Boston a couple of years ago and basically explained to the students that the data, and there is good data to support this, that the data metaphorically says that you are a mirror. Patients and families, every time they have contact with you, they’re looking at that reflection and if they see only their illness, then they feel that they have vanished, they feel they’ve disappeared.
Geraldine Doogue: My guest is Professor Harvey Chochinov, founder of a new end-of-life intervention called Dignity Therapy, which is maybe what we should get to now, Professor Chochinov. Is it a very practical, intense type of intervention? I haven’t heard this phrase before.
Harvey Chochinov: One of the pieces that we came upon during the course of our studies, is that for some patients, besides all of the other anxieties that might undermine sense of dignity, is a sense that nothing of their essence or of their personhood would survive beyond the moment of death, that they will die in the memories of those they loved and life will not have left any ripple effect. In developmental psychology, we refer to this as generativity.
So what we’ve done is we’ve created a therapeutic intervention, if you will, in which they’re invited to discuss things that matter to them, parts of their life perhaps that they would want remembered or known, things they’ve learned along the way, accomplishments, things they feel proud of, hopes, wishes or dreams for individuals, or loved ones, specific advice — these interviews are guided by a skilled therapist, they are edited so that we can turn what is sometimes a meandering dialogue into a more pristine narrative, and then given as a document to the patient, for them to most often bequeath to a family member or loved one.
It all sounds lovely, and perhaps to some extent intuitive, but we live in an era of evidence-based medicine, and we believe that if we’re going to change the field of medicine, or to change the field of palliative medicine, we have to generate good evidence. And so we’ve just finished — we’ve done a couple of studies on dignity therapy, and in fact one of our collaborators, Dr Linda Christiansen in Perth, Australia, has been a long-time research colleague. Together with the group in Perth and in Canada, we did a study on dignity therapy and we showed that 95% of patients were not only satisfied but nearly 80% said it enhanced their sense of dignity, 70% to 75% said this gave them a sense of meaning and purpose, a portion said that it helped them to prepare for death and just over 80% said they believed that it already had, or would help their family member.
Geraldine Doogue: Did it — I think you report an increased will to live on behalf of nearly half the people whom you worked with — what about a more peaceful acceptance for letting go, for dying, is that something that you seek? Is it a by-product?
Harvey Chochinov: I think the thing about nearing end of life is that people cope with it in a variety of ways. Some patients seem to hang on to this construct, will to live for a very long time, which to me is not so much a palliative care finding as it is a finding about the human condition, the wish to be here seems to be something that sustains us and seems to be sustained for a very long time. I don’t think it’s something that we have to try and change or tamper with, it is what it is.
On the other hand, sometimes, for some patients, offering something that engenders a sense of meaning and purpose, can have an influence on outlook and the wish to go on. A story I often tell is of a gentleman who we enrolled in dignity therapy who actually told me that if he could push the button, if he could end his life now, that he would. He decided that breathing could become redundant, there was no point in going on. And so I explained what dignity therapy was about and asked if he would be interested, and he was actually quite taken with the idea, he was a lovely gentlemen, he was taken with the idea and ‘Yes, I would very much like this’, and I arranged to come back the next day. And as I exited his room, I said to him, ‘By the way, if you could press the button right now, would you?’ And he looked at me with this sheepish smile and said, ‘No, we have to do this first.’
Geraldine Doogue: Very interesting. Look finally, just to go back to another quote, Francis Peabody, seeing we started with Broyard — this is him writing in 1927: ‘One of the essential qualities of the clinician is interest in humanity for the secret of the care of the patient is in caring for the patient.’ And I notice that you actually suggest that doctors take on life, literature, films, anthropology, that they throw themselves into the fullest experience of life, not merely the acquisition of the most orthodox medical skills. Why does that matter?
Harvey Chochinov: What I suggest is that people be true to themselves and that what they do should be done with some specificity so that it resonates as personally meaningful. When I was visiting Harvard Medical School the medical students told me that everyone had to keep a diary, reflecting on their experience. And so I asked the medical students, and there were no supervisors around, I said, ‘So, does this work?’ And half of them said it was gorgeous, that it helped them tremendously. And the other half confessed that they were glad that they had spouses or partners who enjoyed creative writing.
So my point is we need to encourage doctors to do things that put them in touch with the experience of living so that they understand that they’re not so different from their patients, and that I think, is what engenders compassion. The truth is, at the end of the day, I mean we all need good care and we’re all deserving of good care, and be mindful of the psychological, the social, the spiritual, the existential realms a patient experienced, I think is the only way that we’re going to be able to deliver holistic, or what I’ve called dignity conserving care.
Geraldine Doogue: Professor Chochinov, good luck to you, all power to you. Thank you very much for joining us.
Harvey Chochinov: It’s been my pleasure.
Geraldine Doogue: Harvey Chochinov is professor in the department of psychiatry at the University of Manitoba, and there’s a link to the Whole Person Care National Symposium on our website where he’s been visiting Australia in order to speak at it. And again, I’d love to hear back from you; I think it might prompt a lot of reflection from listeners.
My Whole Person Conference Talk
The missing data
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