U.S. medical school curricula have long been divided into pre-clinical and clinical years. The early years primarily exist to learn the academic content of medicine — that is, to memorize the basic facts, dissect cadavers, peer through microscopes, and read textbooks. To prevent new medical students from losing sight of what medicine is really about, though, there is typically a longitudinal course teaching the basics of patient care. At my school this course was Introduction to Clinical Medicine (ICM), since renamed Doctoring.
Despite the fact that ICM contained most of the opportunity to learn about clinical medicine in the first biennium of medical school, this class was frequently relegated to the backseat by medical students. The reason is straightforward: learning to interview patients or techniques for auscultating the lungs might make one a better doctor, but these things are unlikely to be on board exams. For better or worse, these exams currently are the major factor in a student’s eventual choice of specialty and residency and thus are where most students focus their efforts. Regardless, I remember looking forward to this class, as it was an opportunity to learn the vocabulary of clinical medicine and actually interface with patients (albeit usually standardized patient actors). In one of the first lectures for this course, we watched a family doctor conduct a patient interview, and then we discussed what was good and bad and how we might begin to think about talking to patients. Shortly after, we were allowed to practice interviewing for the first time. We had 45 minutes to ask questions and were encouraged to be thorough.
Over the course of the first year, we learned all the basic tenets of good communication in medicine. This type of communication includes open-ended questions, active listening, logical organization, avoiding jargon, matching the patient's nonverbal cues and language style, and above all, using empathy and compassion to help the patient feel important. Our lack of medical knowledge was a hindrance in some ways — we didn’t necessarily ask the right questions, since we didn’t know much about any particular disease. In other ways, though, it helped us to be thorough and to listen more carefully. All this, of course, takes time, and it was a beautiful opportunity to learn how doctors and patients communicate.
Or should communicate, that is. Fast-forward to fourth year medical students, who have spent several thousand hours doing full time clinical medicine, watching preceptors, attendings, and residents interview patients in all specialties. By this time, medical students have begun to jettison all these learned skills of listening in favor of the pragmatic. They have learned to not ask open-ended questions, lest the patient actually talk. They have learned to interrupt and "re-direct" patients, seeking just the facts, please. They have learned to brush past the details that are not directly relevant. They have learned, in short, exactly what the system has deemed to teach them. Any student who resists this education will be teased or scolded (perhaps actually having their grade docked) for inefficiency. The ideal student can answer all the attending’s questions and diagnose a patient with absolute certainty after having seen them for the bare minimum amount of time. This is best accomplished by simplifying each patient into a set of numbers and symptoms. Any patient who does not quickly yield to this method is categorized a poor historian – implying much about who is and isn’t responsible for effective communication.
This is a wonderful system that works perfectly to meet its goal: smoothly dispensing with as many patients as quickly as possible, maximizing the quantity of patients that can be seen. Unfortunately, it falls spectacularly short of anything resembling communication, let alone the particularly important “doctor-patient communication.” In most of our minds, this should be of the highest quality, since health and sickness and life and death often depend on how it is conducted.
In her podcast "On Being," Krista Tippett, writer and thinker on a variety of topics, spoke with Rachel Naomi Remen, doctor and teacher probably best known for founding "The Healer’s Art" course for medical students. They discussed how medical students are taught — much the way I was taught in ICM — to communicate. Tippett writes about this ideal kind of communication, which Remen calls “generous listening,” this way: “Generous listening involves a kind of vulnerability, a willingness to be surprised; to let go of assumptions and be ready to take in ambiguity…The generous listener really wants to understand the humanity behind the words of the other and patiently summons one’s own best self and one’s own best words and questions.” This is to me a good standard for how a physician should approach his or her patients – openly, kindly, curiously. It also stands in opposition, often, with efficiency, because listening generously might create space for a patient to tell the doctor many things that the doctor does not want to hear, if they aren’t directly relevant to the perceived “reason for appointment.”
Danielle Ofri more thoroughly explores the idea of listening in medicine in her book, "What Patients Say, What Doctors Hear". She tells many stories which are familiar to anyone in the field: stories of trial and failure to find a better way to listen to one another. Ofri laments what all thoughtful doctors and nearly all patients do: the deck seems stacked against us to be able to listen the way we desire. We have to be honest about this, because what we are really asking for is not that complicated. What we hope for above all is to look at one another, one human to another, and commune about the most meaningful part of ourselves. Being able to do this broadens our capabilities as physicians. It makes the actual diagnosis easier, it makes us feel better about ourselves, and it makes all the difference to patients, both explicitly and implicitly. The feedback given to medical students from patients is often that they are among the most kind and empathetic doctors encountered. I suggest that this is because they have learned the basics of truly good communication, emphasize optimism and compassion, and have yet to be marred by a system that opposes such a style.
I don't have the solution, per se, but perhaps we can learn something from first-year medical students. I chose Psychiatry in part because communication is centralized by default, and it usually affords me the time needed to actually do all those things I want to — and believe I actually need to — if I'm going to humanize and effectively connect with my patients. Other fields of medicine are more constrained by time, by an unfair system that is designed to do something other than prioritize human relationships. But perhaps time is not all there is. Some doctors maintain excellent communication despite systemic limitations. Perhaps reclaiming traits like broad curiosity, true compassion, and a commitment to placing the human spirit above all else — in short, generous listening — will create better communication even within the provided constraints. Clinical medicine is too remarkable an opportunity to share time and space with another person to allow its transformation into something so closed off from the human experience. Regardless of our place in medicine, we can all try to do better.
Brent Schnipke, MD is a writer based in Dayton, OH. He received his MD from Wright State University in 2018 and is a first-year Psychiatry resident at Wright State. His professional interests include writing, medical humanities, and medical education. He is also a 2018–2019 Doximity Author.
Illustration by Jennifer Bogartz