Medical students "taught to listen" in U of T program
Olga Lechky
CMAJ 1997;157:563-4
[ en bref ]
Olga Lechky is a freelance writer living in North York, Ont.
Organizers of the U of T's course in therapeutic communication welcome the referral of patients willing to meet weekly with a medical student at a Toronto teaching hospital. Enquiries should be directed to Dr. Solomon Shapiro, 416 323-9849.
© 1997 Olga Lechky
En bref
La popularité de la communication thérapeutique, un programme périscolaire offert aux étudiants de première année en médecine à l'Université de Toronto, révèle la valeur que les médecins de demain accordent à une communication médecinpatient efficace.
Although the new curriculum introduced at the University of Toronto in 1992 is permeated with the message that communication skills are as important to good medical practice as clinical acumen (CMAJ 1992;1230-3), it appears that some U of T students want additional opportunities to hone their ability to communicate with patients. In addition to the already heavy first-year course load, some students are taking on a time-consuming after-hours commitment for which they receive no formal credit.
Started by Dr. Solomon Shapiro, a staff psychiatrist at the Clarke Institute of Psychiatry and a lecturer at the University of Toronto, and senior faculty psychiatrists Sandford Fleming and Sam Izenberg, the course in therapeutic communication is entering its third year. This month, first-year students will be invited to attend an information session, after which interviews will be conducted to select 20 students who show a serious interest in the course and are willing to dedicate themselves to it for 4 months. They are then assigned to 4- or 5-member groups that are supervised by a member of the U of T's Department of Psychiatry.
The attraction of the course, and its reward, develops when each student enters into a therapeutic relationship with a patient. It involves weekly, 45-minute meetings to discuss difficulties being experienced by the patient.
During the initial assessment of a potential patient, which is carried out by the supervising psychiatrist and a student, other group members observe the interview. By doing this all students have a sense of the patients being discussed when they meet for 90 minutes each week for supervision and group discussion regarding problems and progress.
If the patient and student are deemed a good match after the initial assessment, they meet regularly for the duration of the program. The assessment process continues until all students in each group are matched with a patient.
The patients, who give informed consent to forming a therapeutic alliance with a supervised student, are generally facing psychosocial stresses that are undermining their sense of well-being, daily functioning or physical health. Patients with severe clinical depression, suicidal thoughts or psychosis are screened out before the initial assessment interviews.
Patients who are selected must be functioning at a relatively high level, be able to express themselves well and have a capacity for insight into their situation. Often they are not seeking formal psychotherapy but simply want to air their problems and receive feedback on possible solutions.
Others are on a waiting list for formal psychotherapy but have no objection to talking to a supervised student in the interim. Typical problems include unemployment, divorce and relationship problems.
"The goal is to help students improve their communication skills, especially around psychosocial issues, and to teach them how to have an effective back-and-forth conversation and not just take a medical history," explains Shapiro. "In this course they actually learn how to listen and intervene in a conversation in a way that helps patients feel understood and supported. It also helps them understand the nature and the dynamics of the doctorpatient relationship, to read body language and to read between the lines about what is not being said openly.
"Another goal is to help them work well with colleagues, to overcome that common problem of doctors feeling isolated, feeling that they can't express their doubts and concerns to their peers. A side effect of the program is that students confront their biases and prejudices. For example, students might end up dealing with somebody who has a drug-addiction problem, is gay or lesbian, has been in jail, or is from [a different] ethnic and cultural background. Exposure to these types of people gives them an opportunity to explore all kinds of personal and social issues."
Shapiro says most patients have found that the process helps them to clarify issues and consider some important changes. Some patients, especially younger ones who might have felt intimidated talking with a psychiatrist, reported feeling comfortable talking to a student. Based on their positive experience during the course, some patients have entered formal psychotherapy.
Most students have found the process rewarding. Barbara Crawford, who participated in the program in 1996, said the relationship that developed with her patient "turned out to be a very productive encounter. He had had a lot of reversals in his life, a whole series of events that were really catastrophic for him, like losing his job. He also had some physical problems. Everything was so interrelated that you could see how he would have a great deal of difficulty sorting it all out and regaining control over his life."
Crawford found that the nature of her patient's problems often left her feeling confused and unsure of how to proceed. "That's where the supervision was invaluable, because you could talk about it in the group and get feedback from both the psychiatrist and your peers. You get a perspective on alternate ways of looking at things and other strategies to try.
"I found this very supportive, much better than being told you made a mistake and were criticized for it. Our group turned out to be very compatible and I got to know peers that I might not have known otherwise. We can call upon each other for support if we're going through a hard time or need some help. The whole experience was wonderful."
The patient said he benefited from the experience as well. "I saw a big difference in him from the beginning to the end in the way he handled things," Crawford recalled. "He still had some problems at the end but he seemed to have a better perspective and felt more in control of his life than he had been before."
For Nancy Biddle, another student participant, the greatest value of therapeutic communication was learning how to put abstract notions into practice. With the help of her supervisor and peer group, she learned words and gestures that reassure patients.
Through feedback, she also learned that well-intentioned words can sometimes be misunderstood. "You may have meant one thing but the patient or the other students heard a different message. The course offered a great opportunity to polish up the technical aspects of communication, as well as to learn how to show empathy and be supportive. You really learn to think about what you say and what it means to people and to really listen to what they say and how to interpret it. It's so much more personal and meaningful than words in a textbook or the casual use of buzzwords."
Biddle admits that she often felt unsure of what strategy to pursue in the sessions with her patient, but said she still learned a great deal from the course. "When a patient trusts you enough to tell you something really personal -- something they've never told anyone before -- it makes you feel good about what you're doing. It boosts your confidence, but it's also a bit frightening to know that a doctor has that kind of power and responsibility. It brings home the message that practising medicine means you can have a lot of power over somebody and you need to know how to handle that. But it also gives you a sense of real privilege to have someone confide in you."
Kunuk Rhee, a graduate of the therapeutic-communication course, and fellow student Brian Taylor decided to take matters into their own hands after being disappointed with the lack of opportunities to learn about psychotherapy issues in the first-year curriculum. In the spring of 1996 they started an extracurricular pilot project that gave them and 2 other students intensive exposure to psychiatric and psychosocial subjects such as depression, manic depression, schizophrenia and marital problems, as well as to the proper use of Prime MD -- a tool for primary care evaluation of mental disorders. The topics were covered during a weekly 8-hour session held for 3 weeks.
The students were under the general supervision of Dr. Michael Paré, coordinator of the Medical Clinic for Person-Centred Psychotherapy in North York, Ont., and a lecturer at the University of Toronto. Seven more faculty members donated their time and expertise by using tools that ranged from didactic lectures and open discussion to role playing and video analysis.
"Psychiatry and psychotherapy are integral to the practice of medicine, no matter what field you end up in," says Rhee. "In first year we had 1 week of didactic lectures on the whole area of psychiatry and we didn't feel it was enough."
According to Taylor, early exposure to psychosocial issues helps students appreciate "that there's more to patients than simply a physical being, or a disease with symptoms. You start to get an understanding that a psychological or emotional process might be affecting the patient's overall health, either in addition to a physical illness or by exacerbating a physical disease."
 |
Send a letter to the editor responding to this article
Envoyez une lettre à la rédaction au sujet de cet article |
Features