Monday, July 11, 2011

Finding Nice Physicians

Here's the opening of a fascinating article in today's New York Times:
Doctors save lives, but they can sometimes be insufferable know-it-alls who bully nurses and do not listen to patients. Medical schools have traditionally done little to screen out such flawed applicants or to train them to behave better, but that is changing.

At Virginia Tech Carilion, the nation’s newest medical school, administrators decided against relying solely on grades, test scores and hour long interviews to determine who got in. Instead, the school invited candidates to the admissions equivalent of speed-dating: nine brief interviews that forced candidates to show they had the social skills to navigate a health care system in which good communication has become critical.
I'm embarrassed to acknowledge that although I've done a lot of interviewing, I'd never heard about the technique Virginia Tech Carilion is using - multiple mini interviews (MMI). Applicants are seen at multiple interview "stations," each of which presents them with a specific problem to to address, such as whether a pediatrician should support parents in their wish to have their baby boy circumcised or whether it is ethical to use unproven alternative treatments with a patient. The interviewer is trained in how to probe responses and in a standard form of assessment. Research suggests that multiple short "biopsies" are much better predictors of subsequent performance in the "soft" or "humanistic" components of medicine than standard interviewing is.

The technique was pioneered in 2001 by Dr. Harold Reiter at McMaster University in Ontario. In 2007 McMaster developed a spin-off company to disseminate the technology. The technique is being used at medical and other professional schools in Canada, the U.S. and elsewhere.

The trend towards MMI promotes medical ethics in two ways. First, it appears to improve our ability to identify applicants who are likelier to end up as humanistic practitioners - in colloquial terms, "nice doctors." Second, it sends a message to prospective physicians that humane, thoughtful caring about others is a core value for the profession.

I have the privilege of participating in teaching medical ethics to first year Harvard Medical students. I think of the content of our course as a set of tools that a properly motivated physician can apply. I hope that the course itself models a set of attitudes and behaviors that students will want to apply in whatever area of medicine they end up in. But the phenomena for which we use terms like "caring," "integrity," "human decency," and "niceness" are partly hardwired in our nervous systems and inculcated by experience throughout our growing up. Courses can help to hone our humaneness, but the dispositions we have already formed and bring with us count for a lot.

Early in my practice I learned a lesson I've never forgotten. I inherited as a patient a man twice my age (I was 30, he was 60) who'd suffered from a serious psychiatric ailment throughout his adult life that had impeded his capacity for work and caused suffering for himself, his wife, and his children. By the time we met his condition was quiescent. I met with him and his wife every month or two, gave what counsel I could, and tinkered with his medications. But at heart I felt guilty - I liked him and his wife, and felt I was doing nothing for them.

My wife and I wrote off for tickets to an event. (This was in the pre-internet era.) I received a letter in response:
Dear Dr. Sabin:

There were no tickets left for this event, but when I saw who was asking, I managed to find two. You've been such a wonderful doctor for my parents that I wanted to do something for you.

Gratefully yours

The incident still brings tears to my eyes. At the same time that I was feeling guilty about how little I was doing for my patient, he and his wife had conveyed to their adult child how grateful they were for my ministrations. My "technical" offerings were essentially nil, but the letter I received showed just how much the "soft" element - liking, respecting, and caring about my patient and his wife mattered to them.

In medical school, a brilliant research hematologist was lecturing to us about a blood disease. He described the genetics, chemistry and physiology of the condition eloquently. A student asked him about what the condition meant to patients afflicted with it, how it affected them apart from physical impacts. In a sarcastic voice the lecturer responded - "This is hematology class! What do you think it is - psychiatry?"

In the intervening years, medicine, and medical schools, have caught on to the clinical importance of kindness and niceness. These attitudes and behaviors aren't fancy, but they matter a lot in determining what medical care can accomplish. It's good news to learn that medical schools are trying to do better in selecting students for these characteristics as well as for their braininess!

(For previous posts on this topic, see here and here.)

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