Marcus Welby or Gregory House? Role Modeling the Doctor-Patient Relationship in the Clinical Curriculum Thomas R. Egnew, EdD, LICSW Tacoma Family Medicine

Goals To review characteristics of quality role modeling To describe specific issues associated with role modeling doctor-patient relationship skills To elucidate those skills most facilitative of helping trainees understand the nuances of doctor-patient relationships

Objectives Attendees will be able to state the elements of quality role modeling and to identify those behaviors specifically important to role modeling relational skills Attendees will be able to transparently role model relational skills relative to a specific patient

Learning Through Role Modeling Professionalism Health Advocacy Ethics/Humanism Communication Skills Physical Exam Skills Procedural Skills Doctor-Patient Relationship Skills

Costs of Poor Modeling Unprofessional behavior Unethical behavior Student cynicism Decreased empathy Confusion whether relationship skills can be learned Unintended/unanticipated lessons

Student Evaluation of Role Models Personal Qualities – Enthusiasm, personal warmth, compassion Teaching Skills – Engaging, enjoy teaching, stress interpersonal aspects of care, build supportive relationships with trainees Clinical Skills/Competence – Excellent practice

A Qualitative Study Focus groups with students (N = 33) on 3 clinical campuses in a New Zealand Medical School Individual interviews with students (N = 2) and faculty (N = 15) on the same campuses Verbatim transcripts coded for themes Major Finding: Role modeling is the medium by which students are taught/learning about doctor-patient relationship skills

Themes Related to Role Modeling Variability Incongruity Discernment Transparency

Variability Lack of specific curriculum with no agreement on skills to be learned Focus on relationship skills varied from rotation to rotation – “ There is no formal teaching on doctor-patient relationship... it’s you pick up as you go along.” (5 th year student) – “I think the students do see a whole lot of different forms of medicine being practiced... some are very good examples... some are poor examples.” (Faculty)

Incongruity Difference between what students had been taught and the behaviors they observed Psychiatry & General Practice most likely to focus on relationship skills – “... in General Med wards there’s no time really to develop empathy...” (4 th year student) – “... breaking bad news, any sensitive topics... we are almost always not included...” (Trainee Intern)

Discernment Given incongruity, students must discern between good and bad role models Perceptions of deficient relationship skills which appear effective breed confusion – “... the skill that we need to learn is almost an analytical one in terms of how to analyze the good and the bad and to build from that.” (4 th year student) – “... the ones that learn most from are the doctors that I think, ‘Oh, I hope I’m never like that!’” (Trainee Intern)

Transparency A preceptor sharing observations about/experiences of doctor-patient interactions Helps students learn the intricacies of doctor-patient relationships – “ I had a really great GP... he would pick up instances in a consultation... we’d discuss what techniques he’d used...” (5 th year student) – “... transparency would help because we would have all seen situations where for some reason the doctor’s had a short fuse with the patient... and we just don’t know the background... " (Trainee Intern)

Transparency Skills Making the implicit explicit Awareness – Non-judgmental observation of personal experience Reflection – Systematic, critical evaluation/analysis of actions, beliefs and underlying assumptions Articulation – Communicating the content of mindful/reflective activity

Stimulated Recall Exercise Take a moment to reflect upon a patient interaction that went particularly well or poorly Awareness: What happened? What did you feel? What did you do? How did the patient respond? How did you respond? Reflection: Why did you respond as you did? Articulation: How would you explain your behavior to a learner observing the interaction?

Supporting Role Modeling “Role Modeling Consciousness” Protected time for teaching Transparency: Being aware, reflective and articulate – “reflection in action” – “reflection on action” – “reflection for action” Staff development