 | From left: Medical school student Barbara Wexelman questions standardized patient "Dave Streeval" (portrayed by Don Wagner) with fellow student Roger Goldberg and adviser Dr. Paul Kirwin. |
Rosa Flores had been suffering from heartburn for two weeks and was concerned it might be something more serious. A relative, she told her doctor, had even intimated that Flores might be under an evil spell.
First-year medical student Karen Archabald listened and patiently asked a number of questions: Was there any new stress in Flores' life? What were her eating habits? When was the last time she felt this type of burning?
"The last time I had this was when I was pregnant with my daughter, Samantha, 11 years ago," Flores replied. "I do have stress. I am married, I have an 11-year-old daughter, I work and I'm going to school at night, but I don't know why I have this burning."
Two faculty members and two medical students observed the exchange in a room in Edward S. Harkness Memorial Hall, one of seven new clinical practice suites designed to simulate a medical office or clinic with exam tables, curtains, a desk, chairs and a computer. The exercise is one of two workshops designed for first-year medical students on the art of the patient interview.
Flores, not her real name, is one of a number of "standardized patients" hired by the School of Medicine to feign symptoms indicative of a specific illness. Most are current or retired actors. The director of the Yale Standardized Patient Program is Dr. Frederick Haeseler, associate clinical professor of internal medicine and director of the primary care clerkship. He first began incorporating standardized patients into his clerkship curriculum in 1993.
Haeseler now recruits, trains and rehearses the standardized patients using original scripts with well-defined biomedical and psychosocial elements. The standardized patients learn how to interact spontaneously with students and respond to their behaviors, and to remain idle during the frequent timeouts used for teaching during the simulated interviews. As with real patients, standardized patients have narratives or stories to tell about their illnesses that go beyond the symptoms that brought them to the doctor. These stories have personal, social and emotional dimensions, such as Flores' belief that her illness was the result of an evil eye cast upon her by a jealous relative.
"Do you feel like you have her story?" Dr. Grace Jenq, one of the advisers and a geriatric fellow at the medical school, asked Archabald. "The goal of this workshop is to get you comfortable talking to patients. Remember first to ask open-ended questions and then listen. A lot of the time we feel uncomfortable with a few seconds of silence and we feel we have to fill in the space, but the key is to give the patients some time to tell their story."
The students are trained in the patient-centered interview, which includes a number of prompts designed to elicit the patient's "story." Such phrases as "Tell me more" or "Is there anything else that is bothering you?" often lead to an avalanche of new information. Also sitting in on the interviews are facilitators, faculty members who can advise the students during the interviews but who do not know beforehand what the patient's "story" is.
One of the facilitators, Dr. Jeffrey Stein, assistant professor of internal medicine and pediatrics, says the clinical skills training program gives the students a unique opportunity to experiment and try out different approaches during the interview.
"Students sometimes express concerns that these sessions with the standardized patients are 'artificial,'" he says, "but the beauty of it is that you can use them to practice and even make mistakes without hurting a real patient."
Patient "Sarah Stair," who said she was a graduate student in sociology at Southern Connecticut State University, was a true mystery. Unlike Flores, who, as it turned out, was suffering from gastrointestinal reflux disease, Stair said there was nothing wrong with her. Her parents insisted that she see a doctor because she hadn't been sleeping. Roger Goldberg, the student-doctor, first asked Sarah what she thought was causing the insomnia. Under persistent questioning, she mentioned that her parents also were worried about a recent $3,000 shopping spree.
Goldberg asked question after question: How was school? Was there a significant other in the picture? What did her roommates think of her sleepless nights? What about drug use? His frustration was becoming apparent.
"Sleeplessness is an important symptom. People usually sleep," said the adviser, Dr. Paul Kirwin, associate clinical professor of psychiatry. "It's okay to ask the same questions in a different way, especially when the patient is being elusive."
Goldberg said he felt lost because there was no clearly defined complaint. "I was looking for the magic question," he said. His best guess was hyperthyroidism or stress. Kirwin correctly surmised that the patient was suffering from mania. Left unattended, the condition could progress to psychosis, Kirwin said.
Dr. Auguste Fortin, assistant clinical professor of medicine, is the director of the communication skills training program. He has recruited or trained over 20 faculty to participate as facilitators in this program, which has existed in a variety of medical school locations since 1993. Fortin says it's common for first-year medical students to try to arrive at a diagnosis, although they are told the exercise is primarily to practice interviewing patients.
"The detective part is one of the joys of medicine," Fortin says. "Learning medicine, learning to make a diagnosis, can be seductive. The relationship part is another aspect. It's not a case, it's a person."
For some students, interviewing patients comes naturally; for others, it is a learned skill. "They all come to this to be of service, so that gets them through a lot," Fortin says.
The medical school made an even larger commitment to the program this spring with the dedication of the seven clinical practice suites in the basement of Harkness Hall. In addition to the basic patient interview, second-year students are taught how to broach more sensitive questions about a patient's social history. Third-year students are instructed on the difficult task of delivering a grim prognosis. The medical school this year added a new workshop for third-year students on how to counsel patients to make behavioral changes, such as quitting smoking, limiting their alcohol intake or drug use, dieting and other hot-button lifestyle issues. Another workshop is planned on how to handle difficult patients.
Dr. Margaret Bia, professor of medicine and director of The Clinical Skills Training Program, says the students also use the rooms to practice physical examinations on each other. A compact disc illustrating how to conduct a physical exam can be inserted in the computer and the students can follow along. Students can request a standardized patient if they feel they need more training. At this writing, video cameras were being installed in the rooms to tape the practice sessions for review later by both students and the facilitators.
The emphasis on the patient interview has been steadily gaining more attention in medical schools and the best model to use for doing so has evolved over the years, says Haeseler. Students were at one time taught in larger groups, but found it intimidating, he notes, so the workshop groups are now limited to three students with a facilitator.
"Learning how to interview patients is important because the students have achieved through a conventional system where intellectual and rational powers are rewarded," Haeseler says. "What would seem natural would be to try to make a diagnosis, to try to figure things out, to make hypotheses. What we're teaching them is that while that is one aspect of what a physician does, at this stage in their training it's much more important that they learn how to form a relationship with someone, establish rapport, listen and pay attention, elicit emotions and respond to emotions. It's almost counter-intuitive for the students. It doesn't fit their notion of themselves."
Bia says there are several reasons for the new and added emphasis on formal clinical skills practice. In the past, medical school students spent many hours working on medical floors with medical residents or in physicians' offices and learned by observing and practicing. This is much less true today, she notes, because in the new medical care economy, patient visits and hospital stays are shorter and there is much less time for student observation and practice in front of the clinician. Hence, there is a need for more formal clinical skills training to be built into the curriculum, she adds.
In fact, the agency that monitors accredited medical schools, the Liaison Committee on Medical Education, is requiring more clinical skills training in all medical schools. And, for the first time beginning this year, the students wishing to obtain a medical license will be tested on clinical skills in addition to the three written exams that they take in medical school and during internship.
"We can no longer just assume that doctors are graduating with these skills," Bia says. "Now the students need to prove it. They must travel to one of five locations in the country where they will be observed and assessed as they interview and examine 12 different patients."
In the clinical practice suites, another lesson was brought home with "Dave Streeval," an older, heavy-set man, who sat in the room clutching his side and complaining about intense pain. Medical student Barbara Wexelman said she felt compelled to prescribe something immediately to ease his discomfort. He must be suffering, she said, from either appendicitis or an ulcer.
"Don't jump to a diagnosis," cautioned the facilitator, Kirwin. "Unless you are thorough you might order a series of tests that will not reveal the problem. You have to have broad clinical data before you start to whittle it down. Suppose he has an abusive brother who lives with him and kicked him, but he doesn't want to get him into trouble."
In this case, both doctor and student were right. As Streeval's story unfolded, he related a long history of diabetes and years of heavy drinking and serious car accidents. The right-sided pain could have been caused by a more recent accident he had not disclosed, but in this instance the patient did have acute appendicitis.
-- By Jacqueline Weaver
T H I S
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