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Talking to patients is a virtue
Tomorrow afternoon, 130 second-year medical students will recite a common pledge.
"It is with honour that we don our white coats from this day forth," they will say. "We pledge by what we hold most sacred to use it not as a shield but as a bridge to reach out to those entrusted to our care. We shall strive with passion and humility to create lasting alliances in health, pursue professional integrity and provide compassionate care for all."
The pledge, devised by the medical students themselves, will be the climax of the occasion, McGill's first-ever "white coat ceremony." Held in dozens of medical schools throughout the U.S., the ceremony is intended to highlight a major change in the lives of medical students.
"We're making the transition from what we've been learning in the classroom to being in regular contact with patients," explains Karen Devon, one of the medical students who has been the most active in organizing the event.
The ceremony, entitled "Donning the Healer's Habit," focuses on the white coats that will become the most recognizable component of the students' professional attire from here on in.
"It's a symbol of compassion and patient care," says Devon. "We want to de-emphasize the notion that it's a symbol of power. What we want to emphasize is the trust that's being given to us."
The ceremony will pay homage to Dr. Joseph Wener, the sort of doctor that the students will be promising to become. A well-respected cardiologist and internal medicine specialist, Wener was also a popular teacher. He died last year.
But how easy is it to follow through on the pledge these students will be making? In an era of budget cuts, staff shortages and immense change in the health care system, when you're working ridiculous hours, are the days of Marcus Welby-type doctors -- warm, caring, concerned -- a thing of the past?
Pat O'Rourke, the Royal Victoria Hospital's ombudsman, says doctors tend to be just as upset about being rushed in their dealings with patients as the patients themselves.
"When [doctors] are young and starting out, they want to save the world. Working in this high-pressure system, they often feel they haven't been able to deliver their best selves to their patients and that's a source of frustration. They wish they had more time."
Ask Devon what her principal concern is in terms of dealing with her future patients and she is quick to agree. "Time is everyone's big fear.
"If you have an hour to spare, you can take the time to really listen to your patient, but what if you only have 10 minutes?"
One doctor with an excellent reputation for building strong relationships with her patients is family medicine professor Dr. Vania Jimemez. Jimenez, a family physician at the Côte-des-Neiges CLSC, was named Canada's family doctor of the year by the College of Family Physicians in 1999.
"There is no recipe," says Jimenez in terms of how to teach medical students to build constructive relationships with patients. But there are a few factors to keep in mind.
"One of the most important things a doctor has to do is to be quite conscious of her own culture, her own reactions. I'm a woman, a mother, I'm Western. These factors all affect the way I see the world. You have to be aware of how you see the world and why you see it that way before you can take stock of the person who is in front of you."
The other thing that Jimenez emphasizes to students and medical residents is to take pleasure in the encounter.
"I try to remind them that this can be fun. It's the fun of listening to stories. That why I became a physician. I'm hooked on stories. [Listening to patients] is such a special opportunity."
"The most common difficulty between patients and all hospital staff is poor communications," says O'Rourke.
She is also an authority on the ethical and religious aspects of alternative medicine -- she recently completed a PhD on the subject and teaches at Concordia. Many have speculated that the growing popularity of alternative approaches is tied to a growing dissatisfaction with the way doctors interact with their patients.
O'Rourke allows that, in dealing with alternative medicine practitioners, patients "feel that they get more time, that they have the opportunity to talk and be listened to." But she says studies suggest that people aren't abandoning conventional medicine because they're unhappy with the quality of the care they're receiving.
"Dissatisfaction with physicians isn't the reason. The real reason relates to chronic diseases, things like arthritis or a bad back, that conventional medicine doesn't always deal with very effectively. These people are miserable and dissatisfied and they tend to be the biggest users of alternative medicine. But they continue to use conventional medical treatments too."
And O'Rourke says patients can't put all the blame on doctors when they feel that their medical needs aren't being addressed because of poor communication. Too many patients haven't bothered establishing relationships with family doctors, the sorts of physicians who can keep careful track of their conditions over time.
"A lot of people just turn up in the ER. If you want someone to listen to you, to pay attention, a good family doctor does that."
Dr. Don Boudreau, the Faculty of Medicine's associate dean for medical education and student affairs, says McGill's approach to developing doctors who can deal effectively with their patients starts before any students arrive to receive training.
"The first step is the selection process. My colleagues in admissions are looking for certain kinds of characteristics in the students who are applying." Boudreau says it isn't all about having straight As when prospective students are evaluated. "We ask them, 'How do you define being a good doctor?' 'How would you define empathy?'"
Students take their cues from the actions of the professors they see in the wards, Boudreau adds. "We are very careful about recruiting teachers who are known to be empathic individuals. We want our faculty to be role models."
"You read articles about the stature of the profession and you see that while doctors used to be revered as gods, now we're not. I'm not so sure that's a bad thing," says Dr. Linda Snell, a medicine professor. Patients should have realistic notions about what their doctors can do.
"What I do with patients," says Snell, "is to let them know what my role is. I want to be clear about that from the beginning so that there is mutual understanding and expectations are the same on both sides.
"If I'm only there as a consulting physician to deal with their left upper eyelid, they should know that. If I don't phone patients back when their lab results are normal, they'll know not to worry but that they should call me if they really want to find out."
In her practice, Jimenez deals with patients from a broad assortment of cultural backgrounds. "There are cultures where people don't talk to you -- the Inuit, for instance, or Pakistani women." In cases like that, intuition can play an important role.
"I rely on my own feelings. Why am I feeling sad? Is it something in the patient that I'm sensing?"
Fourth-year medical student Deidre Young finds herself worried sometimes about where the emphasis is placed during the hustle of doing hospital rounds.
"I find you're rewarded if you know obscure facts but if you want to take an extra few minutes to talk to a patient, maybe someone who has received some bad news, the response is often, ' We have to see lots of patients today.'
"Taking that extra time is not emphasized at this point. That's the thing I worry will get lost along the way."
Even the encounters between patients and doctors that take place during medical rounds, encounters that are principally designed to teach residents and students about different patients' conditions, can pay off valuable dividends for the patients themselves.
Snell was part of a recent study that looked into how patients regarded these meetings. "We went along on the rounds, then we went back and asked, 'What did you like about that? What didn't you like?'"
She says her team was surprised to see that patients generally had positive feelings about the rounds. "About two-thirds of the patients felt that the visits helped them better understand their illness, 83% felt it was useful and 80% felt they were included in the discussions."
The times when such visits made patients feel more uncomfortable or anxious tended to involve doctors talking over their heads and using a lot of jargon.
Snell believes such visits should be seen as part of the patient-doctor relationship, and not simply as training. Patients should be warned about the visits, introduced to the participants and invited to take part in the discussion.
The core course that deals with patient-doctor relationships in the Faculty of Medicine is "Introduction to the Patient," a course offered in first year. Students listen to experts from a variety of disciplines offer their take on how to treat patients. Guest lecturers include psychiatrists, pediatricians, palliative care specialists and geriatrics specialists.
Students also follow a single patient's progress for the duration of the course, then discuss their interactions with that patient with other students and a group leader (typically a senior student or resident). "You talk about what worked, what didn't, what felt uncomfortable, why it felt uncomfortable," says Young.
She thinks that aspect of the course is invaluable.
"You go to people's houses and you see the environment they live in. You see for yourself that their illness is about much more just a lab test result. If they can't walk all the way to the grocery store [because of their condition], they can't buy themselves food."
Boudreau says the faculty has been careful to protect its teaching programs during the budget cuts of the past decade.
"In terms of our clinical training, I'm confident in saying that we're one of the top 10 medical faculties in North America.
"There are things I would like to add if we had more money. I would like to use surrogate patients more often." These are volunteers or actors who submit to different sorts of exams from novice doctors and then offer feedback.
"We do employ that method for female pelvic exams. The feedback is immediate. Students are told they're too gentle or too rough or they were too abrupt in how they asked the patients to disrobe."
And doctors need feedback, says Jimenez. They need to know when they're making a difference.
"As physicians we need rewards. We need to know that we're helping. That's why we're in this business."
As Karen Devon gets ready to don her white coat, she is confident that she will make a difference.
"I know I want to help people. I think I'll be able to do it well."