Commentary – July 2012
By Samuel Rogers
I used to belittle any discussion about integrating social sciences into medicine. I knew that doctors need to have some understanding of their patient's feelings, and I also knew that having a good patient-physician relationship is an important factor in delivering good care. However, I underestimated how difficult this is to do.
Midway through my first year as a medical student, personal blunders made during clinical experiences and observations with my physician preceptor showed me firsthand why competency in social sciences is a requisite element of solid clinical skills. Furthermore, I recognize that even those who perceive themselves to be socially adept will probably have difficulty at the bedside or clinic.
My own difficulty at the clinic is where I first discovered my ineptitude. I was examining an adolescent patient complaining of a cough, and I did my best to conduct a history and physical exam. I reported to my preceptor and followed her back to the patient, eager to learn. After examining the patient before and after a treatment with albuterol, my preceptor explained to him that he had asthma. Then, she told the patient not to worry. She explained that there are professional athletes and Olympians with asthma, and when properly managed it usually does not hold a person back. The patient's facial expression suddenly changed as his eyes softened and a smile crept unto his face.
At that moment, I realized I had been focusing so much on the disease that I had ignored the patient. Only then did I see that in my initial interview with him, he showed signs of severe anxiety about his illness. I mistook that anxiety for shyness. I also remembered from lectures that the jovial attitude I carried during our interview was inappropriate with a patient in such distress. I was too preoccupied wondering if I really heard wheezing to notice the patient's feelings. My preceptor, on the other hand, recognized and addressed his fears, taking advantage of an opportunity to build a relationship with the patient and establish trust. That trust surely would have an immediate and future impact on the patient, probably helping him to be more compliant and also more likely to bring future concerns and questions to the table in subsequent encounters.
After this experience, I started to pay more attention to how my preceptor interacted with her patients. I soon realized that, without fail, she always took the time to probe into her patient's social context. Sometimes, she did so by just asking a well-placed follow-up question, letting the patient know she wanted to understand what he or she was feeling, or simply allowing time for the patient to think. She put in effort to appreciate the patient as a person rather than a potential disease that needs fixing.
As a student, it might be fair to say that being overwhelmed by the biomedical aspect of medicine is largely why I have not been great at relating to patients. Surely, as students and doctors progress in their clinical reasoning and exam skills, the social aspect will develop concomitantly. However, I believe this thought is naïve. Indeed, it is well-documented that more often than not, well-trained physicians ignore or miss cues from patients that would otherwise prompt investigation into their feelings or life circumstances.1 The quest to treat patients naturally revolves around the biomedical aspect of disease, and doctors frequently ignore the social facet because the consequences are not always immediately obvious.
Sometimes, doctors do not probe into social context because they do not feel equipped to handle the patient's emotions. I once completely brushed off a standardized patient's concern about contracting Alzheimer's disease because it seemed irrational. I felt awkward; I did not know what to say and did not want to deal with her complex feelings. If this had been a real patient in a real clinic, it is possible I would have taken her concern more seriously. On the other hand, I can imagine that worries about time constraints would actually elevate my desire to avoid "opening Pandora's box."2
Although I subscribe to the cliché that doctors are generally altruistic, I understand that we are also flawed individuals. We want to help people, but we do not always feel equipped to deal with issues outside of the strict biomedical realm. This subdues our ability to always give patients the attention they deserve and particularly blinds us to their social and emotional context. As Texas grows more diverse, cultural differences enhance this challenge. It would be a mistake for doctors and students alike to assume this is a skill we can master without considerable effort and attention.
I am grateful my medical education has already given me the chance to work with an experienced physician preceptor. Her skill in relating to and understanding her patients has been a powerful addition to the class lectures. I have gone from belittling to embracing humanism in medicine, and acknowledging my weakness in this area has freed me to pursue a path of improvement.
Samuel Rogers is a medical student at Baylor College of Medicine.
- Levinson W, Gorawara-Bhat R, Lamb J. A study of patient clues and physician responses in primary care and surgical settings. JAMA. 2000;284:1021-1027.
- Townsend JM. One last question: opening Pandora's box? Ann Fam Med. 2009;7(2):176–177.
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