Johns Hopkins Courses Teaches Students Patient-Centered Communication Skills

Added on May 18, 2017

Johns Hopkins Courses Teaches Students Patient-Centered Communication Skills
By Audrey Doyle
From Industry Edge May 2017

Medical school and residency programs have historically focused on training new doctors in the science of medicine. Increasingly, they’re addressing the art of medicine as well by incorporating into their curricula courses and seminars that teach students how to communicate with compassion and empathy. At the Johns Hopkins University School of Medicine (JHU), students learn these skills through Clinical Foundations of Medicine, a mandatory course that was offered initially  in 2005 and has been part of first-year JHU students’ core curriculum since 2009.

Teaching medical students how to communicate with compassion and empathy is important because a patient’s perception of the quality of their care is affected by the quality of their interaction with their physician—and the better the care experience is, the more likely it is that the patient will trust their physician’s advice and adhere to their medication and treatment plan, according to Dr. Robert Shochet, director of the Clinical Foundations course, director of the Colleges Advisory Program, associate professor of medicine and founding chair of the Learning Communities Institute at JHU. “We teach students the patient-centered communication skills that are fundamental to a high-quality physician-patient relationship now so they can take those skills with them into practice,” he said.

The Art of Patient-Centered Communication

Clinical Foundations is a three-hour course held once a week for 17 weeks. There are 24 instructors, each teaching no more than five students. A primary focus of the course is to teach students how to conduct a patient-centered medical interview.

“As a physician, your goals with a patient-centered interview are to gather information about the patient in order to provide appropriate care, understand the patient’s perception of their illness and make sure the patient feels like you respect them and they matter, all while being aware of your reactions to the patient and how they are perceiving your words and actions so that you can continually adjust to meet their needs,” said Dr. Shochet. “This can be hard to do, especially the self-awareness part. In fact, in many ways conducting a thorough patient- centered medical interview is an art.”

Because effective communication and self-awareness are connected—that is, to communicate effectively you must be aware of how you perceive others and how others perceive you—much of the course focuses on teaching students how to listen, process what they’re hearing and respond in a way that shows their role isn’t just to care for the patient, it’s also to care about the patient. “The main point here is for students to convey respect, compassion and interest for the patient throughout the encounter,” said Dr. Shochet.

To teach JHU students the art of patient-centered communication, Dr. Shochet adapted the model espoused by the American Academy on Communication in Healthcare and divided the interview process into three main phases.

For the first and third phases, students are taught longstanding medical interview steps and techniques. For example, they learn how to begin the interview with introductions and small talk to set the patient’s mind at ease. Then they’re taught to ask the patient to list all their concerns so that the most important issues are addressed during the visit, and so that an important issue isn’t missed, or brought up at the end of the visit when there isn’t enough time to address it. Students end the first phase of the interview by summarizing the patient’s list of concerns, clarifying the chief complaint and creating a plan to address it.

Similarly, students are taught to end the interview using the well-known “ask-teach” technique to assess the patient’s understanding of what’s been discussed. They’re also taught to use the information they’ve gathered to explore the patient’s care and treatment preferences, work with the patient on a plan to address their chief complaint, ask the patient to restate their understanding of what was discussed and decided on, and provide a recap of next steps.

The middle phase is where the interview breaks from tradition, and compassion and empathy take center stage. “This is where students practice gathering information while establishing a relationship with the patient,” said Dr. Shochet. “By building this relationship, they’re building trust, which is key to a relationship-centered approach to physician-patient communication and contributes to more successful patient outcomes.”

For example, students are taught to begin this phase with an open-ended request for the patient to share details of their primary concern, and to listen attentively and reflectively without interrupting, reflect and respond with empathy, and use nonverbal cues such as eye contact and facial expressions to show they’re engaged in the conversation. They also learn how to use these communication skills with the ICE technique—getting the patient to tell them their Ideas, Concerns and Expectations— as a way to learn more about the patient’s chief complaint.

In addition to ICE, another mnemonic students learn to practice during this phase is PEARLS, which “gives students phrases that work particularly well with patients who are worried about their health or their reason for the visit,” said Dr. Shochet. PEARLS stands for Partnership, Empathy, Apology, Respect, Legitimize and Support. Dr. Shochet offered the following as some example PEARLS phrases:

  • Partnership: “Let’s work on this together.”
  • Empathy: “I can imagine from what you’re saying how difficult a time this has been for you.”
  • Apology: “You’ve been waiting an hour to see me; I’m really sorry you had to wait so long.”
  • Respect: “I can see you’ve thought this out very carefully by the amount of research you’ve done on the issue.”
  • Legitimize: “Anyone in your situation would feel that way.”
  • Support: “I’ll be with you all the way.”

According to Dr. Shochet, the communication skills are taught first through role-playing exercises and then using standardized patients. “The standardized patients are actors who work from scripts and evaluate specific things students do, both in how they ask questions and in the information they’re able to obtain from those questions, as an objective method for assessing whether they’re learning to communicate in a patient-centered way,” he said. At the end of the course, students conduct full medical interviews on real patients; faculty members observe the interviews and score the students on their proficiency.

Although students learn the communication skills at the beginning of their first year of medical school, the training and education don’t end once the course is finished. Students continue to apply the skills they’ve learned in additional courses that are offered as Clinical Foundations add-ons and that take place throughout their medical education. The add-ons cover such topics as motivational interviewing (a method of interacting with patients to enhance behavior change), and discussing advance directives, informed consent and the death of a loved one, among other topics.

Students’ assessments of the Clinical Foundations course are generally positive. “The scenarios seem real to them. And because the course is taught in small groups, they feel like the feedback they get from peers and teachers is very meaningful,” Dr. Shochet said.

He acknowledged, however, that some students have noted they feel as though they’re “working from a script for empathy” and that this seems disingenuous to them. “They want to be themselves, and they struggle with seeing the value of being told what to say, and when and how to say it.”

In these situations, Dr. Shochet explains that the course is a general framework, that the meat of the interview should change from patient to patient and that students should be creative in their conversations, weaving comments into the interview that show they view each patient as an individual with specific concerns regarding their ailment.

“For example, if a patient comes in complaining of back pain and worried about how the pain is affecting their job, the student is taught to communicate with words that are on target with that particular situation—instead of just saying ‘That sounds difficult,’ they should say something like ‘I can see how difficult a time you’re having, not only with the pain but also with the fear of losing your job if the pain doesn’t get better’,” he said.

This “shared vulnerability” shows the patient compassion, engagement and an understanding of what they’re going through, but in a way that keeps the student from feeling or experiencing the situation in the same way the patient does. “This is how they learn they’re communicating in service of someone else,” Dr. Shochet explained. “In other words, empathy isn’t about them, it’s about them in their role of health practitioner and expressing care for their patients.”

Down the road, Dr. Shochet expects to bring Clinical Foundations to a new dimension. “What I have in mind is a VR Empathy Lab that will give students an immersive, virtual reality experience in empathy,” he explained. “Students will be able to practice over and over what it’s like to connect with a patient’s feelings and put that connection back into their conversation with the patient. I think that seeing themselves in a virtual world will give them a unique perspective on what this connection and conversation looks and feels like.”

As patients continue to demand more from their physicians, Dr. Shochet said that physicians’ ability to communicate with compassion and empathy will become more important, which will make courses like Clinical Foundations increasingly relevant.

“In terms of medical education and medical care, knowledge of science, technology and medicine isn’t enough. You have to have a framework to build trusting relationships with patients,” he concluded. “Getting that framework in medical school gives students a chance to build these compassionate behaviors into their daily habits so that communicating in this way becomes second-nature to them.”