Fetzer Institute

Accreditation of residency programs and certification of physicians requires assessment of competence in communication and interpersonal skills. Residency and continuing medical education program directors seek ways to teach and evaluate these competencies. This report summarizes the methods and tools used by educators, evaluators, and researchers in the field of physician-patient communication as determined by the participants in the "Kalamazoo II" conference held in April 2002. Communication and interpersonal skills form an integrated competence with two distinct parts. Communication skills are the performance of specific tasks and behaviors such as obtaining a medical history, explaining a diagnosis and prognosis, giving therapeutic instructions, and counseling. Interpersonal skills are inherently relational and process oriented; they are the effect communication has on another person such as relieving anxiety or establishing a trusting relationship. This report reviews three methods for assessment of communication and interpersonal skills: (1) checklists of observed behaviors during interactions with real or simulated patients; (2) surveys of patients' experience in clinical interactions; and (3) examinations using oral, essay, or multiple-choice response questions. These methods are incorporated into educational programs to assess learning needs, create learning opportunities, or guide feedback for learning. The same assessment tools, when administered in a standardized way, rated by an evaluator other than the teacher, and using a predetermined passing score, become a summative evaluation. The report summarizes the experience of using these methods in a variety of educational and evaluation programs and presents an extensive bibliography of literature on the topic. Professional conversation between patients and doctors shapes diagnosis, initiates therapy, and establishes a caring relationship. The degree to which these activities are successful depends, in large part, on the communication and interpersonal skills of the physician. This report focuses on how the physician's competence in professional conversation with patients might be measured. Valid, reliable, and practical measures can guide professional formation, determine readiness for independent practice, and deepen understanding of the communication itself.

We read with great interest the article “Vanquishing Virtue: The Impact of Medical Education,”1 whole-heartedly agree with Drs. Coulehan's and Williams' conclusions, and share their concerns regarding the “tacit” conditioning medical students undergo during their education. One approach we have found helpful at East Carolina University is the incorporation of a longitudinal reflection group experience2 to complement a second-year ambulatory continuity clinical program. We found that participation in a biweekly facilitated discussion/reflection group provided many of the students a needed humanizing effect on their experiences. Reflection groups lessened the sense of individual isolation and allowed the acceptance and deepening of emotional and cognitive responses to suffering, diversity, poverty, fear, etc. We further found that reflection groups provided an integrated learning experience that nurtured the students' self-awareness and lessened the propensity of medical education to encourage detachment. A growing body of evidence suggests that physicians who can utilize their own self-awareness are more effective, satisfied, and efficient in providing care3; that physicians' humanism correlates with patient satisfaction and adherence to medical advice; and that medical students tend to lose their humanistic and altruistic attitudes and values during medical school training. Increased self-awareness allows physicians to use themselves as instruments in the process of caring for patients. The ability to be compassionate is linked to physicians' own emotional responses to patients. Emotion without benefit of self-awareness may actually inhibit compassion and become a source of stress. In our analysis of the first year of experience with reflection groups we were struck by a pattern of collaborative and empathic communication that developed over time. During the initial reflection group sessions students would serially raise topics of individual concern without regard for the previous topic on the floor. Very little discussion and deepening took place in these sessions, and many students left feeling unsatisfied by their experience. Over time, and when it became clear that there would be opportunities for everyone to speak and participate in a safe, supported way, the dialogue assumed a cooperative, generative format in which exploration and empathy were paramount. The results were much more satisfying and meaningful for the group members. Based on our experience, we would hypothesize that Dr. Friccione would have had a very different experience had she had a group of her peers to talk and reflect with during her medical school experience. And while some of her values and attitudes might have changed and become more realistic and mature, the core of her desire to serve and tend to the suffering of others using heart, head, and hands would have been cultivated and reinforced rather than shattered. We would suggest that rather than just “immunize” against tacit values of detachment, self-interest, and objectivity, medical schools need to adopt and integrate approaches that are proactive in fostering self-awareness, social responsibility, and compassion during the process of education. Providing a humanizing experience for medical students will lay the foundation for subsequent humanistic practice.

To examine the differences in physician satisfaction associated with open- versus closed-model practice settings and to evaluate changes in physician satisfaction between 1986 and 1997. Open-model practices refer to those in which physicians accept patients from multiple health plans and insurers (i.e., do not have an exclusive arrangement with any single health plan). Closed-model practices refer to those wherein physicians have an exclusive relationship with a single health plan (i.e., staff- or group-model HMO). Two cross-sectional surveys of physicians; one conducted in 1986 (Medical Outcomes Study) and one conducted in 1997 (Study of Primary Care Performance in Massachusetts). Primary care practices in Massachusetts. General internists and family practitioners in Massachusetts. Seven measures of physician satisfaction, including satisfaction with quality of care, the potential to achieve professional goals, time spent with individual patients, total earnings from practice, degree of personal autonomy, leisure time, and incentives for high quality. Physicians in open- versus closed-model practices differed significantly in several aspects of their professional satisfaction. In 1997, open-model physicians were less satisfied than closed-model physicians with their total earnings, leisure time, and incentives for high quality. Open-model physicians reported significantly more difficulty with authorization procedures and reported more denials for care. Overall, physicians in 1997 were less satisfied in every aspect of their professional life than 1986 physicians. Differences were significant in three areas: time spent with individual patients, autonomy, and leisure time (P < or =.05). Among open-model physicians, satisfaction with autonomy and time with individual patients were significantly lower in 1997 than 1986 (P < or =.01). Among closed-model physicians, satisfaction with total earnings and with potential to achieve professional goals were significantly lower in 1997 than in 1986 (P < or =.01). This study finds that the state of physician satisfaction in Massachusetts is extremely low, with the majority of physicians dissatisfied with the amount of time they have with individual patients, their leisure time, and their incentives for high quality. Satisfaction with most areas of practice declined significantly between 1986 and 1997. Open-model physicians were less satisfied than closed-model physicians in most aspects of practices.

The author describes a model of health that incorporates the spiritual dimension of life, and articulates the relevancy of this model to those with disabilities. The model includes sociocultural, psychological, physical and spiritual aspects of life, around a central inte-grative core. The article enumerates some of the challenges faced by those with disabilities and contrasts the predominantly secular approach to life with examples of an approach which takes into account the spiritual dimension. Some spiritual and religious resources that may help meet these challenges, and help to integrate the life of the disabled person into a meaningful whole are described.

In 1994 ten NIH institutes sponsored an interagency workshop focusing on biobehavioral pain research. The workshop had three major goals: (1) to review the current status of biobehavioral pain research (2) to identify critical research needs, and (3) to enhance interdisciplinary and interagency cooperation in pain research. The purpose of this article is to summarize the presentations at this meeting and to highlight some of the key research recommendations. Research topics addressed include (a) understanding critical interfaces between biology and behavior; (b) pain, suffering, and emotion; (c) pain and behavior; (d) behavior-related interventions; (e) commonalities and differences in pain expression, experience, and treatment; and (f) pain in special populations. The article concludes with a summary of NIH pain research activities that have taken place since the workshop.

A new method to quantify the cardiac wall motion abnormality using 2D ultrasound B scans is proposed. The method is based on enhancement of the cardiac images using fuzzy set terhniqiies. After the enhancement, displacement along the cardiac boundary is plotted while comparing end systole and end diastole images. The wall motion plot is very useful for diagnosis and prognosis of patients. This plot gives an indication about the hypokinesia, akinesia and diskinesia of patients.