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Educators rarely consider the attitudes that determine whether a learner will use the clinical skills we teach. Nevertheless, many learners and practitioners exhibit negative attitudes that can impede the use of patient-centered skills, leading to an isolated focus upon disease and impairing the provider-patient relationship. The problem is compounded because these attitudes often are incompletely recognized by learners and therefore are difficult to change without help.
We present a research-based method for teaching personal awareness of unrecognized and often harmful attitudes. We propose that primary care clinicians without mental health training can follow this method to teach students, residents, faculty, and practitioners. Such teachers/mentors need to possess an abiding interest in the personal dimension, patience with a slowly evolving process of awareness, and the ability to establish strong, ongoing relationships with learners. Personal awareness teaching may occur during instruction in basic interviewing skills but works best if systematically incorporated throughout training.
The formal curriculum of medical education has traditionally focused on teaching knowledge and skills, while attitudes often have been shaped by the “hidden curriculum.”1 The attitudes that determine a learner's willingness to learn and use skills are seldom formally taught.2–16 This may occur, in part, because the attitudes and the closely associated thoughts and emotions that govern skill usage often are incompletely recognized by the learner and therefore can be difficult to change.3,17
Although limited, research does demonstrate that hidden feelings and attitudes harmful to patients are commonly exhibited during doctor-patient interactions, especially avoiding the patient's personal issues.2,18 Thirteen of 15 sophomore medical students5 and 16 of 19 residents and fellows6 exhibited potentially harmful responses when observed in a single interview each. Table 1 lists their feelings and the resulting potentially deleterious behaviors. For example, fear of addressing psychological issues led a resident to overcontrol the interview and to inappropriately interrupt. Consider the life-threatening impact of avoiding data about suicidal intent as well as the harmful effect of these behaviors on communication and the relationship itself. These negative physician reactions do not diminish with age or experience. A study of board-certified physicians with an average age of 50 years showed that these doctors continued to exhibit potentially deleterious responses, particularly when threats to their integrity or self-esteem occurred.19
The rationale and approach for the method we present are modeled upon teaching personal awareness to psychiatry trainees.11,12 Such work originates conceptually from the Freudian, post-Freudian, and person-centered domains where the methods are used to elicit, respond to, and teach about unconscious processes.20–24 For teachers without mental health training, we have adapted these methods to provide teaching guidelines.16,25–28 In accord with these precepts, our focus is improved awareness of personal issues as they relate to education and the patient rather than attempting psychotherapy and seeking wide-ranging personal change.11,12
Influenced and informed by research8–10,29 and by other key recommendations,2,7,14,18,30,31 the method presented here stems from our own research3,5,6,19,25,32 and other teaching experiences4,17,33–36 with primary care trainees. This method was evaluated during a 1-month, full-time course for postgraduate year 1 (PGY1) residents in medical interviewing and other aspects of psychosocial medicine.3,25,32 Qualitative study demonstrated that it was effective.3 Fifty out of 53 residents had negative reactions that interfered with learning patient-centered interviewing.3,25 Using the method presented here, 44 of 50 residents changed their negative reactions and improved their communication and relationship skills—and thus better addressed patients' personal and emotional lives.3
Teaching personal awareness (of incompletely recognized attitudes, emotions, behaviors, and thoughts) often occurs while teaching interviewing skills, but the same principles apply in other venues where patient interactions are evaluated, such as supervising residents' and students' inpatient activities, precepting in a clinic, and reviewing audio/videotaped interactions. We usually defer personal awareness work until learners show some mastery of the skills and knowledge base required for whatever course, activity, or rotation is occurring. Early on, we usually devote no more than 1 to 2 minutes at each critique of an interaction to a learner's personal awareness. Later, however, we can increase our focus on self-awareness to about 5 to 10 minutes at each critique of interactions with patients.
Always, upon recognizing a problem in a learner's interaction, the teacher asks and resolves one fundamental question: is this a skills deficiency, unrecognized resistance to using the skills, or both?3 In Table 2, see Part #1 of an actual teaching vignette that illustrates the teaching of personal awareness.
The goal is to identify potentially harmful responses and, in turn, to facilitate learners' desire to work to change them. Students will learn about their previously unrecognized responses only if such awareness is their own objective.37 To encourage this, teachers review the frequent adverse impact of physicians, residents, and students on patients (see Table 1) and point out that harm can be ameliorated by developing an awareness of the unrecognized emotions, attitudes, thoughts, and behaviors that cause it.3 If these concepts are presented in a safe, caring, sensitive, and noncoercive way, most learners are eager to participate; that is, we achieve buy-in. To increase interest in awareness of one's own fears, frustrations, and other emotions, we can ask learners to tell about difficult patients or other medical circumstances.
After observing interviews and clinical encounters or after reviewing audio/videotapes, we reinforce the primacy of emotions by addressing them first in a critique; for example, “So, before we look at the interaction, how'd that go for you?” is a good open-ended beginning. The teacher gradually becomes more active and focuses on emotions; for example, “How'd that make you feel when the patient talked all the time?”
Self-disclosure by the instructor is a powerful facilitating tool for learners reluctant to share feelings38; for example, “I was feeling irritated with all that talking.” Teachers also may help students or residents to express feelings by asking how they “liked the patient” or how it felt to be watched or videotaped. Raising emotional responses to full awareness is the first task for personal awareness work.
The instructor continues to focus open-endedly on the learner's emotions and handles the emotion with empathic responses;34,39 for example, “That was embarrassing for you and I can sure understand.” As with eliciting the “patient's story,” open-ended inquiry alternating with emotion seeking and emotion handling is necessary to develop the “learner's story.”
Teachers also help the student realize that the feelings she/he experienced will have behavioral consequences; for example, “How might your fear of losing control affect your behavior with the patient?” On the other hand, while critiquing the interview or other interaction, the instructor may identify a problematic behavior before identifying the underlying emotion. If the student or resident does not mention any difficulty or problem, usually because she/he is unaware of it, the teacher can describe the untoward behavior and discuss it with them. If available, it helps to get outside corroboration from observers or to replay a tape to assist the learner in appreciating that a problematic behavior existed; for example, overcontrolling, superficial, avoiding material the patient raises. Then the teacher can seek the underlying emotion, using gentle open-ended inquiry; for example, “You and the group agree, you were taking over from the patient. What were you feeling at the time, you know, emotionally?” Recalling that this is a new experience, the teacher monitors the learner's response to inquiry. Like patients, learners will convey how quickly and how far they want to go into the emotional realm.38
See Table 2 for Part #2 of the vignette.
The teacher tries to discover just how unrecognized and how pervasive problematic emotions and behaviors have been. For example, she/he might ask, “Does this response (e.g., avoiding painful topics, controlling) occur anywhere else in your life?” or “Where does that come from in your past, you know, where'd you learn it?” Typically, students and residents will recognize its presence and its adverse impact in many other areas—with other patients and in their personal lives. They also realize that they had not been fully aware of this feeling, attitude, or thought and its resultant behavior.
Some learners will share emotions about their personal lives. It is appropriate to address personal issues, to the extent comfortable to teacher and learner, because it helps them realize how extensive and pervasive unrecognized emotions and attitudes can be. On the other hand, teachers do not attempt psychotherapy (even if trained to do so) and do not allow personal issues to dominate the teaching. Our focus is linking personal work to the patient and to the training during no more than 5 to 10 minutes of awareness work.11,12,40
Learners also may have feelings about the teacher. When positive, these are acknowledged and bode well; for example, “Thanks for saying that, I appreciate the feedback.” When reactions are negative, teachers foster exploration, address them openly and candidly, and negotiate solutions. Unresolved, negative reactions will become an impediment to the work that depends, above all, upon a positive teacher-learner relationship.38
Teachers actively involve other students if working in a group situation. Others may be uncomfortable observing this work with a peer and they may be fearful for what is about to happen to them or think that the process is too intrusive; for example, “John's been sharing some important stuff, what's your reaction to all this?” The needs of the group usually take precedence over the needs of the individual.38
The teacher encourages a group's use of emotion-handling skills and giving constructive feedback to each other. In time, a group itself can do much of the personal awareness teaching. The teacher models the proper use of feedback: understand where the learner is emotionally, know how prepared she/he is to hear feedback, give appropriate feedback about one or two specific behaviors, avoid general comments, give only a manageable amount of feedback, avoid criticism of the learner as a person, and balance corrective feedback with comments on what they did well.41
After identifying previously unrecognized feelings and behaviors, the learner and teacher (and others if in a group) must decide whether these are harmful or helpful. Harmful responses are not congruent or commensurate with the patient's situation; that is, the student's response does not respond accurately to the patient's comments and behaviors and tends more to reflect the student's own internal process and unrecognized needs; in other words, it is the student's “own stuff.” We seek to avoid these harmful responses to the patient and work with the learner to change them. Helpful responses accurately respond to the patient's circumstance and are reinforced by the teacher as having both diagnostic and therapeutic value in working with the patient. See Table 3 for the specific criteria to differentiate helpful from harmful responses.
Because this often is unexplored territory for the student, exploring the patient's reality must be actively facilitated; for example, “Now, let's look at how closely your response corresponds to the patient's situation.” To guide this process, others in a group are asked to give their emotional responses to the patient, and the teacher shares her/his own. When the learner's response differs from that of group members, this suggests it is not reality based, especially when this response is common across many different patients. When feasible, it is valuable to ask about patients' responses to the interaction being critiqued. When the student's response missed the mark and did not meet the patient's needs, this is even better evidence (see Table 3).
To make this crucial determination of responding to the patient's reality, patient utterances and behaviors from the interaction are the focus.36,42 One asks, for example, “What data are there that the patient didn't want to discuss death, and what data suggest that she/he did?” This reinforces our picture of the interview as a scientific instrument producing hard data about the subject of our science (the person) and our own scientific approach by evaluating only verifiable information.36,42 An entire group can sometimes unconsciously collude in a distorted interpretation, and the teacher must favor data from the interaction over unanimous opinion. Corroborating information, though, sometimes must be sought in later interviews and patient interactions (and in a learner's interactions with others in the group).
When personal awareness work is successful, the student will identify the problematic response as harmful. Although facilitated by the teacher, this recognition must come from the resident or student. Teachers reinforce, praise, and support the new awareness; for example, “That's been a tough problem for you, and you've worked hard and really stuck your neck out. Nice work.” We clearly label the response as a problem so that we can further address it; for example, “It helps us to work on your dislike of discussing death by identifying it as a personal trouble spot or Achilles' heel.”
See Part #3 of the vignette in Table 2.
Teachers continue to identify the harmful responses, improve understanding of their origin, and help the student develop healthier replacements. Better understanding occurs by addressing current personal issues, significant past family and other events, and the way in which the interviewer interacts with the teacher and others in the group; for example, the learner exhibits a pleasing behavior with patients, parents, and teacher—“I was brought up always to be pleasant and avoid painful subjects.”
Although some harmful responses disappear just by identifying them, many do not. To change problematic responses, the teacher emphasizes the student's personal choice and responsibility; for example, “The choice is really up to you.” The teacher can highlight the student's capacity for change, the challenge inherent in the choice, and that the time is right; for example, “I like your energy and willingness to try something new. This likely will take some new, unexpected directions, and you'll have to stretch yourself a bit, but I think you're ready.”43
On the other hand, trainees may recognize they cannot or do not want to change,44 and they may benefit from support for that decision; for example, “Given your circumstances at home, it may be very difficult for you to do anything about this now. I agree that being more assertive could cause more troubles.” Other measures to address the identified problem may be necessary; for example, an exercise program could be devised to ease the resident's tensions.
Role playing helps develop both insight and change. By playing the patient while the teacher or another student takes the learner's role, the learner experiences what her/his problematic behavior feels like as a patient. Students and residents should spend most of their time, however, role playing new and healthier behaviors—a safe and effective method to learn a new repertoire.3 In both situations, feedback from the person playing the other role is essential. Role play also is a way to rehearse new behaviors for situations in daily life, such as using open-ended skills with a spouse.
After effective work in role play, one identifies specific behavioral objectives for subsequent patient encounters; for example, a resident who interrupts frequently can identify remaining silent for 10 seconds on three separate occasions during an interaction as a goal. It is best to limit these behavioral objectives to one or two items that focus on the most important problem and have the best chance for success. It also helps for learners to keep a journal with a log of objectives and specific behaviors they want to master and to record their responses to this work.
See Part #4 of the vignette in Table 2.
Many congruent responses, those accurately responding to the patient's reality, reflect sensitive, caring dimensions of the resident or student, but they may be more difficult to detect because they are less intensely experienced; for example, feeling sad about a patient's biopsy report, caring about one's patient undergoing a painful divorce. Accurate, congruent responses usually are other directed and lack the self-centered intensity often seen with harmful responses. Because these responses reflect the patient's reality, some will have diagnostic value in identifying this reality, often providing clues to what might otherwise have been missed45; for example, when a student felt depressed (observers did also and this was not a stereotypic response of the student) after working with a certain patient, we recognized that the patient had subtle, unrecognized manifestations of depression. Low-grade sexual excitement can indicate a patient's subtle seductive behavior; minor irritation may be the clue to passive-aggressive behavior; and feeling helpless may identify a patient who is indeed feeling helpless.
Congruent responses also have therapeutic value.45 In emotionally perceiving what the patient is truly experiencing, the interviewer becomes truly empathic, a central feature in maximizing the doctor-patient relationship and healing.46 When a resident/student responds appropriately to these feelings, the relationship improves because the patient feels understood. In contrast to diagnostic use of congruent responses, therapeutic use often entails sharing one's response with the patient; for example, “You know, I'm feeling kind of down hearing this, how're you doing?”
This work over time will encourage a strong relationship with the teacher and can lead to a mentoring relationship. It is appropriate toward the conclusion of a particular course or experience to encourage discussion of one's reactions to ending. The teacher and the learner(s) usually experience parting as a loss. At the last session, the individual learner or group can summarize behavioral objectives for continued work on their own, and give and receive final feedback.
Most students and residents become aware of previously unrecognized responses3,4,7,11,12 and are able to make some changes after three to five critique sessions; for example, a resident's frequent interruptions markedly diminished after three sessions although other work remained to be done. Teachers often must focus on several behaviors at once; for example, working on being less controlling and not being afraid to use one's sensitive, caring responses.5,6,26 One notes progress by observing the new behaviors and also by the learner's engagement with the process. Learners usually feel both mildly apprehensive and fascinated with their own personal process as new discoveries and changes occur. Successful learners enjoy doing the work, bring up new issues and expand old ones, and often show increased caring for patients and for the others in the group.
See Part #5 of the vignette in Table 2.
We have used this method in four studies3,5,6,26 and our other teaching, and we have observed no adverse impact on students, residents, and fellows. Nevertheless, one always is vigilant, particularly for subtle signs of depression, anxiety, and substance abuse.
To assure safety, we repeatedly address confidentiality, emphasizing that this work is not discussed with anyone else, nor is it discussed among group members outside specific meeting times. Learners also are advised that personal material will not be used as part of their evaluations, lest they be penalized for sharing, for example, negative thoughts and feelings about some aspects of their training program. The growth and development that occur with personal awareness work should happen without anxiety, depression, disruption of work or personal circumstances, or other adverse side effects. Nevertheless, learners sometimes will cry or otherwise become upset. We handle this like we do with patients: empathy, problem solving, ensuring a return to normal, and offering the option for further discussion (or not) now or later.
There are several situations that usually require mental health consultation for learners. 1) If the learner is depressed or severely anxious, immediate mental health consultation is needed. Even if trained, it is inappropriate for the teacher to treat the learner with, for example, counseling or medications. 2) Far less common, evidence of psychosis or personality disorder, dysfunction at home/work, untoward behaviors, or of substance abuse, also dictates referral. 3) Similarly, the teacher may discover a severe problem that is refractory to personal awareness work and which the learner continues to deny as a problem (e.g., prominent hostility and insensitivity). The teacher and others must develop a plan to better meet the needs of the learner as well as her/his future patients. 4) Finally, when students wish to do more personal awareness work, one may refer for counseling or group work, a healthy outcome of the teaching.
Seemingly adverse outcomes are, in reality, successes of the teaching. Troubled and problem learners have been spotted early, and appropriate actions initiated. If available, a skilled mental health professional on the teaching team can help with assessment and provide emergency consultation. Otherwise, such a professional should be identified beforehand and readily accessible for curbside consultation, clinical assessment, and for the rare emergencies that occur. The program director, key faculty, and experienced colleagues will also be valuable allies and often need to be involved administratively if serious problems arise.
We have no research information on the potential for harm to teachers but, as with learners, we must monitor ourselves in these close teaching relationships for many of the same issues. Similarly, a coteacher with whom one discusses the teaching can help in identifying problematic issues—as well as in providing the support that helps allay and solve them. Certainly, all of the above danger signals apply to teachers as well and indicate the need for personal mental health consultation. In addition, we have observed that the following often are danger signals that could create significant anxiety and stress in the teacher. These require educational consultation from someone familiar with personal awareness work. 1) Recalling that the teaching should be enjoyable, persistent discomfort, dreading upcoming sessions, and intensely negative (or intensely positive) responses to learners warn of the teacher's personal difficulty. 2) Many students consistently giving negative responses and failing to develop personal awareness also suggest a problem and the need for consultation.
Teaching personal awareness is not easy, but we have observed that teachers have experienced a new and wider dimension in their teaching. Not only were successes gratifying, but they also enjoyed the process of getting to know learners better—and, almost inevitably, learning more about themselves. Personal awareness, experience with the interviewing/interactional process, sensitivity to learners' needs, maturity, common sense, patience with the slowness of change, and the capacity to develop a relationship are essential. Training in counseling skills and group dynamics38 can enhance the teacher's work. The American Academy on Physician and Patient (www.physicianpatient.org) has effective training programs for learning these skills as well as for developing one's own personal awareness. Support groups of other teachers and personal supervision of one's teaching by a psychologically trained colleague can also help our teaching skills. Similarly, formal training that includes these teaching approaches can lead to improvement.47
The Appendix (available online at www.jgim.org) provides an overview of several specific curricula for residents and students, their methods, and the procedures for implementing them. It also indicates that additional, more specific teaching resources are available upon request from the authors. Finally, it outlines how one might proceed through initial, early, and later sessions for teaching personal awareness.
This teaching method can provide the basics of a research-based technique for teaching personal awareness in this field where research is both difficult and rare. More qualitative study and rigorous, hypothesis-testing quantitative work will be needed before we can identify a truly evidence-based method. Nonetheless, the method we present provides an evidence-based beginning in an area that is key to improving physician-patient relationships.3