Teaching reflection to doctors to improve physician-patient interactions
Physicians in their medical residency training programs often focus on scientific reasoning and research evidence in their efforts to provide medical care. While appropriate, this focus may overshadow subtle and indirect communication that reveals important information about the patient's experience with their illness that will help the physician provide better care. A new study by researchers at Tufts University School of Medicine and Boston College presents the results of a strategy to train medical residents to reflect on interactions with patients as a way of understanding the meaning of both their patient's, and their own, communication.
The study directors asked 33 family medicine residents in the Tufts University Family Medicine Residency program at Cambridge Health Alliance to write "open-ended reflections" over the course of one year examining their interactions with patients. The project, which used a qualitative research design, resulted in 756 private reflections that the research team iteratively organized into three principal communication themes: (1) recognizing the interdependence of physician-patient communication (2) attention to the subtleties of patient behavior; and (3) images of growth and awareness about physician-patient communication.
In the report in the Journal of Health Communication published this month, the authors provide sample entries from residents on each of the themes and related sub-themes. On the theme of interdependence of the communication behavior, which included sub-themes on how physicians restrict what patients will tell them; how learning and taking the patient's perspective can help, and how better communication might promote behavior change, sample entries included:
- This (teen) patient needed more trust and engagement. I wondered how I could have approached her better...
- Today I had a very rich and satisfying visit supporting a pregnant mom when I considered her needs more broadly in preparing for birth instead of just checking vitals and blood sugar.
- I told him these events could predict dementia. He looked at me blankly and said, "events?" I realized that I have to avoid BOTH jargon and ambiguous language.
The second theme on the subtleties of patient behavior included sub-themes on the need to integrate the patient's background, attentiveness to patient emotion, and implications for drawing conclusions about patients. Quotes included:
- I wonder what point I could have picked up the right clue that he was stressed and depressed by his family situation...
- The patient's fear and sadness about death was like a dagger to me. I grew defensive and tried to be jovial. It was hard to look him in the face...Today I felt helpless, overwhelmed, scared.
- I enjoyed seeing this 21 year-old girl. I was expecting some anxious, non-compliant girl with social challenges, but she was pleasant. I hate that I...make quick assumptions.
Physicians who described images of growth and awareness, the third theme, focused on personal improvement. The sub-themes included recognizing communication missteps, understanding the learning process, and commitment to ongoing learning and growth. Reflections included:
- How do I engage the patient experience rather than trying to get to [the] "right" answer as fast as possible?
- I was surprised that was more than one right answer. I was worried that I was incompetent, but now I realize there are multiple right answers, and the situation and patient preferences make medicine more an art than I'd realized.
- I've come to see reflection as a long-term goal...
"When new physicians notice and make sense of what they may have missed in a patient interaction, they may be prompted to move forward in a different way, instead of unconsciously allowing that behavior to become the norm in future patient interactions," said senior author Allen Shaughnessy, Pharm.D., M.Med.Ed., professor of family medicine at Tufts University School of Medicine and fellowship director of the Tufts University Family Medicine Residency Program at Cambridge Health Alliance.
"Current research suggests that the development of professional awareness among physicians is crucial to developing the skill to respond empathetically to patients. Recognizing the subtleties of communication requires more than understanding the patient's explicit statements but also requires a recognition of what lies below the surface," said first author Ashley Duggan, Ph.D, associate professor in the Communication Department at Boston College, and adjunct associate professor in family medicine at Tufts University School of Medicine.