In Class

Meet the Patients

It’s never too early to start talking to ‘patients,’ first-year medical students discover. By Scott Hauser

PATIENT INTRODUCTION: First-year medical student Marjorie Waterman ’04 (left) interviews a “patient” (played by Wendy Cook of Avon, New York) as part of the class Introduction to Clinical Medicine (Photo by Elizabeth Torgerson-Lamark).

The patient—let’s call her Kit—seems to be doubled over in pain as she sits across from Marjorie Waterman ’04, a first-year medical student at Rochester.

For most of the previous day, Kit says, she’s been having what she thinks is an asthma attack. She’s used her nebulizer nine times, but the medicine hasn’t eased her breathing, so she made an appointment to see her doctor.

Waterman listens closely, asking Kit to describe her symptoms, her history with asthma, and her job as a high school math teacher.

With each answer, Kit gasps for breath, wrapping her arms around herself and leaning into her knees.

“OK. Time out,” Waterman says, standing up to face a group of fellow first-year students. “At this point I would go see my preceptor. . . She’s obviously too uncomfortable to continue. What else can I ask?”

The seven other students gathered in the small conference room in the Medical Center are ready to offer what advice they can, but with only about a month’s worth of medical school behind them, they’re all aware of the limits of their diagnostic skills.

Still, the suggestions come quickly: Ask what medication she’s taking. Ask if anything that she’s done in the past day has made her pain subside. Find out what she was doing when the first attack began. Ask if she’s ever had an episode like this and what has she done for it.

The on-the-spot consultation in last fall’s edition of Introduction to Clinical Medicine, a semester-long course at the School of Medicine and Dentistry, is just one snapshot in an innovative effort to introduce students to working with patients early in their medical education. Unusual in its placement as a first-year requirement, the course focuses on helping students learn the process of conducting interviews and physical examinations.

Playing the part of “patients” are volunteers like Wendy Cook of Avon, New York, in the role of Kit, who work from scripts written by course organizers. Known as “standardized patients,” such volunteers have long played a role in medical education, but in most programs, they usually don’t appear until the second half of medical school when, most commonly, students learn to interact with patients.

But for the past five years, students at Rochester have been interviewing patients like Kit right from the beginning of their first semester. The early introduction is part of the school’s focus on combining patient interaction with basic science throughout all four years of medical school.

By the second semester of the first year, students begin working with actual patients in real clinical settings.

The goal is to help students learn how to incorporate analytical and interpersonal skills with the basic science of medicine, says Timothy Quill, professor of medicine, who helps direct the class with Nancy Shafer Clark, assistant professor of medicine.

“Right from the get-go, students are trying to put what they are learning into context,” Quill says. “Students go from not knowing much to getting some good, fundamental clinical skills, and that’s the name of the game.”

While interviewing often is taught as a way to narrow a diagnostic focus quickly, Quill says the best interviewers try to put together a broader picture of each person’s life and health. In many cases, that information is helpful in understanding why a patient has asked to see a doctor.

The emphasis on listening closely to patients has been a key part of Rochester’s medical education since the 1950s, when widely recognized internist and psychiatrist George Engel created the biopsychosocial model, which emphasizes the connections between the biological dimensions and the psychological and social aspects of illness.

Developing ways for students to work with patients throughout their four years at the Medical Center is a central aspect of the medical school’s Double Helix Curriculum, which began in 1999.

As she finds herself stumped by Kit’s story, Waterman turns to the preceptor for the session, Stephanie Brown Clark, an assistant professor in the Division of Medical Humanities, who commends Waterman for her empathy and for her intuition in thinking the case might be one to call in colleagues.

A pitfall for all physicians, Clark says, is closing off diagnostic possibilities too soon. Later, during a feedback session, the students find out that part of Kit’s profile is that she’s a smoker, a detail that didn’t come out in the interview, but could have played a factor in a diagnosis.

“I totally focused on the asthma and completely forgot about everything else,” Waterman says.

René Myers, a first-year medical student from Ogden, Utah, says being asked to interview patients as a first-year student can cause some trepidation.

“Your heart just goes wild,” Myers says. “But after you sit down and you start to talk to the person, it becomes a lot easier.”

But he says learning to communicate better will serve him well throughout his career.

“If you talk to any patients and ask them what’s the biggest thing that you wished your doctor would do more often, it would be listen to them,” Myers says. “I figure that since it’s a very important skill, and it’s something that we’re going to be doing the most of—over everything else—we might as well start off with it first.”

Keri Allen, a first-year student from Miami, says feedback from classmates—along with course material from other classes—helps students put the interviews into perspective.

“It’s a little bit intimidating, but that goes away once you realize that you’re learning from what you’re doing,” Allen says. “You can ask questions, you can take time outs, and say, ‘OK, what do I do now?’”

Quill says students aren’t expected to be able to make accurate diagnoses at the end of the semester, but he says many discover that they have good interviewing and physical examination skills and better clinical reasoning skills than they might have imagined going into the class.

He hopes the experience emphasizes communication as an important factor in the relationship doctors have with their patients and the role that the patient-physician relationship plays in clinical medicine.

“Students here get the message that the patient’s narrative is important,” Quill says. “To get that, you have to listen.”