The 2015 medical college admission test will include questions that focus on the psychological, social and biological foundations of behavior. These questions recognize the importance of sociocultural and behavioral determinants of health on health outcomes. In a 2012 press release, American Association of Medical Colleges president and CEO Darrell Kirch, M.D., said, "Being a good doctor is about more than scientific knowledge. It also requires an understanding of people."
Premed students are clamoring for classes in social sciences, psychology, sociology and ethics. These subjects are "the building blocks medical students need in order to learn about how cognitive and perceptual processes influence their understanding of health and illness," according to the preview guide to the new MCAT.
Once in medical school, students will be taking courses designed to meet the competencies tested for in the new exam. In a November 2011 report titled "Behavioral and Social Science Foundations for Future Physicians," the AAMC provides recommendations and guidelines for medical educators. "A complete medical education must include, alongside physical and biological science, the perspectives and findings that flow from the behavioral and social sciences," say the report authors.
Mandate for Patient-Centered Care
The Institute of Medicine's 2001 report "Crossing the Quality Chasm: A New Health System for the 21st Century" created a new interest in patient-centered care. The report laid out six aims built around the core needs for health. The absence of patient-centeredness in the physician-patient relationship, the IOM stated, is associated with lower patient satisfaction, poorer adherence to medical recommendations, less well-controlled blood pressure, and greater propensity to sue for medical malpractice in the face of an adverse event.
Since the Flexner Report of 1910 and the subsequent focus in medical education on biomedicine and technology, medicine has been highly successful in eradicating certain diseases, especially acute trauma and infectious disease. However, of the 700 million physician office visits per year that occur now in the United States outside of the hospital setting, half are for non-disease-based conditions, requiring a completely new approach to understanding, empathizing and partnering with patients, says Richard Frankel, Ph.D., professor of medicine at Indiana University School of Medicine.
One example of this approach comes from the Arnold P. Gold Foundation: For several decades, the foundation has been fostering values and behaviors that reflect traits such as empathy, respect, caring, integrity and service. It collaborates with medical schools in supporting curriculum development, professorships, and awards for students and faculty who extol the values of compassionate care, says Ann Bruder, director of programs. "We are looking for ways in which we can counter the negative effects of the hidden medical school curriculum," she says. The foundation is also launching a research initiative that provides funding and technical assistance to expand our understanding of how humanistic care contributes to patient outcomes.
Teaching Communication Skills to Physicians
Once students have graduated from medical school, the realities and challenges of medical practice can take a toll on physicians. Frankel and his colleagues suggest several ways to enhance the patient- and relationship-centered interactions for professionals, including training in mindful practice and communication skills.
One example of communication skill training is found at Kaiser Permanente in California, one of the largest health care organizations in the nation. Kaiser Permanente has been training doctors to use four habits of highly effective physicians: invest in the beginning, elicit the patient's perspective, demonstrate empathy and invest in the end. The four habits approach has been used to train more than 10,000 physicians since 1996 and is the foundation of many of Kaiser's education programs. The training is especially helpful for those physicians who have excellent technical skills but whose patients judge them to have poor communication skills.
Kaiser Permanente is committed to personalized care, says Terry Stein, M.D., director of clinician patient communication in Kaiser Permanente's physician education and development department. The organization's leaders have recognized that a positive physician-patient relationship is crucial to both their members' and physicians' satisfaction. In fact, since the training program began, member satisfaction scores have been rising steadily, while clinicians appreciate improving their communication skills as they deal with the complexity and constant changes they face in their practice. The program also has helped to reduce the organization's medicolegal risk by improving physician-patient communication, Stein said.
At the Program in Narrative Medicine at Columbia University Medical Center, founding director Rita Charon, M.D., has been developing and teaching courses in literature, narrative ethics and life-telling to medical students with the premise that this training will help students recognize, absorb, interpret and be moved by the stories and plight of others and their illness. There is growing evidence that all these efforts are working. A three-year study of diabetic patients showed that patients with empathetic physicians had better clinical outcomes, including lower blood sugar levels, than those who did not.
Better Care Outcomes
We have demonstrated we can improve the health of patients, improve the health status of populations, and dramatically lower costs when we proactively identify patients with chronic diseases and assist them in setting and achieving health improvement goals, says David Vellinga, president and CEO of Mercy Medical Center in Des Moines, Iowa, and CEO of Mercy Health Network. Teaching physicians the value of patient-centeredness from the start will be a huge benefit to patients and to the efforts of health systems everywhere.
Milt Hammerly, M.D., former vice president of medical affairs for Catholic Health Initiatives Institute for Research and Innovation, has been studying the research on "emotional intelligence" in physicians. He has found that higher physician emotional intelligence leads to greater patient satisfaction (which also can be related to reduced medicolegal liability) and better adherence to treatment regimens; it also improves clinical outcomes. In fact, he says, research also suggests that higher physician emotional intelligence reduces medical errors, litigation, and provider burnout and turnover, which can be costly to hospitals.
The new MCAT questions and returning interest in humanism and healing are needed, welcomed and encouraging. As health reform requires a greater emphasis on population health management and more focus on wellness and prevention, this knowledge and the related competencies will be invaluable not only for physicians, but also for the patients, hospitals and health systems they serve.
Sita Ananth, M.H.A.,is a Napa, Calif.-based writer specializing in complementary and alternative medicine. She is also a regular contributor to H&HN Daily.
This article was adapted from a recent article by Sita Ananth and Wayne Jones, "Patient-Centeredness and Caring in Medical Education," with permission from Elsevier. The article appeared in the March/April 2013 issue of Explore: The Journal of Science & Healing (vol. 9, no. 2, pp. 116–117), copyright © 2013 Elsevier Inc.
