Seminar in the Human Side of Medicine

22 May

Appendix: Outline of the Seminar in the Human Side of Medicine” Course at Macalester College.

This is the outline of the course I taught at Macalester College in St. Paul, Minnesota. The limited enrollment of no more than fifteen students en- courages reflective discussion and allows the students and me to get to know each other well.

SEMINAR IN THE HUMAN  SIDE OF MEDICINE: WHAT IT’S LIKE TO BE A PATIENT; WHAT IT’S LIKE TO BE A PHYSICIAN

Laurence A. Savett, M.D.

Macalester College Department of Biology

Wednesday evenings, 7–9 p.m., 2 credit hours.

This course will concentrate on learning about how patients, their fami- lies, and professionals who care for them experience illness; how stories pa- tients tell become the basis for diagnosis and therapeutic action; what it’s like to be a physician; and the therapeutic relationship. Didactic presenta- tions, interactive discussion using stories from patients’, students’, and the instructor’s experiences, and related literature will provide the content of the course. Others, including faculty members, professional colleagues, and patients, will help provide material for our course work and participate in our discussions.

The Context of the Course

Two premises provide the basis for this course:

•  If someone is to be a physician or other health care professional, it is as impor- tant to master the human dimensions as it is to master the mechanistic, bio- logic, and technical dimensions.

•  The human side of medicine can be taught.

At a time when medicine is in transition and aspects of such a career that are most attractive to many prospective physicians relate to the tech- nology of medicine, the community faces the hazard that the human side of medicine may be neglected. The human side of medicine includes a num- ber of elements, among which are:

•  A view of medicine encompassing biological, psychological, and social dimen- sions.

•  Thoughtful medical history-taking techniques and ways to explore the psycho- logical and social issues related to the patient’s illness.

•  The role of collaboration in medicine.

•  The role of uncertainty in clinical medicine.

•  The nature of the doctor-patient relationship.

What patients and their families ask for, and are entitled to, involves all of the above and includes competence in the technology of medicine in the context of a human approach to medical care. One or all of those factors may attract someone to a career in medicine, but the human side is often taught informally at best or “socialized out of ” the student. When that happens, both the physician and the community lose. The physician misses out on those aspects that comprise some of the real joys of medicine, and the community of patients loses when its physicians lack the awareness of the importance of those dimensions.

Unless one is, by nature, a compassionate and understanding person, it is argued, the human side of medicine is difficult to teach. I believe it can be taught, and I believe that exposing undergraduates to those dimensions of a career in medicine should help to attract talented and compassionate peo- ple to such a career and provide a context and a head start for later learning in professional school. The community of patients is the ultimate benefi- ciary.

The Content of the Course

In this course, we will

1. Explore the experience of illness, starting with a detailed story of one patient’s experience and stories of students’ experiences and those of their families and friends, and asking other patients to describe to the students their own experi- ences with illness.

2. Explore what patients and their families expect from a physician.

3. Introduce the concept of “uncertainty” in medicine, how physicians, patients, and families deal with it, and how one can take action, despite the existence of uncertainty.

4. Look at the various ways patients and their families deal with illness.

5. Learn some of the methods of the medical interview as the primary means of gathering information about patients and the context in which their illnesses occur.

6. Introduce the concept of “differential diagnosis,” the process by which physi- cians reason and make a diagnosis.

7. Explore the nuances of the doctor-patient  relationship in order to illustrate that, beyond being a scientist and technician, the physician provides context, perspective, and emotional support for patients and their families.

8. Explore how a physician learns and ultimately becomes his or her own teacher.

9. Explore what the life of a physician is like and what physicians are like.

Methods

1. Each session will have many or all of the following dimensions:

•  A didactic portion.

•  Substantial discussion, using many stories and examples from students,’ pa- tients,’ and the instructor’s experiences.

•  A list of resources.

•  A look at how the lessons learned may have broader application.

•  Homework, exercises, and/or written assignments done in preparation for the session.

2. On most of your assignments, I will encourage you to work in pairs, to empha- size the concept that medicine is a collaborative profession and to illustrate many of the benefits of thoughtful collaboration.

3. Text and other material: We will use the extensive literature relating to the hu- man side of medicine, patients’ experiences, and uncertainty (see Selected Bib- liography).

4. At the first session, we will discuss

•  Who the participants are.

•  Goals of the course, including what participants want from the course.

•   Collaboration.

•  Confidentiality.

•  The instructor’s expectations of the participants.

5. There will no final exam. There will be a final paper on this subject: “Fash- ioning the best system of medical care possible: what would be ideal for the pa- tient,  what would be ideal for the physician.” The content  of the seminar should provide ample material for a thoughtful paper.

6. Your grade will be determined by the quality of your participation in seminar discussions and the quality of your written assignments and final paper. I believe the clarity with which you express yourself is a reflection of how you think. Part of the intent of the seminar is to enhance your ability to think and express your- self and to enhance your self-confidence in that ability.

7. Together we will have an opportunity to evaluate the seminar at the midpoint of the semester. At the end of the semester, you will have an opportunity to evaluate the course more completely.

I am looking forward to learning a great deal from each of you.

Course Outline

What It’s Like to Be a Patient

Session I. Coronary artery bypass surgery: what one can learn from a patient and the patient’s family. Introduction to the medical setting. The discussion will include

•  Presentation of a way to look at each medical encounter as an opportunity to learn and to add to one’s experience, in a five-step process that includes these questions:

1.   What is the story?

2.   What is the medical history?

3.   What are the issues?

4.   What is the role of the doctor-patient relationship?

5.   What did I learn?

•  Introduction to the biopsychosocial model of medicine.

Session II. Seminar participants’ experience with illness. The patient is the center of the drama.

Session III. How do people handle illness? Patients who have had serious illness will tell their stories and talk about how they dealt with their illness. Together we will address a number of themes: collaboration, the family ex- perience of illness, and the role of physicians.

Session IV. Uncertainty. How patients, families, and physicians cope with uncertainty. The value of reason as a tool in diagnosis and treatment.

What It’s Like to Be a Physician

Session V. The medical history. How stories patients tell become the basis for diagnosis and therapeutic action. What physicians need to know about illness. How to get patients to tell about themselves. What gets in the way of patients telling their stories.

Session VI. Diagnosis.

•  The differential diagnosis. Giving a problem a name and then exploring the possi- ble diagnostic solutions to the problem and the process by which a physician es- tablishes a diagnosis.

•  The “problem-oriented system” of medical reasoning and decision making. How to learn. How to become one’s own teacher.

Session VII. What can go wrong.

•  Drug- and treatment-induced illness. “First do no harm.”

•  Prejudice. Viewing people as members of a group rather than as individuals.

What we can learn from examining prejudices. How to apply those lessons to patient care.

•  Abuse.

•  Mistakes.

Session VIII. Defining the issues. Unless all the issues are identified, the care of any patient may be inadequate and incomplete. The clearer the def- inition of the issues, the easier it is to address the problems, and “a problem identified is a problem half solved.”

Session IX. Medicine  is a collaborative profession. During this session, a physician, a social worker, a nurse, and a hospital chaplain will collaborate with the patient and the patient’s family, help clarify and enlarge the story and the clinical history, identify the issues, and show how the relationship with the patient and the patient’s family can facilitate care.

Session X. What is a professional? Four people, none of them in health care, all “real professionals,” will describe their work and talk about what they do that makes them professionals. With them we will explore the pro- fessional dimensions common to their diverse careers and apply what we have learned to the “professional” quality of a medical career.

Session XI. The different faces of physicians. Three physicians will describe their professional lives and how they integrate their professional and per- sonal lives. The role of values. Dealing with change.

The Doctor-Patient Relationship

Session XII. The doctor-patient relationship. What patients expect from physicians. How the doctor-patient relationship is like the teacher-student relationship. The importance of the relationship to the patient and to the physician.

Summing Up

Session XIII. What have we learned about physicians, patients, families, teaching and learning, and choosing a career. The transition from “learn- ing about a patient” to “learning from a patient.” Fashioning the best sys- tem possible: what would be ideal for the patient, what would be ideal for the physician.

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