Psychologists help physicians curb medical machismo

Psychologists train physicians to be more sensitive to patients? emotional needs.

By Rebecca A. Clay<p> When psychologist Joan M. Patterson, PhD, asked parents of chronically ill children about the emotional support they received from physicians and other health-care providers, their answers were shocking. One new mother, for instance, reported that her doctor ?fell apart? when he realized the baby he had just delivered had Down?s syndrome.

?He was mean, rude, and not helpful, saying, ?I?m not treating her,?? the woman told Patterson and her colleagues.

Other parents were told that their children?s doctors didn?t have time to explain things and that they wouldn?t understand what the doctors had to say anyway. Others felt that the people caring for their children were judgmental and failed to respect their parenting skills.

Scenarios like these are by no means uncommon, says Patterson, especially now that managed care is squeezing the amount of time physicians can spend with patients. And such behavior can have a marked impact on the well-being of patients and physicians alike, say psychologists. Results range from hurt feelings to rejection of medical advice to malpractice suits. Convinced that psychosocial skills should go hand-in-hand with medical know-how, Patterson and other psychologists are working to improve doctors? bedside manner.

When Patterson and her colleagues surveyed the parents of 182 children, they came up with 158 instances of negative behavior on the part of health-care professionals. Physicians accounted for almost two-thirds of those cited.

That?s not surprising, says Patterson, chair of the maternal and child health training program at the University of Minnesota?s School of Public Health. It?s perfectly understandable that physicians faced with chronically ill children or other problems they can?t solve might inadvertently let their frustration show, she says.

That?s especially true when you consider the training physicians typically receive, she adds. ?There?s an attitude in medical schools that if you?re attuned to the ?soft? side of medicine?the psychosocial aspects?that means you don?t know the hard science, that you don?t know your medicine,? she says. ?Doctors want to be hard-nosed.?

That medical machismo manifests itself in a lack of respect for patients and their families, Patterson says. To counteract that attitude, University of Minnesota students who are training to become pediatricians supplement lessons in communication by participating in the school?s Parents as Teachers Project.

In this innovative program, students visit patients? homes to see firsthand what it?s like to live with children with disabilities.

?That kind of experiential education has a great potential to change the way physicians see patients,? says Patterson.

Promoting self-awareness is another crucial part of physician training, says Susan H. McDaniel, PhD, co-author of ?Family-Oriented Primary Care: A Manual for Medical Providers? (Springer Verlag, 1990) and director of family programs in the psychiatry department of the University of Rochester School of Medicine and Dentistry.

?Young students and residents are so anxious about what they don?t know biomedically that they act as if there?s not a person sitting across from them, just a machine that?s going to give them data,? says McDaniel, noting that videotaping interactions with patients can help alert students to bad habits they?re not even aware of.

The medical students and primary care residents McDaniel teaches learn more than the how-to?s of interviewing patients or delivering bad news. Actively encouraged by their school, students spend time just thinking about themselves. In one program, small groups come together each week to discuss their anxieties and the defenses they?ve developed to manage their feelings. In another, students gather to discuss their reactions to difficult patients.

The school?s commitment to inculcating sensitivity is also manifested in the way it allocates resources, says McDaniel. Residents are allowed to spend their Continuing Medical Education money on psychotherapy, for example.

Borrowing techniques used to train psychologists is another useful strategy for enhancing physicians? sensitivity, says James H. Bray, PhD, an associate professor of family and community medicine at Baylor College of Medicine in Houston. Like psychology students, students in Bray?s program meet with patients as Bray and other professors watch via videocamera. Before each visit, the student meets with the professors to discuss his or her goals and any areas that need improvement. Halfway through and at the end of the patient?s appointment, the student steps outside for additional feedback.

Bray borrows from psychology?s curriculum as well as from its repertoire of pedagogical techniques. In fact, his goal is to help physicians apply psychologists? skills to their own work.

?Obviously you can?t completely translate what we do as psychologists into 10-minute office visits,? says Bray, noting that he also teaches students when to refer problems to psychologists. ?But we can teach physicians some of the basic things that psychologists do, such as clear communication, problem-solving and behavioral interventions.?

A well-intentioned physician, for example, might try to scare an overweight patient into dropping pounds by describing the dire health hazards that await him or her, says Bray. When the approach doesn?t work, the physician may become confrontive and further alienate the patient. In Bray?s program, physicians learn alternatives to the fear-based approaches.

No matter what approach psychologists take when teaching physicians, they should avoid putting their students on the defensive, says Gerald P. Koocher, PhD, an associate professor of psychology at Harvard Medical School. Well aware that medical students sneer at psychology, he translates psychosocial goals into biomedical ones. Instead of telling students they need to improve their bedside manner, for instance, he tells them their patients will be more likely to follow their advice if they ask nicely. ?You can be an incompetent klutz as a physician, but if your patients like you, they?re going to be much better at following your advice,? Koocher tells students.

He also emphasizes that poor communication skills can result in more than resentment. Physicians should avoid jargon to prevent potentially tragic misunderstandings about medical regimens. They must find the right emotional tone for each patient. Teens, for instance, may rebel against physicians who use a ?do this, do that? approach.

And physicians must be alert to unspoken thoughts, especially in patients making quality-of-life or end-of-life decisions. Listening and asking patients what they want are key, he says.

?It?s a question of the physician making patients partners in care rather than passive battlegrounds on which the war against disease is being fought,? says Koocher.

If nothing else convinces physicians of the importance of good bedside manner, psychologists can appeal to physicians? own self-interest. In a recent issue of the Journal of the American Medical Association, Wendy Levinson, MD, and other researchers revealed that bedside manner has an impact on physicians? fates, too.

They found that primary-care physicians who solicited patients? opinions, used humor and tried to put patients at ease were at lower risk of malpractice suits than their peers.

Rebecca A. Clay is a writer in Washington, D.C.