Teaching Professional Attitudes and Basic Clinical Skills to Medical Students: A Practical Guide 9783031265419, 9783031265426, 3031265416

Table of contents :
Preface to the Second Edition
Preface to the First Edition
Contents
Chapter 1: Paradigmatic Shifts in the Theory, Practice, and Teaching of Medicine Since the 1970s
1.1 Introduction
1.2 Doctor–Patient Relations (See Chap. 2)
1.3 Clinical Reasoning (See Also Chap. 5)
1.3.1 From Denial to Acceptance of Uncertainty
1.3.2 From Intuitive to Analytic Decision-Making
1.3.3 From Pathophysiologic Rationale to Evidence-Based Reasoning
1.3.4 From the Biomedical to the Bio-psycho-social Model of Clinical Practice (See Also Chap. 6)
1.4 Doctor–Society Relations (See Also Chap. 8)
1.4.1 From Accountability to Peers to Accountability to Laymen and Lay Institutions
1.4.2 From an Unrestricted to a Parsimonious Use of Resources
1.4.3 From a Lone Professional to a Member of a Healthcare Team
1.4.4 Change in the Public’s Trust in Health Services
1.5 Medical Education (See Also Chap. 9)
References
Chapter 2: Communicating with Patients
2.1 Introduction
2.2 Learning How to Talk with Patients
2.3 Teaching How to Talk to Patients
2.4 Coping with Barriers to Learning and Teaching Patient Interviewing
2.4.1 Learning Objectives and General Approaches to Achieving Them
2.4.2 The Integrated Learner- and Teacher-Centered Approach
2.4.3 Shifts in Teaching Patient Interviewing
2.4.4 Assessment of Communication Skills
2.5 Proposed Teaching Program
2.5.1 Step I: The Problem
2.5.2 Step II: Discussion of Possible Solutions
2.5.3 Step III: Demonstration of Various Interviewing Techniques and Discussion of Their Advantages and Disadvantages
2.5.4 Step IV: Supervised Practice
2.5.5 Advantages of the Proposed Approach
2.6 Barriers to Doctor–Patient Communication
2.6.1 Doctor–Patient Differences in Age, Race, Gender, Language, and Socioeconomic Status: Underprivileged Patients
2.6.2 Mismatch Between the Patient’s and the Doctor’s Preferences
2.6.3 Doctors’ Failure to Gain Insight into the Patient’s Concerns
2.6.4 Interviewing Habits That May Discourage Patients from Sharing Their Concerns
2.6.4.1 Writing Up the Patient History During Interviewing
2.6.4.2 Focusing on the Chief Complaint Early in the Interview
2.6.4.3 Performing Systems Review
2.6.5 Angry Patients
2.7 Coping with Barriers to Communication with Patients
2.7.1 Language Mismatches
2.7.2 Doctors’ Self-Awareness
2.7.3 Encouraging Patients to Share Their Concerns
2.7.4 Management of Patient Aggression
2.8 Shared Decision-Making
2.8.1 Teaching Shared Decision-Making
2.8.2 Proposed Learning Objectives of Shared Decision-Making
2.8.2.1 Gain an Insight into the Patient’s Concerns
2.8.2.2 Elucidate the Role That the Patient Wants to Assume in Decision-Making
2.8.2.3 Match the Patient’s Preferred Involvement in Decisions
2.8.2.4 Present Options; Discuss Pros, Cons, and Uncertainty
2.8.2.5 Offer the Patient the Option of Obtaining a Second Opinion and Suggest Reliable Websites
2.9 Patient Counseling
2.10 Patients’ Adherence to Doctors’ Advice
2.10.1 Estimating Patients’ Adherence to Doctors’ Recommendations
2.10.2 Reasons for Nonadherence
2.10.3 Ways to Improve Patient Adherence
2.11 Managing Difficult Encounters and Delivering Bad News
2.11.1 Patients’ Preferences
2.11.2 Care-Providers’ Preferences
2.11.3 Suggested Guidelines
2.11.4 Teaching How to Disclose Bad News
References
Chapter 3: The Physical Examination
3.1 Introduction
3.2 Barriers to Teaching and Learning Physical Examination Skills
3.2.1 Attitudes to the Physical Examination
3.2.2 “Inherited” Errors
3.3 Coping with Barriers to Learning the Physical Examination
3.3.1 Teaching the Reflective Physical Examination
3.3.2 Learning for Mastery
3.3.3 Integrating Hand-Held Devices into Teaching the Physical Examination
3.3.4 Teaching Physical Signs by Context and Importance
3.3.5 Use of Simulations
3.4 Diagnostic Utility of the Physical Examination and Ancillary Tests
3.4.1 Test Properties
3.4.2 Sources of Bias in Determining the Validity of Diagnostic Tests
3.4.3 Clinical Prediction Rules
3.4.4 Assessment of the Pretest Probability of a Disease
References
Chapter 4: Recording the Clinical Database
4.1 Introduction
4.2 The Problem-Oriented Record
4.3 The Electronic Medical Record
4.4 Teaching the Recording of the Clinical Database
4.4.1 The Personal and Psychosocial History
4.4.2 Chief Complaint
4.4.3 Symptoms
4.4.4 Problems
4.4.5 Statement of the Patient’s Present Problem(S)
4.4.6 Statement of the Present Problem(S) (Continued)
4.4.7 Statement of the Present Problem(S) (Continued)
4.4.8 Listing Active and Inactive Problems, Past and Family History, Review of Systems
4.5 Common Errors in Recording the History of a Patient’s Present Illness
4.5.1 Overemphasis on Objective History Data
4.5.2 Inadequate Description of the Patient’s Symptoms
4.5.3 Failure to Identify Main Symptoms
4.5.4 Unclear Presentation of Chronological Evolution of Symptoms
4.6 Providing Feedback on Students’ Records of a Patient’s History
References
Chapter 5: Clinical Reasoning
5.1 Introduction
5.2 Reasoning Strategies of Experienced Clinicians
5.2.1 Pattern Recognition and Hypothetico-Deduction
5.2.2 Additional Paths of Clinical Reasoning
5.2.3 Cognitive Task Analysis
5.3 Heuristics and Biases in Clinical Reasoning
5.4 Barriers to Learning Clinical Reasoning
5.5 Teaching and Assessing Clinical Reasoning
5.5.1 Learning Objectives
5.5.2 Assessment
5.6 Decision Support
5.6.1 Decision Analysis
5.6.2 Evidence-Based Medicine
5.7 Interpretation of Research Findings
References
Chapter 6: The Behavioral and Social Sciences in Medical Education
6.1 Introduction
6.1.1 Stress and Stressors
6.1.2 Psychological Distress
6.1.3 Life Events
6.1.4 Social Support
6.1.5 Socio-Economic Status
6.1.6 Personality Traits
6.2 Barriers to Teaching the Behavioral and Social Sciences
6.3 Overcoming Barriers to Student Learning
6.3.1 Risk for Disease and Ability to Cope with It: The Patient’s Personal/Psychosocial History
6.3.2 Implications for Clinical Practice
6.3.3 Who Should Teach Medical Students the Clinically Relevant Aspects of the Behavioral and Social Sciences?
References
Chapter 7: Medical Errors and Quality Assurance of Healthcare
7.1 Introduction
7.2 Medical Errors
7.2.1 Prevalence of Medical Error and Doctors’ Attitude to Mistakes
7.2.2 Prevention of Medical Errors
7.2.3 Patients’ Complaints and Medical Litigation
7.2.4 Disclosure of Medical Errors to Patients
7.3 Incapacitated Doctors
7.3.1 Incidence
7.3.2 Response to the Awareness of Doctors’ Dysfunction
7.3.3 Dealing with Doctors’ Dysfunction
7.4 Quality Assurance of Healthcare
7.4.1 Physicians’ Attitudes to Quality Assurance of Healthcare
7.4.2 Promoting Physician Support for Quality Assurance in Healthcare
7.4.3 Promoting Physician Self-Disclosure of Errors
References
Chapter 8: Shifts in the Structure of Health Care and Doctor–Society Relations
8.1 Introduction
8.2 Managed Care
8.2.1 Bureaucracy: Definition and Negative Connotations
8.2.2 Desirable Facets of Managed Care
8.3 Fair Distribution of Healthcare Resources
8.3.1 Fair Distribution of Resources: Ethical Dilemmas
8.3.2 Controversial Norms
8.3.3 The Need for a Policy of Rationing Resources
8.3.4 Implementing a Policy for Fair Allocation of Medical Resources
8.4 Trust in Medicine
8.4.1 Decline in Patient Confidence in Health Care
8.4.2 Possible Reasons for the Decline of Trust in Health
8.4.3 Impact of Changes in the Status of the Physician in Society
8.5 Medicine and the Media
8.5.1 Media Coverage of Medical Issues: Targets
8.5.2 Media Coverage of Medical Issues: Biases
8.5.3 Medical Recommendations in the Media
References
Chapter 9: Changes in Medical Education
9.1 Ongoing Changes in Medical Education
9.1.1 From Memorization to Self-Directed Learning and Information Management
9.1.2 From Knowledge to Competency-Based Education
9.1.3 From the Biomedical Model to Engel’s Bio-Psycho-Social Model for Clinical Reasoning and Practice
9.1.4 From Intuitive to Analytic Decision-Making
9.1.5 From Hospital to Community Settings
9.1.6 External Reviews of Teaching and Accreditation of Medical Schools
9.1.7 Quality Assurance of Patient Care
9.2 Challenges of Medical Education
9.2.1 Promoting Student Well-being
9.2.2 Personalizing Medical Education and Reducing Its Duration
9.2.3 Selection of Applicants for Medical Training
References
Index

Citation preview

Teaching Professional Attitudes and Basic Clinical Skills to Medical Students A Practical Guide Jochanan Benbassat Second Edition

Teaching Professional Attitudes and Basic Clinical Skills to Medical Students

Jochanan Benbassat

Teaching Professional Attitudes and Basic Clinical Skills to Medical Students A Practical Guide Second Edition

Jochanan Benbassat Department of Medicine (retired) Hadassah-Hebrew University Medical School Jerusalem, Israel

ISBN 978-3-031-26541-9    ISBN 978-3-031-26542-6 (eBook) https://doi.org/10.1007/978-3-031-26542-6 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2015, 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

To Reina, Dorit, and Naomi, with all my love

Preface to the Second Edition

The purpose of this edition is to update the sections on teaching communication skills, physical examination, and clinical reasoning and to introduce medical students to selected professional topics that have generated controversy. The second edition has been expanded to address issues such as the role of the social and behavioral sciences, quality assurance of patient care, and rationing of medical resources in clinical practice. Of course, the goal is not to offer solutions, but to provide insight into these topics, explain their importance, and help students form their own opinions about them. Many readers will disagree with my approach and attitudes, which do not necessarily coincide with the policies of the institutions I have worked at. I also describe some additional insights that I believe are important for medical practice and research. First, the primary goal of teaching the social and behavioral sciences is to raise awareness that age, low socioeconomic status, recent life events, drug dependence, mental illness, high body mass index, and belonging to an ethnic minority are risk indicators for morbidity. Any symptom in such underprivileged patients may indicate more severe disease than in patients without these indicators, just as a neutropenic patient with a fever is more likely to have a life-­threatening infection than a nonneutropenic person. Second, getting a second opinion is a neglected cause of health care disparities. Rather than being offended when patients seek a second opinion, physicians should encourage their patients to do so and schedule a follow-up appointment to help them deal with any discrepancies between the first and second opinions. Finally, unexpected study results should not be ignored, nor should they be considered definitive evidence, but rather hypotheses that should be tested by further studies. Jerusalem, Israel

Jochanan Benbassat

vii

Preface to the First Edition

Doctors differ in their training and practice settings, and ultimately, they adopt diverse approaches to the basic clinical skills of patient interviewing, data collection, and problem-solving. Consequently, medical students may encounter marked differences in the clinical methods of their tutors. For example, some doctors encourage patient narratives through open-ended questions, while others prefer closed-ended questions. Physicians in hospitals and the community may disagree about the value of the physical examination, and tutors differ in how they inform patients, colleagues, and students about clinical uncertainties. Medical students can be confused by these differences and by controversies over topics such as doctor–patient relationships and clinical reasoning. They may be puzzled by contradictions between what they are taught and the way medicine is practiced, such as the patient-centered approach promoted in lectures and the disease orientation of some physicians. Finally, some students have difficulties in mastering certain skills, such as percussion, or in adopting professional rules, such as the requirement to be non-judgmental toward patients. This book is intended to help clinical tutors and students address some of these difficulties. Its sections describe my difficulties in learning and teaching patient interviewing, physical examination, recording the patient database, clinical reasoning, and the behavioral sciences. I describe the approaches that I found useful in overcoming these difficulties, as well as several insights that I believe are important for medical education and practice. The first insight is that clinical problem-solving begins with identifying the patient’s concerns and expectations rather than formulating his or her chief complaint. Some patients make their expectations clear, but many leave their concerns unspoken. Insight into a patient’s concerns and expectations is important because failure to address them can lead to patient dissatisfaction and ineffective medical care. Second, basic clinical skills, including the ability to retrieve information, should be learned for mastery as early as possible rather than expected to be acquired through practice. Practice is certainly important. However, evidence suggests that clerkships do not improve students’ clinical skills, that some physical examination ix

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Preface to the First Edition

skills deteriorate with seniority, and that a physician’s performance may decline with years in practice, likely due to inadequate updating of knowledge and skills. Third, rather than feeding medical students lectures on behavioral and social sciences, faculty should lead students to discover for themselves the relevance of these sciences to clinical practice. Lecturing students to be polite to patients is likely to be viewed as offensive and provoke resistance. However, students react differently when they realize on their own that many clinicians are rude to patients. Finally, observed inconsistencies between theory and practice should not be seen as a sign of personal inadequacy but as an opportunity for further inquiry, and disagreements between authority figures should not lead to confusion or cynicism but rather help identify areas of uncertainty to explore. These views were shaped during my tenure as a physician and teacher in the medical faculties of Hebrew University and Hadassah (1962–1992) and Ben-Gurion University of the Negev (1992–1997). In addition to the publications I cite, my beliefs were shaped by my mentors, colleagues, and students. However, the responsibility for writing is entirely mine, and my opinions do not necessarily reflect the policies of the institutions with which I was affiliated. I may be mistaken in assuming that my earlier learning and teaching difficulties are shared by today’s medical students and faculty. Nevertheless, I hope that this book will help some clinical tutors and lecturers in the behavioral and social sciences to gain insight into students’ difficulties and will help students to make informed choices of professional style and clinical methods. I thank Drs. Reuben Baumal, Rosalie Ber, Jeffrey M.  Borkan, Mayer Brezis, Samuel N. Heyman, Netta Meroz, Dina Pilpel, Anna Schiffman, and Meira Tidhar, who coauthored earlier versions of the various chapters, and the journals that published them for their permission to include the updated versions in this book. I also thank the Myers-Brookdale Institute for hosting me during the editing of this book and my colleagues at the Center for Health Policy Research for their advice and comments. Jerusalem, Israel

Jochanan Benbassat

Contents

1

Paradigmatic Shifts in the Theory, Practice, and Teaching of Medicine Since the 1970s������������������������������������������������������������������������    1 1.1 Introduction������������������������������������������������������������������������������������    1 1.2 Doctor–Patient Relations����������������������������������������������������������������    1 1.3 Clinical Reasoning��������������������������������������������������������������������������    4 1.3.1 From Denial to Acceptance of Uncertainty ����������������������    4 1.3.2 From Intuitive to Analytic Decision-Making��������������������    5 1.3.3 From Pathophysiologic Rationale to Evidence-Based Reasoning��������������������������������������������������������������������������    6 1.3.4 From the Biomedical to the Bio-psycho-social Model of Clinical Practice������������������������������������������������    7 1.4 Doctor–Society Relations ��������������������������������������������������������������    7 1.4.1 From Accountability to Peers to Accountability to Laymen and Lay Institutions ��������������������������������������������    8 1.4.2 From an Unrestricted to a Parsimonious Use of Resources��������������������������������������������������������������������������    8 1.4.3 From a Lone Professional to a Member of a Healthcare Team����������������������������������������������������������������������������������    9 1.4.4 Change in the Public’s Trust in Health Services ��������������    9 1.5 Medical Education��������������������������������������������������������������������������    9 References��������������������������������������������������������������������������������������������������   10

2

 ommunicating with Patients����������������������������������������������������������������   11 C 2.1 Introduction������������������������������������������������������������������������������������   11 2.2 Learning How to Talk with Patients������������������������������������������������   12 2.3 Teaching How to Talk to Patients ��������������������������������������������������   15 2.4 Coping with Barriers to Learning and Teaching Patient Interviewing������������������������������������������������������������������������������������   18 2.4.1 Learning Objectives and General Approaches to Achieving Them����������������������������������������������������������������   18 2.4.2 The Integrated Learner- and Teacher-Centered Approach������������������������������������������������������������������������������  19 xi

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2.4.3 Shifts in Teaching Patient Interviewing����������������������������   20 2.4.4 Assessment of Communication Skills ������������������������������   21 2.5 Proposed Teaching Program ����������������������������������������������������������   22 2.5.1 Step I: The Problem����������������������������������������������������������   22 2.5.2 Step II: Discussion of Possible Solutions��������������������������   23 2.5.3 Step III: Demonstration of Various Interviewing Techniques and Discussion of Their Advantages and Disadvantages��������������������������������������������������������������������   26 2.5.4 Step IV: Supervised Practice ��������������������������������������������   28 2.5.5 Advantages of the Proposed Approach������������������������������   29 2.6 Barriers to Doctor–Patient Communication������������������������������������   30 2.6.1 Doctor–Patient Differences in Age, Race, Gender, Language, and Socioeconomic Status: Underprivileged Patients������������������������������������������������������������������������������   31 2.6.2 Mismatch Between the Patient’s and the Doctor’s Preferences������������������������������������������������������������������������   31 2.6.3 Doctors’ Failure to Gain Insight into the Patient’s Concerns����������������������������������������������������������������������������   32 2.6.4 Interviewing Habits That May Discourage Patients from Sharing Their Concerns��������������������������������������������   33 2.6.5 Angry Patients ������������������������������������������������������������������   34 2.7 Coping with Barriers to Communication with Patients������������������   35 2.7.1 Language Mismatches ������������������������������������������������������   35 2.7.2 Doctors’ Self-Awareness ��������������������������������������������������   35 2.7.3 Encouraging Patients to Share Their Concerns ����������������   36 2.7.4 Management of Patient Aggression����������������������������������   36 2.8 Shared Decision-Making����������������������������������������������������������������   37 2.8.1 Teaching Shared Decision-Making ����������������������������������   37 2.8.2 Proposed Learning Objectives of Shared DecisionMaking������������������������������������������������������������������������������   38 2.9 Patient Counseling��������������������������������������������������������������������������   42 2.10 Patients’ Adherence to Doctors’ Advice ����������������������������������������   44 2.10.1 Estimating Patients’ Adherence to Doctors’ Recommendations ������������������������������������������������������������   45 2.10.2 Reasons for Nonadherence������������������������������������������������   45 2.10.3 Ways to Improve Patient Adherence����������������������������������   46 2.11 Managing Difficult Encounters and Delivering Bad News������������   46 2.11.1 Patients’ Preferences����������������������������������������������������������   47 2.11.2 Care-Providers’ Preferences����������������������������������������������   47 2.11.3 Suggested Guidelines��������������������������������������������������������   48 2.11.4 Teaching How to Disclose Bad News�������������������������������   50 References��������������������������������������������������������������������������������������������������   50 3

 he Physical Examination����������������������������������������������������������������������   59 T 3.1 Introduction������������������������������������������������������������������������������������   59 3.2 Barriers to Teaching and Learning Physical Examination Skills����   60

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3.2.1 Attitudes to the Physical Examination������������������������������   60 3.2.2 “Inherited” Errors��������������������������������������������������������������   60 3.3 Coping with Barriers to Learning the Physical Examination ��������   61 3.3.1 Teaching the Reflective Physical Examination������������������   61 3.3.2 Learning for Mastery��������������������������������������������������������   63 3.3.3 Integrating Hand-Held Devices into Teaching the Physical Examination��������������������������������������������������������   63 3.3.4 Teaching Physical Signs by Context and Importance�������   64 3.3.5 Use of Simulations������������������������������������������������������������   71 3.4 Diagnostic Utility of the Physical Examination and Ancillary Tests������������������������������������������������������������������������������������������������   72 3.4.1 Test Properties ������������������������������������������������������������������   73 3.4.2 Sources of Bias in Determining the Validity of Diagnostic Tests����������������������������������������������������������������   74 3.4.3 Clinical Prediction Rules��������������������������������������������������   75 3.4.4 Assessment of the Pretest Probability of a Disease����������   75 References��������������������������������������������������������������������������������������������������   76 4

 Recording the Clinical Database������������������������������������������������������������   79 4.1 Introduction������������������������������������������������������������������������������������   79 4.2 The Problem-Oriented Record��������������������������������������������������������   80 4.3 The Electronic Medical Record������������������������������������������������������   81 4.4 Teaching the Recording of the Clinical Database��������������������������   82 4.4.1 The Personal and Psychosocial History����������������������������   83 4.4.2 Chief Complaint����������������������������������������������������������������   83 4.4.3 Symptoms��������������������������������������������������������������������������   84 4.4.4 Problems����������������������������������������������������������������������������   84 4.4.5 Statement of the Patient’s Present Problem(S)������������������   85 4.4.6 Statement of the Present Problem(S) (Continued)������������   85 4.4.7 Statement of the Present Problem(S) (Continued)������������   85 4.4.8 Listing Active and Inactive Problems, Past and Family History, Review of Systems����������������������������������������������   86 4.5 Common Errors in Recording the History of a Patient’s Present Illness ��������������������������������������������������������������������������������   86 4.5.1 Overemphasis on Objective History Data ������������������������   87 4.5.2 Inadequate Description of the Patient’s Symptoms����������   88 4.5.3 Failure to Identify Main Symptoms����������������������������������   88 4.5.4 Unclear Presentation of Chronological Evolution of Symptoms��������������������������������������������������������������������������   89 4.6 Providing Feedback on Students’ Records of a Patient’s History��������������������������������������������������������������������������������������������   89 References��������������������������������������������������������������������������������������������������   91

5

Clinical Reasoning ����������������������������������������������������������������������������������   93 5.1 Introduction������������������������������������������������������������������������������������   93 5.2 Reasoning Strategies of Experienced Clinicians����������������������������   94

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5.2.1 Pattern Recognition and Hypothetico-Deduction��������������   94 5.2.2 Additional Paths of Clinical Reasoning����������������������������   95 5.2.3 Cognitive Task Analysis����������������������������������������������������   96 5.3 Heuristics and Biases in Clinical Reasoning����������������������������������   96 5.4 Barriers to Learning Clinical Reasoning����������������������������������������   96 5.5 Teaching and Assessing Clinical Reasoning����������������������������������   98 5.5.1 Learning Objectives����������������������������������������������������������   98 5.5.2 Assessment������������������������������������������������������������������������   98 5.6 Decision Support����������������������������������������������������������������������������   99 5.6.1 Decision Analysis��������������������������������������������������������������   99 5.6.2 Evidence-Based Medicine ������������������������������������������������  102 5.7 Interpretation of Research Findings������������������������������������������������  103 References��������������������������������������������������������������������������������������������������  105 6

 The Behavioral and Social Sciences in Medical Education������������������  109 6.1 Introduction������������������������������������������������������������������������������������  109 6.1.1 Stress and Stressors ����������������������������������������������������������  109 6.1.2 Psychological Distress������������������������������������������������������  110 6.1.3 Life Events������������������������������������������������������������������������  110 6.1.4 Social Support ������������������������������������������������������������������  111 6.1.5 Socio-Economic Status������������������������������������������������������  111 6.1.6 Personality Traits ��������������������������������������������������������������  112 6.2 Barriers to Teaching the Behavioral and Social Sciences��������������  113 6.3 Overcoming Barriers to Student Learning��������������������������������������  114 6.3.1 Risk for Disease and Ability to Cope with It: The Patient’s Personal/Psychosocial History��������������������  114 6.3.2 Implications for Clinical Practice��������������������������������������  118 6.3.3 Who Should Teach Medical Students the Clinically Relevant Aspects of the Behavioral and Social Sciences? ��������������������������������������������������������������������������  119 References��������������������������������������������������������������������������������������������������  120

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 Medical Errors and Quality Assurance of Healthcare ������������������������  125 7.1 Introduction������������������������������������������������������������������������������������  125 7.2 Medical Errors��������������������������������������������������������������������������������  125 7.2.1 Prevalence of Medical Error and Doctors’ Attitude to Mistakes����������������������������������������������������������������������������  126 7.2.2 Prevention of Medical Errors��������������������������������������������  127 7.2.3 Patients’ Complaints and Medical Litigation��������������������  128 7.2.4 Disclosure of Medical Errors to Patients��������������������������  129 7.3 Incapacitated Doctors����������������������������������������������������������������������  130 7.3.1 Incidence����������������������������������������������������������������������������  130 7.3.2 Response to the Awareness of Doctors’ Dysfunction��������  131 7.3.3 Dealing with Doctors’ Dysfunction����������������������������������  132

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7.4 Quality Assurance of Healthcare����������������������������������������������������  133 7.4.1 Physicians’ Attitudes to Quality Assurance of Healthcare��������������������������������������������������������������������������  133 7.4.2 Promoting Physician Support for Quality Assurance in Healthcare����������������������������������������������������������������������  135 7.4.3 Promoting Physician Self-Disclosure of Errors����������������  135 References��������������������������������������������������������������������������������������������������  136 8

Shifts in the Structure of Health Care and Doctor–Society Relations����������������������������������������������������������������������������������������������������  141 8.1 Introduction������������������������������������������������������������������������������������  141 8.2 Managed Care ��������������������������������������������������������������������������������  141 8.2.1 Bureaucracy: Definition and Negative Connotations��������  142 8.2.2 Desirable Facets of Managed Care������������������������������������  142 8.3 Fair Distribution of Healthcare Resources��������������������������������������  144 8.3.1 Fair Distribution of Resources: Ethical Dilemmas������������  144 8.3.2 Controversial Norms����������������������������������������������������������  146 8.3.3 The Need for a Policy of Rationing Resources ����������������  147 8.3.4 Implementing a Policy for Fair Allocation of Medical Resources��������������������������������������������������������������������������  148 8.4 Trust in Medicine����������������������������������������������������������������������������  149 8.4.1 Decline in Patient Confidence in Health Care ������������������  149 8.4.2 Possible Reasons for the Decline of Trust in Health ��������  150 8.4.3 Impact of Changes in the Status of the Physician in Society ������������������������������������������������������������������������������  151 8.5 Medicine and the Media������������������������������������������������������������������  151 8.5.1 Media Coverage of Medical Issues: Targets����������������������  152 8.5.2 Media Coverage of Medical Issues: Biases����������������������  153 8.5.3 Medical Recommendations in the Media��������������������������  154 References��������������������������������������������������������������������������������������������������  155

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 Changes in Medical Education ��������������������������������������������������������������  159 9.1 Ongoing Changes in Medical Education����������������������������������������  159 9.1.1 From Memorization to Self-Directed Learning and Information Management��������������������������������������������������  159 9.1.2 From Knowledge to Competency-Based Education���������  160 9.1.3 From the Biomedical Model to Engel’s Bio-Psycho-­Social Model for Clinical Reasoning and Practice ����������������������������������������������������������������������  160 9.1.4 From Intuitive to Analytic Decision-Making��������������������  160 9.1.5 From Hospital to Community Settings������������������������������  161 9.1.6 External Reviews of Teaching and Accreditation of Medical Schools����������������������������������������������������������������  162 9.1.7 Quality Assurance of Patient Care������������������������������������  162

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9.2 Challenges of Medical Education ��������������������������������������������������  163 9.2.1 Promoting Student Well-being������������������������������������������  163 9.2.2 Personalizing Medical Education and Reducing Its Duration����������������������������������������������������������������������������  164 9.2.3 Selection of Applicants for Medical Training ������������������  165 References��������������������������������������������������������������������������������������������������  166 Index�������������������������������������������������������������������������������������������������������������������� 169

Chapter 1

Paradigmatic Shifts in the Theory, Practice, and Teaching of Medicine Since the 1970s

1.1 Introduction The main difference between what I was taught in medical school in the 1950s and health care today is the increase in medical knowledge and biotechnology. But apart from this increase, physicians have adopted professional standards that would have been considered heretical two generations ago, and what was right in the 1950s became wrong by the end of the twentieth century. These changes took place when I was a resident and attending physician from the 1960s to the 1980s, and they led to controversy between those who upheld traditional patient care values and those who embraced the new professional norms. In this section, I list the changes in physician–patient relationships, clinical reasoning, healthcare delivery, and medical education that have occurred since the 1970s (Table  1.1). Insight into these changes can help students navigate their learning environment and understand issues such as patient involvement in care, evidence-­ based medicine, clinical guidelines, and healthcare delivery.

1.2 Doctor–Patient Relations (See Chap. 2) The shift in doctor–patient relations was from physicians’ paternalism to respect for patient autonomy. In the 1950s, physicians rarely shared health-related information with their patients and seldom involved patients in clinical decisions. A 1961 survey Previous versions of parts of this section were published in: Benbassat J. Paradigmatic shifts in clinical practice in the past 40 years. Harefuah. 1996;130:585–9 (Hebrew). With permission from Harefuah. Benbassat J. Changes in clinical reasoning and practice during the last forty years. In: Chinitz DP, editor. The changing face of health systems. Jerusalem: Gefen Publishing House; 2002. With permission from Gefen Publishing. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Benbassat, Teaching Professional Attitudes and Basic Clinical Skills to Medical Students, https://doi.org/10.1007/978-3-031-26542-6_1

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1  Paradigmatic Shifts in the Theory, Practice, and Teaching of Medicine Since the 1970s

Table 1.1  Summary of the changes in the theory and practice of medicine since the 1970s From Doctor–patient relations Doctors’ paternalism Disclosure of information at the doctors’ discretion No patient access to their medical records Disease-orientation Patients as passive recipients of care Clinical reasoning Denial of clinical uncertainty Intuitive decision-making Decisions based on unsystematic experience and pathophysiologic rationale Biomedical model of clinical practice Doctor–society relations Unrestricted use of resources Loyalty to the patient at hand Solo practice High doctors’ prestige Accountability to peers Doctors only rarely sued for errors Medical Education Knowledge of subject matter Teaching by lectures Unsystematic acquisition of skills by imitating role models Patient interviewing considered an elementary skill that does not need instruction A belief that clinical decision-making is subject to “intuition” or the “art of medicine” Medical errors deemed exceptional, attributed to “bad apples,” and discussed in closed medical conferences Orientation to biomedicine In-hospital clinical training Encouraging competition among students Accountability of teaching to the faculty governance

To Respect for patient autonomy Patients are entitled to receive information and be involved in decisions about their management Patients encouraged to see their medical records Patient-orientation Patients as partners in self-care Acceptance of clinical uncertainty Analytic decision-making Evidence-based reasoning Bio-psycho-social model of clinical practice Parsimonious use of resources Loyalty to all patients Managed care A decline in doctors’ prestige Accountability to lay institutions Litigation of institutions and doctors Ability to retrieve information and apply it in real-time Self-directed learning: reading assignments, use of electronic databases, and learning software Systematic acquisition of skills by supervised practice and simulations Structured instruction for patient interviewing

Demystification of the “art of medicine.” Teaching clinical reasoning, Bayesian inference from diagnostic tests, and evidence-based medicine Awareness of the ubiquity of medical errors, and efforts to reduce them by adhering to quality assurance of care and patient safety Inclusion of the social and behavioral sciences into teaching programs Clinical training in community medical settings Emphasis on teamwork and group assignments Accreditation and re-accreditation of the medical school by external reviews

1.2  Doctor–Patient Relations

3

found that 90% of U.S. physicians reported they did not tell the truth to patients with malignancies [1]. Medical students frequently observed physicians telling patients with malignancies that they had inflammation and witnessed clinical experiments performed without the patient’s consent. I am aware that while deception can be excused as a misguided attempt to protect patients, there is no justification for experimenting on people without their consent. Nevertheless, both examples reflect the belief that physicians knew better. This belief had dominated medical practice for more than 2000 years. Hippocrates advocated “hiding most things from the patient ... [and] to reveal nothing about the patient’s future or present condition” [2]. Oliver Wendell Holmes was quoted in his graduation speech at medical school in 1871 as saying, “Your patient has no more right to the whole truth you know than he has to all the medicines in your handbag....” [3]. However, since the 1970s, respect for patient autonomy has become part of the ethical doctrine of clinical practice, and today the recommended model of clinical practice involves both physicians and patients in clinical decision-making. The change in physician–patient relations since the 1970s occurred on several levels. On a conceptual level, the medical code of ethics added “respect the patient’s autonomy” to the already existing “do no harm” and “do good.” At the legal level, society recognized the right of patients to participate in decisions about their treatment, and many countries legislated for informed patient consent for medical interventions. On a practical level, the change promoted a counseling style of shared decision-making, in which patients share their wishes and knowledge about their problems, while physicians explain possible courses of action. In the past, patients were not allowed to review their medical records. Today, patients are not only encouraged to view their records but they are also allowed to enter their notes [4]. At the research level, doctor–patient relationships became a legitimate topic for study in the behavioral, social, and medical sciences. Finally, since the 1970s, communication with patients became an important component of undergraduate medical education, which will be discussed in more detail in Sect. 2. I am not sure what led to this change. Possible causes could be the introduction of treatment methods that require patient cooperation; surveys indicating that most patients want to be informed about their illness; or the general feeling that doctors’ paternalism, however well-intentioned, creates dependency, which is at odds with today’s focus on respect for the dignity of the individual. Whatever the cause, the change caused physicians to consider not only what patients needed, but also what they wanted. The disease orientation in the 1950s changed to a patient orientation. This orientation led to the realization that patients and physicians often disagree on the choice of alternative treatments. In the 1950s, the goal of treatment was to prolong the patient’s life. Today, physicians consider patients’ wishes regarding the quality of life, even if they reduce the chances of survival. In the 1950s, doctors believed patients were too fearful to trust them to take their blood pressure. Today, by contrast, patients with diabetes are taught how to adjust their insulin treatment to their self-measured blood glucose levels, and patients with bronchial asthma are taught to adjust their corticosteroid medication to their self-tested lung function. From a passive recipient of treatment, the patient became a partner in self-treatment.

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1  Paradigmatic Shifts in the Theory, Practice, and Teaching of Medicine Since the 1970s

1.3 Clinical Reasoning (See Also Chap. 5) Throughout history, clinical thinking has turned to theoretical models to understand disease, derive treatments, and gain further knowledge. As long as these models satisfy clinical needs and are consistent with experience, they are used to guide practice. Modification of the model occurs only when it can no longer accommodate new data [5]. In other words, theory informs practice, and feedback from practice modifies theoretical constructs. Observed inconsistencies between theory and experience should not be viewed as a source of confusion, but rather as an opportunity for investigation. Hippocrates’ humoral model dominated medical thinking for about two millennia. It assumed the existence of four humors and viewed disease as an imbalance between them due to heredity, diet, lifestyle, or weather. Treatment was an attempt to restore stability through bloodletting, purgatives, and emetics, and these measures were the standards of treatment until the nineteenth century. However, the humoral model could not accommodate the discoveries of infectious pathogens and vitamin deficiencies. This led to the emergence of the biomedical model, which now governs medical education, clinical practice, and research. Like the humoral model, the biomedical model is based on causal reasoning that leads from disorders of the organism, conceived as causes, to manifestations of the disease, conceived as effects. However, the models differ in the way they define the causes of disease: The biomedical model describes disease manifestations as resulting from observable structural or biochemical disturbances rather than imbalances between hypothetical bodily fluids. The biomedical model assumes that all diseases can be described as biochemical or structural disorders, that every disease has a single (“etiological”) cause, and that treatment is an attempt to eliminate that cause by pharmacological or physical (surgical, radiological) means. This model must certainly be credited for the unprecedented advances in patient care during the twentieth century. Since the 1960s, however, its premises seem to be incompatible with some clinical observations. This has led to several changes in clinical reasoning, notably a shift from denial to acceptance of uncertainty, from intuitive to analytic decision-making, and from the biomedical to the bio-psycho-social model of clinical practice,

1.3.1 From Denial to Acceptance of Uncertainty The biomedical model assumes that etiological factors inevitably lead to disease. Within this model, chance and uncertainty play a very minor role. In the 1950s, physicians downplayed concepts such as probability and inference from epidemiological data. The conventional wisdom was that epidemiology deals with populations and, as such, is incompatible with clinical medicine, which deals with individuals. The 1965 edition of DeGowin’s Introduction to Clinical Medicine

1.3  Clinical Reasoning

5

stated that “... statistical methods can only be applied to a population of thousands ... [T]he relative incidence of two diseases is completely irrelevant to ... diagnosis. A patient either has or has not a disease” [6]. My tutors also rejected the use of statistical inference in clinical practice, saying, “No one is 70% pregnant” and “Each patient is unique; I learn more from a single case than from epidemiologic studies of a thousand patients.” The deterministic reasoning of the biomedical model also downplayed the concept of uncertainty. I was taught that “nothing is left to chance if the patient is worked up properly.” As late as the 1980s, it was claimed that students were encouraged to ignore uncertainty rather than deal with it [7]; a 1992 review of the sociological literature concluded that denial of uncertainty was one of the most consistent observations of sociologists studying medical education [8]; and as recently as 2021, tolerance of ambiguity was found to decrease during undergraduate medical education [9]. The first indications that this deterministic approach might be inadequate were observations that conditions, like diabetes and smoking, increased the risk of ischemic heart disease, although they were not etiologic agents of atheromatosis. These observations suggested that disease was not the result of a single cause, but rather of a convergence of risk factors. Today, we speak of risk indicators rather than etiologic causes; a patient is more or less likely to have a disease, rather than either have it or not. Subsequent editions of DeGowin’s Diagnostic Examination endorsed the application of statistics to individual patients, and the 2020 edition states that “knowledge, understanding of clinical epidemiology, and experience are necessary to determine when the pursuit of specific symptoms and signs is warranted” [10]. There was a shift in physicians’ attitudes toward diagnostic testing. In the 1950s, teaching emphasized the importance of thoroughly taking a patient’s history and physical and other data. Physicians believed that the more data collected, the greater the chances of a correct diagnosis and that early detection of disease always increased the chances of cure. Therefore, students were required to perform a thorough review of systems and a head-to-toe physical examination. Today, we know that false-positive test results can complicate diagnosis. Therefore, we are selective in our choice of diagnostic tests and in screening asymptomatic individuals for early disease. Paradoxically, the increase in biomedical knowledge increased awareness of its limitations and led to a transition from right/wrong determinism to acceptance of chance and uncertainty in clinical practice.

1.3.2 From Intuitive to Analytic Decision-Making Webster defines “intuition” as a perception that is independent of reasoning. A judgment is said to be intuitive if it is made quickly and without apparent effort. In medicine, the term “intuition” has acquired several meanings. The first equates intuition with the ability to recognize patterns of disease manifestations. The second meaning of intuition refers to judgments that result from simplifying heuristics (mental shortcuts). Finally, the term intuition is used to refer to mastery of the “art of medicine,”

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1  Paradigmatic Shifts in the Theory, Practice, and Teaching of Medicine Since the 1970s

that is, a mystical ability to make clinical decisions that defy analysis or explanation. To avoid confusion, I use the terms “pattern recognition” to refer to the ability to recognize patterns of disease manifestations, “heuristics” to refer to cognitive shortcuts, and “intuitive thinking” or “art of medicine” to refer to the ability to make quick decisions that defy explanation. In the 1950s, intuitive thinking was characterized by confidence in its accuracy. Statements by experienced physicians beginning with “in my judgment” signified the conclusion of a clinical debate. Such authoritarian attitudes are difficult to understand in today’s climate of evidence-based practice. To understand physicians’ belief in the “art of medicine,” one must consider its strengths. First, the belief that there is absolute truth is extremely alluring in the indeterminate realm of clinical practice. Conformity to authority has been identified as a means by which medical students and residents control the anxiety caused by the complexity of clinical practice [11]. Second, intuitive thinking satisfied clinical needs. In the 1950s, physicians were unaware that anything was wrong with clinical decision-making or that it needed improvement. Today, however, clinical decision-making has become more complicated. The number of diagnostic and therapeutic options has increased, and choosing among them is no longer easy, even for experienced clinicians. Clinicians must weigh the benefits of interventions against their risks: the risk of false-positive or false-­negative diagnostic test results and the risk of adverse side effects from treatment. Healthcare spending has increased, and this necessitates considering the trade-off between cost and effectiveness. In today’s reality of unlimited demand and finite resources, economic evaluation is increasingly being used to inform healthcare decisions. Finally, physicians must weigh conflicting values. The medical code of ethics has expanded to include not only the principles of nonmaleficence (“do not harm”) and beneficence (“do good”) but also “respect for patient autonomy” and justice (fair distribution of health care resources to those who need them). Thus, physicians today are much more frequently confronted with ethical dilemmas, i.e., they find themselves in situations in which they cannot adhere to one ethical principle without violating another. These trade-offs can no longer be resolved by intuitive reasoning: First, the claim that the “art of medicine” defies explanation is no longer acceptable when patients, students, colleagues, and courts ask us to justify our decisions. Second, judgments based on simplifying heuristics can be distorted by cognitive biases. Therefore, since the 1970s, there have been ongoing efforts to gain insight into the reasoning of clinical experts and to base clinical decision-making on a critical assessment of risks and benefits.

1.3.3 From Pathophysiologic Rationale to Evidence-Based Reasoning Another assumption of the biomedical model was that patient care should be derived from the etiology and pathophysiology of the disease. In the 1950s, the treatment of patients with left ventricular failure was justified by the positive inotropic effect of

1.4  Doctor–Society Relations

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digitalis on the myocardium. Treating patients with peptic ulcers with aluminum salts was derived from their acid-inhibiting effect. Today, however, physicians are aware that pathophysiologic rationale does not always lead to the expected results. Consequently, there is a growing tendency to base clinical practice on empirical evidence, and in 1992, Guyatt et  al. coined the term “evidence-based medicine” (EBM) [12]. Unlike the traditional paradigm, EBM posits that intuition, nonsystematic experience, and pathophysiologic rationale are insufficient for clinical decision-making. EBM places less value on authority and emphasizes the value of evidence from clinical research. We have moved from deductive reasoning to evidence-based reasoning: Treatment of heart failure with digitalis and treatment of peptic ulcer with antacids are justified not by expected physiological effects but by evidence from clinical trials.

1.3.4 From the Biomedical to the Bio-psycho-social Model of Clinical Practice (See Also Chap. 6) The main flaw of the biomedical model was the assumption that all diseases were structural or biochemical dysfunctions of the body that could only be treated by surgical or pharmacological means. This assumption excluded the characteristics of the patient as a person. There were indeed attempts as early as the 1930s to associate personality types with diseases such as peptic ulcer or bronchial asthma. However, these attempts were mostly based on anecdotal observations. In the 1950s, the prevailing attitude toward psychosomatic medicine was one of distrust. This attitude changed when it was demonstrated that there was a relationship between life events and morbidity and between socioeconomic status (income, education, and housing) and mortality. These findings led to the recognition that some risk indicators for disease could be described as psychosocial and to the adoption of Engel’s bio-psycho-social model for clinical reasoning and practice [13]. This model encourages clinicians to consider the biomedical and psychosocial components of a patient’s predicament and to support and treat both.

1.4 Doctor–Society Relations (See Also Chap. 8) Medical care today offers more effective clinical interventions than ever before. Yet it appears that the privileged status of the medical profession in the twentieth century has declined with an erosion of trust in medical care. This erosion is cause for concern. Distrust promotes litigation and defensive medicine, forcing the healthcare system to divert some of its resources from treatment to self-protection. One of the current challenges is to define the boundary between constructive criticism of health care and destructive distrust.

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The erosion of trust in the medical profession has been associated with several shifts in clinical practice, namely from accountability to colleagues to accountability to lay institutions, from unrestricted to controlled use of resources, and from a lone practitioner to a member of a healthcare team.

1.4.1 From Accountability to Peers to Accountability to Laymen and Lay Institutions In the 1950s, medical errors were thought to be rare and caused by a minority of negligent physicians (“bad apples”). The topic was rarely discussed, and when it was, errors were dealt with in closed sessions. Since the 1970s, however, there has been a rising tide of medical negligence litigation, and physicians are being held accountable not only to their colleagues but also to lay institutions. The high frequency of errors [14] led to the realization that all physicians can make mistakes, and like other professions, medicine began to implement quality control methods. Quality control is based on the recognition that the threat of punitive action does not deter errors. Therefore, the question of “who made the mistake?” is replaced by an effort to determine “why the mistake occurred?” Rather than eliminating poor performers, the goal is to make health care as error-free as possible [15]. To find out why the error occurred, physicians must report any error, whether or not it harmed a patient or even any circumstance in the clinical setting that may lead to errors. A policy of transparency can be effective not only for quality control but also to improve the doctor–patient relationship and even reduce litigation costs [16].

1.4.2 From an Unrestricted to a Parsimonious Use of Resources In the 1950s, a call to reduce healthcare costs would have been viewed as a denial of the sanctity of human life. However, later, the escalating healthcare costs imposed a controlled distribution of resources and today calls for parsimony are no longer rejected as unethical. Accordingly, the code of medical ethics was expanded to accommodate the requirement of distributive justice. All too often, distributive justice is perceived as a novel requirement for doctors to split their loyalty between their patients and their employers. Yet, although it was introduced into the ethical code only in the 1970s, this principle has always guided clinical practice. Doctors have always attempted to distribute their time between patients fairly, according to their needs; the choice of antibiotic therapy has always been guided not only by the needs of the patient at hand but also by the objective of reducing the generation of resistant strains of bacteria, which may harm other patients. A parsimonious use of resources does not demand that doctors split their loyalty between patient and employer, but between the patient at hand and other patients.

1.5  Medical Education

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1.4.3 From a Lone Professional to a Member of a Healthcare Team In the 1950s, medical care was provided in a one-patient–one doctor setting and medical administrators rarely interfered with clinical decisions. In the 1970s, the rising cost of health care led to a transition from a solo practice to what we call today managed care. Initially, its objective was cost containment. But later it evolved into a complex bureaucracy in which physicians are no longer the sole decision-­ makers. They must listen to consultants and other care providers on the team; they must consider patient preferences, and they must function within the confines of the policy of their institution. Managed care is viewed by many as a bureaucracy, with all of its negative connotations.

1.4.4 Change in the Public’s Trust in Health Services Patients place their trust in institutions (social trust) and doctors (personal trust) [17]. Trust in institutions is mainly determined by the media and prevailing informal opinions. Personal trust is largely determined by the physician’s interpersonal skills, his or her concern for the patient’s welfare, his or her empathy, and the extent to which the physician lives up to the expectation of standing by the patient’s side and representing and protecting his or her interests vis-à-vis health insurance companies. Patients give high priority to the belief that the physician is committed to safeguarding their interests. While appearing to understand the limitations of resource utilization, they expect full disclosure of what they need and what they are entitled to from their health insurance [18].

1.5 Medical Education (See Also Chap. 9) The claim that medical schools are resisting change is only partially justified. Since the 1950s, many medical schools have adopted problem-based learning, student exposure to patients from the beginning of medical school, and the objective structured clinical examination (OSCE). Teaching emphasizes information retrieval skills, the use of simulations, clinical reasoning, and behavioral and social sciences. The expansion of medical knowledge and biotechnology has led to a shift from an emphasis on memorization to the ability to self-directed learning and retrieve information in real-time from data stores. Unsystematic learning of clinical skills has evolved toward supervised patient interviewing, resuscitation, clinical reasoning, and the ability to collaborate with others. Finally, some medical schools have replaced rotating clerkships in hospital departments with integrated clerkships that provide 6–12 months of training in a single general practice setting.

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References 1. Oken D. What to tell cancer patients. JAMA. 1961;175:1120–8. 2. Lloyd GER, editor. Hippocrates. ‘Prognosis’ in hippocratic writings. Penguin classics. London: Penguin Books; 1978. As quoted by: Fallowfield LJ, Jenkins VA. Truth may hurt but deceit hurts more: communication in palliative care. Palliative Medicine. 2002;16:297–303. 3. Cone TE Jr. Oliver Wendell on telling the patient the whole truth. Pediatrics. 1982;69:528. 4. Leroy MC, Dupuis M. Patients’ direct access to their electronic medical record using the internet: a literature review. Ramon Llull J Appl Ethics. 2014;5:9–22. 5. Kuhn TS. The structure of scientific revolutions. Chicago: Chicago University; 1970. 6. DeGowin EL. Bedside diagnostic examination. 1st ed. New York: Macmillan; 1965. 7. Atkinson P. Training for certainty. Soc Sci Med. 1984;19:949–56. 8. Gerrity MS, Earp JAL, DeVellis RF, Light DW. Uncertainty and professional work: perception of physicians in clinical practice. Am J Soc. 1992;97:1022–51. 9. Borracci RA, Ciambrone G, Arribalzaga EB. Tolerance for uncertainty, personality traits and specialty choice among medical students. J Surg Educ. 2021;78:1885–95. 10. Suneja M, Szot JF, RF LB, Brown DD, editors. DeGowin’s diagnostic examination, 11th edition. New York: McGraw Hill; 2020. 11. Farnan JM, Johnson JK, Meltzer DO, Humphrey HJ, Arora VM.  Resident uncertainty in clinical decision making and impact on patient care: a qualitative study. BMJ Qual Saf. 2008;17:122–6. 12. Guyatt G, The Evidence-Based Medicine Working Group. Evidence-based medicine. A new approach to teaching the practice of medicine. JAMA. 1992;268:2420–5. 13. Engel GL.  The need for a new medical model. A challenge to biomedicine. Science. 1977;196:129–36. 14. Makary MA, Daniel M.  Medical error—the third leading cause of death in the US. BMJ. 2016;353:i2139. 15. Berwick DM. Continuous improvement as an ideal in health care. N Engl J Med. 1989;320:53–6. 16. Leape LL. A conspiracy of silence: disclosure, apology, and restitution. In: Making healthcare safe. Cham: Springer; 2021. p. 293–317. 17. Hall MA, Dugan E, Zheng B, Mishra AK. Trust in physicians and medical institutions: what is it, can it be measured, and does it matter? Milbank Q. 2001;79:613–39. 18. Mechanic D. The functions and limitations of trust in the provision of medical care. J Health Polit Policy Law. 1998;23:661–86.

Chapter 2

Communicating with Patients

2.1 Introduction My first encounter with a patient made me doubt whether I had chosen the right profession. It happened during the preclinical physical examination course in the fourth of my medical school’s 6-year program. I introduced myself, asked my first question, and dried off. The patient was a friendly lady of about 50 years. When she noticed my embarrassment, she tried to fill in the void by asking about me. I suspect that by the end of the encounter she knew more about me than I knew about her. The recognition that students need help learning how to communicate with patients is a recent development in medical education. Although history taking has always been considered essential to clinical practice, it took a long time for patient interviewing to be incorporated into undergraduate medical education. As late as the 1960s, talking to patients was considered a simple endeavor that did not merit instruction. The 1957 edition of Kampmeier’s textbook on physical examination devoted 3 pages to interviewing patients, 14 pages to recording the history, and 700 pages to physical examination [1]. My only preparation for the first encounter with a patient consisted of a single lecture on the content and structure of the record of the patient’s history. During my clinical rotations, my tutors strove to improve my presentations of the patient history, but like many in my generation, I completed my training without ever having interviewed patients under the supervision of an experienced physician. This attitude changed in 1969 when Morgan and Engel [2] argued that interviewing patients was a neglected skill. Since then, all medical schools offer programs aimed at teaching a communication style that promotes patient-centered care. I use the phrase “communication style” as an all-inclusive term for interviewing techniques (open vs. closed questions), focus (patient vs. illness), habits (active listening), and implicit values (caring, empathy, and respect). “Patient-centered care” is an orientation to the patient’s needs rather than the physician’s agenda. It moves from professional control to patient empowerment. In addition to data collection, its © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Benbassat, Teaching Professional Attitudes and Basic Clinical Skills to Medical Students, https://doi.org/10.1007/978-3-031-26542-6_2

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goals include building relationships and negotiating management decisions that promote the patient’s health while showing respect for the patient. Patient-centered care has been associated with patient satisfaction and self-­ management [3]. Clinician behaviors associated with desirable health outcomes include empathy, reassurance, support, explanations, humor, sharing information, summarizing and clarifying, head nodding, leaning forward, direct body alignment, and uncrossed legs and arms [4]. A 2017 review of the literature found that physician–patient relationships in general and patient education are associated with better health outcomes and reduced healthcare costs [5]. After viewing recorded medical encounters, lay observers commented positively on physicians’ affective communication, competence, and confidence and criticized contrary behavior and repetition. No other communication style elicited positive or negative assessments thereby challenging the idea of general communication guidelines and suggesting that communication approaches should be customized to the individual patient [6]. Patient-centered communication skills are teachable. Teaching improves students’ data collection skills [7], ability to ask fewer closed questions, and provide more empathetic responses [8]. However, as recently as the 2000s, surveys showed difficulties in learning to communicate with patients [9], and a 2010 review of the literature found that medical students’ communication skills deteriorate as they progress through medical school [10]. Moreover, evidence suggests that physicians’ self-perceptions of their communication skills do not match their patients’ perceptions. In other words, physicians and patients may agree on core competencies related to physicians’ communication skills, but they may disagree on the actual presence of these skills. Patients’ assessments of physicians’ communication skills differ from experts’ assessments, and both patients’ assessments and experts’ assessments of physicians’ communication skills differ from other physicians’ assessments [11]. The objective of this section is to identify some of the problems in learning how to talk with patients.

2.2 Learning How to Talk with Patients1 At both medical schools where I served, students rated the preclinical patient interviewing teaching programs very positively, probably because they were excited about meeting patients for the first time. However, during the programs and

 Previous versions of parts of this chapter were published in: Benbassat J, Baumal R. Teaching doctor patient interviewing skills using an integrated learner and teacher-centered approach. Am J Med Sci. 2001;322:349–57. With permission from Elsevier. Baumal R, Benbassat J. Current trends in the educational approach for teaching interviewing skills to medical students. Isr Med Ass J. 2008;10:552–5. With permission from the Israel Medical Association. Benbassat J, Baumal R. A proposal for overcoming problems in teaching interviewing skills to medical students. Adv Health Sci Educ. 2009;14:441–50. With permission from Springer. 1

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subsequent clerkships, students also made some comments that reflected their difficulties (Table 2.1). The most common difficulty was dealing with a patient’s expressions of emotion. While demonstrating an interview, I asked a real patient, “Can you tell me more about your family?” In response, the patient described his children and cried while telling us about his deceased wife. After the interview, one student commented, “You should have changed the subject when the patient started crying,” reflecting a common student’s tendency to avoid emotional topics. Other authors have similarly reported that medical students felt uncomfortable dealing with emotional topics [9] and recommended that education should focus on the emotional aspects of patient interactions and support students during initial clinical encounters [13]. A second comment reflected the mixed messages students received from their tutors. Preclinical students were taught to ask open-ended questions (“Tell me about your pain”) and to listen without interrupting the patient’s narrative. However, during their clerkships, they encountered physicians who frequently interrupted Table 2.1  Summary of students’ learning difficulties encountered in programs of interviewing skills at two medical schools in 1993–1995 (adapted from [12] with permission by Elsevier) Students’ comments “You should have changed the subject when the patient started weeping” “What we learn in the course on interviewing skills is not what real medicine is about” “I felt embarrassed to be lectured on how to talk to other people”

Students’ difficulty Source of difficulty Tolerate A fear of upsetting the expressions of patient and getting involved patients’ emotions

“There are so many rules to remember. I am afraid of making mistakes”

Understand multiple and ambiguous interviewing rules

“Only now do I understand what you meant by .... ” “I feel that we have had enough interviewing practice”

Follow verbal instructions and feedback Appreciate the importance of repeated practice sessions

Reconcile inconsistencies between theory and practice

Differences between interviewing styles that were taught and those that were observed

Accept guidelines

A tendency to “force-feed” students through lecture courses

Proposed solution Reassure that an exploration of a patient’s feelings is legitimate Discuss the strengths and weaknesses of various interviewing styles

Challenge students to identify problems, devise solutions, reflect on, and analyze patients’ complaints A feeling of being Empower students to overwhelmed by rules. Fear formulate of appearing foolish interviewing rules and to choose between interviewing styles Over-reliance on verbal Demonstrate explanations; absence of interviewing skills live demonstrations Lack of a coordinated Gradually expose course structure. Absence of students to patients a feeling of progress in the who are difficult to ability to deal with interview problems of increasing complexity

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their patients with closed-ended questions (“Did the pain radiate down your arm?”). The students’ difficulty reconciling these contradictions fueled the feeling that “what we learn about interviewing skills in the course is not what real medicine is about.” Third, students acquire the ability to communicate before they begin their medical studies, and they bring to class the habits that are believed to make a civilized person. Consequently, at least some students felt uncomfortable and even offended when asked to show what appeared to them to be elementary courtesy, such as greeting a patient. This led to comments such as, “I was embarrassed to be lectured about how to talk to people.” Students also seemed unwilling to adopt interviewing guidelines that were inconsistent with their entrenched attitudes. Examples of “counterintuitive” guidelines included asking patients to sustain their narratives rather than interrupting them with closed-ended questions, and waiting for a second or two after a patient stopped talking rather than immediately asking the next question. Fourth, students seemed overwhelmed by the large number of interview rules and systems review items that they had received in lectures and handouts (“There are so many rules to remember”). In many cases, these rules seemed contradictory to them and gave the impression that patient-centered interviewing was bound by guidelines. Their difficulties may have been compounded by the lack of appropriate vocabulary to understand the rules. For example, some tutors defined “physician control of the interview” as an effort to prevent patient digressions, whereas for others it was an attempt to maintain the patient’s narrative. Students’ difficulties in understanding the guidelines may have contributed to their fears of looking foolish during supervised patient interviews. Fifth, students repeatedly commented, “Only now do I understand what you meant by ...” after they had seen me demonstrate an interview with a real patient. This comment underscored the difficulty students had in receiving only verbal guidance or feedback after communicating with patients. Like any other skill, interviewing patients required demonstration: showing students what to do rather than just telling them what to do. The lack of live demonstrations in the teaching programs may have been due to the belief that verbal explanations to students and viewing a recorded interview by a respected clinician were sufficient. It may also have been because there were not enough tutors who felt confident in demonstrating interview techniques. Although clinicians had the necessary experience, they were rarely familiar with patient-centered techniques. Conversely, social scientists were familiar with the literature on patient-centered care but lacked the experience and confidence to interview patients. Finally, some students complained about the repetitive nature of their practice interviews, in which they had to elicit the same information from different patients (“I feel like we have had enough practice interviewing”). Although their tutors dismissed this complaint (“No two patients are alike,” “Practice makes perfect”), this highlighted a major weakness of the program: the lack of structure. Consequently, it failed to create a sense among students that they were making progress in their ability to deal with increasingly complex problems.

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2.3 Teaching How to Talk to Patients Medical education has a 1000-year tradition of teaching anatomy, 300  years of teaching physiology, but only 50 years of teaching communication skills. There is no gold standard for effective doctor–patient communication, and we do not yet know what the optimal teaching approach is. This has led to the current difficulties in teaching patient interviewing (Table 2.2) and a variety of educational programs. I believe that the teaching of communication skills should take into account the differences between the acquisition of interviewing and other clinical skills. First, unlike other skills, such as physical examination, students already have well-formed habits, values, and preconceived notions about interpersonal communication, so they may resist attempts to preach to them how to behave. This is true even when the “preaching” is consistent with their views; it is even more true for attempts to impose anti-intuitive communication rules on them. For example, the natural tendency of each of us is to run away from emotions and prevent patients from expressing them; the communication guide teaches otherwise. The natural tendency of each Table 2.2  Summary of teaching difficulties encountered in programs of interviewing skills at two medical schools in 1993–1995 (adapted from [12] with permission by Elsevier) Problem Students’ disagreement with interviewing rules presented in lectures Inconsistency between disease-­ centered and patient-centered interviewing approaches

Students’ difficulty Students may resist attempts to teach them how to behave

Source of difficulty Students have well-formed habits and preconceived ideas about interpersonal skills Students may reject Students encounter behaviors that are role models with incompatible with the varying approaches to hidden curriculum of interviewing the clinical rotations

Assessment of students’ interviewing skills

Students’ insecurity regarding what they are expected to learn

Students’ positive feedback breeds unjustified complacency among teachers Who should teach patient interviewing?

None

Inconsistency between disease and patient-centered interviewing

Proposed solution Avoid lecturing. Discuss problems and let students devise solutions

Present disease and patient-centered interviewing as legitimate. Discuss their strengths and weaknesses and let students choose among them Absence of a gold Replace the summative standard for patient assessment of students’ interviewing. Some interviewing skills with methods of assessment repeated, one on one, may reinforce formative discussions of undesirable behaviors the observed student’s performance Students’ enthusiasm Focus on students’ for their first meeting critical comments even if with patients they reflect the views of a minority Inconsistency between Appropriate training of role modeling clinical tutors by behaviors teaching workshops

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of us is to interrupt a patient complaining of abdominal pain by asking, “Did you vomit, too?”; the guide teaches us to wait and ask the questions only at the end of the interview. Thus, unlike other clinical skills, interviewing patients may require a change in students’ preconceived habits. Such “reconditioning” is more intellectually demanding than learning new topics [14]. Students may not respond to authoritarian teaching or written handouts for interviewing. They may be bored with “shoulds” that they take for granted (e.g., respect for patients); they may reject “shouldn’ts” that contradict their natural tendencies (e.g., encouraging patients’ emotional expressions); they may resist attempts to impose certain habits on them (e.g., avoiding “why” questions). In some cases, students may even have difficulty understanding interviewing rules taught outside the clinical context. Second, students are often perplexed by the contradiction between the patient-­ centered style taught in preclinical patient interviewing programs and the messages they receive during clerkships. Students and faculty were reported as claiming that preclinical and clinical communication skills curricula were not aligned and that teaching these skills in the wards was rarely explicit and dependent on role models [15]. This theory-practice gap was puzzling at best and led to cynicism at worst. Communication skills tend to decline over time if not regularly practiced [16]. Yet most medical schools offer communication training only during the preclinical years. All too often, clinical tutors have a negative attitude toward communication training and are poor role models. To optimize communication skills learning in practice, it has been proposed to change the work climate to value, support, and reward communication skills teaching and train clinical tutors from all clinical specialties to teach communication skills [17]. Third, several authors have questioned the appropriateness of methods used to assess students’ interviewing skills. These methods consist of observing trainees interviewing standardized or real patients, either during an entire patient interview or during an objective structured clinical examination (OSCE). Observed performance is assessed using checklists or global assessments. However, current evidence suggests significant deficits in faculty direct observation skills [18]. The use of checklists during OSCE has been reported to be well accepted and leads to a change in resident culture [19]. However, the use of checklists during OSCE may be misinterpreted by students as suggesting that they should ask as many disease-­ related questions as possible to obtain checks, thereby reinforcing a disease-­oriented approach to the interview [20]. Finally, students respond positively to any interview skills teaching program because they are eager to meet real patients for the first time. Their positive feedback leads to unwarranted complacency among teachers, and they tend to ignore criticism. One could argue that these problems are not unique to teaching patient interviewing. Physicians differ not only in communication style but also in the performance of other clinical skills; students may have biases not only about

2.3  Teaching How to Talk to Patients

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interviewing but also about other skills; difficulties in assessing students are not limited to interviewing patients. Nevertheless, these problems seem to be particularly pronounced when teaching interviewing. Students have far more preconceptions about interviewing than other skills. I know of no other clinical skill that is practiced so differently by different clinicians as patient interviewing and no other clinical skill whose assessment can reinforce undesirable behaviors. Communication with patients is a clinical skill, and it is only natural that tutors should be clinicians. The advantage of clinicians is their credibility and experience; their disadvantage is that they are not familiar with current knowledge on teaching interviewing. Most clinical instructors consider their personal experience sufficient to teach communication with patients without being familiar with alternative interviewing methods and the advantages and disadvantages of using them. The alternative to clinical instructors is behavioral scientists. Their advantage is knowledge of the theoretical background; their disadvantage is a lack of personal experience and credibility. So, who should instruct students in communication? Clinicians with no theoretical background or sociologists with no experience? I believe that neither of these options is acceptable and that clinical tutors should have additional training in facilitating small group learning [21] and patient interviewing [22]. The goals of such faculty development programs would be to make patient-centered care a dominant competency in all healthcare interactions and relationship-centered communication skills [23]. The tutor would provide students with relevant data, demonstrate relevant skills, and supervise them as they practice these skills with real, simulated, or standardized patients. Tutors should be sufficiently confident in their abilities to demonstrate live interviews with real patients to small groups of students because such demonstrations seem to attract more attention than recorded or standardized physician–patient encounters, which often seem to lack credibility [12, 18]. Since demonstrations are likely to be followed by students’ questions and comments, tutors should be able to discuss their performance with students after the interviews and tolerate possible criticism without giving defensive responses that might unnecessarily turn a productive discourse into a win/lose conflict. Tutors would also help students overcome their initial shyness, inhibitions, and natural reluctance to invade the privacy of others, understand the importance of the interview for identifying the patient’s problems, and teach students appropriate professional behavior. Tutors would respect students’ autonomy, encourage them to build on their own prior experiences, and avoid an authoritarian approach. Respect for student autonomy appears to enhance their motivation and psychological well-­ being [24]. Tables 2.1 and 2.2 summarize the difficulties in learning and teaching patient talk and suggest ways to overcome them.

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2.4 Coping with Barriers to Learning and Teaching Patient Interviewing2 2.4.1 Learning Objectives and General Approaches to Achieving Them In 2013, a panel of communication experts from 16 European countries agreed on 61 core communication objectives that they considered relevant for the education of health professionals [25]. Table 2.3 lists the objectives that I consider particularly important. Pedagogical approaches can be viewed as a continuum between “teacher-­ centered” and “learner-centered” and combinations of the two in between [26]. The teacher-centered (didactic) approach assigns the teacher the role of defining the learning objectives and teaching methods. Students are recipients of knowledge, usually imparted through lectures, and skills, which are taught by exposure to role models. On the other extreme, learner-centered programs are characterized by students having the freedom and responsibility to direct their learning. This Table 2.3  Learning objectives of patient interviewing. The student will … Identify and cope with environmental barriers to doctor–patient communication (noise, time constraints, need for an interpreter) Attempt to establish a trusting doctor–patient relationship, relieve the patient’s anxiety, and collect data that would guide the physical examination and ancillary testing Listen to the patient without stopping him for about 2 min. Restrain the natural urge to stop the patient by asking clarifying questions before he/she has finished describing the reason for his/ her visit to the doctor Conduct a patient-centered interview using techniques such as active listening, open questions, clear transitions from one subject to another, verbal and nonverbal expressions of empathy, respect for the patient, and formulation of at least one summary of the patient’s main problems. Demonstrate respect by tilting the body forward and making eye contact Elicit information about the patient’s concerns, the perspective of his/her illness, and expectations for receiving health-related information Summarize the patient’s complaints at the end of the interview and correct misunderstandings. Prevent the feeling of the patient that “the doctor did not address my complaints” Ask the patient at least once at the end of the session “Is there anything else you would like to know or tell me?” “Of all the things you told me, what worries you the most?” “It is very important for me to know, what you think caused your illness and what you think we should do.”

 Parts of this sections were published in: Benbassat J, Baumal R. A proposal for overcoming problems in teaching interviewing skills to medical students. Adv Health Sci Educ. 2009;14:441–50. With permission from Springer. Baumal R, Benbassat J. Current trends in the educational approach for teaching interviewing skills to  medical students. IMAJ. 2008;10:552–5. With  permission from  the  Israel Medical Association. 2

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approach casts the tutor as a facilitator of learning whose role is not to teach but to ensure that all students participate in discussions and share their knowledge with the other students in the group. Strictly learner-centered programs assume that tutors do not need content knowledge as long as they are skilled in tutoring students, and even if they have such knowledge, they should not pass it on to students [27]. Neither approach seems to be appropriate for teaching patient interviewing. On the one hand, students have been reported to be uncomfortable with a teacher-­centered approach to patient interviewing [28]. On the other hand, it would be unreasonable to require students to discover patient interviewing skills on their own, without professional guidance, using a strictly learner-centered approach. It appears that teaching patient interviewing requires an integrated learner-centered and teacher-centered approach, also referred to as case-based learning [29].

2.4.2 The Integrated Learner- and Teacher-Centered Approach Like the teacher-centered strategy, the integrated approach is guided by specific learning objectives. A tutor seeks to achieve these objectives by communicating information to students, demonstrating appropriate skills, and supervising students as they practice those skills. As with the learner-centered strategy, the tutor avoids an authoritarian attitude toward students and encourages them to acquire knowledge through discussion and self-directed learning. The tutor is expected to facilitate such discussions, gain insight into the learners’ knowledge of the subject, and help them build on that knowledge. Unlike the teacher-centered approach, which consists of lectures with minimal student participation, and unlike the learner-centered approach, which is limited to self-directed learning with minimal tutor intervention, the integrated approach encourages ongoing dialog between the tutor and students. In contrast to the strictly learner-centered programs, where tutors are expected only to facilitate small group discussions, tutors in the integrated approach are expected to be both proficient in the subject matter and able to foster an open exchange of ideas. The integrated approach is consistent with modern theories of adult learning. Adults are motivated by learning that builds on their prior experiences and requires them to reflect on their behavior [30]. An integrated approach to teaching is also consistent with the premises of [26] that adults learn more effectively when, first, they are self-motivated rather than responding to the demands of others; second, they are exposed to experiential techniques such as discussion or problem-solving rather than listening to lectures; third, they are aware of their learning needs as they arise from real-world problems; and fourth, they are challenged to apply the skills or knowledge they acquire to their life circumstances.

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Evidence suggests that an integrated approach is more effective than a strictly learner-centered approach. Learners and faculty at two academic medical centers overwhelmingly preferred case-based (guided) learning to problem-based (open-­ ended) learning [29]. Comparative studies of small groups led by tutor-facilitators without subject matter expertise (i.e., with a strictly learner-centered approach) and tutors who were both subject matter experts and facilitators (i.e., with an integrated approach) showed that the latter tended to take a more direct role in tutorials, i.e., they spoke more frequently and for longer periods, gave more direct answers to students’ questions, and suggested more topics for discussion. Students tutored by subject matter experts were reported to spend more time on self-study and to perform better on exams than students tutored by non-expert tutors (see [31] for a review).

2.4.3 Shifts in Teaching Patient Interviewing As I stated earlier, patient interviewing was considered a simple task until the 1970s. The “teaching” of interviewing at that time can be regarded as learnercentered in the sense that medical students were left to their own devices and most of them graduated without ever having interviewed a patient under the supervision of an experienced clinician. Since the 1970s, most medical schools have instituted patient interviewing teaching programs. In the 1980s and 1990s, many, if not most, of these programs were teacher-centered [32] and ignored students’ attitudes toward and opinions about patient interviewing [33]. In many cases, such programs were ineffective: British medical students complained that “they had no conceptual understanding of the purpose of history taking.” Some of them even stated that the didactic teaching of interviewing skills during rounds was humiliating and that they would have appreciated a more egalitarian teaching environment in which their observations would have been respected [34]. More recently, several authors have described instructional programs that consist of an ongoing dialog between teachers and learners (see [35] for a review). Some of these programs have used evidence of current deficiencies in doctor–patient communication as a point of departure for small group discussions [36]; others have emphasized student autonomy, collaborative learning, and faculty–learner relationships [37]. Still, other authors have suggested that teachers focus on communication techniques, while patients seek relationships characterized by trust, autonomy, caring, and expertise. They have suggested that research should focus on what patients perceive, want, and need, how their perspectives differ from those of clinicians, and, most importantly, their concerns (Table 2.4) [39].

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Table 2.4  Sources of patient concerns. Adapted from [38] with permission from Elsevier Concern Anxiety about the effect of disease on

Specific reasons Social status Sense of well-being Ability to function Lifespan Failure to share with physician-specific health concerns Feel embarrassed; desire not to seem (e.g., impotence, depression, fear of cancer) because ungrateful they Do not trust their doctors Have trouble communicating A belief that nothing can be done Reluctance to burden the doctor Worry that their fears will be confirmed Reluctance to accept recommended treatment because Fear of side effects of medications or of surgery Incompatibility with financial resources, lifestyle, or other circumstances Fear of anticipated dependence on medical care Disbelief in the effectiveness of the treatment Fear of embarrassment from appearing foolish or from Information about disease offending the physician by asking for: Reading material about their disease A second medical opinion Unorthodox treatment from faith healers, touch therapists, chiropractors Sick leave Assistance from various social service agencies

2.4.4 Assessment of Communication Skills I propose replacing the formal assessment of students’ communication skills in OSCE stations with repeated one-on-one discussions between student and examiner after the latter has observed a student’s encounter with a patient. Such discussions would promote a deliberative approach to interpersonal communication rather than a judgmental right-wrong dualism. In their discussions with students, examiners would not conceal their preferences regarding the style of interviewing. However, they would emphasize that there is no gold standard for patient interviewing. They would treat both students and physicians who have preferences different from their own with respect and encourage a reflective assessment of the strengths and weaknesses of the various communication styles. The principal role of the examiner would be to

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create a supportive environment that encourages examinees to acknowledge their attitudes to patient interviewing, their uncertainties, and, most importantly, to reflect on their communication style (“Why did you choose that question/ comment/answer during the interview?” “What were you trying to accomplish?”).

2.5 Proposed Teaching Program3 The proposed teaching program is based on the premise that student–patient communication is shaped by the student–tutor relationship. Just as physicians should gain insight into their patients’ concerns, tutors should understand their students’ attitudes toward patient interviewing. The proposed teaching program consists of four steps: Definition of the problem, discussion of possible solutions, demonstration of the application of those solutions, and supervised practice. The first three steps are conducted together in a 3–4-h workshop for 25–30 students. The fourth step consists of weekly supervised practice sessions in small groups (5–7 students).

2.5.1 Step I: The Problem After giving a 10-min overview of the workshop and explaining the importance of patient interviewing, I noted that patients often complain about their medical care and asked students if they had heard friends or relatives criticize their physicians. In response, students effortlessly listed numerous reasons for patients’ dissatisfaction with their physicians. I noted these on the board (Table 2.5), and after 30–40 min, when the list had grown to about 30 entries, the students took a break. After the break, I summarized the patient’s complaints and devoted the next 30 min to asking whether these complaints were common. Almost all of the students had heard patients complain about a lack of time, patience, or understanding on the part of physicians. A minority of students had heard complaints of discrimination. In some cases, I told the students about my own experience of hearing almost identical complaints from groups of students, residents, practicing physicians, and participants in an international MPH course. To support the credibility of the patient complaints, I cited a study that found that patient self-reports matched video recordings better than physicians’ records [40]. In support of complaints such as, “The doctor was in a hurry and did not listen to me,” I cited the observation that the average time between the start of a patient’s  A previous version of parts of this section was published in: Benbassat J, Baumal R. Teaching doctor patient interviewing skills using an integrated learner and teacher-centered approach. Am J Med Sci. 2001;322:349–57. With permission by Elsevier. 3

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Table 2.5  Patients’ complaints raised by student participants in the workshop on interviewing skills (reproduced from [12] with permission of Elsevier) Poor patient–doctor communication: The doctor... … was in a hurry (“kept looking at his watch,” “interrupted me repeatedly”) … did not listen (“appeared distracted,” “did not look at me,” “kept reading my file/looking at the computer monitor while I was talking” “was interrupted repeatedly by the phone/by people who entered the room without knocking on the door”) … did not understand (“asked the same questions over and over again,” “made comments that were unrelated to what I told him/her”) … ignored my complaints (“did not examine my chest even though I said I had difficulty in breathing”) Poor doctor’s response to patient’s needs for information: The doctor... … did not explain (“I could not understand what he said”) … did not let me ask questions (“did not respond,” “ignored my questions,” “said ‘Just do it and don’t ask too many questions’”) … expected complete obedience (“said ‘If you don’t stop smoking, I don’t want to ever see you again’”) Poor doctor’s insight into the patient’s state of mind: The doctor... … did not meet my expectations (“shocked me with bad news,” “decided on treatment without consulting me”) … ignored my concerns (“appeared not to believe me,” “changed the subject when I spoke about my troubles”) Bad manners or prejudice: The doctor... … was impolite (“did not greet me,” “did not respond to my greeting,” “did not introduce himself,” “did not apologize for being late,” “shouted at me,” “spoke with his colleagues and ignored me”) ... patronized me (“mispronounced my name,” “interrupted me,” “discriminated against me because I am....”)

narrative and physician interruptions was only 11 s [41]. I also cited reports that the most common patient complaints about physician behavior in the USA were disrespect (36%), disagreement about expectations of care (23%), and inadequate information (24%) [42]; that physicians tend to unintentionally discriminate against poor patients, the elderly, women, or members of ethnic minorities [43]; that clinicians rarely inquire about the patient’s agenda and that failure to inquire about it reduces the chance that clinicians will prioritize a clinical encounter around specific aspects that are important to each patient [44].

2.5.2 Step II: Discussion of Possible Solutions By the end of Step I, students agreed that patients’ complaints about the doctor– patient relationship could not be dismissed as rare or trivial. This conclusion was the starting point for Step II, in which students were asked to suggest ways in which patient dissatisfaction could be reduced.

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In general, students participated enthusiastically in this discussion and proposed reasonable solutions to most problems (Table 2.6). For example, to reduce the likelihood of the complaint “The doctor did not understand me,” students suggested summarizing the patient’s worries at least once toward the end of the interview. To decrease the likelihood of the complaint “The doctor did not let me ask any questions,” students suggested asking at least once: “Is there anything you want to tell me/did not understand?” To reduce the likelihood of a complaint that the doctor was rude, students suggested treating patients with respect. To decrease the likelihood of a complaint “The doctor did not meet my expectations/was inconsiderate of my feelings,” students agreed with my suggestion that a doctor should ask, “Which of your problems worries you the most?” Table 2.6  Possible ways of preventing patients’ complaints, as suggested by participants and tutor in the workshop on interviewing skills (adapted from [12] with permission of Elsevier) Complaint: the doctor ... … was in a hurry

… kept looking at the computer screen while I was talking … did not listen to me

Solutions suggested by participants Explain the time constraints; negotiate an agreed-upon timetable None

Additional solutions suggested by the tutor None

Look at the screen together with the patient. Summarize the encounter together with the patient Listen to the patient. Use open Allow patients to speak for at least questions 1 min. Encourage shy patients to talk, and gently guide the narrative of those who speak for more than 2–3 min … did not seem to Sum up what the patient told A misunderstanding is less likely if the understand/ignored you at least once during the doctor uses open questions and my complaints interview and correct possible postpones the closed questions to the misunderstandings end of the interview … did not explain Explain to the patient your Ask at least once: “Is there anything what was wrong with assessment and suggestions that you want to tell me/want to know/ me/did not let me ask did not understand?” questions … did not fulfill my Ask: “Do you have any Ask: “Do you have any ideas about expectations questions regarding your what caused your illness?” “Do you condition?” have any preferences for treatment?” “what do you think you need,” “What are your plans for the future?” … was inconsiderate – Ask: “Of all you told me what makes of my feelings and you worry most?” concerns … was impolite/ Treat the patient with respect Maintain eye contact; lean forward; patronized me remove physical barriers (desk); speak softly; pronounce the patient’s name correctly

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Unlike the first half of the previous step, in which I merely recorded student input, in this step I offered suggestions, whether through verbal descriptions of various physician behaviors that might reduce the frequency of patient complaints or through role-playings, such as demonstrating nonverbal expressions of interest and respect. The complaint of “the doctor was constantly looking at the computer screen” was not mentioned until after the introduction of the electronic health record (EHR). With appropriate training, EHRs can be an asset in teaching patient-­centered care, as described in Sect. 2.6. Other patient complaints were: “the doctor did not explain anything,” “explained incomprehensibly (you have chronic inflammation)”, “demanded obedience” (“if you do not stop smoking, you have nothing to come to me for”), “was offended when I asked for a second opinion,” “was offended when I wanted to find out about the disease,” “talked to me as if I were a little kid,” “did not talk about therapeutic alternatives,” or other complaints that indicate patients’ expectations to receive information and even be involved in decisions about their treatment. By allowing students to set their own pace, they generally identified the same goals I had in mind, albeit in a somewhat different order. Some students were concerned about the suggestion to listen to a patient’s narrative for longer than the stated 11 s (“How much more?”) and asked how to interrupt talkative patients. I responded that such decisions are a trade-off between the patient’s need to be heard and the physician’s time constraints. The longer the conversation, the greater the physician’s chances of gaining insight into the patient’s problem. The duration of the physician–patient encounter is associated with higher patient and physician satisfaction, lower numbers of malpractice claims, and lower numbers of prescriptions, requests for additional testing, and referrals to specialists [45]. Conversely, time pressure eventually forces the physician to take control of the interview. Students were advised to interrupt the patient’s narrative after 1–3 min by asking an open-­ ended question, such as “You mentioned chest pain. I would like to know more about that.” I emphasized the importance of recognizing patients’ anxieties and distress because failure to do so prevents empathy. Most patients have anxieties even if they are not explicitly described [46]. They describe their concerns only when the physician encourages them to do so by asking questions such as, “What worries you most?” This can make the physician aware of the patient’s fears and reduce the incidence of “doctor did not understand” complaints (Table 2.7). The most important components of the patient–physician encounter are attention that conveys respect, caring, interest, and the absence of value judgments; repeated confirmation that the patient’s message has been understood and the opportunity for the patient to correct or add to it; and a willingness to listen to personal problems. “Why” questions (“Why did not you take the medication?”) should be avoided because they could be taken as criticism.

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Table 2.7  Eliciting the patient’s history (adapted from [47] with permission from Wolters Kluwer) Ensure as much privacy as possible. Express sustained respect and interest by maintaining eye contact and a body posture of slightly leaning forward Listen without interrupting the patient’s account of her/his history for about 1–3 min. Encourage the patient’s spontaneous narrative by nodding and permitting the patient to take control of the interview Watch for verbal and nonverbal clues of a patient’s feelings. Respond with appropriate and explicit acknowledgment of a patient’s emotions/distress Toward the end of the interview, if appropriate, ask one or more of the following questions:  “Of all your problems, which is the one that worries you the most?”  “Do you have any ideas regarding what caused your illness?”  “Do you have any preferences about your treatment?”  “What are your plans for the future?”  “How does all this make you feel?” Encourage the patient to ask questions about her/his disease and main concern(s) by asking, “Do you have any questions regarding your condition?”

2.5.3 Step III: Demonstration of Various Interviewing Techniques and Discussion of Their Advantages and Disadvantages The objective of step III was to show how the solutions proposed in Step II are put into practice. To this end, I interviewed 2 real patients for 15 min each. Students were informed that the two interviews would be conducted using different approaches, that it was not my intention to emphasize the advantages or disadvantages of one approach over the other, that I would not make any intentional mistakes, and that during both interviews I would try to show respect for the patient, maintain a calm and relaxed atmosphere, convey a willingness to listen to the patients as they described their problems, and end the interview with a summary of the patient’s complaints. Students were asked to identify the differences between the two interviews, look for errors by me that will inevitably occur, and comment on these differences and errors after the demonstrations. Almost always, the patients seemed aware of the students’ presence only during the first 30 s and were not distracted by the audience after that. The first interview was “patient-centered.” Its main feature was listening to the patient’s spontaneous narrative and sustaining it by echoing the patient’s last words when necessary. I let the patient take control of the interview and encouraged him/her to talk about his illness and personal problems by asking general open-ended questions, such as: “Is there anything else on your mind?” Only after the patient seemed to have completed his narrative did I ask specific open-ended questions such as, “Ms. ..., you mentioned pain in your stomach. I would like to know more about it,” and closed questions such as: “Did you have heartburn?”

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The second interview was “disease-centered.” I began with a series of questions about the patient’s age, marital status, and occupation and interrupted the patient with questions as soon as she/he mentioned a symptom. I controlled the interview by asking a series of closed-ended questions about the patient’s symptoms and the results of previous examinations. The interview consisted of an inquiry aimed at obtaining information about the patient’s disease and its manifestations (“Was the pain long-lasting or intermittent?”) but not open-ended questions (“Can you describe the pain?”) or those related to the patient’s feelings (“What do you think about your disease?”). After the demonstrations, students explored the advantages and weaknesses of the two interviewing techniques. Students felt that the disease-centered interview provides information in a logical sequence (i.e., in an order consistent with the physician’s view of the patient’s illness) but precludes the expression of empathy. The patient-centered interview avoids these disadvantages, in addition to taking more time, it also requires the physician to take mental notes on the topics to be clarified in closed questions at the end of the interview. In most cases, students concluded that an optimal interview begins with a patient-­ centered approach and open-ended questions and ends with a disease-centered approach and closed-ended questions. I agreed, noting that all medical interviews are conducted using both techniques. Even physicians who use a disease-centered approach begin with an open-ended question (“What brought you to me/hospital?”) and listen to the patient for varying lengths of time before asking closed-ended questions. Conversely, even clinicians using a patient-centered approach must at some point take control of the conversation to explore specific issues raised by the patient through closed-ended questions. Thus, it appears that the difference between physician interviewing styles is simply how much time they devote to patient-­ centered or disease-centered techniques. During the discussions, I did not hide my bias in favor of a patient-centered approach. I pointed out that the various components of this approach were suggested by the students themselves in Step II to solve problems in doctor–patient communication. I informed the students that, surprisingly, the disease-centered interview does not save time [48]. In fact, given equal time constraints, listening to a patient for 1–3 min may be more informative than listening for an average of 11 s and then asking closed-ended questions. However, I recognized that some physicians employ mainly a disease-centered approach. They want to explore a patient’s complaints immediately, because they believe that controlling the conversation saves time, or because they feel uncomfortable confronting patients who try to share personal problems. A common theme that emerged in the discussions was the degree of intrusion into the patient’s feelings and emotions. To overcome the tendency to avoid listening to personal problems, students could be reminded of the relationship between psychosocial issues and health and that insight into patients’ feelings is a legitimate area of inquiry and essential to a therapeutic doctor–patient relationship. Students seemed to need reassurance that their reluctance to explore feelings is normal: we

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all enjoy discussing other people’s problems in their absence, but recoil when they try to share those problems directly with us. I also pointed out that focusing on a patient’s symptom matrix attempts to place him or her in a familiar diagnostic category, i.e., to find out, “What makes this patient similar to others with the same symptoms?” Conversely, insight into a patient’s specific worries encourages the clinician to ask, “What makes this patient unique?” One of the main challenges for the tutor is to have students come to terms with these two notions of patient care and to recognize that diagnostics and understanding a patient’s concerns are not mutually exclusive. To recognize a patient’s concerns, one must acknowledge that they are present but may not be directly expressed. Gaining insight into a patient’s expectations, preferences, and values is much less time-consuming than is commonly believed, requiring only three or four questions. The patient’s answers usually lead to a consensual definition of the problem(s) to be addressed in the consultation. In summary, I tried to convey the message that the patient-centered interview places a high priority on the patient’s spontaneous narrative and open-ended questions; when time is limited, the closed-ended questions of the systems review are foregone. The disease-centered interview gives high priority to identifying symptoms with closed-ended questions; when time is short, the patient’s spontaneous narrative is left out. The basic premise of the patient-centered interview is that it provides reliable information. This is especially important when meeting a new patient. If the schedule prevents a physician from having a casual conversation with a new patient, he or she should explain this to the patient and ask him or her to make another appointment. The workshop ended with the agreement that each student must choose his or her communication style by weighing the strengths and weaknesses of patient-centered and disease-centered conversation. This conclusion encouraged students to view conflicting messages they would receive in the future as opportunities for further exploration and learning, rather than as reasons for perplexity and cynicism.

2.5.4 Step IV: Supervised Practice Step IV consisted of weekly, 3-h small group sessions in various clinical settings. Students interviewed patients in front of their peers and a tutor and discussed their performance after completing the interview. Efforts were made to expose students first to patients with whom interviewing was easy (e.g., young patients with a similar cultural background to that of the student) and only later to patients with some of the communication barriers described below. Difficulties occurred primarily when students met with their first patients. Some students appeared anxious and found silence unbearable. They resorted to closed questions shortly after the interview began and “dried up” after 1–2  min. Attempts to improve their performance through verbal explanations were mostly unsuccessful. Students either did not understand the feedback or even reacted defensively by blaming

2.5  Proposed Teaching Program

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the patient. In such cases, the best way to help the students was to demonstrate: I called the patient back and asked, “Mr. ... You told [the student] that you were having [chest pain]. Could you tell us how that made you feel?” or “Ms. ... what is causing you the most concern in your current situation?” These open-ended questions usually elicited a detailed response that provided new insight into the patient’s predicament. Demonstrations were frequently required during the guided practice phase. Although the terms “closed” and “open” questions were defined during the discussion in Step II and their use was demonstrated in step III, some students did not seem to grasp the difference between them until I demonstrated during the practice sessions that the same patient responded differently to these two types of questions. The more experience the students gained, the more confident they became in interviewing patients and the more receptive they were to criticism of their interviewing technique. They chose a balanced use of disease-centered and patient-centered techniques and open- and closed-ended questions. Other difficulties that arose included how to maintain eye contact with patients and still take notes; how to get shy patients to talk; and, as I mentioned earlier, most students were embarrassed to be confronted with emotional patients. By the end of this phase, students were also expected to be aware of any tendency to give false assurances, ask “why” and “yes– no” questions, patronize, or pass moral judgments, and suppress this tendency. At one point in the teaching, I pointed out that the most important predictor of patient satisfaction is the perception of the physician as caring and empathetic. The message “I care” is conveyed through attentive listening, acceptance of the expression of emotions, and body language that transmits understanding and encouragement. In most cultures, this is done through eye contact and facing the patient without a table separating the patient and the physician.

2.5.5 Advantages of the Proposed Approach The proposed approach provides an opportunity for both students and faculty to discuss and reconsider their views on communicating with patients. It helps students understand why different clinicians use different communication styles. It presents both patient-centered and disease-centered conversational techniques as legitimate and discusses them in an atmosphere of critical reflection, respect for their worth, and empowerment of students to choose their balance among different interviewing styles. Another benefit of the program relates to the assessment of communication skills. Current assessment methods have been criticized for pressuring trainees to adopt the examiners’ preferred model of doctor–patient communication [49] and for using checklists that force trainees to ask as many questions as possible in a limited time frame to earn checks [20]. I propose replacing the assessment of interviewing skills with repeated, face-to-face formative discussions after an examiner observes a student’s encounter with a real patient. Such discussions would promote a deliberative approach to interpersonal communication rather than a judgmental, right/wrong dualism.

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Examiners need not hide their preferences for the style of patient interviewing. However, they should emphasize that there is no gold standard for patient interviewing. By showing respect to students with different preferences, examiners would encourage a reflective appraisal of the strengths and weaknesses of different communication styles. The principal role of the examiner is to create a supportive environment that encourages students to acknowledge their beliefs about patient interviewing, their uncertainties and mistakes, and, most importantly, to reflect on their communication styles. Finally, the proposed teaching approach encourages students to create their interviewing guidelines and does not antagonize them with “should” and “should not” rules. For example, while students resented being lectured about elementary courtesy, they were impressed when they recognized that some physicians are rude to their patients; while students seemed to take for granted the admonition to treat all patients equally, they were impressed to discover, after role-playing, that some patients (elderly, poor, uneducated) indeed receive inadequate counseling about their illness [38]. In other words, rather than feeding students behavioral and social science principles, the proposed approach emphasizes the importance of students themselves figuring out what these principles mean for clinical practice. Encouraging students to formulate their interviewing guidelines also avoids the common misunderstandings of terms used in lectures or handouts. For example, encouraging students to suggest ways to avoid the common patient complaint, “The doctor did not take my feelings into consideration,” can help faculty avoid pointless discussions about the various definitions of “empathy.” The main advantage of the proposed approach is the constant dialog between tutors and learners in an egalitarian and non-hierarchical atmosphere. A hierarchical approach to teaching can be transferred from the teacher to the learner and have further undesirable consequences if students adopt this behavior toward patients [50]. In other words, teacher-dominated patient interviewing programs can reinforce a paternalistic style of communication with patients. It is impossible to humiliate medical students and still teach them to respect patients, just as it is impossible to ignore the students’ point of view and still teach them to consider the patient’s preferences. Like the doctor–patient relationship, the tutor–student relationship should be one of mutual respect and an effort to understand each other’s views.

2.6 Barriers to Doctor–Patient Communication The interaction between two perceptive, calm individuals with similar cultural backgrounds does not pose undue problems. However, any dissimilarity between them and any emotional distress of one of them may interfere with communication. Obstacles to physician–patient interaction may arise from the environment (lack of privacy, noise, unconventional dress of the physician, and disruption of the physician–patient encounter by telephone calls and clinic staff), from differences between the physician and patient (age, language, culture, and socioeconomic status), and the physician’s communication habits and attitudes.

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2.6.1 Doctor–Patient Differences in Age, Race, Gender, Language, and Socioeconomic Status: Underprivileged Patients Evidence suggests that physicians are not immune to bias and reliance on stereotypes, and that patient characteristics—age, race, gender, language, and socioeconomic status—influence physician-patient communication and clinical decisions [51]. Ageism is pervasive [52]. Fear of being perceived as hypochondriacal may discourage patients from describing their complaints. Both older patients and physicians may view disease manifestations as part of normal aging and ignore treatable problems. Both may believe that health promotion, disease prevention, and physical and mental well-being are not realistic goals in old age. There is also evidence that black patients were less likely than whites to receive analgesia for pain [53], thrombolytic treatment [54], and assessment for renal transplantation [55] even after adjusting for severity of illness, health insurance, availability of medical services, socioeconomic status, age, and comorbidities. A 2000 survey showed that patients of African descent elicited less empathy from physicians and that poor and uneducated patients had a negative image of character and ability [56]. In the UK, 20% of an ethnic minority sample reported racial discrimination. During a 2-year follow-up period, those who reported racial discrimination had a higher likelihood of prolonged illness, fair/poor self-rated health, and increased psychological distress [57]. American women perceive gender discrimination in health care [58]. Finally, evidence suggests that patients with mental illness [59] feel discriminated against by health providers and are less likely to seek help. People with mental illness often report negative attitudes from mental health staff. “Diagnostic overlay,” is a misattribution of symptoms of physical illness to concurrent mental disorders, leading to underdiagnosis and mistreatment of physical illness. It appears to be prevalent in healthcare settings [60].

2.6.2 Mismatch Between the Patient’s and the Doctor’s Preferences The law supports the right of patients to refuse treatment. However, it does not prescribe the extent to which physicians are required to agree with patients’ preferences or how to resolve inconsistencies between these preferences and physicians’ adherence to professional norms. The question “What are the limits of patient autonomy?” is relevant in three situations. The first occurs when rational patients have irrational preferences that result from ignoring risks (speeding, smoking), fear of examinations or surgery (refusal of recommended tests or treatments), ideology (refusal of blood transfusions by Jehovah’s Witnesses), or a preference for continuing a futile treatment. The second

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type of unacceptable request is rational for the patient but not for society. For example, an insured patient may insist on an expensive drug because he or she has no motive to weigh the cost of medical treatment against the expected benefits. Similarly, a patient’s refusal to be vaccinated may be irrational socially but not personally, since vaccination reduces not only personal morbidity but also that of society as a whole. The third type of disagreement between physician and patient is a conflict between the patient’s preferences and the physician’s values. At first glance, such a conflict is absurd: two rational persons cannot disagree in choosing between life and death. However, there are situations in which this choice is also between a treatment that prolongs life expectancy but reduces the quality of life and a treatment that does not. In these situations, patients may choose to risk their lives for a better quality of life. Take, for example, the case of a 55-year-old perimenopausal woman with vasomotor symptoms. She and her physician must decide between hormone treatment, which would reduce her vasomotor symptoms and risk of hip fracture but increase the risk of systemic embolism and breast cancer. Symptomatic treatment would be less effective in reducing her symptoms but would not affect embolic risk [61]. In this example, in addition to the desired (life) and undesired (death) outcomes, there is also an intermediate outcome that requires value consideration. There may be situations in which two rational patients prefer different treatment options. In whose hands is the decision? If it is solely in the hands of the physician, should he or she put himself or herself in the patient’s shoes and ask what would the patient have preferred? If the decision is in the hands of the patient, how can he or she be provided with the data necessary to make the decision? If it is in the hands of both, what role does each play in the decision? Ostensibly, physician–patient mismatch in preferences can be ameliorated through patient education. Indeed, a 2007 study found that integrating individualized decision aids into clinical practice is feasible and reduces decision conflict [62].

2.6.3 Doctors’ Failure to Gain Insight into the Patient’s Concerns4 One of the goals of interviewing is to gain insight into a patient’s concerns. Failure to gain such insight precludes empathy and meeting the patient’s expectations. Physicians can encourage patients to share their worries by expressing a willingness to listen. In some cases, this is enough to prompt patients to share their fears and expectations. However, patients often tend to drop hints. In some cases, physicians were observed to respond to such hints with explicit acknowledgment. In most

 A previous version of this section was published in: Benbassat J, Baumal R. What is empathy and how can it be promoted during the clinical clerkships. Acad Med. 2004;79:832–9. With permission by Walter Kluwer. 4

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cases, however, they disregarded these cues and returned to diagnostic exploration of symptoms [63]. Ignoring cues to the patient’s concern may be due to the physician’s interviewing habits, failure to interpret cues to the patient’s anxiety, and intolerance of expressions of emotion [44].

2.6.4 Interviewing Habits That May Discourage Patients from Sharing Their Concerns 2.6.4.1 Writing Up the Patient History During Interviewing Writing the history while the patient is talking assures the physician that he or she does not omit important details and uses time efficiently. Still, patients may not disclose their specific worries when facing a physician who is recording what they say. In addition, writing during the interview prevents eye contact, observation of the patient’s body language, and recognition of nonverbal cues. Recording the history while the patient is talking also forces the physician to control the interview: Instead of listening to the patient’s narrative, the physician must interview in the order of the standard recorded history: Chief Complaint, Present Illness, Past, Social, and Family History and Systems Review, which inevitably leads to a disease-­ centered interviewing style. As detailed in Sect. 2.5, the tendency to write down the history during the patient interview has increased since the introduction of the electronic health record. 2.6.4.2 Focusing on the Chief Complaint Early in the Interview The standard record of the history begins with the chief complaint. Recording the history while the patient is talking forces the physician to identify the chief complaint (e.g., “chest pain”) early in the interview. This leads to a search for other symptoms by asking closed questions (“Did the pain radiate down the arm?”), which in turn explains the observation that physicians interrupt the patient’s narrative within seconds [44]. In many cases, the patient’s main concern emerges later in the encounter, and its premature definition can be misleading for the physician’s diagnostic considerations. 2.6.4.3 Performing Systems Review It is generally agreed that the interview should end with a series of closed-ended questions designed to determine the presence or absence of specific symptoms. This approach has been taught to medical trainees for decades as an integral part of taking a medical history. The purpose of the systems review is twofold. First, it teaches students to associate symptoms with different organ systems. Second, it can uncover

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symptoms that patients have not mentioned in their narratives. This is supported by studies showing that a full systems review led to new diagnoses in 5% [64], 7% [65], and 11% [66] of new patients. Conversely, a complete systems review may provide irrelevant information and hinder the diagnostic process. In addition, novices may perform the review as a substitute for listening to a patient’s narrative, creating an atmosphere of detachment and formality that is detrimental to the expression of empathy. Therefore, there is now a tendency to replace system reviews with patient self-report questionnaires.

2.6.5 Angry Patients Anger is a likely response to injured self-esteem and feelings of helplessness, shame, fear, and victimhood. In most cases, anger is suppressed because its expression is not accepted by cultural norms; however, it can lead to verbal and physical aggression. Violence toward caregivers is on the rise, and assaults occur nearly four times more frequently in health care than in all other private sector industries combined [67]. A 2019 review found that 62% of a total of 331,544 healthcare workers reported being exposed to some form of violence, and 24% stated to have experienced physical violence in the past year. This was particularly common in hospital emergency departments, psychiatric units, geriatric facilities, and the community [68]. Violence may be triggered by environmental factors such as crowding, noise, and long wait times. However, it is mostly due to patient-related factors, such as volatile people, especially those under the influence of drugs or alcohol, or patients with a history of psychotic diagnoses [67]. A 2015 review found that approximately 20% of patients in psychiatric units commit violent acts, with male gender, schizophrenia diagnosis, substance use, and life history of violence associated with violence [69]. Patient violence may be influenced by caregivers. A study in a psychiatric hospital found an association between patient violence and caregivers’ trait anxiety and authoritarianism [70]. Most incidents of violence occurred immediately after contact with care providers or in response to their comments. Restricting patients’ freedoms through some type of restraint or denying a patient request, such as during showering the patient with the assistance of a nurse, was the most common trigger for incidents [71]. A 2020 review of the literature found that staff fatigue, burnout, racism, sexism, and other negative cultural values appeared to increase the risk of violence. There was also an increased risk of aggression when patients did not feel included in treatment decisions or did not feel they had meaningful contact with staff [72]. Patient violence affects caregivers’ well-being. Having experienced aggression has been reported to cause burnout, insomnia, anorexia, and flashbacks [73]; increased stress and anxiety levels; feelings of guilt, and insecurity [74]; and inability to interpret patients’ violent behavior, feelings of helplessness, and most importantly, awareness of “forbidden feelings” toward patients [75].

2.7  Coping with Barriers to Communication with Patients

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2.7 Coping with Barriers to Communication with Patients Although unavoidable, communication barriers can be reduced by improving the appearance of the clinic, avoiding disruptions during the patient encounter, overcoming deafness by allowing the patient to read the physician’s lips, and reducing the distance between patient and physician without raising the voice.

2.7.1 Language Mismatches The best way to overcome language mismatch is to refer patients to caregivers with the same background. This has been reported to reduce the need for urgent admissions to psychiatric hospitals [76]. When such matching is not possible, clinicians typically enlist the help of translators from the family or treatment team. However, observations of the effectiveness of such translators revealed an average of 19 translation errors at each encounter, and 63% of these errors had clinical implications [77]. Professional translators, including those available by telephone, are more effective than occasionally available translators [78]. When using translators, clinicians should speak directly to the patient, address the patient in the second person, maintain eye contact with the patient and not the interpreter, and ask the patient to speak to the doctor and not the translator; pay attention to and respond to the patient’s nonverbal cues; and, most importantly, check for understanding by summarizing the problem periodically for back translation and confirmation by the patient. Failure to follow these rules results in a doctor–interpreter rather than a doctor–patient dialog and leads to misunderstandings.

2.7.2 Doctors’ Self-Awareness Self-awareness is an introspection into one’s emotions, prejudices, attitudes, and preconceived notions that may arise in response to certain situations. I have already referred to possible stereotypes of physicians based on race, class, gender, and other characteristics that influence the interpretation of behavior and symptoms [79]. Such stereotypes are often beyond conscious awareness. Self-awareness is therefore a prerequisite for reducing the confounding effect of a physician’s emotional state on his or her attitude toward patients. The acquisition of self-awareness by students of their feelings and attitudes has become a learning objective in many medical schools. Attempts to improve students’ self-awareness consisted of classroom discussions about physicians’ emotional responses to various clinical situations; small group discussions in which students recalled their personal clinical experiences and talked about how their feelings influenced their behavior toward patients; and feedback and consultation with

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individual students by behavioral scientists after observing their interactions with patients [80]. However, the most important way to overcome communication barriers created by physicians’ preconceived notions is to be aware of their existence and the physician’s responsibility to overcome them.

2.7.3 Encouraging Patients to Share Their Concerns To encourage patients to share their concerns, students should listen to the patient’s history; watch for verbal and nonverbal expressions of emotion, inquire about the causes of the patient’s distress if appropriate, verbally summarize the patient’s history, agree with the patient on his/her chief complaint and major worries, and only then write down the history in the sequence of the standard record. Students should be cautioned to avoid taking copious notes while the patient is talking and to give lower priority to performing a systems review. They may be advised that in cases where time is short, it is more informative to listen to the patient’s narrative than to use closed-ended questions. In these cases, the systems review can be replaced with open-ended questions, such as “Is there anything else on your mind?” Conducting a full system check can be limited to doctor–patient encounters where there are no time constraints and to patients who do not respond to the doctor’s attempt to maintain their spontaneous narratives.

2.7.4 Management of Patient Aggression A 2018 literature review suggested the following approaches to preventing and managing patient aggression. First, avoid crowding and noise in the clinic in general and in waiting rooms in particular; these should be as quiet, comfortable, clean, air-­ conditioned, and ventilated, and most importantly, patients should be informed of the waiting time. Second, early diagnosis of suppressed anger by correctly identifying a raised voice, jaw muscle tension or hand movements, signs of drug or alcohol intoxication, hallucinations, threats to leave the clinic, or verbal and physical threats [81]. Training staff to deal with violence is an important approach to preventing and managing patient aggression. A comparison of medical and social work students found that medical students had experienced patient violence more frequently than social work students (80% vs. 44% knew about workplace violence; 9% vs. 6% were victims of a physical assault). Nevertheless, it was found that only 23% of medical students had received training in coping with verbal violence, compared with 31% of social work students [82]. The most important features of such training are communication, de-escalation, and recognition of risk behaviors. Training increases participants’ confidence in dealing with patient violence and improves care-providers attitudes and ability to de-escalate incidents. Indeed, violent assaults

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by patients of untrained nurses occurred more frequently [83], and training of nurses reduced the number of violent incidents in psychogeriatric wards [84]. In such a situation, the care-provider role is to relieve tension through eye contact and a relaxed posture without crossing the arms or tilting the body forward. Without judging whether or not the anger is justified, the caregiver would confirm that he or she accepts the patient’s anger as legitimate.

2.8 Shared Decision-Making5 Shared decision-making (SDM) is a consultation style in which patients share their knowledge and specific worries while doctors explain the available courses of action in a way that allows patients to make a choice. SDM improves patients’ affective-­ cognitive outcomes. However, there is no evidence that it improves patients’ health [85] or quality of life [86]. Nevertheless, there is agreement that physicians should understand the patient’s need for information, while patients need to be aware of the uncertainty in medicine, want to participate in decisions related to their care, and understand the trade-offs among available options. Integration of SDM into clinical practice has been slow. A 2019 survey found that 31% of physicians reported using a paternalistic approach in daily practice [87], and many physicians could not distinguish between SDM, informed consent, risk assessment, and decision support [88]. The purpose of this section is to suggest that, similar to patient-centered care, teaching SDM should (a) be included in undergraduate medical education and not just offered to residents and practicing physicians [89] and (b) emphasize the physician’s ability to understand the patient’s specific concerns and only then provide health-related information.

2.8.1 Teaching Shared Decision-Making The objectives of SDM are generally defined as (a) identifying situations in which SDM is critical; (b) communicating with the patient about the need for a decision; (c) describing available options, risks, benefits, and associated uncertainty; (d) determining patient preferences; and (e) agreeing on next steps [90–92]. Attempts to achieve these objectives have consisted of the distribution of educational materials, educational sessions, audits and feedback, and decision aids for patients. However, they had little impact on resident and practicing physician knowledge [89]. The only attempt to teach students that I am aware of was a one-hour small group intervention that consisted of a critique of a pre-recorded role-play. Two  A previous version of this section was published in: Tidhar M, Benbassat J. Teaching shared decision making to undergraduate medical students. Rambam Maimonides Med J. 2021;12. Authors’ copyright. 5

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weeks after the intervention, participants rated their skills, attitudes toward, and confidence in SDM significantly better [93]. Communicating treatment options and uncertainties, using decision support tools, identifying patient preferences, and reaching an agreement on treatment are certainly worthwhile goals. However, I disagree with the first two recommended steps of SDM training, namely recognizing when a decision is needed and communicating that need to the patient. I believe that all physician–patient encounters require SDM and that the starting point should not be recognizing the need for a decision but understanding the patient’s concerns.

2.8.2 Proposed Learning Objectives of Shared Decision-Making 2.8.2.1 Gain an Insight into the Patient’s Concerns Patients expect their physician to address the specifics of their case and are disappointed when she/he cites only prognostic statistics [94]. Gaining an insight into the patient’s specific worries is necessary to meet this expectation. It is also the beginning of the multistep process of empathy, whereby the physician’s awareness of the patient’s apprehensions elicits a sequence of emotional engagement, compassion, and a desire to help the patient. The first step in this sequence, insight into the patient’s distress, is a skill that can be learned. It requires conducting a patient-­ centered interview and using the questions I listed earlier. 2.8.2.2 Elucidate the Role That the Patient Wants to Assume in Decision-Making Doctor–patient relations can be viewed as a continuum between the “paternalistic model” (doctor decides, patient complies without explanations) and the “informative model” (physician informs, the patient decides), with varying degrees of patient involvement between these two extremes (Table 2.8). A 1998 review indicated that 92–97% of patients wanted to be informed about their disease. About half of them wanted information with a view of leaving the decision to their physician, and the other half wanted to participate in planning their treatment. The remaining 3–8% preferred a passive role without being informed about their disease [95]. A 2012 review similarly revealed that while most patients wanted to participate in decision-­ making, some patients wanted to delegate decisions. There was a temporal trend in patient preferences: Respondents preferred a shared decision-making role in 71% of studies from 2000 and later, but only in 50% of studies before 2000 [96]. Understanding patients’ preferences is complicated by their varying desires for information, self-treatment, and participation in clinical decisions [97]. For example, patients’ preferred involvement in decisions about their treatment is different

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Table 2.8  Alternative models of physician–patient relationships Model Paternalistic

Informative

Shared decisions

Self-care

Assumptions – The doctor and the patient have the same values and goals – The doctor has more knowledge than the patient about the disease – The knowledge gap between the doctor and the patient prevents the provision of information – The role of the physician is to identify the patient’s needs and recommend treatment – The patient’s role is to accept the doctor’s recommendations – The doctor and the patient may have different values and goals – The doctor has more knowledge than the patient about the disease – The doctor must meet the patient’s needs for information about his illness – The patient’s role is to decide how to proceed and whether to accept the doctor’s recommendations – The doctor must meet the patient’s needs for information – The doctor’s duty to recommend a treatment plan – The patient may disagree with the doctor in the choice between different treatment options – Clinical decisions are an agreed compromise between the patient’s preferences and the doctor’s recommendations – A patient who has received appropriate information and has been properly instructed by his caregivers can self-regulate his behavior and treatment of his illness

from their desire to participate in solving diagnostic problems [98]. The multidimensionality of the variable “patient preferences” contradicts the simple linearity in the sequence between the paternalistic model and the self-care model. This variability exists not only between patients but also within patients over time [99]. Therefore, the only way for a physician to gain insight into the preferences of individual patients is through direct questioning. Insight into the patient’s wishes is a prerequisite for respecting patient autonomy. Patients from lower social classes are often disadvantaged because the physician may misjudge their desire for information and their ability to participate in the treatment process. Therefore, it is important to distinguish between patients who prefer a passive relationship with their physician and those who are reluctant to ask questions even though they prefer to be involved in their treatment. To make this distinction, a physician may ask, “Before I answer your questions, it would help me if you told me what you already know about your disease?” The purpose of this question is to gain insight into the patient’s perception of his or her disease and to state an intent to answer questions. The patient may respond by expressing concern (“I hope this is just a temporary headache, but I fear it may be cancer”). Other patients may not respond to the physician’s prompting (“I have not the faintest idea”). In such cases, the physician may insist by saying, “I am very interested in your opinion about what we should do” or “Would you like me to share with you my thoughts about your disease or the various options for its further

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treatment.” The patient’s response (“Please just tell me what to do,” “Yes, tell me what the options are,” or “Yes, tell me what you think about my disease”) is likely to make his/her preferences about SDM clear. 2.8.2.3 Match the Patient’s Preferred Involvement in Decisions Physicians can optimize their encounters with patients by matching their needs for information and involvement in treatment [100]. Patients may need information about their diagnosis (“What is the name of the disease?” “Is the diagnosis certain?”), the need for treatment (“What are the risks of surgery?” “What if I do not have surgery?”), or implications of the disease (“Will I be a burden to the family?” “Will I suffer from pain?”), or treatment (“What should I do?” “How long will it take?”), or help with decision-making (“Could you explain to me again ...,” “What would you do if you were in my place?”). It is advisable to answer these questions honestly and to elicit the patient’s preferences about sharing decisions with others (“Would you like to talk to me alone or with someone else present?” “Would you prefer to talk to someone in the family first?”). To the extent that this is possible, the doctor would avoid making a time-based prediction. When necessary, he or she should give the patient a rough realistic time frame for getting personal affairs in order. 2.8.2.4 Present Options; Discuss Pros, Cons, and Uncertainty Physicians have difficulties in applying SDM because first, they may feel that acknowledging uncertainty would undermine patient trust and increase anxiety [101]. This feeling is at odds with the view of bioethicists that patients can handle information about uncertainty, that disclosure protects patient trust, and that special vigilance is needed in situations of significant uncertainty to ensure that patients receive the tools and information they need to participate in SDM [102]. Second, SDM requires doctors to communicate the risk and benefits of an intervention in a way that patients can understand. In response to evidence that many physicians are not up to this challenge, Koch et al. [103] reported the successful implementation of a 15-h course that integrated basic statistics, bias detection, and communication skills. All of these topics had been taught separately during the undergraduate program; the objective of the course is to reorganize previously acquired knowledge and apply it to SDM. Still, the optimal way to convey information to patients is uncertain. Even when clinicians understand the patient’s expectations, they may have difficulty determining the best way to convey probabilistic information and information about the patient’s expected quality of life. Patients may perceive the same information differently, for example, if it is presented as a probability of survival or death, or if it is presented from the worst to the best option or vice versa. There is evidence that even educated individuals can be biased by the framing and sequence

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of data presented [104]. However, this evidence was derived from the responses of study populations to hypothetical situations. These (rapid/immediate) responses in experimental settings cannot be generalized to the (slow, unhurried, and thorough) deliberations during physician–patient encounters in clinical settings. Decisions, where the stakes are high, require slow thinking to avoid the biases of the fast system. Third, providing information on the quality of life is difficult, because of its uncertain definition. According to one definition, quality of life is the function of the patient or his or her body systems by examinations such as exercise tests of a cardiac patient or laboratory markers of disease activity. The second definition of quality of life refers to the patient’s psychological (freedom from anxiety or depression) and social (ability to communicate and participate in community life) well-being. The third dimension of quality of life is the value that the patient attaches to the limitation. The same paralysis of the vocal cords has a different meaning for a singer and a painter. The same limp has a different meaning for a dancer and a math teacher. The first dimension of quality of life is based on objective clinical and laboratory tests. The second one is based on psychometric assessment. However, the third dimension of quality of life is subjective and the reliability of its measurement is uncertain. Still, SDM requires that clinicians understand the preferences of individual patients and their subjective perceptions of quality of life. Hence, the current efforts to develop methods that allow patients to assess their quality of life with an expected limitation and express their preferences. 2.8.2.5 Offer the Patient the Option of Obtaining a Second Opinion and Suggest Reliable Websites Discrepancies between experts’ interpretations of imaging, histopathologic, and clinical findings have led to the agreement that patients have a right to a second opinion unless it delays a life-saving intervention. A second opinion has been reported to confirm the original diagnosis or treatment in 43–82% of cases and to change the diagnosis, treatment, or prognosis in 12–69% of cases [105]. The main barriers that prevent patients from seeking a second opinion are patient information overload and fear of jeopardizing the doctor–patient relationship [106]. Therefore, patients should be encouraged to do so (“Would you like to consult another doctor?” “Would you like to consult a doctor of your choice or would you like me to recommend an expert?”) and assured that this will not affect future doctor–patient encounters (“I shall not be offended if you want to seek another doctor’s opinion; on the contrary—I will be happy to hear his or her opinion on how to proceed”). Patient education is a cornerstone of SDM, and its main sources are physicians and the Internet. About half of the patients search the Internet before consulting a physician [107]. A 2021 study confirmed that searching for established, safe treatments online (as opposed to seeking emerging treatments) has a positive impact on patients’ trust in their physicians and on the doctor–patient relationship [108]. Evidence on the impact of online information seeking on health outcomes is

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inconclusive. A 2022 review found that online information search was associated with better medication adherence among HIV/AIDS patients, but not in general [109]. Some physicians discourage their patients from bringing outside information. As recently as 2018, it was claimed that by googling their symptoms, patients are forming their own opinions about their medical problems and resisting their doctor’s advice [110]. Another survey in the UK found that GPs felt considerable anxiety when patients brought information from the Internet into the consultation for fear of being perceived as ignorant; however, they learned to respond appropriately to such patients by buying time (“I am not familiar with this particular website. I’d like to read it and think about it”) or using the Web as an ally (“In the meantime, you can check the websites ...”) [111]. Patients may not talk to physicians about health information because they are afraid to question their authority or because they feel that the physician does not want to discuss seeking online health information, especially within the limited time of the physician visit. However, it stands to reason that physicians who talk to their patients about health information and guide them in searching for and using this information can shorten the length of the consultation and improve their communication with patients [112].

2.9 Patient Counseling6 The term “patient counseling” refers to an individualized process of finding out what the patient thinks about his or her illness, responding to his or her information needs, providing guidance, and solving problems together. Evidence suggests that training improves student ability to provide counseling and that simulation-based training is the most effective way to do so [113]. In the 1990s, I tried to incorporate patient counseling into my teaching. After a student presented a patient at the bedside, I checked the patient’s physical findings and asked the patient questions, such as “Do you have any idea what caused your illness?” and “What makes you worry most?” The teaching session then moved to a conference room. Students listed the patient’s problems and formulated a plan for treatment and obtaining additional data. I stated that patient education had generally a low priority in the hospital setting. Some students responded that patients indeed ask about their illness and that physicians often do not meet their need for information. Although students seemed to accept this as an inevitable consequence of the hectic hospital routine, they agreed that all patients are entitled to at least one conversation with their attending physician before being discharged from the hospital.

 A previous version of parts of this section was published in: Benbassat J, Baumal R.  A  step-wise role-playing approach for  teaching patient counseling skills to medical students. Patient Educ Couns. 2002;46:147–52. With permission by Elsevier. 6

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The next step was a simulation of such a meeting. The student who presented the patient was asked to take the role of the doctor, and I took the role of the patient. While pretending to have the real patient’s illness, I maintained my medical background. This facilitated communication, eliminated cultural or language barriers, and allowed for an in-depth exploration of the various aspects of the real patient’s illness. In most cases, the student made an opening statement (“Mr ... I would like to advise you about your treatment after you are discharged and answer any questions you have about your illness”). Then the student answered my questions (“I still feel very weak. Do you think I shall feel better after discharge from the hospital?” “When do you think I should see my doctor?”), addressed my specific worries (“Can I have sex?” “Do you think I will be able to resume my usual activities?”) and adapted the treatment plan to my preferences (“If possible, I would like to postpone the decision about... until after my daughter’s wedding”). As the simulation progressed, some students noted that the real patient was not similarly informed about his or her illness. When students did not make such comments, I steered the discussion by asking, “Were the real patient’s questions about his illness similarly addressed?” My prerogative for information was accepted as self-evident. Real patients, however, are rarely given the same attention, even though their needs are similar. This double standard made students aware that they are not free from stereotyping patients. Physicians admit to having negative feelings about certain patients; however, few are aware that these feelings can lead to unconscious discrimination against elderly, uneducated, and poor patients. The most frequently cited reasons were “The real patient never asked questions like the ones you asked” or “It is impossible to explain the nature of the disease, its treatment, or prognosis to the patient because he... [is deaf or poorly educated or speaks a different language].” I acknowledged the legitimacy of these reasons and agreed that circumstances often force the physician to settle for a less-than-perfect solution; however, the gap between the best counseling and that offered to patients, while inevitable, is not irreducible. The discussion that followed focused on the ways to reduce this gap. In response to the claim that the real patient never asked questions, I pointed out that all patients want to be informed about their illnesses. However, physicians usually assign less importance to provide such information than patients. In response to the claim that it was impossible to provide counseling because of the communication barriers, I asked the students to name the specific difficulties they had in communicating with the real patient. They were then asked to resume the simulation and demonstrate how to overcome these difficulties. Even without prior knowledge of the topic, students generally found reasonable ways to overcome communication barriers, such as using an interpreter if the patient was a foreigner, using simple, nonmedical terms if the patient was a layperson, or speaking more slowly, lip-­ reading, and reducing the distance between the physician and the patient if the patient had a hearing impairment. The combined duration of the last 2 steps may be as short as 30 min for patients with an acute, transient problem who communicate well with the physician. In such a case, the teaching session consisted only of informing the patients about their

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management and answering questions about their disease. Conversely, if the patient was an indigent or poorly educated person, the session was longer. In such cases, discrepancies between the best possible advice and the actual advice occurred shortly after the session started, cut short the simulation, and triggered a discussion about possible ways to reduce the discrepancies. Judging from student participation in the discussions, this approach provided several learning opportunities in addition to those offered by the usual teaching round. During the initial presentation of the patient, students were repeatedly surprised when, in response to my questions, patients expressed worries that they had not mentioned during the initial intake. Students often preferred to examine these worries rather than the problem list. In one case, a patient responded to my question, “Of all you have told us, what worries you the most?” by asking, “Is this coronary bypass surgery really necessary for me?” The subsequent discussions included alternative interpretations of this response, such as a request for information, fear of the recommended surgery, or a desire to get a second opinion without offending the attending physician. A learning opportunity also arose when planning for post-discharge management. Appropriate post-discharge management may be taken for granted with well-­ educated patients. However, not all patients are familiar with the outpatient healthcare system, and some need information about the availability of social assistance for certain disabilities. Student interest in these aspects of patient care opened the door to discussions about the importance of pre-discharge review and a post-­ discharge management plan. In summary, the described approach highlighted the discrepancy between providing the best possible care and the inevitable trade-offs in adapting management to the patient’s actual circumstances. Students were first projected into an ideal situation in which they can conduct a dialog with a simulated patient with no communication barriers and no constraints on financial or other resources. They then identified discrepancies between the counseling given to the simulated patient and the real patient. I believe that by using small group discussions after bedside patient presentations and by allowing students to focus on a single problem they have identified for as long as they want, this approach improves on previous attempts to promote patient-centered practice. Rather than forcing solutions, this approach challenges students to identify for themselves some of the problems patients face and find solutions. It is not necessary to complete all steps in full or in the order described here. Each step has its objective, and each step can be modified as the instructor sees fit to meet students’ preferences.

2.10 Patients’ Adherence to Doctors’ Advice Adherence to medical advice refers to the extent to which the patient attends scheduled medical appointments, takes medications, completes examinations recommended by the physician, and responds to health-promoting recommendations such

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as diet, exercise, or abstinence from dangerous habits. Nonadherence limits patients’ ability to achieve treatment goals. A 2019 study found that nonadherence to recommendations was associated with hospitalization rates and mortality in older adults [114]. In this section, I will attempt to describe the methods used to assess nonadherence, its causes, and approaches to reduce it.

2.10.1 Estimating Patients’ Adherence to Doctors’ Recommendations Nonadherence is influenced by multiple factors, and predicting it in individual patients is difficult [115]. The most common method of assessing adherence is the physician’s judgment based on his or her familiarity with the patient. However, in most cases, this judgment is not confirmed by more accurate measures of patient adherence, such as drug/metabolite concentration in body fluids, counting of tablets to determine the number of doses skipped, drug dispensing, and electronic monitoring systems for the percentage of doses taken (drug container openings) [116]. These measures are complex, expensive, and not applicable in daily clinical practice. Self-reports are more reliable when patients do not feel threatened by the truth. Physicians should phrase questions about adherence without making value judgments, for example, by asking, “Most people find it difficult to take all their medications properly. Do you also have this kind of difficulty?” If the patient answers in the affirmative, the physician needs to find out the extent of nonadherence in a non-­ threatening way and work with the patient to find its causes. Estimates for nonadherence vary from 50% for medications, 25% for patient-initiated appointments, and 20–60% for early medication discontinuation [117].

2.10.2 Reasons for Nonadherence Patients do not follow physicians’ recommendations because first, they may misunderstand the recommendations. For example, a study of blood medication levels in patients with epilepsy and bronchial asthma found that 63% of them did not comply with their medications, mainly because they did not understand that they needed to take the medications continuously [118]. Lack of understanding is one of the main reasons for the association of nonadherence with older age, low educational level, and ethnicity [119]. Second, patients may forget. Therefore, it is important to link medication adherence to regular events on the patient’s agenda, such as meals or going to work. Third, patients may consciously decide not to take the medication because it has side effects or is felt to be not effective [120]. Therefore, the physician needs to know how the patient views his or her disease and whether the patient agrees with the physician’s recommendations. The chances of success with an agreed-upon therapeutic approach are greater than the chances of following dry instructions.

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Finally, in some cases, nonadherence led to a better insight into the dosage of a medication, leading patients to the correct conclusion that they can achieve the treatment goal with a lower dose than recommended by the physician [121].

2.10.3 Ways to Improve Patient Adherence Adherence is high when treatment is supervised and when it addresses an acute condition; it is low in chronic patients or those who are not in acute distress. Therefore, it is recommended that efforts to improve adherence be focused on three patient groups: Those with treatable conditions, patients who miss follow-up visits, and patients who do not meet treatment goals, such as those with diabetes or blood pressure. Of course, meeting treatment goals is not necessarily a sign of poor adherence. However, some treatment failures are due to nonadherence, and interventions to reduce this phenomenon can improve treatment outcomes. Ways to improve adherence include providing clear information to the patient, encouraging regular patterns of behavior by linking medications to the patient’s agenda and attempting to increase patient motivation through emotional support. Effective interventions usually include a combination of information, counseling, reminders, self-monitoring of treatment outcomes, as well as motivational interviewing [122, 123]. Motivational interviewing is a communication style designed to help patients address not only nonadherence but also other behaviors such as substance abuse. Specific strategies include exploring the patient’s values and motivation, providing health information, and asking questions that promote change. Findings from recent meta-analyzes support the use of motivational interviewing to promote weight loss [124] and treatment adherence [125]. A 2020 review of motivational interviewing teaching methods found that the most commonly used interventions included role-­ playing, lectures, and videos/demonstrations. The effectiveness of the interventions suggests that their implementation in medical schools is feasible and effective for student acquisition of knowledge and skills [126].

2.11 Managing Difficult Encounters and Delivering Bad News The most common difficult doctor–patient encounters involve the delivery of a serious diagnosis, disclosing a medical error, and end-of-life planning. Breaking bad news presents the physician with the dilemma between respecting the patient’s autonomy by disclosure or adhering to the principle of beneficence by hiding the bad news. Telling the truth, especially when done blatantly, can have an undesirable emotional effect. Conversely, deception can damage the patient’s trust when he or she learns the truth, whereas information can alleviate the patient’s uncertainty and anxiety and support his or her self-care.

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Until the 1960s, physicians believed that patients should be protected from the truth. Today, that view is considered a misconception. A 2011 review found an association between adequate information provision and patients’ health-related quality of life, and an inverse association between the amount of information provided and patients’ depression and anxiety [127]. Still, in 2014, only 46% of cancer patients were satisfied with the way they were told bad news [128], and a 2018 study found poor agreement between clinicians’ and patients’ perceptions of how bad news should be communicated [129].

2.11.1 Patients’ Preferences Studies of patients’ preferences for dealing with bad news are biased by differences between respondents and nonrespondents. Patients appear to react to bad news with a sequence of denial (“That’s not true!”), anger (“Why did this have to happen to me?”), bargaining (“Maybe it’s not so bad after all?”), and acceptance (“I am ready”) [130]. Patients’ responses may depend on where they are in this sequence at the time of the survey. Surveys found that the most important predictors of patients’ satisfaction with the way bad news was delivered were their level of understanding and the duration of the encounter. Adequate time and an undisturbed environment were two of the most important requests. Patients wanted to be informed about expected symptoms, the course of the disease, and changes in their daily lives; prognosis ranked second among requests for information. Patients also wanted their physicians to allow them to ask questions. About half of the patients reported that it was not possible to make important decisions during the first meeting and wanted a second one, preferably accompanied by a relative [128]. Studies using video-based encounters with physicians have shown that most respondents preferred a patient-centered communication style [131]. Reasons for patient dissatisfaction, up to the point of discontinuing treatment, included negative physician behavior, use of medical terminology, and lack of support [132]. Lack of emotional support could not be fully compensated by high-quality information and vice versa [133].

2.11.2 Care-Providers’ Preferences Physicians’ attitudes toward the delivery of bad news have been studied through surveys, self-reports, direct observation, and controlled studies. All of these methods are subject to bias: physicians who respond to surveys or have researchers observe them at work are likely to be more confident about their interpersonal skills than those who do not. Reported attitudes may not reflect actual behavior, and observed behavior may differ from unobserved physician–patient encounters.

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A 2010 survey of pediatric residents and attending physicians at an academic center found that they felt inadequately prepared to deliver bad news to patients and families [134]. Focus groups and interviews with oncologists revealed that, although they acknowledged the importance of breaking bad news appropriately, their communication habits were affected by personal experiences and the wishes of the patient’s family [135]. The statement “Ask the patient how much he wants to know” was ranked second by patients and seventh by physicians, and the statement “Tell the patient the bad news clearly and understandably” was ranked third by patients and sixth by physicians [136]. Other authors have reported similar inconsistencies between physicians and patients when it comes to delivering bad news [137]. Oncologists who had to deliver bad news have reported feeling varying levels of stress and anxiety [138]. Physicians may feel threatened by the patient’s emotional response. They may use defense mechanisms, such as focusing on the biomedical aspects of the disease or nonverbal behaviors that indicate time pressure. Such defense mechanisms weaken the alliance with the patient. It has been suggested that instead of suppressing their anxiety, physicians should try to identify its source (the effect of the information on the patient? their ability to deliver bad news? what the patient might ask? and how to respond?), explore the patient’s point of view, and let the patient express his or her feelings instead of defending themselves as if they were being blamed [139]. Controlled trials encounter methodological difficulties and have yielded sparse evidence on the effects of different approaches to informing patients. A major difficulty is the selection of study populations. In theory, study participants should be patients who are unaware of their disease. In practice, patients referred to oncology units differ in terms of the information they have received from previous caregivers and the extent to which they are aware of and reconciled with their diagnosis. Second, the interventions studied were primarily technical: providing printed information to the patient, recording and giving the tape to the patient, contacting the patient by telephone to determine further information needs, and a final letter documenting the conversation with the patient. Patients place a high value on receiving audio recordings of the encounter and most of them benefit from listening to these recordings [140]. Recording the consultation for later use by the patient improved the patient’s satisfaction, recall, and decision-making. Consultation recordings positively influenced patients’ affective, cognitive, and behavioral outcomes, and the negative effects of consultation recordings were small [141].

2.11.3 Suggested Guidelines The limitations of studies on the communication of bad news do not allow definitive recommendations. The only evidence-based guideline suggests gaining insight into patients’ prior knowledge of their disease, the amount of

2.11  Managing Difficult Encounters and Delivering Bad News

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information they want to receive about diagnosis and treatment, and their desire to share information with their families [142] in addition to providing patients with audio recordings of the encounter [141]. The remaining guidelines are based on the need to acknowledge the stress physicians may feel when delivering bad news, the importance of an environment that ensures privacy and limits interruptions, clear wording, avoidance of medical jargon, time for patients to process bad news, and to the awareness that different patients need different information. The need to break bad news to the patient can arise in two situations. Even before the diagnosis is made, the physician may learn what a cancer diagnosis means to the patient by asking “Do you have any thoughts about what caused your disease?” Sometimes the patient will express concern about the possibility of cancer. In such cases, the concern should be accepted as reasonable, but other diagnostic possibilities should also be mentioned. In the second situation, the bad news is delivered by a physician who is seeing the patient for the first time, such as the surgeon who performed the biopsy. In such cases, the conversation with the patient should take place in the privacy of the physician’s office, not in the hallway, not on the phone, and not during rounds [143]. The physician can say, “The test results are already in. If you would like, I can tell you about your disease and its treatment,” “Would you like to talk to me in private or with someone else present?” and “Would you like me to talk to someone in the family first?” Most patients, especially those from lower socioeconomic backgrounds, have difficulty taking the initiative to seek information. These difficulties may be interpreted by physicians as reluctance to obtain information. The distinction between a patient’s difficulty in asking and his or her reluctance to receive information can be made by expressing a willingness to answer any question in an atmosphere of unlimited time. Physicians should find out what the patient knows about his or her illness, expectations, and plans for the future by saying, “Before I answer your questions, I want to know what you already know about your illness.” Other questions that can give the physician insight into the patient’s preferences include: “It’s important for me to know what you think about your disease,” or “Of all these things, what worries you the most?” Patients need time to absorb information. Therefore, it is important to make an appointment for the next meeting as soon as possible to answer further questions. The physician’s role is to be available and be a constant source of information and support while communicating to the patient that expressions of sadness, hopelessness, or anger are normal. If the patient wants to consider treatment options or seek another opinion, he or she should be allowed to do so. Doctors should be ready to accompany the patient even when a cure is not possible; convey to the patient the message that fear of death should not interfere with the joy of living; prepared to respond “I do not know”; and absorb the patient’s anger and doubts about his or her professional abilities.

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2.11.4 Teaching How to Disclose Bad News Teaching how to handle difficult encounters cannot employ real patients. It rather uses small group discussions and role-playing with standardized or analog patients (healthy individuals asked to put themselves in the patients’ shoes) followed by reflections, feedback, and written presentations that allow students to reflect and gain a deeper understanding of how to deliver bad news. These teaching approaches are feasible and highly rated by learners [144, 145]. Most instructional interventions were associated with improvement in observer-rated skills [146]; however, evidence comparing different types of training was lacking [147]. In 2000, Baile et al. developed the SPIKES—a six-step protocol for breaking bad news that includes the four main goals of bad news delivery: Asking for information from the patient, conveying medical information to the patient, providing support, and obtaining the patient’s cooperation in developing a treatment plan. A 2019 survey of Canadian medical schools found that 10 of 12 responding schools used the SPIKES model and that the guidelines it contains were consistent with patients’ preferences for breaking bad news. Content analysis of patient responses revealed that the most important components of SPIKES were clinicians’ expressions of empathy, explanations of the diagnosis and its implications, and asking the patient if they understood [148]. Other authors have suggested the following principles for handling difficult encounters: “Do not be judgmental” and avoid turning the conversation into an argument; “Do not mislead” and do not try to soften the message by being evasive; “Do not confuse vagueness with compassion” and do not obscure the core message; “Offer hope and comfort” by pointing a way forward without downplaying the seriousness of the situation; “Be calm and soothing” and avoid an accusatory, dismissive, or condescending tone; “Be an active listener” without interrupting and by occasionally paraphrasing what is being said; and “Pauses are your friend” by speaking slowly and clearly and always watching for the listener’s reaction. Pauses and periods of silence demonstrate respect and allow each party to understand what is being said [149]. The main difficulty in evaluating bad news teaching measures is how to assess outcomes. A comparative analysis of measurement instruments and assessors has shown that different assessment instruments lead to different results [150]. Similarly, the 2011 review paper I referred to earlier found that only one of eight studies of educational interventions showed a positive association with better quality of life [127]. Therefore, the delivery of bad news has yet to be validated by its impact on patient health.

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136. Perry ZH, Rosenblatt A, Biderman A. Breaking bad news: attitudes of physicians and patients in primary care. Ann Behav Sci Med Educ. 2011;17:17–25. 137. Girgis A, Sanson-Fisher RW, Schofield MJ.  Is there a consensus between breast cancer patients and providers on guidelines for breaking bad news? Behav Med. 1999;25:69–77. 138. Shaw J, Brown R, Heinrich P, Dunn S. Doctors’ experience of stress during simulated bad news consultations. Patient Educ Couns. 2013;93:203–8. 139. Stiefel F, Krenz S. Psychological challenges for the oncology clinician who has to break bad news. In: New challenges in communication with cancer patients. Boston, MA: Springer; 2013. p. 51–62. 140. Tsulukidze M, Durand MA, Barr PJ, Mead T, Elwyn G.  Providing recording of clinical consultation to patients—a highly valued but underutilized intervention: a scoping review. Patient Educ Couns. 2014;95:297–304. 141. Dommershuijsen LJ, Dedding CW, Van Bruchem-Visser RL. Consultation recording: what is the added value for patients aged 50 years and over? A systematic review. Health Commun. 2021;36:168–78. 142. Berkey FJ, Wiedemer JP, Vithalani ND.  Delivering bad or life-altering news. Am Fam Physician. 2018;98:99–104. 143. McElroy JA, Proulx CM, Johnson L, Heiden-Rootes KM, Albright EL, Smith J, Brown MT. Breaking bad news of a breast cancer diagnosis over the telephone: an emerging trend. Support Care Cancer. 2019;27:943–50. 144. Karnieli-Miller O, Palombo M, Meitar D.  See, reflect, learn more: qualitative analysis of breaking bad news reflective narratives. Med Educ. 2018;52:497–512. 145. Rosenbaum ME, Ferguson KJ, Lobas JG. Teaching medical students and residents skills for delivering bad news: a review of strategies. Acad Med. 2004;79:107–17. 146. Johnson J, Panagioti M. Interventions to improve the breaking of bad or difficult news by physicians, medical students, and interns/residents: a systematic review and meta-analysis. Acad Med. 2018;93:1400–12. 147. MacLaine TD, Lowe N, Dale J. The use of simulation in medical student education on the topic of breaking bad news: a systematic review. Patient Educ Couns. 2021;104(11):2670–81. 148. Mirza RD, Ren M, Agarwal A, Guyatt GH.  Assessing patient perspectives on receiving bad news: a survey of 1337 patients with life-changing diagnoses. AJOB Empir Bioeth. 2019;10:36–43. 149. Prober CG, Grousbeck HI, Meehan WF III. Managing difficult conversations: an essential communication skill for all professionals and leaders. Acad Med. 2022;97:973–6. 150. Schildmann J, Kupfer S, Burchardi N, Vollmann J.  Teaching and evaluating breaking bad news: a pre-post evaluation study of a teaching intervention for medical students and a comparative analysis of different measurement instruments and raters. Patient Educ Couns. 2012;86:210–9. 151. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP.  SPIKES—a six-­ step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5:302–11.

Chapter 3

The Physical Examination

3.1 Introduction In contrast to the changes that have occurred in the teaching of doctor–patient communication since the 1970s, the teaching of physical examination (PE) has remained the same over the past century. Textbooks of PE continue to provide an unselective array of signs, including those no longer considered useful, while important PE signs are often excluded [1], and as recently as 2018, 56% of medical schools in the USA taught the “head-to-toe”/“complete”/“comprehensive”/“routine” PE along an organ-based sequence [2]. Teaching head-to-toe PE has been criticized because it is learned but rarely put into practice and does not fully achieve its objective. Students demonstrate poor PE skills during their clerkships [3]. In 2011, US medical graduates scored an average of 78% on history taking on the Medical Licensing Examinations, but only 60% on PE [4]. PE errors have been reported to lead to misdiagnosis in up to 5% of outpatients [5], in 22 of 100 consecutive inpatients [6], and a 2015 study confirmed that PE errors are preventable causes of medical mistakes [7]. Finally, a 2020 survey of interns at an academic hospital found that 45% of respondents had witnessed a patient safety issue that was due to inadequate PE [8]. Consequently, since the 1970s, there have been calls to teach PE by encouraging students to approach clinical problems in the same way that physicians approach diagnostic problems, namely by making diagnostic hypotheses and then conducting a “reflective”/“hypothesis-driven”/"selective”/“targeted”/“focused”/“purpose-­ driven” PE to test those hypotheses [3, 9–16]. Indeed, when students are confronted with clinical problems, they can form diagnostic hypotheses, and instructional interventions that promote expert reasoning are feasible at all stages of medical education. However, this approach may miss an unexpected finding that could have been detected by a head-to-toe PE and hence the ambiguity about the optimal teaching method of PE [17]. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Benbassat, Teaching Professional Attitudes and Basic Clinical Skills to Medical Students, https://doi.org/10.1007/978-3-031-26542-6_3

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The objective of this section is to suggest that teaching PE should first overcome specific barriers to student learning, second, that teaching should be transferred from hospitals to community clinics where ancillary tests are not readily available, and third, to explain the Bayesian approach to using additional data to reduce diagnostic uncertainty.

3.2 Barriers to Teaching and Learning Physical Examination Skills 3.2.1 Attitudes to the Physical Examination It has been claimed that “the traditional course of physical diagnosis … does not match what students … see during their clinical years. They are surprised that the house staff … carry very few of the instruments that the student has acquired: Reflex hammers are occasionally sighted, but ophthalmoscopes are quite rare” [18]. Too often, students interpret the difference between the PE, which is performed by physicians, and the head-to-toe PE, which they are required to perform, as an indication that the latter is not important, but rather a time-honored ritual for the record. The debate over whether PE has outlived its usefulness began with the introduction of X-rays in the early twentieth century [19]. The diagnostic value of PE signs is difficult to assess because attempts to determine their sensitivity and specificity usually do not take into account the severity of the disease and the examiners’ skills. The sensitivity of PE signs increases with the severity of the disease [20], and different skills of the examiners reduce the reliability of PE findings [21]. These two biases may have led to an underestimation of the diagnostic value of the PE. A 2010 review of the value of the PE respiratory signs found that most had low to moderate reliability and a sensitivity of 0.5 or less. These results argue against the utility of PE for screening asymptomatic individuals. Screening for disease requires the test to have a high sensitivity well above 0.7. The review also found likelihood ratios-negative (LR−) of 0.3 or less for some PE findings such as dullness on percussion and LR+ values of 4.0 or more for findings such as the asymmetric expansion of the chest [22]. These high specificities and high LRs+ indicate that some PE findings are useful in certain clinical contexts. Therefore, a carefully performed PE, aimed at exploring a diagnostic hypothesis, as opposed to a PE, aimed at detecting disease in an asymptomatic individual, remains one of the cornerstones of clinical practice.

3.2.2 “Inherited” Errors Textbooks of the PE describe alternative examination techniques, e.g., of the thyroid gland (facing or behind the patient) or the spleen (from the patient’s right or left side). Apart from such legitimate variations, however, I have often found glaring

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errors in students’ PE skills that could be traced back to their tutors. Other authors have commented similarly on the poor PE skills of residents, noting that relying on them to teach PE can lead to situations in which “the blind lead the blind” [23]. Inherited errors included defining paradoxical breathing, synchronizing the examiner’s hand movement with the patient’s breathing during palpation of the liver margin, palpation of the thyroid gland, and assessment of chest expansion. Students and faculty whom I confronted with such errors had to be shown the correct technique in textbooks before they admitted that what they had been taught was wrong. Tutors needed to be reminded of the anatomical landmarks of the Lewis angle (second intercostal space) and the tip of the scapula (seventh intercostal space). They also needed to be shown that the diaphragm is located in the sixth, eighth, and tenth intercostals on exhalation; that emphysema can be diagnosed by the absence of cardiac dullness on percussion; and that limiting the examination of the lungs to the back leaves the upper lobe unexamined. Therefore, students should be required to read the appropriate chapter in textbooks after their tutors demonstrate a particular PE skill and discuss with their tutors possible discrepancies in the technique of the examination.

3.3 Coping with Barriers to Learning the Physical Examination 3.3.1 Teaching the Reflective Physical Examination1 The reflective PE is guided by one or more of the following five goals (Table 3.1): Search for essential signs of life-threatening conditions in all patients and especially in patients in acute distress; search for important signs to test diagnostic hypotheses in patients with focal complaints; and search for important signs that would provide a diagnostic clue in patients without focal complaints. The fewer diagnostic clues that can be derived from the medical history, the broader the differential diagnosis and the more comprehensive the required PE. A reflective PE is also purposeful if it aims to follow patients with a known chronic disease. For example, a change in treatment should be considered when patients with vascular disease develop foot ulcers or when patients with asymptomatic valvular disorders develop heart failure. It is a widely held belief that asymptomatic individuals should have a complete annual examination. Although this belief was questioned as early as 1945 [24], it was not challenged until the 1970s, when Frame and Carlson [25] recommended replacing the annual examination with periodic examinations tailored to a patient’s

 Parts of this section were published in: Benbassat J, Schiffmann A. An approach to teaching the introduction to clinical medicine. Ann Intern Med. 1976;84:477–81. With permission of the American College of Physicians. Benbassat J, Baumal R, Heyman SN, Brezis M. Viewpoint: suggestions for a shift in teaching clinical skills to medical students: the reflective clinical examination. Acad Med. 2005;80:1121–6. With permission of Wolters Kluwer. 1

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Table 3.1  Examples of symptoms and signs to be sought in specific patient contexts to test diagnostic hypotheses (parentheses) by the purpose of the examination (adapted from [9] with permission from Wolters Kluwer) Purpose of Patient population and context examination (one or more of the following) Pediatric Adult Detect essential signs Stridor (acute croup) Sudden tachycardia, of life-threatening cannonball waves in a conditions patient with myocardial infarction (ventricular tachycardia) Test diagnostic Pulmonary Reduced knee jerk hypotheses in consolidation in a and muscle weakness patients with focal child with fever, of the leg in a patient complaints cough, dyspnea, and with low back pain abdominal pain (herniated disk) (pneumonia) Search for a cue for Neglect in failure to Skin rash in a patient diagnosis in patients thrive (malnutrition) with fever (erysipelas) with nonspecific complaints Monitor a known Fever in a patient with Leg ulcers in a disease for cystic fibrosis diabetic patient complications (pneumonia) Screening for Hypertension Breast cancer diseases for which early treatment has been shown to reduce mortality

Geriatric Neglect and multiple traumata in an institutionalized patient (abuse)

Tender L1 in a patient with low back pain and osteoporosis (compressed vertebral fracture) Swollen tympanic abdomen in a confused patient (fecal impaction) Proteinuria in a patient with multiple myeloma Inappropriate medications

age, gender, and risk indicators for disease. These periodic examinations would consist of screening for high-risk behaviors and focus on the most common causes of death in persons of the same gender and age. Within a decade, these recommendations were supplemented by those of the Canadian Task Force on the Periodic Health Examination and the US Preventive Services Task Force. Teaching reflective PE appears to be more effective than teaching head-to-toe PE [11, 13]. By asking students to search for relevant physical findings, the reflective PE transforms a routine task into an intellectually exciting experience; it is consistent with current trends in education that promote reflective practice [26], and it stands to reason that the gap between experienced clinicians and novices is more effectively narrowed by teaching the reflective than the head-to-toe PE. Students’ diagnostic hypotheses may be nonspecific (e.g., “shortness of breath may be caused by disease of the heart or lungs”). However, even nonspecific hypotheses encourage a further search for information (“What findings suggest cardiac disease?”). The advantages of the head-to-toe PE are that it introduces students to the skills needed for practice; it is important in patients with non-localizing complaints or symptoms that originate in multiple organ systems; it may detect unsuspected findings

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in up to 5% of patients [27]; it assures both physicians and patients that a complete examination has been performed, and every physician can recall instances of serendipitous diagnoses made by adherence to a head-to-toe PE.  Hence the attempts to define an optimal mix of head-to-toe and reflective PEs. In 2014, Gowda et al. developed a 45-maneuver “core” PE, which should be performed on every newly admitted patient and supplemented by a reflective PE.  Certainly, a combined reflective and head-to-toe PE is more likely to uncover important PE findings than alternative teaching methods. However, I suggest teaching students that in situations where time is short, reflective PE is more likely to yield important findings than head-to-toe PE.

3.3.2 Learning for Mastery Teachers often disagree about what level of competency is required of students when they graduate, i.e., what should be taught for mastery, what should be taught for general knowledge only, or what should be taught for an intermediate level of competency. The concept of learning for mastery was introduced by Bloom in 1968 [28]. Its unique feature is derived from the view that uncorrected errors lead to learning difficulties. Therefore, it begins by dividing the subject matter into small units. Each student’s progress is assessed through supervised practice, and students are not allowed to move on to another unit until they have mastered the previous one. I suggest that the basic clinical skills (patient interviewing, PE, and self-directed learning) be taught for mastery. Learning for mastery is more likely to improve the teaching of PE than the current expectation that students’ PE skills will improve with repeated reinforcement during the clerkship rotations. First, a low initial standard of required proficiency may persist into the future. Second, repeated reinforcement of PE throughout the curriculum spreads the responsibility for teaching among many, so that individual tutors are no longer accountable for the outcomes of their teaching. Third, the assumption that students, having been introduced to PE during the preclinical program, will improve their examination skills during the clerkship is inconsistent with reports of deterioration in PE skills during the clerkship [29] and in cardiology [30] and respiratory [31, 32] PE skills with seniority.

3.3.3 Integrating Hand-Held Devices into Teaching the Physical Examination2 The ability to use PoCUS is commonly considered the domain of specialists. However, the miniaturization of diagnostic technology signals a shift in practice that should begin with student education.  A previous version of parts of this section was published in: Benbassat J, Gilon D. Teaching the physical examination by context and by integrating hand-­ held ultrasound devices. Med Teach. 2020;42(9):993–99. With permission from Taylor and Francis. 2

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PoCUS skills can be taught to medical students who seem to enjoy experiential training programs. PoCUS training is commonly integrated into gross anatomy and PE courses. It provides real-time feedback on examination results, thereby improving students’ traditional PE techniques [33, 34]. Incorporating PoCUS into PE education can lead to more reliable and rapid bedside diagnoses, triage, and appropriate treatment and reduce patient management costs [35]. Medical students trained in PoCUS for 18 h reportedly detected pathology in 75% of patients with known heart disease, whereas cardiologists using a stethoscope did so in only 49% [36].

3.3.4 Teaching Physical Signs by Context and Importance As discussed below, the diagnostic value of a given sign is determined by its sensitivity, specificity, and the pretest probability of the diagnosis in question. The pretest probability of the diagnosis depends on the clinical context. Therefore, I propose structuring both teaching and textbooks of PE according to clinical context rather than organ systems and limiting head-to-toe PE to patients with nonlocalized complaints or symptoms originating in multiple organ systems. Textbook sections would consist of the diagnostic hypotheses to be tested (e.g., “Does this patient have ascites?”) and provide answers based on selected physical signs that are reproducible, sensitive, and specific enough to alter the likelihood of a diagnosis [11]. I also suggest distinguishing between essential, important, and optional PE signs. Table 3.2 provides examples of essential PE and point-of-care ultrasound (PoCUS) findings in life-threatening conditions. Students would be expected to immediately treat hypoxemic patients who have any degree of respiratory abnormality (tachypnea, bradypnea, apnea, labored breathing, stridor, accessory muscle recruitment, or paradoxical breathing) with oxygen and look for stridor (croup, epiglottitis), wheezing (bronchial asthma, bronchitis), decreased breath sounds and altered percussion sounds (pneumothorax or pleural effusion), and signs suggestive of pulmonary embolism. Students would be also expected to recognize cannonball jugular waves associated with tachycardia (ventricular tachycardia); S3 gallop; use PoCUS to determine inferior vena cava caliber and differentiate between hypovolemic, obstructive, cardiogenic, and distributive shock [37]; detect decreased left ventricular contractility or right ventricular strain in patients with hypoxemia; acute aortic regurgitation in patients with infective endocarditis; and acute mitral regurgitation or ventricular septal defect in patients with myocardial infarction who develop sudden left ventricular failure [38]. Important physical signs (Tables 3.3 and 3.4) are those that may influence the likelihood of disease that is not immediately life-threatening in patients with and without focal symptoms. The diagnostic errors in primary care that could be attributed to PE were hypertension, knee and ankle effusions, hepatomegaly, cellulitis, pneumonia, and pleural effusion [5]. In hospitalized patients, the overlooked findings were purulent thrombophlebitis, toe gangrene, dialysis catheter tunnel infection, and erysipelas [6].

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Table 3.2  Examples of symptoms and signs of possible life-threatening conditions in specific contexts. Adapted from [39] with permission from Taylor and Francis Context

Sign or symptom

Possible cause/diagnosis

Any context

Preoccupation with death, hopelessness, acting recklessly (e.g., speeding), calling people to say goodbye, getting affairs in order, saying things like “everyone would be better off without me”

Depression; suicide risk

Absent carotid pulse

Cardiac arrest, hypovolemic, obstructive, cardiogenic, or distributive shock

Sweaty cold extremities, capillary refill time > 2 s; S3

Low cardiac output, hypovolemic, obstructive, cardiogenic, or distributive shock

Pulse oximetry: Low oxygen levels

Hypoxemia

Sudden pain at any location

Vascular event (occlusion, dissection, or hemorrhage), obstruction of a hollow organ

Sensory loss, muscle weakness, urinary retention

Spinal cord compression, spinal stroke, Brownsequard syndrome

Sudden abnormalities in consciousness and orientation

Cerebrovascular ischemic or hemorrhagic event

Diastolic pressure above 120 mm, retinal hemorrhages

Malignant hypertension

Abdominal pulsating mass

Aneurysm of the abdominal aorta

Tachycardia with “cannonball” jugular waves

Ventricular tachycardia

Abdominal pain, fever

Peritoneal signs

Acute appendicitis, ruptured perinephric abscess, pelvic inflammatory disease, cholecystitis/ cholelithiasis, pancreatitis, bowel obstruction, ovarian cyst, perforated viscus, ectopic pregnancy, retroperitoneal hemorrhage

Sudden chest pain

Reduced breath sounds, change in percussion note, tracheal deviation. PoCUS: Pneumothorax

Pneumothorax

S3, systolic blood pressure  120/min, asymmetric expansion of the chest, increased vocal fremitus, dullness on percussion, pleural friction rub, bronchial breathing, increased vocal resonance, inspiratory crackles Jugular distention, respiratory rales, sweaty cold extremities

Acute exacerbation of chronic obstructive airway disease, primary pulmonary hypertension

Wheezing, absent cardiac dullness. Peak-flow meter: Reduced airflow

Bronchial asthma, emphysema, acute bronchitis, COPD exacerbation

Uplift of the left or right lower sternal area, palpable or loud P2. PoCUS: Right ventricular strain and hypertrophy

Pulmonary hypertension

Tachypnea

Left ventricular failure, pulmonary emboli, pneumothorax, hyperthyroidism, pneumonia

Periodic breathing (Cheyne–stokes respiration, biot breathing)

Heart failure, increased intracranial pressure (meningitis, subarachnoid hemorrhage, intracerebral hemorrhage), stroke, head injury, drugs

Elevated jugular pressure; Kussmaul’s sign Severe heart failure, pulmonary emboli, right (paradoxical elevation of jugular pressure ventricular infarction, constrictive/restrictive during inspiration) pericarditis, tamponade Jugular distention, abdomino-jugular reflux, apical impulse lateral to the midclavicular line, S3. PoCUS: Reduced left ventricular function

Left ventricular failure, high pulmonary capillary wedge pressure (>/ = 18 mmHg)

Dyspnea, decline in blood pressure on sitting or standing, paradoxical pulse, swollen leg, cardiac third sound, asymmetric chest percussion and breath sounds

Massive pulmonary embolus

Dyspnea, decline in blood pressure on sitting or standing, paradoxical pulse, asymmetric chest percussion and breath sounds. PoCUS: Pneumothorax

Tension pneumothorax

Chest trauma, respiratory rate > 20/min, breath sounds unilaterally diminished. PoCUS: Pleural air and effusion

Hemo-pneumothorax

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Table 3.2 (continued) Context

Sign or symptom

Possible cause/diagnosis

Shock, decline in blood pressure on sitting or standing

Dry axilla, dry mucous membranes of mouth, PoCUS: Reduced inferior vena cava diameter

Hypovolemia: Dehydration, blood loss (gastrointestinal, ruptured aneurism, ectopic pregnancy)

Smell of acetone

Diabetic acidosis

Excessive urine production, PoCUS: Reduced inferior vena cava diameter

Hypovolemia: Diabetic acidosis, Addisonian crisis, salt losing nephritis

Dyspnea, S3, PoCUS: Reduced left ventricular contractility

Cardiogenic shock: Myocardial infarction, end-stage cardiomyopathy/valvular heart disease

Fever or hypothermia. PoCUS: Normal inferior vena cava diameter

Distributive shock: Sepsis

Exposure to vaccination, medication, bee sting, PoCUS: Normal inferior vena cava diameter

Distributive shock: Anaphylaxis

Abdominal pain, chest pain, vomiting, confusion, fever, tachycardia, PoCUS: Normal inferior vena cava diameter

Distributive shock: Porphyria

Trauma, no blood loss. PoCUS: Normal inferior vena cava diameter

Distributive shock: Cervical or thoracic spinal cord injury

Asymmetric tenderness and swelling of the Obstructive shock: Pulmonary embolus calf/leg. PoCUS: Increased size of the right ventricle relative to the left ventricle

Fever

Headache, acute visual change, or diastolic blood pressure of >120 mmHg

Transient/ permanent loss of consciousness or confusion

Chest pain, paradoxical pulse. PoCUS: Pericardial effusion

Obstructive shock: Pericardial tamponade

Chest pain, asymmetric chest percussion and breath sounds, PoCUS: Pneumothorax

Obstructive shock: Tension pneumothorax

Neck rigidity, skin petechiae

Meningitis

Roth’s spots on funduscopic examination, splenomegaly, finger clubbing

Infective endocarditis

Neck rigidity

Subarachnoid hemorrhage

Papilledema

High intracranial pressure

Retinal hemorrhages in patients with high blood pressure

Hypertensive encephalopathy

Retinal artery occlusion

Arteritis

Retinal hemorrhages, cotton-wool spots, Roth’s spots

Septicemia, bacterial endocarditis

Reduced or absent A2, ejection murmur on Aortic stenosis the right clavicle and the right 2d or left fourth–fifth space with carotid radiation, delayed upstroke of carotid pulse; PoCUS: Aortic stenosis Differences in blood pressure between the arms

Subclavian steal syndrome

Elevated blood pressure

Intracranial lesion (stroke or brain tumor)

Asymmetric facial, arm, and leg weakness; Stroke, embolic, thrombotic, hemorrhagic speech defect History of asystole, syncope, right ventricular failure

Asystole

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Table 3.3  Examples of “important” symptoms and signs to be sought in specific contexts to test diagnostic hypotheses in patients with focal complaints Context Fever, sore throat, no cough Running nose, cough, sore throat Fever, colored nasal discharge Chronic respiratory symptoms

Sign or symptom Tonsillar exudates, cervical adenopathy No tonsillar exudates

Possible respiratory cause/diagnosis Streptococcal tonsillitis

Blurred sinus trans-illumination Hyper-resonance, reduced breath sounds. Peak-flow meter: Reduced airflow Reduced diaphragmatic motion, barrel chest. Peak-flow meter: Reduced airflow Dry crackles Clubbing of the fingers

Sinusitis

Shortness of breath, Typical angina, prior chest pain myocardial infarction, ankle-brachial index  12 mmHg

Aortic stenosis and regurgitation, cardiomyopathy, ventricular aneurysm Pulmonary hypertension, pulmonic stenosis, atrial septal defect, tricuspid regurgitation, mitral stenosis and regurgitation Atrial fibrillation, premature beats Musculoskeletal pain

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Table 3.3 (continued) Context Sign or symptom Peripheral edema or Normal central venous ascites pressure Elevated jugular pressure, hepatomegaly

Hypertension

Claudication

Elevated jugular pressure and retracting apex beat, Kussmaul’s sign Elevated jugular pressure, pulsatile hepatomegaly Jugular distension, hepatomegaly Peak-flow meter: Reduced airflow. PoCUS: Right ventricular strain and hypertrophy Different blood pressure, arms, and legs, continuous murmur over the back Abdominal bruits with systolic-­diastolic components Foot ulcers, atrophic skin, pallor on elevation, rubor on lowering, asymmetric coolness, different blood pressure between arms and legs

Possible respiratory cause/diagnosis Hypoalbuminemia: Chronic liver disease, nephrotic syndrome, local venous obstruction Left or right ventricular failure, chronic lung disease, primary pulmonary hypertension, pulmonic stenosis Constrictive pericarditis

Severe tricuspid regurgitation Obstructive airway disease, primary pulmonary hypertension

Coarctation of the aorta

Reno-vascular disease Chronic leg ischemia

Auscultation of the heart has traditionally been considered an important clinical skill. However, residents [23], pediatricians [40], and family physicians [41] perform poorly in interpreting audiotaped cardiac murmurs. Therefore, the ability to diagnose nonemergent abnormalities such as atrial septal defect, ductus arteriosus, and Austin-Flint murmur on real patients, mannequins, or audiotapes by auscultation does not seem to be a realistic goal of undergraduate medical education and should be considered optional. I suggest that students should be expected to be able to distinguish between normal and abnormal findings on auscultation of the heart, which might indicate the need for further investigation. The least important (optional) PE signs (Table 3.5) are those that are no longer used because of the availability of easily performed ancillary tests. For example, PoCUS can detect left ventricular dysfunction at an earlier stage than pulsus

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Table 3.4  Examples of “important” signs to be sought to find a cue for a diagnosis in patients with nonspecific complaints (e.g., fatigue, palpitations) and without localizing symptoms Sign Goiter, tachycardia, moist and warm skin, eyelid retraction, eyelid lag, fine finger tremor Pallor Cool, dry, and coarse skin, “hypothyroid speech,” bradycardia, delayed ankle reflex Tachycardia, transient slowing of the pulse during vagal maneuvers Tachycardia, abrupt slowing of the pulse during vagal maneuvers The pulse quickens with inspiration, slows with expiration Pause in otherwise regular pulse rate Pulse pressure > 80 mmHg Displaced apex beat lateral to the midclavicular line; elevated jugular pressure, positive abdomino-jugular test, S3 gallop. Abnormal Valsalva response Sustained movement of the left or right lower sternal area

Palpable or loud P2 Loud S1 Faint or absent S1 Regular rhythm, varying intensity of S1 Fixed wide splitting of S2 A systolic murmur from the apex to the anterior axillary line Physiologic wide splitting of S2

Paradoxical splitting of S2 A mid-systolic click followed by a murmur

Possible cause/diagnosis Hyperthyroidism Anemia Hypothyroidism Sinus tachycardia Paroxysmal supraventricular tachycardia Sinus arrhythmia Premature contractions, heart block Aortic regurgitation Left ventricular failure

Mitral stenosis, pulmonary hypertension, atrial septal defect, tricuspid regurgitation, mitral regurgitation Pulmonary hypertension Thyrotoxicosis, prolapsed mitral valve, mitral stenosis Myocardial infarction, left bundle branch block Atrioventricular dissociation Atrial septal defect Mitral regurgitation P2 late: Right bundle branch block, pulmonic stenosis, cor pulmonale, A2 early: Mitral regurgitation Left bundle branch block, aortic stenosis, ischemic heart disease Mitral valve prolapse

alternans. Hand spirometry provides an easier and more accurate assessment of obstructive airway disease than Hoover sign and pulsus paradoxus. Spirometry can also alert physicians to the possibility of mild pulmonary disease and can be used to monitor patients with conditions such as asthma and cystic fibrosis. Pulse oximetry can detect decreased blood oxygenation at an earlier stage than central cyanosis, and the availability of laboratory measurements of thyroid function has reduced the importance of ocular signs of hyperthyroidism beyond lid lag.

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Table 3.5  Examples of optional symptoms and signs Sign or symptom Cyanosis Pulsus paradoxus in a patient with engorged neck veins, tachycardia, dyspnea Skodaic resonance Grocco’s triangle

Kronig’s isthmus

Abnormal vocal resonance (sound of the patient’s voice heard through a stethoscope placed on the patient’s chest) Bronchophony (loud voice) Pectoriloquy (intelligible spoken words) Egophony (“E to A change” of the patient’s voice) Hoover’s sign Pulsus alternans Dicrotic pulse Pulsus bisferiens Hyperkinetic or collapsing pulse or hyperkinetic apex beat Percussion of the heart S4 heart sound Ejection sound Pericardial knock Asymptomatic carotid bruits Arcus lipidus

Possible cause/diagnosis Hypoxemia Bronchial asthma Hyper-resonance on percussion above a pleural effusion Right-angled triangle of dullness over the posterior region of the chest opposite a large pleural effusion A narrow band of resonance over each lung apex. Reduced with infiltrates of the lung apices Pneumonia (lung consolidation)

Chronic obstructive airway disease Severe left ventricular dysfunction Severe left ventricular dysfunction Moderate to severe aortic regurgitation Severe aortic regurgitation Cardiac size Prognostic indicator after myocardial infarction Aortic stenosis at valvular level Constrictive pericarditis No prognostic value for stroke Dyslipidemia

3.3.5 Use of Simulations3 Simulation technology provides opportunities to teach PE skills through photographs [42], audio-video simulations [43], mannequins [44], and simulations of breast and pelvic examinations [45]. To teach percussion, I used a tabletop to simulate the chest wall and a foam sponge to simulate the overlying skin and subcutaneous tissue. I asked the students to compare the clear sound produced by tapping on the bare tabletop with the muffled sound produced by tapping on the sponge, and

 A previous version of this section was published in: Benbassat J, Meroz N. The foam sponge as a teaching aid in the examination of the chest. Med Educ. 1988;22:554–55. With permission from Blackwell Publishing Ltd. 3

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with the sounds produced by percussion after varying degrees of pressure on the sponge. Once students understood the importance of applying appropriate pressure with the pleximeter, they quickly learned the technique of striking with the wrist rather than the elbow and striking the end phalanx, which exerts the maximum pressure [46]. I also used the sponge to simulate the lung parenchyma. Students learned to recognize bronchial breathing by placing the stethoscope directly on the trachea and vesicular breathing by listening to the lower parts of the chest. A dry sponge placed between the stethoscope and the trachea simulated vesicular breathing. A water- or air-filled bag (or surgical glove) placed over the dry sponge further attenuated breath sounds and simulated the effects of pleural effusion or pneumothorax. Auscultation on a water-soaked sponge (simulating lung consolidation) placed on the trachea produced bronchial breath sounds not unlike those obtained when the chest piece was placed directly on the trachea.

3.4 Diagnostic Utility of the Physical Examination and Ancillary Tests The diagnostic process is a recursive examination of the question: are the available data about the patient sufficient to make a treatment decision? If yes, the physician proceeds to treatment; if not, additional information is needed. Such information may include further questioning of the patient (have you recently traveled abroad?), a physical examination (palpable spleen?), or imaging and laboratory tests. The terms “additional information” and “diagnostic test results” are used interchangeably and refer to data that may reduce diagnostic uncertainty. To express uncertainty, physicians use terms such as “maybe” or “cannot be ruled out.” These terms are not helpful in diagnostic reasoning. It is not enough to know that a diagnosis is uncertain or that a test result would reduce this uncertainty; we need to know how much the test result changes the probability of disease. To this end, qualitative expressions, such as “probable (diagnosis),” are replaced by the term “probability (of diagnosis)” (p), which describes the likelihood of disease in quantitative terms. The statement “The probability of rheumatoid arthritis is 30–50%” expresses the belief that out of 100 patients with the same manifestations, 30–50 will have rheumatoid arthritis, while the remaining 50–70% will have some other disease. A test that, if positive, increases the probability of disease from 40% to 95% is more useful than a test that increases the probability to 70%. Test characteristics are described in detail in textbooks. The goal of this section is to provide only a summary of the information about diagnostic tests and clinical prediction rules that medical students need to understand the value of the physical examination.

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3.4.1 Test Properties The decision to use a diagnostic test is guided by the trade-off between cost and expected benefit. Cost refers to the adverse effects of a test, the time required to obtain results (delay in treatment), inconvenience to the patient, and the price of materials and labor. Benefits refer to the extent to which a test is expected to reduce diagnostic uncertainty, and this depends on the reliability and validity of the test. “Reliability” means reproducibility: a test of serum glucose levels is reliable if repeated testing of the same sample yields the same results; an observer’s assessment is reliable if two or more observers (e.g., cardiologists interpreting the same electrocardiogram) agree. Most commonly, interobserver reliability is reported as kappa statistics on a scale from −1 (complete disagreement) to 0 (random agreement) to +1 (perfect agreement) [47]. “Validity” is the ability of a test to discriminate between patients with and without the disease in question. This ability is determined by applying the test to individuals in whom the presence or absence of the disease of interest has been established using a gold standard. The phrase “gold standard” refers to the best available method for making a diagnosis, such as an autopsy, biopsy, bacteriological findings, imaging studies, and prolonged follow-up. To be useful, a test must be easier to use than the gold standard. Once a gold standard is agreed upon, the performance of the test in patients with the disease can be compared to that in patients without the disease. The results of this comparison are expressed in terms of the sensitivity and specificity of the test. Sensitivity is the proportion of all patients with a disease (according to the gold standard) who test positive (“true-positives”). Specificity is the proportion of all patients without the disease (according to the gold standard) who test negative (“true-negatives”). A false-positive rate (1 − specificity) is the probability of a positive test result when the patient does not have the disease. A false-negative rate (1 − sensitivity) is the probability of a negative test result when the patient has the disease. To determine these conditional probabilities, physicians use Bayes’ theorem. It has been claimed that the Bayes’ rule, although rarely used explicitly in clinical practice, is a natural part of a physician’s clinical reasoning, in which the probability of disease is continuously readjusted by the history and findings of PE and ancillary tests [48]. Others have argued that Bayes’ rule, similar to many other statistical inferences, is difficult to understand and therefore should be taught [49]. There is undisputed evidence that Bayesian reasoning is teachable and that it improves the accuracy of probability estimates of novice clinicians [50]. The most commonly used representations of Bayes’ rule are two-by-two tables and likelihood ratios. Two-by-two tables (Table  3.6) focus on the sensitivity [a/ (a + c)] and specificity [d/(b + d)] of the test. However, the question of interest is not the sensitivity or specificity of the test, but the positive predictive value of a test [a/ (a + b)], i.e., the probability of disease given a positive test result. This probability depends on the prevalence of the disease in the population [(a + c)/(a + b + c + d)].

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Table 3.6  Two by two table of the distribution of test results in patients with and without the disease of interest Number of patients with the disease Test positive a Test negative c Total a + c

Number of patients without the disease b d b + c

Total a + b c + d a + b + c + d

The numbers in parentheses indicate the number of patients

The main difficulty students appeared to have in understanding the two-by-two table presentation of Bayes’ rule was the need to translate the sensitivity and specificity data, usually presented as proportions, into absolute numbers of patients with and without the disease under consideration. Therefore, I have found odds and likelihood ratios more useful in explaining Bayes’ rule to students. “Odds” are the ratio between the probability (p) that an event occurs and the probability that the event does not occur [Odds = p/(1 – p)]. The term “pretest odds” refers to the estimated likelihood of the disease before the application of the test. Post-test odds refer to the likelihood of the disease after the application of the test. Post-test odds are calculated by using the equation

Post-test odds = pretest odds ∗ likelihood ratio,

where the likelihood ratio (LR) after a positive test result (“LR positive”) equals [sensitivity/(1 − specificity)], and the likelihood ratio after a negative test finding (LR negative”) equals [(1 − sensitivity)/specificity]. Likelihood ratios seem to be the best approximation to diagnostic reasoning because they provide a one-step calculation of the post-test probability of disease.

3.4.2 Sources of Bias in Determining the Validity of Diagnostic Tests Determination of test validity can be thwarted by several sources of bias. The first is variability in test performance in different clinical settings and population groups [51]. Therefore, doctors should consider the characteristics of the patient population in which the test was evaluated, such as gender (exercise testing performs differently in men and women), race (alcohol screening questionnaires perform differently in different ethnic groups), the severity of illness (tests perform better in patients with more severe illness), and prevalence of illness (sensitivity and specificity of the test may vary with the prevalence of the illness in question) [52]. Another pitfall is the nature of the controls. Tests are usually studied by comparing patients with controls recruited from the medical staff. However, a test is not intended to distinguish between sick and healthy individuals, but between patients with the disease in question and patients with another disease that could be mistaken for it. For example, if a test is to distinguish between patients with bacterial

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pneumonia and viral disease, then the controls must be patients with fever. A third pitfall can occur when a test is interpreted by an observer who knows the patient’s previous test results and is subject to the influence of that knowledge [53]. Finally, the validity of tests that involve assessment depends on the competence of the tester [54].

3.4.3 Clinical Prediction Rules Like any diagnostic test, clinical prediction rules help physicians identify patients who need further diagnostic testing or treatment. These rules are derived from clinical observations. Some prediction rules assign relative weights to specific clinical manifestations. Other prediction rules consist of algorithms or more complex mathematical models [55]. However, deriving a prediction rule is only the first step. As with any diagnostic test, prediction rules require confirmation that the rule’s predictions are indeed consistent with observed outcomes, that they apply to patients in specific clinical settings, and that their application improves doctors’ decisions [56]. Similar to other diagnostic tests, the value of prediction rules is affected by differences in disease prevalence in different settings. Failure to recognize and account for these differences can either thwart decision-making or cause valid rules to be prematurely discarded. The number of published studies on prediction rules suggests that their popularity has increased since the 1990s. Clinical prediction rules, for example, have provided three-tiered scores that distinguished between patients with low, intermediate, and high probability of pulmonary embolism [57] and bacteremia [58]. Although increasingly used to support diagnostic reasoning, few clinical prediction rules have been properly validated [56, 59]. Systematic reviews of the literature have revealed either significant methodologic flaws or limited accuracy of prediction rules for ruling out acute coronary syndrome in emergencies [60] and for assessing the risk of major bleeding in patients taking oral anticoagulants [61] and their clinical impact has rarely been evaluated [62]. The validity and applicability of clinical prediction rules need further investigation and development.

3.4.4 Assessment of the Pretest Probability of a Disease The application of Bayes’ rule requires an assessment of the pretest probability of the disease in question. In clinical settings, the pretest probability of the disease is subject to the doctor’s estimate. The starting point for this estimate is the prevalence of the disease in the population. This probability is then adjusted based on relevant data such as the setting of the encounter, the patient’s age and gender, and the presence of risk indicators for disease, symptoms, and PE findings. For example, in 2004 the LR positive for ischemic heart disease (gold standard: coronary angiography) was estimated to be 5.8 for typical angina, 1.2 for atypical angina, 0.1 for nonanginal chest pain, 3.8 for prior myocardial infarction, and 2.3 for diabetes [63].

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References 1. Cook CJ, Smith GB. Do textbooks of clinical examination contain information regarding the assessment of critically ill patients? Resuscitation. 2004;60:129–36. 2. Uchida T, Park YS, Ovitsh RK, Hojsak J, Gowda D, Farnan JM, Boyle M, Blood AD, Achike FI, Silvestri RC. Approaches to teaching the physical exam to Preclerkship medical students: results of a National Survey. Acad Med. 2019;94:129–34. 3. Alexander EK. Perspective: moving students beyond an organ-based approach when teaching medical interviewing and physical examination skills. Acad Med. 2008;83:906–9. 4. Peitzman SJ, Cuddy MM. Performance in physical examination on the USMLE step 2 clinical skills examination. Acad Med. 2014;90(2):209–13. 5. Singh H, Giardina TD, Meyer AND, Forjuoh SN, Reis MD, Thomas EJ. Types and origins of diagnostic errors in primary care settings. JAMA. 2013;173:418–25. 6. Reilly BM.  Physical examination in the care of medical inpatients: an observational study. Lancet. 2003;362:1100–5. 7. Verghese A, Charlton B, Kassirer JP, Ramsey M, Ioannidis JP. Inadequacies of physical examination as a cause of medical errors and adverse events: a collection of vignettes. Am J Med. 2015;128:1322–4. 8. Russo S, Berg K, Davis J, Davis R, Riesenberg LA, Morgan C, Chambers L, Berg D. Incoming interns recognize inadequate physical examination as a cause of patient harm. J Med Educ Curric Dev. 2020;7:1–7. 9. Benbassat J, Baumal R, Heyman SN, Brezis M.  Viewpoint: suggestions for a shift in teaching clinical skills to medical students: the reflective clinical examination. Acad Med. 2005;80:1121–6. 10. Benbassat J, Schiffman A. An approach to teaching the introduction to clinical medicine. Ann Intern Med. 1976;84:477–81. 11. Fagan MJ, Griffith RA, Obbard L, O’Connor CJ. Improving the physical diagnosis skills of third-year medical students. A controlled trial of a literature-based curriculum. J Gen Intern Med. 2003;18:652–5. 12. Frye AW, Carlo MD, Litwins SD, Karnath B, Stroup-Benham C, Lieberman SA.  Effect of curriculum reform on students’ preparedness for clinical clerkships: a comparison of three curricular approaches in one school. Acad Med. 2002;77(Suppl):S54–7. 13. Kamel H, Dhaliwal G, Navi BB, Pease AR, Shah M, Dhand A, Johnston SC, Josephson SA. A randomized trial of hypothesis-driven vs screening neurologic examination. Neurology. 2011;77:1395–400. 14. Kassirer JP. Teaching clinical medicine by iterative hypothesis testing. Let’s preach what we practice. N Engl J Med. 1983;309:921–3. 15. Nishigori H, Masuda K, Kikukawa M, Kawashima A, Yudkowsky R, Bordage G, Otaki J.  A model teaching session for the hypothesis-driven physical examination. Med Teach. 2011;33:410–7. 16. Yudkowsky R, Otaki J, Lowenstein T, Riddle J, Nishigori H, Bordage G. A hypothesis-driven physical examination learning and assessment procedure for medical students: initial validity evidence. Med Educ. 2009;43:729–40. 17. Gowda D, Blatt B, Fink MJ, Kosowicz LY, Baecker A, Silvestri RC. A core physical exam for medical students: results of a national survey. Acad Med. 2014;89:436–42. 18. Kugler J, Verghese A.  The physical exam and other forms of fiction. J Gen Intern Med. 2010;25:756–7. 19. Auld AG. The roentgen rays in the diagnosis of pulmonary disease. Lancet. 1903;162:341–2. 20. Garcia-Pachon E. Padilla-navas I frequency of Hoover’s sign in stable patients with chronic obstructive pulmonary disease. Int J Clin Pract. 2006;60:514–7. 21. Mukkamala SG, Gennings C, Wenzel RP. R = 20: bias in the reporting of respiratory rates. Am J Emerg Med. 2008;26:237–9.

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22. Benbassat J, Baumal R. Narrative review: should teaching of the respiratory physical examination be restricted only to signs with proven reliability and validity? J Gen Intern Med. 2010;25:865–72. 23. Mangione S, Nieman LZ, Gracely E, Kaye D. The teaching and practice of cardiac auscultation during internal medicine and cardiology training. A nationwide survey. Ann Intern Med. 1993;119:47–54. 24. Roemer MI.  A program of preventive medicine for the individual. Milbank Mem Fund Q. 1945;23:209–26. 25. Frame PS, Carlson SJ. A critical review of periodic health screening using specific screening criteria. J Fam Pract. 1975;2:29–36. 26. Schon DA. Educating the reflective practitioner. London: Jossey-Bass; 1987. 27. Boland BJ, Wollan PC, Silverstein MD. Review of systems, physical examination, and routine tests for case-finding in ambulatory patients. Am J Med Sci. 1995;309:194–200. 28. Bloom BS. Learning for mastery. instruction and curriculum. regional education laboratory for the carolinas and virginia, topical papers and reprints, number 1. Eval Comment. 1968;1(2):n2. ED053419.pdf. Accessed Mar 2022. 29. Lee KC, Dunlop D, Dolan NC. Do clinical breast examination skills improve during medical school? Acad Med. 1998;73:1013–9. 30. Vukanovic-Criley JM, Criley S, Warde CM, Boker JR, Guevara-Matheus L, Churchill WH, Nelson WP, Criley JM. Competency in cardiac examination skills in medical students, trainees, physicians, and faculty. Arch Intern Med. 2006;166:610–6. 31. Mangione S, Nieman LZ. Pulmonary auscultatory skills during training in internal medicine and family practice. Am J Respir Crit Care Med. 1999;159:1119–24. 32. Mulrow CD, Dolmatch BL, Delong ER, Feussner JR, Benyunes MC, Dietz JL, Lucas SK, Pisano ED, Svetkey LP, Volpp BD, Ware RE, Neelon FA. Observer variability in the pulmonary examination. J Gen Intern Med. 1986;1:364–7. 33. Birrane J, Misran H, Creaney M, Shorten G, Nix CM. A scoping review of ultrasound teaching in undergraduate medical education. Med Sci Educ. 2018;28:45–56. 34. Sadeqi H, Valiani A, Avizhgan M, Ebrahimi SA, Manteghinejad A, Miralai P, Omid A. The effect of teaching an integrated course of physical examination and radiological anatomy in practical limb anatomy on medical students’ learning outcomes. BMC Med Educ. 2021;21:1–7. 35. Thomas F, Flint N, Setareh-Shenas S, Rader F, Kobal SL, Siegel RJ. Accuracy and efficacy of hand-held echocardiography in diagnosing valve disease: a systematic review. Am J Med. 2018;131:1155–60. 36. Kobal SL, Trento L, Baharami S, Tolstrup K, Naqvi TZ, Cercek B, Neuman Y, Mirocha J, Kar S, Forrester JS, Siegel RJ. Comparison of the effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. Am J Cardiol. 2005;96:1002–6. 37. Smallwood N, Dachsel M.  Point-of-care ultrasound (POCUS): unnecessary gadgetry or evidence-­based medicine? Clin Med. 2018;18:219. 38. Lewis D, Rang L, Kim D, Robichaud L, Kwan C, Pham C, Shefrin A, Ritcey B, Atkinson P, Woo M, Jelic T, Dallaire G, Henneberry R, Turner J, Andani R, Demsey R, Olszynski P. Recommendations for the use of point-of-care ultrasound (POCUS) by emergency physicians in Canada. CJEM. 2019;21:721–6. 39. Benbassat J, Gilon D. Teaching the physical examination by context and by integrating handheld ultrasound devices. Med Teach. 2020;42(9):993–99. 40. Haney I, Ipp M, Feldman W, McCrindle BW. Accuracy of clinical assessment of heart murmurs by office-based (general practice) pediatricians. Arch Dis Child. 1999;81:409–12. 41. Gardezi SKM, Myerson SG, Chambers J, Coffey S, D’arcy J, Hobbs FDR, Holt J, Kennedy A, Loudon M, Prendergast A, Prothero A, Wilson J, Prendergast BD. Cardiac auscultation poorly predicts the presence of valvular heart disease in asymptomatic primary care patients. Heart. 2018;104:1832–5.

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42. Milani BY, Majdi M, Green W, Mehralian A, Moarefi M, Oh FS, Riddle JM, Djalilian AR. The use of peer optic nerve photographs for teaching direct ophthalmoscopy. Ophthalmology. 2013;120:761–5. 43. Hatala R, Kassen BO, Nishikawa J, Cole G, Issenberg SB. Incorporating simulation technology in a Canadian internal medicine specialty examination: a descriptive report. Acad Med. 2005;80:554–6. 44. McKinney J, Cook DA, Wood D, Hatala R. Simulation-based training for cardiac auscultation skills: systematic review and meta-analysis. J Gen Intern Med. 2013;28:283–91. 45. Dilaveri CA, Szostek JH, Wang AT, Cook DA. Simulation training for breast and pelvic physical examination: a systematic review and meta-analysis. BJOG. 2013;120:1171–82. 46. Benbassat J, Meroz N. The foam sponge as a teaching aid in the examination of the chest. Med Educ. 1988;22:554–5. 47. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159–74. 48. Gill CJ, Sabin L, Schmid CH. Why clinicians are natural bayesians. BMJ. 2005;330:1080–3. 49. Rosenberg JM, Kubsch M, Wagenmakers EJ, Dogucu M. Making sense of uncertainty in the science classroom. Sci Educ (Dordr). 2022;14:1–24. 50. Brush JE, Lee M, Sherbino J, Taylor-Fishwick JC, Norman G.  Effect of teaching bayesian methods using learning by concept vs learning by example on medical students’ ability to estimate the probability of a diagnosis: a randomized clinical trial. JAMA Netw Open. 2019;2:e1918023. 51. Mulherin SA, Miller WC. Spectrum bias or spectrum effect? Subgroup variation in diagnostic test evaluation. Ann Intern Med. 2002;137:598–602. 52. Leeflang MM, Bossuyt PM, Irwig L.  Diagnostic test accuracy may vary with prevalence: implications for evidence-based diagnosis. J Clin Epidemiol. 2009;62:5–12. 53. Whiting P, Rotes AW, Reitsma JB, Glas AS, Bossuyt PM, Kleijnen J. Sources of variation and bias in studies of diagnostic accuracy: a systematic review. Ann Intern Med. 2004;140:189–202. 54. Sonnenberg A. We only see what we already know–a modified Bayes formula to explain inherent limitations of diagnostic tests. Med Hypotheses. 2004;63:759–63. 55. Adams ST, Leveson SH. Clinical prediction rules. BMJ. 2012;344:d8312. 56. Reilly BM, Evans AT. Translating clinical research into clinical practice: impact of using prediction rules to make decisions. Ann Intern Med. 2006;144:201–9. 57. Ceriani E, Combescure C, Le Gal G, Nendaz M, Perneger T, Bounameaux H, Perrier A, Righini M. Clinical prediction rules for pulmonary embolism: a systematic review and meta-­ analysis. J Thromb Haemost. 2010;8:957–70. 58. Paul M, Andreassen S, Nielsen AD, Tacconelli E, Almanasreh N, Fraser A, Yahav D, Ram R, Leibovici L. Prediction of bacteremia using TREAT, a computerized decision-support system. Clin Infect Dis. 2006;42:1274–82. 59. Maguire JL, Kulik DM, Laupacis A, Kuppermann N, Uleryk EM, Parkin PC. Clinical prediction rules for children: a systematic review. Pediatrics. 2011;128:e666–77. 60. Hess EP, Thiruganasambandamoorthy V, Wells GA, Erwin P, Jaffe AS, Hollander JE, Montori VM, Stiell IG. Diagnostic accuracy of clinical prediction rules to exclude acute coronary syndrome in the emergency department setting: a systematic review. CJEM. 2008;10:373–82. 61. Loewen P, Dahri K. Risk of bleeding with oral anticoagulants: an updated systematic review and performance analysis of clinical prediction rules. Ann Hematol. 2011;90:1191–200. 62. Gallagher J, McCormack D, Zhou S, Ryan F, Watson C, McDonald K, Ledwidge MT. A systematic review of clinical prediction rules for the diagnosis of chronic heart failure. ESC Heart Fail. 2019;6:499–508. 63. Chun AA, McGee SR. Bedside diagnosis of coronary artery disease: a systematic review. Am J Med. 2004;117:334–43.

Chapter 4

Recording the Clinical Database

4.1 Introduction The record of the clinical database is more than a compilation of information: Sorting patient data is an exercise in clinical reasoning. The definition of the symptom matrix is the beginning of the generation of diagnostic hypotheses and their subsequent modification in light of additional information. The progression of symptoms over time can indicate the prognosis of the disease. The degree of disability of the patient may influence therapeutic decisions. Disorganized, redundant, and inaccurate statements about the patient’s history and physical findings not only reflect inadequate interpersonal communication and record-keeping skills but also indicate deficiencies in critical thinking, data selection, and analysis. Textbooks on clinical methods recommend recording the clinical database in a sequence that begins with personal data and chief complaint, then moves to the present illness, past, family, personal, and social history, and ends with a review of systems, physical examination, and diagnoses. Since the 1970s, this format has been the subject of two developments: problem-oriented and electronic medical records.

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4.2 The Problem-Oriented Record Until the 1970s, the purpose of medical documentation was to remind physicians of the patient’s database and to provide communication with other healthcare providers. The patient record was oriented to diagnoses, whether certain or suspected. Physicians were not required to document their reasoning, and the medical record did not consider alternative treatment options. In 1968, Weed proposed an alternative approach to maintaining medical records, the problem-oriented record (POR) [1]. It differs from the traditional record by first, its orientation to problems rather than diagnoses. A problem is defined as any symptom (e.g., epigastric pain), finding (pulmonary infiltrate, fasting blood glucose 180 mg/dL), established diagnosis (bacterial endocarditis, Strep viridans), mental condition (depression), social status (welfare recipient), or treatment (anticoagulation) that may affect the patient’s health. A problem is expected to be certain and not suspected: The problem of a patient seeing a physician for epigastric pain would be “epigastric pain” and not “suspected peptic ulcer.” If subsequent endoscopy reveals an ulcer, the patient’s problem of “epigastric pain” would be updated to “duodenal ulcer.” The problem list has contributed to clinical reasoning by promoting a taxonomy that separates the unresolved and ambiguous from the diagnosed and clearly defined. The list appears at the beginning of the patient’s record: it summarizes what is known about the patient when he or she was last seen and is continually updated as more data become available. At each subsequent visit, the problem list would revise problems that have been resolved, add newly identified problems, track unresolved problems, and track the patient’s response to treatment. A second difference between the traditional record and the POR is the way the patient’s history is presented. Its traditional presentation used to adhere to a chronological sequence. Such a presentation was difficult to follow in patients with more than one problem developing simultaneously. Unlike this chronological sequence, the POR presents separately the manifestations of each of the patient’s problems. Third, the POR requires that the history of the present illness follows a predetermined sequence that begins with a description of symptoms (onset, characteristics, and development) and continues with a list of “negative” symptoms (symptoms whose absence may be important), the objective data (results of previous medical tests), and ends with the treatment the patient has received in the past. This sequence gives a physician, even a novice, the ability to distinguish important data (symptoms) from less important data (opinions of other physicians). Errors in processing the patient’s history are more easily detected and corrected, and finally, communication of the data is easier because the listener expects to receive them in the order in which they are presented. Fourth, the POR contains a summary. The problem list serves as the starting point for this summary, which includes the reported data, the objective findings, the physician’s assessment, and the plan for addressing each of the patient’s problems. It also contains “patient education”—a record of what the patient was told about his or her

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condition and role in treatment. It is a summary of the dialog between the physician and the patient, aimed at meeting the patient’s expectations and reducing anxiety. Recording patient education forces the physician to reflect on an often-­neglected topic: the need to provide the patient with health-related information. It also informs other healthcare providers about the information shared with the patient. The strengths of POR are not limited to improved documentation. The POR also requires physicians to be explicit about their reasoning. It is expected that their assessment of the patient is consistent with the patient’s symptoms and findings and that the treatment plan is consistent with that assessment. The POR provides a means of communication not only with other healthcare providers but also with medical students: it is a tool for teaching. Because physicians must document and justify their decisions, the POR also allows for a review of clinical decision-making and more effective monitoring of the quality of patient care.

4.3 The Electronic Medical Record Since the 2000s, computerized electronic medical records (EMRs) have become an essential part of patient care. Patients accept this development and are even more interested in seeing their computerized records than those on paper [2]. Patients believe that EMRs facilitate patient–physician communication and support the idea of having their input on their records [3]. Most practicing physicians agree that EMRs are effective in organizing and reviewing data [4]. Health administrators believe EMRs are cost-effective, improve the quality of care and staff satisfaction, save pharmacy waste, and reduce nursing overtime [5]. Finally, EMRs improve communication and care coordination among clinicians, especially those caring for patients with multiple disorders. However, EMRs harm patient-centeredness [4]. Many physicians behave in a “screen-driven” manner, asking questions as they appear on the screen rather than following the patient’s narrative. As physicians spend more time interacting with the computer, they have less time to interact with the patient. It has been argued that physician–patient interaction is more “computer-driven” than “computer-assisted” [6]. To reduce the undesirable consequences of EMR, it has been suggested that physicians position the screen as a bridge rather than a divider so that they can view it with the patient. Physician comments such as “I am going to look at your test results now. Would you like to look at them together?” could facilitate a shared assessment of the patient’s current health status and identify opportunities for active patient participation [7]. Other authors have similarly identified strategies, best practices, and facilitating factors that clinicians can use to have a patient-centered conversation in the era of the EMR [8]. The EMR is particularly useful for patient education at the end of the conversation. At this stage, clinicians can read aloud what they have written and give patients copies of care plans, health information, website referrals, information about community support services, medication side effects, and follow-up appointments [9].

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4.4 Teaching the Recording of the Clinical Database1 The proposed approach to teaching the recording of the clinical database applies the principles of learning for mastery by dividing the subject matter into small units (steps). Table 4.1 lists the objectives of these steps. In each of them, students (a) interview a patient and perform a partial physical examination; (b) record the patient’s history, examination findings, and diagnostic hypotheses; (c) share these records with the other four to six students in the group and the tutor; and (d) watch the tutor demonstrate selected physical examination procedures and practice these procedures on each other. Students are asked to read the description of these procedures in the physical diagnosis textbooks and note any differences between what they read and the tutor’s demonstration. Students are also repeatedly reminded to hold off on recording the clinical database until the patient interview is complete and not to take extensive notes while listening to the patient. A teaching session begins with each student reading his/her report on the patient she/he examined in the previous session. The other students in the group and the Table 4.1  Proposed method for teaching the recording of the patient’s history Step Topic Objective I Patient’s bio-psychosocial Identify and report the relevant aspects of the patient’s history personal and psychosocial history, in addition to risk indicators of disease and resources II Chief complaint Formulate the chief complaint and its duration. Identify the anatomic region from which the complaint may originate III Symptoms List the patient’s symptoms in the order of their appearance. Propose a diagnostic hypothesis IV Problems Differentiate between groups of symptoms that may indicate different medical problems. Propose diagnostic hypotheses V Statement of the patient’s Define the characteristics of the symptoms: Time of onset, present illness or problems quality, duration, frequency, course, aggravating or alleviating factors, and associated symptoms. Become familiar with the natural history of common diseases VI Statement of the patient’s Record “negative data,” i.e., symptoms from the same organ present illness or problems system as the chief complaint, the absence of which may serve as diagnostic cues VII Statement of the patient’s A complete statement of the present illness, including present illness or problems “objective data,” i.e., previous medical findings, opinions, and treatment VIII Active and inactive (a) List separately active and inactive problems; (b) obtain the problems, past and family patient’s history and family history; (c) perform a review of history, review of systems systems IX Practice A complete recorded clinical database

 An earlier version of this section was published in: Benbassat J, Schiffmann A. An approach to teaching the introduction to clinical medicine. Ann Intern Med. 1976;84:477–81. With permission from the American College of Physicians. 1

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tutor discuss the reports. Allowing 15  min per student, this part takes about 60–90  min. Then the tutor focuses on one or two of the patients presented and encourages the students to suggest diagnostic hypotheses or at least the organ system that might be the cause of the patient’s complaints. The tutor demonstrates the physical examination of this organ system and supervises the students as they practice these skills on each other. Finally, each student is assigned a new patient to interview on his/her own and prepare a written record of the patient’s history for the next session.

4.4.1 The Personal and Psychosocial History Students are reminded of the principles of patient-centered interviewing that they learned in their first year. Students interview their assigned patients and take their personal and psychosocial histories as detailed in Sect. 4.6.

4.4.2 Chief Complaint The objective of this step is to formulate and record the chief complaint (CC) and its duration. The chief complaint is defined as the immediate reason that caused the patient to seek medical attention. Examples: CC: Chest pain of 3 hours duration CC: Low back pain for one week CC: None, patient was referred with an incidental finding of a round shadow on chest X-ray.

In this phase, students are encouraged to formulate hypotheses about the origin of the patient’s complaint and to list additional symptoms that, if present, would support these hypotheses. CCs are categorized into pain (e.g., abdominal pain), symptoms due to organ dysfunction (e.g., cough), incidental findings (e.g., jaundice), and general symptoms (fever, fatigue, weight loss). The tutor strives to select patients whose CCs are localized pain or symptoms of organ dysfunction. The student’s initial hypotheses are limited to naming the anatomic region from which the discomfort originates, e.g., “Chest pain could be a manifestation of heart, lung, or esophageal disease; possible additional symptoms. Dyspnea, cough, dysphagia”; or “Epigastric pain could be from a disease of the stomach, duodenum, pancreas, or gallbladder; possible additional symptoms: vomiting and heartburn”; or “Diarrhea could be caused by disease of the small or large intestine; possible additional symptoms: Abdominal pain, vomiting.” I have already emphasized the importance of understanding the patient’s concerns, which may or may not be identical to the chief complaint. For example, a patient’s chief complaint may be “chest pain on exertion for the past three months”

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and this may also be his or her main concern. However, the patient’s main concern may be something else, such as obtaining a disability certificate. The advantage of recording the patient’s main concern(s), preferably in the patient’s own words, is that they are brought to the doctor’s attention, thereby initiating the empathy process. While the chief complaint is limited to symptoms and signs, the patient’s specific worries encompass all possible causes of her/his distress and need for help. By making the main concern, rather than the main complaint, the starting point for further patient management, doctors may considerably expand their ability to help their patients.

4.4.3 Symptoms The objective of this step is to identify and list the patient’s symptoms. Students listen to the patient’s narrative, paying particular attention to the symptoms and listing them in order of appearance. At this stage, students refrain from giving a detailed description of the symptoms and their course. The required written report consists of the first two sentences of the statement of the present illness (PI) for example: PI began 3 years ago. It manifested itself in chest pain, shortness of breath, and swelling of the legs. PI began 3 days ago, with fever (39 oC), chills, dry cough, and sore throat.

As in the previous step, students interview patients with a single problem, preferably localized pain or organ dysfunction. If the student identifies the diseased organ or system, he or she is referred to appropriate sources and encouraged to propose a more specific diagnostic hypothesis, for example, “Right flank pain and dysuria may be due to urinary tract disease, possibly a bacterial infection or stone,” or “Fever, cough, and chest pain of 2 days duration may be due to respiratory inflammation, such as bronchitis or pneumonia.”

4.4.4 Problems This step initiates the student to the problem-oriented approach. In this phase, patients with more than one problem are selected for interview and examination. Students must now distinguish between groups of symptoms that may indicate different medical problems. The criteria for grouping symptoms are (a) origin in the same organ system and (b) similar duration, simultaneous onset, or both. For example: 1. The present illness began 6 h before hospitalization. Symptoms included chest pain, sweating, and palpitations. 2. In the past 2 years, the patient has complained of epigastric pain and heartburn.

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The symptoms in this example are grouped into two categories based on their non-simultaneous onset. They could originate in two different organ systems (cardiovascular and gastrointestinal) and the patient could be suffering from two diseases (acute myocardial infarction and peptic ulcer). Alternatively, these two sets of symptoms could originate in the same organ system (gastrointestinal) and be manifestations of the same disease (a perforated peptic ulcer). The various diagnostic hypotheses are considered during the post-interview discussions. At such an early stage of the interview, neither experienced physicians nor inexperienced students have sufficient information to test their alternative hypotheses. If there appears to be no obvious connection between two or more problems, students are advised to treat each problem separately and only then look for a possible link between them.

4.4.5 Statement of the Patient’s Present Problem(S) At this step, students are taught to define the characteristics of a patient’s symptoms, i.e., time of onset, duration, frequency, course, and aggravating or alleviating factors. Students also begin to focus on prototypical disease processes. The tutor assigns patients with histories and physical findings of common diseases, such as viral hepatitis, hyperthyroidism, peptic ulcer, ulcerative colitis, tonsillitis, urinary tract infections, rheumatoid arthritis, left and right ventricular failure, and expects students to make more accurate preliminary diagnoses. Again, students are referred to texts and asked to suggest a differential diagnosis at a higher level of resolution, such as urinary tract infection with causative microorganisms or left ventricular failure with possible causes.

4.4.6 Statement of the Present Problem(S) (Continued) Students complete the symptom list and collect “negative data”: they ask the patient about symptoms that they know are from the same organ or organ system as the chief complaint and note the answer, even if negative, e.g., absence of dyspnea or palpitations in a patient with chest pain or absence of pain in the flanks in a patient with dysuria.

4.4.7 Statement of the Present Problem(S) (Continued) Students inquire about previous medical findings, opinions, and treatments that the student feels are relevant to the present illness.

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At the end of this step, the student is expected to provide a statement of the patient’s PI that will present the patient’s major symptoms, their onset, characteristics, course, and degree of induced disability and will be followed by a description of “secondary” symptoms, “negative” symptoms, and “objective” data from the history. Secondary symptoms are those that the student considers relatively unimportant. Negative symptoms are absent complaints of possible diagnostic significance. Objective history data include the results of previous examinations and previously made diagnoses. For example: PI began 2 days ago with fever, abdominal pain, and diarrhea. All of these symptoms persist until today. The fever is continuous between 38 and 39.5 oC. The pain is severe, i­ ntermittent, and aggravated during bowel movements. The patient has stools of watery consistency five to ten times a day, occasionally with mucus and blood. There was no vomiting, chills, or headache. A few hours after the onset of symptoms, the patient was seen by a physician who determined that he had dysentery. He was treated with 2 g of ampicillin daily without improvement

The available data suggest an acute inflammatory disease of the colon. After further reading, students should suggest a more specific differential diagnosis, such as shigellosis, the first bout of ulcerative colitis, or amoebic dysentery.

4.4.8 Listing Active and Inactive Problems, Past and Family History, Review of Systems The objectives of this step are to identify inactive problems, obtain the patient’s family history, and perform a systems review. At the end of this step, students should be able to communicate with the patient and take the medical history in a problem-­ oriented manner. The remaining training sessions are devoted to improving student performance and refining their use of medical vocabulary, with an increasing emphasis on diagnostic problem-solving.

4.5 Common Errors in Recording the History of a Patient’s Present Illness2 Converting the patient’s experience into a written report involves several steps. First, the patient describes his or her symptoms with spoken words, body language, and voice and facial expressions. Second, the doctor apprehends the message and finally converts it into a written narrative. These stages are not unlike consecutive Xerox

 A previous version of this section was published in: Benbassat J. Common errors in the statement of the present illness. Med Educ. 1984;18:417–22. With permission from Blackwell Publishing Ltd. 2

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Table 4.2  Proposed format for recording the statement of the present illness (PI) First paragraph (data of probable importance): (a) Time and mode of onset of the PI (b) List of main symptoms (c) Characteristics of main symptoms (add nonverbal cues when appropriate) (d) Chronological description of the course of the main symptoms (e) Disability assessment Second paragraph (data of possible importance): (f) List of additional (“secondary”) symptoms (g) “negative” pertinent symptoms (h) Pertinent “objective” data: Past diagnoses and treatment (if not already reported in the first paragraph) Adapted from [14] with permission from Blackwell Publishing Ltd

copies that produce increasingly blurred reproductions. Patients’ experiences of their complaints are more varied than the expressions available for their descriptions, and patients’ descriptions are influenced by their capacity for self-expression. Perception of the patient’s message is influenced by the physician’s sensitivity to verbal and nonverbal cues, diagnostic hypotheses, and preconceived notions about the patient. The write-up depends on the physician’s precision in reporting and his or her ability to critically analyze the data. Finally, symptoms are recorded in written words that rarely reflect the patient’s entire verbal and nonverbal message. Recording the history becomes even more complicated in patients who have seen a physician before. The information on PI is then expected to include the results of these encounters, and this requires selecting relevant data and determining the order in which they are presented. Some loss and distortion of the patient’s experience are inevitable when translating it into a written statement, and medical students too often fail to adequately describe the patient’s PI. Students’ difficulties in recording the statement of the PI are often compounded by inconsistent feedback from tutors and differing recommendations in clinical methods textbooks. For example, some textbooks, e.g., [10], recommend organizing the PI history in chronological order, while others, e.g., [11], recommend starting with the immediate cause of the patient’s referral and probing backward into the development of the present illness. In this section, I propose a format for recording the PI (Table 4.2) that is a synthesis of previously described guidelines [12, 13] and suggest using it to identify and correct errors in student presentations of a patient’s history. The most common errors that I identified in the recorded patients’ PI can be grouped into the following four categories.

4.5.1 Overemphasis on Objective History Data In cases of patients with previous physician visits or hospitalizations, students focus on the objective data available and their recorded PI consists predominantly of diagnoses and findings as reported by the patient (example “a1”) or as taken from his or

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her previous hospital records (example “a2”). The patient’s symptoms and their course are either omitted or almost completely lost in the objective history data. (a1) Five years ago Mr. D was told he had congestive heart failure. He was referred to the hospital and treated with furosemide. Over the next three years, Mr. D was treated at the hospital's OPD and had repeated blood tests. On one occasion, he was readmitted to the hospital. One year ago, he was told that he had fluid in his abdomen. During the last few weeks, his abdominal swelling increased despite treatment with furosemide, and therefore he was referred for hospitalization. (a2) For 30 years Mrs. K has been an alcoholic. On her first admission five years ago, she had a liver span of 12 cm, splenomegaly, ascites, hemoglobin - 10 gm/dl, platelets - 70,000 per ml, WBC - 1,900 per ml, serum albumin - 3.0 gm/dl, globulin - 4.1 gm/dl and prothrombin time - 100%. A barium swallow revealed esophageal varices. She was treated with a low-salt diet, furosemide, and vitamins. On her second admission two years ago, she had ascites and venous congestion at her abdominal wall. Her hemoglobin was 8.8 gm/dl, platelets - 39,000 and WBC 3,000 per ul, albumin 2.0 gm/dl, and globulin 3.0 gm/dl. On her last admission six months ago, her prothrombin time was 40%. She was brought to ER by her husband, who found her unconscious in bed this morning.

4.5.2 Inadequate Description of the Patient’s Symptoms This error consists of describing a patient’s symptoms in vague or possibly misleading terms, such as “ulcer pain,” “asthmatic breathing,” or “pain in the gallbladder.” It occurs in the histories of patients whose complaints seem typical of known medical conditions. In such cases, students substitute their interpretations for the symptom descriptions (example “b1”). The error also occurs when a patient was quoted verbatim, even if he/she reports his/her conclusions rather than what he/she felt or observed (example “b2”). (b1) Mr. G presented two days ago with anginal pain, paroxysmal nocturnal dyspnea, and intermittent claudication of one-year duration. (b2) Ms. H reported on admission that four days ago she had pain in her kidneys and blood in her urine.

4.5.3 Failure to Identify Main Symptoms Some students failed to discern between major and secondary symptoms in a patient with multiple symptoms. Common errors in formulating the CC included listing more than two symptoms (example “c1”) and overemphasizing the referral source to the exclusion of the chief complaint (example “c2”). Failure to highlight and emphasize the main symptoms in the CC may carry over to the PI and result in a statement, not unlike the computer printout obtained through a yes/no query (example “c3”).

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(c1) CC: Loss of weight, irritability, increased appetite, menorrhagia, tremor, and palpitations of two months duration. (c2) CC: Referred from the cardiology OPD for further investigations. (c3) PI: A week ago Mrs. S felt a short bout of pain in her right flank. Since then, she complains of a burning sensation at urination and passes urine 3–4 times at night. Recently, she has had pain in her 'spine' and moderate shortness of breath on exertion. In the past month, she has been using laxatives for constipation. In the past two weeks, Mrs. S has had bouts of giddiness and frontal headaches.

4.5.4 Unclear Presentation of Chronological Evolution of Symptoms Given a patient with a prolonged PI, some students fail to describe the progression of symptoms from their onset to the time of admission and the resulting disability. In some cases, the most recent symptoms are recorded first, while subsequent paragraphs of the PI probe “backward” into the patient’s past, disregarding the chronological sequence of events (example “d1”). In other cases, the PI consists of a description of all symptoms at a given time and repeated, circuitous accounts of the same symptoms as they progress (example “d2”). (d1) On the night of her admission, Mrs. W experienced a sudden wave of heat, shortness of breath, a 'flutter' in the chest, and a loss of sensation in her left arm for several seconds. There was no pain, nausea, or vomiting. She had slight dizziness when getting up from bed. Two years ago, she had a similar bout of numbness and weakness in her left arm. At that time her ECG and chest x-ray were normal. Four years ago, she noted a moderate swelling of her legs. She was told she had hypertension and was started on Normitten 25 mg and a low-salt diet. The swelling of her legs disappeared, and her blood pressure fluctuated between 160/90 and 140/80. (d2) Five days ago, Miss C started complaining of watery diarrhea, lower abdominal pain, and a fever of 38.8 °C. On the second day of her illness, she had about 15 bowel movements. Her fever reached 39 °C and her pain increased in intensity and duration. Diarrhea continued on the third day of her illness, and she noted spots of 'blood' in her stool. Her 'cramps' became unbearable during bowel movements. Her fever reached 39.8 °C. On the fourth day of her illness, she was seen by Dr. J. She was told she had ‘gastroenteritis’ and was given Lomotil. Still, her fever remained at 39 °C, she had about 20 bowel movements on that day and her abdominal cramps persisted. On the day of her admission, her fever reached 40 °C, and her pain became almost continuous. Since this morning she has had no bowel movement and during the last hours, she has vomited repeatedly. She is too weak to sit in a chair.

4.6 Providing Feedback on Students’ Records of a Patient’s History Students have no apparent difficulty in listing previous medical examinations and established diagnoses. Their main problem seems to be in identifying and describing a patient’s symptoms and their course. Some students avoid describing

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symptoms altogether, preferring to present conclusions, interpretations, previous findings, and diagnoses. It is easier to list previous findings than to gain insight into feelings, complaints, and disabilities. Therefore, training in history taking and recording consists of teaching students to recognize, list, and describe symptoms, their course, and resulting disability. Students’ difficulties with history recording should be acknowledged and accepted as legitimate. When errors are uncovered, they should be discussed in a non-­ threatening atmosphere without suggesting that they indicate basic incompetence. Students would be told that there is no gold standard for a well-written history and therefore, textbook recommendations vary; that physicians use different styles in recording the patient database, just as they differ in their approach to patient interviewing, data collection, and problem-solving; and that the tutor’s approach to teaching and recording the database is intended to serve as an initial guide for students until they choose their individual style. Tutors may use the format outlined in Table 4.2 as a frame of reference for identifying and explaining errors and for introducing students to clinical reasoning. Diagnostic thinking and problem-solving begin with categorizing available data. Adherence to this format can help students group history data and present them in order of probable importance. This format is particularly well suited for corrective feedback to students who overemphasize objective history data while ignoring the patient’s symptoms (error type a). To correct the tendency to describe symptoms in vague and misleading terms (error type b), tutors would explain the difficulties of translating a patient’s experience into a written statement, as described earlier in this section, and advise students to describe as accurately as possible what the patient felt and to avoid interpretation and inference. When appropriate, tutors may even encourage students to describe in parentheses the patient’s nonverbal expressions, e.g.: “The pain in the shoulder is sharp (the patient winces in pain when he tries to move his left arm)” or, “The bouts of headache (the patient holds his head in both hands) usually occur in the afternoon.” I believe that asking students to describe the patient’s behavior enhances their observational skills and their sensitivity to nonverbal messages. The difference between main and secondary symptoms (error type c) is best explained by defining main symptoms as those reported in the patient’s spontaneous narrative. Secondary symptoms, however, are usually elicited through closed-ended questions later in the interview. Students are cautioned that some patients may baffle the interviewer by “changing their story.” In such cases, students are advised to identify the main symptoms by summarizing the history at several stages of the interview to confront patients with their stories and to allow them to correct possible misunderstandings. To avoid type d errors, students are advised that the evolution of the patient’s symptoms provides insight into the natural history of the illness and identifies recent changes in disability that may necessitate a change in treatment or revision of established diagnoses. Therefore, the statement of the PI should describe the progression of symptoms with the clarity of a chart [15] that plots the course of the patient’s history in “horizontal” order, describing each symptom (or group of symptoms with

References

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a similar course) from its onset to the present time. Thus, a corrected version of example “d1” would follow a chronological sequence: Four years ago, Mrs. W noticed swelling in her legs. She consulted Dr. J who told her she had hypertension and prescribed a low-salt diet and Normitten 25 mg daily. Over the next four years, the swelling in her legs disappeared, she was able to go about her daily activities and her blood pressure was between 160/90 and 140/80. Two years ago, she experienced a few seconds of weakness in her right arm. On the night of her admission, Ms. W felt shortness of breath (the patient clutches her neck), a 'fluttering in the chest (the patient taps rapidly on the table), and a loss of sensation in her right arm that persisted for several minutes and subsided before she arrived at the hospital. In addition, Ms. W complains of brief dizzy spells when she gets out of bed. There is no pain, nausea, or vomiting. Dr. J states in his letter that two years ago her EKG and chest x-ray were interpreted as normal.

A corrected version of example “d2” would follow a “horizontal” sequence, whereby each symptom is described separately from its onset to the time of admission: PI began five days ago with fever, abdominal pain, and diarrhea. Her temperature has fluctuated between 38 °C in the morning and 39–40 °C in the evening. Her pain is described as ‘cramps’ (pt places her palms on her lower abdomen) during bowel movements and has gradually increased over the past two days. Her diarrhea was ‘watery’; during the first three days of her illness, she had about 15 bowel movements per day. On the third day, her diarrhea became ‘bloody’. In the last few days, it has become less frequent and since this morning she has had no bowel movements. In the last few hours, she has been vomiting, unable to take fluids by mouth, and feeling too weak to sit on a chair. Other symptoms include headache and some stiffness in the muscles. There were no chills. On the fourth day of her illness, Dr. J examined her. She was told she had gastroenteritis and treated with Lomotil.

References 1. Weed LL. Medical records that guide and teach. N Engl J Med. 1968;278:593–600. 2. Richter JG, Becker A, Koch T, Willers R, Nixdorf M, Schacher B, Monser R, Specker C, Alten R, Schneider M. Changing attitudes towards online electronic health records and online patient documentation in rheumatology outpatients. Clin Exp Rheumatol. 2010;28:261–4. 3. Honeyman A, Cox B, Fisher B.  Potential impacts of patient access to their electronic care records. Inform Prim Care. 2005;13:55–60. 4. Shachak A, Reis S. The impact of electronic medical records on patient-doctor communication during consultation: a narrative literature review. J Eval Clin Pract. 2009;15:641–9. 5. Cherry BJ, Ford EW, Peterson LT. Experiences with electronic health records: early adopters in long-term care facilities. Health Care Manage Rev. 2011;36:265–74. 6. Shachak A, Montgomery C, Dow R, Barnsley J, Tu K, Jadad AR, Lemieux-Charles L. End-­ user support for primary care electronic medical records: a qualitative case study of users’ needs, expectations, and realities. Health Syst. 2013;2:198–212. 7. White A, Danis M. Enhancing patient-centered communication and collaboration by using the electronic health record in the examination room. JAMA. 2013;309:2327–8. 8. Ventres WB, Kooienga S, Marlin R. EHRs in the exam room: tips on patient-centered care. Fam Pract Manag. 2006;13:45.

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9. Duke P, Frankel RM, Reis S.  How to integrate the electronic health record and patient-­ centered communication into the medical visit: a skills-based approach. Teach Learn Med. 2013;25:358–65. 10. Seidel HM, Ball JW, Dains JE, Benedict GW. Mosby’s guide to physical examination. 6th ed. St. Louis, MO: Mosby, Elsevier; 2006. 11. Bickley LS, Szilagyi PG. Bates’ guide to physical examination and history taking. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013. 12. Morgan WL, Engel GL, editors. The clinical approach to the patient. Philadelphia, PA: WB Saunders; 1969. p. 197–204. 13. Weed LL. Medical records, medical education and patient care. 5th ed. Cleveland, OH: Case Western Reserve; 1971. 14. Benbassat J. Common errors in the statement of the present illness. Med Ed, 1984;18:417–22. 15. Prior JA, Silberstein JS. (eds) Physical Diagnosis, (Fourth edition). C. V. Mosby Co., St Louis. 1973.

Chapter 5

Clinical Reasoning

5.1 Introduction Clinical problems vary in complexity. At one extreme are “simple” questions such as “Does this patient have atrial fibrillation?” Their answer requires examination. At the other extreme are “complex” questions such as “Should a patient with atrial fibrillation and a history of gastrointestinal bleeding be treated with anticoagulants?” The answer to such questions requires predictions with varying degrees of uncertainty. Uncertainty is pervasive in clinical reasoning because diagnostic tools are imperfect and interventions carry risks. Yet, during my studies in the 1950s, uncertainty was rarely acknowledged. Clinical reasoning was guided by pathophysiologic rationale and the “art of medicine.” Physicians’ authority was based on their unsystematic experience, which they translated into intuitive decisions. The advantage of intuitive decisions is that they are quick and usually correct. However, they defy explanations, can be influenced by bias, and do not allow for control and accountability. Since the second half of the twentieth century, there has been a growing awareness of the need for such control. In 1953, Yerushalmy [1] reported that two radiologists disagreed in interpreting chest radiographs one-third of the time and that a single interpreter disagreed with his previous findings one-fifth of the time. In 1964, Schimmel [2] reported that of a total of 1252 consecutive admissions to an academic hospital, 16 patients had died as a result of medical procedures. The high incidence of medical errors [3] and unexplained variations in clinical practice [4] suggest that intuition can go wrong, and today, physicians are increasingly challenged to justify their decisions. Attempts are made to demystify clinical reasoning to allow for their rational analysis. The continuum of reasoning, problem-solving, and decision-making has become the subject of scientific inquiry and attempts to teach it to medical students [5, 6]. The goal of these attempts is to impart to students © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Benbassat, Teaching Professional Attitudes and Basic Clinical Skills to Medical Students, https://doi.org/10.1007/978-3-031-26542-6_5

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the reasoning strategies used by experts and a recognition of situations in which these strategies may fail [7]. Still, as recently as 2020, only 28% of 313 medical schools from 76 countries reported teaching clinical reasoning [8]. It was claimed that “…the creation of explicit, theory-informed clinical reasoning curricula… and assessment tools has proceeded slowly” [9], and the optimal methods for teaching clinical reasoning remain uncertain.

5.2 Reasoning Strategies of Experienced Clinicians Studies of physicians’ clinical reasoning have used three main methods. The first consists of retrospective reviews of detected or self-reported errors, discussed in Sect. 5.7. The second, the “naturalistic decision-making approach,” attempts to gain insight into the self-reported problem-solving strategies of experienced clinicians [10]. Finally, the “heuristics and biases” examine whether clinicians’ diagnostic decisions are consistent with Bayes’ theorem and whether treatment decisions are consistent with maximizing expected utility [11].

5.2.1 Pattern Recognition and Hypothetico-Deduction Studies using the naturalistic decision-making approach have attempted to find a general reasoning process by analyzing think-aloud reports of physicians during simulated encounters with patients or while viewing replays of recorded encounters [10]. Later studies analyzed the relationship between visual stimuli (e.g., ECG tracings or skin lesions) and their interpretation (diagnosis) [12]. Two major findings emerged from these studies. First, clinician performance varied and the outcome in one case was a poor predictor of performance in another case. This finding suggests that expertise is not a general attribute but rather depends on case-specific knowledge. Second, clinical reasoning seemed to follow two different paths. The usual path was “pattern recognition,” or the retrieval of clinical presentations from memory, such as skin lesions and Dawn syndrome. The most efficient way to recognize a pattern is to see it, store it in memory, and identify it when encountered again. Not all patients have recognizable patterns, however, some present with symptoms that fit more than one disease. In such cases, physicians use a “hypothetico-­ deductive” approach: they generate several diagnostic hypotheses while listening to the patient’s history. Each hypothesis then leads to a search for additional symptoms and signs that should be present if it were true [10, 13]. Confirmation of a hypothesis leads to diagnosis; its rejection leads to testing of other hypotheses. These two paths are consistent with the dual process theory [14]. It states that reasoning occurs in an implicit, automatic, unconscious process (System 1) similar to pattern

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recognition and an explicit, conscious, systematic, analytic process (System 2) similar to the hypothetico-deductive approach. At all levels, from novice to experienced clinicians, pattern recognition is the most common path of diagnostic reasoning [15]. It resolves simple cases, whereas complex cases require a generation of hypotheses [16]. Whether a case is simple or complex depends on the physician’s knowledge, which develops in stages. In-between novice and expert, there is an intermediate stage that is typified by considering more diagnostic hypotheses and requesting more laboratory tests than novices (who lack the knowledge to perform irrelevant searches) and experts (who are more parsimonious in their differential diagnosis than intermediates). Experts perform better in their domain than outside their domain, suggesting a four-tiered theory: novices, intermediate students, generic experts, and domain experts [17].

5.2.2 Additional Paths of Clinical Reasoning Other reasoning paths include algorithmic diagnosis (flowchart), which consists of an entry point (e.g., anemia) and a series of yes–no questions that lead to either the next question or the diagnosis. The schema-based [18] and script-based [19] approaches assume that problem-solving is based on pre-stored knowledge structures (“schemas” or “scripts”) that are used to process clinical information and to generate and test diagnostic hypotheses. Finally, the traditional “complete database” involves taking a detailed history, performing a head-to-toe examination, and ordering a series of standard tests. The reasoning process begins only after all the information has been gathered. All these paths regard clinical reasoning as a process controlled by physicians. Its context, such as time pressures and interruptions, is considered secondary undesirable “noise.” Differences in physician performance are explained by differences in case-specific knowledge. However, studies have shown that differences in individual problem-solving did not correlate with responses to questions that targeted the same content knowledge. These findings led to hypotheses about how context might influence knowledge storage and retrieval, and how clinicians and their environment interact (see [20] for a review). Today there is a growing recognition that clinical reasoning is not only a cognitive endeavor but also a contextually and socially mediated activity, and that it can be influenced by circumstantial factors, such as the setting of the physician–patient encounter, the patient’s verbal skills, emotional volatility, or incorrect suggestions. This influence changes the understanding of decision-making and the definition of medical error, as they depend on both the doctors’ actions and the context in which they acted. However, since the number of contextual factors is limitless, it is difficult to determine which features of context should be considered, and how they might influence the thought processes of clinicians. In 2022, Watsjold et al. [20] concluded that “context specificity … may absolve us from seeking singular definitions of expertise.”

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5.2.3 Cognitive Task Analysis Cognitive task analysis [21] aims to translate the tacit knowledge of experts into diagnostic criteria. The analysis uses data collected through interviews, observation, think-aloud exercises, and focus groups and has generated useful decision support guides, such as the Apgar score [22], diagnosis of neonatal sepsis [23], and training and assessment for the care of war casualties [24].

5.3 Heuristics and Biases in Clinical Reasoning The “heuristics and biases” approach compares management decisions with those established by decision theory (the normative models). Systematic violations of the normative models are conceptualized as errors caused by shortcuts (heuristics) in the reasoning process. Heuristics are correct in most cases. However, they can be affected by biases. Since the seminal work of Tversky and Kahneman [25], it has been recognized that experts can violate the normative principles of decision-making. Biases can occur at any stage of clinical decision-making, whether unconscious (System 1) or controlled and conscious (System 2). The first three biases identified by Tversky and Kahneman were representativeness, availability, and anchoring. “Representativeness” is the tendency to be guided by prototypical features of a condition and to overlook atypical variants. “Availability” is the tendency to overestimate the likelihood of available (vivid, recent, easily remembered) events and underestimate the likelihood of events that are ordinary or difficult to recall. “Anchoring refers to predictions based on initial information (anchoring) and subsequently modified as more information becomes available (adjustment). The final prediction may be biased toward the initial information, which is given more weight than later information. Other biases that may influence diagnostic reasoning include the tendency to ignore actual disease rates and pursue rarer, exotic diagnoses, to ignore relevant normal findings, and to give more weight to evidence that confirms a decision than to information that refutes it. Biases that can affect management decisions include the tendency to be influenced by the way information is presented, such as whether prognostic information is presented in terms of mortality or terms of the proportion of survivors [26].

5.4 Barriers to Learning Clinical Reasoning Learning clinical reasoning requires overcoming intellectual, cultural, and emotional barriers to acceptance of the uncertainties of clinical practice. At the intellectual level, medical students must come to terms first, with the shift from a

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science-based education to the inclusion of relevant topics from the behavioral sciences [27]. Prescriptive clinical decisions (what will happen? what treatment can improve this patient’s predicament?) require probability estimates. The cause-and-­ effect approach of the basic sciences (what happened? what caused the disease?) requires deterministic thinking in terms of right/wrong. Deterministic thinking is still encouraged by an emphasis on science courses and multiple-choice exams with “only one correct answer.” The intellectual barriers hinder students’ ability to generate hypotheses, synthesize data, and formulate a management plan [28]. In 1983, Feinstein argued that “[d]uring the 20th century … the acts of prediction and intervention that constitute patient care have not been regarded as basic scientific challenges. The general belief has been that explication of pathophysiologic … mechanisms is the only important, fundamental scientific work for clinical academicians” [29]. At the cultural level, it has been suggested that the clinical teaching environment inhibits the development of tolerance of uncertainty in students [30]. The clinical environment rarely refers to risk and uncertainty. As recently as 2011, it was asserted that “the culture of medicine has little tolerance for ambiguity and uncertainty” and that there is a disconnect between the uncertainties of clinical practice and their denial in teaching [31]. At the emotional level, medical students do not expect uncertainties in medicine [32]. Shuval [33] noted that medical students were surprised by “the existence of ambiguity and uncertainty in a profession that prides itself on its rationality and competence.” Similarly, Fox [34] and Katz [35] reported that disagreement among authorities was a major cause of student anxiety. Recognizing that clinical decisions must be made with incomplete evidence and that good interventions can lead to bad outcomes is emotionally demanding. A commonly used intellectual and ethical developmental model of college students is Perry’s sequence of stages, which he called dualism, multiplicity, relativism, and commitment in relativism [36]. During dualism, students think in terms of right and wrong. The transition to multiplicity begins when they encounter conflicting opinions. Now students consider multiple opinions legitimate, but only in areas where the correct answer has not yet been found. In these areas, students believe that “opinions cannot be judged.” Toward the end of multiplicity, they recognize that even in areas of uncertainty, opinions can be judged based on their fit to the available data. This signals the transition to relativism. At this stage, students acknowledge that there is no absolute truth. They progress to the stage of commitment in relativism when they understand that unless they are to remain frozen in indecision, they must commit themselves to a choice, even if they will regret it in the future. Uncertainty is rejected in dualism, seen as temporary in multiplicity, accepted as legitimate in relativism, and dealt with when students affirm themselves in their commitments. The transition from novice to expert requires a commitment in relativism (“a decision must be made even if it must be revised/regretted in light of future knowledge”) is difficult. The assumption that there is an absolute truth known to role models is extremely attractive. Conformity to authority has been identified as a means by which medical students control the anxiety created by the complexity of

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the clinical environment [37]. In other words, it is easier to imitate role models than to confront the uncertainties inherent in clinical practice. Reflectivity requires more complex thinking than a social code grounded in dominance, hierarchies, and conformity [38]. Furthermore, certain aspects of reflective ability, such as self-­awareness [39] and awareness of others’ feelings [40], are associated with higher levels of psychological distress and less positive self-perception. Unlike other college students [41, 42], most medical students “appeared to express predominantly simplistic levels of epistemological thinking” [43], and their reflective ability scores declined in the final year of study [44]. These findings are consistent with earlier observations of denial of uncertainty during medical education (see [45] for a review), of an absence of change in tolerance of ambiguity by year of study [46], and medical student belief that judgments are either true or false [47]. Medical students seem to need help to mature into reflective professionals, develop a critical attitude, question the messages they receive from clinical tutors and the hidden curriculum, and break away from the inherent comfort of conformity.

5.5 Teaching and Assessing Clinical Reasoning 5.5.1 Learning Objectives As of 2021, the teaching of clinical reasoning in medical schools has focused on five areas: (a) concepts of clinical reasoning (theories, cognitive errors); (b) using pattern recognition and resorting to hypothetico-deductive reasoning when faced with uncertainty; (c) interpretation of diagnostic tests (Bayes theorem); (d) problem identification and management (problem list, differential diagnosis, management plans); and (e) shared decision-making [48, 49]. All these topics are teachable. Even before clinical training, students can be taught to recognize chest radiographic patterns [50] and dermatologic lesions [51] and to perform a hypothesis-driven examination [52]. I suggest that the teaching of clinical reasoning should also be guided by students’ difficulties in developing tolerance of uncertainty. Earlier, I referred to Perry’s view that this development begins when students realize that they are not alone and that their instructors share their doubts and uncertainties. Therefore, one of the characteristics of role models would be openness to express doubts and visibility of deliberations. Seeing how role models reflect encourages student reflectivity, and student reflectivity is a prerequisite for effective role modeling [53].

5.5.2 Assessment The proposed methods for assessing clinical reasoning fall broadly into three categories: Off-the-job assessments (multiple-choice questions, creation of decision trees reflecting disease scripts, discussion of written clinical cases, the script

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concordance test—SCT [54]); assessments in simulated clinical settings (objective structured clinical examinations and technology-based simulations); and workplace-based assessments (direct observations, global assessments, oral case presentations, written notes) [55]. Assessments of students’ clinical judgment based on their responses to clinical vignettes found that students often ordered unnecessary tests because they tended to overestimate the likelihood of disease in low-probability settings [56] or underestimate the influence of physical examination findings, especially negative findings, on the assessment of the likelihood of disease [57]. Therefore, clinical education should also focus on the diagnostic value of a patient’s history and physical examination. In particular, efforts should be made to emphasize the importance of negative (normal) physical examination findings in ruling out disease. This includes not only the ability to recognize physical signs when they are present but also the confidence necessary to determine the absence of a physical sign. The difficulties in implementing workplace-based assessments are, first, the influence of the context-specificity of clinical problems that I mentioned earlier. Second, the wide variation among assessors necessitates repeated assessments to produce reliable results. Third, attempts to validate assessment methods have shown that they are differentially associated with each other, suggesting that they measure different components of the construct of clinical reasoning [58]. In addition, some assessment methods, such as SCT [54], require significant investment in faculty and student training and are unlikely to be used in clinical teaching. Therefore, until an easily applicable test is developed, the measure of students’ reasoning will remain the assessment of their summaries of the patient’s problem-oriented records (problem list, relevant history, physical examination data, differential diagnosis, hypothesis-­driven diagnostic tests, and treatment plan) [59].

5.6 Decision Support Attempts to support doctors’ reasoning have included maximizing the predicted utility of clinical decisions (decision analysis) and assessing the evidence for the efficacy of management interventions (evidence-based medicine).

5.6.1 Decision Analysis Any responsible decision must be based on an evaluation of the risks and benefits of the various interventions. Even clinicians who have never been introduced to decision theory use informal or quasi-formal decision analysis to identify available courses of action and consider their possible outcomes. When making treatment decisions, physicians consider expected benefits in terms of chances of recovery and harms in terms of side effects, patient suffering, and costs. In diagnostic decisions, physicians consider benefits in terms of true-positive and true-negative results

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and risks in terms of delay in treatment until the test is performed, its cost, falsepositive and false-negative results, and side effects. In this section, I summarize the strengths and weaknesses of formal analyzes of clinical decisions. It is not intended to enable readers to perform decision analyzes. Interested readers are referred to review articles and software applications. Formal analysis of a clinical decision first requires identification of all possible strategies, e.g., anticoagulation and no treatment for a patient with chronic atrial fibrillation. Second, consideration of all possible outcomes of each strategy, e.g., embolism, and bleeding. Third, an estimate of how likely it is that the event will occur. Fourth, an assessment of the desirability (utility) of the outcomes by asking about the patient’s preferences. Finally, weigh the benefits against the risk of each strategy. An approach that I have found useful in introducing medical students to decision trees begins by presenting them with the case of a patient who presents with fever, physical and radiographic evidence of right lower lobe consolidation, and intracellular diplococci in the sputum. The choice of treatment with antibiotics is straightforward. It does not require a decision tree for the following three reasons. The first reason is the wide differences between the outcomes of the two treatment options. A review of previous unblinded studies found that mortality from lobar pneumonia in 1938 was 5–8% in patients treated with sulfapyridine and 19–27% in untreated controls [60]. However, formal decision analysis may be helpful when the outcomes of alternative treatments are not as widely different as in pneumonia. Consider the following hypothetical case: A patient has a neoplasm that may be treated by radiotherapy or by attempted surgical excision. The 5-year survival after radiotherapy is 80%. On attempted surgical excision some cancers may be resectable and others may not. Resectable cancers carry a 5-year survival rate of 95%; the 5-year survival rate of patients with non-resectable cancers is 50%.

In this case, a formal analysis using a decision tree shows that if surgical mortality is 1% and there is a 60% probability that the neoplasm is resectable, the 5-year survival would be 76% after surgery and 80% after radiotherapy. In other words, both strategies would lead to similar outcomes, so the choice between them should be based on other considerations such as cost and patient preference. If the probability of a resectable tumor is uncertain, a sensitivity analysis can be performed by repeating the analysis with different values for this probability. In this case, such a sensitivity analysis indicates that surgical treatment is preferable if the patient has a probability of a resectable tumor greater than 70%. The formal analysis of the decision has identified the specific area of uncertainty that should be further explored. The second reason why the choice of treatment for pneumonia does not require formal analysis is the narrow time horizon of the decision: It the case of pneumonia, predictions relate to developments in the coming weeks, and near predictions are easier to make than those for the distant future. However, formal decision analysis may be helpful when the outcomes of alternative treatment strategies have a more distant time horizon. Consider the following example. An asymptomatic person is found to have gallstones. Surgical treatment is associated with (low) mortality; however, survivors are free of the risk of recurrent biliary complications.

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Expectant treatment is risk-free in the short term; however, the patient may at any time during his/her remaining life sustain a complication that will be more difficult to treat.

In this case, the decision analysis may help the choice between surgical and expectant treatment by using a recursive computerized calculation of the risk of age-related death from natural causes and biliary complications over the patient’s remaining lifespan. Finally, in the example of the patient with pneumonia, the health states of interest are alive and dead. Complications of lobar pneumonia that can lead to permanent disability are extremely rare. However, in other cases, the decision-maker must consider states other than life and death, such as survival with varying degrees of disability. Consider the following example: A diabetic patient has an infected wound in his foot. The treatment options are antibiotic treatment and below-the-knee amputation. Below-the-knee amputation is associated with surgical mortality; however, those who survive will live with below-the-knee amputation. Antibiotic treatment is not associated with any surgical mortality; at best, the wound may heal and the patient may survive with his leg intact. At worst, he will die of sepsis. An intermediate outcome would be the spread of infection, which would require above-the-knee amputation, in which case the patient may die in surgery or survive.

Apart from the states “alive” and “dead,” there are two intervening states of health in this example, amputation below the knee and above the knee. Different people have different values. Therefore, in examples such as this, the benefit should be determined by the patient. As stated in Sect. 5.2, the same limp has a different meaning for a dancer and a math teacher. Several methods are commonly used to quantitatively determine utilities in quantitative terms, and interested readers are referred to review articles [61]. In summary, some clinical decisions are difficult because they involve choosing among treatments with similar efficacy, predicting remote events, or considering multiple utilities. In these cases, formal analysis can assist decision-making. First, in cases of unexplained variability in practice, formal analysis can help health policy analysts identify the practice that maximizes utilities. When the choice between legitimate options is a toss-up, cost-effectiveness analysis can identify the option that minimizes cost and inconvenience to patients. Second, physicians have historically relied on their judgment of patient preferences. However, public dissatisfaction with health care has drawn attention to the risk of such physician judgments, and attempts are now being made to involve patients in clinical decisions. Despite their discomfort with expressing utility in numbers, clinicians are increasingly aware of the need to find formal or informal ways to quantify patients’ utilities. Third, in the event of a “toss-up,” formal analysis can help identify important areas of clinical uncertainty and direct research toward those areas. Finally, decision trees, with their explicit analysis of the choice of different clinical strategies, have proven effective in helping students and patients understand the rationale for choosing a particular clinical strategy under conditions of uncertainty.

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Nevertheless, formal decision analysis has not gained acceptance in clinical medicine [62]. First, it is time-consuming and cannot be performed at the bedside. Second, the data needed for analysis are not always available, and clinicians are reluctant to use subjective probabilities in cases of uncertainty. Third, both patients and clinicians are uncomfortable expressing utility in numbers. Fourth, decision analysis does not reflect clinical thinking because clinicians do not make decisions by multiplying probabilities by utilities. Fifth, for many clinicians, formal decision theory is either too simple to reflect the complexity of clinical reality or too complicated to understand and apply. Finally, it appears that in most cases, differences in outcomes among alternative treatment approaches are so obvious that they obviate the need for the use of formal decision analysis, whereas in cases where these differences are not obvious, formal analysis almost always suggests a “toss-up.”

5.6.2 Evidence-Based Medicine The shift in clinical reasoning from pathophysiological rationale to reasoning based on empirical evidence can be traced back to 1948 when the Streptomycin in Tuberculosis Trial Committee published the first randomized controlled clinical experiment. Since the late 1960s, there has been an increasing reliance on epidemiologic research to apply findings from population-based studies to the treatment of individual patients. Clinical epidemiology teaches the rules of inference from population-­based data. The methods for identifying the best empirical evidence from population-based studies were developed primarily at McMaster College by Drs. Sackett and Guyatt who coined the term “evidence-based medicine” (EBM) [63]. Its formal definition is “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” [64]. Since the 1990s, EBM has gained acceptance in clinical practice, and clinically integrated teaching programs on EBM have been shown to improve students’ knowledge, skills, attitudes, and behaviors [65]. Today, terms such as evidence-­ based guidelines are part of the medical discourse. EBM is based on the premise that clinical decisions should be guided by both clinical expertise and the best available external evidence [64]. “Clinical expertise” is the competence and judgment that clinicians acquire through experience. “Best available external evidence” comes from patient-based research on diagnostic tests, prognostic markers, and the efficacy and safety of clinical interventions. An important contribution of EBM is the differentiation of levels of evidence according to the risk of bias, from strongest (systematic reviews of randomized, triple-blind, placebo-controlled trials) to weakest (case reports, expert opinions based on unsystematic personal experience). The U.S.  Preventive Services Task Force recommends categorizing evidence of treatment/screening effectiveness as that derived from at least one properly designed randomized controlled trial (level I), well-designed controlled trials without randomization (level II-1), well-designed cohort or case-control studies (level II-2), multiple time series with or without

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intervention (level II-3), and opinions of respected authorities or reports of expert committees (level III). Randomized controlled trials have a low risk of bias. However, the view that randomized controlled trials provide the best evidence should not be misunderstood as a requirement that all clinical decisions must be based on the results of such trials. EBM is a call for clinicians to realize that their clinical decisions vary in certainty. When evidence from controlled trials is not available, treatment decisions must be based on lower levels of evidence.

5.7 Interpretation of Research Findings1 The interpretation of research findings, such as the effectiveness of interventions, is commonly based on statistical significance. The conventional wisdom is that a significance level (p-value) of less than 0.05 is considered to confirm differences between the values of interest. This interpretation is flawed. It is commonly referred to as the “p-value fallacy,” and in 2005 Ioannidis even claimed that “most [sic!] published research findings are false” [66]. The p-value fallacy is due to the failure to recognize that the probability of observed findings given the hypothesis is not the same as the question of interest, which is the probability of the hypothesis given the observed findings. In other words, discussions about which statistic to use have distracted scientists from examining the more important question: what they want to know when they conduct scientific research [67]. To assess the likelihood of the hypothesis given the observed results, it is not sufficient to know only the p-value, just as to assess the predictive value of a diagnostic test it is not sufficient to know only its specificity. Bayesian rules of inference also require estimates of the statistical power of the experiment to reject the null hypothesis if it is false, and of the prior probability (before the study) that the hypothesis is correct. The probability that a tested hypothesis is true depends on the prior probability that it is true, the statistical power of the study, and the statistical significance level [68]. Research can be viewed as the degree of belief a person has about a hypothesis and the change in that belief in light of new evidence. Learners’ epistemic beliefs change over time. Bayesian reasoning provides learners with a way to approach research by countering the intuitive tendency to seek answers in terms of right or wrong. Teaching Bayes’ theorem can help students move from a dichotomous right/ wrong view of knowledge to a realistic understanding of scientific ideas, data, and evidence. This can impact students’ epistemological development by making them aware that uncertainty can be reduced but not eliminated [69].

 A previous version of this section was published in: Benbassat J. Inferences from unexpected findings of scientific research: common misconceptions. Eur J Int Med 2016;8:188–89. With permission from Elsevier. 1

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Consider the case of complementary and alternative medicine (CAM). Medical education, practice, and research follow the premises of the biomedical (BM) model. Conversely, CAM is an all-inclusive term for clinical practices based on theories about a disease that differ from those of BM as well as from each other. Both CAM and BM are based on theoretical models. Both BM and CAM may draw on interventions based on lower levels of evidence in the EBM hierarchy. They both strive to test the effectiveness of their interventions through controlled trials. Some controlled trials of CAM have been interpreted as supporting the efficacy of chiropractic for low back pain [70] and acupuncture for hypertension [71]. There is evidence that tai chi affects autonomic modulation [72], and that scalp acupuncture improves infarct volume and neurological function in animals with experimental ischemic stroke [73]. Should these findings be interpreted as confirmation of the efficacy of these interventions? The CAM controversy is mainly due to different estimates of the prior probability of the hypothesis being tested. Proponents of CAM would rate this probability as high because it is consistent with their theory of the disease: they would therefore interpret positive study results as evidence of efficacy. Proponents of BM would estimate this probability to be nil because it is inconsistent with existing scientific BM notions and would ignore research suggesting a benefit of CAM. Should findings suggesting that CAM treatments are effective then be ignored? The history of medicine is replete with unexpected observations that led to paradigmatic shifts in clinical reasoning. For example, contrary to the prevailing belief at the time, treatment with quinidine was found to increase mortality in patients with cardiac arrhythmias, and treatment with beta-blockers was found to improve left ventricular function. Contrary to the BM premise that disease is the result of structural or biochemical disturbances, the observed associations between life events and morbidity and between socioeconomic status and mortality led to the acceptance of psychosocial predictors of disease. Therefore, observed inconsistencies between theory and practice should not be ignored, but rather prompt further investigation. Random observations, unexpected research findings, and positive findings of trials testing hypotheses with very low prior probabilities do not provide definitive evidence for associations or cause-and-­ effect relationships. However, such observations generate hypotheses that should be confirmed by independent controlled studies. If CAM practitioners want to be accepted by the BM mainstream, they must seek such confirmatory evidence through statistically sound, controlled studies. A second way to support CAM interventions is through n-of-1 controlled trials [74]. A patient is assigned to receive a sequence of experimental and control interventions in random order. The patient’s problem is assessed at baseline, then again during and after treatment. If the problem disappears during treatment, it can be determined that it was effective. N-of-1 studies are consistent with the requirement that evaluation of the effectiveness of CAM practices should only be done in the context of a specific individual [75], and the Oxford Center for EBM classified such studies as level 1 evidence for treatment decisions in individual patients [76]. I

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believe that future research on the effectiveness of CAM will focus on n-of-1 rather than population-based clinical trials. As an aside, my attitude toward CAM is ambivalent. On the one hand, CAM is a social process that should be studied scientifically. BM physicians could emulate CAM in the trust that characterizes their relationship with patients, and in their non-­ judgmental attitude toward patients. A CAM practitioner is not likely to think that a patient’s complaint is imaginary. On the other hand, while both BM and CAM abound with anecdotal reports of individual successes, only BM can claim breakthrough treatments, such as vaccines, insulin, antibiotics, antiviral drugs, and the treatment of hypertension. Assumptions such as those of homeopathy that dilutions of a substance have a biological effect are not only incompatible with BM; they also violate the laws of physics and chemistry. Most CAM theories assume that the cause of the disease and the ability to treat it are within the patient and attribute a failure of CAM therapy to the patient’s inability to believe in the value of the treatment [77]. Finally, the ethical principle of equitable distribution of health care resources implies that the health care system cannot provide free CAM services with largely unproven or untested efficacy and yet exclude drugs and technologies with proven efficacy from the basket of benefits because of their cost.

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62. Elstein AS. On the origins and development of evidence-based medicine and medical decision-­ making. Inflamm Res. 2004;53(Supplement 2):S184–9. 63. Guyatt G, The Evidence-Based Medicine Working Group. Evidence-Based Medicine. A new approach to teaching the practice of medicine. JAMA. 1992;268:2420–5. 64. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence-based medicine: what it is and what it isn't. BMJ. 1996;312(7023):71–2. 65. Flores-Mateo G, Argimon JM. Evidence-based practice in postgraduate healthcare education: a systematic review. BMC Health Serv Res. 2007;7:119. 66. Ioannidis JPA. Why most published research findings are false. PLoS Med. 2005;2:e124. 67. Lakens D.  The practical alternative to the p-value is the correctly used p-value. Perspect Psychol Sci. 2021;16(3):639–48. 68. Pharoah P. How not to interpret a p-value? J Natl Cancer Inst. 2007;99:332–3. 69. Rosenberg JM, Kubsch M, Wagenmakers EJ, Dogucu M. Making sense of uncertainty in the science classroom. Sci Educ (Dordr). 2022;14:1–24. 70. Walker BF, French SD, Grant W, Green S. Combined chiropractic interventions for low-back pain. Cochrane Database Syst Rev. 2010;4:CD005427. 71. Li DZ, Zhou Y, Yang YN, Ma YT, Li XM, Yu J, Zhao Y, Zhai H, Lao L. Acupuncture for essential hypertension: a meta-analysis of randomized sham-controlled clinical trials. Evid Based Complement Alternat Med. 2014;2014:279478. 72. Lu WA, Kuo CD. Breathing frequency-independent effect of tai chi chuan on autonomic modulation. Clin Auton Res. 2014;24:47–52. 73. Wang WW, Xie CL, Lu L, Zheng GQ.  A systematic review and meta-analysis of Baihui (GV20)-based scalp acupuncture in experimental ischemic stroke. Sci Rep. 2014;4:3981. 74. Johnston BC, Mills E. N-of-1 randomized controlled trials: an opportunity for complementary and alternative medicine evaluation. J Altern Complement Med. 2004;10:979–84. 75. Tonelli MR, Callahan TC. Why alternative medicine cannot be evidence-based. Acad Med. 2001;76:1213–20. 76. Howick J, Chalmers I, Glasziou P, Greenhalgh T, Heneghan C, Liberati A, Moschetti I, Phillips B, Thornton H, Goddard O, Hodgkinson M. OCEBM levels of evidence working group. The Oxford 2011 levels of evidence. 2011. 77. Davidoff F.  Weighting the alternatives: lessons from the paradoxes of alternative medicine. Ann Intern Med. 1998;129:1068–70.

Chapter 6

The Behavioral and Social Sciences in Medical Education

6.1 Introduction An 1838 treatise entitled “Further Discussions of the Foundations of Somato-­ psychic Medicine” appears to be the first formulation of psychosomatic medicine [1]. However, its publication only triggered a reaction against psychiatry, as medicine at that time was transforming into a science based on physics and chemistry. Psychosomatic medicine reappeared in the 1930s but remained outside the mainstream, and as late as the 1950s medical education focused on the patient’s organs and tissues but not on her/his feelings and emotional distress. It was not until the 1950s that emotional distress became the subject of scientific study. The main variables in this study were “stress,” defined as the reaction to a stimulus, and “stressor,” defined as the stimulus. The purpose of this section is to describe these variables and summarize the evidence of their relationship with morbidity, the implications of this relationship for clinical practice, and the barriers to teaching the behavioral and social sciences (BSS) to medical students.

6.1.1 Stress and Stressors Stressors trigger a chain of reactions called stress. These include mobilization of energy, stimulation of the heart and respiratory rates, constriction of peripheral blood vessels, elevation of blood pressure, and interruption of unnecessary physiological processes such as salivation. Originally, the stressors studied were physical,

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such as cold. Later, people were found to respond similarly to emotional and social stressors (see [2] for a review). The main difficulty in studying stressors is their uncertain quantification: what is perceived as a stressor by one person may be a pleasant challenge for another. In experimental animals, stressors such as electric shocks suppress cellular immunity, and feelings of helplessness and lack of control over the stressor amplify its effects [3, 4]. Attempts to explore whether stress causes disease and not just physiological responses have consisted of looking for associations between morbidity and psychological distress, personality, life events, social support, and socioeconomic metrics.

6.1.2 Psychological Distress The construct of psychological well-being has included experiencing that one’s life has meaning, realizing that one is moving forward, perceiving that one is in control of life, and feeling worthwhile, happy, enthusiastic, proud, and optimistic. There is evidence that psychological distress is associated with all-cause mortality [5] even after adjustment for behavioral and biological risk factors [6]. Unfavorable scores on the Childhood Family Environment questionnaire were associated with all-cause mortality later in life [7], and both preexisting and new-onset mental illness in cancer patients were associated with higher all-cause and cancer-specific mortality [8]. The main limitations of these observations are possible reverse causation, in which participants’ declining physical health would affect their psychological well-­ being [9].

6.1.3 Life Events The first evidence of the relationship between life events and morbidity was provided by Holmes and Rahe [10]. They conducted a survey in which participants were asked to name experiences that they would define as “life events” and to rate these events according to their severity on a scale of 1–100. The survey revealed 43 such life events. The death of a spouse was defined as the most serious event while receiving a parking report was ranked as the lightest event. The researchers then asked a group of US navy soldiers to indicate the life events they had experienced and when and tracked the soldiers’ morbidity over the next 6  months. Results showed a correlation between the intensity of life events in the previous 6 months and morbidity during the six-month follow-up. This correlation was confirmed by later studies. The number of patients with myocardial infarction during the missile attack on Israel in the Gulf War was higher than during the corresponding period of the previous year [11]. Prospective studies have shown that life events predict cancer morbidity [12], and that family life events

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predict the incidence of pneumonia, diarrhea, and accidents in children [13]. Despite criticisms of some aspects of the Holmes and Rahe experiment [14], it is considered the first evidence that life events, like age, are a nonspecific risk factor for disease [15].

6.1.4 Social Support “Social support" is a framework that provides individuals with love, recognition for their achievements, and intimacy that allows for the expression of emotions. Such frameworks are the family, the workplace, social clubs, religion, or counseling services (doctors, clergy). Social support systems are health-promoting [16], while loneliness and social isolation in older adults are associated with an increased risk of developing dementia, coronary heart disease or stroke, and all-cause mortality [17]. A 2018 review showed that loneliness increases all-cause mortality and that this effect is independent of the effect of depression [18]. Therefore, efforts are being made to improve the prognosis of patients through various psychosocial interventions. It has been shown that providing individual or group therapy significantly reduced loneliness [19] and improved depression and anxiety in patients with coronary artery disease [20]. A meta-analysis of randomized trials showed that patients who received a psychosocial intervention were, on average, 20% more likely to be alive at the end of the study than controls [21]. Other interventions consist of teaching patients how to manage their illnesses. A 2017 review found that self-­management reduced all-cause mortality in patients with type 2 diabetes [22]. Attempts to influence the course of cancer through psychosocial interventions have been based on the assumption that reducing stress would enhance the immune response to cancer cells. Indeed, the presence of newly diagnosed psychiatric disorders in cancer patients was found to be associated with significantly higher mortality than in cancer patients without psychiatric disorders [23]. A 2015 randomized controlled trial of cognitive stress management in breast cancer found that the intervention group had a lower risk of all-cause mortality compared with the control group. Restricting analyses to patients with invasive disease revealed significant effects of the intervention on breast cancer-related mortality and disease-free interval [24].

6.1.5 Socio-Economic Status No society can prevent social and health inequalities. A 2017 meta-analysis of 48 prospective cohort studies with a total population of 1,751,479 people from seven high-income countries found that 310,277 participants died during a mean

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follow-­up of 13–3 years. Participants with low socioeconomic status had a higher mortality rate than participants with high socioeconomic status (hazard ratio 1.42 for men and 1.34 for women); this association remained significant after adjustment for high alcohol consumption, obesity, diabetes, hypertension, physical inactivity, and current smoking [25]. An unhealthy lifestyle explained only a small portion of the impact of socioeconomic status on health [26]. One of the most important socioeconomic variables is income. Poverty predicts morbidity, and there is an inverse correlation between income and mortality [27, 28]. Morbidity and mortality are also influenced by occupational status, neighborhood, and social equality. For example, in a 7-year follow-up of 17,530 civil servants in London, cardiovascular disease mortality was 4% among the lowest-paid workers and less than 1% among managers, even after adjustment for cholesterol, smoking, and blood pressure [29]. Regardless of income, education, or occupational status, residents of slums are more prone to heart disease than residents of established neighborhoods [30]. Life expectancy in the USA was higher in states with more equitable income distribution. In other words, social equity appears to increase life expectancy [31]. How socioeconomic status affects morbidity and mortality is uncertain. People with low status are more likely to report underutilization of their potential, unfair working conditions, and poor social ties [29]. It is possible, therefore, that low socioeconomic status is associated with a higher incidence of feelings of frustration and stress.

6.1.6 Personality Traits The association between personality traits and morbidity is uncertain. The theory of psychosomatic specificity assumes a one-to-one relationship between a particular psychosocial configuration and a particular disease. According to this theory, a particular set of circumstances (bereavement, job loss) combined with specific personality traits (submissive, manipulative) would lead to a certain illness (bronchial asthma, peptic ulcer) [32]. Thus, hostility has been linked to hypertension, separation anxiety to bronchial asthma, and an A personality (characterized by the drive to accomplish more in less time) to heart attacks. However, the theory of psychosomatic specificity is supported only by anecdotal observations. Studies have shown that type A behaviors increase the risk of heart disease only slightly [33] or not at all [34] or to any disease and not just heart disease [35]. Conversely, the association between life events and morbidity and between socioeconomic status and mortality supports the theory of psychosomatic nonspecificity. According to this theory, any life event or low socioeconomic status can increase the risk for any disease, regardless of personality traits [36]. The relationship between disease and psychosocial determinants and personality patterns is still in need of study.

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6.2 Barriers to Teaching the Behavioral and Social Sciences1 The BSS have been part of the medical curriculum since the 1940s [37]. Until the 1980s, sociologists faced restrictions on their access to medical students. However, since the 2000s, the evidence that the primary determinants of health inequities are social, rather than biomedical [38, 39] has reinstated the BSS in the curriculum and led to the inclusion of teaching the consequences of societal problems into the requirements for accreditation of medical schools. Still, the implementation of BSS programs in medical education remains problematic [40]. BSS programs have been subject to revision, discontinued courses, high teacher turnover, and changes in course directors. The objective of this section is to describe the intricacies of teaching the BSS and possible approaches to their solution. In 2022, Bann et al. [41] identified several difficulties in teaching the BSS. At the professional level, faculty were poorly prepared to teach concepts such as the social determinants of health. At the organizational level, participants pointed to a lack of time, faculty, and resources and described the development of the course as rushed and suboptimal (“building the airplane as it’s taking off”). Finally, at the interactional and intrapersonal levels, in some cases, faculty communication with students was strained [41]. These difficulties are related to two main barriers to teaching the BSS: the dominance of the biomedical model and the undefined content of the BSS. Even doctors who recognize the social determinants of illness question their clinical relevance. Doctors are interested in the diagnosis and treatment of individual patients and not in solving social problems. A 2006 survey indicated that one-third of US primary care physicians believed that addressing psychosocial issues would lead to minimal or no improvement in patient outcomes [42]. Similarly, a 2008 survey indicated that UK medical faculty perceived BSS topics as “nice to know” rather than “need to know” [40]. As late as 2020, it was found that despite BSS constituting a mandatory component of the UK medical curriculum, medical students did not perceive BSS as useful for their future practice as doctors, nor did they find it to be clinically relevant [43]. Second, the content of the BSS remains undefined [44]. BSS programs have included social determinants of health, cultural competence, antiracism, social justice, indigenous health, and LGBT care [41]. Other BSS teaching programs have focused on patient interviewing and ethical (e.g., informed consent) or psychosocial (e.g., family violence) problems [45]. In 2004, the Institute of Medicine identified 26 different topics clustered into six categories: health policy and economics, patient behavior, physician–patient interaction, mind–body interactions, physician role and behavior, and social and cultural issues [46]. There is not sufficient curricular time

 A previous version of this section was published in: Benbassat J, Baumal R, Borkan JM, Ber R. Overcoming barriers to teaching the behavioral and  social sciences to  medical students. Acad Med. 2003;78:372–80. With  permission from Wolters Kluwer. 1

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for all these subjects and their inclusion is frequently guided by the availability of teachers rather than by their perceived importance [40].

6.3 Overcoming Barriers to Student Learning An essential requirement for teaching the BSS is an agreed-upon program that prioritizes learning objectives according to their clinical relevance. Meeting this requirement would give the highest priority to two learning objectives: acquisition of doctor–patient communication skills and identifying psychosocial factors that may increase the risk for disease, or decrease patients’ ability to cope with the disease. Other learning objectives of the BSS, such as medical ethics, models of the doctor–patient relationship, doctor–society relations, healthcare delivery systems, occupational health, and social responsibility of the medical profession, would be decided by the faculty of individual medical schools. Whatever the educational philosophy, a list of teaching priorities is an essential step toward defining the BSS core curriculum, a commitment to attaining specified learning objectives, and making an effort to maintain a pool of teachers for the agreed-upon BSS core. The acquisition of doctor–patient communication skills was described in Sect. 2. Identifying psychosocial factors that may increase the risk for disease or decrease patients’ ability to cope with the disease are described in this section.

6.3.1 Risk for Disease and Ability to Cope with It: The Patient’s Personal/Psychosocial History2 The patient’s personal history was part of the medical record as early as the 1950s [47]. Morgan and Engel [48] suggested including in it the patient’s expectations, while Weed [49] recommended adding a description of the patient’s state of mind to the “profile of the patient.” However, like other students, I was not sure what should be considered important in the patient’s personal history and how it would contribute to solving the patient’s problem. The traditional justifications for taking the personal history (“a doctor should take care of patients, not treat diseases” and “it is more important to know what kind of person has a disease than what kind of disease a person has”) seemed to me to be meaningless slogans that neither explained the purpose nor provided criteria for evaluating the recorded personal history.  Previous versions of this section were published in: Benbassat J, Baumal R. Viewpoint: a proposal for teaching basic clinical skills for mastery: the  case against vertical integration. Acad Med. 2007;82:83–91. With  permission from Walters Kluwer. Benbassat J. The social worker’s record of the hospitalized patient. A physician’s perspective. Isr J Psychiatr Relat Sci. 1996;33:246–52. With permission from Gefen publishing. 2

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Other authors have quoted students as saying that “the relationships between psychosocial determinants and health are either so obvious that they require little … explanation, or so fanciful that they … exist only as a psychiatric or sociological delusion” [50]. The perception of the BSS as clinically irrelevant is further reinforced by the differences between what students are taught and what they see during their clerkship rotations. For example, in 2011, fourth-year US students who were exposed to a BSS curriculum in the first 2 years of medical school commented that its precepts were not integrated into patient care [45]. This feeling seems pervasive even today. Time constraints and pressure to focus on the patient’s immediate problems limit the medical record to data relevant to crisis intervention. The patient’s personal history is rarely included in published case reports. Although most medical schools offer programs in the social and behavioral sciences, the identification and treatment of psychosocial problems is too often considered the domain of social workers and liaison psychiatrists. It has been claimed that teaching the BSS to medical students requires moving away from the view of the student as a vessel into which knowledge is “deposited,” and towards one in which students and teachers learn together in dialogue [41]. To initiate such a dialogue, I have found it useful to ask students to consider the following hypothetical case. You are a family physician and meet for the first time Mr. T. who has recently moved to this neighborhood, and “just wants to say hello.” Mr. T.is 50 years old and states that he and his family are in excellent health. However, having decided to be your patient in case of need, he came to introduce himself.

Since there are no complaints to address, students commonly suggested that the conversation with Mr. T should include counseling on health promotion. With varying degrees of help from me, students identified the two types of information that a doctor needs for such counseling: identification of risk indicators that would increase Mr. T’s susceptibility to disease, and of resources, which may help him cope with it. The ensuing dialog with students defined “risk indicators for disease” as host factors (e.g., heredity) and environmental factors (e.g., exposure to occupational hazards). Some risk indicators, such as a family history of diabetes or smoking, may increase the likelihood of specific diseases. Other risk indicators, such as age, may increase the likelihood of disease in general. I contributed to the discussion evidence that I outlined earlier in this section, namely that disease is also more common in individuals who have experienced recent life events; that markers of socioeconomic status (income, education, housing) are better predictors of health status than biomedical risk indicators, such as blood lipids; that the morbidity of poor people is higher than that of people with better incomes; and that regardless of income and education, residents of poor neighborhoods have higher morbidity rates than residents of affluent neighborhoods. With my help, students defined “resistance resources” as systems that help an individual cope with the disease. The immune system and nutrition are examples of physiological resistance resources. I contributed to the discussion of psychosocial

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resources such as socioeconomic status. The distinction between resistance resources and risk factors is somewhat blurred: the absence of a resistance resource may in itself be considered a risk indicator. However, the phrase “resistance resources” is useful mainly in understanding the contribution of social support systems that I described earlier. Table 6.1 attempts to provide a guide for querying clinically relevant data in the patient’s personal history and to simplify this query by dividing it into categories that standardize key issues. Some students argued that the identification of risk indicators and resources in a patient is not useful for making clinical decisions. Doctors obviously cannot alter an individual’s past, just as they cannot combat poverty. I responded that neither can doctors alter an individual’s heredity and age nor, in many cases, an individual’s immunity. Still, information on risk indicators and resources is important because they may affect a patient’s susceptibility to disease and determine his/her needs for help in case of disease. Similarly, doctors cannot do anything to correct loneliness or socioeconomic deprivation. However, they must consider these personal features in counseling patients about treatment modalities that are not covered by insurance, determining the frequency of follow-up visits, and assessing the need for home care or referral to the hospital, just as they should consider a patient’s age and comorbidity in assessing his or her healthcare needs. There is a difference between an employee with a stable job and health insurance who continues to receive a salary during illness and a self-employed patient without Table 6.1  Proposed format for the bio-psychosocial history Risk indicators of disease:  Age  Gender  Ethnic group  Family history (health and age of parents, history of hereditary disorders in relatives)  Occupation (exposure to occupational hazards)  Living conditions (number of occupants per room, sleeping arrangements)  Typical daily routine  Life events (separation from parents, change of school, divorce, loss of close relatives, change of job, travel, and vacation)  Comorbidity  Exposure to medication, surgery, or contagious diseases  Habits: alcohol, drugs, cigarette smoking Resources:  Education  Income  Medical insurance (effect of disease on patient’s income)  Marital status and number of children  Relations with colleagues, work tension, and satisfaction  Social contacts

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health insurance whose illness worsens his or her financial situation. There is a difference between a childless elderly widower who lives alone and eats convenience foods indiscriminately and a patient of the same age who lives with his wife, attends a senior citizens club, and enjoys visits from his children and grandchildren. The lower the patient’s educational level, the more encouragement he needs to ask questions about his illness and to receive longer explanations. Conversely, an educated patient may be satisfied with a brief explanation accompanied by written material or a reference to a website on the Internet. The description of susceptibility in the format of a statement of risk factors and resistance resources provides a purposeful definition of data to be looked for and criteria to evaluate the record of a patient profile. The conversation with Mr. T. may be recorded either in the form of a checklist or as a narrative, such as: Mr. T. aged 55 years, of North African Jewish extraction, lives with his wife and one child aged 10 years in a three-bedroom apartment. When Mr. T was 13 years old, his father died after a stroke, and he discontinued his schooling to help support the family. He has two sisters with hypertension. Until about six months ago, Mr. T was employed in an automobile repair shop before he moved to this town to establish his own business. Three months ago, his daughter was married. His health insurance covers primary and secondary care and hospital bills. A typical daily routine includes work that involves physical exertion. He spends his evenings with his wife entertaining friends at home or visiting them. His diet includes bread, vegetables, cheese, and eggs for breakfast; a cheese sandwich for lunch; and beef for dinner. He smokes one to two packs of cigarettes a day since he was 19, but he seldom drinks alcohol. He describes himself as asymptomatic and active, with an optimistic outlook about his future, and he denies any worries. On examination, he was calm, alert, and in no apparent distress. His pulse rate was 80/minute, blood pressure of 145/95 mm Hg, height of 180 cm, and weight of 73 kg.

This summary indicates that Mr. T is a physically active man with a structured daily routine, fair income, health insurance, an optimistic frame of mind, and good social support systems. Nonspecific risk indicators: limited education and recent life events (wedding of a daughter, change of residence, and a change in occupation). Specific risk indicators: family history of hypertension and stroke, personal history of cigarette smoking, excess of animal fats in the diet, and a PE finding of borderline hypertension. The following is an example of the profile of a patient with chronic heart disease: Dr. B, age 60, lives with his wife in a three-room apartment. They have three married children living in the same city. The patient holds a Ph.D. degree in history and, until about six months ago, was a college professor. He had to retire because of his disease and in recent months, he has been mostly homebound. Although capable of performing the activities of daily life, he tires easily and experiences shortness of breath even after a little effort. The family income includes his pension allowance and the salary of Mrs. B who is a librarian. His health insurance covers outpatient, in-hospital, and home care. The patient describes himself as a “loner” with only a few friends beyond his wife and extended family. For the past 10 years, he knows that he has had heart disease. He adheres to a low-fat diet, regular exercise, and immunizations. Although satisfied with the home care he receives from a nurse specialist in heart disease and a cardiologist, the patient is worried about the deterioration in his health in the past year, and is pessimistic about the future.

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During the discussions, I presented to students Engel’s bio-psychosocial model [51], first as a link between the BSS and clinical practice, and second, as a reference point for setting priorities among the various BSS topics [21, 52]. Engel defined patient interviewing (“the doctor–patient dialogue”) as the only “instrument for investigating the human realm” i.e., for gaining insight into a patient’s preferences and lifestyle, and into the psychosocial determinants that may increase the risk of developing a disease and reduce the ability to cope with it. Similarly, a 2010 survey indicated that UK medical faculty viewed the patient–doctor relationship as the most important BSS subject [53] and a 2016 review of the literature indicated that communication skills were the most commonly assessed BSS competency [54]. Therefore, the highest priority in teaching the BSS would be the skills of doctor– patient communication (interviewing), patient counseling (sharing of information, breaking bad news, discharge planning, instructions, and adapting management to a patient’s lifestyle), and dealing with emotions (anxiety, anger, shame). Students appear to appreciate the importance of the BSS more during their clerkship rotations. Contrary to the negative attitudes of preclinical students to BSS lectures, students in clinical clerkships have been reported to perceive positively physicians who stress the psychosocial aspects of medicine [55]. Therefore, the optimal timing for BSS instruction seems to be during the clinical methods course and the clerkship rotations and the optimal teaching approach is small group discussions, rather than lectures and reading assignments. During these discussions, an effort would be made to encourage students to explore the biomedical and psychosocial aspects of a patient’s condition in an atmosphere of respect for the worth of both the biomedical and bio-psychosocial models of clinical reasoning and with reflection on their merits and weaknesses. Rather than force-feed medical students with lecture courses, faculty would make students discover for themselves the relevance of the BSS to clinical problem-solving and agree on a hierarchy of learning priorities.

6.3.2 Implications for Clinical Practice Awareness of the relationship between socioeconomic factors and morbidity has two main implications for clinical practice: First, it emphasizes the importance of patient-centered medicine. The purpose of the medical interview is not only to obtain information but also to offer therapy by identifying and attempting to alleviate stress, anxiety, or depression. Ignoring patients’ psychological needs during treatment leads to avoidable patient suffering and treatment costs [56]. Second, many physicians hold unconsciously to stereotypes, and some physicians tend to consciously dismiss the complaints of patients with psychosocial problems, acute (e.g., recent bereavement) or chronic stress (e.g., caring for ill family members), or following a life event as “somatization,” “psychosomatic illness,” or “functional disorder.” Medical educators try to reduce this tendency by getting physicians to treat such patients like any other patient. This approach is only partially

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correct. Underprivileged patients, patients with acute or chronic stress, or following a life event are not like any other patient: they are at higher risk. Socioeconomic status [57], life events [10], drug dependence [58], severe mental illness [59], and high body mass index [60] are associated with increased morbidity and mortality. African Americans have higher mortality rates than whites for most leading causes of death (heart disease, cancer, stroke, diabetes, kidney disease, hypertension, cirrhosis, and homicide), with a difference in life expectancy of 7 years in 1960 and 5 years in 2005, even after adjusting for socioeconomic status (SES) [61]. The higher prevalence of disease in disadvantaged individuals suggests that any symptom in a child from a dysfunctional family, in a poor, elderly, or uneducated person who is addicted to drugs or is mentally ill, or in a person who has experienced a significant life event, may herald more severe disease than in patients without these risk indicators. In other words, the likelihood of serious illness is higher in patients with psychosocial risk indicators than in patients without these risk indicators, just as the likelihood of life-threatening infection is higher in an immunocompromised patient than in an otherwise healthy person. Rather than trying to promote an egalitarian attitude, physicians should select such patients for special attention.

6.3.3 Who Should Teach Medical Students the Clinically Relevant Aspects of the Behavioral and Social Sciences? In an ideal situation, clinical tutors would address both biomedical and psychosocial issues. However, most clinicians lack the training and willingness to teach the BSS, while social scientists lack clinical expertise. Hence the suggestion that both clinicians and social scientists should teach the BSS in general and patient interviewing in particular [62]. Engel has cautioned, however, that such combinations may inadvertently perpetuate the separation between biomedical and psychosocial problems by implying that the latter is the domain of social workers and psychiatrists rather than part of the clinical practice of all physicians. The challenge for medical education, therefore, is to support training programs for “social science clinicians” or “clinical ethicists” who would feel comfortable demonstrating appropriate interview techniques and conducting group discussions. An additional barrier to teaching the BSS is the uncertain status of social scientists in medical schools. Many medical schools lack career opportunities for social scientists who feel isolated from their root discipline (sociology) and marginalized by the host discipline (medicine) [44]. To overcome this barrier, career paths for BSS scholars in the health professions and their teaching responsibilities should be defined at the university level and decisions about curricular reforms would be based on a dialog between clinicians and BSS scholars. Such discussions would aim to reduce tensions, negotiate educational goals, and define the content of teacher-­ training programs. A dialog between clinicians and BSS scientists would be a positive experience for both sides and would lead to an agreement on the content and educational methods of BSS courses.

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Third, much of the knowledge in the field of health sociology was originally generated in a tradition of critical attitude towards medicine [63]. This tradition has alienated medical students and faculty. In the 1980s, it was claimed that “…some departments of behavioral sciences have adopted an intellectual stance at times antagonistic to the rest of the medical school by emphasizing the shortcomings of the profession in its delivery of healthcare” [50], and some heads of clinical departments in the USA have spoken of an “anti-physician stance of medical sociology” [64]. Certainly, the tradition of critical attitudes toward medicine has contributed to an understanding of the role of medicine in society. However, I believe that it is time for BSS faculty to suggest how the deficiencies they have identified in health care can be addressed. If BSS scholars are to fulfill their mission, they should team up with clinicians to educate a more humane, professional, and effective physician.

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14. Rabkin JG, Struening EL. Life events, stress, and illness. Science. 1976;194:1013–20. 15. Noone PA. The Holmes–Rahe stress inventory. Occup Med. 2017;67:581–2. 16. Seeman TE. Health-promoting effects of friends and family on health outcomes in older adults. Am J Health Promot. 2000;14:362–70. 17. Donovan NJ, Blazer D. Social isolation and loneliness in older adults: review and commentary of a National Academies report. Am J Geriatr Psychiatry. 2020;28:1233–44. 18. Rico-Uribe LA, Caballero FF, Martín-María N, Cabello M, Ayuso-Mateos JL, Miret M.  Association of loneliness with all-cause mortality: a meta-analysis. PLoS One. 2018;13:e0190033. 19. Hickin N, Käll A, Shafran R, Sutcliffe S, Manzotti G, Langan D. The effectiveness of psychological interventions for loneliness: a systematic review and meta-analysis. Clin Psychol Rev. 2021;88:102066. 20. Richards SH, Anderson L, Jenkinson CE, Whalley B, Rees K, Davies P, Bennett P, Liu Z, West R, Thompson DR, Taylor RS.  Psychological interventions for coronary heart disease. Cochrane Database Syst Rev. 2017;4(4):CD002902. 21. Smith TB, Workman C, Andrews C, Barton B, Cook M, Layton R, Morrey A, Petersen D, Holt-Lunstad J. Effects of psychosocial support interventions on survival in inpatient and outpatient healthcare settings: a meta-analysis of 106 randomized controlled trials. PLoS Med. 2021;18:e1003595. 22. He X, Li J, Wang B, Yao Q, Li L, Song R, Shi X, Zhang JA. Diabetes self-management education reduces the risk of all-cause mortality in type 2 diabetes patients: a systematic review and meta-analysis. Endocrine. 2017;55:712–31. 23. Lee SA, Nam CM, Kim YH, Kim TH, Jang SI, Park EC.  Impact of onset of psychiatric disorders and psychiatric treatment on mortality among patients with cancer. Oncologist. 2020;25:e733–42. 24. Stagl JM, Lechner SC, Carver CS, Bouchard LC, Gudenkauf LM, Jutagir DR, Diaz A, Yu Q, Blomberg BB, Ironson G, Glück S. A randomized controlled trial of cognitive-behavioral stress management in breast cancer: survival and recurrence at 11-year follow-up. Breast Cancer Res Treat. 2015;154:319–28. 25. Stringhini S, Carmeli C, Jokela M, Avendaño M, Muennig P, Guida F, Ricceri F, d'Errico A, Barros H, Bochud M, Chadeau-Hyam M. Socioeconomic status and the 25× 25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1· 7 million men and women. Lancet. 2017;389:1229–37. 26. Zhang YB, Chen C, Pan XF, Guo J, Li Y, Franco OH, Liu G, Pan A. Associations of a healthy lifestyle and socioeconomic status with mortality and incident cardiovascular disease: two prospective cohort studies. BMJ. 2021;373:n604. 27. McCally M, Haines A, Fein O, Addington W, Lawrence RS, Cassel CK. Poverty and ill health: physicians can and should make a difference. Ann Intern Med. 1998;129:726–33. 28. Pappas G, Queen S, Hadden W, Fisher G. The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986. N Engl J Med. 1993;329:103–9. 29. Marmot MG, Rose G, Shipley M, Hamilton PJ. Employment grade and coronary heart disease in British civil servants. J Epidemiol Community Health (1978). 1978;32:244–9. 30. Diet Roux AV, Merkin SS, Amett D, Chambless L, Massing M, Nieto FJ, Sorlie P, Szklo M, Tyroler HA, Watson RL. Neighborhood of residence and incidence of coronary heart disease. N Engl J Med. 2001;345:99–106. 31. Lochner K, Pamuk E, Makuc D, Kennedy BP, Kawachi I. State-level income inequality and individual mortality risk: a prospective, multilevel study. Am J Public Health. 2001;91:385–91. 32. Nemiah JC.  A reconsideration of psychological specificity in psychosomatic disorders. Psychother Psychosom. 1982;38:39–45. 33. Myrtek M. Meta-analyses of prospective studies on coronary heart disease, type A personality, and hostility. Int J Cardiol. 2001;79:245–51. 34. Šmigelskas K, Žemaitienė N, Julkunen J, Kauhanen J. Type A behavior pattern is not a predictor of premature mortality. Int J Behav Med. 2015;22:161–9.

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35. Shoham-Yakubovich I, Ragiand DR, Brand RJ, Syme SL. Type A behavior pattern and health status after 22 years of follow-up in the Western Collaborative Group Study. Am J Epidemiol. 1988;128:579–88. 36. Kimball CP.  Conceptual developments in psychosomatic medicine: 1939-1969. Ann Intern Med. 1970;73:307–16. 37. Jenkins TM, Underman K, Vinson AH, Olsen LD, Hirshfield L. The resurgence of medical education in sociology: a return to our roots and an agenda for the future. J Health Soc Behav. 2021;63:255–70. 38. Clouston SAP, Link BG. A retrospective on fundamental cause theory: state of the literature, and goals for the future. Annu Rev Sociol. 2021;47:131–56. 39. Magesh S, John D, Li WT, Li Y, Mattingly-App A, Jain S, Chang EY, Ongkeko WM. Disparities in COVID-19 outcomes by race, ethnicity, and socioeconomic status: a systematic review and meta-analysis. JAMA Netw Open. 2021;4:e2134147. 40. Litva A, Peters S.  Exploring barriers to teaching behavioral and social sciences in medical education. Med Educ. 2008;42:309–14. 41. Bann M, Larimore S, Wheeler J, Olsen LD. Implementing a social determinants of health curriculum in undergraduate medical education: a qualitative analysis of faculty experience. Acad Med. 2022;97:1665. https://doi.org/10.1097/acm.0000000000004804. 42. Astin JA, Soeken K, Sierpina VS, Clarridge BR.  Barriers to the integration of psychosocial factors in medicine: results of a National Survey of Physicians. J Am Board Fam Med. 2006;19:557–65. 43. Dikomitis L, Wenning B, Ghobrial A, Adams KM. Embedding behavioral and social sciences across the medical curriculum:(auto) ethnographic insights from medical schools in the United Kingdom. Societies. 2022;12:101. 44. Tabatabaei Z, Yazdani S, Sadeghi R. Barriers to integration of behavioral and social sciences in the general medicine curriculum and recommended strategies to overcome them: a systematic review. J Adv Med Educ Prof. 2016;4:111. 45. Peterson CD, Rdesinski RE, Biagioli FE, Chappelle KG, Elliot DL. Medical student perceptions of a behavioral and social science curriculum. Ment Health Fam Med. 2011;8:215–26. 46. Institute of Medicine. Improving medical education: enhancing the social and behavioral science content of medical school curricula. Washington, DC: National Academy Press; 2004. 47. Kampmeier RH. Physical examination in health and disease. 2d ed. Philadelphia: FA Davis Co; 1957. 48. Morgan WL, Engel GL, editors. The clinical approach to the patient. Philadelphia: WB Saunders Co.; 1969. p. 197–204. 49. Weed LL. Medical records that guide and teach. N Engl J Med. 1968;278:593–600. 50. Rakoff V. The behavioral sciences and undergraduate education in psychiatry. Can J Psychiatr. 1984;29:642–7. 51. Engel GL.  The need for a new medical model. A challenge to biomedicine. Science. 1977;196:129–36. 52. Smith RC, Fortin AH, Dwamena F, Frankel RM. An evidence-based patient-centered method makes the biopsychosocial model scientific. Patient Educ Couns. 2013;91:265–70. 53. Satterfield JM, Adler SR, Chen HC, Hauer KE, Saba GW, Salazar R. Creating an ideal social and behavioral sciences curriculum for medical students. Med Educ. 2010;44:1194–202. 54. Carney PA, Palmer RT, Miller MF, Thayer EK, Estroff SE, Litzelman DK, Biagioli FE, Teal CR, Lambros A, Hatt WJ, Satterfield JM. Tools to assess behavioral and social science competencies in medical education: a systematic review. Acad Med. 2016;91:730. 55. Wright SM, Kern DE, Kolodner K, Howard DM, Frederick L, Brancati FL. Attributes of excellent attending-physician role models. N Engl J Med. 1998;339:1986–93. 56. Devine EC. Effect of psychoeducational care for adult surgical patients. A meta-analysis of 191 studies. Patient Educ Couns. 1992;19:129–42. 57. Antonovsky A.  Social class, life expectancy, and overall mortality. Milbank Mem Fund Q. 1967;45:31–73.

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Chapter 7

Medical Errors and Quality Assurance of Healthcare

7.1 Introduction Western norms grant physicians professional autonomy in exchange for a commitment to provide quality health care. However, the term “quality health care” defies definition. Since the outcomes of clinical care are uncertain, “quality” should encompass both outcome and process dimensions, including the physician–patient relationship and equitable distribution of resources. Therefore, health care quality can be tentatively defined as “an intervention that is acceptable to the patient, the physician, and the institution providing health care services and meets professional and ethical standards.” In this section I describe, first, the incidence of medical errors; second, the attitude of physicians toward quality assurance and corrective interventions; and third, the management of incapacitated physicians.

7.2 Medical Errors Medical errors elude definition [1]. Outcome-based definitions focus on interventions that have been shown to be incorrect in autopsies, morbidity/mortality conferences, self-reports, and claims audits. Although these studies have provided unique insights into misdiagnosis [2], they have not helped to understand the reasoning of individual clinicians because they cannot accurately reconstruct the context in which the decision was made. It is common to distinguish between three categories of medical accidents. The first includes non-fault accidents caused by properly performed medical procedures, such as a hypersensitivity reaction to a drug administered to a patient for the first time. The second is negligent medical errors resulting from a physician’s failure to

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meet the expected standard in his or her specialty, such as severing the ureters during abdominal surgery. The third category includes medical errors that do not indicate negligence or incompetence. This last category is the gray area between the previous two. The ambiguity of its definition is due to our limited insight into the disease process, which makes perfect diagnoses and treatments unattainable. Just as we must accept that every drug has side effects, standards of clinical practice must also come to terms with the fact that some degree of error is inevitable, and that it is often difficult to distinguish between errors due to the limitations of the physician and the limitations of current medical knowledge. This distinction is usually based on expert opinions. However, their reliability (reproducibility, interobserver agreement) is poor to moderate [3]. The limited reliability of expert opinions is due in part to varying degrees of hindsight bias—a tendency to view events that have already occurred as more predictable than in advance [4]. The only reason we continue to rely on expert opinion, despite its limited reliability, is that there is no better alternative. Physicians who find themselves in a situation where they must evaluate another physician’s decisions should humbly remind themselves that there is no gold standard for clinical reasoning. They should not ask themselves the question, “What would I have done under these circumstances?” which can be biased in hindsight, but rather, “Was the decision in question extremely unreasonable?”

7.2.1 Prevalence of Medical Error and Doctors’ Attitude to Mistakes The prevalence of medical errors is usually determined by retrospective reviews of autopsies, medical records, physician and patient surveys, malpractice claims, and prospective studies with participatory observation. In 1984, the Harvard Medical Practice review of a sample of patient records from New York hospitals found medical errors in 3.7% of the records, and error was considered the sole or additional cause of death in 1 of 400 inpatients [5, 6]. More recent studies found diagnostic discrepancies that would have changed management in 10–20% of autopsies [2]. A 2016 review found fatal preventable adverse events in 0.4–1.1% of hospitalizations [7]. Finally, a 2018 systematic review found that the prevalence of self-reported medication errors was 2–6% in patients older than 18  years and 75% in older patients [8]. The main victims of medical errors are the patients. However, medical errors also affect healthcare providers. Physicians’ reactions to medical errors are cognitive, emotional, and functional. The cognitive domain includes physicians’ awareness of past errors, possible future errors, and of inadequate training. Mizrahi [9] also identified responses such as repression (ignoring and forgetting the medical error), denial (defining the error as a non-error), reduction of responsibility (shifting blame to others, such as the system, supervisors, colleagues, diseases, and patients), and distancing (“no one is perfect,” “errors are inevitable”).

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The culture in clinical education is not tolerant of error. When errors occur, the pursuit of excellence evokes emotions such as fear of litigation and stress due to uncertainty. In 1984, Hilfiker [10] described the guilt, shame, and frustration he felt after making mistakes while working in a remote area in the USA. These feelings have been repeatedly confirmed in recent surveys. North American physicians reported anxiety (61%), loss of confidence (44%), sleep disturbance (42%), and decreased job satisfaction (42%) after making mistakes [11]. Feelings of shame and guilt are compounded by physicians’ failure to share them with others, leaving them unsupported in their distress [12]. Discussions of physician errors in closed sessions are ineffective in providing support. On the contrary, the critical and threatening atmosphere in these discussions only increases anxiety and guilt [13, 14]. The functional consequences of these emotions are reduced self-disclosure of errors, even to colleagues and friends; support for self-regulation and reluctance to be accountable to lay people or lay institutions; and defensive practice characterized by ordering tests even when clinically deemed unnecessary [15], avoiding “like” patients or procedures [14], or early retirement [16]. The proportion of physicians who feel shame, guilt, and frustration after medical errors, who have accepted responsibility for their errors and learned lessons, or who respond with repression, denial, blaming others, and distancing is uncertain. One can only wonder which of these reactions is desirable or dysfunctional. Helping physicians deal with the consequences of their mistakes remains an unexplored area.

7.2.2 Prevention of Medical Errors As recently as 2002, the public and many physicians advocated the use of sanctions against individual professionals found responsible for errors [17]. The assumption that medical errors are caused by incompetence is very tempting: it is the basis for physicians’ belief that “it will not happen to me” and for patients’ trust in the health care system. Causal relationships dominate our thinking [18]. We all want to believe that errors do not just happen, but are caused and that the task of attributing medical errors to incompetence and identifying those who are prone to error, while difficult, is not impossible and may even improve our understanding of the causal structure of the environment [19]. However, this view is not supported by evidence. Although some physicians are more likely than others to be sued for negligence [20], lawsuits in the physician’s professional past do not predict future lawsuits [21], and very large cohorts are needed to confirm habitual substandard performance [22]. Moreover, the high prevalence of medical errors suggests that they are random events that affect most physicians. Even assuming that 1% of all physicians are 10 times more likely to make errors than their colleagues (i.e., 1% of physicians are responsible for 10% of all medical errors), the remaining 90% would be committed by the other 99% of physicians. Thus, it appears that even if negligent physicians could be identified, their removal would not eliminate medical errors, as any physician may commit an error

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due to fatigue, lack of sleep, mental stress, or momentary distraction. Similar to diseases, medical errors are not caused by a single factor, but by multiple factors converging at the same place at a given time. Clinical practice involves dozens of procedures per patient. Therefore, estimates of the frequency of errors suggest an accuracy of more than 99%. But even 99.9% accuracy is less than that expected in other systems such as civil aviation, banking, or postal services. All of these systems are human-designed; their activities and failures can be predicted and analyzed, whereas diseases are subject to biological variability. Nevertheless, medical errors are considered one of the biggest problems in healthcare, and efforts have been made to learn from other systems, such as civil aviation, how to deal with them. Civil aviation assumes that errors are random. Avoiding them requires honest self-disclosure to find out why they happened, rethinking the process, and standardizing professional practice through regulations and algorithms. Pilots are required to pass exams at regular intervals to prove their proficiency, and aviation safety is institutionalized under independent administration. These assumptions and the resulting conclusions for civil aviation are quite different from those for health care. Unlike civil aviation, there are inexplicable differences in how physicians approach the same clinical problem between countries and even within a country [23, 24]. Unlike pilots, physicians are only examined at the end of their clerkship and are not required to undergo regular examinations. Quality assurance of medical care assumes that mishaps are not random but are due to “human error.” However, the assumption that mishaps are due to “human error” is similar to the conclusion that people fall because of gravity: it is correct, but not helpful as all medical errors are human errors. Hence the suggestion to deal with them not by punishment but by their continuous analysis to make the health care system as error-­ free as possible [25]. To achieve this, several taxonomies have been proposed to explain why a particular error occurred and develop interventions for each type of error [26]. Indeed, the rise in anesthesia safety in recent decades is the result of open reporting of errors and intelligent efforts to make the system resistant to errors. The achievements of anesthesiologists can also be applied to other areas of clinical practice.

7.2.3 Patients’ Complaints and Medical Litigation Evidence suggests that the primary cause of patients’ complaints is a difficult physician–patient relationship [27, 28]. Compared with physicians who had filed two or more lawsuits in their careers, physicians who had not filed lawsuits used more orientation statements (educating patients about what to expect), laughed more, used more humor, and tended to use more facilitation (seeking patients’ opinions, checking for understanding, and encouraging patients to talk) [29]. Similarly, a survey of patients who took legal action found that they wanted honesty, an

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appreciation of the severity of the trauma they had suffered, and reassurance that lessons had been learned from their experience [30]. The main goals of malpractice litigation are to compensate patients and to deter negligence. These goals appear to be only partially achieved. The number of lawsuits is 8–10 times lower than the estimated number of malpractice cases in the USA [31], and not all lawsuits against doctors are justified: Of the 313 negligence cases uncovered in the Harvard Medical Practice Study, only eight resulted in a lawsuit. Thus, the legal system compensates only a small proportion of those injured by medical errors [32]. While it is difficult to assess the deterrent effect of the threat of a lawsuit, it is a strong motivator for the concealment of errors and defensive clinical practices that include multiple examinations and avoidance of necessary risky medical interventions. For these reasons, physicians distrust the legal system. However, their claim that it is arbitrary and that only physicians can judge their colleagues is incorrect: there is a high correlation between court rulings in medical malpractice lawsuits and independent judgments by medical specialists. Also, contrary to the claim that juries in the USA tend to favor severely injured patients, there is no correlation between the severity of the injury and the amount of compensation [33].

7.2.4 Disclosure of Medical Errors to Patients Healthcare providers and patients are aware that errors can occur despite the best efforts of physicians and institutions. Yet patients who have experienced a medical error report struggling with a variety of consequences for years after the mistake. Most reported long-term effects, such as changes in seeking medical care, anger, and vivid memories; more than half reported ongoing physical effects, and one-­ third reported financial effects [34]. Patients who have been victims of medical accidents need to understand what went wrong. An inadequate explanation increases the patient’s distress, whereas a full explanation can alleviate that distress and, in at least some cases, is received with understanding. Sometimes the primary motive for a complaint is the patient’s desire to understand what happened. Open communication, which includes disclosure of what happened, an apology, and a description of attempts to prevent it from happening to someone else, reportedly reduces feelings of sadness and betrayal in patients [35]. Moreover, it has been reported to reduce [36] or not affect [37] malpractice litigation. For this reason, the U.S. Joint Commission requires that patients be informed of unanticipated outcomes of care and has linked this requirement to hospital accreditation. In 2006, the Working Group of Harvard Hospitals released a statement emphasizing the importance of disclosure, apologies, and discussion about preventing the recurrence of errors and defining this disclosure as a core component of quality health care rather than a risk management issue. The statement

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acknowledged that disclosure of errors is a difficult conversation and called for adequate preparation, support, and training of healthcare workers before disclosure [36]. These requirements have been only partially implemented. As recently as 2020, an analysis of disclosure and apology outcomes after medical errors found that of 434 malpractice claims, 4.6% of errors were disclosed to the patient at the time of the error and 5.9% were followed by an apology. Of the errors disclosed, 26.1% had resulted in an adverse reaction, and 17.4% were fatal. However, no apology was issued for 54.5% of medical errors that were considered serious [38].

7.3 Incapacitated Doctors A 53-year-old physician has been complaining of work overload, fatigue, and anxiety for about a year. His colleagues smelled alcohol on his breath and found errors in the medications he prescribed. They did their best to correct and cover up these errors but did not advise him to seek help because of the expected impact on his status. Only after he caused a car accident while under the influence of alcohol was he referred for treatment.

This scenario is hypothetical, but not unrealistic. Alcohol addiction, depression, and burnout can interfere with physician functioning.

7.3.1 Incidence Clinical practice offers satisfaction and better health than the general population: in 2000, physicians in the USA died at an older age than lawyers and other professionals [39]. However, the profession of medicine also requires lengthy training, frequent job changes, responsiveness to the medical and psychological needs of others, and sometimes witnessing suffering and death. Physicians today are working longer hours and enjoying the practice of medicine less. They experience more stress than in the past, escalating rates of burnout, dissatisfaction with career choices, depressive disorders, and suicide. The specific sources of stress appear to be fear of medical errors and malpractice suits, time pressure, fatigue, workload and lack of free time, therapeutic failure, failure in the doctor–patient relationship, fear of violence from patients, and criticism from colleagues [40]. All of these factors are particularly severe during internship and residency [41]. The prevalence of substance abuse among physicians is difficult to assess because of the stigma attached to those concerned and the different methods used in studies. It is estimated that 8–15% of all physicians are affected by substance abuse [42]. Recent studies have found that alcohol was the most commonly abused substance among US physicians, followed by opioids, marijuana, cocaine, tranquilizers, and amphetamines [43] and that the prevalence of smoking was 21% among physicians in general and 25% among medical students [44].

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Despite their financial security, high status, and rewarding jobs, physicians have higher rates of depression and anxiety compared with the general population and other professions across all ages, genders, specialties, and years of service. In 2001, suicide rates per 100,000 years/male in Norway were 47.7 among physicians but only 20.1 among other academics and 22.7 among males without higher education; rates among females were 32.3 among physicians but only 13.0 among other academics and 7.7 among women without higher education [45]. Suicide rates among male and female physicians declined after 1980. A 2020 review of studies since 1980 found higher suicide rates among female physicians compared with women in general (1.46) and lower suicide rates among male physicians compared with men in general (0.67) [46]. The distinction between depression and burnout is controversial. The diagnosis of depression is based on symptoms such as low mood, loss of interest, fatigue, low self-esteem, suicidal thoughts, difficulty concentrating, memory problems, sleep disturbances, feelings of guilt, helplessness, dissatisfaction, hopelessness, and feeling that others are doing better [47]. Unlike depression, which is considered to be independent of context, burnout is commonly viewed as an occupational syndrome of emotional exhaustion, depersonalization/cynicism, and feelings of diminished personal accomplishment [48, 49]. A 2018 survey of practicing physicians in the USA found that 54.3% reported symptoms of burnout, 32.8% reported excessive fatigue, 6.5% reported recent suicidal thoughts, and 10.5% reported a medical error in the past 3 months [50]. A 2020 review similarly indicated that about half of practicing physicians in the USA report burnout and up to 14% report suicidal thoughts [51]. However, estimates of burnout among surgical residents varied widely depending on the definition: under the most common definition, 43.2% of general surgery residents reported burnout symptoms; subtle changes in the definition of burnout resulted in prevalence estimates that ranged from 3.2% to 91.4% [52]. These findings do not support conclusions about the prevalence of burnout among physicians and underscore the importance of developing a standard definition of burnout.

7.3.2 Response to the Awareness of Doctors’ Dysfunction The culture of clinical medicine expects physicians to “cope alone.” Therefore, they fear that seeking medical help will be interpreted as a weakness. Denial of illness stems primarily from the urge to maintain an image of success, strength, and stability. Physicians find it difficult to abandon the role of caregiver and assume the role of patient. In addition, physicians have doubts about the significance of their symptoms and fear being labeled as hypochondriacs if they turn out to be healthy. As a result, physicians resort to self-diagnosis and self-treatment or seek advice from close friends in the hallways of clinics and hospitals. For example, a survey of German general practitioners found that 68% were self-diagnosed, 60% were self-­ treated, and only 19% were registered as patients with a general practitioner [53]. In

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particular, physicians in mental health crises and alcohol or drug abusers tend to deny their condition and believe in their ability to self-treat their addiction. Having devoted about a third of his/her life to preparing for practice, a physician may be unwilling to admit to a mismatch between clinical reality and his/her expectations. Denial may also be based on prejudice against mental illness. Consequently, many clinicians reject any offer of help and create a bond of silence for those around them.

7.3.3 Dealing with Doctors’ Dysfunction The medical profession has a responsibility to prevent harm resulting from physician dysfunction and to provide programs for its treatment. Physicians should be aware of the occupational risks posed by workload, anxiety, access to medications, and depression. They should also be aware of their tendency to self-medicate health problems and of ways to get help. Foreign graduates deserve special attention. They struggle to adjust, learn a language, and get a license; they endure the humiliation of failing the exam; and when they do succeed, they often have to work in a different profession than the one they once specialized in. Barriers that prevent impaired physicians from seeking help include fear of stigma and professional and economic consequences of diagnosis [42]. Addressing physician dysfunction requires eliminating the stigma associated with mental illness and illness in general and raising awareness that mentally ill physicians deserve as much compassion and support as any other patient. Physicians should politely and gently refrain from any attempt by patients in general, and colleagues in particular, to obtain medical advice in a non-binding “corridor.” One may respond to such a request by saying “I am not sure I can give you an answer to your question right now. However, let us go to my office to discuss the problem and at the same time I can examine you.” Care must be taken to examine the sick physician and to provide immediate and effective treatment, fully involving the patient in clinical decisions and seeking a rapid return to clinical activity. In California, a 1980 law offered physicians the option of receiving rehabilitation treatment funded by the Health Care Quality Assurance Board while providing immediate response, individualized care, and confidentiality. An evaluation of the first two and a half years of the program found that 109 of the 117 physicians were able to continue their clinical work while receiving rehab [54]. Similarly, a 2019 position paper from the American College of Physicians outlines principles that should guide the response of colleagues to physician impairment. It recommends that, first, an impaired physician should be rehabilitated and reintegrated into the practice of medicine whenever possible without compromising patient safety; second, physicians must seek help if they are unable to provide safe care; and third, when identifying colleagues who may be impaired, physicians should act out of collegial concern as well as ethical and legal guidelines that mandate reporting of behavior that puts patients at risk [55].

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A 2021 review found that about three-quarters of health professionals with substance abuse who participated in monitoring programs were abstinent and maintained this for up to 8  years. However, none of the studies reviewed used a randomized control trial or quasi-experimental design, and the observational design of the studies did not allow clear conclusions about the effectiveness of monitoring programs for health professionals with substance use disorders [56]. Nevertheless, it is clear that physicians’ health should be monitored at regular intervals, much like the fitness of drivers and pilots, and that physicians would benefit from medical surveillance throughout their careers. Therefore, medical facilities in the USA need to have a framework for treating addiction in physicians, educate their staff about their policies on addiction and disorders, establish an orderly process for referral to counseling, and encourage those who need rehab treatment to seek it.

7.4 Quality Assurance of Healthcare1 Health care is evaluated in terms of structure (facilities and organization), process (efficiency, cost-effectiveness), and outcomes (mortality, adverse events) [57, 58]. Quality assurance can be viewed as a sequence of identifying deficiencies in any of these three components, implementing corrective actions, and evaluating their consequences. Deficiencies may be identified by patients, physicians, and audits of care. Patient surveys indicate that most respondents are satisfied with their health care. However, they do not provide insight into why a minority of patients are not. It would be more informative to express patient survey results in terms of the proportion who are dissatisfied and to add questions such as “Was there anything that bothered you during your care?” or “Do you have any suggestions for improving our service?” Deficiencies in health care can be identified by physicians. Questions such as “What are the main barriers to improving your service?” or “What are you doing now that you could do better?” can identify processes such as communication failures or equipment needs. Such questions, especially when coupled with a request to find a solution, are an incentive for stakeholders to work together.

7.4.1 Physicians’ Attitudes to Quality Assurance of Healthcare When quality assurance was introduced in health care in the 1990s, physicians reacted with “skepticism or simply disinterest” [59]. There are several plausible reasons for this attitude. First, physicians perceive quality assurance as a threat. The  Parts of this section were published in: Benbassat J, Taragin M. What is adequate health care and how can quality of care be improved? Int J Health Care Qual Assur Inc Leadersh Health Serv. 1998;11:58–64. With  permission from Emerald. 1

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prevailing culture in clinical education is one of perfectionism. As I mentioned earlier, the conflict between this culture and the awareness of one’s inadequacy can lead to anxiety and reluctance to be held accountable by lay institutions. Second, physicians are unsure why quality assurance is necessary (to improve cost-effectiveness? to respond to public demand? to avoid lawsuits? because we care?), where to look for it (individual performance? health system performance?), and how to achieve it (retraining? Elimination of “bad apples”? Changes in health care delivery?). On the one hand, physicians are encouraged to report medical errors and investigate why the error occurred. On the other hand, however, this approach is at odds with current societal norms, which seem to assume that all errors are preventable and blameworthy and that only incompetent physicians make mistakes. Third, quality measures currently in use, such as hospital mortality, have been criticized for their limited reliability and validity. An example of the limited validity of a measure of the quality of care is the rate of hospital readmissions. It stands to reason that improved patient care during and after hospitalization would prevent readmissions. However, in about half of the studies, no association was found between readmissions and other measures of quality of care [60]. The lower the actual incidence of error, the higher the likelihood that current quality measures will misidentify appropriate clinical interventions as errors [61]. An ideal measure with 100% sensitivity and 100% specificity would correctly identify all medical errors. However, no diagnostic test is ideal. For example, a test with a sensitivity of 95% would detect 95 of 100 medical errors and identify the other five medical procedures as correct, even though they are incorrect. A test with a specificity of 95% would detect 95 out of 100 correct clinical interventions and identify the other five as errors, even though they are correct. Applying such a test to a sample of 10,000 clinical interventions with a true error rate of 1% (a total of 100 incorrect interventions) will identify 95 of these 100 as errors and the remaining 5 would be incorrectly identified as correct. Of the 9900 correct interventions, the test will falsely identify 495 as errors. In total, the test will identify 590 (5.9%) errors, or about six times higher than the true error rate [61]. The uncertain validity of quality indicators precludes their use in penalty decisions. Publication of the results of comparative studies is in and of itself punitive because it damages the reputation of institutions or physicians without due process of law. A reasonable compromise between the public’s right to know and the limited quality of quality information seems to make it available while emphasizing its limitations and the risk of jumping to conclusions. However, a finding that a particular medical service differs significantly from other services in terms of outcomes warrants feedback and, if necessary, remedial action. Finally, open disclosure of medical errors is critical to improving patient safety. However, fear of self-incrimination is a major barrier to such disclosure. Ideally, the focus of quality assurance would shift from finding the culprit for an adverse outcome to improving the clinical practice process. A 2008 survey of US faculty and residents found that most respondents believe that reporting errors improves the quality of patient care and would likely report a hypothetical error that resulted in harm to a patient. However, 16.9% of respondents admitted to not reporting a minor

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error, and 3.8% admitted to not reporting a major error [62]. A 2021 survey showed that barriers to reporting medical errors varied widely across centers, with fear of the consequences of such reporting and work climate/culture being the most commonly cited barriers [63].

7.4.2 Promoting Physician Support for Quality Assurance in Healthcare Promoting physician support for quality assurance in health care requires its evaluation by valid measures. The current approach to quality assurance is based primarily on outcome measures. These measures are intrusive, threatening, and of limited reliability and validity. Therefore, rather than focusing on outcomes of care, quality assurance has already today focused on processes, such as medication management systems, analysis of unexplained variation in practice, and implementation of clinical practice guidelines. Recognizing variation in processes and outcomes is fundamental to quality control, and industry experts have long developed quality improvement principles and techniques based on such variation. Audits of care have identified substantial geographic variation in clinical practice and hospital utilization. The identification of such differences has triggered several types of action. First, formal decision analysis can identify the intervention that maximizes utility. Second, simple feedback of data on practice patterns can reduce variation. Third, studies of practice variability have led to important findings about unintentional discrimination against patients. The most important types of effective interventions are clinical decision support systems [64]. Finding unexplained variability in practice requires agreement on the right process and translating that agreement into clinical guidelines. The advantage of such guidelines is that they provide quality control not only by detecting errors in practice but also errors of omission, such as failure to monitor patients with diabetes for ophthalmologic complications. As early as 1995, guidelines were increasingly used by attorneys in malpractice litigation to both exonerate and incriminate the defendant physician [65].

7.4.3 Promoting Physician Self-Disclosure of Errors A 2010 review found that both patients and healthcare professionals support the disclosure of adverse events to patients and their families [66]. However, surveys also found that physicians were much less likely than the general public to believe that quality of care was a problem. Physicians perceived several barriers to successful error reduction. These barriers were, first, fear of punishment, career-threatening disciplinary actions, and potential malpractice lawsuits and liability claims. Second,

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the lack of a definition of what constitutes errors. Finally, the lack of an error reporting system, the lack of information on how to report an error, and the lack of feedback to the reporter [67]. A prerequisite for reporting errors is a guarantee of impunity to those who commit errors and those who report them. This may require changes in attitudes, practice norms, and professional behavior. Encouraging physician self-report of errors would require physicians to accept that it is their responsibility to monitor their performance and to identify and report errors or deficiencies in the health care system. The position of individuals who commit errors and do not report them also needs to be clarified. For the system to be effective, individuals who do not report errors they notice must bear some risk for not reporting them. All of these conditions are unlikely to be ensured, and a 2003 editorial in the Journal of the American College of Surgeons asserted that reporting medical errors and near misses is a naïve, costly, and misguided goal [68].

References 1. Grober ED, Bohnen MA. Defining medical error. Can J Surg. 2005;48:39–44. 2. Graber ML.  The incidence of diagnostic error in medicine. BMJ Qual Saf. 2013;22(Suppl 2):ii21–7. 3. Lilford R, Edwards A, Girling A, Hofer T, Di Tanna GL, Petty J, Nicholl J. Inter-rater reliability of case-note audit: a systematic review. J Health Serv Res Policy. 2007;12:173–80. 4. Fischhoff B, Beyth R. “I knew it would happen” remembered probabilities of once-future things. Org Behav Hum Perf. 1975;13:1–16. 5. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse P, Weiler PC, Hiatt HH. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard medical practice study. N Engl J Med. 1991;324:370–6. 6. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H. The nature of adverse events in hospitalized patients. Results of the Harvard medical practice study. N Engl J Med. 1991;324:377–84. 7. Makary MA, Daniel M.  Medical error—the third leading cause of death in the US. BMJ. 2016;353:i2139. 8. Assiri GA, Shebl NA, Mahmoud MA, Aloudah N, Grant E, Aljadhey H, Sheikh A. What is the epidemiology of medication errors, error-related adverse events, and risk factors for errors in adults managed in community care contexts? A systematic review of the international literature. BMJ Open. 2018;8:e019101. 9. Mizrahi T.  Managing medical mistakes: ideology, insularity, and accountability among internists-­in-training. Soc Sci Med. 1984;19:135–46. 10. Hilfiker D. Facing our mistakes. N Engl J Med. 1984;310:118–22. 11. Waterman AD, Garbutt J, Hazel E, Dunagan WC, Levinson W, Fraser VJ, Gallagher TH. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf. 2007;33:467–76. 12. Christiansen JF, Levinson W, Dunn PM. The heart of the darkness: the impact of perceived mistakes on physicians. J Gen Intern Med. 1992;7:424–31. 13. Wu AW, Folkman S, McPhee SJ, Lo B.  Do house officers learn from their mistakes? JAMA. 1991;265:2089–94. 14. Wu AW, Folkman S, McPhee SJ, Lo B. How house officers cope with their mistakes. West J Med. 1993;15:565–9.

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15. Cook WR, Neff C. Attitudes of physicians to medical malpractice litigation in Canada. Medical Law. 1992;11:557–78. 16. Davenport OW.  A survey of obstetric practice activity in Florida. J Florida Med Assoc. 1983;70:293–6. 17. Blendon RJ, DesRoches CM, Brodie M, Benson JM, Rosen AB, Schneider E, Altman DE, Zapert K, Herrmann MJ, Steffenson AE.  Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347:1933–40. 18. Tversky A, Kahneman D. Causal schemas in judgments under uncertainty. Prog Soc Psychol. 2015;1:49–72. 19. Einhorn HJ. Accepting error to make less error. J Person Assess. 1986;50:387–95. 20. Sloan FA, Mergenhagen PM, Burfield WB, Bovbjerg RR, Hassan M.  Medical malpractice experience of physicians: predictable or haphazard? JAMA. 1989;262:3291–7. 21. Taragin MI, Martin K, Shapiro S, Trout R. Physician malpractice: does the past predict the future? J Gen Intern Med. 1995;10:550–6. 22. Singh R, Smeeton N, O'Brien TS.  Identifying underperforming surgeons. BJU Int. 2003;91:780–4. 23. Prior A, Vestergaard CH, Ribe AR, Sandbæk A, Bro F, Vedsted P, Smith S, Vestergaard M, Fenger-Grøn M.  Chronic care services and variation between Danish general practices: a nationwide cohort study. Br J Gen Pract. 2022;72:e285–92. 24. Sohn S, Moon S, Prokop LJ, Montori VM, Fan JW.  A scoping review of medical practice variation research within the informatics literature. Int J Med Inform. 2022;165:104833. 25. Berwick DM. Continuous improvement as an ideal in health care. N Engl J Med. 1989;320:53–6. 26. Zhang J, Patel VL, Johnson TR, Shortliffe EH. Toward an action-based taxonomy of human errors in medicine. Proceedings of the twenty-fourth annual conference of the cognitive science society; 2019. p. 970–975. 27. Beckman HB, Markakis KM, Suchman AL, Frankel-RM. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med. 1994;154:1365–70. 28. Hickson GB, Clayton EL, Entman SS. Obstetrician prior malpractice experience and patients’ satisfaction with care. JAMA. 1994;272:1583–7. 29. Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM.  Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;277:553–9. 30. Vincent C, Young M, Phillips A. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet. 1994;343:1609–13. 31. Leape LL. Error in medicine. JAMA. 1994;272:1851–7. 32. Studdert DM, Mello MM, Gawande AA, Gandhi TK, Kachalia A, Yoon C, Puopolo AL, Brennan TA. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med. 2006;354:2024–33. 33. Taragin MI, Willett LR, Wilczek AP, Trout R, Carson JL. The influence of standard of care and severity of injury on the medical malpractice claims. Ann Intern Med. 1992;117:780–4. 34. Ottosen MJ, Sedlock EW, Aigbe AO, Bell SK, Gallagher TH, Thomas EJ. Long-term impacts faced by patients and families after harmful healthcare events. J Patient Saf. 2021;17:e1145–51. 35. Prentice JC, Bell SK, Thomas EJ, Schneider EC, Weingart SN, Weissman JS, Schlesinger MJ.  Association of open communication and the emotional and behavioral impact of medical error on patients and families: a state-wide cross-sectional survey. BMJ Qual Saf. 2020;29:883–94. 36. Gallagher TH, Studdert D, Levinson W. Disclosing harmful medical errors to patients. N Engl J Med. 2007;356:2713–9. 37. Kachalia A, Sands K, Niel MV, Dodson S, Roche S, Novack V, Yitshak-Sade M, Folcarelli P, Benjamin EM, Woodward AC, Mello MM. Effects of a communication-and-resolution program on hospitals’ malpractice claims and costs. Health Aff. 2018;37:1836–44. 38. Giraldo P, Sato L, Castells X. The impact of incident disclosure behaviors on medical malpractice claims. J Patient Saf. 2020;16:e225–9.

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39. Frank E, Biola H, Burnett CA. Mortality rates and causes among US physicians. Am J Prev Med. 2000;19:155–9. 40. O’Dowd E, O’Connor P, Lydon S, Mongan O, Connolly F, Diskin C, McLoughlin A, Rabbitt L, McVicker L, Reid-McDermott B, Byrne D.  Stress, coping, and psychological resilience among physicians. BMC Health Serv Res. 2018;18:1–1. 41. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136:358–67. 42. Vayr F, Herin F, Jullian B, Soulat JM, Franchitto N. Barriers to seeking help for physicians with substance use disorder: a review. Drug Alcohol Depend. 2019;199:116–21. 43. Merlo LJ, Teitelbaum SA, Thompson K. Substance use disorders in physicians: epidemiology, clinical manifestations, identification, and engagement. UpToDate. Waltham, MA: UpToDate; 2018. 44. Besson A, Tarpin A, Flaudias V, Brousse G, Laporte C, Benson A, Navel V, Bouillon-Minois JB, Dutheil F. Smoking prevalence among physicians: a systematic review and meta-analysis. Int J Environ Res Public Health. 2021;18:13328. 45. Aasland OG, Ekeberg O, Schweder T. Suicide rates from 1960 to 1989 in Norwegian physicians compared with other educational groups. Soc Sci Med. 2001;52:259–65. 46. Duarte D, El-Hagrassy MM, TCE C, Gurgel W, Fregni F, Correa H. Male and female physician suicidality: a systematic review and meta-analysis. JAMA Psychiat. 2020;77:587–97. 47. Sjöberg L, Karlsson B, Atti AR, Skoog I, Fratiglioni L, Wang HX. Prevalence of depression: comparisons of different depression definitions in population-based samples of older adults. J Affect Disord. 2017;221:123–31. 48. Canu IG, Marca SC, Dell’Oro F, Balázs Á, Bergamaschi E, Besse C, Bianchi R, Bislimovska J, Bjelajac AK, Bugge M, Busneag CI. Harmonized definition of occupational burnout: a systematic review, semantic analysis, and Delphi consensus in 29 countries. Scand J Work Environ Health. 2021;47:95. 49. Maslach C, Schaufel WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397–422. 50. Tawfik DS, Profit J, Morgenthaler TI, Satele DV, Sinsky CA, Dyrbye LN, Tutty MA, West CP, Shanafelt TD. Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. Mayo Clin Proc. 2018;93:1571–80. 51. Yates SW. Physician stress and burnout. Am J Med. 2020;133:160–4. 52. Hewitt DB, Ellis RJ, Hu YY, Cheung EO, Moskowitz JT, Agarwal G, Bilimoria KY. Evaluating the association of multiple burnout definitions and thresholds with prevalence and outcomes. JAMA Surg. 2020;155:1043–9. 53. Schulz S, Einsle F, Schneider N, Wensing M, Gensichen J. Illness behavior of general practitioners—a cross-sectional survey. Occup Med. 2017;67:33–7. 54. Gualtieri AC, Cosentino JP, Becker JS. The California experience with the diversion program for impaired physicians. JAMA. 1983;249:226–9. 55. Candilis PJ, Kim DT, Sulmasy LS. Physician impairment and rehabilitation: reintegration into medical practice while ensuring patient safety: a position paper from the American College of Physicians. Ann Intern Med. 2019;170:871–9. 56. Geuijen PM, van den Broek SJ, Dijkstra BA, Kuppens JM, de Haan HA, de Jong CA, Schene AH, Atsma F, Schellekens AF. Success rates of monitoring for healthcare professionals with a substance use disorder: a meta-analysis. J Clin Med. 2021;10:264. 57. Brook RH, McGlynn EA, Cleary PD. Quality of care. Part 2 – measuring quality of care. N Engl J Med. 1996;335:966–70. 58. Donabedian A. The quality of care: how can it be managed? JAMA. 1988;260:1743–8. 59. Blumenthal D. Quality of care. Part 1 - what is it. N Engl J Med. 1996;335:891–4. 60. Benbassat J, Taragin M. Hospital readmissions as a measure of quality of health care: advantages and limitations. Arch Intern Med. 2000;160:1074–81. 61. Phelps CE. The methodological foundations of studies of the appropriateness of medical care. N Engl J Med. 1993;329:1241–5.

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62. Kaldjian LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi BH, Rosenthal GE.  Reporting medical errors to improve patient safety: a survey of physicians in teaching hospitals. Arch Intern Med. 2008;168:40–6. 63. Aljabari S, Kadhim Z. Common barriers to reporting medical errors. Sci World J. 2021;2021:1. 64. Mahadevaiah G, Rv P, Bermejo I, Jaffray D, Dekker A, Wee L. Artificial intelligence-based clinical decision support in modern medical physics: selection, acceptance, commissioning, and quality assurance. Med Phys. 2020;47:e228–35. 65. Hyams AL, Brandenburg JA, Lipsitz SR, Shapiro DW, Brennan TA. Practice guidelines and malpractice litigation: a two-way street. Ann Intern Med. 1995;122:450–5. 66. O'Connor E, Coates HM, Yardley IE, Wu AW. Disclosure of patient safety incidents: a comprehensive review. Int J Qual Health Care. 2010;22:371–9. 67. Schectman JM, Plews-Ogan ML. Physician perception of hospital safety and barriers to incident reporting. Jt Comm J Qual Patient Saf. 2006;32:337–43. 68. Andrus CH, Villasenor EG, Kettelle JB, Roth R, Sweeney AM, Matolo NM. “To err is human”: uniformly reporting medical errors and near misses, a naïve, costly, and misdirected goal. J Am Coll Surg. 2003;196:911–8.

Chapter 8

Shifts in the Structure of Health Care and Doctor–Society Relations

8.1 Introduction Medical professionalism is a set of values, behaviors, and relationships guided by a commitment to patients, colleagues, and the employing healthcare institution. All of these shape the organizational infrastructure and cultural environment of health care [1]. Since the 1970s, the rise in health care costs has led to a restructuring of medical practice to what is now known as “managed care” and since the 1980s, social scientists, bioethicists, and physicians have adopted the concept of the “social contract” to describe physician–society relationships [2]. This section will describe some of the features of managed care, its potential impact on public trust in physicians, and the relationship between physicians and the media.

8.2 Managed Care Managed care was originally intended to improve efficiency and reduce costs. Today, however, it also involves a transition from care provided by individual physicians to multi-professional teams. The physician is no longer the sole decision-­ maker; he or she must consider the patient’s preferences, the advice of consultants, and the policies of the employing institution. Managed care also involves monitoring and ensuring the quality of care through clinical guidelines. All of this requires a “bureaucracy” that has drawn criticism from both physicians and patients.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Benbassat, Teaching Professional Attitudes and Basic Clinical Skills to Medical Students, https://doi.org/10.1007/978-3-031-26542-6_8

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8.2.1 Bureaucracy: Definition and Negative Connotations1 The term bureaucracy refers to an organization run by a central mechanism. Over the years, however, this term has acquired several negative connotations. The first is burdensome paperwork that leaves no time for patient care. The second is the desire for self-protection. The bureaucrat fears criticism and tends to act defensively. The third is loyalty to the employer. A bureaucrat is suspected of caring only about his employer and being insensitive to the needs of the client he is supposed to serve. The fourth connotation of bureaucracy is adherence to procedures. While “professionalism” is defined as an orientation to outcomes, “bureaucracy” is defined as an orientation to process. At their extremes, a professional believes that the end justifies the means, while a bureaucrat adheres to process to the point of harming the outcomes this process is intended to achieve. All of these negative connotations seem to apply to managed care. Medical records are seen as paperwork that cuts into the time it takes to examine a patient. Malpractice litigation promotes “defensive” medicine. The calls to conserve resources cause physicians to feel divided between the patient and the employer. Finally, adherence to clinical guidelines is seen as limiting physician autonomy. It is no wonder, then, that physicians resist this new world that requires lots of paperwork, defensive medicine, a split loyalty between patient and institution, and a commitment to follow clinical guidelines. What are the desirable aspects of all these scourges?

8.2.2 Desirable Facets of Managed Care Until the 1970s, the purpose of documentation was to ensure continuity of care. At that time, the clinical record did not include explicit justification of the diagnosis or planned treatment. The adoption of the problem-oriented record in the 1970s required an addition of a summary of the data, an assessment consistent with the data, and a plan for further investigation, treatment, and patient education consistent with the assessment. This requirement opened the door to a new era in clinical teaching in which clinical decisions had to be justified rather than made intuitively. Initially, the problem-oriented medical record was criticized for limiting physicians’ freedom of expression and for requiring management decisions to be justified. Physicians complained that the additional paperwork would prevent appropriate patient care. Notwithstanding these arguments, physicians today agree on the benefits of the problem-oriented record. Documentation has evolved from a tool for communication between physicians to a tool for educating students and ensuring  Previous version of parts of this section were published in: Benbassat J.  Bureaucratic features of  managed care. Harefuah. 1998;134:412–15 (Hebrew). With permission from the Harefuah. 1

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the quality of care. The advantages of paperwork outweigh its disadvantages, and although it is time-consuming, we must accept it. The second connotation of bureaucracy, self-protection, is the desirable awareness of accountability and quality control. When I was in medical school, the concepts of accountability and quality control did not exist. Quality of care was the implicit responsibility of department heads. It was not until the 1970s that physicians realized that medical errors were common and not committed by a few incompetent physicians. Quality control of patient care can lead to undesirable defensive medicine; however, today physicians accept it as necessary, and since the 1970s, medicine has begun to implement methods to make the system as error-resistant as possible. As threatening as the term “quality control” may sound, we must come to terms with it. Managed care is felt to require doctors to split their loyalty between the patient and their employer in order to reduce medical costs. Patients’ medical needs are unlimited. Not so the resources for health care, and no society can meet all the medical needs of its members. Therefore, an equitable distribution of resources among patients is necessary. To save resources, the physician’s loyalty must be divided not between the patient and the employing institution, but between the patient and other patients. An important negative connotation of bureaucracy is adherence to process. Medicine is primarily outcome-based, and any attempt to impose practice guidelines is perceived as a threat to the profession. Yet medical standards allow for significant variation in clinical practice. These variations are not desirable. Uncertainty about the correct clinical intervention can be reduced by evaluating alternative options and choosing the one that leads to the best outcome. If two alternative therapeutic options lead to the same outcome, the one that is more favorable in terms of patient suffering and cost should be chosen. Therefore, in cases of unexplained differences in clinical practice, agreement on best practice must be reached and translated into clinical guidelines. Resistance to clinical guidelines is based first on concerns about suppressing the physician’s thinking and turning him into a computer-like automaton. I do not share this concern. A computer cannot replace an empathetic physician, and a reflective clinician will need to update and refresh clinical guidelines regularly, reviewing and adapting them to the innovations of medicine and local conditions. The second objection to clinical guidelines stems from the false impression that they are binding. They are not. No one would treat a patient with penicillin if he/she is allergic to that drug. Just as knowledge from textbooks should not be considered applicable to all patients, deviation from clinical guidelines in individual cases remains the responsibility of the physician. Clinical guidelines, like medical textbooks, should therefore be viewed as decision-making support; as a means of education that can accelerate the acquisition of clinical skills by medical students; as a safeguard against litigation, thereby avoiding defensive medicine; but most importantly, clinical guidelines will reduce unexplained variance in clinical practice. As much as our identity as professionals requires a focus on outcomes, we must come to terms with the need to follow procedures and professional rules.

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For all these reasons, the question is not whether we should accept the implications of managed care on documentation, control, allocation of resources, and the need to justify deviations from clinical guidelines, but how we can minimize their undesirable aspects. We need to find a way to keep proper documentation without getting lost in paperwork; to recognize errors without acting defensively, and above all—to deal with the need to divide our loyalties between the patient and other patients.

8.3 Fair Distribution of Healthcare Resources2 As recently as the 1960s, the call for a parsimonious use of medical resources would have been interpreted as a violation of the sanctity of life. But since the 1970s, the question “Is the price of saving a life too high?” is no longer rhetorical. The cost of medical care has led to a shift toward managed care, in which the physician must consider the constraints on the use of resources and thereby creating a seemingly irreconcilable tension between physicians’ obligations to individual patients and their employers. Although there is agreement on the need to limit resource use, it remains unclear how this need will be translated into policy. The uncertainty stems primarily from the ambiguity of guiding ethical principles and contested norms of clinical practice.

8.3.1 Fair Distribution of Resources: Ethical Dilemmas I shall use the terms “restriction,” “distribution,” “rationing,” and “allocation” of resources interchangeably to refer to the need to deny a patient a medical intervention deemed useful because of its cost. Rationing does not apply only to expensive biotechnologies. Physicians accept the need to divide their time equitably among patients, to use antibiotics sparingly to minimize the formation of resistant strains of bacteria, and to perform transplants only when organs are available. Time, antibiotics, and transplants are examples of resources that must be rationed because of their limited availability rather than their cost. Therefore, rationing of medical resources can be defined as the “denial of a medical intervention that is considered beneficial because it must be distributed equally to other patients.” Equitable distribution is guided by three principles: Commitment to all patients, equity, and utilitarianism. Commitment to all patients assigns physicians a dual role: to advocate for both individual patients and all patients while seeking to help as many patients as possible within available resources. Equity rejects discrimination against patients. Utilitarianism favors clinical interventions based on their  A previous version of parts of this section was published in: Benbassat J. Barriers to the fair allocation of health care resources. Harefuah. 2003;142:103–8 (Hebrew). With permission from Harefuah. 2

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effectiveness, such as antibiotics for meningitis, over those whose effectiveness is only partially proven, such as acupuncture for pain management. The implementation of these principles raises difficulties. Equity is incompatible with utilitarianism. Equity requires that every patient have an equal opportunity to benefit from health care services, regardless of the level of benefit [3], whereas utilitarianism prioritizes clinical interventions according to expected utility. The term “benefit” has been variously defined as “rescue”—saving a person’s life [4] or extending years of life [5]. Consider two candidates for heart transplantation. Under the first definition, they have equal priority; under the second, the younger patient comes first. If the benefit is measured by life extension, the older patient is disadvantaged. If it is measured in terms of rescue, limits must be defined in the treatment of terminally ill patients or neonatal intensive care units. Finally, one may question the need to favor interventions for specific patients over preventive interventions that may prolong the lives of unidentifiable patients [6]. The decision to use ventilators is often a life-and-death decision. An example of this is the shortage of ventilators that occurred in Italy during the COVID-19 pandemic. As recently as the 1970s, ventilator withdrawal was considered an act of killing. Today, such withdrawal is the most common cause of death in ICU patients and is considered an ethical and legal obligation when performed at the request of the patient or the patient’s representative. However, unilateral withdrawal of life support may be an intolerable burden for physicians. Therefore, some authors have advocated the use of triage committees to relieve bedside physicians of the responsibility for such decisions [7]. What should be the criteria for rationing decisions when demand for ventilators exceeds supply? A 2020 review found that there is significant variation among US guidelines in the models used to determine priority. Six states prioritize pregnant patients, medical staff, and younger patients. Most states use life expectancy and comorbidity to rank patients, and about half of the states exclude certain categories of patients from ventilatory support. A commonly accepted guideline for prioritizing patients for mechanical ventilation is based on their likelihood of survival to hospital discharge, as assessed by an objective measure of disease severity, and the presence or absence of comorbidities [8, 9]. However, the use of exclusion criteria may discriminate against populations, such as those of lower socioeconomic status who may have more comorbidities, those with disabilities, or children with metabolic abnormalities. Some states exclude patients with end-stage renal disease who are undergoing dialysis, even though they may otherwise live for years and be eligible for kidney transplantation [10]. Rescue of identifiable patients dominates opinion polls on priority for health resource allocation. However, it has been pointed out that despite its intuitive appeal, it would be prudent to set it aside in many cases involving futile interventions. On the one hand, there are anecdotal reports of recovery against all odds. On the other hand, performing futile interventions as a rescue attempt makes it difficult to identify the morally egregious features of wasting resources, fomenting false hopes, being seduced by technology, neglecting palliative care, or refusing to acknowledge the limits of medicine [11].

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The incompatibility between equity and utilitarianism raises other questions, such as whether we should provide expensive treatment (e.g., liver transplantation) to alcohol-dependent patients who will not benefit from treatment outcomes because of self-neglect [12]. Or whether a small benefit to the many (dental care) is preferable to a large benefit to the few (mechanical ventilation). According to the principle of equity, every patient has the right to equal access to medical care and attention. However, different patients have different needs: Is the higher use of health care services by poor populations unjustified, or is it due to a greater need for care? How can we ensure access to health services and address the needs of populations in remote areas?

8.3.2 Controversial Norms Several contentious norms have taken root in clinical practice in some countries with universal health insurance. The first is to give physicians the authority to decide how to allocate resources. On the one hand, decentralization of budget control has led to cost containment without affecting patient satisfaction [13] and infant mortality [14, 15]. On the other hand, decentralization has been reported to lead to higher health expenditures and infant mortality [16]. In addition, the potential for unintentional discrimination by physicians against older patients, ethnic minorities, and patients of low socioeconomic status [17] has raised concerns that physicians may be creating an unfair variance in their practice [18]. A second controversial norm is to offer medical services with unproven efficacy, such as complementary medicine, to meet patient preferences. On the one hand, this norm is consistent with the principle of respecting patient autonomy. On the other hand, a healthcare system cannot offer treatments of unproven efficacy while denying patients treatment modalities of proven efficacy because of their cost. At the top of the list of debatable norms is private care. "Private care" refers to the purchase of services that are not included in the package of benefits, whether in private or public institutions, whether paid for directly by the patient or by his or her supplementary or private insurance, or whether through grants to institutions or research projects. The provision of private services by physicians employed by public hospitals raises several ethical dilemmas. On the one hand, respect for patient autonomy requires that patients' willingness to pay for their care be respected, and some payment for private care flows to the hospital, benefiting all patients. On the other hand, the provision of private services by physicians employed by public hospitals violates equity. Equity requires that care be based on the needs of patients, regardless of their ability to pay or the likelihood of a benefit. The likelihood of benefit should certainly drive patient triage in emergencies. However, in non-emergency clinical settings equity prevails on utilitarianism (i.e., giving priority to those most likely to benefit from health care) and respect for patient autonomy (in choosing a private health care provider). Second, private care competes with public patient care for

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physicians’ time and infringes on the rights of other patients. Since the 1990s, efforts have been made to limit physicians’ work and give them time for rest, continuing education, and family. It could be argued that physicians can use their off-­ work time as they see fit and that caring for private patients is no different from keeping updated and leisure. This assertion ignores the relative importance of off-­ hours activities: keeping up to date is important for maintaining expertise; taking time for recreation, leisure, and family is important for well-being; caring for private patients is neither. Third, health care is a public service. Just as it would be unthinkable for police officers to work as private investigators after hours, private care by physicians employed by public hospitals can undermine patients’ trust in the health care system. Forth, private care in public hospitals can blur the lines between legal and illegal charges and degenerate into black medicine [19], with under-the-table payments for preferential patient care [20]. Finally, public hospitals where physicians can care for private patients do not provide a suitable learning environment for medical students. There is undisputed evidence that physicians unintentionally discriminate against patients [17]. However, a learning environment that tolerates role models who care for both private and public patients may also legitimize intentional discrimination against patients. Preferential treatment of some patients may elicit cynical attitudes in students and interfere with the development of their humanistic values. One way to preserve the benefits of private care while avoiding its negative consequences would be to separate the public and private care sectors. Just as a police officer can open a private detective agency only after leaving the police force, physicians can care for private patients or engage in other activities only after leaving public healthcare institutions. Physicians employed by public hospitals would be required to devote their time exclusively to the hospital. They would be prohibited from enjoying both the prestige of working in public hospitals, most of which are academic, and the income from private treatment. Hopefully, this will ensure an equitable distribution of physicians’ time between work, leisure, and continuing education.

8.3.3 The Need for a Policy of Rationing Resources The different attitudes toward the distribution of medical resources indicate the need for a policy of rationing. Yet it has been noted that “no country has yet designed a process for explicit rationing” [21], and as recently as 2021, a multinational survey of policymakers and researchers concluded that “[E]fforts to establish formal and explicit processes and rationales for decision-making in priority setting and resource allocation have been still rare” [22]. Decisions about baskets of benefits are usually based on mutual influences among ethicists, lawyers, administrators, and representatives of the public. Many countries use formal thresholds for cost-effectiveness for new treatments. A 2018

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systematic review identified 17 countries with cost-effectiveness threshold data and 13 countries with willingness-to-pay data per quality-adjusted life-year. Most cost-­ effectiveness thresholds were within the range recommended by WHO of one to three times gross domestic product per capita [5]. To be ethical, resource rationing policies must be responsive to consumer values. Public surveys in several countries using a variety of methods showed that the most important considerations in determining treatment priority were rescue, the prospect of recovery, and younger age [23]. A 2010 review found that 90% of respondents preferred that organ allocation be based on medical urgency, the severity of illness, and rescue; 70% of respondents preferred younger age, non-­alcoholics, and a longer waiting period, while 50% preferred registered donors and having dependents [24]. A 2018 Australian survey found that the severity of illness was the most important criterion, followed by medications for children and cancer patients. “Endof-life treatments” and “rare disease therapies” received the lowest priority [25]. A discussion among US public officials about chronic hepatitis C treatment in 2020 found that most favored a “sickest first” policy over a “first come, first served” policy [26]. Different groups in society have different values, and decisions about the allocation of medical resources based on population surveys can lead to discrimination against certain patients. For example, there is evidence that respondents older than 65  years prefer more egalitarian resource allocation than younger people [27]. Under the quality-adjusted life-years system, disabled patients may be unfairly discriminated against in healthcare resource allocation [28]. Public preferences in resource allocation for critically ill patients are significantly affected by minor changes in the formulation of the scenario presented [29] or in the presentation of the results of relevant studies [30]. For all these reasons, physicians should be partners in resource rationing decisions to ensure that the preferences of the majority do not conflict with the rights of the minority of patients, especially those from the weaker classes.

8.3.4 Implementing a Policy for Fair Allocation of Medical Resources The allocation of medical resources requires that patients be educated about the limitations in the basket of benefits both when they join the health insurance program and during medical treatment. I have already pointed out the dangers of decentralizing budget control and creating incentives for physicians to decide how to save [31]. The alternative to such incentives is a policy based on clinical guidelines that would provide physicians with up-to-date, evidence-based, or widely agreed-upon information. Clinical guidelines are designed to improve the quality of care, not to save medical resources. But sometimes medical care based on clinical guidelines is also the cheapest and saves unnecessary medical interventions. The better we can

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understand not only the disease but also how the patient perceives it, the more surprised we will be to find that some patients prefer cheaper treatment options. For example, terminally ill patients often prefer less rather than more treatment. In cases when the most effective drug is not included in the package of benefits because of its cost, physicians should remember that they are primarily the patients’ advocates. They should provide comprehensive information about the pros and cons of all therapeutic options, including those not included in the package of benefits. Once the information is provided, the physician and patient must accept the constraints on resource allocation and work together to find the optimal way to implement the desired treatment, including the possibility that the patient may be forced to self-fund the treatment. In cases where the physician and patient disagree about the desired treatment, physicians can use Pearson’s [18] approach. This approach begins with the physician’s justification for savings (“The treatment you prefer is good, but there are two reasons why I prefer a different treatment. First, it is effective. Second, it is cheaper, and we are all trying to save on medical expenses”), followed by stating that decisions about savings apply to everyone (“I would recommend the same treatment to every patient in your condition”); and finally, keeping a channel open for objections (“If you think my recommendation is unfair, you can get a second opinion or appeal directly to the registry appeals committee”) [18].

8.4 Trust in Medicine Trust in people or institutions is the expectation that they will protect the interests of the trustee when needed. Patient trust in individual physicians and institutions involves values and competence. Values refer to fidelity and honesty, while competence refers to the trusted party’s ability to provide expected services [32, 33]. Evidence suggests that trust in the health care system (hospitals, insurers, pharmaceutical companies) is not mediated by the trust in physicians [34].

8.4.1 Decline in Patient Confidence in Health Care Medicine today offers patients more effective interventions than in the past. It is more egalitarian and less paternalistic, its decisions are more transparent and allow patients to participate in their care, and the monitoring of clinical practice allows for more effective quality control. All of this should have increased public confidence in physicians. But the opposite is true. In 1966, nearly three-quarters (73%) of Americans said they had confidence in physicians. In 2012, only 34% held this view [35]. A 2021 survey of cancer patients in the USA showed that trust scores were lower among white patients (36.4) than Hispanic (40.5) and black (38.2) patients [36].

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Despite declining trust in institutions, most respondents in the USA say they have confidence in the physicians who treat them. Patients eventually seem to find a physician who meets their expectations. In European countries, the decline in public trust in health care has been accompanied by declines in trust in other institutions, such as education or government [37]. This is particularly likely in countries where the health care system is funded by the government. In these countries, the trustworthiness of physicians is a critical factor in people’s opinions of the public sector in general [33]. This is worrisome because trust is the “glue” that maintains the functioning of society by preventing suspicion and excessive legislation. The erosion of trust leads to outside intervention, such as lawsuits, and one of the challenges of modern society is to distinguish between reasonable criticism of its institutions and destructive mistrust.

8.4.2 Possible Reasons for the Decline of Trust in Health In-depth interviews with US patients revealed that their trust in physicians is ambivalent and characterized by uncertainty, fear, and a sense of risk. However, in the case of serious illness, this feeling is replaced by emotional dependence [38]. Patient trust depends largely on the physician’s communication skills, concern for the patient’s well-being, empathy, attentiveness, and, above all, the extent to which he or she meets patients’ expectations to stand by them, represent them, and defend their interests against health insurers. Patients attach great importance to the belief that the physician does not make impartial decisions, but works to protect their interests. Possible reasons for patients’ diminishing trust in health care services include, first, the seemingly dual obligation to patients and the need to balance the institution’s budget. Second, patients have high expectations: Hopes arising from reports of medical breakthroughs lead patients to feel cheated in the event of medical failure. Third, there is a recent trend in society to distrust science [36]. Finally, health services worldwide have been in a period of restructuring since the 1970s. Organizational change creates a sense of uncertainty about what patients are entitled to and what they can expect. Hopefully, as the public adjusts to the implementation of the new standards and as cracks in service delivery are mended, public confidence in medical institutions will grow [39]. Distrustful patients are less satisfied with their health care overall and have shorter relationships with their physicians; they have poorer health status, lower medication adherence, and a tendency to ignore recommendations to change their lifestyle and avoid risky behaviors [40]. Caution should be exercised in inferring cause-and-effect relationships from these associations. Patients’ distrust sometimes manifests itself in angry criticism of resource scarcity and rationing policies. Sometimes this criticism is exaggerated and even wrong. But as recently as 2021, it was claimed that three premises about patient trust were false. The first was that lack of trust is something that needs to be changed, not something that healthcare

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providers need to change. Second, the assumption that physicians are trustworthy is inconsistent with the history of unethical research and practices in public health. And third, the assumption that all patients have the same access to care and receive the same quality of care as other patients (e.g., white Americans) is unfounded [41].

8.4.3 Impact of Changes in the Status of the Physician in Society Social scientists have proposed two views on the impact of changes in the status of medicine. One school of thought sees an erosion of the power of the profession as a result of “proletarianization” and “de-professionalization” [42]. Proletarianization is the diminution of physicians’ autonomy through the transition from independent to salaried status, the shaping of their relationships with patients through the Patient Rights Act, and the restriction of their use of health care resources [43]. De-professionalization is the reduction of physicians’ monopoly on medical information as a result of patient access to information, transparency of clinical thinking, and increasing sophistication of the population. The second sociological school [44, 45] argues that medicine has not lost its power: Its influence has increased as the cost of health care services has increased. What has changed is the hierarchy of the profession. Until the 1970s, the elites were clinicians and heads of hospital departments. That is over: today they are proletarians. The new elite includes medical managers (health insurers and hospitals), physician representatives (heads of professional associations), and academics [43]. The two schools may be complementary: proletarianization and de-­ professionalization refer to individual clinicians, while the second school describes the organizational changes in the profession. Clinicians may have lost their autonomy and forfeited sole decision-maker status, but the profession has retained its status and authority. There are also similarities between the predictions of the two schools. Proletarianization holds a continued erosion of physician power. However, even the second school does not rule out the possibility that the status of the medical profession will be weakened if there is a rift between the new elites and rank clinicians. Such a rift may occur if clinicians no longer see the elites as part of the medical profession and no longer treat them as colleagues.

8.5 Medicine and the Media The media shape and reflect public opinion and provide a platform for debate on controversial issues such as quality control of clinical practice and informed use of health services [46]. In some countries, they have played a role in the transition from medical paternalism to respect for patient autonomy and in supporting the right of a terminally ill person to refuse treatment. The most important effect of the

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media, however, has been to influence health by disseminating information about the dangers of smoking, unprotected sex, obesity, addiction, and sedentary lifestyles [47]. Media coverage requires the translation of complex information into language that can be understood by all. This is sometimes difficult to achieve. In many cases, media reporters work under time constraints; their stories are subject to pressure from interested parties and editors who may omit important parts. This section addresses the goals of reporting on medical issues, the responsibilities of physicians in providing information to the media, and the biases that can thwart that information. The term “misinformation” refers to information that is inadvertently false and given without the intent to cause harm, while “disinformation” refers to false information that is knowingly created and disseminated.

8.5.1 Media Coverage of Medical Issues: Targets The main challenge for the news media is to provide a platform for public debate about health care and a fair presentation of alternative views while avoiding bias. For example, newspaper coverage of the debate over genetically modified foods in the UK in 2004 was criticized for focusing on political arguments rather than science and technology [48]. A second role of the media is to facilitate the use of information about healthcare quality and choice among providers by reporting on comparative surveys of surgery-specific outcomes and the range of services offered by different health insurers. However, a 2020 survey found that 73% of patients did not know they had access to reports on surgery-specific outcomes, and most of those who did know indicated that these reports did not influence their choice of the surgeon [49]. The use of information about services offered by different health plans depends on an understanding of quality indicators, and evidence suggests that beneficiaries with inadequate health literacy are at risk of choosing plans that do not meet their health needs [50]. The third role of the media is to report on medical innovations. However, these reports often come from press releases from universities, medical centers, and scientific journals that can play up the importance of their findings. The primary sources of such exaggerations are the press releases themselves, not the journalists [51, 52], and both scientists and journalists violate the tenets of their professions when they prematurely release clinical research findings to the public and allow physicians to express their hypotheses unchallenged [53]. A 2014 review of medical news in the USA rated most reports unsatisfactory. Drugs, medical devices, and other interventions were generally portrayed positively, while potential harms were downplayed and costs ignored [54]. A survey of 75 widely circulated newspapers from 25 countries found that 51 (68%) of them made at least one comparison of COVID-19 cases or deaths between regions of their country or between countries. However, only 37% adjusted data for population size [55]. Another study found an association between measles/mumps/rubella

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vaccination and autism. Although the study was later retracted, its publication led to a years-long decline in childhood vaccination rates [56]. One study was described in the Institute’s press release as a “historic discovery [that] has the potential to prevent miscarriages,” although it was not conducted in humans and only examined the effects of niacin supplementation in mice [57]. Media reports tend to highlight bad news, serious diseases, and innovative treatments and ignore more common problems [58]. Reports have also been criticized for promoting treatments with unproven efficacy, presenting biased data on diagnostic methods, and raising false hopes or unnecessary fears [59]. A 2019 study used in-depth interviews, focus groups, and a survey of medical experts in 21 countries to identify issues experts face when interacting with the media. The study found that barriers to improving the quality of medical reporting in the media include deadlines for journalists and the level of medical knowledge [60]. To improve the quality of medical reporting, health correspondents need not only the motivation to serve the public but also professional training. Since their sources of information are physicians and scientific publications, they need to be able to assess the reliability of these sources and distinguish between different levels of evidence. Social media platforms provide opportunities for people to communicate; however, they also enable misinformation. A 2019 study found that misinformation is prevalent online and is often more popular than accurate information. Disseminators of misinformation were mostly individuals with no official or institutional affiliation. Their narratives were characterized by personal, negative, and opinionated tones and often triggered fear and distrust of institutions [61]. In some cases, the researchers who provided the information claimed that they were not properly cited. This claim does not absolve them of responsibility for the harm that may result. Therefore, it is essential to improve the quality of media coverage through closer collaboration between reporters and scientists [62]. On the surface, such collaboration is difficult. Scientific thinking emphasizes uncertainty and doubt; journalists seek a confrontation between right and wrong. Despite their obligation to compare information from different sources, some reporters uncritically provide a platform for individual physicians to disseminate controversial opinions and for patients to describe their tragedies. This precludes factual debate because it is impossible to confront a suffering patient, even one who makes claims that society cannot meet, or a physician who is passionately critical of healthcare institutions, even one whose claims are based on personal experience rather than controlled observations.

8.5.2 Media Coverage of Medical Issues: Biases In 1997, Schumann and Wilkes identified four causes of misleading media reporting: a tendency to sensationalize, conflicts of interest, failure to follow-up on reported information, and disregard for important medical issues. Sensational

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reporting is not just the domain of journalists. Researchers also contribute to this tendency by sometimes exaggerating the importance of their findings. Media coverage can be biased by conflicts of interest: objectivity sometimes conflicts with the pursuit of self-publication, financial gain, obtaining research funding, and promoting the reputation of the institution. Media coverage can also be distorted by researchers’ failure to release to the press the results of follow-up studies that challenge their earlier press releases. For example, the press reported an association between coffee drinking and pancreatic cancer but did not report subsequent studies that failed to confirm the association [63]. Hopefully, health reporters will be aware of this bias and attempt to reduce its impact by interviewing independent researchers and by relying on written sources of information rather than the opinions of individual physicians.

8.5.3 Medical Recommendations in the Media The core of a patient-initiated doctor–patient encounter is the assumption that the doctor will do his or her best. If a patient does not respond to the usual treatment, the physician may offer another treatment whose efficacy is only partially proven. Conversely, making unsolicited medical recommendations through the media is tantamount to a physician-initiated relationship with the patient. In such cases, the recommendation requires a more solid evidentiary basis. If treatment is recommended (e.g., statins for hyperlipidemia) or if tests are recommended for early detection of a disease (e.g., mammography), then the benefit of the treatment or early treatment of the disease must be proven beyond a reasonable doubt. There is considerable variation in the reliability and validity of the evidence for a given medical recommendation, and the public is largely unaware of this variation. Presenting the degree of uncertainty is a complex task that is challenging for professionals and journalists alike. For example, when reporting on screening tests, the media seem to focus more on the benefits than the harms. One study of media coverage found that 63% of reports focused only on the benefits and only 37% of reports mentioned the harms. Overdiagnosis, the biggest harm of screening tests, was mentioned in only 5% of reports. As many as 55% of all reports included the views of commentators with conflicts of interest, but only 12% disclosed these conflicts [64]. In some cases, it is possible to influence the public decision to accept or reject a particular medical recommendation by the way the data are presented. Stating that regular mammograms in women reduce breast cancer mortality by 15–20% (i.e., presenting the data as a relative benefit) creates a positive impression. It is a different story when the same data are presented as an absolute benefit, namely that regular mammograms will save the lives of 1 in 2000 women aged 40–49 years, 1 in 1000 women aged 50–59 years, and 4 in 1000 women aged 60–69 years over the next 10 years [65].

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Today, there is consensus that the effectiveness of mammograms justifies their performance in women aged 50–69 years [66]. However, the value of mammograms in women aged 40–49 years remains uncertain. A 2001 review of US press coverage of this uncertainty found that the press tended to present the opinions of oncologists, radiologists, and policymakers who consistently favored mammography at ages 40–49 and to ignore the opinions of epidemiologists and government officials who opposed it [67]. Journalists rely on information from clinicians and researchers. The advantage of clinicians is that they reflect the views of those at the forefront of medical practice. However, sometimes their positions are confounded by personal clinical impressions and by the way data are presented in scientific articles (relative versus absolute benefits). Therefore, it is important to obtain information from epidemiology experts, not just clinicians. Epidemiologists are best qualified to evaluate the risk– benefit ratio of a particular intervention and have better tools for the specific evaluation of diagnostic or therapeutic interventions.

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37. Foster C, Frieden J. Crisis of trust: socio-economic determinants of Europeans’ confidence in government. Eur Union Polit. 2017;18:511–35. 38. Lupton D. Your life in their hands: trust in the medical encounter. In: James V, Gabe J, editors. Health and the sociology of emotions. Oxford: Blackwell; 1996. p. 157–72. 39. Mechanic D. Physicians and patients in transition. Hast Cent Rep. 1985;15:9–12. 40. O'Malley AS, Sheppard VB, Schwartz M, Mandelblatt J. The role of trust in the use of preventive services among low-income African-American women. Prev Med. 2004;38:777–85. 41. Griffith DM, Bergner EM, Fair AS, Wilkins CH. Using mistrust, distrust, and low trust precisely in medical care and medical research advances health equity. Am J Prev Med. 2021;60:442–5. 42. McKinley JB, Stoeckle JD.  In: Salmon JW, editor. Corporatization and the social transformation of doctoring. In: the corporate transformation of health care: issues and directions. Amityville, NY: Baywood Publishing; 1990. 43. Light D, Levine S. The changing character of the medical profession: a theoretical overview. Manag Health Care. 2019;8:301–24. 44. Freidson E. The reorganization of the medical profession. Med Care Rev. 1985;42(1):1–35. 45. Mechanic D.  Sources of countervailing power in medicine. J Health Polit Policy Law. 1991;16:485–98. 46. Grilli R, Freemantle N, Minozzi S, Domenigheai G, Finer D. Mass media interventions: effects on health services utilization (Cochrane Review). In: The Cochrane Library, issue 2, 2001. Oxford: Update Software. 47. Sowden AJ, Arblaster L. Mass media interventions for preventing smoking in young people. Cochrane Database Syst Rev. 2000;2:CD001006. 48. Augoustinos M, Crabb S, Shepherd R. Genetically modified food in the news: media representations of the GM debate in the UK. Public Underst Sci. 2010;19:98–114. 49. Lam K, Nazarian S, Gadi N, Hakky S, Moorthy K, Tsironis C, Ahmed A, Kinross JM, Purkayastha S. Patient perspectives on surgeon-specific outcome reports in bariatric surgery. Surg Obes Relat Dis. 2022;18:704–13. 50. Braun RT, Barnes AJ, Hanoch Y, Federman AD. Health literacy and plan choice: implications for Medicare managed care. Health Lit Res Pract. 2018;2:e40–54. 51. Dempster G.  The communication of scientific research in news media: contemporary challenges and opportunities. J Sci Commun. 2020;19:C06. 52. Sumner P, Vivian-Griffiths S, Boivin J, Williams A, Bott L, Adams R, Venetis CA, Whelan L, Hughes B, Chambers CD. Exaggerations and caveats in press releases and health-related science news. PLoS One. 2016;11:e0168217. 53. Johnson T. Medicine and the media. N Engl J Med. 1998;339:87–92. 54. Schwitzer G. A guide to reading health care news stories. JAMA Intern Med. 2014;174:1183–6. 55. Hammes LS, Rossi AP, Pedrotti LG, Pitrez PM, Mutlaq MP, Rosa RG. Is the press properly presenting the epidemiological data on COVID-19? An analysis of newspapers from 25 countries. J Public Health Policy. 2021;42:359–72. 56. Godlee F, Smith J, Marcovitch H. Wakefield’s article linking MMR vaccine and autism was fraudulent. BMJ. 2011;342:c7452. 57. Dempster G, Sutherland G, Keogh L. Scientific research in news media: a case study of misrepresentation, sensationalism and harmful recommendations. J Sci Commun. 2022;21:A06. 58. Bomlitz LJ, Brezis M.  Misrepresentation of health risks by mass media. J Public Health. 2008;30:202–4. 59. Schwitzer G.  How do US journalists cover treatments, tests, products, and procedures? An evaluation of 500 stories. PLoS Med. 2008;5:e95. 60. Larsson A, Appel S, Sundberg CJ, Rosenqvist M. Medicine, and the media: medical experts’ problems and solutions while working with journalists. PLoS One. 2019;14:e0220897. 61. Wang Y, McKee M, Torbica A, Stuckler D.  Systematic literature review on the spread of health-related misinformation on social media. Soc Sci Med. 2019;240:112552. 62. Nelkin D.  An uneasy relationship: the tensions between medicine and the media. Lancet. 1996;347:1600–3.

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63. Shuchman M, Wilkes MS. Medical scientists, and health news reporting: a case of miscommunication. Ann Intern Med. 1997;126:976–82. 64. Doherty TS, Carroll AE. Media representation of the benefits and harms of early testing: implications for public health. JAMA Intern Med. 2021;181:868–9. 65. Pace LE, Keating NL. A systematic assessment of benefits and risks to guide breast cancer screening decisions. JAMA. 2014;311:1327–35. 66. Myers ER, Moorman P, Gierisch JM, Havrilesky LJ, Grimm LJ, Ghate S, Davidson B, Mongtomery RC, Crowley MJ, McCrory DC, Kendrick A. Benefits and harms of breast cancer screening: a systematic review. JAMA. 2015;314:1615–34. 67. Wells J, Marshall P, Crowley B, Dickersin K. Newspaper reporting of screening mammography. Ann Intern Med. 2001;135:1029–37.

Chapter 9

Changes in Medical Education

9.1 Ongoing Changes in Medical Education 9.1.1 From Memorization to Self-Directed Learning and Information Management Advances in information technology, smartphone applications, and e-learning have facilitated self-directed learning [1]. Instead of lecturing, instructors increasingly ask their students to learn outside of class and use class time for specific instructional activities (“flipped classrooms”). The COVID-19 pandemic was a catalyst for the promotion of distance learning, e-learning, novel student assessment methods, and Zoom instruction [2]. Technology-enhanced teaching methods such as virtual simulations will likely be part of medical education after COVID [3]. Online teaching via videoconferencing and virtual classrooms does not appear to differ in effectiveness from traditional education and has higher satisfaction rates [4]. Online education may also be more cost-effective than classroom learning because faculty do not have to relocate and more individuals from different institutions can participate in courses [5]. Interactive computer simulations of clinical scenarios improve student learning motivation, knowledge application, assessment, and clinical reasoning. Learners engage with content designed to match the level of difficulty to students’ abilities and receive individualized feedback [6]. Distance learning provides learners with control over the content, sequence, and pace of learning. It promotes individualized (adaptive) and collaborative learning and transforms the role of the tutor from a distributor of content to a facilitator of learning and assessor of skills [7]. Therefore, it appears that face-to-face instruction will be limited to topics that require student–tutor contacts, such as patient interactions and hands-on practice. The challenge in implementing online teaching is to overcome the barriers to its development, namely lack of time, inadequate infrastructure, lack of institutional policies and support, and negative attitudes among stakeholders [8]. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Benbassat, Teaching Professional Attitudes and Basic Clinical Skills to Medical Students, https://doi.org/10.1007/978-3-031-26542-6_9

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9.1.2 From Knowledge to Competency-Based Education As recently as the 2010s, medical school graduates were claimed to have inadequate skills in teamwork, information management [9], and basic surgical procedures [10]. As a result, medical schools are increasingly emphasizing competency-based education that focuses on what students can do rather than what they know [11]. Medical educators accept that learners may progress at different rates. Rather than requiring learners to spend a predefined amount of time on a unit of study, future medical educators will provide learners with clear goals and allow them to self-­direct their learning [12]. Skills such as bladder drainage, taking a blood sample, first aid, and resuscitation are already taught in skills labs. Anatomy courses teach students to interpret imaging studies; simulators are used to teach emergency interventions; and virtual patients are used to address specific clinical encounters. Students must demonstrate that they have achieved a certain standard of performance before being admitted to the clerkships. Aside from its contribution to patient safety, simulation-based teaching appears to be superior to traditional clinical education in skill acquisition and is associated with better patient outcomes compared to no intervention and non-­ simulation-­based teaching [13].

9.1.3 From the Biomedical Model to Engel’s Bio-Psycho-­Social Model for Clinical Reasoning and Practice The development of biotechnology has raised concerns that it may undermine the humanistic attitudes of physicians. In response to these concerns, most medical schools offer their students teaching programs in the social and behavioral sciences. However, the implementation of these programs encounters the difficulties I described in Sect. 6. I suggest that teaching the behavioral sciences should focus on the gap between ideal patient care and reality. While this gap is inevitable, it can be narrowed, and teaching should encourage reflection on its causes. This can be done through small group discussions of specific cases, such as when a physician’s behavior did not meet appropriate standards. The goal of such discussions would be to identify the factors that promote or inhibit inappropriate behavior and to raise awareness that none of us is immune from misjudgment or unacceptable behavior.

9.1.4 From Intuitive to Analytic Decision-Making In many medical schools today, students are taught how to conduct a hypothesis-­ driven patient examination, how to use Bayes’ theorem in making diagnostic inferences, and how to apply evidence-based medicine in evaluating information. It is

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hoped that these teaching activities will help students move from the determinism of basic science to probabilistic clinical thinking and will support students’ development of tolerance of uncertainty. The learning environment that can provide such support can be inferred from Perry’s observation that the transition to multiplicity began when students encountered teachers who responded with “I do not know.” Therefore, I concur with the call for clinical tutors to make their reasoning visible, help students understand that doubt is not an expression of incompetence but rather part of the nature of clinical practice, and provide opportunities for students to practice their clinical reasoning in an environment where they are trusted and supported to change their performance.

9.1.5 From Hospital to Community Settings Clinical education follows the tradition of “bedside” teaching and exposes medical students to inpatients. Until the 1960s, the lack of consultation services in the community made it necessary to refer patients with a variety of diseases to hospitals for second opinions. Since then, however, the development of community consultation services has resulted in a hospital population limited primarily to patients requiring crisis intervention. As a result, medical students may now graduate without ever having seen patients with a range of nonacute conditions, such as hypothyroidism, peptic ulcers, uncomplicated rheumatoid arthritis, influenza, and tonsillitis, who are treated in community clinics. Medical students also do not see chronic patients treated at home, hospice, and nursing facilities who come to the hospital only for an acute event. The implicit assumption of restricting medical education to hospitals views clinical problem-solving as a general skill that, once acquired, can be applied in other settings. This assumption is at odds with evidence that competence is subject-­ specific rather than general [14]. The constraints of the hospital learning environment have therefore led medical schools, first, to use virtual patients and, second, to replace traditional block clerkships in hospital departments with 6–12 month rounds in a single community clinic. A student in community clinics is exposed to common diseases and follows patients through their entire experience, including hospitalizations. Continuity of student–patient relationships fosters empathy more than short-term relationships with inpatients. Student–staff relationships allow for continuity in education, responsiveness to learning needs, and guidance in clinical reasoning [15]. Replacing block clerkships in the hospital with longitudinal clerkships in the outpatient setting enhances students’ clinical reasoning not only by exposing them to a broader range of diseases but also by giving them insight into the thinking and doubts of their tutors [16]. Finally, if the student–tutor relationship shapes the student’s future relationship with their patients [17, 18], then the setting in clinics is likely to provide an environment in which the student is accepted as a trusted colleague.

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Outcome studies have shown that the performance of graduates of longitudinal primary care clerkships was equivalent to, and in some cases better than, that of their peers who completed block clerkships [19, 20]. Graduates of longitudinal clerkships were better in the areas of patient-centered communication, understanding psychosocial contributions to medicine, responsibility to patients, and dealing with ethical dilemmas. Students felt supported by the continuity of the student–tutor relationship [21]. The only longitudinal study I am aware of suggests that students in community clinics are better able to cope with uncertainty than students in traditional inpatient rotations [22]. I believe that future studies will further compare the outcomes of the two types of placements and examine whether training in community settings also improves students’ professionalism, moral judgment, and reflective skills.

9.1.6 External Reviews of Teaching and Accreditation of Medical Schools Most countries attempt to improve the quality of their undergraduate programs through periodic external reviews to ensure that medical schools meet certain accreditation standards. However, accreditation of medical schools has still to overcome two types of difficulties. First, accreditation visits in North America occur at 4–10 year intervals, so problems are not immediately identified when they occur. Therefore, since 2015, the Standards of Medical Education have required medical schools to continuously monitor their teaching programs [23]. It is my impression that most medical schools have not yet complied with this requirement. Second, despite the agreement that accreditation standards are not equally important, there is no uniform taxonomy of standards [24]. Therefore, it is uncertain whether ongoing monitoring should be guided by all or only selected accreditation standards and, if the latter, how they should be selected. An agreed taxonomy of standards for accreditation will prioritize standards by importance and remove this uncertainty.

9.1.7 Quality Assurance of Patient Care Quality assurance and patient safety programs have been offered at medical schools since the 1990s, and a 2010 systematic review found that they were well received. Most of them resulted in improved knowledge, and some were reported to improve processes of care [25]. Such educational interventions are expected to achieve, first, tolerance for and constructive management of errors and, second, admission of and open reporting of errors for their analysis with a view to their prevention.

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The challenge for medical educators is to find ways to overcome the cognitive, cultural, and emotional barriers to the implementation of such programs. The main cognitive barrier is the unconfirmed assumption that only incompetent physicians make errors. The main cultural barrier to acceptance of medical errors is their exclusion from discussions at teaching sites and denial of uncertainty [25]. In the late 1970s, it was felt that physicians are “trained to be certain” by adhering to a deterministic school of thought [26]. A 1992 literature review stated, “Strong defenses against criticism and denial of [the] uncertainty [of clinical practice] are one of the most consistent observations made by sociologists studying medical training” [27]. Recognized errors provide opportunities for improvement, whereas fear of punishment promotes alienation, information distortion, and loss of motivation. Quality assurance and patient safety programs may also shift learners’ orientation from knowledge (“What accessory pathways cause Wolff-Parkinson-White syndrome?”) to clinical skills (“Is this ECG tracing suggestive of WPW?”). An orientation to knowledge promotes deterministic thinking, denial of uncertainty, and punitive morality. An orientation to supervised clinical skills training can not only improve competence, but also separate the concepts of “error” and “blame” by allowing students to make mistakes in an atmosphere where they are not condemned or ridiculed, but where they are trusted and supported to change their performance.

9.2 Challenges of Medical Education 9.2.1 Promoting Student Well-being Improving the clinical learning environment and reducing student burnout remain the greatest challenges for clinical education. As early as 1973, Atkinson noted that tutors varied between those who view students as subordinates progressing along an obstacle course and those who view students as colleagues to be “treated in an egalitarian manner and … groomed for full professional status as soon as possible” [28]. Indeed, students’ assessments of their learning environment vary across medical schools and correlate with student learning [29], quality of life, resilience, preparation for practice, and well-being [30] and are inversely related to burnout [31]. Clear expectations, autonomy, and frequent feedback were cited as desirable features of the clinical learning environment, while tutors’ disinterest in students, dismissal of questions, lack of autonomy, and unclear expectations lead to withdrawal and student vulnerability [32]. As recently as 2019, student humiliation [33] and neglect [34] by faculty were reported to be common in clinical settings. As recently as 2022, it was asserted that “many of the fundamental components of psychological safety are lacking in the current clinical learning environments for medical students” [32]. It is impossible to ignore student distress and still teach them how to manage patient distress, and it is impossible to humiliate medical students and still teach them how to respect patients.

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Therefore, one of the main roles of medical education is to provide students with well-being initiatives that are aimed at teaching them how to use psychological and emotional support resources [35], as well as constructive student relationships with their clinical role models. In educational research, a “role model” is a person whose characteristics are a standard of excellence [36]. This definition is at odds with the original definition, of a person who “occupies the social role to which an individual aspires,” and with the assertion that medical students are attracted to persons of status [37]. During my training in the 1950s and 1960s, I aspired to the prestige of some of my tutors and accepted their behavior, even though I was troubled by their belief that humiliating trainees would motivate learning and by their professed intolerance of stupidity that made me afraid to ask questions. The awareness that some clinical tutors lack the qualities that students say they look for in role models [38] has encouraged training programs for faculty members [39]. I believe that these programs will be sustained, that students will be admonished to distinguish between behaviors rather than tutors because no one person always has all the qualities of the ideal clinician, and that faculty will improve their systems of counseling for medical students and ensure that their teaching programs take place in a professional and respectful environment.

9.2.2 Personalizing Medical Education and Reducing Its Duration1 In both North America and Europe, the combined duration of undergraduate and residency training is 9–13  years. Nevertheless, it does not meet the needs of the physicians’ workforce: since the 1950s, there has been a shortage of family physicians [40] and, more recently, of other specialties [41]. Undergraduate medical education has been criticized also for its assumption that it is relevant to all medical specialties. This assumption is incorrect: human anatomy is important to radiologists but not to epidemiologists, and behavioral science is important to family physicians but not to pathologists. To address these two problems, it has been suggested that current medical curricula be replaced with shorter courses of study focused on training for different medical professions [42], such as those for dentistry and nursing. This approach would require medical school applicants to commit to different four-year programs, such as one that prepares them for residency training in secondary and tertiary specialties, a second for primary care (family medicine, pediatrics, and psychiatry),

 A previous version of this section was published in: Benbassat J, Baumal R. Expected benefits of streamlining undergraduate medical education by an  early commitment to  specific medical specialties. Adv Health Sci Educ. 2012;17:145–55. With permission from Springer. 1

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a third for diagnostic laboratories and physician-scientists, and a fourth for careers in epidemiology, health administration, public health, and preventive medicine. An alternative to this proposal would offer applicants to medical school personalized teaching programs based on their expectations and career plans. Personalized learning (also known as adaptive learning, individualized instruction, customized learning, or student-directed learning) is defined as teaching that is tailored to an individual learner’s needs, abilities, preferences, and goals and continuously adapted to their evolving skills and knowledge. It is widely agreed that a personalized learning approach can increase learner motivation and engagement [43]. A 2021 systematic review of studies of personalized learning in schools, universities, and adults confirmed the diversity of learner characteristics and desired outcomes. Most studies focused on student “interests” and “needs” but failed to define these terms operationally. Student achievement, perception, and satisfaction were the most common outcomes, and most studies examining these outcomes found a positive relationship between them and personalized learning [44]. I am not aware of any attempts to introduce personalized learning into medical education. However, shifting the focus of education from knowledge to skills will, in and of itself, personalize medical education through repetitive practice until the learning goal is achieved.

9.2.3 Selection of Applicants for Medical Training Medical schools select their students from a pool of applicants with high past academic achievements. Most medical schools also try to select applicants with desirable “nonacademic” skills such as compassion and social orientation by using interviews. However, a 2016 review of the literature [45] found that interviews lack the reliability and validity needed for high-stakes screening. As a result, more and more medical schools are using written tests, multiple interviews, short tasks, and personality tests in their admissions policies to select applicants with desired nonacademic skills. Even Holland has abandoned its traditional lottery-based admissions policy and adopted multiple assessments of applicants’ nonacademic attributes. These efforts have several limitations. First, nonacademic skills are difficult to identify and measure. There are about 80 such skills [46]; it is impossible to test them all, and it is uncertain whether they are permanent or situational [47]. Correlations between assessed nonacademic skills and student outcomes are around 0.30 [48], i.e., predicting less than 10–20% of the variance in outcomes, leaving room for significant false positives and false negatives. Second, candidates who are rejected due to inadequate academic performance are likely to understand the reason for their failure. Not so rejected candidates after “failing” tests for nonacademic qualities. Such an experience can have an impact on self-esteem, especially when there is no feedback.

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Finally, it is doubtful that society will accept the lack of nonacademic qualifications as a reason to deny an applicant the opportunity to become a physician. After all, society needs not only clinicians, but also physicians who work in research, administration, preventive medicine, public health, and diagnostic medicine. Different career paths require different qualities. Therefore, it seems to me that attempts to identify nonacademic qualities are costly and not-needed, and that future research needs to re-examine their benefits.

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41. Lupu D. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manag. 2010;40:899. 42. Benbassat J, Baumal R. Expected benefits of streamlining undergraduate medical education by an early commitment to specific medical specialties. Adv Health Sci Educ. 2012;17:145–55. 43. Shemshack A, Spector JM.  A systematic literature review of personalized learning terms. Smart Learning Environ. 2020;7:1–20. 44. Bernacki ML, Greene MJ, Lobczowski NG. A systematic review of research on personalized learning: personalized by whom, to what, how, and for what purpose (s)? Educ Psychol Rev. 2021;33:1675–715. 45. Patterson F, Knight A, Dowell J, Nicholson S, Cousans F, Cleland J. How effective are selection methods in medical education? A systematic review. Med Educ. 2016;50:36–60. 46. Koenig TW, Parrish SK, Terregino CA, Williams JP, Dunleavy D, Volsch JM. Core personal competencies important to entering students’ success in medical school: what are they and how could they be assessed early in the admission process? Acad Med. 2013;88:603–13. 47. Ferguson E, Lievens F.  Future directions in personality, occupational and medical selection: myths, misunderstandings, measurement, and suggestions. Adv Health Sci Educ. 2017;22:387–99. 48. Hojat M. Assessments of empathy in medical school admissions: what additional evidence is needed? Int J Med Educ. 2014;5:7–10.

Index

A Allocation of resources, 144 Anchoring, 96 B Bayes, theorem, 94, 103, 160 Behavioural and social sciences (BSS) barriers, 113, 114 clinical tutors, 119, 120 doctor-patient communication skills, 114 implications for clinical practice, 118, 119 risk indicators for disease, 114–118 stress and stressor life events, 110, 111 personality traits, 112 psychological distress, 110 social support, 111 socio-economic status, 111, 112 Biomedical (BM) model, 104 Bureaucracy, 142 C Case-based learning, 19 Clinical database EMRs, 81 POR, 80, 81 present illness (PI) recording format chronological evolution, 89 inadequate description of patient's symptoms, 88 objective history data, 87 self-expression, 87

symptoms identification failure, 88, 89 students’ records, feedback on, 89–91 teaching method active and inactive problems, 86 chief complaint, 83, 84 objectives, 82 patient's symptoms, 84 personal and psychosocial history, 83 present illness (PI) problem statement, 85, 86 problem-oriented approach, 84, 85 Clinical reasoning assessment, 98, 99 barriers, 96–98 biomedical model, 4 bio-psycho-social model, 7 decision analysis, 99–102 from denial to acceptance of uncertainty, 4, 5 EBM, 102, 103 evidence-based reasoning, 6, 7 heuristics and biases approach, 96 humoral model, 4 from intuitive to analytic decision-­making, 2, 5, 6 learning objectives, 98 reasoning strategies algorithmic diagnosis, 95 cognitive task analysis, 96 factors, 95 hypothetico-deduction, 94, 95 pattern recognition, 94, 95 time pressures and interruptions, 95 research findings, 103–105

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Benbassat, Teaching Professional Attitudes and Basic Clinical Skills to Medical Students, https://doi.org/10.1007/978-3-031-26542-6

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170

Index

Cognitive task analysis, 96 Complementary and alternative medicine (CAM), 104 COVID -19 pandemic, 145

E Electronic medical records (EMRs), 81 Equity, 146 Evidence-based medicine (EBM), 102, 103

D Doctor-patient encounter adherence to medical advice, 44–46 barriers ageism, 31 gender discrimination, 31 interviewing habits, 33, 34 patient's and doctor's preferences, 31, 32 patient's concern, gain insight, 33 racial discrimination, 31 language mismatch, 35 management care-providers' preferences, 47, 48 evidence-based guideline, 48, 49 patients' preferences, 47 teaching approaches, 50 medical recommendation, 154, 155 patient aggression management, 36, 37 patient counselling, 42–44 patient interviewing communication skills assessment, 21, 22 learner-centered strategy, 19, 20 learning objectives, 18, 19 shifts in teaching, 20 teacher-centered strategy, 19, 20 self-awareness, 35, 36 shared decision-making informative model, 38–40 integration, 37 paternalistic model, 38–40 patient's concerns, 38 patient's preferred involvement, 40 second opinion, 41, 42 teaching, 37, 38 uncertainty, 40, 41 sharing concerns, encouraging patients for, 36 students' learning difficulties, 12–14 teaching difficulties, 15–17 teaching program advantages, 26–30 disadvantages, 26–28 patient complaints, 22, 23 solutions for complaints, 23–26 supervised practice, 28, 29

H Healthcare resources allocation, 148, 149 controversial norms, 146, 147 fair distribution of resources, 144–146 policy of rationing, 147, 148 I Impaired physicians doctors' dysfunction dealing with, 132, 133 response to awareness, 131, 132 incidence, 130, 131 L Learner-centered approach, 19, 20 M Managed care accountability and quality control, 143 bureaucracy, 142 clinical guidelines, 143 clinical practice, 143 documentation, 144 medical costs, 143 problem-oriented record, 142 Media coverage biases, 153, 154 medical recommendation, 154, 155 targets, 152, 153 Medical education, 9 applicants selection, 165, 166 community settings, 161, 162 competency-based education, 160 Engel's bio-psycho-social model, 160 external reviews, 162 information management, 159 intuitive to analytic decision making, 160, 161 patient safety programs, 162, 163 personalized learning, 164, 165 quality assurance, 162, 163 self-directed learning, 159 student well-being, 163, 164

Index Medical errors definition, 125, 126 disclosure, 129, 130 doctors' attitude to mistakes, 126, 127 malpractice litigation, 128, 129 patients' complaints, 128, 129 prevalence of, 126, 127 prevention, 127, 128 Medical negligence, 126, 129 Motivational Interviewing, 46

171 Q Quality assurance of healthcare components, 133 patient surveys, 133 physicians' attitudes, 133–135 physician self-disclosure of errors, 135, 136 physician support promotion, 135 R Reliability, 73

O Objective structured clinical examination (OSCE), 16 P Patient-centered communication skills, 12 Personality traits, 112 Physical examination (PE) teaching barriers attitudes, 60 inherited errors, 60, 61 diagnostic process, 72 clinical prediction rules, 75 pretest probability, 75 sources of bias, 74, 75 test properties, 73, 74 learning for mastery, 63 point-of-care ultrasound (PoCUS), 63, 64 reflective PE, 61–63 simulation technology, 71, 72 symptoms and signs, 64–71 Physician–patient relations, 1, 3 Physician-society relations healthcare team, 9 medical errors, 8 parsimonious use of resources, 8 public's trust, health services, 9 quality control, 8 Problem-oriented record (POR), 80, 81 Psychological distress, 110

S Shared decision-making (SDM) informative model, 38–40 integration, 37 paternalistic model, 38–40 patient's concerns, 38 patient's preferred involvement, 40 second opinion, 41, 42 teaching, 37, 38 uncertainty, 40, 41 Social support, 111 Socioeconomic status (SES), 111, 112, 119 T Teacher-centered (didactic) approach, 18–20 Tolerance of uncertainty, 97, 98 Trust in health care institutions declining trust in institutions, 149–151 proletarianization and de-professionalization, 151 values, 149 Trust in physicians, 149 U Utilitarianism, 146