As an associate professor emeritus of general surgery at the School of Medicine, Ronald Fishbein says he's known some rather elite, gold-medal-quality physicians in his day. He mentions various doctors who have elevated surgery to a higher art form, and clinicians who could spout off the entire history of a disease, both backwards and forwards.
But some of these people lacked one fundamental trait, a lack that prohibited them, at least in Fishbein's eyes, from becoming truly great physicians. That trait, he says, is genuine human compassion.
Fishbein agrees with the assessment--put forth in a number of recent articles in prominent magazines, newspapers and medical journals--that there is in this country a growing number of health professionals who lack empathy for their patients. One of the factors attributed to this trend is that in this era of the HMO doctors are under increasing economic pressure to see more patients, thus spending less time with each. Former Surgeon General C. Everett Koop has gone so far as to chair a council that is now training physicians in communication skills in an effort to improve their bedside manner.
"I could tell you stories that would make your ears curl," says Fishbein, who is now a Pre-Health Professions adviser at Homewood, "stories about residents-in-training who have said things to patients--thoughtless, hurtful things. And then the patients would tell me afterward, and I would be just horrified. 'Do you know what that tall guy in the white coat just said to me? You have to talk with him!' "
Part of the problem, Fishbein says, is that while these people were learning to become doctors, they may have lacked proper role models who represented the humanistic side of health care.
"Students, you know," Fishbein says, "often learn by example."
To that end, Fishbein this year created a one-week, noncredit intersession course titled The Master Clinician, which places Hopkins premed students in a clinical setting so they can observe master physicians interacting with their patients. The goal of the course is to expose these undergraduates to the human element of their intended profession, both the good and the bad, in addition to the facts and theories taught in class.
During each week of the three-week intersession period, a group of three students travels four days a week to the Outpatient Center of The Johns Hopkins Hospital, where they spend time observing a group of 22 doctors, and nursing staff, in various patient consultations, treatment sessions and checkups. The students' day lasts from 8 a.m. to 5 p.m., during which time they are paired with health professionals from fields that range from pediatrics to plastic surgery.
The students are allowed to ask questions, Fishbein says, but he encourages them to just stand back and watch.
"I tell them to be a fly on the wall, to just listen to what is going on--not with the intention of learning science or medicine but just being there simply to hear how doctor and patient, including the patient's family, communicate with each other," says Fishbein, who adds that he is not aware of any similar course being offered at other universities.
Following their Outpatient Center experience, the students end their week in a conference room in Merryman Hall, discussing their observations and sharing their experiences with Gershon Efron, associate professor of general surgery at the School of Medicine. Efron says a course like this is needed because medical students can go their entire education without really experiencing the human side of caregiving.
The course was open to juniors and seniors who are entering the medical school-application cycle during the spring semester. A total of nine students, out of more than 200 applicants, was chosen to participate in the initial offering of this unique intersession course. Fishbein says he was not prepared for the large response he got and therefore, in fairness, chose not to screen the students who were ultimately selected: He merely picked their names out of a hat.
"I would like to be able to put a lot of kids through this," Fishbein says. "But, unfortunately, some of the [Outpatient Center] rooms are small, and you are sort of violating the sanctity of that little consultation room with a crowd of people."
Fishbein, who has written several articles on the physician-patient relationship, says it's a mistake to underestimate the power of good communication skills as they relate to caregiving. Doctors who can make a patient feel at ease and can offer hope often can have a profound effect on the patient's recovery, he says. For someone trying to fight a life-threatening disease such as cancer, for example, a positive mental attitude could mean the difference between life and death. Similarly, a physician who delivers test results or a diagnosis bluntly, or talks over the patient's head with medical jargon, can often frustrate the patient and have a negative impact on his health.
"That is just the human aspect of this profession," Fishbein says. "There are patients who despite their doctor being curt, discourteous or cruel--but treating them medically properly--will get better. Sure it will leave [the patient] upset, but better. And there are some doctors who just by holding the hand of a patient seem to have a placebo effect on making them well."
Fishbein says that some people, despite their smarts and abilities, have terrible bedside manners. Students who do well academically, he says, can still make poor doctors because they are so wrapped up in the scientific aspect that they treat just the disease, not the patient.
"You just don't become a compassionate, empathetic individual all of sudden after you enter medical school," Fishbein says.
Thus, one of Fishbein's hopes for the new intersession class is that it might help to identify students--before they begin their medical education--who are not suited for the profession.
Douglas Housman, a senior neuroscience major who attended the course, says he thought the week spent at the Outpatient Center was a valuable experience. Housman says he got to see some "incredible" and "caring" clinicians at work, in addition to witnessing some physicians who alienated their patients and made them feel uncomfortable. However, it was the very last doctor he spent time with, Housman says, who made the biggest impact on him.
"There was just this constant sort of care that she was showing. She was always making the patient feel comfortable; there was always a connection between doctor and the patient," Housman says. "She talked in the same voice to the patients as she did to the other doctors in the room. They never felt like they were weren't part of the experience."
Fishbein says if these students meet just one positive role model during this course, he considers it a success.
On the subject of physician-patient relationships, Fishbein says he is often reminded of his days as a medical student, when he trained under a "very famous, world-renowned surgeon."
"He was this really gruff guy who always said, 'I would rather have some tough, mean academician who was smart take care of me than a kindly general practitioner who didn't know a damn thing but would hold my hand,' " Fishbein says. "I used to say to him, 'Why can't somebody be both? To be both smart and kind.'"
Gershon Efron agrees.
"I often tell my students, 'Patients are important; you are not,' " Efron says. "It's about altruism. To be a doctor, you should like people."