Wednesday, January 26, 2011

Teaching Residents Soft Skills

Professionalism.  Communication.  Empathy.  Skills needed for all physicians.  Unfortunately, with the hustle and bustle of everyday work and the "do more in less time" mentality that pervades our practice, relationship skills are often overlooked or frankly ignored.   If one was to look at the satisfaction with practice in emergency medicine, they would find a significant amount of burnout and unhappiness with practice.  Keeping this in mind, how do you work with residents to teach them the soft skills which lead to the rewarding practice of medicine and a more satisfying relationship with patients?

Wright et al set out to identify a list of practices that lead to a more fulfilling practice life.  The list that they have created captures behaviors and attitudes that may help achieve this goal on a personal level.  Even more helpful to the educator, the list creates a wonderful set of tasks that you use to help a trainee assess themselves and continue on the journey to personal and professional growth.

To use the list, I've begun to create a set of cards, each containing one precept.  I like to start a shift by asking the resident what they want to learn on that particular shift.  I often find that their list is somewhat generic, such as "I want to work on my procedures."  Instead, by pulling out these cards resident can pick any card and suddenly we have a simple task to practice.  I can then observe their behavior and offer simple feedback on their success with the task.  

The list can be customized, expanded, and is designed to change as medicine changes.  Look it over and try it out.  I think that you'll find it helps both the learner and the teacher.  As Robert Heinlein pointed out, "When one teaches, two learn."

The List:

Promotion of relationships with patients
1. Greet patients by their names, tell them you name and your role in their care
2. Smile
3. Sit down when talking to patients
4. Listen
5. Be wholly present when interacting with patients and avoid unnecessary interuptions
6. Learn who your patients are and consider sharing something about yourself with them
7. Show the utmost respect for all patients
8. Be humanistic, compassionate and caring
9. Even if it is a struggle to think positively of a patient, always speak of them in a positive way; this will influence your thinking positively
10. If you are feeling negative emotions towards a patient, try to understand why you are feeling this way

Principles of the effective clinician
11. The history and physical examination are not like a biopsy fixed in formalin, but are dynamic entities that should be revisited frequently
12. A patient’s history should not be “aspirated”; it should instead be “built” purposefully with effective communication skills
13. Be curious – seek to find out exactly how and why events occurred and do not accept diagnoses and conclusions made by others
14. Recognize the patient as teacher
15. Elaborate a differential diagnosis that is as broad as the history and physical examination dictate
16. After forming a diagnostic hypothesis, focus on any symptoms or signs that are either atypical or incompatible with the diagnosis; these must be explained and not ignored
17. Always consider and exclude catastrophic treatable diseases
18. Continually strive to improve your diagnostic skills by mentally committing to a specific answer or conclusion before definitive testing
19. Watching patients walk is a critical component of the physical examination, particularly if their level of function is compromised
20. Look at the sacrum and heels of any patient who is bed-bound
21. Think about and plan for how to best deliver the information before telling important news to patients about their health
22. Explain medical concepts in simple language; avoid medical jargon and make sure that the patient understands
23. Teach patients what they need to know to make an informed decision
24. Strive to become a healer
25. Solicit help when you are stumped or at a loss in caring for a patient
26. Review your patient’s drug list and require explicit justification for every medication
27. Remember that the ill patient is not at his best
28. Do not discuss patients in public places (eg, elevators)
29. Appreciate the contributions of all members of the health care team
30. Try to be as organized as possible – be prepared and be thorough yet efficient
31. Focused reading to answer specific clinical questions is more nourishing leafing through a current issue of a medical journal
32. Know that much practice, reading, and years of hard work are essential parts of becoming an excellent physician
33. When you have made a mistake in the care of a patient, follow these steps: (a) admit it, (b) inform the patient, (c) if possible, initiate reparation, (d) institute a mechanism whereby you will not repeat the error, (e) attempt to establish a mechanism whereby others in the system cannot make the error, (f) forgive yourself

Growth and improvement
34. Strive to achieve personal awareness and an understanding of your beliefs, values, and attitudes
35. Recognize and acknowledge powerful experiences
36. Seek out and embrace helping relationships
37. Make time for reflection
38. Observe other physicians carefully and learn from role models
39. Realize that people are watching you closely – strive to be a role model for others
40. Be creative and innovative
41. Try to look into an accurate mirror

Values to guide one’s career in medicine
42. Avoid being cynical
43. Understand that medicine is a public trust
44. Be humble
45. Be ethical in all of your work as it relates to the profession of medicine
46. Aspire to become a great teacher
47. Stand up for what you believe in
48. Aim for a comfortable balance between your personal and professional lives
49. Try your best
50. Continually search for meaning in your work in medicine
51. Celebrating successes may help to avoid burnout
52. Be thankful and happy that you are in medicine


Wright SM, Hellmann DB, Ziegelstein RC. 52 precepts that medical trainees and physicians should consider regularly. Am J Med. 2005 Apr;118(4):435-8. PMID: 15808145

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