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The concept of relationship-centered care was first introduced approximately 20 years ago, but this important concept has not yet been widely disseminated in clinical practice. Relationship-centered care in the health profession focuses on all relevant relationships in health care, not only between health care professionals and patients but also among colleagues, staff members, students, community, and self. This review summarizes the key literature to date on relationship-centered care as it pertains to the physician-patient relationship. Becoming more aware of the physician (self) and patient is a form of metacognition, thinking about what is happening in the moment as physicians and patients come together. Considering the complexity of the physician-patient relationship, we can implement simple metacognitive techniques toward the daily habitual practice of relationship-centered care.

Introduction Medical students often lack training in advanced communication skills encompassing emotionally fraught situations and those in which an intense emotional response is expected. Such skills are required for clinical situations encountered during residency. We created and evaluated an advanced communication skills workshop (ACSW) using standardized patients for senior medical students. The workshop emphasized communication skills for four scenarios—strong emotion, goals of care, medical error, and palliative care assessment—and utilized formative peer assessment and feedback. Methods We created the four ACSW cases with case-specific communication behavior checklists and a common modified Master Interview Rating Scale in a Capstone Course for senior medical students. In groups of three, students rotated through three of four stations. Each student conducted one of the interviews while the other two completed the checklists and provided verbal feedback. We performed one-way analyses of variance on Likert responses and content analysis on open responses on a post-ACSW survey. Results Ninety-one students completed the ACSW and survey. Students assigned high value to all four ACSW student roles: interviewer, observer, feedback recipient, and feedback provider. Students rated the experience above average to excellent on nearly all survey items. Open-response themes included “liked the opportunity to give or receive peer feedback” (46%) and “found the checklists helpful” (45%). Discussion Feasible and well received by senior medical students, our ACSW offers an opportunity to practice and observe advanced communication skills and peer feedback. A peer-assisted, formative learning model, the ACSW efficiently addresses a key aspect of residency preparation.

Construct: The construct addressed in this study is assessment of advanced communication skills among senior medical students. Background: The question of who should assess participants during objective structured clinical examinations (OSCEs) has been debated, and options discussed in the literature have included peer, self, standardized patient, and faculty assessment models. What is not known is whether same-level peer assisted learning can be utilized for formative assessment of advanced communication skills when no faculty, standardized patients, or other trained assessors are involved in providing feedback. If successful, such an educational model would optimize resource utilization and broaden the scope of topics that could be covered in formative OSCEs. Approach: The investigators developed a 4-station formative OSCE focused on advanced communication skills for senior medical students, and evaluated the concordance of assessment done by same-level peers, self, standardized patients, and faculty for 45 students. After each station, examinees completed a self-assessment checklist and received checklist-based assessment and verbal feedback from same-level peers only. Standardized patients completed checklist-based assessments outside the room, and faculty did so after the OSCE via video review; neither group provided direct feedback to examinees. The investigators assessed inter-rater agreement and mean difference scores on the checklists using faculty score as the gold standard. Findings: There was fair to good overall agreement among self, same-level peer, standardized patient, and faculty-assessment of advanced communication skills. Relative to faculty, peer and standardized patient assessors overestimated advanced communication skills, while self-assessments underestimated skills. Conclusions: Self and same-level peer-assessment may be a viable alternative to faculty assessment for a formative OSCE on advanced communication skills for senior medical students.

Objective Patients often seek mental health treatment through primary care. Training primary care physicians (PCPs) in approaches to address common mental health concerns may be a useful method for narrowing gaps in care. Cognitive Behavioral Therapy (CBT) is especially applicable in medical settings given its brief, skill-based approach and strong evidence for a number of presenting problems. This paper reviews the current literature on training PCPs in CBT with a focus on PCP-level outcomes. Methods We reviewed studies that described and evaluated CBT training programs for PCPs. Of 652 records identified and screened, 33 full-text articles were assessed for eligibility, resulting in 9 articles identified for inclusion. Results We extracted and report information about study design, participants, intervention and dose, training content, and outcomes (PCP reaction, learning, and performance; patient outcomes). Conclusion There was substantial variability in sample size, methodology, training content and design, and assessment of outcomes, which translated into mixed findings across studies. In order to best assess effectiveness and allow replicability, future studies should provide adequate information about training curricula and assess multiple levels of learning outcomes. Practice implications Additional studies are needed to determine whether PCPs effectively implement skills within routine practice after CBT training.

Objective:To assess whether communication training for house staff via role-playing exercises (1) is well received and (2) improves patient experience scores in house staff clinics.Methods:We conducted a pre–post study in which the house staff for 3 adult hospital departments participated in communication training led by trained faculty in small groups. Sessions centered on a published 5-step strategy for opening patient-centered interviews using department-specific role-playing exercises. House staff completed posttraining questionnaires. For 1 month prior to and 1 month following the training, patients in the house staff clinics completed surveys with Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) questions regarding physician communication, immediately following clinic visits. Preintervention and postintervention results for top-box scores were compared.Results:Forty-four of a possible 45 house staff (97.8%) participated, with 31 (70.5%) indicating that the role-playing exercise increased their perception of the 5-step strategy. No differences in patient responses to CG-CAHPS questions were seen when comparing 63 preintervention surveys to 77 postintervention surveys.Conclusion:Demonstrating an improvement in standard patient experience surveys in resident clinics may require ongoing communication coaching and investigation of the “hidden curriculum” of training.

PURPOSE Relationship-centered care attends to the entire network of human relationships essential to patient care. Few faculty development programs prepare faculty to teach principles and skills in relationship-centered care. One exception is the Facilitator Training Program (FTP), a 25-year-old training program of the American Academy on Communication in Healthcare. The authors surveyed FTP graduates to determine the efficacy of its curriculum and the most important elements for participants' learning. METHOD In 2007, surveys containing quantitative and narrative elements were distributed to 51 FTP graduates. Quantitative data were analyzed using descriptive statistics. The authors analyzed narratives using Burke's dramatistic pentad as a qualitative framework to delineate how interrelated themes interacted in the FTP. RESULTS Forty-seven respondents (92%) identified two essential acts that happened in the program: an iterative learning process, leading to heightened personal awareness and group facilitation skills; and longevity of learning and effect on career. The structure of the program's learning community provided the scene, and the agents were the participants, who provided support and contributed to mutual success. Methods of developing skills in personal awareness, group facilitation, teaching, and feedback constituted agency. The purpose was to learn skills and to join a community to share common values. CONCLUSIONS The FTP is a learning community that provided faculty with skills in principles of relationship-centered care. Four further features that describe elements of this successful faculty-based learning community are achievement of self-identified goals, distance learning modalities, opportunities to safely discuss workplace issues outside the workplace, and self-renewing membership.

Objective To review the scientific status of the biopsychosocial (BPS) model and to propose a way to improve it. Discussion Engel's BPS model added patients’ psychological and social health concerns to the highly successful biomedical model. He proposed that the BPS model could make medicine more scientific, but its use in education, clinical care, and, especially, research remains minimal. Many aver correctly that the present model cannot be defined in a consistent way for the individual patient, making it untestable and non-scientific. This stems from not obtaining relevant BPS data systematically, where one interviewer obtains the same information another would. Recent research by two of the authors has produced similar patient-centered interviewing methods that are repeatable and elicit just the relevant patient information needed to define the model at each visit. We propose that the field adopt these evidence-based methods as the standard for identifying the BPS model. Conclusion Identifying a scientific BPS model in each patient with an agreed-upon, evidence-based patient-centered interviewing method can produce a quantum leap ahead in both research and teaching. Practice implications A scientific BPS model can give us more confidence in being humanistic. In research, we can conduct more rigorous studies to inform better practices.

Patients are increasingly provided facilitated access to their medical notes. Physicians have reported concerns that patients will find notes confusing and offensive, and that typographical errors will appear unprofessional. This exploratory study quantifies the prevalence of potentially confusing or offensive medical language and typographic errors within notes.The authors performed a retrospective, cross-sectional review of 400 inpatient History and Physical notes from a tertiary care center. All notes were from admissions to general internal medicine services. Words and phrases of interest were codified into five pre-established categories and subdivisions.Of 400 notes, 337 notes written by residents and hospitalists were analyzed. The most prevalent characteristics identified per note were General Medical Acronyms (99.1%), Medical Jargon (96.7%), and Typographical Errors (49%). Residents used a greater number of acronyms and abbreviations (p0.01). All subdivisions within Subjective Descriptors and Mental and Personal Health appeared in less than 20% of notes.While the place of medical shorthand, jargon, and sensitive history in the note is unlikely to change in the near future, this study identifies typographical errors as a modifiable area for improvement. The examination of medical note language may prove beneficial to the patient-physician relationship in the digital era.

CONTEXT Research has demonstrated the potential adverse impact of pharmaceutical company marketing techniques on doctor knowledge and prescribing practices. Lack of experience may make resident doctors particularly vulnerable to pharmaceutical industry influence. Curricula addressing resident-pharmaceutical industry relations have been reported, but there is no consensus regarding the best approach to take. OBJECTIVE This study aimed to review published curricula that address resident-pharmaceutical industry relations and to assess them for content, validity and outcomes measures. METHODS Curricula were identified via searches of electronic databases and bibliographies of collected articles. Inclusion criteria required articles to describe an educational curriculum, applied in graduate medical education, on relations between doctors and the pharmaceutical industry. RESULTS The search identified 9 curricula. Most addressed detailing of residents by pharmaceutical representatives. Two articles described curriculum development. Eight articles included an evaluation component; only 1 included a control group for comparison. Modest improvements were noted in resident confidence, knowledge of guidelines, belief in the potential influence of marketing on behaviour, and self-reported acceptance of gifts. Only 2 evaluations used a validated outcome instrument, and no studies included longterm follow-up. CONCLUSIONS A limited number of curricula have addressed resident-pharmaceutical industry interactions. Inconsistency in content, application and evaluation methodology prevents any meaningful synthesis of data. Resident attitudes and behaviours may be affected, but the outcome measures used lacked sufficient validity to assess improvements in knowledge and analytic skills. A clearer delineation of the curriculum development process and the use of standardised outcome measures would facilitate the reproduction of positive results at other institutions.

This case report focuses on withdrawal dystonia, a movement disorder associated with neuroleptics. Its occurrence in a patient with Tourette's disorder complicated the clinical picture. A misinterpretation of the symptoms led to ineffective management of the movement disorder. The presence of increased blinking with facial pain, dystonic movements, and other facial movements at each neuroleptic dose reduction pointed toward withdrawal dystonia rather than toward a worsening of Tourette's disorder. Implications for diagnosis and treatment are discussed.

A B S T R A C T Objective: Many express concern that modern medicine fails to provide adequate psychosocial and mental health care. Our educational system has not trained the primary care providers who care for most of these patients. Our objective here is to propose a quantum change: prepare residents and students during all years of training so that they are as effective in treating psychosocial and mental health issues as they are medical problems. Method: We operationalize this objective, following Kern, by developing an intensive 3-year curriculum in psychosocial and mental health care for medical residents based on models with a strong evidence-base. Results: We report an intensive curriculum that can guide others with similar training interests and also initiate the conversation about how best to prepare residency graduates to provide effective mental health and psychosocial care. Conclusion: Identifying specific curricula informs education policy-makers of the specific requirements they will need to meet if psychosocial and mental health training are to improve. Practice Implications: Training residents in mental health will lead to improved care for this very prevalent primary care population.

Objectives In 2005, the authors developed and tested a curriculum to teach Year 3 Yale University medical students a behaviour change counselling approach called ‘brief motivational interviewing’ (BMI). Brief motivational interviewing is a patient-centred approach designed to promote changes in patient behaviour within the time constraints imposed by a busy medical practice. Methods Standardised patients/instructors delivered the curriculum within a single 2-hour training episode using a teaching acronym called ‘CHANGE’ to promote the students' learning. The authors used a pretest, post-test and 4-week follow-up design to assess students' BMI skills (as measured by the Helpful Response Questionnaire), knowledge and attitudes toward the approach. Results Students successfully increased their use of BMI-consistent behaviours, primarily by increasing the frequency and depth of their reflections and by reducing the frequency with which they incorporated communication roadblocks and closed questions into their responses (all P-values ≤ 0.05). Students also showed increases in BMI knowledge, interest in the approach, confidence in their ability to use BMI, and commitment to incorporating BMI skills into their future medical practice (all P-values ≤ 0.05). Conclusions The findings suggest that Year 3 medical students can learn basic BMI skills and knowledge and develop positive attitudes toward the approach within a relatively short period of time. The authors discuss the study's limitations and future directions for teaching students BMI.

Learning environments overtly or implicitly address patient-centered values and have been the focus of research for more than 40 years, often in studies about the "hidden curriculum." However, many of these studies occurred at single medical schools and used time-intensive ethnographic methods. This field of inquiry lacks survey methods and information about how learning environments differ across medical schools.To examine patient-centered characteristics of learning environments at 9 U.S. medical schools.Cross-sectional internet-based survey.Eight-hundred and twenty-three third- and fourth-year medical students in the classes of 2002 and 2003.We measured the patient-centeredness of learning environments with the Communication, Curriculum, and Culture (C3) Instrument, a 29-item validated measure that characterizes the degree to which a medical school's environment fosters patient-centered care. The C3 Instrument contains 3 content areas (role modeling, students' experiences, and support for students' patient-centered behaviors), and is designed to measure these areas independent of respondents' attitudes about patient-centered care. We also collected demographic and attitudinal information from respondents.The variability of C3 scores across schools in each of the 3 content areas of the instrument was striking and statistically significant (P values ranged from .001 to .004). In addition, the patterns of scores on the 3 content areas differed from school to school.The 9 schools demonstrated unique and different learning environments both in terms of magnitude and patterns of characteristics. Further multiinstitutional study of hidden curricula is needed to further establish the degree of variability that exists, and to assist educators in making informed choices about how to intervene at their own schools.

Governing bodies for medical education recommend that spirituality and medicine be incorporated into training.To pilot a workshop on spirituality and medicine on a convenience sample of preclinical medical students and internal medicine residents and determine whether content was relevant to learners at different levels, whether preliminary evaluation was promising, and to generate hypotheses for future research.Private medical school and university primary care internal medicine residency program, both in the Northeast.The authors designed and implemented a required 2-hour workshop for all second-year medical students and a separate required 1.5-hour workshop for all primary care internal medicine house staff. The workshops used multiple educational strategies including lecture, discussion, and role-play to address educational objectives.Learners completed optional, anonymous pre and postworkshop surveys with six 5-point Likert-rated statements and space to cite the most useful part of the curriculum and their remaining questions. One hundred and thirty-seven learners participated and 100 completed both surveys. Medical students and residents had increased (all Por =.002): agreement regarding the appropriateness of inquiring about spiritual and religious beliefs in the medical encounter, their perceived competence in taking a spiritual history, and their perceived knowledge of available pastoral care resources. Medical students, but not residents, had an increase in their perceived comfort in working with hospital chaplains.A brief pilot workshop on spirituality and medicine had a modest effect in improving attitudes and perceived competence of both medical students and residents.

Educators rarely consider the attitudes that determine whether a learner will use the clinical skills we teach. Nevertheless, many learners and practitioners exhibit negative attitudes that can impede the use of patient-centered skills, leading to an isolated focus upon disease and impairing the provider-patient relationship. The problem is compounded because these attitudes often are incompletely recognized by learners and therefore are difficult to change without help. We present a research-based method for teaching personal awareness of unrecognized and often harmful attitudes. We propose that primary care clinicians without mental health training can follow this method to teach students, residents, faculty, and practitioners. Such teachers/mentors need to possess an abiding interest in the personal dimension, patience with a slowly evolving process of awareness, and the ability to establish strong, ongoing relationships with learners. Personal awareness teaching may occur during instruction in basic interviewing skills but works best if systematically incorporated throughout training.

While clinicians face increasing time pressure in caring for patients, communication with the patient can suffer. Communication is especially important in caring for the increasingly culturally diverse patient population in the United States. Different values, beliefs, and attitudes about health, illness, and health care can affect illness outcomes. These are best understood through dialogue. Patient-centered communication skills are associated with improved health outcomes, improved patient and clinician satisfaction, and less risk of malpractice suits. This paper reviews techniques to efficiently incorporate patient-centered communication into the medical encounter, with emphasis on interacting with patients of different cultures.

Teaching medical students to integrate patient-centered skills into the medical interview is challenging. Longitudinal training requires significant curricular and faculty time. Unsupervised students risk harm if they uncover and inappropriately manage psychosocial issues in actual patients. They fear saying the wrong thing in emotionally charged situations. Two half-day workshops for pre-clinical students integrate patient- and physician-centered interviewing. The first occurs early in the first year. The second, late in the second year, presents interview challenges (e.g., breaking bad news). Ten professional actors portray standardized patients (SPs). Groups of 10 to 15 students interview an SP, each eliciting a part of the patient's story. Qualitative evaluation revealed that, for many students, SPs afford the opportunity to experiment without harming real patients. Students view the workshops as effective (mean score for first-year students, 6.6 [standard deviation (SD), 1.0], second-year students, 7.1 [SD, 0.7] on a Likert-type scale: 1 = not at all effective to 8 = very effective).

Administrative communication is increasingly challenging for residency programs as the number of training sites expands. The Internet provides a cost-effective opportunity to address these needs. Using the World Wide Web, we developed a single, reliable, accurate, and accessible source of administrative information for residents, faculty, and staff in a multisite internal medicine residency at reduced costs. Evaluation of the effectiveness of the website was determined by tracking website use, materials and personnel costs, and resident, staff, and faculty satisfaction. Office supply and personnel costs were reduced by 89% and personnel effort by 85%. All users were highly satisfied with the web communication tool and all reported increased knowledge of program information and a greater sense of “connectedness.” We conclude that an internet-based communication system that provides a single, reliable, accurate, and accessible source of information for residents, faculty, and staff can be developed with minimum resources and reduced costs.

PURPOSE: To prioritize competencies that should be addressed in the medicine core clerkship, assess factors influencing this prioritization, and estimate the percentage of clerkship time that should be devoted to inpatient versus outpatient care. METHODS: A national survey of the Clerkship Directors in Internal Medicine (CDIM) was used. Using explicit criteria, respondents assigned priority scores, on a 1 to 5 scale, to 17 general competencies and 60 disease-specific clinical competencies pertinent to care of adult patients in inpatient. ambulatory, intensive care, and emergency settings. RESULTS: Ninety-three (75%) of 124 CDIM members responded. The highest mean priority scores were assigned to 6 general competencies: case presentation skills (4.65), diagnostic decision-making (4.64), history and physical diagnosis (4.61), test interpretation (4.47), communication with patients (4.35), and therapeutic decision-making (4.12). Disease-specific clinical competency areas receiving the highest mean priority scores were: hypertension (4.57), coronary disease (4.53), diabetes mellitus (4.45), heart failure (4.42), pneumonia (4.39), chronic obstructive pulmonary disease (4.26), acid-base/electrolyte disorders (4.19), and acute chest pain (4.08). Priorities for general competencies were moderately correlated with importance to the practice of general internists (mean Spearman rho 0.49) and with importance to students pursuing careers outside internal medicine (mean Spearman rho 0.45), but only weakly correlated with the adequacy with which a competency was addressed in other parts of the curriculum. Respondents' mean recommended allocation of clerkship time was: 52% inpatient, 33% ambulatory care, 8% intensive care, and 7% emergency medicine. This time allocation did not differ by any characteristics of respondents. CONCLUSION: There is consensus among medicine clerkship directors that the medicine core clerkship should emphasize fundamental competencies and devote at least one third of the time to clinical competencies pertinent to ambulatory care.

A GROWING NUMBER OF MEDICAL SCHOOLS ARE OFFERING courses in spirituality in medicine. In 1994, only 17 of the 126 accredited US medical schools offered courses on spirituality in medicine. By 1998, this number had increased to 39, and by 2004, to 84 schools. To characterize the curricula, we conducted a search of PubMed, PsychINFO, the Educational Resources Information Clearinghouse (ERIC), and the Social Science Citation Index (details are available from the authors). We then determined whether the articles reported on curriculum development, curricular goals and objectives, topical content, educational strategies, evaluation methods, or evaluation of outcomes. Ten reports met these inclusion criteria. Three programs had been developed for first-year students, 2 for firstand second-year students, 2 for second-year students, and 2 for third-year students. Four of these 10 curricula specifically focused on spirituality and medicine, while 2 other courses included additional components on cultural competency and end-of-life care. Three curricula taught students in the context of a medical humanities course that included spirituality as a component topic. Although authors generally described the content of their courses, most did not report the key steps of the curriculum development process. Only one described a needs assessment, though only for the local community and not for the medical students. Four included objectives, the most common of which were to understand how patients’ spiritual beliefs impact health; to understand how medical students’ own belief systems can affect the care they provide; and to develop skills to take a spiritual history. Most curricula used several educational methods, such as lectures, small group discussion, standardized patient interviews, and readings. One included a 6-hour on-call experience with a hospital chaplain. The majority of reports in the reviewed literature failed to specify what particular aspects of spirituality and medicine the courses covered. For example, several articles stated that students attended lectures on “spirituality and medicine” without providing additional details. Other articles mentioned the assignment of “selected readings” but did not list any of the assigned references. Most schools evaluated their programs’ effectiveness with student surveys of satisfaction or self-reported changes in attitude or knowledge. However, to evaluate the effectiveness of psychiatry clerkship problem-based case studies concerning spiritual issues at one school, Musick et al randomized students to either a case that involved spiritual issues or cases that made no mention of spirituality. At the end of the course they interviewed a standardized patient with spiritual issues and were assigned to write the patient’s spiritual history. Only the students who worked with the spiritual case study had a statistically significant increase in self-reported knowledge about taking a spiritual history. Students in the intervention and control groups obtained statistically equivalent scores on the standardized patient interview. Unfortunately,most curricula were not presented in enough detail to replicate and few assessed outcomes on effectiveness. The lack of detail in these published reports is not unique; recent reviews of resident research and evidence-based medicine curricula note similar deficiencies. Our review has several limitations. First, we included only published reports; and though unpublished curricula could be just as useful to educators they are difficult to access. Second, our search strategy, though thorough according to accepted standards of literature review, may still have missed some of the published curricula. Indeed, spirituality may be taught in several venues, including courses on holistic medicine and complementary and alternative medicine (CAM). Brokaw et al surveyed CAM course directors at 53 medical schools and found that 64% included teaching about spirituality, faith, and/or prayer.