LawInfo Forum

Enhancing Physician-Patient Rapport

Lewis Owen Amack

November 8, 1995

INTRODUCTION
DISCUSSION
The Biopsychosocial Approach to Medical Education
Physician Communication Skills and the Biopsychosocial Model
Factors Associated with Successful Physician-Patient Relationships
Physician Communication Skills Education
Methods of IPS Training
Recommendations Concerning Physician IPS Education
CONCLUSION
BIBLIOGRAPHY

INTRODUCTION

Medicine has traditionally been disease- and doctor-oriented, relying on a narrow, dualistic, reductionistic, biomedical model and de-emphasizing macroscopic patient concerns (Henderson, 1935). This perspective may be traced to the fifteenth century, when Christian orthodoxy lifted the prohibition against dissection as long as physicians would not presume to deal with the human soul, mind, morals, or behavior (Rasmussen, 1975). Consequently, the interpersonal dynamics and ethical aspects of the physician-patient relationship receive scant attention (Andre, 1992). Instead of applying consumer-oriented policies familiar to market-oriented organizations, many physicians continue to treat patients as an automobile mechanic might treat a car (Werner & Schneider, 1974). Clinical training reinforces this dehumanizing perspective and fosters negative attitudes toward patients (de Monchy, 1992). Lamentably, psychosocial training is so inadequate that student self-evaluations of communication skills are inversely related to objective evaluations (Marteau, Humphrey, Matoon, Kidd, Lloyd, & Horden, 1991). Yet physician-patient communication is vitally important, since 85% of patients are distressed, 75% have psychosocial problems requiring attention, and primary care physicians must devote up to half of their time to psychiatric and psychosocial problems (Bertakis, Roter, & Putnam, 1991). Even more seriously, as many as half of patients have significant psychiatric problems which go undetected by primary care providers (Markel, Margolis, & Smith, 1990).

Fortunately, greater attention is now focused on more holistic approaches to medicine, and to the qualities of physician-patient interaction. Two reasons for this change are: (1) increasing concern about malpractice litigation and the possibility of further regulation of the health care industry (Engler, Saltzman, Walker, & Wolf, 1981), and (2) the realization that problem-centeredness, while pragmatic in acute care, is far less effective than patient-centeredness for preventive medicine, chronic care, and rehabilitation (Moorhead & Winefield, 1991). The touchstone of the patient-centered movement is the biopsychosocial systems approach, which humanizes the patient and recognizes the importance of psychological, social, organizational, and even cultural and environmental factors in health care (Engel, 1978). A biopsychosocial approach to physician-patient communication should lead to optimal health behavior, as well as patient participation in the wellness process. Furthermore, a biopsychosocial orientation is helpful during the process of designing clinical training programs for the enhancement of physician interpersonal and interviewing skill (IPS).

IPS is positively associated with patient satisfaction, adherence, and favorable health outcomes. Several methods of IPS training have proven successful, including observation, case presentation, small group discussions, role-playing, simulated patients, and videotape feedback. IPS development is further enhanced by multimodal programs. In addition, medical students benefit from multidisciplinary instruction, faculty development, support groups, and the availability of psychotherapeutic services.

DISCUSSION

The Biopsychosocial Approach to Medical Education

Only fifteen years ago, medical education programs focused almost exclusively on anatomical and physiological phenomena--the hard sciences. Bedside manner or physician-patient rapport was regarded as an innate talent; as an art rather than a science; or as a vaguely-defined set of skills which could be developed through observing other physicians, or through trial and error during internship and residency (DiMatteo, 1979). Consequently, senior medical students often manifested poorer interviewing skills than freshmen (Helfer, 1970). Although the psychosocial aspects of the physician-patient interchange are now receiving greater attention (Rossmanith, 1990), the biomedical and psychosocial aspects of medicine generally continue to be segregated into distinct disciplines, and the psychosocial realm is often a casualty of misguided cost-cutting (Markel et al., 1990) or efficiency (Reiser, 1988) considerations. Nevertheless, a minority of programs now utilize a biopsychosocial approach, integrating the acquisition of biomedical knowledge with the development of interpersonal and interviewing skills from the outset of the medical education experience.

There are three advantages to a biopsychosocial approach to medical education. First, the student can concentrate upon and practice the full set of skills which a physician needs to be an effective healer. Secondly, the future physician learns to appreciate patients not just in terms of their bodily dysfunctions, but as human beings with unique personal histories, acting within social and cultural milieus. Lastly, a biopsychosocial approach can lead to a collaborative, mutually beneficial partnership between the physician and patient. As a consequence, the medical student will be motivated to learn whatever is necessary to achieve the best diagnostic and treatment results for each patient.

Physician Communication Skills and the Biopsychosocial Model

In order to effectively apply the biopsychosocial model, a physician should possess the requisite interviewing and interpersonal skills. Physician IPS is directly related to patient satisfaction and recall of information, perception of physician competence, adherence with the treatment regimen, and rapport with other health practitioners (Engel, 1978). On the other hand, IPS correlates negatively with malpractice litigiousness and adverse patient reactions to potentially distressing procedures (Sanson-Fisher & Maguire, 1980). Essentially all of the effect of physician IPS upon adherence appears to be mediated by patient satisfaction and recall (Bartlett, Grayson, Barker, Levine, Golden, & Libber, 1984). Adherence in turn results in beneficial health outcomes. Thus, IPS is directly related to favorable physiological (e.g., lower blood pressure or blood sugar level), behavioral (e.g., functional status), and subjective measures (Kaplan, Greenfield, & Ware, 1989). Because of the association between IPS and health outcomes, and the inadequacy and dehumanization of traditional clinical training, IPS training programs have become an increasingly important component of medical education (Kramer, Ber, & Moore, 1989).

Factors Associated with Successful Physician-Patient Relationships

Before designing an IPS training program, it is necessary to examine the characteristics of physician-patient communication. Physician-patient relationships can be qualitatively classified according to their styles of communication. Physician communication styles were first described by Szasz and Hollender (1956), who identified three modes of physician-patient interaction: (1) activity-passivity, which is appropriate in emergencies; (2) guidance-cooperation, a disease-oriented approach which emphasizes compliance; and (3) mutual cooperation, characterized by egalitarianism, physician-patient partnership, and primary prevention (Hollender, 1958). Stewart (1984) described nine style typologies--dominant, dramatic, contentious, animated, impression-leaving, relaxed, attentive, open, and friendly. However, two primary communication styles, affiliation and control, are particularly relevant to health outcomes. Controlling physicians tend to be authoritarian, power-seeking, and professionally detached. On the other hand, affiliative physicians--who typically rate higher in patient satisfaction and compliance--tend to convey interest in their patients' welfare, friendliness, empathy, warmth, genuineness, candor, honesty, compassion, a desire to help, devotion, sympathy, authenticity, a nonjudgmental attitude, humor, and a sociable orientation (Buller & Buller, 1987). In addition, a consultative interviewing style encouraging active patient participation has been found to be associated with patient and doctor satisfaction, as well as positive health outcomes (Moorhead & Winefield, 1991).

Physician-patient relationships can also be analyzed in terms of the factors that are relevant to health outcomes. The interpersonal factors which are positively associated with health outcomes include patient control, patient information-seeking, conversational communication by the patient, and negative expression of affect--including tension, impatience, strain, misgivings, stammering, nervous laughter, frustration, anxiety, self-consciousness, anger, and role tension between the physician and patient (Kaplan et al., 1989). The therapeutic value of negative expression was an unexpected discovery. Expressions of tension and anxiety by either the physician or patient were found to be positively associated with patient satisfaction and compliance (Waitzkin, 1984). In contrast, another study found that while tension release by patients was positively associated with both satisfaction and adherence, expressions of tension by physicians were inversely related to patient satisfaction (Carter, Inui, Kukull, & Haigh, 1982). These results may be harmonized by the finding that adherence is maximized if the physician projects positive affect verbally while exhibiting nonverbal negativity, thereby signaling the seriousness of the need to adhere to the treatment, in addition to concern for the patient's welfare (Hall, Roter, & Rand, 1981). Therefore, good communicators, especially those with nonverbal adeptness, are more likely to engender both patient satisfaction and adherence (Waitzkin, 1984). Developing such communication skills is the purpose of IPS education.

Physician Communication Skills Education

Goals

The primary goal of IPS education is to provide medical students with knowledge and skills that will enable them to develop positive, mutually productive relationships with patients. There are at least four benefits to a positive physician-patient relationship: reduced malpractice litigiousness, a more pleasant clinical experience, improved diagnostic accuracy, and increased adherence. Patient satisfaction is the most frequent criterion for measuring the quality of the physician-patient relationship. A study of 800 out-patients revealed that 24% were grossly dissatisfied, 11% noncompliant, and 38% only moderately compliant (Sommers, 1985). Reasons for patient dissatisfaction include lack of friendliness, failure to consider the patient's concerns, and the use of medical jargon (Korsch, Gozzi, & Francis, 1968). Noncompliance is associated with distrust, unmet expectations, lack of warmth, inadequate diagnostic explanations, complexity in the prescribed regimen, and dissatisfaction with the physician-patient encounter (Francis, Korsch, & Morris, 1969). Therefore, IPS programs should focus on the techniques and processes by which physicians can augment patient satisfaction, thereby increasing adherence and positive health outcomes.

IPS education and the biopsychosocial model should be integrated into all phases of clinical training. According to a recent survey, the proportion of medical schools with curricula concerning physician-patient communications are as follows: interviewing, 83%; humanistic aspects of care, 44%; medical ethics, 43%; managing the dying patient, 41%; management of difficult patients, 40%; psychosomatic disorders, 39%; interviewing skills, 36%; sociocultural influences, 33%; patient education and prevention, 33%; countertransference problems, 26%; the impacts of stress on the patient (26%) and physician (25%); the biopsychosocial model, 24%; the doctor-patient relationship, 20%; assessing and improving compliance, 17%; interpersonal skills, 17%; empathy, 15%; and counseling, 13% (Markel et al., 1990). Each of these numbers should ideally approach 100%. An effective medical education program should inculcate humanistic, biopsychosocial, empathetic, and patient-centered perspectives throughout the interview training process (Novack, Dubé, & Goldstein, 1992). Furthermore, physician-patient communication skills should be taught systematically and sequentially, from simple to complex, and with frequent feedback and evaluation (Novack, 1993).

Research is needed both to describe optimal physician-patient communication and to determine the optimal methods of IPS education. However, the benefits of all but the most abbreviated IPS programs are already well-documented. Whereas graduates of traditional clinical programs demonstrate no improvement in their understanding of the emotional aspects of illness, students with IPS training are more effective diagnosticians (Barbee & Feldman, 1970). While students who received no IPS training were able to elicit 47% of available data and displayed 62% of optimal process skills, IPS-trained students elicited 76% of the data and demonstrated 86% of the process skills (Hutter, Dungy, Zakus, Moore, Ott, & Favret, 1977). IPS training is also known to be more effective if it is comprehensive (Kauss, Robbins, Abrass, Bakaitis, & Anderson, 1980) and ongoing throughout the medical education process (Engler et al., 1981). Nevertheless, the optimal IPS training methodology has yet to be developed, because most IPS studies: (1) are not blinded and controlled (Sanson-Fisher, Fairbairn, & Maguire, 1981), and (2) focus almost exclusively upon the content of the interview, as opposed to the emotional and process-oriented aspects of physician-patient rapport (Ward & Stein, 1975). The goal of future studies should be to quantify the health effects of specific behavioral units within the physician-patient relationship.

Training Objectives

An IPS training program is more likely to be successful if all of the learning objectives and evaluative criteria are explicitly defined (Cassata, Harris, Bland, & Ronning, 1976). For example, the IPS program materials should include a checklist of all skills and content areas to be mastered (Novack et al., 1992). The overall structure and function of the interview should be explained, including the therapeutic benefits of patient-centeredness and responsiveness to socioemotional concerns (Novack et al., 1992). Additionally, opportunities should be provided for practicing each interviewing technique until it is mastered. A list of interviewing techniques might include the following:

Greeting: Handshake, apology for waiting time, self-introduction (name, status, names of other health personnel), ask patient how he or she should be addressed, refer to previous visit (Foley & Sharf, 1981).

Orienting: Comfortable, propitious seating arrangement; clarify the purpose of the visit; determine and state time requirements; ask whether note-taking is permissible, and whether the patient is at ease; minimize distractions (Foley & Sharf, 1981).

Establishing rapport: Overcome sociolinguistic, cultural, and class barriers to communication (Waitzkin, 1984); convey integrity, respect, compassion (Markel et al., 1990); reciprocity, warmth (i.e., accepting the patient as a person), nonjudgmentalness, trust (Kason & Rothman, 1988).

Facilitation: Enhance information elicitation via encouragement; alternate exploratory, open-ended queries with clarifying (yes-no, short-answer, or multiple-choice) questions (Kauss et al., 1980); avoid leading, complex, and multiple questions; eliminate jargon; listen; maintain relevance; request patient opinions (Stewart, 1984).

Socioemotional expression: Provide encouragement, support, reassurance (Maguire, 1990); express empathy and understanding for patient's feelings (Evans, Stanley, Burrows, & Sweet, 1989).

Nonverbal communication: Be aware of and effectively use speaking style, paralanguage (speech tempo, volume, pitch, and pitch changes), body display (e.g., openness), and kinesis (eye contact, gaze characteristics, facial expressions, limb movements, posture, touch) (Foley & Sharf, 1981).

Discussion methods: Allow patient complete freedom of expression, pick up verbal leads and explore, clarify in depth, resolve ambiguities, encourage precision, avoid repetition, tactfully employ controlling behaviors (structuring, sequencing), handle emotionally loaded matters sensitively, periodically summarize (Foley & Sharf, 1981).

Discussion topics: Job, social activities, leisure activities, sex.

Psychosocial history: Major life experiences, personality, family, key interpersonal relationships, stressors (Stewart, 1984).

Patient education: Explain the diagnosis, provide counseling and advice, encourage preventive health behaviors (Novack, 1993).

Informed consent: Explain the advantages, disadvantages, and side effects of the proposed treatment plan and any alternatives (Maguire, 1990); negotiate and consensus-build (Stewart, 1984).

Establishing a long-term relationship (Novack et al., 1992): Monitor adherence, involve family in treatment, work toward family well-being (Engel, 1980).

Ending the interview: Summarize succinctly and accurately, ask for any questions (Maguire, Roe, Goldberg, Jones, Hyde, & O'Dowd, 1978); express appreciation; bring about an effective, clear closure (Evans et al., 1989).

Self-evaluation: Be self-aware throughout the interviewing process (Kahn, Cohen, & Jason, 1979); critically assess your interviewing performance, and note areas in need of improvement (Novack et al., 1992).

Empathy

The most important determinant of patient satisfaction and compliance is the degree to which a physician projects a genuinely caring attitude toward the patient (Woolley, Kane, & Hughes, 1978). Yet physicians have traditionally been taught to avoid empathizing with patients, in order to protect themselves emotionally from disappointing medical outcomes. Consequently, even after IPS training, medical students may measure no higher in empathy or nonverbal sensitivity (Evans, Stanley, Coman, & Burrows, 1989). On the other hand, only eight hours of training focused on empathy was found to be effective (Winefield, 1982).

Nonverbal Skills

Both skill in using nonverbal communication and in interpreting nonverbal cues from patients are important (Evans et al., 1989). It is surprising that nonverbal communication is often overlooked, since it is usually easy to learn and can have profound effects. For example, the simple practice of leaning forward is associated with patient relaxation, satisfaction, and recall (Larsen & Smith, 1981). Also, nonverbal cues can be used to tactfully interrupt the patient and redirect the interview (Evans et al., 1989). Audiovisual methods are particularly effective for learning nonverbal skills. Nonverbal phenomena can be simulated on videotape and practiced through visual modeling (Schoonover, Bassuk, Smith, & Gaskill, 1983).

Special problems

Students should not only acquire the standard interviewing techniques, but also the skills necessary to handle the less frequent and more problematic phenomena of physician-patient encounters. Among these skills are breaking bad news, handling uncertainty, reducing distress, dealing with anger, overcoming denial, establishing a dialogue with reticent patients (Maguire, 1990), and detecting and minimizing interviewer bias (Grayson, Nugent, & Oken, 1977).

Methods of IPS Training

IPS can be taught by a variety of methods, some more effective than others, and ideally in a multimodal program. A recent survey of interview training methods revealed the following: (1) the traditional methods of interview training--didactic presentation and shadowing (i.e., observing faculty with patients)--which were the only methods available at most medical schools prior to the mid-1970's, are still practiced respectively by 97% and 91% of medical schools, although only 57% and 24% respectively employ these methods on a regular basis. (2) The proportion of medical students receiving interview skills training with real patients has risen to 96% from 58% in 1977, and it is a major aspect of clinical training in 73% of medical schools. (3) Group discussions of interviewing and the doctor-patient relationship are now included in 88% of programs, and are regularly scheduled in 28% of schools. (4) Role-playing is also growing in popularity and is practiced in 76% of schools, although only 18% use it regularly. (5) The effectiveness of simulated patients is evidenced by the fact that while they are included in only 65% of programs, 35% now employ them regularly during clinical education. (6) Video and audiotaped feedback are provided respectively in 59% and 24% of schools, and 23% use videotape feedback throughout the clinical training process (Novack, 1993). The major methods of IPS training are presented below.

Mentoring and Tutoring

Traditionally, clinical training was based almost entirely on the observation of faculty physicians in classroom presentations and while conducting hospital rounds. Not only do these methods remain an important part of medical education, but mentoring and tutoring programs typically follow a similar paradigm. Mentors (Markel et al., 1990) and tutors (Price & Mitchell, 1993) can serve as role models during the clinical training process. However, one-third of tutors were found to be ineffective or detrimental to the academic atmosphere because they provided conflictual information; arrived late and departed early, or failed to show frequently; displayed anger; projected a patronizing attitude; demonstrated favoritism; or ridiculed students (Harth, Bavanandan, Thomas, Lai, & Thong, 1992). One-third of tutored students reported that they were mistreated by their preceptors on the basis of gender, appearance, religion, or race; unfairly graded; or subjected to public humiliation (Harth et al., 1992). These findings suggest that tutors should be selectively screened, trained in IPS, and evaluated regularly. Above all, an effective tutor or mentor must be able to provide encouragement and emotional support (Novack et al., 1992).

Multidisciplinary Small-Group Workshops

The chief advantage of workshops or discussion groups is that the student can receive feedback and advice from peers, faculty, and specialists in interviewing techniques. IPS training groups are most effective with eight or fewer students and a teaching team which includes a behavioral scientist, such as a psychiatrist (Kimball, 1970), educational psychologist (Cassata et al., 1976), social worker, community health specialist, medical sociologist, or medical anthropologist (Flaherty & Sharf, 1981). A team which includes a mental health professional and a communication specialist is even more effective. Students receiving IPS training with communication specialists demonstrated superiority in questioning techniques, appropriateness of words and phrases, perception of nonverbal behavior, and sociocultural awareness (Flaherty & Sharf, 1981).

Role-Playing

Role-playing or psychodrama may be applied within discussion workshops, or conducted by professional actors. Using "time-outs" at any desired times during role-playing sessions is especially useful in developing awareness of patient emotional needs (Coonar et al., 1991). Structured role-playing using hidden agendas is an effective way to teach biopsychosocial interviewing skills. The interviewee follows a scripted psychosocial history which the interviewer must evince in order to make a correct diagnosis. In learning how to uncover the hidden biopsychosocial issues, students develop patient-centered interviewing skills (Nathan, Hohmann, & Nusbaum, 1991).

Simulated Patients

Simulated patients are generally nonphysicians trained to act simultaneously as a patient, teacher, and evaluator of interviewing skills (Stillman, Burpeau-Di Gregorio, Nicholson, Sabers, & Stillman, 1983). One advantage of simulated patients is that they are less costly than physicians as IPS educators (Stillman, Sabers, & Redfield, 1976). Another advantage is that simulated patients are able to portray a variety of standardized patient situations, so that students can efficiently learn how best to handle each problem (Maguire, 1990). Furthermore, simulated patients can provide risk-free training in delicate matters such as bereavement and breaking bad news (McAvoy, 1988). Professional actors are probably the ideal simulated patients, because they can provide detailed feedback concerning both verbal and nonverbal skills (Coonar, Dooley, Daniels, & Taylor, 1991). IPS training is even more effective if simulated patients are paired with behavioral science consultants (Batenburg & Gerritsma, 1983) or videotaped feedback (Jason, Kagan, Werner, Elstein, & Thomas, 1971).

Successful IPS development depends critically upon the skills of the simulated patients. Also, simulated patients are more effective if they are available throughout the clinical training process. Hence, one year after a nine-week IPS training course with "screened" patients trained in interviewing skills, students showed a significant decline in their process-oriented skills (Engler et al., 1981). However, IPS improvements with simulated patients have generally been impressive. Fifth-year medical students who received interviewing skills training with simulated patients in their first year were found to be superior at caring, empathy, and listening. They were also more facilitative of patient expression, less confrontational, asked more open-ended questions, interrupted less frequently, and elicited more problem-relevant information (Davis & Nicholau, 1992).

Audiovisual Instruction

There are two primary applications of audiovisual media in interviewing skills training. First, audiovisual materials can be used for instructional purposes. Prerecorded materials can demonstrate how to handle a variety of physician-patient problem situations, and can be utilized in programmed instruction. In one successful example of programmed instruction, a series of films portrayed a variety of interviewing situations. At critical points, the interview was interrupted, the interviewer's options were presented, and the consequences of each choice were illustrated and explained by the narrator (Enelow, Adler, & Wexler, 1970).

Secondly, students can be taped during the course of practice interviews. These tapes can be used for self-instruction (Mason, Barkley, Kappelman, Carter, & Beachy, 1988), and replayed in group sessions for feedback from peers (Pilowsky, 1978), physicians (Scheidt, Lazoritz, Ebbeling, Figelman, Moessner, & Singer, 1986), and behavioral scientists (Engler et al., 1981). A study comparing traditional clinical training, practice interviews, interviewing with audiotape feedback, and interviewing with videotape feedback revealed that students receiving audio- or videotape feedback were most advanced in interviewing techniques, and all except the traditional training group significantly improved in the elicitation of accurate, relevant information (Brown & O'Shea, 1980). Videotaped feedback during didactic sessions was also found to strengthen interview organization and history-taking skills (Engler et al., 1981).

Other IPS Training Modalities

Storytelling

Storytelling can help students and residents to vent and overcome difficulties in the doctor-patient relationship (Hensel & Rasco, 1992).

Schools of Psychotherapy

The psychosocial dynamics of patient care can be better appreciated if students are exposed to the major psychotherapies, including behaviorism, gestalt doctrine, the Adlerian school, the rational-emotive approach, and reality therapy (Engler et al., 1981).

Independent Learning

Independent learning opportunities allow students to explore areas of special interest and exercise their creative potentials (Novack et al., 1992).

Future Developments

In the future, computer-assisted instruction (Ware, Adler, & Newman, 1974), virtual imagery, and robotic patients will be increasingly important methods for IPS training (Cline & Garrard, 1973).

Multimodal IPS Training

An IPS educational program is most effective if combining several training techniques. For example, the Harvard program includes shared autobiographies (i.e., telling life stories and career goals), mentoring, self-directed tutorials, preceptor shadowing, discussions of shadowing experiences, small group interviewing workshops with multidisciplinary faculty, post-interview discussion and feedback (problem-sharing), faculty development, and "inventing the interview." During the interview invention process, the student applies the biopsychosocial model to medical and social history-taking; emphasizes health promotion and disease prevention; and focuses upon the ethical, financial, and social coping concerns of the patient (Branch, Arky, Woo, Stoeckle, Levy, & Taylor, 1991).

Feedback and Evaluation

Because feedback and evaluation provide both motivational and didactical benefits, there is a direct relationship between their use and the success of IPS training (Carroll & Monroe, 1979). Unfortunately, medical interview assessments typically have low inter-rater reliability. However, tabulation of specific acts results in greater reliability than global assessments of interviewing ability (Scott, Donnelly, & Hess, 1975). Additionally, communication skills ratings are significantly more valid if done by numerous examiners on repeated occasions (McLeod, 1988). Furthermore, measures of interviewing skills tend to be more reliable and to have greater didactic value if performed not only by physicians but also by consumers and simulated patients--each of which provide unique perspectives on the physician-patient relationship (Thomson, 1993). Physicians should also be taught to evaluate their own performance (Novack et al., 1992).

Ancillary Support

The traditional medical education system resembles a physically neglectful and emotionally abusive family. Like such families, medical education is often characterized by unrealistic expectations, denial, indirect communication patterns, rigidity, and isolationism. Whatever feedback is provided tends to be blaming and punishing rather than nurturing, demanding perfectionism and lowering self-esteem. The inadequacy of honest, constructive feedback leads to the avoidance of supervision. Mistakes are regarded as shameful, and rather than triumphing over them most students fastidiously hide them away. Moreover, because of the need to falsely portray perfectionism and the consequent secrecy and isolation, the healing role of other professionals and health staff tends to be ignored (McKegney, 1989).

Because of these dysfunctions in health education, counselors and psychiatrists should be readily available to reduce distress and humanize the health care environment (Reuben, Novack, Wachtel, & Wartmann, 1984). Support groups are also strongly recommended, since they enable students to learn from their experiences, and engender appreciation of the psychosocial domain of medicine (Williamson, 1991). Balint groups are support groups in which a case is presented, then a psychodynamic expert helps the group to reflect on how the management of the case is related to their psychosocial concerns. The goal is to increase psychological well-being and self-knowledge, so that the participants will be better healers (Williamson, 1991). After all, therapeutic success is more likely if the health care provider is psychosocially well-adjusted and enjoys the interpersonal dynamics of clinical practice.

Recommendations Concerning Physician IPS Education

A major problem with the medical care system is its excessive focus on biophysical aspects of health. The remedy is to integrate biopsychosocial systems theory into every facet of the health industry. Secondly, health care providers need to be humanized. Such humanization is unlikely unless medical students are encouraged not merely to master biophysical information, but also to develop psychosocially. Therefore, interpersonal and interviewing skills education should be an ongoing process during clinical training. In addition, the personal growth of medical students should be fostered through discussion workshops and support groups. Furthermore, psychiatric and psychological counseling should be readily available to assist health care providers who have personal difficulties, or who need psychosocial advice in handling a problematic medical situation.

The medical education system itself may be in need of transformation. First, the role of the physician within the health care system should be reformulated. A positive step in that direction would be to increase enrollment in medical schools. A larger population of physicians would probably result in greater emphasis on primary care and preventive health, and in more egalitarian relationships with other health personnel. Secondly, medical education should be more humane. For instance, assigning medical students and residents to 48-hour on-call shifts is not only an outmoded, hazing-like ritual, but is also potentially dangerous to patients. Additionally, instead of constant, patronizing pressures for perfectionism, medical trainees should be given the necessary time to reflect on psychological and social concerns, both for their own growth and for the benefit of their patients. Thirdly, medical education should be multidisciplinary. Thus, clinical training programs should include behavioral scientists and communications specialists, particularly for IPS development.

A primary problem with the medical education system is the inadequacy of IPS training. This inadequacy stems from uncertainty about the value of IPS training, because very few controlled, blinded studies of IPS training have been conducted. Such studies could determine which IPS training methods and multimodal approaches are most effective. For example, an experimental design to determine the effectiveness of simulated patients might involve two experimental groups, one in which all interviewing is done with simulated patients, and another which interviews both simulated and real patients. The control group would obtain all of their interviewing practice with real patients. The research hypothesis might be that mean post-treatment interviewing skills ratings will be highest in the group which uses only simulated patients, and lowest in the group which uses only real patients. An experimental design to determine the optimal multimodal approach to IPS training might compare pre-and post-training interviewing skills of students exposed to simulated patients, videotaped feedback, discussion workshops, and support groups with a group exposed to the same conditions excepting support groups. Every medical school should be conducting such studies, because the results are vital in terms of both designing efficient educational programs and developing high-quality health practitioners.

CONCLUSION

A biopsychosocial health perspective is more effective, efficient, and humane than the traditional biomedical model. A biopsychosocial orientation is useful for health educators during their interactions with students, and for physicians during patient care. A biopsychosocial approach is particularly useful during patient interviews. However, to fully apply biopsychosocial strategies, physicians often need to improve their interpersonal skills. The benefits of interpersonal and interviewing skill development include fewer malpractice lawsuits, more satisfied patients, stronger adherence, and better health outcomes. Therefore, programs which enhance physician communication skills should be an integral part of the clinical training process. More controlled studies are needed to determine how best to teach interpersonal skills, but current instructional methods include simulated patients, group workshops, videotaped feedback, role-playing, and mentoring. These methods are likely to be more effective if part of a multidisciplinary, multimodal program. Physician interpersonal skill development is also more likely to succeed if support groups, psychiatrists, psychologists, and social workers are employed both as part of the clinical training program and to assist physicians when facing personal or professional difficulties.

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