Every Monday during my first year of medical school I joined a team of psychiatrists for Introduction to Clinical Medicine (ICM)—a course focused on developing patient-communication skills. While similar courses abound across the country, I found myself initially doubting the possibility that a class could make someone a better communicator. Wasn’t this an innate skill, like artistic or athletic abilities? For med students, who have given so many presentations and taken part in so many interviews, how much better could we get?
In ICM, I shadowed several psychiatrists. Most impressive was “Dr. E,” whose bedside manner appeared confident but approachable, realistic yet always reassuring. If he could pass along some of his savoir faire, it would certainly disprove my belief about the innate nature of communicating with patients.
As I followed along, I noticed that during the first several minutes of any patient interaction, Dr. E never looked at his clipboard or touched his pen. Instead, he inquired about family members, or asked about a patient’s recent trip out of state. Before rushing to jot down details, he simply listened, nodded his head, and asked follow-up questions.
Observation and Communication
A few weeks into the rotation, we met a troubled, intractably reticent teenage girl. Dr. E was struggling to get her to talk; she made a few grunts of affirmation when asked about her home and family life. That’s when Dr. E asked her about rap music. Noticing the name of a concert on her sweatshirt, he made the leap.
“So, you like rap, huh?”
“You wouldn’t know ’em.”
“Ooh, nice. How about 21 Savage?”
“How’d you know?”
“I just had a feeling. So tell me, other than music, what do you do for fun?”
Instantly, the girl’s eyes lit up. Starting with her favorite rappers led to her sharing some of her homemade beats. In turn, this led to her trusting the psych team and her eventually accepting its recommendations for treatment and therapy.
Another time, Dr. E struck up a conversation with a patient about Japanese anime and got the patient talking about his own favorite shows and comics.
I watched Dr. E with other patients and marveled at how adeptly my preceptor pinpointed a patient’s passion and was able to elicit the patient’s excitement—and develop trust. When I asked him how he managed to communicate so adroitly, he encouraged me to be observant and to remember that each patient arrived at the hospital with a different background—and therefore required a different set of questions.
This advice seemed more daunting than instructive, though. What if a patient didn’t have a passion? What if I didn’t know anything about the patient’s area of interest, and made the relationship worse by appearing out of touch and naive? Dr. E’s brand of communication seemed to demand a near-encyclopedic knowledge of pop culture, geography, and history. My doubts grew. Perhaps Dr. E was one of a handful of the conversationally gifted, and I was doomed to mediocrity.
Big Answers from “Small Talk”
As I shadowed other psychiatrists, I came to understand that each had a unique style of connecting with patients. One used jokes and slang to build rapport. Another built bridges to patients using sports.
These questions were more than filler, though; they served a purpose in the mental status exam. Asking patients what they liked to do for fun (or what they used to do for fun) could help the physician evaluate anhedonia or a patient’s level of social engagement. Asking about sports could also help the doctor gauge a patient’s state of mind. If someone claimed to be a Yankees fan, but the last good player the patient could remember was Lou Gehrig, it was a red flag.
At the beginning of the year, I often wondered whether these conversational nuances were mere banter—the ordinary small talk we all engage in. This wasn’t what doctors did, was it? But as my ICM rotation progressed, I realized that these interactions had big implications. Showing sincere interest in another person tears down what can appear to be a mechanical interaction and is a foundation for the humane art of healing.
With these precepts in mind, and after a bit of practice with Dr. E, I found that my initial doubts about my ability to improve at patient communication evaporated. It did not matter if I didn’t know everything about rappers or anime; that’s where asking questions, and listening keenly, came into play. In fact, Dr. E told me he didn’t listen to rap or watch cartoons. He wasn’t an expert in many of the subjects he discussed; instead, he had picked up precious details about these references from conversations with previous patients. Dr. E stressed the importance of “being curious” about one’s patients. If I was truly interested in the person in front of me, my attempts at connecting could never be construed by a patient as a mere checking of boxes. Although I am not yet a doctor, I appreciate the natural power imbalance that exists between the people wearing the white coats and those wearing hospital gowns.
As ICM progressed, I developed my own approach to patient connections. My goal was to learn from the patients and create opportunities for them to teach me things about which they were experts. In a patient interview, one of my preceptors and I spoke to an elderly woman with depression. She stated that she had previously worked as the manager of a Mexican restaurant. I tried to use this detail to help the patient open up, asking friendly questions about her former profession. “What was it like to run a restaurant?” “What is the secret to making really good fajitas?”
I wanted her to share her knowledge with us. Until that point in the conversation, she might have been feeling clueless as we rattled off a litany of antidepressant names and mechanisms of action. But with the tables metaphorically turned, she became more comfortable with the situation.
Of course, such rich and serendipitous conversations will not always occur. Indeed, some patients simply may not want to talk freely about their lives. Still, I believe that communication in all of medicine demands this level of observation, empathy, and personal inquiry. For most patients, even if they are not ready to respond, I believe that a physician’s curiosity is a sign of good faith and a refreshing reminder that the doctor is, and will always be, human.