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Teaching the intagibles

Learning technical skills and biomedical knowledge is important, of course, but there's much more to becoming a physician. The medical curriculum at Geisel offers students training in the less concrete aspects of the profession of medicine.

By Matthew C. Wiencke

Matthew C. Wiencke is the associate editor for Dartmouth Medicine.

With his strong, reassuring voice, Frank Macht, a chaplain at DHMC, has all the students' attention. Their cell phones, laptops, and iPads are all off and put away. Macht sits on the stage of Kellogg Auditorium and talks to Arnold Katz, an honorary professor of medicine and physiology at Geisel, whose warm, smiling face belies the struggle he has faced over the past decade.

In 2002, Katz explains to the students, he had massive pain in his back, hips, and ribs. It turned out he had extensive bone disease and many fractures in his skeleton. Soon after, he was diagnosed with diffuse non-Hodgkin lymphoma. In the years since, he has undergone numerous treatments, including seven courses of chemotherapy and surgery for peritonitis (a burst bowel). Although the cancer is terminal, with the support of his family, including his wife, Phyllis, and of oncologist Marc Gautier, Katz has had what he describes as "very good years."

Peter "Pano" Rodis has spent years finding ways to teach slippery concepts such as compassion.

Macht and Katz are joined on the stage by a panel of experts in end-of-life care that includes Manish Mishra, a psychiatrist at DHMC and ordained Hindu priest, and Timothy Siegel, a surgeon and palliative care expert. They are there as part of a course for first-year medical students called the Profession of Medicine, which introduces students to some of the complex issues they will face as physicians.

Talking to the first-year class, Macht offers some of the questions he uses when talking to a patient facing terminal illness: "Where is the spirit? Where is the soul? What is stirred on the inside, in the patient and in you?"

Katz tells the students, "The patient needs to have someone there for support to help you through the first few days dealing with the bad news, dealing with it physically, emotionally, spiritually." Gautier played that role in his interactions with Katz, helping Katz manage in the first few days after learning about his diagnosis.

As they talk on the stage, Macht tells Katz he can hear the pain in his voice, and that it affects him too. Turning to the class, Macht says, "how you position yourself with the patient is important," and he asks Katz permission to move closer to him. He moves his chair next to Katz, looks him in the eyes, and says he can hear his pain. "I want to put my hand on your hand," Macht says to Katz. The room is silent as the students watch Macht intently.

"People don't tend to express their feelings quite like that, but it's kind of refreshing," says Megan LaPorte ('17), one of the students in the class.

A difficult definition
Originally developed by Joseph O'Donnell, senior advising dean and a professor of medicine at Geisel, and Peter "Pano" Rodis, a clinical psychologist and researcher, the Profession of Medicine course centers on the human side of medicine, focusing on these questions: What is compassion? What is compassionate care in medicine? What is the heart of medicine? And how do you fulfill the vision of becoming a good doctor?

POM's roots are in Rodis's unique brand of research (he has a PhD in school and counseling psychology). He uses ethnographic and qualitative methods to understand the complexities of the individual and his or her subjective experience. In 2001 he published the book Learning Disabilities and Life Stories, in which he compiled autobiographical essays by college students with a learning disability who wrote about being labeled and their relations to their peers. This work led him to a project at DHMC working with adolescents with chronic illness, and then to a position as facilitator of the pediatric Schwartz Rounds at DHMC, where a care team and other clinicians and nurses discuss the emotional and logistical burdens of challenging patient cases. Soon after, O'Donnell asked Rodis to help develop and lead Profession of Medicine to bring additional compassion training to Geisel students.

Rodis says that compassion might sound like a simple concept, but, in fact, it can be a "pretty slippery" term. He describes compassion in medicine as beginning with a "profound respect for and interest in the other . . .who has fallen ill or suffered an injury." Yet it is more than just a feeling. "Providing compassionate care involves maintaining that interest and respect for the personhood of the person being treated and for the social worlds—their families to which they belong," he says. "Too often medicine is applied to the bodies of individuals without much interest or consideration of how those people are feeling at the time."

Geisel medical students Andrew Pintea ('17) and Vivienne Meljen ('17) visit with Arnold Katz at his Norwich, Vt., home as part of Geisel's Patient Partnership Program. Pintea and Meljen attended doctor's visits with Katz and learned about his treatment for non-Hodgkin lymphoma.

Both Rodis and Nancy Cochran, a professor of family medicine and longtime director of Geisel's On Doctoring course, stress that taking time for the patient's story shows respect for the person as a whole. Cochran tells students, "If you're meeting a patient for the first time, say, 'Tell me about yourself. What should I know about you? What are your goals for your care?' . . . I'm always fascinated at the answers people give you, because they don't relate to their diabetes or their heart disease, they relate to their grandchildren, their activities. . . . We're really trying to convey understanding that the patient's story is much bigger than simply the biomedical components of that story."

Teaching compassion
The Profession of Medicine course is a central component of that effort to teach the skill of dealing with patients compassionately. All first-year students take the course, which consists of four to six sessions a year. Each session begins with a presentation of a medical case by an interdisciplinary care team of providers and a patient. Students then discuss with each other and the care team issues related to the case and are guided by a facilitator as they explore elements of the case they find inspiring or difficult.

At one POM session last spring, Geisel faculty and Dartmouth-Hitchcock clinicians shared personal experiences related to anxiety, fear, and illness. Students discussed their reactions to the stories, and, with Rodis facilitating, how they might manage anxiety in a patient and anxiety in their own lives.

"When somebody shares their fear with us, what are they giving us?" asks Rodis, facilitating at the POM session. "They're giving us an opportunity for compassion . . . to do something that can be really beautiful and rewarding to them and rewarding to ourselves. We have the habit of keeping fear quiet. Why do we do that?"

Emmanuel (Manny) Aryee ('17) responds, "If you expose your vulnerabilities, people are very competitive and will figure out ways to use it against you."

"The showing of fear is the showing of vulnerability and somehow people will think less of us," Rodis says. "But do you think less of these people who shared stories of their anxiety? Be honest." The class answers no.

"Sometimes psychological pain and fear are very difficult for people to notice," says Aryee, who is interested in a career as an oncologist—both as a physician and researcher. "But if you [the physician] can find it, just reducing that does wonders for people," he says.

One of the faculty on the panel, Martha McDaniel, a professor of anatomy and surgery, shares a story from early in her career when she was the vascular surgeon on call at Dartmouth-Hitchcock. She had to treat a medical student who suffered a bad leg injury. During the days following surgery, it soon became clear that the leg would not recover, and that amputation should follow—an unhappy result for both the team and the patient. The patient seemed "leaden" and didn't react much to the prospect. McDaniel was sad and anxious.

"What I didn't know back then was how to calm myself down and to be mindful, in the moment," she says. "What I did know was how to work very hard, and my way of coping with the anxiety was to spend a lot of time with the student." Her strategy paid off when she discovered he was troubled with religious concerns that her team was able to address. She tells the students she was only able to do this because she spent quality time talking with him. It also helped her deal with her own anxiety and grief.

Finding balance
For students, achieving the right balance between learning the science side of medicine and making time for the human side—learning how to care for the whole patient—is a challenge. The science is extremely important, says Rodis, but often there's a tension between the two parts, between the head and the heart.

"I really appreciate that Geisel creates that tension and says this is important for you and throughout your career," says Sarah Kleinschmidt ('17), who took part in the POM course as a first-year student last year. "This is a human and humane profession."

Katz has navigated this divide in his own career, going back to his days as a student at Harvard Medical School. "Mainly I've been a scientist," he says. "I have clinical training, but my reputation is based on my scientific knowledge." Only recently, Katz says, has he come to appreciate intuition, which he learned in the 1950s at Harvard, from the chair of medicine at that time, Hermann Blumgart. "What we learned from him that first day, watching him deal with a patient with great compassion—he was the role model," he says. "You introduce yourself to the patient, . . . you shake hands with the patient. You see what the hands feel like, see if the patient grabs you, if the patient pulls away. You learn a lot that way," Katz says.

"Joe O'Donnell said you can do more good with compassion than you can with all of these chemotherapies. And I think he's absolutely right."

Compassion connections

Profession of Medicine is more than a single course. The program started with pilot projects in 2007, and it consists of several components for different years of medical school. First-year students take the course titled Profession of Medicine and a complementary class on the psychology of illness where they practice compassion skills through role playing.

The model for second-year students is called Connecting Hearts and Minds Rounds. Unlike Profession of Medicine, it is not a stand-alone course. Instead, the directors of second-year courses adopt it into their course once a year by having panel discussions that are often connected with a specific disease or a basic science topic the students are studying. Third- and fourth-year training, currently under development, will take values and pedagogies that inform POM in the first two years and work them into the clinical clerkships. In the fourth year, students will focus on strategies and tools for easing patient suffering.

POM is complemented by a program at DHMC, started in 2009, named From the Other Side of the Stethoscope (FOSS). Students participate in FOSS during their pediatrics clerkship. They write a reflection on a challenging encounter with a family in which there was a question about the best way to offer compassionate care. Students share their reflections with the other students, and with a group of parents with children who have special health-care needs, called "family faculty." The family faculty discuss the reflections with the students. "There are these incredible discussions where students say, 'I tried to break the bad news this way, was that the right way?'" says Steven Chapman, as assistant professor of pediatrics at Geisel who is involved in the course.

This fall marks the start of a new compassion-centered program called Reflection Rounds, which is part of the third-year surgery clerkship, led by Timothy Siegel, a Dartmouth-Hitchcock surgeon who is trained in palliative care. Students in the clerkship will meet weekly with Siegel, a chaplain, and a spiritual care nurse to talk about their own spirituality, "the spirituality of their patients, and their patients' families as a way of connecting to their patients," says Siegel.

Working with FOSS and Reflective Rounds, Rodis and his colleagues plan to develop POM into a continuous training program in compassion-centered care at Geisel that will run from the first year of medical school through the training of residents. Much of their future planning—expanding the Profession of Medicine course and Hearts and Minds Rounds and integrating compassionate-care training into third-year clerkships—is funded by a grant from the Dolan Family Foundation. More broadly, the Dolan grant is funding creation of The Center for Training in Compassion-Centered Medical Care at Geisel, Dartmouth College, and DHMC.

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