“The core skills of being a physician,” observes Dr. Peter Marzuk, a professor of psychiatry and the Gertrude Feil Associate Dean of Curricular Affairs, “are what they probably were 500 years ago—talking to patients and the laying on of hands.” At Weill Cornell Medicine, physician educators pass on those essential skills—connecting with patients, taking a comprehensive history, conducting the physical exam—while preparing students to practice medicine in a modern era marked by scientific innovations and rapid change. But as technology takes on an ever-larger role in healthcare, the doctor-patient relationship will only become more vital. And the Weill Cornell Medicine curriculum is continuing to evolve to meet the challenge—educating future physicians in how to use every resource in their arsenal to give patients the best, most compassionate care modern medicine can provide. As a new academic year begins, Weill Cornell Medicine asked faculty and alumni physicians to contemplate the essential things that today’s doctors need to know—the kinds of key skills that Weill Cornell Medical College is teaching its students about how healthcare is delivered in the 21st century, and what today’s patients need. “Regardless of what the healthcare system looks like, or how technology enhances clinical care, the patient-clinician relationship will remain a focus,” stresses Dr. Yoon Kang, the Richard P. Cohen, MD, Associate Professor of Medical Education and director of the Margaret and Ian Smith Clinical Skills Center. “Our foundation of core clinical skills is never going to change— because it can’t.” Empathy and Connection Are Essential As Dr. Keith LaScalea, associate professor of clinical medicine, notes, “The literature is rife with evidence that suggests that the more you’re connected to your patient—the more a patient trusts their doctor—the better they’ll adhere to their treatment plan. It’s not enough to tell people to do things; when you partner with them and they trust you, it works better for the patient.” Weill Cornell Medicine students get a grounding in the importance of connecting with patients from day one with the Essential Principles of Medicine course, which teaches not only basic scientific concepts but core clinical skills and the fundamentals of physicianship. “It’s so important to listen to your patient, to look them in the eye,” says Dr. Shari Midoneck, MD ’89, an internist and Weill Cornell Medicine clinical associate professor of medicine, “to meet them where they’re at, whatever that situation is.” Dr. Stuart Mushlin, MD ’73, an internist at Brigham and Women’s Hospital and president of the Weill Cornell Medical College Alumni Association, is a firm believer in the importance of the hands-on physical exam as a point of connection between physician and patient, even—or, he says, especially—in an era when so much of practicing medicine entails ordering tests. “Nothing can replace the shamanistic act of touching people—or in the hospital setting, sitting on their bed, with permission, and either examining them or just holding their hand,” he says. “I think it has important anthropologic meaning, and it shouldn’t vanish, but it takes time. Our job is to be, to the best of our ability and knowledge, healers.” You Have to Be Able to Translate Complex Information to Patients As Dr. Mushlin puts it simply: “If you’re a clinician, you have to make sure that when your patient is leaving, they understand what you were talking about.” Dr. Kang notes that when Weill Cornell Medicine students work in the Smith Clinical Skills Center—where they conduct simulated encounters with trained actors, called “standardized patients”—they receive a checklist that stresses the importance of avoiding overly technical terms. Another good habit that students are encouraged to adopt, Dr. Kang says, is “always allowing patients to ‘ask the last question,’ to confirm understanding of the discussion and agreement with the management plan. As medicine becomes more complex, that’s going to become more and more important.” And it isn’t only a matter of couching scientific concepts in a way that laypeople can understand. Dr. LaScalea points out that even the seemingly straightforward suggestion that a patient exercise more needs precision and clarification to be most effective. “You should actually write down on a prescription pad what you want the patient to do,” he says. “You’re not just saying, ‘Exercise is good for you.’ You’re saying, ‘I want you to commit to walking a mile a day and doing 20 pushups every other day’—translating a broad concept into a specific skill. Then you put it in their chart, and when your patient sees you again, you ask, ‘How did it go?” You’ll Be Caring for People with Different Backgrounds, Beliefs, and Opinions from Your Own As America has grown increasingly diverse, the issue of cultural competency has become more important in society in general, and in medicine in particular. In the clinical sphere, cultural competency is the ability to understand and appreciate the differences (be they due to racial, ethnic, socioeconomic, religious or other factors) that can affect a patient’s healthcare experiences and outcomes—for example, understanding that a person from a disadvantaged household might have trouble finding transportation to medical appointments, or that certain religious beliefs might guide a patient’s treatment choices. The concept has been part of the Weill Cornell Medicine curriculum for years—both in the classroom and on the wards—and this summer, a new student-faculty task force has been charged with examining how it can be better taught. Students learn culturally competent approaches to patient interviews and management through didactic sessions and case-based discussions, and apply them during standardized patient sessions and through patient care activities. “We are so blessed to live in the most diverse city in the world, to have such a rich and diverse patient population with whom students are able to engage as part of their clinical curriculum,” says Dr. Kang, noting that “as we work more with our clinical affiliates in Queens and Brooklyn, there will be an increased spectrum of patient care opportunities for our students.” Practicing Medicine Is a Team Sport “Doctors are increasingly just one of many providers in the healthcare system,” says Dr. Marzuk, “so being able to work with other professions such as physician assistants, nurse practitioners and social workers is going to take on even more importance.” At Weill Cornell Medicine, students learn that lesson in myriad ways; for instance, during the medicine clerkship, they spend a day working solely with a nursing team. And they’re exposed to how teamwork enhances care as part of the LEAP (Longitudinal Educational Experience Advancing Patient Partnerships) Program, a required part of the curriculum that assigns students to follow specific patient cases throughout their education. As Dr. LaScalea notes, the program includes sessions in which a complex patient case is presented, and representatives of the entire care team—from areas such as nursing, medicine, physical and occupational therapy, social work, and even the clergy—weigh in. “Each person talks about their various piece,” he says, “and how they can benefit the patient as they’re going through their care.” Dr. Kang notes that as patients spend less time in direct encounters with their doctors, the role of these non-MD clinicians will become even more prominent. “We have to be really effective in how we interface with all providers,” she says, “to ensure that we’re collaborating to give patients the very best care.” Know When to Use Technology—and When Not To As Dr. Midoneck notes, information technology has greatly enhanced care—from the ability to consolidate a patient’s entire history in an electronic record to the ease of looking up a potential drug interaction in seconds during an appointment. “But at the same time, it interferes with the doctor-patient relationship,” she says, “because you’re typing away as you talk to your patient, and you’re not looking at them.” The question, she says, is, “How do we responsibly use technology to improve what we can do for our patients, but at the same time feel like we’re present in that interaction?” One of the lessons that students receive in the Smith Clinical Skills Center is the importance of making direct eye contact when asking questions, Dr. Kang says—“but even more importantly, at the beginning of the encounter, if you’re going to use electronic medical records, lay out this expectation up front and say, ‘It’s not that I’m not paying attention to you, but I would like to capture what we’re discussing accurately in your record, so I’ll need to type.’” Dr. Marzuk teaches his students that the beginning and end of a patient encounter are often the key moments. “That’s when you don’t want to be using technology,” he says. “When you’re greeting the patient and establishing rapport, you want to have a personal interaction. And at the end—when you’re counseling a patient, giving them advice or dealing with bad news—that’s the point not to be looking at your computer screen. It’s common sense; the computer is useful for gathering and organizing information, but these key points are times to step away from it and interact.” The Digital Age Offers New Ways to Help Patients Take Charge of Their Own Health and Wellness As part of an elective called Foundations in Lifestyle Medicine, Dr. LaScalea teaches medical students how to help their future patients make positive changes in their daily habits regarding sleep, exercise, diet, stress-reduction and more. From the beginning, one element has been counting how many steps they take each day (though since today’s smartphones are equipped with accelerometers, he no longer has to hand out pedometers). Today, step counting is just the most basic way that patients can monitor their own activity and health metrics. Gizmos like the Fitbit and Apple Watch can track various forms of exercise; wearable devices can monitor heart rate or blood sugar; and myriad apps help guide everything from healthy eating to mindfulness meditation to post-surgical recovery. “Clinicians will have to help patients adjust to the fact that some of their care is going to be much more in their own hands,” says Dr. Kang. “A lot of the new clinical tools are self-management tools, and an ongoing focus in our curriculum will be to familiarize students with these technologies and how they and their patients might utilize them to enhance management of a given condition.” Practicing Medicine Means Being a Lifelong Learner As Dr. Mushlin puts it, medicine “is a commitment and a calling”—and one of its fundamentals is that a physician is never done learning. For one thing, of course, medical science is constantly evolving and expanding, and continuing medical education courses are an inherent (and required) part of the profession. “At some point, there are going to be topic areas, procedures and technologies where the most seasoned attending will be learning it at the same time as the students,” says Dr. Kang. “The most important thing we can do is give students the tools to apply new data and advances effectively.” One key concept that Weill Cornell Medicine has promoted in recent years is “self-directed learning”; in contrast to traditional lecture courses, students are expected to come to class having absorbed key concepts, ready to take their understanding to the next level. And, as Dr. Marzuk notes: “The students really become lifelong learners when they get to the wards and they’re confronted with real patients who don’t exactly follow the textbook, and they have to be inquisitive and figure out the best way to help. We try to teach them how to find information that’s authoritative, efficiently and quickly—either in real time, or when they get home that evening and have to ponder a complex case.” The Rise of Telemedicine Will Demand New Skills Telemedicine—in which patients consult with care providers over video chat, apps or other interfaces—is becoming more and more popular. That shift has given rise to new aspects of medical education, as students learn specialized skills for examining and connecting with patients remotely— developing what Dr. Kang has called “webside” manner. In the Smith Clinical Skills Center, a specialized checklist offers tips (such as making sure to stay in the camera frame), and the Department of Emergency Medicine hosts a two-week elective in telemedicine using remote standardized patient encounters. As Dr. Kang notes, such communication skills are increasingly essential in various arenas; for example, fourth-years applying for emergency medicine residency nationwide now have to do web-based video interviews in which they receive written questions and have three minutes to record their responses in front of the camera. “As telemedicine and virtual healthcare modalities increase, students are going to need even better core clinical skills related to communication, interviewing and history-taking,” she says. “Once we put any technical platform between the provider and the patient, it becomes even more critical that those skills are nuanced and effective.” Precision Medicine Is a Game-Changer In many ways still in its infancy, precision—or “personalized” medicine—has the potential to revolutionize healthcare. In precision medicine, a patient’s care is guided not only by understanding of their disease’s general principles, but by their own individual case—informed by such factors as genetics, family history and data on the outcomes that specific treatments have had in similar patients. (An early example, Dr. LaScalea notes: the identification of the BRCA genes, which carry increased risk of breast and ovarian cancer, and may prompt patients to have their breasts or ovaries removed as a preventive measure.) Today, doctors treating patients with certain types of cancer can make decisions about whether to prescribe radiation or chemotherapy—and if so, which drug—based on analysis of the patient’s particular tumor. “In precision medicine, patient education and counseling become increasingly important,” Dr. Kang observes. “As we’re able to individualize healthcare, that’s a very different dialogue than we’re used to having. Interpreting that scientific data, coupled with taking into account a patient’s preferences, then integrating it into a completely personalized plan—it’s a much more complex discussion.” As she and Dr. Marzuk note, it’s not so much a question of teaching students the details of all precision approaches—although in their future practice, they’ll be expected to keep abreast of such options in their individual specialties, in part through self-directed learning—but putting it into the context of core clinical skills. For instance: how do you explain to a patient that despite the promising headlines, there’s no precision approach for their disease? “We already teach the students counseling skills in the context of some of the clerkships—issues like talking to patients about losing weight, breaking bad news, or when someone wants a certain medication and it’s not right for them,” Dr. Kang says. “The communication skill set is not that different.” Remember to Take Care of Yourself In the past, says Dr. Dana Zappetti, assistant professor of medicine and associate dean for student affairs, “there wasn’t a lot of education in medical school about self-care. We tell our patients to do a lot of things that we don’t practice ourselves.” Several years ago, Weill Cornell Medicine launched Well at Weill, a multi-faceted program aimed at instilling healthy, sustainable habits in future doctors. It offers a variety of activities including lectures, an advising system that matches students with early-career physicians, peer-to-peer counseling and events promoting wellness activities. The messages, she says, include the importance of keeping up with your own healthcare maintenance, recognizing signs of potential burnout, taking time for exercise and family—and even basics like not skipping lunch. “The responsibilities of being a physician are many, and there’s a long-standing culture of self-sacrifice, which the students and most of us who practice still feel,” Dr. Zappetti says. “We really do believe the patient comes first—but you have to figure out how to keep yourself well, while taking good care of your patients.” Source
