Unteachable Things Hard To Teach, Study Suggests

From Journal of the American Medical Association: About 500 doctors (and a handful of nurses) in training participated in a randomized controlled trial on communication skills. Half received thirty hours of intensive state-of-the-art communication skills training; the other half didn’t. Then they all saw a bunch of patients with really serious diseases, who rated the quality of the care they received. Doctors who got the training were rated no better than doctors who hadn’t, and in fact did significantly worse on the secondary outcome of how depressed their patients became about their illnesses. So even very very good communication skills training seems to have either zero or negative effect.

I would like to note for the record that I totally called this one.

To be fair, there is a large body of contradictory research. And if someone challenges me in the comments, I’ll be happy to go over why I trust this study more than some of the others.

But you know who agrees with me here? The New York Times. Their analysis is very, very close to my own heart:

In response to the growing recognition that effective communication with patients is a basic competency of our profession, and that doctors often have inadequate training in it, medical schools and hospitals have invested substantial resources over the past decade to teaching communication skills. […]

But can giving doctors a script for empathy actually make them more empathetic? Our patients know better. […]

Perhaps those residents participating in the study were too early in their training to lead these sorts of difficult conversations and participation in the study emboldened them in inappropriate ways.

It is also possible that, as we devote more time to teaching students and doctors effective communication techniques, we risk muting their authentic human voices, and instead of learning to connect they apply rote tools and scripts.

No communications course will magically transform lifelong introverts to hand-holders and huggers. At the same time, we must ensure that we are not converting people who genuinely care about their patients into people who only sound as if they care. Having physicians sound like customer service representatives is not the goal.

For those doctors who are emotionally challenged, communications courses can provide the basics of relating to other human beings in ways that, at the very least, won’t be offensive. But for the rest of us, we should take care to ensure the techniques and words we learn in such courses don’t end up creating a barrier to authentic human contact.

The doctors who wrote the NYT article (one of whom runs a leukaemia clinic! Talk about jobs that require communication skills!) go on to describe a horrendous communication skills class they attended, which somehow ended up being taught by a doctor who was legendary in the area for his total lack of communication skills and human empathy.

This, too, was close to my own heart. When I work with a new attending, I will very often check them out on ratemds.com or healthgrades.com to see what their patients think of them. These sites are not very valuable on the margin; you do sometimes get one guy who had to sit in the waiting room a little too long going on a personal campaign to destroy someone’s reputation. But on the tails, if there’s a doctor who is universally hated by every single one of her patients, this can be a strong warning sign.

And so when some of my attendings try to “correct” my communication style or give me helpful tips for “how to make patients like me”, it sometimes takes everything I’ve got not to retort “I think I’m going to limit myself to taking advice from doctors with better than a 1.0/5 stars patient rating.”

The doctor I’m working for now has a better than 1.0/5 stars patient rating. In fact, he has a 5.0/5 star patient rating. He has not tried to give me any advice on communication skills, which I am starting to notice is a common thread among doctors with excellent communication skills. But I have been trying to absorb what I can through osmosis.

Yesterday I watched him diagnose a woman with very advanced metastatic lung cancer – pretty much a death sentence. He showed the patient a CT image, told her she had cancer, and pointed out the location of the primary tumor in the right mainstem bronchus. Then he started talking about the anatomy of the bronchial tree.

The bronchial tree, for those of you not lucky enough to know, is the system of airways that gets oxygen into the lungs. It starts with the trachea, or “windpipe”, which divides at an area called the carina – around the level of the fifth thoracic vertabra – into the right and left mainstem bronchi. These bronchi then divide into smaller bronchi, which themselves divide into structures called “bronchioles”…

…and there is no point in continuing because by this point you are asleep. I do not blame you. No human being on Earth cares about the anatomy of the bronchial tree. I voluntarily went into medicine and even I have to make an extraordinary effort of will not to immediately change the subject to something less mind-numbing. If a communications skills tutor saw you discussing the anatomy of the bronchial tree immediately after diagnosing a patient with metastatic lung cancer, she would arrange to have you shot.

And I was thinking about this later, and I realized that what my attending was doing was providing white noise. If he had done the proper Communications Skills thing and said “And how does this make you feel?”, our patient would have been put on the spot. We would have been demanding some kind of coherent reaction to the diagnosis, and how in the world are you supposed to react to that five seconds after hearing about it? And if my attending had asked her if she needed a few minutes to collect her thoughts, she would have been socially obligated to say no, because it would have made her look weak and wasted a busy doctor’s time.

So instead he started talking about all this anatomical stuff, stuff that no human being could reasonably be expected to listen to, and it was his way of saying “Go on, tune me out, pull yourself together, and then when I’m done we can have a discussion about cancer and what to expect from it.”

And it worked. I’m not saying there aren’t ninety-nine ways this could have gone horribly wrong, but in this case and for this patient, it worked. And he knew it was going to work because he’d been seeing this patient for twenty years.

And I have no particular moral to this anecdote, or thoughts about how it relates to teaching communication skills. I just thought it was interesting. But…

Economist James Miller recently gave the following advice to LW college students pondering lucrative earning-to-give careers:

If you have a high IQ and are good at math go into finance. If you have a high IQ, strong social skills but are bad at math go into law. If you have a high IQ and a good memory but weak social skills, become a medical doctor.

There are a couple of different ways to have weak social skills. There is the way where you’re scared of large groups and being the focus of attention. There is the way where you dress unfashionably and smell bad. There is my personal preferred way, which is to have no idea what to do at a party and end up sitting in the corner really awkwardly and not being invited back. But there’s also the way where you consider human emotions an annoying inconvenience and prefer to just plow through them like a rhinoceros in a china shop.

If you are the last one, and you insist on going into medicine, do everyone a favor and become a pathologist, a radiologist, or a surgeon who works with a really good anesthesiologist.

Because communication skills classes won’t save you.