Teaching and Learning Moments

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Using fresh tissue dissection to teach human

Teaching and Learning Moments

The Teachable Moment
Two students, Stephen and Peggy,
were ready to do their videotaped
interviews to demonstrate the
fundamental skills and tasks of a
medical interview with a standardized
patient. Stephen, appearing shy,
reluctantly agreed to go first while
Peggy and I watched through the
video monitor.
Stephens interview went smoothly
until the patient said emphatically,
Well, certainly when I started having
so much trouble breathing, I was really
very scared! Although Stephen asked
some good clarifying questions, he
never responded to the patients
repeated statements of anxiety. He
continued being extremely professional
and thorough, but never showed a
scintilla of compassion or empathy,
verbally or nonverbally, to the patients
repeated statements of fear.
After the interview, I knew we needed
to pursue this empathic black hole. I
had an exasperated muffled scream in
my headbut didnt you see my
lectures and videos on relationship
building and empathy? Or observe
your peers demonstrating this? WHAT
HAPPENED? But, instead I went with
an analogy, often a useful strategy
when covering more directive assaults.
I asked Stephen: When you are really
nervous about an upcoming test, how
would you respond if I simply asked
you more details about the test?
Stephen responded Oh, Id feel much
better than if you said: Yeah, I can see
how youd be nervous. I would never
want someone to acknowledge my

958

fears. I would think that means there

truly is something to be fearful of. It
would only confirm to me that I should
be scared.
LIGHT BULB! Now I understood. We
had totally different frames for making
empathic statements. I could lecture all
I wanted, demonstrate examples
galore, include patient testimonials,
but until I understood Stephens
perspective, it was useless. Students
arrive with their own experiences of
communicating in their families of
origin, which often dictate their
inclinations towards exploring
emotions, dealing with conflict, etc.
But, there is little time to really dig and
understand the students map of
communicating. Without exploring
these maps and comparing them to
the official communication map of
the schools communication model, we
are often missing a rich opportunity for
more authentic integration of skillful
medical interviewing. Stephen, Peggy,
and I discussed the different ways
people respond to emotion, to anxiety,
to conflict. Stephen offered his
personal preference for avoiding
acknowledgement of difficulties,
thinking acknowledgement only
amplifies or legitimizes the fear. We
didnt disavow Stephen of his way of
dealing with these situations for him.
We posed the possibility of many
patients hoping for some empathic
comment, some witnessing of their
fear or suffering. This discussion was
full of personal discovery.
Stephen went back into the room. We
rewound the patient to where she

first said her fears. This time Stephen

tried the alternative way of
respondingstill not sure it was the
best approach, but willing to give it a
try. This time Stephen responded to
her concern. Despite the awkwardness
he felt inside, it appeared natural and
well integrated. Stephen came back
into our room and was more animated
than I had ever seen him.
Every time I see Stephen in the hall
since this experience, we have a
knowing exchange. He is a caring,
kind, and compassionate student. I am
now confident he will convey that to
patients in a way that feels more and
more genuine. Hell still be doing it in
a self-conscious manner, knowing its
not how he would necessarily want it
done to him, but he had the
unforgettable experience of clicking
with a patient who did benefit from
the empathic approach.
I asked Stephen soon after that
experience how he would feel if I
wrote up what I had learned from this
experience. He encouraged me to do
so. I still am wrestling with the best
ways to tap into the students own
map. Ill continue to think more about
that.
Acknowledgments
The names have been changed to protect the
confidentiality of these individuals.
Kathy Cole-Kelly, MS, MSW
Ms. Cole-Kelly is a professor of family medicine
and director of Communication in Medicine
Program, Case School of Medicine, Cleveland, Ohio.

Academic Medicine, Vol. 81, No. 11 / November 2006