October 1999 Bulletin

Doctors learn to SEGUE to good communications

Actors. Videotapes. Role-playing. Omnidirectional microphones. Closed-circuit cameras. Although Northwestern University in Evanston, Ill., has a well-known theatre department, you'll find all of the above-mentioned learning tools at the university's medical school.

First-year medical students at Northwestern utilize these tools while learning how to break the news to a patient that he has cancer, screen a female patient for potential domestic violence or put a child at ease during a routine check-up. The 12-week communications skills unit is just one component of the school's two-year "Patient, Physician and Society" course.

"With this course, we're acknowledging early on that difficult situations will arise," says Gregory Makoul, PhD, director of the program in communications and medicine. "The students certainly won't master their approach to such situations, but they can see what it feels like. We provide a safe environment for the students to try out different approaches, and to identify their strengths and weaknesses."

Northwestern utilizes the SEGUE framework for teaching and evaluating communication in medical encounters. (SEGUE is an acronym for Skills needed to set the stage, Elicit information, Give information, Understand the patient, and End the encounter.)

"The SEGUE framework is key, because it's a flexible framework, not a script," Makoul says. "Our job is to help the students to develop a repertoire of skills and strategies that can be used when tailoring their approach to different patients and situations."

Charles Carroll, IV, MD, an orthopaedic surgeon who has served as a course instructor for the past four years, along with his partner David Kalainov, MD, says, "People don't expect surgeons to want to talk, or to know how to talk. I want to play a role in changing that. I started hearing about the importance of talking to your patients in the early 1980's, before it became de rigueur. One of the former chiefs of medicine at the University of Maryland, Theodore Woodward, MD, really stressed communication skills."

Dr. Carroll teaches a group of 10 to 12 students, highlighting the communication tasks set out by the SEGUE framework, and discussing skills and strategies for accomplishing them. "I try to flesh out the material with examples from my own practice," he says. "I tell stories about my interactions with patients-what's worked and what hasn't."

In addition to lectures, the students see a different patient-instructor each week-a person trained to portray a patient and give feedback on students' communication skills and strategies. While the patient-instructors pretend to have the same biomedical problems throughout this phase of the instruction, they change their demeanor (e.g., they are timid, frightened or angry) and psychosocial profile (e.g., their living situation, work and relationships) as they interact with the different students in their group. This allows the students to interact with a diverse sample of patients.

Students receive immediate feedback from their patient-instructors and their peers, and all sessions are videotaped so that the students can review their verbal and nonverbal communication during the encounters.

Do the students take this instruction seriously?

"They understand the concept that improved medical communication will make them a better doctor," says Dr. Carroll, "and they respond to that. Most take it seriously, but of course their interest level fades in and out by virtue of what biochemistry test is coming up. The real challenge in teaching a course like this is getting those students who are more introverted to speak up, and those who talk a lot to talk less."

Before they can be successful in communicating with patients, Dr. Carroll says, the students have to learn to be comfortable enough to ask difficult questions-deeply personal questions-of another human being.

"They have to learn to focus on the person in front of them and be comfortable with that person, which is hard. They also have to be sensitive to cultural issues and the education of their patients, for example, in order to tap into the patient's understanding of their problems. They have to be sensitive."

Is the first year of medical school too early to learn these skills?

"It's only a worry if the skills are not reinforced," says Makoul, "but it's important to have people start working on good habits early, rather than having to break bad habits later."

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