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Doctors gain insight from theater training

Virginia residents learn to read body language to give patients better care.

By Myrle Croasdale, amednews staff. Dec. 3, 2007.

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What can an actor teach a physician? A lot, according to a team of physicians and theater professors at Virginia Commonwealth University in Richmond.

A flick of a hand. A clenched jaw. The body communicates more than words, but are physicians listening? Not if they are glued to a computer reading an electronic medical record or flipping through a paper chart.

The art of effective communication, considered a key attribute of a good physician, is one aspect of medical training that often is not dealt with explicitly, said Alan Dow, MD, associate internal medicine residency director at the VCU Medical Center.

This is why this seemingly disparate group of individuals have joined forces. The theater professors, armed with their understanding of verbal and nonverbal communication, are collaborating with VCU Medical Center physicians to turn medical residents into effective communicators able to build trust with patients and get to the heart of patients' clinical concerns.

Pilot program results in the August Journal of General Internal Medicine show that the class seems to have made a difference in physician-patient communication. Trained observers rated residents' overall empathetic communication 6.88 on a 10-point scale before the class and 8.56 four months later. That compares with a control group where the rating slipped from 6.38 to 5.82 in the same time frame.

"Communication skills are important, but we've forgotten how to teach them," said study co-author Dr. Dow. "It's an area we don't know much about."

As students, physicians learn that they should make eye contact and ask open-ended questions, Dr. Dow said. But the curriculum he and several VCU theater faculty developed delves more deeply into doctor-patient interactions.

The program walks residents through communication's key elements. To build clinical empathy -- the ability to recognize a patient's emotional state and respond in the moment for a better clinical outcome -- the team emphasized being present in a conversation and practical how-tos for observing a patient's emotional state.

"Ninety-three percent of information that is conveyed is through body language, tone of voice," said David Leong, VCU theater department chair and co-author of study. "What is said is only 7% of the equation."

A study in the May 15, 2004, American Family Physician found that patients consider understanding, listening and honesty important traits in their physicians, Dr. Dow said. From the physician's perspective, such empathetic communication allows the doctor to unearth the medical matter more efficiently.

The original six-hour multisession program, conducted three years ago, was considered successful enough that it has been refined and repeated this year for internal medicine interns and nurses.

The course included lectures on the elements of communication, practical scenarios with patient simulators and instructor feedback.

Delivering bad news to a patient or family member was one of the scenarios residents faced. In this situation, the physician's ability to empathize was key, Leong said.

"The grieving process is unavoidable," Leong said. "You can't do anything about the loss, but you can do something about the anxiety."

The physician may deliver bad news to hundreds of patients and recall few of the encounters. The patient will remember forever the moment he learned he had cancer, Leong said, and whether the physician communicated this news with empathy.

A second paper on the project is in the works and will include patient perceptions of residents' empathy. Programs also are being tailored for VCU's surgical residents and area community physicians.

Eye-opening experience

Rabih Halabi, MD, a second-year internal medicine resident at VCU, went through the course this spring. He was skeptical at first, but after he tried a few techniques, he said he "was shocked that it actually worked."

Dr. Halabi had not realized that what he considered simple multitasking, writing in a chart or looking at the computer, was signaling disinterest. "In my mind, I was always listening," he said.

When he stopped and gave patients his full attention, they opened up.

Dr. Halabi found the session on body language cues particularly helpful. He was unaware that crossed legs or arms conveyed that a person was closing himself or herself off. Now he watches for this in himself and his patients. To put them at ease, he has learned to sit at their level, make eye contact and mirror their speech patterns. If they talk slowly, he does, too. He has found that patients are not only more free about sharing their health concerns, but also more receptive to his recommendations.

This is what Aaron Anderson, PhD, was aiming for. Dr. Anderson, an associate professor of theater at VCU, helped design and teach the course.

"We're not teaching doctors acting skills," he said. "We worked on what to say to patients, how to organize the information, how the communication takes place, body language, tone of voice, eye contact and to apply them in a clinical setting."

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