Nature vs. Nurture in Medical Education: The Case of Student Bedside Manner

Sir William Osler at the bedside

Believe it or not, it’s been a major news week about the soft stuff in medicine, bedside manner.   First, a Time magazine story about a new study showing that patients cared for by physicians with greater empathy had better diabetes control.  That study comes on the heels of an editorial in the New York Times written by a patient (who also happens to be a science journalist and an outstanding writer) with mitral valve prolapse who graciously volunteered herself to be examined by preclinical medical students learning to do the physical exam and lived to vividly document the experience for all of us.  As she eloquently describes, some students seemed like naturals, whereas others were awkward and clunky.   

These articles add more fuel to the fire for the most hotly contested question in medical education – Can you teach these behaviors?  One on side, you have the nature supporters, saying that the role of admissions committees is to screen these behaviors out.  The nurture supporters say that these behaviors can be taught and its medical schools responsibility to do so.  While it is true that some pathologic behaviors need to be screened in admissions, the question for most students is more refined—is it true that some students come in ‘empathetic’ and others are just hopeless oafs that can’t empathize with patients?  Well, it was refreshing to read Number Needed to Treat blog written by a medical student who says the NYT article was eating away at her soul…She nails it by saying the following:

“Almost every single med student I know is, in fact, an affable person. Yet it doesn’t always come through in the exam room.”

Why is this so hard?  Well, it is not easy to learn how to do a physical exam while also forming your bedside manner.  Our students have to pass a national standardized exam that requires doing the over 100 step “head to toe” physical exam.  As a ‘dinosaur’, I never had to take such a test. I’m not even sure what all the steps are but have asked my colleague, Dr. Farnan, who runs our Clinical Skills program for medical students who informed me of all the points and that they are to be memorized.  Let’s be honest- most of our faculty could not do this without referring to a cheat sheet.  If they had to memorize it for a test, they may even come across robotic and unempathetic at first. 

So, what does this mean for students’ bedside manners while they are learning?  Well, mental capacity is finite.  Workload has been well described as a construct that includes the mental and physical challenge of the work.  For complex tasks, it is important to consider how much ‘spare capacity’ one has after the ‘primary task’ is dealt with.  Elegant studies have shown that experienced physicians are BETTER at performing a secondary task than novice physicians when both are doing the same primary task.  Why?  The experienced physicians have more ‘spare capacity’ to deal with the second task.  

So what is the primary and secondary task in interviewing a patient?  Well, the primary task is learning the physical exam and how to take a history.  As we celebrate this week’s residency match, the job of medical school is to produce physicians that can perform these basic functions during residency training.  While our medical students acquire these skills, of course some will be naturals, and therefore have more spare capacity to key in on their bedside manner.  In contrast, others may struggle with basic skills and have difficulty with both.  The majority, however, will first initially put all their mental effort into learning how to do a history and physical, leaving little ‘spare capacity’ for bedside manner.  Is there hope?  Yes, as these students get better at taking a history and physical, they will be more at ease.  This will then free up the necessary spare capacity to be continuously cognizant of their bedside behaviors.  Consistent with this philosophy, one school has had success actively reinforcing bedside manner skills while prerounding during the third year clerkship.

This progression is important, and highlights the learned art of medicine.  This was articulated beautifully by our recent keynote speaker, Dr. Joel Schwab, for the Gold Humanism Society senior student honorees.   On the subject of being humanistic, he said that he THINKS about the landmark article on etiquette-based medicine every time he sees the patient and he follows the 6 steps –

  1. Knock on the Door (wait permission to enter)
  2. Introduce yourself (with name badge on display)
  3. Shake hands (wear glove if needed)
  4. Sit down (smile if appropriate)
  5. Briefly explain your role on the team
  6. Ask the patient how he or she is feeling 

While working at a free clinic last Saturday, I too thought about this article for every patient I saw.  The first year students I was working with came from a variety of medical schools in Chicago and were volunteering their Saturday to do this.  I had no doubt that they all cared about the patients.  But, I did notice that they were taking time to think very hard about the chief complaint, figure out the right questions to ask, and how to present it coherently.  So, the role of medical education is to make sure that doing a history and physical becomes second nature for our students, and that thinking about bedside manner becomes the primary task.

–Vineet Arora, MD


One comment

  1. Hello Dr. Arora,

    My name is Apple Lopez and I work for Freelance MD.

    We are always on the hunt for doctors who have passion about a particular subject to write on our site. I have read your blog posts and I believe our members would find your thoughts of interest 🙂

    We are hoping that you would like to write a guest post on our site. Freelance MD is the leading site for physicians interested in improving their income and lifestyle and has tens of thousands of physician
    visitors each month.

    Here’s a link that explains everything about guest posting including readers, backlinks and requirements:

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s