A brief window for a deep connection

In the brief window of a doctor’s appointment, doctors and patients traverse an interaction that isn’t easy to teach in a classroom. Auguste H. Fortin VI, M.D., M.P.H., has spent the last 16 years teaching medical students at Yale how to interact with patients while inviting emotion, narrative, and connection into the interview.

In 1985, when he graduated from Tufts University School of Medicine, Fortin found himself frustrated. “I wasn’t making the sort of connections that I felt I should be making as a doctor,” he said. It wasn’t until he met Robert Smith, M.D., an internist at Michigan State University and a scholar, that he learned about a different approach to interacting with patients: patient-centered interviewing.

Fortin, an associate professor of medicine, began to follow the patient-centered model developed by Smith. The model’s focus on open-ended questions, he found, encouraged patients to tell their own stories about their illness. His patients felt better just by talking with him, they said. “That was incredibly reinforcing for me because that’s the sort of doctor I had always wanted to be—somebody who could be therapeutic in real time.”

Fortin has been teaching patient-centered interviewing to medical students at Yale since 2000, when he started teaching the medical interview component of the preclinical clerkship. The model consists of five basic steps: establishing a relationship, setting an agenda for the appointment, asking open-ended questions, learning the personal and emotional context of the symptoms, and transitioning to the next part of the interview—collecting information like blood pressure.

At Yale, students learn to listen and ask questions that let the patient do the talking. Witnessing patients’ emotional burdens is the best way to get them on a path toward feeling better, Fortin says. “Over the last 100 years, many patients have been cured of disease but have not been healed,” he says. “We’re hoping that we can both cure disease and heal the patient in the process. The interaction between doctor and patient is one way to do that.”

Initially, medical students may see this technique as counterintuitive. “I think in a lot of students’ eyes, acting like a doctor means hammering off questions and taking charge of the interview,” said Anna B. Reisman, M.D., associate professor of medicine and director of the Standardized Patient Program at Yale. Interacting with standardized patients gives students the opportunity to exercise their ability to let patients tell their stories. “The medical stuff is straightforward. The patient’s personality, emotional state, life experience—these complicate and enrich the interaction. Being interested in the person beyond their symptoms not only makes for a more interesting conversation, but it’s more therapeutic.”

Fortin and Reisman acknowledge that students often don’t often see this type of interviewing modeled when they begin their residencies. Fortin plans to extend his training to include residents and attending physicians, in the hopes of establishing patient-centered interviewing as the norm. Michael Bennick, M.D., director of patient experience at Yale New Haven Hospital, says that in order to incorporate good communication between doctors and patients, the culture in hospitals needs to change. Training people across departments will create a lingua franca of communication skills, says Bennick. “The fact is—words matter. What clinicians say and how they say it hugely affects patients,” he said.

Bennick, Fortin, and Reisman hope that by training the next generation of doctors to communicate, they will enter the workforce ready to address some of the problems that face a system that often seems to be increasingly impersonal. “My argument is that we can change the nature of health care,” said Bennick, “by changing how we interact with our patients.”