The University X School of Medicine offers an innovative orientation program to new medical students. The four-course program, entitled Introduction to Clinical Medicine, presents students with various learning experiences aimed at developing therapeutic communication techniques, empathy, and coping skills while being instructed in the mechanics of taking a medical history and performing a physical examination. The program while highly successful in terms of student's evaluations, now faces substantial opposition from the University and the School of Medicine. Program opponents cite high program costs from the use of physician mentors and facilitators that they believe are not justified in terms of student learning outcomes. In particular MD 301: The Doctor-Patient Relationship has received the most vocal objections and some appear in favor of eliminating what they believe are "soft skills" that will be covered later in the program.

The purpose of this paper is to outline proposed curricular changes to the Introduction to Clinical Medicine in an effort to both save and enhance the program. Through the use of nurse practitioners as leaming facilitators, medical students will learn communication techniques for creating a therapeutic environment, come to value nurses as colleagues and vital members of the health team, and develop empathy for patients experiencing the stress of disease. This will be accomplished with a reduction in cost of more than $106,000 for MD 301.

Each year colleges and universities across the country develop and implement student orientation programs to acclimate new students to the campus environment, familiarize them with the programs and services offered at the institution, and acquaint the students with the social and cultural opportunities of the surrounding communities. The goal of these orientation programs is to provide a positive transition for students by helping them to adapt to the envirorunental changes of campus life as well as the academic challenges experienced as they move from high school into undergraduate programs thereby increasing the likelihood of their success (Taylor, B.E. & Massey, W.F., 1996).

Scaled down orientation programs for new students entering graduate programs are frequently offered by universities. Unlike undergraduate orientation services, program planners of graduate student orientations often assume that students are already acculturated to the academic environment hence these programs are shorter in durationthan their undergraduate counterparts and focus more on the graduate program of study and student resources, although some incorporate information concerning the educational, research, employment and cultural opportunities of the community (Bean, J. P., 1990).

The purpose of this paper is to outline proposed curriculum changes to the innovative orientation program offered medical students at the University X School of Medicine. As with most graduate schools, the new student orientation provided students entering medical school often reflects an orientation philosophy almost exclusively focused on the curriculum of study and the requirements students must meet to successfully progress in the program. The Schools of Medicine of Temple University, Johns Hopkins University, Jefferson University, Ohio State University and Harvard offer new student orientation programs that reflect this philosophy. In additional to academic orientations, medical schools offer students clinical orientation programs which focus on the expected routines and practices of the hospital setting, and spell out for the students what to expect with regard to student dress, hours, assignments and locations of clinical experiences. While these programs are usually high in details, they offer little, if any, support to acculturating students to the clinical environment of the hospital or ambulatory clinic, or to helping the students develop empathy and the coping skills necessary for working with the sick and dying. Perhaps this may account for the seemingly cold and indifferent attitudes of many physicians, who, left to their own devices, use emotional detachment as a coping skill.

As with many of its counterparts, the School of Medicine of the University X presents students with a formal orientation to the four-year academic program and offers specific clinical orientations for each medical service or clinical rotation the student does throughout the program.

In addition to these traditional orientation programs, however, the University X's School of Medicine is attempting to change how new physicians are educated through a two year orientation program called Introduction to Clinical Medicine. The program aims to develop both the clinical and behavioral competencies of its students and to facilitate the development of the necessary coping skills for working with sick people.

The program is administered within the Department of Medicine's Education Office that coordinates the various courses and student services offered with the School of Medicine's Student Services Division and the other Clinical Departments. A number of staff and faculty positions are involved with developing and presenting the Introduction to Clinical Medicine new medical student orientation program most notably the Department of Medicine's Vice-Chair for Education, Dr. L.B. and Dr. J.H., the program Course Director.

The new medical student orientation, Introduction to Clinical Medicine, is presented during the first two years of medical school and is designed to develop the behavioral competencies necessary for the development of an appropriate doctor-patient relationship, hone student communication skills, and acquaint students with the clinical environment of the hospital. It uses the framework of the patient history and physical examination process to present the relevant concepts. The orientation curriculum is divided into four separate courses that progressively build upon the knowledge and learning of the previous courses. The courses consist of six to eight sessions and the 160 students of the incoming class are broken into small groups of six students each for the experiences. The proposed curricular changes, while maintaining the four course format of the program, will shift the sequencing of the learning experiences to allow the students to better develop the necessary communication skills for success in later courses, and utilize nurse practitioners as facilitators of the leaming experience. To better understand the program revisions proposed, a brief description of the four courses as they currently exist is presented (University X, 2000).

MD 301: The Doctor-Patient Relationship: This is the first course of the orientation series. It is offered in the Fall Semester of year one and runs for eight sessions. The primary goal of MD 301 is to familiarize the students with the healthcare envirom-nent, allow them to develop the communication skills that will later be necessary for appropriate patient history taking, and to have students relate to real patients in a clinical setting.

MD302: Introduction to the Medical History:

Using the communication skills that were introduced in MD 301, students are formally introduced to the format and content of the medical history. The program lasts for six sessions and is presented in the Spring semester of year one.

MD 303: Introduction to the Physical Examination: This course lasts for a minimum of eight sessions and spans the last part of year one Spring Semester and the first part of the Fall semester of year two. Students practice physical examination skills on each other and standardized patients, ending the course with the completion of a physical examination on a real patient.

MD 304: Clinical Problem Solving - Introduction to Differential Diagnosis: This course may aptly be called "putting it all together." Students are expected to utilize the communication skills, behavioral approaches, and technical skills mastered in the first three programs to complete a medical history and physical exam on a real patient. The course forms almost a "right of passage" for the students at the end of the Fall Semester of year two and serves as a transition into the study of clinical medicine.

A review of the literature reveals that very little has been written on orientation programs for medical students that focus on the development of behavioral competencies, methods to familiarize students with the clinical environment and caring for the sick, or ways to facilitate student coping strategies and reduce stress. Almost without exception, orientation programs for newly enrolled medical students stress the required course content, the mechanics of course progression, and the technical skills competencies that will be needed to successfully finish the program of study and graduate. Barzansky, Jonas and Etzel (1997) emphatically illustrate this point in their review and summary of educational programs in United States medical schools. The article is replete with discussions of student admission criteria to the nation's medical schools, student schedules, the content specifics of the medical curriculum, and the requirements set forth by the various clinical services which need to be completed over the four year medical school period. The authors (Barzansky effective et al, 1997) also provide information on how students are evaluated at 111 medical schools. While some differences in the evaluation requirements and processes are noted among the 111 schools included in the report, only 5 of the medical schools evaluate students in the behavioral sciences.

These findings are startling and are dramatically different from the requirements and evaluation procedures of academic programs that educate nurses (Reynolds, W., Scott, P.A., & Austin, W., 2000). The source of this variation may be a direct result of basic distinctions between the medical and the nursing models. The medical model takes a dichotomous view of the individual and of health: you are either well or you are sick, these symptoms are present or they are not. Hence the basis of medical decision-making rests in the concept of the differential diagnosis in which a hypothesis concerning the cause of the illness is made and either proven or ruled out (Wright, S., Kern, D., Kolodner, K., Howard, D.M., & Brancati, F.L., 1998). The nursing model, on the other hand, is predicated on a holistic view of the individual stressing the uniqueness of the person and placing them in the context of a social structure as a member of a family and a community. Likewise, the nursing view of illness and health views these concepts as a continuum, not a dichotomy, recognizing that at any given point in time an individual may be at one point or another along the continuum. Perhaps it is as a result of these two fundamental nursing principles, that nursing education programs strive to orient new students in more behavioral ternis than their medical school counterparts stressing the psychosocial aspects of health and disease.

Introduction to Clinical Medicine Program

The University X School of Medicine's Introduction to Clinical Medicine program attempts to address some of the psychosocial aspects of caring for the sick in the first course of its series MD 301: The Doctor-Patient Relationship. In discussing the orientation programs with Dr. L.B., Vice-Chair of the Department of Medicine, she admits that much of the behavioral aspects of the course were taken directly from the nursing literature (L. Bellini, Personal communication, Noverner 6, 2000). Dr. L.B. feels that nursing school curriculums have done a job superior to their medical school partners particularly in the area of communication skills and the concept of creating a therapeutic milieu. Ellis and Nowlis (1992) describe a therapeutic milieu as an "environment or setting that provides support and an atmosphere conducive to meeting an individual's needs" (p.577). The therapeutic environment is essential for effective communication between a healthcare professional and a patient since what is at stake is often more than what the weather is today or what one feels like eating.

Dr. L.B. states the primary goals of MD 301 are for the students to: 1) relate to patients as people and develop a comfort level being around individuals who may be sick and in pain, 2) become familiar with the clinical environinent of the hospital, 3) learn communication techniques for eliciting information, and 4) develop a sense of ease in just talking to patients. Dr. L.B. feels this latter objective is an extremely important one. She states, "sometimes the students get so caught up in worrying whether or not they have asked the question just right or have gotten the response expected by their professor, that they lose sight of the fact that patients are people with their own individual needs and cares" (L.Bellini, Personal communication, November 6, 2000). For this reason, the students in MD 301 are assigned to talk to patients and are not presented with a specific set of questions that they must get answered.

To meet its goals and objectives, MD 301 focuses on specific communication skills and behavioral approaches to patients. Infori-nation on communication skills is first presented to the students using lecture forinat, group discussion, and role-playing techniques prior to the students actually sitting down and talking to patients. Topics are presented to students in seven separate sessions and the material covered includes: the use of open-ended questions, the mechanics of an interview, validation of the information elicited, how to note evidence of perceived threats by the patient, signs of patient adaptation to stress, and patient responses to illness (University X, MD 301, curriculum syllabus). Many comparisons can be made between the curriculum of this course and the subject matter often presented in a student's first introductory course in nursing (Heller, B. R., Oros, M. T. & Durney-Crowley, J, 2000). Strikingly missing, however, is information on the concept of non-verbal communication and the role that non-verbal cues play in the actual communication process.

I discussed the curriculum of MD 301 with Dr. L.B. and Dr. J.H., the Program Director, to understand how subject matter was selected for inclusion in the program and why some communication concepts, for example non-verbal communication cues, were omitted. Both Dr. L.B. and Dr. J.H. discussed the limitations on course content necessitated by the brevity of the program. Dr. J.H. related that the course, topics, and concepts presented were constantly being tweaked based upon feedback received from both students and patients (J. Hines, Personal communication, November 15, 2000). She also related that her personal belief was that the program should last a full 15 week semester, rather than the current eight, and not only increase the topics covered but also delve into the subject matter presented in greater detail. She and Dr. L.B. are staunch advocates of the orientation series and the need to acclimate medical students to the clinical setting to aid the development of student coping skills, and to develop in the students the appropriate behavioral competencies to allow them to not only complete the subject matter appropriately, but also to relate to their patients with empathy. Interestingly, when Doctors L.B. and J.H. were asked how successful they believe the program is in meeting these objectives, they both responded that they thought it only marginally successful particularly in the area of teaching empathy to the students. Dr. J.H. went on to say that she emphatically believed that nurses were more empathetic than physicians in general, thought this may be due to how nurses were socialized into their profession, and thought that medical education programs could learn from this.

Bennett (1995) describes empathy as the ability to communicate an understanding of a client's world that she feels is a crucial component of all helping relationships. Using this working definition of empathy, the construct becomes an integral aspect of both the nursing and medical professions. Yet despite Dr. J. H.'s perception of nurses' empathy, the literature reveals that empathy, as a construct, has been poorly measured among nursing professionals and not effectively taught by nursing curriculum. Researchers have shown that a client's perception of the helping relationship is an essential component of empathy (Egan, 1986). If clients are able to perceive the amount and nature of the empathy existing in the helping relationship, they will be in the position to advise the professional about how best to offer empathy (Rogers, 1975). Further, this collaborative process would enable the client's view about helping behavior to be reflected in scales developed to measure the degree of empathy existing in the helping relationship (Gladstein, 1977). To date, the empathy scales that have been developed represent the professional views of empathy and fail to sufficiently incorporate the clients' perceptions into the analysis. Reynold (1998), however, has developed a clientcentered measure of empathy that is currently undergoing validity and reliability testing with encouraging results.

Without knowing about the work on empathy of the previously noted researchers, Dr. J. H. has incorporated a piece of client-centered feedback into the instructional model of MD 301. The eighth and final session of MD 301 is a patient-student panel. Here, patients who had volunteered to talk to medical students are asked to provide students with feedback on the experience. The patients are encouraged to freely discuss with the students: how they felt about the conversations they had with their student, what they expect from a patient-doctor relationship, how and what they expect their doctor to communicate to them, and to what degree they felt the student empathized with them. Dr. J.H. shared that some interesting comments and observations have come from these panels. She reported on a woman who said she felt the experience was very positive and that it was the first time a medical professional spoke to her as a person and not a thing. The woman went on to say that she hoped the student didn't change after graduation. An elderly gentleman reported that he was concerned that the student appeared very uncomfortable and had trouble looking at him during the first two sessions. On the third session, the man stated that he asked the student if he did anything wrong because the student seemed so uncomfortable. The young man then told the old man that his grandfather had died last Spring and that he couldn't help thinking about his grandfather every time he looked at the man. The old man states that he and the student spent the next few sessions talking about the deceased grandfather and what it meant to get old, become sick and eventually die. Dr. J.H. stated that the interactions were therapeutic for both the student and the patient and wished that more students got as much out of the exercise.

With many positive benefits of the program noted, Dr. L. B. reported that one would think it an overwhelming success that would strongly be supported by the University. Unfortunately, she states such is not the case. The Introduction to Clinical Medicine has become for her both a source of pride and one way in which the University X distinguishes itself from its peers, and an albatross causing her much frustration and concern each year. Dr. L.B. feels this is true because her colleagues within the medical profession do not always value many of the "soft" skills that the orientation program tries to incorporate in it. An added problem, she states, is that the program is extremely costly to administer. Dr. L.B. states the high cost of the program is directly related to the fact that all of the skills and information presented in the four series Introduction to Clinical Medicine are taught or facilitated by faculty physician mentors. This results not only in high direct costs for program instruction but in very high opportunity costs because of lost physician revenue. To illustrate this point, consider the following faculty analysis. Dr. J.H. is a physician specializing in the diagnosis and treatment of infectious diseases. The average revenue she generates from inpatient and outpatient services is approximately $500/hour. As the Program Director for MD 301, Dr. J.H. spends roughly 36 hours of time during the eight weeks of the session on the program resulting in a loss of $18,000 of revenue to the health system. Additionally, there are 14 physician mentors that work with the new medical students as part of MD 301 to facilitate learning and orient them to the clinical setting and role of doctoring. Each of these physician mentors spend approximately 20 hours of time over the eight week period working with the students. The areas of medical specialty covered by the mentors include cardiology, gastroenterology, oncology and general internal medicine/primary care. With the average hourly revenue generated by this group of physician mentors ranging from a low of approximately $300/hour for a primary care physician to greater than $1 000/hour for an interventional cardiologist (one who does cardiac catheterizations) the lost revenue represented by the mentors exceeds $112,000.

Putting this into perspective, MD 301 represents a lost revenue opportunity to the University X Health System of $130,000 ($18,000 + $112,000).

II. Proposed Changes to MD 301

After discussion of the merits and problems of MD 301: The Doctor-Patient Relationship with Doctors L. B and J. H. and reviewing the literature on orientation programs for health professionals, the following proposed revision and enhancement in the Introduction to Clinical Medicine is suggested. The biggest change to the program will occur with MD 301: which will now be called Creating a Therapeutic Patient Relationship. As a result, the course outline and description, staffing and budget analysis will be confined to this segment of Introduction to Clinical Medicine only. The discussion of what constitutes the doctor-patient relationship currently covered as part of MD 301 will be moved to MD 302. The curriculum and teaching methods for MD 302, MD 303 and MD 304 will not be altered except as stated above.

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MD 301 will be the first course in the series Introduction to Clinical Medicine and will be presented during the Fall Semester of year 1. It is a required course for all medical students.

Course Objectives: At the completion of the program, the student will be able to:

1. Define what is meant by a therapeutic environment.

2. Demonstrate the use of effective communication skills including open-ended questions, reflection, clarification, and non-verbal techniques.

3. Identify coping strategies for patient and practitioner stressors.

4. Recognize perceived threats experienced by patients.

5. Relate in an empathic manner to patients' responses to illness.

Course Faculty:

Dr. J.H. will serve as Program Director and role model for medical students. Minimum time commitment for Dr. J.H. will be 20 hours for the eight-week session. In addition to Dr. J.H., faculty from the schools of Nursing and Social Work will teach and facilitate the information on communication skills and creating a therapeutic envirom-nent for the students as well as serving as mentors on the inpatient floors during the interview process. A minimum of 12 faculty members will be needed as the small group mentors each giving about 32 hours during the course.

1. Course Logistics

a. Appropriate conduct with patients
b. Attire
c. How to identify yourself to the patient
d. Patient "secrets" or inforination told "in confidence"
e. Hospital infection control
f. Expectations of the course
g. Mentors - Who they are. What is their role.

2. Student-Patient Interviews (Cohen-Cole, S.A., 1991). a. b.

a. Phases of interaction

b. Using verbal communications

c. Non-verbal communication cues

d. Techniques of verbal communications

1) Open-ended questions

2) Facilitating responses

3) Non-directive comments

4) Exploratory responses

5) Aids to decision making

6) Validation

7) Reflection

Methods of Instruction: Outline material will be presented using lecture forinat, group discussion and roleplaying. Students will be encouraged to discuss and explore areas of concern with the techniques presented, the clinical setting, and the patient interview process.

Session 2: Student-Patient Interview

Patients will be pre-selected and screened by the mentors concerning the patient's willingness to talk to a new medical student. Students and patients will be paired one to one. If the patient's illness requires them to be hospitalized for a prolonged period of time and they are willing to speak to a student on repeated occasions, attempts will be made to keep the same patient and student together.

The interview topic for session two relates to the humanitarian aspects of illness. The goal for the session is to aid the student to explore their personal belief system of illness and the sick and to develop a sense of comfort with the environment. The students are encouraged to discuss the patient's experience with their illness. Possible interview topics include:

· "What has your experience with this illness been like?"

· "How has your illness affected your life?"

· "How has your experience in the hospital been?"

Following the interview sessions, students will meet with their mentors in a postconference fon-nat to discuss their experience, problems encountered, and what they think they learned from the interview.

Session 3: Student-Patient Interview

Topic for this interview session will focus on identification of patient and practitioner stressors including evidence of the presence or absence of coping mechanisms. Post-conference and discussion with the mentor will follow the interview session.

Session 4: Student-Patient Interview

This session will focus on relationship skills to develop empathy. These include reflection, legitimation, personal support, partnership, and respect. Post-conference with mentor follows.

Session 5: Student-Patient Interview

Building on previously learned skills, the student will attempt to identify threats perceived by the patient including loss of efficacy, separation /loss of love, loss of bodily function/body parts, loss of rationality or pain. Post-conference discussion with mentor follows patient interview session.

Session 6: Student-Patient Interview

This session focuses on patient responses to illness. The students will identify the presence or absence of regression, denial, anxiety, anger and sadness. Post-conference with mentor follows interview session.

Session 7: Student-Patient Interview

Utilizing effective communication skills, the student will elicit a history of present illness (why the patient is in the hospital) from the patient concentrating on context, timing, quality and location of symptoms, modifying factors, and associated signs and symptoms. Post-conference with mentor follows.

Session 8: Patient-Student Panel

Approximately six to eight patients will be invited to present to the students their experience with the interview process. Patients will be encouraged to discuss how they felt about the interviews, what was asked, and what they wished had been asked. Students will also have an opportunity to question the patients as to how they wish to receive information and how doctors can best meet the needs of their patients.

Budget:

Program Director (Lost Revenue Cost) $10,000

Mentors/Facilitators (12 @ 32 hours/each) $13,440

Support Staff $5,000

Supplies $1,000

TOTAL $ 29,400

The cost for support staff and supplies for MD 301 is the same under either format, MD 301: The Doctor-Patient Relationship or MD 301: Creating a Therapeutic

Relationship and accounts for $6,000 of the proposed budget. Dramatic cost savings are noted, however, with the new proposed forinat because of the decrease in Program Director time and the elimination of physician mentors for the communication skills. With the nursing and social work faculty costing approximately only $35/hour compared to the physician costs of upward of $1000/hour the entire MD301 program would cost only $29,440 resulting in a net savings to the institution of $106,560. Further, the added benefit of this program will be the fostering of a collegial relationship between physicians, nurses and other allied health professionals earlier in the development of their professional career. This enhanced collaboration will benefit physicians and nurses and create a truly collaborative relationship where the patient, the physician and the nurse are all seen as partners in wellness.

Program Evaluation:

Students will be asked to complete evaluation forms at the end of MD 301. Particular areas of evaluation will include : how well the students were able to meet the course objectives, the role and effectiveness of non-physician mentors, the benefits of MD 301 - what they learned or got from the course, and how well the orientation prepared them for further study in the clinical environment. Additionally, physician mentors of MD 302 will be asked to complete an evaluation form discussing how well the students were prepared to meet the requirements and objectives of MD 302 with a particular reference to the students' communication skills and ability to create a therapeutic relationship.

The University X School of Medicine utilizes an approach to orienting new medical students that is unique among its peers. Through a four series program entitled Introduction to Clinical Medicine students are introduced to the healthcare environment and the competencies needed to foster a good doctor-patient relationship. Because of the high cost of the program, both direct and lost opportunity costs, the program has become a liability and is injeopardy of being dramatically altered or eliminated. The proposed changes to the program curriculum will not only maintain the essential behavioral aspects of the course, but also enhance collegiality in the healthcare setting. I believe it has merit and should be considered for future implementation.

Barzansky, B., Jonas, H.S., & Etzel, S. 1. (1999). Educational programs in US medical schools, 1998-1999. JAMA, 282(9), 840-846.

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Bennett, J. (1995). Methodological notes on empathy: further considerations. Advanced Nursing Science, 18, 36-50.

Cohen-Cole, S.A. (1991). The medical interview: The three-function approach. Philadelphia: Mosby Year Book.

Egan, G. (1986). The skilled helper. Monterey, CA: Brooks-Cole.

Ellis, J.R. & Nowlis, E. A. (1992). Nursing: A human needs approach, 3 d edition. Boston: Houghton Mifflin Company.

Gladstein, G. (1997). Empathy and counseling outcome: An empirical and conceptual review. The Counseling Psychologist , 6, 70-79.

Heller, B. R., Oros, M.T. & Durney-Crowley, J. (2000). The future of nursing education: 10 trends to watch. Nursing & Health Care Perspectives, 21(l), 9-13.

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Reynolds, W. (1998). A study on the effects of an empathy education programme on registered nurses' empathy. Ph.D. thesis. Open University. Buckingham.

Reynolds, W., Scott, P.A. & Austin, W. (2000). Nursing, empathy and perception of the moral. Journal of Advanced Nursing, 32(l), 235-242.

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University X, School of Medicine (2000). Introduction to Clinical Medicine, course description.

University X, School of Medicine (2000). MD 301, MD 302, MD 303, MD 304, curriculum syllabus.

Wright, S.M., Kern, D.E., Kolodner, K., Howard, D.M. & Brancati, F.L. (1998). Attributes of excellent attending-physician role models. The New England Journal of Medicine. 339(27), 1986- 1993.

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