El mito del corazón / The Heart Myth

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Mejorando la calidad de la enseñanza de entrevista clínica: evaluación de una intervención en estudiantes de medicina / Improving the quality of interviewing teaching to medical students: an evaluation

Background: Quality of clinical interview is a key issue both for patient satisfaction and for diagnostic efficiency. Its adequacy relates to better clinical diagnosis treatment plans and patient compliance. Aim: To measure the quality of interviews performed by medical students in three Chilean medical schools before receiving specific training on the subject and to compare the scores obtained after introductory courses on interview. Material and methods: The interviews were videotaped and then evaluated using an objective scale, that measures 33 skills grouped in six areas: opening, problem exploration, non verbal facilitation, interpersonal. patient reaction and closing. The students were assigned to an experimental group that received an interactive workshop with roleplays, vignettes and videotape feedback, and to a non intervention group that received the usual bedside training on medical interviews. Results: Both groups shared the same skill level before the training, with better scores on nonverbal, patient reaction and problem exploration, and worse ones on closing and interpersonal skills. Comparing pre and post-test results, the overall score improved in the experimental group (from 33.2 to 38.3, p=0.002) and worsened among non intervened students. There were statistically significant changes for opening (p< 0.002), problem exploration (p< 0.05), non verbal facilitation (p< 0.0001) and closing (p< 0.0001). Conclusions: It is important to train students not only in specific knowledge contents but in the process of interview. This training should encourage the development of empathy and closing skills

¿Cómo entrevistan los estudiantes de medicina? / How do medicine students make interviews?

Las entrevistas clínicas son una parte esencial del quehacer médico. La comunicación efectiva es una parte integral del diagnóstico, aumentan la satisfacción de los pacientes, su aceptación del tratamiento y contribuyen a un mejor uso de los recursos de salud. A pesar de lo anterior, el entrenamiento en las Escuelas de Medicina chilenas no es suficiente como para establecer una adecuada comunicación entre médico y paciente, ni para manejar las emociones que surgen en la entrevista. La mayoría de los clínicos aprende a entrevistar intuitivamente o bien lo hace imitando a sus profesores. Este trabajo describe un estudio realizado en tres Facultades de Medicina, dos públicas (Universidad de Chile y Universidad de Concepción) y otra privada (Universidad de los Andes). Para ello se filmaron entrevistas realizadas por 122 estudiantes que estaban ingresando a la etapa clínica de su formación, que luego fueron revisadas independientemente por dos jueces entrenados en aplicar una pauta de evaluación previamente validada. Se describen las características de estas entrevistas

Dificultades en la comunicación durante la entrevista médica / Communications difficulties during medical interview

The aims of medical interview are to obtain diagnostic information, to obtain an empathetic communication with the patient, to educate him about his disease and to establish a personal link allowing a lasting relationship. We analyze some features of communication with patients. Individualized communication, recognizing his identity and personal aspects, "looking from the patient". Context, a shared but not mentioned value, part of the world of emotions and ideas. An analog and digital language, the former precise in words and the latter more diffuse, with gestures, not verbal. Coherence, as the similitude between what we think, feel and say. If there is no coherence, communication is impaired. Emotions, always present, rending communication more valid and real. We need to recognize, express and respond to emotions. An emotionless patient becomes a distant and impersonal object, an "it". When emotions are incorporated the patient is a "him" with whom I share and dialog. Empathy is an emotional comprehension, a personal bond. It improves relationships and creates links. Compassion is a variation of empathy that includes spiritual aspects and values. Negative emotions as rage, frustration and aggression creates communicational difficulties. We must recognize, express and clarify them to improve the situation. Difficult patients with whom communication is difficult such as confuse, agitated, terminal, elder, manipulating or hypochondriac subjects. The idea of transference and counter transference in these complicated situations is analyzed

¿Por qué los hospitales? Ideas para mirar / Why do we work in public hospitals? Some ideas to have in mind

Why do we work in public hospitals, what do we look for and what do we find working at these places? There are several answers. The beritage, the places where we learnt, the places where medicine is practiced. A model that feeds us. They cannot be improved and it is difficult to accept their limitations. However, many factors such as teaching, research and group work, encourage us to continue working in them. Variation and simultaneity, they are places with many variables, a living organism. The myth, the mother, that transmits its principles and behaviors, gives us a sense of life, feeds us and allows us to feed others Ecomical reasons and performance. When performance of physicians is analyzed positive values such as contact with patients, hours of discussion ans study, quality of care, risks dedication and training difficulties must be taken into consideration. Hospitals are not a patient assembly line. Fantasies and representations. We are participating in a health community and hospitals become a place for personal growth. Respect towards poverty. Helping the less fortunate. Knowledge and learning. Experiencing values. Forgotten words. Bioethics brought back several principles that are present in hospitals such as compassion, empathy, sweetness, service, humility, gratitude

Características generales de la comunicación médico-paciente / General features of patient-physician relationship

The communication between physician and patients is often deficient. Little time is devoted to it and the patient receives scanty information with a low emotional content. Some features of our medicine can explain this situation. The rationalist and mechanistic biological model, allows to study only those things that can be undertaken with the scientific method. Psychological, social and spiritual aspects are surpassed. It only looks at material aspects of people, limiting the communication. Patients express their symptoms in an emotional way, with multiple beliefs and fears. The physician converts them to a precise, scientific, measurable and rational medical logical type. This language is not understood by patients, generating hesitancy in the communication. The paternalism is based in the power that physicians have over patients. We give knowledge and ask the patient to subordinate and accept our power. The patients looses his moral right to be informed, to ask, to have doubts or to disagree. Our personal communication is almost always formal, unemotional and with no explanations, further limiting communication

Consentimiento informado / Informed Consent

The informed consent, in which the physician informs about procedures to be performed and requests approval, puts into practice the communication between physicians and patients. The consent will always be verbal and will put writing in complex or risk situations. This doctrine, that promotes the recognition of patients autonomy, is employed since the end of World War II. Its main features are mental competence to know and elect, adequate and comprehensive information and voluntary acceptance or dental. In the situations of requested paternalism, therapeutic provilege and placebo use, information is not given and the consent is not requested. In all research protocols, a written informed consent must be requested. The consent is a form of communication that tries to defend patients rights as something close and alive and should not become a ritual

En busca de un lenguaje para la ética médica / Searching a language for medical ethics

After World War II the interest in medical ethics increased and several international codes defending patients rights appreared. Four pragmatic, non ideological and non religious principles were defined to analyze clinical ethical problems. Autonomy, the capacity of self management and to reach our own informed decisions; the informed consent is the way to accomplish this principles. Beneficence, the basic principle of medical acts, with the risk of being transformed in an extreme paternalism. A reinterpretation of beneficence equilibrates the rights of patients physicians. Non wickedness, first of all not to harm, a Hippocratic idea to prevent iatrogenesis and Justice, to maintain personal, social and political equity. These principles are a language, an ethical analysis methodology and give clues for our relationship with patients. They are a guide for personal analysis, reflection and change and show a collective and individual path to incorporate ethics to our daily work