Student Study Guide

COLLEGE OF MEDICINE
University of the Philippines Manila
“Towards Leadership and Excellence in

Community Oriented Medical Education Directed to the Underserved.”
INTERDISCIPLINARY COURSE 202
THE ART OF MEDICINE I:

The Making of a Physician
STUDENT STUDY GUIDE

Course Syllabus and Learning Modules
For Learning Unit III Batch 2026
Workbook:
______________________________________________________
Edited by:
Ma. Lourdes Rosanna E. de Guzman, MD, MS Epi, FPPA
Course Coordinator
1
Introduction
The essence of being a physician is the ability to integrate excellent medical treatment with compassionate
care of the patient. The primary emphasis, however, in medical training is devoted to assimilating an evidence-based
scientific knowledge and practicing the technical aspects of medical diagnosis and treatment. Unfortunately, this
may lead to a narrow and fundamentally mistaken viewpoint, since little consistent attention is being given to
acquiring and developing the necessary knowledge, attitude and behavioral skills to understand and attend to the
psychosocial needs of the patients and their families. In its broadest sense, the good practice of medicine, includes
the vital importance of the personal relationship of the physician and the patient, which is an art. This course was
designed to prepare medical students in the practice of medicine by laying the foundations on which to build the
Art of Medicine and the science of medicine. According to Dr. Francis Peabody, the art of medicine and the science
of medicine are not antagonistic but supplementary to each other.
The Biopsychosocial Perspective is the general framework for the development of the different modules of
Interdisciplinary Course 202 (IDC 202): The Art of Medicine: The Making of a Physician, which consists of the
following elements. First of all, the medical student must develop Personal and Intra-relational skills such as Self-
awareness and Values Clarification in order to know oneself since the essence of the practice of medicine is that it
is an intensely personal and relational matter. Secondly, the need to understand the Learning Process since medical
education is a lifetime endeavor of learning. Thirdly, the medical student also needs to acquire Interactional,
Relational and Communication skills necessary to be able to do a good clinical history; address conflict management
and resolution in medical practice; and, demonstrate leadership and organizational skills. Finally, guided by the
Environmental Norms that are emphasized in the goals of the University of the Philippines – College of Medicine, the
medical student needs to understand the different bioethical issues involved in gender-sensitive patient care and
service, which is based on the fundamental principles of the utmost respect for the dignity and human rights of the
person. These will include Bioethics; Gender and Health; Human Rights of Patients and Physicians; and, Medical
Jurisprudence. All these elements influence and contribute to the making of a 5 – Star Physician who is Competent,
Compassionate, Caring and Ethical. Thus, according to Dr. F. Peabody, one of the essential qualities of the clinician
is interest in humanity, for the secret of the care of the patient is in caring for the patient. (AMA, 1927)
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Table of Contents
Introduction .................................................................................................................................................... 2
Table of Contents ........................................................................................................................................... 3
Course Syllabus and Schedule for AY 2020-2021 ........................................................................................... 6
Module 1: Values Workshop .......................................................................................................................... 9
Activity 1: ORIENTATION TO THE COURSE ............................................................................................... 10
MANAGEMENT OF LEARNING .................................................................................................................. 11
Learning Journal ................................................................................................................................... 14
Activity 2: EXPECTATION SETTING ............................................................................................................ 15
ROAD MAP ................................................................................................................................................ 16
Activity 3: INTRODUCTION TO VALUES: Patch Adams ............................................................................. 17
LIST OF VALUES..................................................................................................................................... 18
Activity 4: EXPLORING VALUE INDICATORS ............................................................................................. 20
ACTIVITY A1: STARRY NIGHT ................................................................................................................ 20
ACTIVITY A2: ENVISIONING THE FUTURE ............................................................................................. 21
ACTIVITY B: REVIEWING THE PAST: REQUISITES FOR PERSONAL GROWTH AND CHANGE
EXPERIENCING ONE’S UNIQUENESS: .................................................................................................... 22
The Hand Language .............................................................................................................................. 22
ACTIVITY C: ASESSING THE PRESENT .................................................................................................... 24
LEARNING FROM VALUE DILEMMAS .................................................................................................... 24
VALUES GRID ........................................................................................................................................ 25
Activity 5: Charting Your Personal Consciousness Track .......................................................................... 26
CONSTRUCTION OF YOUR PERSONAL CONSCIOUSNESS TRACK ......................................................... 27
CONTINUING THE INWARD JOURNEY: Skills Inventory ........................................................................ 28
Activity 6 : PLANNING FOR THE FUTURE .................................................................................................. 33
PERSONAL PROGRAM OF CHANGE ...................................................................................................... 33
LIFE GOALS................................................................................................................................................ 34
Module 2: Pedagogy 1 .................................................................................................................................. 35
Table of Contents: The Learning Process ................................................................................................. 36
GOALS AND OBJECTIVES OF THE U.P. COLLEGE OF MEDICINE ................................................................ 37
Session 1: Introduction and Expectation Setting................................................................................. 40
Session 2: Physician’s Knowledge, Attitude and Skills ......................................................................... 41
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Session 3: Time Management .............................................................................................................. 42
Session 4: Learning Preferences 1 ........................................................................................................ 46
Session 5: Learning Preferences 2 ........................................................................................................ 47
Session 6: Approach to Learning 1 ....................................................................................................... 55
Figure 1. Model of Student Approaches to Learning by John Biggs ..................................................... 59
Session 7: Approaches to Learning 2 .................................................................................................... 61
EVALUATION OF THE COURSE .................................................................................................................. 62
Module 3: Communication Skills .................................................................................................................. 63
Module 4: Interviewing Skills ....................................................................................................................... 78
Module 5: Bioethics ................................................................................................................................... 113
Module 6: Introduction to Human Rights and Medical Practice ................................................................ 115
Module 7: Introduction to Gender and Health ......................................................................................... 121
Module 8: Medical Jurisprudence .............................................................................................................. 126
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Concept MAP: THE 6-STAR PHYSICIAN
The Art of Medicine I:
PERSONAL SKILLS
Self-awareness
Values Development
Teaching- learning skills
INTERPERSONAL SKILLS
Communication Skills
Interviewing Skills
Listening Skills
Conflict Management
ENVIRONMENTAL NORMS
UPCM goals is influenced
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Bioethics
Human Rights
Gender and Health
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Course Syllabus and Schedule for AY 2021-2022
I. Course Description:
The course is about the development of self-awareness, teaching-learning skills, communication and interviewing
skills for medical students, and the clarification of one’s personal values towards becoming a caring, compassionate,
competent and ethical physician who is attuned not just to the disease but to the person behind the illness.
II. Course Coordinator:

Ma. Lourdes Rosanna E. de Guzman, M.D., MS Epi , , FPPA
Department of Psychiatry and Behavioral Medicine, Psych Ward 7, Room 107
Tel nos. 554-8400 loc. 2436 or 554-8470
Office hours: 8:00 – 5:00 p.m. Secretary: Ms. Vivian or Ms. Kat
E-mail: medeguzman@up.edu.ph
Mobil phone: +63-917-5152155
III. Faculty (Department):
• Dr. Ma. Rosanna E. de Guzman (Psychiatry, UPCM)

• Mr. Benjamin David (Social Medicine Unit – History of Medicine, UPCM)
• Dr. Mary Ann Abacan (Social Medicine Unit – History of Medicine and Human Rights)
• Dr. Leilanie Apostol-Nicodemus (Center for Gender and Women Studies in Health, UP Manila)
• Dr. Ricardo Manalastas (Social Medicine Unit – Bioethics, UPCM)
• Dr. Doris Buenavides (Social Medicine Unit – Bioethics, UPCM)
• Dr. & Atty Ivy Patdu (Social Medicine Unit, UPCM)
IV. Learning Objectives
Art of Medicine, First Semester:

1. To increase knowledge and awareness of the History of Medicine and its new developments.
2. To become aware of one’s personal values and relate one’s personal values to becoming a competent, caring
and compassionate physician.
3. To describe the learning process to facilitate the attainment of the UPCM and personal goals.
4. To identify the basic elements of communication and impart basic skills in communication.
5. To demonstrate the skills necessary in interviewing
Art of Medicine, Second Semester:

1. To develop gender awareness and sensitivity.
2. To study the major concepts and principles of bioethics.
3. To describe the basic principles of human rights in the child, adult and doctor-patient relationship
4. To enumerate the rights of patients and the corresponding responsibilities of physicians.
V. Detailed Course Schedule:
Art of Medicine, First Semester:

Week Hrs. Date and Time Topic Faculty Room
1 4 8:00 am – 12:00 nn Art of Medicine Orientation Dr. R. de Guzman
1 4 1:00 pm – 3:00 pm History of Medicine Mr. Benjamin David
1 8 8:00 am – 5:00 pm Values Clarification Dr. R. de Guzman

Development of Self-awareness Faculty Facilitators
1 4 Phases of Consciousness Dr. R. de Guzman
Faculty Facilitators
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1 4 8:00 – 12:00:00 pm – Pedagogy I Dr. R. de Guzman
5:00 pm (Learning Process) Faculty Facilitators
4 2 3:00 pm – 5:00 pm Mentoring 1 Faculty
5 4 1:00 pm – 5:00 pm Pedagogy I Dr. R. de Guzman
(Learning Process) Faculty Facilitators
6 2 3:00 pm – 5:00 pm Communication Skills - A Dr. R. de Guzman
7 2 3:00 pm – 5:00 pm Communication Skills - B Dr. R. de Guzman
8 2 3:00 pm – 5:00 pm Mentoring 2 Faculty
10 2 3:00 pm – 5:00 pm Interviewing Skills - A Dr. R. de Guzman
11 2 3:00 pm – 5:00 pm Interviewing Skills - B Dr. R. de Guzman
13 2 3:00 pm – 5:00 pm Special Lectures Dr. R. de Guzman
Art of Medicine Synthesis &
Evaluation
Art of Medicine, Second Semester:

Week Hrs. Time Topic Faculty Room
2 3:00 pm – 5:00 pm Art of Medicine Dr. Doris Buenavides
Orientation (20 mins) Dr. R. Manalastas
Bioethics – 1
2 3:00 pm – 5:00 pm Bioethics - 2 Dr. Doris Buenavides
Dr. R. Manalastas
Dr. R. Manalastas
Dr. R. Manalastas
2 3:00 pm – 5:00 pm Mentoring Program Faculty
2 3:00 pm – 5:00 pm Human Rights – 1 Dr. Mary Anna Abacan
2 3:00 pm – 5:00 pm Human Rights – 2 Dr. Mary Ann Abacan
2 3:00 pm – 5:00 pm Gender & Health – 1 Dr. Lani Nicodemus
2 3:00 pm – 5:00 pm Gender & Health - 2 Dr. Lani Nicodemus
2 3:00 pm – 5:00 pm Mentoring Program Faculty
2 3:00 pm – 5:00 pm Medical Jurisprudence Dr./Atty. Ivy Patdu
2 3:00 pm – 5:00 pm Medical Jurisprudence Dr./Atty. Ivy Patdu
2 3:00 pm – 5:00 pm Special Lectures Dr. R. de Guzman
2 3:00 pm – 5:00 pm Synthesis and Evaluation Dr. R. de Guzman
2 3:00 pm – 5 :00 Mentoring Program Faculty Buenafe
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VI. Evaluation
1. REPORTING OF GRADES
▪ Attendance will be checked every class meeting.

▪ There will be a numerical grade for Medical Jurisprudence based on attendance and written examinations.
▪ Final reporting of grades will be SATISFACTORY (S) or UNSATIFACTORY (U)
2. GRADING SYSTEM
1st Semester, AY 2021-2022 Percentage

Attendance 60%
Course orientation and synthesis
History of Medicine
Pedagogy I
Self Awareness and Values Clarification as a Physician
Phases of Consciousness
Communication Skills
Interviewing skills
Paper 40%
Communication skills: group presentation (20%)
Interviewing skills: individual case summaries (20%)
TOTAL 100%
2nd Semester, AY 2021-2022

Attendance: Course orientation and synthesis 60%
Introduction to Gender and Health
Human Rights, Bioethics , Medical Jurisprudence
Paper 40%
Report on Philippine Bioethical Issues (10%)
Introduction to Gender and Health: reaction paper (15%)
Human Rights: written evaluation (15%)
Exam2 (Grade requirement)
Medical Jurisprudence: attendance and exam
Bioethics
TOTAL 100%
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COLLEGE OF MEDICINE


Module 1: Values Workshop
Self-awareness and
Values Clarification as a Physician
The Phases of Consciousness
June Pagaduan-Lopez, MD, FPPA
Evangeline Bascara-de la Fuente, MD, MHA, FPPA
Ma. Lourdes Rosanna E. de gUzman, MD, MS Epi, FPPA
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Activity 1: ORIENTATION TO THE COURSE
Values Workshop: Self-awareness and Values Clarification
Basic to the care of the patient, is the interaction between the patient and the physician, as well as the other
health professionals. Through this interaction, rapport is built, open discussions are facilitated, and attempts at
treatment and cure is maximized. For this transaction to be truly beneficial and helpful towards the ultimate aim of
a humanistic patient care, the physician must develop personal tools to understand and maximize this relationship.
It is therefore not enough that the physician has the competent knowledge and skills of medical science to treat the
illness. It has become imperative that the physician combine these with an understanding of interpersonal
relationships and social responsibilities towards the patient and the family, and with other health professionals one
interacts with.
Therefore, a basic understanding of the physician–patient transaction is necessary. It is important for the
physician to be aware of three levels of transactions: with one self, with the patient, and the process of interaction
between the self and the other in the physician-patient relationship.
The general objectives of these modules are as follows:

1. To commit oneself to learning and self-development as well as openness to life’s challenges.
2. To provide opportunities to learn and to acquire the values and skills for self-empowerment.
3. To learn how to build relationships with the patient, the family and the other allied health professionals.
Module 1: Self-Awareness and Values Clarification as a Physician aims to create the above consciousness. It
is intended to generate aspects of self-knowledge regarding a medical student’s personal response as he/she enters
a new stage in one’s life journey. It will help the medical student clarify aspects of one’s psychological make-up:
needs, values, strengths, opportunities and areas for improvement. Eventually, this understanding is expected to
help create alternate responses for change and development, and increase the options for IMPROVING ONESELF, and
going beyond unsatisfactory habitual course of actions and behaviors. It is hoped that such self-knowledge will lead
to greater creativity, realistic perceptions and expectations, and a greater sense of responsibility.
The specific objectives of the module are expressed in terms of what the participants will learn. At the end of
the module, each participant would have been able to:
1. To reflect and articulate on their personal insights and new understandings about themselves.
2. To recognize their personal, social and professional values.
3. To relate their personal values with their life decisions.
4. To assess their state of being: strengths, coping styles, sources of stress, and areas for improvement.
5. To receive feedback on how they affect others in an open manner with nobility, grace and gratitude.
6. To learn to give feedback in a constructive and non-judgmental way.
7. To freely react and to express their feelings behaviorally.
8. To acquire and to put into practice skills on how to manage stress more effectively.
9. To formulate an action plan to modify or to change identified areas of improvement.
Program objectives are best achieved through the use of learning methodologies that enhance an active
involvement of the participants, from which each one is able to draw from their own valuable experiences and
resources. Such methods of learning include small group discussions, movie review and critique, self-disclosure and
feedback sessions, listening, and other structure exercises. Short lectures will be utilized to provide cognitive inputs
for the integration of learning.
In the final analysis, the whole Values Workshop will guide the Facilitator and the participants in achieving
self-knowledge, as well as awareness of oneself, of the others and of the world around them.
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STUDY GUIDE
Module 1: Values Workshop
Self-awareness and Values Clarification as a Physician
The Phases of Consciousness
Components Contents of each part

MANAGEMENT OF LEARNING
Overview of the topic In order for Values Education to become part and parcel of medical school, the
closest possible link need to be found between the world of teachers and students.
The true potential of the teacher (and through the teacher, the UPCM) is to make a
difference in the life of the students and to effect change in student achievement.
This Quality Teaching provides a perspective that speaks of intellectual depth, inter-
relational capacity and self-reflection as being among the factors that characterize the
kind of learning that makes a difference.
Values Education reflects good practice pedagogy. Impelled by intellectual depth,

the workshop will be building on factual knowledge to develop in medical students the
kind of communicative capacities, interpretative skills and powers of negotiation that
are at the heart of social conscience, and moreover, the reflective and self-reflective
growth that is the foundation of a personal morality and social citizenry. In other
words, the goal is to discover how one can live life with greater consciousness,
responsibility and freedom as one reflects on and chooses the values to guide
ourselves in our career, relationships and other life issues. (Values Education and the
Teacher’s Work: A Quality Teaching Perspective, Prof. Terence Lovat, 2005) This can
only be achieved by gaining self-knowledge, demonstrate self-acceptance and skill in
self-reflection and self-management.
Course outcomes and At the end of this module, you will be able,
content
To demonstrate self-knowledge and plan towards personally attaining the
shared vision and values of an ideal physician determined by the group through a
facilitated process.
Specific Objectives:
1. To define values and to explore one’s choices as a result of one’s values.
2. To review some value indicators and find out how we could identify some of
our values through them.
3. To describe the four Phases of Consciousness and chart one’s Personal
Consciousness Track.
4. To assess one’s skills and abilities in terms of the consciousness track.
5. To formulate and commit to a Personal Program of Change.
Course content to help surface and identify values:

- Orientation to the Course
- Expectations Setting
- Preparation work for Value Indicators
- Movie: ‘Patch Adams”
- The Value Process
- Values and Personal Consciousness
o Personal Consciousness Track
o Phases of Consciousness
o Skills profile
- Personal Program of Change
- Life Goals
Prerequisites None
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Timetable First day (4 hours) Activity 1: Orientation to the Course
Movie: Patch Adams
Second Day (5 hours)
30 mins Activity 2: Expectation Setting: Road Map
30 mins Activity 3: Introduction to Values:
Processing of the movie: Patch Adams
List of Values
30 mins Activity 4: Value Clarifications
Activity A: Envisioning the Future
Activity B: Reviewing the Past: Hand Language
1 hour Lunch Break
30 mins Activity C: Assessing the Present
Learning from Value Dilemmas
30 mins Activity 5: Personal Consciousness Track
30 mins Skills profile
30 mins Activity 6: Planning for the Future
Personal Program of Change
LIFE GOAL
30 mins Synthesis and Evaluation of the Course
Learning opportunities Small group discussions
Lecture: Learning Methodologies
Individual learning
Learning Journal
Assessment details Mandatory attendance – no make-up classes
Staff contacts Faculty Facilitators (24 pax)

Psychiatry MLR de Guzman (Course Coordinator)
Personal comments The truth is that as the struggle for survival has subsided, the question that has
emerged: survival for what? Ever more people today have the means to live, but no
meaning to live for. (Frankl, Victor, Man’s Search for Meaning)
INFORMATION ON THE TOPIC

Information on the Values clarification is a process which help people arrive at an answer. It will help us
subject or topics look deeper into ourselves to make judgments concerning prized values and discern our
feelings, attitudes and behaviors. It is a methodology to help us make a decision, to act
to determine what has meaning for ourselves because it is directed to the present and
the future. Values clarification is positive, personally affirming, individually focused and
success oriented. For this the following lectures will be given:
1. Values: The Personal Nature of Values and the Value Process

2. Value Transmission and Value Development
3. Values clarification: practical strategies
4. The Clarifying Response
An essential aspect of the program is the active participation and contribution of the
participants in the group learning process. Unlike in lecture sessions, where one mainly
sits and listens, in these experiential sessions, one has to actively participate and gain
his/her own insights. Moreover, it should be emphasized that the law of economics
holds here: the more one invests, the more one gets in return.
STUDENT ACTIVITIES RELATED TO LEARNING
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Interaction with texts To fully maximize your valuing process it would be good for you to read a book.
or other learning Reading is the very strong link for having extensive vocabulary and achieving school
resource materials success. Reading can give us many benefits and advantage in life. Especially in
medicine, they say that reading books help the brain improve in the way of creativity
and mentally. Because the more we read, the more we learn. Knowledge is a gift, so
we can have more knowledge in reading books.
Do you have a reading list?
Application of theory to You are encouraged to actively participate in small group learning with your peers and
practice facilitator. This is an effective way of developing critical thinking, communication skills
and the ability to perform as team members and leaders.
Self-assessment After each activity take time out for reflection. Each participant will have their own
Learning Journal, where you will write down personal insights after each activity. Below
are some guide questions to help you.
1. What have you discovered about yourself?
2. How do you feel about your discovery? Do you agree with what has surfaced?
3. Do you feel good about it? Or would there be some changes that you would like to
happen?
4. In what ways are your inclinations manifested? Do your behavior(s) harmonize with
your inclinations? What can be further improved/removed in your behavior(s) to
ensure that your inclination may be fully manifested?
Personal information At the end of the two-day value processing workshop, you will be asked to make a
bank personal reaction paper (1-page) the content of which is to face the challenges you need
to explore and to include the dimensions of values clarification and development you
would need in order to arrive at a more holistic and integrated medical education. The
reaction paper will have to be submitted to the course coordinator the following
working day.
Evaluation of the guide Without undermining the course, there will be no grade requirement, merely Pass-
Fail. The basis for evaluation will be on the Learning Journal and the reaction paper to
the entire Values Workshop. It is for this reason that attendance is mandatory.
Requirements:
• PUNCTUALITY
• ATTENDANCE
• ACTIVE PARTICIPATION IN THE SMALL GROUP DISCUSSION
• DILIGENCE IN THE ASSIGNMENTS
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Learning Journal
Learning Journal:
• Primarily a personal account of one’s experience in the workshop
• An articulation of the changes one experiences in oneself as a result of one’s participation in the workshop
• An analysis of what may have helped or may have hindered one’s learning
• A list of areas for further clarification or discussion
• A description of some of the major implications and consequences of one’s role.
Learning Journal/ Reflection Paper/ Feedback Diary:

IS NOT:
• An evaluation of the program outputs, e.g. specify topics or exercises, facilitators, facilities, etc.
• A summary of major program ideas or concepts
IS:
• Primarily a personal account of one’s experience in the workshop
• An articulation of the changes one experiences in oneself as a result of one’s participation in the workshop
• An analysis of what may have helped or may have hindered one’s learning
• A list of areas for further clarification or discussion
• A description of some of the major implications and consequences of one’s role.
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Activity 2: EXPECTATION SETTING
Dear Participant:
Please answer the following questions:
a) What tangible benefits do you expect to derive from the Values Workshop, personally & professionally?
b) How do you see the role of the Faculty Facilitator and the other participants in the group?
c) What can you personally contribute to make this Values Workshop a success?
d) What conditions could prevent you from participating fully and effectively in the entire workshop?
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Planning for the Future
University of the Philippines-

College of Medicine
Assessing the present
Reviewing the past
Envisioning the Future
ROAD MAP
ME
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Activity 3: INTRODUCTION TO VALUES: Patch Adams
PROCESSING OF THE MOVIE
INSTRUCTIONS: Write down the following :
a. What are your personal reactions in relation to the movie?

b. Please make a ranking among the following movie characters, from the one you like/ admire best to the
one you like/admire least and state your personal reasons.
1. Patch Adams
2. Psych Unit Doctor
3. Dean Wolcott
4. Dean Anderson
5. Patch Adams’ roommate
6. Corinne
7. Patch Adams’ best friend, Truman
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LIST OF VALUES
The symbols in the listing below relate each value to its appropriate place in the Phases of Consciousness (Code)
and to the skill associated with it (Skill).
1. ACHIEVEMENT Recognition from others for what 27. FLEXIBILITY Code: 3A Me. Skill: IP; P/M
you have done. Code: 2B Me. Skill: IS; W. 28. GENEROSITY Code: 3A Me. Skill: IP; 2/M
2. BEAUTY As enjoyed for its own sake. Code: 3A Pr. 29. HONOR Earning recognition by keeping the code.
Skill: IM; P/K Code: 2N Me. Skill: SS; W/M
3. BEING LIKED Code: 2A Me. Skill: IP; M. 30. HUMAN DIGNITY Code: 3B Pr. Skill: SS; W
4. BEING YOUR OWN PERSON Accountable to self 31. INDEPENDENT Code: 3A Me. Skill: IP; P/M
rather than to others. Code: 3B Pr. Skill: SS; P/M 32. INITIATIVE Code: 3A Me. Skill: SS; P/M
5. BELONGING Membership in a group or institution, 33. INSIGHT Code: 3B Pr. Skill: IM; P/F
e.g. family, church, club, corporation, etc. Code: 2A 34. INTERDEPENDENCE Code: 4A Me. Skill: SS; W
Pr. Skill: IP; W/M 35. INTIMACY Code: 3B Pr. Skill: IP; P/F
6. BUILDING A NEW WORLD Working to change the 36. LAW AS GUIDE Law not as absolute rule but as a
World for the better. Code: 3B Pr. Skill: SS; W. basis for rational decision making. Code: 3A Me. Skill:
7. CANDIDNESS Unflinching; honesty. Code: 3A Me. SS; P/F
Skill: IP; W/M 37. LEISURE Time free from obligations. Code: 2B Pr.
8. CARE AND NURTURING Code: 2A Me. Skill: IP; M Skill: IM; P/F
9. COMMUNICATION Code: 2B Me. Skill: IS; W/M 38. LIVING IN HARMONY WITH NATURE Code : 4B Pr.
10. COMPANIONSHIP A social relationship with a Skill: SS; P/F
person who makes me feels good about me. Code: 2A 39. LIVING SIMPLY Getting along with a minimum of
Me. Skill: IP; P/M material things. Code: 3A Me. Skill: IS; W
11. COMPETENCE Code: 2B Pr. Skill: IS ; W 40. LOYALTY Code: 2b Me. Skill: IP; W/M
12. COMPETITION Code : 2B Me. Skill : IS ; W/M 41. MONETARY PROFIT Code: 1B Me. Skill: IS; W
13. CONTEMPLATION Reflection on the meaning of a 42. MUTUAL ACCOUNTABILITY Willingness to
thing or event. Code: 3A Pr. Skill: IS; B/F evaluate and to be evaluated in a peer relationship.
14. CONTROL OF OTHERS Code: 2B Me. Skill: IS; M. Code: 3B Me. Skill: SS; W
15. COOPERATION Code: 3B Me. Skill: IS; P/M 43. OBEYING THE RULES Law as rule. Code 2B Me.
16. COURAGE To take the risks and to bear hardships Skill: IS; W/M
to achieve what you think is right. Code: 3A Me. 44. OBJECTIVITY Recognition of one’s own bias in
17. COURTESY Politeness, good manners, Code: 2A looking at things; separating fact from personal bias.
Me. Skill: IP; M. Code: 2B Me. Skill: SS; W/M
18. CREATIVITY Code: 3B Me. Skill: IM; P 45. OBLIGATION/DUTY Code: 2B Me. Skill: IP; W/M
19. EDUCATION AS CERTIFICATION Going to school 46. ORDERLINESS Arranging time, belongings, tools,
to get a degree. Code: 2B Me. Skill: IS; W. etc. in an acceptable way. Code: 2A Me. Skill: IS; M.
20. EDUCATION AS KNOWLEDGE Learning for its own 47. OWNERSHIP OF PROPERTY Code: 2B Me. Skill: IS;
sake. Code: 3B Me. Skill: IS; W M
21. EFFICIENCY Code: 2B Me. Skill: IS; W 48.PAID WORK Code: 2B Pr. Skill: IS; P/M
22. EMPATHY To be aware of another’s feelings and 49. PATRIOTISM Code: 2B Me. Skill: IM; P/M
share in them. Code: 3A Me. Skill: IP; P/M 50. PEER SUPPORT/SOCIAL AFFIRMATION Being
23. EQUALITY Code: 3B Me. Skill: SS; P/M accepted and encouraged as a member of your
24. EXPRESSIVENESS Code: 3A Me. Skill: SS; P/M group. Code: 2A Me. Skill: IP; P/M
25. FAIRNESS FOR ALL Code: 3B Me. Skill: SS; W/M 51. PERSEVERANCE Code: 3B Me. Skill: IS; W
26. FATE Code: 1A Pr. Skill: W/M 52. PERSONAL GROWTH To make an effort for self-
53. PERSONAL HEALTH Code: 3A Me. Skill: SS; M. understanding and self-development. Code: 3A Pr.
54. PHYSICAL AFFECTION Code: 1B Me. Skill: IP; M Skill: IP; P/M
55. PHYSICAL PLEASURE Code: 1B Me. Skill: IP; M 84. WHOLENESS Code: 4A Pr. Skill; SS; P/F/M.
56. PRODUCTIVITY Code: 2B Me. Skill: IS; W 85. WONDER/CURIOSITY Urge to know. Code: 1B Me.
57. RECREATION/FREEDOM Time free from duties, Skill; IM; IP.
obligations, and necessary tasks, etc. 86. WORKMANSHIP Code: 2B Me. Skill; IS; W.
58. RELAXATION Code: 3A Me. Skill: SS; M 87. WORSHIP AS DUTY Code: 2B Pr. Skill; IS; W.
59. RISK TAKING Code: 3B Me; Skill: IP; P 88. WORSHIP AS CELEBRATION Code: 4ode: 4B Me.
60. SEARCH FOR MEANING Code: 3A Me. Skill: IM; Skill; SS; P/F.
P/M
18
61. SECURITY Code: 1B Pr. Skill: IP; M
62. SELF-ACTUALIZATION The process by which the
self listens to its own voice and freely chooses its The meaning of the symbols are as follows:
path for growth. Code: 3A Pr. Skill: IP; P/M
63. SELF-ASSERTION The middle ground between 1,2,3,4 are the Phases of Consciousness (This are
aggression (trampling on others) and passivity (letting the columns found in the Consciousness Chart).
others trample on oneself). Code:: 3A Pr. Skill: IP; P/M
64. SELF-CENTERDNESS Code: 1A Pr. Skill; IP; M.
65. SELF-CONFIDENCE Code: 2B Pr. Skill; IS; W.
A and B indicates the two stages of each phase.
66. SELF-CONTROL Code: 2A Pr. Skill; IS; W. The A stage focuses on individual values, values
67. SELF-DELIGHT Code: 1B Pr. Skill; IS; W. viewed as qualities of the person. The B stage
68. SELF-DIRECTEDNESS Code: 3A Me. Skill; IP; M. focuses on values in their public and institutional
69. SELF-DISCIPLINE Code: 3A Me. Skill; IP; M. aspect.
70. SELF-EVALUATION Code: 3A Me. Skill; IP; M.
71. SELF-PRESERVATION Code: 1a Pr. Skill; IP: W/M. Pr stands for primary or end values, those chosen
72. SELF-WORTH Code: 2A Pr. Skill; IP; M. Me. for their own sake. Pr values appear at the top
73. SERVICE VOCATION Finding satisfaction in serving section of the columns.
others through your work. Code: 3A Pr. Skill; SS; W.
74. SEXUAL PLEASURE Code: 1B Me. Skill; IP; P/M.
75. SOLITUDE The capacity to be at peace with
Me stands for means values, those that are
oneself alone as well as with the other. Code: 3B Me. desired not so much for their own sake, but for
Skill; SS; P/F. what they can lead to.
76. SPONTANIETY The ability to act with openness
and immediacy. Code: 3B Me. Skill; IM; P. IS means Instrumental Skills
77. STATUS/RANK Code: 2B Me. Skill; IP; P/M. IP means Interpersonal Skills
78. SUPPORTING YOUR COMMUNITY Code: 3B Me. IM means Imaginal Skills
Skill; SS;P. SS means System Skills
79. SURVIVAL Code: 1A Me. Skill; IS; M W stands for Work
80. SYNGERY A process of pooling people’s energies
M stands for Maintenance
in which more creativity is generated than could
result from their separate efforts. Code: 4A Me. Skill;
P stands for Play
SS; P/F. F stands for Freesence
81. TRADITION A sense of one’s own roots. Code: 2A
Me. Skill; SS; P/M.
82. TRUST Code: 3A Me. Skill; IP; M.
83. TRUST/WISDOM Code: 4A Pr. Skill; IM; P/F.
19
Activity 4: EXPLORING VALUE INDICATORS
ACTIVITY A1: STARRY NIGHT - An Exercise on Learning how to Visualize
INSTRUCTIONS: This is an exercise on visualization. Below is a painting of “Stary Night” by Dutch Post-impressionist
painter Vincent Van Gogh in June 1889. Try to answer these without googling... that is, by simply spending first some
10 minutes gazing at the painting, absorbing it, and then naturally allowing what comes to mind and heart the
following the questions.
Accompanying guide questions to the painting:
What do you find interesting and noticeable about the sky?
How does the sky contrast with the town below?
What do you notice about the cypress tree to the left?
20
ACTIVITY A2: ENVISIONING THE FUTURE
INSTRUCTIONS: Drawing and verbalizing:
My Vision of What I will be as an Ideal Physician 25 years from now.
Draw a vision of yourself, emphasizing your success as a person, as a professional and as part of the community
based on the ideal values that are important. Identify (in writing) the values that are reflected in your vision. Then
write a short paragraph to explain your vision making use of the guide questions.
Reflective/Guide Questions::
a) What are your successes both as a person and as a professional, and as part of the community?
b) What impact do you hope to achieve?
c) What purpose do you have in life?
d) What relationships are important to you?
21
ACTIVITY B: REVIEWING THE PAST: REQUISITES FOR PERSONAL GROWTH AND CHANGE EXPERIENCING
ONE’S UNIQUENESS:
The Hand Language

Instructions: Draw and outline of your left hand to include the wrist area)
What factors contributed to your

growth as a person? Greatest growth
experience: An event in your life
What factor(s) contributed to your

failure? Major blocks in your growth
as a person
What is the greatest success in

my life? God’s greatest gift to you
as a person
Think of a word or a phrase which

best describes you.
What keeps me going?
Who is the most significant

person in my life?
Name you feel most comfortable

with
22
Reflective/Guide Questions:
a) What were the feelings you experienced while working on the activity and while sharing your hand
language?
b) How can you reconcile the values surfaced in this activity with those in the previous activity?
c) What impact or effect did this activity have on you? In what way did it affect you?
d) What significant learning experiences, realizations, and discoveries did you have from this activity?
23
ACTIVITY C: ASESSING THE PRESENT
LEARNING FROM VALUE DILEMMAS

BRIDGING IDEAL AND ACTUAL VALUES
Instructions:
Review a past experience where you had to make a major decision and encountered a value dilemma. You had to
choose at least between two alternatives. Write down the values you were acting on when you made the
decision. Describe in your journal the personal meanings of the choices you made.
24
Instructions: Go through the questions of the Values Grid and to a place a check mark if they have an affirmative
answer or leave it blank if either in doubt or have a negative answer.
VALUES GRID
A. Was your decision made freely?
B. Did you feel that you were the one

who made the decision even if there are many
people who tried to influence you?
C. Was your decision made considering several

alternatives?
D. Was there a careful and thorough consideration

of the consequences of your decision before you opted for it?
E. Did you clearly see more advantages than

disadvantages in making the choice?
F. Are you happy with this decision you made?
G. Are you proud of this decision you have made?
H. Do you feel comfortable letting people know about your

decision?
I. Have you taken actual steps with regard to your decision?
J. Given the same situation and chance to freely make your

decision again, will you make the same decision?
Reference: Tan, Earnest I. The Clarification and Integration of Values, Values Education Program of the Graduate
School of Miriam College Foundation, Inc.1989.
25
Activity 5: Charting Your Personal Consciousness Track
INSTRUCTIONS: For this exercise, you will need to chart your own Consciousness Track. To do this, please review your
insights from past activities with the help of Learning Journal.
For step 1: Carefully go over the List of Values (pp.19-20). Pick out twenty values that are important to you at present,
not values you wish to possess. You must choose values that you presently hold dear and important; values you notice
yourself choosing, prizing, and acting on. Encircle the values you picked.
For step 2: Plot the values listed into the Personal Conscious Track
Step 1: Place twenty values (20) you have chosen from the List of Values with code in the table
below.
Most Important Values Code Other Important Values Code
Note that:
1,2,3,4 Refer to the four Phases of Consciousness

A.B Refer to the two stages of each phase
A - Values are values that are more personal and are viewed as qualities of the person. (Example from our
workshop: Nurturing is a personal quality)
B - Values are values that are more social in nature and are expressed more in the public and institutional
sphere.
Pr - Stands for primary or end values, which are chosen for their own sake and are parallel to long-range goals.
Pr values appear on the top section of the section of the columns.
Me - Stand for means values, chosen to help achieve primary values and are parallel to short-term goals. Me
values appear on the bottom section of the columns.
26
CONSTRUCTION OF YOUR PERSONAL CONSCIOUSNESS TRACK
Step 2: List the values on the Personal Consciousness Track Form
I II III IV
World as Center World as Belonging World as World as Life-givers
Independent
A B A B A B A B
P
R
I
M
A
R
Y
M
E
A
N
S
Code:
1,2,3,4 - Refer to the Four Phases of Consciousness
A, B - Refer to the two stages of each phase
Primary - Refer to the primary values
Means - Refer to the means values
27
CONTINUING THE INWARD JOURNEY: Skills Inventory
INSTRUCTIONS: Having gone through the Consciousness Track, begin now to look over your skills and assess your
abilities in the given area. You were given a list of items under each skill area - Instrumental, Interpersonal,
Imaginal and System Skills.. Follow this direction as you perform the given task:
Encircle
0, if you have no skill at all in the item indicated;
1, if you feel you have minimal skill in the area;
2, if you feel you have an average skill in that area; and,
3, if you have maximum skill in the area.
After assessing each item in each page, add all your ratings.
Then answer the Guide Questions/Reflections:
a) In what phase of consciousness do you presently belong?

b) Among the four skills, what particular skill is most developed in you?
c) Among the four skills, what particular skill is least developed in you?
d) Does your most developed skills correlate with your Phase of Consciousness?
e) What are your insights and learning experiences from this activity?
*The above activities were adapted from Human Intimacy by Earnest Tan. He cited his reference as Value
Development: A Practical Guide by Kalven, Rosen and Taylor. Revisions were made based on the session with IPC
Facilitators Batch 2002-2003.
28
SKILLS INVENTORY
1. INSTRUMENTAL SKILLS
Instrumental Skills: The abilities that enable one to get a job done; the intellectual, physical competencies that enable one to shape
both ideas and the immediate eternal environment; the skills involved on physical dexterity; handicrafts and cognitive
accomplishments.
SKILL SCORE
1. Coordinating one’s physical self in some form of support or exercise. 0 1 2 3
2. Speaking effectively about what one thinks and feels in one-to-one setting. 0 1 2 3
3. Speaking effectively about what one thinks and feels in a small group setting. 0 1 2 3
4. Speaking effectively about what one thinks and feels before a large audience. 0 1 2 3
5. Listening attentively and paraphrasing accurately. 0 1 2 3
6. Expressing one’s thoughts and feelings clearly and forcefully in writing personal 1 2 3
letters or diaries. 0
7. Expressing one’s thoughts and feeling clearly and effectively in writing memos 0 1 2 3
and reports.
8. Expressing one’s thought, feelings, and observations in poetic or fictional form. 0 1 2 3
9. Using a large and discriminating vocabulary. 0 1 2 3
10. Reading quickly and with comprehension newspapers, periodicals, and light 0 1 2 3
fiction.
11. Reading poetry and serious fiction with comprehension. 0 1 2 3
12. Reading research reports and scholarly works and comprehension. 0 1 2 3
13. Participating effectively in role playing. 0 1 2 3
14. Identifying and constructing role-plays suitable for a given group. 0 1 2 3
15. Able to use mathematical techniques to synthesize and present data. 0 1 2 3
16. Able to make and manage budgets. 0 1 2 3
17. Able to manage one’s time and prioritize activities. 0 1 2 3
18. Able to research a topic or question and summarize findings clearly and 0 1 2 3
cogently.
19. Able to analyze and criticize another’s argument. 0 1 2 3
20. Able to marshal evidences and frame arguments in support of a position. 0 1 2 3
21. Able to master new skill in one’s job. 0 1 2 3
22. Able to plan and carry out learning activities for oneself. 0 1 2 3
23. Able to plan and carry out learning activities for others. 0 1 2 3
24. Able to utilize active and involving modes of learning: games, stimulations, 0 1 2 3
role-plays, and experienced-based exercise.
25. Able to plan for and facilitate meetings. 0 1 2 3
26. Able to utilize a variety of problem-solving techniques. 0 1 2 3
27. Able to identify problem areas and define problems. 0 1 2 3
28. Able to use ordinary household tools, e.g. hammer, screwdriver, kitchen 0 1 2 3
utensils, paintbrush, plunger.
29. Able to use modern machines and technologies, e.g. drive a car, use a 0 1 2 3
calculator, use office machines, etc.
30. Able to observe and record accurately small and large group interactions. 0 1 2 3
Take the total number and numerical value of the numbers you have encircled and write in the space provided.
29
SKILLS INVENTORY
2. INTERPERSONAL SKILLS
Interpersonal Skills: The ability to perceive self and others accurately, in ways that facilitate communication, mutual
understanding and cooperation.
SKILL SCORE
1. Identifying my own feelings accurately. 0 1 2 3
2. Identifying other’s feelings accurately. 0 1 2 3
3. Expressing my feeling openly. 0 1 2 3
4. Accepting my own worth, feeling happy with myself. 0 1 2 3
5. Being aware of my “self-talk”, i.e., my expectations of myself. 0 1 2 3
6. Accepting my limitations peacefully. 0 1 2 3
7. Identifying and expressing my negative feelings. 0 1 2 3
8. Accepting positive feedback non-apologetically. 0 1 2 3
9. Accepting negative feedback non-defensively. 0 1 2 3
10. Reading another’s non-verbal communication accurately. 0 1 2 3
11. Showing empathy, identifying with another’s feeling. 0 1 2 3
12. Expressing my goals and intentions clearly. 0 1 2 3
13. Dealing effectively with mixed messages, e.g., body says one thing, words say 0 1 2 3
another.
14. Remaining calm in a high stress situation. 0 1 2 3
15. Giving positive feedback so that the other feels affirmed. 0 1 2 3
16. Giving negative feedback appropriately. 0 1 2 3
17. Coping effectively with conflict. 0 1 2 3
18. Expressing feelings non-verbally and symbolically. 0 1 2 3
19. Accepting others as they are. 0 1 2 3
20. Describing another’s behavior non-judgmentally. 0 1 2 3
21. Accepting person whose values are very much unlike my own. 0 1 2 3
22. Showing appreciation for the strengths of others, enjoying others. 0 1 2 3
23. Checking my perceptions of another’s ideas, feelings, or values with them. 0 1 2 3
24. Taking responsibility for meeting my own needs rather than expecting the other 0 1 2 3
to meet them.
25. Negotiating needs and wants (mine and another’s) in an intimate relationship. 0 1 2 3
26. Asking accountability of another in a relationship. 0 1 2 3
27. Being accountable to another in a relationship. 0 1 2 3
28. Distinguishing my feelings from my opinion. 0 1 2 3
29. Expressing my own values without judging different values held by another. 0 1 2 3
30. Being open to new values, attitudes, experiences. 0 1 2 3
30
SKILLS INVENTORY
3. IMAGINAL SKILLS
Imaginal Skills: That blends of fantasy and feeling that enables us to combine images and ideas in new ways, to see alternatives,
to change conventional ways of doing things, to remedy deficiencies.
SKILL SCORE
1. The ability to “break set,” i.e., to identify one’s unconscious assumptions 0 1 2 3
about the limits in a situation.
2. The ability to defer judgment to avoid the habitual response. 0 1 2 3
3. The ability to tolerate ambiguity. 0 1 2 3
4. The ability to daydream creatively. 0 1 2 3
5. The ability to play with a problem, looking at it from a fresh angle, 0 1 2 3
redefining it new ways.
6. Fluency in making fresh associations, perceiving connections or similarities 0 1 2 3
between disparate realms of experience.
7. Fluency in communicating verbally. 0 1 2 3
8. Fluency in communicating through two-dimensional constructions, e.g., 0 1 2 3
charts and graphs.
9. Fluency in communicating through three-dimensional constructions, e.g., 0 1 2 3
models.
10. Fluency in communicating through gesture and pantomime. 0 1 2 3
11. Fluency in communicating through movement and dance. 0 1 2 3
12. Awareness of and sensitivity to the natural environment. 0 1 2 3
13. Awareness of and sensitivity to the visual and tactile to color, line, texture, 0 1 2 3
and composition.
14. Awareness of and sensitivity to the auditory dimension-pitch, tone, quality, 0 1 2 3
rhythm, melody, and harmony.
15. Sensitivity to language, to the origins, and meanings of words, ability to 0 1 2 3
play with words.
16. Fluency in communicating through poetry and drama. 0 1 2 3
17. Trust in one’s own perceptions and confidence in expressing them. 0 1 2 3
18. Able to generate alternative solutions to problems. 0 1 2 3
19. Able to put together existing elements or data in new ways. 0 1 2 3
20. Able to imagine behavioral alternatives for one’s self, alternative ways of 0 1 2 3
expressing one’s value.
21. Able to elaborate on an idea or plan developing the details. 0 1 2 3
22. Able to make alternative long-term plans for one’s self. 0 1 2 3
23. Able to make alternative long-term plans for a group or organization. 0 1 2 3
24. Able to make up stories, generate plots, tell a tale. 0 1 2 3
25. Able to see the consequences of alternative courses of action. 0 1 2 3
26. Able to prioritize among alternatives. 0 1 2 3
27. Able to use brainstorming with a group to generate alternative solutions. 0 1 2 3
28. Able to devise a variety of ways to learn in small and large groups. 0 1 2 3
29. Able to call upon a variety of alternatives in the heat of tension or 0 1 2 3
situations of conflict.
30. Able to facilitate others in generating new ideas. 0 1 2 3
Take the total number and numeric value of the numbers you have encircled and write in the space provided.
31
SKILLS INVENTORY
4. SYSTEM SKILLS
System Skills: The ability to see the various parts of a system as they release to the whole and plan for systematic changes.
SKILL SCORE
1. Identifying the various systems at work in one’s own life. 0 1 2 3
2. Identifying a system in terms of its component parts and their function and 0 1 2 3
interactions.
3. Distinguish between process and content in a small group. 0 1 2 3
4. Distinguish between process and content in a large, formal group. 0 1 2 3
5. Distinguish between personal and system needs in small group interactions. 0 1 2 3
6. Distinguish between personal and system needs in large, formal 0 1 2 3
organizations.
7. Understanding one’s own body as a system. 0 1 2 3
8. Taking responsibility for one’s own health (being one’s own doctor). 0 1 2 3
9. Acquiring sufficient knowledge of nutrition, exercise, relaxation techniques, 0 1 2 3
and to choose those which are best suited to one’s self.
10. Making a system analysis of one’s family. 0 1 2 3
11. Defining one’s role in one’s family system. 0 1 2 3
12. Defining one’s role in one’s school. 0 1 2 3
13. Defining one’s role in one’s workplace. 0 1 2 3
14. Defining one’s role in one’s social or friendship group or church. 0 1 2 3
15. Ability to cope with bureaucratic paperwork (license applications, 0 1 2 3
registration forms, tax forms).
16. Defining one’s role in one’s political group. 0 1 2 3
17. Assessing the strong and weak points of one’s family system. 0 1 2 3
18. Assessing the strong and weak points of one’s school. 0 1 2 3
19. Assessing the strong and weak points of one’s workplace. 0 1 2 3
20. Assessing the strong and weak points of one’s church. 0 1 2 3
21. Assessing the strong and weak points of one’s social grouping. 0 1 2 3
22. Assessing the strong and weak points of one’s political group (neighborhood, 0 1 2 3
city, state, country, political party).
23. Synthesizing data from a variety of sources (e.g., personal experience, 0 1 2 3
statistics, interviews, research reports, emotional inputs).
24. Ability to make sense out of an apparently disparate idea. 0 1 2 3
25. Ability to organize a task, dividing it into its component parts. 0 1 2 3
26. Ability to write job descriptions. 0 1 2 3
27. Developing informal communication and support networks within a formal 0 1 2 3
organizational system.
28. Engaging in long term planning and goal setting for one’s self. 0 1 2 3
29. Engaging in long term planning and goal setting for a system of which one is 0 1 2 3
part.
30. Communicating effectively with persons at different levels in a given system. 0 1 2 3
(e.g., peers, superiors, subordinates).
32
Activity 6 : PLANNING FOR THE FUTURE
PERSONAL PROGRAM OF CHANGE
Designing a Personal Growth Contract:
Life goals are classified into goals for the family, career, and self. Rank these according to importance.
Formulate an action plan based on your strengths, weaknesses, opportunities, and threats. This action plan should
guide you in attaining your goals for the next 3 – 5 years.
Look into your individual map:

• Check
o Where do you want to go?
o Where are you now?
o How did you get here?
• Assess your present location
o Where you are presently?
o Looking into your present life, review your resources in getting there.
o What opportunities can you take advantage of?
o What blocks are there?
• In planning for your activities, you have to consider that each should be based on the criteria of SMARTA.
o Promote the strengths
o Correct the weaknesses
o Take advantage of the opportunities
o Work on only one goal
o Pay attention to the values.
33
LIFE GOALS
I, ____________________________________ (state your name) commit myself to achieve
these life goals within 25 years from now or even earlier.
INSTRUCTIONS: Designing a Personal Growth Contract
GOAL
1ST RANK OPTION
2ND RANK OPTION
3RD RANK OPTION
__________________________________
(Print name and signature)
Witnesses :__________________________________________
__________________________________________
34
COLLEGE OF MEDICINE


Module 2: Pedagogy 1
(The Learning Process)
Coralie Diquino-Dimacali, MD
Edited by:
Ma. Lourdes Rosanna E. de Guzman, MD, MS Epi, FPPA
Course Coordinator
35
PEDAGOGY 1:
Table of Contents: The Learning Process
Goals and Objectives of the UP College of Medicine
Module 2: Study Guide

Session 1 Introduction and Expectation Setting
Session 2 Physician’s Knowledge, Attitude and

Skills
Session 3 Time Management

Time Management Inventory
Scoring Key
How to Manage Time and Set Priorities?
Session 4 Learning Preferences 1

(Factors Affecting Learning)
Session 5 Learning Preferences 2

(Learning Preferences and Learning
Skills)
Rezzler Learning Preference Inventory
Analysis of Learning Preferences
Inventory
Learning How to Learn
Session 6 Approach to Learning 1

Medical Learning Styles and
Interpretation
Interpretation and Meaning of Scales
Figure 1. Model of Student Approaches
to Learning
Deep versus Surface Learning Strategies
Session 7 Approach to Learning 2

Learning Insights
How to Identify your Best Learning Styles
Evaluation of the Course
36
GOALS AND OBJECTIVES OF THE U.P. COLLEGE OF MEDICINE
GOAL:
Excellence and leadership in medical education research and service which is community-oriented and directed
to underserved areas.
OBJECTIVES ON MEDICAL EDUCATION
To train and educate physicians who:
▪ possess the requisite knowledge, attitudes and skills to promote and maintain health, prevent and treat
disease, and rehabilitate, as fully as possible, the victims of these diseases.
▪ are socially conscious and who shall continually seek ways and means to help solve the health problems of the
country.
▪ are well-motivated to practice their profession in underserved communities and are unable to adopt to local
conditions.
▪ are properly motivated to pursue quality continuing medical education.
37
INTERDISCIPLINARY COURSE 202:
THE ART OF MEDICINE: The Making of a Physician
STUDY GUIDE
Module 2: Pedagogy 1 (The Learning Process)
Overview of the topic Medical knowledge is immense and constantly changing, making medical
education a lifetime endeavor. Cognitive processes and skills of decision-making,
reasoning and problem solving are essential in medical practice because of the
tremendous amount of details that must be acquired by the health professional.
Attitudes are relevant, as well, in making sound judgment. For these reasons,
learning becomes a way of life for a physician, punctuated by respect for evidence,
logic and inquisitiveness directed towards the delivery of compassionate, ethical care.
Course outcomes and At the end of this module, you will be able,
content To understand the learning process that will facilitate the attainment of one’s
personal goals and the goals of the UPCM.
1. To clarify the goals of the UPCM undergraduate program.
2. To identify learning abilities that need to be developed in order to attain the
UPCM goals.
3. To analyze individual learning strategies and their effectiveness in the study
and practice of medicine.
a. To identify the factors that affect the learning process.
b. To be able to derive the principles of learning from the analysis of these
factors.
4. To apply a more effective approach to various learning situations (simulated
or actual).
Course content:
- Time Management
- Learning preferences
- Approach to Learning
- Learning insights
Prerequisite Session 1: Introduction to the Course 1 hour
Film showing
Written exercises
Time Table for SGDs 20 min Session 2: Expectation Setting
20 min Session 3: Time Management
20 min Session 4: Learning Preferences
20 min Session 5: Approach to Learning
20 min Session 6: Learning Insights
Session 7 (Plenary): Presentation of Class Profile
and Evaluation of the Course
Learning opportunities Movie: The Gifted Hands
Workshop with small group discussions (8 - 10 students/ group)
Individual learning
Readings
Learning Journal
Assessment details Attendance
Staff contacts Faculty Facilitators
Personal comments What is learning? Malcolm Knowles, the pioneer in the field of adult learning defines
learning as a process by which behavior is changed, shaped or controlled. Can adults
learn? Certainly they can. It is important however to learn how adults learn. Knowles
suggests the following characteristics of adult learners:
38
1. Adults need to know why they need to learn something.
2. Adults need to learn experientially.
3. Adults approach learning as problem solving.
4. Adults learn best when the topic is of immediate value.
5. Adults view learning as an active process in the construction of meaning.
Thus, since adults have accumulated a foundation of life experiences and
knowledge, they tend to be autonomous, pragmatic, self-directed, goal and relevancy-
oriented. The challenge you are faced with is to investigate your own learning styles,
preferences and strategies to motivate yourselves to be life-long learners, inculcating
the value of self-directed learning which should come as secondary nature to
physicians.
Information on the The different topics to be covered are the following:
subject or topics 1. How to Manage Time and Set Priorities will help to motivate you to manage your
time well.
2. Learning preferences will help you become aware of the different factors
affecting learning so that adequate preparations can be made to attain optimal
learning.
3. Approach to Learning will help you gain insight into the different approaches to
learning and to realize their different consequences towards becoming a
professional.
Interaction with texts Further readings will be recommended to help you reinforce and further develop
or other learning time management skills and learning skills throughout training in medical school and
resource materials continuing education levels. A film showing entitled The Ben Carson Story: Gifted
Hand: will encapsulate what the process of being life-long learners means.
Application of theory to You are encouraged to actively participate in small group learning with your peers
practice and facilitator.
Self-assessment For the first activity, you will be asked to answer a set of questionnaires. The results
of which will be processed in small group discussions and after which, a short lecture
will be given on Time Management.
The second activity, you will be asked to share a personal experience, after which there
will be a group discussion on the factors affecting learning. Another questionnaire will
need to be answered regarding learning preferences, whose results will be processed
in a small group discussion.
The third activity, will also require answering a questionnaire, whose results will also
be processed in a small group discussion regarding approaches to learning.
Finally, the last activity will call for a plenary where the facilitator will present the class
profile regarding the different approaches to learning.
Personal information At the end of the module, you will be asked to write in the Learning Journal, your
reactions to the workshop, the content of which is to define for yourselves the best
approach to learning which you will need to acquire and to develop so as to be able to
meet the challenges of medical school.
Guide questions:
1. What would be an ideal distribution of time between work, rest & recreation,
family and personal growth and development?
2. What are the barriers to achieving balance in my life?
3. In what ways could my assumptions and beliefs be a barrier to change?
4. In what ways is the current imbalance benefiting me and would I be willing to
give that up?
Fail. The basis for evaluation will be on your performance in the group process. It is
for this reason that attendance is mandatory.
39
Session 1: Introduction and Expectation Setting
INSTRUCTIONS: Write down your expectations in this Pedagogy I Workshop.
40
Session 2: Physician’s Knowledge, Attitude and Skills
INSTRUCTIONS: List down your personal observations and experiences regarding the different physician activities
and training to becoming a doctor.
41
Session 3: Time Management
TIME MANAGEMENT INVENTORY
INSTRUCTIONS: Do you know how to make time work for you? How many hours do you waste and how many do you
put to really good practical use? Is the day too long or too short for you? Do the following questionnaire carefully to
find out, and perhaps get some useful tips in the bargain. Encircle the letter of your answer.
1. Do you make lists of things to be done?

A. Rarely B. Often C. Sometimes
2. If you answered B or C to question #1, what usually happens after you have made the list?
A. You do not seem to get round to tackling the tasks.
B. You complete the tasks methodically.
C. You get at least some of them done.
3. Do you feel that you are very busy, but that you do not seem to accomplish much?
A. Often B. Sometimes C. Rarely
4. When did you last take time off to relax? (Choose the closest time)
A. within the last three days
B. not within the last three months
C. within the last four weeks
5. Are you rushed at the last minute because you have wasted time?
A. Sometimes B. Rarely C. Often
6. Would you say that you are? A. Always punctual B. Sometimes late C. Very unpunctual?
7. You have a bus to catch and arrive at the station just as the bus is about to pull away. Would you bother to run
for the bus? A. Yes B. No. C. Only if it was really urgent for you to catch it.
8. If you studied/worked through the night, would it be because?

A. You like to study/work at night when there are fewer interruptions?
B. You had got into a tight spot and had left yourself no other time to study/work?
C. The study/work was urgent and unexpected?
9. Do you feel that you are too busy to do the things you want to do? A. Sometimes B. Often C. Not really
10. Are you in a habit of hurrying, even when you do not need to? A. Yes B. No
11. Do you need someone else to put pressure on you before you can work at full capacity?
A. Yes B. No C. Sometimes, if you are tired or the work is not particularly interesting.
12. Have you ever made a special effort to get up early in order to be on time, then somehow managed to finish up
late anyway? A. Yes B. No
13. Would you prefer?

A. A lazy beach holiday
B. A tightly packed holiday, with lots of places to see and lots of different things to do
C. A mixture of relaxation and activities
14. Do other people ask you how you manage to do so much?

A. Quite frequently B. No – the thought is laughable C. Sometimes
15. Have you ever decided to fit a regular activity, say a ten minute exercise program, into your life?
A. Yes B. No
42
16. If you answered A to #15, did you?
A. Keep it up for a few days only
B. Keep it up for weeks or months
C. Keep it up, but not so regularly as you planned
17. When you have unpleasant tasks to do, do you?

A. Get them over quickly?
B. Postpone them, hoping they will go away?
C. Get them done, a bit at a time?
18. Do you say, “I have no time to….” as an excuse? A. Often? B. Only when it is true? C. Sometimes?
19. As a child, were you?

A. free to plan your own time to a great extent?
B. forced to submit to a timetable worked out by your parents?
C. free to play you leisure activities, but made to do homework and other tasks at fixed time?
20. If you had the chance to work free-lance, would you?

A. Take it with pleasure
B. Wonder if you could work without the discipline of having to go out each day.
C. Know that you would never do anything
21. Does other people’s lateness worry you?

A. Yes, it is very irritating B. No C. Sometimes
22. Do you ever feel that someone is preventing you from setting down to do something? A. Yes B. No
23. When you have to spend half an hour waiting for something, do you?
A. Find something to do or read
B. Just relax
C. Feel impatient and restless but do nothing
24. In the evenings, do you?

A. Flop down in exhaustion
B. Have a good time, sometimes relaxed, sometimes energetic
C. Go on working, or turn to domestic tasks or hobbies that you enjoy
25. Which is your best time of day? A. Morning B. Afternoon C. Evening
26. Does your busiest time coincide with your best time in the day? A. Yes B. No
27. Do you feel that you have tackled too much? A. Rarely B. Sometimes C. Often
28. Are you in general? A. very patient B. very impatient C. reasonably patient
29. Do you finish things before you have to? A. Once in a blue moon B. Often C. Sometimes
30. When you go on a journey, do you?

A. Pack carefully well in advance.
B. Throw things haphazardly into a suitcase at the very last minute.
C. Give yourself a small but comfortable margin of time to spare.
Check and total your scores for analysis.
43
SCORING KEY
1. A.3 B.5 C.1 16. A.1 B.5 C.3
2. A.1 B.5 C.3 17. A.5 B.1 C.3
3. A5 B.3 C.1 18. A.1 B.5 C.3
4. A.5 B.1 C.3 19. A.3 B.1 C.5
5. A.3 B.5 C.1 20. A.5 B.3 C.1
6. A.3 B.3 C.1 21. A.5 B.3 C.1
7. A.3 B.3 C.5 22. A.1 B.3
8. A.3 B.1 C.5 23. A.5 B.3 C.1
9. A.3 B.1 C.5 24. A.1 B.3 C.5
10. A.1 B.3 25. A.5 B.3 C.3
11. A.1 B.5 C.3 26. A.5 B.1
12. A.1 B.5 27. A.5 B.3 C.1
13. A.3 B.1 C.5 28. A.3 B.1 C.5
14. A.5 B.1 C.3 29. A.1 B.5 C.3
15. A.5 B.1 30. A.5 B.1 C.3
TOTAL SCORE: ______________

Tabulate
1 2 3 4
30 – 50
51 – 70
71 – 95
96 – 120
>120
44
How to Manage Time and Set Priorities
Rule 1: Do not create impossible situations

▪ Do not get trapped in doing too much.
▪ Use time to create success, not failure
▪ Plan to study 2 hours for every 1 hour of class
▪ Make time your friend, not your enemy.
Rule 2: Define Priorities
▪ Create a weekly calendar

▪ Write down daily “things to do”
▪ Put down short and long term goals in the list
▪ Plan to study first priority classes when you work best.
▪ Use list as a reminder, to put you on track.
▪ Check off items as you accomplish them and praise yourself.
Rule 3: Avoid Distractions and Lack of focus
▪ Procrastination
▪ Crises management
▪ Switching and Floundering
▪ Television, telephone and friends
▪ Emotional blocks
▪ Sickness
Recognize, resolve, improve!
45
Session 4: Learning Preferences 1
(Factors affecting Learning)
INSTRUCTIONS: Briefly describe a peak personal learning experience by writing the experience in your Learning
Journal.
46
Session 5: Learning Preferences 2
(Learning Preferences & Learning Skills)
REZZLER LEARNING PREFERENCE INVENTORY
This inventory gives you the chance to indicate those conditions or situations which most facilitate your learning. The
aim of the inventory is to describe how you learn, not to evaluate your learning ability.
The inventory has two parts. In Part I there re six sets of six words listed. In Part II there are nine items each of which
contain six statements.
INSTRUCTIONS FOR ANSWERING PART I
1. Read all six words carefully in each Column and rank order them from nos. 1 - 6. Write 6 for the word in Column
that best promotes learning for you, write 5 for the word that promotes learning next best, and so on, until you write
1 for the word that promotes learning least of all. Be sure to assign a different rank to each of the six words in each
Column and continue the same procedure for the remaining columns until all words are ranked.
2. Record all your answers on the Answer Sheet for Part I.

The following example illustrates the ranking procedure:
Rank the following colors in the order in which you prefer them:
Answer Sheet
Column A Column A
a. Yellow a. 6
b. Green b. 3
c. Blue c. 4
d. Red d. 5
e. White e. 2
f. Black f. 1
The number in the spaces on the sample answer sheet show that “yellow” is preferred most; followed by “red”
second; “blue” third; “green” fourth; “white” fifth; and “black” least. You are to rank the responses and mark your
answers to each word in Part I Column A through F in the same way.
Rank each work; do not omit any. Be sure to assign a different rank to each of the six words in each column.
RANKING:
6 = Promotes learning most for you

5 = Promotes learning second best
4 = Promotes learning third best
3 = Promotes learning fourth best
2 = Promotes learning fifth best
1 = Promotes learning least for you
47
PART I:
COLUMN A COLUMN B
A. Factual A. Self-instructional
B. Teacher-directed B. Myself
C. Teamwork C. Hypothetical
D. Reading D. Interpersonal
E. Self-evaluation E. Teacher-defined
F. Theoretical F. Practical
COLUMN C COLUMN D
A. Sharing A. Teacher-structured
B. Doing B. Concrete
C. Guided C. Writing
D. Self-initiated D. Group
E. Thinking E. Conceptual
F. Solitary F. Self-directed
COLUMN E COLUMN F
A. Scientific A. Individual
B. Assigned B. Applied
C. Skill-0riented C. Supervised
D. Personal D. Autonomous
E. Self-designed E. Abstract
F. Team-oriented F. Interactive
48
INSTRUCTIONS FOR ANSWERING PART II
1. Read all six statements in each numbered item and rank order them from nos. 1 - 6. Write 6 for the statement
that promotes learning next best; and so on, until you write 1 for the statement that promotes learning least of all.
Be sure to assign a different rank to each of the six statements in each no. and continue the same procedure with
the remaining items until all statements are ranked.
2. Record all your answers on the Answer Sheet for Part II.
RANKING: 6 = Promotes learning most for you

5 = Promotes learning second best
4 = Promotes learning third best
3 = Promotes learning fourth best
2 = Promotes learning fifth best
1 = Promotes learning least for you
PART II:
1. Read the following statements and then rank them in terms of how well they describe the teachers in
whose classes you have done the best.
A. The teacher gave many practical, concrete examples.
B. The teacher let me set my own goals and try different approaches to reach them.
C. The teacher encouraged me to work by myself.
D. The teacher was friendly and outgoing.
E. The teacher made the relationship between different schools of thought clear.
F. The teacher made clear and definite assignments, and I knew exactly what was expected.
2. Number the following kinds of work in the order in which they would interest you.
A. Work that would require cooperation among team members.
B. Work with specific and practical ways of handling things.
C. Work that would let me do things on my own.
D. Work that would permit me to deal with ideas rather than things.
E. Work that I could plan and organize myself.
F. Work that would clearly define and specified by my supervisor.
3. Rank the following in terms of their effects on how you work and how much you accomplish in a class.
A. I can set my own goals and proceed accordingly.
B. I can address myself to a concrete, practical task.
C. I have an opportunity to discuss or work on something with other students.
D. I can examine different schools of thought.
E. I understand what is expected, when work is due, and how it will be evaluated.
F. I can accomplish most tasks by myself.
4. The evaluation of student performance is a part of nearly all courses. Rank the following in terms of
how you feel about such evaluation.
A. It should be assembled from questions provided by students.
B. It should focus on individual performances.
C. It should consist of a written examination dealing with written concepts.
D. It should consist of a practical examination dealing with skills.
E. It should be consistent with clearly specified requirements.
F. It should not interfere with good relationships between the teacher and student.
5. Rank the following in terms of their general value to you as ways to learn.
A. Study a textbook.
B. Engage in an internship or practicum.
49
C. Prepare a class project with other students.
D. Search for reasons to explain occurrences.
E. Follow an outline prepared by the teacher.
F. Prepare your own outline.
6. Rank the following in terms of how much they would attract you to an elective class.
A. Good personal relationships between teachers and students.
B. Clearly spelled-out standards and requirements.
C. Emphasis on practicing skills.
D. Emphasis on individual study.
E. Opportunity to determine own activities.
F. Emphasis on theoretical concepts.
7. Consider the following in terms of their general effect on how will you do in a class.
A. I can study on my own.
B. I can work with something tangible.
C. I can focus on ideas and concepts.
D. I can organize things on my own.
E. I can work with others.
F. I can work on clear-cut assignments.
8. Rank the following in order to in which you think teachers should possess these characteristics of
skills.
A. Getting students to set their own goals.
B. Getting students to demonstrate concrete skills.
C. Involving students in generating hypothesis.
D. Preparing of self-instructional materials.
E. Relating well to students.
F. Planning all aspects of courses and learning activities.
9. Rank the following in terms of how much they generally help you learn and remember.
A. Studying alone instead of studying with fellow students.
B. Performing a specific task.
C. Having a knowledgeable teacher discuss the theory upon which a practice is built.
D. Determining your own approach and proceeding accordingly.
E. Joining a student group to study together and share ideas.
F. Getting an outline of the course from the teacher and a clear understanding of what will occur in the
course.
50
ANSWER SHEET: _________________________________________
PART I
COLUMN A COLUMN B COLUMN C

(26) a. ________ (32) a. ________ (38) a. ________
(27) b. ________ (33) b. ________ (39) b. ________
(28) c. ________ (34) c. ________ (40) c. ________
(29) d. ________ (35) d. ________ (41) d. ________
(30) e. ________ (36) e. ________ (42) e. ________
(31) f. ________ (37) f. ________ (43) f. ________
COLUMN D COLUMN E COLUMN F

(44) a. ________ (50) a. ________ (56) a. ________
(45) b. ________ (51) b. ________ (57) b. ________
(46) c. ________ (52) c. ________ (58) c. ________
(47) d. ________ (53) d. ________ (59) d. ________
(48) e. ________ (54) e. ________ (60) e. ________
(49) f. ________ (55) f. ________ (61) f. ________
PART II
Item 1 Item 2 Item 3

(26) a. ________ (32) a. ________ (38) a. ________
(27) b. ________ (33) b. ________ (39) b. ________
(28) c. ________ (34) c. ________ (40) c. ________
(29) d. ________ (35) d. ________ (41) d. ________
(30) e. ________ (36) e. ________ (42) e. ________
(31) f. ________ (37) f. ________ (43) f. ________

(44) a. ________ (50) a. ________ (56) a. ________
(45) b. ________ (51) b. ________ (57) b. ________
(46) c. ________ (52) c. ________ (58) c. ________
(47) d. ________ (53) d. ________ (59) d. ________
(48) e. ________ (54) e. ________ (60) e. ________
(49) f. ________ (55) f. ________ (61) f. ________

(62) a. ________ (68) a. ________ (74) a. ________
(63) b. ________ (69) b. ________ (75) b. ________
(64) c. ________ (70) c. ________ (76) c. ________
(65) d. ________ (71) d. ________ (77) d. ________
(66) e. ________ (72) e. ________ (78) e. ________
(67) f. ________ (73) f. ________ (79) f. ________
51
NAME ______________________________________________________
DATE ______________________________________________________
REZLER LEARNING REFERENCE

SUMMARY SHEET
Use this page to summarize your scores. Each of the numbers in Parts I and II below corresponds to items in the
questionnaire. For each item, write the rank (from 1 to 6) that you gave it. After filling in your ranks, total them
separately for Part I and II. At the bottom of the page, combine the totals of both parts. To check the accuracy of
your calculations, the bottom total of the six should be 315.
PART I
AB CO TS SS IP
IN
(31) ______ (26) ______ (27) ______ (30) ______ (28) ______ (29) ______
(34) ______ (37) ______ (36) ______ (32) ______ (35) ______ (33) ______
(42) ______ (39) ______ (40) ______ (41) ______ (38) ______ (43) ______
(48) ______ (45) ______ (44) ______ (49) ______ (47) ______ (46) ______
(50) ______ (52) ______ (51) ______ (54) ______ (55) ______ (53) ______
(60) ______ (57) ______ (58) ______ (59) ______ (61) ______ (56) ______
Part I Sub-Total:
______ + ______ + ______ + _______ + ______ + ______ = 126
(AB) (CO) (TS) (SS) (IP) (IN)
PART II
(30) ______ (26) ______ (31) ______ (27) ______ (29) ______ (28) ______
(35) ______ (33) ______ (37) ______ (36) ______ (32) ______ (34) ______
(41) ______ (39) ______ (42) ______ (38) ______ (40) ______ (43) ______
(46) ______ (47) ______ (48) ______ (44) ______ (49) ______ (45) ______
(53) ______ (51) ______ (54) ______ (55) ______ (52) ______ (50) ______
(61) ______ (58) ______ (57) ______ (60) ______ (56) ______ (59) ______
(64) ______ (63) ______ (67) ______ (65) ______ (66) ______ (62) ______
(70) ______ (69) ______ (73) ______ (68) ______ (72) ______ (71) ______
(76) ______ (75) ______ (79) ______ (77) ______ (78) ______ (74) ______
Part II Sub-Total:
______ + ______ + ______ + ______ + ______ + ______ = 189
(AB) (CO) (TS) (SS) (IP) (IN)
Totals:
______ + ______ + ______ + ______ + ______ + _______ = 315
(AB) (CO) (TS) ( SS) (IP) (IN)
52
ANALYSIS: LEARNING PREFERENCES INVENTORY
Categories Description
(AB) Abstract preference for learning theories, general principles, concepts, and
generating hypothesis.
(CO) Concrete preference for learning tangible, specific, practical tasks and skills.
(TS) Teacher-structured preference for well-organized, teacher-directed classes, with clear

expectations, assignments, and goals defined by the teacher
(SS) Student-structured preference for learner-generated tasks, autonomy, and self-direction.
(IP) Interpersonal preference for learning or working with others; emphasis on harmonious
relations between students and teacher and among students.
(IN) Individual preference for learning and working alone with emphasis on self-reliance
and tasks which are solitary, such as reading.
53
Learning How to Learn
Rule 1: Develop the habit of self-management
Try to complete the learning cycle
Memorize

Assimilate and Organize

Analyze, Synthesize and Solve Problems

Evaluate, Judge and Predict
Rule 2: Develop the habit of positive thinking
▪ Self-confidence and esteem

▪ Set goals and enjoy learning
Rule 3: Develop the habit of hierarchical thinking
▪ Set priorities and time management

▪ Summarize ideas and organize information
Rule 4: Develop the habit of creative and critical thinking
▪ Make decisions and solve problems

▪ Synthesize and create new associations
Rule 5: Develop the habit of asking questions
▪ Identify main ideas and supporting evidence

▪ Generate interest and information
54
Session 6: Approach to Learning 1
MEDICAL LEARNING STYLES
Please complete this form. The form does not assess your ability nor predict success or failure. It will give
you feedback on your readiness for study and the way you approach study.
Rate each statement using scale below:

4 – Definitely agree
3 – Agree with reservation
1 – Disagree with reservation
0 – Disagree strongly
2 – Use only if you cannot make up your mind one way or the other
Encircle the number corresponding to your answer to each of these statements.
1. I find it easy to organize my study time 4 3 1 0 2 A

effectively.
2. I try to relate ideas in one subject to those in others. 4 3 1 0 2 C
3. Although I have a fairly good general idea of many 4 3 1 0 2 G
things, my knowledge of the details in rather weak.
4. I like to told precisely what to do in essays and other 4 3 1 0 2 B
assignments.
5. The best way for me to understand what technical 4 3 1 0 2 F
terms mean is to remember the textbook definitions.
6. It is important to me to do well in the courses here. 4 3 1 0 2 A
7. I usually set out to understand thoroughly the 4 3 1 0 2 D
meaning of what I am asked to read.
8. When I am reading I try to memorize important 4 3 1 0 2 B
facts which may come in useful later.
9. When I am doing a piece of work, I try to bear in 4 3 1 0 2 A
mind exactly what that particular teacher seems to
want.
10. I am usually cautious in drawing conclusions unless 4 3 1 0 2 E
they are well supported by evidence.
11. My main reason for being here is so that I can 4 3 1 0 2 D
learn more about the subjects which really interest
me.
12. In trying to understand new ideas, I try to relate 4 3 1 0 2 C
them in real life situations to which they might apply.
13. I am more interested in the qualifications I’ll get 4 3 1 0 2 B
than in the courses I’m taking.
14. I am usually prompt in starting work in the 4 3 1 0 2 A
evenings.
15. Although I generally remember facts and details I 4 3 1 0 2 F
find it difficult to fit them together into an overall
picture.
16. I generally put a lot of efforts into trying to 4 3 1 0 2 D
understand things which initially seem difficult.
17. I often get criticized for introducing irrelevant 4 3 1 0 2 G
ideas into essays.
55
Often I find I have to read things without having a 4 3 1 0 2 B
chance to really understand them.
19. If conditions are not often for me to study, I 4 3 1 0 2 A
generally manage to do something to change them.
20. Puzzles and problems fascinate me particularly 4 3 1 0 2 E
where you have to work through the material to reach
logical conclusion.
21. I often find myself questioning things that I hear in 4 3 1 0 2 D
lectures or read in books.
22. I find it helpful to “map out” a new topic for myself 4 3 1 0 2 C
by seeing how ideas fit together.
23. I tend to read very little beyond what is required 4 3 1 0 2 B
for completing assignments.
24. It is important to me to do things better than my 4 3 1 0 2 A
friends, if possibly can.
25. Teachers seem to want to be more adventurous in 4 3 1 0 2 F
making use of my own ideas.
I26. I spend a good deal of my spare time in finding 4 3 1 0 2 D
out more about interesting topics which have been
discussed in classes.
27. I seem to be a bit too ready to jump to conclusions 4 3 1 0 2 G
without waiting for all the evidence.
28. I find academic topics so interesting; I should like 4 3 1 0 2 D
to continue with them after I finish this course.
29. I think it is important to look at problems rationally 4 3 1 0 2 E
and logically without making intuitive jumps.
30. I find I have to concentrate on memorizing a good 4 3 1 0 2 B
deal of what we have to learn.
Total Scores for:
A ________
B ________
C ________
D ________
E _________
F _________
G ________
56
INTERPRETATION
COMPUTE THE SUB-SCORES FOR:
ACHIEVING = A__
24
REPRODUCING = B__
24
MEANING = ___D__
24
COMPREHENSION LEARNING = C + G__

24
OPERATION LEARNING = ___E + F__
24
VERSATILE APPROACH = D + C + E___

48
LEARNING PATHOLOGIES = B + F + G____

48
PREDICTION FOR SUCCESS = A + D + C + E + (48 – B – F G)_______

120
57
MEANING OF SCALES:
Category
Achieving organized study methods, competitive, motivated to achieve.
Reproducing note-learning and memorization, extrinsically motivated, influenced by

lure of rewards, surface approach to learning.
Meaning “deep” approach to learning, interested in medicine for itself,

intrinsically motivated.
Comprehensive Learning “holist” approach, broad prospective of learning task, relates concepts to
wider context.
Operation Learning “serialist” approach, step-by-step sequential and detailed approach.
Versatile Approach Ability to adopt either approach according to demands of learning task
Learning Pathologies Jumping to conclusions on insufficient evidence, failing to see how topics
fit topics into overall picture, overall emphasis on details
Prediction for Success Best prediction for all academic success, highly organized study methods
with versatile approach, strong motivation, some tendency towards
competitiveness, lack of doubts or fear of failure.
58
Figure 1. Model of Student Approaches to Learning by John
Biggs
59
Deep versus Surface Learning Strategies
Levels of Processing
▪ Deep (meaning)
▪ Surface (reproducing)
▪ Strategic (achieving)
The Deep Approach The Surface Approach

- Intention of understanding what is to be - Reproducing what teachers desire
learned - Instrumental motivation or fear of failure
- Intrinsic motivation (interest in the subject) - Concerned primarily with memorization, not
understanding
Characteristics
▪ Focuses on what is of significance Characteristics
▪ Relates previous knowledge to new knowledge ▪ Focuses on the signs (i.e. words and sentences of
▪ Relates knowledge from different courses the text, or unthinkingly, on the formula needed
▪ Relates theoretical ideas to everyday experiences to solve a problem
▪ Relate and distinguishes between evidence and ▪ Focuses on unrelated parts of the task
argument ▪ Memorizes information for assessments
▪ Organizes and structures content into a coherent ▪ Associates facts and concepts unreflectively
whole. ▪ Fails to distinguish principles from examples
▪ Treats the task as an external imposition
Promoting factors/ strategies
▪ Emphasizes concepts over isolated facts Promoting factors or strategies
▪ Essay questions ▪ Using factually oriented short answer or multiple
▪ Problem solving choice questions
▪ Project reports ▪ Providing detailed study guides
▪ Alternative/ authentic assessments ▪ Breadth of coverage over depth
▪ No study guides ▪ “Spoon feeding” students
▪ Depth of coverage over breath ▪ Teaching to test
▪ Clear explanations and challenging ideas ▪ Low teacher expectations
▪ Deal with relevant and interesting topics
▪ Utilize cooperative learning
▪ High teacher expectations
The Strategic Approach
▪ A combination of deep and surface strategies

▪ Desire for the highest possible grades
▪ Competitive form of motivations
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Session 7: Approaches to Learning 2
Learning Insights
INSTRUCTIONS: Write down your thoughts about learning and share this with the group.
Guide questions:
1. What would be an ideal distribution of time between work, rest & recreation, family and personal growth
and development?
2. What are the barriers to achieving balance in my life?
3. In what ways could my assumptions and beliefs be a barrier to change?
4. In what ways is the current imbalance benefiting me and would I be willing to give that up?
61
EVALUATION OF THE COURSE
Please respond to the following questions as honestly best as you can. Your responses will assist us in the
improvement of the course.
A. COURSE CONTENT AND PROCESS (YES) (NO)

COMMENTS
1. Were the following objectives attained?
a. Clarify the goals of the UPCM under graduate program?
b. Identify the abilities necessary to develop in order to attain College goals.
c. Analyzing learning outcomes under different situations
2. Do you think you will be able to apply what you learned in this course
in your situation as a student of UPCM?
3. Did the course help you understand the expectation and goals of the UPCM
4. Were you able to cover materials and perform the activities within the time
Allowed time?
5. Were the course content and activities clearly presented?
B. TRANSPORTABILITY AND EFFECTIVENESS
1. What are your new major learning’s?
2. What did you find most effective about the course in terms of:
a. activities
b. topics
3. Please comment on the following:
a. course material
b. physical setting
c. length of session hours
d. group facilitators
4. What further changes or improvements you would like to suggest about the course?
[ 62
Module 3: Communication Skills

STUDY GUIDE

Overview of the topic Doctor-Patient Communication: the cornerstone of good medical practice
Effective doctor-patient interaction and communication is central to doctor and
patient satisfaction, to the clinical competence of doctors, and to the health
outcomes of their patients. There are indications that many doctors do not
communicate effectively in medical practice, and that training in interactional and
relationship skills deserves to be included as an important part of medical training.
The introduction of training in interactional and communication skills represents a
relatively low cost investment in time and resources in comparison with the
considerable potential benefits for patients, doctors, medical schools and health
care systems.
WHO, Doctor-Patient: Interaction and Communication, 1993
Hornsby, JL. and Payne, F. , Interpersonal Communication Skills for Physician, 1979,
NTTC-HP
Course outcomes and At the end of this module, you will be able
content To acquire the necessary interactional, relational and communication skills to
become an attentive listener, a careful observer, a sensitive and effective
communicator.
1. To define the basic elements of effective communication.
2. To describe the communication model and identify the road blocks to
effective communication.
3. To impart core communication skills and advanced communication skills
Course content:
- Doctor-Patient Communication: the cornerstone of good medical practice
- Do doctors communicate effectively?
- Why invest in communication skills training?
- The Content of Communication Skills Training
a. Core communication skills
b. Advanced communication skills
- Exercises in communication skills
Prerequisites None
Timetable 6 hours / 2 hours every week for 3 weeks
Learning opportunities Lectures
• Basic communication techniques
• Doctor – Patient Communication
Video showing
• Communicating the Impact of Alzheimer’s Disease to Patients and Caregivers.
John Hopkins University School of Medicine
• Relating Effectively to Surgical Patients
Special Lecture

Staff contacts Dr. Ma. Rosanna de Guzman (Course Coordinator)
Psychiatry
Personal comments Good doctor-patient communication has been described as the cornerstone of good
medical practice. This may well be the case considering the research findings that 60
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– 80% of medical diagnosis are made on the basis of information arising from the
medical interview alone, as are a similar proportion of treatment decisions. The basis
of the medical interview is communication and the medical interview is itself the basis
of medical practice.

Information on the The learning of communication skills should be largely experiential. The core
subject or topics learning process will include demonstration and practice of communication skills with
feedback on performance in a supportive leaning environment under the guidance of
the faculty facilitator.

Interaction with texts Further readings will be recommended to augment your knowledge and practical
or other learning skills on effective communication.
resource materials • Annex 1: Peabody, F., The Care of the Patient, Journal of the American Medical
Association, March 1927; 88 (12): 877-882
• Annex 2: Quill, Timothy, Recognizing and Adjusting to Barriers in Doctor-Patient
Communication, Annals of Internal Medicine, 1989; 111(1): 51-57
Application of theory to You are encouraged to actively participate in small group learning for the Interviewing
practice Skills with your peers and facilitator. This is an effective way of developing the
necessary communication skills : both the basic and advanced skills, conflict skills,
social skills and public skills to improve your personal and professional relationships.
Self-assessment As with all other clinical skills, assessment of communication skills has the dual
function of educational feedback for the student (formative assessment), and the
rating of competence of performance as part of student evaluation (summative
assessment).
Formative assessment will be given through the feedback of performance by peers
and facilitator and the use of objective, standardized evaluation methods.
Summative assessment will be given through a written tests that will require that all
students to obtain a minimum standard of competence in communication skills.
Personal information At the end of the 6 hour workshop on communication skills, you will have the
bank necessary:
Core communication skills
• Doctor-patient interpersonal skills
• Information gathering skills
• Information giving skills and patient education
Advanced communication skills
• Skills for motivating patient adherence to treatment plans
• Other applications of core communication skills in specific situations
•
Fail. The basis for evaluation will be on your performance in the group presentations
and written exercises. It is for this reason that attendance is mandatory.
[ 64
Annex 1 but supplementary to each other. There is no more
contradiction between the science of medicine and the art
of medicine than between the science of aeronautics and
Journal of the American Medical Association the art of flying. Good practice presupposes an
Vol. 88, pp. 877-882, Mar. 19, 1927 understanding of the sciences which contribute to the
The Care of the Patient structure of modern medicine, but it is obvious that sound
by Francis W. Peabody, MD professional training should include a much broader
equipment.
Harvard Medical School, Boston, MA The problem that I wish to consider, therefore, is whether
this larger view of the profession cannot be approached
It is probably fortunate that systems of education are even under the conditions imposed by the present
constantly under the fire of general criticism, for if
curriculum of the medical school. Can the practitioner's art
education were left solely in the hands of teachers the
be grafted on the main trunk of the fundamental sciences in
chances are good that it would soon deteriorate. Medical
education, however, is less likely to suffer from such such a way that there shall arise a symmetrical growth, like
stagnation, for whenever the lay public stops criticizing the an expanding tree, the leaves of which may be for the
type of modern doctor, the medical profession itself may be "healing of the nations"?
counted on to stir up the stagnant pool and cleanse it of its One who speaks of the care of patients is naturally thinking
sedimentary deposit. The most common criticism made at about circumstances as they exist in the practice of
present by older practitioners is that young graduates have medicine; but the teacher who is attempting to train
been taught a great deal about the mechanism of disease, medical students is immediately confronted by the fact that,
but very little about the practice of medicine—or, to put it even if he could, he cannot make the conditions under
more bluntly, they are too "scientific" and do not know how which he has to teach clinical medicine exactly similar to
to take care of patients. those of actual practice.
One is, of course, somewhat tempted to question how The primary difficulty is that instruction has to be carried out
completely fitted for his life work the practitioner of the largely in the wards and dispensaries of hospitals rather
older generation was when he first entered on it, and how than in the patient's home and the physician's office. Now
much the haze of time has led him to confuse what he the essence of the practice of medicine is that it is an
learned in the school of medicine with what he acquired in intensely personal matter, and one of the chief differences
the harder school of experience. But the indictment is a between private practice and hospital practice is that the
serious one and it is concurred in by numerous recent latter always tends to become impersonal. At first sight this
graduates, who find that in the actual practice of medicine may not appear to be a very vital point, but it is, as a matter
they encounter many situations which they had not been of fact, the crux of the whole situation. The treatment of a
led to anticipate and which they are not prepared to meet disease may be entirely impersonal; the care of a patient
effectively. Where there is so much smoke, there is must be completely personal. The significance of the
undoubtedly a good deal of fire, and the problem for intimate personal relationship between physician and
teachers and for students is to consider what they can do to patient cannot be too strongly emphasized, for in an
extinguish whatever is left of this smoldering distrust. extraordinarily large number of cases both diagnosis and
To begin with, the fact must be accepted that one cannot treatment are directly dependent on it, and the failure of
expect to become a skillful practitioner of medicine in the the young physician to establish this relationship accounts
four or five years allotted to the medical curriculum. for much of his ineffectiveness in the care of patients.
Medicine is not a trade to be learned but a profession to be
entered. It is an ever widening field that requires continued INSTRUCTION IN TREATMENT OF DISEASE
study and prolonged experience in close contact with the Hospitals, like other institutions founded with the highest
sick. All that the medical school can hope to do is to supply human ideals, are apt to deteriorate into dehumanized
the foundations on which to build. When one considers the machines, and even the physician who has the patient's
amazing progress of science in its relation to medicine welfare most at heart finds that pressure of work forces him
during the last thirty years, and the enormous mass of to give most of his attention to the critically sick and to those
scientific material which must be made available to the whose diseases are a menace to the public health. In such
modern physician, it is not surprising that the schools have cases he must first treat the specific disease, and there then
tended to concern themselves more and more with this remains little time in which to cultivate more than a
phase of the educational problem. And while they have superficial personal contact with the patients. Moreover,
been absorbed in the difficult task of digesting and the circumstances under which the physician sees the
correlating new knowledge, it has been easy to overlook the patient are not wholly favorable to the establishment of the
fact that the application of the principles of science to the intimate personal relationship that exists in private practice,
diagnosis and treatment of disease is only one limited for one of the outstanding features of hospitalization is that
aspect of medical practice. The practice of medicine in its it completely removes the patient from his accustomed
broadest sense includes the whole relationship of the environment. This may, of course, be entirely desirable, and
physician with his patient. It is an art, based to an increasing one of the main reasons for sending a person into the
extent on the medical sciences, but comprising much that hospital is to get him away from home surroundings, which,
still remains outside the realm of any science. The art of be he rich or poor, are often unfavorable to recovery; but at
medicine and the science of medicine are not antagonistic
[ 65
the same time it is equally important for the physician to knows that by quieting the cough, getting the patient to
know the exact character of those surroundings. sleep, and giving a bit of encouragement, he can save his
Everybody, sick or well, is affected in one way or another, patient's strength and lift him through many distressing
consciously or subconsciously, by the material and spiritual hours. The institutional eye tends to become focused on the
forces that bear on his life, and especially to the sick such lung, and it forgets that the lung is only one member of the
forces may act as powerful stimulants or depressants. When body.
the general practitioner goes into the home of a patient, he
may know the whole background of the family life from past PATIENTS WHO HAVE "NOTHING THE MATTER WITH
experience; but even when he comes as a stranger he has THEM"
every opportunity to find out what manner of man his But if teachers and students are liable to take a limited point
patient is, and what kind of circumstances make his life. He of view even toward interesting cases of organic disease,
gets a hint of financial anxiety or of domestic they fall into much more serious error in their attitude
incompatibility; he may find himself confronted by a toward a large group of patients who do not show objective,
querulous, exacting, self-centered patient, or by a gentle organic pathologic conditions, and who are generally
invalid overawed by a dominating family; and as he spoken of as having "nothing the matter with them." Up to
appreciates how these circumstances are reacting on the a certain point, as long as they are regarded as diagnostic
patient he dispenses sympathy, encouragement or problems, they command attention; but as soon as a
discipline. physician has assured himself that they do not have organic
What is spoken of as a "clinical picture" is not just a disease, he passes them over lightly.
photograph of a man sick in bed; it is an impressionistic Take the case of a young woman, for instance, who entered
painting of the patient surrounded by his home, his work, the hospital with a history of nausea and discomfort in the
his relations, his friends, his joys, sorrows, hopes and fears. upper part of the abdomen after eating. Mrs. Brown had
Now, all of this background of sickness which bears so "suffered many things of many physicians." Each of them
strongly on the symptomatology is liable to be lost sight of gave her a tonic and limited her diet. She stopped eating
in the hospital: I say "liable to" because it is not by any everything that any of her physicians advised her to omit,
means always lost sight of, and because I believe that by and is now living on a little milk and a few crackers; but her
making a constant and conscious effort one can almost symptoms persist. The history suggests a possible gastric
always bring it out into its proper perspective. The difficulty ulcer or gallstones, and with a proper desire to study the
is that in the hospital one gets into the habit of using the oil case thoroughly, she is given a test meal, gastric analysis and
immersion lens instead of the low power, and focuses too duodenal intubation, and roentgen-ray examinations are
intently on the center of the field. made of the gastro-intestinal tract and gallbladder. All of
When a patient enters a hospital, one of the first things that these diagnostic methods give negative results, that is, they
commonly happens to him is that he loses his personal do not show evidence of any structural change. The case is
identity. He is generally referred to, not as Henry Jones, but immediately much less interesting than if it had turned out
as "that case of mitral stenosis in the second bed on the to be a gastric ulcer with atypical symptoms. The visiting
left." There are plenty of reasons why this is so, and the physician walks by and says "Well, there's nothing the
point is, in itself, relatively unimportant; but the trouble is matter with her." The clinical clerk says "I did an awful lot of
that it leads, more or less directly, to the patient being work on that case and it turned out to be nothing at all." The
treated as a case of mitral stenosis, and not as a sick man. intern, who wants to clear out the ward so as to make room
The disease is treated, but Henry Jones, lying awake nights for some interesting cases, says "Mrs. Brown, you can send
while he worries about his wife and children, represents a for your clothes and go home tomorrow. There really is
problem that is much more complex than the pathologic nothing the matter with you, and fortunately you have not
physiology of mitral stenosis, and he is apt to improve very got any of the serious troubles we suspected. We have used
slowly unless a discerning intern happens to discover why it all the most modern and scientific methods and we find that
is that even large doses of digitalis fail to slow his heart rate. there is no reason why you should not eat anything you
Henry happens to have heart disease, but he is not disturbed want to. I'll give you a tonic to take when you go home."
so much by dyspnea as he is by anxiety for the future, and a Same story, same colored medicine! Mrs. Brown goes home,
talk with an understanding physician who tries to make the somewhat better for her rest in new surroundings, thinking
situation clear to him, and then gets the social service that nurses are kind and physicians are pleasant, but that
worker to find a suitable occupation, does more to they do not seem to know much about the sort of medicine
straighten him out than a book full of drugs and diets. that will touch her trouble. She takes up her life and the
Henry has an excellent example of a certain type of heart symptoms return—and then she tries chiropractic, or
disease, and he is glad that all the staff find him interesting, perhaps it is Christian Science.
for it makes him feel that they will do the best they can to It is rather fashionable to say that the modern physician has
cure him; but just because he is an interesting case he does become "too scientific." Now, was it too scientific, with all
not cease to be a human being with very human hopes and the stomach tubes and blood counts and roentgen-ray
fears. Sickness produces an abnormally sensitive emotional examinations? Not at all. Mrs. Brown's symptoms might
state in almost every one, and in many cases the emotional have been due to a gastric ulcer or to gallstones, and after
state repercusses, as it were, on the organic disease. The such a long course it was only proper to use every method
pneumonia would probably run its course in a week, that might help to clear the diagnosis. Was it, perhaps, not
regardless of treatment, but the experienced physician scientific enough? The popular conception of a scientist as a
[ 66
man who works in a laboratory and who uses instruments indicates that there is a close relation between the
of precision is as inaccurate as it is superficial, for a scientist appearance of the symptoms and the threshold of the
is known, not by his technical processes, but by his patient's nervous reactions. The ultimate causes of these
intellectual processes; and the essence of the scientific disturbances are to be found, not in any gross structural
method of thought is that it proceeds in an orderly manner changes in the organs involved, but rather in nervous
toward the establishment of a truth. Now the chief criticism influences emanating from the emotional or intellectual life,
to be made of the way Mrs. Brown's case was handled is that which, directly or indirectly, affect in one way or another
the staff was contented with a half truth. The investigation organs that are under either voluntary or involuntary
of the patient was decidedly unscientific in that it stopped control.
short of even an attempt to determine the real cause of the Every one has had experiences that have brought home the
symptoms. As soon as organic disease could be excluded the way in which emotional reactions affect organic functions.
whole problem was given up, but the symptoms persisted. Some have been nauseated while anxiously waiting for an
Speaking candidly, the case was a medical failure in spite of important examination to begin, and a few may even have
the fact that the patient went home with the assurance that vomited; others have been seized by an attack of diarrhea
there was "nothing the matter" with her. under the same circumstances. Some have had polyuria
A good many "Mrs. Browns," male and female, come to before making a speech, and others have felt thumping
hospitals, and a great many more go to private physicians. extrasystoles or a pounding tachycardia before a football
They are all characterized by the presence of symptoms that game. Some have noticed rapid shallow breathing when
cannot be accounted for by organic disease, and they are all listening to a piece of bad news, and others know the type
liable to be told that they have "nothing the matter" with of occipital headache, with pain down the muscles of the
them. Now my own experience as a hospital physician has back of the neck that comes from nervous anxiety and
been rather long and varied, and I have always found that, fatigue.
from my point of view, hospitals are particularly interesting These are all simple examples of the way that emotional
and cheerful places; but I am fairly certain that, except for a reactions may upset the normal functioning of an organ.
few low grade morons and some poor wretches who want Vomiting and diarrhea are due to abnormalities of the
to get in out of the cold, there are not many people who motor function of the gastro-intestinal tract—one to the
become hospital patients unless there is something the production of an active reversed peristalsis of the stomach
matter with them. and a relaxation of the cardiac sphincter, the other to
And, by the same token, I doubt whether there are many hyperperistalsis of the large intestine. The polyuria is caused
people, except for those stupid creatures who would rather by vasomotor changes in renal circulation, similar in
go to the physician than go to the theater, who spend their character to the vasomotor changes that take place in the
money on visiting private physicians unless there is peripheral vessels in blushing and blanching of the skin, and
something the matter with them. In hospital and in private in addition there are quite possibly associated changes in
practice, however, one finds this same type of patient, and the rate of blood flow and in blood pressure. Tachycardia
many physicians whom I have questioned agree in saying and extrasystoles indicate that not only the rate but also the
that, excluding cases of acute infection, approximately half rhythm of the heart is under a nervous control that can be
of their patients complained of symptoms for which an demonstrated in the intact human being as well as in the
adequate organic cause could not be discovered. experimental animal. The ventilatory function of the
Numerically, then, these patients constitute a large group, respiration is extraordinarily subject to nervous influences;
and their fees go a long way toward spreading butter on the so much so, in fact, that the study of the respiration in man
physician's bread. Medically speaking, they are not serious is associated with peculiar difficulties. Rate, depth and
cases as regards prospective death, but they are often rhythm of breathing are easily upset by even minor stimuli,
extremely serious as regards prospective life. and in extreme cases the disturbance in total ventilation is
Their symptoms will rarely prove fatal, but their lives will be sometimes so great that gaseous exchange becomes
long and miserable, and they may end by nearly exhausting affected. Thus, I remember an emotional young woman who
their families and friends. Death is not the worst thing in the developed a respiratory neurosis with deep and rapid
world, and to help a man to a happy and useful career may breathing, and expired so much carbon dioxide that the
be more of a service than the saving of life. symptoms of tetany ensued. The explanation of the occipital
headaches and of so many pains in the muscles of the back
PHYSIOLOGIC DISTURBANCES FROM EMOTIONAL is not entirely clear, but they appear to be associated with
REACTIONS changes in muscular tone or with prolonged states of
What is the matter with all these patients? Technically, most contraction. There is certainly a very intimate correlation
of them come under the broad heading of the between mental tenseness and muscular tenseness, and
"psychoneuroses"; but for practical purposes many of them whatever methods are used to produce mental relaxation
may be regarded as patients whose subjective symptoms will usually cause muscular relaxation, together with relief
are due to disturbances of the physiologic activity of one or of this type of pain. A similar condition is found in the so-
more organs or systems. These symptoms may depend on called writers' cramp, in which the painful muscles of the
an increase or a decrease of a normal function, on an hand result, not from manual work, but from mental work.
abnormality of function, or merely on the subjects One might go on much further, but these few illustrations
becoming conscious of a wholly normal function that will suffice to recall the infinite number of ways in which
normally goes on unnoticed; and this last conception physiologic functions may be upset by emotional stimuli,
[ 67
and the manner in which the resulting disturbances of satisfaction of seeing some of his patients get well, not as
function manifest themselves as symptoms. These the result of drugs, or as the result of the disease having run
symptoms, although obviously not due to anatomic its course, but as the result of his own individual efforts.
changes, may, nevertheless, be very disturbing and Here, then, is a great group of patients in which it is not the
distressing, and there is nothing imaginary about them. disease but the man or the woman who needs to be treated.
Emotional vomiting is just as real as the vomiting due to In general hospital practice physicians are so busy with the
pyloric obstruction, and so-called "nervous headaches" may critically sick, and in clinical teaching are so concerned with
be as painful as if they were due to a brain tumor. Moreover, training students in physical diagnosis and attempting to
it must be remembered that symptoms based on functional show them all the types of organic disease, that they do not
disturbances may be present in a patient who has, at the pay as much attention as they should to the functional
same time, organic disease, and in such cases the disorders. Many a student enters practice having hardly
determination of the causes of the different symptoms may heard of them except in his course in psychiatry, and
be an extremely difficult matter. Every one accepts the without the faintest conception of how large a part they will
relationship between the common functional symptoms play in his future practice. At best, his method of treatment
and nervous reactions, for convincing evidence is to be is apt to be a cheerful reassurance combined with a placebo.
found in the fact that under ordinary circumstances the The successful diagnosis and treatment of these patients,
symptoms disappear just as soon as the emotional cause has however, depends almost wholly on the establishment of
passed. that intimate personal contact between physician and
But what happens if the cause does not pass away? What if, patient which forms the basis of private practice. Without
instead of having to face a single three-hour examination, this, it is quite impossible for the physician to get an idea of
one has to face a life of being constantly on the rack? The the problems and troubles that lie behind so many
emotional stimulus persists, and continues to produce the functional disorders. If students are to obtain any insight
disturbances of function. As with all nervous reactions, the into this field of medicine, they must also be given
longer the process goes on, or the more frequently it goes opportunities to build up the same type of personal
on, the easier it is for it to go on. The unusual nervous track relationship with their patients.
becomes an established path. After a time, the symptom
and the subjective discomfort that it produces come to STUDENT'S OPPORTUNITY IN THE HOSPITAL
occupy the center of the picture, and the causative factors Is there, then, anything inherent in the conditions of clinical
recede into a hazy background. The patient no longer thinks teaching in a general hospital that makes this impossible?
"I cannot stand this life," but he says out loud "I cannot stand Can you form a personal relationship in an impersonal
this nausea and vomiting. I must go to see a stomach institution? Can you accept the fact that your patient is
specialist." entirely removed from his natural environment and then
Quite possibly the comment on this will be that the reconstruct the background of environment from the
symptoms of such "neurotic" patients are well known, and history, from the family, from a visit to the home or
they ought to go to a neurologist or a psychiatrist and not to workshop, and from the information obtained by the social
an internist or a general practitioner. In an era of internal service worker? And while you are building up this
medicine, however, which takes pride in the fact that it environmental background, can you enter into the same
concerns itself with the functional capacity of organs rather personal relationship that you ought to have in private
than with mere structural changes and which has developed practice? If you can do all this, and I know from experience
so many "functional tests" of kidneys, heart, and liver, is it that you can, then the study of medicine in the hospital
not rather narrow minded to limit one's interest to those actually becomes the practice of medicine, and the
disturbances of function which are based on anatomic treatment of disease immediately takes its proper place in
abnormalities? There are other reasons, too, why most of the larger problem of the care of the patient.
these "functional" cases belong to the field of general When a patient goes to a physician he usually has
medicine. In the first place, the differential diagnosis confidence that the physician is the best, or at least the best
between organic disease and functional disturbance is often available person to help him in what is, for the time being,
extremely difficult, and it needs the broad training in the use his most important trouble. He relies on him as on a
of general clinical and laboratory methods which forms the sympathetic adviser and a wise professional counselor.
equipment of the internist. Diagnosis is the first step in When a patient goes to a hospital he has confidence in the
treatment. In the second place, the patients themselves reputation of the institution, but it is hardly necessary to add
frequently prefer to go to a medical practitioner rather than that he also hopes to come into contact with some
to a psychiatrist, and in the long run it is probably better for individual who personifies the institution and will also take
them to get straightened out without having what they a human interest in him. It is obvious that the first physician
often consider the stigma of having been "nervous" cases. A to see the patient is in the strategic position—and in
limited number, it is true, are so refractory or so complex hospitals all students can have the satisfaction of being
that the aid of the psychiatrist must be sought, but the regarded as physicians.
majority can be helped by the internist without highly Here, for instance, is a poor fellow who has just been jolted
specialized psychological technique, if he will appreciate the to the hospital in an ambulance. A string of questions about
significance of functional disturbances and interest himself himself and his family have been fired at him, his valuables
in their treatment. The physician who does take these cases and even his clothes have been taken away from him, and
seriously—one might say scientifically—has the great he is wheeled into the ward on a truck, miserable, scared,
[ 68
defenseless and, in his nakedness, unable to run away. He is If you keep him in the hospital, it is probably good for him to
lifted into a bed, becomes conscious of the fact that he is see certain people, and bad for him to see others.
the center of interest in the ward, wishes that he had stayed He has business problems that must be considered. What
at home among friends, and just as he is beginning to take kind of a compromise can you make on them? How about
stock of his surroundings, finds that a thermometer is being the financial implications of eight weeks in bed followed by
stuck under his tongue. It is all strange and new, and he a period of convalescence? Is it, on the whole, wiser to try a
wonders what is going to happen next. The next thing that strict regimen for a shorter period, and, if he does not
does happen is that a man in a long white coat sits down by improve, take up the question of operation sooner than is in
his bedside, and starts to talk to him. Now it happens that general advisable? These, and many similar problems arise
according to our system of clinical instruction that man is in the course of the treatment of almost every patient, and
usually a medical student. Do you see what an opportunity they have to be looked at, not from the abstract point of
you have? The foundation of your whole relation with that view of the treatment of the disease, but from the concrete
patient is laid in those first few minutes of contact, just as point of view of the care of the individual.
happens in private practice. Suppose, on the other hand, that all your clinical and
Here is a worried, lonely, suffering man, and if you begin by laboratory examinations turn out entirely negative as far as
approaching him with sympathy, tact, and consideration, revealing any evidence of organic disease is concerned.
you get his confidence and he becomes your patient. Interns Then you are in the difficult position of not having
and visiting physicians may come and go, and the hierarchy discovered the explanation of the patient's symptoms. You
gives them a precedence; but if you make the most of your have merely assured yourself that certain conditions are not
opportunities he will regard you as his personal physician, present. Of course, the first thing you have to consider is
and all the rest as mere consultants. Of course, you must not whether these symptoms are the result of organic disease
drop him after you have taken the history and made your in such an early stage that you cannot definitely recognize
physical examination. Once your relationship with him has it. This problem is often extremely perplexing, requiring
been established, you must foster it by every means. Watch great clinical experience for its solution, and often you will
his condition closely and he will see that you are alert be forced to fall back on time in which to watch
professionally. Take time to have little talks with him—and developments. If, however, you finally exclude recognizable
these talks need not always be about his symptoms. organic disease, and the probability of early or very slight
Remember that you want to know him as a man, and this organic disease, it becomes necessary to consider whether
means you must know about his family and friends, his work the symptomatology may be due to a functional disorder
and his play. What kind of a person is he—cheerful, which is caused by nervous or emotional influences. You
depressed, introspective, careless, conscientious, mentally know a good deal about the personal life of your patient by
keen or dull? Look out for all the little incidental things that this time, but perhaps there is nothing that stands out as an
you can do for his comfort. These, too, are a part of "the care obvious etiologic factor, and it becomes necessary to sit
of the patient." Some of them will fall technically in the field down for a long intimate talk with him to discover what has
of "nursing" but you will always be profoundly grateful for remained hidden.
any nursing technic that you have acquired. It is worth your Sometimes it is well to explain to the patient, by obvious
while to get the nurse to teach you the right way to feed a examples, how it is that emotional states may bring about
patient, change the bed, or give a bed pan. Do you know the symptoms similar to his own, so that he will understand
practical tricks that make a dyspneic patient comfortable? what you are driving at and will cooperate with you. Often
Assume some responsibility for these apparently minor the best way is to go back to the very beginning and try to
points and you will find that it is when you are doing some find out the circumstances of the patient's life at the time
such friendly service, rather than when you are a formal the symptoms first began. The association between
questioner, that the patient suddenly starts to unburden symptoms and cause may have been simpler and more
himself, and a flood of light is thrown on the situation. direct at the onset, at least in the patient's mind, for as time
Meantime, of course, you will have been active along strictly goes on, and the symptoms become more pronounced and
medical lines, and by the time your clinical and laboratory distressing, there is a natural tendency for the symptoms to
examinations are completed you will be surprised at how occupy so much of the foreground of the picture that the
intimately you know your patient, not only as an interesting background is completely obliterated. Sorrow,
case but also as a sick human being. And everything you disappointment, anxiety, self-distrust, thwarted ideals or
have picked up about him will be of value in the subsequent ambitions in social, business or personal life, and
handling of the situation. Suppose, for instance, you find particularly what are called maladaptations to these
conclusive evidence that his symptoms are due to organic conditions—these are among the commonest and simplest
disease; say, to a gastric ulcer. As soon as you face the factors that initiate and perpetuate the functional
problem of laying out his regimen you find that it is one thing disturbances. Perhaps you will find that the digestive
to write an examination paper on the treatment of gastric disturbances began at the time the patient was in serious
ulcer and quite another thing to treat John Smith who financial difficulties, and they have recurred whenever he is
happens to have a gastric ulcer. You want to begin by giving worried about money matters. Or you may find that ten
him rest in bed and a special diet for eight weeks. Rest years ago a physician told the patient he had heart disease,
means both nervous and physical rest. Can he get it best at cautioning him "not to worry about it." For ten years the
home or in the hospital? What are the conditions at home? patient has never mentioned the subject, but he has
avoided every exertion, and has lived with the idea that
[ 69
sudden death was in store for him. You will find that under which you, as students, come into contact with
physicians, by wrong diagnoses and ill considered patients with functional disturbances are not wholly
statements, are responsible for many a wrecked life, and unfavorable, and with very little effort they can be made to
you will discover that it is much easier to make a wrong simulate closely the conditions in private practice.
diagnosis than it is to unmake it.
Or, again, you may find that the pain in this woman's back IMPORTANCE OF PERSONAL RELATIONSHIP
made its appearance when she first felt her domestic It is not my purpose, however, to go into a discussion of the
unhappiness, and that this man's headaches have been methods of treating functional disturbances, and I have
associated, not with long hours of work, but with a constant dwelt on the subject only because these cases illustrate so
depression due to unfulfilled ambitions. The causes are clearly the vital importance of the personal relationship
manifold and the manifestations protean. Sometimes the between physician and patient in the practice of medicine.
mechanism of cause and effect is obvious; sometimes it In all your patients whose symptoms are of functional origin,
becomes apparent only after a very tangled skein has been the whole problem of diagnosis and treatment depends on
unraveled. your insight into the patient's character and personal life,
If the establishment of an intimate personal relationship is and in every case of organic disease there are complex
necessary in the diagnosis of functional disturbances, it interactions between the pathologic processes and the
becomes doubly necessary in their treatment. Unless there intellectual processes which you must appreciate and
is complete confidence in the sympathetic understanding of consider if you would be a wise clinician. There are
the physician as well as in his professional skill, very little can moments, of course, in cases of serious illness when you will
be accomplished; but granted that you have been able to think solely of the disease and its treatment; but when the
get close enough to the patient to discover the cause of the corner is turned and the immediate crisis is passed, you
trouble, you will find that a general hospital is not at all an must give your attention to the patient. Disease in man is
impossible place for the treatment of functional never exactly the same as disease in an experimental
disturbances. The hospital has, indeed, the advantage that animal, for in man the disease at once affects and is affected
the entire reputation of the institution, and all that it by what we call the emotional life. Thus, the physician who
represents in the way of facilities for diagnosis and attempts to take care of a patient while he neglects this
treatment, go to enhance the confidence which the patient factor is as unscientific as the investigator who neglects to
has in the individual physician who represents it. This gives control all the conditions that may affect his experiment.
the very young physician a hold on his patients that he could The good physician knows his patients through and through,
scarcely hope to have without its support. Another and his knowledge is bought dearly. Time, sympathy and
advantage is that hospital patients are removed from their understanding must be lavishly dispensed, but the reward is
usual environment, for the treatment of functional to be found in that personal bond which forms the greatest
disturbances is often easier when patients are away from satisfaction of the practice of medicine. One of the essential
friends, relatives, home, work and, indeed, everything that qualities of the clinician is interest in humanity, for the
is associated with their daily life. It is true that in a public secret of the care of the patient is in caring for the patient.
ward one cannot obtain complete isolation in the sense that Boston City Hospital.
this is a part of the Weir Mitchell treatment, but the main
object is accomplished if one has obtained the psychological * One in a series of talks before the students of the Harvard
effect of isolation which comes with an entirely new and Medical School on "The Care of the Patient."
unaccustomed atmosphere. The conditions, therefore,
[ 70
Doctor-Patient Communication
71
Annex 2
Table 1. Possible Indirect Signs that a Barrier Exists
Verbal-nonverbal mismatch
Cognitive dissonance
Unexpected resistance
Physician discomfort Noncompliance
Treatment not working
Exacerbation of chronic disease
barrier is the fatigued patient whose physician

extensively explores for thyroid problems, liver
disease, or "viral illness" without discussing the
possibility of depression or life stresses. The physician
tells the patient that it "doesn't sound serious," and
that no follow-up will be needed if the tests are
negative. Here the physician's limited knowledge
about the differential diagnosis of fatigue provides the
barrier to fully exploring the patient's problem.
Another example of an implicit barrier would be the
patient with shotty lymphadenopathy who fears
having the acquired immunodeficiency syndrome, but
does not feel comfortable discussing these fears with
his physician because he feels ashamed and also does
not want to risk ridicule.
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the patient has certainly "been through a lot," the
73
74
75
76
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Module 4: Interviewing Skills

STUDY GUIDE

Overview of the topic The Interviewing program will help the student develop or enhance his/her
interviewing skills. It provides an opportunity to conduct actual interviews with and
subsequent feedback. The student will interview a patient/caregiver who has had a
significant experience with the health care system. There are two hour sessions
occur with fellow students, a consultant, and a patient/ caregiver. Feedback is
provided from everyone involved.
Course outcomes and By the end of the course the student should be able to:
content 1. To practice such basic interviewing techniques as the open-ended question, use
of facilitating remarks, and the appropriate use of silence.
2. To develop appreciation for the significance of patient’s non-verbal
communications (facial expression, hand gestures, lack of response, etc.)
3. To assess the patient’s feelings regarding his/her medical and psychosocial
problems and learn to respond appropriately.
4. To identify personal attitudes, through self-observation, instances when one’s
behavior, mannerisms, and feelings, and values which could interfere with or
facilitate optimal patient management
5. To begin to develop skill in collecting factual information from a patient in a
logical orderly way.
Prerequisites Communication skills
Timetable 8 hours / 2 hours every week for 4 weeks
Interviewing skills
Lectures and Video showing
Dr. R. de Guzman
Faculty Facilitators – Interview exercise I – Presentation of Student Interviews
(Clinical Departments)
Faculty Facilitators – Interview exercise II – Presentation of Student Interviews
(Clinical Departments)
Patient Interview (PGH Wards)
Patient Case Summary and Evaluation
Dr. R. de Guzman
Learning opportunities Small group discussions
Lectures and Readings
Individual learning which includes an actual interview with a patient/
caregiver and Feedback
Assessment details Attendance and presentation of the student interview with a patient.
Each student will be given 20 mins. to interview a patient admitted in the clinical
wards of PGH.
Preceptor Evaluation of Student Interview and Feedback will be given.
Each student will have to interview an individual patient and caregiver from the
charity wards, emergency room or out-patient of the hospital.
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For submission at the end of the semester will be a written report of a Patient Case
Summary.
Personal comments Good doctor-patient communication has been described as the cornerstone of good
medical practice. This may well be the case considering the research findings that 60
– 80% of medical diagnosis are made on the basis of information arising from the
medical interview alone, as are a similar proportion of treatment decisions. The basis
of the medical interview is communication and the medical interview is itself the
basis of medical practice.

Information on the The learning of Interviewing Skills should be largely experiential. The core
subject or topics learning process will include demonstration and practice of communication skills with
feedback on performance in a supportive leaning environment under the guidance of
the Faculty Facilitator.

Interaction with texts Further readings will be recommended to augment your knowledge and practical
or other learning skills on interviewing .
resource materials
Application of theory to You are encouraged to actively participate in small group learning with your peers
practice and facilitator. This is an effective way of developing the necessary interviewing skills
: both the basic and advanced skills, conflict skills, social skills and public skills to
improve your personal and professional relationships.
Self-assessment As with all other clinical skills, assessment of interviewing skills has the dual
function of educational feedback for the student (formative assessment), and the
rating of competence of performance as part of student evaluation (summative
assessment).
Formative assessment will be given through the feedback of performance by peers

and facilitator and the use of objective, standardized evaluation methods, after the
interview. Among the skills to be assessed are opening the interview, putting the
patient at ease, use of open-ended questions, use of direct questions, following-up
patient cues, responding to patient’s feelings, developing an adequate data base for
the purpose at hand, and closing the interview
Summative assessment will be given through a written report that will require
that all students to obtain a minimum standard of competence in interviewing skills.
Personal information At the end of the 8 hour workshop on interviewing skills, you will have the
bank necessary:
Core communication skills
• Doctor-patient interpersonal skills
• Information gathering skills
• Information giving skills and patient education
• Other applications of core interviewing skills in specific situations
Reference and Reading materials

Annex 1 A Dozen Notes for Conducting a Well Orchestrated Interview,
Kachur E. and Preven D., Waters J. (Unpublished)
Annex 2 Patient Simulation and Actual Patient Interview
Annex 3 Interview Rating Sheet
79
Annex 4 Interviewing Skills
Instructions for Patient Summaries
Sample Patient Summary – 1 Interview with a Terminally Patient
Sample Patient Summary – 2 Interview with and adolescent with IDDM
Annex 5 Evidence-Based Patient-Centered Interviewing

Lyles JS, Divamena FC, et al, JCOM, July 2001 Vol. 8 No. 7
Annex 6 Platt F. and McMath J., Clinical Hypocompetence, Interview, Annals of Internal
Medicine, 1979; 91:.898-902
Annex 7 Trillin, Alice Stewart, Of Dragons and Garden Peas: A Cancer Patient Talks to Doctors,
The New England Journal of Medicine, 1981: 304 (12): 599-601.
Annex 8 Beckman H and Frankel R, The Effect of Physician Behavior on Collection of Data,
Annals of Internal Medicine, 1984: 101 (5): 692-696
Fail. The basis for evaluation will be on the student’s performance in the group
process and the medical student’s written case summary to be submitted at the
end of the semester. It is for this reason that attendance is mandatory.
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Annex 1
A Dozen Notes For

CONDUCTING A WELL ORCHESTRATED INTERVIEW by Kachur E et al
Overture:
1. Introduce yourself, ask the patient’s name and explain the reason for the interview.
2. You have a choice of two acceptable ways of proceeding:
I II
a) Chief complaint (e.g. What brought you here a) Identifying Data (e.g. age, marital status, but state
today?) and Present Illness that you will soon inquire about the reasons for the
visit or hospital stay)
b) Identifying data after exploring the chief b) Chief Complaint and Present Illness
complaint to a sufficient degree
3. Start your exploration of the history using open-ended questions. Since any patients will provide ample responses
to such questions, it may be unnecessary to ask closed-ended questions except for specific details. However, if
you cannot get a clear picture from an open-ended question (such as, “Can you describe exactly what it felt
like?”), then proceed with a closed ended question (such as, “Was the pain sharp or dull?”)
Opus:
4. Listen carefully to what the patient has to say. Allow him/her to tell you his/her story in his/her own words. He/
she will usually lead you to the important issues. Worrying about what to ask next instead of concentrating on
the patient’s story is a common problem encountered by first-time interviewers. The interviewer’s main task is
to pay attention to what is said and to ask questions, which will clarify the patient’s story.
5. Keep your questions simple: one issue per question. For example, make two questions out of “How old are your
children and how long have you been married?”
6. First time interviewers are often uncomfortable with brief periods of silence. They are important, however,
because that time is used by the patient to remember details and clarify thoughts and feelings. Allow the patient
sufficient time to answer your questions. Do not bombard the patient as in a cross-examination. If you happen
to start thinking at the same time as the patient, stop and permit the patient to continue.
7. Learn to observe non-verbal cues while questioning. Trust emotional tone more than comment when they are
at variance; e.g. the student denies anxiety about a forthcoming exam, but he looks anxious and his voice quivers.
Comment on an obvious behavior or affect, such as an angry tone of voice, finger drumming or crying. Say that
you noticed it and tactfully explore its meaning tot he patient. Also attend to your non-verbal behavior so that
it is facilitating. Sit comfortably, lean towards the patient and maintain eye contact without staring directly into
the patient’s eyes.
8. Use words, which are appropriate to the patient’s background, education and vocabulary. This can be achieved
by using the same words as the patient when talking about symptoms or life events. Be sure you understand
what the patient is saying and that the patient understands you. In order to check that you were understood,
ask the patient to repeat what you said in his/her own words.
9. Make sure the interview covers the following questions:

a) Why did the patient come today and not another time? (Unless of course it was an emergency situation
when the patient was hospitalized.)
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b) Have there been any significant changes in the patient’s life, which occurred within the past year? There
sometimes is a delayed reaction to stressful events, which the patients do not associate with their
symptoms. Therefore, your inquiry should cover any stressful event within the year prior to the week of the
illness.
c) What does the patient think is wrong? How has it changed since the onset of the symptoms?
d) What are the patient’s responses to past stressors? How has she/ he coped? This information will guide
you in your coping management of the patient. It will offer guidelines for assisting the patient in a crisis
situation such as an operation and it will enable you to predict how cooperative the patient will be in his/her
management.
Finale:
10. There are two important aspects in ending the interview, which need emphasis.
a) Encourage the patient to add any important information: e.g. we are about to stop now, but before we do,
is there anything else, which you think I should know about?”
b) Before ending the interview ask if the patient has any questions, e.g. “Before we stop are there any questions
you would like to ask me?”
Wait ten seconds for a response to each of the above. One of the most common errors in interviewing is failure
to allow the patient sufficient time to formulate a question. Try to discover the latent content, which may be
more important: e.g. a patient with chest pain secondary to muscle strain who asks “Is it serious? I am really
worried about possible cardiac disease.” Therefore, before reassuring, you should ask, “What are your worries
about?” It is acceptable not to have the answer. You can make a commitment to find out or refer the patient to
someone else who can help. Also, remember that you will not be able to answer all of the patient’s questions.
11. As you end the interview, formulate some plan of action and explain it tot he patient so he/she will know the
next step: e.g. a physical examination or a consultation with your supervisor.
12. In summary, you have the responsibility of beginning and ending the interview, insuring that the patient had the
opportunity to express himself/herself and obtaining all the relevant information. If the patient is very quiet:
e.g. because he is depressed or shy, you will have to ask more questions and generally be more active. If the
patient rambles, you might have to interrupt in order to cover all the important areas. As you are ending the
interview, ask yourself if you have a clear picture of all the biological, psychological and social factors contributing
tot he case.
Compiled by: Kachur, E., Preven, D and Waters J.

Albert Eisntein College of Medicine
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Annex 2
PATIENT SIMULATION AND ACTUAL PATIENT INTERVIEW
I. Objectives
A. During these sessions, the student will interview (or observe interviewed) at least two patients: a
simulated interview and an actual patient interview.
B. The student will be able to demonstrate basic history gathering skills, as described in “A Dozen Notes
for Conducting a Well Orchestrated Interview,” by Kachur, E. and Preven D.
C. The student will have developed sufficient observational skills to write a maximum two-page description
of the patient.
D. At the end of these sessions, the student will be able to discuss the impact of disease and/or
hospitalization on these individuals.
E. Following the interviews, the student will be able to give a concise presentation of the patient, organized
in the standard clinical format as follows:
1. Identifying Data
2. Chief complaint
3. History of Present Illness
4. Past Medical History
5. Psychosocial History
6. Psychosocial Impact of Illness and Hospitalization
II. Strategies
A. Patient simulation
The patient simulation has been designed primarily as a means of teaching medical students
communication skills, which are useful in all specialties of medicine.
A simulated (or programmed) patient is an individual who has learned actual case material and can
consistently reproduce this information just as a patient would. Programmed patients provide students
with opportunities to take risks, to try out new roles, and to improve interviewing skills. The simulator
can be the supervisor or co-student.
1. The Faculty Facilitator will provide the medical cases for the simulated patient.
2. Each student interviews a simulated patient for twenty minutes (20 mins). The students are to
assume a role of a medical intern who is seeing this patient in a medical ambulatory clinic. The
student is responsible for the management of the case. The “patient” comes with a medical chief
complaint as well as some relevant psychosocial issues which the student needs to explore.
3. Immediately after the interview, the supervisor and student briefly discuss and evaluate the
interview on the Interview Rating Sheet. The duration of the session is 2 hours.
B. Ward visits for actual patient

For all ward interviews, divide the students into pairs or trios. Using the provided patient list given by
the chief resident of each department, the students will be assigned to interview one patient for 30
minutes. One student should interview; the other take notes as necessary and complete the interview
rating sheet. Faculty facilitators will observe the student interviews and complete the interview rating
sheet. The duration of the interviewing sessions will be a total of 4 hours.
• The group will make personal arrangements with their faculty facilitator as to the available schedule given.
Special arrangements can be made with the group of students assigned if the faculty facilitator cannot make it
on that day.
• Time slots available for the faculty facilitator to choose from for the Interviewing sessions is given at the start of
the semester.
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C. Small group discussions
After the student interviews, the faculty facilitator will meet with the students in small groups.
1. Each student member of the group will present the person he/she interviewed to the rest of the
group.
2. Students discuss reactions to interviewing and being interviewed.
D. Case Summary
Case summary of the actual patients interviewed by the students will be submitted at the end of the course
module. Each student will have to submit a Case Summary of an individual patient they have interviewed in the
ward. Failure to submit will be given an incomplete grade
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Annex 3
INTERVIEW RATING SHEET
IDENTIFYING DATA:
Student’s Name: ____________________________________________ Faculty Facilitator:__________________________________________
Student no.: ____________________________________________ Date: ____________________________________________________
Patient’s Name.: ____________________________________________ Ward No./ Bed____________________________________________
Instructions: Rate each of these basic interviewing techniques using the

scale below.
Accomplished = 2 Not Accomplished = 0
Somewhat Accomplished = 1 Not Applicable = 9
COMMENST ABOUT TECHNIQUE AND CONTENT:
BEGINNING OF INTERVIEW:
Introduces self to patient
Explains purpose of the interview
Attends to physical setting
TECHNIQUE DURIGNT HE INTERVIEW
Attempts to put patient at ease
Maintains appropriate balance between open- and
closed-ended questions
Follows lead of patient’s response
Seeks to clarify unclear statements and discrepancies
Allows expression of emotions and feelings
Responds appropriately to patient’s non-verbal behavior
Non-verbal behavior is facilitative not inhibiting
Allows silence
Non-judgmental acceptance of information
Uses language appropriate to the patient’s
END OF THE INTERVIEW
Invites patient to contribute to additional information
Invites patient to ask questions
Provides clear instructions
Negotiates further management
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Annex 4
Instructions for Patient Summaries
Each student must turn in one case report of an individual patient interview in order to pass the course. The
case summary must be handed in within two weeks of interviewing the patient. The case summaries must
follow these instructions:
General suggestions:
1. Finish your write-up as soon after the interview as much as possible. Your memory will be clear. This is an
excellent practice for the future, when you have to write-up cases quickly or else you will easily fall behind
in your work.
2. Restrict your work to no more than two pages. It is important to learn to be concise, to convey a lot of
information succinctly. Legibility is also very important if your summaries are hand written.
3. When quoting a patient use quotation marks. Otherwise do not use slang. Plain English works bets.
4. Beware of judgments and stereotypes. Stick to the facts as presented by the patient and observed by you.
Of course, everything said ad observed is somewhat subjective but strive to be as objective as possible.
5. Reserve speculations (not value judgments) about the person’s coping skills for the last section of this
write-up. Most of the rest of the summary is a report of data rather than analysis of data.
Format for Write-ups.
1. Identifying data
Here one presents one or two sentence overview to introduce the patient. One includes initials (to
preserve confidentiality in the course), age, sex, religion, marital status, occupation and current residence
and living arrangements.
2. Chief Complaint
This refers only to the person’s subjective complaint related to the illness (e.g. sumsakit ang dibdib ko).
If the person is being interviewed for teaching purposes and is currently well, there is no chief complaint.
If the person being interviewed in the hospital, the chief complaint is whatever distress brought the
patient to the hospital (e.g. I broke my legs). The chief complaint should be a brief sentence or phrase
preferably using the person’s words in quotation marks.
3. History of Present Illness

Here one writes a chronological history of the facts or the main illness, including details of onset, the
patient’s subjective experiences, the medical treatment, and complications, the results of the treatment
and the follow-up of the illness to the time of the interview.
4. Past Relevant Medical History

Here just state in a sentence or two, any other important medical problems revealed. If there have been
none, make statements to that effect. If you do not know because the information was not elicited, say
so. You can also include here any significant family history of diseases related to the person’s present
illness (e.g. family history of cardiovascular diseases in a person who has heart disease).
5. Current Life Situation

Describe the person’s concrete life situation paying particular attention to the following:
A. Psychosocial stressors (past year)
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What is going on in the person’s life (from now to one year ago – not more). What stressful events
occurred within the past year (e.g. a loss, a change, and the anticipation of impending changes).
Remember the positive changes can be stressful too (e.g. starting a new job). The stressors do not
have to be directly related to the present illness. Also give a one-word assessment of the severity of
the illness.
B. Adaptive functioning (past year)
Describe what life was like for this person within the past year and at the present time. Include social
and family relationships, occupational functioning, and the use of leisure time. Give a brief
assessment of the adjustment when things were at their best – the highest level of adaptive
functioning.
6. Past Psychosocial History

This should provide a concise, factual (as reported by the patient) history of the family background,
childhood, adolescence, education, occupation, marital or other close relationships.
7. Description of the patient

Again without editorial comments, write down what your perceptions are (e.g. personal appearance,
grooming, behavior). For example, the patient is slim, pale, neatly dressed 16 year old girl. She is
cooperative with the interviewer, appears articulate and speaks in a quite, slightly hoarse voice.
8. Patient’s understanding of the illness

Write a few sentence describing what you have learned of the patient’s understanding of what is going on
in his body and/or mind, why it is happening (or what has happened), what will happen in connection with
this illness in the future and how he/she can or cannot influence the illness with his/her behavior. Describe
what you hear.
9. Psychosocial impact of Illness or Hospitalization

Here is your chance to speculate about all you have learned about this person. Discuss the impact of the
patient’s illness on him/her and evaluate (with examples as possible) the person’s coping style. Have this
coping styles been adaptive or maladaptive? In summary, how well has this person adjusted to these
difficult situations? What problems might you, as the person’s physicians anticipate in the future.
Sample Patient Summary – 1 Interview with a Terminally-ill Patient

Sample Patient Summary – 2 Interview with an Adolescent with Insulin Dependent Diabetes
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SAMPLE PATIENT SUMMARY -1
INTERVIEW WITH A TERMINAL PATIENT
Identifying Data
MJ is a 64-year old windowed (and divorced – see below) Black woman from Brooklyn who currently lives in Calvary
Hospital, a terminal care facility.
Chief Complaint:
MJ is feeling increasing weakness and pain from her bone and lung cancer. She has “been going downhill” since
1978, and has recurrent “hits” or “spasms” of feeling particularly ill.
History of Present Illness:
MJ first felt a lump in her breast in 1975, and she reported it to her doctor. She subsequently had a one-step biopsy
and non-radical mastectomy. She was told at the time that the cancer was gone. In 1977, it was discovered she had
bone cancer. In 1978, a tap of her lungs showed fluid that was “tumorous” – the cancer had spread from her breast she
was told. She went on chemotherapy regimen for a few months but decided to quit because the treatments every three
weeks made her extremely sick (loss of appetite, vomiting, weakness, hair loss). Her doctor consented on her decision
and put her on Nolvadex. Her condition continued to worsen and on her doctor’s recommendation, she entered Calvary
Hospital 5 months ago. She was told at that time that Calvary was a terminal hospital. At Calvary she continues to
weaken at the same rate as before; she takes “majestic,” a hormone pill for the cancer, as well as Percodan for pain and
some other drugs for the mucus in her throat.
Past Relevant Medical History:
There was none given and no family history of breast cancer was mentioned.
Current Life Situation: Adaptive Function Past Year:
MJ is adapting remarkably well to her incurable cancer and to life at Calvary. Her faith in God is the overwhelming
factor in her coping and functioning ability. She is an extremely religious woman who believes in an afterlife in a better
place as part of “God’s plan for redemption.” She said, “If He performs a miracle, I’ll go home, If He don’t, I’ll go to the
other home.” Her daily activities in Calvary include visiting other patients, reading (mostly religious material), resting,
and taking part in a Bible study group with visitors from her church. She describes Calvary as a wonderful place, saying
“the care and love you get, you don’t feel you’re in a hospital.”
Current Life Situation: Current Psychosocial Stressors:
Although her condition is worsening and she knows that she will die at Calvary relatively soon, her complete
acceptance and sincere belief in a better afterlife make it seem, remarkably, that there are few if any psychosocial
stressors in her life beyond the physical symptoms. Her social worker did relate to us later that, (1) she had split away
from her family’s strong Pentecostal faith to join the interdenominational Consecrated Bible Student’s Church, and (2)
that after she was widowed, she had remarried and divorced. She continues to see her ex-husband on occasion. MJ
failed to mention these potential stressors.
Past Psychosocial History:
The patient was born in South Carolina, one of eight children, in a very religious family. Her mother taught them
religion and prayer in the home and brought them to church regularly. They were taught that, “God would be able to
do anything for us if we trusted in Him and that He had a plan for the human race which included redemption for being
under the curse of death.” She was married at age 15 and lost her husband 24 years later to kidney disease. She said
88
they “had a good life together.” She mentioned that her mother and two brothers have also died. Although she missed
her mother the most, she, “never grieved or fretted … (she) knew she was resurrected and that death was the beginning
of a wonderful life.” MJ never had any children of her own but raised her husband’s daughter and through his step-
daughter has 6 grandchildren and 10 great-grandchildren. MJ worked as a domestic which included housekeeping and
childcare. She continues to be active in her church group and receives many visits from both church friends and family.
She described herself as having served the Lord all her life and having both given and received a lot in life.
Description of Patient:
MJ is a pleasant looking Black woman with light chestnut-colored skin and combed and parted gray and black hair.
She visited us in her wheelchair, wheeled in by her social worker. She wore a red and white bathrobe and pick slippers,
and it seemed she wore no breast prosthesis. She smelled like faintly perfumed soap. She had a large mouth and wide
grin and would look straight into your eyes with bright eyes and much warmth. She spoke with a soft Southern accent
and dialect, claiming, “I’m progressing fastly,” and “(Cancer) can attack your organism, your heart, your kidneys …” Her
religious conviction and knowledge were her strongest feature. She interpreted every life event in terms of her faith
and at one point even related the story and lessons of Adam in the Garden of Eden to explain her point. She spoke
candidly of her condition, using the words “cancers” and “death” easily. For a person with her degree of cancer, she
looked very healthy.
Mental Status:
The patient was very alert and articulate. When speaking of her faith in God, she became rapturous.
Patient’s Understanding of Illness:
MJ explained symptoms from both the cancer and chemotherapy and realizes fully that her cancer is incurable and
life threatening. She understood that cancer can affect many organ systems but did not understand the relationship of
lymph nodes to her cancer’s spread. Having found the lump in her breast she knew that it was only possibly malignant
as she had friends who had non-malignant lumps. In explaining her decision to stop chemotherapy she said that, “…
(chemotherapy) might have been helping the cancer, but it’s killing me otherwise.”
Psychosocial Impact of Illness:
She told us that she had “accepted” cancer when she had her mastectomy and had “no bad or angry feelings …
(she) didn’t worry about it … was thankful to God that I found it, grateful to the Lord.” She described no anger nor
surprise about the recurrence of the cancer although she had been told that the cancer was gone at the time of her
mastectomy. She described her relationship with all her doctors, as with all her friends, family, acquaintances, etc., as
wonderful. She repeated over and over that the cancer, “never bothered me,” and that, “my hope is beyond the grave.”
The chemotherapy did bother her however, and she willfully decided that a shorter but less sick life was preferable to
the painful prolongation with chemotherapy.
MJ is a woman whose great faith in God and an afterlife makes her approaching death acceptable and natural to
her. She continues to love life and to give generously of herself to those around her. It was impossible to ascertain and
seemed doubtful that she harbors many unresolved conflicts and/or unfinished tasks in her life. She interprets all as
“God’s wonderful plan” for which she is grateful and thankful. She was indeed inspiring.
89
SAMPLE PATIENT SUMMARY – 2
INTERVIEW OF AN ADOLESCENT WITH INSULIN-DEPENDENT DIABETES
Identifying Data:
Ms. X is a 17 –year old female, who is a student. She is single, of Puerto Rican extraction, and lives at home with her
parents and brother.
Chief Complaint:
During the interview, Ms. X discussed primarily the process of her adjustment to being an insulin-dependent
diabetic. At this point, four years after the diagnosis has been made, her major complaint regarding her physical status
is that she is unable to engage in physical exercise without experiencing chest pain and shortness of breath.
History of Present Illness:
The patient was diagnosed four years ago (age 13 years) with diabetes. The diagnosis was made in Puerto Rico,
where her family was living at that time. The patient had first been brought to medical attention because of excessive
urination, sleeping and eating of candies. Her mother was the first to be informed of the diagnosis, followed by the
patient. Ms. X states that immediately after the diagnosis was made, she was an in-patient in a hospital in Puerto Rico
for one year so that attempts could be made to control the diabetes. (She was able to come home weekends). The
patient has had additional hospital admissions due to episodes of uncontrolled diabetes both in Puerto Rico and since
moving to New York, approximately two years ago. Recently, her condition was complicated by an infection, for which
she was again hospitalized. It is unclear as to whether this infection was related to her diabetes.
Past Relevant Medical History:
The patient mentioned that when she was very young, she needed a blood transfusion. It is unclear as to whether
she may have additional problems (cardiac?) which may account for chest pain and shortness of breath upon exercising.
Current Life Situation:
1. Adaptive Functioning Past Year
The patient’s adaptive function is very good. She has learned to monitor and managed her condition. There
was a recent episode where the patient had stopped taking insulin and developed diabetic complications in
response to her boyfriend breaking up with her. Yet, she stats that she has learned from this experience to “not
handle her problems with her body,” but to express her anger at the other person. It seems that she
internalized the anger that she felt towards her boyfriend. She says that since this episode, she is better able
to control her diabetes, and she has been able to concentrate more efficiently on her studies.
The patient states that she has had a variety of boyfriends. She has at least one close girlfriend in New
York. The patient has a close relationship with her mother. She says that she ignores her father, who has
physically abused her in the past. She attempts to understand his behavior towards her in the light of his own
childhood experiences; yet, she is realistic and knows that she cannot count on him to be there for her, as she
can count on her mother.
The patient is taking nursing courses, as she plans to become a nurse. She says that she is optimistic about
marriage and about having a family.
2. Psychosocial Stressors:
A. The patient has had experience of friends rejecting her because of her illness.
B. Recently she broke up with her boyfriend.
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C. The school system is unwilling to give her permission to bring medical equipment to school that is
necessary for the control of diabetes.
Past Psychosocial History:
The patient seems to have had a good relationship with her mother. She says that her relationship with her father
was adequate until she reached her early teens. Since that time her father has been verbally and physically abusive
towards her (more so than towards the patient’s brother, according to the patient). When she was diagnosed as having
diabetes, he said that her poor eating habits had caused the condition. She says that he no longer physically abuses her,
and that she avoids him.
Description of the Patient:
The patient is an attractive 17-year old female who appears older in both physical appearance and emotional
maturity. She was appropriately dressed. Her speech is understandable; she has a Hispanic accent. She seemed anxious
at the start of the interview but relaxed as the interview progressed. She was cooperative, answered all questions, and
made eye contact with members of the class, as well as with the interviewer.
Mental Status:
The patient was alert and oriented.
Patient’s Understanding of Her Illness:
The patient seems to have a partial understanding of her illness. She comprehends that there is a relationship
between monitoring her urine and taking insulin shots and being able to avoid diabetic complications. In addition, she
understands that this condition is not contagious.
However, it seems that Ms. X does not understand the physiological basis of the disease or the function of the
insulin shots. For example, in the beginning of the interview, she suggested that the transfusions that she had as a baby
may have caused the diabetes. Her certainty that her difficulties with physical exercise stem from diabetes also reflects
a lack of complete understanding of the disease.
The patient is extremely optimistic about having healthy children and stated “In fact, babies are more healthy;
that’s why they are bigger.” Ms. X appears unaware that there are some increased risks associated with child-bearing
when the mother is diabetic.
Psychosocial Impact of Illness:
The patient has demonstrated a very good coping capacity with a serious disorder. She seems to be starting to
assert herself as an independent person who knows that it is her responsibility to control her disease. She appears to
have a positive relationship with her mother and with friend. She has made a career choice to be a nurse. This seems to
reflect her need to be in control of the disease.
Ms. X is able to verbalize the limitations that she has faced as a result of her condition and the frequent negative
reactions that others had regarding her illness, particularly when the diabetes was first diagnosed. Given that her
boyfriend recently rejected her, I question whether her apparent blanket optimism regarding marriage in the future
may represent denial of some her fears about whether she will be a suitable mate. I would recommend that this issue,
in particular, be followed up in subsequent sessions.
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PATIENT-CENTERED INTERVIEW
Annex 5
Evidence-Based Patient-Centered Interviewing

Judith Swiss Lyles, PhD, Francesca C. Dwamena, MD, Catherine Lein, MS, FNP, and Robert C. Smith, MD, ScM
I nterest in the medical interview has increased

dramatically over the past 2 decades as researchers
have come to better understand the relationship
between communication and health. Until the early
The Benefits of Patient-Centered Interviewing
Research on the impact of communication patterns
between physicians and patients has reinforced the
1970s, the clinical perspective of illness was almost importance of patient-centered interviewing. Patient-
entirely biomedical, and disease was defined as centered interviewing skills have proved to be
“deviations from the norm of measurable biological advantageous in a number of areas, including patient
(somatic) variables” [1]. Data gathered for diagnosis and health, patient and physician satisfaction, and general
treatment almost exclusively consisted of information practice management.
concerning possible disease symptoms, biomedical
history, and diagnostic tests. In 1977, George Engel Clinical Outcomes
advocated expanding the medical paradigm [1]. He Research has linked effective patient-centered
argued that to fully account for health or disease, the interviewing with improved health outcomes. Among
social and psychological dimensions of human existence patients with chronic diseases, reduced physician
had to be considered along with biomedical data. This information-giving and low levels of patient control in
requires not only gathering personal or psychosocial data the doctor-patient dialogue have been directly associated
from patients but also competency in interviewing with poorer health outcomes [8]. Kaplan, Greenfield, and
techniques that elicit this information as well as Ware found that patients who were encouraged to
relationship-building skills that nurture confidence and participate in their care by asking questions during
human understanding [2–4]. medical appointments had greater improvement in blood
The application of these skills in practice is called pressure and glucose levels and functional status
patient-centered interviewing [2–6]. In doctor-centered compared with patients whose doctors were more
interviewing, the doctor takes the lead to obtain symptom authoritarian [8]. These researchers posit that the
details and other data to make a disease diagnosis [2,4]. physician’s act of giving information at the patient’s
A problem in medical practice has been the use of doctor- request affects the outcomes of patients with chronic
centered skills in isolation, an approach that excludes the disease by “shaping how patients feel about disease, their
personal and emotional components of patient health sense of commitment to the treatment process, and their
[2,4]. However, when the patient-centered interview is ability to control or contain its impact on their lives” [8].
integrated with the doctor-centered interview, patients This work demonstrated that patients benefit from
have an opportunity to be heard before disease data are relationships in which control of the medical interview is
collected. During the patient-centered interview, the shared and in which their information needs are met.
patient is encouraged to take the conversational lead [7], Such relationships are consistent with a patient-centered
initiating topics in the areas of their experience and interviewing approach.
expertise: symptoms, worries, preferences, and values Additional research has linked effective patient-centered
[2]. The physician does not insert new ideas into interviews with improved health outcomes. In Stewart’s
conversation but instead allows and facilitates the patient comprehensive review of 21 studies in which the
to direct the conversation [7]. The approach is aptly relationship between effective doctor-patient
labeled patient-centered because the physician communication and various aspects of physical and
acknowledges and meets the patient’s need to express mental health were explored, 16 reported positive results
problems, emotions, and concerns, obtain information, [9]. The data from those studies indicated that reduction
and help determine the agenda for the medical in psychological distress and symptom resolution were
appointment. When well performed, the patient-centered associated with physicians’ checking on patients’
interview operationalizes the biopsychosocial model and, concerns, expectations, and understanding of the
as such, is associated with numerous positive outcomes problem; asking about feelings; and showing support and
for both patients and physicians. empathy [9]. Several other studies in Stewart’s review
In this article, we give a brief overview of the positive reported that patients’ expressions of feelings, opinions,
outcomes associated with patient-centered interviewing and information and their perception that their problem
and describe an evidence-based method for conducting a had been fully discussed led to reduced role and physical
patient-centered interview. limitations, improved health or functional status, blood
pressure reduction, or symptom resolution.
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From the Departments of Medicine (Drs. Lyles, Dwamena, and Smith) Using patient-centered skills effectively teaches that
and the College of Nursing (Ms. Lein), Michigan State University, East
valuable lesson to physicians as well. There is research
Lansing, MI.
that suggests that residents trained extensively in patient-
Similar findings were associated with effective centered interviewing experience increased professional
discussion of the management plan in which patient- and personal satisfaction [13–16]. Lyles found that
centered approaches (e.g. eliciting patient questions, residents who were interviewed 2 or more years
giving clear information and emotional support, sharing following intensive interviewing training indicated that
decision-making) were used. A more recent summary of they were better able to help their patients, regardless of
research involving relationship-centered care focusing diagnosis, by using patient-centered techniques [16].
on support of patients’ autonomy corroborated and Some also reported that the rewards of patient-centered
complemented previous findings: relationship-centered interactions were instrumental in their decision to
care was more likely to increase compliance with continue in primary care. The training not only increased
medications, weight loss, smoking cessation, and the their understanding of the biopsychosocial model, but
maintenance of these effects [10]. also bolstered their confidence in treating the whole
patient, addressing and seeking patient emotions, and
Patient Satisfaction and Quality of Life trusting in the therapeutic value of the doctor-patient
Among the positive outcomes of patient-centered relationship [16]. The rewards derived from effectively
interviewing is the satisfaction that it brings to both deploying patient-centered skills also may have
patients [11,12] and physicians [13–16]. Patient implications for a recent study exploring physician
satisfaction is important because it influences patients’ satisfaction. Researchers found that physicians who are
compliance with medical treatment, which in turn satisfied with their work are more likely to have patients
impacts health [13,14,17]. There is a body of literature who are satisfied with their health care [24]. Although
that relates patients’ dissatisfaction with physicians’ the authors suggested that satisfied physicians may
communication skills (e.g., lack of warmth, poor communicate better or more empathically with their
explanations, failure to address patient concerns) to patients [24], it is equally possible that patient-centered
noncompliance with medical treatment [18–21], communication is the source of the satisfaction for both
breaking appointments, and seeking other medical the physicians and the patients.
providers [18]. On quantitative measures, patient-
centered interviewing has been associated with both Pragmatic Benefits for Medical Practice
higher general satisfaction and greater confidence in the Perceived lack of physician empathy has practical
physician [12]. ramifications for medical practice as well. It can lead to
There is also evidence that patient-centered increased litigation and poor time management. There is
approaches improve patients’ well-being in ways not a long history of research associating poor
always captured in quantitative research. In a recent communication with malpractice litigation. Researchers
study, patients were asked about symptom reduction and have noted that less than 3% of hospitalized patients who
activity levels [22]. Qualitative methods corroborated the have negligence-related injuries actually initiate lawsuits
quantitative findings, and also provided significant [25]; the critical differentiating factor between those who
additional information. During follow up interviews, sue and those who do not appears to be the quality of the
patients talked about quality of life issues, such as coping physician-patient interaction [26,27]. More than 30 years
better with their symptoms between treatments, having ago, Blum reported that patients’ malpractice suits and
more hope, and feeling supported [22]. Patients credited failure to pay doctors’ bills were related to problems with
their relationship with their providers for improvements doctor-patient communication [28]. Later, Valente et al
in their attitudes toward their health problems [22]. That corroborated this link, noting specifically that lack of
these benefits were attained illustrates a primary tenet of physician empathy, lack of information, and perceived
the biopsychosocial model: therapeutic treatment for lack of physician remorse for negative outcomes often
patients does not require curing all symptoms or disease. led to medical liability claims [29]. More recently, it has
As Frank has pointed out, simply being with a patient in been estimated that over 70% of all claims [26] and 75%
a supportive way is therapeutic in itself, even under the of the malpractice suits lost by physicians reflect poor
worst of medical circumstances [23]. Patient-centered communication [30]. The recommended remedy calls for
skills ensure that we always have something to offer. physicians to convey understanding and support of the
patient’s perspective and provide the information that
Physician Satisfaction patients and their families want [26]. This strongly
suggests the need for communication training to improve
physicians’ skills in gathering data, handling
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[2,4,16]. Although there is often resistance to learning
patient-centered interviewing techniques because “they
take too much time,” recent research indicates that
soliciting the patient’s agenda can take as little as 6
seconds [32]. Other researchers have also shown that
Table 1. Basic Skills for Patient-Centered Interviewing patient-centered interviewing takes no additional time
[35].
Non-focusing open-ended skills Basic Skills for Patient-Centered Interviewing
Silence Over time, a core of experienced patient-centered
Nonverbal encouragement (head nodding, leaning forward) educators and researchers have reached a consensus on
Neutral utterances, continuers (“um-hmm”) the essential interviewing and relationship skills that
Focusing open-ended skills should be included in a patient-centered interviewing
Reflection, echoing (eg, patient says: “I’m worried;” physician curriculum [2,3,4,6,7,36–41] (Table 1). Open-ended
echoes, “Worried?”) skills, both non-focusing (e.g., silence, neutral
Open-ended requests (“Can you say more about that?”) utterances, nonverbal encouragement) and focusing (e.g.,
Summary, paraphrasing echoing, requests, and summary statements) elicit patient
Emotion-seeking skills talk. As mentioned above, focusing skills respectfully
Direct (“How did that make you feel?”) keep the patient on track during a medical interview
Indirect: self-disclosure, impact on life, impact on others, and [2,4]. When a patient initiates a topic, focusing questions
belief about problem are used to develop the topic further. When a patient
Emotion-handling skills (N U R S) begins to introduce side topics that may compromise
Naming, labeling (eg, “You sound sad.”) what can be accomplished in a finite appointment time,
Understanding, legitimation (eg,”I can sure understand why . . .”) focusing skills redirect patients so that they continue to
Respecting, praising (eg, “You have been through a lot.”) discuss topics that enhance understanding of their
Supporting, partnership (eg, “I am here to help you any way I primary concerns. By learning when and how to use non-
can.”) focusing and focusing open-ended skills to elicit patient
talk, providers are more likely to gather accurate and
reliable information about the patient [2,4]. Becoming
Adapted with permission from Smith RC. The patient’s story: proficient in these skills requires that providers learn to
integrated patient-doctor interviewing. Boston: Little, Brown; 1996:4.
resist shifting topics and interrupting the patient to
introduce new ideas not initiated by the patient.
Mastery of relationship skills [2,4] are equally critical
emotions, and ascertaining patients’ needs—key
to effective patient-centered interviewing. Emotion-
elements of a patient-centered interview [31].
seeking skills (e.g., “How did that make you feel?”) and
In addition to mitigating the factors that precipitate
emotion handling skills (i.e., naming, understanding,
litigation, another practical element of patient-centered
respecting and supporting emotions) are the building
interviewing is better time management for physicians.
blocks of the doctor-patient relationship; the patient’s
Patient-centered interviewing includes 2 elements that
feelings provide access to underlying concerns and,
are crucial to conducting efficient office visits: agenda-
consequently, to the psychological aspects of the
setting and focusing. Agenda setting entails eliciting a
patient’s story. By addressing emotion using the skills
complete list of the patient’s concerns followed by
outlined in Table 1 (and easily remembered by the
negotiating what can be accomplished in the allotted
mnemonic N U R S), the physician has an enhanced
time. By summarizing what the physician needs to
opportunity to make the patient feel better [2,4,6,7].
accomplish during the visit (e.g., medical history,
physical examination) and which patient concerns will be
discussed, expectations are clear [2,4]. The prevalence of Table 2 shows how the basic patient-centered skills
new patient concerns arising at the end of the may be applied during an interview. The basic patient-
appointment and missed opportunities for data gathering centered interviewing method [2,4,7] is a 5-step approach
diminish considerably with use of agenda-setting that synthesizes recommendations embraced by scholars
techniques [2,4,32–34]. Focusing, which keeps the in the medical education and patient-centered research
patient on track during a medical interview (discussed in literature. This method was the centerpiece of a
more detail below), complements agenda-setting by randomized controlled study that examined the
functioning to ensure that appointment time is used to effectiveness of patient-centered interviewing training.
meet both the patients’ and physicians’ specified needs
94
Residents trained using this method showed significant Step 3: Non-focused Interviewing
improvement in their knowledge, attitudes, self- Dr:. . . So, that’s a lot going on, how are you doing with
confidence, skills in interviewing patients (both real and it?
simulated), and dealing with relationships [7,36]. Pt: Oh, okay I guess.
Dr: (silence)
Pt: At least now.
Putting it All Together: The Vignette of Mrs. Jones Dr: (sits forward slightly) Uh-huh.
Pt: Things weren’t so good last week, though, when I
The following interview, excerpted from The Patient’s
made the appointment.
Story [2], illustrates many of the elements of the 5-step
Dr: Mmmm….
patient-centered interviewing process. Medical student
Pt: That’s when my boss really got on me. Well, he’s kind
Mr. White conducts the interview with his patient, Mrs.
of uptight anyway, but he was saying how I was
Jones.
upsetting the whole office operation because I was
off so much . . .
Step 1: Setting the Stage
Dr: I see.
Dr: (enters examining room and shakes hands) Welcome
Pt: These headaches are right here (points at right temple)
to the clinic, Mrs. Jones. I’m Mr. White, the
and just throb and throb. And I get sick to my
medical student who will be working with you
stomach and just don’t feel good. All I want to do
along with
is go home and go to bed . . .
Dr. Black. I’ll be getting much of the information
about you and will be in close contact with you Table 2. Basic Patient-Centered Interviewing Method
about our findings and your subsequent care.
Pt: Hi. I wasn’t sure whom I was going to see. This is
my first time here. Step 1. Setting the stage
Dr: If it is okay with you, I’ll close the door so we can Welcome the patient
hear each other better and have some privacy. Use the patient’s name
Pt: Sure, that’s fine. Introduce self and identify specific role
Dr:Is there anything I can help with before we get started? Ensure patient readiness and privacy
Remove barriers to communication
Step 2: Setting the Agenda Ensure comfort and put the patient at ease
Dr: . . . Well, we’ve got about an hour today, and I know Step 2. Chief complaint/agenda setting
I’ve got a lot of questions to ask and that we need Indicate time available
to do a physical exam. Before we get started,
Indicate own needs
though, it’s most important to find out what you
Obtain list of all issues patient wants to discuss (eg, specific
want to cover today. symptoms, requests, expectations, understanding)
Pt: It’s these headaches. They start behind my eye . . . My
Summarize and finalize the agenda; negotiate specifics if too
boss is really getting upset with me. He thinks that many agenda items
I don’t have anything really wrong with me and Step 3. Non-focused interviewing
says he’s going to report me . . . Open-ended beginning question
Dr: That sounds difficult and really important. Before we
Attentive listening (non-focusing open-ended skills)
get into the details, though, I’d like to find out if
Obtain additional data from nonverbal sources: nonverbal cues,
there are any other problems you’d like to look into physical characteristics, autonomic changes, accoutrements,
today so we can cover everything that you want to. environment
We’ll get back to your headaches and your boss Step 4. Focused interviewing
after that—that’s 2 things (holding up 2 fingers). Is Obtain description of the physical symptoms (focusing open-
there anything else? ended skills)
Pt: Well, I did want to find out about this cold that doesn’t Develop the more general personal/psychosocial context of the
seem to go away. I’ve been coughing for 3 weeks. physical symptoms (focusing open-ended skills)
Dr: (holding up 3 fingers now) Anything else you want Develop an emotional focus (emotion-seeking skills)
to look at today? Address the emotion(s) (emotion-handling skills)
Pt: . . . No. The headache is the main thing. Expand the story to new chapters (focusing open-ended skills,
Dr: So, we want to cover the headaches and the problem emotion-seeking and -handling skills)
they cause at work . . . the cough . . . Is that right? Step 5. Transition to the doctor-centered process
Brief summary
95
Check accuracy Address the emotion (N U R S):
Indicate that both content and style of inquiry will change if the Dr: . . . So you get mad when he gets on you? [N]
patient is ready Pt: Yeah, he really gets me mad. I just get so furious I
could scream sometimes (clenches fist and strikes
Adapted with permission from Smith RC. The patient’s story: table firmly).
integrated patient-doctor interviewing. Boston: Little, Brown; 1996. Dr: . . . It sure makes sense. [U] It seems like you’ve done
so much there to help and all you get is grief from
him. [R] I appreciate the way you’re able to talk
Step 4: Focused Interviewing about it. [R] He sure gets you mad . . . [N]
This step is the most complex and requires the integration Pt: He sure does. Just talking about it gets me upset and
of focusing open-ended skills with emotion-seeking and gives me a headache right now.
emotion-handling skills. First, develop the patient’s Dr: I can imagine. [U] You’ve put up with a lot. [R] Let’s
personal description of the symptoms, the physical work on this together. [S]
symptom story:
Dr: Say more about the headaches. Expand the story to new chapters:
Pt: Well, I never had any trouble until I got here. Pt: . . . You know the head of the Board even told me my
Dr: How long’s that been? boss is a good guy who was looking forward to me
Pt: Only 4 months. The headache started about 3 coming so he could retire!
months ago. Dr: The head of the Board?
Dr: You mentioned your boss. Pt: She’s the one who recruited me . . . she convinced
me it was such a good chance for me.
Pt: It seems like every time I see him any more I get
Dr:Sounds like you didn’t get a full picture of this place?
one of these headaches. I sometimes just get a little
Pt: Yeah, it’s not really fair.
nauseated but, if he’s around much, there’s the Dr: How’s that make you feel?
headache. Pt: Well, I am upset . . .
Dr: Keep going . . . Dr: (uses N U R S again)
Continue to develop the personal/psychosocial story: Step 5: Transition to the Doctor-Centered Process
Pt: . . . I’m on the road a lot. No trouble then, either. Dr: . . . So, you’re in a new job that hasn’t worked out
Except one time when he called me. quite like you were led to believe and that has
Dr: Tell me more about your boss. caused you some upset with at least a couple people
Pt: Well, he’s been there a long time and I’ve replaced and quite bad headaches. Do you want to add
him in every way there is, except he is still in anything?
charge, at least in his title. He yells at everybody.
Pt: No. I think you’ve pretty much got it.
Nobody likes him and he doesn’t do much. That’s
why they got me in there, the Board, so something Dr: If it’s okay then, I’d like to shift gears and ask you
would get done. These headaches have all come some different types of questions about your
since I got this job— right here. They throb behind headaches. . . .
my eye and . . . I’ll be asking a lot more questions about specifics.
Dr: Wait a second, you’re getting ahead of me. You say Pt: Sure, that’s what I came in for.
he’s in charge, but you are the lead attorney?
Pt: Yeah, they are phasing him out but he’s still there in The Issue of Self-Awareness
the meantime. Who knows how long it’ll take. I Learning the basic patient-centered interviewing method
hope I last . . . Sounds kinda bad, huh? is just the first step in conducting an effective interview.
As Stewart and Roter note, expertise in communicating
Establish an emotional focus by using emotion- requires more than knowledge or ability to completely
seeking skills, the patient’s emotional story: perform skills; it involves attitudes, life skills, and
Dr: How do you feel about that? experience [3]. Physicians’ personal attitudes and
Pt: Oh, I don’t know. The headache is what bothers. feelings about pain, drugs, poverty, and death (for
Dr: But how’d you feel, you know, personally, your example) influence not only how they talk to patients
emotions . . . about these issues, but also if they talk about them
Pt: . . . Well, I just want to throw something at him. He [42,43]. Patient-centered interviewing cannot be
makes me so mad . . . mastered without the development of physician self-
awareness.
96
Fear of Feelings avoid or choose topics that do not meet the patient’s
Many physicians find dealing with patients’ emotions needs. By acknowledging those feelings and the
more difficult than treating disease symptoms. As a association, it is far more likely that the patient will be
result, when patients express an emotion, some treated and listened to as an individual [2].
physicians may unconsciously avoid feelings by
interrupting or shifting topics; others may preclude Explore personal reactions. Exploring attitudes and
emotional expressions by aggressively controlling the feelings about social behaviors that have medical
interview from the outset [42,44,45]. Reasons for consequences presents a second opportunity to work on
avoidance are deep-seated and may entail fears of self-awareness. Many physicians have strong personal
causing the patient harm (eg, that talking about death or feelings about AIDS, birth control, abortion, substance
emotions will upset the patient) or losing control of the abuse, smoking, and alcohol use, to name a few. By
interview and their own emotions [42,44,45]. Such acknowledging that certain behaviors evoke personal
actions can restrict the growth of the doctor-patient reactions, physicians can prevent those responses from
relationship—not only by denying patients an interfering with patient communication and care.
opportunity to communicate what is important to them,
but also by denying physicians the opportunity to offer Talk to other physicians. Finally, physicians can help
comfort and support. improve self-awareness by talking about difficult
physician-patient encounters with other physicians 1-on-
Most patient-centered educators agree that patient- 1 or in groups designated for this purpose. Their
centered teaching should include helping new learners to discussions should mirror the patient-centered process,
recognize and understand the variety of behaviors, using open-ended focusing skills, emotion-seeking and
feelings, and attitudes that can become barriers to the emotion-handling skills to help elicit feelings, explore
development of sound doctor-patient relationships personal responses, and provide support. The American
[3,37,42–46]. Smith and colleagues [42,46,47] have Academy on Physician and Patient
noted that once residents learn basic interviewing skills, (www.physicianpatient.org) offers courses in both self-
the persistence of poor interviewing performance is often awareness and interviewing and is an excellent resource
due to unrecognized feelings about aspects of the doctor- for additional information about this topic.
patient relationship. Until such feelings are
acknowledged and addressed, both the interview and the Beyond Basic Interviewing
doctor-patient relationship will suffer. In this paper, we have focused on the essentials of
patient-centered interviewing and acquiring basic
Improving Self-Awareness patient-centered skills. Subsequent training requires
In the absence of a structured patient-centered education reinforcement of these basic skills and gradual expansion
program, there are some things physicians can do on their into new patient-centered areas: working effectively with
own to improve self-awareness. the reticent patient and the talkative patient, delivering
Recognize the unrecognized. The first step toward self- bad news, educating patients, working effectively with
awareness is simply to start paying attention to one’s difficult patients, learning negotiation skills, and
feelings (emotions), or to begin to “recognize the managing psychosocial issues that present themselves in
unrecognized.” Lyles found that residents trained in primary care (eg, depression, anxiety). Many of these
patient-centered interviewing were mindful of situations advanced skills interface specifically with treatment and
that signal the need to focus inwardly and explore their management. It is important to remember, however, that
feelings. According to the residents, it is particularly basic patient-centered interviewing is highly therapeutic
important to sit back and ask themselves if they have in itself and is always valuable in the medical encounter
been listening to the patient when (1) they have a [2,4,23].
negative experience with a patient or the patient “pushes
their buttons;” (2) their plan for the patient isn’t working
and the relationship is uncomfortable; and (3) they notice Corresponding author: Judith Swiss Lyles, PhD, B322
their attitude about a patient is changing [16]. The latter Clinical Center, Michigan State University, East Lansing, MI
48824, lylesj@pilot.msu.edu
is worth noting because the need for self-reflection is
often overlooked when feelings are positive, even though
positive feelings require equal assessment. For example, References
1. Engel GL. The need for a new medical model: a challenge
if a patient reminds a physician of a favorite elderly
for biomedicine. Science 1977;196:129–36.
relative, the physician may unconsciously attribute
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interviewing. Boston: Little, Brown; 1996. patient relationship. Psychol Rep 1985;57:399–427.
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editors. Communicating with medical patients. Newbury Communication, compliance, and concordance between
Park (CA): Sage Publications; 1989:252–5. physicians and patients with prescribed medications. Am
4. Smith RC. Patient-centered interviewing: an evidence- J Public Health 1976;66:847–53.
based method [videotape]. East Lansing (MI): Marketing 20. Korsch BM, Gozzi EK, FrancisV. Gaps in doctor-patient
Division, Instructional Media Center, Michigan State communication. 1. Doctor-patient interaction and patient
University; 2001. satisfaction. Pediatrics 1968;42:855–71.
5. Lipkin M. The medical interview and related skills. In: 21. Davis M. Variation in patients’ compliance with doctors’
Branch WT Jr, editor. Office practice of medicine. 3rd ed. orders: medical practice and doctor-patient interaction.
Philadelphia: WB Saunders; 1994:1287–306. Psychiatry Med 1971;2:31–54.
6. Stewart M, Brown JB, Weston WW, et al, editors. Patient- 22. Paterson C, Britten N. In pursuit of patient-centred
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Thousand Oaks (CA): Sage Publications; 1995. Yourself Medical Outcome Profile. J Health Serv Res
7. Smith RC, Marshall-Dorsey AA, Osborn GG, et al. Policy 2000;5:27–36.
Evidence-based guidelines for teaching patient-centered 23. Frank AW. Just listening: narrative and deep illness. Fam
interviewing. Patient Educ Couns 2000;39:27–36. Syst Health 1998;16:197–212.
8. Kaplan SH, Greenfield S, Ware JE. Impact of the doctor- 24. Haas JS, Cook EF, Puopolp AL, et al. Is the professional
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Stewart M, Roter D, editors. Communicating with medical satisfaction? J Gen Intern Med 2000;15:122–8.
patients. Newbury Park (CA): Sage Publications; 25. Brennan TA, Leape LL, Laird NM, et al. Incidence of
1989:228–45. adverse events and negligence in hospitalized patients.
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and health outcomes: a review. CMAJ 1995;152:1423–33. 1991;324:370–6.
10. Williams GC, Frankel RM, Campbell TL, Deci EL. 26. Beckman HB, Markakis KM, Suchman AL, Frankel RM.
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outcomes from the Rochester Biopsychosocial Program: a from plantiff depositions. Arch Intern Med
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2000;18:79–90. 27. Levinson W. Physician-patient communication. Akey to
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centredness of consultations and outcome in primary care. 28. Blum RH. The management of the doctor-patient
Br J Gen Pract 1999;49:711–6. relationship. New York: McGraw-Hill; 1960.
12. Smith RC, Lyles JS, Mettler JA, et al. A strategy for 29. Valente CM, Antlitz AM, Boyd MD, Troisi AJ. The
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randomized study. Acad Med 1995;70:729–32. 30. Nazario SL. Medical science seeks a cure for doctors
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14. Hall JA, Roter DL, Katz NR. Meta-analysis of correlates effective communication. Am J Manag Care 1997;3:649–
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[dissertation]. East Lansing (MI), Michigan State 1994; 9:24–8
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randomized, controlled study. Ann Intern Med patients. Psychosomatics 1988;29:392–7.
1998;128:118–26. 46. Smith RC, Dorsey AM, Lyles JS, Frankel RM. Teaching
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in interviewing skills and the psychosocial domain of interviewing. Acad Med 1999;74:1242–8.
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31. countertransference. Am J Gastroenterol 1995:90:4–8.
38. Lipkin M Jr, Quill TE, Napodano RJ. The medical
interview: a core curriculum for residencies in internal
medicine. Ann Intern Med 1984;100:277–84.
39. Williamson PR, Smith RC, Kern DE, et al. The medical
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curricula for residents. J Gen Intern Med 1992;7:235–42.`
40. Novack DH, Goldberg RJ, Rowland-Morin P, et al.
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41. Cohen-Cole SA, Boker J, Bid J, Freeman AM 3rd.
Psychiatric education for primary care: a pilot study of
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42. Smith RC. Unrecognized responses and feelings of
residents and fellows during interviews of patients. J Med
Educ 1986; 61:982–4.
43. Korsch BM. The past and the future of research on doctor-
patient relations. In: Stewart M, Roter D, editors.
Communicating with medical patients. Newbury Park
(CA): Sage Publications; 1989:247–51. Copyright 2001 by Turner White Communications Inc.,
44. Smith RC. Teaching interviewing skills to medical Wayne, PA. All rights reserved.
students:
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Annex 6
100
In observing more than 300 clinical interviews, we have seen a high COMMENT:
frequency of physician-engendered defects. Most of the defective
Although physicians realize that a patient suffers from more than
examples can be classified as one or a combination of five
syndromes: therapeutic lack; inattention to primary data pain, many have not systematized the features of the patient's distress.
(symptoms); a high control style; an incomplete data base usually Many physicians are unaware of the therapeutic opportunities that
omitting patientcentered data and active problems other than the present during an interaction with patients. It is news to many of our
present illness; and a thoughtless interview in which the physician house staff that a diagnostic interview should be therapeutic to the
fails to formulate needed working hypotheses. Proper diagnosis of
these defects allows for better prescription of educational
patient. (Fortunately it is good news.) The term therapeutic implies a
correction. process that is sensitive and helpful to emotional distress. In response to
illness, hospitalization, and ongoing treatment, the patient has
undergone a disruption of emotional equilibrium and needs help in
A F T E R the American Board of Internal Medicine (ABIM) requested
establishing a new equilibrium. Therapeutic measures need not be
that program directors observe their residents' clinical skills 6 years ago,
directed solely to a disease but to an understanding of the patient, his
we began regular observations of our house staff, students, and some
personality, and his distress.
attending staff physicians. At this writing we have observed more than
This exemplified interview was bound to exacerbate fears the
300 clinical interviews (complete or comprehensive history-taking and
hospitalized patient suffers: fears of the unknown, of dreadful outcomes,
physical examinations) and many hundreds of brief interactions. To our
of disability, or of death. The hospitalized patient suffers depressing loss
surprise all did not seem as it should be. Physicians at all levels who had
of adult status, privacy, and control of the space he lives and works in.
previously been thought quite competent appeared defective in their
Most painfully, he becomes isolated from his usual support systems and
interactions with patients. Our initial reaction was to distrust our
people—isolated with his fears. An effective diagnostic interview
observations, but repeated observations have shown great consistency,
provides the patient with support through understanding his feelings,
whether made on videotaped interviews or by a single observer present
while failure to respond humanely to the patient can further his distress.
at the event. Although there has been much written about the optimal
Therapeutic behavior includes the following.
features of the physician-patient interaction and the ABIM has recently
published a careful analysis of the components of these interactions (1, 1. Adult-to-adult amenities—knock on door to request permission
before entering room, clear introductions, use of names in direct
2), our observations do not exactly parallel these analyses. Rather, the
address, appropriate goodbye on leaving (3). The use of the familiar
defects of interviews that we have seen seem to be classifiable into five
rituals
Annals of Internal Medicine. 1979;91:898-902. ©1979 American College of Physicians
major syndromes (Table 1). These syndromes are disorders of of
physicians and of their processes, not of patients. This paper exemplifies meeting is therapeutic in itself, for it affirms that the patient has not
and discusses these five syndromes and the implications of such strayed beyond the bounds of civilization into the hands of the
technicians. These are probably the easiest thera-
findings. The examples cited are real and are drawn from observed
peutic steps to teach to our students and staff.
interviews. The discussions are the results of 2 years of weekly
2. Attention to the patient's comfort, an effort to achieve privacy,
interview conferences held with house staff and focusing on "the
problem interview—what can go wrong." initial explanation of the steps of the history and examination.
3. Careful listening during the interview; space and time must be
Syndrome 1: Low Therapeutic Content
provided for the patient to tell his story.
CASE 1 Thoroughness of the history and examination.
The interviewer failed to knock at the patient's door. He introduced himself in 4. Understanding or supportive statements made during the
a hasty mumble so that the patient never had his name clearly in mind. He interview. Such support leads the patient to know that the physician
mispronounced the patient's name once and never used it again. The physician understands his feelings (4). The message a therapeutic physician sends
conducted the interview while seated in a chair about 7 feet from the pa- is always on the order of "I am with you." In fact, the task of support
can be viewed simply as being with the patient.
• From the Department of Medicine, Presbyterian Medical Center, and the Department of In the two quoted excerpts of this interview the interviewer might
Psychiatry, University of Colorado Medical Center; Denver, Colorado.
have responded to A with, "You are doing well. I think you are doing
tient. There was no physical contact during the interview. On several occasions
the patient expressed her emotional distress. On each occasion the interviewer just fine" (reassurance about her part in the project), and to B with, "It
ignored the emotional content of her statements. sounds like a very frightening experience" (supportive).
A. Dr. X: "Exactly where is this pain?" Novice interviewers are sometimes so eager to get the right diagnoses
Patient Y: "It's so hard for me to explain. I'm trying to do as well as I can." that they do not allow themselves to be receptive to the patient's feelings
(Turning to husband:) "Aren't I doing as well as I can?"
about the interview process itself. Most patients are eager to be helpful
Dr. X: "Well, is the pain up high in your belly, or down low?"
in their treatment. A physician who sees the patient as an ally, an adult
B. Patient Y: "I kept getting weaker and weaker. I didn't want to come to the
hospital. I was so frightened" (weeping).
like himself, burdened with discomfort they both want to relieve, will
Dr. X: "Did the pain come before the weakness or afterward?" enlist the patient as a part of his treatment rather than viewing him as an
The physical examination was brusque, the examiner never warning his patient object to be treated. The novice physician frequently views the patient
when painful maneuvers (for example, stroking the sole of the foot) were to be as a container of disease, not a person with pains or problems. He has
done. At the end of the examination the physician failed to comment on his studied body
findings or his plans. He said in parting, "We'll do some tests and see if we can
find out just what's the matter with you," and left the room before the patient had
an opportunity to question him.
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Annex 7
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106
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Annex 8
ACADEMIA AND CLINIC
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influence or shape patients' initial expressions of concerns, we studied the linguistic structure of the
opening segment of the clinical encounter. We studied not only what the patient said in response to
the physician's opening query, but the timing and appropriateness of the physician's response as
well.
Expanding the scope of analysis to include the physician's participation in the development of the
patient's concerns has the advantage of providing an empirical basis for assessing the completeness
of such concerns and providing a potential link between early termination or interruption by the
physician and the so-called "hidden agenda." Using detailed transcriptions of actual visits to a
primary care internal medicine practice, the role of the physician in soliciting and responding to
information was evaluated. The results suggest that internists and internal medicine residents
frequently, and perhaps unwittingly, inhibit or interrupt their patients' initial expression of
concerns.
Methods
Between July 1980, and June 1982, 74 complete visits to the Primary Care Internal Medicine Practice at Wayne State University were audiotaped and
transcribed using a coding method sensitive to the production and timing of dialog (5). During the study period 2 faculty internists and 13 internal medicine
residents at all levels of training practiced in this setting; all participated in the study. Selection of the 74 visits was based upon the availability of equipment and
research personnel. No specific selection controls were used. The project was approved by the Human Experimentation Committee at Wayne State University.
Before taping, informed consent was obtained from both physicians and patients after the nature of the study was described. Characteristics of the encounters
recorded were sex of patient, sex of physician, new or return visit, and physician level of training.
The segment of the encounter studied began with the physician's solicitation of the chief complaints. The solicitation was denned as a request for information
such as "What brings you to the office or clinic?" or "What seems to be the problem?" If no solicitation occurred, and the physician opened by explaining the
purpose of the visit ("I had you come back today to check your blood pressure"), the sequence was coded as "chief complaint not solicited." The segment was
concluded when either the physician began to recount the history of
109
110
111
13. KORSH BN, Gozzi EK, FRANCIS V. Gaps in doctor-patient communi - versity Park Press; 1977.
cation: 1. Doctor-patient interaction and patient satisfaction. Pediatrics. 16. KRAYTMAN M. The Complete Patient History. New York: McGraw-
1968;42:855-71 . Hill Book Company; 1979.
14. ROTER DL. Patient participation in the patient-provider interaction: the 17. REISER DE, SCHRODER AK. Patient Interviewing: The Human Dimen-
effects of patient question asking on the quality of interaction, satisfac- sion. Baltimore, Maryland: Williams and Wilkins; 1980.
tion and compliance. In: WOLF GA. Collecting Data from Patients. 18. WASSERMAN RC, INUI TS. Systematic analysis of clinician-patient in -
teraction: a critique of recent approaches with suggestions for future
Baltimore, Maryland: University Park Press; 1977.
15. WOLF GA. Collecting Data from Patients. Baltimore, Maryland: Uni- research. Med Care. 1983;21:279-93.
November 1984 • Annals of Internal Medicine • Volume 101 • Number 5
112
INTERDISIPLINARY COURSE 202:
THE ART OF MEDCINE: The Making of A Physician
Module 5: Bioethics
STUDY GUIDE

Overview of the topic
Bioethics evolved from the urgent need of health professionals to have
concrete guidelines in dealing appropriately with decisions concerning the health
and, therefore, the lives of patients. Involves making tough therapeutic His
discipline, however, is greatly misunderstood or even ignored by even the more
experienced doctors. It is more than finesse or piety. It involves making tough
therapeutic decisions with patients and anchoring these decisions on sound moral
principle that respect the natural law and the dignity of the human person. It is this
reason that we should remind ourselves that our role as doctors is more than
mitigation of disease and alleviation of suffering. It involves, more importantly, the
promotion of a better quality of life.
Course outcomes and T the end of this module, you will be able to:
content 1. To examine one’ personal beliefs, professional and moral values as the basis for
understanding Bioethical Principles
2. To describe the origin of Medical Ethics
3. To enumerate the basic Theories and Principles of Bioethics
4. To describe how social-cultural factors influence Bioethics
5. To identify the various methods, the relevance of Bioethics in health care.
6.
Prerequisites None
Coordinators Dr. Ricardo Manalastas

Dr. Doris Buenavides
Timetable 8 hours/ 2 hours every week for 4 weeks
I. Bioethics: History and Background
Film showing
II. Introduction to Ethical Approaches
III. Theories of Bioethics: Utilitarianism, Kantian Perspective and Casuistry
IV. Principalism, Virtue Ethics and Care Ethics
Learning opportunities ▪ Lecture: Importance of Bioethics in Medicine

Theories and Principles of Bioethics
▪ Facilitated in group discussion: Ethical issues which are extracted from media or
personal experiences; how do students feel about these issues, which have
ethical implications
▪ Video showing: Where Medical Ethics Come From?
Socio-cultural Influence in Philippine Bioethics
▪ Individual learning: report on Bioethical issues, showing depth and understanding
Assessment details Attendance and group presentations

Personal comments
Do no harm, commands the Hippocratic oath to those within the fold of the medical
profession. The tradition of non-malificence is indeed the axis from where medical
ethics revolve, guarding in black and white, the welfare of the patient.
113
Information on the
subject or topics 1. Respect for a person’s autonomy
2. Principle of non-malificence
3. Principle of beneficence
4. Principle of justice
STUDENT ACTIVIIES RELATED TO LEARNING

Interaction with texts
or other learning Further readings will be recommended to augment your knowledge and practical
resource materials skills on bioethical issues.
Application of theory to
practice You are encouraged to actively participate in group discussions. This is an effective
way of surfacing the bioethical and medical issues that are influenced by their own
personal experiences and socio-cultural factors.
Reference and Reading

materials
Evaluation of the guide
The basis for evaluation will be performance in the group process. It is for this reason
that attendance is mandatory and completion and submission of an individual report
and written examination.
114
Module 6: Introduction to Human Rights and Medical Practice

STUDY GUIDE
Doctors will inevitably be faced with human rights challenges in the course of their work – these may be dramatic or
subtle, overt or covert. Most doctors are not adequately prepared to deal with these challenges. Being aware and
seriously committed to human rights standards make for a more responsible, more compassionate and holistic
physician.
Learning objectives
Learn the rationale for Human Rights Education for health professionals
Understand the context of violation of human rights and their relevance to health and medical practice
Clarify the standards for prevention, redress and medical Intervention
Internalize the fundamental concepts and principles in the different global human rights conventions, declarations and
standards currently in use
Session 1 Helps students develop an understanding about

• Important historical perspectives on how Human Rights principles relate to medical practice
• The WHO Human Rights Domains in the Assessment of the Responsiveness Health System
• Why Abuse/Violations Occur
• What Constitutes /Violation Abuse
• Range of Violations from Deprivation of Adequate Services to Willful Infliction of Pain
• Some factors identified as contributing to medical involvement in abuse
• The Role and Responsibility of Health Professionals, Medical Associations, other NGOs and GOs
Session 2
1. Presents:
• The Universal Declaration of Human Rights
• The Hippocratic Oath
• The Tokyo Declaration of the WMA
• The Geneva Conventions
• The CAT of the UN
• Various Standards and Universal Declarations on Human Rights
• Why Abuse/Violations Occur
• What Constitutes /Violation Abuse
• Range of Violations from Deprivation of Adequate Services to Willful Infliction of Pain
• The Role and Responsibility of Health Professionals, Medical Associations, other NGOs and GOs
• Range of Violations from Deprivation of Adequate Services to Willful Infliction
• Other Codes and Ethical Standards
2. Allows the students to critique and apply the concepts and principles behind these standards and codes by way
of a personalized “Group Code”.
What lessons do we take into the new millennium:

• Doctors will inevitably be faced with human rights challenges in the course of their work –
these may be dramatic or subtle, overt or covert;
• Most doctors are not adequately prepared to deal with these challenges
115
• “Doctors must be quick to point out to their fellow members of society the likely
consequences of policies that degrade or deny fundamental human rights. The profession
must be vigilant to observe and to combat developments which might ensnare its
members and debase the high purpose of its ideals.” (BMA Report of Council, 1947).
SESSION 1 Human Rights and Medical Practice- Historical and Social-Political Perspectives
Specific objectives:
• Internalize important historical and socio-perspectives on how Human Rights principles relate to medical
practice
• Develop an understanding of the use of Human Rights Domains in the Assessment of Health System
Responsiveness as proposed by the WHO
• Clarify why Abuse/Violations Occur
• Learn what Constitutes Violation/ Abuse
• Recognize factors identified as contributing to medical involvement in abuse
• Identify Roles and Responsibilities of Health Professionals, Medical Associations, other NGOs and GOs
Readings
British Medical Association. The Medical Profession and Human Rights-Handbook for a Changing Agenda and Zed
Press BMA 2001.
The WHO paper on Human Rights Domains in the Assessment of Responsiveness of Health Care Systems
Activity 1: Input: Historical Perspectives and Conceptual Frameworks
“Throughout the history, society has charged healers with the duty of understanding and alleviating causes of human
suffering. In the past century, the world has witnessed ongoing epidemics of armed conflicts and violation of
international human rights; epidemics that have devastated and continue to devastate health and well-being of
humanity. As we enter the twenty-first century, the nature and extent of human suffering has compelled health
providers to redefine their understanding of health and the scope of their professional interests and responsibilities”
(AMERICAN ASSOCIATION FOR THE ADVANCEMENT OF SCIENCE, PHYSICIANS FOR HUMAN RIGHTS, 1998)
International Tribunals
Medical evidence, particularly specialist forensic expertise, came to the forefront in providing detailed information
useful for identifying the victims, the manner of death and sometimes the perpetrators
Support for colleagues who protest

These included support from colleagues and medical associations, within and outside the country, and the
development of reporting mechanisms
Medicine in conflict
In the late 80’s to the 90’s, ten international wars and 25 civil wars were being fought. At least 110,000 people were
killed every year. Up to 84% of the dead in some of these conflicts are estimated to have been civilians
Activity 2: The Human Rights: Definition and Concepts, Roles and Responsibilities of the Health Professional
WHO has proposed that a health system’s performance also be evaluated from a human rights perspective
Notion of a “human rights-based approach to health” which pays equal attention to process (how people’s rights are
respected within the health system) as well as outcome (the goal of improving health)
These principles include rights to :

• security
• health
116
• life
• privacy
• free expression
• freedom of association
• non-discrimination
• respect for human dignity
• Human rights provide or support appropriate standards for human conduct. Human rights are internationally
recognized and globally accepted.
• Promoting the health of populations is also a prime goal of human rights. Indeed health is a human right. The
right to health may be defined as the duty of society to ensure the conditions necessary for the health of
individuals and populations.
• Protecting human rights is synergistic with improving public health.
• Promoting the health of people enables them to exercise their fundamental rights; safeguarding the human
rights of people empowers them to lead safe and healthy lives; and thus protecting human rights and public
health are mutually re-enforcing
• By ensuring that people are treated in ways that correspond to their needs they are empowered to lead
healthier lives.
• Respect for the dignity of persons in the delivery of public health and individual health services is a core
component of health system responsiveness because it protects each individual from potential abusive
practices, bodily infringements, and mental harms.
The Domains of Health Responsiveness: A Human Rights Analysis

Human rights and the domains of health system responsiveness share a common goal: furthering the rights of
individuals and communities in the context of the health system.
Key components, or domains, of health system responsiveness

• Respect for the dignity of persons
• Autonomy to participate in health-related decisions
• Confidentiality of information
• Prompt attention
• Adequate quality of basic amenities
• Clarity of communication (to patients)
• Access to social support networks (at the time of writing this paper there was discussion of changing the
domain label to “family and community involvement and, or, support”)
• Choice of health care providers
The most important way of ensuring human dignity is to fight insidious discrimination
Discrimination on the basis of race, sex, religion, ethnicity, political views, property, birth, disability, or other status is
deeply hurtful to the human condition.
The right not to be subject to discrimination is especially important in health care and public health.
Since health services are so fundamental to human well-being, they must be allocated fairly among all-persons and
based primarily on need.
Autonomy to Participate in Health-related Decisions

Human rights support the autonomy of individuals to participate fully in health-related decisions.
Doctrine of Informed Consent

• Competent adults are empowered to make inherently personal decisions, such as whether to accept or
refuse medical treatment.
117
• The right to security of persons requires that for an individual to provide meaningful consent to medical
procedures, she must be informed of the risks and purposes of the medical intervention.
• In the absence of complete and objective information, an individual cannot make an autonomous decision
about one’s medical services.
Privacy and Confidentiality

In the health care setting, privacy and confidentiality refer to the patient’s right to expect that HCWs or others will not
improperly access, use, or disclose identifiable health date without the person’s consent.
Prompt Attention
• This responsiveness domain refers to having timely service so as to avoid potential anxiety and inconvenience
created by any delays in receiving attention or care
• Whenever an individual’s life is jeopardized by her medical status, a human right to life supports the
obligation of the state to assure that medical attention is accessible and provided
Overlapping Dimensions
• Non-discrimination
• Physical Accessibility
• Economic Accessibility
• Information Accessibility
Adequate Quality of Basic Amenities

• This domain links to the right of everyone to an adequate standard of living for himself and his family,
including adequate food, clothing and housing, and to the continuous improvement of living conditions
including health and edible food
• HCWs must be prepared to provide health information to patients in language and format that furthers a
patient’s understanding.
• The transfer of information between health care workers would impact on the patient’s experience of
continuity.
Access to Social Support networks, family and community support

• Access to social support networks can be a key condition for the amelioration of negative health traits among
individuals.
• Unwarranted limitations on the ability of a person to seek to their family, friends, or others within a social
network for support concerning the person’s health status may infringe these rights
Activity 3: Exploring human rights issues, forms of violations/abuse
Why Abuse/Violations Occur
“The fundamental issue really concerns the morality of the by-stander. In most cases, most of us are neither victims or
perpetrators of human rights violation; we occupy the role of bystanders…even though some of us may intellectually
appreciate the ethical duty to aid and rescue suffering strangers, by far the greatest number of us are sitting behind a
veil of indifference which prevents us from acting.” MORTON WINSTON, HUMAN RIGHTS EXPERT, 1996
What Constitutes Violation/ Abuse

Two Categories of Abuse
• Abuse of human rights, which are defined by the relevant international conventions, and the second concerns
deviation from accepted standards of medical ethics.
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• The purpose of medicine is to provide benefit; actions intended to cause deliberate harm to people
constitute an “abuse” of medical skills…
• Included, therefore, in this definition of abuse are government actions which use medical expertise for aims
contrary to the patient’s interests, including actions sanctioned.
• To be ethical, medical actions should conform with patient’s best interests but determining “best interests” is
complicated and can involve contradictory imperatives.
Some factors identified as contributing to medical involvement in abuse

• Isolation
• lack of leadership
• lack of training in medical ethics and heavy workloads.
• Isolation and lack of very commonly cited for collaboration in abuse.
• Doctors isolated from their medical counterparts and working in a closed institution are at risk of absorbing
the dominant values of the group with whom they work, such as prisoner warders, the police or military.
• Lack of training in medical ethics can also mean that doctors are ill-equipped to deal with the inevitable
conflicts arising from having dual obligations.
WHAT TRIGGERS ABUSE

AMERICAN ASSOCIATION FOR THE ADVANCEMENT OF SCIENCE 1998
Perceived threats to national security

• Fundamental moral values are most likely to be sacrificed in extreme situations where they are most needed.
Violations of human rights and medical ethics commonly occur when law and order break down or are on the
verge of doing so.
• Suspension of Basic Rights
• Gross violations are facilitated by suspension of basic rights, such as rights to free expression, association,
movement, and due process.
Impunity
• Impunity means power without accountability. It was seen by the human rights community as one of the
bulwarks of torture and enforced disappearances in Latin America.
• Resocializaton or rigid training, such as military training, involving brutality and blind obedience to orders,
with severe penalties for non-conformity.
• …Just as the trainers were all powerful and immune from criticism, so the military and police trainees learned
to mimic their brutality.
Moral Disengagement
“Moral disengagement by perpetrators of violence often hinges on the view that their victims are somehow less
human than they are because of the political culture under which they live…”
CONCERN FOR LAW

• Governments’ repressive strategies are also changing in the direction of criminalization of political activity.
• Doctors working with the prisoners believed that this can increase tolerance of human rights violations
involving detainees who have been labeled as criminals rather than prisoners of conscience.
TORTURE, CRUEL AND DEGRADING TREATMENT

Universal Declaration of Human Rights 1946
“No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment.”
TORTURE
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• Any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted in order to
obtain a confession, to punish or intimidate in cases where such suffering is inflicted with the connivance of a
public official UN Convention against Torture 1984
• The use of methods upon a person intended to obliterate the personality of the victim. Inter-American
Convention to Prevent and Punish Torture
Some factors identified as contributing to medical involvement in abuse

• Isolation
• lack of leadership
• lack of training in medical ethics and heavy workloads.
• Isolation and lack of very commonly cited for collaboration in abuse.
• Doctors isolated from their medical counterparts and working in a closed institution are at risk of absorbing
the dominant values of the group with whom they work, such as prisoner warders, the police or military.
• Lack of training in medical ethics can also mean that doctors are ill-equipped to deal with the inevitable
conflicts arising from having dual obligations
THE MEDICAL RESPONSE TO ABUSE

• Identifying safeguards
• Punishing the perpetrators
• Training and awareness-raising measures
• Providing rehabilitation for victims
• Developing early warning systems
SESSION 2 Medical Ethics and Professional Standards
Students will:
• Recognize the fundamental concepts and principles in the different global human rights conventions,
declarations and standards currently in use such as the
• The Universal Declaration of Human
• The Hippocratic Oath, The Tokyo Declaration of the WMA
• The Geneva Conventions
• The CAT of the UN
• Be able to critique these standards and arrive at their own version of a “code” which they can uphold and
adhere to during their entire life as a medical student and beyond
Readings
• British Medical Association. The Medical Profession and Human Rights-Handbook for a Changing Agenda and
Zed Press BMA 2001.
• The WHO paper on Human Rights Domains in the Assessment of Health Care Systems
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STUDY GUIDE
Module 7: Introduction to Gender and Health1
What students should get out of the Gender Module
Students will:
• be familiar with the conceptual differences between sex and gender, and develop a common understanding
about how gender is constructed, maintained, and reinforced
• become aware of the common areas and variations in the construction of gender in different social and cultural
contexts
• understand and apply concepts and tools for gender roles are related to gender-based inequalities in workloads
and to unequal access to education, access to and control over economic and social resources, and access to
power
• examine and interpret evidence from international (and national) data sets on gender-based inequalities in
education, and in economic, social and political status
• learn how to apply the tools of gender analysis to specific health conditions and understand how gender
impacts on health
The thinking behind the module

Gender as a social construct. Starting with students’ own life experiences, this module introduces them to the concept
of gender as a social construct. The module looks at how gender as a social construct attributes different roles and
responsibilities to females and males, and gives them unequal access to resources and power. You introduce tools, to
help students understand the mechanisms that underlie and contribute to gender-based differences, and apply these
tools to health issues to see how gender impacts on health. The Gender Module lays the basis for understanding the
themes of the three application modules: how gender issues permeate health information; evidence used for making
decisions in the health sector; health policies; and planning and implementing health programs.
Session 1A helps students develop an understanding about how gender is constructed, maintained and reinforced
It also clarifies terms like gender equality and gender-based discrimination. The session starts from students’ life
experiences of how they have been socialized into playing gender roles. You then lead them to discover that the gender
roles they play as adults are a result of messages they have learned and internalized since childhood. Further, they
begin to see the roles that the family, school, religious institutions, work organizations, media and other social
institutions play in constructing what men and women do in society. By reflecting on their own experiences, they begin
to understand that the social constructions of gender can also be determined by race, class, caste, age, marital status
and so on.
In Session 1B, students revisits the concept of gender and sex and do an exercise to clarify the differences between
the two concepts
Gender differences are sometimes confused with biology: for example when we assume that women are better suited
for the caring professions such as nursing and child-minding, because they are naturally made that way. This session
also introduces some basic concepts and tools for analyzing gender: the gender-based division of labor; gender roles
and norms; access to and control over resources; and access to decision making and power.
1
Adapted by June Pagaduan-Lopez MD, Assoc. Prof. from the WHO Training Manual: Transforming
Health Systems-Reproductive Health and Human Rights
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Session 2A illustrates how gender-based division of labor is far from a simple-sharing of responsibilities, and is at the
root of women being under-valued and their low status in society.
You introduce students to international (and/or national) data sets that are how gender differences are transformed
into gender-based inequalities in the way resources and power are distributed. Students then apply the gender-based
concepts they have learnt in the previous sessions to interpret these data sets.
Session 2B helps the links between gender and health introduces the concept of gender mainstreaming.
Using the case study of a health condition affecting both women and men, students unravel the differentials between
males and females in health seeking behavior and health outcomes arising from biological and gender differences.
Gender inequality is embedded in many institutions in society, including health institutions. If society does not value
women input, social institutions are unlikely to do so either. If society does not give access to decision-making, social
institutions will not either. Likewise, if society does not value women’s health, health institutions will not either. It is
also important to analyze whether and how institutions reinforce gender inequalities actively and explicitly, or more
passively, by omission.
This session aims to help students become sensitive to how the skills, information and tools that you have introduced
them to during the course can help them in gender mainstreaming their own health institutions, as well as the health
programs they run, fund or use.
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INTRODUCTION TO GENDER & HEALTH
Objectives Content Learning Activities Human Time Allotment Evaluation

Resources Physical
1.Inroduction to definitions of The Social Activity I: Going back to childhood: Ask Four faculty -marker pens Input 15 mins. Journal
gender & sex Construction students to think as far back as possible in their members -at least 3 Flip charts individual work 15 Peer
2. Develop a common of lives and to write down their first experience of divided into 5 mins. Evaluation
understanding of how gender is Gender realizing that they were different from columns Whole group
constructed, maintained & members of the opposite sex and/or expected labeled as such discussion 1 hr
reinforced to behave differently and treated differently Age 30 mins.
3. Understand concepts of gender from members of the opposite sex. In one or People
equality & gender discrimination two paragraphs they should try to record: Place
• how old they were What the incident was
• who was involved about
• where the incident took place Feelings associated
• what the incident was about with the incident
• how they felt about it
• how other aspects of their identity (race, -overhead flipchart:
religious identity, nationality, ethnicity, “Sex & Gender”
caste) came into play in this incident “Gender equality,
gender equity, and
Activity 2: Exploring sex, gender, and gender discrimination
socialization
Put up the flipcharts you have made. Ask one
of the pairs to volunteer to report on each
other’s stories to the whole group. Write the
essential details under the specific columns
Step 1: Report back to group
Step 2: Input: introducing Sex and Gender
Step 3: Group discussion: personal
experiences
Step 4: Group discussion: Institutions of
Gender socialization
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Objectives Content Learning Activities Resources Time Allotment Evaluation
Human Material
1. Learn to examine & interpret Gender-based Activity 1: sex & gender Handout1: Group activity, 1
evidence from data sets on inequalities, statements on sex & hr
gender-based inequalities in the evidence Step 1: Individual work gender Whole group
education, economics, political & linking Step 2: whole group discussion Handout 2: concepts discussion, input
status gender & Step 3: summary & tools for gender 30 mins.
2. Learn to apply tools of gender health Activity 2: tools & concepts for analyzing analysis
analysis to selected health gender Overhead: the social
conditions & how gender impacts construction of
on health system Step 1: definitions sexuality
Step 2: clarifying some concepts Overhead: summary
of sex & gender
Overhead of Handout
2
Overhead: access to
& control over
resources
1. become aware of the ways in Gender-based Activity 1: Looking at the evidence Handout 1: data
which norms & values about inequalities- Step 1: handout 1 & 2 about women,
gender roles are related to gender- the evidence Step 2: Looking at the tables education & politics
based inequalities in work loads & Step 3: Group work with the tables Handout 2: data about
to inequalities in access to Activity 2: Analyzing structural gender gaps the economic value of
education, access to & control Step 1: group presentations activities & time
over economic & social resources, Step2: whole group discussion Overhead: women &
& access to power girls are Kenya’s
2. Learn to examine & interpret breadwinners
evidence from international (and Overhead: women do
national)data sets on gender- 60% of the work in
based inequalities in education, Venezuela
economic & political status Overhead: more paid
work doesn’t reduce
unpaid work
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Students will learn to apply the Linking Activity 1: the links between gender & health Handout: sex & 1 hr & 40 mins.
tools of gender analysis to specific gender & Activity 2: sex, gender & tuberculosis tuberculosis
health conditions & understand health Step 1: Reading individually Overhead: the links
how gender impacts on health Step 2: group discussions between gender &
status Activity 3: Report back and discussion health
Step 1: Report back
Step 2: Discussion
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Module 8: Medical Jurisprudence

STUDY GUIDE

Overview of the topic Medical Jurisprudence denotes knowledge of the law in relation to the practice
of medicine. It includes the study of the rights, duties and obligations of the medical
practitioner arising from the doctor-patient relationship.
Course outcomes and By the end of the course, the student should be able to have the basic knowledge of
content the following:
I. Rights and Duties of Physicians

1. Rights of Physicians
a. Inherent rights of Physician
b. Incidental Rights of the Physician
2. Physician’s Right to compensation
3. Rights of the Patients
4. Duties of physicians
a. To the patient
b. To the profession
c. To their colleagues
d. To the community
e. To special groups
5. Liabilities of Physicians
a. Administrative cases
b. Civil case
c. Criminal case
6. Legal doctrines relevant to Medical Practice
a. Laws governing medical negligence and medical malpractice
b. Risk Management
II. Philippine Jurisprudence affecting the practice of Medicine
Prerequisites None
Timetable 4 lecture hours/ 2 hours every week for 2 weeks

UPCM Social Medicine Unit and the UP College of Law
Learning opportunities Lectures

Readings: The Code of Medical Ethics of the Medical Profession of the Philippines
Written examination
Staff contacts Atty. & Dr. IVY Patdu

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Information on the Legal Medicine – the application of basic, clinical, medical and paramedical sciences to
subject or topics elucidate legal matters (Solis, Legal Medicine)
Forensic Medicine – the science which teaches the application of every branch of
medical knowledge to the purposes of the law.
Medical Jurisprudence - the science which applies the principles and practice of the
different branches of medicine to the elucidation of doubtful questions in a court of
justice. It may be considered as common ground tot eh practitioners both of law and
medicine (Black’s Law Dictionary)

Interaction with texts
or other learning Further readings will be recommended to augment your knowledge on Philippine
resource materials Jurisprudence affecting the practice of Medicine
Evaluation of the guide The basis for evaluation will be the student’s performance in the written
examination at the end of the 2nd semester. A quantitative value will be given and the
passing grade is 75% for the written examinations. The final grade for Legal Medicine
and Medical Jurisprudence will be accumulated at the end of the 4-year course.
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Code of Ethics of the Medical Profession in the Philippines.
Formulated by the Philippine Medical Association and promulgated as Republic Act No. 4224, this Code of Ethics
outlines the different duties of Filipino physicians: to their patients, to the community, to allied professionals, and to
their colleagues and the profession.
Article I
GENERAL PRINCIPLES
Section 1. The primary objectives of the practice of medicine is service to mankind irrespective or race, creed or
political affiliation. In its practice, reward of financial gain should be a subordinate consideration.
Section 2. On entering his profession, a physician assumes the obligation of maintaining the honorable tradition that
confers upon him the well deserved title of “friend of man”. He should cherish a proper pride in his calling, conduct
himself as a gentleman, and endeavor to exalt the
standards and extend the sphere of usefulness of his profession. He should adhere to the generally accepted
principles of the International Code of Medical Ethics adopted by the Third General Assembly of the World Medical
Association at London, England in October, 1949 as part of his professional conduct.
Section 3. In his relation to the state and to the community, a physician should fulfill his civic duties as a good citizen,
conform to the laws and endeavor to cooperate with the proper authorities in the due application of medical
knowledge for the promotion of the common welfare.
Section 4. In his relation to the state and to the community, a physician should fulfill his civic duties as a good citizen,
conform to the laws and endeavor to cooperate with the proper authorities in the due application of medical
knowledge for the promotion of the common welfare.
Section 5. With respect to the relation of the physician to his colleagues, he should safeguard their legitimate
interests, reputation, and dignity-bearing always in mind the golden rule “whatever ye would that man should do
unto you, do you even so to them.”
Section 6. The ethical principles actuating and governing a clinic or a group of physicians are exactly the same as
those applicable to the individual physician. Specialties in the various fields of medical sciences are not exempt from
the application of these principles.
Article II
DUTIES OF PHYSICIANS TO THEIR PATIENTS

Section 1. A physician should attend to his patients faithfully and conscientiously. He should secure for them all
possible benefits that may depend upon his professional skill and care. As the sole tribunal to adjudge the physician’s
failure to fulfill his obligation to his patients is, in most cases, his own conscience, and violation of this rule on his part
is discreditable and inexcusable.
Section 2. A physician is free to choose whom he will serve. He may refuse calls, or other medical services for reasons
satisfactory to his professional conscience. He should, however, always respond to any request for his assistance in an
emergency. Once he undertakes a case, he should not abandon nor neglect it. If for any reason he wants to be
released from it, he should announce his desire previously, giving sufficient time or opportunity to the patient or his
family to secure another medical attendant.
Section 3. In cases of emergency, wherein immediate action is necessary, a physician should administer at least first
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aid treatment and then refer the patient to a more qualified and competent physician if the case does not fall within
his particular line.
Section 4. In serious cases which are difficult to diagnose and treat, or when the circumstances of the patient or the
family so demand or justify, the attending physician should seek the assistance of his colleagues in consultation.
Section 5. A physician must exercise good faith and strict honesty in expressing his opinion as to the diagnosis,
prognosis, and treatment of the cases under his care. Timely notice of the serious tendency of the disease should be
given to the family or friends of the patients, and even to the
patient himself if such information will serve the best interest of the patient and his family. It is highly unprofessional
to conceal the gravity of the patient’s condition, or to pretend to cure or alleviate a disease for the purpose of
persuading the patient to take or continue the course of treatment, knowing that such assurance is without accepted
basis. It is also unprofessional to exaggerate the condition of the patient.
Section 6. The medical practitioner should guard as a sacred trust anything that is confidential or private in nature
that he may discover or that may be communicated to him in his professional relation with his patients, even after
their death. He should never divulge this confidential information, or anything that may reflect upon the moral
character of the person involved, except when it is required in the interest of justice, public health, or public safety.
Section 7. The medical profession not being a business and service its primary concern, a physician should not charge
exorbitant or excessive fees. In determining the amount of the fee, he should always consider the financial status of
the patient, the nature of the case, the time
consumed, his professional standing and skill and the average fees charged by physicians of the same standing in the
same locality.
Article III
DUTIES OF PHYSICIANS TO THE COMMUNITY

Section 1. Physician should cooperate with the proper authorities in the enforcement of sanitary laws and regulations
and in the education of the people on matters relating to the promotion of the health of the individual as well as of
the community. They should enlighten the public on the
dangers of communicable diseases and other preventable diseases, and on all the measures for their prevention and
cure, particularly in times of epidemic or public calamity. On such occasions, it is their duty to attend to the needs of
the sufferers, even at the risk of their own lives and without regard to financial returns. At all times, it is the duty of
the physician to notify the properly constituted public health authorities of every case of communicable disease
under his care in accordance with the laws, rules and regulations of the health authorities of the Philippines.
Section 2. It is the duty of every physician, when called upon by the judicial authorities, to assist in the administration
of justice on matters which are medico-legal in character.
Section 3. It is the duty of physicians to warn the public against the dangers and false pretensions of charlatans and
quacks, since, their deceitful practice may cause injury to health and even loss of life.
Section 4. A physician should never cover up, help, aid or act as a dummy of any illegal practitioner, quack or
charlatan.
Section 5. Solicitations of patients, directly or indirectly, through solicitors or agents, is unethical. Modest advertising
may be allowed through professional cards, classified advertising, directories of signboard. In all these
advertisements only the name, title or profession, office hours and office and residence addresses should appear. In
case of physicians specializing on a definite branch of medicine, the specialty may be advertised by stating “Practice
limited to (specialty)” or by merely stating: “Obstetrician”, “Orthopedic surgeon”, “Ophthalmologist”, etc. Advertising
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and publishing personal superiority, possession of special certificates or diplomas, post-graduate training abroad,
specific methods of treatment or operative techniques or advertising former connection with hospitals or clinics are
likewise unethical. Guaranteeing or warranting treatments
or operations is objectionable.
Section 6. No physician should advertise through the radio, television or movies not allow the publication or reports
or comments on cases or methods of treatment in any newspaper or magazine. Only medical articles which will
contribute to the knowledge and education of the public on general health matters may be published and the author
may be identified provided the article is neither self-laudatory not in any way related to his clinical practice. In case
any picture of a laudatory article is published by any body without the consent or knowledge of the physician
concerned, the latter should make a written protest and disclaimer to be published in the same newspaper or
magazine where the original article in question was published. A copy of this letter should also be furnished the
component society to whom the physician belongs and to the PMA
Secretariat.
Section 7. The physician-columnist must be well informed and up-to-date in the subject matter of his column. The
scope of the medical column should be in the form of general information, of education value and of public interest,
such as needs for yearly periodic consultations, preventive measures, formation of good health habits, explanation of
need for diagnostic sides, emergency measures, and other topics of general interest to the health of the public.
Medical columns should not make specific diagnosis or therapy or be projected to individual cases. The physician-
columnist should not be in active clinical practice. If however, the physician-columnist is in active clinical practice, his
authorship must be in the form of pseudonym or the columns may be published under the sponsorship of a medical
society or a specialty society to which he belongs.
Section 8. Humanity requires every physician to render his services gratuitously to poor and indigent persons who are
in need of his attendance. The endowed institution and organization for mutual benefit or for accident, sickness or
life insurance or for analogies purposes have no claim upon physicians for unremunerated service.
Article IV
DUTIES OF PHYSICIANS TO THEIR COLLEAGUES AND TO THE PROFESSION

Section 1. Physicians should labor together in harmony, each giving freely to others whatever advantage he may have
to contribute.
Section 2. A physician should willingly render gratuitous service to a colleague, to his wife and minor children or even
to his father or mother provided the latter are aged and are being supported by the colleague. He should however, be
furnished the necessary traveling expenses and compensated for all medicines and supplies necessary in the
treatment of the patient. This provision shall not apply to physicians who are no longer in practice nor to physicians
who are engaged only or purely in business.
Section 3. In difficult and serious cases or in those which are outside the competence of the attending physician, he
should always suggest and ask consultation. Only experienced physicians who are senior to the attending physician or
who have had special training and experience in a particular line of medicine should be selected by the latter as
consultants.
Section 4. Out of consideration for the object of consultation and for the physician’s duty to uphold the honor and
dignity of his profession, no physician should meet in consultation with anyone who is not qualified by law to practice
medicine. In arranging for a consultation the attending physician should fix the hours of the meeting. However, it is
his duty to make the appointment in a way satisfactory to the consultant.
130
Section 5. Every physician participating in a consultation should endeavor to observe punctuality. Unless the cause of
delay is known, if the attending physician does not arrive within a reasonable time after the appointed hour, the
consultant should, according to the circumstances attending the case, be at liberty either to regard the consultation
as postponed or to see the patients alone. In the latter case, he should leave his conclusions in writing in a sealed
envelope. On the other hand, if the consultant does not appear at the fixed time, the attending physician, after a
reasonable period of waiting, and with the consent of the patient, or his family, may either arrange for another
consultation or give permission for the consultant to examine the patient and forward to him a written opinion, the
consultant must see to it that the opinion is under seal and that his statements are courteously worded.
Section 6. The attending physician should give the consultant all necessary information relating to the case. This
should be done in a place away from the patient and his family. After this, the consultant should be brought in and
introduced to the patient by the attending physician, who may examine the patient again, if he thinks it necessary to
note any possible change before turning his patient over to the consultant. The latter then should proceed to make a
thorough examination. During the examination, the attending physician may make patient remarks or observation.
While in the presence of the patient or of his family, the consultant should not make any remarks about the
diagnosis, etiology, prognosis, or treatment or hint of any possible error of the attending physician.
Section 7. In a secluded place away from the patient, the physicians should discuss the case and determine the course
of treatment to be followed. Neither statement nor discussion of the case should take place before the patient or his
family or friend, not only to save the attending physician from possible embarrassment, but also to prevent all
possible misapprehension which susceptible lay persons might easily derive from the plain discussion usually
unavoidable in such cases.
Section 8. Once the discussion is terminated, the result of the deliberations should be announced. The duty of
announcing it to the patient’s family or friends should be mutually arranged between the attending physician and the
consultant, and no opinion or information should be announced without previous deliberation and concurrence.
Section 9. Differences of opinion should not be divulged; but when there is an irreconcilable disagreement, the
circumstances should be frankly, courteously, and impartially explained to the patient’s family or friends.
Section 10. When a consultation is over and the physician in charge is designated, the latter shall be responsible for
the care and treatment of the patient. He may, however, suggest calling in any other physician whom he regards as
competent to help or to advise. He may at anytime change or abandon the course of treatment outlined and agreed
upon at the consultation, if and when, in his opinion, such action is required by the condition of the patient. If he
does this, he should at the next consultation state his reasons for departing from the course previously agreed upon
because
it is his duty to follow the treatment, outlined and refrain from changing if for trivial motives. If an emergency occurs
and the physician in charge is not available, the consultant should attend to the case until the arrival of his colleague,
but should not take further charge of it except with the consent of the attending physician.
Section 11. Cases which appear to be out of the proper line of practice of the physician in charge or refractory in spite
of the usual clinical treatment, or with a grave prognosis should be referred to those who specialize in that class of
ailments. It is desirable that the patient brings with him a letter of introduction giving the history of the case, its
diagnosis and treatment, and all the details that may be of service to the specialist. The latter should, in turn reply in
writing to the physician in charge, giving his opinion of the case together with the course of treatment he
recommends. These opinions or suggestions must be regarded as strictly confidential.
Section 12. A physician should observe utmost caution, tact and prudence, both in words and in action, as regards the
professional conduct of another physician, particularly when it concerns a patient previously treated by the latter or
actually under his care. In his dealings with patients not under his care, he should not say or do anything that might
lessen the patient’s confidence reposed in the attending physician.
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Section 13. Whenever a physician is compelled to make a social or business call on a patient under the professional
care of another physician, he should not make inquiries or comments as to the etiology diagnosis, treatment, or
prognosis of the case. The most that may be mentioned is the general physical condition of the patient or other
topics foreign to the case.
Section 14. A physician should not take charge of or prescribe for a patient already under the care of another
physician, unless the case is one of emergency, or the physician in attendance has relinquished the case, or the
services of the attending physician has been dispensed with.
Section 15. A physician should never examine or treat a hospitalized patient without the latter’s knowledge and
consent except in cases of emergency, but in the latter instance, the physician should not continue the treatment but
return the patient to his attending physician after the emergency has passed.
Section 16. A physician called upon to attend a patient of another physician either because of an emergency, or
because the family physician asks for it, or is not available should attend only to the patient’s immediate needs. His
attendance ceases when the emergency is over or on the arrival of the physician in charge after he has reported the
condition found and treatment administered; and he should not charge the patient for his services without the
knowledge of the attending physician.
Section 17. Whenever in the absence of the family physician several physicians have been simultaneously called in an
emergency case because of the alarm and anxiety of the family or friends, the first to arrive should be considered as
physician in charge, unless the patient or his family has special preference for some other one among those who are
present. As a matter of courtesy, the acting physician in charge should request, at the start, that the family physician
be called. When the patient is taken to the hospital, the attending physician of the hospital, likewise should
communicate with the family physician so as to give him the option of attending the case.
Section 18. Public interest demands that the relation between government and private physicians should be friendly
and cordial for the promotion and protection of public health depend greatly upon the cooperation of government
and private physicians.
Section 19. The physician should carefully refrain from making unfair and unwarranted criticism of other physicians
and, even in justified circumstances, criticism should be made in a constructive way and only directly and privately to
the physicians involved. Whenever there is an irreconcilable difference of opinion, or conflict of interest between
physicians, which cannot be adjusted by both sides alone, the matter should be referred to a committee of impartial
physicians or other competent bodies for arbitration.
Section 20. When a physician is requested by a colleague to take care of a patient during his temporary absence or
when because of an emergency he is asked to see the patient of a colleague, the physician should treat the patient in
the same manner and with the same delicacy
as he would have wanted his own patient cared for under similar conditions. The patient should be returned to the
care of the attending physician as soon as possible.
Section 21. When a physician attends a woman in labor in the absence of another who has been engaged to attend,
such physician should relinquish the patient to the one first engaged upon his arrival. The physician is entitled to
compensation for the professional services he may have rendered.
Section 22. A true physician does not base his practice on exclusive dogma or sectarian system for medicine is a
liberal profession. It has no creed, no party, no master. Neither is it subject to any bond except that of truth. A
physician should keep abreast of the advancement of medical
science; contribute to its progress; and associate with his colleagues in any of the recognized medical societies, so
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that he may broaden his horizon through the exchange of ideas, and in order that he may contribute his time, energy,
and means towards making these societies represent the ideas of the profession. The medical journal is one of the
most important instruments through which these objectives may be accomplished. It is therefore necessary that
editors and members of editorial boards of medical journals should possess adequate qualifications. And to the end
in view all editors and members of the editorial boards of national medical journals will be recommended by the
Philippine Association of Medical Writers, Inc. to the Executive Council, and in case of specialty and component
medical society journals, the appointment of editors an members of editorial boards will be left at the discretion of
their respective affiliate specialty or component medical societies concerned. Furthermore, the contents of medical
journals should conform to accepted standards as provided for by the Philippine Association of Medical Writers, Inc.
Section 23. A physician should be upright, diligent, sober, modest and well-versed in both the science and the art of
his profession. Extravagance, intemperance, and superstitious are most destructive to the professional reputation,
influence, and confidence; and they are not only financially but also morally disastrous.
Section 24. Advertising by means of untruthful or improbable statements in newspapers or other publications, or
exaggerated announcements on shingles and signboards, calculated to mislead or deceive the public, or made in
manner not consistent with good moral and right professional dealings with a patient, is unprofessional.
Announcements in newspaper, or in signboards or shingles, should be restricted to the facts about the location of
clinics, office hours, and limitation of practice. It is equally incompatible with honorable standing in the profession to
solicit patients by circulars, by advertisements, of by personal relations to procure patients indirectly through
solicitors or agents.
Section 25. It is unprofessional for a physician to help or to employ unqualified persons for the purpose of evading the
legal restriction governing the practice of medicine.
Section 26. It is degrading to the good name of the medical profession to prescribe, dispense or manufacture secret
remedies or to promote their use in any way. It is likewise unprofessional to promise or boast or radical cures or to
exhibit publicly testimonial of success in the treatment of diseases.
Section 27. It is degrading to the professional character for physicians to deliberately to prolong the progress of
treatment of diseases for questionable motives, or to establish an unjust competition among physicians in the
community by unwarranted lowering of fees.
Section 28. When a patient is referred by one physician to another for consultation or for treatment whether the
physician in charge accompanies the patient or not, it is unprofessional to give or to receive commission by whatever
term it may be called or under any guise or pretext
whatsoever. It is unprofessional for a physician to pay or offer to pay, or to receive or solicit commission for the
purpose of gaining patients or for recommending professional service.
Section 29. Physicians should expose without fear or favor, before the proper medical or legal tribunals, corrupt or
dishonest conduct of members of the profession. All questions affecting the professional reputation of a member or
members of the medical society should be considered only before proper medical tribunals, in executive sessions or
by special or duly appointed committees on ethical relations. Every physician should aid in safeguarding the
profession against the admission to its ranks of those who are unfit or unqualified because of deficiency in moral
character or education.
Article V
DUTIES OF PHYSICIANS TO ALLIED PROFESSIONALS

Section 1. Physicians should cooperate with and safeguard the interest, reputation, and dignity of every pharmacist,
133
dentist, and nurse; because all of them have as their objective the amelioration of human suffering. But, should they
violate their respective professional ethics, they thereby forfeit all claims to favorable considerations of the public
and of physicians.
Section 2. Physicians should never sign or allow to be published any testimonial certifying the efficacy value and
superiority and recommending the use of any drug, medicine, food product, instrument or appliance or any other
object or product related to their practice specially when
published in a lay newspaper or magazine or broadcast through the radio or television. When such testimonials are
published or broadcast without his knowledge and consent, he should immediately make the necessary rectification
and order the discontinuance thereof.
Section 3. A physician should neither pay commissions to any person who refers cases to or help him in acquiring
patient nor receive commission from druggist, laboratory men, radiologists or other co-workers in the diagnosis and
treatment of patients for referring patients to them.
Article VI
AMENDMENTS
Section 1. The House of Delegates of the Philippine Medical Association, upon recommendation of the Executive
Council, by a majority vote of all the delegates may amend or repeal this Code or adopt new Code of Ethics of the
Medical Profession in the Philippines. Any amendment shall be a part of this Code of Medical Ethics and such
amendments shall become effective after thirty (30) days following the completion of its publication in the Official
Gazette.
Article VII
PENAL PROVISIONS
Section 1. This Code of Ethics shall be published in the Official Gazette to have the force and effect of law. Copies of
this Code shall be distributed every year to all physicians during their Annual Conventions and published once a year
in all medical journals published in the Philippines for the proper information and guidance of all physicians both in
private practice and in the government service and shall also be distributed among all new physicians immediately
following their oath taking. It shall be included in the curriculum of all medical schools as part of the course of study
of legal medicine, ethics and medical jurisprudence.
Section 2. Violation of anyone of the provisions of this Code of Ethics shall constitute unethical and unprofessional
conduct and therefore a sufficient ground for the reprimand, suspensions, or revocation of the certificate of
registration of the offending physician in accordance with the provisions of Section 24, paragraph (12) of the Medical
Act of 1959, Republic Act 2382.
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From the website of the Professional Regulation Commission
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COLLEGE OF MEDICINE

University of the Philippines Manila

“Towards Leadership and Excellence in

INTERDISCIPLINARY COURSE 202

THE ART OF MEDICINE I: