Teaching Professional Attitudes and Basic Clinical Skills To Medical

Teaching Professional
Attitudes and Basic Clinical

Skills to Medical Students
A Practical Guide
Jochanan Benbassat
Second Edition
Teaching Professional Attitudes and Basic Clinical
Jochanan Benbassat
Teaching Professional
Attitudes and Basic Clinical
A Practical Guide
Second Edition
Jochanan Benbassat
Department of Medicine (retired)
Hadassah-Hebrew University Medical School
Jerusalem, Israel
ISBN 978-3-031-26541-9 ISBN 978-3-031-26542-6 (eBook)

https://doi.org/10.1007/978-3-031-26542-6
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To Reina, Dorit, and Naomi, with all my love
Preface to the Second Edition
The purpose of this edition is to update the sections on teaching communication

skills, physical examination, and clinical reasoning and to introduce medical stu-
dents to selected professional topics that have generated controversy. The second
edition has been expanded to address issues such as the role of the social and behav-
ioral sciences, quality assurance of patient care, and rationing of medical resources
in clinical practice. Of course, the goal is not to offer solutions, but to provide
insight into these topics, explain their importance, and help students form their own
opinions about them. Many readers will disagree with my approach and attitudes,
which do not necessarily coincide with the policies of the institutions I have
worked at.
I also describe some additional insights that I believe are important for medical
practice and research. First, the primary goal of teaching the social and behavioral
sciences is to raise awareness that age, low socioeconomic status, recent life events,
drug dependence, mental illness, high body mass index, and belonging to an ethnic
minority are risk indicators for morbidity. Any symptom in such underprivileged
patients may indicate more severe disease than in patients without these indicators,
just as a neutropenic patient with a fever is more likely to have a life-threatening
infection than a nonneutropenic person. Second, getting a second opinion is a
neglected cause of health care disparities. Rather than being offended when patients
seek a second opinion, physicians should encourage their patients to do so and
schedule a follow-up appointment to help them deal with any discrepancies between
the first and second opinions. Finally, unexpected study results should not be
ignored, nor should they be considered definitive evidence, but rather hypotheses
that should be tested by further studies.
Jerusalem, Israel Jochanan Benbassat
vii
Preface to the First Edition
Doctors differ in their training and practice settings, and ultimately, they adopt
diverse approaches to the basic clinical skills of patient interviewing, data collec-
tion, and problem-solving. Consequently, medical students may encounter marked
differences in the clinical methods of their tutors. For example, some doctors
encourage patient narratives through open-ended questions, while others prefer
closed-ended questions. Physicians in hospitals and the community may disagree
about the value of the physical examination, and tutors differ in how they inform
patients, colleagues, and students about clinical uncertainties.
Medical students can be confused by these differences and by controversies over
topics such as doctor–patient relationships and clinical reasoning. They may be
puzzled by contradictions between what they are taught and the way medicine is
practiced, such as the patient-centered approach promoted in lectures and the dis-
ease orientation of some physicians. Finally, some students have difficulties in mas-
tering certain skills, such as percussion, or in adopting professional rules, such as
the requirement to be non-judgmental toward patients.
This book is intended to help clinical tutors and students address some of these
difficulties. Its sections describe my difficulties in learning and teaching patient
interviewing, physical examination, recording the patient database, clinical reason-
ing, and the behavioral sciences. I describe the approaches that I found useful in
overcoming these difficulties, as well as several insights that I believe are important
for medical education and practice.
The first insight is that clinical problem-solving begins with identifying the
patient’s concerns and expectations rather than formulating his or her chief com-
plaint. Some patients make their expectations clear, but many leave their concerns
unspoken. Insight into a patient’s concerns and expectations is important because
failure to address them can lead to patient dissatisfaction and ineffective medi-
cal care.
Second, basic clinical skills, including the ability to retrieve information, should
be learned for mastery as early as possible rather than expected to be acquired
through practice. Practice is certainly important. However, evidence suggests that
clerkships do not improve students’ clinical skills, that some physical examination
ix
x Preface to the First Edition
skills deteriorate with seniority, and that a physician’s performance may decline
with years in practice, likely due to inadequate updating of knowledge and skills.
Third, rather than feeding medical students lectures on behavioral and social sci-
ences, faculty should lead students to discover for themselves the relevance of these
sciences to clinical practice. Lecturing students to be polite to patients is likely to be
viewed as offensive and provoke resistance. However, students react differently
when they realize on their own that many clinicians are rude to patients. Finally,
observed inconsistencies between theory and practice should not be seen as a sign
of personal inadequacy but as an opportunity for further inquiry, and disagreements
between authority figures should not lead to confusion or cynicism but rather help
identify areas of uncertainty to explore.
These views were shaped during my tenure as a physician and teacher in the
medical faculties of Hebrew University and Hadassah (1962–1992) and Ben-Gurion
University of the Negev (1992–1997). In addition to the publications I cite, my
beliefs were shaped by my mentors, colleagues, and students. However, the respon-
sibility for writing is entirely mine, and my opinions do not necessarily reflect the
policies of the institutions with which I was affiliated. I may be mistaken in assum-
ing that my earlier learning and teaching difficulties are shared by today’s medical
students and faculty. Nevertheless, I hope that this book will help some clinical
tutors and lecturers in the behavioral and social sciences to gain insight into stu-
dents’ difficulties and will help students to make informed choices of professional
style and clinical methods.
I thank Drs. Reuben Baumal, Rosalie Ber, Jeffrey M. Borkan, Mayer Brezis,
Samuel N. Heyman, Netta Meroz, Dina Pilpel, Anna Schiffman, and Meira Tidhar,
who coauthored earlier versions of the various chapters, and the journals that pub-
lished them for their permission to include the updated versions in this book. I also
thank the Myers-Brookdale Institute for hosting me during the editing of this book
and my colleagues at the Center for Health Policy Research for their advice and
comments.
Jerusalem, Israel Jochanan Benbassat

Contents
1 Paradigmatic Shifts in the Theory, Practice, and Teaching of

Medicine Since the 1970s�� 1
1.1 Introduction�� 1
1.2 Doctor–Patient Relations�� 1
1.3 Clinical Reasoning�� 4
1.3.1 From Denial to Acceptance of Uncertainty �� 4
1.3.2 From Intuitive to Analytic Decision-Making�� 5
1.3.3 From Pathophysiologic Rationale to Evidence-Based
Reasoning�� 6
1.3.4 From the Biomedical to the Bio-psycho-social
Model of Clinical Practice�� 7
1.4 Doctor–Society Relations �� 7
1.4.1 From Accountability to Peers to Accountability to
Laymen and Lay Institutions �� 8
1.4.2 From an Unrestricted to a Parsimonious Use of
Resources�� 8
1.4.3 From a Lone Professional to a Member of a Healthcare
Team�� 9
1.4.4 Change in the Public’s Trust in Health Services �� 9
1.5 Medical Education�� 9
References�� 10
2 ommunicating with Patients�� 11
C
2.2 Learning How to Talk with Patients�� 12
2.3 Teaching How to Talk to Patients �� 15
2.4 Coping with Barriers to Learning and Teaching Patient
Interviewing�� 18
2.4.1 Learning Objectives and General Approaches to
Achieving Them�� 18
2.4.2 The Integrated Learner- and Teacher-Centered
Approach�� 19
xi
xii Contents
2.4.3 Shifts in Teaching Patient Interviewing�� 20

2.4.4 Assessment of Communication Skills �� 21
2.5 Proposed Teaching Program �� 22
2.5.1 Step I: The Problem�� 22
2.5.2 Step II: Discussion of Possible Solutions�� 23
2.5.3 Step III: Demonstration of Various Interviewing
Techniques and Discussion of Their Advantages and
Disadvantages�� 26
2.5.4 Step IV: Supervised Practice �� 28
2.5.5 Advantages of the Proposed Approach�� 29
2.6 Barriers to Doctor–Patient Communication�� 30
2.6.1 Doctor–Patient Differences in Age, Race, Gender,
Language, and Socioeconomic Status: Underprivileged
Patients�� 31
2.6.2 Mismatch Between the Patient’s and the Doctor’s
Preferences�� 31
2.6.3 Doctors’ Failure to Gain Insight into the Patient’s
Concerns�� 32
2.6.4 Interviewing Habits That May Discourage Patients
from Sharing Their Concerns�� 33
2.6.5 Angry Patients �� 34
2.7 Coping with Barriers to Communication with Patients�� 35
2.7.1 Language Mismatches �� 35
2.7.2 Doctors’ Self-Awareness �� 35
2.7.3 Encouraging Patients to Share Their Concerns �� 36
2.7.4 Management of Patient Aggression�� 36
2.8 Shared Decision-Making�� 37
2.8.1 Teaching Shared Decision-Making �� 37
2.8.2 Proposed Learning Objectives of Shared Decision-
Making�� 38
2.9 Patient Counseling�� 42
2.10 Patients’ Adherence to Doctors’ Advice �� 44
2.10.1 Estimating Patients’ Adherence to Doctors’
Recommendations �� 45
2.10.2 Reasons for Nonadherence�� 45
2.10.3 Ways to Improve Patient Adherence�� 46
2.11 Managing Difficult Encounters and Delivering Bad News�� 46
2.11.1 Patients’ Preferences�� 47
2.11.2 Care-Providers’ Preferences�� 47
2.11.3 Suggested Guidelines�� 48
2.11.4 Teaching How to Disclose Bad News�� 50
References�� 50
3 he Physical Examination�� 59
T
3.2 Barriers to Teaching and Learning Physical Examination Skills�� 60
Contents xiii
3.2.1 Attitudes to the Physical Examination�� 60

3.2.2 “Inherited” Errors�� 60
3.3 Coping with Barriers to Learning the Physical Examination �� 61
3.3.1 Teaching the Reflective Physical Examination�� 61
3.3.2 Learning for Mastery�� 63
3.3.3 Integrating Hand-Held Devices into Teaching the
Physical Examination�� 63
3.3.4 Teaching Physical Signs by Context and Importance�� 64
3.3.5 Use of Simulations�� 71
3.4 Diagnostic Utility of the Physical Examination and Ancillary
Tests�� 72
3.4.1 Test Properties �� 73
3.4.2 Sources of Bias in Determining the Validity of
Diagnostic Tests�� 74
3.4.3 Clinical Prediction Rules�� 75
3.4.4 Assessment of the Pretest Probability of a Disease�� 75
References�� 76
4
Recording the Clinical Database�� 79
4.2 The Problem-Oriented Record�� 80
4.3 The Electronic Medical Record�� 81
4.4 Teaching the Recording of the Clinical Database�� 82
4.4.1 The Personal and Psychosocial History�� 83
4.4.2 Chief Complaint�� 83
4.4.3 Symptoms�� 84
4.4.4 Problems�� 84
4.4.5 Statement of the Patient’s Present Problem(S)�� 85
4.4.6 Statement of the Present Problem(S) (Continued)�� 85
4.4.7 Statement of the Present Problem(S) (Continued)�� 85
4.4.8 Listing Active and Inactive Problems, Past and Family
History, Review of Systems�� 86
4.5 Common Errors in Recording the History of a Patient’s
Present Illness �� 86
4.5.1 Overemphasis on Objective History Data �� 87
4.5.2 Inadequate Description of the Patient’s Symptoms�� 88
4.5.3 Failure to Identify Main Symptoms�� 88
4.5.4 Unclear Presentation of Chronological Evolution of
Symptoms�� 89
4.6 Providing Feedback on Students’ Records of a Patient’s
History�� 89
References�� 91
5 Clinical Reasoning �� 93
5.2 Reasoning Strategies of Experienced Clinicians�� 94
xiv Contents
5.2.1 Pattern Recognition and Hypothetico-Deduction�� 94

5.2.2 Additional Paths of Clinical Reasoning�� 95
5.2.3 Cognitive Task Analysis�� 96
5.3 Heuristics and Biases in Clinical Reasoning�� 96
5.4 Barriers to Learning Clinical Reasoning�� 96
5.5 Teaching and Assessing Clinical Reasoning�� 98
5.5.1 Learning Objectives�� 98
5.5.2 Assessment�� 98
5.6 Decision Support�� 99
5.6.1 Decision Analysis�� 99
5.6.2 Evidence-Based Medicine �� 102
5.7 Interpretation of Research Findings�� 103
References�� 105
6
The Behavioral and Social Sciences in Medical Education�� 109
6.1.1 Stress and Stressors �� 109
6.1.2 Psychological Distress�� 110
6.1.3 Life Events�� 110
6.1.4 Social Support �� 111
6.1.5 Socio-Economic Status�� 111
6.1.6 Personality Traits �� 112
6.2 Barriers to Teaching the Behavioral and Social Sciences�� 113
6.3 Overcoming Barriers to Student Learning�� 114
6.3.1 Risk for Disease and Ability to Cope with It:
The Patient’s Personal/Psychosocial History�� 114
6.3.2 Implications for Clinical Practice�� 118
6.3.3 Who Should Teach Medical Students the Clinically
Relevant Aspects of the Behavioral and Social
Sciences? �� 119
7
Medical Errors and Quality Assurance of Healthcare �� 125
7.2 Medical Errors�� 125
7.2.1 Prevalence of Medical Error and Doctors’ Attitude to
Mistakes�� 126
7.2.2 Prevention of Medical Errors�� 127
7.2.3 Patients’ Complaints and Medical Litigation�� 128
7.2.4 Disclosure of Medical Errors to Patients�� 129
7.3 Incapacitated Doctors�� 130
7.3.1 Incidence�� 130
7.3.2 Response to the Awareness of Doctors’ Dysfunction�� 131
7.3.3 Dealing with Doctors’ Dysfunction�� 132
Contents xv
7.4 Quality Assurance of Healthcare�� 133

7.4.1 Physicians’ Attitudes to Quality Assurance of
Healthcare�� 133
7.4.2 Promoting Physician Support for Quality Assurance
in Healthcare�� 135
7.4.3 Promoting Physician Self-Disclosure of Errors�� 135
8 Shifts in the Structure of Health Care and Doctor–Society
Relations�� 141
8.2 Managed Care �� 141
8.2.1 Bureaucracy: Definition and Negative Connotations�� 142
8.2.2 Desirable Facets of Managed Care�� 142
8.3 Fair Distribution of Healthcare Resources�� 144
8.3.1 Fair Distribution of Resources: Ethical Dilemmas�� 144
8.3.2 Controversial Norms�� 146
8.3.3 The Need for a Policy of Rationing Resources �� 147
8.3.4 Implementing a Policy for Fair Allocation of Medical
Resources�� 148
8.4 Trust in Medicine�� 149
8.4.1 Decline in Patient Confidence in Health Care �� 149
8.4.2 Possible Reasons for the Decline of Trust in Health �� 150
8.4.3 Impact of Changes in the Status of the Physician in
Society �� 151
8.5 Medicine and the Media�� 151
8.5.1 Media Coverage of Medical Issues: Targets�� 152
8.5.2 Media Coverage of Medical Issues: Biases�� 153
8.5.3 Medical Recommendations in the Media�� 154
9
Changes in Medical Education �� 159
9.1 Ongoing Changes in Medical Education�� 159
9.1.1 From Memorization to Self-Directed Learning and
Information Management�� 159
9.1.2 From Knowledge to Competency-Based Education�� 160
9.1.3 From the Biomedical Model to Engel’s
Bio-Psycho-Social Model for Clinical Reasoning
and Practice �� 160
9.1.4 From Intuitive to Analytic Decision-Making�� 160
9.1.5 From Hospital to Community Settings�� 161
9.1.6 External Reviews of Teaching and Accreditation of
Medical Schools�� 162
9.1.7 Quality Assurance of Patient Care�� 162
xvi Contents
9.2 Challenges of Medical Education �� 163

9.2.1 Promoting Student Well-being�� 163
9.2.2 Personalizing Medical Education and Reducing Its
Duration�� 164
9.2.3 Selection of Applicants for Medical Training �� 165
Index�� 169
Chapter 1
Paradigmatic Shifts in the Theory,
Practice, and Teaching of Medicine Since
the 1970s
1.1 Introduction
The main difference between what I was taught in medical school in the 1950s and
health care today is the increase in medical knowledge and biotechnology. But apart
from this increase, physicians have adopted professional standards that would have
been considered heretical two generations ago, and what was right in the 1950s
became wrong by the end of the twentieth century.
These changes took place when I was a resident and attending physician from the
1960s to the 1980s, and they led to controversy between those who upheld tradi-
tional patient care values and those who embraced the new professional norms. In
this section, I list the changes in physician–patient relationships, clinical reasoning,
healthcare delivery, and medical education that have occurred since the 1970s
(Table 1.1). Insight into these changes can help students navigate their learning
environment and understand issues such as patient involvement in care, evidence-
based medicine, clinical guidelines, and healthcare delivery.
1.2 Doctor–Patient Relations (See Chap. 2)
The shift in doctor–patient relations was from physicians’ paternalism to respect for
patient autonomy. In the 1950s, physicians rarely shared health-related information
with their patients and seldom involved patients in clinical decisions. A 1961 survey
Previous versions of parts of this section were published in:

Benbassat J. Paradigmatic shifts in clinical practice in the past 40 years. Harefuah. 1996;130:585–9
(Hebrew). With permission from Harefuah.
Benbassat J. Changes in clinical reasoning and practice during the last forty years. In: Chinitz DP,
editor. The changing face of health systems. Jerusalem: Gefen Publishing House; 2002. With per-
mission from Gefen Publishing.
© The Author(s), under exclusive license to Springer Nature 1

Switzerland AG 2023
J. Benbassat, Teaching Professional Attitudes and Basic Clinical Skills to
Medical Students, https://doi.org/10.1007/978-3-031-26542-6_1
2 1 Paradigmatic Shifts in the Theory, Practice, and Teaching of Medicine Since the 1970s
Table 1.1 Summary of the changes in the theory and practice of medicine since the 1970s
From To
Doctor–patient relations
Doctors’ paternalism Respect for patient autonomy
Disclosure of information at the doctors’ Patients are entitled to receive information and be
discretion involved in decisions about their management
No patient access to their medical records Patients encouraged to see their medical records
Disease-orientation Patient-orientation
Patients as passive recipients of care Patients as partners in self-care
Clinical reasoning
Denial of clinical uncertainty Acceptance of clinical uncertainty
Intuitive decision-making Analytic decision-making
Decisions based on unsystematic Evidence-based reasoning
experience and pathophysiologic rationale
Biomedical model of clinical practice Bio-psycho-social model of clinical practice
Doctor–society relations
Unrestricted use of resources Parsimonious use of resources
Loyalty to the patient at hand Loyalty to all patients
Solo practice Managed care
High doctors’ prestige A decline in doctors’ prestige
Accountability to peers Accountability to lay institutions
Doctors only rarely sued for errors Litigation of institutions and doctors
Medical Education
Knowledge of subject matter Ability to retrieve information and apply it in
real-time
Teaching by lectures Self-directed learning: reading assignments, use of
electronic databases, and learning software
Unsystematic acquisition of skills by Systematic acquisition of skills by supervised
imitating role models practice and simulations
Patient interviewing considered an Structured instruction for patient interviewing
elementary skill that does not need
instruction
A belief that clinical decision-making is Demystification of the “art of medicine.” Teaching
subject to “intuition” or the “art of clinical reasoning, Bayesian inference from
medicine” diagnostic tests, and evidence-based medicine
Medical errors deemed exceptional, Awareness of the ubiquity of medical errors, and
attributed to “bad apples,” and discussed in efforts to reduce them by adhering to quality
closed medical conferences assurance of care and patient safety
Orientation to biomedicine Inclusion of the social and behavioral sciences into
teaching programs
In-hospital clinical training Clinical training in community medical settings
Encouraging competition among students Emphasis on teamwork and group assignments
Accountability of teaching to the faculty Accreditation and re-accreditation of the medical
governance school by external reviews
1.2 Doctor–Patient Relations 3
found that 90% of U.S. physicians reported they did not tell the truth to patients with
malignancies [1]. Medical students frequently observed physicians telling patients
with malignancies that they had inflammation and witnessed clinical experiments
performed without the patient’s consent. I am aware that while deception can be
excused as a misguided attempt to protect patients, there is no justification for
experimenting on people without their consent. Nevertheless, both examples reflect
the belief that physicians knew better.
This belief had dominated medical practice for more than 2000 years. Hippocrates
advocated “hiding most things from the patient ... [and] to reveal nothing about the
patient’s future or present condition” [2]. Oliver Wendell Holmes was quoted in his
graduation speech at medical school in 1871 as saying, “Your patient has no more
right to the whole truth you know than he has to all the medicines in your hand-
bag....” [3]. However, since the 1970s, respect for patient autonomy has become part
of the ethical doctrine of clinical practice, and today the recommended model of
clinical practice involves both physicians and patients in clinical decision-making.
The change in physician–patient relations since the 1970s occurred on several
levels. On a conceptual level, the medical code of ethics added “respect the patient’s
autonomy” to the already existing “do no harm” and “do good.” At the legal level,
society recognized the right of patients to participate in decisions about their treat-
ment, and many countries legislated for informed patient consent for medical inter-
ventions. On a practical level, the change promoted a counseling style of shared
decision-making, in which patients share their wishes and knowledge about their
problems, while physicians explain possible courses of action. In the past, patients
were not allowed to review their medical records. Today, patients are not only
encouraged to view their records but they are also allowed to enter their notes [4].
At the research level, doctor–patient relationships became a legitimate topic for
study in the behavioral, social, and medical sciences. Finally, since the 1970s, com-
munication with patients became an important component of undergraduate medi-
cal education, which will be discussed in more detail in Sect. 2.
I am not sure what led to this change. Possible causes could be the introduction
of treatment methods that require patient cooperation; surveys indicating that most
patients want to be informed about their illness; or the general feeling that doctors’
paternalism, however well-intentioned, creates dependency, which is at odds with
today’s focus on respect for the dignity of the individual. Whatever the cause, the
change caused physicians to consider not only what patients needed, but also what
they wanted. The disease orientation in the 1950s changed to a patient orientation.
This orientation led to the realization that patients and physicians often disagree
on the choice of alternative treatments. In the 1950s, the goal of treatment was to
prolong the patient’s life. Today, physicians consider patients’ wishes regarding the
quality of life, even if they reduce the chances of survival. In the 1950s, doctors
believed patients were too fearful to trust them to take their blood pressure. Today, by
contrast, patients with diabetes are taught how to adjust their insulin treatment to their
self-measured blood glucose levels, and patients with bronchial asthma are taught to
adjust their corticosteroid medication to their self-tested lung function. From a pas-
sive recipient of treatment, the patient became a partner in self-treatment.
1.3 Clinical Reasoning (See Also Chap. 5)
Throughout history, clinical thinking has turned to theoretical models to understand

disease, derive treatments, and gain further knowledge. As long as these models
satisfy clinical needs and are consistent with experience, they are used to guide
practice. Modification of the model occurs only when it can no longer accommodate
new data [5]. In other words, theory informs practice, and feedback from practice
modifies theoretical constructs. Observed inconsistencies between theory and expe-
rience should not be viewed as a source of confusion, but rather as an opportunity
for investigation.
Hippocrates’ humoral model dominated medical thinking for about two millen-
nia. It assumed the existence of four humors and viewed disease as an imbalance
between them due to heredity, diet, lifestyle, or weather. Treatment was an attempt
to restore stability through bloodletting, purgatives, and emetics, and these mea-
sures were the standards of treatment until the nineteenth century. However, the
humoral model could not accommodate the discoveries of infectious pathogens and
vitamin deficiencies. This led to the emergence of the biomedical model, which now
governs medical education, clinical practice, and research.
Like the humoral model, the biomedical model is based on causal reasoning that
leads from disorders of the organism, conceived as causes, to manifestations of the
disease, conceived as effects. However, the models differ in the way they define the
causes of disease: The biomedical model describes disease manifestations as result-
ing from observable structural or biochemical disturbances rather than imbalances
between hypothetical bodily fluids.
The biomedical model assumes that all diseases can be described as biochemical
or structural disorders, that every disease has a single (“etiological”) cause, and that
treatment is an attempt to eliminate that cause by pharmacological or physical (sur-
gical, radiological) means. This model must certainly be credited for the unprece-
dented advances in patient care during the twentieth century. Since the 1960s,
however, its premises seem to be incompatible with some clinical observations. This
has led to several changes in clinical reasoning, notably a shift from denial to accep-
tance of uncertainty, from intuitive to analytic decision-making, and from the bio-
medical to the bio-psycho-social model of clinical practice,
1.3.1 From Denial to Acceptance of Uncertainty
The biomedical model assumes that etiological factors inevitably lead to disease.
Within this model, chance and uncertainty play a very minor role. In the 1950s,
physicians downplayed concepts such as probability and inference from epidemio-
logical data. The conventional wisdom was that epidemiology deals with popula-
tions and, as such, is incompatible with clinical medicine, which deals with
individuals. The 1965 edition of DeGowin’s Introduction to Clinical Medicine
1.3 Clinical Reasoning 5
stated that “... statistical methods can only be applied to a population of thousands
... [T]he relative incidence of two diseases is completely irrelevant to ... diagnosis.
A patient either has or has not a disease” [6].
My tutors also rejected the use of statistical inference in clinical practice, saying,
“No one is 70% pregnant” and “Each patient is unique; I learn more from a single
case than from epidemiologic studies of a thousand patients.” The deterministic
reasoning of the biomedical model also downplayed the concept of uncertainty. I
was taught that “nothing is left to chance if the patient is worked up properly.” As
late as the 1980s, it was claimed that students were encouraged to ignore uncer-
tainty rather than deal with it [7]; a 1992 review of the sociological literature con-
cluded that denial of uncertainty was one of the most consistent observations of
sociologists studying medical education [8]; and as recently as 2021, tolerance of
ambiguity was found to decrease during undergraduate medical education [9].
The first indications that this deterministic approach might be inadequate were
observations that conditions, like diabetes and smoking, increased the risk of isch-
emic heart disease, although they were not etiologic agents of atheromatosis. These
observations suggested that disease was not the result of a single cause, but rather of
a convergence of risk factors. Today, we speak of risk indicators rather than etio-
logic causes; a patient is more or less likely to have a disease, rather than either have
it or not. Subsequent editions of DeGowin’s Diagnostic Examination endorsed the
application of statistics to individual patients, and the 2020 edition states that
“knowledge, understanding of clinical epidemiology, and experience are necessary
to determine when the pursuit of specific symptoms and signs is warranted” [10].
There was a shift in physicians’ attitudes toward diagnostic testing. In the 1950s,
teaching emphasized the importance of thoroughly taking a patient’s history and
physical and other data. Physicians believed that the more data collected, the greater
the chances of a correct diagnosis and that early detection of disease always
increased the chances of cure. Therefore, students were required to perform a thor-
ough review of systems and a head-to-toe physical examination. Today, we know
that false-positive test results can complicate diagnosis. Therefore, we are selective
in our choice of diagnostic tests and in screening asymptomatic individuals for early
disease. Paradoxically, the increase in biomedical knowledge increased awareness
of its limitations and led to a transition from right/wrong determinism to acceptance
of chance and uncertainty in clinical practice.
1.3.2 From Intuitive to Analytic Decision-Making
Webster defines “intuition” as a perception that is independent of reasoning. A judg-

ment is said to be intuitive if it is made quickly and without apparent effort. In medi-
cine, the term “intuition” has acquired several meanings. The first equates intuition
with the ability to recognize patterns of disease manifestations. The second meaning
of intuition refers to judgments that result from simplifying heuristics (mental short-
cuts). Finally, the term intuition is used to refer to mastery of the “art of medicine,”
that is, a mystical ability to make clinical decisions that defy analysis or explana-
tion. To avoid confusion, I use the terms “pattern recognition” to refer to the ability
to recognize patterns of disease manifestations, “heuristics” to refer to cognitive
shortcuts, and “intuitive thinking” or “art of medicine” to refer to the ability to make
quick decisions that defy explanation.
In the 1950s, intuitive thinking was characterized by confidence in its accuracy.
Statements by experienced physicians beginning with “in my judgment” signified the
conclusion of a clinical debate. Such authoritarian attitudes are difficult to understand
in today’s climate of evidence-based practice. To understand physicians’ belief in the
“art of medicine,” one must consider its strengths. First, the belief that there is absolute
truth is extremely alluring in the indeterminate realm of clinical practice. Conformity
to authority has been identified as a means by which medical students and residents
control the anxiety caused by the complexity of clinical practice [11]. Second, intuitive
thinking satisfied clinical needs. In the 1950s, physicians were unaware that anything
was wrong with clinical decision-making or that it needed improvement.
Today, however, clinical decision-making has become more complicated. The
number of diagnostic and therapeutic options has increased, and choosing among
them is no longer easy, even for experienced clinicians. Clinicians must weigh the
benefits of interventions against their risks: the risk of false-positive or false-negative
diagnostic test results and the risk of adverse side effects from treatment. Healthcare
spending has increased, and this necessitates considering the trade-off between cost
and effectiveness. In today’s reality of unlimited demand and finite resources, eco-
nomic evaluation is increasingly being used to inform healthcare decisions.
Finally, physicians must weigh conflicting values. The medical code of ethics
has expanded to include not only the principles of nonmaleficence (“do not harm”)
and beneficence (“do good”) but also “respect for patient autonomy” and justice
(fair distribution of health care resources to those who need them). Thus, physicians
today are much more frequently confronted with ethical dilemmas, i.e., they find
themselves in situations in which they cannot adhere to one ethical principle with-
out violating another.
These trade-offs can no longer be resolved by intuitive reasoning: First, the claim
that the “art of medicine” defies explanation is no longer acceptable when patients,
students, colleagues, and courts ask us to justify our decisions. Second, judgments
based on simplifying heuristics can be distorted by cognitive biases. Therefore,
since the 1970s, there have been ongoing efforts to gain insight into the reasoning
of clinical experts and to base clinical decision-making on a critical assessment of
risks and benefits.
1.3.3 From Pathophysiologic Rationale

to Evidence-Based Reasoning
Another assumption of the biomedical model was that patient care should be derived
from the etiology and pathophysiology of the disease. In the 1950s, the treatment of
patients with left ventricular failure was justified by the positive inotropic effect of
1.4 Doctor–Society Relations 7
digitalis on the myocardium. Treating patients with peptic ulcers with aluminum
salts was derived from their acid-inhibiting effect. Today, however, physicians are
aware that pathophysiologic rationale does not always lead to the expected results.
Consequently, there is a growing tendency to base clinical practice on empirical
evidence, and in 1992, Guyatt et al. coined the term “evidence-based medicine”
(EBM) [12].
Unlike the traditional paradigm, EBM posits that intuition, nonsystematic expe-
rience, and pathophysiologic rationale are insufficient for clinical decision-making.
EBM places less value on authority and emphasizes the value of evidence from
clinical research. We have moved from deductive reasoning to evidence-based rea-
soning: Treatment of heart failure with digitalis and treatment of peptic ulcer with
antacids are justified not by expected physiological effects but by evidence from
clinical trials.
1.3.4 From the Biomedical to the Bio-psycho-social Model

of Clinical Practice (See Also Chap. 6)
The main flaw of the biomedical model was the assumption that all diseases were
structural or biochemical dysfunctions of the body that could only be treated by
surgical or pharmacological means. This assumption excluded the characteristics of
the patient as a person. There were indeed attempts as early as the 1930s to associate
personality types with diseases such as peptic ulcer or bronchial asthma. However,
these attempts were mostly based on anecdotal observations. In the 1950s, the pre-
vailing attitude toward psychosomatic medicine was one of distrust.
This attitude changed when it was demonstrated that there was a relationship
between life events and morbidity and between socioeconomic status (income, edu-
cation, and housing) and mortality. These findings led to the recognition that some
risk indicators for disease could be described as psychosocial and to the adoption of
Engel’s bio-psycho-social model for clinical reasoning and practice [13]. This
model encourages clinicians to consider the biomedical and psychosocial compo-
nents of a patient’s predicament and to support and treat both.
1.4 Doctor–Society Relations (See Also Chap. 8)
Medical care today offers more effective clinical interventions than ever before. Yet
it appears that the privileged status of the medical profession in the twentieth cen-
tury has declined with an erosion of trust in medical care. This erosion is cause for
concern. Distrust promotes litigation and defensive medicine, forcing the healthcare
system to divert some of its resources from treatment to self-protection. One of the
current challenges is to define the boundary between constructive criticism of health
care and destructive distrust.
The erosion of trust in the medical profession has been associated with several
shifts in clinical practice, namely from accountability to colleagues to accountabil-
ity to lay institutions, from unrestricted to controlled use of resources, and from a
lone practitioner to a member of a healthcare team.
1.4.1 From Accountability to Peers to Accountability

to Laymen and Lay Institutions
In the 1950s, medical errors were thought to be rare and caused by a minority of
negligent physicians (“bad apples”). The topic was rarely discussed, and when it
was, errors were dealt with in closed sessions. Since the 1970s, however, there has
been a rising tide of medical negligence litigation, and physicians are being held
accountable not only to their colleagues but also to lay institutions. The high fre-
quency of errors [14] led to the realization that all physicians can make mistakes,
and like other professions, medicine began to implement quality control methods.
Quality control is based on the recognition that the threat of punitive action does
not deter errors. Therefore, the question of “who made the mistake?” is replaced by
an effort to determine “why the mistake occurred?” Rather than eliminating poor
performers, the goal is to make health care as error-free as possible [15]. To find out
why the error occurred, physicians must report any error, whether or not it harmed
a patient or even any circumstance in the clinical setting that may lead to errors. A
policy of transparency can be effective not only for quality control but also to
improve the doctor–patient relationship and even reduce litigation costs [16].
1.4.2 From an Unrestricted to a Parsimonious Use

of Resources
In the 1950s, a call to reduce healthcare costs would have been viewed as a denial
of the sanctity of human life. However, later, the escalating healthcare costs imposed
a controlled distribution of resources and today calls for parsimony are no longer
rejected as unethical. Accordingly, the code of medical ethics was expanded to
accommodate the requirement of distributive justice.
All too often, distributive justice is perceived as a novel requirement for doctors to
split their loyalty between their patients and their employers. Yet, although it was
introduced into the ethical code only in the 1970s, this principle has always guided
clinical practice. Doctors have always attempted to distribute their time between
patients fairly, according to their needs; the choice of antibiotic therapy has always
been guided not only by the needs of the patient at hand but also by the objective of
reducing the generation of resistant strains of bacteria, which may harm other patients.
A parsimonious use of resources does not demand that doctors split their loyalty
between patient and employer, but between the patient at hand and other patients.
1.5 Medical Education 9
1.4.3 From a Lone Professional to a Member

of a Healthcare Team
In the 1950s, medical care was provided in a one-patient–one doctor setting and
medical administrators rarely interfered with clinical decisions. In the 1970s, the
rising cost of health care led to a transition from a solo practice to what we call
today managed care. Initially, its objective was cost containment. But later it evolved
into a complex bureaucracy in which physicians are no longer the sole decision-
makers. They must listen to consultants and other care providers on the team; they
must consider patient preferences, and they must function within the confines of the
policy of their institution. Managed care is viewed by many as a bureaucracy, with
all of its negative connotations.
1.4.4 Change in the Public’s Trust in Health Services
Patients place their trust in institutions (social trust) and doctors (personal trust)
[17]. Trust in institutions is mainly determined by the media and prevailing informal
opinions. Personal trust is largely determined by the physician’s interpersonal skills,
his or her concern for the patient’s welfare, his or her empathy, and the extent to
which the physician lives up to the expectation of standing by the patient’s side and
representing and protecting his or her interests vis-à-vis health insurance compa-
nies. Patients give high priority to the belief that the physician is committed to
safeguarding their interests. While appearing to understand the limitations of
resource utilization, they expect full disclosure of what they need and what they are
entitled to from their health insurance [18].
1.5 Medical Education (See Also Chap. 9)
The claim that medical schools are resisting change is only partially justified. Since
the 1950s, many medical schools have adopted problem-based learning, student
exposure to patients from the beginning of medical school, and the objective struc-
tured clinical examination (OSCE). Teaching emphasizes information retrieval
skills, the use of simulations, clinical reasoning, and behavioral and social sciences.
The expansion of medical knowledge and biotechnology has led to a shift from an
emphasis on memorization to the ability to self-directed learning and retrieve infor-
mation in real-time from data stores. Unsystematic learning of clinical skills has
evolved toward supervised patient interviewing, resuscitation, clinical reasoning,
and the ability to collaborate with others. Finally, some medical schools have
replaced rotating clerkships in hospital departments with integrated clerkships that
provide 6–12 months of training in a single general practice setting.
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Chapter 2
Communicating with Patients
2.1 Introduction
My first encounter with a patient made me doubt whether I had chosen the right
profession. It happened during the preclinical physical examination course in the
fourth of my medical school’s 6-year program. I introduced myself, asked my first
question, and dried off. The patient was a friendly lady of about 50 years. When she
noticed my embarrassment, she tried to fill in the void by asking about me. I suspect
that by the end of the encounter she knew more about me than I knew about her.
The recognition that students need help learning how to communicate with
patients is a recent development in medical education. Although history taking has
always been considered essential to clinical practice, it took a long time for patient
interviewing to be incorporated into undergraduate medical education. As late as the
1960s, talking to patients was considered a simple endeavor that did not merit instruc-
tion. The 1957 edition of Kampmeier’s textbook on physical examination devoted 3
pages to interviewing patients, 14 pages to recording the history, and 700 pages to
physical examination [1]. My only preparation for the first encounter with a patient
consisted of a single lecture on the content and structure of the record of the patient’s
history. During my clinical rotations, my tutors strove to improve my presentations of
the patient history, but like many in my generation, I completed my training without
ever having interviewed patients under the supervision of an experienced physician.
This attitude changed in 1969 when Morgan and Engel [2] argued that interview-
ing patients was a neglected skill. Since then, all medical schools offer programs
aimed at teaching a communication style that promotes patient-centered care. I use
the phrase “communication style” as an all-inclusive term for interviewing tech-
niques (open vs. closed questions), focus (patient vs. illness), habits (active listen-
ing), and implicit values (caring, empathy, and respect). “Patient-centered care” is
an orientation to the patient’s needs rather than the physician’s agenda. It moves
from professional control to patient empowerment. In addition to data collection, its

Switzerland AG 2023
12 2 Communicating with Patients
goals include building relationships and negotiating management decisions that

promote the patient’s health while showing respect for the patient.
Patient-centered care has been associated with patient satisfaction and self-
management [3]. Clinician behaviors associated with desirable health outcomes
include empathy, reassurance, support, explanations, humor, sharing information,
summarizing and clarifying, head nodding, leaning forward, direct body alignment,
and uncrossed legs and arms [4]. A 2017 review of the literature found that physi-
cian–patient relationships in general and patient education are associated with better
health outcomes and reduced healthcare costs [5]. After viewing recorded medical
encounters, lay observers commented positively on physicians’ affective communi-
cation, competence, and confidence and criticized contrary behavior and repetition.
No other communication style elicited positive or negative assessments thereby
challenging the idea of general communication guidelines and suggesting that com-
munication approaches should be customized to the individual patient [6].
Patient-centered communication skills are teachable. Teaching improves stu-
dents’ data collection skills [7], ability to ask fewer closed questions, and provide
more empathetic responses [8]. However, as recently as the 2000s, surveys showed
difficulties in learning to communicate with patients [9], and a 2010 review of the
literature found that medical students’ communication skills deteriorate as they
progress through medical school [10].
Moreover, evidence suggests that physicians’ self-perceptions of their communi-
cation skills do not match their patients’ perceptions. In other words, physicians and
patients may agree on core competencies related to physicians’ communication
skills, but they may disagree on the actual presence of these skills. Patients’ assess-
ments of physicians’ communication skills differ from experts’ assessments, and
both patients’ assessments and experts’ assessments of physicians’ communication
skills differ from other physicians’ assessments [11]. The objective of this section is
to identify some of the problems in learning how to talk with patients.
2.2 Learning How to Talk with Patients1
At both medical schools where I served, students rated the preclinical patient inter-
viewing teaching programs very positively, probably because they were excited
about meeting patients for the first time. However, during the programs and
1
Previous versions of parts of this chapter were published in:
Benbassat J, Baumal R. Teaching doctor patient interviewing skills using an integrated learner
and teacher-centered approach. Am J Med Sci. 2001;322:349–57. With permission from Elsevier.
Baumal R, Benbassat J. Current trends in the educational approach for teaching interviewing
skills to medical students. Isr Med Ass J. 2008;10:552–5. With permission from the Israel Medical
Association.
Benbassat J, Baumal R. A proposal for overcoming problems in teaching interviewing skills
to medical students. Adv Health Sci Educ. 2009;14:441–50. With permission from Springer.
2.2 Learning How to Talk with Patients 13
subsequent clerkships, students also made some comments that reflected their dif-
ficulties (Table 2.1).
The most common difficulty was dealing with a patient’s expressions of emo-
tion. While demonstrating an interview, I asked a real patient, “Can you tell me
more about your family?” In response, the patient described his children and cried
while telling us about his deceased wife. After the interview, one student com-
mented, “You should have changed the subject when the patient started crying,”
reflecting a common student’s tendency to avoid emotional topics. Other authors
have similarly reported that medical students felt uncomfortable dealing with emo-
tional topics [9] and recommended that education should focus on the emotional
aspects of patient interactions and support students during initial clinical encoun-
ters [13].
A second comment reflected the mixed messages students received from their
tutors. Preclinical students were taught to ask open-ended questions (“Tell me
about your pain”) and to listen without interrupting the patient’s narrative. However,
during their clerkships, they encountered physicians who frequently interrupted
Table 2.1 Summary of students’ learning difficulties encountered in programs of interviewing

skills at two medical schools in 1993–1995 (adapted from [12] with permission by Elsevier)
Students’ comments Students’ difficulty Source of difficulty Proposed solution
“You should have Tolerate A fear of upsetting the Reassure that an
changed the subject expressions of patient and getting involved exploration of a
when the patient patients’ emotions patient’s feelings is
started weeping” legitimate
“What we learn in Reconcile Differences between Discuss the strengths
the course on inconsistencies interviewing styles that and weaknesses of
interviewing skills is between theory and were taught and those that various interviewing
not what real practice were observed styles
medicine is about”
“I felt embarrassed Accept guidelines A tendency to “force-feed” Challenge students to
to be lectured on students through lecture identify problems,
how to talk to other courses devise solutions,
people” reflect on, and analyze
patients’ complaints
“There are so many Understand A feeling of being Empower students to
rules to remember. I multiple and overwhelmed by rules. Fear formulate
am afraid of making ambiguous of appearing foolish interviewing rules and
mistakes” interviewing rules to choose between
interviewing styles
“Only now do I Follow verbal Over-reliance on verbal Demonstrate
understand what you instructions and explanations; absence of interviewing skills
meant by .... ” feedback live demonstrations
“I feel that we have Appreciate the Lack of a coordinated Gradually expose
had enough importance of course structure. Absence of students to patients
interviewing repeated practice a feeling of progress in the who are difficult to
practice” sessions ability to deal with interview
problems of increasing
complexity
their patients with closed-ended questions (“Did the pain radiate down your arm?”).
The students’ difficulty reconciling these contradictions fueled the feeling that
“what we learn about interviewing skills in the course is not what real medicine
is about.”
Third, students acquire the ability to communicate before they begin their medi-
cal studies, and they bring to class the habits that are believed to make a civilized
person. Consequently, at least some students felt uncomfortable and even offended
when asked to show what appeared to them to be elementary courtesy, such as
greeting a patient. This led to comments such as, “I was embarrassed to be lectured
about how to talk to people.” Students also seemed unwilling to adopt interviewing
guidelines that were inconsistent with their entrenched attitudes. Examples of
“counterintuitive” guidelines included asking patients to sustain their narratives
rather than interrupting them with closed-ended questions, and waiting for a second
or two after a patient stopped talking rather than immediately asking the next
question.
Fourth, students seemed overwhelmed by the large number of interview rules
and systems review items that they had received in lectures and handouts (“There
are so many rules to remember”). In many cases, these rules seemed contradictory
to them and gave the impression that patient-centered interviewing was bound by
guidelines. Their difficulties may have been compounded by the lack of appropriate
vocabulary to understand the rules. For example, some tutors defined “physician
control of the interview” as an effort to prevent patient digressions, whereas for oth-
ers it was an attempt to maintain the patient’s narrative. Students’ difficulties in
understanding the guidelines may have contributed to their fears of looking foolish
during supervised patient interviews.
Fifth, students repeatedly commented, “Only now do I understand what you
meant by ...” after they had seen me demonstrate an interview with a real patient.
This comment underscored the difficulty students had in receiving only verbal guid-
ance or feedback after communicating with patients. Like any other skill, interview-
ing patients required demonstration: showing students what to do rather than just
telling them what to do. The lack of live demonstrations in the teaching programs
may have been due to the belief that verbal explanations to students and viewing a
recorded interview by a respected clinician were sufficient. It may also have been
because there were not enough tutors who felt confident in demonstrating interview
techniques. Although clinicians had the necessary experience, they were rarely
familiar with patient-centered techniques. Conversely, social scientists were famil-
iar with the literature on patient-centered care but lacked the experience and confi-
dence to interview patients.
Finally, some students complained about the repetitive nature of their practice
interviews, in which they had to elicit the same information from different patients
(“I feel like we have had enough practice interviewing”). Although their tutors dis-
missed this complaint (“No two patients are alike,” “Practice makes perfect”), this
highlighted a major weakness of the program: the lack of structure. Consequently,
it failed to create a sense among students that they were making progress in their
ability to deal with increasingly complex problems.
2.3 Teaching How to Talk to Patients 15
2.3 Teaching How to Talk to Patients
Medical education has a 1000-year tradition of teaching anatomy, 300 years of

teaching physiology, but only 50 years of teaching communication skills. There is
no gold standard for effective doctor–patient communication, and we do not yet
know what the optimal teaching approach is. This has led to the current difficulties
in teaching patient interviewing (Table 2.2) and a variety of educational programs.
I believe that the teaching of communication skills should take into account the
differences between the acquisition of interviewing and other clinical skills. First,
unlike other skills, such as physical examination, students already have well-formed
habits, values, and preconceived notions about interpersonal communication, so
they may resist attempts to preach to them how to behave. This is true even when the
“preaching” is consistent with their views; it is even more true for attempts to
impose anti-intuitive communication rules on them. For example, the natural ten-
dency of each of us is to run away from emotions and prevent patients from express-
ing them; the communication guide teaches otherwise. The natural tendency of each
Table 2.2 Summary of teaching difficulties encountered in programs of interviewing skills at two
medical schools in 1993–1995 (adapted from [12] with permission by Elsevier)
Problem Students’ difficulty Source of difficulty Proposed solution
Students’ Students may resist Students have Avoid lecturing. Discuss
disagreement with attempts to teach well-formed habits and problems and let students
interviewing rules them how to behave preconceived ideas devise solutions
presented in about interpersonal
lectures skills
Inconsistency Students may reject Students encounter Present disease and
between disease- behaviors that are role models with patient-centered
centered and incompatible with the varying approaches to interviewing as
patient-centered hidden curriculum of interviewing legitimate. Discuss their
interviewing the clinical rotations strengths and weaknesses
approaches and let students choose
among them
Assessment of Students’ insecurity Absence of a gold Replace the summative
students’ regarding what they standard for patient assessment of students’
interviewing skills are expected to learn interviewing. Some interviewing skills with
methods of assessment repeated, one on one,
may reinforce formative discussions of
undesirable behaviors the observed student’s
performance
Students’ positive None Students’ enthusiasm Focus on students’
feedback breeds for their first meeting critical comments even if
unjustified with patients they reflect the views of a
complacency minority
among teachers
Who should teach Inconsistency Inconsistency between Appropriate training of
patient between disease and role modeling clinical tutors by
interviewing? patient-centered behaviors teaching workshops
interviewing
of us is to interrupt a patient complaining of abdominal pain by asking, “Did you

vomit, too?”; the guide teaches us to wait and ask the questions only at the end of
the interview.
Thus, unlike other clinical skills, interviewing patients may require a change in
students’ preconceived habits. Such “reconditioning” is more intellectually demand-
ing than learning new topics [14]. Students may not respond to authoritarian teach-
ing or written handouts for interviewing. They may be bored with “shoulds” that
they take for granted (e.g., respect for patients); they may reject “shouldn’ts” that
contradict their natural tendencies (e.g., encouraging patients’ emotional expres-
sions); they may resist attempts to impose certain habits on them (e.g., avoiding
“why” questions). In some cases, students may even have difficulty understanding
interviewing rules taught outside the clinical context.
Second, students are often perplexed by the contradiction between the patient-
centered style taught in preclinical patient interviewing programs and the mes-
sages they receive during clerkships. Students and faculty were reported as
claiming that preclinical and clinical communication skills curricula were not
aligned and that teaching these skills in the wards was rarely explicit and depen-
dent on role models [15]. This theory-practice gap was puzzling at best and led to
cynicism at worst.
Communication skills tend to decline over time if not regularly practiced [16].
Yet most medical schools offer communication training only during the preclinical
years. All too often, clinical tutors have a negative attitude toward communication
training and are poor role models. To optimize communication skills learning in
practice, it has been proposed to change the work climate to value, support, and
reward communication skills teaching and train clinical tutors from all clinical spe-
cialties to teach communication skills [17].
Third, several authors have questioned the appropriateness of methods used to
assess students’ interviewing skills. These methods consist of observing trainees
interviewing standardized or real patients, either during an entire patient interview
or during an objective structured clinical examination (OSCE). Observed perfor-
mance is assessed using checklists or global assessments. However, current evi-
dence suggests significant deficits in faculty direct observation skills [18]. The use
of checklists during OSCE has been reported to be well accepted and leads to a
change in resident culture [19]. However, the use of checklists during OSCE may be
misinterpreted by students as suggesting that they should ask as many disease-
related questions as possible to obtain checks, thereby reinforcing a disease-oriented
approach to the interview [20]. Finally, students respond positively to any interview
skills teaching program because they are eager to meet real patients for the first
time. Their positive feedback leads to unwarranted complacency among teachers,
and they tend to ignore criticism.
One could argue that these problems are not unique to teaching patient inter-
viewing. Physicians differ not only in communication style but also in the per-
formance of other clinical skills; students may have biases not only about
2.3 Teaching How to Talk to Patients 17
interviewing but also about other skills; difficulties in assessing students are not
limited to interviewing patients. Nevertheless, these problems seem to be par-
ticularly pronounced when teaching interviewing. Students have far more pre-
conceptions about interviewing than other skills. I know of no other clinical
skill that is practiced so differently by different clinicians as patient interview-
ing and no other clinical skill whose assessment can reinforce undesirable
behaviors.
Communication with patients is a clinical skill, and it is only natural that tutors
should be clinicians. The advantage of clinicians is their credibility and experience;
their disadvantage is that they are not familiar with current knowledge on teaching
interviewing. Most clinical instructors consider their personal experience sufficient
to teach communication with patients without being familiar with alternative inter-
viewing methods and the advantages and disadvantages of using them. The alterna-
tive to clinical instructors is behavioral scientists. Their advantage is knowledge of
the theoretical background; their disadvantage is a lack of personal experience and
credibility.
So, who should instruct students in communication? Clinicians with no theoreti-
cal background or sociologists with no experience? I believe that neither of these
options is acceptable and that clinical tutors should have additional training in facil-
itating small group learning [21] and patient interviewing [22]. The goals of such
faculty development programs would be to make patient-centered care a dominant
competency in all healthcare interactions and relationship-centered communication
skills [23].
The tutor would provide students with relevant data, demonstrate relevant
skills, and supervise them as they practice these skills with real, simulated, or
standardized patients. Tutors should be sufficiently confident in their abilities to
demonstrate live interviews with real patients to small groups of students
because such demonstrations seem to attract more attention than recorded or
standardized physician–patient encounters, which often seem to lack credibility
[12, 18]. Since demonstrations are likely to be followed by students’ questions
and comments, tutors should be able to discuss their performance with students
after the interviews and tolerate possible criticism without giving defensive
responses that might unnecessarily turn a productive discourse into a win/lose
conflict.
Tutors would also help students overcome their initial shyness, inhibitions, and
natural reluctance to invade the privacy of others, understand the importance of the
interview for identifying the patient’s problems, and teach students appropriate pro-
fessional behavior. Tutors would respect students’ autonomy, encourage them to
build on their own prior experiences, and avoid an authoritarian approach. Respect
for student autonomy appears to enhance their motivation and psychological well-
being [24]. Tables 2.1 and 2.2 summarize the difficulties in learning and teaching
patient talk and suggest ways to overcome them.
2.4 Coping with Barriers to Learning and Teaching

Patient Interviewing2
2.4.1 Learning Objectives and General Approaches

to Achieving Them
In 2013, a panel of communication experts from 16 European countries agreed on

61 core communication objectives that they considered relevant for the education of
health professionals [25]. Table 2.3 lists the objectives that I consider particularly
important.
Pedagogical approaches can be viewed as a continuum between “teacher-
centered” and “learner-centered” and combinations of the two in between [26].
The teacher-centered (didactic) approach assigns the teacher the role of defining
the learning objectives and teaching methods. Students are recipients of knowl-
edge, usually imparted through lectures, and skills, which are taught by exposure
to role models. On the other extreme, learner-centered programs are characterized
by students having the freedom and responsibility to direct their learning. This
Table 2.3 Learning objectives of patient interviewing. The student will …

Identify and cope with environmental barriers to doctor–patient communication (noise, time
constraints, need for an interpreter)
Attempt to establish a trusting doctor–patient relationship, relieve the patient’s anxiety, and
collect data that would guide the physical examination and ancillary testing
Listen to the patient without stopping him for about 2 min. Restrain the natural urge to stop the
patient by asking clarifying questions before he/she has finished describing the reason for his/
her visit to the doctor
Conduct a patient-centered interview using techniques such as active listening, open questions,
clear transitions from one subject to another, verbal and nonverbal expressions of empathy,
respect for the patient, and formulation of at least one summary of the patient’s main problems.
Demonstrate respect by tilting the body forward and making eye contact
Elicit information about the patient’s concerns, the perspective of his/her illness, and
expectations for receiving health-related information
Summarize the patient’s complaints at the end of the interview and correct misunderstandings.
Prevent the feeling of the patient that “the doctor did not address my complaints”
Ask the patient at least once at the end of the session “Is there anything else you would like to
know or tell me?” “Of all the things you told me, what worries you the most?” “It is very
important for me to know, what you think caused your illness and what you think we should
do.”
2
Parts of this sections were published in:
Benbassat J, Baumal R. A proposal for overcoming problems in teaching interviewing skills
to medical students. Adv Health Sci Educ. 2009;14:441–50. With permission from Springer.
Baumal R, Benbassat J. Current trends in the educational approach for teaching interviewing
skills to medical students. IMAJ. 2008;10:552–5. With permission from the Israel Medical
Association.
2.4 Coping with Barriers to Learning and Teaching Patient Interviewing 19
approach casts the tutor as a facilitator of learning whose role is not to teach but to
ensure that all students participate in discussions and share their knowledge with
the other students in the group. Strictly learner-centered programs assume that
tutors do not need content knowledge as long as they are skilled in tutoring stu-
dents, and even if they have such knowledge, they should not pass it on to stu-
dents [27].
Neither approach seems to be appropriate for teaching patient interviewing.
On the one hand, students have been reported to be uncomfortable with a
teacher-centered approach to patient interviewing [28]. On the other hand, it
would be unreasonable to require students to discover patient interviewing skills
on their own, without professional guidance, using a strictly learner-centered
approach. It appears that teaching patient interviewing requires an integrated
learner-centered and teacher-centered approach, also referred to as case-based
learning [29].
2.4.2 The Integrated Learner- and Teacher-Centered Approach
Like the teacher-centered strategy, the integrated approach is guided by specific

learning objectives. A tutor seeks to achieve these objectives by communicating
information to students, demonstrating appropriate skills, and supervising students
as they practice those skills. As with the learner-centered strategy, the tutor avoids
an authoritarian attitude toward students and encourages them to acquire knowledge
through discussion and self-directed learning. The tutor is expected to facilitate
such discussions, gain insight into the learners’ knowledge of the subject, and help
them build on that knowledge. Unlike the teacher-centered approach, which con-
sists of lectures with minimal student participation, and unlike the learner-centered
approach, which is limited to self-directed learning with minimal tutor intervention,
the integrated approach encourages ongoing dialog between the tutor and students.
In contrast to the strictly learner-centered programs, where tutors are expected only
to facilitate small group discussions, tutors in the integrated approach are expected
to be both proficient in the subject matter and able to foster an open exchange
of ideas.
The integrated approach is consistent with modern theories of adult learning.
Adults are motivated by learning that builds on their prior experiences and requires
them to reflect on their behavior [30]. An integrated approach to teaching is also
consistent with the premises of [26] that adults learn more effectively when, first,
they are self-motivated rather than responding to the demands of others; second,
they are exposed to experiential techniques such as discussion or problem-solving
rather than listening to lectures; third, they are aware of their learning needs as they
arise from real-world problems; and fourth, they are challenged to apply the skills
or knowledge they acquire to their life circumstances.
Evidence suggests that an integrated approach is more effective than a strictly

learner-centered approach. Learners and faculty at two academic medical centers
overwhelmingly preferred case-based (guided) learning to problem-based (open-
ended) learning [29]. Comparative studies of small groups led by tutor-facilitators
without subject matter expertise (i.e., with a strictly learner-centered approach) and
tutors who were both subject matter experts and facilitators (i.e., with an integrated
approach) showed that the latter tended to take a more direct role in tutorials, i.e.,
they spoke more frequently and for longer periods, gave more direct answers to
students’ questions, and suggested more topics for discussion. Students tutored by
subject matter experts were reported to spend more time on self-study and to per-
form better on exams than students tutored by non-expert tutors (see [31] for a
review).
2.4.3 Shifts in Teaching Patient Interviewing
As I stated earlier, patient interviewing was considered a simple task until the
1970s. The “teaching” of interviewing at that time can be regarded as learner-
centered in the sense that medical students were left to their own devices and
most of them graduated without ever having interviewed a patient under the
supervision of an experienced clinician. Since the 1970s, most medical schools
have instituted patient interviewing teaching programs. In the 1980s and 1990s,
many, if not most, of these programs were teacher-centered [32] and ignored
students’ attitudes toward and opinions about patient interviewing [33]. In
many cases, such programs were ineffective: British medical students com-
plained that “they had no conceptual understanding of the purpose of history
taking.” Some of them even stated that the didactic teaching of interviewing
skills during rounds was humiliating and that they would have appreciated a
more egalitarian teaching environment in which their observations would have
been respected [34].
More recently, several authors have described instructional programs that
consist of an ongoing dialog between teachers and learners (see [35] for a
review). Some of these programs have used evidence of current deficiencies in
doctor–patient communication as a point of departure for small group discus-
sions [36]; others have emphasized student autonomy, collaborative learning,
and faculty–learner relationships [37]. Still, other authors have suggested that
teachers focus on communication techniques, while patients seek relationships
characterized by trust, autonomy, caring, and expertise. They have suggested that
research should focus on what patients perceive, want, and need, how their per-
spectives differ from those of clinicians, and, most importantly, their concerns
(Table 2.4) [39].
2.4 Coping with Barriers to Learning and Teaching Patient Interviewing 21
Table 2.4 Sources of patient concerns. Adapted from [38] with permission from Elsevier
Concern Specific reasons
Anxiety about the effect of disease on Social status
Sense of well-being
Ability to function
Lifespan
Failure to share with physician-specific health concerns Feel embarrassed; desire not to seem
(e.g., impotence, depression, fear of cancer) because ungrateful
they Do not trust their doctors
Have trouble communicating
A belief that nothing can be done
Reluctance to burden the doctor
Worry that their fears will be
confirmed
Reluctance to accept recommended treatment because Fear of side effects of medications or
of surgery
Incompatibility with financial
resources, lifestyle, or other
circumstances
Fear of anticipated dependence on
medical care
Disbelief in the effectiveness of the
treatment
Fear of embarrassment from appearing foolish or from Information about disease
offending the physician by asking for: Reading material about their disease
A second medical opinion
Unorthodox treatment from faith
healers, touch therapists, chiropractors
Sick leave
Assistance from various social service
agencies
2.4.4 Assessment of Communication Skills
I propose replacing the formal assessment of students’ communication skills in

OSCE stations with repeated one-on-one discussions between student and examiner
after the latter has observed a student’s encounter with a patient. Such discussions
would promote a deliberative approach to interpersonal communication rather than
a judgmental right-wrong dualism.
In their discussions with students, examiners would not conceal their prefer-
ences regarding the style of interviewing. However, they would emphasize that
there is no gold standard for patient interviewing. They would treat both stu-
dents and physicians who have preferences different from their own with respect
and encourage a reflective assessment of the strengths and weaknesses of the
various communication styles. The principal role of the examiner would be to
create a supportive environment that encourages examinees to acknowledge

their attitudes to patient interviewing, their uncertainties, and, most importantly,
to reflect on their communication style (“Why did you choose that question/
comment/answer during the interview?” “What were you trying to
accomplish?”).
2.5 Proposed Teaching Program3
The proposed teaching program is based on the premise that student–patient com-
munication is shaped by the student–tutor relationship. Just as physicians should
gain insight into their patients’ concerns, tutors should understand their students’
attitudes toward patient interviewing. The proposed teaching program consists of
four steps: Definition of the problem, discussion of possible solutions, demonstra-
tion of the application of those solutions, and supervised practice. The first three
steps are conducted together in a 3–4-h workshop for 25–30 students. The fourth
step consists of weekly supervised practice sessions in small groups (5–7
students).
2.5.1 Step I: The Problem
After giving a 10-min overview of the workshop and explaining the importance of
patient interviewing, I noted that patients often complain about their medical care
and asked students if they had heard friends or relatives criticize their physicians. In
response, students effortlessly listed numerous reasons for patients’ dissatisfaction
with their physicians. I noted these on the board (Table 2.5), and after 30–40 min,
when the list had grown to about 30 entries, the students took a break.
After the break, I summarized the patient’s complaints and devoted the next
30 min to asking whether these complaints were common. Almost all of the students
had heard patients complain about a lack of time, patience, or understanding on the
part of physicians. A minority of students had heard complaints of discrimination.
In some cases, I told the students about my own experience of hearing almost identi-
cal complaints from groups of students, residents, practicing physicians, and par-
ticipants in an international MPH course.
To support the credibility of the patient complaints, I cited a study that found that
patient self-reports matched video recordings better than physicians’ records [40].
In support of complaints such as, “The doctor was in a hurry and did not listen to
me,” I cited the observation that the average time between the start of a patient’s
3
A previous version of parts of this section was published in:
Benbassat J, Baumal R. Teaching doctor patient interviewing skills using an integrated learner
and teacher-centered approach. Am J Med Sci. 2001;322:349–57. With permission by Elsevier.
2.5 Proposed Teaching Program 23
Table 2.5 Patients’ complaints raised by student participants in the workshop on interviewing
skills (reproduced from [12] with permission of Elsevier)
Poor patient–doctor communication: The doctor...
… was in a hurry (“kept looking at his watch,” “interrupted me repeatedly”)
… did not listen (“appeared distracted,” “did not look at me,” “kept reading my file/looking at
the computer monitor while I was talking” “was interrupted repeatedly by the phone/by people
who entered the room without knocking on the door”)
… did not understand (“asked the same questions over and over again,” “made comments that
were unrelated to what I told him/her”)
… ignored my complaints (“did not examine my chest even though I said I had difficulty in
breathing”)
Poor doctor’s response to patient’s needs for information: The doctor...
… did not explain (“I could not understand what he said”)
… did not let me ask questions (“did not respond,” “ignored my questions,” “said ‘Just do it and
don’t ask too many questions’”)
… expected complete obedience (“said ‘If you don’t stop smoking, I don’t want to ever see you
again’”)
Poor doctor’s insight into the patient’s state of mind: The doctor...
… did not meet my expectations (“shocked me with bad news,” “decided on treatment without
consulting me”)
… ignored my concerns (“appeared not to believe me,” “changed the subject when I spoke about
my troubles”)
Bad manners or prejudice: The doctor...
… was impolite (“did not greet me,” “did not respond to my greeting,” “did not introduce
himself,” “did not apologize for being late,” “shouted at me,” “spoke with his colleagues and
ignored me”)
... patronized me (“mispronounced my name,” “interrupted me,” “discriminated against me
because I am....”)
narrative and physician interruptions was only 11 s [41]. I also cited reports that the
most common patient complaints about physician behavior in the USA were disre-
spect (36%), disagreement about expectations of care (23%), and inadequate infor-
mation (24%) [42]; that physicians tend to unintentionally discriminate against poor
patients, the elderly, women, or members of ethnic minorities [43]; that clinicians
rarely inquire about the patient’s agenda and that failure to inquire about it reduces
the chance that clinicians will prioritize a clinical encounter around specific aspects
that are important to each patient [44].
2.5.2 Step II: Discussion of Possible Solutions
By the end of Step I, students agreed that patients’ complaints about the doctor–
patient relationship could not be dismissed as rare or trivial. This conclusion was the
starting point for Step II, in which students were asked to suggest ways in which
patient dissatisfaction could be reduced.
In general, students participated enthusiastically in this discussion and pro-

posed reasonable solutions to most problems (Table 2.6). For example, to reduce
the likelihood of the complaint “The doctor did not understand me,” students
suggested summarizing the patient’s worries at least once toward the end of the
interview. To decrease the likelihood of the complaint “The doctor did not let
me ask any questions,” students suggested asking at least once: “Is there any-
thing you want to tell me/did not understand?” To reduce the likelihood of a
complaint that the doctor was rude, students suggested treating patients with
respect. To decrease the likelihood of a complaint “The doctor did not meet my
expectations/was inconsiderate of my feelings,” students agreed with my sug-
gestion that a doctor should ask, “Which of your problems worries you
the most?”
Table 2.6 Possible ways of preventing patients’ complaints, as suggested by participants and tutor
in the workshop on interviewing skills (adapted from [12] with permission of Elsevier)
Complaint: the Solutions suggested by Additional solutions suggested by the
doctor ... participants tutor
… was in a hurry Explain the time constraints; None
negotiate an agreed-upon
timetable
… kept looking at None Look at the screen together with the
the computer screen patient. Summarize the encounter
while I was talking together with the patient
… did not listen to Listen to the patient. Use open Allow patients to speak for at least
me questions 1 min. Encourage shy patients to talk,
and gently guide the narrative of those
who speak for more than 2–3 min
… did not seem to Sum up what the patient told A misunderstanding is less likely if the
understand/ignored you at least once during the doctor uses open questions and
my complaints interview and correct possible postpones the closed questions to the
misunderstandings end of the interview
… did not explain Explain to the patient your Ask at least once: “Is there anything
what was wrong with assessment and suggestions that you want to tell me/want to know/
me/did not let me ask did not understand?”
questions
… did not fulfill my Ask: “Do you have any Ask: “Do you have any ideas about
expectations questions regarding your what caused your illness?” “Do you
condition?” have any preferences for treatment?”
“what do you think you need,” “What
are your plans for the future?”
… was inconsiderate – Ask: “Of all you told me what makes
of my feelings and you worry most?”
concerns
… was impolite/ Treat the patient with respect Maintain eye contact; lean forward;
patronized me remove physical barriers (desk); speak
softly; pronounce the patient’s name
correctly
Unlike the first half of the previous step, in which I merely recorded student
input, in this step I offered suggestions, whether through verbal descriptions of vari-
ous physician behaviors that might reduce the frequency of patient complaints or
through role-playings, such as demonstrating nonverbal expressions of interest and
respect. The complaint of “the doctor was constantly looking at the computer
screen” was not mentioned until after the introduction of the electronic health record
(EHR). With appropriate training, EHRs can be an asset in teaching patient-centered
care, as described in Sect. 2.6.
Other patient complaints were: “the doctor did not explain anything,”
“explained incomprehensibly (you have chronic inflammation)”, “demanded obe-
dience” (“if you do not stop smoking, you have nothing to come to me for”), “was
offended when I asked for a second opinion,” “was offended when I wanted to
find out about the disease,” “talked to me as if I were a little kid,” “did not talk
about therapeutic alternatives,” or other complaints that indicate patients’ expec-
tations to receive information and even be involved in decisions about their
treatment.
By allowing students to set their own pace, they generally identified the same
goals I had in mind, albeit in a somewhat different order. Some students were con-
cerned about the suggestion to listen to a patient’s narrative for longer than the
stated 11 s (“How much more?”) and asked how to interrupt talkative patients. I
responded that such decisions are a trade-off between the patient’s need to be heard
and the physician’s time constraints. The longer the conversation, the greater the
physician’s chances of gaining insight into the patient’s problem. The duration of
the physician–patient encounter is associated with higher patient and physician sat-
isfaction, lower numbers of malpractice claims, and lower numbers of prescriptions,
requests for additional testing, and referrals to specialists [45]. Conversely, time
pressure eventually forces the physician to take control of the interview. Students
were advised to interrupt the patient’s narrative after 1–3 min by asking an open-
ended question, such as “You mentioned chest pain. I would like to know more
about that.”
I emphasized the importance of recognizing patients’ anxieties and distress
because failure to do so prevents empathy. Most patients have anxieties even if they
are not explicitly described [46]. They describe their concerns only when the physi-
cian encourages them to do so by asking questions such as, “What worries you
most?” This can make the physician aware of the patient’s fears and reduce the
incidence of “doctor did not understand” complaints (Table 2.7).
The most important components of the patient–physician encounter are attention
that conveys respect, caring, interest, and the absence of value judgments; repeated
confirmation that the patient’s message has been understood and the opportunity for
the patient to correct or add to it; and a willingness to listen to personal problems.
“Why” questions (“Why did not you take the medication?”) should be avoided
because they could be taken as criticism.
Table 2.7 Eliciting the patient’s history (adapted from [47] with permission from Wolters Kluwer)
Ensure as much privacy as possible. Express sustained respect and interest by maintaining eye
contact and a body posture of slightly leaning forward
Listen without interrupting the patient’s account of her/his history for about 1–3 min. Encourage
the patient’s spontaneous narrative by nodding and permitting the patient to take control of the
interview
Watch for verbal and nonverbal clues of a patient’s feelings. Respond with appropriate and
explicit acknowledgment of a patient’s emotions/distress
Toward the end of the interview, if appropriate, ask one or more of the following questions:
“Of all your problems, which is the one that worries you the most?”
“Do you have any ideas regarding what caused your illness?”
“Do you have any preferences about your treatment?”
“What are your plans for the future?”
“How does all this make you feel?”
Encourage the patient to ask questions about her/his disease and main concern(s) by asking,
“Do you have any questions regarding your condition?”
2.5.3 Step III: Demonstration of Various Interviewing

Techniques and Discussion of Their Advantages
and Disadvantages
The objective of step III was to show how the solutions proposed in Step II are put
into practice. To this end, I interviewed 2 real patients for 15 min each. Students
were informed that the two interviews would be conducted using different
approaches, that it was not my intention to emphasize the advantages or disadvan-
tages of one approach over the other, that I would not make any intentional mis-
takes, and that during both interviews I would try to show respect for the patient,
maintain a calm and relaxed atmosphere, convey a willingness to listen to the
patients as they described their problems, and end the interview with a summary of
the patient’s complaints. Students were asked to identify the differences between
the two interviews, look for errors by me that will inevitably occur, and comment on
these differences and errors after the demonstrations.
Almost always, the patients seemed aware of the students’ presence only during
the first 30 s and were not distracted by the audience after that. The first interview
was “patient-centered.” Its main feature was listening to the patient’s spontaneous
narrative and sustaining it by echoing the patient’s last words when necessary. I let
the patient take control of the interview and encouraged him/her to talk about his
illness and personal problems by asking general open-ended questions, such as: “Is
there anything else on your mind?” Only after the patient seemed to have completed
his narrative did I ask specific open-ended questions such as, “Ms. ..., you men-
tioned pain in your stomach. I would like to know more about it,” and closed ques-
tions such as: “Did you have heartburn?”
The second interview was “disease-centered.” I began with a series of questions

about the patient’s age, marital status, and occupation and interrupted the patient
with questions as soon as she/he mentioned a symptom. I controlled the interview
by asking a series of closed-ended questions about the patient’s symptoms and the
results of previous examinations. The interview consisted of an inquiry aimed at
obtaining information about the patient’s disease and its manifestations (“Was the
pain long-lasting or intermittent?”) but not open-ended questions (“Can you describe
the pain?”) or those related to the patient’s feelings (“What do you think about your
disease?”).
After the demonstrations, students explored the advantages and weaknesses of
the two interviewing techniques. Students felt that the disease-centered interview
provides information in a logical sequence (i.e., in an order consistent with the phy-
sician’s view of the patient’s illness) but precludes the expression of empathy. The
patient-centered interview avoids these disadvantages, in addition to taking more
time, it also requires the physician to take mental notes on the topics to be clarified
in closed questions at the end of the interview.
In most cases, students concluded that an optimal interview begins with a patient-
centered approach and open-ended questions and ends with a disease-centered
approach and closed-ended questions. I agreed, noting that all medical interviews
are conducted using both techniques. Even physicians who use a disease-centered
approach begin with an open-ended question (“What brought you to me/hospital?”)
and listen to the patient for varying lengths of time before asking closed-ended
questions. Conversely, even clinicians using a patient-centered approach must at
some point take control of the conversation to explore specific issues raised by the
patient through closed-ended questions. Thus, it appears that the difference between
physician interviewing styles is simply how much time they devote to patient-
centered or disease-centered techniques.
During the discussions, I did not hide my bias in favor of a patient-centered
approach. I pointed out that the various components of this approach were sug-
gested by the students themselves in Step II to solve problems in doctor–patient
communication. I informed the students that, surprisingly, the disease-centered
interview does not save time [48]. In fact, given equal time constraints, listening to
a patient for 1–3 min may be more informative than listening for an average of 11 s
and then asking closed-ended questions. However, I recognized that some physi-
cians employ mainly a disease-centered approach. They want to explore a patient’s
complaints immediately, because they believe that controlling the conversation
saves time, or because they feel uncomfortable confronting patients who try to share
personal problems.
A common theme that emerged in the discussions was the degree of intrusion
into the patient’s feelings and emotions. To overcome the tendency to avoid listen-
ing to personal problems, students could be reminded of the relationship between
psychosocial issues and health and that insight into patients’ feelings is a legitimate
area of inquiry and essential to a therapeutic doctor–patient relationship. Students
seemed to need reassurance that their reluctance to explore feelings is normal: we
all enjoy discussing other people’s problems in their absence, but recoil when they
try to share those problems directly with us.
I also pointed out that focusing on a patient’s symptom matrix attempts to place
him or her in a familiar diagnostic category, i.e., to find out, “What makes this
patient similar to others with the same symptoms?” Conversely, insight into a
patient’s specific worries encourages the clinician to ask, “What makes this patient
unique?” One of the main challenges for the tutor is to have students come to terms
with these two notions of patient care and to recognize that diagnostics and under-
standing a patient’s concerns are not mutually exclusive. To recognize a patient’s
concerns, one must acknowledge that they are present but may not be directly
expressed. Gaining insight into a patient’s expectations, preferences, and values is
much less time-consuming than is commonly believed, requiring only three or four
questions. The patient’s answers usually lead to a consensual definition of the
problem(s) to be addressed in the consultation.
In summary, I tried to convey the message that the patient-centered interview
places a high priority on the patient’s spontaneous narrative and open-ended ques-
tions; when time is limited, the closed-ended questions of the systems review are
foregone. The disease-centered interview gives high priority to identifying symp-
toms with closed-ended questions; when time is short, the patient’s spontaneous
narrative is left out. The basic premise of the patient-centered interview is that it
provides reliable information. This is especially important when meeting a new
patient. If the schedule prevents a physician from having a casual conversation with
a new patient, he or she should explain this to the patient and ask him or her to make
another appointment.
The workshop ended with the agreement that each student must choose his or her
communication style by weighing the strengths and weaknesses of patient-centered
and disease-centered conversation. This conclusion encouraged students to view
conflicting messages they would receive in the future as opportunities for further
exploration and learning, rather than as reasons for perplexity and cynicism.
2.5.4 Step IV: Supervised Practice
Step IV consisted of weekly, 3-h small group sessions in various clinical settings.
Students interviewed patients in front of their peers and a tutor and discussed their
performance after completing the interview. Efforts were made to expose students
first to patients with whom interviewing was easy (e.g., young patients with a simi-
lar cultural background to that of the student) and only later to patients with some
of the communication barriers described below.
Difficulties occurred primarily when students met with their first patients. Some
students appeared anxious and found silence unbearable. They resorted to closed ques-
tions shortly after the interview began and “dried up” after 1–2 min. Attempts to
improve their performance through verbal explanations were mostly unsuccessful.
Students either did not understand the feedback or even reacted defensively by blaming
the patient. In such cases, the best way to help the students was to demonstrate: I called
the patient back and asked, “Mr. ... You told [the student] that you were having [chest
pain]. Could you tell us how that made you feel?” or “Ms. ... what is causing you the
most concern in your current situation?” These open-ended questions usually elicited
a detailed response that provided new insight into the patient’s predicament.
Demonstrations were frequently required during the guided practice phase.
Although the terms “closed” and “open” questions were defined during the discus-
sion in Step II and their use was demonstrated in step III, some students did not
seem to grasp the difference between them until I demonstrated during the practice
sessions that the same patient responded differently to these two types of questions.
The more experience the students gained, the more confident they became in
interviewing patients and the more receptive they were to criticism of their inter-
viewing technique. They chose a balanced use of disease-centered and patient-cen-
tered techniques and open- and closed-ended questions. Other difficulties that arose
included how to maintain eye contact with patients and still take notes; how to get
shy patients to talk; and, as I mentioned earlier, most students were embarrassed to
be confronted with emotional patients. By the end of this phase, students were also
expected to be aware of any tendency to give false assurances, ask “why” and “yes–
no” questions, patronize, or pass moral judgments, and suppress this tendency.
At one point in the teaching, I pointed out that the most important predictor of
patient satisfaction is the perception of the physician as caring and empathetic. The
message “I care” is conveyed through attentive listening, acceptance of the expres-
sion of emotions, and body language that transmits understanding and encourage-
ment. In most cultures, this is done through eye contact and facing the patient
without a table separating the patient and the physician.
2.5.5 Advantages of the Proposed Approach
The proposed approach provides an opportunity for both students and faculty to
discuss and reconsider their views on communicating with patients. It helps stu-
dents understand why different clinicians use different communication styles. It
presents both patient-centered and disease-centered conversational techniques as
legitimate and discusses them in an atmosphere of critical reflection, respect for
their worth, and empowerment of students to choose their balance among different
interviewing styles.
Another benefit of the program relates to the assessment of communication skills.
Current assessment methods have been criticized for pressuring trainees to adopt the
examiners’ preferred model of doctor–patient communication [49] and for using check-
lists that force trainees to ask as many questions as possible in a limited time frame to
earn checks [20]. I propose replacing the assessment of interviewing skills with
repeated, face-to-face formative discussions after an examiner observes a student’s
encounter with a real patient. Such discussions would promote a deliberative approach
to interpersonal communication rather than a judgmental, right/wrong dualism.
Examiners need not hide their preferences for the style of patient interviewing. However,
they should emphasize that there is no gold standard for patient interviewing. By show-
ing respect to students with different preferences, examiners would encourage a reflec-
tive appraisal of the strengths and weaknesses of different communication styles. The
principal role of the examiner is to create a supportive environment that encourages
students to acknowledge their beliefs about patient interviewing, their uncertainties and
mistakes, and, most importantly, to reflect on their communication styles.
Finally, the proposed teaching approach encourages students to create their inter-
viewing guidelines and does not antagonize them with “should” and “should not”
rules. For example, while students resented being lectured about elementary cour-
tesy, they were impressed when they recognized that some physicians are rude to
their patients; while students seemed to take for granted the admonition to treat all
patients equally, they were impressed to discover, after role-playing, that some
patients (elderly, poor, uneducated) indeed receive inadequate counseling about
their illness [38]. In other words, rather than feeding students behavioral and social
science principles, the proposed approach emphasizes the importance of students
themselves figuring out what these principles mean for clinical practice. Encouraging
students to formulate their interviewing guidelines also avoids the common misun-
derstandings of terms used in lectures or handouts. For example, encouraging stu-
dents to suggest ways to avoid the common patient complaint, “The doctor did not
take my feelings into consideration,” can help faculty avoid pointless discussions
about the various definitions of “empathy.”
The main advantage of the proposed approach is the constant dialog between
tutors and learners in an egalitarian and non-hierarchical atmosphere. A hierarchical
approach to teaching can be transferred from the teacher to the learner and have
further undesirable consequences if students adopt this behavior toward patients
[50]. In other words, teacher-dominated patient interviewing programs can rein-
force a paternalistic style of communication with patients. It is impossible to humil-
iate medical students and still teach them to respect patients, just as it is impossible
to ignore the students’ point of view and still teach them to consider the patient’s
preferences. Like the doctor–patient relationship, the tutor–student relationship
should be one of mutual respect and an effort to understand each other’s views.
2.6 Barriers to Doctor–Patient Communication
The interaction between two perceptive, calm individuals with similar cultural
backgrounds does not pose undue problems. However, any dissimilarity between
them and any emotional distress of one of them may interfere with communication.
Obstacles to physician–patient interaction may arise from the environment (lack of
privacy, noise, unconventional dress of the physician, and disruption of the physi-
cian–patient encounter by telephone calls and clinic staff), from differences between
the physician and patient (age, language, culture, and socioeconomic status), and
the physician’s communication habits and attitudes.
2.6 Barriers to Doctor–Patient Communication 31
2.6.1 Doctor–Patient Differences in Age, Race, Gender,

Language, and Socioeconomic Status:
Underprivileged Patients
Evidence suggests that physicians are not immune to bias and reliance on stereo-
types, and that patient characteristics—age, race, gender, language, and socioeco-
nomic status—influence physician-patient communication and clinical decisions
[51]. Ageism is pervasive [52]. Fear of being perceived as hypochondriacal may
discourage patients from describing their complaints. Both older patients and physi-
cians may view disease manifestations as part of normal aging and ignore treatable
problems. Both may believe that health promotion, disease prevention, and physical
and mental well-being are not realistic goals in old age.
There is also evidence that black patients were less likely than whites to receive
analgesia for pain [53], thrombolytic treatment [54], and assessment for renal trans-
plantation [55] even after adjusting for severity of illness, health insurance, avail-
ability of medical services, socioeconomic status, age, and comorbidities. A 2000
survey showed that patients of African descent elicited less empathy from physi-
cians and that poor and uneducated patients had a negative image of character and
ability [56]. In the UK, 20% of an ethnic minority sample reported racial discrimi-
nation. During a 2-year follow-up period, those who reported racial discrimination
had a higher likelihood of prolonged illness, fair/poor self-rated health, and
increased psychological distress [57].
American women perceive gender discrimination in health care [58]. Finally,
evidence suggests that patients with mental illness [59] feel discriminated against
by health providers and are less likely to seek help. People with mental illness often
report negative attitudes from mental health staff. “Diagnostic overlay,” is a misat-
tribution of symptoms of physical illness to concurrent mental disorders, leading to
underdiagnosis and mistreatment of physical illness. It appears to be prevalent in
healthcare settings [60].
2.6.2 Mismatch Between the Patient’s and the Doctor’s

Preferences
The law supports the right of patients to refuse treatment. However, it does not pre-
scribe the extent to which physicians are required to agree with patients’ prefer-
ences or how to resolve inconsistencies between these preferences and physicians’
adherence to professional norms. The question “What are the limits of patient
autonomy?” is relevant in three situations.
The first occurs when rational patients have irrational preferences that result
from ignoring risks (speeding, smoking), fear of examinations or surgery (refusal of
recommended tests or treatments), ideology (refusal of blood transfusions by
Jehovah’s Witnesses), or a preference for continuing a futile treatment. The second
type of unacceptable request is rational for the patient but not for society. For exam-
ple, an insured patient may insist on an expensive drug because he or she has no
motive to weigh the cost of medical treatment against the expected benefits.
Similarly, a patient’s refusal to be vaccinated may be irrational socially but not per-
sonally, since vaccination reduces not only personal morbidity but also that of soci-
ety as a whole. The third type of disagreement between physician and patient is a
conflict between the patient’s preferences and the physician’s values. At first glance,
such a conflict is absurd: two rational persons cannot disagree in choosing between
life and death. However, there are situations in which this choice is also between a
treatment that prolongs life expectancy but reduces the quality of life and a treat-
ment that does not. In these situations, patients may choose to risk their lives for a
better quality of life.
Take, for example, the case of a 55-year-old perimenopausal woman with vaso-
motor symptoms. She and her physician must decide between hormone treatment,
which would reduce her vasomotor symptoms and risk of hip fracture but increase
the risk of systemic embolism and breast cancer. Symptomatic treatment would be
less effective in reducing her symptoms but would not affect embolic risk [61]. In
this example, in addition to the desired (life) and undesired (death) outcomes, there
is also an intermediate outcome that requires value consideration. There may be
situations in which two rational patients prefer different treatment options.
In whose hands is the decision? If it is solely in the hands of the physician,
should he or she put himself or herself in the patient’s shoes and ask what would the
patient have preferred? If the decision is in the hands of the patient, how can he or
she be provided with the data necessary to make the decision? If it is in the hands of
both, what role does each play in the decision? Ostensibly, physician–patient mis-
match in preferences can be ameliorated through patient education. Indeed, a 2007
study found that integrating individualized decision aids into clinical practice is
feasible and reduces decision conflict [62].
2.6.3 Doctors’ Failure to Gain Insight into the Patient’s

Concerns4
One of the goals of interviewing is to gain insight into a patient’s concerns. Failure
to gain such insight precludes empathy and meeting the patient’s expectations.
Physicians can encourage patients to share their worries by expressing a willingness
to listen. In some cases, this is enough to prompt patients to share their fears and
expectations. However, patients often tend to drop hints. In some cases, physicians
were observed to respond to such hints with explicit acknowledgment. In most
4
A previous version of this section was published in:
Benbassat J, Baumal R. What is empathy and how can it be promoted during the clinical clerk-
ships. Acad Med. 2004;79:832–9. With permission by Walter Kluwer.
2.6 Barriers to Doctor–Patient Communication 33
cases, however, they disregarded these cues and returned to diagnostic exploration
of symptoms [63]. Ignoring cues to the patient’s concern may be due to the physi-
cian’s interviewing habits, failure to interpret cues to the patient’s anxiety, and intol-
erance of expressions of emotion [44].
2.6.4 Interviewing Habits That May Discourage Patients

from Sharing Their Concerns
2.6.4.1 Writing Up the Patient History During Interviewing
Writing the history while the patient is talking assures the physician that he or she
does not omit important details and uses time efficiently. Still, patients may not
disclose their specific worries when facing a physician who is recording what they
say. In addition, writing during the interview prevents eye contact, observation of
the patient’s body language, and recognition of nonverbal cues. Recording the his-
tory while the patient is talking also forces the physician to control the interview:
Instead of listening to the patient’s narrative, the physician must interview in the
order of the standard recorded history: Chief Complaint, Present Illness, Past,
Social, and Family History and Systems Review, which inevitably leads to a disease-
centered interviewing style. As detailed in Sect. 2.5, the tendency to write down the
history during the patient interview has increased since the introduction of the elec-
tronic health record.
2.6.4.2 Focusing on the Chief Complaint Early in the Interview
The standard record of the history begins with the chief complaint. Recording the
history while the patient is talking forces the physician to identify the chief com-
plaint (e.g., “chest pain”) early in the interview. This leads to a search for other
symptoms by asking closed questions (“Did the pain radiate down the arm?”),
which in turn explains the observation that physicians interrupt the patient’s narra-
tive within seconds [44]. In many cases, the patient’s main concern emerges later in
the encounter, and its premature definition can be misleading for the physician’s
diagnostic considerations.
2.6.4.3 Performing Systems Review
It is generally agreed that the interview should end with a series of closed-ended
questions designed to determine the presence or absence of specific symptoms. This
approach has been taught to medical trainees for decades as an integral part of tak-
ing a medical history. The purpose of the systems review is twofold. First, it teaches
students to associate symptoms with different organ systems. Second, it can uncover
symptoms that patients have not mentioned in their narratives. This is supported by
studies showing that a full systems review led to new diagnoses in 5% [64], 7%
[65], and 11% [66] of new patients. Conversely, a complete systems review may
provide irrelevant information and hinder the diagnostic process. In addition, nov-
ices may perform the review as a substitute for listening to a patient’s narrative,
creating an atmosphere of detachment and formality that is detrimental to the
expression of empathy. Therefore, there is now a tendency to replace system reviews
with patient self-report questionnaires.
2.6.5 Angry Patients
Anger is a likely response to injured self-esteem and feelings of helplessness,

shame, fear, and victimhood. In most cases, anger is suppressed because its expres-
sion is not accepted by cultural norms; however, it can lead to verbal and physical
aggression. Violence toward caregivers is on the rise, and assaults occur nearly four
times more frequently in health care than in all other private sector industries com-
bined [67]. A 2019 review found that 62% of a total of 331,544 healthcare workers
reported being exposed to some form of violence, and 24% stated to have experi-
enced physical violence in the past year. This was particularly common in hospital
emergency departments, psychiatric units, geriatric facilities, and the commu-
nity [68].
Violence may be triggered by environmental factors such as crowding, noise, and
long wait times. However, it is mostly due to patient-related factors, such as volatile
people, especially those under the influence of drugs or alcohol, or patients with a
history of psychotic diagnoses [67]. A 2015 review found that approximately 20%
of patients in psychiatric units commit violent acts, with male gender, schizophrenia
diagnosis, substance use, and life history of violence associated with violence [69].
Patient violence may be influenced by caregivers. A study in a psychiatric hospi-
tal found an association between patient violence and caregivers’ trait anxiety and
authoritarianism [70]. Most incidents of violence occurred immediately after con-
tact with care providers or in response to their comments. Restricting patients’ free-
doms through some type of restraint or denying a patient request, such as during
showering the patient with the assistance of a nurse, was the most common trigger
for incidents [71]. A 2020 review of the literature found that staff fatigue, burnout,
racism, sexism, and other negative cultural values appeared to increase the risk of
violence. There was also an increased risk of aggression when patients did not feel
included in treatment decisions or did not feel they had meaningful contact with
staff [72].
Patient violence affects caregivers’ well-being. Having experienced aggression
has been reported to cause burnout, insomnia, anorexia, and flashbacks [73];
increased stress and anxiety levels; feelings of guilt, and insecurity [74]; and inabil-
ity to interpret patients’ violent behavior, feelings of helplessness, and most impor-
tantly, awareness of “forbidden feelings” toward patients [75].
2.7 Coping with Barriers to Communication with Patients 35
2.7 Coping with Barriers to Communication with Patients
Although unavoidable, communication barriers can be reduced by improving the

appearance of the clinic, avoiding disruptions during the patient encounter, over-
coming deafness by allowing the patient to read the physician’s lips, and reducing
the distance between patient and physician without raising the voice.
2.7.1 Language Mismatches
The best way to overcome language mismatch is to refer patients to caregivers with
the same background. This has been reported to reduce the need for urgent admis-
sions to psychiatric hospitals [76]. When such matching is not possible, clinicians
typically enlist the help of translators from the family or treatment team. However,
observations of the effectiveness of such translators revealed an average of 19 trans-
lation errors at each encounter, and 63% of these errors had clinical implications
[77]. Professional translators, including those available by telephone, are more
effective than occasionally available translators [78].
When using translators, clinicians should speak directly to the patient, address
the patient in the second person, maintain eye contact with the patient and not the
interpreter, and ask the patient to speak to the doctor and not the translator; pay
attention to and respond to the patient’s nonverbal cues; and, most importantly,
check for understanding by summarizing the problem periodically for back transla-
tion and confirmation by the patient. Failure to follow these rules results in a doc-
tor–interpreter rather than a doctor–patient dialog and leads to misunderstandings.
2.7.2 Doctors’ Self-Awareness
Self-awareness is an introspection into one’s emotions, prejudices, attitudes, and

preconceived notions that may arise in response to certain situations. I have already
referred to possible stereotypes of physicians based on race, class, gender, and other
characteristics that influence the interpretation of behavior and symptoms [79].
Such stereotypes are often beyond conscious awareness. Self-awareness is therefore
a prerequisite for reducing the confounding effect of a physician’s emotional state
on his or her attitude toward patients.
The acquisition of self-awareness by students of their feelings and attitudes has
become a learning objective in many medical schools. Attempts to improve stu-
dents’ self-awareness consisted of classroom discussions about physicians’ emo-
tional responses to various clinical situations; small group discussions in which
students recalled their personal clinical experiences and talked about how their feel-
ings influenced their behavior toward patients; and feedback and consultation with
individual students by behavioral scientists after observing their interactions with

patients [80]. However, the most important way to overcome communication barri-
ers created by physicians’ preconceived notions is to be aware of their existence and
the physician’s responsibility to overcome them.
2.7.3 Encouraging Patients to Share Their Concerns
To encourage patients to share their concerns, students should listen to the patient’s
history; watch for verbal and nonverbal expressions of emotion, inquire about the
causes of the patient’s distress if appropriate, verbally summarize the patient’s his-
tory, agree with the patient on his/her chief complaint and major worries, and only
then write down the history in the sequence of the standard record. Students should
be cautioned to avoid taking copious notes while the patient is talking and to give
lower priority to performing a systems review. They may be advised that in cases
where time is short, it is more informative to listen to the patient’s narrative than to
use closed-ended questions. In these cases, the systems review can be replaced with
open-ended questions, such as “Is there anything else on your mind?” Conducting a
full system check can be limited to doctor–patient encounters where there are no
time constraints and to patients who do not respond to the doctor’s attempt to main-
tain their spontaneous narratives.
2.7.4 Management of Patient Aggression
A 2018 literature review suggested the following approaches to preventing and

managing patient aggression. First, avoid crowding and noise in the clinic in general
and in waiting rooms in particular; these should be as quiet, comfortable, clean, air-
conditioned, and ventilated, and most importantly, patients should be informed of
the waiting time. Second, early diagnosis of suppressed anger by correctly identify-
ing a raised voice, jaw muscle tension or hand movements, signs of drug or alcohol
intoxication, hallucinations, threats to leave the clinic, or verbal and physical
threats [81].
Training staff to deal with violence is an important approach to preventing and
managing patient aggression. A comparison of medical and social work students
found that medical students had experienced patient violence more frequently than
social work students (80% vs. 44% knew about workplace violence; 9% vs. 6%
were victims of a physical assault). Nevertheless, it was found that only 23% of
medical students had received training in coping with verbal violence, compared
with 31% of social work students [82]. The most important features of such training
are communication, de-escalation, and recognition of risk behaviors. Training
increases participants’ confidence in dealing with patient violence and improves
care-providers attitudes and ability to de-escalate incidents. Indeed, violent assaults
2.8 Shared Decision-Making 37
by patients of untrained nurses occurred more frequently [83], and training of nurses
reduced the number of violent incidents in psychogeriatric wards [84]. In such a
situation, the care-provider role is to relieve tension through eye contact and a
relaxed posture without crossing the arms or tilting the body forward. Without judg-
ing whether or not the anger is justified, the caregiver would confirm that he or she
accepts the patient’s anger as legitimate.
2.8 Shared Decision-Making5
Shared decision-making (SDM) is a consultation style in which patients share their

knowledge and specific worries while doctors explain the available courses of action
in a way that allows patients to make a choice. SDM improves patients’ affective-
cognitive outcomes. However, there is no evidence that it improves patients’ health
[85] or quality of life [86]. Nevertheless, there is agreement that physicians should
understand the patient’s need for information, while patients need to be aware of the
uncertainty in medicine, want to participate in decisions related to their care, and
understand the trade-offs among available options.
Integration of SDM into clinical practice has been slow. A 2019 survey found
that 31% of physicians reported using a paternalistic approach in daily practice [87],
and many physicians could not distinguish between SDM, informed consent, risk
assessment, and decision support [88]. The purpose of this section is to suggest that,
similar to patient-centered care, teaching SDM should (a) be included in under-
graduate medical education and not just offered to residents and practicing physi-
cians [89] and (b) emphasize the physician’s ability to understand the patient’s
specific concerns and only then provide health-related information.
2.8.1 Teaching Shared Decision-Making
The objectives of SDM are generally defined as (a) identifying situations in which
SDM is critical; (b) communicating with the patient about the need for a decision;
(c) describing available options, risks, benefits, and associated uncertainty; (d)
determining patient preferences; and (e) agreeing on next steps [90–92]. Attempts
to achieve these objectives have consisted of the distribution of educational materi-
als, educational sessions, audits and feedback, and decision aids for patients.
However, they had little impact on resident and practicing physician knowledge
[89]. The only attempt to teach students that I am aware of was a one-hour small
group intervention that consisted of a critique of a pre-recorded role-play. Two
5
Tidhar M, Benbassat J. Teaching shared decision making to undergraduate medical students.
Rambam Maimonides Med J. 2021;12. Authors’ copyright.
weeks after the intervention, participants rated their skills, attitudes toward, and
confidence in SDM significantly better [93].
Communicating treatment options and uncertainties, using decision support
tools, identifying patient preferences, and reaching an agreement on treatment are
certainly worthwhile goals. However, I disagree with the first two recommended
steps of SDM training, namely recognizing when a decision is needed and commu-
nicating that need to the patient. I believe that all physician–patient encounters
require SDM and that the starting point should not be recognizing the need for a
decision but understanding the patient’s concerns.
2.8.2 Proposed Learning Objectives of Shared

Decision-Making
2.8.2.1 Gain an Insight into the Patient’s Concerns
Patients expect their physician to address the specifics of their case and are disap-
pointed when she/he cites only prognostic statistics [94]. Gaining an insight into the
patient’s specific worries is necessary to meet this expectation. It is also the begin-
ning of the multistep process of empathy, whereby the physician’s awareness of the
patient’s apprehensions elicits a sequence of emotional engagement, compassion,
and a desire to help the patient. The first step in this sequence, insight into the
patient’s distress, is a skill that can be learned. It requires conducting a patient-
centered interview and using the questions I listed earlier.
2.8.2.2 Elucidate the Role That the Patient Wants to Assume

in Decision-Making
Doctor–patient relations can be viewed as a continuum between the “paternalistic

model” (doctor decides, patient complies without explanations) and the “informa-
tive model” (physician informs, the patient decides), with varying degrees of patient
involvement between these two extremes (Table 2.8). A 1998 review indicated that
92–97% of patients wanted to be informed about their disease. About half of them
wanted information with a view of leaving the decision to their physician, and the
other half wanted to participate in planning their treatment. The remaining 3–8%
preferred a passive role without being informed about their disease [95]. A 2012
review similarly revealed that while most patients wanted to participate in decision-
making, some patients wanted to delegate decisions. There was a temporal trend in
patient preferences: Respondents preferred a shared decision-making role in 71% of
studies from 2000 and later, but only in 50% of studies before 2000 [96].
Understanding patients’ preferences is complicated by their varying desires for
information, self-treatment, and participation in clinical decisions [97]. For exam-
ple, patients’ preferred involvement in decisions about their treatment is different
Table 2.8 Alternative models of physician–patient relationships

Model Assumptions
Paternalistic – The doctor and the patient have the same values and goals
– The doctor has more knowledge than the patient about the disease
– The knowledge gap between the doctor and the patient prevents the provision
of information
– The role of the physician is to identify the patient’s needs and recommend
treatment
– The patient’s role is to accept the doctor’s recommendations
Informative – The doctor and the patient may have different values and goals
– The doctor has more knowledge than the patient about the disease
– The doctor must meet the patient’s needs for information about his illness
– The patient’s role is to decide how to proceed and whether to accept the
doctor’s recommendations
Shared – The doctor must meet the patient’s needs for information
decisions – The doctor’s duty to recommend a treatment plan
– The patient may disagree with the doctor in the choice between different
treatment options
– Clinical decisions are an agreed compromise between the patient’s preferences
and the doctor’s recommendations
Self-care – A patient who has received appropriate information and has been properly
instructed by his caregivers can self-regulate his behavior and treatment of his
illness
from their desire to participate in solving diagnostic problems [98]. The multidi-
mensionality of the variable “patient preferences” contradicts the simple linearity in
the sequence between the paternalistic model and the self-care model. This vari-
ability exists not only between patients but also within patients over time [99].
Therefore, the only way for a physician to gain insight into the preferences of indi-
vidual patients is through direct questioning.
Insight into the patient’s wishes is a prerequisite for respecting patient autonomy.
Patients from lower social classes are often disadvantaged because the physician
may misjudge their desire for information and their ability to participate in the treat-
ment process. Therefore, it is important to distinguish between patients who prefer
a passive relationship with their physician and those who are reluctant to ask ques-
tions even though they prefer to be involved in their treatment.
To make this distinction, a physician may ask, “Before I answer your questions,
it would help me if you told me what you already know about your disease?” The
purpose of this question is to gain insight into the patient’s perception of his or her
disease and to state an intent to answer questions. The patient may respond by
expressing concern (“I hope this is just a temporary headache, but I fear it may be
cancer”). Other patients may not respond to the physician’s prompting (“I have not
the faintest idea”). In such cases, the physician may insist by saying, “I am very
interested in your opinion about what we should do” or “Would you like me to share
with you my thoughts about your disease or the various options for its further
treatment.” The patient’s response (“Please just tell me what to do,” “Yes, tell me
what the options are,” or “Yes, tell me what you think about my disease”) is likely
to make his/her preferences about SDM clear.
2.8.2.3 Match the Patient’s Preferred Involvement in Decisions
Physicians can optimize their encounters with patients by matching their needs for
information and involvement in treatment [100]. Patients may need information
about their diagnosis (“What is the name of the disease?” “Is the diagnosis cer-
tain?”), the need for treatment (“What are the risks of surgery?” “What if I do not
have surgery?”), or implications of the disease (“Will I be a burden to the family?”
“Will I suffer from pain?”), or treatment (“What should I do?” “How long will it
take?”), or help with decision-making (“Could you explain to me again ...,” “What
would you do if you were in my place?”). It is advisable to answer these questions
honestly and to elicit the patient’s preferences about sharing decisions with others
(“Would you like to talk to me alone or with someone else present?” “Would you
prefer to talk to someone in the family first?”). To the extent that this is possible, the
doctor would avoid making a time-based prediction. When necessary, he or she
should give the patient a rough realistic time frame for getting personal affairs
in order.
2.8.2.4 Present Options; Discuss Pros, Cons, and Uncertainty
Physicians have difficulties in applying SDM because first, they may feel that
acknowledging uncertainty would undermine patient trust and increase anxiety
[101]. This feeling is at odds with the view of bioethicists that patients can handle
information about uncertainty, that disclosure protects patient trust, and that special
vigilance is needed in situations of significant uncertainty to ensure that patients
receive the tools and information they need to participate in SDM [102].
Second, SDM requires doctors to communicate the risk and benefits of an inter-
vention in a way that patients can understand. In response to evidence that many
physicians are not up to this challenge, Koch et al. [103] reported the successful
implementation of a 15-h course that integrated basic statistics, bias detection, and
communication skills. All of these topics had been taught separately during the
undergraduate program; the objective of the course is to reorganize previously
acquired knowledge and apply it to SDM. Still, the optimal way to convey informa-
tion to patients is uncertain.
Even when clinicians understand the patient’s expectations, they may have dif-
ficulty determining the best way to convey probabilistic information and informa-
tion about the patient’s expected quality of life. Patients may perceive the same
information differently, for example, if it is presented as a probability of survival or
death, or if it is presented from the worst to the best option or vice versa. There is
evidence that even educated individuals can be biased by the framing and sequence
of data presented [104]. However, this evidence was derived from the responses of
study populations to hypothetical situations. These (rapid/immediate) responses in
experimental settings cannot be generalized to the (slow, unhurried, and thorough)
deliberations during physician–patient encounters in clinical settings. Decisions,
where the stakes are high, require slow thinking to avoid the biases of the fast system.
Third, providing information on the quality of life is difficult, because of its
uncertain definition. According to one definition, quality of life is the function of the
patient or his or her body systems by examinations such as exercise tests of a car-
diac patient or laboratory markers of disease activity. The second definition of qual-
ity of life refers to the patient’s psychological (freedom from anxiety or depression)
and social (ability to communicate and participate in community life) well-being.
The third dimension of quality of life is the value that the patient attaches to the
limitation. The same paralysis of the vocal cords has a different meaning for a singer
and a painter. The same limp has a different meaning for a dancer and a math teacher.
The first dimension of quality of life is based on objective clinical and laboratory
tests. The second one is based on psychometric assessment. However, the third
dimension of quality of life is subjective and the reliability of its measurement is
uncertain. Still, SDM requires that clinicians understand the preferences of indi-
vidual patients and their subjective perceptions of quality of life. Hence, the current
efforts to develop methods that allow patients to assess their quality of life with an
expected limitation and express their preferences.
2.8.2.5 Offer the Patient the Option of Obtaining a Second Opinion

and Suggest Reliable Websites
Discrepancies between experts’ interpretations of imaging, histopathologic, and

clinical findings have led to the agreement that patients have a right to a second
opinion unless it delays a life-saving intervention. A second opinion has been
reported to confirm the original diagnosis or treatment in 43–82% of cases and to
change the diagnosis, treatment, or prognosis in 12–69% of cases [105].
The main barriers that prevent patients from seeking a second opinion are patient
information overload and fear of jeopardizing the doctor–patient relationship [106].
Therefore, patients should be encouraged to do so (“Would you like to consult
another doctor?” “Would you like to consult a doctor of your choice or would you
like me to recommend an expert?”) and assured that this will not affect future doc-
tor–patient encounters (“I shall not be offended if you want to seek another doctor’s
opinion; on the contrary—I will be happy to hear his or her opinion on how to
proceed”).
Patient education is a cornerstone of SDM, and its main sources are physicians
and the Internet. About half of the patients search the Internet before consulting a
physician [107]. A 2021 study confirmed that searching for established, safe treat-
ments online (as opposed to seeking emerging treatments) has a positive impact on
patients’ trust in their physicians and on the doctor–patient relationship [108].
Evidence on the impact of online information seeking on health outcomes is
inconclusive. A 2022 review found that online information search was associated
with better medication adherence among HIV/AIDS patients, but not in gen-
eral [109].
Some physicians discourage their patients from bringing outside information. As
recently as 2018, it was claimed that by googling their symptoms, patients are form-
ing their own opinions about their medical problems and resisting their doctor’s
advice [110]. Another survey in the UK found that GPs felt considerable anxiety
when patients brought information from the Internet into the consultation for fear of
being perceived as ignorant; however, they learned to respond appropriately to such
patients by buying time (“I am not familiar with this particular website. I’d like to
read it and think about it”) or using the Web as an ally (“In the meantime, you can
check the websites ...”) [111].
Patients may not talk to physicians about health information because they are
afraid to question their authority or because they feel that the physician does not
want to discuss seeking online health information, especially within the limited time
of the physician visit. However, it stands to reason that physicians who talk to their
patients about health information and guide them in searching for and using this
information can shorten the length of the consultation and improve their communi-
cation with patients [112].
2.9 Patient Counseling6
The term “patient counseling” refers to an individualized process of finding out

what the patient thinks about his or her illness, responding to his or her information
needs, providing guidance, and solving problems together. Evidence suggests that
training improves student ability to provide counseling and that simulation-based
training is the most effective way to do so [113].
In the 1990s, I tried to incorporate patient counseling into my teaching. After a
student presented a patient at the bedside, I checked the patient’s physical findings
and asked the patient questions, such as “Do you have any idea what caused your
illness?” and “What makes you worry most?” The teaching session then moved to a
conference room. Students listed the patient’s problems and formulated a plan for
treatment and obtaining additional data. I stated that patient education had generally
a low priority in the hospital setting. Some students responded that patients indeed
ask about their illness and that physicians often do not meet their need for informa-
tion. Although students seemed to accept this as an inevitable consequence of the
hectic hospital routine, they agreed that all patients are entitled to at least one con-
versation with their attending physician before being discharged from the hospital.
6
Benbassat J, Baumal R. A step-wise role-playing approach for teaching patient counseling
skills to medical students. Patient Educ Couns. 2002;46:147–52. With permission by Elsevier.
2.9 Patient Counseling 43
The next step was a simulation of such a meeting. The student who presented the
patient was asked to take the role of the doctor, and I took the role of the patient.
While pretending to have the real patient’s illness, I maintained my medical back-
ground. This facilitated communication, eliminated cultural or language barriers,
and allowed for an in-depth exploration of the various aspects of the real patient’s
illness. In most cases, the student made an opening statement (“Mr ... I would like
to advise you about your treatment after you are discharged and answer any ques-
tions you have about your illness”). Then the student answered my questions (“I still
feel very weak. Do you think I shall feel better after discharge from the hospital?”
“When do you think I should see my doctor?”), addressed my specific worries
(“Can I have sex?” “Do you think I will be able to resume my usual activities?”) and
adapted the treatment plan to my preferences (“If possible, I would like to postpone
the decision about... until after my daughter’s wedding”).
As the simulation progressed, some students noted that the real patient was not
similarly informed about his or her illness. When students did not make such com-
ments, I steered the discussion by asking, “Were the real patient’s questions about
his illness similarly addressed?” My prerogative for information was accepted as
self-evident. Real patients, however, are rarely given the same attention, even though
their needs are similar. This double standard made students aware that they are not
free from stereotyping patients. Physicians admit to having negative feelings about
certain patients; however, few are aware that these feelings can lead to unconscious
discrimination against elderly, uneducated, and poor patients.
The most frequently cited reasons were “The real patient never asked questions
like the ones you asked” or “It is impossible to explain the nature of the disease, its
treatment, or prognosis to the patient because he... [is deaf or poorly educated or
speaks a different language].” I acknowledged the legitimacy of these reasons and
agreed that circumstances often force the physician to settle for a less-than-perfect
solution; however, the gap between the best counseling and that offered to patients,
while inevitable, is not irreducible. The discussion that followed focused on the
ways to reduce this gap.
In response to the claim that the real patient never asked questions, I pointed out
that all patients want to be informed about their illnesses. However, physicians usu-
ally assign less importance to provide such information than patients. In response to
the claim that it was impossible to provide counseling because of the communica-
tion barriers, I asked the students to name the specific difficulties they had in com-
municating with the real patient. They were then asked to resume the simulation and
demonstrate how to overcome these difficulties. Even without prior knowledge of
the topic, students generally found reasonable ways to overcome communication
barriers, such as using an interpreter if the patient was a foreigner, using simple,
nonmedical terms if the patient was a layperson, or speaking more slowly, lip-
reading, and reducing the distance between the physician and the patient if the
patient had a hearing impairment.
The combined duration of the last 2 steps may be as short as 30 min for patients
with an acute, transient problem who communicate well with the physician. In such
a case, the teaching session consisted only of informing the patients about their
management and answering questions about their disease. Conversely, if the patient
was an indigent or poorly educated person, the session was longer. In such cases,
discrepancies between the best possible advice and the actual advice occurred
shortly after the session started, cut short the simulation, and triggered a discussion
about possible ways to reduce the discrepancies.
Judging from student participation in the discussions, this approach provided
several learning opportunities in addition to those offered by the usual teaching
round. During the initial presentation of the patient, students were repeatedly sur-
prised when, in response to my questions, patients expressed worries that they had
not mentioned during the initial intake. Students often preferred to examine these
worries rather than the problem list. In one case, a patient responded to my question,
“Of all you have told us, what worries you the most?” by asking, “Is this coronary
bypass surgery really necessary for me?” The subsequent discussions included
alternative interpretations of this response, such as a request for information, fear of
the recommended surgery, or a desire to get a second opinion without offending the
attending physician.
A learning opportunity also arose when planning for post-discharge manage-
ment. Appropriate post-discharge management may be taken for granted with well-
educated patients. However, not all patients are familiar with the outpatient
healthcare system, and some need information about the availability of social assis-
tance for certain disabilities. Student interest in these aspects of patient care opened
the door to discussions about the importance of pre-discharge review and a post-
discharge management plan.
In summary, the described approach highlighted the discrepancy between pro-
viding the best possible care and the inevitable trade-offs in adapting management
to the patient’s actual circumstances. Students were first projected into an ideal situ-
ation in which they can conduct a dialog with a simulated patient with no commu-
nication barriers and no constraints on financial or other resources. They then
identified discrepancies between the counseling given to the simulated patient and
the real patient. I believe that by using small group discussions after bedside patient
presentations and by allowing students to focus on a single problem they have iden-
tified for as long as they want, this approach improves on previous attempts to pro-
mote patient-centered practice. Rather than forcing solutions, this approach
challenges students to identify for themselves some of the problems patients face
and find solutions. It is not necessary to complete all steps in full or in the order
described here. Each step has its objective, and each step can be modified as the
instructor sees fit to meet students’ preferences.
2.10 Patients’ Adherence to Doctors’ Advice
Adherence to medical advice refers to the extent to which the patient attends sched-
uled medical appointments, takes medications, completes examinations recom-
mended by the physician, and responds to health-promoting recommendations such
2.10 Patients’ Adherence to Doctors’ Advice 45
as diet, exercise, or abstinence from dangerous habits. Nonadherence limits patients’

ability to achieve treatment goals. A 2019 study found that nonadherence to recom-
mendations was associated with hospitalization rates and mortality in older adults
[114]. In this section, I will attempt to describe the methods used to assess nonad-
herence, its causes, and approaches to reduce it.
2.10.1 Estimating Patients’ Adherence

to Doctors’ Recommendations
Nonadherence is influenced by multiple factors, and predicting it in individual

patients is difficult [115]. The most common method of assessing adherence is the
physician’s judgment based on his or her familiarity with the patient. However, in
most cases, this judgment is not confirmed by more accurate measures of patient
adherence, such as drug/metabolite concentration in body fluids, counting of tablets
to determine the number of doses skipped, drug dispensing, and electronic monitor-
ing systems for the percentage of doses taken (drug container openings) [116].
These measures are complex, expensive, and not applicable in daily clinical practice.
Self-reports are more reliable when patients do not feel threatened by the truth.
Physicians should phrase questions about adherence without making value judg-
ments, for example, by asking, “Most people find it difficult to take all their medica-
tions properly. Do you also have this kind of difficulty?” If the patient answers in the
affirmative, the physician needs to find out the extent of nonadherence in a non-
threatening way and work with the patient to find its causes. Estimates for nonad-
herence vary from 50% for medications, 25% for patient-initiated appointments,
and 20–60% for early medication discontinuation [117].
2.10.2 Reasons for Nonadherence
Patients do not follow physicians’ recommendations because first, they may misunder-
stand the recommendations. For example, a study of blood medication levels in patients
with epilepsy and bronchial asthma found that 63% of them did not comply with their
medications, mainly because they did not understand that they needed to take the med-
ications continuously [118]. Lack of understanding is one of the main reasons for the
association of nonadherence with older age, low educational level, and ethnicity [119].
Second, patients may forget. Therefore, it is important to link medication adherence to
regular events on the patient’s agenda, such as meals or going to work.
Third, patients may consciously decide not to take the medication because it has
side effects or is felt to be not effective [120]. Therefore, the physician needs to
know how the patient views his or her disease and whether the patient agrees with
the physician’s recommendations. The chances of success with an agreed-upon
therapeutic approach are greater than the chances of following dry instructions.
Finally, in some cases, nonadherence led to a better insight into the dosage of a
medication, leading patients to the correct conclusion that they can achieve the
treatment goal with a lower dose than recommended by the physician [121].
2.10.3 Ways to Improve Patient Adherence
Adherence is high when treatment is supervised and when it addresses an acute

condition; it is low in chronic patients or those who are not in acute distress.
Therefore, it is recommended that efforts to improve adherence be focused on three
patient groups: Those with treatable conditions, patients who miss follow-up visits,
and patients who do not meet treatment goals, such as those with diabetes or blood
pressure. Of course, meeting treatment goals is not necessarily a sign of poor adher-
ence. However, some treatment failures are due to nonadherence, and interventions
to reduce this phenomenon can improve treatment outcomes.
Ways to improve adherence include providing clear information to the patient,
encouraging regular patterns of behavior by linking medications to the patient’s agenda
and attempting to increase patient motivation through emotional support. Effective
interventions usually include a combination of information, counseling, reminders,
self-monitoring of treatment outcomes, as well as motivational interviewing [122, 123].
Motivational interviewing is a communication style designed to help patients
address not only nonadherence but also other behaviors such as substance abuse.
Specific strategies include exploring the patient’s values and motivation, providing
health information, and asking questions that promote change. Findings from recent
meta-analyzes support the use of motivational interviewing to promote weight loss
[124] and treatment adherence [125]. A 2020 review of motivational interviewing
teaching methods found that the most commonly used interventions included role-
playing, lectures, and videos/demonstrations. The effectiveness of the interventions
suggests that their implementation in medical schools is feasible and effective for
student acquisition of knowledge and skills [126].
2.11 Managing Difficult Encounters and Delivering

Bad News
The most common difficult doctor–patient encounters involve the delivery of a seri-
ous diagnosis, disclosing a medical error, and end-of-life planning. Breaking bad
news presents the physician with the dilemma between respecting the patient’s
autonomy by disclosure or adhering to the principle of beneficence by hiding the
bad news. Telling the truth, especially when done blatantly, can have an undesirable
emotional effect. Conversely, deception can damage the patient’s trust when he or
she learns the truth, whereas information can alleviate the patient’s uncertainty and
anxiety and support his or her self-care.
2.11 Managing Difficult Encounters and Delivering Bad News 47
Until the 1960s, physicians believed that patients should be protected from the
truth. Today, that view is considered a misconception. A 2011 review found an asso-
ciation between adequate information provision and patients’ health-related quality
of life, and an inverse association between the amount of information provided and
patients’ depression and anxiety [127]. Still, in 2014, only 46% of cancer patients
were satisfied with the way they were told bad news [128], and a 2018 study found
poor agreement between clinicians’ and patients’ perceptions of how bad news
should be communicated [129].
2.11.1 Patients’ Preferences
Studies of patients’ preferences for dealing with bad news are biased by differences
between respondents and nonrespondents. Patients appear to react to bad news with
a sequence of denial (“That’s not true!”), anger (“Why did this have to happen to
me?”), bargaining (“Maybe it’s not so bad after all?”), and acceptance (“I am
ready”) [130]. Patients’ responses may depend on where they are in this sequence at
the time of the survey.
Surveys found that the most important predictors of patients’ satisfaction with
the way bad news was delivered were their level of understanding and the duration
of the encounter. Adequate time and an undisturbed environment were two of the
most important requests. Patients wanted to be informed about expected symptoms,
the course of the disease, and changes in their daily lives; prognosis ranked second
among requests for information. Patients also wanted their physicians to allow them
to ask questions. About half of the patients reported that it was not possible to make
important decisions during the first meeting and wanted a second one, preferably
accompanied by a relative [128]. Studies using video-based encounters with physi-
cians have shown that most respondents preferred a patient-centered communica-
tion style [131]. Reasons for patient dissatisfaction, up to the point of discontinuing
treatment, included negative physician behavior, use of medical terminology, and
lack of support [132]. Lack of emotional support could not be fully compensated by
high-quality information and vice versa [133].
2.11.2 Care-Providers’ Preferences
Physicians’ attitudes toward the delivery of bad news have been studied through
surveys, self-reports, direct observation, and controlled studies. All of these
methods are subject to bias: physicians who respond to surveys or have research-
ers observe them at work are likely to be more confident about their interper-
sonal skills than those who do not. Reported attitudes may not reflect actual
behavior, and observed behavior may differ from unobserved physician–patient
encounters.
A 2010 survey of pediatric residents and attending physicians at an academic

center found that they felt inadequately prepared to deliver bad news to patients and
families [134]. Focus groups and interviews with oncologists revealed that, although
they acknowledged the importance of breaking bad news appropriately, their com-
munication habits were affected by personal experiences and the wishes of the
patient’s family [135]. The statement “Ask the patient how much he wants to know”
was ranked second by patients and seventh by physicians, and the statement “Tell
the patient the bad news clearly and understandably” was ranked third by patients
and sixth by physicians [136]. Other authors have reported similar inconsistencies
between physicians and patients when it comes to delivering bad news [137].
Oncologists who had to deliver bad news have reported feeling varying levels of
stress and anxiety [138]. Physicians may feel threatened by the patient’s emotional
response. They may use defense mechanisms, such as focusing on the biomedical
aspects of the disease or nonverbal behaviors that indicate time pressure. Such
defense mechanisms weaken the alliance with the patient. It has been suggested that
instead of suppressing their anxiety, physicians should try to identify its source (the
effect of the information on the patient? their ability to deliver bad news? what the
patient might ask? and how to respond?), explore the patient’s point of view, and let
the patient express his or her feelings instead of defending themselves as if they
were being blamed [139].
Controlled trials encounter methodological difficulties and have yielded sparse
evidence on the effects of different approaches to informing patients. A major dif-
ficulty is the selection of study populations. In theory, study participants should be
patients who are unaware of their disease. In practice, patients referred to oncology
units differ in terms of the information they have received from previous caregivers
and the extent to which they are aware of and reconciled with their diagnosis.
Second, the interventions studied were primarily technical: providing printed infor-
mation to the patient, recording and giving the tape to the patient, contacting the
patient by telephone to determine further information needs, and a final letter docu-
menting the conversation with the patient.
Patients place a high value on receiving audio recordings of the encounter and
most of them benefit from listening to these recordings [140]. Recording the consul-
tation for later use by the patient improved the patient’s satisfaction, recall, and
decision-making. Consultation recordings positively influenced patients’ affective,
cognitive, and behavioral outcomes, and the negative effects of consultation record-
ings were small [141].
2.11.3 Suggested Guidelines
The limitations of studies on the communication of bad news do not allow defin-
itive recommendations. The only evidence-based guideline suggests gaining
insight into patients’ prior knowledge of their disease, the amount of
2.11 Managing Difficult Encounters and Delivering Bad News 49
information they want to receive about diagnosis and treatment, and their desire
to share information with their families [142] in addition to providing patients
with audio recordings of the encounter [141]. The remaining guidelines are
based on the need to acknowledge the stress physicians may feel when deliver-
ing bad news, the importance of an environment that ensures privacy and limits
interruptions, clear wording, avoidance of medical jargon, time for patients to
process bad news, and to the awareness that different patients need different
information.
The need to break bad news to the patient can arise in two situations. Even before
the diagnosis is made, the physician may learn what a cancer diagnosis means to the
patient by asking “Do you have any thoughts about what caused your disease?”
Sometimes the patient will express concern about the possibility of cancer. In such
cases, the concern should be accepted as reasonable, but other diagnostic possibili-
ties should also be mentioned. In the second situation, the bad news is delivered by
a physician who is seeing the patient for the first time, such as the surgeon who
performed the biopsy.
In such cases, the conversation with the patient should take place in the pri-
vacy of the physician’s office, not in the hallway, not on the phone, and not dur-
ing rounds [143]. The physician can say, “The test results are already in. If you
would like, I can tell you about your disease and its treatment,” “Would you like
to talk to me in private or with someone else present?” and “Would you like me
to talk to someone in the family first?” Most patients, especially those from lower
socioeconomic backgrounds, have difficulty taking the initiative to seek informa-
tion. These difficulties may be interpreted by physicians as reluctance to obtain
information. The distinction between a patient’s difficulty in asking and his or
her reluctance to receive information can be made by expressing a willingness to
answer any question in an atmosphere of unlimited time. Physicians should find
out what the patient knows about his or her illness, expectations, and plans for
the future by saying, “Before I answer your questions, I want to know what you
already know about your illness.” Other questions that can give the physician
insight into the patient’s preferences include: “It’s important for me to know
what you think about your disease,” or “Of all these things, what worries you
the most?”
Patients need time to absorb information. Therefore, it is important to make an
appointment for the next meeting as soon as possible to answer further questions.
The physician’s role is to be available and be a constant source of information and
support while communicating to the patient that expressions of sadness, hopeless-
ness, or anger are normal. If the patient wants to consider treatment options or seek
another opinion, he or she should be allowed to do so. Doctors should be ready to
accompany the patient even when a cure is not possible; convey to the patient the
message that fear of death should not interfere with the joy of living; prepared to
respond “I do not know”; and absorb the patient’s anger and doubts about his or her
professional abilities.
2.11.4 Teaching How to Disclose Bad News
Teaching how to handle difficult encounters cannot employ real patients. It rather
uses small group discussions and role-playing with standardized or analog patients
(healthy individuals asked to put themselves in the patients’ shoes) followed by
reflections, feedback, and written presentations that allow students to reflect and
gain a deeper understanding of how to deliver bad news. These teaching approaches
are feasible and highly rated by learners [144, 145]. Most instructional interventions
were associated with improvement in observer-rated skills [146]; however, evidence
comparing different types of training was lacking [147].
In 2000, Baile et al. developed the SPIKES—a six-step protocol for breaking bad
news that includes the four main goals of bad news delivery: Asking for information
from the patient, conveying medical information to the patient, providing support, and
obtaining the patient’s cooperation in developing a treatment plan. A 2019 survey of
Canadian medical schools found that 10 of 12 responding schools used the SPIKES
model and that the guidelines it contains were consistent with patients’ preferences for
breaking bad news. Content analysis of patient responses revealed that the most impor-
tant components of SPIKES were clinicians’ expressions of empathy, explanations of
the diagnosis and its implications, and asking the patient if they understood [148].
Other authors have suggested the following principles for handling difficult
encounters: “Do not be judgmental” and avoid turning the conversation into an
argument; “Do not mislead” and do not try to soften the message by being evasive;
“Do not confuse vagueness with compassion” and do not obscure the core message;
“Offer hope and comfort” by pointing a way forward without downplaying the seri-
ousness of the situation; “Be calm and soothing” and avoid an accusatory, dismis-
sive, or condescending tone; “Be an active listener” without interrupting and by
occasionally paraphrasing what is being said; and “Pauses are your friend” by
speaking slowly and clearly and always watching for the listener’s reaction. Pauses
and periods of silence demonstrate respect and allow each party to understand what
is being said [149].
The main difficulty in evaluating bad news teaching measures is how to assess
outcomes. A comparative analysis of measurement instruments and assessors has
shown that different assessment instruments lead to different results [150]. Similarly,
the 2011 review paper I referred to earlier found that only one of eight studies of
educational interventions showed a positive association with better quality of life
[127]. Therefore, the delivery of bad news has yet to be validated by its impact on
patient health.
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Chapter 3
The Physical Examination
3.1 Introduction
In contrast to the changes that have occurred in the teaching of doctor–patient com-
munication since the 1970s, the teaching of physical examination (PE) has remained
the same over the past century. Textbooks of PE continue to provide an unselective
array of signs, including those no longer considered useful, while important PE
signs are often excluded [1], and as recently as 2018, 56% of medical schools in the
USA taught the “head-to-toe”/“complete”/“comprehensive”/“routine” PE along an
organ-based sequence [2].
Teaching head-to-toe PE has been criticized because it is learned but rarely put
into practice and does not fully achieve its objective. Students demonstrate poor PE
skills during their clerkships [3]. In 2011, US medical graduates scored an average
of 78% on history taking on the Medical Licensing Examinations, but only 60% on
PE [4]. PE errors have been reported to lead to misdiagnosis in up to 5% of outpa-
tients [5], in 22 of 100 consecutive inpatients [6], and a 2015 study confirmed that
PE errors are preventable causes of medical mistakes [7]. Finally, a 2020 survey of
interns at an academic hospital found that 45% of respondents had witnessed a
patient safety issue that was due to inadequate PE [8].
Consequently, since the 1970s, there have been calls to teach PE by encouraging
students to approach clinical problems in the same way that physicians approach
diagnostic problems, namely by making diagnostic hypotheses and then conducting
a “reflective”/“hypothesis-driven”/"selective”/“targeted”/“focused”/“purpose-
driven” PE to test those hypotheses [3, 9–16]. Indeed, when students are confronted
with clinical problems, they can form diagnostic hypotheses, and instructional inter-
ventions that promote expert reasoning are feasible at all stages of medical educa-
tion. However, this approach may miss an unexpected finding that could have been
detected by a head-to-toe PE and hence the ambiguity about the optimal teaching
method of PE [17].

Switzerland AG 2023
60 3 The Physical Examination
The objective of this section is to suggest that teaching PE should first overcome
specific barriers to student learning, second, that teaching should be transferred
from hospitals to community clinics where ancillary tests are not readily available,
and third, to explain the Bayesian approach to using additional data to reduce diag-
nostic uncertainty.
3.2 Barriers to Teaching and Learning Physical

Examination Skills
3.2.1 Attitudes to the Physical Examination
It has been claimed that “the traditional course of physical diagnosis … does not
match what students … see during their clinical years. They are surprised that the
house staff … carry very few of the instruments that the student has acquired: Reflex
hammers are occasionally sighted, but ophthalmoscopes are quite rare” [18]. Too
often, students interpret the difference between the PE, which is performed by phy-
sicians, and the head-to-toe PE, which they are required to perform, as an indication
that the latter is not important, but rather a time-honored ritual for the record.
The debate over whether PE has outlived its usefulness began with the introduc-
tion of X-rays in the early twentieth century [19]. The diagnostic value of PE signs
is difficult to assess because attempts to determine their sensitivity and specificity
usually do not take into account the severity of the disease and the examiners’ skills.
The sensitivity of PE signs increases with the severity of the disease [20], and dif-
ferent skills of the examiners reduce the reliability of PE findings [21].
These two biases may have led to an underestimation of the diagnostic value of
the PE. A 2010 review of the value of the PE respiratory signs found that most had
low to moderate reliability and a sensitivity of 0.5 or less. These results argue against
the utility of PE for screening asymptomatic individuals. Screening for disease
requires the test to have a high sensitivity well above 0.7. The review also found
likelihood ratios-negative (LR−) of 0.3 or less for some PE findings such as dull-
ness on percussion and LR+ values of 4.0 or more for findings such as the asym-
metric expansion of the chest [22]. These high specificities and high LRs+ indicate
that some PE findings are useful in certain clinical contexts. Therefore, a carefully
performed PE, aimed at exploring a diagnostic hypothesis, as opposed to a PE,
aimed at detecting disease in an asymptomatic individual, remains one of the cor-
nerstones of clinical practice.
3.2.2 “Inherited” Errors
Textbooks of the PE describe alternative examination techniques, e.g., of the thyroid

gland (facing or behind the patient) or the spleen (from the patient’s right or left
side). Apart from such legitimate variations, however, I have often found glaring
3.3 Coping with Barriers to Learning the Physical Examination 61
errors in students’ PE skills that could be traced back to their tutors. Other authors
have commented similarly on the poor PE skills of residents, noting that relying on
them to teach PE can lead to situations in which “the blind lead the blind” [23].
Inherited errors included defining paradoxical breathing, synchronizing the exam-
iner’s hand movement with the patient’s breathing during palpation of the liver mar-
gin, palpation of the thyroid gland, and assessment of chest expansion. Students and
faculty whom I confronted with such errors had to be shown the correct technique in
textbooks before they admitted that what they had been taught was wrong. Tutors
needed to be reminded of the anatomical landmarks of the Lewis angle (second inter-
costal space) and the tip of the scapula (seventh intercostal space). They also needed
to be shown that the diaphragm is located in the sixth, eighth, and tenth intercostals
on exhalation; that emphysema can be diagnosed by the absence of cardiac dullness
on percussion; and that limiting the examination of the lungs to the back leaves the
upper lobe unexamined. Therefore, students should be required to read the appropri-
ate chapter in textbooks after their tutors demonstrate a particular PE skill and dis-
cuss with their tutors possible discrepancies in the technique of the examination.
3.3 Coping with Barriers to Learning

the Physical Examination
3.3.1 Teaching the Reflective Physical Examination1
The reflective PE is guided by one or more of the following five goals (Table 3.1):
Search for essential signs of life-threatening conditions in all patients and especially
in patients in acute distress; search for important signs to test diagnostic hypotheses
in patients with focal complaints; and search for important signs that would provide
a diagnostic clue in patients without focal complaints. The fewer diagnostic clues
that can be derived from the medical history, the broader the differential diagnosis
and the more comprehensive the required PE. A reflective PE is also purposeful if it
aims to follow patients with a known chronic disease. For example, a change in
treatment should be considered when patients with vascular disease develop foot
ulcers or when patients with asymptomatic valvular disorders develop heart failure.
It is a widely held belief that asymptomatic individuals should have a complete
annual examination. Although this belief was questioned as early as 1945 [24], it
was not challenged until the 1970s, when Frame and Carlson [25] recommended
replacing the annual examination with periodic examinations tailored to a patient’s
1
Parts of this section were published in:
Benbassat J, Schiffmann A. An approach to teaching the introduction to clinical medicine. Ann
Intern Med. 1976;84:477–81. With permission of the American College of Physicians.
Benbassat J, Baumal R, Heyman SN, Brezis M. Viewpoint: suggestions for a shift in teaching
clinical skills to medical students: the reflective clinical examination. Acad Med. 2005;80:1121–6.
With permission of Wolters Kluwer.
Table 3.1 Examples of symptoms and signs to be sought in specific patient contexts to test
diagnostic hypotheses (parentheses) by the purpose of the examination (adapted from [9] with
permission from Wolters Kluwer)
Purpose of Patient population and context
examination (one or
more of the
following) Pediatric Adult Geriatric
Detect essential signs Stridor (acute croup) Sudden tachycardia, Neglect and multiple
of life-threatening cannonball waves in a traumata in an
conditions patient with institutionalized patient
myocardial infarction (abuse)
(ventricular
tachycardia)
Test diagnostic Pulmonary Reduced knee jerk Tender L1 in a patient
hypotheses in consolidation in a and muscle weakness with low back pain and
patients with focal child with fever, of the leg in a patient osteoporosis
complaints cough, dyspnea, and with low back pain (compressed vertebral
abdominal pain (herniated disk) fracture)
(pneumonia)
Search for a cue for Neglect in failure to Skin rash in a patient Swollen tympanic
diagnosis in patients thrive (malnutrition) with fever (erysipelas) abdomen in a confused
with nonspecific patient (fecal
complaints impaction)
Monitor a known Fever in a patient with Leg ulcers in a Proteinuria in a patient
disease for cystic fibrosis diabetic patient with multiple myeloma
complications (pneumonia)
Screening for Hypertension Breast cancer Inappropriate
diseases for which medications
early treatment has
been shown to reduce
mortality
age, gender, and risk indicators for disease. These periodic examinations would
consist of screening for high-risk behaviors and focus on the most common causes
of death in persons of the same gender and age. Within a decade, these recommen-
dations were supplemented by those of the Canadian Task Force on the Periodic
Health Examination and the US Preventive Services Task Force.
Teaching reflective PE appears to be more effective than teaching head-to-toe PE
[11, 13]. By asking students to search for relevant physical findings, the reflective
PE transforms a routine task into an intellectually exciting experience; it is consis-
tent with current trends in education that promote reflective practice [26], and it
stands to reason that the gap between experienced clinicians and novices is more
effectively narrowed by teaching the reflective than the head-to-toe PE. Students’
diagnostic hypotheses may be nonspecific (e.g., “shortness of breath may be caused
by disease of the heart or lungs”). However, even nonspecific hypotheses encourage
a further search for information (“What findings suggest cardiac disease?”).
The advantages of the head-to-toe PE are that it introduces students to the skills
needed for practice; it is important in patients with non-localizing complaints or
symptoms that originate in multiple organ systems; it may detect unsuspected findings
in up to 5% of patients [27]; it assures both physicians and patients that a complete

examination has been performed, and every physician can recall instances of seren-
dipitous diagnoses made by adherence to a head-to-toe PE. Hence the attempts to
define an optimal mix of head-to-toe and reflective PEs. In 2014, Gowda et al. devel-
oped a 45-maneuver “core” PE, which should be performed on every newly admitted
patient and supplemented by a reflective PE. Certainly, a combined reflective and
head-to-toe PE is more likely to uncover important PE findings than alternative teach-
ing methods. However, I suggest teaching students that in situations where time is
short, reflective PE is more likely to yield important findings than head-to-toe PE.
3.3.2 Learning for Mastery
Teachers often disagree about what level of competency is required of students

when they graduate, i.e., what should be taught for mastery, what should be taught
for general knowledge only, or what should be taught for an intermediate level of
competency. The concept of learning for mastery was introduced by Bloom in 1968
[28]. Its unique feature is derived from the view that uncorrected errors lead to
learning difficulties. Therefore, it begins by dividing the subject matter into small
units. Each student’s progress is assessed through supervised practice, and students
are not allowed to move on to another unit until they have mastered the previous one.
I suggest that the basic clinical skills (patient interviewing, PE, and self-directed
learning) be taught for mastery. Learning for mastery is more likely to improve the
teaching of PE than the current expectation that students’ PE skills will improve
with repeated reinforcement during the clerkship rotations. First, a low initial stan-
dard of required proficiency may persist into the future. Second, repeated reinforce-
ment of PE throughout the curriculum spreads the responsibility for teaching among
many, so that individual tutors are no longer accountable for the outcomes of their
teaching. Third, the assumption that students, having been introduced to PE during
the preclinical program, will improve their examination skills during the clerkship
is inconsistent with reports of deterioration in PE skills during the clerkship [29]
and in cardiology [30] and respiratory [31, 32] PE skills with seniority.
3.3.3 Integrating Hand-Held Devices into Teaching

the Physical Examination2
The ability to use PoCUS is commonly considered the domain of specialists.

However, the miniaturization of diagnostic technology signals a shift in practice
that should begin with student education.
2
Benbassat J, Gilon D. Teaching the physical examination by context and by integrating hand-
held ultrasound devices. Med Teach. 2020;42(9):993–99. With permission from Taylor and Francis.
PoCUS skills can be taught to medical students who seem to enjoy experiential
training programs. PoCUS training is commonly integrated into gross anatomy and
PE courses. It provides real-time feedback on examination results, thereby improv-
ing students’ traditional PE techniques [33, 34]. Incorporating PoCUS into PE edu-
cation can lead to more reliable and rapid bedside diagnoses, triage, and appropriate
treatment and reduce patient management costs [35]. Medical students trained in
PoCUS for 18 h reportedly detected pathology in 75% of patients with known heart
disease, whereas cardiologists using a stethoscope did so in only 49% [36].
3.3.4 Teaching Physical Signs by Context and Importance
As discussed below, the diagnostic value of a given sign is determined by its sensi-
tivity, specificity, and the pretest probability of the diagnosis in question. The pretest
probability of the diagnosis depends on the clinical context. Therefore, I propose
structuring both teaching and textbooks of PE according to clinical context rather
than organ systems and limiting head-to-toe PE to patients with nonlocalized com-
plaints or symptoms originating in multiple organ systems. Textbook sections would
consist of the diagnostic hypotheses to be tested (e.g., “Does this patient have asci-
tes?”) and provide answers based on selected physical signs that are reproducible,
sensitive, and specific enough to alter the likelihood of a diagnosis [11].
I also suggest distinguishing between essential, important, and optional PE signs.
Table 3.2 provides examples of essential PE and point-of-care ultrasound (PoCUS)
findings in life-threatening conditions. Students would be expected to immediately
treat hypoxemic patients who have any degree of respiratory abnormality (tachy-
pnea, bradypnea, apnea, labored breathing, stridor, accessory muscle recruitment,
or paradoxical breathing) with oxygen and look for stridor (croup, epiglottitis),
wheezing (bronchial asthma, bronchitis), decreased breath sounds and altered per-
cussion sounds (pneumothorax or pleural effusion), and signs suggestive of pulmo-
nary embolism.
Students would be also expected to recognize cannonball jugular waves associ-
ated with tachycardia (ventricular tachycardia); S3 gallop; use PoCUS to determine
inferior vena cava caliber and differentiate between hypovolemic, obstructive, car-
diogenic, and distributive shock [37]; detect decreased left ventricular contractility
or right ventricular strain in patients with hypoxemia; acute aortic regurgitation in
patients with infective endocarditis; and acute mitral regurgitation or ventricular
septal defect in patients with myocardial infarction who develop sudden left ven-
tricular failure [38].
Important physical signs (Tables 3.3 and 3.4) are those that may influence the
likelihood of disease that is not immediately life-threatening in patients with and
without focal symptoms. The diagnostic errors in primary care that could be attrib-
uted to PE were hypertension, knee and ankle effusions, hepatomegaly, cellulitis,
pneumonia, and pleural effusion [5]. In hospitalized patients, the overlooked find-
ings were purulent thrombophlebitis, toe gangrene, dialysis catheter tunnel infec-
tion, and erysipelas [6].
Table 3.2 Examples of symptoms and signs of possible life-threatening conditions in specific contexts. Adapted from
[39] with permission from Taylor and Francis
Context Sign or symptom Possible cause/diagnosis
Any context Preoccupation with death, hopelessness, Depression; suicide risk
acting recklessly (e.g., speeding), calling
people to say goodbye, getting affairs in
order, saying things like “everyone would
be better off without me”
Absent carotid pulse Cardiac arrest, hypovolemic, obstructive, cardiogenic,
or distributive shock
Sweaty cold extremities, capillary refill Low cardiac output, hypovolemic, obstructive,
time > 2 s; S3 cardiogenic, or distributive shock
Pulse oximetry: Low oxygen levels Hypoxemia
Sudden pain at any location Vascular event (occlusion, dissection, or hemorrhage),
obstruction of a hollow organ
Sensory loss, muscle weakness, urinary Spinal cord compression, spinal stroke, Brown-
retention sequard syndrome
Sudden abnormalities in consciousness Cerebrovascular ischemic or hemorrhagic event
and orientation
Diastolic pressure above 120 mm, retinal Malignant hypertension
hemorrhages
Abdominal pulsating mass Aneurysm of the abdominal aorta
Tachycardia with “cannonball” jugular Ventricular tachycardia
waves
Abdominal Peritoneal signs Acute appendicitis, ruptured perinephric abscess,
pain, fever pelvic inflammatory disease, cholecystitis/
cholelithiasis, pancreatitis, bowel obstruction, ovarian
cyst, perforated viscus, ectopic pregnancy,
retroperitoneal hemorrhage
Sudden chest Reduced breath sounds, change in Pneumothorax
pain percussion note, tracheal deviation.
PoCUS: Pneumothorax
S3, systolic blood pressure < 100 mmHg; Myocardial infarction, reduced ejection fraction,
PoCUS: Reduced left ventricular myocarditis
contractility
Differences in blood pressure or pulse Aortic dissection
amplitude on the right radial and femoral
arteries
Pericardial rub; PoCUS: Pericardial Pericarditis, myocardial infarction
effusion
Kussmaul’s sign (paradoxical elevation of Severe heart failure, pulmonary emboli, right
jugular pressure during inspiration), ventricular infarction, constrictive pericarditis
elevated jugular pressure
Sudden left Tachycardia, Duroziez’s sign, early Acute aortic regurgitation
ventricular diastolic murmur at the left fourth–fifth
failure in a space. PoCUS: Aortic regurgitation
patient with
bacterial
endocarditis
Sudden left Systolic murmur intensifies during hand Mitral regurgitation, ventricular septal defect
ventricular grip
failure in a
patient with
myocardial
infarction
(continued)
Table 3.2 (continued)

Hypoxemia or Stridor, fever Croup, epiglottitis
any respiratory Stridor, swelling of lips and tongue after Anaphylaxis
abnormality / exposure to vaccination, medication, bee
distress sting
Stridor, while swallowing Aspiration
Stridor, at night, during sleep Gastroesophageal reflux with aspiration
Shallow breathing (hypopnea), paradoxical Life-threatening bronchial asthma, left ventricular
breathing, confusion, silent chest failure, myasthenia gravis, amyotrophic lateral
sclerosis, Guillain-Barre, drugs
Bradypnea Exposure to toxins, drugs, and head injury
Reduced breath sounds and changes in Pneumothorax, pleural effusion
percussion, and tracheal deviation.
PoCUS: Pneumothorax, pleural effusion
Swollen leg, pleuritic chest pain, syncope, Pulmonary emboli
hemoptysis, tachycardia, jugular
distention, Kussmaul’s sign
Fever, acute respiratory symptoms, acute Pneumonia
cough heart rate > 120/min, asymmetric
expansion of the chest, increased vocal
fremitus, dullness on percussion, pleural
friction rub, bronchial breathing, increased
vocal resonance, inspiratory crackles
Jugular distention, respiratory rales, Acute exacerbation of chronic obstructive airway
sweaty cold extremities disease, primary pulmonary hypertension
Wheezing, absent cardiac dullness. Bronchial asthma, emphysema, acute bronchitis,
Peak-flow meter: Reduced airflow COPD exacerbation
Uplift of the left or right lower sternal Pulmonary hypertension
area, palpable or loud P2. PoCUS: Right
ventricular strain and hypertrophy
Tachypnea Left ventricular failure, pulmonary emboli,
pneumothorax, hyperthyroidism, pneumonia
Periodic breathing (Cheyne–stokes Heart failure, increased intracranial pressure
respiration, biot breathing) (meningitis, subarachnoid hemorrhage, intracerebral
hemorrhage), stroke, head injury, drugs
Elevated jugular pressure; Kussmaul’s sign Severe heart failure, pulmonary emboli, right
(paradoxical elevation of jugular pressure ventricular infarction, constrictive/restrictive
during inspiration) pericarditis, tamponade
Jugular distention, abdomino-jugular Left ventricular failure, high pulmonary capillary
reflux, apical impulse lateral to the wedge pressure (>/ = 18 mmHg)
midclavicular line, S3. PoCUS: Reduced
left ventricular function
Dyspnea, decline in blood pressure on Massive pulmonary embolus
sitting or standing, paradoxical pulse,
swollen leg, cardiac third sound,
asymmetric chest percussion and breath
sounds
Dyspnea, decline in blood pressure on Tension pneumothorax
sitting or standing, paradoxical pulse,
asymmetric chest percussion and breath
sounds. PoCUS: Pneumothorax
Chest trauma, respiratory rate > 20/min, Hemo-pneumothorax
breath sounds unilaterally diminished.
PoCUS: Pleural air and effusion

Shock, decline Dry axilla, dry mucous membranes of Hypovolemia: Dehydration, blood loss
in blood mouth, PoCUS: Reduced inferior vena (gastrointestinal, ruptured aneurism, ectopic
pressure on cava diameter pregnancy)
sitting or Smell of acetone Diabetic acidosis
standing
Excessive urine production, PoCUS: Hypovolemia: Diabetic acidosis, Addisonian crisis,
Reduced inferior vena cava diameter salt losing nephritis
Dyspnea, S3, PoCUS: Reduced left Cardiogenic shock: Myocardial infarction, end-stage
ventricular contractility cardiomyopathy/valvular heart disease
Fever or hypothermia. PoCUS: Normal Distributive shock: Sepsis
inferior vena cava diameter
Exposure to vaccination, medication, bee Distributive shock: Anaphylaxis
sting, PoCUS: Normal inferior vena cava
diameter
Abdominal pain, chest pain, vomiting, Distributive shock: Porphyria
confusion, fever, tachycardia, PoCUS:
Normal inferior vena cava diameter
Trauma, no blood loss. PoCUS: Normal Distributive shock: Cervical or thoracic spinal cord
inferior vena cava diameter injury
Asymmetric tenderness and swelling of the Obstructive shock: Pulmonary embolus
calf/leg. PoCUS: Increased size of the
right ventricle relative to the left ventricle
Chest pain, paradoxical pulse. PoCUS: Obstructive shock: Pericardial tamponade
Pericardial effusion
Chest pain, asymmetric chest percussion Obstructive shock: Tension pneumothorax
and breath sounds, PoCUS: Pneumothorax
Fever Neck rigidity, skin petechiae Meningitis
Roth’s spots on funduscopic examination, Infective endocarditis
splenomegaly, finger clubbing
Headache, Neck rigidity Subarachnoid hemorrhage
acute visual Papilledema High intracranial pressure
change, or
diastolic blood Retinal hemorrhages in patients with high Hypertensive encephalopathy
pressure of blood pressure
>120 mmHg Retinal artery occlusion Arteritis
Retinal hemorrhages, cotton-wool spots, Septicemia, bacterial endocarditis
Roth’s spots
Transient/ Reduced or absent A2, ejection murmur on Aortic stenosis
permanent loss the right clavicle and the right 2d or left
of fourth–fifth space with carotid radiation,
consciousness delayed upstroke of carotid pulse; PoCUS:
or confusion Aortic stenosis
Differences in blood pressure between the Subclavian steal syndrome
arms
Elevated blood pressure Intracranial lesion (stroke or brain tumor)
Asymmetric facial, arm, and leg weakness; Stroke, embolic, thrombotic, hemorrhagic
speech defect
History of asystole, syncope, right Asystole
ventricular failure
Table 3.3 Examples of “important” symptoms and signs to be sought in specific contexts to test
diagnostic hypotheses in patients with focal complaints
Context Sign or symptom Possible respiratory cause/diagnosis
Fever, sore throat, Tonsillar exudates, cervical Streptococcal tonsillitis
no cough adenopathy
Running nose, No tonsillar exudates Viral respiratory infection
cough, sore throat
Fever, colored nasal Blurred sinus Sinusitis
discharge trans-illumination
Chronic respiratory Hyper-resonance, reduced Chronic obstructive airway disease
symptoms breath sounds. Peak-flow
meter: Reduced airflow
Reduced diaphragmatic Emphysema
motion, barrel chest. Peak-flow
meter: Reduced airflow
Dry crackles Interstitial lung disease/fibrosis
Clubbing of the fingers Lung tumor, bronchiectasis, lung
abscess, empyema, interstitial fibrosis,
cystic fibrosis
Shortness of breath, Typical angina, prior Acute on chronic ischemic heart disease,
chest pain myocardial infarction, peripheral arterial disease
ankle-brachial index <0.9
Systolic murmur, pulsus Aortic stenosis
parvus and tardus, PoCUS:
Aortic stenosis
Apex beat lateral to the Heart failure: Low ejection fraction,
midclavicular line, elevated increased left ventricular diastolic
jugular pressure, abdomino- volume, pulmonary capillary wedge
jugular reflux, S3, abnormal pressure > 12 mmHg
Valsalva response, PoCUS:
Reduced left ventricular
function
Sustained apex beat Aortic stenosis and regurgitation,
cardiomyopathy, ventricular aneurysm
Right ventricular uplift, Pulmonary hypertension, pulmonic
PoCUS: Right ventricular stenosis, atrial septal defect, tricuspid
strain and hypertrophy regurgitation, mitral stenosis and
regurgitation
Chaotic irregular rhythm Atrial fibrillation, premature beats
Local chest tenderness Musculoskeletal pain

Context Sign or symptom Possible respiratory cause/diagnosis
Peripheral edema or Normal central venous Hypoalbuminemia: Chronic liver disease,
ascites pressure nephrotic syndrome, local venous
obstruction
Elevated jugular pressure, Left or right ventricular failure, chronic
hepatomegaly lung disease, primary pulmonary
hypertension, pulmonic stenosis
Elevated jugular pressure and Constrictive pericarditis
retracting apex beat,
Kussmaul’s sign
Elevated jugular pressure, Severe tricuspid regurgitation
pulsatile hepatomegaly
Jugular distension, Obstructive airway disease, primary
hepatomegaly pulmonary hypertension
Peak-flow meter: Reduced
airflow. PoCUS: Right
ventricular strain and
hypertrophy
Hypertension Different blood pressure, arms, Coarctation of the aorta
and legs, continuous murmur
over the back
Abdominal bruits with Reno-vascular disease
systolic-diastolic components
Claudication Foot ulcers, atrophic skin, Chronic leg ischemia
pallor on elevation, rubor on
lowering, asymmetric
coolness, different blood
pressure between arms and
legs
Auscultation of the heart has traditionally been considered an important clinical

skill. However, residents [23], pediatricians [40], and family physicians [41] per-
form poorly in interpreting audiotaped cardiac murmurs. Therefore, the ability to
diagnose nonemergent abnormalities such as atrial septal defect, ductus arteriosus,
and Austin-Flint murmur on real patients, mannequins, or audiotapes by ausculta-
tion does not seem to be a realistic goal of undergraduate medical education and
should be considered optional. I suggest that students should be expected to be able
to distinguish between normal and abnormal findings on auscultation of the heart,
which might indicate the need for further investigation.
The least important (optional) PE signs (Table 3.5) are those that are no longer
used because of the availability of easily performed ancillary tests. For example,
PoCUS can detect left ventricular dysfunction at an earlier stage than pulsus
Table 3.4 Examples of “important” signs to be sought to find a cue for a diagnosis in patients with
nonspecific complaints (e.g., fatigue, palpitations) and without localizing symptoms
Sign Possible cause/diagnosis
Goiter, tachycardia, moist and warm skin, eyelid Hyperthyroidism
retraction, eyelid lag, fine finger tremor
Pallor Anemia
Cool, dry, and coarse skin, “hypothyroid speech,” Hypothyroidism
bradycardia, delayed ankle reflex
Tachycardia, transient slowing of the pulse during Sinus tachycardia
vagal maneuvers
Tachycardia, abrupt slowing of the pulse during vagal Paroxysmal supraventricular tachycardia
maneuvers
The pulse quickens with inspiration, slows with Sinus arrhythmia
expiration
Pause in otherwise regular pulse rate Premature contractions, heart block
Pulse pressure > 80 mmHg Aortic regurgitation
Displaced apex beat lateral to the midclavicular line; Left ventricular failure
elevated jugular pressure, positive abdomino-jugular
test, S3 gallop. Abnormal Valsalva response
Sustained movement of the left or right lower sternal Mitral stenosis, pulmonary
area hypertension, atrial septal defect,
tricuspid regurgitation, mitral
regurgitation
Palpable or loud P2 Pulmonary hypertension
Loud S1 Thyrotoxicosis, prolapsed mitral valve,
mitral stenosis
Faint or absent S1 Myocardial infarction, left bundle
branch block
Regular rhythm, varying intensity of S1 Atrioventricular dissociation
Fixed wide splitting of S2 Atrial septal defect
A systolic murmur from the apex to the anterior Mitral regurgitation
axillary line
Physiologic wide splitting of S2 P2 late: Right bundle branch block,
pulmonic stenosis, cor pulmonale, A2
early: Mitral regurgitation
Paradoxical splitting of S2 Left bundle branch block, aortic
stenosis, ischemic heart disease
A mid-systolic click followed by a murmur Mitral valve prolapse
alternans. Hand spirometry provides an easier and more accurate assessment of

obstructive airway disease than Hoover sign and pulsus paradoxus. Spirometry can
also alert physicians to the possibility of mild pulmonary disease and can be used to
monitor patients with conditions such as asthma and cystic fibrosis. Pulse oximetry
can detect decreased blood oxygenation at an earlier stage than central cyanosis,
and the availability of laboratory measurements of thyroid function has reduced the
importance of ocular signs of hyperthyroidism beyond lid lag.
Table 3.5 Examples of optional symptoms and signs

Sign or symptom Possible cause/diagnosis
Cyanosis Hypoxemia
Pulsus paradoxus in a patient with engorged Bronchial asthma
neck veins, tachycardia, dyspnea
Skodaic resonance Hyper-resonance on percussion above a
pleural effusion
Grocco’s triangle Right-angled triangle of dullness over the
posterior region of the chest opposite a large
pleural effusion
Kronig’s isthmus A narrow band of resonance over each lung
apex. Reduced with infiltrates of the lung
apices
Abnormal vocal resonance (sound of the Pneumonia (lung consolidation)
patient’s voice heard through a stethoscope
placed on the patient’s chest)
Bronchophony (loud voice)
Pectoriloquy (intelligible spoken words)
Egophony (“E to A change” of the patient’s
voice)
Hoover’s sign Chronic obstructive airway disease
Pulsus alternans Severe left ventricular dysfunction
Dicrotic pulse Severe left ventricular dysfunction
Pulsus bisferiens Moderate to severe aortic regurgitation
Hyperkinetic or collapsing pulse or hyperkinetic Severe aortic regurgitation
apex beat
Percussion of the heart Cardiac size
S4 heart sound Prognostic indicator after myocardial
infarction
Ejection sound Aortic stenosis at valvular level
Pericardial knock Constrictive pericarditis
Asymptomatic carotid bruits No prognostic value for stroke
Arcus lipidus Dyslipidemia
3.3.5 Use of Simulations3
Simulation technology provides opportunities to teach PE skills through photo-

graphs [42], audio-video simulations [43], mannequins [44], and simulations of
breast and pelvic examinations [45]. To teach percussion, I used a tabletop to simu-
late the chest wall and a foam sponge to simulate the overlying skin and subcutane-
ous tissue. I asked the students to compare the clear sound produced by tapping on
the bare tabletop with the muffled sound produced by tapping on the sponge, and
3
Benbassat J, Meroz N. The foam sponge as a teaching aid in the examination of the chest. Med
Educ. 1988;22:554–55. With permission from Blackwell Publishing Ltd.
with the sounds produced by percussion after varying degrees of pressure on the
sponge. Once students understood the importance of applying appropriate pressure
with the pleximeter, they quickly learned the technique of striking with the wrist
rather than the elbow and striking the end phalanx, which exerts the maximum pres-
sure [46].
I also used the sponge to simulate the lung parenchyma. Students learned to rec-
ognize bronchial breathing by placing the stethoscope directly on the trachea and
vesicular breathing by listening to the lower parts of the chest. A dry sponge placed
between the stethoscope and the trachea simulated vesicular breathing. A water- or
air-filled bag (or surgical glove) placed over the dry sponge further attenuated breath
sounds and simulated the effects of pleural effusion or pneumothorax. Auscultation
on a water-soaked sponge (simulating lung consolidation) placed on the trachea
produced bronchial breath sounds not unlike those obtained when the chest piece
was placed directly on the trachea.
3.4 Diagnostic Utility of the Physical Examination

and Ancillary Tests
The diagnostic process is a recursive examination of the question: are the available
data about the patient sufficient to make a treatment decision? If yes, the physician
proceeds to treatment; if not, additional information is needed. Such information
may include further questioning of the patient (have you recently traveled abroad?),
a physical examination (palpable spleen?), or imaging and laboratory tests. The
terms “additional information” and “diagnostic test results” are used interchange-
ably and refer to data that may reduce diagnostic uncertainty.
To express uncertainty, physicians use terms such as “maybe” or “cannot be
ruled out.” These terms are not helpful in diagnostic reasoning. It is not enough to
know that a diagnosis is uncertain or that a test result would reduce this uncer-
tainty; we need to know how much the test result changes the probability of dis-
ease. To this end, qualitative expressions, such as “probable (diagnosis),” are
replaced by the term “probability (of diagnosis)” (p), which describes the likeli-
hood of disease in quantitative terms. The statement “The probability of rheuma-
toid arthritis is 30–50%” expresses the belief that out of 100 patients with the same
manifestations, 30–50 will have rheumatoid arthritis, while the remaining 50–70%
will have some other disease. A test that, if positive, increases the probability of
disease from 40% to 95% is more useful than a test that increases the probabil-
ity to 70%.
Test characteristics are described in detail in textbooks. The goal of this section
is to provide only a summary of the information about diagnostic tests and clinical
prediction rules that medical students need to understand the value of the physical
examination.
3.4 Diagnostic Utility of the Physical Examination and Ancillary Tests 73
3.4.1 Test Properties
The decision to use a diagnostic test is guided by the trade-off between cost and
expected benefit. Cost refers to the adverse effects of a test, the time required to
obtain results (delay in treatment), inconvenience to the patient, and the price of
materials and labor. Benefits refer to the extent to which a test is expected to reduce
diagnostic uncertainty, and this depends on the reliability and validity of the test.
“Reliability” means reproducibility: a test of serum glucose levels is reliable if
repeated testing of the same sample yields the same results; an observer’s assess-
ment is reliable if two or more observers (e.g., cardiologists interpreting the same
electrocardiogram) agree. Most commonly, interobserver reliability is reported as
kappa statistics on a scale from −1 (complete disagreement) to 0 (random agree-
ment) to +1 (perfect agreement) [47].
“Validity” is the ability of a test to discriminate between patients with and with-
out the disease in question. This ability is determined by applying the test to indi-
viduals in whom the presence or absence of the disease of interest has been
established using a gold standard. The phrase “gold standard” refers to the best
available method for making a diagnosis, such as an autopsy, biopsy, bacteriological
findings, imaging studies, and prolonged follow-up. To be useful, a test must be
easier to use than the gold standard. Once a gold standard is agreed upon, the per-
formance of the test in patients with the disease can be compared to that in patients
without the disease. The results of this comparison are expressed in terms of the
sensitivity and specificity of the test.
Sensitivity is the proportion of all patients with a disease (according to the gold
standard) who test positive (“true-positives”). Specificity is the proportion of all
patients without the disease (according to the gold standard) who test negative
(“true-negatives”). A false-positive rate (1 − specificity) is the probability of a posi-
tive test result when the patient does not have the disease. A false-negative rate
(1 − sensitivity) is the probability of a negative test result when the patient has the
disease. To determine these conditional probabilities, physicians use Bayes’ theorem.
It has been claimed that the Bayes’ rule, although rarely used explicitly in clini-
cal practice, is a natural part of a physician’s clinical reasoning, in which the prob-
ability of disease is continuously readjusted by the history and findings of PE and
ancillary tests [48]. Others have argued that Bayes’ rule, similar to many other sta-
tistical inferences, is difficult to understand and therefore should be taught [49].
There is undisputed evidence that Bayesian reasoning is teachable and that it
improves the accuracy of probability estimates of novice clinicians [50].
The most commonly used representations of Bayes’ rule are two-by-two tables
and likelihood ratios. Two-by-two tables (Table 3.6) focus on the sensitivity [a/
(a + c)] and specificity [d/(b + d)] of the test. However, the question of interest is not
the sensitivity or specificity of the test, but the positive predictive value of a test [a/
(a + b)], i.e., the probability of disease given a positive test result. This probability
depends on the prevalence of the disease in the population [(a + c)/(a + b + c + d)].
Table 3.6 Two by two table of the distribution of test results in patients with and without the
disease of interest
Number of patients with the Number of patients without the
disease disease Total
Test positive a b a+b
Test negative c d c+d
Total a+c b+c a+b+c+d
The numbers in parentheses indicate the number of patients
The main difficulty students appeared to have in understanding the two-by-two

table presentation of Bayes’ rule was the need to translate the sensitivity and speci-
ficity data, usually presented as proportions, into absolute numbers of patients with
and without the disease under consideration. Therefore, I have found odds and like-
lihood ratios more useful in explaining Bayes’ rule to students. “Odds” are the ratio
between the probability (p) that an event occurs and the probability that the event
does not occur [Odds = p/(1 – p)].
The term “pretest odds” refers to the estimated likelihood of the disease before
the application of the test. Post-test odds refer to the likelihood of the disease after
the application of the test. Post-test odds are calculated by using the equation
Post-test odds = pretest odds ∗ likelihood ratio,
where the likelihood ratio (LR) after a positive test result (“LR positive”) equals
[sensitivity/(1 − specificity)], and the likelihood ratio after a negative test finding
(LR negative”) equals [(1 − sensitivity)/specificity]. Likelihood ratios seem to be
the best approximation to diagnostic reasoning because they provide a one-step
calculation of the post-test probability of disease.
3.4.2 Sources of Bias in Determining the Validity

of Diagnostic Tests
Determination of test validity can be thwarted by several sources of bias. The first is
variability in test performance in different clinical settings and population groups
[51]. Therefore, doctors should consider the characteristics of the patient population
in which the test was evaluated, such as gender (exercise testing performs differ-
ently in men and women), race (alcohol screening questionnaires perform differ-
ently in different ethnic groups), the severity of illness (tests perform better in
patients with more severe illness), and prevalence of illness (sensitivity and specific-
ity of the test may vary with the prevalence of the illness in question) [52].
Another pitfall is the nature of the controls. Tests are usually studied by compar-
ing patients with controls recruited from the medical staff. However, a test is not
intended to distinguish between sick and healthy individuals, but between patients
with the disease in question and patients with another disease that could be mistaken
for it. For example, if a test is to distinguish between patients with bacterial
3.4 Diagnostic Utility of the Physical Examination and Ancillary Tests 75
pneumonia and viral disease, then the controls must be patients with fever. A third
pitfall can occur when a test is interpreted by an observer who knows the patient’s
previous test results and is subject to the influence of that knowledge [53]. Finally,
the validity of tests that involve assessment depends on the competence of the tes-
ter [54].
3.4.3 Clinical Prediction Rules
Like any diagnostic test, clinical prediction rules help physicians identify patients
who need further diagnostic testing or treatment. These rules are derived from clinical
observations. Some prediction rules assign relative weights to specific clinical mani-
festations. Other prediction rules consist of algorithms or more complex mathemati-
cal models [55]. However, deriving a prediction rule is only the first step. As with any
diagnostic test, prediction rules require confirmation that the rule’s predictions are
indeed consistent with observed outcomes, that they apply to patients in specific clini-
cal settings, and that their application improves doctors’ decisions [56]. Similar to
other diagnostic tests, the value of prediction rules is affected by differences in disease
prevalence in different settings. Failure to recognize and account for these differences
can either thwart decision-making or cause valid rules to be prematurely discarded.
The number of published studies on prediction rules suggests that their popular-
ity has increased since the 1990s. Clinical prediction rules, for example, have pro-
vided three-tiered scores that distinguished between patients with low, intermediate,
and high probability of pulmonary embolism [57] and bacteremia [58]. Although
increasingly used to support diagnostic reasoning, few clinical prediction rules have
been properly validated [56, 59]. Systematic reviews of the literature have revealed
either significant methodologic flaws or limited accuracy of prediction rules for rul-
ing out acute coronary syndrome in emergencies [60] and for assessing the risk of
major bleeding in patients taking oral anticoagulants [61] and their clinical impact
has rarely been evaluated [62]. The validity and applicability of clinical prediction
rules need further investigation and development.
3.4.4 Assessment of the Pretest Probability of a Disease
The application of Bayes’ rule requires an assessment of the pretest probability of

the disease in question. In clinical settings, the pretest probability of the disease is
subject to the doctor’s estimate. The starting point for this estimate is the prevalence
of the disease in the population. This probability is then adjusted based on relevant
data such as the setting of the encounter, the patient’s age and gender, and the pres-
ence of risk indicators for disease, symptoms, and PE findings. For example, in
2004 the LR positive for ischemic heart disease (gold standard: coronary angiogra-
phy) was estimated to be 5.8 for typical angina, 1.2 for atypical angina, 0.1 for
nonanginal chest pain, 3.8 for prior myocardial infarction, and 2.3 for diabetes [63].
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Chapter 4
Recording the Clinical Database
4.1 Introduction
The record of the clinical database is more than a compilation of information:

Sorting patient data is an exercise in clinical reasoning. The definition of the symp-
tom matrix is the beginning of the generation of diagnostic hypotheses and their
subsequent modification in light of additional information. The progression of
symptoms over time can indicate the prognosis of the disease. The degree of dis-
ability of the patient may influence therapeutic decisions. Disorganized, redundant,
and inaccurate statements about the patient’s history and physical findings not only
reflect inadequate interpersonal communication and record-keeping skills but also
indicate deficiencies in critical thinking, data selection, and analysis.
Textbooks on clinical methods recommend recording the clinical database in a
sequence that begins with personal data and chief complaint, then moves to the
present illness, past, family, personal, and social history, and ends with a review of
systems, physical examination, and diagnoses. Since the 1970s, this format has
been the subject of two developments: problem-oriented and electronic medical
records.

Switzerland AG 2023
80 4 Recording the Clinical Database
4.2 The Problem-Oriented Record
Until the 1970s, the purpose of medical documentation was to remind physicians of
the patient’s database and to provide communication with other healthcare provid-
ers. The patient record was oriented to diagnoses, whether certain or suspected.
Physicians were not required to document their reasoning, and the medical record
did not consider alternative treatment options.
In 1968, Weed proposed an alternative approach to maintaining medical records,
the problem-oriented record (POR) [1]. It differs from the traditional record by first,
its orientation to problems rather than diagnoses. A problem is defined as any symp-
tom (e.g., epigastric pain), finding (pulmonary infiltrate, fasting blood glucose
180 mg/dL), established diagnosis (bacterial endocarditis, Strep viridans), mental
condition (depression), social status (welfare recipient), or treatment (anticoagula-
tion) that may affect the patient’s health. A problem is expected to be certain and not
suspected: The problem of a patient seeing a physician for epigastric pain would be
“epigastric pain” and not “suspected peptic ulcer.” If subsequent endoscopy reveals
an ulcer, the patient’s problem of “epigastric pain” would be updated to “duode-
nal ulcer.”
The problem list has contributed to clinical reasoning by promoting a taxonomy
that separates the unresolved and ambiguous from the diagnosed and clearly defined.
The list appears at the beginning of the patient’s record: it summarizes what is
known about the patient when he or she was last seen and is continually updated as
more data become available. At each subsequent visit, the problem list would revise
problems that have been resolved, add newly identified problems, track unresolved
problems, and track the patient’s response to treatment.
A second difference between the traditional record and the POR is the way the
patient’s history is presented. Its traditional presentation used to adhere to a chrono-
logical sequence. Such a presentation was difficult to follow in patients with more
than one problem developing simultaneously. Unlike this chronological sequence,
the POR presents separately the manifestations of each of the patient’s problems.
Third, the POR requires that the history of the present illness follows a predeter-
mined sequence that begins with a description of symptoms (onset, characteristics,
and development) and continues with a list of “negative” symptoms (symptoms
whose absence may be important), the objective data (results of previous medical
tests), and ends with the treatment the patient has received in the past. This sequence
gives a physician, even a novice, the ability to distinguish important data (symp-
toms) from less important data (opinions of other physicians). Errors in processing
the patient’s history are more easily detected and corrected, and finally, communica-
tion of the data is easier because the listener expects to receive them in the order in
which they are presented.
Fourth, the POR contains a summary. The problem list serves as the starting point
for this summary, which includes the reported data, the objective findings, the physi-
cian’s assessment, and the plan for addressing each of the patient’s problems. It also
contains “patient education”—a record of what the patient was told about his or her
4.3 The Electronic Medical Record 81
condition and role in treatment. It is a summary of the dialog between the physician
and the patient, aimed at meeting the patient’s expectations and reducing anxiety.
Recording patient education forces the physician to reflect on an often-neglected
topic: the need to provide the patient with health-related information. It also informs
other healthcare providers about the information shared with the patient.
The strengths of POR are not limited to improved documentation. The POR also
requires physicians to be explicit about their reasoning. It is expected that their
assessment of the patient is consistent with the patient’s symptoms and findings and
that the treatment plan is consistent with that assessment. The POR provides a
means of communication not only with other healthcare providers but also with
medical students: it is a tool for teaching. Because physicians must document and
justify their decisions, the POR also allows for a review of clinical decision-making
and more effective monitoring of the quality of patient care.
4.3 The Electronic Medical Record
Since the 2000s, computerized electronic medical records (EMRs) have become an
essential part of patient care. Patients accept this development and are even more
interested in seeing their computerized records than those on paper [2]. Patients
believe that EMRs facilitate patient–physician communication and support the idea
of having their input on their records [3]. Most practicing physicians agree that
EMRs are effective in organizing and reviewing data [4]. Health administrators
believe EMRs are cost-effective, improve the quality of care and staff satisfaction,
save pharmacy waste, and reduce nursing overtime [5]. Finally, EMRs improve
communication and care coordination among clinicians, especially those caring for
patients with multiple disorders.
However, EMRs harm patient-centeredness [4]. Many physicians behave in a
“screen-driven” manner, asking questions as they appear on the screen rather than
following the patient’s narrative. As physicians spend more time interacting with
the computer, they have less time to interact with the patient. It has been argued that
physician–patient interaction is more “computer-driven” than “computer-assisted”
[6]. To reduce the undesirable consequences of EMR, it has been suggested that
physicians position the screen as a bridge rather than a divider so that they can view
it with the patient. Physician comments such as “I am going to look at your test
results now. Would you like to look at them together?” could facilitate a shared
assessment of the patient’s current health status and identify opportunities for active
patient participation [7]. Other authors have similarly identified strategies, best
practices, and facilitating factors that clinicians can use to have a patient-centered
conversation in the era of the EMR [8]. The EMR is particularly useful for patient
education at the end of the conversation. At this stage, clinicians can read aloud
what they have written and give patients copies of care plans, health information,
website referrals, information about community support services, medication side
effects, and follow-up appointments [9].
4.4 Teaching the Recording of the Clinical Database1
The proposed approach to teaching the recording of the clinical database applies the
principles of learning for mastery by dividing the subject matter into small units
(steps). Table 4.1 lists the objectives of these steps. In each of them, students (a)
interview a patient and perform a partial physical examination; (b) record the
patient’s history, examination findings, and diagnostic hypotheses; (c) share these
records with the other four to six students in the group and the tutor; and (d) watch
the tutor demonstrate selected physical examination procedures and practice these
procedures on each other. Students are asked to read the description of these proce-
dures in the physical diagnosis textbooks and note any differences between what
they read and the tutor’s demonstration. Students are also repeatedly reminded to
hold off on recording the clinical database until the patient interview is complete
and not to take extensive notes while listening to the patient.
A teaching session begins with each student reading his/her report on the patient
she/he examined in the previous session. The other students in the group and the
Table 4.1 Proposed method for teaching the recording of the patient’s history
Step Topic Objective
I Patient’s bio-psychosocial Identify and report the relevant aspects of the patient’s
history personal and psychosocial history, in addition to risk
indicators of disease and resources
II Chief complaint Formulate the chief complaint and its duration. Identify the
anatomic region from which the complaint may originate
III Symptoms List the patient’s symptoms in the order of their appearance.
Propose a diagnostic hypothesis
IV Problems Differentiate between groups of symptoms that may indicate
different medical problems. Propose diagnostic hypotheses
V Statement of the patient’s Define the characteristics of the symptoms: Time of onset,
present illness or problems quality, duration, frequency, course, aggravating or alleviating
factors, and associated symptoms. Become familiar with the
natural history of common diseases
VI Statement of the patient’s Record “negative data,” i.e., symptoms from the same organ
present illness or problems system as the chief complaint, the absence of which may
serve as diagnostic cues
VII Statement of the patient’s A complete statement of the present illness, including
present illness or problems “objective data,” i.e., previous medical findings, opinions, and
treatment
VIII Active and inactive (a) List separately active and inactive problems; (b) obtain the
problems, past and family patient’s history and family history; (c) perform a review of
history, review of systems systems
IX Practice A complete recorded clinical database
1
An earlier version of this section was published in:
Benbassat J, Schiffmann A. An approach to teaching the introduction to clinical medicine. Ann
Intern Med. 1976;84:477–81. With permission from the American College of Physicians.
4.4 Teaching the Recording of the Clinical Database 83
tutor discuss the reports. Allowing 15 min per student, this part takes about
60–90 min. Then the tutor focuses on one or two of the patients presented and
encourages the students to suggest diagnostic hypotheses or at least the organ sys-
tem that might be the cause of the patient’s complaints. The tutor demonstrates the
physical examination of this organ system and supervises the students as they prac-
tice these skills on each other. Finally, each student is assigned a new patient to
interview on his/her own and prepare a written record of the patient’s history for the
next session.
4.4.1 The Personal and Psychosocial History
Students are reminded of the principles of patient-centered interviewing that they

learned in their first year. Students interview their assigned patients and take their
personal and psychosocial histories as detailed in Sect. 4.6.
4.4.2 Chief Complaint
The objective of this step is to formulate and record the chief complaint (CC) and its
duration. The chief complaint is defined as the immediate reason that caused the
patient to seek medical attention. Examples:
CC: Chest pain of 3 hours duration
CC: Low back pain for one week
CC: None, patient was referred with an incidental finding of a round shadow on chest X-ray.
In this phase, students are encouraged to formulate hypotheses about the origin
of the patient’s complaint and to list additional symptoms that, if present, would
support these hypotheses. CCs are categorized into pain (e.g., abdominal pain),
symptoms due to organ dysfunction (e.g., cough), incidental findings (e.g., jaun-
dice), and general symptoms (fever, fatigue, weight loss). The tutor strives to select
patients whose CCs are localized pain or symptoms of organ dysfunction. The stu-
dent’s initial hypotheses are limited to naming the anatomic region from which the
discomfort originates, e.g., “Chest pain could be a manifestation of heart, lung, or
esophageal disease; possible additional symptoms. Dyspnea, cough, dysphagia”; or
“Epigastric pain could be from a disease of the stomach, duodenum, pancreas, or
gallbladder; possible additional symptoms: vomiting and heartburn”; or “Diarrhea
could be caused by disease of the small or large intestine; possible additional symp-
toms: Abdominal pain, vomiting.”
I have already emphasized the importance of understanding the patient’s con-
cerns, which may or may not be identical to the chief complaint. For example, a
patient’s chief complaint may be “chest pain on exertion for the past three months”
and this may also be his or her main concern. However, the patient’s main concern
may be something else, such as obtaining a disability certificate. The advantage of
recording the patient’s main concern(s), preferably in the patient’s own words, is
that they are brought to the doctor’s attention, thereby initiating the empathy pro-
cess. While the chief complaint is limited to symptoms and signs, the patient’s spe-
cific worries encompass all possible causes of her/his distress and need for help. By
making the main concern, rather than the main complaint, the starting point for
further patient management, doctors may considerably expand their ability to help
their patients.
4.4.3 Symptoms
The objective of this step is to identify and list the patient’s symptoms. Students
listen to the patient’s narrative, paying particular attention to the symptoms and list-
ing them in order of appearance. At this stage, students refrain from giving a detailed
description of the symptoms and their course. The required written report consists
of the first two sentences of the statement of the present illness (PI) for example:
PI began 3 years ago. It manifested itself in chest pain, shortness of breath, and swelling of
the legs.
PI began 3 days ago, with fever (39 oC), chills, dry cough, and sore throat.
As in the previous step, students interview patients with a single problem, prefer-
ably localized pain or organ dysfunction. If the student identifies the diseased organ
or system, he or she is referred to appropriate sources and encouraged to propose a
more specific diagnostic hypothesis, for example, “Right flank pain and dysuria
may be due to urinary tract disease, possibly a bacterial infection or stone,” or
“Fever, cough, and chest pain of 2 days duration may be due to respiratory inflam-
mation, such as bronchitis or pneumonia.”
4.4.4 Problems
This step initiates the student to the problem-oriented approach. In this phase,
patients with more than one problem are selected for interview and examination.
Students must now distinguish between groups of symptoms that may indicate dif-
ferent medical problems. The criteria for grouping symptoms are (a) origin in the
same organ system and (b) similar duration, simultaneous onset, or both. For
example:
1. The present illness began 6 h before hospitalization. Symptoms included chest
pain, sweating, and palpitations.
2. In the past 2 years, the patient has complained of epigastric pain and heartburn.
4.4 Teaching the Recording of the Clinical Database 85
The symptoms in this example are grouped into two categories based on their
non-simultaneous onset. They could originate in two different organ systems
(cardiovascular and gastrointestinal) and the patient could be suffering from two
diseases (acute myocardial infarction and peptic ulcer). Alternatively, these two
sets of symptoms could originate in the same organ system (gastrointestinal)
and be manifestations of the same disease (a perforated peptic ulcer). The vari-
ous diagnostic hypotheses are considered during the post-interview
discussions.
At such an early stage of the interview, neither experienced physicians nor inex-
perienced students have sufficient information to test their alternative hypotheses. If
there appears to be no obvious connection between two or more problems, students
are advised to treat each problem separately and only then look for a possible link
between them.
4.4.5 Statement of the Patient’s Present Problem(S)
At this step, students are taught to define the characteristics of a patient’s symptoms,
i.e., time of onset, duration, frequency, course, and aggravating or alleviating fac-
tors. Students also begin to focus on prototypical disease processes. The tutor
assigns patients with histories and physical findings of common diseases, such as
viral hepatitis, hyperthyroidism, peptic ulcer, ulcerative colitis, tonsillitis, urinary
tract infections, rheumatoid arthritis, left and right ventricular failure, and expects
students to make more accurate preliminary diagnoses. Again, students are referred
to texts and asked to suggest a differential diagnosis at a higher level of resolution,
such as urinary tract infection with causative microorganisms or left ventricular
failure with possible causes.
4.4.6 Statement of the Present Problem(S) (Continued)
Students complete the symptom list and collect “negative data”: they ask the patient
about symptoms that they know are from the same organ or organ system as the
chief complaint and note the answer, even if negative, e.g., absence of dyspnea or
palpitations in a patient with chest pain or absence of pain in the flanks in a patient
with dysuria.
4.4.7 Statement of the Present Problem(S) (Continued)
Students inquire about previous medical findings, opinions, and treatments that the
student feels are relevant to the present illness.
At the end of this step, the student is expected to provide a statement of the
patient’s PI that will present the patient’s major symptoms, their onset, characteris-
tics, course, and degree of induced disability and will be followed by a description
of “secondary” symptoms, “negative” symptoms, and “objective” data from the his-
tory. Secondary symptoms are those that the student considers relatively unimport-
ant. Negative symptoms are absent complaints of possible diagnostic significance.
Objective history data include the results of previous examinations and previously
made diagnoses. For example:
PI began 2 days ago with fever, abdominal pain, and diarrhea. All of these symptoms persist
until today. The fever is continuous between 38 and 39.5 oC. The pain is severe, i ntermittent,
and aggravated during bowel movements. The patient has stools of watery consistency five
to ten times a day, occasionally with mucus and blood.
There was no vomiting, chills, or headache. A few hours after the onset of symptoms, the
patient was seen by a physician who determined that he had dysentery. He was treated with
2 g of ampicillin daily without improvement
The available data suggest an acute inflammatory disease of the colon. After
further reading, students should suggest a more specific differential diagnosis, such
as shigellosis, the first bout of ulcerative colitis, or amoebic dysentery.
4.4.8 Listing Active and Inactive Problems, Past and Family

History, Review of Systems
The objectives of this step are to identify inactive problems, obtain the patient’s
family history, and perform a systems review. At the end of this step, students should
be able to communicate with the patient and take the medical history in a problem-
oriented manner. The remaining training sessions are devoted to improving student
performance and refining their use of medical vocabulary, with an increasing
emphasis on diagnostic problem-solving.
4.5 Common Errors in Recording the History of a Patient’s

Present Illness2
Converting the patient’s experience into a written report involves several steps. First,
the patient describes his or her symptoms with spoken words, body language, and
voice and facial expressions. Second, the doctor apprehends the message and finally
converts it into a written narrative. These stages are not unlike consecutive Xerox

2
Benbassat J. Common errors in the statement of the present illness. Med Educ. 1984;18:417–22.
With permission from Blackwell Publishing Ltd.
4.5 Common Errors in Recording the History of a Patient’s Present Illness 87
Table 4.2 Proposed format for recording the statement of the present illness (PI)
First paragraph (data of probable importance):
(a) Time and mode of onset of the PI
(b) List of main symptoms
(c) Characteristics of main symptoms (add nonverbal cues when appropriate)
(d) Chronological description of the course of the main symptoms
(e) Disability assessment
Second paragraph (data of possible importance):
(f) List of additional (“secondary”) symptoms
(g) “negative” pertinent symptoms
(h) Pertinent “objective” data: Past diagnoses and treatment (if not already reported in the first
paragraph)
Adapted from [14] with permission from Blackwell Publishing Ltd
copies that produce increasingly blurred reproductions. Patients’ experiences of their

complaints are more varied than the expressions available for their descriptions, and
patients’ descriptions are influenced by their capacity for self-expression. Perception
of the patient’s message is influenced by the physician’s sensitivity to verbal and
nonverbal cues, diagnostic hypotheses, and preconceived notions about the patient.
The write-up depends on the physician’s precision in reporting and his or her ability
to critically analyze the data. Finally, symptoms are recorded in written words that
rarely reflect the patient’s entire verbal and nonverbal message. Recording the history
becomes even more complicated in patients who have seen a physician before. The
information on PI is then expected to include the results of these encounters, and this
requires selecting relevant data and determining the order in which they are presented.
Some loss and distortion of the patient’s experience are inevitable when translat-
ing it into a written statement, and medical students too often fail to adequately
describe the patient’s PI. Students’ difficulties in recording the statement of the PI
are often compounded by inconsistent feedback from tutors and differing recom-
mendations in clinical methods textbooks. For example, some textbooks, e.g., [10],
recommend organizing the PI history in chronological order, while others, e.g.,
[11], recommend starting with the immediate cause of the patient’s referral and
probing backward into the development of the present illness.
In this section, I propose a format for recording the PI (Table 4.2) that is a syn-
thesis of previously described guidelines [12, 13] and suggest using it to identify
and correct errors in student presentations of a patient’s history. The most common
errors that I identified in the recorded patients’ PI can be grouped into the following
four categories.
4.5.1 Overemphasis on Objective History Data
In cases of patients with previous physician visits or hospitalizations, students focus

on the objective data available and their recorded PI consists predominantly of diag-
noses and findings as reported by the patient (example “a1”) or as taken from his or
her previous hospital records (example “a2”). The patient’s symptoms and their
course are either omitted or almost completely lost in the objective history data.
(a1) Five years ago Mr. D was told he had congestive heart failure. He was referred to the
hospital and treated with furosemide. Over the next three years, Mr. D was treated at the
hospital's OPD and had repeated blood tests. On one occasion, he was readmitted to the
hospital. One year ago, he was told that he had fluid in his abdomen. During the last few
weeks, his abdominal swelling increased despite treatment with furosemide, and therefore
he was referred for hospitalization.
(a2) For 30 years Mrs. K has been an alcoholic. On her first admission five years ago, she
had a liver span of 12 cm, splenomegaly, ascites, hemoglobin - 10 gm/dl, platelets - 70,000
per ml, WBC - 1,900 per ml, serum albumin - 3.0 gm/dl, globulin - 4.1 gm/dl and prothrom-
bin time - 100%. A barium swallow revealed esophageal varices. She was treated with a
low-salt diet, furosemide, and vitamins. On her second admission two years ago, she had
ascites and venous congestion at her abdominal wall. Her hemoglobin was 8.8 gm/dl, plate-
lets - 39,000 and WBC 3,000 per ul, albumin 2.0 gm/dl, and globulin 3.0 gm/dl. On her last
admission six months ago, her prothrombin time was 40%. She was brought to ER by her
husband, who found her unconscious in bed this morning.
4.5.2 Inadequate Description of the Patient’s Symptoms
This error consists of describing a patient’s symptoms in vague or possibly mislead-

ing terms, such as “ulcer pain,” “asthmatic breathing,” or “pain in the gallbladder.”
It occurs in the histories of patients whose complaints seem typical of known medi-
cal conditions. In such cases, students substitute their interpretations for the symp-
tom descriptions (example “b1”). The error also occurs when a patient was quoted
verbatim, even if he/she reports his/her conclusions rather than what he/she felt or
observed (example “b2”).
(b1) Mr. G presented two days ago with anginal pain, paroxysmal nocturnal dyspnea, and
intermittent claudication of one-year duration.
(b2) Ms. H reported on admission that four days ago she had pain in her kidneys and blood
in her urine.
4.5.3 Failure to Identify Main Symptoms
Some students failed to discern between major and secondary symptoms in a patient
with multiple symptoms. Common errors in formulating the CC included listing
more than two symptoms (example “c1”) and overemphasizing the referral source
to the exclusion of the chief complaint (example “c2”). Failure to highlight and
emphasize the main symptoms in the CC may carry over to the PI and result in a
statement, not unlike the computer printout obtained through a yes/no query (exam-
ple “c3”).
4.6 Providing Feedback on Students’ Records of a Patient’s History 89
(c1) CC: Loss of weight, irritability, increased appetite, menorrhagia, tremor, and palpita-
tions of two months duration.
(c2) CC: Referred from the cardiology OPD for further investigations.
(c3) PI: A week ago Mrs. S felt a short bout of pain in her right flank. Since then, she com-
plains of a burning sensation at urination and passes urine 3–4 times at night. Recently, she
has had pain in her 'spine' and moderate shortness of breath on exertion. In the past month,
she has been using laxatives for constipation. In the past two weeks, Mrs. S has had bouts
of giddiness and frontal headaches.
4.5.4 Unclear Presentation of Chronological Evolution

of Symptoms
Given a patient with a prolonged PI, some students fail to describe the progression
of symptoms from their onset to the time of admission and the resulting disability.
In some cases, the most recent symptoms are recorded first, while subsequent para-
graphs of the PI probe “backward” into the patient’s past, disregarding the chrono-
logical sequence of events (example “d1”). In other cases, the PI consists of a
description of all symptoms at a given time and repeated, circuitous accounts of the
same symptoms as they progress (example “d2”).
(d1) On the night of her admission, Mrs. W experienced a sudden wave of heat, shortness
of breath, a 'flutter' in the chest, and a loss of sensation in her left arm for several seconds.
There was no pain, nausea, or vomiting. She had slight dizziness when getting up from bed.
Two years ago, she had a similar bout of numbness and weakness in her left arm. At that
time her ECG and chest x-ray were normal. Four years ago, she noted a moderate swelling
of her legs. She was told she had hypertension and was started on Normitten 25 mg and a
low-salt diet. The swelling of her legs disappeared, and her blood pressure fluctuated
between 160/90 and 140/80.
(d2) Five days ago, Miss C started complaining of watery diarrhea, lower abdominal pain,
and a fever of 38.8 °C. On the second day of her illness, she had about 15 bowel movements.
Her fever reached 39 °C and her pain increased in intensity and duration. Diarrhea contin-
ued on the third day of her illness, and she noted spots of 'blood' in her stool. Her 'cramps'
became unbearable during bowel movements. Her fever reached 39.8 °C. On the fourth day
of her illness, she was seen by Dr. J. She was told she had ‘gastroenteritis’ and was given
Lomotil. Still, her fever remained at 39 °C, she had about 20 bowel movements on that day
and her abdominal cramps persisted. On the day of her admission, her fever reached 40 °C,
and her pain became almost continuous. Since this morning she has had no bowel move-
ment and during the last hours, she has vomited repeatedly. She is too weak to sit in a chair.
4.6 Providing Feedback on Students’ Records

of a Patient’s History
Students have no apparent difficulty in listing previous medical examinations and

established diagnoses. Their main problem seems to be in identifying and describ-
ing a patient’s symptoms and their course. Some students avoid describing
symptoms altogether, preferring to present conclusions, interpretations, previous

findings, and diagnoses. It is easier to list previous findings than to gain insight into
feelings, complaints, and disabilities.
Therefore, training in history taking and recording consists of teaching students
to recognize, list, and describe symptoms, their course, and resulting disability.
Students’ difficulties with history recording should be acknowledged and accepted
as legitimate. When errors are uncovered, they should be discussed in a non-
threatening atmosphere without suggesting that they indicate basic incompetence.
Students would be told that there is no gold standard for a well-written history and
therefore, textbook recommendations vary; that physicians use different styles in
recording the patient database, just as they differ in their approach to patient inter-
viewing, data collection, and problem-solving; and that the tutor’s approach to
teaching and recording the database is intended to serve as an initial guide for stu-
dents until they choose their individual style.
Tutors may use the format outlined in Table 4.2 as a frame of reference for iden-
tifying and explaining errors and for introducing students to clinical reasoning.
Diagnostic thinking and problem-solving begin with categorizing available data.
Adherence to this format can help students group history data and present them in
order of probable importance. This format is particularly well suited for corrective
feedback to students who overemphasize objective history data while ignoring the
patient’s symptoms (error type a).
To correct the tendency to describe symptoms in vague and misleading terms
(error type b), tutors would explain the difficulties of translating a patient’s experi-
ence into a written statement, as described earlier in this section, and advise students
to describe as accurately as possible what the patient felt and to avoid interpretation
and inference. When appropriate, tutors may even encourage students to describe in
parentheses the patient’s nonverbal expressions, e.g.: “The pain in the shoulder is
sharp (the patient winces in pain when he tries to move his left arm)” or, “The bouts
of headache (the patient holds his head in both hands) usually occur in the after-
noon.” I believe that asking students to describe the patient’s behavior enhances
their observational skills and their sensitivity to nonverbal messages.
The difference between main and secondary symptoms (error type c) is best
explained by defining main symptoms as those reported in the patient’s spontaneous
narrative. Secondary symptoms, however, are usually elicited through closed-ended
questions later in the interview. Students are cautioned that some patients may baf-
fle the interviewer by “changing their story.” In such cases, students are advised to
identify the main symptoms by summarizing the history at several stages of the
interview to confront patients with their stories and to allow them to correct possible
misunderstandings.
To avoid type d errors, students are advised that the evolution of the patient’s
symptoms provides insight into the natural history of the illness and identifies recent
changes in disability that may necessitate a change in treatment or revision of estab-
lished diagnoses. Therefore, the statement of the PI should describe the progression
of symptoms with the clarity of a chart [15] that plots the course of the patient’s
history in “horizontal” order, describing each symptom (or group of symptoms with
References 91
a similar course) from its onset to the present time. Thus, a corrected version of
example “d1” would follow a chronological sequence:
Four years ago, Mrs. W noticed swelling in her legs. She consulted Dr. J who told her she
had hypertension and prescribed a low-salt diet and Normitten 25 mg daily. Over the next
four years, the swelling in her legs disappeared, she was able to go about her daily activities
and her blood pressure was between 160/90 and 140/80. Two years ago, she experienced a
few seconds of weakness in her right arm. On the night of her admission, Ms. W felt short-
ness of breath (the patient clutches her neck), a 'fluttering in the chest (the patient taps
rapidly on the table), and a loss of sensation in her right arm that persisted for several min-
utes and subsided before she arrived at the hospital.
In addition, Ms. W complains of brief dizzy spells when she gets out of bed. There is no
pain, nausea, or vomiting. Dr. J states in his letter that two years ago her EKG and chest
x-ray were interpreted as normal.
A corrected version of example “d2” would follow a “horizontal” sequence,

whereby each symptom is described separately from its onset to the time of
admission:
PI began five days ago with fever, abdominal pain, and diarrhea. Her temperature has fluc-
tuated between 38 °C in the morning and 39–40 °C in the evening. Her pain is described as
‘cramps’ (pt places her palms on her lower abdomen) during bowel movements and has
gradually increased over the past two days. Her diarrhea was ‘watery’; during the first three
days of her illness, she had about 15 bowel movements per day. On the third day, her diar-
rhea became ‘bloody’. In the last few days, it has become less frequent and since this morn-
ing she has had no bowel movements. In the last few hours, she has been vomiting, unable
to take fluids by mouth, and feeling too weak to sit on a chair.
Other symptoms include headache and some stiffness in the muscles. There were no chills.
On the fourth day of her illness, Dr. J examined her. She was told she had gastroenteritis and
treated with Lomotil.
References
1. Weed LL. Medical records that guide and teach. N Engl J Med. 1968;278:593–600.
2. Richter JG, Becker A, Koch T, Willers R, Nixdorf M, Schacher B, Monser R, Specker C, Alten
R, Schneider M. Changing attitudes towards online electronic health records and online patient
documentation in rheumatology outpatients. Clin Exp Rheumatol. 2010;28:261–4.
3. Honeyman A, Cox B, Fisher B. Potential impacts of patient access to their electronic care
records. Inform Prim Care. 2005;13:55–60.
4. Shachak A, Reis S. The impact of electronic medical records on patient-doctor communication
during consultation: a narrative literature review. J Eval Clin Pract. 2009;15:641–9.
5. Cherry BJ, Ford EW, Peterson LT. Experiences with electronic health records: early adopters
in long-term care facilities. Health Care Manage Rev. 2011;36:265–74.
6. Shachak A, Montgomery C, Dow R, Barnsley J, Tu K, Jadad AR, Lemieux-Charles L. End-
user support for primary care electronic medical records: a qualitative case study of users’
needs, expectations, and realities. Health Syst. 2013;2:198–212.
7. White A, Danis M. Enhancing patient-centered communication and collaboration by using the
electronic health record in the examination room. JAMA. 2013;309:2327–8.
8. Ventres WB, Kooienga S, Marlin R. EHRs in the exam room: tips on patient-centered care.
Fam Pract Manag. 2006;13:45.
9. Duke P, Frankel RM, Reis S. How to integrate the electronic health record and patient-
centered communication into the medical visit: a skills-based approach. Teach Learn Med.
2013;25:358–65.
10. Seidel HM, Ball JW, Dains JE, Benedict GW. Mosby’s guide to physical examination. 6th ed.
St. Louis, MO: Mosby, Elsevier; 2006.
11. Bickley LS, Szilagyi PG. Bates’ guide to physical examination and history taking. 11th ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2013.
12. Morgan WL, Engel GL, editors. The clinical approach to the patient. Philadelphia, PA: WB
Saunders; 1969. p. 197–204.
13. Weed LL. Medical records, medical education and patient care. 5th ed. Cleveland, OH: Case
Western Reserve; 1971.
14. Benbassat J. Common errors in the statement of the present illness. Med Ed, 1984;18:417–22.
15. Prior JA, Silberstein JS. (eds) Physical Diagnosis, (Fourth edition). C. V. Mosby Co.,
St Louis. 1973.
Chapter 5
Clinical Reasoning
5.1 Introduction
Clinical problems vary in complexity. At one extreme are “simple” questions such
as “Does this patient have atrial fibrillation?” Their answer requires examination. At
the other extreme are “complex” questions such as “Should a patient with atrial
fibrillation and a history of gastrointestinal bleeding be treated with anticoagu-
lants?” The answer to such questions requires predictions with varying degrees of
uncertainty.
Uncertainty is pervasive in clinical reasoning because diagnostic tools are imper-
fect and interventions carry risks. Yet, during my studies in the 1950s, uncertainty
was rarely acknowledged. Clinical reasoning was guided by pathophysiologic ratio-
nale and the “art of medicine.” Physicians’ authority was based on their unsystem-
atic experience, which they translated into intuitive decisions. The advantage of
intuitive decisions is that they are quick and usually correct. However, they defy
explanations, can be influenced by bias, and do not allow for control and
accountability.
Since the second half of the twentieth century, there has been a growing aware-
ness of the need for such control. In 1953, Yerushalmy [1] reported that two radiolo-
gists disagreed in interpreting chest radiographs one-third of the time and that a
single interpreter disagreed with his previous findings one-fifth of the time. In 1964,
Schimmel [2] reported that of a total of 1252 consecutive admissions to an aca-
demic hospital, 16 patients had died as a result of medical procedures. The high
incidence of medical errors [3] and unexplained variations in clinical practice [4]
suggest that intuition can go wrong, and today, physicians are increasingly chal-
lenged to justify their decisions. Attempts are made to demystify clinical reasoning
to allow for their rational analysis. The continuum of reasoning, problem-solving,
and decision-making has become the subject of scientific inquiry and attempts to
teach it to medical students [5, 6]. The goal of these attempts is to impart to students

Switzerland AG 2023
94 5 Clinical Reasoning
the reasoning strategies used by experts and a recognition of situations in which

these strategies may fail [7].
Still, as recently as 2020, only 28% of 313 medical schools from 76 countries
reported teaching clinical reasoning [8]. It was claimed that “…the creation of
explicit, theory-informed clinical reasoning curricula… and assessment tools has
proceeded slowly” [9], and the optimal methods for teaching clinical reasoning
remain uncertain.
5.2 Reasoning Strategies of Experienced Clinicians
Studies of physicians’ clinical reasoning have used three main methods. The first
consists of retrospective reviews of detected or self-reported errors, discussed in
Sect. 5.7. The second, the “naturalistic decision-making approach,” attempts to gain
insight into the self-reported problem-solving strategies of experienced clinicians
[10]. Finally, the “heuristics and biases” examine whether clinicians’ diagnostic
decisions are consistent with Bayes’ theorem and whether treatment decisions are
consistent with maximizing expected utility [11].
5.2.1 Pattern Recognition and Hypothetico-Deduction
Studies using the naturalistic decision-making approach have attempted to find a

general reasoning process by analyzing think-aloud reports of physicians during
simulated encounters with patients or while viewing replays of recorded encounters
[10]. Later studies analyzed the relationship between visual stimuli (e.g., ECG trac-
ings or skin lesions) and their interpretation (diagnosis) [12].
Two major findings emerged from these studies. First, clinician performance var-
ied and the outcome in one case was a poor predictor of performance in another
case. This finding suggests that expertise is not a general attribute but rather depends
on case-specific knowledge. Second, clinical reasoning seemed to follow two differ-
ent paths. The usual path was “pattern recognition,” or the retrieval of clinical pre-
sentations from memory, such as skin lesions and Dawn syndrome. The most
efficient way to recognize a pattern is to see it, store it in memory, and identify it
when encountered again.
Not all patients have recognizable patterns, however, some present with symp-
toms that fit more than one disease. In such cases, physicians use a “hypothetico-
deductive” approach: they generate several diagnostic hypotheses while listening to
the patient’s history. Each hypothesis then leads to a search for additional symptoms
and signs that should be present if it were true [10, 13]. Confirmation of a hypoth-
esis leads to diagnosis; its rejection leads to testing of other hypotheses. These two
paths are consistent with the dual process theory [14]. It states that reasoning occurs
in an implicit, automatic, unconscious process (System 1) similar to pattern
5.2 Reasoning Strategies of Experienced Clinicians 95
recognition and an explicit, conscious, systematic, analytic process (System 2) sim-

ilar to the hypothetico-deductive approach.
At all levels, from novice to experienced clinicians, pattern recognition is the
most common path of diagnostic reasoning [15]. It resolves simple cases, whereas
complex cases require a generation of hypotheses [16]. Whether a case is simple or
complex depends on the physician’s knowledge, which develops in stages.
In-between novice and expert, there is an intermediate stage that is typified by con-
sidering more diagnostic hypotheses and requesting more laboratory tests than nov-
ices (who lack the knowledge to perform irrelevant searches) and experts (who are
more parsimonious in their differential diagnosis than intermediates). Experts per-
form better in their domain than outside their domain, suggesting a four-tiered the-
ory: novices, intermediate students, generic experts, and domain experts [17].
5.2.2 Additional Paths of Clinical Reasoning
Other reasoning paths include algorithmic diagnosis (flowchart), which consists of

an entry point (e.g., anemia) and a series of yes–no questions that lead to either the
next question or the diagnosis. The schema-based [18] and script-based [19]
approaches assume that problem-solving is based on pre-stored knowledge struc-
tures (“schemas” or “scripts”) that are used to process clinical information and to
generate and test diagnostic hypotheses. Finally, the traditional “complete database”
involves taking a detailed history, performing a head-to-toe examination, and order-
ing a series of standard tests. The reasoning process begins only after all the infor-
mation has been gathered.
All these paths regard clinical reasoning as a process controlled by physicians.
Its context, such as time pressures and interruptions, is considered secondary unde-
sirable “noise.” Differences in physician performance are explained by differences
in case-specific knowledge. However, studies have shown that differences in indi-
vidual problem-solving did not correlate with responses to questions that targeted
the same content knowledge. These findings led to hypotheses about how context
might influence knowledge storage and retrieval, and how clinicians and their envi-
ronment interact (see [20] for a review).
Today there is a growing recognition that clinical reasoning is not only a cogni-
tive endeavor but also a contextually and socially mediated activity, and that it can
be influenced by circumstantial factors, such as the setting of the physician–patient
encounter, the patient’s verbal skills, emotional volatility, or incorrect suggestions.
This influence changes the understanding of decision-making and the definition of
medical error, as they depend on both the doctors’ actions and the context in which
they acted. However, since the number of contextual factors is limitless, it is diffi-
cult to determine which features of context should be considered, and how they
might influence the thought processes of clinicians. In 2022, Watsjold et al. [20]
concluded that “context specificity … may absolve us from seeking singular defini-
tions of expertise.”
5.2.3 Cognitive Task Analysis
Cognitive task analysis [21] aims to translate the tacit knowledge of experts into
diagnostic criteria. The analysis uses data collected through interviews, observation,
think-aloud exercises, and focus groups and has generated useful decision support
guides, such as the Apgar score [22], diagnosis of neonatal sepsis [23], and training
and assessment for the care of war casualties [24].
5.3 Heuristics and Biases in Clinical Reasoning
The “heuristics and biases” approach compares management decisions with those
established by decision theory (the normative models). Systematic violations of the
normative models are conceptualized as errors caused by shortcuts (heuristics) in
the reasoning process. Heuristics are correct in most cases. However, they can be
affected by biases.
Since the seminal work of Tversky and Kahneman [25], it has been recognized
that experts can violate the normative principles of decision-making. Biases can
occur at any stage of clinical decision-making, whether unconscious (System 1) or
controlled and conscious (System 2). The first three biases identified by Tversky
and Kahneman were representativeness, availability, and anchoring.
“Representativeness” is the tendency to be guided by prototypical features of a con-
dition and to overlook atypical variants. “Availability” is the tendency to overesti-
mate the likelihood of available (vivid, recent, easily remembered) events and
underestimate the likelihood of events that are ordinary or difficult to recall.
“Anchoring refers to predictions based on initial information (anchoring) and sub-
sequently modified as more information becomes available (adjustment). The final
prediction may be biased toward the initial information, which is given more weight
than later information.
Other biases that may influence diagnostic reasoning include the tendency to
ignore actual disease rates and pursue rarer, exotic diagnoses, to ignore relevant
normal findings, and to give more weight to evidence that confirms a decision than
to information that refutes it. Biases that can affect management decisions include
the tendency to be influenced by the way information is presented, such as whether
prognostic information is presented in terms of mortality or terms of the proportion
of survivors [26].
5.4 Barriers to Learning Clinical Reasoning
Learning clinical reasoning requires overcoming intellectual, cultural, and emo-

tional barriers to acceptance of the uncertainties of clinical practice. At the intel-
lectual level, medical students must come to terms first, with the shift from a
5.4 Barriers to Learning Clinical Reasoning 97
science-based education to the inclusion of relevant topics from the behavioral sci-
ences [27]. Prescriptive clinical decisions (what will happen? what treatment can
improve this patient’s predicament?) require probability estimates. The cause-and-
effect approach of the basic sciences (what happened? what caused the disease?)
requires deterministic thinking in terms of right/wrong.
Deterministic thinking is still encouraged by an emphasis on science courses and
multiple-choice exams with “only one correct answer.” The intellectual barriers hin-
der students’ ability to generate hypotheses, synthesize data, and formulate a man-
agement plan [28]. In 1983, Feinstein argued that “[d]uring the 20th century … the
acts of prediction and intervention that constitute patient care have not been regarded
as basic scientific challenges. The general belief has been that explication of patho-
physiologic … mechanisms is the only important, fundamental scientific work for
clinical academicians” [29].
At the cultural level, it has been suggested that the clinical teaching environment
inhibits the development of tolerance of uncertainty in students [30]. The clinical
environment rarely refers to risk and uncertainty. As recently as 2011, it was asserted
that “the culture of medicine has little tolerance for ambiguity and uncertainty” and
that there is a disconnect between the uncertainties of clinical practice and their
denial in teaching [31].
At the emotional level, medical students do not expect uncertainties in medicine
[32]. Shuval [33] noted that medical students were surprised by “the existence of
ambiguity and uncertainty in a profession that prides itself on its rationality and
competence.” Similarly, Fox [34] and Katz [35] reported that disagreement among
authorities was a major cause of student anxiety. Recognizing that clinical decisions
must be made with incomplete evidence and that good interventions can lead to bad
outcomes is emotionally demanding.
A commonly used intellectual and ethical developmental model of college stu-
dents is Perry’s sequence of stages, which he called dualism, multiplicity, relativism,
and commitment in relativism [36]. During dualism, students think in terms of right
and wrong. The transition to multiplicity begins when they encounter conflicting
opinions. Now students consider multiple opinions legitimate, but only in areas
where the correct answer has not yet been found. In these areas, students believe that
“opinions cannot be judged.” Toward the end of multiplicity, they recognize that even
in areas of uncertainty, opinions can be judged based on their fit to the available data.
This signals the transition to relativism. At this stage, students acknowledge that
there is no absolute truth. They progress to the stage of commitment in relativism
when they understand that unless they are to remain frozen in indecision, they must
commit themselves to a choice, even if they will regret it in the future. Uncertainty is
rejected in dualism, seen as temporary in multiplicity, accepted as legitimate in rela-
tivism, and dealt with when students affirm themselves in their commitments.
The transition from novice to expert requires a commitment in relativism (“a
decision must be made even if it must be revised/regretted in light of future knowl-
edge”) is difficult. The assumption that there is an absolute truth known to role
models is extremely attractive. Conformity to authority has been identified as a
means by which medical students control the anxiety created by the complexity of
the clinical environment [37]. In other words, it is easier to imitate role models than
to confront the uncertainties inherent in clinical practice. Reflectivity requires more
complex thinking than a social code grounded in dominance, hierarchies, and con-
formity [38]. Furthermore, certain aspects of reflective ability, such as self-awareness
[39] and awareness of others’ feelings [40], are associated with higher levels of
psychological distress and less positive self-perception.
Unlike other college students [41, 42], most medical students “appeared to
express predominantly simplistic levels of epistemological thinking” [43], and their
reflective ability scores declined in the final year of study [44]. These findings are
consistent with earlier observations of denial of uncertainty during medical educa-
tion (see [45] for a review), of an absence of change in tolerance of ambiguity by
year of study [46], and medical student belief that judgments are either true or false
[47]. Medical students seem to need help to mature into reflective professionals,
develop a critical attitude, question the messages they receive from clinical tutors
and the hidden curriculum, and break away from the inherent comfort of conformity.
5.5 Teaching and Assessing Clinical Reasoning
5.5.1 Learning Objectives
As of 2021, the teaching of clinical reasoning in medical schools has focused on five
areas: (a) concepts of clinical reasoning (theories, cognitive errors); (b) using pat-
tern recognition and resorting to hypothetico-deductive reasoning when faced with
uncertainty; (c) interpretation of diagnostic tests (Bayes theorem); (d) problem
identification and management (problem list, differential diagnosis, management
plans); and (e) shared decision-making [48, 49].
All these topics are teachable. Even before clinical training, students can be
taught to recognize chest radiographic patterns [50] and dermatologic lesions [51]
and to perform a hypothesis-driven examination [52]. I suggest that the teaching of
clinical reasoning should also be guided by students’ difficulties in developing tol-
erance of uncertainty. Earlier, I referred to Perry’s view that this development begins
when students realize that they are not alone and that their instructors share their
doubts and uncertainties. Therefore, one of the characteristics of role models would
be openness to express doubts and visibility of deliberations. Seeing how role mod-
els reflect encourages student reflectivity, and student reflectivity is a prerequisite
for effective role modeling [53].
5.5.2 Assessment
The proposed methods for assessing clinical reasoning fall broadly into three cate-
gories: Off-the-job assessments (multiple-choice questions, creation of decision
trees reflecting disease scripts, discussion of written clinical cases, the script
5.6 Decision Support 99
concordance test—SCT [54]); assessments in simulated clinical settings (objective

structured clinical examinations and technology-based simulations); and work-
place-based assessments (direct observations, global assessments, oral case presen-
tations, written notes) [55].
Assessments of students’ clinical judgment based on their responses to clinical
vignettes found that students often ordered unnecessary tests because they tended to
overestimate the likelihood of disease in low-probability settings [56] or underesti-
mate the influence of physical examination findings, especially negative findings,
on the assessment of the likelihood of disease [57]. Therefore, clinical education
should also focus on the diagnostic value of a patient’s history and physical exami-
nation. In particular, efforts should be made to emphasize the importance of nega-
tive (normal) physical examination findings in ruling out disease. This includes not
only the ability to recognize physical signs when they are present but also the con-
fidence necessary to determine the absence of a physical sign.
The difficulties in implementing workplace-based assessments are, first, the
influence of the context-specificity of clinical problems that I mentioned earlier.
Second, the wide variation among assessors necessitates repeated assessments to
produce reliable results. Third, attempts to validate assessment methods have shown
that they are differentially associated with each other, suggesting that they measure
different components of the construct of clinical reasoning [58]. In addition, some
assessment methods, such as SCT [54], require significant investment in faculty and
student training and are unlikely to be used in clinical teaching. Therefore, until an
easily applicable test is developed, the measure of students’ reasoning will remain
the assessment of their summaries of the patient’s problem-oriented records (prob-
lem list, relevant history, physical examination data, differential diagnosis,
hypothesis-driven diagnostic tests, and treatment plan) [59].
5.6 Decision Support
Attempts to support doctors’ reasoning have included maximizing the predicted

utility of clinical decisions (decision analysis) and assessing the evidence for the
efficacy of management interventions (evidence-based medicine).
5.6.1 Decision Analysis
Any responsible decision must be based on an evaluation of the risks and benefits of
the various interventions. Even clinicians who have never been introduced to deci-
sion theory use informal or quasi-formal decision analysis to identify available
courses of action and consider their possible outcomes. When making treatment
decisions, physicians consider expected benefits in terms of chances of recovery
and harms in terms of side effects, patient suffering, and costs. In diagnostic deci-
sions, physicians consider benefits in terms of true-positive and true-negative results
and risks in terms of delay in treatment until the test is performed, its cost, false-
positive and false-negative results, and side effects. In this section, I summarize the
strengths and weaknesses of formal analyzes of clinical decisions. It is not intended
to enable readers to perform decision analyzes. Interested readers are referred to
review articles and software applications.
Formal analysis of a clinical decision first requires identification of all possible
strategies, e.g., anticoagulation and no treatment for a patient with chronic atrial
fibrillation. Second, consideration of all possible outcomes of each strategy, e.g.,
embolism, and bleeding. Third, an estimate of how likely it is that the event will
occur. Fourth, an assessment of the desirability (utility) of the outcomes by asking
about the patient’s preferences. Finally, weigh the benefits against the risk of each
strategy. An approach that I have found useful in introducing medical students to
decision trees begins by presenting them with the case of a patient who presents
with fever, physical and radiographic evidence of right lower lobe consolidation,
and intracellular diplococci in the sputum. The choice of treatment with antibiotics
is straightforward. It does not require a decision tree for the following three reasons.
The first reason is the wide differences between the outcomes of the two treat-
ment options. A review of previous unblinded studies found that mortality from
lobar pneumonia in 1938 was 5–8% in patients treated with sulfapyridine and
19–27% in untreated controls [60]. However, formal decision analysis may be help-
ful when the outcomes of alternative treatments are not as widely different as in
pneumonia. Consider the following hypothetical case:
A patient has a neoplasm that may be treated by radiotherapy or by attempted surgical exci-
sion. The 5-year survival after radiotherapy is 80%. On attempted surgical excision some
cancers may be resectable and others may not. Resectable cancers carry a 5-year survival
rate of 95%; the 5-year survival rate of patients with non-resectable cancers is 50%.
In this case, a formal analysis using a decision tree shows that if surgical mortal-
ity is 1% and there is a 60% probability that the neoplasm is resectable, the 5-year
survival would be 76% after surgery and 80% after radiotherapy. In other words,
both strategies would lead to similar outcomes, so the choice between them should
be based on other considerations such as cost and patient preference. If the probabil-
ity of a resectable tumor is uncertain, a sensitivity analysis can be performed by
repeating the analysis with different values for this probability. In this case, such a
sensitivity analysis indicates that surgical treatment is preferable if the patient has a
probability of a resectable tumor greater than 70%. The formal analysis of the deci-
sion has identified the specific area of uncertainty that should be further explored.
The second reason why the choice of treatment for pneumonia does not require
formal analysis is the narrow time horizon of the decision: It the case of pneumonia,
predictions relate to developments in the coming weeks, and near predictions are
easier to make than those for the distant future. However, formal decision analysis
may be helpful when the outcomes of alternative treatment strategies have a more
distant time horizon. Consider the following example.
An asymptomatic person is found to have gallstones. Surgical treatment is associated with
(low) mortality; however, survivors are free of the risk of recurrent biliary complications.
5.6 Decision Support 101
Expectant treatment is risk-free in the short term; however, the patient may at any time dur-
ing his/her remaining life sustain a complication that will be more difficult to treat.
In this case, the decision analysis may help the choice between surgical and
expectant treatment by using a recursive computerized calculation of the risk of
age-related death from natural causes and biliary complications over the patient’s
remaining lifespan.
Finally, in the example of the patient with pneumonia, the health states of interest
are alive and dead. Complications of lobar pneumonia that can lead to permanent
disability are extremely rare. However, in other cases, the decision-maker must con-
sider states other than life and death, such as survival with varying degrees of dis-
ability. Consider the following example:
A diabetic patient has an infected wound in his foot. The treatment options are antibiotic
treatment and below-the-knee amputation. Below-the-knee amputation is associated
with surgical mortality; however, those who survive will live with below-the-knee
amputation. Antibiotic treatment is not associated with any surgical mortality; at best,
the wound may heal and the patient may survive with his leg intact. At worst, he will die
of sepsis. An intermediate outcome would be the spread of infection, which would
require above-the-knee amputation, in which case the patient may die in surgery or
survive.
Apart from the states “alive” and “dead,” there are two intervening states of
health in this example, amputation below the knee and above the knee. Different
people have different values. Therefore, in examples such as this, the benefit should
be determined by the patient. As stated in Sect. 5.2, the same limp has a different
meaning for a dancer and a math teacher. Several methods are commonly used to
quantitatively determine utilities in quantitative terms, and interested readers are
referred to review articles [61].
In summary, some clinical decisions are difficult because they involve choosing
among treatments with similar efficacy, predicting remote events, or considering
multiple utilities. In these cases, formal analysis can assist decision-making. First,
in cases of unexplained variability in practice, formal analysis can help health pol-
icy analysts identify the practice that maximizes utilities. When the choice between
legitimate options is a toss-up, cost-effectiveness analysis can identify the option
that minimizes cost and inconvenience to patients.
Second, physicians have historically relied on their judgment of patient prefer-
ences. However, public dissatisfaction with health care has drawn attention to the
risk of such physician judgments, and attempts are now being made to involve
patients in clinical decisions. Despite their discomfort with expressing utility in
numbers, clinicians are increasingly aware of the need to find formal or informal
ways to quantify patients’ utilities. Third, in the event of a “toss-up,” formal analysis
can help identify important areas of clinical uncertainty and direct research toward
those areas. Finally, decision trees, with their explicit analysis of the choice of dif-
ferent clinical strategies, have proven effective in helping students and patients
understand the rationale for choosing a particular clinical strategy under conditions
of uncertainty.
Nevertheless, formal decision analysis has not gained acceptance in clinical

medicine [62]. First, it is time-consuming and cannot be performed at the bedside.
Second, the data needed for analysis are not always available, and clinicians are
reluctant to use subjective probabilities in cases of uncertainty. Third, both patients
and clinicians are uncomfortable expressing utility in numbers. Fourth, decision
analysis does not reflect clinical thinking because clinicians do not make decisions
by multiplying probabilities by utilities. Fifth, for many clinicians, formal decision
theory is either too simple to reflect the complexity of clinical reality or too compli-
cated to understand and apply. Finally, it appears that in most cases, differences in
outcomes among alternative treatment approaches are so obvious that they obviate
the need for the use of formal decision analysis, whereas in cases where these dif-
ferences are not obvious, formal analysis almost always suggests a “toss-up.”
5.6.2 Evidence-Based Medicine
The shift in clinical reasoning from pathophysiological rationale to reasoning based

on empirical evidence can be traced back to 1948 when the Streptomycin in
Tuberculosis Trial Committee published the first randomized controlled clinical
experiment. Since the late 1960s, there has been an increasing reliance on epidemio-
logic research to apply findings from population-based studies to the treatment of
individual patients. Clinical epidemiology teaches the rules of inference from
population-based data. The methods for identifying the best empirical evidence
from population-based studies were developed primarily at McMaster College by
Drs. Sackett and Guyatt who coined the term “evidence-based medicine” (EBM)
[63]. Its formal definition is “the conscientious, explicit, and judicious use of cur-
rent best evidence in making decisions about the care of individual patients” [64].
Since the 1990s, EBM has gained acceptance in clinical practice, and clinically
integrated teaching programs on EBM have been shown to improve students’
knowledge, skills, attitudes, and behaviors [65]. Today, terms such as evidence-
based guidelines are part of the medical discourse. EBM is based on the premise
that clinical decisions should be guided by both clinical expertise and the best avail-
able external evidence [64]. “Clinical expertise” is the competence and judgment
that clinicians acquire through experience. “Best available external evidence” comes
from patient-based research on diagnostic tests, prognostic markers, and the effi-
cacy and safety of clinical interventions.
An important contribution of EBM is the differentiation of levels of evidence
according to the risk of bias, from strongest (systematic reviews of randomized,
triple-blind, placebo-controlled trials) to weakest (case reports, expert opinions
based on unsystematic personal experience). The U.S. Preventive Services Task
Force recommends categorizing evidence of treatment/screening effectiveness as
that derived from at least one properly designed randomized controlled trial (level
I), well-designed controlled trials without randomization (level II-1), well-designed
cohort or case-control studies (level II-2), multiple time series with or without
5.7 Interpretation of Research Findings 103
intervention (level II-3), and opinions of respected authorities or reports of expert

committees (level III).
Randomized controlled trials have a low risk of bias. However, the view that
randomized controlled trials provide the best evidence should not be misunderstood
as a requirement that all clinical decisions must be based on the results of such tri-
als. EBM is a call for clinicians to realize that their clinical decisions vary in cer-
tainty. When evidence from controlled trials is not available, treatment decisions
must be based on lower levels of evidence.
5.7 Interpretation of Research Findings1
The interpretation of research findings, such as the effectiveness of interventions, is

commonly based on statistical significance. The conventional wisdom is that a sig-
nificance level (p-value) of less than 0.05 is considered to confirm differences
between the values of interest. This interpretation is flawed. It is commonly referred
to as the “p-value fallacy,” and in 2005 Ioannidis even claimed that “most [sic!]
published research findings are false” [66].
The p-value fallacy is due to the failure to recognize that the probability of
observed findings given the hypothesis is not the same as the question of interest,
which is the probability of the hypothesis given the observed findings. In other
words, discussions about which statistic to use have distracted scientists from exam-
ining the more important question: what they want to know when they conduct
scientific research [67]. To assess the likelihood of the hypothesis given the observed
results, it is not sufficient to know only the p-value, just as to assess the predictive
value of a diagnostic test it is not sufficient to know only its specificity. Bayesian
rules of inference also require estimates of the statistical power of the experiment to
reject the null hypothesis if it is false, and of the prior probability (before the study)
that the hypothesis is correct. The probability that a tested hypothesis is true depends
on the prior probability that it is true, the statistical power of the study, and the
statistical significance level [68].
Research can be viewed as the degree of belief a person has about a hypothesis
and the change in that belief in light of new evidence. Learners’ epistemic beliefs
change over time. Bayesian reasoning provides learners with a way to approach
research by countering the intuitive tendency to seek answers in terms of right or
wrong. Teaching Bayes’ theorem can help students move from a dichotomous right/
wrong view of knowledge to a realistic understanding of scientific ideas, data, and
evidence. This can impact students’ epistemological development by making them
aware that uncertainty can be reduced but not eliminated [69].
1
Benbassat J. Inferences from unexpected findings of scientific research: common misconcep-
tions. Eur J Int Med 2016;8:188–89. With permission from Elsevier.
Consider the case of complementary and alternative medicine (CAM). Medical

education, practice, and research follow the premises of the biomedical (BM)
model. Conversely, CAM is an all-inclusive term for clinical practices based on
theories about a disease that differ from those of BM as well as from each other.
Both CAM and BM are based on theoretical models. Both BM and CAM may draw
on interventions based on lower levels of evidence in the EBM hierarchy. They both
strive to test the effectiveness of their interventions through controlled trials.
Some controlled trials of CAM have been interpreted as supporting the efficacy
of chiropractic for low back pain [70] and acupuncture for hypertension [71]. There
is evidence that tai chi affects autonomic modulation [72], and that scalp acupunc-
ture improves infarct volume and neurological function in animals with experimen-
tal ischemic stroke [73]. Should these findings be interpreted as confirmation of the
efficacy of these interventions?
The CAM controversy is mainly due to different estimates of the prior probabil-
ity of the hypothesis being tested. Proponents of CAM would rate this probability as
high because it is consistent with their theory of the disease: they would therefore
interpret positive study results as evidence of efficacy. Proponents of BM would
estimate this probability to be nil because it is inconsistent with existing scientific
BM notions and would ignore research suggesting a benefit of CAM. Should find-
ings suggesting that CAM treatments are effective then be ignored?
The history of medicine is replete with unexpected observations that led to para-
digmatic shifts in clinical reasoning. For example, contrary to the prevailing belief
at the time, treatment with quinidine was found to increase mortality in patients
with cardiac arrhythmias, and treatment with beta-blockers was found to improve
left ventricular function. Contrary to the BM premise that disease is the result of
structural or biochemical disturbances, the observed associations between life
events and morbidity and between socioeconomic status and mortality led to the
acceptance of psychosocial predictors of disease.
Therefore, observed inconsistencies between theory and practice should not be
ignored, but rather prompt further investigation. Random observations, unexpected
research findings, and positive findings of trials testing hypotheses with very low
prior probabilities do not provide definitive evidence for associations or cause-and-
effect relationships. However, such observations generate hypotheses that should be
confirmed by independent controlled studies. If CAM practitioners want to be
accepted by the BM mainstream, they must seek such confirmatory evidence
through statistically sound, controlled studies.
A second way to support CAM interventions is through n-of-1 controlled trials
[74]. A patient is assigned to receive a sequence of experimental and control inter-
ventions in random order. The patient’s problem is assessed at baseline, then again
during and after treatment. If the problem disappears during treatment, it can be
determined that it was effective. N-of-1 studies are consistent with the requirement
that evaluation of the effectiveness of CAM practices should only be done in the
context of a specific individual [75], and the Oxford Center for EBM classified such
studies as level 1 evidence for treatment decisions in individual patients [76]. I
References 105
believe that future research on the effectiveness of CAM will focus on n-of-1 rather
than population-based clinical trials.
As an aside, my attitude toward CAM is ambivalent. On the one hand, CAM is a
social process that should be studied scientifically. BM physicians could emulate
CAM in the trust that characterizes their relationship with patients, and in their non-
judgmental attitude toward patients. A CAM practitioner is not likely to think that a
patient’s complaint is imaginary. On the other hand, while both BM and CAM
abound with anecdotal reports of individual successes, only BM can claim break-
through treatments, such as vaccines, insulin, antibiotics, antiviral drugs, and the
treatment of hypertension. Assumptions such as those of homeopathy that dilutions
of a substance have a biological effect are not only incompatible with BM; they also
violate the laws of physics and chemistry. Most CAM theories assume that the cause
of the disease and the ability to treat it are within the patient and attribute a failure
of CAM therapy to the patient’s inability to believe in the value of the treatment
[77]. Finally, the ethical principle of equitable distribution of health care resources
implies that the health care system cannot provide free CAM services with largely
unproven or untested efficacy and yet exclude drugs and technologies with proven
efficacy from the basket of benefits because of their cost.
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65. Flores-Mateo G, Argimon JM. Evidence-based practice in postgraduate healthcare education:
a systematic review. BMC Health Serv Res. 2007;7:119.
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science classroom. Sci Educ (Dordr). 2022;14:1–24.
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pain. Cochrane Database Syst Rev. 2010;4:CD005427.
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tial hypertension: a meta-analysis of randomized sham-controlled clinical trials. Evid Based
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ulation. Clin Auton Res. 2014;24:47–52.
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Chapter 6
The Behavioral and Social Sciences
in Medical Education
6.1 Introduction
An 1838 treatise entitled “Further Discussions of the Foundations of Somato-

psychic Medicine” appears to be the first formulation of psychosomatic medicine
[1]. However, its publication only triggered a reaction against psychiatry, as medi-
cine at that time was transforming into a science based on physics and chemistry.
Psychosomatic medicine reappeared in the 1930s but remained outside the main-
stream, and as late as the 1950s medical education focused on the patient’s organs
and tissues but not on her/his feelings and emotional distress.
It was not until the 1950s that emotional distress became the subject of scientific
study. The main variables in this study were “stress,” defined as the reaction to a
stimulus, and “stressor,” defined as the stimulus. The purpose of this section is to
describe these variables and summarize the evidence of their relationship with mor-
bidity, the implications of this relationship for clinical practice, and the barriers to
teaching the behavioral and social sciences (BSS) to medical students.
6.1.1 Stress and Stressors
Stressors trigger a chain of reactions called stress. These include mobilization of

energy, stimulation of the heart and respiratory rates, constriction of peripheral
blood vessels, elevation of blood pressure, and interruption of unnecessary physio-
logical processes such as salivation. Originally, the stressors studied were physical,

Switzerland AG 2023
110 6 The Behavioral and Social Sciences in Medical Education
such as cold. Later, people were found to respond similarly to emotional and social
stressors (see [2] for a review). The main difficulty in studying stressors is their
uncertain quantification: what is perceived as a stressor by one person may be a
pleasant challenge for another.
In experimental animals, stressors such as electric shocks suppress cellular
immunity, and feelings of helplessness and lack of control over the stressor amplify
its effects [3, 4]. Attempts to explore whether stress causes disease and not just
physiological responses have consisted of looking for associations between morbid-
ity and psychological distress, personality, life events, social support, and socioeco-
nomic metrics.
6.1.2 Psychological Distress
The construct of psychological well-being has included experiencing that one’s life
has meaning, realizing that one is moving forward, perceiving that one is in control
of life, and feeling worthwhile, happy, enthusiastic, proud, and optimistic. There is
evidence that psychological distress is associated with all-cause mortality [5] even
after adjustment for behavioral and biological risk factors [6]. Unfavorable scores
on the Childhood Family Environment questionnaire were associated with all-cause
mortality later in life [7], and both preexisting and new-onset mental illness in can-
cer patients were associated with higher all-cause and cancer-specific mortality [8].
The main limitations of these observations are possible reverse causation, in which
participants’ declining physical health would affect their psychological well-
being [9].
6.1.3 Life Events
The first evidence of the relationship between life events and morbidity was pro-
vided by Holmes and Rahe [10]. They conducted a survey in which participants
were asked to name experiences that they would define as “life events” and to rate
these events according to their severity on a scale of 1–100. The survey revealed 43
such life events. The death of a spouse was defined as the most serious event while
receiving a parking report was ranked as the lightest event. The researchers then
asked a group of US navy soldiers to indicate the life events they had experienced
and when and tracked the soldiers’ morbidity over the next 6 months. Results
showed a correlation between the intensity of life events in the previous 6 months
and morbidity during the six-month follow-up.
This correlation was confirmed by later studies. The number of patients with
myocardial infarction during the missile attack on Israel in the Gulf War was higher
than during the corresponding period of the previous year [11]. Prospective studies
have shown that life events predict cancer morbidity [12], and that family life events
6.1 Introduction 111
predict the incidence of pneumonia, diarrhea, and accidents in children [13]. Despite
criticisms of some aspects of the Holmes and Rahe experiment [14], it is considered
the first evidence that life events, like age, are a nonspecific risk factor for dis-
ease [15].
6.1.4 Social Support
“Social support" is a framework that provides individuals with love, recognition for
their achievements, and intimacy that allows for the expression of emotions. Such
frameworks are the family, the workplace, social clubs, religion, or counseling ser-
vices (doctors, clergy). Social support systems are health-promoting [16], while
loneliness and social isolation in older adults are associated with an increased risk
of developing dementia, coronary heart disease or stroke, and all-cause mortality
[17]. A 2018 review showed that loneliness increases all-cause mortality and that
this effect is independent of the effect of depression [18]. Therefore, efforts are
being made to improve the prognosis of patients through various psychosocial
interventions.
It has been shown that providing individual or group therapy significantly
reduced loneliness [19] and improved depression and anxiety in patients with cor-
onary artery disease [20]. A meta-analysis of randomized trials showed that
patients who received a psychosocial intervention were, on average, 20% more
likely to be alive at the end of the study than controls [21]. Other interventions
consist of teaching patients how to manage their illnesses. A 2017 review found
that self-management reduced all-cause mortality in patients with type 2 diabe-
tes [22].
Attempts to influence the course of cancer through psychosocial interventions
have been based on the assumption that reducing stress would enhance the immune
response to cancer cells. Indeed, the presence of newly diagnosed psychiatric disor-
ders in cancer patients was found to be associated with significantly higher mortal-
ity than in cancer patients without psychiatric disorders [23]. A 2015 randomized
controlled trial of cognitive stress management in breast cancer found that the inter-
vention group had a lower risk of all-cause mortality compared with the control
group. Restricting analyses to patients with invasive disease revealed significant
effects of the intervention on breast cancer-related mortality and disease-free inter-
val [24].
6.1.5 Socio-Economic Status
No society can prevent social and health inequalities. A 2017 meta-analysis of 48

prospective cohort studies with a total population of 1,751,479 people from seven
high-income countries found that 310,277 participants died during a mean
follow-up of 13–3 years. Participants with low socioeconomic status had a higher
mortality rate than participants with high socioeconomic status (hazard ratio 1.42
for men and 1.34 for women); this association remained significant after adjustment
for high alcohol consumption, obesity, diabetes, hypertension, physical inactivity,
and current smoking [25]. An unhealthy lifestyle explained only a small portion of
the impact of socioeconomic status on health [26].
One of the most important socioeconomic variables is income. Poverty predicts
morbidity, and there is an inverse correlation between income and mortality [27,
28]. Morbidity and mortality are also influenced by occupational status, neighbor-
hood, and social equality. For example, in a 7-year follow-up of 17,530 civil ser-
vants in London, cardiovascular disease mortality was 4% among the lowest-paid
workers and less than 1% among managers, even after adjustment for cholesterol,
smoking, and blood pressure [29]. Regardless of income, education, or occupational
status, residents of slums are more prone to heart disease than residents of estab-
lished neighborhoods [30]. Life expectancy in the USA was higher in states with
more equitable income distribution. In other words, social equity appears to increase
life expectancy [31].
How socioeconomic status affects morbidity and mortality is uncertain. People
with low status are more likely to report underutilization of their potential, unfair
working conditions, and poor social ties [29]. It is possible, therefore, that low
socioeconomic status is associated with a higher incidence of feelings of frustration
and stress.
6.1.6 Personality Traits
The association between personality traits and morbidity is uncertain. The theory
of psychosomatic specificity assumes a one-to-one relationship between a par-
ticular psychosocial configuration and a particular disease. According to this
theory, a particular set of circumstances (bereavement, job loss) combined with
specific personality traits (submissive, manipulative) would lead to a certain ill-
ness (bronchial asthma, peptic ulcer) [32]. Thus, hostility has been linked to
hypertension, separation anxiety to bronchial asthma, and an A personality
(characterized by the drive to accomplish more in less time) to heart attacks.
However, the theory of psychosomatic specificity is supported only by anecdotal
observations. Studies have shown that type A behaviors increase the risk of heart
disease only slightly [33] or not at all [34] or to any disease and not just heart
disease [35].
Conversely, the association between life events and morbidity and between
socioeconomic status and mortality supports the theory of psychosomatic nonspeci-
ficity. According to this theory, any life event or low socioeconomic status can
increase the risk for any disease, regardless of personality traits [36]. The relation-
ship between disease and psychosocial determinants and personality patterns is still
in need of study.
6.2 Barriers to Teaching the Behavioral and Social Sciences 113
6.2 Barriers to Teaching the Behavioral and Social Sciences1
The BSS have been part of the medical curriculum since the 1940s [37]. Until the
1980s, sociologists faced restrictions on their access to medical students. However,
since the 2000s, the evidence that the primary determinants of health inequities are
social, rather than biomedical [38, 39] has reinstated the BSS in the curriculum and
led to the inclusion of teaching the consequences of societal problems into the
requirements for accreditation of medical schools. Still, the implementation of BSS
programs in medical education remains problematic [40]. BSS programs have been
subject to revision, discontinued courses, high teacher turnover, and changes in
course directors. The objective of this section is to describe the intricacies of teach-
ing the BSS and possible approaches to their solution.
In 2022, Bann et al. [41] identified several difficulties in teaching the BSS. At the
professional level, faculty were poorly prepared to teach concepts such as the social
determinants of health. At the organizational level, participants pointed to a lack of
time, faculty, and resources and described the development of the course as rushed
and suboptimal (“building the airplane as it’s taking off”). Finally, at the interac-
tional and intrapersonal levels, in some cases, faculty communication with students
was strained [41].
These difficulties are related to two main barriers to teaching the BSS: the domi-
nance of the biomedical model and the undefined content of the BSS. Even doctors
who recognize the social determinants of illness question their clinical relevance.
Doctors are interested in the diagnosis and treatment of individual patients and not
in solving social problems. A 2006 survey indicated that one-third of US primary
care physicians believed that addressing psychosocial issues would lead to minimal
or no improvement in patient outcomes [42]. Similarly, a 2008 survey indicated that
UK medical faculty perceived BSS topics as “nice to know” rather than “need to
know” [40]. As late as 2020, it was found that despite BSS constituting a mandatory
component of the UK medical curriculum, medical students did not perceive BSS as
useful for their future practice as doctors, nor did they find it to be clinically rele-
vant [43].
Second, the content of the BSS remains undefined [44]. BSS programs have
included social determinants of health, cultural competence, antiracism, social jus-
tice, indigenous health, and LGBT care [41]. Other BSS teaching programs have
focused on patient interviewing and ethical (e.g., informed consent) or psychosocial
(e.g., family violence) problems [45]. In 2004, the Institute of Medicine identified
26 different topics clustered into six categories: health policy and economics, patient
behavior, physician–patient interaction, mind–body interactions, physician role and
behavior, and social and cultural issues [46]. There is not sufficient curricular time
1
Benbassat J, Baumal R, Borkan JM, Ber R. Overcoming barriers to teaching the behavioral
and social sciences to medical students. Acad Med. 2003;78:372–80. With permission
from Wolters Kluwer.
for all these subjects and their inclusion is frequently guided by the availability of
teachers rather than by their perceived importance [40].
6.3 Overcoming Barriers to Student Learning
An essential requirement for teaching the BSS is an agreed-upon program that pri-
oritizes learning objectives according to their clinical relevance. Meeting this
requirement would give the highest priority to two learning objectives: acquisition
of doctor–patient communication skills and identifying psychosocial factors that
may increase the risk for disease, or decrease patients’ ability to cope with the dis-
ease. Other learning objectives of the BSS, such as medical ethics, models of the
doctor–patient relationship, doctor–society relations, healthcare delivery systems,
occupational health, and social responsibility of the medical profession, would be
decided by the faculty of individual medical schools. Whatever the educational phi-
losophy, a list of teaching priorities is an essential step toward defining the BSS core
curriculum, a commitment to attaining specified learning objectives, and making an
effort to maintain a pool of teachers for the agreed-upon BSS core.
The acquisition of doctor–patient communication skills was described in Sect. 2.
Identifying psychosocial factors that may increase the risk for disease or decrease
patients’ ability to cope with the disease are described in this section.
6.3.1 Risk for Disease and Ability to Cope with It:

The Patient’s Personal/Psychosocial History2
The patient’s personal history was part of the medical record as early as the 1950s
[47]. Morgan and Engel [48] suggested including in it the patient’s expectations,
while Weed [49] recommended adding a description of the patient’s state of mind to
the “profile of the patient.” However, like other students, I was not sure what should
be considered important in the patient’s personal history and how it would contrib-
ute to solving the patient’s problem. The traditional justifications for taking the
personal history (“a doctor should take care of patients, not treat diseases” and “it is
more important to know what kind of person has a disease than what kind of disease
a person has”) seemed to me to be meaningless slogans that neither explained the
purpose nor provided criteria for evaluating the recorded personal history.
2
Previous versions of this section were published in:
Benbassat J, Baumal R. Viewpoint: a proposal for teaching basic clinical skills for mastery:
the case against vertical integration. Acad Med. 2007;82:83–91. With permission
from Walters Kluwer.
Benbassat J. The social worker’s record of the hospitalized patient. A physician’s perspective.
Isr J Psychiatr Relat Sci. 1996;33:246–52. With permission from Gefen publishing.
6.3 Overcoming Barriers to Student Learning 115
Other authors have quoted students as saying that “the relationships between
psychosocial determinants and health are either so obvious that they require little …
explanation, or so fanciful that they … exist only as a psychiatric or sociological
delusion” [50]. The perception of the BSS as clinically irrelevant is further rein-
forced by the differences between what students are taught and what they see during
their clerkship rotations. For example, in 2011, fourth-year US students who were
exposed to a BSS curriculum in the first 2 years of medical school commented that
its precepts were not integrated into patient care [45].
This feeling seems pervasive even today. Time constraints and pressure to focus
on the patient’s immediate problems limit the medical record to data relevant to
crisis intervention. The patient’s personal history is rarely included in published
case reports. Although most medical schools offer programs in the social and behav-
ioral sciences, the identification and treatment of psychosocial problems is too often
considered the domain of social workers and liaison psychiatrists.
It has been claimed that teaching the BSS to medical students requires moving
away from the view of the student as a vessel into which knowledge is “deposited,”
and towards one in which students and teachers learn together in dialogue [41]. To
initiate such a dialogue, I have found it useful to ask students to consider the follow-
ing hypothetical case.
You are a family physician and meet for the first time Mr. T. who has recently moved to this
neighborhood, and “just wants to say hello.” Mr. T.is 50 years old and states that he and his
family are in excellent health. However, having decided to be your patient in case of need,
he came to introduce himself.
Since there are no complaints to address, students commonly suggested that the
conversation with Mr. T should include counseling on health promotion. With vary-
ing degrees of help from me, students identified the two types of information that a
doctor needs for such counseling: identification of risk indicators that would
increase Mr. T’s susceptibility to disease, and of resources, which may help him
cope with it.
The ensuing dialog with students defined “risk indicators for disease” as host
factors (e.g., heredity) and environmental factors (e.g., exposure to occupational
hazards). Some risk indicators, such as a family history of diabetes or smoking, may
increase the likelihood of specific diseases. Other risk indicators, such as age, may
increase the likelihood of disease in general. I contributed to the discussion evi-
dence that I outlined earlier in this section, namely that disease is also more com-
mon in individuals who have experienced recent life events; that markers of
socioeconomic status (income, education, housing) are better predictors of health
status than biomedical risk indicators, such as blood lipids; that the morbidity of
poor people is higher than that of people with better incomes; and that regardless of
income and education, residents of poor neighborhoods have higher morbidity rates
than residents of affluent neighborhoods.
With my help, students defined “resistance resources” as systems that help an
individual cope with the disease. The immune system and nutrition are examples of
physiological resistance resources. I contributed to the discussion of psychosocial
resources such as socioeconomic status. The distinction between resistance

resources and risk factors is somewhat blurred: the absence of a resistance resource
may in itself be considered a risk indicator. However, the phrase “resistance
resources” is useful mainly in understanding the contribution of social support sys-
tems that I described earlier.
Table 6.1 attempts to provide a guide for querying clinically relevant data in the
patient’s personal history and to simplify this query by dividing it into categories
that standardize key issues.
Some students argued that the identification of risk indicators and resources in a
patient is not useful for making clinical decisions. Doctors obviously cannot alter an
individual’s past, just as they cannot combat poverty. I responded that neither can
doctors alter an individual’s heredity and age nor, in many cases, an individual’s
immunity. Still, information on risk indicators and resources is important because
they may affect a patient’s susceptibility to disease and determine his/her needs for
help in case of disease. Similarly, doctors cannot do anything to correct loneliness
or socioeconomic deprivation. However, they must consider these personal features
in counseling patients about treatment modalities that are not covered by insurance,
determining the frequency of follow-up visits, and assessing the need for home care
or referral to the hospital, just as they should consider a patient’s age and comorbid-
ity in assessing his or her healthcare needs.
There is a difference between an employee with a stable job and health insurance
who continues to receive a salary during illness and a self-employed patient without
Table 6.1 Proposed format for the bio-psychosocial history

Risk indicators of disease:
Age
Gender
Ethnic group
Family history (health and age of parents, history of hereditary disorders in relatives)
Occupation (exposure to occupational hazards)
Living conditions (number of occupants per room, sleeping arrangements)
Typical daily routine
Life events (separation from parents, change of school, divorce, loss of close relatives, change
of job, travel, and vacation)
Comorbidity
Exposure to medication, surgery, or contagious diseases
Habits: alcohol, drugs, cigarette smoking
Resources:
Education
Income
Medical insurance (effect of disease on patient’s income)
Marital status and number of children
Relations with colleagues, work tension, and satisfaction
Social contacts
health insurance whose illness worsens his or her financial situation. There is a dif-
ference between a childless elderly widower who lives alone and eats convenience
foods indiscriminately and a patient of the same age who lives with his wife, attends
a senior citizens club, and enjoys visits from his children and grandchildren. The
lower the patient’s educational level, the more encouragement he needs to ask ques-
tions about his illness and to receive longer explanations. Conversely, an educated
patient may be satisfied with a brief explanation accompanied by written material or
a reference to a website on the Internet.
The description of susceptibility in the format of a statement of risk factors and
resistance resources provides a purposeful definition of data to be looked for and
criteria to evaluate the record of a patient profile. The conversation with Mr. T. may
be recorded either in the form of a checklist or as a narrative, such as:
Mr. T. aged 55 years, of North African Jewish extraction, lives with his wife and one child
aged 10 years in a three-bedroom apartment. When Mr. T was 13 years old, his father died
after a stroke, and he discontinued his schooling to help support the family. He has two
sisters with hypertension. Until about six months ago, Mr. T was employed in an automo-
bile repair shop before he moved to this town to establish his own business. Three months
ago, his daughter was married. His health insurance covers primary and secondary care and
hospital bills.
A typical daily routine includes work that involves physical exertion. He spends his
evenings with his wife entertaining friends at home or visiting them. His diet includes
bread, vegetables, cheese, and eggs for breakfast; a cheese sandwich for lunch; and beef for
dinner. He smokes one to two packs of cigarettes a day since he was 19, but he seldom
drinks alcohol. He describes himself as asymptomatic and active, with an optimistic out-
look about his future, and he denies any worries. On examination, he was calm, alert, and
in no apparent distress. His pulse rate was 80/minute, blood pressure of 145/95 mm Hg,
height of 180 cm, and weight of 73 kg.
This summary indicates that Mr. T is a physically active man with a structured
daily routine, fair income, health insurance, an optimistic frame of mind, and good
social support systems. Nonspecific risk indicators: limited education and recent
life events (wedding of a daughter, change of residence, and a change in occupa-
tion). Specific risk indicators: family history of hypertension and stroke, personal
history of cigarette smoking, excess of animal fats in the diet, and a PE finding of
borderline hypertension.
The following is an example of the profile of a patient with chronic heart disease:
Dr. B, age 60, lives with his wife in a three-room apartment. They have three married chil-
dren living in the same city. The patient holds a Ph.D. degree in history and, until about six
months ago, was a college professor. He had to retire because of his disease and in recent
months, he has been mostly homebound. Although capable of performing the activities of
daily life, he tires easily and experiences shortness of breath even after a little effort. The
family income includes his pension allowance and the salary of Mrs. B who is a librarian.
His health insurance covers outpatient, in-hospital, and home care. The patient describes
himself as a “loner” with only a few friends beyond his wife and extended family.
For the past 10 years, he knows that he has had heart disease. He adheres to a low-fat
diet, regular exercise, and immunizations. Although satisfied with the home care he receives
from a nurse specialist in heart disease and a cardiologist, the patient is worried about the
deterioration in his health in the past year, and is pessimistic about the future.
During the discussions, I presented to students Engel’s bio-psychosocial model

[51], first as a link between the BSS and clinical practice, and second, as a reference
point for setting priorities among the various BSS topics [21, 52]. Engel defined
patient interviewing (“the doctor–patient dialogue”) as the only “instrument for
investigating the human realm” i.e., for gaining insight into a patient’s preferences
and lifestyle, and into the psychosocial determinants that may increase the risk of
developing a disease and reduce the ability to cope with it. Similarly, a 2010 survey
indicated that UK medical faculty viewed the patient–doctor relationship as the
most important BSS subject [53] and a 2016 review of the literature indicated that
communication skills were the most commonly assessed BSS competency [54].
Therefore, the highest priority in teaching the BSS would be the skills of doctor–
patient communication (interviewing), patient counseling (sharing of information,
breaking bad news, discharge planning, instructions, and adapting management to a
patient’s lifestyle), and dealing with emotions (anxiety, anger, shame).
Students appear to appreciate the importance of the BSS more during their clerk-
ship rotations. Contrary to the negative attitudes of preclinical students to BSS lec-
tures, students in clinical clerkships have been reported to perceive positively
physicians who stress the psychosocial aspects of medicine [55]. Therefore, the
optimal timing for BSS instruction seems to be during the clinical methods course
and the clerkship rotations and the optimal teaching approach is small group discus-
sions, rather than lectures and reading assignments. During these discussions, an
effort would be made to encourage students to explore the biomedical and psycho-
social aspects of a patient’s condition in an atmosphere of respect for the worth of
both the biomedical and bio-psychosocial models of clinical reasoning and with
reflection on their merits and weaknesses. Rather than force-feed medical students
with lecture courses, faculty would make students discover for themselves the rel-
evance of the BSS to clinical problem-solving and agree on a hierarchy of learning
priorities.
6.3.2 Implications for Clinical Practice
Awareness of the relationship between socioeconomic factors and morbidity has

two main implications for clinical practice: First, it emphasizes the importance of
patient-centered medicine. The purpose of the medical interview is not only to
obtain information but also to offer therapy by identifying and attempting to allevi-
ate stress, anxiety, or depression. Ignoring patients’ psychological needs during
treatment leads to avoidable patient suffering and treatment costs [56].
Second, many physicians hold unconsciously to stereotypes, and some physi-
cians tend to consciously dismiss the complaints of patients with psychosocial prob-
lems, acute (e.g., recent bereavement) or chronic stress (e.g., caring for ill family
members), or following a life event as “somatization,” “psychosomatic illness,” or
“functional disorder.” Medical educators try to reduce this tendency by getting phy-
sicians to treat such patients like any other patient. This approach is only partially
correct. Underprivileged patients, patients with acute or chronic stress, or following

a life event are not like any other patient: they are at higher risk. Socioeconomic
status [57], life events [10], drug dependence [58], severe mental illness [59], and
high body mass index [60] are associated with increased morbidity and mortality.
African Americans have higher mortality rates than whites for most leading causes
of death (heart disease, cancer, stroke, diabetes, kidney disease, hypertension, cir-
rhosis, and homicide), with a difference in life expectancy of 7 years in 1960 and
5 years in 2005, even after adjusting for socioeconomic status (SES) [61].
The higher prevalence of disease in disadvantaged individuals suggests that any
symptom in a child from a dysfunctional family, in a poor, elderly, or uneducated
person who is addicted to drugs or is mentally ill, or in a person who has experi-
enced a significant life event, may herald more severe disease than in patients with-
out these risk indicators. In other words, the likelihood of serious illness is higher in
patients with psychosocial risk indicators than in patients without these risk indica-
tors, just as the likelihood of life-threatening infection is higher in an immunocom-
promised patient than in an otherwise healthy person. Rather than trying to promote
an egalitarian attitude, physicians should select such patients for special attention.
6.3.3 Who Should Teach Medical Students the Clinically

Relevant Aspects of the Behavioral and Social Sciences?
In an ideal situation, clinical tutors would address both biomedical and psychosocial
issues. However, most clinicians lack the training and willingness to teach the BSS,
while social scientists lack clinical expertise. Hence the suggestion that both clini-
cians and social scientists should teach the BSS in general and patient interviewing
in particular [62]. Engel has cautioned, however, that such combinations may inad-
vertently perpetuate the separation between biomedical and psychosocial problems
by implying that the latter is the domain of social workers and psychiatrists rather
than part of the clinical practice of all physicians. The challenge for medical educa-
tion, therefore, is to support training programs for “social science clinicians” or
“clinical ethicists” who would feel comfortable demonstrating appropriate inter-
view techniques and conducting group discussions.
An additional barrier to teaching the BSS is the uncertain status of social scien-
tists in medical schools. Many medical schools lack career opportunities for social
scientists who feel isolated from their root discipline (sociology) and marginalized
by the host discipline (medicine) [44]. To overcome this barrier, career paths for
BSS scholars in the health professions and their teaching responsibilities should be
defined at the university level and decisions about curricular reforms would be
based on a dialog between clinicians and BSS scholars. Such discussions would aim
to reduce tensions, negotiate educational goals, and define the content of teacher-
training programs. A dialog between clinicians and BSS scientists would be a posi-
tive experience for both sides and would lead to an agreement on the content and
educational methods of BSS courses.
Third, much of the knowledge in the field of health sociology was originally
generated in a tradition of critical attitude towards medicine [63]. This tradition has
alienated medical students and faculty. In the 1980s, it was claimed that “…some
departments of behavioral sciences have adopted an intellectual stance at times
antagonistic to the rest of the medical school by emphasizing the shortcomings of
the profession in its delivery of healthcare” [50], and some heads of clinical depart-
ments in the USA have spoken of an “anti-physician stance of medical sociology”
[64]. Certainly, the tradition of critical attitudes toward medicine has contributed to
an understanding of the role of medicine in society. However, I believe that it is time
for BSS faculty to suggest how the deficiencies they have identified in health care
can be addressed. If BSS scholars are to fulfill their mission, they should team up
with clinicians to educate a more humane, professional, and effective physician.
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Chapter 7
Medical Errors and Quality Assurance
of Healthcare
7.1 Introduction
Western norms grant physicians professional autonomy in exchange for a commit-

ment to provide quality health care. However, the term “quality health care” defies
definition. Since the outcomes of clinical care are uncertain, “quality” should
encompass both outcome and process dimensions, including the physician–patient
relationship and equitable distribution of resources. Therefore, health care quality
can be tentatively defined as “an intervention that is acceptable to the patient, the
physician, and the institution providing health care services and meets professional
and ethical standards.” In this section I describe, first, the incidence of medical
errors; second, the attitude of physicians toward quality assurance and corrective
interventions; and third, the management of incapacitated physicians.
7.2 Medical Errors
Medical errors elude definition [1]. Outcome-based definitions focus on interven-

tions that have been shown to be incorrect in autopsies, morbidity/mortality confer-
ences, self-reports, and claims audits. Although these studies have provided unique
insights into misdiagnosis [2], they have not helped to understand the reasoning of
individual clinicians because they cannot accurately reconstruct the context in
which the decision was made.
It is common to distinguish between three categories of medical accidents. The
first includes non-fault accidents caused by properly performed medical procedures,
such as a hypersensitivity reaction to a drug administered to a patient for the first
time. The second is negligent medical errors resulting from a physician’s failure to

Switzerland AG 2023
126 7 Medical Errors and Quality Assurance of Healthcare
meet the expected standard in his or her specialty, such as severing the ureters dur-
ing abdominal surgery. The third category includes medical errors that do not indi-
cate negligence or incompetence. This last category is the gray area between the
previous two. The ambiguity of its definition is due to our limited insight into the
disease process, which makes perfect diagnoses and treatments unattainable. Just as
we must accept that every drug has side effects, standards of clinical practice must
also come to terms with the fact that some degree of error is inevitable, and that it is
often difficult to distinguish between errors due to the limitations of the physician
and the limitations of current medical knowledge.
This distinction is usually based on expert opinions. However, their reliability
(reproducibility, interobserver agreement) is poor to moderate [3]. The limited reli-
ability of expert opinions is due in part to varying degrees of hindsight bias—a
tendency to view events that have already occurred as more predictable than in
advance [4]. The only reason we continue to rely on expert opinion, despite its lim-
ited reliability, is that there is no better alternative. Physicians who find themselves
in a situation where they must evaluate another physician’s decisions should hum-
bly remind themselves that there is no gold standard for clinical reasoning. They
should not ask themselves the question, “What would I have done under these cir-
cumstances?” which can be biased in hindsight, but rather, “Was the decision in
question extremely unreasonable?”
7.2.1 Prevalence of Medical Error and Doctors’ Attitude

to Mistakes
The prevalence of medical errors is usually determined by retrospective reviews of

autopsies, medical records, physician and patient surveys, malpractice claims, and
prospective studies with participatory observation. In 1984, the Harvard Medical
Practice review of a sample of patient records from New York hospitals found medi-
cal errors in 3.7% of the records, and error was considered the sole or additional
cause of death in 1 of 400 inpatients [5, 6]. More recent studies found diagnostic
discrepancies that would have changed management in 10–20% of autopsies [2]. A
2016 review found fatal preventable adverse events in 0.4–1.1% of hospitalizations
[7]. Finally, a 2018 systematic review found that the prevalence of self-reported
medication errors was 2–6% in patients older than 18 years and 75% in older
patients [8].
The main victims of medical errors are the patients. However, medical errors also
affect healthcare providers. Physicians’ reactions to medical errors are cognitive,
emotional, and functional. The cognitive domain includes physicians’ awareness of
past errors, possible future errors, and of inadequate training. Mizrahi [9] also iden-
tified responses such as repression (ignoring and forgetting the medical error),
denial (defining the error as a non-error), reduction of responsibility (shifting blame
to others, such as the system, supervisors, colleagues, diseases, and patients), and
distancing (“no one is perfect,” “errors are inevitable”).
7.2 Medical Errors 127
The culture in clinical education is not tolerant of error. When errors occur, the
pursuit of excellence evokes emotions such as fear of litigation and stress due to
uncertainty. In 1984, Hilfiker [10] described the guilt, shame, and frustration he felt
after making mistakes while working in a remote area in the USA. These feelings
have been repeatedly confirmed in recent surveys. North American physicians
reported anxiety (61%), loss of confidence (44%), sleep disturbance (42%), and
decreased job satisfaction (42%) after making mistakes [11]. Feelings of shame and
guilt are compounded by physicians’ failure to share them with others, leaving them
unsupported in their distress [12]. Discussions of physician errors in closed sessions
are ineffective in providing support. On the contrary, the critical and threatening
atmosphere in these discussions only increases anxiety and guilt [13, 14].
The functional consequences of these emotions are reduced self-disclosure of
errors, even to colleagues and friends; support for self-regulation and reluctance to
be accountable to lay people or lay institutions; and defensive practice characterized
by ordering tests even when clinically deemed unnecessary [15], avoiding “like”
patients or procedures [14], or early retirement [16]. The proportion of physicians
who feel shame, guilt, and frustration after medical errors, who have accepted
responsibility for their errors and learned lessons, or who respond with repression,
denial, blaming others, and distancing is uncertain. One can only wonder which of
these reactions is desirable or dysfunctional. Helping physicians deal with the con-
sequences of their mistakes remains an unexplored area.
7.2.2 Prevention of Medical Errors
As recently as 2002, the public and many physicians advocated the use of sanctions
against individual professionals found responsible for errors [17]. The assumption
that medical errors are caused by incompetence is very tempting: it is the basis for
physicians’ belief that “it will not happen to me” and for patients’ trust in the health
care system. Causal relationships dominate our thinking [18]. We all want to believe
that errors do not just happen, but are caused and that the task of attributing medical
errors to incompetence and identifying those who are prone to error, while difficult,
is not impossible and may even improve our understanding of the causal structure
of the environment [19].
However, this view is not supported by evidence. Although some physicians are
more likely than others to be sued for negligence [20], lawsuits in the physician’s
professional past do not predict future lawsuits [21], and very large cohorts are
needed to confirm habitual substandard performance [22]. Moreover, the high prev-
alence of medical errors suggests that they are random events that affect most physi-
cians. Even assuming that 1% of all physicians are 10 times more likely to make
errors than their colleagues (i.e., 1% of physicians are responsible for 10% of all
medical errors), the remaining 90% would be committed by the other 99% of physi-
cians. Thus, it appears that even if negligent physicians could be identified, their
removal would not eliminate medical errors, as any physician may commit an error
due to fatigue, lack of sleep, mental stress, or momentary distraction. Similar to

diseases, medical errors are not caused by a single factor, but by multiple factors
converging at the same place at a given time.
Clinical practice involves dozens of procedures per patient. Therefore, estimates
of the frequency of errors suggest an accuracy of more than 99%. But even 99.9%
accuracy is less than that expected in other systems such as civil aviation, banking,
or postal services. All of these systems are human-designed; their activities and
failures can be predicted and analyzed, whereas diseases are subject to biological
variability. Nevertheless, medical errors are considered one of the biggest problems
in healthcare, and efforts have been made to learn from other systems, such as civil
aviation, how to deal with them.
Civil aviation assumes that errors are random. Avoiding them requires honest
self-disclosure to find out why they happened, rethinking the process, and standard-
izing professional practice through regulations and algorithms. Pilots are required
to pass exams at regular intervals to prove their proficiency, and aviation safety is
institutionalized under independent administration. These assumptions and the
resulting conclusions for civil aviation are quite different from those for health care.
Unlike civil aviation, there are inexplicable differences in how physicians approach
the same clinical problem between countries and even within a country [23, 24].
Unlike pilots, physicians are only examined at the end of their clerkship and are not
required to undergo regular examinations. Quality assurance of medical care
assumes that mishaps are not random but are due to “human error.”
However, the assumption that mishaps are due to “human error” is similar to the
conclusion that people fall because of gravity: it is correct, but not helpful as all
medical errors are human errors. Hence the suggestion to deal with them not by
punishment but by their continuous analysis to make the health care system as error-
free as possible [25]. To achieve this, several taxonomies have been proposed to
explain why a particular error occurred and develop interventions for each type of
error [26]. Indeed, the rise in anesthesia safety in recent decades is the result of open
reporting of errors and intelligent efforts to make the system resistant to errors. The
achievements of anesthesiologists can also be applied to other areas of clinical
practice.
7.2.3 Patients’ Complaints and Medical Litigation
Evidence suggests that the primary cause of patients’ complaints is a difficult physi-
cian–patient relationship [27, 28]. Compared with physicians who had filed two or
more lawsuits in their careers, physicians who had not filed lawsuits used more
orientation statements (educating patients about what to expect), laughed more,
used more humor, and tended to use more facilitation (seeking patients’ opinions,
checking for understanding, and encouraging patients to talk) [29]. Similarly, a sur-
vey of patients who took legal action found that they wanted honesty, an
7.2 Medical Errors 129
appreciation of the severity of the trauma they had suffered, and reassurance that
lessons had been learned from their experience [30].
The main goals of malpractice litigation are to compensate patients and to deter
negligence. These goals appear to be only partially achieved. The number of law-
suits is 8–10 times lower than the estimated number of malpractice cases in the USA
[31], and not all lawsuits against doctors are justified: Of the 313 negligence cases
uncovered in the Harvard Medical Practice Study, only eight resulted in a lawsuit.
Thus, the legal system compensates only a small proportion of those injured by
medical errors [32].
While it is difficult to assess the deterrent effect of the threat of a lawsuit, it is a
strong motivator for the concealment of errors and defensive clinical practices that
include multiple examinations and avoidance of necessary risky medical interven-
tions. For these reasons, physicians distrust the legal system. However, their claim
that it is arbitrary and that only physicians can judge their colleagues is incorrect:
there is a high correlation between court rulings in medical malpractice lawsuits and
independent judgments by medical specialists. Also, contrary to the claim that juries
in the USA tend to favor severely injured patients, there is no correlation between
the severity of the injury and the amount of compensation [33].
7.2.4 Disclosure of Medical Errors to Patients
Healthcare providers and patients are aware that errors can occur despite the best
efforts of physicians and institutions. Yet patients who have experienced a medical
error report struggling with a variety of consequences for years after the mistake.
Most reported long-term effects, such as changes in seeking medical care, anger,
and vivid memories; more than half reported ongoing physical effects, and one-
third reported financial effects [34].
Patients who have been victims of medical accidents need to understand what
went wrong. An inadequate explanation increases the patient’s distress, whereas a
full explanation can alleviate that distress and, in at least some cases, is received
with understanding. Sometimes the primary motive for a complaint is the patient’s
desire to understand what happened. Open communication, which includes disclo-
sure of what happened, an apology, and a description of attempts to prevent it from
happening to someone else, reportedly reduces feelings of sadness and betrayal in
patients [35]. Moreover, it has been reported to reduce [36] or not affect [37] mal-
practice litigation.
For this reason, the U.S. Joint Commission requires that patients be informed of
unanticipated outcomes of care and has linked this requirement to hospital accredi-
tation. In 2006, the Working Group of Harvard Hospitals released a statement
emphasizing the importance of disclosure, apologies, and discussion about prevent-
ing the recurrence of errors and defining this disclosure as a core component of
quality health care rather than a risk management issue. The statement
acknowledged that disclosure of errors is a difficult conversation and called for

adequate preparation, support, and training of healthcare workers before disclo-
sure [36].
These requirements have been only partially implemented. As recently as 2020,
an analysis of disclosure and apology outcomes after medical errors found that of
434 malpractice claims, 4.6% of errors were disclosed to the patient at the time of
the error and 5.9% were followed by an apology. Of the errors disclosed, 26.1% had
resulted in an adverse reaction, and 17.4% were fatal. However, no apology was
issued for 54.5% of medical errors that were considered serious [38].
7.3 Incapacitated Doctors
A 53-year-old physician has been complaining of work overload, fatigue, and anxiety for
about a year. His colleagues smelled alcohol on his breath and found errors in the medica-
tions he prescribed. They did their best to correct and cover up these errors but did not
advise him to seek help because of the expected impact on his status. Only after he caused
a car accident while under the influence of alcohol was he referred for treatment.
This scenario is hypothetical, but not unrealistic. Alcohol addiction, depression,

and burnout can interfere with physician functioning.
7.3.1 Incidence
Clinical practice offers satisfaction and better health than the general population: in
2000, physicians in the USA died at an older age than lawyers and other profession-
als [39]. However, the profession of medicine also requires lengthy training, fre-
quent job changes, responsiveness to the medical and psychological needs of others,
and sometimes witnessing suffering and death. Physicians today are working longer
hours and enjoying the practice of medicine less. They experience more stress than
in the past, escalating rates of burnout, dissatisfaction with career choices, depres-
sive disorders, and suicide. The specific sources of stress appear to be fear of medi-
cal errors and malpractice suits, time pressure, fatigue, workload and lack of free
time, therapeutic failure, failure in the doctor–patient relationship, fear of violence
from patients, and criticism from colleagues [40]. All of these factors are particu-
larly severe during internship and residency [41].
The prevalence of substance abuse among physicians is difficult to assess because
of the stigma attached to those concerned and the different methods used in studies.
It is estimated that 8–15% of all physicians are affected by substance abuse [42].
Recent studies have found that alcohol was the most commonly abused substance
among US physicians, followed by opioids, marijuana, cocaine, tranquilizers, and
amphetamines [43] and that the prevalence of smoking was 21% among physicians
in general and 25% among medical students [44].
7.3 Incapacitated Doctors 131
Despite their financial security, high status, and rewarding jobs, physicians have
higher rates of depression and anxiety compared with the general population and
other professions across all ages, genders, specialties, and years of service. In 2001,
suicide rates per 100,000 years/male in Norway were 47.7 among physicians but
only 20.1 among other academics and 22.7 among males without higher education;
rates among females were 32.3 among physicians but only 13.0 among other aca-
demics and 7.7 among women without higher education [45]. Suicide rates among
male and female physicians declined after 1980. A 2020 review of studies since
1980 found higher suicide rates among female physicians compared with women in
general (1.46) and lower suicide rates among male physicians compared with men
in general (0.67) [46].
The distinction between depression and burnout is controversial. The diagnosis
of depression is based on symptoms such as low mood, loss of interest, fatigue, low
self-esteem, suicidal thoughts, difficulty concentrating, memory problems, sleep
disturbances, feelings of guilt, helplessness, dissatisfaction, hopelessness, and feel-
ing that others are doing better [47]. Unlike depression, which is considered to be
independent of context, burnout is commonly viewed as an occupational syndrome
of emotional exhaustion, depersonalization/cynicism, and feelings of diminished
personal accomplishment [48, 49].
A 2018 survey of practicing physicians in the USA found that 54.3% reported
symptoms of burnout, 32.8% reported excessive fatigue, 6.5% reported recent sui-
cidal thoughts, and 10.5% reported a medical error in the past 3 months [50]. A
2020 review similarly indicated that about half of practicing physicians in the USA
report burnout and up to 14% report suicidal thoughts [51]. However, estimates of
burnout among surgical residents varied widely depending on the definition: under
the most common definition, 43.2% of general surgery residents reported burnout
symptoms; subtle changes in the definition of burnout resulted in prevalence esti-
mates that ranged from 3.2% to 91.4% [52]. These findings do not support conclu-
sions about the prevalence of burnout among physicians and underscore the
importance of developing a standard definition of burnout.
7.3.2 Response to the Awareness of Doctors’ Dysfunction
The culture of clinical medicine expects physicians to “cope alone.” Therefore, they
fear that seeking medical help will be interpreted as a weakness. Denial of illness
stems primarily from the urge to maintain an image of success, strength, and stabil-
ity. Physicians find it difficult to abandon the role of caregiver and assume the role
of patient. In addition, physicians have doubts about the significance of their symp-
toms and fear being labeled as hypochondriacs if they turn out to be healthy.
As a result, physicians resort to self-diagnosis and self-treatment or seek advice
from close friends in the hallways of clinics and hospitals. For example, a survey of
German general practitioners found that 68% were self-diagnosed, 60% were self-
treated, and only 19% were registered as patients with a general practitioner [53]. In
particular, physicians in mental health crises and alcohol or drug abusers tend to
deny their condition and believe in their ability to self-treat their addiction. Having
devoted about a third of his/her life to preparing for practice, a physician may be
unwilling to admit to a mismatch between clinical reality and his/her expectations.
Denial may also be based on prejudice against mental illness. Consequently, many
clinicians reject any offer of help and create a bond of silence for those around them.
7.3.3 Dealing with Doctors’ Dysfunction
The medical profession has a responsibility to prevent harm resulting from physi-
cian dysfunction and to provide programs for its treatment. Physicians should be
aware of the occupational risks posed by workload, anxiety, access to medications,
and depression. They should also be aware of their tendency to self-medicate health
problems and of ways to get help. Foreign graduates deserve special attention. They
struggle to adjust, learn a language, and get a license; they endure the humiliation of
failing the exam; and when they do succeed, they often have to work in a different
profession than the one they once specialized in.
Barriers that prevent impaired physicians from seeking help include fear of
stigma and professional and economic consequences of diagnosis [42]. Addressing
physician dysfunction requires eliminating the stigma associated with mental ill-
ness and illness in general and raising awareness that mentally ill physicians deserve
as much compassion and support as any other patient. Physicians should politely
and gently refrain from any attempt by patients in general, and colleagues in par-
ticular, to obtain medical advice in a non-binding “corridor.” One may respond to
such a request by saying “I am not sure I can give you an answer to your question
right now. However, let us go to my office to discuss the problem and at the same
time I can examine you.” Care must be taken to examine the sick physician and to
provide immediate and effective treatment, fully involving the patient in clinical
decisions and seeking a rapid return to clinical activity.
In California, a 1980 law offered physicians the option of receiving rehabilitation
treatment funded by the Health Care Quality Assurance Board while providing
immediate response, individualized care, and confidentiality. An evaluation of the
first two and a half years of the program found that 109 of the 117 physicians were
able to continue their clinical work while receiving rehab [54]. Similarly, a 2019
position paper from the American College of Physicians outlines principles that
should guide the response of colleagues to physician impairment. It recommends
that, first, an impaired physician should be rehabilitated and reintegrated into the
practice of medicine whenever possible without compromising patient safety; sec-
ond, physicians must seek help if they are unable to provide safe care; and third,
when identifying colleagues who may be impaired, physicians should act out of
collegial concern as well as ethical and legal guidelines that mandate reporting of
behavior that puts patients at risk [55].
7.4 Quality Assurance of Healthcare 133
A 2021 review found that about three-quarters of health professionals with sub-
stance abuse who participated in monitoring programs were abstinent and main-
tained this for up to 8 years. However, none of the studies reviewed used a
randomized control trial or quasi-experimental design, and the observational design
of the studies did not allow clear conclusions about the effectiveness of monitoring
programs for health professionals with substance use disorders [56]. Nevertheless,
it is clear that physicians’ health should be monitored at regular intervals, much like
the fitness of drivers and pilots, and that physicians would benefit from medical
surveillance throughout their careers. Therefore, medical facilities in the USA need
to have a framework for treating addiction in physicians, educate their staff about
their policies on addiction and disorders, establish an orderly process for referral to
counseling, and encourage those who need rehab treatment to seek it.
7.4 Quality Assurance of Healthcare1
Health care is evaluated in terms of structure (facilities and organization), process

(efficiency, cost-effectiveness), and outcomes (mortality, adverse events) [57, 58].
Quality assurance can be viewed as a sequence of identifying deficiencies in any of
these three components, implementing corrective actions, and evaluating their con-
sequences. Deficiencies may be identified by patients, physicians, and audits of care.
Patient surveys indicate that most respondents are satisfied with their health care.
However, they do not provide insight into why a minority of patients are not. It
would be more informative to express patient survey results in terms of the propor-
tion who are dissatisfied and to add questions such as “Was there anything that
bothered you during your care?” or “Do you have any suggestions for improving
our service?” Deficiencies in health care can be identified by physicians. Questions
such as “What are the main barriers to improving your service?” or “What are you
doing now that you could do better?” can identify processes such as communication
failures or equipment needs. Such questions, especially when coupled with a request
to find a solution, are an incentive for stakeholders to work together.
7.4.1 Physicians’ Attitudes to Quality Assurance of Healthcare
When quality assurance was introduced in health care in the 1990s, physicians
reacted with “skepticism or simply disinterest” [59]. There are several plausible
reasons for this attitude. First, physicians perceive quality assurance as a threat. The
1
Parts of this section were published in:
Benbassat J, Taragin M. What is adequate health care and how can quality of care be improved?
Int J Health Care Qual Assur Inc Leadersh Health Serv. 1998;11:58–64. With permission
from Emerald.
prevailing culture in clinical education is one of perfectionism. As I mentioned ear-

lier, the conflict between this culture and the awareness of one’s inadequacy can
lead to anxiety and reluctance to be held accountable by lay institutions.
Second, physicians are unsure why quality assurance is necessary (to improve
cost-effectiveness? to respond to public demand? to avoid lawsuits? because we
care?), where to look for it (individual performance? health system performance?),
and how to achieve it (retraining? Elimination of “bad apples”? Changes in health
care delivery?). On the one hand, physicians are encouraged to report medical errors
and investigate why the error occurred. On the other hand, however, this approach
is at odds with current societal norms, which seem to assume that all errors are pre-
ventable and blameworthy and that only incompetent physicians make mistakes.
Third, quality measures currently in use, such as hospital mortality, have been
criticized for their limited reliability and validity. An example of the limited validity
of a measure of the quality of care is the rate of hospital readmissions. It stands to
reason that improved patient care during and after hospitalization would prevent
readmissions. However, in about half of the studies, no association was found
between readmissions and other measures of quality of care [60].
The lower the actual incidence of error, the higher the likelihood that current
quality measures will misidentify appropriate clinical interventions as errors [61].
An ideal measure with 100% sensitivity and 100% specificity would correctly iden-
tify all medical errors. However, no diagnostic test is ideal. For example, a test with
a sensitivity of 95% would detect 95 of 100 medical errors and identify the other
five medical procedures as correct, even though they are incorrect. A test with a
specificity of 95% would detect 95 out of 100 correct clinical interventions and
identify the other five as errors, even though they are correct. Applying such a test
to a sample of 10,000 clinical interventions with a true error rate of 1% (a total of
100 incorrect interventions) will identify 95 of these 100 as errors and the remaining
5 would be incorrectly identified as correct. Of the 9900 correct interventions, the
test will falsely identify 495 as errors. In total, the test will identify 590 (5.9%)
errors, or about six times higher than the true error rate [61].
The uncertain validity of quality indicators precludes their use in penalty deci-
sions. Publication of the results of comparative studies is in and of itself punitive
because it damages the reputation of institutions or physicians without due process
of law. A reasonable compromise between the public’s right to know and the limited
quality of quality information seems to make it available while emphasizing its
limitations and the risk of jumping to conclusions. However, a finding that a particu-
lar medical service differs significantly from other services in terms of outcomes
warrants feedback and, if necessary, remedial action.
Finally, open disclosure of medical errors is critical to improving patient safety.
However, fear of self-incrimination is a major barrier to such disclosure. Ideally, the
focus of quality assurance would shift from finding the culprit for an adverse out-
come to improving the clinical practice process. A 2008 survey of US faculty and
residents found that most respondents believe that reporting errors improves the
quality of patient care and would likely report a hypothetical error that resulted in
harm to a patient. However, 16.9% of respondents admitted to not reporting a minor
7.4 Quality Assurance of Healthcare 135
error, and 3.8% admitted to not reporting a major error [62]. A 2021 survey showed
that barriers to reporting medical errors varied widely across centers, with fear of
the consequences of such reporting and work climate/culture being the most com-
monly cited barriers [63].
7.4.2 Promoting Physician Support for Quality Assurance

in Healthcare
Promoting physician support for quality assurance in health care requires its evalu-
ation by valid measures. The current approach to quality assurance is based primar-
ily on outcome measures. These measures are intrusive, threatening, and of limited
reliability and validity. Therefore, rather than focusing on outcomes of care, quality
assurance has already today focused on processes, such as medication management
systems, analysis of unexplained variation in practice, and implementation of clini-
cal practice guidelines.
Recognizing variation in processes and outcomes is fundamental to quality con-
trol, and industry experts have long developed quality improvement principles and
techniques based on such variation. Audits of care have identified substantial geo-
graphic variation in clinical practice and hospital utilization. The identification of
such differences has triggered several types of action. First, formal decision analysis
can identify the intervention that maximizes utility. Second, simple feedback of data
on practice patterns can reduce variation. Third, studies of practice variability have
led to important findings about unintentional discrimination against patients.
The most important types of effective interventions are clinical decision support
systems [64]. Finding unexplained variability in practice requires agreement on the
right process and translating that agreement into clinical guidelines. The advantage
of such guidelines is that they provide quality control not only by detecting errors in
practice but also errors of omission, such as failure to monitor patients with diabetes
for ophthalmologic complications. As early as 1995, guidelines were increasingly
used by attorneys in malpractice litigation to both exonerate and incriminate the
defendant physician [65].
7.4.3 Promoting Physician Self-Disclosure of Errors
A 2010 review found that both patients and healthcare professionals support the
disclosure of adverse events to patients and their families [66]. However, surveys
also found that physicians were much less likely than the general public to believe
that quality of care was a problem. Physicians perceived several barriers to success-
ful error reduction. These barriers were, first, fear of punishment, career-threatening
disciplinary actions, and potential malpractice lawsuits and liability claims. Second,
the lack of a definition of what constitutes errors. Finally, the lack of an error report-
ing system, the lack of information on how to report an error, and the lack of feed-
back to the reporter [67].
A prerequisite for reporting errors is a guarantee of impunity to those who com-
mit errors and those who report them. This may require changes in attitudes, prac-
tice norms, and professional behavior. Encouraging physician self-report of errors
would require physicians to accept that it is their responsibility to monitor their
performance and to identify and report errors or deficiencies in the health care sys-
tem. The position of individuals who commit errors and do not report them also
needs to be clarified. For the system to be effective, individuals who do not report
errors they notice must bear some risk for not reporting them. All of these condi-
tions are unlikely to be ensured, and a 2003 editorial in the Journal of the American
College of Surgeons asserted that reporting medical errors and near misses is a
naïve, costly, and misguided goal [68].
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Chapter 8
Shifts in the Structure of Health Care
and Doctor–Society Relations
8.1 Introduction
Medical professionalism is a set of values, behaviors, and relationships guided by a

commitment to patients, colleagues, and the employing healthcare institution. All of
these shape the organizational infrastructure and cultural environment of health care
[1]. Since the 1970s, the rise in health care costs has led to a restructuring of medical
practice to what is now known as “managed care” and since the 1980s, social scien-
tists, bioethicists, and physicians have adopted the concept of the “social contract”
to describe physician–society relationships [2]. This section will describe some of
the features of managed care, its potential impact on public trust in physicians, and
the relationship between physicians and the media.
8.2 Managed Care
Managed care was originally intended to improve efficiency and reduce costs.
Today, however, it also involves a transition from care provided by individual physi-
cians to multi-professional teams. The physician is no longer the sole decision-
maker; he or she must consider the patient’s preferences, the advice of consultants,
and the policies of the employing institution. Managed care also involves monitor-
ing and ensuring the quality of care through clinical guidelines. All of this requires
a “bureaucracy” that has drawn criticism from both physicians and patients.

Switzerland AG 2023
142 8 Shifts in the Structure of Health Care and Doctor–Society Relations
8.2.1 Bureaucracy: Definition and Negative Connotations1
The term bureaucracy refers to an organization run by a central mechanism. Over

the years, however, this term has acquired several negative connotations. The first is
burdensome paperwork that leaves no time for patient care. The second is the desire
for self-protection. The bureaucrat fears criticism and tends to act defensively. The
third is loyalty to the employer. A bureaucrat is suspected of caring only about his
employer and being insensitive to the needs of the client he is supposed to serve.
The fourth connotation of bureaucracy is adherence to procedures. While “profes-
sionalism” is defined as an orientation to outcomes, “bureaucracy” is defined as an
orientation to process. At their extremes, a professional believes that the end justi-
fies the means, while a bureaucrat adheres to process to the point of harming the
outcomes this process is intended to achieve.
All of these negative connotations seem to apply to managed care. Medical
records are seen as paperwork that cuts into the time it takes to examine a patient.
Malpractice litigation promotes “defensive” medicine. The calls to conserve
resources cause physicians to feel divided between the patient and the employer.
Finally, adherence to clinical guidelines is seen as limiting physician autonomy. It
is no wonder, then, that physicians resist this new world that requires lots of paper-
work, defensive medicine, a split loyalty between patient and institution, and a com-
mitment to follow clinical guidelines. What are the desirable aspects of all these
scourges?
8.2.2 Desirable Facets of Managed Care
Until the 1970s, the purpose of documentation was to ensure continuity of care. At
that time, the clinical record did not include explicit justification of the diagnosis or
planned treatment. The adoption of the problem-oriented record in the 1970s
required an addition of a summary of the data, an assessment consistent with the
data, and a plan for further investigation, treatment, and patient education consistent
with the assessment. This requirement opened the door to a new era in clinical
teaching in which clinical decisions had to be justified rather than made intuitively.
Initially, the problem-oriented medical record was criticized for limiting physi-
cians’ freedom of expression and for requiring management decisions to be justi-
fied. Physicians complained that the additional paperwork would prevent appropriate
patient care. Notwithstanding these arguments, physicians today agree on the ben-
efits of the problem-oriented record. Documentation has evolved from a tool for
communication between physicians to a tool for educating students and ensuring
Previous version of parts of this section were published in:

1
Benbassat J. Bureaucratic features of managed care. Harefuah. 1998;134:412–15 (Hebrew).

With permission from the Harefuah.
8.2 Managed Care 143
the quality of care. The advantages of paperwork outweigh its disadvantages, and
although it is time-consuming, we must accept it.
The second connotation of bureaucracy, self-protection, is the desirable aware-
ness of accountability and quality control. When I was in medical school, the con-
cepts of accountability and quality control did not exist. Quality of care was the
implicit responsibility of department heads. It was not until the 1970s that physi-
cians realized that medical errors were common and not committed by a few incom-
petent physicians. Quality control of patient care can lead to undesirable defensive
medicine; however, today physicians accept it as necessary, and since the 1970s,
medicine has begun to implement methods to make the system as error-resistant as
possible. As threatening as the term “quality control” may sound, we must come to
terms with it.
Managed care is felt to require doctors to split their loyalty between the patient
and their employer in order to reduce medical costs. Patients’ medical needs are
unlimited. Not so the resources for health care, and no society can meet all the medi-
cal needs of its members. Therefore, an equitable distribution of resources among
patients is necessary. To save resources, the physician’s loyalty must be divided not
between the patient and the employing institution, but between the patient and other
patients.
An important negative connotation of bureaucracy is adherence to process.
Medicine is primarily outcome-based, and any attempt to impose practice guide-
lines is perceived as a threat to the profession. Yet medical standards allow for sig-
nificant variation in clinical practice. These variations are not desirable. Uncertainty
about the correct clinical intervention can be reduced by evaluating alternative
options and choosing the one that leads to the best outcome. If two alternative thera-
peutic options lead to the same outcome, the one that is more favorable in terms of
patient suffering and cost should be chosen. Therefore, in cases of unexplained dif-
ferences in clinical practice, agreement on best practice must be reached and trans-
lated into clinical guidelines.
Resistance to clinical guidelines is based first on concerns about suppressing the
physician’s thinking and turning him into a computer-like automaton. I do not share
this concern. A computer cannot replace an empathetic physician, and a reflective
clinician will need to update and refresh clinical guidelines regularly, reviewing and
adapting them to the innovations of medicine and local conditions. The second
objection to clinical guidelines stems from the false impression that they are bind-
ing. They are not. No one would treat a patient with penicillin if he/she is allergic to
that drug. Just as knowledge from textbooks should not be considered applicable to
all patients, deviation from clinical guidelines in individual cases remains the
responsibility of the physician. Clinical guidelines, like medical textbooks, should
therefore be viewed as decision-making support; as a means of education that can
accelerate the acquisition of clinical skills by medical students; as a safeguard
against litigation, thereby avoiding defensive medicine; but most importantly, clini-
cal guidelines will reduce unexplained variance in clinical practice. As much as our
identity as professionals requires a focus on outcomes, we must come to terms with
the need to follow procedures and professional rules.
For all these reasons, the question is not whether we should accept the implications
of managed care on documentation, control, allocation of resources, and the need to
justify deviations from clinical guidelines, but how we can minimize their undesirable
aspects. We need to find a way to keep proper documentation without getting lost in
paperwork; to recognize errors without acting defensively, and above all—to deal
with the need to divide our loyalties between the patient and other patients.
8.3 Fair Distribution of Healthcare Resources2
As recently as the 1960s, the call for a parsimonious use of medical resources would
have been interpreted as a violation of the sanctity of life. But since the 1970s, the
question “Is the price of saving a life too high?” is no longer rhetorical. The cost of
medical care has led to a shift toward managed care, in which the physician must
consider the constraints on the use of resources and thereby creating a seemingly
irreconcilable tension between physicians’ obligations to individual patients and
their employers. Although there is agreement on the need to limit resource use, it
remains unclear how this need will be translated into policy. The uncertainty stems
primarily from the ambiguity of guiding ethical principles and contested norms of
clinical practice.
8.3.1 Fair Distribution of Resources: Ethical Dilemmas
I shall use the terms “restriction,” “distribution,” “rationing,” and “allocation” of

resources interchangeably to refer to the need to deny a patient a medical interven-
tion deemed useful because of its cost. Rationing does not apply only to expensive
biotechnologies. Physicians accept the need to divide their time equitably among
patients, to use antibiotics sparingly to minimize the formation of resistant strains of
bacteria, and to perform transplants only when organs are available. Time, antibiot-
ics, and transplants are examples of resources that must be rationed because of their
limited availability rather than their cost. Therefore, rationing of medical resources
can be defined as the “denial of a medical intervention that is considered beneficial
because it must be distributed equally to other patients.”
Equitable distribution is guided by three principles: Commitment to all patients,
equity, and utilitarianism. Commitment to all patients assigns physicians a dual
role: to advocate for both individual patients and all patients while seeking to help
as many patients as possible within available resources. Equity rejects discrimina-
tion against patients. Utilitarianism favors clinical interventions based on their
2
Benbassat J. Barriers to the fair allocation of health care resources. Harefuah. 2003;142:103–8
(Hebrew). With permission from Harefuah.
8.3 Fair Distribution of Healthcare Resources 145
effectiveness, such as antibiotics for meningitis, over those whose effectiveness is

only partially proven, such as acupuncture for pain management.
The implementation of these principles raises difficulties. Equity is incompatible
with utilitarianism. Equity requires that every patient have an equal opportunity to
benefit from health care services, regardless of the level of benefit [3], whereas utili-
tarianism prioritizes clinical interventions according to expected utility. The term
“benefit” has been variously defined as “rescue”—saving a person’s life [4] or
extending years of life [5]. Consider two candidates for heart transplantation. Under
the first definition, they have equal priority; under the second, the younger patient
comes first. If the benefit is measured by life extension, the older patient is disad-
vantaged. If it is measured in terms of rescue, limits must be defined in the treatment
of terminally ill patients or neonatal intensive care units. Finally, one may question
the need to favor interventions for specific patients over preventive interventions
that may prolong the lives of unidentifiable patients [6].
The decision to use ventilators is often a life-and-death decision. An example of
this is the shortage of ventilators that occurred in Italy during the COVID-19 pan-
demic. As recently as the 1970s, ventilator withdrawal was considered an act of
killing. Today, such withdrawal is the most common cause of death in ICU patients
and is considered an ethical and legal obligation when performed at the request of
the patient or the patient’s representative. However, unilateral withdrawal of life
support may be an intolerable burden for physicians. Therefore, some authors have
advocated the use of triage committees to relieve bedside physicians of the respon-
sibility for such decisions [7].
What should be the criteria for rationing decisions when demand for ventilators
exceeds supply? A 2020 review found that there is significant variation among US
guidelines in the models used to determine priority. Six states prioritize pregnant
patients, medical staff, and younger patients. Most states use life expectancy and
comorbidity to rank patients, and about half of the states exclude certain categories
of patients from ventilatory support. A commonly accepted guideline for prioritiz-
ing patients for mechanical ventilation is based on their likelihood of survival to
hospital discharge, as assessed by an objective measure of disease severity, and the
presence or absence of comorbidities [8, 9]. However, the use of exclusion criteria
may discriminate against populations, such as those of lower socioeconomic status
who may have more comorbidities, those with disabilities, or children with meta-
bolic abnormalities. Some states exclude patients with end-stage renal disease who
are undergoing dialysis, even though they may otherwise live for years and be eli-
gible for kidney transplantation [10].
Rescue of identifiable patients dominates opinion polls on priority for health
resource allocation. However, it has been pointed out that despite its intuitive appeal,
it would be prudent to set it aside in many cases involving futile interventions. On
the one hand, there are anecdotal reports of recovery against all odds. On the other
hand, performing futile interventions as a rescue attempt makes it difficult to iden-
tify the morally egregious features of wasting resources, fomenting false hopes,
being seduced by technology, neglecting palliative care, or refusing to acknowledge
the limits of medicine [11].
The incompatibility between equity and utilitarianism raises other questions,

such as whether we should provide expensive treatment (e.g., liver transplantation)
to alcohol-dependent patients who will not benefit from treatment outcomes because
of self-neglect [12]. Or whether a small benefit to the many (dental care) is prefer-
able to a large benefit to the few (mechanical ventilation). According to the principle
of equity, every patient has the right to equal access to medical care and attention.
However, different patients have different needs: Is the higher use of health care
services by poor populations unjustified, or is it due to a greater need for care? How
can we ensure access to health services and address the needs of populations in
remote areas?
8.3.2 Controversial Norms
Several contentious norms have taken root in clinical practice in some countries
with universal health insurance. The first is to give physicians the authority to decide
how to allocate resources. On the one hand, decentralization of budget control has
led to cost containment without affecting patient satisfaction [13] and infant mortal-
ity [14, 15]. On the other hand, decentralization has been reported to lead to higher
health expenditures and infant mortality [16]. In addition, the potential for uninten-
tional discrimination by physicians against older patients, ethnic minorities, and
patients of low socioeconomic status [17] has raised concerns that physicians may
be creating an unfair variance in their practice [18].
A second controversial norm is to offer medical services with unproven efficacy,
such as complementary medicine, to meet patient preferences. On the one hand, this
norm is consistent with the principle of respecting patient autonomy. On the other
hand, a healthcare system cannot offer treatments of unproven efficacy while deny-
ing patients treatment modalities of proven efficacy because of their cost.
At the top of the list of debatable norms is private care. "Private care" refers to
the purchase of services that are not included in the package of benefits, whether in
private or public institutions, whether paid for directly by the patient or by his or her
supplementary or private insurance, or whether through grants to institutions or
research projects. The provision of private services by physicians employed by pub-
lic hospitals raises several ethical dilemmas. On the one hand, respect for patient
autonomy requires that patients' willingness to pay for their care be respected, and
some payment for private care flows to the hospital, benefiting all patients. On the
other hand, the provision of private services by physicians employed by public hos-
pitals violates equity.
Equity requires that care be based on the needs of patients, regardless of their
ability to pay or the likelihood of a benefit. The likelihood of benefit should cer-
tainly drive patient triage in emergencies. However, in non-emergency clinical set-
tings equity prevails on utilitarianism (i.e., giving priority to those most likely to
benefit from health care) and respect for patient autonomy (in choosing a private
health care provider). Second, private care competes with public patient care for
8.3 Fair Distribution of Healthcare Resources 147
physicians’ time and infringes on the rights of other patients. Since the 1990s,
efforts have been made to limit physicians’ work and give them time for rest, con-
tinuing education, and family. It could be argued that physicians can use their off-
work time as they see fit and that caring for private patients is no different from
keeping updated and leisure. This assertion ignores the relative importance of off-
hours activities: keeping up to date is important for maintaining expertise; taking
time for recreation, leisure, and family is important for well-being; caring for pri-
vate patients is neither.
Third, health care is a public service. Just as it would be unthinkable for police
officers to work as private investigators after hours, private care by physicians
employed by public hospitals can undermine patients’ trust in the health care sys-
tem. Forth, private care in public hospitals can blur the lines between legal and
illegal charges and degenerate into black medicine [19], with under-the-table pay-
ments for preferential patient care [20].
Finally, public hospitals where physicians can care for private patients do not
provide a suitable learning environment for medical students. There is undisputed
evidence that physicians unintentionally discriminate against patients [17].
However, a learning environment that tolerates role models who care for both pri-
vate and public patients may also legitimize intentional discrimination against
patients. Preferential treatment of some patients may elicit cynical attitudes in stu-
dents and interfere with the development of their humanistic values.
One way to preserve the benefits of private care while avoiding its negative con-
sequences would be to separate the public and private care sectors. Just as a police
officer can open a private detective agency only after leaving the police force, physi-
cians can care for private patients or engage in other activities only after leaving
public healthcare institutions. Physicians employed by public hospitals would be
required to devote their time exclusively to the hospital. They would be prohibited
from enjoying both the prestige of working in public hospitals, most of which are
academic, and the income from private treatment. Hopefully, this will ensure an
equitable distribution of physicians’ time between work, leisure, and continuing
education.
8.3.3 The Need for a Policy of Rationing Resources
The different attitudes toward the distribution of medical resources indicate the
need for a policy of rationing. Yet it has been noted that “no country has yet designed
a process for explicit rationing” [21], and as recently as 2021, a multinational survey
of policymakers and researchers concluded that “[E]fforts to establish formal and
explicit processes and rationales for decision-making in priority setting and resource
allocation have been still rare” [22].
Decisions about baskets of benefits are usually based on mutual influences
among ethicists, lawyers, administrators, and representatives of the public. Many
countries use formal thresholds for cost-effectiveness for new treatments. A 2018
systematic review identified 17 countries with cost-effectiveness threshold data and

13 countries with willingness-to-pay data per quality-adjusted life-year. Most cost-
effectiveness thresholds were within the range recommended by WHO of one to
three times gross domestic product per capita [5].
To be ethical, resource rationing policies must be responsive to consumer values.
Public surveys in several countries using a variety of methods showed that the most
important considerations in determining treatment priority were rescue, the pros-
pect of recovery, and younger age [23]. A 2010 review found that 90% of respon-
dents preferred that organ allocation be based on medical urgency, the severity of
illness, and rescue; 70% of respondents preferred younger age, non-alcoholics, and
a longer waiting period, while 50% preferred registered donors and having depen-
dents [24]. A 2018 Australian survey found that the severity of illness was the most
important criterion, followed by medications for children and cancer patients. “End-
of-life treatments” and “rare disease therapies” received the lowest priority [25]. A
discussion among US public officials about chronic hepatitis C treatment in 2020
found that most favored a “sickest first” policy over a “first come, first served”
policy [26].
Different groups in society have different values, and decisions about the alloca-
tion of medical resources based on population surveys can lead to discrimination
against certain patients. For example, there is evidence that respondents older than
65 years prefer more egalitarian resource allocation than younger people [27].
Under the quality-adjusted life-years system, disabled patients may be unfairly dis-
criminated against in healthcare resource allocation [28]. Public preferences in
resource allocation for critically ill patients are significantly affected by minor
changes in the formulation of the scenario presented [29] or in the presentation of
the results of relevant studies [30]. For all these reasons, physicians should be part-
ners in resource rationing decisions to ensure that the preferences of the majority do
not conflict with the rights of the minority of patients, especially those from the
weaker classes.
8.3.4 Implementing a Policy for Fair Allocation

of Medical Resources
The allocation of medical resources requires that patients be educated about the
limitations in the basket of benefits both when they join the health insurance pro-
gram and during medical treatment. I have already pointed out the dangers of decen-
tralizing budget control and creating incentives for physicians to decide how to save
[31]. The alternative to such incentives is a policy based on clinical guidelines that
would provide physicians with up-to-date, evidence-based, or widely agreed-upon
information. Clinical guidelines are designed to improve the quality of care, not to
save medical resources. But sometimes medical care based on clinical guidelines is
also the cheapest and saves unnecessary medical interventions. The better we can
8.4 Trust in Medicine 149
understand not only the disease but also how the patient perceives it, the more sur-
prised we will be to find that some patients prefer cheaper treatment options. For
example, terminally ill patients often prefer less rather than more treatment.
In cases when the most effective drug is not included in the package of benefits
because of its cost, physicians should remember that they are primarily the patients’
advocates. They should provide comprehensive information about the pros and cons
of all therapeutic options, including those not included in the package of benefits.
Once the information is provided, the physician and patient must accept the con-
straints on resource allocation and work together to find the optimal way to imple-
ment the desired treatment, including the possibility that the patient may be forced
to self-fund the treatment.
In cases where the physician and patient disagree about the desired treatment,
physicians can use Pearson’s [18] approach. This approach begins with the physi-
cian’s justification for savings (“The treatment you prefer is good, but there are two
reasons why I prefer a different treatment. First, it is effective. Second, it is cheaper,
and we are all trying to save on medical expenses”), followed by stating that deci-
sions about savings apply to everyone (“I would recommend the same treatment to
every patient in your condition”); and finally, keeping a channel open for objections
(“If you think my recommendation is unfair, you can get a second opinion or appeal
directly to the registry appeals committee”) [18].
8.4 Trust in Medicine
Trust in people or institutions is the expectation that they will protect the interests
of the trustee when needed. Patient trust in individual physicians and institutions
involves values and competence. Values refer to fidelity and honesty, while compe-
tence refers to the trusted party’s ability to provide expected services [32, 33].
Evidence suggests that trust in the health care system (hospitals, insurers, pharma-
ceutical companies) is not mediated by the trust in physicians [34].
8.4.1 Decline in Patient Confidence in Health Care
Medicine today offers patients more effective interventions than in the past. It is
more egalitarian and less paternalistic, its decisions are more transparent and allow
patients to participate in their care, and the monitoring of clinical practice allows for
more effective quality control. All of this should have increased public confidence
in physicians. But the opposite is true. In 1966, nearly three-quarters (73%) of
Americans said they had confidence in physicians. In 2012, only 34% held this view
[35]. A 2021 survey of cancer patients in the USA showed that trust scores were
lower among white patients (36.4) than Hispanic (40.5) and black (38.2) patients [36].
Despite declining trust in institutions, most respondents in the USA say they
have confidence in the physicians who treat them. Patients eventually seem to find a
physician who meets their expectations. In European countries, the decline in public
trust in health care has been accompanied by declines in trust in other institutions,
such as education or government [37]. This is particularly likely in countries where
the health care system is funded by the government. In these countries, the trustwor-
thiness of physicians is a critical factor in people’s opinions of the public sector in
general [33]. This is worrisome because trust is the “glue” that maintains the func-
tioning of society by preventing suspicion and excessive legislation. The erosion of
trust leads to outside intervention, such as lawsuits, and one of the challenges of
modern society is to distinguish between reasonable criticism of its institutions and
destructive mistrust.
8.4.2 Possible Reasons for the Decline of Trust in Health
In-depth interviews with US patients revealed that their trust in physicians is ambiv-
alent and characterized by uncertainty, fear, and a sense of risk. However, in the case
of serious illness, this feeling is replaced by emotional dependence [38]. Patient
trust depends largely on the physician’s communication skills, concern for the
patient’s well-being, empathy, attentiveness, and, above all, the extent to which he
or she meets patients’ expectations to stand by them, represent them, and defend
their interests against health insurers. Patients attach great importance to the belief
that the physician does not make impartial decisions, but works to protect their
interests.
Possible reasons for patients’ diminishing trust in health care services include,
first, the seemingly dual obligation to patients and the need to balance the institu-
tion’s budget. Second, patients have high expectations: Hopes arising from reports
of medical breakthroughs lead patients to feel cheated in the event of medical fail-
ure. Third, there is a recent trend in society to distrust science [36]. Finally, health
services worldwide have been in a period of restructuring since the 1970s.
Organizational change creates a sense of uncertainty about what patients are enti-
tled to and what they can expect. Hopefully, as the public adjusts to the implementa-
tion of the new standards and as cracks in service delivery are mended, public
confidence in medical institutions will grow [39].
Distrustful patients are less satisfied with their health care overall and have
shorter relationships with their physicians; they have poorer health status, lower
medication adherence, and a tendency to ignore recommendations to change their
lifestyle and avoid risky behaviors [40]. Caution should be exercised in inferring
cause-and-effect relationships from these associations. Patients’ distrust sometimes
manifests itself in angry criticism of resource scarcity and rationing policies.
Sometimes this criticism is exaggerated and even wrong. But as recently as 2021, it
was claimed that three premises about patient trust were false. The first was that lack
of trust is something that needs to be changed, not something that healthcare
8.5 Medicine and the Media 151
providers need to change. Second, the assumption that physicians are trustworthy is
inconsistent with the history of unethical research and practices in public health.
And third, the assumption that all patients have the same access to care and receive
the same quality of care as other patients (e.g., white Americans) is unfounded [41].
8.4.3 Impact of Changes in the Status of the Physician

in Society
Social scientists have proposed two views on the impact of changes in the status of
medicine. One school of thought sees an erosion of the power of the profession as a
result of “proletarianization” and “de-professionalization” [42]. Proletarianization
is the diminution of physicians’ autonomy through the transition from independent
to salaried status, the shaping of their relationships with patients through the Patient
Rights Act, and the restriction of their use of health care resources [43].
De-professionalization is the reduction of physicians’ monopoly on medical infor-
mation as a result of patient access to information, transparency of clinical thinking,
and increasing sophistication of the population.
The second sociological school [44, 45] argues that medicine has not lost its
power: Its influence has increased as the cost of health care services has increased.
What has changed is the hierarchy of the profession. Until the 1970s, the elites were
clinicians and heads of hospital departments. That is over: today they are proletari-
ans. The new elite includes medical managers (health insurers and hospitals), physi-
cian representatives (heads of professional associations), and academics [43].
The two schools may be complementary: proletarianization and de-
professionalization refer to individual clinicians, while the second school describes
the organizational changes in the profession. Clinicians may have lost their auton-
omy and forfeited sole decision-maker status, but the profession has retained its
status and authority. There are also similarities between the predictions of the two
schools. Proletarianization holds a continued erosion of physician power. However,
even the second school does not rule out the possibility that the status of the medical
profession will be weakened if there is a rift between the new elites and rank clini-
cians. Such a rift may occur if clinicians no longer see the elites as part of the medi-
cal profession and no longer treat them as colleagues.
8.5 Medicine and the Media
The media shape and reflect public opinion and provide a platform for debate on
controversial issues such as quality control of clinical practice and informed use of
health services [46]. In some countries, they have played a role in the transition
from medical paternalism to respect for patient autonomy and in supporting the
right of a terminally ill person to refuse treatment. The most important effect of the
media, however, has been to influence health by disseminating information about

the dangers of smoking, unprotected sex, obesity, addiction, and sedentary life-
styles [47].
Media coverage requires the translation of complex information into language
that can be understood by all. This is sometimes difficult to achieve. In many cases,
media reporters work under time constraints; their stories are subject to pressure
from interested parties and editors who may omit important parts. This section
addresses the goals of reporting on medical issues, the responsibilities of physicians
in providing information to the media, and the biases that can thwart that informa-
tion. The term “misinformation” refers to information that is inadvertently false and
given without the intent to cause harm, while “disinformation” refers to false infor-
mation that is knowingly created and disseminated.
8.5.1 Media Coverage of Medical Issues: Targets
The main challenge for the news media is to provide a platform for public debate
about health care and a fair presentation of alternative views while avoiding bias.
For example, newspaper coverage of the debate over genetically modified foods in
the UK in 2004 was criticized for focusing on political arguments rather than sci-
ence and technology [48]. A second role of the media is to facilitate the use of
information about healthcare quality and choice among providers by reporting on
comparative surveys of surgery-specific outcomes and the range of services offered
by different health insurers. However, a 2020 survey found that 73% of patients did
not know they had access to reports on surgery-specific outcomes, and most of those
who did know indicated that these reports did not influence their choice of the sur-
geon [49]. The use of information about services offered by different health plans
depends on an understanding of quality indicators, and evidence suggests that ben-
eficiaries with inadequate health literacy are at risk of choosing plans that do not
meet their health needs [50].
The third role of the media is to report on medical innovations. However, these
reports often come from press releases from universities, medical centers, and sci-
entific journals that can play up the importance of their findings. The primary
sources of such exaggerations are the press releases themselves, not the journalists
[51, 52], and both scientists and journalists violate the tenets of their professions
when they prematurely release clinical research findings to the public and allow
physicians to express their hypotheses unchallenged [53].
A 2014 review of medical news in the USA rated most reports unsatisfactory.
Drugs, medical devices, and other interventions were generally portrayed positively,
while potential harms were downplayed and costs ignored [54]. A survey of 75
widely circulated newspapers from 25 countries found that 51 (68%) of them made
at least one comparison of COVID-19 cases or deaths between regions of their
country or between countries. However, only 37% adjusted data for population size
[55]. Another study found an association between measles/mumps/rubella
8.5 Medicine and the Media 153
vaccination and autism. Although the study was later retracted, its publication led to
a years-long decline in childhood vaccination rates [56]. One study was described
in the Institute’s press release as a “historic discovery [that] has the potential to
prevent miscarriages,” although it was not conducted in humans and only examined
the effects of niacin supplementation in mice [57]. Media reports tend to highlight
bad news, serious diseases, and innovative treatments and ignore more common
problems [58]. Reports have also been criticized for promoting treatments with
unproven efficacy, presenting biased data on diagnostic methods, and raising false
hopes or unnecessary fears [59].
A 2019 study used in-depth interviews, focus groups, and a survey of medical
experts in 21 countries to identify issues experts face when interacting with the
media. The study found that barriers to improving the quality of medical reporting
in the media include deadlines for journalists and the level of medical knowledge
[60]. To improve the quality of medical reporting, health correspondents need not
only the motivation to serve the public but also professional training. Since their
sources of information are physicians and scientific publications, they need to be
able to assess the reliability of these sources and distinguish between different levels
of evidence.
Social media platforms provide opportunities for people to communicate; how-
ever, they also enable misinformation. A 2019 study found that misinformation is
prevalent online and is often more popular than accurate information. Disseminators
of misinformation were mostly individuals with no official or institutional affilia-
tion. Their narratives were characterized by personal, negative, and opinionated
tones and often triggered fear and distrust of institutions [61].
In some cases, the researchers who provided the information claimed that they
were not properly cited. This claim does not absolve them of responsibility for the
harm that may result. Therefore, it is essential to improve the quality of media cov-
erage through closer collaboration between reporters and scientists [62]. On the
surface, such collaboration is difficult. Scientific thinking emphasizes uncertainty
and doubt; journalists seek a confrontation between right and wrong. Despite their
obligation to compare information from different sources, some reporters uncriti-
cally provide a platform for individual physicians to disseminate controversial opin-
ions and for patients to describe their tragedies. This precludes factual debate
because it is impossible to confront a suffering patient, even one who makes claims
that society cannot meet, or a physician who is passionately critical of healthcare
institutions, even one whose claims are based on personal experience rather than
controlled observations.
8.5.2 Media Coverage of Medical Issues: Biases
In 1997, Schumann and Wilkes identified four causes of misleading media report-
ing: a tendency to sensationalize, conflicts of interest, failure to follow-up on
reported information, and disregard for important medical issues. Sensational
reporting is not just the domain of journalists. Researchers also contribute to this
tendency by sometimes exaggerating the importance of their findings. Media cover-
age can be biased by conflicts of interest: objectivity sometimes conflicts with the
pursuit of self-publication, financial gain, obtaining research funding, and promot-
ing the reputation of the institution. Media coverage can also be distorted by
researchers’ failure to release to the press the results of follow-up studies that chal-
lenge their earlier press releases. For example, the press reported an association
between coffee drinking and pancreatic cancer but did not report subsequent studies
that failed to confirm the association [63]. Hopefully, health reporters will be aware
of this bias and attempt to reduce its impact by interviewing independent research-
ers and by relying on written sources of information rather than the opinions of
individual physicians.
8.5.3 Medical Recommendations in the Media
The core of a patient-initiated doctor–patient encounter is the assumption that

the doctor will do his or her best. If a patient does not respond to the usual treat-
ment, the physician may offer another treatment whose efficacy is only partially
proven. Conversely, making unsolicited medical recommendations through the
media is tantamount to a physician-initiated relationship with the patient. In such
cases, the recommendation requires a more solid evidentiary basis. If treatment
is recommended (e.g., statins for hyperlipidemia) or if tests are recommended
for early detection of a disease (e.g., mammography), then the benefit of the
treatment or early treatment of the disease must be proven beyond a reason-
able doubt.
There is considerable variation in the reliability and validity of the evidence for
a given medical recommendation, and the public is largely unaware of this varia-
tion. Presenting the degree of uncertainty is a complex task that is challenging for
professionals and journalists alike. For example, when reporting on screening tests,
the media seem to focus more on the benefits than the harms. One study of media
coverage found that 63% of reports focused only on the benefits and only 37% of
reports mentioned the harms. Overdiagnosis, the biggest harm of screening tests,
was mentioned in only 5% of reports. As many as 55% of all reports included the
views of commentators with conflicts of interest, but only 12% disclosed these con-
flicts [64].
In some cases, it is possible to influence the public decision to accept or reject a
particular medical recommendation by the way the data are presented. Stating that
regular mammograms in women reduce breast cancer mortality by 15–20% (i.e.,
presenting the data as a relative benefit) creates a positive impression. It is a differ-
ent story when the same data are presented as an absolute benefit, namely that regu-
lar mammograms will save the lives of 1 in 2000 women aged 40–49 years, 1 in
1000 women aged 50–59 years, and 4 in 1000 women aged 60–69 years over the
next 10 years [65].
References 155
Today, there is consensus that the effectiveness of mammograms justifies their

performance in women aged 50–69 years [66]. However, the value of mammograms
in women aged 40–49 years remains uncertain. A 2001 review of US press coverage
of this uncertainty found that the press tended to present the opinions of oncologists,
radiologists, and policymakers who consistently favored mammography at ages
40–49 and to ignore the opinions of epidemiologists and government officials who
opposed it [67].
Journalists rely on information from clinicians and researchers. The advantage of
clinicians is that they reflect the views of those at the forefront of medical practice.
However, sometimes their positions are confounded by personal clinical impres-
sions and by the way data are presented in scientific articles (relative versus absolute
benefits). Therefore, it is important to obtain information from epidemiology
experts, not just clinicians. Epidemiologists are best qualified to evaluate the risk–
benefit ratio of a particular intervention and have better tools for the specific evalu-
ation of diagnostic or therapeutic interventions.
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Chapter 9
Changes in Medical Education
9.1 Ongoing Changes in Medical Education
9.1.1 From Memorization to Self-Directed Learning

and Information Management
Advances in information technology, smartphone applications, and e-learning have

facilitated self-directed learning [1]. Instead of lecturing, instructors increasingly
ask their students to learn outside of class and use class time for specific instruc-
tional activities (“flipped classrooms”). The COVID-19 pandemic was a catalyst for
the promotion of distance learning, e-learning, novel student assessment methods,
and Zoom instruction [2]. Technology-enhanced teaching methods such as virtual
simulations will likely be part of medical education after COVID [3].
Online teaching via videoconferencing and virtual classrooms does not appear to
differ in effectiveness from traditional education and has higher satisfaction rates [4].
Online education may also be more cost-effective than classroom learning because
faculty do not have to relocate and more individuals from different institutions can
participate in courses [5]. Interactive computer simulations of clinical scenarios
improve student learning motivation, knowledge application, assessment, and clinical
reasoning. Learners engage with content designed to match the level of difficulty to
students’ abilities and receive individualized feedback [6]. Distance learning provides
learners with control over the content, sequence, and pace of learning. It promotes
individualized (adaptive) and collaborative learning and transforms the role of the
tutor from a distributor of content to a facilitator of learning and assessor of skills [7].
Therefore, it appears that face-to-face instruction will be limited to topics that
require student–tutor contacts, such as patient interactions and hands-on practice.
The challenge in implementing online teaching is to overcome the barriers to its
development, namely lack of time, inadequate infrastructure, lack of institutional
policies and support, and negative attitudes among stakeholders [8].

Switzerland AG 2023
160 9 Changes in Medical Education
9.1.2 From Knowledge to Competency-Based Education
As recently as the 2010s, medical school graduates were claimed to have inadequate
skills in teamwork, information management [9], and basic surgical procedures [10].
As a result, medical schools are increasingly emphasizing competency-based education
that focuses on what students can do rather than what they know [11]. Medical educa-
tors accept that learners may progress at different rates. Rather than requiring learners
to spend a predefined amount of time on a unit of study, future medical educators will
provide learners with clear goals and allow them to self-direct their learning [12].
Skills such as bladder drainage, taking a blood sample, first aid, and resuscitation
are already taught in skills labs. Anatomy courses teach students to interpret imag-
ing studies; simulators are used to teach emergency interventions; and virtual
patients are used to address specific clinical encounters. Students must demonstrate
that they have achieved a certain standard of performance before being admitted to
the clerkships. Aside from its contribution to patient safety, simulation-based teach-
ing appears to be superior to traditional clinical education in skill acquisition and is
associated with better patient outcomes compared to no intervention and non-
simulation-based teaching [13].
9.1.3 From the Biomedical Model to Engel’s

Bio-Psycho-Social Model for Clinical Reasoning
and Practice
The development of biotechnology has raised concerns that it may undermine the
humanistic attitudes of physicians. In response to these concerns, most medical
schools offer their students teaching programs in the social and behavioral sciences.
However, the implementation of these programs encounters the difficulties I
described in Sect. 6.
I suggest that teaching the behavioral sciences should focus on the gap between
ideal patient care and reality. While this gap is inevitable, it can be narrowed, and
teaching should encourage reflection on its causes. This can be done through small
group discussions of specific cases, such as when a physician’s behavior did not
meet appropriate standards. The goal of such discussions would be to identify the
factors that promote or inhibit inappropriate behavior and to raise awareness that
none of us is immune from misjudgment or unacceptable behavior.
9.1.4 From Intuitive to Analytic Decision-Making
In many medical schools today, students are taught how to conduct a hypothesis-
driven patient examination, how to use Bayes’ theorem in making diagnostic infer-
ences, and how to apply evidence-based medicine in evaluating information. It is
9.1 Ongoing Changes in Medical Education 161
hoped that these teaching activities will help students move from the determinism
of basic science to probabilistic clinical thinking and will support students’ develop-
ment of tolerance of uncertainty.
The learning environment that can provide such support can be inferred from
Perry’s observation that the transition to multiplicity began when students encoun-
tered teachers who responded with “I do not know.” Therefore, I concur with the
call for clinical tutors to make their reasoning visible, help students understand that
doubt is not an expression of incompetence but rather part of the nature of clinical
practice, and provide opportunities for students to practice their clinical reasoning
in an environment where they are trusted and supported to change their
performance.
9.1.5 From Hospital to Community Settings
Clinical education follows the tradition of “bedside” teaching and exposes medical
students to inpatients. Until the 1960s, the lack of consultation services in the com-
munity made it necessary to refer patients with a variety of diseases to hospitals for
second opinions. Since then, however, the development of community consultation
services has resulted in a hospital population limited primarily to patients requiring
crisis intervention.
As a result, medical students may now graduate without ever having seen patients
with a range of nonacute conditions, such as hypothyroidism, peptic ulcers, uncom-
plicated rheumatoid arthritis, influenza, and tonsillitis, who are treated in commu-
nity clinics. Medical students also do not see chronic patients treated at home,
hospice, and nursing facilities who come to the hospital only for an acute event.
The implicit assumption of restricting medical education to hospitals views clini-
cal problem-solving as a general skill that, once acquired, can be applied in other
settings. This assumption is at odds with evidence that competence is subject-
specific rather than general [14]. The constraints of the hospital learning environ-
ment have therefore led medical schools, first, to use virtual patients and, second, to
replace traditional block clerkships in hospital departments with 6–12 month rounds
in a single community clinic.
A student in community clinics is exposed to common diseases and follows
patients through their entire experience, including hospitalizations. Continuity of
student–patient relationships fosters empathy more than short-term relationships
with inpatients. Student–staff relationships allow for continuity in education,
responsiveness to learning needs, and guidance in clinical reasoning [15]. Replacing
block clerkships in the hospital with longitudinal clerkships in the outpatient setting
enhances students’ clinical reasoning not only by exposing them to a broader range
of diseases but also by giving them insight into the thinking and doubts of their
tutors [16]. Finally, if the student–tutor relationship shapes the student’s future rela-
tionship with their patients [17, 18], then the setting in clinics is likely to provide an
environment in which the student is accepted as a trusted colleague.
Outcome studies have shown that the performance of graduates of longitudinal

primary care clerkships was equivalent to, and in some cases better than, that of
their peers who completed block clerkships [19, 20]. Graduates of longitudinal
clerkships were better in the areas of patient-centered communication, understand-
ing psychosocial contributions to medicine, responsibility to patients, and dealing
with ethical dilemmas. Students felt supported by the continuity of the student–tutor
relationship [21]. The only longitudinal study I am aware of suggests that students
in community clinics are better able to cope with uncertainty than students in tradi-
tional inpatient rotations [22]. I believe that future studies will further compare the
outcomes of the two types of placements and examine whether training in commu-
nity settings also improves students’ professionalism, moral judgment, and reflec-
tive skills.
9.1.6 External Reviews of Teaching and Accreditation

of Medical Schools
Most countries attempt to improve the quality of their undergraduate programs

through periodic external reviews to ensure that medical schools meet certain
accreditation standards. However, accreditation of medical schools has still to over-
come two types of difficulties.
First, accreditation visits in North America occur at 4–10 year intervals, so prob-
lems are not immediately identified when they occur. Therefore, since 2015, the
Standards of Medical Education have required medical schools to continuously
monitor their teaching programs [23]. It is my impression that most medical schools
have not yet complied with this requirement. Second, despite the agreement that
accreditation standards are not equally important, there is no uniform taxonomy of
standards [24]. Therefore, it is uncertain whether ongoing monitoring should be
guided by all or only selected accreditation standards and, if the latter, how they
should be selected. An agreed taxonomy of standards for accreditation will priori-
tize standards by importance and remove this uncertainty.
9.1.7 Quality Assurance of Patient Care
Quality assurance and patient safety programs have been offered at medical
schools since the 1990s, and a 2010 systematic review found that they were well
received. Most of them resulted in improved knowledge, and some were reported
to improve processes of care [25]. Such educational interventions are expected to
achieve, first, tolerance for and constructive management of errors and, second,
admission of and open reporting of errors for their analysis with a view to their
prevention.
9.2 Challenges of Medical Education 163
The challenge for medical educators is to find ways to overcome the cognitive,
cultural, and emotional barriers to the implementation of such programs. The main
cognitive barrier is the unconfirmed assumption that only incompetent physicians
make errors. The main cultural barrier to acceptance of medical errors is their exclu-
sion from discussions at teaching sites and denial of uncertainty [25]. In the late
1970s, it was felt that physicians are “trained to be certain” by adhering to a deter-
ministic school of thought [26]. A 1992 literature review stated, “Strong defenses
against criticism and denial of [the] uncertainty [of clinical practice] are one of the
most consistent observations made by sociologists studying medical training” [27].
Recognized errors provide opportunities for improvement, whereas fear of pun-
ishment promotes alienation, information distortion, and loss of motivation. Quality
assurance and patient safety programs may also shift learners’ orientation from
knowledge (“What accessory pathways cause Wolff-Parkinson-White syndrome?”)
to clinical skills (“Is this ECG tracing suggestive of WPW?”). An orientation to
knowledge promotes deterministic thinking, denial of uncertainty, and punitive
morality. An orientation to supervised clinical skills training can not only improve
competence, but also separate the concepts of “error” and “blame” by allowing
students to make mistakes in an atmosphere where they are not condemned or ridi-
culed, but where they are trusted and supported to change their performance.
9.2 Challenges of Medical Education
9.2.1 Promoting Student Well-being
Improving the clinical learning environment and reducing student burnout remain
the greatest challenges for clinical education. As early as 1973, Atkinson noted that
tutors varied between those who view students as subordinates progressing along an
obstacle course and those who view students as colleagues to be “treated in an egali-
tarian manner and … groomed for full professional status as soon as possible” [28].
Indeed, students’ assessments of their learning environment vary across medical
schools and correlate with student learning [29], quality of life, resilience, prepara-
tion for practice, and well-being [30] and are inversely related to burnout [31]. Clear
expectations, autonomy, and frequent feedback were cited as desirable features of
the clinical learning environment, while tutors’ disinterest in students, dismissal of
questions, lack of autonomy, and unclear expectations lead to withdrawal and stu-
dent vulnerability [32].
As recently as 2019, student humiliation [33] and neglect [34] by faculty were
reported to be common in clinical settings. As recently as 2022, it was asserted that
“many of the fundamental components of psychological safety are lacking in the
current clinical learning environments for medical students” [32]. It is impossible to
ignore student distress and still teach them how to manage patient distress, and it is
impossible to humiliate medical students and still teach them how to respect patients.
Therefore, one of the main roles of medical education is to provide students with
well-being initiatives that are aimed at teaching them how to use psychological and
emotional support resources [35], as well as constructive student relationships with
their clinical role models.
In educational research, a “role model” is a person whose characteristics are a
standard of excellence [36]. This definition is at odds with the original definition, of
a person who “occupies the social role to which an individual aspires,” and with the
assertion that medical students are attracted to persons of status [37]. During my
training in the 1950s and 1960s, I aspired to the prestige of some of my tutors and
accepted their behavior, even though I was troubled by their belief that humiliating
trainees would motivate learning and by their professed intolerance of stupidity that
made me afraid to ask questions.
The awareness that some clinical tutors lack the qualities that students say they
look for in role models [38] has encouraged training programs for faculty members
[39]. I believe that these programs will be sustained, that students will be admon-
ished to distinguish between behaviors rather than tutors because no one person
always has all the qualities of the ideal clinician, and that faculty will improve their
systems of counseling for medical students and ensure that their teaching programs
take place in a professional and respectful environment.
9.2.2 Personalizing Medical Education and Reducing

Its Duration1
In both North America and Europe, the combined duration of undergraduate and
residency training is 9–13 years. Nevertheless, it does not meet the needs of the
physicians’ workforce: since the 1950s, there has been a shortage of family physi-
cians [40] and, more recently, of other specialties [41]. Undergraduate medical edu-
cation has been criticized also for its assumption that it is relevant to all medical
specialties. This assumption is incorrect: human anatomy is important to radiolo-
gists but not to epidemiologists, and behavioral science is important to family physi-
cians but not to pathologists.
To address these two problems, it has been suggested that current medical cur-
ricula be replaced with shorter courses of study focused on training for different
medical professions [42], such as those for dentistry and nursing. This approach
would require medical school applicants to commit to different four-year programs,
such as one that prepares them for residency training in secondary and tertiary
specialties, a second for primary care (family medicine, pediatrics, and psychiatry),
1
Benbassat J, Baumal R. Expected benefits of streamlining undergraduate medical education by
an early commitment to specific medical specialties. Adv Health Sci Educ. 2012;17:145–55.
With permission from Springer.
9.2 Challenges of Medical Education 165
a third for diagnostic laboratories and physician-scientists, and a fourth for careers
in epidemiology, health administration, public health, and preventive medicine.
An alternative to this proposal would offer applicants to medical school per-
sonalized teaching programs based on their expectations and career plans.
Personalized learning (also known as adaptive learning, individualized instruc-
tion, customized learning, or student-directed learning) is defined as teaching
that is tailored to an individual learner’s needs, abilities, preferences, and goals
and continuously adapted to their evolving skills and knowledge. It is widely
agreed that a personalized learning approach can increase learner motivation and
engagement [43].
A 2021 systematic review of studies of personalized learning in schools, univer-
sities, and adults confirmed the diversity of learner characteristics and desired out-
comes. Most studies focused on student “interests” and “needs” but failed to define
these terms operationally. Student achievement, perception, and satisfaction were
the most common outcomes, and most studies examining these outcomes found a
positive relationship between them and personalized learning [44]. I am not aware
of any attempts to introduce personalized learning into medical education. However,
shifting the focus of education from knowledge to skills will, in and of itself, per-
sonalize medical education through repetitive practice until the learning goal is
achieved.
9.2.3 Selection of Applicants for Medical Training
Medical schools select their students from a pool of applicants with high past aca-
demic achievements. Most medical schools also try to select applicants with desir-
able “nonacademic” skills such as compassion and social orientation by using
interviews. However, a 2016 review of the literature [45] found that interviews lack
the reliability and validity needed for high-stakes screening. As a result, more and
more medical schools are using written tests, multiple interviews, short tasks, and
personality tests in their admissions policies to select applicants with desired non-
academic skills. Even Holland has abandoned its traditional lottery-based admis-
sions policy and adopted multiple assessments of applicants’ nonacademic
attributes.
These efforts have several limitations. First, nonacademic skills are difficult to
identify and measure. There are about 80 such skills [46]; it is impossible to test
them all, and it is uncertain whether they are permanent or situational [47].
Correlations between assessed nonacademic skills and student outcomes are around
0.30 [48], i.e., predicting less than 10–20% of the variance in outcomes, leaving
room for significant false positives and false negatives. Second, candidates who are
rejected due to inadequate academic performance are likely to understand the rea-
son for their failure. Not so rejected candidates after “failing” tests for nonacademic
qualities. Such an experience can have an impact on self-esteem, especially when
there is no feedback.
Finally, it is doubtful that society will accept the lack of nonacademic qualifica-
tions as a reason to deny an applicant the opportunity to become a physician. After
all, society needs not only clinicians, but also physicians who work in research,
administration, preventive medicine, public health, and diagnostic medicine.
Different career paths require different qualities. Therefore, it seems to me that
attempts to identify nonacademic qualities are costly and not-needed, and that future
research needs to re-examine their benefits.
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Index
A symptoms identification failure, 88, 89

Allocation of resources, 144 students’ records, feedback on, 89–91
Anchoring, 96 teaching method
active and inactive problems, 86
chief complaint, 83, 84
B objectives, 82
Bayes, theorem, 94, 103, 160 patient's symptoms, 84
Behavioural and social sciences (BSS) personal and psychosocial history, 83
barriers, 113, 114 present illness (PI) problem
clinical tutors, 119, 120 statement, 85, 86
doctor-patient communication skills, 114 problem-oriented approach, 84, 85
implications for clinical practice, 118, 119 Clinical reasoning
risk indicators for disease, 114–118 assessment, 98, 99
stress and stressor barriers, 96–98
life events, 110, 111 biomedical model, 4
personality traits, 112 bio-psycho-social model, 7
psychological distress, 110 decision analysis, 99–102
social support, 111 from denial to acceptance of
socio-economic status, 111, 112 uncertainty, 4, 5
Biomedical (BM) model, 104 EBM, 102, 103
Bureaucracy, 142 evidence-based reasoning, 6, 7
heuristics and biases approach, 96
humoral model, 4
C from intuitive to analytic
Case-based learning, 19 decision-making, 2, 5, 6
Clinical database learning objectives, 98
EMRs, 81 reasoning strategies
POR, 80, 81 algorithmic diagnosis, 95
present illness (PI) recording format cognitive task analysis, 96
chronological evolution, 89 factors, 95
inadequate description of patient's hypothetico-deduction, 94, 95
symptoms, 88 pattern recognition, 94, 95
objective history data, 87 time pressures and interruptions, 95
self-expression, 87 research findings, 103–105
© The Editor(s) (if applicable) and The Author(s), under exclusive license to 169
Springer Nature Switzerland AG 2023
Medical Students, https://doi.org/10.1007/978-3-031-26542-6
170 Index
Cognitive task analysis, 96 E

Complementary and alternative medicine Electronic medical records (EMRs), 81
(CAM), 104 Equity, 146
COVID -19 pandemic, 145 Evidence-based medicine (EBM), 102, 103
D H
Doctor-patient encounter Healthcare resources
adherence to medical advice, 44–46 allocation, 148, 149
barriers controversial norms, 146, 147
ageism, 31 fair distribution of resources, 144–146
gender discrimination, 31 policy of rationing, 147, 148
interviewing habits, 33, 34
patient's and doctor's
preferences, 31, 32 I
patient's concern, gain insight, 33 Impaired physicians
racial discrimination, 31 doctors' dysfunction
language mismatch, 35 dealing with, 132, 133
management response to awareness, 131, 132
care-providers' preferences, 47, 48 incidence, 130, 131
evidence-based guideline, 48, 49
patients' preferences, 47
teaching approaches, 50 L
medical recommendation, 154, 155 Learner-centered approach, 19, 20
patient aggression management, 36, 37
patient counselling, 42–44
patient interviewing M
communication skills Managed care
assessment, 21, 22 accountability and quality control, 143
learner-centered strategy, 19, 20 bureaucracy, 142
learning objectives, 18, 19 clinical guidelines, 143
shifts in teaching, 20 clinical practice, 143
teacher-centered strategy, 19, 20 documentation, 144
self-awareness, 35, 36 medical costs, 143
shared decision-making problem-oriented record, 142
informative model, 38–40 Media coverage
integration, 37 biases, 153, 154
paternalistic model, 38–40 medical recommendation, 154, 155
patient's concerns, 38 targets, 152, 153
patient's preferred involvement, 40 Medical education, 9
second opinion, 41, 42 applicants selection, 165, 166
teaching, 37, 38 community settings, 161, 162
uncertainty, 40, 41 competency-based education, 160
sharing concerns, encouraging Engel's bio-psycho-social model, 160
patients for, 36 external reviews, 162
students' learning difficulties, 12–14 information management, 159
teaching difficulties, 15–17 intuitive to analytic decision making,
teaching program 160, 161
advantages, 26–30 patient safety programs, 162, 163
disadvantages, 26–28 personalized learning, 164, 165
patient complaints, 22, 23 quality assurance, 162, 163
solutions for complaints, 23–26 self-directed learning, 159
supervised practice, 28, 29 student well-being, 163, 164
Index 171
Medical errors Q
definition, 125, 126 Quality assurance of healthcare
disclosure, 129, 130 components, 133
doctors' attitude to mistakes, 126, 127 patient surveys, 133
malpractice litigation, 128, 129 physicians' attitudes, 133–135
patients' complaints, 128, 129 physician self-disclosure of errors,
prevalence of, 126, 127 135, 136
prevention, 127, 128 physician support promotion, 135
Medical negligence, 126, 129
Motivational Interviewing, 46
R
Reliability, 73
O
Objective structured clinical examination
(OSCE), 16 S
Shared decision-making (SDM)
informative model, 38–40
P integration, 37
Patient-centered communication skills, 12 paternalistic model, 38–40
Personality traits, 112 patient's concerns, 38
Physical examination (PE) teaching patient's preferred involvement, 40
barriers second opinion, 41, 42
attitudes, 60 teaching, 37, 38
inherited errors, 60, 61 uncertainty, 40, 41
diagnostic process, 72 Social support, 111
clinical prediction rules, 75 Socioeconomic status (SES), 111,
pretest probability, 75 112, 119
sources of bias, 74, 75
test properties, 73, 74
learning for mastery, 63 T
point-of-care ultrasound (PoCUS), 63, 64 Teacher-centered (didactic)
reflective PE, 61–63 approach, 18–20
simulation technology, 71, 72 Tolerance of uncertainty, 97, 98
symptoms and signs, 64–71 Trust in health care institutions
Physician–patient relations, 1, 3 declining trust in institutions, 149–151
Physician-society relations proletarianization and
healthcare team, 9 de-professionalization, 151
medical errors, 8 values, 149
parsimonious use of resources, 8 Trust in physicians, 149
public's trust, health services, 9
quality control, 8
Problem-oriented record (POR), 80, 81 U
Psychological distress, 110 Utilitarianism, 146

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Teaching Professional

Attitudes and Basic Clinical

ISBN 978-3-031-26541-9 ISBN 978-3-031-26542-6 (eBook)

The purpose of this edition is to update the sections on teaching communication

Jerusalem, Israel Jochanan Benbassat

Jerusalem, Israel Jochanan Benbassat

1 Paradigmatic Shifts in the Theory, Practice, and Teaching of

2.4.3 Shifts in Teaching Patient Interviewing���������������������������� 20

3.2.1 Attitudes to the Physical Examination������������������������������ 60

5.2.1 Pattern Recognition and Hypothetico-Deduction�������������� 94

7.4 Quality Assurance of Healthcare���������������������������������������������������� 133

9.2 Challenges of Medical Education �������������������������������������������������� 163

1.2 Doctor–Patient Relations (See Chap. 2)

Previous versions of parts of this section were published in:

© The Author(s), under exclusive license to Springer Nature 1

1.3 Clinical Reasoning (See Also Chap. 5)

Throughout history, clinical thinking has turned to theoretical models to understand

1.3.1 From Denial to Acceptance of Uncertainty

1.3.2 From Intuitive to Analytic Decision-Making

Webster defines “intuition” as a perception that is independent of reasoning. A judg-

1.3.3 From Pathophysiologic Rationale

1.3.4 From the Biomedical to the Bio-psycho-social Model

1.4 Doctor–Society Relations (See Also Chap. 8)

1.4.1 From Accountability to Peers to Accountability

1.4.2 From an Unrestricted to a Parsimonious Use

1.4.3 From a Lone Professional to a Member

1.4.4 Change in the Public’s Trust in Health Services

1.5 Medical Education (See Also Chap. 9)

1. Oken D. What to tell cancer patients. JAMA. 1961;175:1120–8.

© The Author(s), under exclusive license to Springer Nature 11

goals include building relationships and negotiating management decisions that

2.2 Learning How to Talk with Patients1

Table 2.1 Summary of students’ learning difficulties encountered in programs of interviewing

2.3 Teaching How to Talk to Patients

Medical education has a 1000-year tradition of teaching anatomy, 300 years of

of us is to interrupt a patient complaining of abdominal pain by asking, “Did you

2.4 Coping with Barriers to Learning and Teaching

2.4.1 Learning Objectives and General Approaches

In 2013, a panel of communication experts from 16 European countries agreed on

Table 2.3 Learning objectives of patient interviewing. The student will …

2.4.2 The Integrated Learner- and Teacher-Centered Approach

Like the teacher-centered strategy, the integrated approach is guided by specific

Evidence suggests that an integrated approach is more effective than a strictly

2.4.3 Shifts in Teaching Patient Interviewing

2.4.4 Assessment of Communication Skills

I propose replacing the formal assessment of students’ communication skills in

create a supportive environment that encourages examinees to acknowledge

2.5 Proposed Teaching Program3

2.5.1 Step I: The Problem

2.5.2 Step II: Discussion of Possible Solutions

In general, students participated enthusiastically in this discussion and pro-

2.5.3 Step III: Demonstration of Various Interviewing

The second interview was “disease-centered.” I began with a series of questions

2.5.4 Step IV: Supervised Practice

2.5.5 Advantages of the Proposed Approach

2.6 Barriers to Doctor–Patient Communication

2.6.1 Doctor–Patient Differences in Age, Race, Gender,

2.6.2 Mismatch Between the Patient’s and the Doctor’s

2.6.3 Doctors’ Failure to Gain Insight into the Patient’s

2.6.4 Interviewing Habits That May Discourage Patients

2.6.4.1 Writing Up the Patient History During Interviewing

2.6.4.2 Focusing on the Chief Complaint Early in the Interview

2.6.4.3 Performing Systems Review

Jerusalem, Israel Jochanan Benbassat

Jerusalem, Israel Jochanan Benbassat

1 Paradigmatic Shifts in the Theory, Practice, and Teaching of

2.4.3 Shifts in Teaching Patient Interviewing�� 20

3.2.1 Attitudes to the Physical Examination�� 60

5.2.1 Pattern Recognition and Hypothetico-Deduction�� 94

7.4 Quality Assurance of Healthcare�� 133

9.2 Challenges of Medical Education �� 163

1.2 Doctor–Patient Relations (See Chap. 2)

1.3 Clinical Reasoning (See Also Chap. 5)

1.3.1 From Denial to Acceptance of Uncertainty

1.3.2 From Intuitive to Analytic Decision-Making

1.3.3 From Pathophysiologic Rationale

1.3.4 From the Biomedical to the Bio-psycho-social Model

1.4 Doctor–Society Relations (See Also Chap. 8)

1.4.1 From Accountability to Peers to Accountability

1.4.2 From an Unrestricted to a Parsimonious Use

1.4.3 From a Lone Professional to a Member

1.4.4 Change in the Public’s Trust in Health Services

1.5 Medical Education (See Also Chap. 9)

2.2 Learning How to Talk with Patients1

2.3 Teaching How to Talk to Patients

2.4 Coping with Barriers to Learning and Teaching

2.4.1 Learning Objectives and General Approaches

2.4.2 The Integrated Learner- and Teacher-Centered Approach

2.4.3 Shifts in Teaching Patient Interviewing

2.4.4 Assessment of Communication Skills

2.5 Proposed Teaching Program3

2.5.1 Step I: The Problem

2.5.2 Step II: Discussion of Possible Solutions

2.5.3 Step III: Demonstration of Various Interviewing

2.5.4 Step IV: Supervised Practice

2.5.5 Advantages of the Proposed Approach

2.6 Barriers to Doctor–Patient Communication

2.6.1 Doctor–Patient Differences in Age, Race, Gender,

2.6.2 Mismatch Between the Patient’s and the Doctor’s

2.6.3 Doctors’ Failure to Gain Insight into the Patient’s

2.6.4 Interviewing Habits That May Discourage Patients

2.6.4.1 Writing Up the Patient History During Interviewing

2.6.4.2 Focusing on the Chief Complaint Early in the Interview

2.6.4.3 Performing Systems Review

2.7 Coping with Barriers to Communication with Patients

2.7.3 Encouraging Patients to Share Their Concerns

2.7.4 Management of Patient Aggression

2.8.1 Teaching Shared Decision-Making

2.8.2 Proposed Learning Objectives of Shared

2.8.2.1 Gain an Insight into the Patient’s Concerns

2.8.2.2 Elucidate the Role That the Patient Wants to Assume

2.8.2.3 Match the Patient’s Preferred Involvement in Decisions

2.8.2.4 Present Options; Discuss Pros, Cons, and Uncertainty

2.8.2.5 Offer the Patient the Option of Obtaining a Second Opinion

2.10 Patients’ Adherence to Doctors’ Advice

2.10.1 Estimating Patients’ Adherence

2.10.2 Reasons for Nonadherence

2.10.3 Ways to Improve Patient Adherence

2.11 Managing Difficult Encounters and Delivering

2.11.4 Teaching How to Disclose Bad News

3.2 Barriers to Teaching and Learning Physical

3.2.1 Attitudes to the Physical Examination

3.3 Coping with Barriers to Learning

3.3.1 Teaching the Reflective Physical Examination1

3.3.2 Learning for Mastery

3.3.3 Integrating Hand-Held Devices into Teaching

3.3.4 Teaching Physical Signs by Context and Importance

3.4 Diagnostic Utility of the Physical Examination

3.4.2 Sources of Bias in Determining the Validity

3.4.3 Clinical Prediction Rules

3.4.4 Assessment of the Pretest Probability of a Disease

4.2 The Problem-Oriented Record

4.3 The Electronic Medical Record

4.4 Teaching the Recording of the Clinical Database1

4.4.1 The Personal and Psychosocial History

4.4.5 Statement of the Patient’s Present Problem(S)

4.4.6 Statement of the Present Problem(S) (Continued)

4.4.7 Statement of the Present Problem(S) (Continued)

4.4.8 Listing Active and Inactive Problems, Past and Family

4.5 Common Errors in Recording the History of a Patient’s