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THE COMMONS ROOM

PATIENT LEARNING

IT'S A TYPICAL teaching-hospital scene: one doctor and half a dozen medical students (plus me, the writer), gathered around a patient, discussing her case. Finally one of the students speaks up.

"Hi, Miss Culver. My name is Margery. I'm a medical student. Can I talk to you for a few minutes?"

"I get my next pill in two hours and 15 minutes," the patient, who looks to be college age replies. "You can go away until then."

This sudden influx of tension causes my gut to tighten. I had come to see how med students learn their craft. I hadn't expected this.

The student, however, only pauses at this rejection, then presses on. "I'm here to ask you a few questions. I'd like to learn from you."

The patient looks heavenward, as if she finally understands the humor. "Oh, they're playing a joke on you," she says-- not kindly but dismissively. "They want you to talk to me because I'm such a pain in the ass."

"How are you a pain?" the student asks, seeking some entree past this young woman's anger.

"Because I called one of the nurses fat. Well, she called me bald first, so there." The patient scratches at a bandana atop her scalp. "And they caught me smoking a joint. And they bruised my arm when they drew blood, so I kicked them out."

My breathing becomes a little uneven. I recognize all the tell-tale makings of an ugly, perhaps physical, confrontation: an edgy, college-age patient feeling victimized vs. an eager (but also young) authority figure seeking crucial information.

Miraculously, the med student defuses the situation. "I don't blame you," she says. "I might have done the same thing myself."

For an instant, the patient smiles. "I'll bet you took a lot of psychology courses," the patient says, now looking up. The med student nods, and they both laugh. The color returns to our collective cheeks.

"What about you?" the med student asks, friendly - almost conspiratorial - now. "Are you taking courses?"

"Was," the patient says. "Until this happened." Again she flashes the barely contained bitterness. I-we, all of us-recognize the depths of the patient's pain. She will not be placate by a couple of laughs. But the med student surprises us all by spying an opening: "This may sound like a dumb question," she begins.

"No such thing as a dumb question," the patient says. "Only dumb doctors."

Undaunted, the student moves on. "Okay, then, a dumb doctor question: What is your diagnosis?"

"Lymphatic leukemia," the patient says, matter-of-factly. "I've got a year to live." She pauses, the adds acidly, "Do you still want to be my friend?"

"I think so," the student says. "I think we have the same sense of humor."

Well, you'll probably have to find someone else to laugh with," the patient responds, "because I'm not going to be here much longer."

After a few exchanges like this, the med student looks at the attending physician and says, "Time out."

Time out? What is this? A game?

Of sorts, yes. It's playacting. The students are real, but the "patient" is an actress. We're not in a hospital room but a classroom in Pitt's Scaife Hall, where first-year medical students like Margery are learning the Art of the Interview - or, in medical parlance, how to get a history.

But "getting" - as in taking- information is too often the attitude of many dctors, says Laurel Milberg (Education '77), who teaches this required course in Patient Interviewing. Time was when doctors were trained to simply extract information, a learned skill of asking pointed questions to get a discrete, direct response. But concentrating solely on questions and answers ignores the broader human interaction, Milberg says, and may alienate the patient.

"It's a balance," she notes. "The doctor obviously needs medical informtion. But you can't forget that you're talking to a real person."

Although Milberg's course has been part of the medical school since 1978, it fits in well with Pitt's new medical curriculum, an innovative program that emphasizes real-world learning over rote memorization. Instead of daily lectures and labs, Pitt's med students combine book knowledge and research with experiential classes such as patient interviews. First- and second-year students also apprentice doctors' offices and outpatient clinics, shadowing experienced physicians as they make their visits with patients. The goal is not only to learn medical techniques but to better understand the delicate patient-doctor dynamic.

The actors in Milberg's class are coordinated by Ken Gargaro (Arts and Sciences '81), a local theater producer who trains the actors and oversees their evaluations.

These experienced "patient simulators" can provide two things that a real patient cannot: a chance for some feedback and a safe place to make mistakes.

"The sessions aren't always dramatic," Gargaro says, noting my experience with the actress playing the cancer patient. "Most of them are very practical - 'patients' complaining of back pain or ulcers or headaches. But as the course progresses, the cases get more difficult, and the students have to confront someone who is dying or in denial about alcoholism or is simply angry at being sick."

The actors study actual case histories to get a sense of the patient. They can also draw from their own experiences. But it's more than simply role playing. Gargaro also looks for actors who are articulate and empathetic, since they play a part in critiquing the student's interview and must remain "in character" while answering questions about the student's technique.

Acting like a patient isn't all that difficult for Barb Pacini (Education '85). At the med school, Pacini gets to act out her own life-long battle with chronic disease. "I've been through this," Pacini says about her simulated roles. "I like the chance for students to benefit from some of my experience." Classes like Patient Interviewing, Pacini says, can help students realize the kind of honesty required in a patient-doctor relationship. "I don't have the time to dance around difficult topics," she says. "But some doctors aren't always comfortable with their patient's pain. They're healers, and they don't like to confront certain things. Well, I need to feel like I can be angry and upset, and the doctor won't fall apart on me."

She's especially quick to make sure that students are listening. If they simply want to extract information, then Pacini throws them a curve. "One student asked me if I used illegal drugs," she remembers. "Now if I really used drugs, would I answer honestly? So instead I asked him, 'Why? Do you?' He stopped and said, 'Time out.'"

It's this ability to "stop the tape," to ask for a time out, that provides the student with a rare chance to seek the counsel of fellow students and an experienced teacher.

In that way, Milberg's course isn't all that different from the students' other lab experiences in biochemistry or physiology: experimenting with different methods, testing different theories to find which works best.

B "I dunno. Watching TV," the patient says. "Watching stupid talk shows. Watching goofball infomercials about people who are healthy."

"Well," Margery asks, "maybe between the stupid talk shows and the goofball infomercials, could we talk some more?"

"Only if you have absolutely nothing better to do," the patient says, and smiles at Margery.

"When quizzed after the interview, Margery says she decided to use her initial meeting to cement their relationship for a later time - a time when the two will have a better chance to talk. "I didn't want to get into too-deep water," Margery says.

"What is deep water?" asks Phil Phelps, a licensed social worker who facilitates the class. (Each lab section of Milberg's course is team-taught by a medical doctor and a clinical psychologist or social worker.)

"Why did you end the session where you did?"

"Well, I guess I was trying to figure her out, what she was saying about dying. And maybe it was a matter of my own tolerance level."

"Then it was uncomfortable for you, and not necessarily the patient?" Phelps asks.

Margery nods. "I didn't want to get really, really uncomfortable," she adds. "I didn't want to reach my max."

Margery's strategy - to "cement" her relationship with the patient - may have been a sound one, Milberg says later, or it could have been self-preservation, a tactic meant to delay a painful confrontation. Phelps' questions helped Margery and her classmates recognize that what's "learned" in a patient interview is often a two-way street.

It's these moments of self-discovery, Milberg says, where she finds the most satisfaction. While the patient simulators provide excellent drama, their real role is one of the teacher -- giving first-year students to diagnose not only the physical symptoms, but the vital, intimate bond between the patient and the doctor.

PROMETHEUS UNDERGRADUATE

OVER A TABLE IN Pitt's William Pitt Union, a student with long hair, a moustache, and a leather jacket is holding forth on what is clearly his favorite subject - the fate of humankind. The future is bright, he tells a baby-faced, crew-cut friend who sits across the table from him listening somemnly. Nuclear fusion will solve our energy woes, injections will put an instant stop to cancer, and, most importantly, anti-matter drive engines will enable us to travel through space at velocities approaching light speed. "The people who don't believe it," he announces, "are the people who said we'd never fly."

It's true, he concedes, that there are dangers to playing around with antimatter - those subatomic particles that cause instant annihilation when they come into contact with matter. But people should not let danger stand in their way, he tells the friend, who mutters his agreement. His voice booming, the long-haired student issues a proclamation: "I think the human race isn't going to get anywhere until we start playing with fire."

"Of course," he continues cheerfully, "we might get burned. We could, like, collapse the universe or something." But he makes this admission with such exuberance that the prospect of universal destruction intrigues him as much as the prospect of medical miracles and light-speed travel. And for one strange, whimsical moment, he makes the end of existence as we know it seem like an adventure that's almost worth the price.

WORDS IN A CIRCLE

SOMETIMES WE FORGET how democracy can work in America, how good, how beautiful it can be. I saw for myself recently here on the campus of the University of Pittsburgh.

We had gathered at dawn in the William Pitt Union Ballroom, some 230 of us, for a Regional Mini-White House Conference on Aging. Among our hosts: Pitt's Generations Together, which coordinates creative programs linking the young and the old. Or contingent numbered social workers and public health officials, doctors and lawyers, elementary school teachers and university professors. Others boasted no credentials of expertise other than this: They were older than 65, and they were willing to put their experiences into plain, sometimes impassioned, speech.

This gathering was one of a series held across America, collectively serving as the prelude to a national White House Conference on Aging this May. That conference will set the Clinton administration's policy on aging. And in the course of public debate and political give-and-take, new legislation will be passed to succeed the Older Americans Act. Such was our purpose of the day. We were called upon as citizens, in a town meeting of sorts, pitching in our two cents, but with national issues at stake that will affect the lives of older Americans - of all Americans - well into the next century.

Arriving a tad late, I hurried into the ballrom, my peripheral vision registering a black-and-white photo exhibit across the hall. I made a mental note to return.

Sally Newman, executive director of Generations Together, was in mid-introduction. She explained matter-of-factly that Allegheny county has the highest percentage of older adults in the United States. We then pondered the implications of national demographics: 28 million of us are over 65 now, by 2030 that figure will nearly double.

Up to the podium stepped our keynote speaker, Boston-accented David Leiderman, head of the Child Welfare League of America. A children's advocate! What was he doing here?

Leiderman, in short order, put the question to rest. He had come not to appease the elderly, but to appeal to them. "We need your help," he said. After documenting the plight of poor children in America today, the broken homes, the beleagured schools, the terrifying ubiquity of drugs and violence, he said in a rising voice, "We have a war on our hands."

He continued, "Where is the senior citizen community going to be? We need you as advocates for kids. In Chicago alone, the child welfare system is overwhelmed with 1,500 new cases a month. Meanwhile, our seniors lock themselves in high rise apartments" Leiderman concluded: "The very young and the very old. They are the most vulnerable groups in our society. How we treat one group determines how we will treat the other. We're in this together."

His words were later echoed by Pitt sociologist Anna Blevins. "Ours is the only country that specializes in isolating generations," she chillingly reminded us.

With that discomforting thought we began our appointed task. We were split into nine working groups, each with a differing focus, and directed to "think hard all day." By late afternoon we would have to account for the rigor of our thoughts, presenting three "realistic and clear" recommendations before a panel of local, state, and national politicians.

Moved by Leiderman's remarks, I joined group number one, "Intergenerational Practices," as two dozen of us arranged our chairs in a circle.

And then the talk began, seemingly disconnected, but building to its own coherence and logic.

Frustration was the first emotion to surface.

A man in a maroon sweater: "This country has lost respect for the aged."

A woman, recently retired after a teaching career: "I dont' want to be shunted aside. I won't be shunted aside."

Another retired woman: "Young people sometimes look right through you. So I decided whenever I ride the bus, I would get their attention. I told jokes and hammed it up. And now they tell me, with affection I hope, 'You know, you're really funny.'"

A tiny woman wearing a blue beret raised her hand. She gave her age as 80, but her unlined face was that of an ageless cherub. She is a foster grandparent for two African immigrants now attending Pitt. In a whispered voice she said, "I love this work, but it can be so hard. I've had health problems. My patience and strength aren't what they were. Can't we find ways to help people like me: grandparents raising grandkids?" After a pause, "It is important to provide love to our young people. Every life is so valuable."

Vince is a burly lay chaplain whose ministry takes place in nursing homes. He spoke with fire in his eyes: "We've got to get back to traditional values. We're all so busy, our lives move so fast. We've got to slow down and spend time with our sons and daughters, our grandmas and grandpas." He gazed at each of us in turn, eye to eye. "Every one of us must be an agent for change."

A teacher whose husband is dying of Alzheimer's told us a wonderful story. "Earlier this year I took two bus loads of third graders to a retirement complex, assigning each student a person to interview. A week later we returned, and my students read their 'biographies' to the abundant delight of the audience."

A retired civil engineer explains why he sits in with freshman engineers at Pitt: "I enjoy their energy and good company. And I think I can help them learn. One time they were talking about how to remove a concrete barrier. They suggested sledgehammers. I told them a little piece of plastic explosive expertly placed could do the job. I know the tricks of the trade. I can help them do things wiser."

As the day advanced, I listened to these words around a circle, words of fierce honesty, words that demanded respect, words that connected generations. But the afternoon was waning, and we had formulated no policy, not one of our three recommendations. Meanwhile we overheard the murmuring of political officials arriving to recieve our report. And so, with dispatch, we began to hammer out appropriate language, finishing with a minute to spare and applauding ourselves heartily.

Here's the list of our recommendations.

One: Two develop a curriculum, K-12, that teaches the aging process, in all of its dimensions.

Two: To agressively promote public awareness of intergenerational initiatives and policies that address social issues.

Three: To develop and utilize advocacy groups among the private and public sectors.

Even though the tone of our conversation was one of good will, it was difficult for 24 independent spirits to speak as one, to articulate specific counsel to the White House. Especially vexing was the question of federal funding. Did we want more help from Washington or didn't we? Each of us possessed the same rights as the other. We took our task seriously. Compromises were made. Things got messy. But we stuck together, and our circle held. Other people in Washington and elsewhere will expand on, revise, and rework what we came up with. That's how democracy functions. It functioned well at the University of Pittsburgh.

After the ballroom emptied, I was still not ready to go. I was drawn to that art exhibit, part of Generations Together's artist resource program. It was the idea of an African-American man named Charles Martin, described as an "old master photographer and artist." Collaborating with student photographers from area high schools, he documented "young and old in their commonalty."

And here is what I saw before I went hme from my day at the Mini-White House Conference. I saw an old woman in a babushka and a very small boy lighting an altar candle in church, the light reflected in their eyes. I saw a grandmother and granddaughter, their faces lit in glee during a game of patty-cake.

I saw an elderly African-American man and a young child, arm-in-arm, ascending to the top of a steep stone stairway. I do not believe they could have succeeded without the help of one another.


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