Patient Education and Counseling 41 (2000) 137–144

www.elsevier.com / locate / pateducou

Communication and professionalism

Michael E. Whitcomb *,1

Division of Medical Education, Association of American Medical Colleges, 2450 N. Street NW, Washington, DC 20037, USA

Received 10 January 2000; received in revised form 18 April 2000; accepted 8 May 2000

Abstract

The text of this lecture was presented in July 1999 at the international Chicago meeting on Communication in Medicine.
The topic ‘Communication and professionalism’ has been approached by drawing on the work at the Association of
American Medical Colleges (AAMC). The challenge is to align medical education content with societal needs, practice
patterns and scientific developments. In this perspective, the goals of medicine have been presented, however, also related to
experienced real life situations, the changes within medical practice and the erosion of the doctor–patient relationship. It is
stressed that we must produce excellent clinicians, who have good communication skills, and being able to use those skills in
the care of their patients. This implies that the current focus on communication in medicine is very important in the medical
education.  2000 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Medical education; Medical profession; Doctor–patient communication

1. Introduction on work that we are doing at the Association —

work that aims to ensure that doctors who are being
It is a pleasure to be here today, in part, because I educated in our member institutions are prepared to
always enjoy interacting with Greg Makoul. He has meet their responsibilities to the patients whom they
taught me a great deal about communication in will care for on an individual basis and to the society
medicine during the past couple of years. When he at large. To put this work in context, it is important
invited me to give this talk, he challenged me to to recognize that the member institutions of the
make a connection between communication skills AAMC include all of the medical schools in the
and professionalism — a challenge that I agreed to United States and Canada. The Association’s educa-
accept. I decided to approach the topic by drawing tion portfolio includes not only medical student
education, but also graduate medical education, and
continuing medical education. Traditionally, the As-
sociation has focused much of its efforts in assisting
*Tel.: 1 1-202-828-0505; fax: 1 1-202-828-1125. our member institutions as they pursue their in-
E-mail address: [email protected] (M.E. Whitcomb). dividual missions.
1
Senior Vice President. When I joined the Association in 1995, the

0738-3991 / 00 / $ – see front matter  2000 Elsevier Science Ireland Ltd. All rights reserved.
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138 M.E. Whitcomb / Patient Education and Counseling 41 (2000) 137 – 144

AAMC was in the midst of a strategic planning 2. Goals of medicine

process. One of the strategic commitments that
evolved from that process is that the AAMC should Since this is not a concept that everyone is
stimulate changes in medical education to create a familiar with, I think it would be useful to take a few
better alignment of the content and goals of these minutes to explore the linkage between the goals of
programs with societal needs, practice patterns, and medicine and the content of medical education
scientific developments. The responsibility for pursu- programs, and what this has to do with the linkage
ing this strategic commitment lies in the Division of between communication and professionalism. First,
Medical Education, which I head. When you consider we must acknowledge that as medical educators we
the dramatic changes occurring in the environment in are not free to produce physicians for our own
which our member institutions exist and the extra- purposes. Medical education must be informed by an
ordinary challenges that they face because of the understanding of the expectations that society has for
changes in the organization and financing of health physicians. If we at the AAMC could define those
care, it is heart warming to see the incredible expectations or at least create a framework for
changes that are occurring in medical education. In thinking about them, we should gain insight into the
fact, despite the environmental forces acting on these individual and collective responsibilities that physi-
institutions, I think we will look back on this period cians have to society. If we understand those re-
of time and recognize that more change occurred in sponsibilities, we should be able to determine the
the education of medical students in this country than attributes physicians should possess — that is the
at any other time in the modern history of medical knowledge, skills, attitudes, and behaviors that doc-
education. So, I think we have a lot to be proud of as tors need — in order to be able to meet those
we work to meet our strategic commitment, but we responsibilities. If we fail to prepare physicians to
have a lot of work to do. That is, in part, why you meet their responsibilities to society, we have failed
are here today. both them and the society. The point I am trying to
Let me share with you how we approached our make is that medical educators have a responsibility
commitment to align educational content with societ- not just to do things as we have always done them,
al needs, practice patterns, and scientific develop- but to make sure that we are conducting educational
ments. As we thought about this challenge, we programs to serve the purposes and goals of medi-
concluded that we had a pretty good understanding cine.
of changes occurring in practice patterns and of the In the hope of ensuring that the medical school
scientific developments impacting on medical care. experience would contribute to the preparation of
We concluded that the real challenge we faced was doctors to meet their individual and collective re-
trying to reach an understanding of evolving societal sponsibilities, we decided that it would be important
needs and expectations. If you think about that first to identify the desired attributes of practicing
challenge, it is one that is at the core of the purpose physicians. Based on an understanding of those
of medical education, or at least it should be. We attributes, one could then determine what ex-
believe that both individually and collectively physi- periences should be provided during medical school,
cians have a responsibility to serve societal needs in and what could be more appropriately provided
a way that is consistent with the history, tradition, during the period of residency training. We reasoned
and culture of Western medicine. As we thought that this approach would allow us to develop a set of
about that responsibility, we recognized that we did learning objectives for medical student education.
not have a particularly good understanding of socie- Medical educators in other countries have done this
ty’s needs and expectations. We decided to approach as well, although they have taken a bit of a different
this issue by seeing if we could reach an understand- approach in the way they have framed the linkage
ing of the goals of medicine, reasoning that the goals between the expectations of physicians by society
of medicine would reflect society’s needs and ex- and the design and content of medical education
pectations. programs. As we approached this issue, we tried to
 M.E. Whitcomb / Patient Education and Counseling 41 (2000) 137 – 144 139

be clear that the appropriate expectation for the range of ethical and socio-economic issues confront-
medical school graduate is that he / she has a founda- ing modern medicine. In combination with the work
tion in medicine that they can be built on during the of the Hastings Center, these interviews allowed us
course of residency training. To be clear, one should to develop a more complete understanding of the
not expect a medical school graduate to be a purposes of medical education.
competent practitioner. The reality is that most of the The end result of our effort to understand more
knowledge and skills that physicians need to practice clearly the goals of medicine was to expand our view
medicine competently are acquired during the period on the way that doctors should be educated. For
of residency training. many years, and certainly during the course of my
We decided to take a relatively simple approach in career, medical education has been heavily influ-
identifying the attributes that physicians should have enced by the promise of the science of medicine.
for the practice of medicine. We decided that physi- When I was a medical student and resident physician
cians should be altruistic, knowledgeable, skillful, in the mid-late 1960s, the emphasis of medical
and dutiful. In the report we issued, we provided an education was on the diagnosis and cure of disease.
explanation of the meaning of each of those attri- In fact, the rapidly evolving understanding of the
butes, and assigned learning objectives for the medi- mechanism of disease and improved approaches to
cal school experience related to each [1]. The the diagnosis and treatment of disease were what
behaviors associated with medical professionalism motivated many of us to embark on careers in
are embedded in the attributes of altruism and academic medicine. The emphasis placed on the
dutifulness. Together these attributes have relevance science of medicine transformed many medical
not only for how a physician treats an individual schools into large, research-focused institutions. This
patient, but also for how the physician meets his / her transformation was followed by a growing emphasis
responsibilities to society. Because this is a new on the application of new approaches to diagnosis
concept, it may take a while for you to grasp the and treatment within academic institutions. During
significance of the approach that we have taken. I the course of these transformations, some of the old
think if you take the time to reflect on this approach, traditions of medical education seemed to be cast
it will make more sense to you. Needless to say, the aside, perhaps, in part, because we had lost sight of
approach we took requires some understanding of the the goals of medicine and the meaning of those goals
goals of medicine and the way that those goals define for the education of medical students.
individual and collective responsibilities of physi- The Hastings Center Project set forth four goals.
cians. This is not an approach that has been used in
the past in thinking about the design, content, and 1. The prevention of disease and injury and promo-
conduct of the medical school curriculum. tion and maintenance of health.
In order to gain some sense of the goals of 2. The relief of pain and suffering caused by
medicine, we were fortunate that the Hastings Center maladies.
was engaged in a project aimed at setting forth these 3. The care and cure of those with a malady and the
goals [2]. Thus, we were able to use the Hastings care of those who cannot be cured.
Center work during the course of our own project. 4. The avoidance of premature death and the pursuit
We also took the opportunity to gain insight into of a peaceful death.
views about the goals of medicine held by a group of
scholars of contemporary medicine. The group in- The Hastings Center did not the rank order these
cluded individuals like Leon Kass at the University goals because they considered them all to be equally
of Chicago, Ed Pellegrino at Georgetown University, important. If you accept that view, then medical
Jim Todd, the former Executive Vice President of the educators have a responsibility to consider how each
American Medical Association, Bud Relman, Editor should influence the education of medical students.
Emeritus of the New England Journal of Medicine, This examination is essential if we are truly to
and others who have written extensively about a provide students with an educational foundation that
140 M.E. Whitcomb / Patient Education and Counseling 41 (2000) 137 – 144

they can build on during residency training to implications for the teaching of communication
achieve the attributes needed for medical practice. skills. I have lifted from the Hastings Center’s goal
For the purpose of this talk, I am going to focus on statements the relevant phrases that we should focus
those goals that create a linkage between communi- on — the relief of suffering, the care of patients, and
cation and medical professionalism. This approach is the pursuit of a peaceful death. I would suggest that
based on my view that physicians cannot demon- these phrases begin to get at the very essence of
strate professionalism and professional behaviors doctoring. I think it is extremely important to reflect
unless they are serving all of the goals of medicine on them a bit, because we have not paid adequate
adequately within the context of their speciality of attention to these aspects of doctoring in the ways
practice, and that it is impossible to serve some of that we educate medical students and resident physi-
these goals adequately if one does not have good cians. After a little reflection, I think everyone would
communication skills. It is within this construct, that agree that absent good communication skills a
I see clearly a linkage between communication skills physician cannot meet adequately these elements of
and medical professionalism. When I use the turn the goals of medicine — the relief of suffering, the
medical professionalism, I am talking about certain care of patients, and the pursuit of peaceful death.
behaviors that physicians demonstrate in their profes- The physician who is unable to meet these goals can
sional lives. I am not referring to some sociological hardly be considered a medical professional. Once
construct of what a profession is. I am talking about again, careful consideration of the Hastings Center’s
the individual behaviors of physicians that are essen- goals of medicine allows us to link communication
tial for an effective doctor–patient relationship. I and professionalism. It should now be apparent that
would argue that absent appropriate communication the ability to communicate is essential if a physician
skills, doctors cannot meet their responsibilities as is to be able to meet his / her responsibilities to
medical professionals. In a nutshell, this is the main individual patients, and to the society at large. It
message that I want you to take home with you. It is follows, therefore, that the teaching of communica-
a message that acknowledges the importance of the tion skills has to be emphasized in the medical
work that you do, and I hope that it challenges you school curriculum if we hope to prepare physicians
to help us to be more effective in addressing this who can meet the highest standards of medical
issue. professionalism.
To illustrate this point, let us consider for a
moment the first of the goals set forth by the
Hastings Center, which focuses on disease preven-
tion and health promotion. This goal has very 3. Real life situations
significant implications for thinking about the com-
munication skills that physicians need to pursue So far I have been trying to develop a conceptual
adequately the goals of medicine. In order to contrib- framework that recognizes communication in medi-
ute in a meaningful way to disease prevention and cine as an integral component of medical profes-
health promotion activities, physicians must serve at sionalism. In my view, it is an essential component.
least in part as educators, counsellors, and public But, I recognize that the development of the con-
health advocates. I do not think we have done a very ceptual framework I have presented is a bit abstract.
good job in our medical schools in preparing physi- I think it is important to consider whether the
cians to play these roles. The reason is that we have conceptual framework has any meaning for real life
not paid adequate attention to disease prevention and situations. I want to address this issue in two ways. I
health promotion in the medical school curriculum. will begin with a personal anecdote and then share
This particular goal of medicine provides a linkage with you the reflections of a select group of authors
between certain kinds of communication skills and who have written about personal experiences that are
the ability of doctors to meet their responsibilities. relevant to our topic today.
In the same vein, there are elements of the other A good friend of mine recently had a ‘lump’
three goals of medicine, which have very significant removed from one of his extremities. He was com-
 M.E. Whitcomb / Patient Education and Counseling 41 (2000) 137 – 144 141

pletely asymptotic and entirely well until he learned will demonstrate the behaviors of medical profes-
that the lump was a malignancy. While he remained sionals and meet their responsibilities to patients.
without physical symptoms after his diagnosis was
made, he was no longer well — he was now
experiencing illness. As he talked to me about his 4. Changes in medical practice
feelings, he expressed many of the thoughts that
plague the ill. He wanted to know why this had I want to begin by reading a few excerpts from
happened to him, and what it was going to mean for Lewis Thomas [3]. Over the course of his remark-
his life. The uncertainty about the future had made it able career, he observed the changes in medical
difficult for him and his wife to make even the practice and medical education that have led us to
simplest of decisions. They were in the process of the situation in which we now find ourselves. In
selecting a new rug for their home, but after learning weighing Thomas’ comments, remember that this
that he had a malignancy he could not go through was a man that had an extraordinary career as a
with the purchase. The purchase of a new rug no scientist, teacher, administrator, and who was very
longer made sense to him. He was more focused on much involved in the evolution of academic medical
whether or not he was going to die. He wanted to centers that occurred in the post-World War II
know the point of the suffering he was going period. As a leader of academic medicine, he has an
through. All of the questions that he posed are interesting perspective to share based on personal
incredibly profound ones, and they all relate to the observations over his lifetime. He begins by reflect-
goals of medicine. How can a doctor adequately care ing on medicine as practiced by his father in the
for my friend, if he / she has no insight into the issues early years of the 20th century. He used to accom-
that really concern him or does not have the ability pany his father on house calls and observed his
or inclination to help him deal with these concerns? I father at work. In one of his books he writes:
think, however, this is not an infrequent occurrence
in medicine. As I reflected on my own education, I
do not ever remember having a member of the ‘‘In my father’s time, talking with the patient
faculty sitting with me to talk about my feelings was the biggest part of medicine, for it was
about death and suffering, or attempt to help me almost all there was to do. The doctor–patient
reach an understanding about what many patients go relationship was, for better or worse, a long
through. My education focused on the diagnosis and conversation in which the patient was at the
cure of disease! As I said earlier, the ability to epicenter of concern and knew it.’’
address the issues that concern my friend is really the
essence of doctoring. It follows that good communi- Thomas was reflecting on medicine as he observed
cation skills are an essential element of medical it, long before the focus of medical practice and
professionalism. medical education shifted away from the patient to
To build on this line of thought, let me read a an understanding of, diagnosis of, and treatment of
couple of brief excerpts from some books in which disease. But, despite the remarkable advances that
the authors explore these issues from the perspective have occurred over the years that characterize much
of their own personal experiences. I suspect that of modern medicine, it seems to me that it would be
some of you may use these books in teaching useful to at least begin to turn our attention, to some
communication skills to your students. Three of the degree, to the old tradition that Lewis Thomas
five authors of the books I will read from are describes. In another part of his book he comments
physicians who provide insight into some of the on the impact that changes in medicine were having
ways that the education of medical students fails to on patients. Based on his own observations of the
prepare them to communicate adequately with their medicine being practiced in the 1970s he states:
patients. In sum, I think the brief excerpts help us
understand the challenges that we as medical ‘‘It looks to the patient like a different ex-
educators face in trying to produce physicians who perience from what his parents told him about.’’
142 M.E. Whitcomb / Patient Education and Counseling 41 (2000) 137 – 144

What Thomas is saying is that the patient’s parents, That is a pretty profound statement! Arthur Frank
who had experienced the medicine of Thomas’ shares with us the impact on the patient of the
father, had described to their children an experience inability of the doctor to communicate with the
that was quite different than the medicine ex- patient. This is critically important, but what often
perienced by their children. He goes on to say based gets overlooked is that it may also have an adverse
on this observation that, impact on the doctor. Let me return to Lewis
Thomas as he reflects on the changes he observed in
‘‘Something important is left out. The doctor the doctor–patient relationship. He states the follow-
seems less like a close friend and confidant, less ing:
interested in him, the patient as a person, wholly
concerned with treating the disease. And there is ‘‘There are costs to be faced [referring to the
no changing this, no going back; nor, when you changes he has observed]. The real and heavy
think about it, is there really any reason for costs are not money. The close up reassuring,
wanting go back.’’ warm touch of a physician, the comfort and
concern, the long, leisurely discussions in which
Clearly I am not suggesting that we go back to the everything can be worked into the conversation,
medicine practiced in Thomas’ fathers time. We now are disappearing from the practice of medicine,
have extraordinary tools at hand to bring to bear on and this may turn out to be too great a loss for
the care of patients that simply were not available the doctor as well as the patient. This uniquely
during that period. But, the fact that we have these subtle, personal relationship has roots that go
powerful tools and can apply them in many extra- back into the beginning of medicine’s history, and
ordinary ways has blurred our vision of the central needs to be preserved. To do it right has never
importance of the doctor–patient relationship, and of been easy; it takes the best of doctors, the best of
communication as an essential component of that friends. Once lost even for a short of time as one
relationship. As Thomas would say, we need doctors generation, it may be difficult to bring it back into
who, in addition to using the powerful tools of the lives of physicians.’’
modern medicine, will engage in long conversations
with patients in which the patient is at the epicenter He goes on to say,
of concern, and the patient understands that.
More from Thomas later, but let me build on that ‘‘If I were a medical student or an intern, just
theme by sharing with you a patient’s perspective getting ready to begin, I would be more worried
[4]. Arthur Frank is a sociologist who has had about this aspect of my future than anything else.
training in psychology. Because of his own profes- I would be apprehensive that my real job, caring
sional experience, he has tremendous insight into for sick people, might soon be taken away,
modern medicine. When he experienced serious leaving me with a quite different occupation of
diseases at a young age, he was able to apply this looking after machines. I would be trying to figure
insight in providing his perspective as a patient. In out ways to keep this from happening.’’
one of his books he states,
In looking at today’s medicine, I cannot help but
‘‘Talking to doctors always makes me con- note that Lewis Thomas had real insight into the
scious, of what I am not supposed to say. Thus, I future. His observation that the erosion of communi-
am particularly silent when I have been given bad cation in medical practice might have a serious
news. I know I am only supposed to ask about the impact on doctors may well be reflected in the
disease, but what I feel is illness. The questions I apparent erosion of medical professionalism that is
want to ask about my life are not allowed, not manifest in discussions of things like unionization of
speakable, not even thinkable. The gap between physicians. There is no question that we have highly
what I feel and what I feel allowed to say widens knowledgeable and highly skilled physicians who
and deepens and swallows my voice.’’ can do wonderful things, but we need to acknowl-
 M.E. Whitcomb / Patient Education and Counseling 41 (2000) 137 – 144 143

edge that a central aspect of doctoring has been lost based courses designed to improve doctor–pa-
along the way. Anatole Broyard comments from his tient relationships cannot succeed without chang-
perspective on the same issue that concerned Lewis ing education on the wards and in the clinics.
Thomas [5]. Medical students and doctors need to learn more
on the wards, in clinics, and in the community
‘‘Not every patient can be saved, but his illness about the experience of illness and healthcare for
may be eased by the way the doctor responds to patients.’’
him — and in responding to him the doctor may
save himself, but first he must become a student I suggest that the excerpts that I have shared with
again; he must dissect the cadaver of his profes- you are not the musings of disgruntled individuals
sional persona; he must see that his silence and who are simply taking out their frustrations on
neutrality are unnatural. It may be necessary to physicians and medical educators. There are many
give up some of his authority in exchange for his more writings that address the same issues discussed
humanity, but as the old family doctors knew, this in those excerpts. I suspect that those of you in the
is not a bad bargain. In learning to talk to room who are physicians can relate quite readily to
patients, the doctor may talk himself back into the observations described. I know when I reflect
loving his work. He has little to lose and every- back on my own experience as a medical student in
thing to gain by letting the sick man into his the mid-1960s, I recall clearly that teaching rounds
heart. If he does, they can share, as few others were made at the bedside. We had discussions about
can, the wonder, terror, and exaltation of being aspects of medicine in other settings, but basically
on the edge of being, between the natural and the major element of the teaching experience
supernatural.’’ occurred at the bedside. In that situation as a student,
I had the opportunity to see senior physicians talking
with patients and listening to patients. But, as I
5. Erosion of the doctor–patient relationship reflect on the rest of my career, I remember bedside
rounds becoming less frequent. Discussions in con-
I could go on and on about this theme, I think you ference rooms became the predominant teaching
get the point. Let me add just one final observation activity in the in-patient setting. As a young faculty
that links concerns about the erosion of the doctor– member, I learned that sit down rounds was the
patient relationship and the practice of medicine with preferred method for teaching clinical medicine in
the way that we educate medical students and the hospital, and I carried that learning with me
resident physicians. Jody Heymann, writing as a throughout most of my career. In my view, it is time
young physician in training in Boston, describes her that we moved some of our clinical teaching back to
experience as a patient after she developed a seizure the bedside, or as Jody Heymann would say, ‘‘to the
disorder [6]. In her book, she reflects back on her community’’.
own experience as a medical student and resident, Despite my personal views and the views ex-
and her reflection helps us gain insight into some of pressed in the excerpts I read, it would be nice to
the frightening experiences that she had as a patient. know whether the public at large is concerned about
She states, these issues. Perhaps, patients are so taken by the
power of modern medicine that they are not as
‘‘When doctor–patient relationships are dis- concerned with whether doctors communicate
cussed in medical education, it is often far from adequately. Since, the Association has been trying to
hospital wards and outpatient clinics. At Harvard, understand what individuals in society expect of
third-year medical students attend a 2-h-a-week doctors and of the institutions that educate them, we
course on doctor–patient relationships and work have been engaged in conducting public opinion
more than 80 h per week as apprentices on the surveys and focus sessions to get some sense of how
hospital wards. We desperately need to change the public feels about these issues. Some of the
physician training in all settings. Classroom- information that has been gathered is relevant to our
144 M.E. Whitcomb / Patient Education and Counseling 41 (2000) 137 – 144

discussion today. When individuals were asked to Another major challenge we face relates to the
choose which among a number of options would extraordinary diversity of the population that doctors
most influence their choice of a new doctor, almost care for. We have got to learn a lot more about the
all chose, ‘‘how well the doctor communicates with way that people from all over the world view
patients and shows a caring attitude’’. Additional Western medicine, because many of them are coming
work indicates that individuals wanted doctors who to the United States. We are encountering, therefore,
will explain medical procedures to them in a way patients from other cultures that we have little
they can understand. We know from many anecdotes understanding off. Even though we have begun to
that patients frequently do not fully understand the focus more on the importance of spirituality in
procedures that they are about to undergo. We know medicine, we are encountering more and more
that there is hesitancy on the part of patients to say to patients who are members of religious traditions that
doctors, ‘‘would you please take time to tell me what we have had little experience with. We have to do a
you are talking about because I do not understand a much better job than we have in the past by helping
word you have said’’. So, I think it is clear that it is physicians to understand the importance of religious,
not just those of us in the medical education com- ethnic, and cultural differences, and the meaning that
munity who are concerned about the communication those have for the practice of medicine. Of course,
skills that doctors possess and the way they manifest the challenge is that we must at the same time not
those skills. It is a concern that individuals have lose sight of the fact that we must produce know-
about the kind of care they expect to receive when ledgeable and skillful physicians who can use the
they are sick. powerful tools of modern medicine to help their
patients. It is not enough that we produce good
communicators; we must produce excellent clinicians
6. Challenges who have good communication skills, and who are
able to use those skills in the care of their patients.
Clearly, there is a lot of work to do. In my mind, The current focus on communication in medicine is,
one of the key things we must do is to get members in my view, extremely important as we consider the
of our community to understand that when we talk meaning of medical professionalism and how we
about communication in medicine, we are not talking educate doctors as medical professionals.
about how to take a history — that is only one small
part of what a doctor must be able to do in the caring
of a patient. Traditionally, most of the focus on References
communication skills has been on teaching students
how to take a medical history. We have to get [1] Learning objectives for medical student education: guidelines
students and residents to understand that this is the for medical schools. Washington, DC: Association of Ameri-
can Medical Colleges, 1998.
easy part. We have to teach them how to communi-
[2] The goals of medicine: setting new priorities. Hastings
cate with patients, and more important, how to listen Center Report (Special Supplement), November–December,
to patients. Really listen! Not only to what the 1996.
patient is saying, but what it is that has been left [3] Thomas L. The youngest science: notes of a medicine-
unsaid. As Arthur Frank has told us, ‘‘we need to watcher. New York: The Viking Press, 1983.
[4] Frank A. At the will of the body: reflections on illness.
create opportunities for patients to feel comfortable
Boston: Houghton Mifflin, 1991.
in expressing those things that are of most concern to [5] Broyard A. Intoxicated by my illness. New York: Fawcett
them to their doctors’’. The doctors we educate need Columbine, 1992.
to understand the importance of that discussion and [6] Heymann J. Equal partners: a physician’s call for a new
need to be able to help patients with their concerns. spirit of medicine. Boston: Little, Brown, 1995.
We have to get students and residents to understand,
as Lew Thomas’ father understood, that the patient is
at the epicenter of their concern.