Bedside Manners

Kate Finlayson is a medical mystery literally begging to be solved. Plenty of doctors have tried to help, yet Finlayson continues to suffer intermittently from symptoms of multiple sclerosis, depression, panic disorder, chronic fatigue syndrome and even HIV. The scenario is nearly always the same: she meets with doctors, they review her symptoms, then halt the interview without ever having fully resolved her malady.

Enter Joan Tetel-Hanks, stage right. She steps into the scene and coaches the doctor, resident or student on how best to elicit meaningful responses from Finlayson, an actress who is depicting a patient. A few well-timed questions posed in a sensitive, compassionate manner can elicit a kernel of information, otherwise hidden from view, that is vital to her diagnosis and treatment.

"Time Out," she calls to the resident conducting the interview. "Was that the most effective way to inquire about her sexual behavior? Did you get the information you needed, or could you have learned more by asking that question in a manner that did not convey judgment of her lifestyle?"

For the past decade it has been Tetel-Hanks' job - indeed, her passion - to impart a sense of compassion and depth to the doctor-patient relationship; to help doctors delve beyond superficial questions and their personal biases to achieve a deeper understanding of the patient as a person, not as an illness devoid of human emotions. Last month, she stepped down from her role as director of the Standardized Patient Program to enter into semi-retirement.

The program's results are often life-changing for students and physicians alike, said Dr. Annie Drapkin Lyerly, a former medical student and now a close friend of Tetel-Hanks.

And patients reap the rewards of their budding physicians' newly acquired skills.

"Within the safe confines of a classroom, doctors and medical students have the opportunity to make horrible mistakes and do no damage to this patient," said Finlayson. "Joan has an opportunity to tell the doctor that his or her behavior was inappropriate and to suggest more productive ways of communicating. This just doesn't happen in real life without the potential for irreparable harm to the patient."

Many physicians speak admiringly of Tetel-Hanks' knack for teaching doctors how to unveil layers of emotions such as fear, confusion, guilt and denial that lie beneath the surface of the doctor-patient exchange. Emotions such as these often contain clues to the problem at hand. Releasing them can enable the patient and doctor to arrive at a productive solution.

It isn't an easy task. Medical students and residents must work hard to break free of the predominantly scientific confines of medical education to wrangle with the psychosocial quandaries presented in such vignettes, said Dr. Barbara Sheline, an assistant professor of family medicine at Duke and a collaborator on many of the scenarios.

Far more than an academic exercise, the patient vignettes evoke such powerful transformations in participants that even highly respected physicians have been sent to Tetel-Hanks for advice on how to interact with patients. In quite a few cases, they don't come voluntarily but are sent by their department chairs or supervisors. Yet doctors nearly always say they leave feeling grateful and even inspired by Tetel-Hanks' ability to improve their skills in a positive and validating manner.

"My students sometimes ask me how I know what to say, etc., when they're observing me with patients, and I tell them of you," wrote a pediatrician in a note to Tetel-Hanks. "I like to think I'm a pretty good, that is, sensitive doctor, and it's mostly your fault."

Another Duke physician, wary at first of being sent to Tetel-Hanks for skills training, emerged an ardent supporter.

"Through these sessions. ... I have matured as a physician and as a person, to handle challenging patients with a large range of emotions and issues," the physician wrote to Tetel-Hanks. "I was especially fond of the format in which I received direct, constructive feedback from the standardized patient and from Joan. I have learned what is important to the patient on many different levels and for all types of patients."

Such comments cut to the heart of what is most daunting for many physicians to practice and master: getting to know the person inside the patient. Understanding the backdrop against which the illness has occurred, the richness of the patient's life down to the most intimate details of who they are, is vital to developing workable hypotheses that will lead to an accurate diagnosis and effective treatment, said Lyerly.

"Initially prescribing a blood-pressure medication to a person whose cultural bias makes them leery of drugs and distrustful of mainstream medicine is not going to be an effective approach for the patient, even if the disease is clearly diagnosed and well understood," said Tetel-Hanks. "Doctors must develop a mode of treatment that is consistent with the patient's beliefs, cultural norms and behaviors."

No one has taken that message to heart more than Lyerly. The first baby she delivered at Duke was a 700-gram (less than 1‚ pounds) newborn whose mother was addicted to cocaine during pregnancy. Lyerly said she was overwhelmed by the joy of childbirth, yet felt ambivalent toward the mother for jeopardizing her baby.

"I ultimately became quite bonded to this woman and got a better grip on her story and her circumstances," Lyerly said. "It gave me a better understanding of drug addiction, and I asked myself how I could use this experience to help other students. So I teamed up with Joan to produce a video about this woman's story and how doctors could approach addiction as a larger issue."

Lyerly said the entire experience changed her life, and she has now adopted a more philosophical approach to practicing medicine. She is specializing in life ethics and health policy, and a big part of that career move was her experience with Tetel-Hanks, she said.

Indeed, students and faculty members who have helped Tetel-Hanks devise the medical aspects of patient vignettes say she has skillfully crafted her technique into one of the most effective and well-respected standardized patient programs in the nation. Her "patients" become so real that many take on a persona of their own, in some cases achieving folklore status among Duke faculty. Take the irascible Ralph Boyle, a character so true-to-life that Boyle (portrayed by Dr. Joe Corless) sent a written invitation asking Tetel-Hanks to lunch.

Working in the program has been "great fun, extremely rewarding and gratifying," said Tetel-Hanks. She may be retired, yet just a day after her "last day of work" she was back at Duke consulting on yet another standardized patient case at the request of faculty members who won't let her go.