“It's important to connect with patients on a personal level,” he said. “It’s important to ask questions about them as individuals and emphasize to our students that this is not just another person with asthma. They are a unique individual.”

Since its founding, the UMKC School of Medicine has been committed to preparing future generations of primary care physicians to help meet the critical needs of patients in Missouri and nationwide. That includes equipping today’s students with the skills to identify and help care for underlying health-related issues from mental health problems or drug addiction to domestic abuse.

To be effective, these first-line physicians must develop a unique position of trust with their patients and an eye to seek out the less obvious.

Salzman emphasizes to his students the necessity of getting as much information about the person as possible. He calls it “narrative medicine,” a relatively new term, he says, but a method of caregiving used for centuries by physicians who want to know more about their patients.

It means asking questions or, quite simply, carrying on a conversation.

“That’s when you learn the individual is a grandmother with six grandkids who likes to bake cookies,” Salzman says.

Betty Drees, M.D, dean emerita, a former docent and current associate program director of the school’s endocrinology, diabetes and metabolism fellowship, focuses on questions that give the physician a better sense of the patients’ viewpoint toward the disease they’re battling.

“Empathy — being able to see the perspective of the patient — is critical,” Drees said. “I think that in any setting, whether it's a one-time visit in an emergency department or it's longitudinal care for a chronic disease, you have to find ways to make that connection.”

Taking care of patients with diabetes, Drees says, she “may be very concerned about their blood sugar, controlling their blood pressure, all those things. But when you ask them ‘what's of concern to you today,’ it might be an ill family member. Or, ‘my son is in the hospital and I'm not sure he's going to live.’ Well, that's important. You have to leave some open-ended time for people to talk about that because those things that take up people's attention directly affect their ability to care for themselves, especially with chronic disease.”

The relationship between doctor and patient follows closely our basic need for a connection that occurs at birth, says Judith Ovalle, M.D., clinical assistant professor of psychiatry and director of the school’s psychiatric clerkship. She compares the doctor-patient relationship to being a “good enough” mother. With this concept created by pediatrician and psychoanalyst Donald Winnicott, M.D., newborns develop a close bond and deep level of trust with their mother, who doesn’t have to be perfect but good enough to help the child learn the basic life skills to survive and have an enjoyable life.

“As providers, we are replicating that model of a mom and baby, because when a patient comes to us, they are in a vulnerable state,” Ovalle said. “They're ill, so that makes them even more vulnerable. It’s very difficult for some people to look for help. And it’s very difficult for some people to accept having to take medicine because sometimes they feel like that makes them a failure. It’s amazing that people have those feelings.”

Growing emphasis on health maintenance

These relationships between doctor and patient are particularly important in today’s medicine, as the role of care provider extends beyond merely treating the present condition to placing a greater emphasis on health maintenance through preventive medicine. It means developing a rapport with the patient and a trust that allows the physician to engage patients in those serious conversations about how to stay healthy. Those discussions can range from diet issues or promoting not smoking or drinking, to taking care of the routine preventive maintenance procedures such as mammograms and colonoscopies.

“The emphasis in primary care is not just treating people when they're sick,” Salzman said. “It's trying to maintain their health, to stay healthy, and to live a long and fruitful life.”

At the UMKC School of Medicine, developing the patient relationship is a major point of emphasis. And it is reinforced with students throughout their curriculum. Early training in the fundamentals of medicine includes courses on communication skills. More than merely taking a patient’s history, it’s about learning the patient’s story. Salzman says that doctors today too often don’t spend enough time listening to their patients and giving them time to tell their story.

The ability to comfortably carry on those conversations comes naturally for some people. For others who are less outgoing, it can be more difficult. But students at the School of Medicine get plenty of opportunities to develop those skills. They include spending half a day each week during their final four years in the continuity care clinics treating patients. From their clinical experiences to observing their docents and senior partners, these students cultivate those vital communications skills.

Drees said the experience is crucial in the student’s development as a physician.

“I think it's a jewel of the curriculum, the way it's designed,” she said.

Salzman recalled a former student who struggled with being extremely shy and having trouble talking to people. A patient he saw regularly in the clinic had high blood pressure but wasn’t taking his medicine. Then the student and Salzman learned the patient’s story. He had financial and other problems that made filling the prescription difficult. They found an affordable medicine and connected the patient to a pharmacy that would deliver it to him.

During a follow-up visit, the patient said how much he appreciated the student and how his ability to take his medicine and get better was related to help the student had provided.

“That positive reinforcement — the student hearing that from the patient — I think we really sent a message to that student that connecting with the patient is important,” Salzman said. “All the work he had done trying to be more outgoing and more relatable to his patients really made a difference. It made a difference in this patient's life.”

Health care from the patient’s point of view

Understanding the patient’s health care goals and readiness to make changes if necessary is equally important, Drees said. She points to the classic example of weight loss. Simply telling a patient they need to lose weight is typically unsuccessful.

“That doesn’t really help them develop the lifestyle changes that they need,” Drees said. “First, you have to assess whether they’re ready to make those changes. And they may tell you that they can’t.”

The key, she says, is to help the patient set realistic goals. For instance, getting back to their weight when they were 19 years old may not be realistic, but losing 5 percent of their body weight could make a large impact on their health.

As well as the art of listening, Ovalle said, it’s important for physicians to develop the skills to look beyond physical symptoms. Physicians say depression is a condition that goes under-diagnosed, so more screenings are being done to recognize mental health diseases. That comes, Ovalle said, with recognizing the social issues surrounding the patients. A trained psychoanalyst, Ovalle says the social aspects associated with mental health largely appear in two areas of life — work and relationships.

Part of the diagnosis of mental illness, she says, is a discernable impairment of social functioning, whether that’s in the form of having trouble holding down a job or maintaining a relationship.

“We want to look at how they’re functioning in these areas, and this is going to give us a big piece of their mental health picture,” she said. “Work and love, relationships and occupation. They can tell us a lot. We are not just body. We are mind and emotions. That's not just in psychiatry. These are not skills you need to know just for handling psychiatric patients. They are for any patient.”

Those listening and connecting skills are equally important when helping patients and their families deal with end-of-life issues. Salzman says families facing the impending loss of a loved one often ask him questions such as, “If this was your mother, what would you do?”

“I say, ‘Tell me about your mother,’” Salzman says. “Those discussions are much easier when you know the patient and the family on a deeper level.”

He shares the story of a student who was caring for a terminally ill patient who, even though she was dying, insisted on continuing an aggressive medical intervention. In the afternoons, the student returned after her shift to spend time quietly watching television with the patient. After a few days together, the woman became more trusting of the student and the doctors’ recommendations.

In a short time, her expectations began to change, and she agreed to reducing the harsh interventions that were being administered.

“She had a peaceful death, not a painful death,” Salzman said. “And that was because this student made that connection with her just by sitting and watching television with her in the afternoon.”

Salzman knows that learning to connect with people builds trust.

“It helps the patient in all aspects of life, diagnosis, treatment, maintenance, smoking cessation, alcohol,” he said. “I think all of those issues are much better addressed when we have a connection to the patient, when you know their story, and when they know that you really care about the person.”