Teaching Personal Awareness
Robert C. Smith, MD, ScM,1Francesca C. Dwamena, MD,1Auguste H. Fortin VI, MD, MPH2
1Department of General Internal Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA;2Yale University
School of Medicine, New Haven, CT, USA.
Educators rarely consider the attitudes that determine whether a learn-
er will use the clinical skills we teach. Nevertheless, many learners and
practitioners exhibit negative attitudes that can impede the use of pa-
tient-centered skills, leading to an isolated focus upon disease and im-
pairing the provider-patient relationship. The problem is compounded
because these attitudes often are incompletely recognized by learners
and therefore are difficult to change without help.
We present a research-based method for teaching personal aware-
ness of unrecognized and often harmful attitudes. We propose that pri-
mary care clinicians without mental health training can follow this
method to teach students, residents, faculty, and practitioners. Such
teachers/mentors need to possess an abiding interest in the personal
dimension, patience with a slowly evolving process of awareness, and
the ability to establish strong, ongoing relationships with learners. Per-
sonal awareness teaching may occur during instruction in basic inter-
viewing skills but works best if systematically incorporated throughout
KEY WORDS: self-awareness; countertransference; attitudes; provider-
patient relationship; communication; medical education.
J GEN INTERN MED 2005; 20:201–207.
titudes often have been shaped by the ‘‘hidden curriculum.’’1
The attitudes that determine a learner’s willingness to learn
and use skills are seldom formally taught.2–16This may occur,
in part, because the attitudes and the closely associated
thoughts and emotions that govern skill usage often are in-
completely recognized by the learner and therefore can be dif-
ficult to change.3,17
Although limited, research does demonstrate that hidden
feelings and attitudes harmful to patients are commonly ex-
hibited during doctor-patient interactions, especially avoiding
the patient’s personal issues.2,18Thirteen of 15 sophomore
medical students5and 16 of 19 residents and fellows6exhib-
ited potentially harmful responses when observed in a single
interview each. Table 1 lists their feelings and the resulting
potentially deleterious behaviors. For example, fear of ad-
dressing psychological issues led a resident to overcontrol
the interview and to inappropriately interrupt. Consider the
life-threatening impact of avoiding data about suicidal intent
as well as the harmful effect of these behaviors on communi-
cation and the relationship itself. These negative physician re-
actions do not diminish with age or experience. A study of
he formal curriculum of medical education has tradition-
ally focused on teaching knowledge and skills, while at-
board-certified physicians with an average age of 50 years
showed that these doctors continued to exhibit potentially del-
eterious responses, particularly when threats to their integrity
or self-esteem occurred.19
The rationale and approach for the method we present are
modeled upon teaching personal awareness to psychiatry
trainees.11,12Such work originates conceptually from the
Freudian, post-Freudian, and person-centered domains where
the methods are used to elicit, respond to, and teach about
unconscious processes.20–24For teachers without mental
health training, we have adapted these methods to provide
teaching guidelines.16,25–28In accord with these precepts, our
focus is improved awareness of personal issues as they relate
to education and the patient rather than attempting psycho-
therapy and seeking wide-ranging personal change.11,12
Influenced and informed by research8–10,29and by other
key recommendations,2,7,14,18,30,31the method presented here
stems from our own research3,5,6,19,25,32and other teaching
experiences4,17,33–36with primary care trainees. This method
was evaluated during a 1-month, full-time course for post-
graduate year 1 (PGY1) residents in medical interviewing and
other aspects of psychosocial medicine.3,25,32Qualitative
study demonstrated that it was effective.3Fifty out of 53 res-
idents had negative reactions that interfered with learning pa-
tient-centered interviewing.3,25Using the method presented
here, 44 of 50 residents changed their negative reactions and
improved their communication and relationship skills—and
thus better addressed patients’ personal and emotional lives.3
Teaching personal awareness (of incompletely recognized atti-
tudes, emotions, behaviors, and thoughts) often occurs while
teaching interviewing skills, but the same principles apply in
other venues where patient interactions are evaluated, such as
supervising residents’ and students’ inpatient activities, pre-
cepting in a clinic, and reviewing audio/videotaped interac-
tions. We usually defer personal awareness work until learners
show some mastery of the skills and knowledge base required
for whatever course, activity, or rotation is occurring. Early on,
we usually devote no more than 1 to 2minutes at each critique
of an interaction to a learner’s personal awareness. Later, how-
ever, we can increase our focus on self-awareness to about 5 to
10minutes at each critique of interactions with patients.
Always, upon recognizing a problem in a learner’s inter-
action, the teacher asks and resolves one fundamental ques-
tion: is this a skills deficiency, unrecognized resistance to
using the skills, or both?3In Table 2, see Part #1 of an actu-
al teaching vignette that illustrates the teaching of personal
Accepted for publication July 1, 2004
The authors are aware of no conflicts of interest.
Address correspondence and requests for reprints to Dr. Smith: B312
Clinical Center, 138 Service Road, Michigan State University, East
Lansing, MI 48824 (e-mail: Robert.Smith@HT.msu.edu).
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training for residents in interviewing. A randomized, controlled study.
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Smith et al., Teaching Personal Awareness