Straight from the horse's mouth: New elective wins kudos from med students

Sharon North-Pohl

Second-year medical student Katalin Szabo examines a horse named Apache for telling signals of discomfort.

It's hard to ignore a patient who weighs 1,200 pounds, stands 7 feet tall and won't hesitate to nip you if she doesn't like what you're doing.

But those attributes are precisely why medical students can benefit from working with horses, according to the philosophy behind a new elective course at the medical school, "Medicine and horses: A communications model for the doctor-patient relationship." Not intended for veterinary students, it's geared toward making medical students more conscious of how they come across when interacting with others.

For many people, the idea of horses helping medical students hone their communication skills might conjure up images of Mr. Ed, the "talking" horse of TV fame, the bangs of his palomino mane flopping around as he tossed his head while lip-syncing to the soundtrack. But Mr. Ed would have no place in this class, as horses who can't speak the language are preferred: The point is to improve nonverbal communication.

Still, why don't the students just stick to human beings?

"Animals in general respond to people in ways that are so transparent and honest," said Sam LeBaron, MD, PhD, professor of medicine and director of the Center for Education in Family and Community Medicine. "They hold up a mirror for students that they may not get from human patients."

Beverley Kane, MD, added that just because patients can talk doesn't mean they will. "Human patients don't always tell you what's on their mind," she explained. "We've all been socialized into hiding our feelings and reactions, especially from somebody in a white coat. Horses will tell you in no uncertain terms how you're affecting them—if you pay attention to the right signals."

Kane is the head instructor of the class, which she previously taught at UC-San Francisco. Her class is modeled on a class at the University of Arizona medical school that has been taught for five years. Evaluations of UA medical students showed that the class improved their patient interaction skills.

On a recent, sunny afternoon, several of the six Stanford students who took the course last spring reconvened at a dusty horse corral in Portola Valley for an additional lesson. Diana Wertz and Katalin Szabo, both second-year medical students, said they decided to take the class in part due to feedback they got from exercises in another class where actors played the roles of patients. "One patient said I made him nervous with my lack of confidence with the equipment," said Wertz. Szabo said her "patients" commented that she was too focused on going down the checklist of medical tasks to be done and didn't pay enough attention to them.

During every class, the students encounter a new horse, so just like a doctor with a new patient, the first task is always the introduction. This day, the next task was to listen to the heartbeat. Kane said a common complaint is that doctors come at patients with a cold stethoscope, without taking time to establish rapport. Instructor Lucia Mokres, DVM, demonstrated how to avoid that complaint from a horse and then the students tried.

Szabo, with her hand on the horse's side, gently applied the stethoscope, sliding it down to the belly, behind the foreleg, to the heart. After a few moments, she said she could hear the heart as well as a good amount of "digestive rumbling." But the real measure of success was her patient's calm—no ears laid back, no fidgeting, no walking away.

Kane said different exercises focus on different aspects of the various situations doctors encounter. Some are designed to help them sort out whether they're more comfortable in a leadership role or being directed by someone else. Others bring up the issues encountered in trying to set boundaries: Maintaining a degree of distance from a patient while still being empathetic and understanding.

"I became a lot more conscious of how I behaved in certain situations," said fifth-year medical student Tracy Dooley. "What my body language would be telling a patient, or in this case what it was communicating to the horses, as opposed to verbal signals."

But the class is about more than just making students aware of how their behavior affects a patient. Many medical students who don't have experience dealing with horses are intimidated when they have to approach such a large animal, which LeBaron said is another thing of which doctors need to be aware. "We want to become more mindful, as doctors, how we behave when we feel a little stressed or a little intimidated," LeBaron said. "That's something that virtually is never talked about, and the truth is doctors are as human as anybody else."

Last spring was the first time the course was offered at the medical school, but LeBaron, Kane and the students, would like to see the class continue. It's an elective and is completely supported by donations, so the future isn't guaranteed. Still, all are hopeful that funding can be found to continue it.