Hektoen International

A Journal of Medical Humanities

The checklist mentality

Graham T. McMahon
Boston, Massachusetts, USA
Ruri Ashida


 Photography by Daniel Kulinski

Whether in Boston or in Tokyo, we share the same joy and swell with pride when we see our students grow into competent clinicians. In our classes we have helped them ask open-ended questions, make eye-contact, express empathy, and learn how to interact with patients. We have modeled and encouraged, corrected and remediated.

Increasingly however, we have noticed a troubling trend. We have observed a student interviewing a patient with troubling diarrhea and ask, “What bothers you the most?” When the patient said she had become housebound for fear of public embarrassment, the student expressed her empathy as taught by saying, “Oh, that must be hard for you,” and then promptly changed the subject to ask about tobacco use. When faced with a patient who could not sleep at night because of headaches, another student replied, “That must be difficult for you” and moved on to ask about her diet. One after another, students asked patients about their concerns, replied with empathetic words, then continued their interviews uninterrupted, and went no further to find out how an incident or relationship might have indeed affected the patient. They seemed content to have asked an important question and left it at that. At the end of the interview, we have watched our students appropriately inquire whether their patients had some question they had forgotten to mention. One patient hesitatingly replied, “No . . . nothing about . . . myself . . .” whereupon the student drew the encounter to a close. The student knew he had asked all the requisite questions and showed empathy, but had failed to see the patient. The patient was never given a chance to reveal her predicament that her son had caused an accident, was in hospital, and in trouble. The student failed to notice the tone or the weakness that lay in the patient’s word, “myself.” It seemed that our students were hearing, but not listening.

So what could be driving this behavior among our well-intentioned motivated students? Had we been too busy ourselves, unavailable to observe students at length and give feedback?1,2 Or was it that our own dependence on using checklists from standardized patient encounters had contributed to this problem. We use checklists to make sure our students have asked all the questions, but inadvertently may have been encouraging an algorithmic approach instead of a responsive and nuanced encounter.

It would be a great shame if our examinations have indeed contributed to a loss of humanism and attentiveness to the patient. Skills learnt intellectually should be practiced by the heart. William Osler wrote:

As the practice of medicine is not a business and can never be one, the education of the heart―the moral side of the man―must keep pace with the education of the head.3

The loneliness expressed by a patient housebound by illness and the frustration of a functional disability express our patients’ real concerns. When those hesitant expressions go unheard, the real opportunity to connect with the patient is lost. It seems that our students had acquired the skills intellectually without acknowledging the significance of acquiring those skills, which is to connect themselves to the human side of medicine: to emotionally engage themselves with the patients, to understand their feelings and their sufferings.

With every passing year, there are increasing calls to increase “quality.” But this drive to conformity increases standardization and diminishes the opportunity to express individuality and personality. Developing interviewing skills should be an empathetic endeavor that cannot be diminished into checklists. To let students glimpse the joy of being part of our patients’ lives, we need to step back and understand how we can nourish the kind of sustaining relationships that are created through interviews that express the humanism and caring that have defined our profession for generations.



  1. Brazeau CM, Schroeder R, Rovi S, Boyd L. Relationships between medical student burnout, empathy, and professionalism climate. Acad Med. 2010 Oct;85(10 Suppl):S33-6.
  2. Weissmann PF, Branch WT, Gracey CF, Haidet P, Frankel RM. Role modeling humanistic behavior: learning bedside manner from the experts. Acad Med. 2006 Jul;81(7):661-7.
  3. Osler W. On the Educational Value. In: Aequanimitas With Other Addresses to Medical Students, Nurses, and Practitioners of Medicine. 3rd ed. Philadelphia: P. Blakiston’s Son; 1932:268.



GRAHAM MCMAHON, MD, MMSc, is an Associate Professor of Medicine at Harvard Medical School and a faculty member in the Division of Endocrinology, Diabetes, and Hypertension at the Brigham and Women’s Hospital in Boston, where he completed his postgraduate training. Dr. McMahon received his Master’s degree in clinical research from Harvard Medical School, and his doctorate in education from the National University of Ireland. He is Editor for Medical Education at the New England Journal of Medicine.

RURI ASHIDA, MA, is an Assistant Professor at Tokyo Medical University, where she teaches English for medicine. She received her Masterʼs degree in English literature from the University of Toronto. With a background in humanities, she is interested in doctor-patient relationships and is currently working to enhance Japanese studentsʼ international/intercultural communication skills by introducing English-speaking simulated patients into the curriculum.


Highlighted in Frontispiece Spring 2014 – Volume 6, Issue 2

Spring 2014  |  Sections  |  Education

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