A Communication Model for the Doctor-Patient Relationship

Beverley Kane, MD Stanford University School of Medicine

TOC: Purpose | Course Materials | Bibliography


A major challenge for medical students in their clinical years and for physicians throughout our careers is to conduct our relationships with patients, colleagues, "superiors," and employees in a manner that is professional, sensitive, perceptive, confident, and authentic. Especially with regard to patients, our interactions must be characterized by compassion, insight, and respect.

The aim of the Medicine and Horsemanship course is to help medical students develop awareness of the subtleties of self-presentation and communication that are necessary for the physician-patient relationship and other professional interactions. These relationships are based on the student’s interpersonal behaviors as much as on the factual clinical information that he or she brings to the therapeutic transaction. Because medical schools often select for intellectual proficiency over other forms of intelligence, even medical students with premedical clinical and community experience have often not developed the people skills required for clinical excellence.

Horsemanship requires an appreciation of the nonverbal as well as verbal messages that we give to others. It requires patience, gentleness, self-confidence, perceptiveness, focus, and awareness. Horses are large, but nevertheless easily frightened, prey animals whose survival has depended on becoming exquisitely sensitive to body language, innuendo, and emotional tone, and to the position and movement of objects in their sensory fields. By reflecting back to us the signals and intents of which we aren’t even aware—much less aware that we’re communicating outward—horses train us to notice at all times the information that we convey.

Horses develop in us the three nonintellectual, nonrational aspects of our intelligence— instinctual, emotional, and sensory—that may have atrophied in our quest for the correct answers on exams, the right diagnosis, or the most relevant journal article. Yet all four forms of intelligence are necessary in the clinical encounter. Unlike cats and dogs, horses make little use of the reasoning function, excelling instead at the other three ways of imparting information.

As swift, powerful, and sometimes intimidating animals, horses create a natural opportunity for students to overcome fear and develop confidence. Because it’s difficult if not impossible to bluff one’s command of a situation around horses, students learn how to cope with feelings of insecurity, ask for help, and succeed at developing authentic self-assurance.

While we are careful not to equate patients with horses, horses and humans have much in common. Horses are social animals with defined roles within their herds. They have distinct personalities, attitudes, and moods. An approach that works with one horse does not necessarily work with another. At times, they seem stubborn and defiant. We must win their respect on their terms before imposing our own. Because horses react to the most subtle human signals, they hold up a magnifying mirror to ourselves and our behaviors. In this mirror we see the image and path for our professional development and our personal growth. objectives

Developmental goals of the course include:

Becoming aware of subtleties of verbal and nonverbal communication

Many times in the patient interview, physicians are oblivious to indicators we get from and give to patients about attitudes, moods, and boundaries—theirs and our own. We are unaware of body positions and other nonverbal cues that signal respect or lack of it, incongruency between words and deeds, and flagging self-assurance. In working with horses, we receive clear and explicit feedback about messages that we may not be aware we are sending.

Improving attention, mindfulness, and focusing abilities

How many times do we as physicians seem to be listening to our patients while surreptitiously glancing at our watches, thoughts elsewhere, tittering with impatience while uttering our absent-minded "Uh-huh, uh-huhs"? We think our patients don’t notice our divided attention, but they do. Horses are not too polite to tell us when our concentration has lapsed. Even grooming a horse demands an unbroken immersion in the task, performing it mindfully and with focused awareness.

Becoming aware of incongruency of intention vs. behavior

Patients can tell when we say one thing and mean another. But they don’t often tell us. Horses unabashedly react to our behavior and to our inner intentions, not to the surface appearances we try to create. Through work in the round pen, the culminating crucible of equine experiential learning, students will see how the horses, their classmates, and our instructors perceive and respond to their often contradictory intentions and behaviors in a nonjudgmental and often humorous way.

Identifying and respecting boundaries in ourselves and others

Physicians need to sense when we are making other people uncomfortable, especially people from other cultures and traditions. We need to notice when we ourselves feel uncomfortable with intimacy and physical contact. Horses give unequivocal cues for recognizing personal space and for modulating the gentility vs. roughness of touch and contact.

Recognizing the nature of projection

In any relationship, especially a therapeutic relationship where we presume to try to "cure" or "fix" someone, much of what we see in others is that which exists in ourselves. We project our hopes, fears, issues, moods, and personalities onto our patients, colleagues, loved ones, and animals. In psychiatric models we speak of transference and counter-transference as doctors and patients re-enact lifetime patterns of psychological behaviors and roles. When we look at a horse and say, "He’s a loner" or "She’s the leader of the herd" we are often projecting our own feelings and self-images. In the "Choose or Be Chosen" exercise, students often elect to work with a horse that embodies for them some quality with which the student identifies, usually unconsciously.

The round pen session that is the culmination of our work with the horses is a quintessential exercise in projection, not only in the psychological sense, but in the sense of the felt energies we project into the horse’s physical sphere of awareness. After each person plays in the round pen, the group discusses the individual and consensus realities of the experience. We use the form, " [Person’s name], when I see you [perform a task], I feel [an emotion or opinion]. Is this true for you?" In this way, we see where our perceptions may vary from those of others—not that one is right and one is wrong, just how they might differ. If we intend to act one way and are perceived as acting another way, we get valuable feedback on our communication styles and our congruency of thought and action.

Confronting fear and developing confidence

So often in medicine we are called on to summon courage and good judgment in the face of fear and uncertainty. Especially in training, there is often a premium placed on never letting them see you sweat. We walk a fine line between false bravado and overplayed insecurities. Horsemanship demands that we develop true confidence by dealing honestly with both our strengths and weaknesses. In the "Lead While Following" exercise and throughout the course, the horses teach us how to avoid using aggression to compensate for lack of command, to ask for help, to give cooperations, and to build self-assurance.

Adjusting to the relativity of time, expanding the moment

Related to our inability to be present in the moment, physicians tend to rush around, leaving things undone, never being fully located in one place. We are spread thin among beepers, cell phones, e-mail, and overhead pagers. We leave patients in the exam room without proper goodbyes or closure. There is never enough time in the day. Horses restore our sense of duration and location by teaching us that we cannot take short cuts, that things happen in their own good time, and that each task deserves whatever time is necessary for its completion.

"Closing ceremonies" at the end of each day teach the importance of respectfully taking leave.

Coping with stress

Students will learn basic techniques of centering, grounding, and relaxation both for stress management and as a prerequisite for mindfulness in the other exercises.

Course Materials

Each student will receive a syllabus with:


Goleman, Daniel. Emotional Intelligence. Bantam. 1995
Hamilton, Allan and Hamilton, Jane. Horses teach bedside manners. EAGALA News. Fall 2005
Hillman, James. Dream Animals. Chronicle Books. 1997. Paintings by Margot McLean.
Irwin, Chris. Horses Don’t Lie. Marlow & Co. 2001
Jung, Carl Gustav. Psychological Types. Collected Works. Vol 6. Bollingen. 1921
Kohanov, Linda.
— The Tao of Equus—A Woman’s Journey of Healing & Transformation through the Way of the Horse. New World Library. 2001
Riding Between the Worlds. New World Library. 2003
Lyons, John. Lyons on Horses. Doubleday. 1991
McCormick, Adele von Rust and Marlena Deborah. Horse Sense and the Human Heart: What Horses Can Teach Us About Trust, Bonding, Creativity, and Spirituality. Health Communications. 1997
McCormick, MD, Thomas; Horses and the Mystical Path-The Celtic Way of Expanding the Human Soul. New World Library. 2004
Midkiff, Mary D. She Flies Without Wings-How Horses Touch a Woman’s Soul. Delacorte Press. 2001
Rashid, Mark. Horses Never Lie: The Heart of Passive Leadership. Johnson Books. 2000
Rector, Barbara. Adventures in Awareness—Learning with the Help of Horses. Author House. 2005
Smith, Penelope. Animal Talk. Beyond Words Pub Co. 1999
Taylor, Jeremy. Dreamwork. Chapter XIV on projection. Paulist Press. 1983.
Witter, Rebekah. Living With Horsepower! Personally Empowering Life Lessons Learned. Trafalgar Square. 1998
Winning With Horsepower! Achieving Personal Success Through Horses. Trafalgar Square. 1999
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