UA medical students learn the importance of body language
by trying to get horses to complete simple tasks.

Somewhere among the shady mesquites and towering cottonwoods of Tucson's far East Side, young men and women are learning how to whisper to horses to heal humans.

They are students at the University of Arizona College of Medicine, who are taking what is considered the only medical school class of its kind in the nation.

Welcome to "Medicine and Horsemanship: An Introduction to Nonverbal Human Interaction at the Bedside" - a course that is attracting national attention.

But it also has surfaced at the center of a growing controversy over teaching what some critics call "soft skills" - at the expense of hard science - to young doctors.

The high-spirited Arabian mare trots nervously around the pen, tossing her head and snorting. She's not pleased about things at the moment.
Standing in the middle of the round pen, second-year UA medical student Holly Buschhorn knows she's doing something wrong.

"She's anxious. I'm trying to lower my energy level," says the doctor-to-be as the mare ignores her physical cues to slow down, turn around and come to her.

"I don't think we're connected at all yet," Holly says, trying to quiet her own body language, to lower whatever threat she may be signaling to the horse.

It doesn't work. The animal turns toward her for an instant, then spins away, bucking. She wants no part of this human she does not know and clearly does not trust.

The minutes pass. Slowly, almost imperceptibly, Holly changes her posture and motion. It is a tiny, relaxing move almost no one notices - except the mare.

"I can feel her coming back to me," Holly says softly.
Now intently watching Holly, the horse stops and slowly turns around, as Holly is directing her to do, then walks right up to the young woman and puts her head in Holly's hands.

"Super," cheers Dr. Allan Hamilton, the UA's chief of surgery and Holly's professor in this class, who is perched on the fence at his horse ranch on Tucson's East Side.

"The friendly game"
"OK, now play 'the friendly game,'" he says, as Holly touches and pats and praises the calmed horse. There is trust.

The idea came to Hamilton - a nationally renowned, pioneering brain surgeon - about four years ago, after his lifelong interest in horses led him to study and practice "horse whispering" techniques on his own animals. Among his teachers was the famed "horse whisperer" Monty Roberts.

Building trust
That is exactly the point of horse whispering, Hamilton pointed out. In stark contrast to the old horse-training methods - breaking a horse with force and domination - horse whisperers work with, not against the horse. They use gentle, non-verbal cues through subtle body language to show and persuade the horse what to do.

"The horse gains trust in the human, and becomes a willing partner," Hamilton said. "That is exactly what we want to happen with our patients, who then join us in the healing effort, rather than being afraid of what we're doing to them."

And therein lies one of the keys to becoming a great doctor, said the UA's Dr. Jack G. Copeland, one of the world's top heart transplant surgeons, who routinely handles terrified patients on the brink of death.
"A highly sensitive prey species - that seems to me to describe horses, as well as patients going into surgery," Copeland said.

"Each must be approached with a great deal of sensitivity, and certainly the non-verbal cues are an important part of the doctor-patient encounter."

Working with human patients is obviously more complex, he said.
That is especially true today in this era of managed care, when doctors are forced to see as many patients as possible in a day. The seven-minute patient - as this phenomenon is known - makes it especially tough for a doctor to effectively bond with a patient.

And so, every Friday afternoon, a handful of UA medical students - from two to the maximum six in a class - gather at Rancho Bosque, to spend two hours working with a horse they have never met. No saddles, no bridles, no riding. No student works with the same horse twice.

"That's the way it's going to be with patients - each one will be different, each one will react to your body language in a different way. It is up to the doctor to figure out, quickly, what works best with each patient," said Hamilton.

"Too much energy"
Ace is cantering easily in the round pen, seemingly calm and collected, as Hans Bradshaw - a second-year med student planning to specialize in pediatrics - prepares to work with him.

Almost out of nowhere, the horse's calm is shattered, and he bolts, then bucks in alarm. Hans has too suddenly raised his arm, waving it at the horse, in a failing effort to get Ace to stop and turn around.

"Too much energy, way too much," said Hamilton from his fence perch. "Breathe, now breathe, slowly and deeply."

As Hans does just that, the effect is stunning. Immediately, Ace is back to his slow canter. Then he stops, looks at the strange man in the middle of the pen, and walks over to him.

"See what happened, as soon as you took the time to breathe and relax?" Hamilton said. "His connection to your body movement is very powerful."

What students say
Ask the students themselves what they think of all this, and they basically say two things:

They are convinced it is helping them become better doctors. And they simply love coming out to the ranch on Friday afternoons to be with the horses.

An elective course, Medicine and Horsemanship has so far attracted 25 UA students, at all levels of training, since it was first offered in spring 2001.

"Just learning to open up and make a connection with patients can make all the difference in the world. It can turn a crappy event in the waiting room into a fantastic appointment with the doctor," said Bradshaw.

"I absolutely think what we learn here translates directly to interacting with humans. So many people have no awareness at all about the effect their body language has on others. After this, you are very aware."

The class is not just horses. During each session, the students take a break from the round pen, to study videotapes of themselves interviewing human patients in UA clinics - before, during and after taking this course. They also study, and critique, Hamilton working with patients.

In one tape, he is about to use his stethoscope on a teen-age girl who has been suffering seizures from a brain tumor. Before slapping the metal instrument on her, Hamilton moves his free hand in the direction he is going to go with the scope, so she is not startled.

"It's exactly like moving around a horse - you always let them know where you are and what you're going to do," he said.

Not for everyone
But linking horse-whispering to doctoring doesn't work for everyone. This particular course has been specifically named in a national journal as an example of critical time wasted on touchy-feely issues at the expense of the vital medical science students must learn.

"When a patient comes to a doctor, he wants to be cured, not cuddled," Dr. John Robinson, professor of medicine and microbiology at the Stritch School of Medicine at Loyola University, told the Chronicle of Higher Education.

In an article titled "Horse Sense or Nonsense" - meaning Hamilton's class - Robinson noted the explosion of biomedical knowledge during the past decade.

"What's frustrating is that at the same time, (medical schools) are taking a 180-degree turn, with all kinds of soft topics infiltrating in the first two years," he said.

Robinson is a member of the National Association of Scholars, a group that is actively fighting what it calls this "softening" of medical education.
But that is going to be a tough fight. If anything, such courses are going to increase. By 2005, all U.S. medical students for the first time will be required to pass tests on their clinical skills - including patient communication - to obtain medical licenses.

But some physicians think the best way to teach students how to handle humans is with humans - called "patient instructors" - not horses. All medical schools, including the UA, use real people posing as patients for student doctors to practice on.

"When I am teaching physicians in training, I encourage them to shut their mouths and listen quietly to what the patient has to say, and to observe the human behavior," said Dr. James Reifschneider, a longtime Tucson internist.

Tucson pediatrician Dr. Eve Shapiro likes the theory behind the horsemanship class, but wants some tangible proof it really works.
"It sounds good. But it would be nice to see some validation, some actual results that students come out of this more skilled with patients," she said.

Hamilton freely admits other doctors often tell him his horse class is "a bunch of baloney."

"But I have seen students uncomfortable with giving a physical exam - fumbling, not knowing how to approach or touch the patient. Then they come out here and work out the kinks with the horses, and all of that changes.

"When you see that breakthrough, that's a very big thing for me - to see the student in that good moment."