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Escalating health care costs are affecting patients across the country. As employers and insurance companies face higher expenses, they may move to a cost‐sharing strategy, which potentially increases financial burdens on patients. In this situation, physicians may find themselves serving as both medical and financial advisors for their patients. Clinical encounters in which patients experience financial hardship can be awkward and frustrating for both parties. Physicians must learn to discuss issues of affordability in a manner that builds, rather than detracts, from a therapeutic alliance. This article describes our experiences using several communication skills that can help in the discussion of health care costs with patients. The primary skill, empathic communication, which includes “we” statements and “I wish …” statements, serves to create a platform for shared decision‐making, negotiation, and a search for alternatives. In addition, it is helpful if physician offices have resource materials available and strategies identified to assist patients facing financial hardship.

Standardized patients have been utilized for nearly 40 years in teaching medical curricula. Since the introduction of this teaching methodology in the early 1960s, the use of standardized patients has steadily gained acceptance and is now incorporated into medical education across the country. This "standardization" was useful for teaching and evaluating medical students and residents. However, as this modality expanded beyond medical schools to include seasoned physicians, the limitations of "one-sizefits-all" clinical scenarios became apparent. In teaching clinician-patient communication (CPC) courses to practicing physicians, we have discovered that flexibility and improvisation on the part of the actor enhances the educational experience. The term "care actor" more accurately describes this role than standardized patient. The care actors in our CPC courses have become integral contributors to the education process, serving not only as simulated patients but also as coaches and collaborators. This article outlines the history of standardized patients in medical education and presents a three-part framework for effectively using care actors to teach clinician-patient communication: setting the stage, skill practice, and providing feedback.James T Hardee, MD, (left) is the physician lead for Clinician-Patient Communication in the KP Colorado Region (CPMG) and is on the CPMG Board of Directors.

The study's objective was to survey what and how psychiatry residents want to learn about ethics during residency. A 4-page questionnaire developed for this study was sent to 305 residents at 10 adult psychiatry programs in the United States. One-hundred and eighty-one (59%) of those surveyed responded. Seventy-six percent reported facing an ethical dilemma in residency for which they felt unprepared. Forty-six percent reported having received no ethics training during residency. More than 50% of the respondents requested that "more" curricular attention be paid to 19 specific ethics topics and more than 40% for 25 topics. Preferences with respect to learning methods are presented. This survey may provide guidance in structuring the content and process of ethics education for psychiatry residents. These findings should stimulate the efforts of faculty to commit time and attention to this important curricular area.