Orwik

Empathy, and Attitudes Among

CME course CME course Related Articles published in the same issue

Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians.

CONTEXT: Primary care physicians report high levels of distress, which is linked to burnout, attrition, and poorer quality of care. Programs to reduce burnout before it results in impairment are rare; data on these programs are scarce. OBJECTIVE: To ... expand abstractdetermine whether an intensive educational program in mindfulness, communication, and self-awareness is associated with improvement in primary care physicians' well-being, psychological distress, burnout, and capacity for relating to patients. DESIGN, SETTING, AND PARTICIPANTS: Before-and-after study of 70 primary care physicians in Rochester, New York, in a continuing medical education (CME) course in 2007-2008. The course included mindfulness meditation, self-awareness exercises, narratives about meaningful clinical experiences, appreciative interviews, didactic material, and discussion. An 8-week intensive phase (2.5 h/wk, 7-hour retreat) was followed by a 10-month maintenance phase (2.5 h/mo). MAIN OUTCOME MEASURES: Mindfulness (2 subscales), burnout (3 subscales), empathy (3 subscales), psychosocial orientation, personality (5 factors), and mood (6 subscales) measured at baseline and at 2, 12, and 15 months. RESULTS: Over the course of the program and follow-up, participants demonstrated improvements in mindfulness (raw score, 45.2 to 54.1; raw score change [Delta], 8.9; 95% confidence interval [CI], 7.0 to 10.8); burnout (emotional exhaustion, 26.8 to 20.0; Delta = -6.8; 95% CI, -4.8 to -8.8; depersonalization, 8.4 to 5.9; Delta = -2.5; 95% CI, -1.4 to -3.6; and personal accomplishment, 40.2 to 42.6; Delta = 2.4; 95% CI, 1.2 to 3.6); empathy (116.6 to 121.2; Delta = 4.6; 95% CI, 2.2 to 7.0); physician belief scale (76.7 to 72.6; Delta = -4.1; 95% CI, -1.8 to -6.4); total mood disturbance (33.2 to 16.1; Delta = -17.1; 95% CI, -11 to -23.2), and personality (conscientiousness, 6.5 to 6.8; Delta = 0.3; 95% CI, 0.1 to 5 and emotional stability, 6.1 to 6.6; Delta = 0.5; 95% CI, 0.3 to 0.7). Improvements in mindfulness were correlated with improvements in total mood disturbance (r = -0.39, P < .001), perspective taking subscale of physician empathy (r = 0.31, P < .001), burnout (emotional exhaustion and personal accomplishment subscales, r = -0.32 and 0.33, respectively; P < .001), and personality factors (conscientiousness and emotional stability, r = 0.29 and 0.25, respectively; P < .001). CONCLUSIONS: Participation in a mindful communication program was associated with short-term and sustained improvements in well-being and attitudes associated with patient-centered care. Because before-and-after designs limit inferences about intervention effects, these findings warrant randomized trials involving a variety of practicing physicians. collapse abstract

Enhancing the informal curriculum of a medical school: a case study in organizational culture change.

BACKGROUND: Calls for organizational culture change are audible in many health care discourses today, including those focused on medical education, patient safety, service quality, and translational research. In spite of many efforts, traditional "to... expand abstractp-down" approaches to changing culture and relational patterns in organizations often disappoint. OBJECTIVE: In an effort to better align our informal curriculum with our formal competency-based curriculum, Indiana University School of Medicine (IUSM) initiated a school-wide culture change project using an alternative, participatory approach that built on the interests, strengths, and values of IUSM individuals and microsystems. APPROACH: Employing a strategy of "emergent design," we began by gathering and presenting stories of IUSM's culture at its best to foster mindfulness of positive relational patterns already present in the IUSM environment. We then tracked and supported new initiatives stimulated by dissemination of the stories. RESULTS: The vision of a new IUSM culture combined with the initial narrative intervention have prompted significant unanticipated shifts in ordinary activities and behavior, including a redesigned admissions process, new relational practices at faculty meetings, student-initiated publications, and modifications of major administrative projects such as department chair performance reviews and mission-based management. Students' satisfaction with their educational experience rose sharply from historical patterns, and reflective narratives describe significant changes in the work and learning environment. CONCLUSIONS: This case study of emergent change in a medical school's informal curriculum illustrates the efficacy of novel approaches to organizational development. Large-scale change can be promoted with an emergent, non-prescriptive strategy, an appreciative perspective, and focused and sustained attention to everyday relational patterns. collapse abstract

A new theoretical foundation for relationship-centered care

Relationship-centered care (RCC) is a clinical philosophy that stresses partnership, careful attention to relational process, shared decision-making, and self-awareness. A new complexity-inspired theory of human interaction called complex responsive ... expand abstractprocesses of relating (CRPR) offers strong theoretical confirmation for the principles and practices of RCC, and thus may be of interest to communications researchers and reflective practitioners. It points out the nonlinear nature of human interaction and accounts for the emergence of self-organizing patterns of meaning (e.g., themes or ideas) and patterns of relating (e.g., power relations). CRPR offers fresh new perspectives on the mind, self, communication, and organizations. For observers of interaction, it focuses attention on the nature of moment-to-moment relational process, the value of difference and diversity, and the importance of authentic and responsive participation, thus closely corresponding to and providing theoretical support for RCC. Key words  patient-centered care - complexity - relationship - communication research The authors have no conflicts of interest to report. collapse abstract

Toward an informal curriculum that teaches professionalism

The social environment or “informal” curriculum of a medical school profoundly influences students’ values and professional identities. The Indiana University School of Medicine is seeking to foster a social environment that consist... expand abstractently embodies and reinforces the values of its formal competency-based curriculum. Using an appreciative narrative-based approach, we have been encouraging students, residents, and faculty to be more mindful of relationship dynamics throughout the school. As participants discover how much relational capacity already exists and how widespread is the desire for a more collaborative environment, their perceptions of the school seem to shift, evoking behavior change and hopeful expectations for the future. Key words  medical education - professionalism - curriculum - competencies - relationship-centered care Supported by a grant from the Fetzer Institute, Kalamazoo, MI. collapse abstract

Research on patient-clinician relationships

No abstrct available for this article

Reducing unnecessary coronary care unit admissions

Objective:To determine whether published decision rules for ischemic heart disease have practical value in reducing unnecessary admissions to coronary care units. Design:Prospective cohort study.

Physician reactions to quantitative individual performance reports.

The purpose of this study was to learn how primary care physicians experienced the introduction and evolution of an individual physician pay-for-performance program. Thirty primary care physicians participated in audiotaped focus groups 13 and 26 mon... expand abstractths after beginning the program. Transcribed audiotapes were used to group comments into themes. Ten thematic groups were identified. Practitioners reviewed their profiles but found it difficult to use them to change behaviors. They were concerned about the data accuracy, the influence of specialists and patients on their "scores," and, less, the validity of quality measures. They described ways the program changed their practices and consideration of cost, quality, and satisfaction. There were important concerns about the influence of pay-for-performance programs on professionalism. Primary care physicians were skeptical of this pay-for-performance program. On the other hand, physicians described positive influences on making improvements in quality, satisfaction, and practice efficiency. collapse abstract

A new theoretical foundation for relationship-centered care. Complex responsive processes of relating.

Relationship-centered care (RCC) is a clinical philosophy that stresses partnership, careful attention to relational process, shared decision-making, and self-awareness. A new complexity-inspired theory of human interaction called complex responsive ... expand abstractprocesses of relating (CRPR) offers strong theoretical confirmation for the principles and practices of RCC, and thus may be of interest to communications researchers and reflective practitioners. It points out the nonlinear nature of human interaction and accounts for the emergence of self-organizing patterns of meaning (e.g., themes or ideas) and patterns of relating (e.g., power relations). CRPR offers fresh new perspectives on the mind, self, communication, and organizations. For observers of interaction, it focuses attention on the nature of moment-to-moment relational process, the value of difference and diversity, and the importance of authentic and responsive participation, thus closely corresponding to and providing theoretical support for RCC. collapse abstract

Control and relation: two foundational values and their consequences.

This paper explores and contrasts personal philosophies based on two different core values, control and relation, with respect to expectations, social relationships, habits of perception and interpretation, and ways of feeling grounded in the world. ... expand abstractThe paradigm of control is widespread in medicine and certain other health professions, but because it fosters unrealistic expectations, evokes fear and shame, and inhibits effective partnerships, it can actually compromise health outcomes. The paradigm of relation calls attention to interpersonal process and fosters receptivity and adaptability, thus enhancing partnership. A mature clinical approach combines these two perspectives, respecting both the benefits and limitations of reductionistic science and making room for self-organization and emergence. collapse abstract

Uncertainty, competence, and opioids.

The biopsychosocial model 25 years later: principles, practice, and scientific inquiry.

The biopsychosocial model is both a philosophy of clinical care and a practical clinical guide. Philosophically, it is a way of understanding how suffering, disease, and illness are affected by multiple levels of organization, from the societal to th... expand abstracte molecular. At the practical level, it is a way of understanding the patient's subjective experience as an essential contributor to accurate diagnosis, health outcomes, and humane care. In this article, we defend the biopsychosocial model as a necessary contribution to the scientific clinical method, while suggesting 3 clarifications: (1) the relationship between mental and physical aspects of health is complex--subjective experience depends on but is not reducible to laws of physiology; (2) models of circular causality must be tempered by linear approximations when considering treatment options; and (3) promoting a more participatory clinician-patient relationship is in keeping with current Western cultural tendencies, but may not be universally accepted. We propose a biopsychosocial-oriented clinical practice whose pillars include (1) self-awareness; (2) active cultivation of trust; (3) an emotional style characterized by empathic curiosity; (4) self-calibration as a way to reduce bias; (5) educating the emotions to assist with diagnosis and forming therapeutic relationships; (6) using informed intuition; and (7) communicating clinical evidence to foster dialogue, not just the mechanical application of protocol. In conclusion, the value of the biopsychosocial model has not been in the discovery of new scientific laws, as the term "new paradigm" would suggest, but rather in guiding parsimonious application of medical knowledge to the needs of each patient. collapse abstract

Partnering with citizens to reform Wisconsin health care: a report of the first citizen congress.

Research on patient-clinician relationships: celebrating success and identifying the next scope of work.

What do doctors find meaningful about their work?

The influence of health care organizations on well-being.

Story, medicine, and healthcare.

The path to professionalism: cultivating humanistic values and attitudes in residency training.

Though few question the importance of incorporating professionalism and humanism in the training of physicians, traditional residency programs have given little direct attention to the processes by which professional and humanistic values, attitudes,... expand abstract and behaviors are cultivated. The authors discuss the underlying philosophy of their primary care internal medicine residency program, in which the development of professionalism and humanism is an explicit educational goal. They also describe the specific components of the program designed to create a learner-centered environment that supports the acquisition of professional values; these components include a communication-skills training program, challenging-case conferences, home visits with patients, a resident support group, and a mentoring program. The successful ten-year history of the program shows how a residency program can enable its trainees to develop not only the requisite excellent diagnostic and technical tools and skills but also the humane and professional attributes of the fully competent physician. collapse abstract

Exploring the ethics of clinical role conflicts.

Rationale, principles, and educational approaches of organizational transformation.

The role of bioethics and business ethics.

The meaning of symptoms in 10 women with somatization disorder and a history of childhood abuse.

OBJECTIVE: To understand the associated experiences and illness behavior in patients with somatization disorder and a history of childhood abuse. DESIGN: In-depth interviews were conducted with patients who had somatization disorder and a history of ... expand abstractchildhood abuse; qualitative content analysis was then performed. SETTING: Patients were recruited from 2 primary care teaching practices. PARTICIPANTS: Physicians were asked to refer patients suspected of having both conditions, yielding 21 potential participants. Eight declined, and 3 did not meet standardized screening questionnaire criteria, yielding 10 women who participated in the study. Participants and nonparticipants had a similar range of socioeconomic variables. RESULTS: An analysis of the interviews yielded 22 themes. Seven themes relevant to understanding the link between illness behavior and abuse were the abuse experiences, emotional and behavioral reactions to the abuse, relationship of abuse to somatoform symptoms, relationship of abuse to health care use, attempts to tell about the abuse, relationships with physicians, and physician behavior. Childhood attempts to tell adults about the abuse resulted in threats of punishment, contributing to lifelong patterns of secrecy, even with physicians. Six women reported having childhood physicians who were family members, friends, or the abuser's physician, reinforcing their subsequent secrecy. The women reported that their current physicians denied their physical pain as adults, just as the abusers denied their emotional and physical pain in childhood. Seven women reported decreased health care use once they associated symptoms with abuse experiences. Nine women reported spousal abuse. CONCLUSIONS: Somatization and childhood abuse may involve a paradoxical pattern of hiding feelings and reality, while seeking acknowledgment of suffering. Patient insight may decrease health care use. Therefore, the exploration of patient experiences may be useful for women with somatization disorder and a history of childhood abuse. The risks of spousal abuse and denial and rejection in the physician-patient relationship could also be important. collapse abstract

Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient.

Physicians' personal characteristics, their past experiences, values, attitudes, and biases can have important effects on communication with patients; being aware of these characteristics can enhance communication. Because medical training and contin... expand abstractuing education programs rarely undertake an organized approach to promoting personal awareness, we propose a "curriculum" of 4 core topics for reflection and discussion. The topics are physicians' beliefs and attitudes, physicians' feelings and emotional responses in patient care, challenging clinical situations, and physician self-care. We present examples of organized activities that can promote physician personal awareness such as support groups, Balint groups, and discussions of meaningful experiences in medicine. Experience with these activities suggests that through enhancing personal awareness physicians can improve their clinical care and increase satisfaction with work, relationships, and themselves. collapse abstract

A model of empathic communication in the medical interview.

OBJECTIVE: To formulate an empirically derived model of empathic communication in medical interviews by describing the specific behaviors and patterns of interaction associated with verbal expressions of emotion. DESIGN: A descriptive, qualitative st... expand abstractudy of verbal exchanges using 11 transcripts and 12 videotapes of primary care office visits to a total of 21 physicians. SETTING: An urban health maintenence organization (HMO), an urban university-based general medicine clinic, and an urban community hospital general medicine clinic. ANALYTIC METHOD: Individual review of transcripts by each research team member to identify instances of expressed or implied emotional themes and to observe the physicians' responses. Individual ratings were compared in group discussions to achieve consensus about the classifications. Similar consensus-based classification was used for review of videotapes. RESULTS: We observed that patients seldom verbalize their emotions directly and spontaneously, tending to offer clues instead. If invited to elaborate, patients may then express the emotional concern directly, and the physician may respond with an accurate and explicit acknowledgment. In most of the interviews, the physicians allowed both clues and direct expressions of affect to pass without acknowledgment, returning instead to the preceding topic, usually the diagnostic exploration of symptoms. With emotional expression so terminated, some patients attempted to raise the topic again, sometimes repeatedly and with escalating intensity. We noted a parallel dynamic for encounters in which patients sought praise. We summarized the full interactional sequence in a simple descriptive model. CONCLUSIONS: This empirically derived model of empathic communication has practical implications for clinicians and students who want to improve their communication and relationship skills. Based on our observations, the basic empathic skills seem to be recognizing when emotions may be present but not directly expressed, inviting exploration of these unexpressed feelings, and effectively acknowledging these feelings so the patient feels understood. The frequent lack of acknowledgment by physicians of both direct and indirect expressions of affect poses a threat to the patient-physician relationship and warrants further study. collapse abstract

Physician job satisfaction: reversing the decline.