Residents' Experiences of Negative Emotions toward Patients: Challenges to their Identities.

PhenomenonMedical learners are more likely than practicing physicians to experience negative emotions toward some patients whom they find challenging, and medical students experience such emotions related to their identity as learners. Little is known about experiences of residents, who are further along in their physician identity formation and have greater autonomy and competence. We explored and characterized how residents understand their experiences of the phenomenon of feeling negative emotions toward patients in relation to their identities as residents. Approach: In 2018, 305 final-year obstetrics and gynecology residents were invited to participate in interviews, which we conducted until reaching theoretical sufficiency. In semi-structured interviews conducted by phone, we probed interactions when residents felt negative emotions toward patients, including reasons for their feelings related to their professional identities, strategies, and curricular desires. The authors coded data and identified patterns using thematic analysis. Findings: Nineteen residents were interviewed by phone. Residents experienced negative emotions toward patients because of challenges to their identities as: physicians - wanting respect and specific unexpected patient behaviors; learners - desiring complete autonomy and experiencing challenges with attending physicians; teachers - wanting to be a role model and protect junior learners; and workers - trying to complete tasks. Among the strategies used to manage feelings toward patients, they struggled with "venting", or complaining about patients, which was not always helpful and residents recognized as perceived negatively by students. They desired curricular support for these interactions such as debriefs and other supported reflection, faculty modeling, and communication skills training. Insights: Like medical students and physicians in practice, residents experience negative emotions toward patients, often because of and made more difficult by their identities as physicians, learners, teachers, and workers. Educators should support residents' reflections about these interactions, model compassionate behavior when feeling challenged by patients, and address unhealthy coping strategies.

What Do Medical Students Do and Want When Caring for "Difficult Patients"?

Phenomenon: Medical students, like physicians, experience negative emotions such as frustration when interacting with some patients, and many of these interactions occur for the first time during clinical clerkships. Students receive preclinical training in the social and behavioral sciences, often including learning about "difficult patient" interactions, yet little is known about their desire for training during clinical education. We explored students' strategies in these difficult clinical interactions, whether they felt prepared by the curriculum, and what support they would have liked. These data inform proposed strategies for supporting clinical learning. Approach: We interviewed 4th-year students about interactions with patients toward whom they felt negative emotions and sought to identify strategies and supports needed in these interactions. Interviews ended when theoretical sufficiency was achieved. We used qualitative content analysis to organize strategies into themes about areas benefiting from curricular supports. We mapped students' desired curricular support examples to cognitive apprenticeship teaching methods-modeling, coaching, reflection, scaffolding, exploration, and articulation-and aligned them with traditional pedagogical techniques. Findings: We interviewed 26 medical students (44 volunteered/180 invited). Their strategies formed five themes: finding empathy (with a subtheme of focusing on social determinants of health), using learned communication approaches, anticipating challenging interactions, seeking support, and considering it an opportunity for more responsibility. Students described ideal clinical teaching, including postinteraction debriefs with an emphasis on validating their emotional reactions and challenges. Students mentioned all cognitive apprenticeship teaching methods, most prominently modeling (observing supervisors in such interactions) and supported oral reflection. They also identified a need for faculty and resident development to enact these teaching methods. Insights: Although students use some learned strategies in interactions in which they feel negative emotions toward patients, they desire more preparation and support during their clinical rotations. Their desires map to traditional pedagogical techniques and to methods of cognitive apprenticeship. Our findings point to the need to use these techniques to enhance clinical learning for students who experience emotionally challenging patient interactions.

What Makes "Difficult Patients" Difficult for Medical Students?

PURPOSE: Physicians can find it challenging to provide high-quality care to "difficult patients." While studies support that medical students also find some patients "difficult," little is known about why they do or how being a student affects their perceptions. The authors conducted this study to gain a deeper understanding of students' experiences with "difficult patients" to inform clinical teaching about effective patient communication and patient-centered care. METHOD: In 2016, the authors conducted interviews with fourth-year medical students, who were asked to describe patient interactions in which they felt negative emotions toward the patient, as well as describe the clinical setting and their feelings. The authors audiorecorded and transcribed the interviews. Then, using a constructivist grounded theory approach, they reviewed the transcripts, coded the data using a codebook they had developed, and grouped the codes into themes. RESULTS: Twenty-six students (of 44 volunteers and 180 students invited) were interviewed. Students described negative feelings toward patients and patients' behaviors, which were exacerbated by three situations related to their role and expectations as learners: (1) patients' interference with students' ability to "shine"; (2) patients' interference with students' expectations of patient-centered care; and (3) students' lack of the tools or authority to improve patients' health. CONCLUSIONS: Educators should consider these findings, which can be explained by the professional identity formation and goal orientation theory frameworks, as they teach medical students to provide high-quality care for patients they find "difficult."

Exploring How Residents Who Partially Participate in Family Planning Training Determine Their Level of Participation.

OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) requires that obstetrics and gynecology residency programs provide access to abortion training, though residents may elect to opt out of participating due to religious or moral objections. While clinical benefits of partial participation have previously been explored, our study aimed to explore how residents navigate partial participation in abortion training and determine their limits. STUDY DESIGN: This study was qualitative in nature. Between June 2010 and June 2011, we conducted 26 semi-structured phone interviews with residents who opted out of some or all of the family planning rotation at 19 programs affiliated with The Ryan Residency Training Program. Faculty directors identified eligible residents, or residents self-reported in routine program evaluation. We analyzed data using the conventional content analysis method. RESULTS: We interviewed all 26 (46%) of 56 eligible residents willing to be interviewed. Three main categories constituted the general concepts concerning resident decision-making in training participation: (1) variation in timing of when residents determined the extent of participation, (2) a diversity of influences on the residents' level of participation, and (3) the perception of support or pressure related to their participation decision. CONCLUSIONS: The findings indicated that residents who partially participate in abortion training at programs with specialized opt-out family planning training weigh many factors when deciding under what circumstances, if any, they will provide abortions and participate in training.

Impact of partial participation in integrated family planning training on medical knowledge, patient communication and professionalism.

INTRODUCTION: Obstetrics and gynecology residency programs are required to provide access to abortion training, but residents can opt out of participating for religious or moral reasons. Quantitative data suggest that most residents who opt out of doing abortions participate and gain skills in other aspects of the family planning training. However, little is known about their experience and perspective. METHODS: Between June 2010 and June 2011, we conducted semistructured interviews with current and former residents who opted out of some or all of the family planning training at ob-gyn residency programs affiliated with the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning. Residents were either self-identified or were identified by their Ryan Program directors as having opted out of some training. The interviews were transcribed and coded using modified grounded theory. RESULTS: Twenty-six physicians were interviewed by telephone. Interviewees were from geographically diverse programs (35% Midwest, 31% West, 19% South/Southeast and 15% North/Northeast). We identified four dominant themes about their experience: (a) skills valued in the family planning training, (b) improved patient-centered care, (c) changes in attitudes about abortion and (d) miscommunication as a source of negative feelings. DISCUSSION: Respondents valued the ability to partially participate in the family planning training and identified specific aspects of their training which will impact future patient care. Many of the effects described in the interviews address core competencies in medical knowledge, patient care, communication and professionalism. We recommend that programs offer a spectrum of partial participation in family planning training to all residents, including residents who choose to opt out of doing some or all abortions. IMPLICATIONS: Learners who morally object to abortion but participate in training in family planning and abortion, up to their level of comfort, gain clinical and professional skills. We recommend that trainers should offer a range of participation levels to maximize the educational opportunities for these learners.

Availability and characteristics of abortion training in US ob-gyn residency programs: a national survey.

OBJECTIVE: To assess the availability and characteristics of abortion training in US ob-gyn residency programs. METHODS: We surveyed fourth-year residents at US residency programs by email regarding availability and type of abortion training, procedural experience and self-assessed competence in abortion skills. We conducted multivariable, ordinal logistic regression with general estimating equations to determine individual-level and resident-reported, program-level correlates of quantity of uterine evacuation procedures done during residency. RESULTS: Three hundred sixty-two residents provided data, representing 161 of the 240 residency programs contacted. Access to training in elective abortion was available to most respondents: 54% reported routine training--where abortion training was routinely scheduled; 30% reported opt-in training--where training was available but not routinely integrated; and 16% reported that elective abortion training was not available. Residents in programs with routine elective abortion training and those who intended to do abortions before residency did a greater number of first-trimester manual uterine aspiration and second-trimester dilation and evacuation procedures than those without routine training. Similarly, routine, integrated training, even for indications other than elective abortion, correlated with more clinical experience (all p<.01, odds ratio and confidence interval shown below). CONCLUSION: There is a strong independent relationship between routine training and greater clinical experience with uterine aspiration procedures.

Opting out of abortion training: benefits of partial participation in a dedicated family planning rotation for ob-gyn residents.

BACKGROUND: This study was conducted to describe the experiences of residents who opt out of some components of a dedicated abortion rotation. STUDY DESIGN: Eligible residents at programs receiving funding from the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning were invited to complete a cross-sectional, online survey. RESULTS: The majority of residents who opted out of some portion of the family planning training reported that the rotation positively affected skills in pregnancy options counseling, cervical dilation, first-trimester ultrasound, techniques of first-trimester uterine evacuation and other skills. Twenty-one of the 65 (31%) did an elective abortion, and 56 (84%) completed aspirations for at least one non-elective indication including therapeutic abortion and miscarriage. While no resident desired additional elective abortion training, 11 (16%) wanted additional uterine aspiration and 14 (21%) wanted additional second-trimester uterine aspiration training for non-elective indications. CONCLUSION: Providing access to an abortion rotation for residents who do not plan to do elective abortions gives them the opportunity to improve their skills in family planning, therapeutic abortion and miscarriage management.

Women's perspectives on ultrasound viewing in the abortion care context.

PURPOSE: In recent years, states have passed a range of regulations regarding ultrasound procedures in abortion care. Abortion rights opponents have promoted ultrasound viewing, believing that women who view their own ultrasound images are likely to be dissuaded from abortion. Abortion rights advocates, in contrast, routinely oppose these regulations, citing concerns that ultrasound viewing in the abortion context will be emotionally difficult for women. However, no empirical research has examined the effects of ultrasound viewing in unwanted pregnancies. METHODS: We conducted in-depth interviews with 20 respondents who received an ultrasound as part of their abortion care in one of two states in the American heartland. Interview transcripts were analyzed using grounded theory and a matrix technique for discussion of ultrasound viewing and regulations about ultrasound viewing. RESULTS: Respondents' accounts offer support for anti-abortion claims that ultrasound viewing can dissuade women from abortion, as well as support for abortion rights claims that viewing an ultrasound can cause emotional difficulty for a woman planning to abort. Interviews point to unexpected outcomes of ultrasound viewing, including reports that viewing better enabled respondents to cope with their abortion. CONCLUSIONS: Ultrasound viewing does not have a singular effect. These data suggest that current assumptions about viewing effects are inaccurate, or at the least incomplete. We do not find support for legislating mandatory ultrasound viewing in abortion care. Questions about clinical care practices are best address in the medical context, not the legislative arena.

Impact of formal family planning residency training on clinical competence in uterine evacuation techniques.

BACKGROUND: The goal of this study was to assess the impact of formal opt-out family planning training on clinical competence in uterine evacuation. STUDY DESIGN: Residents who participated in newly established, routine opt-out family planning training completed surveys before and after their rotations. The surveys asked residents to report clinical experience and competence in family planning. RESULTS: One hundred ninety-six pre- and postrotation questionnaires were collected for a total response rate of 63%. After completing the rotation, residents reported higher competence in medical abortion, manual uterine aspiration, electric uterine aspiration and dilation and evacuation (p<.001). Residents also reported increased clinical experience with methods of termination, postabortion contraception, including intrauterine contraception, ultrasound and perioperative pain management. CONCLUSIONS: Participation in a formal opt-out family planning rotation results in increased clinical exposure to family planning and in reported competence in pregnancy termination.