Communication as a High-Stakes Clinical Skill: "Just-in-Time" Simulation and Vicarious Observational Learning to Promote Patient- and Family-Centered Care and to Improve Trainee Skill.

Patient-provider communication is a hallmark of high-quality care and patient safety; however, the pace and increasingly complex challenges that face overextended teams strain even the most dedicated clinicians. The COVID-19 pandemic has further disrupted communication between clinicians and their patients and families. The dependence on phone communication and the physical barriers of protective gear limit nonverbal communication and diminish clinicians' ability to recognize and respond to emotion. Developing new approaches to teach communication skills to trainees who are often responsible for communicating with patients and their families is challenging, especially during a pandemic or other crisis. "Just-in-time" simulation-simulation-based training immediately before an intervention-provides the scaffolding and support trainees need for conducting difficult conversations, and it enhances patients' and families' experiences. Using a realistic scenario, the author illustrates key steps for effectively using just-in-time simulation-based communication training: assessing the learner's understanding of the situation; determining what aspects of the encounter may prove most challenging; providing a script as a cognitive aid; refreshing or teaching a specific skill; preparing learners emotionally through reflection and mental rehearsal; coaching on the approach, pace, and tone for a delivery that conveys empathy and meaning; and providing specific, honest, and curious feedback to close a performance gap. Additionally, the author acknowledges that clinical conditions sometimes require learning by observing rather than doing and has thus provided guidance for making the most of vicarious observational learning: identify potential challenges in the encounter and explicitly connect them to trainee learning goals, explain why a more advanced member of the team is conducting the conversation, ask the trainee to observe and prepare feedback, choose the location carefully, identify everyone's role at the beginning of the conversation, debrief, share reactions, and thank the trainee for their feedback and observations.

Brain activation during social cognition predicts everyday perspective-taking: A combined fMRI and ecological momentary assessment study of the social brain.

Identifying distinct neural networks underlying social affect (empathy, compassion) and social cognition (Theory of Mind) has advanced our understanding of social interactions. However, little is known about the relation of activation in these networks to psychological experience in daily life. This study (N = 122) examined the ecological validity of neural activation patterns induced by a laboratory paradigm of social affect and cognition with respect to social interactions in everyday life. We used the EmpaToM task, a naturalistic video-based paradigm for the assessment of empathy, compassion, and Theory of Mind, and combined it with a subsequent 14-day ecological momentary assessment protocol on social interactions. Everyday social affect was predicted by social affect experienced during the EmpaToM task, but not by related neural activation in regions of interest from the social affect network. In contrast, everyday social cognition was predicted by neural activation differences in the medial prefrontal cortex - a region of interest from the social cognition network - but not by social cognition performance in the EmpaToM task. The relationship between medial prefrontal cortex activation and everyday social cognition was stronger for spontaneous rather than deliberate perspective taking during the EmpaToM task, pointing to a distinction between propensity and capacity in social cognition. Finally, this neural indicator of Theory of Mind explained variance in everyday social cognition to a similar extent as an established self-report scale. Taken together, this study provides evidence for the ecological validity of lab-based social affect and cognition paradigms when considering relevant moderating factors.

I expect what you expect: An electrophysiological study on social expectation of pain.

Expectations and motor reactions related to pain are mainly acquired through personal experiences. Contingent negative variation (CNV) has been shown to be an informative electrophysiological measure of this pain anticipation. Expectations can also arise while observing others in painful conditions. However, it still remains unclear what are the neural correlates of this phenomenon and how the observation of others in pain can subsequently change our personal pain perception as well as our motor reaction to pain. Using CNV as a measure of expectation, this study aims to assess whether expectations formed through observation change the observer's own experience of pain and reaction to pain. A new cooperative task was designed where one participant, the model, received an electrical stimulation while another, the observer, watched the experiment and both were asked to stop the stimulation as fast as possible. Crucially, in a successive session, participants inverted their roles so that models became observers and vice versa. CNV was recorded in both participants simultaneously by means of two synchronized electroencephalograms. Results showed that CNV area did not differ between models and observers and reaction times were significantly faster in observers compared to models. Moreover, observers' pain perception was correlated to models' pain perception as well as to observers' empathy scores. These data show how expectations, perceptions as well as reactions related to pain are crucially affected not only by observation but by personal attitudes toward others and all these changes can be clearly described through CNV.

Do dominant group members have different emotional responses to observing dominant-on-dominant versus dominant-on-disadvantaged ostracism? Some evidence for heightened reactivity to potentially discriminatory ingroup behavior.

The importance of social connection to well-being is underscored by individuals' reactivity to events highlighting the potential for rejection and exclusion, which extends even to observing the social exclusion of others ("vicarious ostracism"). Because responses to vicarious ostracism depend at least in part on empathy with the target, and individuals tend to empathize less readily with outgroup than ingroup members, the question arises as to whether there is a boundary condition on vicarious ostracism effects whereby individuals are relatively immune to observing ingroup-on-outgroup ostracism. Of particular interest is the case where members of a dominant ethnic group observe fellow ingroup members ostracize a member of a disadvantaged ethnic minority group, as here there is a compelling potential alternative: Perceived violation of contemporary social norms condemning prejudice and discrimination might instead lead dominant group members to be especially upset by "dominant-on-disadvantaged" ostracism. Accordingly, the present research examines, across four studies and 4413 participants, individuals' affective reactions to observing dominant-on-disadvantaged versus dominant-on-dominant ostracism. In each study, dominant group members (White/Europeans) observed dominant group members include or ostracize a fellow dominant group member or a disadvantaged ethnic minority group member (a Black individual) in an online Cyberball game. Results revealed that dominant group members felt more guilt, anger, and sadness after observing severe ostracism of a disadvantaged as opposed to dominant group member. Although no direct effects emerged on behavioral outcomes, exploratory analyses suggested that observing ostracism of a disadvantaged (versus dominant) group member had indirect effects on behavior via increased feelings of anger. These results suggest that observing ostracism may be a sufficiently potent and relatable experience that when it occurs across group boundaries it awakens individuals' sensitivity to injustice and discrimination.

How bodily expressions of emotion after norm violation influence perceivers' moral judgments and prevent social exclusion: A socio-functional approach to nonverbal shame display.

According to a socio-functional perspective on emotions, displaying shame with averted gaze and a slumped posture following a norm violation signals that the person is ready to conform to the group's moral standards, which in turn protects the person from social isolation and punishment. Although the assumption is intuitive, direct empirical evidence for it remains surprisingly limited and the mediating social-psychological mechanisms are poorly understood. Therefore, three experimental studies were conducted to investigate the social function of nonverbal displays of shame in the context of everyday norm violations. In Study 1, participants evaluated ten different expressions of emotion in regard to their affective valence, arousal, dominance, as well as social meaning in the context of norm violations. Displays of shame and sadness were seen as the most similar expressions with respect to the three affective dimensions and were perceived to communicate the perpetrator's understanding of the group's moral standards most effectively. In Study 2, participants read vignettes concerning norm violations and afterward saw a photograph of the perpetrator displaying nonverbal shame, sadness or a neutral expression. Perpetrators' displays of shame and sadness increased perceived moral sense and amplified the observers' willingness to cooperate with the perpetrators. However, neither display weakened the observer's willingness to punish the perpetrator. In Study 3, the perpetrator was shown to display shame, sadness, anger or a neutral expression after getting caught at mild or severe norm violation. The results replicated previous findings but revealed also that the social effects of shame and sadness displays on punitive and cooperative intentions were mediated by different social appraisals. For example, display of shame uniquely reduced punitive intentions by increasing the perpetrator's perceived moral sense, whereas expressions of both shame and sadness evoked empathy in the observers, which in turn reduced the punitive intentions. These results give support to the assumption that nonverbal shame displays serve a unique social function in preventing moral punishment and social exclusion. However, this support is only partial as the social functions of displaying shame are largely parallel to those of expressing sadness in the situation.

Burnout and Self Care for Palliative Care Practitioners.

Burnout is common in physicians who care for patients with serious illness, with rates greater than 60% in some studies. Risk factors for burnout include working on small teams and/or in small organizations, working longer hours and weekends, being younger than 50 years, burdensome documentation requirements, and regulatory issues. Personal factors that can protect against burnout include mindfulness, exercise, healthy sleep patterns, avoiding substance abuse, and having adequate leisure time. Institutional and work factors that can buffer against burnout include working on adequately staffed teams, having a manageable workload, and minimally burdensome electronic health record documentation.

Psychosocial assessment of families caring for a child with acute lymphoblastic leukemia, epilepsy or asthma: Psychosocial risk as network of interacting symptoms.

The purpose of this study is to assess psychosocial risk across several pediatric medical conditions and test the hypothesis that different severe or chronic pediatric illnesses are characterized by disease specific enhanced psychosocial risk and that risk is driven by disease specific connectivity and interdependencies among various domains of psychosocial function using the Psychosocial Assessment Tool (PAT). In a multicenter prospective cohort study of 195 patients, aged 5-12, 90 diagnosed with acute lymphoblastic leukemia (ALL), 42 with epilepsy and 63 with asthma, parents completed the PAT2.0 or the PAT2.0 generic version. Multivariate analysis was performed with disease as factor and age as covariate. Graph theory and network analysis was employed to study the connectivity and interdependencies among subscales of the PAT while data-driven cluster analysis was used to test whether common patterns of risk exist among the various diseases. Using a network modelling approach analysis, we observed unique patterns of interconnected domains of psychosocial factors. Each pathology was characterized by different interdependencies among the most central and most connected domains. Furthermore, data-driven cluster analysis resulted in two clusters: patients with ALL (89%) mostly belonged to cluster 1, while patients with epilepsy and asthma belonged primarily to cluster 2 (83% and 82% respectively). In sum, implementing a network approach improves our comprehension concerning the character of the problems central to the development of psychosocial difficulties. Therapy directed at problems related to the most central domain(s) constitutes the more rational one because such an approach will inevitably carry over to other domains that depend on the more central function.

Your losses are mine: The influence of empathic concern on evaluative processing of others' outcomes.

Neural responses to others' decision-making outcomes can be modulated by many social factors. Using the event-related potential (ERP) technique, we explored the neural mechanisms of empathic concern modulating evaluative processing of others' outcomes. Participants were asked to perform a gambling task for three beneficiaries: themselves and two strangers. One stranger was an economically underprivileged student requiring help (high-empathy condition); the other stranger was a student with no upsetting information to induce empathic concern (low-empathy condition). ERP results showed that the valence effect of the feedback-related negativity (FRN) was larger when participants exhibited high empathic concern than when they did not. The FRN responses to strangers' outcomes in the high-empathy condition were as strong as those to their own outcomes. The P300 showed no differences between the low- and high-empathy conditions. These findings indicate that empathic concern could modulate the early stage of outcome processing, implying empathic emotional/altruistic motivational impacts of others' outcomes.

Breastfeeding and offspring's compassion and empathy in adulthood: A study with an over 30-year follow-up.

This study investigated whether breastfeeding predicts offspring's dispositional compassion and empathy from early adulthood to middle age. The parents of the participants (N = 1,394) of the Young Finns study answered questions about breastfeeding in 1983, and the participants' compassion and empathy were evaluated in 1997-2012 (participants were aged 20-50 years). Breastfeeding did not predict the course of compassion or empathy in adulthood at the age of 20-50 years. The associations remained non-significant, when adjusted for age, gender, socioeconomic factors, and a wide range of characteristics of the family environment (including mother's gestational age; premature birth; birth weight; number of other children at home; parental mental disorder; parental relationship status; parental postnatal smoking; parental postnatal alcohol use; parenting behavior; and child's externalizing behavior). In conclusion, breastfeeding seems not to predict offspring's compassion or empathy in adulthood. The findings may present a hopeful perspective for children growing up with non-breastfeeding caregivers.

Childhood Adversity, Socioeconomic Instability, Oxytocin-Receptor-Gene Methylation, and Romantic-Relationship Support Among Young African American Men.

Men's emerging adult romantic relationships forecast downstream relationship behavior, including commitment and quality. Accumulating evidence implicates methylation of the oxytocin-receptor-gene (OXTR) system in regulating relationship behavior. We tested hypotheses regarding the links between (a) childhood adversity and (b) socioeconomic instability in emerging adulthood on supportive romantic relationships via their associations with OXTR methylation. Hypotheses were tested using path analysis with data from 309 participants in the African American Men's Project. Consistent with our hypotheses, results showed that OXTR methylation proximally predicted changes in relationship support during a 1.5-year period. Childhood adversity was not directly associated with OXTR methylation but, rather, with contemporaneous socioeconomic instability, which in turn predicted elevated OXTR methylation. Findings suggest that early adversity is indirectly associated with OXTR methylation by links with downstream socioeconomic instability. Findings must be considered provisional, however, because preregistered replications are needed to establish more firmly the relations among these variables.

Increased similarity of neural responses to experienced and empathic distress in costly altruism.

Empathy-affective resonance with others' sensory or emotional experiences-is hypothesized to be an important precursor to altruism. However, it is not known whether real-world altruists' heightened empathy reflects true self-other mapping of multi-voxel neural response patterns. We investigated this relationship in adults who had engaged in extraordinarily costly real-world altruism: donating a kidney to a stranger. Altruists and controls completed fMRI testing while anticipating and experiencing pain, and watching as a stranger anticipated and experienced pain. Machine learning classifiers tested for shared representation between experienced and observed distress. Altruists exhibited more similar representations of experienced and observed fearful anticipation spontaneously and following an empathy prompt in anterior insula and anterior/middle cingulate cortex, respectively, suggesting heightened empathic proclivities and abilities for fear. During pain epochs, altruists were distinguished by spontaneous empathic responses in anterior insula, anterior/mid-cingulate cortex and supplementary motor area, but showed no difference from controls after the empathy prompt. These findings (1) link shared multi-voxel representations of the distress of self and others to real-world costly altruism, (2) reinforce distinctions between empathy for sensory states like pain and anticipatory affective states like fear, and (3) highlight the importance of differentiating between the proclivity and ability to empathize.

Empathy is hard work: People choose to avoid empathy because of its cognitive costs.

Empathy is considered a virtue, yet it fails in many situations, leading to a basic question: When given a choice, do people avoid empathy? And if so, why? Whereas past work has focused on material and emotional costs of empathy, here, we examined whether people experience empathy as cognitively taxing and costly, leading them to avoid it. We developed the empathy selection task, which uses free choices to assess the desire to empathize. Participants make a series of binary choices, selecting situations that lead them to engage in empathy or an alternative course of action. In each of 11 studies (N = 1,204) and a meta-analysis, we found a robust preference to avoid empathy, which was associated with perceptions of empathy as more effortful and aversive and less efficacious. Experimentally increasing empathy efficacy eliminated empathy avoidance, suggesting that cognitive costs directly cause empathy choice. When given the choice to share others' feelings, people act as if it is not worth the effort. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Gender differences in empathic responses to others' economic payoffs: an event-related potentials study.

Although gender differences in empathy have been well established through measuring subjective outcomes, some studies of the neural mechanisms of pain empathy have not found gender differences. This inconsistent evidence may be caused by different research methods or different paradigms. The present study adopted a different approach from the pain empathy paradigm to examine gender differences in empathic responses to others' economic payoffs using event-related potentials. The results showed that the N2 amplitudes in female participants were more negative than those in male participants, indicating a greater female than male susceptibility to facial expressions at the early stage of empathy. The LPP amplitudes for male participants were found to be more positive in the observation condition (involving no self-interest) than in the participation condition (involving self-interest), but there was no significant difference in the LPP amplitudes for the female participants between the two conditions. The results suggest that females' empathic responses are more likely to be elicited automatically by the perception of others' emotional states. In contrast, males' empathic responses are more likely to be mediated by self-interest, which subsequently reduces their empathic responses.

Assessment of Physician Well-being, Part One: Burnout and Other Negative States.

Physician well-being is a complex and multifactorial issue. A large number of tools have been developed in an attempt to measure the nature, severity, and impact of both burnout and well-being in a range of clinical populations. This two-article series provides a review of relevant tools and offers guidance to clinical mentors and researchers in choosing the appropriate instrument to suit their needs, whether assessing mentees or testing interventions in the research setting. Part One begins with a discussion of burnout and focuses on assessment tools to measure burnout and other negative states. Part Two of the series examines the assessment of well-being, coping skills, and other positive states.

Children's sympathy and sensitivity to excluding economically disadvantaged peers.

Economically disadvantaged children often lack the resources to purchase popular goods and participate in their preferred social groups' activities, making it difficult to fit in. Meanwhile, children from middle socioeconomic status (SES) families may have additional influence over whether low SES children are included in such groups. We examined how a middle SES sample of 333 4- and 8-year-olds felt and reasoned about excluding a child who is economically disadvantaged (i.e., a needy child) versus a child who attends another school (i.e., a less needy child). We also examined whether children's dispositional sympathy was associated with their negatively valenced moral emotions (NVMEs) after hypothetically excluding. Older children reported feeling more NVMEs for both targets of exclusion. Furthermore, unlike 4-year-olds, 8-year-olds differentiated between the targets of exclusion by reporting more NVMEs after excluding a child who is economically disadvantaged. Lastly, children's sympathy was positively associated with their NVMEs after excluding a child who is economically disadvantaged but not a child who attends another school. We conclude that with increasing sympathy and age, children likely become more sensitive to the needs of their disadvantaged peers-an effect with meaningful implications for improving peer relationships across socioeconomic spheres. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Prosocial behavior in aging: which factors can explain age-related differences in social-economic decision making?

OBJECTIVES: Older adults tend to exhibit more prosocial behavior than younger adults. However, little research has focused on understanding the factors that may explain such differences in the social decision-making process. The first aim was to examine if, and to what degree, the content of social information about a recipient has an impact on young vs. older adults' prosocial behavior. The second aim was to understand if empathic concern, Theory of Mind, and reasoning explain the (expected) age differences in prosociality. DESIGN: Cross-sectional study. SETTING: The study was conducted in northern Italy in a laboratory setting. PARTICIPANTS: Forty-eight younger adults (Mage = 23.29; SD = 2.20) and 48 older adults (Mage = 70.19; SD = 5.13). MEASUREMENTS: Prosocial behavior was measured using the Dictator Game in which participants split a sum of money with recipients presented with four levels of description: no information, physical description, positive psychological description, and negative psychological description. In addition, participants performed tasks on emphatic concern, Theory of Mind, and reasoning. RESULTS: Results showed that older adults are more prosocial than younger adults in the Dictator Game. This finding was evident when the recipient was described with positive psychological and physical features. This pattern of results was statistically explained by the reduction in reasoning ability. CONCLUSION: These findings suggest a relationship between age-related reduction in reasoning ability and older adults' prosocial behavior. The theoretical and practical implication of the empirical findings are discussed.

The development of children's preferences for equality and equity across 13 individualistic and collectivist cultures.

A concern for fairness is a fundamental and universal element of morality. To examine the extent to which cultural norms are integrated into fairness cognitions and influence social preferences regarding equality and equity, a large sample of children (N 2,163) aged 4-11 were tested in 13 diverse countries. Children participated in three versions of a third-party, contextualized distributive justice game between two hypothetical recipients differing in terms of wealth, merit, and empathy. Social decision-making in these games revealed universal age-related shifts from equality-based to equity-based distribution motivations across cultures. However, differences in levels of individualism and collectivism between the 13 countries predicted the age and extent to which children favor equity in each condition. Children from the most individualistic cultures endorsed equitable distributions to a greater degree than children from more collectivist cultures when recipients differed in regards to wealth and merit. However, in an empathy context where recipients differed in injury, children from the most collectivist cultures exhibited greater preferences to distribute resource equitably compared to children from more individualistic cultures. Children from the more individualistic cultures also favored equitable distributions at an earlier age than children from more collectivist cultures overall. These results demonstrate aspects of both cross-cultural similarity and divergence in the development of fairness preferences.

[The philosophical roots of "connectedness": The care clinic]. / Les racines philosophiques du « rester en lien ¼ : la clinique du souci.

If suicide remains "the only really serious philosophical problem" (A. Camus), historically a certain number of philosophers have legitimized it while others have condemned it. Among the philosophers who admitted that suicide could be a possibility, some showed understanding and others remained more modest. Kierkegaard's philosophical stance, demonstrating that one can never decide for the other where existential problems are concerned, opens a third way. Following him, Michel Cornu coined the expression "ethics of concern". That restlessness, etymologically, can be understood at the same time at the epistemological level (lack of a single constituted knowledge, hence the need to resort to a fully interdisciplinary approach of the "suicide" object), but as a relational attitude as well, namely a restlessness vis-à-vis the other, in other words concern for the other. This concept of concern does not exist in philosophical literature as such, but it has been addressed by philosophers. Therefore, it is essential to begin with a differential reflection on the notions of concern, care and solicitude. Then three "philosophies of solicitude" will be developed, those of Heidegger (concern in itself), Ricœur (concern as reciprocity) and Levinas (concern as responsibility). The monitoring devices, which will be widely discussed in other articles of this special issue, are based on philosophical notions borrowed from Heidegger (thoughtful solicitude), or Ricœur (solicitude) and Levinas (responsibility) or Cornu (ethics of concern). In addition, throughout our text we have mentioned a certain number of tensions inherent to these notions themselves, such as that intrinsic to the term solicitude (both care and concern), or peculiar to the authors' work (substitutive solicitude - thoughtful solicitude for Heidegger), or related to the debate of ideas (solicitude for Ricœur - responsibility for Levinas). Implementing these monitoring devices in clinical practice as well as in the territories will raise other problems, in particular, between benevolence and monitoring, but also between justice and equity, which will be our conclusion.

Physical symptom complaints, cognitive emotion regulation strategies, self-compassion and diabetes distress among adults with Type 2 diabetes.

AIMS: Diabetes-related distress is common among adults with Type 2 diabetes and is consistently associated with poorer self-management and treatment outcomes. However, little is known about the psychological factors that may contribute to or protect against diabetes distress. This study examined illness burden, and positive and negative ways of thinking and relating to oneself in times of stress, as independent correlates of diabetes distress, cross sectionally and longitudinally. METHOD: A total of 120 adults treated for Type 2 diabetes reported their physical symptom complaints, cognitive emotion regulation, self-compassion and diabetes distress at baseline; 110 completed a 3-month follow-up assessment of diabetes distress. Pearson correlations and multivariable linear regression tested baseline and longitudinal relationships. RESULTS: Baseline diabetes distress was associated with greater use of negative cognitive emotion regulation strategies (r = 0.43, P < 0.01), greater tendency towards self-criticism, self-judgement and over-identification (r = 0.37, P < 0.01), and greater physical symptom burden (r = 0.50, P < 0.01). Baseline physical symptoms and negative cognitive emotion regulation were independently associated with baseline diabetes distress. Baseline physical symptoms and negative aspects of self-compassion significantly predicted diabetes distress over 3 months. Positive aspects of cognitive emotion regulation and self-compassion were not independently associated with diabetes distress cross sectionally or longitudinally. CONCLUSION: Greater symptom burden along with the use of negative cognitive emotion regulation and negative aspects of self-compassion were independently associated with diabetes distress. If these relations are explained by causal influence, these modifiable factors could be fruitful targets for intervention research.

Empathy by default: Correlates in the brain at rest.

BACKGROUND: Empathy, defined as the ability to access and respond to the inner world of another person, is a multidimensional construct involving cognitive, emotional and self-regulatory mechanisms. Neuroimaging studies report that empathy recruits brain regions which are part of the social cognition network. Among the different resting state networks, the Default Mode Network (DMN) may be of particular interest for the study of empathy since it has been implicated in social cognition tasks. METHOD: The current study compared the cognitive and emotional empathy scores, as measured by the Interpersonal Reactivity Index, with the patterns of activation within the DMN, through the neuroimaging methodology of resting-state functional magnetic resonance. RESULTS: Results suggest a significant positive correlation between cognitive empathy and activation of the bilateral superior medial frontal cortex nodes of the DMN. Contrastingly, a negative correlation was found between emotional empathy and the same brain region. CONCLUSIONS: Overall, this data highlights a critical role of the medial cortical regions of the DMN, specifically its anterior node, for both cognitive and emotional domains of the empathic process.