Physicians' approach to end of life care: comparison of two tertiary care university hospitals in Lebanon.

BACKGROUND: The care of terminally ill patients is fraught with ethical and medical dilemmas carried by healthcare professionals. The present study aims to explore the approaches of Lebanese attending physicians towards palliative care, end of life (EOL) care, and patient management in two tertiary care university hospitals with distinct medical culture. METHODS: Four hundred attending physicians from the American University of Beirut Medical Center (AUBMC) and Hotel Dieu de France (HDF) were recruited. Participants were Medical Doctors in direct contact with adult patients that could be subject to EOL situations providing relevant demographic, educational, religious as well as personal, medical or patient-centric data. RESULTS: The majority of physicians in both establishments were previously exposed to life-limiting decisions but remains uncomfortable with the decision to stop or limit resuscitation. However, physicians with an American training (AUBMC) were significantly more likely to exhibit readiness to initiate and discuss DNR with patients (p<0.0001). While the paternalistic medicinal approach was prevalent in both groups, physicians with a European training (HDF) more often excluded patient involvement based on family preference (p<0.0001) or to spare them from a traumatic situation (p=0.003). The majority of respondents reported that previous directives from the patient were fundamental to life-limiting decisions. However, the influence of patient and medical factors (e.g. culture, religion, life expectancy, age, socioeconomic status) was evidenced in the HDF group. CONCLUSION: Early physician-initiated EOL discussions remain challenged in Lebanon. Paternalistic attitudes limit shared decision making and are most evident in European-trained physicians. Establishing a sound and effective framework providing legal, ethical and religious guidance is thus needed in Lebanon.

Compassion in the Clinical Context: Constrained, Distributed, and Adaptive.

BACKGROUND: Compassion is intrinsically situated within particular contexts and how these contexts can shape compassion has not been well-described. OBJECTIVE: The purpose of the study was to describe how individual and contextual challenges can impact compassion within critical care and palliative care settings. DESIGN: This qualitative study adopted phenomenology and autoethnography to inform data collection, and principles of activity theory and realist inquiry for data interpretation. PARTICIPANTS: Five clinicians who work in critical care (n = 3) and palliative care (n = 3) participated in the study. APPROACH: Qualitative data were obtained from ethnographic observations, interviews, and focus groups. Participants observed and recorded field notes (n = 53) on instances of suffering and compassion in their workplace settings. At the end of the study period, they participated in a focus group or individual interview to reflect on their experiences. Data was analyzed using constructivist grounded theory techniques and iteratively synthesized through group discussion and model building. KEY RESULTS: The findings reflected four phenomena associated with compassion in context: individual gaps and lapses in compassion, relational challenges, contextual constraints on compassion, and distributed compassion. Individual gaps and lapses in compassion involved inattention, intention vs. perception, personal capacity, and personal toll. Relational challenges included receptivity, fragmentation, and lack of shared understanding. Contextual constraints consisted of situational pressures, the clinical environment, gaps in education, and organizational culture. The distribution of compassion within teams and how teams adapt their behaviors in response to perceived needs for greater compassion modulated these challenges. CONCLUSIONS: The study illustrates the many ways in which compassion can be shaped by context and highlights the role of teamwork in identifying gaps and lapses in compassion and responding in a way that supports patients, families, and colleagues.

Time Pressure During Primary Care Office Visits: a Prospective Evaluation of Data from the Healthy Work Place Study.

BACKGROUND: The relationship between worklife factors, clinician outcomes, and time pressure during office visits is unclear. OBJECTIVE: To quantify associations between time pressure, workplace characteristics ,and clinician outcomes. DESIGN: Prospective analysis of data from the Healthy Work Place randomized trial. PARTICIPANTS: 168 physicians and advanced practice clinicians in 34 primary care practices in Upper Midwest and East Coast. MAIN MEASURES AND METHODS: Time pressure was present when clinicians needed more time than allotted to provide quality care. Other metrics included work control, work pace (calm to chaotic), organizational culture and clinician satisfaction, stress, burnout, and intent to leave the practice. Hierarchical analysis assessed relationships between time pressure, organizational characteristics, and clinician outcomes. Adjusted differences between clinicians with and without time pressure were expressed as effect sizes (ESs). KEY RESULTS: Sixty-seven percent of clinicians needed more time for new patients and 53% needed additional time for follow-up appointments. Time pressure in new patient visits was more prevalent in general internists than in family physicians (74% vs 55%, p < 0.05), women versus men (78% vs 55%, p < 0.01), and clinicians with larger numbers of complex psychosocial (81% vs 59%, p < 0.01) and Limited English Proficiency patients (95% vs 57%, p < 0.001). Time pressure in new patient visits was associated with lack of control, clinician stress, and intent to leave (ESs small to moderate, p < 0.05). Time pressure in follow-up visits was associated with chaotic workplaces and burnout (small to moderate ESs, p's < 0.05). Time pressure improved over time in workplaces with values alignment and an emphasis on quality. CONCLUSIONS: Time pressure, more common in women and general internists, was related to chaos, control and culture, and stress, burnout, and intent to leave. Future studies should evaluate these findings in larger and more geographically diverse samples.

Eliminating Gender-Based Bias in Academic Medicine: More Than Naming the "Elephant in the Room".

Gender-based discrimination and bias are widespread in professional settings, including academic medicine. Overt manifestations such as sexual harassment have long been identified but attention is only more recently turning towards subtler forms of bias, including inequity in promotion and compensation. Barriers to progress vary across institutions and include lack of awareness, inadequate training, poor informational transparency, and challenging power dynamics. We propose five solutions that the academic medical community can adopt to not only name, but also address, gender-based bias as the proverbial elephant in the room: definitively identify the systemic nature of the problem, prompt those with influence and power to advance a culture of equity, broadly incorporate evidence-based explicit anti-sexist training, increase transparency of information related to professional development and compensation, and use robust research methods to study the drivers and potential solutions of gender inequity within academic medicine. While implementing these proposals is no small task, doing so is an important step in helping the academic medical community become more just.

Colorado Medical Students' Attitudes and Beliefs About Marijuana.

BACKGROUND: Over the past two decades, state and local governments across the U.S. have been increasingly reforming marijuana laws. Despite growing support for marijuana as a medical treatment, little is known about medical students' perceptions of marijuana use. OBJECTIVE: To assess Colorado medical students' personal and professional opinions on current and future marijuana use in a healthcare setting. DESIGN: A voluntary, anonymous, online cross-sectional survey. PARTICIPANTS: Medical students (n = 624) at the University of Colorado School of Medicine between January and February 2014 were invited to participate. MAIN MEASURES: Numerical responses were quantified using counts and percentages, and Likert scale responses were collapsed for bivariate analysis. Items were gathered thematically and additively scored for each subscale. Internal consistency reliability statistics were calculated for each subscale to ensure that items were assessing similar constructs. Unadjusted t tests and one-way analysis of variance (ANOVA) were used to calculate mean differences in subscale scores between subgroups. KEY RESULTS: We received 236 responses (37%). Students indicated support for marijuana legalization (64%), and few believed that physicians should be penalized for recommending marijuana to patients (6%). Nearly all (97%) believed that further marijuana research should be conducted, and believed marijuana could play a role in the treatment of various medical conditions. Seventy-seven percent reported that they believed marijuana use had the potential for psychological harm, and 68% indicated concern for potential physical harm. Only a minority of students would recommend marijuana to a patient under current law (29%), or if it were legally available (45%). Acceptability of marijuana for treatment of approved conditions was not correlated with age or gender, but was positively correlated with living in Colorado prior to medical school (p < 0.001) and with prior marijuana use (p < 0.001). CONCLUSIONS: Medical students support marijuana legal reform, medicinal uses of marijuana, and increased research, but have concerns regarding risks of marijuana use, and appear hesitant to recommend marijuana to patients.

Medicine: in need of culture change.

Compared with other health professionals and the general population, doctors and medical students reported higher rates of psychological distress, burnout, diagnosed mental illness, suicidal ideation and attempted suicide. Where possible, the problematic and unnecessarily stressful aspects of working as a doctor must be improved. Collectively, we must change the often toxic culture of medicine into a culture that promotes a nurturing and supportive approach to teaching and supervision. The goal should be to develop medical practices that facilitate well-being and quality of life, where sustainable medical careers can develop and better serve the community.

The experiences of students with mental health difficulties at medical school: a qualitative interview study.

BACKGROUND: High rates of burnout, anxiety, and depression in medical students are widespread, yet we have limited knowledge of the medical school experiences of students with mental health issues. The aim of the study is to understand the impact of mental health issues on students' experience and training at medical school by adopting a qualitative approach. METHODS: Qualitative study using in-depth semi-structured interviews with 20 students with mental health issues from eight UK medical schools of varying size and location. Students were purposefully sampled to gain variety in the type of mental health issue experienced and demographic characteristics. Reflexive thematic analysis was employed using NVivo software. RESULTS: Three themes were identified. 1) Culture of medicine: medical culture contributed to causing mental ill-health through study demands, competitiveness with peers, a 'suck it up' mentality where the expectation is that medical school is tough and medical students must push through, and stigma towards mental ill-health. 2) Help-seeking: students feared others discovering their difficulties and thus initially tried to cope alone, hiding symptoms until they were severe. There were multiple barriers to help-seeking including stigma and fear of damage to their career. 3) Impact on academic life: mental health issues had a detrimental impact on academic commitments, with students' unable to keep up with their studies and some needing to take time out from medical school. CONCLUSION: This study provides insight into how medical culture contributes both to the cause of mental health difficulties and the reluctance of medical students to seek help. Mental health issues had a considerable negative impact on medical students' ability to learn and progress through their degree. Addressing the medical culture factors that contribute to the cause of mental health issues and the barriers to help-seeking must be a priority to ensure a healthier medical workforce.

Medical History in Canadian Undergraduate Medical Education, 1939-2012.

The virtues of learning medical history for medical students have long been argued. Surveys of Canadian medical schools were done in 1939, 1968, and 1999 to discover details about the inclusion of medical history in undergraduate medical education (UME). In 2012, we completed our own survey. While medical history is more commonly included in the core UME curriculum now than in the past, half of Canada's schools still do not require it. An analysis of trends over time reveals the central importance of longstanding and emergent prejudices and cultural influences as barriers to more widespread inclusion of medical history.

The power of connected clinical teams: from loneliness to belonging.

BACKGROUND: We need to preserve the lessons of the COVID-19 pandemic in caring for the mental health of clinicians, of shared experiences, interdependence, team cohesion and vulnerability, among others. We need reform in the way that clinicians are cared for, and a resistance to the idea of a post-pandemic 'return to normal'. MAIN TEXT: To build connected and optimally functioning clinical teams, we need to create an inclusive culture in which difficult conversations and caring are the expectation. If we are to be better at solving problems and better at serving our patients, we should be vigilant about creating a psychologically safe medical culture in which colleagues feel safe, seen, heard, and respected. CONCLUSION: Going forward, each of us, regardless of seniority, needs to take responsibility for this culture change. We need to create and participate in weekly collegial peer support sessions that feel nurturing and safe, that allow us to reveal parts of ourselves, to be vulnerable with each other in a way that reduces loneliness, and encourages and maintains social connections and a sense of belonging within clinical teams, improves clinician well-being and reduces the risk of burnout. "Care is a practice of informed responsive actions on behalf of the one cared for and authentically aimed toward their growth and flourishing." Care Ethics in the Age of Precarity; Maurice Hamington and Michael Flower.

Lifestyle Medicine: Overcoming Systemic and Cultural Barriers to Better, More Affordable Care.

The 6 pillars of lifestyle medicine have strong scientific backing and plenty of supportive evidence to validate their integration into routine clinical practice. However, two barriers stand in the way of their widespread adoption: the system of healthcare and the culture of medicine. This article describes changes necessary to overcome these systemic and cultural obstacles and outlines steps necessary to achieve what traditional healthcare has so-far failed to deliver: higher quality, lower costs, and greater access to care.

Decision-making and Poor Prognosis: When Death is Silenced by Action.

In the hospital milieu, daily questions relate to highly invested areas such as quality of life and death issues, choices to continue or stop active treatment, and the legitimacy of those who take part in such decisions. Stemming from an ethnographic study carried out in a hematology-oncology transplant unit in a Montreal pediatric hospital, we discuss the decision-making process (or lack thereof) when a patient faces poor prognosis and the change of trajectory from a curative/disease directed to a palliative perspective. The intricate relationship between science, caregiver, and care receiver sustains action even when (near) death is the probable outcome.

Voices from the Front Lines: An Analysis of Physicians' Reflective Narratives about Flaws with the 'System'.

Physicians often express frustration with the 'system' in which they work. Over time, this frustration may put them at risk of burnout and disengagement, which may impact patient care. In this study, we aimed to understand the nature of the system flaws that physicians identified in their published narratives and to explore their self-representation as agents of change. We reviewed all reflective narratives published in four medical journals (NEJM, JAMA, CMAJ, Annals IM) between January 2015 and December 2017 (n = 282). By consensus, we identified those that addressed system flaws (n = 87). Using content and narrative analysis, we analyzed the types of flaws and the physicians' orientation to the flawed system. We identified seven recurring system flaws-five related to medical culture: failures of communication, erosive impact of the hidden curriculum, inadequate health advocacy, frenzied pace of work, and experience of stigma. Less frequently, physicians' narratives also exposed limited and disparate healthcare resources and restrictive institutional practices as impeding patient-centered care. Physicians expressed agency to create change foremost when writing about flaws related to medical culture. While physicians are challenged by system flaws, they strive to practice in ways that do not succumb to them. We saw tension between the elements outside the physician's control and those within it. This tension becomes a source of distress when the compromises that emerge from system flaws move physicians away from the values that define their professional identity.

Negotiating uncertainty in clinical encounters: A narrative exploration of naturally occurring primary care consultations.

Based on a narrative analysis of 20 naturally occurring clinical consultations between general practitioners and patients in England, sourced from the One in a million data archive, we explore how they conceptualize and negotiate medical and existential uncertainty. To capture the interactional element, which is often overlooked, three consultations receive special attention. While exploring the ongoing dynamics of the moment-to-moment realization of negotiations, we relate their actions to the institutionalized positions of doctor and patient. Situating their negotiations in the sociocultural context in which their interaction is embedded reveals how consultations unfold as a result of communication between two different positions in a normatively structured system. When uncertainty prevails, both patients and GPs mainly conceptualize uncertainty indirectly. By conceptualizing uncertainty indirectly and in a depersonalized manner, GPs manage to safeguard against clinical errors without compromising their authority and credibility. Contrary to medical uncertainty, which is continuously discussed, existential uncertainty usually recedes in the background. However, as our consultations unfold it becomes evident that medical and existential dimensions of uncertainty are inextricably linked. By acknowledging that clinical uncertainty is not only an epistemic concern but also an existential one, existential aspects may usefully rise to the surface.

Views of medical practitioners about deprescribing in older adults: Findings from an Italian qualitative study.

BACKGROUND: Even though increasing attention is given to deprescribing owing to the risks related to polypharmacy in older adults, deprescribing is not yet part of clinical culture. METHODS: We conducted three focus groups with 25 internists, geriatricians and general practitioners to explore the factors influencing the implementation of deprescribing in the Italian context, and more specifically: i. to investigate the barriers to deprescribing; ii. to define strategies and actions to address these barriers; and iii. to identify skills and tools that may assist in implementing deprescribing in clinical practice. Thematic analysis was used. RESULTS: Six themes were identified: Good reasons for deprescribing, Difficulties and doubts about deprescribing, System factors affecting polypharmacy and deprescribing, Perspectives on how to practically approach polypharmacy, Need for effective communication with patients and caregivers, Taking responsibility and starting action. Participants reported a willingness to challenge themselves by addressing the barriers to deprescribing through regular review of prescriptions and collaboration with colleagues and patients. CONCLUSIONS: Italian internists, geriatricians and general practitioners reported many system-level barriers to deprescribing as well as some doubts about its necessity. Strategies to address the barriers to deprescribing include regular medication review and enhancing collaboration with colleagues and patients. Additionally, participants were willing to challenge themselves and use uncertainty as an impetus for deprescribing.

Perfectionism, impostor phenomenon, and mental health in medicine: a literature review.

OBJECTIVES: The aims of this review, focused on medical students, residents, and physicians, were a) to determine the levels of perfectionism and prevalence of impostor phenomenon, b) to assess the relationship between perfectionism, impostor phenomenon, and mental health, and c) explore how medical culture may influence these personality characteristics. METHODS: A narrative literature review was conducted. Search terms were entered into PubMed, PsychINFO, Web of Science, EMBASE, and Google Scholar without date or geographic restrictions. The McMaster Critical Review Forms for Quantitative and Qualitative Studies were used for article appraisal. Final decisions on inclusion and exclusion were reached through discussion. Sixteen articles were included in this review and summarized in a data extraction table. RESULTS: Medical students had similar perfectionism scores to other student groups but scored lower in maladaptive perfectionism. The overall prevalence of the impostor phenomenon ranged from 22.5% to 46.6%. More females (41% - 52%) experienced clinical levels of impostor phenomenon compared to males (23.7% - 48%). Most studies did not find an association between the impostor phenomenon and academic year of training. Both personality characteristics were associated with negative mental health effects. Medical culture can train for and/or exacerbate these characteristics, affecting professional identity formation. Both characteristics contribute to distress for learners during commonly-used teaching methods in medical education. CONCLUSIONS: Comprehensive changes in medical education that consider the relationship between medical culture, professional identity formation, impostor phenomenon, and perfectionism are needed. Longitudinal studies will help identify the implications of these findings for professional identity formation and medical education.

Understanding the Barriers to Introducing Early Palliative Care for Patients with Advanced Cancer: A Qualitative Study.

Background: Palliative care is often underutilized or initiated late in the course of life-threatening illness. Randomized clinical Early Palliative Care (EPC) trials provide an opportunity for changing oncologists' perceptions of palliative care and their attitudes to referring patients to palliative care services. Aim: To describe French oncologists' perceptions of EPC and their effects on referral practices before a clinical EPC trial was launched. Design: A qualitative study involving semistructured face-to-face interviews. The data were analyzed using the Grounded Theory coding method. Setting/Participants: Thirteen oncologists and 19 palliative care specialists (PCSs) working at 10 hospitals all over France were interviewed. Most of them were involved in clinical EPC trials. Results: The findings suggest that referral to PCSs shortly after the diagnosis of advanced cancer increases the terminological barriers, induces avoidance patterns, and makes early disclosure of poor prognosis harder for oncologists. This situation is attributable to the widespread idea that palliative care means terminal care. In addition, the fact that the EPC concept is poorly understood increases the confusion between EPC and supportive care. Conclusion: Defining the EPC concept more clearly and explaining to health professionals and patients what EPC consists of and what role it is intended to play, and the potential benefits of palliative care services could help to overcome the wording barriers rooted in the traditional picture of palliative care. In addition, training French oncologists how to disclose "bad news" could help them cope with the emotional issues involved in referring patients to specialized palliative care.

Third Things as Inspiration and Artifact: A Multi-Stakeholder Qualitative Approach to Understand Patient and Family Emotions after Harmful Events.

Patient and family emotional harm after medical errors may be profound. At an Agency for Healthcare Research and Quality (AHRQ) conference to establish a research agenda on this topic, the authors used visual images as a gateway to personal reflections among diverse stakeholders. Themes identified included chaos and turmoil, profound isolation, organizational denial, moral injury and betrayal, negative effects on families and communities, importance of relational skills, and healing effects of human connection. The exercise invited storytelling, enabled psychological safety, and fostered further collaborative discussion. The authors discuss implications for quality/safety, educational innovation, and qualitative research.

Homing in on the Social: System-Level Influences on Overly Aggressive Treatments at the End of Life.

CONTEXT: The American Medical System is programmed to a default setting of aggressive care for the terminally ill. Institutional norms of decision making have been shown to promote high-intensity care, regardless of consistency with patient preferences. There are myriad factors at a system, clinician, surrogate, and patient level that drive the culture of overly aggressive treatments in American hospitals. OBJECTIVE: The objective of this study was to understand physician perspective of the ways systems-level factors influence patient, physician, and surrogate perceptions and consequent behavior. METHODS: Semi-structured in-depth qualitative interviews with 42 internal medicine physicians across three American academic medical centers were conducted. This qualitative study was exploratory in nature, intended to enhance conceptual understanding of underlying phenomena that drive physician attitudes and behavior. RESULTS: The interviews revealed many factors that contributed to overly aggressive treatments at the end of life. Systemic factors, which describe underlying cultures (including institutional, professional, or community-based cultures), typical practices of care, or systemic defaults that drive patterns of care, manifested its influence both directly and through its impact on patient, surrogate, and physician behaviors and attitudes. CONCLUSION: Institutional cultures, social norms, and systemic defaults influence both normative beliefs regarding standards of care and treatments plans that may not benefit seriously ill patients.

A multimodal high-value curriculum affects drivers of utilization and performance on the high-value care component of the internal medicine in-training exam.

Background: Teaching the practice of high-value care (HVC) is an increasingly important function of graduate medical education but best practices and long-term outcomes remain unknown. Objective: Whether a multimodal curriculum designed to address specific drivers of low-value care would affect resident attitudes, skills, and performance of HVC as tested by the Internal Medicine In-Training Exam (ITE). Methods: In 2012, we performed a baseline needs assessment among internal medicine residents at a community program regarding drivers of healthcare utilization. We then created a multimodal curriculum with online interactive worksheets, lectures, and faculty buy-in to target specific skills, knowledge, and culture deficiencies. Perceived drivers of care and performance on the Internal Medicine ITE were assessed yearly through 2016. Results: Fourteen of 27 (52%) residents completed the initial needs assessment while the curriculum was eventually seen by at least 24 of 27 (89%). The ITE was taken by every resident every year. Long-term, 3-year follow-up demonstrated persistent improvement in many drivers of utilization (patient requests, reliance on subspecialists, defensive medicine, and academic curiosity) and improvement with sustained high performance on the high-value component of the ITE. Conclusion: A multimodal curriculum targeting specific drivers of low-value care can change culture and lead to sustained improvement in the practice of HVC.

Patient empowerment: A critique of individualism and systematic review of patient perspectives.

OBJECTIVE: The purpose of this review is two-fold: 1) to broaden conceptualization of patient empowerment by synthesizing qualitative research on patient perspectives, and 2) to examine how researcher's method and background may have affected their framing of patient empowerment, thereby shaping the results. METHODS: A systematic search for qualitative research on patient definitions of power, powerlessness, and empowerment was completed. Articles were analyzed at three levels (theory, method, and data) as suggested by the meta-study method for qualitative synthesis. RESULTS: The search yielded 13 articles from 11 investigator teams across 9 countries (the United Kingdom, Norway, Australia, Taiwan, New Zealand, China, Iran, Belgium and Italy). Emergent themes from patient perspectives included control, psychological coping, legitimacy, support, knowledge, and participation. CONCLUSIONS: Despite variation in diagnosis, age, ethnicity, income and country of origin, patients share many perspectives on empowerment. Furthermore, there are indications that interview questions may have influenced findings such that structural barriers to empowerment were not deeply explored. PRACTICE IMPLICATIONS: This review provides knowledge that can be of direct use to medical professionals who aim to increase patient empowerment (via findings on patient perspectives) and to researchers who can use the critical appraisal of past work to improve future research on this topic.