Beyond empathy decline: Do the barriers to compassion change across medical training?

BACKGROUND: Despite being a mandated, foundational value in healthcare, research on compassion remains limited. Studying the individual, patient, clinical, and contextual factors that interfere with compassion-the "barriers"-may clarify our understanding of the origins of compassion and identify potential targets for improving patient-centred care. Studies of the related construct of empathy have suggested that medical students report declines with increasing clinical experience. In contrast, when comparing physicians with medical students, increased clinical experience predicts lower barriers to compassion. Whether-and how-a similar experience-related decline in the factors that interfere with compassion occurs across medical training remains unknown. AIMS: To describe how the barriers to compassion vary across clinical training in medical students. METHOD: New Zealand medical students (N = 351) in their clinical years (Years 4-6) completed measures of the Barriers to Physician Compassion (BPCQ) and potential covariates such as demographics, work burden factors, and dispositional factors. The BPCQ indexes the extent to which barriers in four domains (individual, patient, clinical, and contextual) interfere with a physician/student's compassion towards patients. Analyses of variance and regression analyses were used to explore the effect of year level on the four types of barriers. RESULTS: Year 4 students reported slightly lower student-related, environmental and patient/family-related (but not clinical) barriers than Year 6 students (effect size: É·2 < 0.05); all barriers increased comparably across training. Controlling for relevant confounds, regression analyses confirmed that lower year level predicted lower barriers to compassion. Higher self-compassion, but not gender, predicted lower barriers. CONCLUSIONS: In extending studies of empathy decline, this report suggests that students experience higher barriers to compassion as clinical training progresses. This is in contrast to existing studies contrasting physicians with medical students, where greater experience was associated with lower perceived barriers to compassion. Self-compassion may offset increases in barriers to care.

Forensic Evaluation of Sexsomnia.

Sexsomnia is a non-rapid eye movement parasomnic behavior characterized by sexual activity during sleep. Recognized in the most recent editions of the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Sleep Disorders, sexsomnia is likely to arise with increasing frequency in court as a potential explanation for sexual offending. The forensic psychiatrist has a unique role in the evaluation and management of sexsomnia. The psychosexual evaluation may elucidate the presence or absence of paraphilias and paraphilic disorders and identify any overlap between the alleged sexsomnic behavior and paraphilic interest. In addition, forensic psychiatrists may assess for malingered sexsomnia, provide an opinion regarding criminal responsibility, or evaluate the risk for committing future sexual offenses. Forensic psychiatrists should therefore understand basic information regarding the disorder, as well as how to conduct a psychosexual evaluation effectively in cases of alleged sexsomnia. This article describes the various considerations involved in the forensic evaluation of sexsomnia.

Self-compassion as a Stress Moderator: A Cross-sectional Study of 1700 Doctors, Nurses, and Medical Students.

OBJECTIVES: Work stress is common in healthcare and reliably predicts negative outcomes, including burnout and lower quality of life (QOL). However, few studies have investigated factors that might attenuate the impact of stress on these negative outcomes. We investigated whether the tendency to be kind to the self during times of difficulty-self-compassion-might buffer the effect of work stress on outcomes. METHODS: Registered nurses (n = 801), physicians (n = 516), and medical students (n = 383) were recruited using convenience sampling in New Zealand. Following consent, participants (N = 1700) completed a survey including the Copenhagen Burnout Inventory, Satisfaction with Life Scale, and Self-Compassion Scale-Short Form. RESULTS: Across groups, greater work stress consistently predicted greater burnout and lower QOL, while greater self-compassion predicted lower burnout and better QOL. Self-compassion moderated the relationship between stress and burnout in nurses (albeit in the opposite direction to what had been predicted), but not in doctors or medical students. CONCLUSIONS: While self-compassion predicted better outcomes (and may thus represent a target to enhance wellbeing), it strengthened the association between stress and burnout in nurses. How self-compassion impacts the experience of stress and its correlates and why it does so differently in different groups of professionals remains unclear.

How Do Health Professionals Maintain Compassion Over Time? Insights From a Study of Compassion in Health.

Although compassion in healthcare differs in important ways from compassion in everyday life, it provides a key, applied microcosm in which the science of compassion can be applied. Compassion is among the most important virtues in medicine, expected from medical professionals and anticipated by patients. Yet, despite evidence of its centrality to effective clinical care, research has focused on compassion fatigue or barriers to compassion and neglected to study the fact that most healthcare professionals maintain compassion for their patients. In contributing to this understudied area, the present report provides an exploratory investigation into how healthcare professionals report trying to maintain compassion. In the study, 151 professionals were asked questions about how they maintained compassion for their patients. Text responses were coded, with a complex mixture of internal vs. external, self vs. patient, and immediate vs. general strategies being reported. Exploratory analyses revealed reliable individual differences in the tendency to report strategies of particular types but no consistent age-related differences between older and younger practitioners emerged. Overall, these data suggest that while a range of compassion-maintaining strategies were reported, strategies were typically concentrated in particular areas and most professionals seek to maintain care using internal strategies. A preliminary typology of compassion maintaining strategies is proposed, study limitations and future directions are discussed, and implications for the study of how compassion is maintained are considered.

Variation in the barriers to compassion across healthcare training and disciplines: A cross-sectional study of doctors, nurses, and medical students.

BACKGROUND: Despite the established importance of compassion in health, studies examining the specific barriers to compassionate care in healthcare are few. Recent work suggests that examining differences as a function of professional development and identifying variation in barriers to compassionate care across professions may highlight the origins of barriers and inform the development of compassion-enhancing interventions suited to the unique challenges of different professions and stages of training. OBJECTIVES: To explore whether the barriers to compassion vary (a) between physicians and nurses and (b) across samples of physicians and medical students (i.e., as a function of development and clinical experience). It was expected that medical students would report greater barriers than physicians and that nurses would generally report lower barriers to compassion, other than for external barriers. METHODS: Registered nurses, physicians, and medical students were recruited using convenience sampling in New Zealand. Following consent, 1700 participants (801 nurses, 516 physicians, and 383 medical students) completed a survey including the Copenhagen Burnout Inventory and the Barriers to Physician Compassion questionnaire. RESULTS: As expected, medical students reported greater barriers to compassion than physicians and nurses, with both professions generally reporting lower barriers. However, and also consistent with hypotheses, nurses reported greater work-environment-related barriers relative to physicians. DISCUSSION: Students reported greater barriers than physicians. While nurses generally reported lower barriers than physicians, they specifically reported greater work environment-related barriers. For nurses, results highlight the importance of implementing interventions that reduce external barriers to compassion, specifically the need to alleviate the structural barriers and restrictions that nurses face. For medical students and younger healthcare professionals, the results highlight the importance of mentorship, support, and ongoing professional and emotional development.

Does self-compassion mitigate the relationship between burnout and barriers to compassion? A cross-sectional quantitative study of 799 nurses.

BACKGROUND: Burnout has numerous negative consequences for nurses, potentially impairing their ability to deliver compassionate patient care. However, the association between burnout and compassion and, more specifically, barriers to compassion in medicine is unclear. This article evaluates the associations between burnout and barriers to compassion and examines whether dispositional self-compassion might mitigate this association. HYPOTHESIS: Consistent with prior work, the authors expected greater burnout to predict greater barriers to compassion. We also expected self-compassion - the ability to be kind to the self during times of distress - to weaken the association between burnout and barriers to compassion among nurses. METHODS: Registered nurses working in New Zealand medical contexts were recruited using non-random convenience sampling. Following consent, 799 valid participants completed a cross-sectional survey including the Copenhagen Burnout Inventory, the Barriers to Physician Compassion scale, and a measure of dispositional self-compassion. RESULTS: As expected, greater burnout predicted greater barriers to compassion while self-compassion predicted fewer barriers. However, self-compassion mitigated the association between burnout and burnout related barriers to compassion (but not other barriers). The interaction suggested that suggested that the association was stronger (rather than weaker) among those with greater self-compassion. DISCUSSION: Understanding the lack of compassion and the effects of burnout in patient care are priorities in health. This report extends evidence on the association between burnout and compassion-fatigue to show that burnout also predicts the experience of specific barriers to compassion. While self-compassion predicted lower burnout and barriers, it may not necessarily reduce the extent to which burnout contributes to the experience of barriers to compassion in medicine. Implications for understanding how burnout manifests in barriers to clinical compassion, interventions and professional training, and future directions in nursing are discussed.

Barriers to Medical Compassion as a Function of Experience and Specialization: Psychiatry, Pediatrics, Internal Medicine, Surgery, and General Practice.

CONTEXT: Compassion is an expectation of patients, regulatory bodies, and physicians themselves. Most research has, however, studied compassion fatigue rather than compassion itself and has concentrated on the role of the physician. The Transactional Model of Physician Compassion suggests that physician, patient, external environment, and clinical factors are all relevant. Because these factors vary both across different specialities and among physicians with differing degrees of experience, barriers to compassion are also likely to vary. OBJECTIVES: We describe barriers to physician compassion as a function of specialization (psychiatry, general practice, surgery, internal medicine, and pediatrics) and physician experience. METHODS: We used a cross-sectional study using demographic data, specialization, practice parameters, and the Barriers to Physician Compassion Questionnaire. Nonrandom convenience sampling was used to recruit 580 doctors, of whom 444 belonged to the targeted speciality groups. The sample was characterized before conducting a factorial Multivariate Analysis of Covariance and further post hoc analyses. RESULTS: A 5 (speciality grouping) × 2 (more vs. less physician experience) Multivariate Analysis of Covariance showed that the barriers varied as a function of both speciality and experience. In general, psychiatrists reported lower barriers, whereas general practitioners and internal medicine specialists generally reported greater barriers. Barriers were generally greater among less experienced doctors. CONCLUSION: Documenting and investigating barriers to compassion in different speciality groups have the potential to broaden current foci beyond the physician and inform interventions aimed at enhancing medical compassion. In addition, certain aspects of the training or practice of psychiatry that enhance compassion may mitigate barriers to compassion in other specialities.

Computer Assisted Learning for the Mind (CALM): the mental health of medical students and their use of a self-help website.

AIMS: The aim of this study was to develop an evidence-based self-help website, Computer Assisted Learning for the Mind (CALM) designed to improve mental health amongst medical students; and to assess the proportion, demographics and mental health of students who chose to use the site. METHODS: All 2nd and 3rd year medical students from one New Zealand university were invited to participate. Demographics and mental health scores of those accessing CALM were compared with those not accessing it. Outcome measures included depression (PHQ-9) and anxiety (GADS-7) scores recorded at baseline. Anonymous identifiers were used to track website use. RESULTS: Baseline questionnaires were completed by 279/321 (87%) of eligible students. CALM was accessed by 80/321 (25%) of the students over a 5 week period. Those who accessed CALM and could be linked by unique identifier (n=49) had significantly higher anxiety scores (p=0.01) but not higher depression scores (p=0.067) at baseline, than those who did not access CALM (n=230). Of those students with both PHQ-9 scores and GAD-7 scores =10 (at risk of significant depression and anxiety) at baseline, 41% went on to access CALM. CONCLUSIONS: The CALM website was used by 25% of medical students, particularly those with poorer anxiety scores. Self-selection to a web-based resource may provide assistance to those most in need, but further research would be needed to assess effectiveness.

Sleep disorders, depression, anxiety and satisfaction with life among young adults: a survey of university students in Auckland, New Zealand.

AIM: Sleep symptoms, depression and anxiety often coexist and tertiary students are a population group that are increasingly recognised to be at risk. However the rates of these conditions in the New Zealand population are poorly understood. The aim of this study was to determine the rates of sleep disorders, depression and anxiety, and identify correlations between satisfactions with life among university students in Auckland. METHOD: Auckland Sleep Questionnaire (ASQ) was administered to undergraduate students from six schools of The University of Auckland. The different types of sleep disorders were calculated for the students who reported a significant sleep problem lasting more than 1 month. The rate of depression, anxiety and substance use as well as the satisfaction with life scale scores were also calculated for the whole cohort. RESULTS: A total of 1933 students were invited to participate and 66.8% completed the questionnaire. The median age was 20 years (range 16-38) and women represented 63.9% of the total group. A total of 39.4% of the students surveyed reported having significant sleep symptoms lasting longer than 1 month. The most prevalent causes for sleep symptoms were depression and anxiety. Delayed sleep phase disorder was found in 24.9% of students and parasomnias were reported by 12.4%. Depression and anxiety were present in 17.3% and 19.7% of the total group respectively, and 7.3% of students had thoughts of "being better off dead" or self-harm. A total of 15.5% students were found to have a CAGE score greater than or equal to 2 and 9.3% reported using recreational drugs in the last 3 months. Moderate negative correlations between SWLS scores and depression and anxiety were found (r=-0.45 and r=-0.37 respectively). CONCLUSION: A large number of university students are suffering from significant sleep symptoms. Mood disorders, substance use, and circadian rhythm disorders can greatly contribute to sleep difficulties in this population group. The study also showed that harmful alcohol and drug use was common among this population group and is associated with clinically significant depression and anxiety. Accurate diagnosis using defined criteria will enable effective treatment for these conditions that impact greatly on the quality of life.

Development and initial psychometric properties of the Barriers to Physician Compassion questionnaire.

OBJECTIVE: Physicians are expected to be compassionate. However, most compassion research focuses on compassion fatigue--an outcome variable--rather than examining the specific factors that may interfere with compassion in a physician's practice. This report describes the development and early psychometric data for a self-report questionnaire assessing barriers to compassion among physicians. METHODS: In 2011, a pilot sample of 75 physicians helped to generate an initial list of barriers to compassion. A final 34 item Barriers to Physician Compassion (BPC) questionnaire was administered to 372 convenience-sampled physicians together with measures of demographics, practice-related variables, stress, locus of control and trait compassion. RESULTS: The barriers to physician compassion were not one-dimensional. Principal component analysis revealed the presence of four distinct, face-valid and discriminable factors--physician burnout/overload, external distractions, difficult patient/family and complex clinical situation. All barrier components had adequate internal reliabilities (>0.70) and meaningful patterns of convergent and divergent validity. CONCLUSIONS: Remaining compassionate in medical practice is difficult. With the newly developed BPC questionnaire, specific barriers to compassion can be assessed. These barriers illuminate potential targets for future self- and practice management, interventions and compassion training among physicians.

Beyond compassion fatigue: the transactional model of physician compassion.

Physician compassion is expected by both patients and the medical profession and is central to effective clinical practice. Yet, despite the centrality of compassion to medical practice, most compassion-related research has focused on compassion fatigue, a specific type of burnout among health providers. Although such research has highlighted the phenomenon among clinicians, the focus on compassion fatigue has neglected the study of compassion itself. In this article, we present the Transactional Model of Physician Compassion. After briefly critiquing the utility of the compassion fatigue concept, we offer a view in which physician compassion stems from the dynamic but interrelated influences of physician, patient and family, clinical situation, and environmental factors. Illuminating the specific aspects of physicians' intrapersonal, interpersonal, clinical, and professional functioning that may interfere with or enhance compassion allows for targeted interventions to promote compassion in both education and practice as well as to reduce the barriers that impede it.

Sleep disorders among high school students in New Zealand.

INTRODUCTION: Adolescents are known to have high risk factors for sleep disorders, yet the youth rates of sleep disturbances are unknown. AIM: This study aimed to determine the prevalence of sleep disorders among New Zealand high school students. METHODS: The Auckland Sleep Questionnaire (ASQ) was administered to high school students at six schools in the North Island. Schools were chosen to reflect a range of ethnicities and school deciles, which identify the socioeconomic status of households in the school catchment area. RESULTS: A total of 1388 students completed the ASQ. The median age was 17 years (range 14-23) and females represented 43.5% (n=604) of the total group. A total of 37.2% of the students surveyed reported having significant sleep symptoms lasting longer than one month. Depression and anxiety were present in 51.7% and 44.8% of students reporting a sleep problem, respectively. A moderate correlation was observed between sleep problems and depression (r=0.34, p<0.01), and sleep problems and anxiety (r=0.31, p<0.01). Problem alcohol use and other substance use were more common in students with sleep symptoms (12.2% and 5.5% respectively). No difference was found in the rate of sleep problems reported by different ethnic groups. DISCUSSION: A considerable proportion of students surveyed reported significant sleep symptoms. This study has the potential to aid physicians within New Zealand in better appreciating the burden of sleep disorders faced by young people and in effectively assessing and managing different causes of sleep symptoms in this demographic.

Insomnia: prevalence, consequences and effective treatment.

Insomnia is common and can have serious consequences, such as increased risk of depression and hypertension. Acute and chronic insomnia require different management approaches. >Chronic insomnia is unlikely to spontaneously remit, and over time will be characterised by cycles of relapse and remission or persistent symptoms. Chronic insomnia is best managed using non-drug strategies such as cognitive behaviour therapy. For patients with ongoing symptoms, there may be a role for adjunctive use of medications such as hypnotics.

Satisfaction with life and depression among medical students in Auckland, New Zealand.

AIM: The aim of this study was to assess the satisfaction with life among undergraduate medical and other students in Auckland and identify associations with depression and anxiety disorders. METHODS: The study was conducted at The University of Auckland, New Zealand in 2008 and 2009. The sample population was derived from five undergraduate classes in four courses (medicine (two classes), nursing, health science and architecture). A battery of questionnaires including the Satisfaction with Life Scale (SWLS), Patient Health Questionnaire (PHQ) for depression and Generalised Anxiety Disorder Questionnaire (GAD) were administered to the cohort. Subgroup analysis between medical and other students were also carried out. RESULTS: A total of 778 students were eligible, and 594 (76.4%) students (255 medical, 208 health science, 36 nursing and 95 architecture) completed the questionnaire. The median age was 20 years (range 17-45) and women represented 67.2% (n=399) of the total group. The mean SWLS score for the total group was 24.9 (SD 6.4), with medical students on average having higher satisfaction with life compared to other students. The rate of depression (PHQ = 10) and anxiety (GAD score = 8) among medical students was 16.9% (95% CI 12.2-21.5) and 13.7% (95%CI 9.5-18.0) respectively. Female students had higher rates of depression and anxiety compared to males. A statistically significant moderate correlation between SWLS score and PHQ score [r = -0.37 (p<0.001)] and SWLS score and GAD score [r = - 0.23 (p<0.001)] were also observed. CONCLUSIONS: Medical students are more satisfied with life compared to other students. A significant proportion of students surveyed in this study have clinically significant depression and anxiety. Promoting positive wellbeing and improving satisfaction with life may enhance the quality of life as well as the social and academic performance of university students.

Circadian-related sleep disorders and sleep medication use in the New Zealand blind population: an observational prevalence survey.

STUDY OBJECTIVES: To determine the prevalence of self-reported circadian-related sleep disorders, sleep medication and melatonin use in the New Zealand blind population. DESIGN: A telephone survey incorporating 62 questions on sleep habits and medication together with validated questionnaires on sleep quality, chronotype and seasonality. PARTICIPANTS: PARTICIPANTS WERE GROUPED INTO: (i) 157 with reduced conscious perception of light (RLP); (ii) 156 visually impaired with no reduction in light perception (LP) matched for age, sex and socioeconomic status, and (iii) 156 matched fully-sighted controls (FS). SLEEP HABITS AND DISTURBANCES: The incidence of sleep disorders, daytime somnolence, insomnia and sleep timing problems was significantly higher in RLP and LP compared to the FS controls (p<0.001). The RLP group had the highest incidence (55%) of sleep timing problems, and 26% showed drifting sleep patterns (vs. 4% FS). Odds ratios for unconventional sleep timing were 2.41 (RLP) and 1.63 (LP) compared to FS controls. For drifting sleep patterns, they were 7.3 (RLP) and 6.0 (LP). MEDICATION USE: Zopiclone was the most frequently prescribed sleep medication. Melatonin was used by only 4% in the RLP group and 2% in the LP group. CONCLUSIONS: Extrapolations from the current study suggest that 3,000 blind and visually impaired New Zealanders may suffer from circadian-related sleep problems, and that of these, fewer than 15% have been prescribed melatonin. This may represent a therapeutic gap in the treatment of circadian-related sleep disorders in New Zealand, findings that may generalize to other countries.

Rapid antidepressant response after nocturnal TRH administration in patients with bipolar type I and bipolar type II major depression.

BACKGROUND: Thyrotropin-releasing hormone (TRH) is a tripeptide that produces endocrine and behavioral effects in animals and humans. Some studies have shown transient antidepressant activity after morning administration of TRH. We hypothesized that nocturnal administration of TRH, when the circadian sensitivity of the TRH receptor is at its peak, may result in a more robust antidepressant effect. METHODS: Twenty patients with bipolar (BP) type I or BP type II major depressive episode (MDE) were given nocturnal intravenous TRH 500 microg (n = 10) or saline (n = 10) at midnight in a randomized, double-blind fashion. Antidepressant activity was assessed using the Hamilton Depression Rating (HAM-D), Young Mania Rating (YMR), and Profile of Mood (POMS) scales over a 48-hour period. Thyrotropin (TSH), total T4, and free T3 concentrations were measured before and after TRH administration. Data were analyzed using chi test, Fisher exact test, and repeated-measures ANOVA. RESULTS: Sixty percent of the TRH group and 10% of the saline group showed a > or =50% reduction in baseline total HAM-D score within 24 hours (P = 0.03). HAM-D ratings fell by an average of 52% after TRH administration versus 12% after saline administration (P = 0.038). There was a modest increase in YMR scores after TRH compared with saline (P < 0.032). No manic or hypomanic episodes were observed. Antidepressant effects of TRH lasted up to 48 hours. There was no correlation between DeltaTSH, DeltaT4, or DeltaT3 measures after TRH (or saline) administration and the change in HAM-D scores. CONCLUSIONS: Nocturnal TRH administration may produce a rapid antidepressant effect in some patients with BP I and BP II MDE.