Assertiveness in physicians' interpersonal professional encounters: A scoping review.

PURPOSE: Good relationships between physicians, patients, families and the healthcare team are essential for high-quality care. Medical encounters are sometimes challenging. They may include conflicts, requiring physicians to be assertive: that is to share and protect their needs, rights and values while preserving those of others. Whereas assertiveness has been studied in patients and nursing staff (those with less power in healthcare), physicians' assertiveness, which must be mindful of these power differences, lacks a comprehensive review. Thus, this scoping review focuses on assertive communication in physicians' encounters. METHODS: A literature search of four online databases: MEDLINE, Embase, PsycINFO and WoS, seeking articles on physicians' assertiveness as a communication style published until February 2022. The Joanna Briggs Institute approach and the Preferred Reporting Items for Systematic Reviews checklist underpinned the review protocol. RESULTS: We identified 1513 articles relating to assertiveness, reviewed 153 full-text articles and selected 22 for full review, 68% from the last decade. The articles focused mainly on assertive communication and relationships with medical staff, with 54% focusing on bottom-up power relations. In 40% of the articles, no clear definition of assertiveness was included. Definitions included had varied focus: on self, on the other or both. Overall, assertiveness measures varied widely, precluding a methodical comparison. CONCLUSIONS: Despite the growing interest in physicians' assertiveness, a clearer definition and in-depth exploration of assertiveness are needed alongside development of valid measures of assertiveness appropriate to physicians. Based on the review, we offer a relational definition of assertiveness as the capacity to communicate one's views, concerns, rights and needs while respecting others and preserving therapeutic, collegial and educational professional alliances. This definition may serve to expand research in the field while offering a professional alternative to problematic communication styles-passive and self-denying or paternalistic and aggressive -that obfuscate and thus undermine physician-patient relationships.

The hidden curriculum of breaking bad news: Identification of three dimensions and four communication patterns.

OBJECTIVES: To explore students' observations in the hidden curriculum of physicians' breaking bad news interactions and identify dimensions and patterns within them. METHODS: We qualitatively analyzed 156 written narrative descriptions of bad news encounters in the clinics written by senior medical students. RESULTS: The analysis identified three dimensions within the encounters: providing information, dealing with emotions, and discussing treatment plans. These dimensions were observed in different proportions, identifying four communication patterns. Half of the encounters focused solely on presenting a treatment plan. Within them, the news was communicated abruptly while neglecting to share information or address emotions. CONCLUSIONS: Compared to the main literature on breaking bad news that focuses on two dimensions-the present study identified a third, prominent dimension-discussing the treatment plan. Half of the hidden curriculum experiences contradict the taught protocol, paying little/no attention to emotion and information. PRACTICE IMPLICATIONS: When teaching breaking bad news, it is essential to address the day-to-day practices students' observe. Students exposed to these encounters might misinterpret the physician's reliance on a single dimension as best practice. To mitigate this and help recognize their and others' tendency to focus primarily or solely on one dimension, we suggest a simple reflective prompt.

Burnout in Israeli medical students: a national survey.

INTRODUCTION: Professional burnout is characterized by loss of enthusiasm for work, cynicism, and a low sense of personal efficacy. Burnout may adversely affect medical professionalism. Burnout is common in clinicians and varying rates have been reported in medical students. No data exist regarding the prevalence of burnout among Israeli medical students. The aims of this study were to assess the rate of burnout in Israeli medical students and to identify students who were particularly susceptible to burnout. METHODS: A cross-sectional questionnaire design was employed, gathering data from medical students in all years of study across three medical schools. Burnout was measured using the Maslach Burnout Inventory Student Survey (MBI-SS), translated into Hebrew. RESULTS: Of the 2160 students in the participating medical schools, 966 (44.7%) completed MBI-SS and demographic questionnaires. The overall burnout rate was 50.6%. Multivariate logistic regression analysis yielded that female gender, age under 25, advanced year of study, studying at a specific medical school and not being a parent are all significantly correlated with higher levels of burnout. CONCLUSIONS: A high rate of burnout was found. The identification of young women who are not parents during advanced years of studies as being at-risk is important, in order to guide the development of burnout prevention interventions.

More Than Just an Entertainment Show: Identification of Medical Clowns' Communication Skills and Therapeutic Goals.

Medical clowns (MCs) are trained professionals who aim to change the hospital environment through humor. Previous studies focused on their positive impact and began identifying their various skills in specific situations. When placed in pediatrics, MCs face various challenges, including approaching frustrated adolescents who are unwilling to cooperate with their care, dealing with their anxious parents, and communicating in a team in the presence of other health professionals. Research that systematically describes MCs' skills and therapeutic goals in meeting these challenges is limited. This article describes a qualitative, immersion/crystallization study, triangulating between 26 video-recorded simulations and 12 in-depth-semi-structured interviews with MCs. Through an iterative consensus-building process we identified 40 different skills, not limited to humor and entertainment. Four main therapeutic goals emerged: building a relationship, dealing with emotions, enhancing a sense of control, caring, and encouragement, and motivating treatment adherence. Mapping MCs' skills and goals enhances the understanding of MCs' role and actions to illustrate their unique caring practices. This clarification may help other healthcare professionals to recognize their practices and the benefits in involving them in care. Furthermore, other health professionals may apply some of the identified skills when faced with these challenges themselves.

Food-seeking behavior is triggered by skin ultraviolet exposure in males.

Sexual dimorphisms are responsible for profound metabolic differences in health and behavior. Whether males and females react differently to environmental cues, such as solar ultraviolet (UV) exposure, is unknown. Here we show that solar exposure induces food-seeking behavior, food intake, and food-seeking behavior and food intake in men, but not in women, through epidemiological evidence of approximately 3,000 individuals throughout the year. In mice, UVB exposure leads to increased food-seeking behavior, food intake and weight gain, with a sexual dimorphism towards males. In both mice and human males, increased appetite is correlated with elevated levels of circulating ghrelin. Specifically, UVB irradiation leads to p53 transcriptional activation of ghrelin in skin adipocytes, while a conditional p53-knockout in mice abolishes UVB-induced ghrelin expression and food-seeking behavior. In females, estrogen interferes with the p53-chromatin interaction on the ghrelin promoter, thus blocking ghrelin and food-seeking behavior in response to UVB exposure. These results identify the skin as a major mediator of energy homeostasis and may lead to therapeutic opportunities for sex-based treatments of endocrine-related diseases.

Position paper: Teaching breaking bad news (BBN) to undergraduate medical students.

Sharing new medical information that is perceived as seriously effecting people's lives, i.e., breaking bad news (BBN) is important in caring for patients and relatives and is challenging for healthcare professionals. Optimal BBN requires incorporation and implementation of multiple professional competencies acquired gradually throughout years of training. The BBN encounter has implications for all participants: the patient, family members, their close social environments, and the deliverer of the news. Due to these implications and the accountability involved, medical schools invest educational resources in helping medical students develop this competency. The current paper summarizes literature, research, and teaching experiences while suggesting practical guidelines for designing and teaching a BBN course to undergraduate students. The following principles lie behind the recommendations: stepwise spiral continuity of exposure to and teaching of communication skills in various contexts while focusing on BBN in the advanced clinical years; relating the developing skills to broader humanistic studies; enhancing awareness of self-perspectives and beliefs regarding BBN; connecting to patients' and family members experiences and needs; providing a BBN protocol and opportunities for structured experiential learning followed by reflection and feedback; using observation and reflection to address gaps between theory and real-life practice; and creating continuity of learning about BBN through undergraduate, graduate, and continuing medical education. Applying this learning process can help enhance the management of these difficult conversations to improve patients' care during these difficult, life-changing encounters, and physicians' well-being.

Time to rise to the challenge of truly implementing patient-centered care and shared decision-making in Israel: The educational and policy mission.

Five years ago, Israel was perceived to be on the verge of implementing shared decision making (SDM). However, as presented in this paper, SDM in Israel remains relatively unexplored, is implemented in only few research interventions, and is rarely taught in medical schools or continuing education. Furthermore, policies on patient-centered care and SDM are limited and lack clear regulations and training on how to apply them. This situation is of concern. The paper describes the current state of SDM, identifying higher-level barriers to implementation. They include the need to address healthcare professionals' attitudes regarding patients and relationships; the need to rename and clearly define SDM terminology in Hebrew; the need to place SDM in the larger context and training of PCC; and the call for the development of clear policies, regulations, and training truly to rise to the need for national implementation of PCC and SDM.

Caring for the health and well-being of our learners in medicine as critical actions toward high-quality care.

A recent paper has focused on residents' poor lifestyle habits and their potential negative impact on patients' lifestyles. This commentary argues that there are even greater reasons to be concerned about the health and well-being of residents and medical students and the resultant effects on patients throughout the careers of these learners. There is a "hidden curriculum", i.e., customs, rituals and norms of behavior, in medical education and in the training at the healthcare setting, often contradicts the formal curriculum and include messages that neglect the basic needs of the learners as well as the patients. Due to the impact of these messages on the professional identity formation of learners, including a deterioration in their own wellbeing as well as impairment of their ability to empathize with and care for patients, we must align our formal and hidden curricula to show dignity and caring for learners, colleagues, and patients. To do this well, we need to change our approach. We need to add processes for learners to support them in dealing with the stresses of their education and training and allow them to build their families and commit fully to medicine as a vocation, not just a job. We also must add faculty development processes to help align the formal and hidden curricula and help faculty empower and constructively assist their learners to handle challenging situations, e.g., where they see a resident struggling with patient care and day-to-day workload, through empathic feedback. When our learners are treated with kindness and respect they will lead more fulfilling lives and be better able to provide the high-quality care and caring all patients deserve.

Reflective writing in the teaching of communication skills for medical students-A systematic review.

OBJECTIVE: To analyse the use, assessment, and measured outcomes of reflective writing (RW) in teaching communication to medical students. METHODS: Systematic search of seven electronic databases, focused on using RW in teaching communication skills. Three reviewers selected and prepared the synthesis of the studies. The synthesis was based on thematic analysis using Braun and Clarke's approach. RESULTS: We identified 1325 studies, reviewed 101 full-text articles, and included 12 articles in the analysis. The four themes identified showed that RW is not a stand-alone practice. RW is blended with other teaching strategies. Through RW, students identified structural, emotional, and relational aspects and challenges of communication. Only a few studies found a positive correlation between reflective ability and communication skills CONCLUSION: RW can be integrated with various teaching methods, at all stages of learning, to stimulate discussion of interpersonal and intrapersonal topics. Through RW, students explore theirs and their patient's emotions, values, behaviours, and needs identifying challenges and practices relevant to communication. PRACTICE IMPLICATIONS: RW can address different structural, relational, and emotional issues that are relevant to communication learning. Further educational development and high-quality empirical research on the use of RW and unique outcomes are needed to support communication skills learning.

Twelve tips to manage a breaking bad news process: Using S-P-w-ICE-S - A revised version of the SPIKES protocol.

Breaking bad news (BBN) is a difficult task that requires multiple professional competencies. The way it is managed has implications for all involved in the encounter: the patient, family members, and the news provider. Existing guidelines were developed mainly at the turn of the millennium and require updating based on identification of daily clinical needs and pedagogical challenges while teaching the current protocols. Furthermore, there is a need to provide an overview of BBN encounters as a process, rather than a subdivided event, to help practitioners adopt an approach that might serve them in their daily routines. This twelve tips article summarizes research and practical experience for handling BBN encounters, from their preparation, through delivering the news while attending patients and family members' needs, toward documenting the news, and critically reflecting on the interaction. The tips are structured and explained to serve both practitioners and medical educators.

Skin exposure to UVB light induces a skin-brain-gonad axis and sexual behavior.

Ultraviolet (UV) light affects endocrinological and behavioral aspects of sexuality via an unknown mechanism. Here we discover that ultraviolet B (UVB) exposure enhances the levels of sex-steroid hormones and sexual behavior, which are mediated by the skin. In female mice, UVB exposure increases hypothalamus-pituitary-gonadal axis hormone levels, resulting in larger ovaries; extends estrus days; and increases anti-Mullerian hormone (AMH) expression. UVB exposure also enhances the sexual responsiveness and attractiveness of females and male-female interactions. Conditional knockout of p53 specifically in skin keratinocytes abolishes the effects of UVB. Thus, UVB triggers a skin-brain-gonadal axis through skin p53 activation. In humans, solar exposure enhances romantic passion in both genders and aggressiveness in men, as seen in analysis of individual questionaries, and positively correlates with testosterone level. Our findings suggest opportunities for treatment of sex-steroid-related dysfunctions.

[THE EXPERIENCE OF OBSTETRICIANS DURING THE FIRST OUTBURST OF COVID-19].

INTRODUCTION: The COVID-19 pandemic posed unique challenges to medical teams in general and in the field of obstetrics in particular, where the provision of medical services could not be postponed. Optimal care during the COVID-19 outburst required rapid adjustment to changes, ensuring staff and patients' safety while maintaining close and direct contact with patients. OBJECTIVES: To explore obstetricians' experiences during the first outburst, focusing on their challenges, needs and ways of coping. METHODS: Semi-structured in-depth interviews were conducted online with 13 senior physicians and residents (7 women, 6 men) from four hospitals, who worked in obstetrics. The interviews were analyzed using the Immersion/Crystallization method developed in medicine focused on their experiences. RESULTS: The findings revealed that alongside the impressive mobilization of the teams during this period, physicians encountered various challenges. These included being overwhelmed with the ever-changing and often conflicting guidelines; a feeling of lack of transparency and loss of trust in the system that did not always protect them nor provided their basic needs; difficulty in maintaining daily needed routines, such as communication within the team; dealing with patients' and their families anxiety; and striving to maintain a positive childbirth atmosphere along with having to set boundaries and keep distance. The teams felt the need for training in dealing with patients' and staff's emotional needs as well as finding ways to maintain a professional-friendly relationship among team members. CONCLUSIONS: The COVID-19 period forced obstetricians to change procedures and conduct themselves differently. They demonstrated a great commitment to assuring that women have a positive childbirth experience, even within the limitations of COVID. They experienced great difficulty as they themselves were dealing with fears of the virus, distancing from others, and addressing new emerging needs. DISCUSSION: Reports from around the world and the findings of the current study indicate the importance of developing processes that will enhance physicians' and patients' trust, to allow physicians to feel safe and cared for and to be able to provide high-quality care Identifying the challenges, needs and strengths of the medical teams can help in dealing with this and future pandemics. This requires caring for physicians, as individuals, as family members, as team members, along with provision of training that can help them communicate well to provide high-quality safe care.

The Delivery of Diagnosis by Child Psychiatrists: Process Characteristics and Correlates of Distress.

We describe the attitudes of child psychiatrists toward diagnosis delivery (DD) and explore potential stressful factors associated with the process. Eighty Israeli child psychiatrists completed a questionnaire on their perceptions of DD of schizophrenia, autism spectrum disorder (ASD), and attention deficit/hyperactivity disorder (ADHD). We also conducted semi-structured in-depth interviews with 12 child psychiatrists who were asked to share their personal experience with DD. The questionnaire responses revealed that child psychiatrists perceived schizophrenia and ADHD as the most and least severe disorders, respectively, and its treatment as being ineffective and effective, respectively. They expressed negative perceptions toward DD of schizophrenia and positive perceptions toward DD of ADHD. The results of linear regressions revealed that some factors predicted distress accompanying DD in all three diagnoses, such as lack of professional experience, negative perceptions of DD, and the effect of parents' attitudes of opposition to the diagnosis. The interviews revealed that DD was often described by psychiatrists as an emotional experience and that the psychiatrists' age, and whether the psychiatrists identified more with the child or the parent, affected their attitude toward DD. Lastly, the psychiatrists expressed feelings of loneliness in the procedure of DD and their wish to share and reflect on their experiences with others. These findings may contribute to a better understanding of the clinically important topic of DD in child psychiatry that has not been adequately addressed and help deal with psychiatrists' challenges in this task.

Core experiences of parents of children with autism during the COVID-19 pandemic lockdown.

LAY ABSTRACT: The lockdown and home isolation due to the COVID-19 pandemic led to significant transformation in lifestyles. Being a parent in this situation was not easy for anyone, much less for parents of children with special needs. The shutting down of special education systems meant that parents lost a vital support network and had to be the sole full-time caregivers despite often lacking the skills to cope with this new and daunting situation. We interviewed parents and learned that the main difficulties faced by homebound autistic children stemmed from the change in routine, lack of special education services, limited physical space, and food- and sleep-related issues. Some children experienced worsening in behavioral, social, and developmental domains, yet others seemed to not only overcome the challenges of changing conditions but even benefit from them. The children's success or failure was directly related to how their parents coped. The key factors that enabled successful coping were the parents' ability to accommodate to the child's needs, their own creativeness and resourcefulness, and a generally positive outlook. The results of this analysis revealed that the best way to benefit autistic children caught up in drastic changes in their routine lifestyle is to invest in a strong support system for their parents.

Medical Students' and Trainees' Country-By-Gender Profiles: Hofstede's Cultural Dimensions Across Sixteen Diverse Countries.

PURPOSE: The global mobility of medical student and trainee populations has drawn researchers' attention to consider internationalization in medical education. Recently, researchers have focused on cultural diversity, predominately drawing on Hofstede's cross-cultural analysis of cultural dimensions from general population data to explain their findings. However, to date no research has been specifically undertaken to examine cultural dimensions within a medical student or trainee population. This is problematic as within-country differences between gender and professional groups have been identified within these dimensions. We address this gap by drawing on the theoretical concept of national context effects: specifically Hofstede's six-dimensional perspective. In doing so we examine medical students' and trainees' country profiles across dimensions, country-by-gender clustering, and differences between our data and Hofstede's general population data. METHODS: We undertook a cross-cultural online questionnaire study (eight languages) containing Hofstede's 2013 Values Survey. Our questionnaire was live between 1st March to 19th Aug 2018, and December 2018 to mitigate country holiday periods. We recruited undergraduate medical students and trainees with at least 6-months' clinical training using school-specific methods including emails, announcements, and snowballing. RESULTS: We received 2,529 responses. Sixteen countries were retained for analyses (n = 2,307, 91%): Australia, Chile, China, Hong Kong, India, Indonesia, Ireland, Israel, Japan, Malaysia, New Zealand, Pakistan, South Africa, South Korea, Sri-Lanka, Taiwan. Power distance and masculinity are homogenous across countries. Uncertainty avoidance shows the greatest diversity. We identified four country clusters. Masculinity and uncertainty are uncorrelated with Hofstede's general population data. CONCLUSIONS: Our medical student and trainee data provides medical education researchers with more appropriate cultural dimension profiles than those from general population data. Country cluster profiles stimulate useful hypotheses for further research, especially as patterning between clusters cuts across traditional Eastern-Western divides with national culture being stronger than gendered influences. The Uncertainty dimension with its complex pattern across clusters is a particularly fruitful avenue for further investigation.

The associations between reflective ability and communication skills among medical students.

OBJECTIVES: Assess associations between medical students' reflective ability demonstrated in written narratives, and communication skills demonstrated later in simulated-patient breaking bad news interactions. METHODS: We analyzed 66 medical students' reflective ability, using 'REFLECT' rubric and four newly developed parameters: Noticing Explanations provided to patients, Noticing Emotions, Remoteness/Connectedness in their writing, and mentioning Self-Emotions. 'BAS' and 'SPIKES' questionnaires measured students' communication skills. Spearman and Chi-square tests examined correlations among all variables. Multiple regressions examined associations between reflective ability and demographic variables with communication skills. RESULTS: Significant positive correlations between students' reflective ability, measured by REFLECT and three of the new parameters, and global communication skill scores. Reflective ability of Noticing Explanations in writing was associated with ability to tailoring information to patients' needs and address emotions. CONCLUSIONS: High reflective ability may improve communication skills. Specifically, ability to notice explanations to patients may enhance later capability to tailor information to patients and address emotions empathically. PRACTICE IMPLICATIONS: Encourage educational interventions enhancing reflective ability; specifically observation and detailed writing about how explanations are given to patients and patients' reactions to them. This process may help students develop competency to share and tailor difficult information sensitively-a critical skill when communicating bad news.

Medical students' experiences and needs from written reflective journal feedback.

INTRODUCTION: Reflective ability is an important skill for enhancing professionalism and developing communication skills. To improve reflective ability, medical educators encourage use of written reflective journals, for which feedback is important. It is difficult for educators to anticipate how their feedback will be perceived. Therefore, this study examined students' experiences with educators' written feedback on reflective journals. METHODS: A qualitative, immersion/crystallization analysis of 60 written feedback texts to 15 medical students (30 identified by students as meaningful and 30 as less meaningful) and in-depth semi-structured interviews with these students. We did not define 'meaningful', to leave room for students' own interpretations. We analysed the feedback to identify what it includes (its components) and analysed the interviews to learn about students' experiences of receiving the feedback and the specific components. RESULTS: Students experienced five components as meaningful: supportive and encouraging statements; legitimisation of their emotions; educators sharing personal-professional experiences; asking questions to enhance reflection; and focusing on the students' main concern. These components enhanced students' willingness to read and learn from the feedback. Three components were experienced as less meaningful: detached, impersonal feedback; negative tone (criticism); and technical issues, for example brevity. These disappointing and hurtful components led students to pay less attention to the feedback or to invest less effort in future written assignments. CONCLUSIONS: The present study identified components in written reflective journal feedback texts and the experience and needs of students who received them. It showed the complexity of writing reflective feedback because of the need to support students through it, help them deal with emotions, identify and focus on personal content that matters to them, and provide opportunities to develop and enhance their reflective ability, while being mindful of their emotional state. To help educators in this challenging task, a self-assessment mnemonic ('FEEDBACK') for use before sending the initial feedback was developed.

Deepening the teaching and learning of clinical communication: the importance of reflection and feedback in health education / Aprofundando o ensino e aprendizagem de comunicação clínica: a importância da reflexão e do feedback no ensino em saúde

Aims: clinical communication (CC) relates to health professionals' interaction with patients/families. CC is fundamental for the physicians' role. This paper aims to contribute to the discussion about reflection and feedback for meaningful teaching and learning of CC. Methods: the authors provided a short review and conceptual discussion of the history and nature of CC teaching, followed by exploring the role of reflection and feedback in teaching CC. Results: communicating well can be challenging as it requires medical students and professionals to adapt their communication to each patient/family while obtaining all the needed information, conveying trustworthiness, care, and compassion. The teaching of CC to medical students involves deepening the doctor-patient relationship's technical, relational, and emotional elements. CC requires teaching that is flexible and tailored to the participants' needs. Therefore, teaching CC must go beyond asking the appropriate question or applying specific checklist-based behaviours. In teaching CC, it is crucial to give medical students support to discuss personal and institutional barriers and attitudes and explore how to transfer their learning to clinical practice. To that end, reflection should be encouraged to allow students to express difficulties and feelings and enhance their understanding of themselves and others. Within this process, feedback is essential to moving beyond skill-based teaching to reflection-based learning. Conclusion: the move from skills-based learning requires using reflective processes and feedback to allow students to learn about their communication tendencies and needs to become more flexible and attuned to different patient's needs in clinical encounters.

Objetivos: a comunicação clínica (CC) está relacionada à interação entre profissionais de saúde e pacientes ou familiares, sendo fundamental para prática médica. Este artigo tem como objetivo contribuir para a discussão sobre reflexão e feedback no ensino e aprendizagem significativos de CC. Métodos: os autores realizaram uma breve revisão e discussão conceitual da história e da natureza do ensino do CC, seguida pela exploração do papel da reflexão e do feedback no ensino de CC. Resultados: comunicar-se bem pode ser desafiador, pois exige que os estudantes de medicina e profissionais adaptem sua comunicação a cada paciente/família enquanto obtêm todas as informações necessárias, transmitindo confiabilidade, cuidado e compaixão. O ensino do CC para estudantes de medicina envolve o aprofundamento de elementos técnicos, relacionais e emocionais da relação médico-paciente. A CC requer um ensino flexível e adaptado às necessidades dos estudantes. Portanto, ensinar CC deve ir além de fazer a pergunta apropriada ou aplicar comportamentos específicos baseados em listas de verificação. No ensino do CC, é crucial dar aos estudantes de medicina apoio para discutir as barreiras e atitudes pessoais e institucionais e explorar como transferir seu aprendizado para a prática clínica. Para tanto, deve-se estimular a reflexão para permitir que os alunos expressem dificuldades e sentimentos e ampliem sua compreensão de si e dos outros. Nesse processo, o feedback é essencial para ir além do ensino baseado em habilidades para o aprendizado baseado em reflexão. Conclusão: a mudança de uma aprendizagem baseada em habilidades requer o uso de um processo reflexivo e feedback para permitir que os alunos aprendam sobre si, assim como, sobre se tornarem mais flexíveis e sintonizados com as diferentes necessidades do paciente nos encontros clínicos.