Storylines of family medicine V: ways of thinking-honing the therapeutic self.

Storylines of Family Medicine is a 12-part series of thematically linked essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'V: ways of thinking-honing the therapeutic self', authors present the following sections: 'Reflective practice in action', 'The doctor as drug-Balint groups', 'Cultivating compassion', 'Towards a humanistic approach to doctoring', 'Intimacy in family medicine', 'The many faces of suffering', 'Transcending suffering' and 'The power of listening to stories.' May readers feel a deeper sense of their own therapeutic agency by reflecting on these essays.

Clinical empathy as perceived by patients with chronic illness in Canada: a qualitative focus group study.

BACKGROUND: Although clinical empathy - the ability of a physician to understand a patient's illness experience, communicate this understanding and act collaboratively to create a treatment plan - provides substantial benefits to both physicians and patients, medical students typically experience a decline in empathy during training. The primary objective of this study was to generate a model of clinical empathy grounded in the perspectives of people with chronic illness living in Canada, to promote empathy-focused curricular development in Canadian medical education. METHODS: We conducted a qualitative focus group study using a constructivist grounded theory approach. We recruited adults (age ≥ 18 yr) with chronic illness who had recently seen a physician in Canada from virtual support groups. Six semistructured virtual focus groups with 3-5 participants each were scheduled between June and September 2021. We coded the transcripts using the constant comparative method, allowing for the construction of an overarching theory. RESULTS: Twenty patients (17 women and 3 men) participated in the focus groups; 1 group had 2 participants because 1 participant failed to appear. The majority of participants (14 [70%]) had at least a college degree. The mean rating for overall satisfaction with the Canadian health care system was 5.4/10.0 (median 5.0). The emergent theory showed that the perceived presence of physician empathy engendered positive internal processing by patients, leading to increased health care efficacy and enhanced mental health outcomes. Negative patient processing in response to the perceived absence of empathy led to reduced quality of health care delivery (e.g., ineffective referrals and more appointments), increased use of health care resources, disruptions in patients' personal lives, and negative physical and mental health outcomes. INTERPRETATION: Clinical empathy can have life-altering impacts on patients, and its absence may increase resource use. As empathy involves understanding patients' lived experiences, any valid intervention to improve clinical empathy must be informed by patient perspectives.

A randomized, controlled study to assess if allopathic-osteopathic collaboration influences stereotypes, interprofessional readiness, and doctor-patient communication.

Despite the growing similarities between allopathic (MD) and osteopathic (DO) medical education, few studies have examined allopathic-osteopathic collaboration. The following study focused on stereotypes and student readiness for interprofessional learning. Patient perceptions were also evaluated. Osteopathic and allopathic students were randomly allocated 1:1:1 to work in pairs (MD/DO, MD/MD, DO/DO) at the start of each shift. A questionnaire evaluating student communication was collected from patients at the end of each encounter. Surveys assessing stereotypes and interprofessional readiness were obtained from students at the end of each workday. Data collection was stopped early due to Coronavirus-related safety measures. In the ITT analysis, there were a total of 126 participants (57 students 69 patients). A per-protocol analysis was performed to account for repeat clinic volunteers. No significant differences were detected between student pairs; however, the sensitivity analysis of the questionnaire assessing interprofessional readiness was 8 points higher in the DO/DO group compared to the MD/MD and MD/DO groups (P = 0.0503). In the content analysis of qualitative responses, the MD/DO group was more likely to respond with themes of enjoyment and less concern about stereotypes than the DO/DO group. The MD/DO group was also less likely to report concerns about differences in expectations, methods, and thinking than the MD/MD group. Early trends from this study suggest that DO students may be better positioned to engage in interprofessional learning than their MD counterparts. Additionally, the findings from our content analysis provide evidence that the collaborative experience improved feelings associated with professional legitimacy and credibility among DO students. Taken in aggregate, this study provides justification for a follow-up investigation, as well as a framework for how such studies could best be executed in the future.

The impact of a mindfulness bracelet on emotional affect in medical students: a prospective cohort study.

BACKGROUND: There is concern that negative changes in emotional outlook among medical students may impair the behavior of students, diminish learning, and ultimately affect patient care. Although most medical students begin their professional education with idealism, enthusiasm, and attention to humanity, they often have difficulty balancing their happiness with social and professional responsibilities. The following study aimed to determine if a simple mindfulness reminder (in the form of a bracelet) will impact emotional affect in first-year medical students. The second aim is to better understand the changes in emotional affect as students start medical school. METHODS: First year medical students were invited to participate at the start of the academic year. Baseline survey data and demographic data were obtained prior to participants being given the mindfulness bracelet and a standardized presentation explaining its purpose. Follow-up surveys were obtained at one- and two-month intervals. Statistical analysis was based on sum score of the survey. Change of sum score over time was tested by using repeated measurement analysis. RESULTS: Data collection included 104 students at the initial distribution of the survey. Follow-up surveys were obtained from 78 and 69 students at the first- and second-month mark, respectively. No significant associations were detected between frequency of mindfulness bracelet usage and emotional affect. However, there was a significant decrease in positive affect over the first month of medical school (p < 0.01), followed by a significant recovery in positive affect in the second month of medical school (p < 0.01). Demographic data did not reveal statistically significant differences among demographic groups and progression of emotional affect. CONCLUSIONS: Although the mindfulness bracelet intervention did not yield significant improvement in emotional affect, our results are consistent with other studies demonstrating that the first year of medical school negatively impacts the emotional outlook of students. Future studies are needed to explore practical interventions and to better understand and address the negative effect that early medical school education has on student's emotional state.

Views from the trenches: California family physicians' challenges and resilience factors while providing patient care during the initial wave of COVID-19.

This study examined challenges and factors promoting resilience among 20 California family physicians (FPs) during the first six months of the COVID-19 pandemic. A subset of academic, community, and resident FPs who responded to an online survey also participated in a semi-structured interview that explored concerns, moral distress, burnout, resource needs, support systems, coping strategies, and motivation to continue caring for patients. Thematic analysis was used to identify common themes in participant interviews. Interviewees demonstrated adaptability, resilience, and grit (i.e., commitment to completing a valued goal in the face of setbacks and adversity) despite challenges disrupting patient care, fears for family and self, and frustration due to the politicization of the pandemic. Factors promoting well-being and perseverance included professional and personal support, strong coping skills, and focusing on the meaning derived from practicing medicine. A service orientation that permeates family medicine philosophy and values motivated practitioners to continue to provide patient care while dealing with overwhelming personal and structural challenges. FPs drew strength from their internal coping skills, core family medicine values, and external support, notwithstanding demoralizing effects of mixed messages and politicization of the pandemic. FPs demonstrated resilience and grit in the face of challenges created by the COVID-19 pandemic. Ensuring adequate resources to promote a physically and psychologically healthy workforce while increasing access to care for all patients is crucial to prepare for the next healthcare crisis.

Speaking with Frankenstein.

This collaborative essay experimentally applies the insights of Mary Shelley's 1818 gothic fantasy Frankenstein to clinical interactions between present-day physicians and the patients they, akin to Shelley's human protagonist, so often seem to bring (back) to life. Because that process is frequently fraught with unspoken elements of ambivalence, disappointment, frustration, and failure, we find in Shelley's speculative fiction less a cautionary tale of overreach than a dynamic parable of the role that the unspoken, the invisible, and the unknown might play in contemporary physician/patient relationships. Playing with that parable, we consider its relevance to four often unacknowledged dynamics that shape physician/patient interaction: commitment to a false binary of life and death; the tyranny of normative aesthetics; shared negative affect; and the ethics of care and care-denial. To "speak with Frankenstein" is, we show, to make space for the otherwise unspeakable. The result is a more complete model of narrative medicine that accommodates to its ideal of open communication and full attention the persistence of what cannot be said, seen, or known--only imagined and approximated.

Medical Students' Creation of Original Poetry, Comics, and Masks to Explore Professional Identity Formation.

INTRODUCTION: This study examines differences in students' perceived value of three artmaking modalities (poetry, comics, masks) and whether the resulting creative projects offer similar or different insights into medical students' professional identity formation. METHODS: Mixed-methods design using a student survey, student narrative comments and qualitative analysis of students' original work. RESULTS: Poetry and comics stimulated insight, but masks were more enjoyable and stress-reducing. All three art modalities expressed tension between personal and professional identities. DISCUSSION: Regardless of type of artmaking, students express concern about encroachments of training on personal identity but hoped that personal and professional selves could be integrated.

Healing words: My journey with poetry and medicine.

In this essay, I reflect on the origins of my relationship to writing, as well as my journey with poetry and medicine as a health psychologist, medical educator, medical/health humanities scholar, and poet. I explore how these two seemingly disparate disciplines became entwined in my life and how I came to understand poetry as a kind of healing art. The essay concludes with gratitude for the opportunity to have mentored other writers, poets, and students on their paths to more deeply comprehend and honor our shared humanity. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The human kindness curriculum: An innovative preclinical initiative to highlight kindness and empathy in medicine.

Background: Prior studies have shown a marked drop in empathy among students during their third (clinical) year of medical school. Curricula developed to address this problem have varied greatly in content and have not always been subjected to validated measures of impact. Methods: In 2015, we initiated a Human Kindness (HK) curriculum for the initial 2 years of medical school. This mandatory 12-h curriculum (6 h/year) included an innovative series of lectures and patient interactions with regard to compassion and empathy in the clinical setting. Both quantitative (Jefferson Scale of Empathy [JSE]) and qualitative data were collected prospectively to evaluate the impact of the HK curriculum. Results: In the initial Pilot Year, neither 1st (Group 1) nor 2nd (Group 2) year medical students showed pre-post changes in JSE scores. Substantial changes were made to the curriculum based on faculty and student evaluations. In the following Implementation Year, both the new 1st (Group 3) and the now 2nd year (Group 4) students, who previously experienced the Pilot Year, showed significant improvements in post-course JSE scores; this improvement remained valid across subanalyses of gender, age, and student career focus (e.g., internal medicine, surgery, etc.). Despite the disappointingly flat initial Pilot Year JSE scores, the 3rd year students (Group 2) who experienced only the Pilot Year of the curriculum (i.e., 2nd year students at the time of the Pilot Year) had subsequent JSE scores that did not show the typical decline associated with the clinical years. Students generally evaluated the HK curriculum positively and rated it as being important to their medical education and development as a physician. Discussion: A required preclinical curriculum focused on HK resulted in significant improvements in medical student empathy; this improvement was maintained during the 1st clinical year of training.

Medical Students' Efforts to Integrate and/or Reclaim Authentic Identity: Insights from a Mask-Making Exercise.

Medical students' mask-making can provide valuable insights into personal and professional identity formation and wellness. A subset of first- and second-year medical students attending a medical school wellness retreat participated in a mask-making workshop. Faculty-student teams examined student masks and explanatory narratives using visual and textual analysis techniques. A quantitative survey assessed student perceptions of the experience. We identified an overarching theme: "Reconciliation/reclamation of authentic identity." The combination of nonverbal mask-making and narrative offers rich insights into medical students' experience and thinking. This activity promoted reflection and self-care, while providing insight regarding personal and professional development.

"Violence" in medicine: necessary and unnecessary, intentional and unintentional.

We are more used to thinking of medicine in relation to the ways that it alleviates the effects of violence. Yet an important thread in the academic literature acknowledges that medicine can also be responsible for perpetuating violence, albeit unintentionally, against the very individuals it intends to help. In this essay, I discuss definitions of violence, emphasizing the importance of understanding the term not only as a physical perpetration but as an act of power of one person over another. I next explore the paradox of a healing profession that is permeated with violence sometimes necessary, often unintentional, and almost always unrecognized. Identifying the construct of "physician arrogance" as contributory to violence, I go on to identify different manifestations of violence in a medical context, including violence to the body; structural violence; metaphoric violence; and the practice of speaking to or about patients (and others in the healthcare system in ways that minimize or disrespect their full humanity. I further suggest possible explanations for the origins of these kinds of violence in physicians, including the fear of suffering and death in relation to vicarious trauma and the consequent concept of "killing suffering"; as well as why patients might be willing to accept such violence directed toward them. I conclude with brief recommendations for attending to root causes of violence, both within societal and institutional structures, and within ourselves, offering the model of the wounded healer.

Medical Student Interpretation of Visual Art: Who's Got Empathy?

This article was migrated. The article was marked as recommended. Introduction: Physician empathy is a highly desired characteristic in clinical practice with benefits for both patients and doctors. Increasingly, medical educators have acknowledged the importance of empathy and sought effective ways of inculcating and strengthening this quality in medical students. However, empathy remains difficult to measure because of differing definitions and theoretical dimensions. Our goal was to develop a de novo visual Art scale, devised to evaluate empathetic response in medical students as well as a de novo Biosocial scale to measure medical student socioeconomic and experiential stress during childhood and adolescence; and to compare these exploratory measures to the reliable and well-validated Jefferson Scale of Empathy JSE). Methods: We constructed a survey incorporating a visual Art empathy measure, a Biosocial scale, and the JSE, which we sent to approximately 200 allopathic preclinical medical students at our home institution. We received 71 complete responses. Results: Cronbach's alpha testing found that the items in both new scales had adequate reliability. Multivariate regression analysis found a significant, positive association between both the visual art and biosocial scores and the JSE. Discussion: These results support the idea that response to visual stimuli, as well as life stressors, may be factors in medical students' capacity to formulate an empathetic response to patients.

Ways of knowing: Howard Stein's border-crossing use of poetry to interrogate clinical medicine, medical education, and health care organizations.

This article explores how medical anthropologist Howard Stein's poetry and his unique practice of sharing this poetry with the patients, physicians, and administrators who inspired it create ways of knowing that are at once revelatory and emancipatory. Stein's writing shows readers that poetry can be considered as a form of data and as a method of investigation into the processes of the human soul. Furthermore, it represents a kind of intervention that invites health professional readers toward connection, bridge building, and solidarity with their patients and with one another. (PsycINFO Database Record

The stories they tell: How third year medical students portray patients, family members, physicians, and themselves in difficult encounters.

BACKGROUND: Physicians have long had patients whom they have labeled "difficult", but little is known about how medical students perceive difficult encounters with patients. METHODS: In this study, we analyzed 134 third year medical students' reflective essays written over an 18-month period about difficult student-patient encounters. We used a qualitative computerized software program, Atlas.ti to analyze students' observations and reflections. RESULTS: Main findings include that students described patients who were angry and upset; noncompliant with treatment plans; discussed "nonmedical" problems; fearful, worried, withdrawn, or "disinterested" in their health. Students often described themselves as anxious, uncertain, confused, and frustrated. Nevertheless, they saw themselves behaving in empathic and patient-centered ways while also taking refuge in "standard" behaviors not necessarily appropriate to the circumstances. Students rarely mentioned receiving guidance from attendings regarding how to manage these challenging interactions. CONCLUSIONS: These third-year medical students recognized the importance of behaving empathically in difficult situations and often did so. However, they often felt overwhelmed and frustrated, resorting to more reductive behaviors that did not match the needs of the patient. Students need more guidance from attending physicians in order to approach difficult interactions with specific problem-solving skills while maintaining an empathic, patient-centered context.

Medical students' creative projects on a third year pediatrics clerkship: a qualitative analysis of patient-centeredness and emotional connection.

BACKGROUND: Increasingly, medical educators are incorporating reflective writing and original creative work into educational practices with the goals of stimulating student self-awareness, appreciation of multiple perspectives, and comfort with ambiguity and uncertainty. This study investigated students' creative projects to assess the extent to which they adopted a patient/relationship-centered, emotionally connected position toward patients and families. METHODS: Over a 10 year period, students on a required third year pediatrics clerkship individually or in groups completed either a reflection or an education project using a creative medium. 520 projects (representing 595 students, 74.7 % of total eligible students) were qualitatively analyzed according to various thematic and emotion-based dimensions. RESULTS: The majority of projects were personal narrative essays and poetry. The largest number of project themes related to the importance of patient/relationship-centered medicine with patients. The next largest number of projects focused on health education of parents, patients, or classmates. In telling their stories, students were more likely to use a personal voice representing either their or the patient's perspective than an objective, impersonal one. In terms of emotional tone, projects were more likely to be serious than humorous. The largest number of students' emotions expressed an empathic tone. Students identified a large number and wide range of both negative and positive feelings in themselves and their patients. The majority of student emotions were positive, while the majority of patient and family emotions were negative. CONCLUSIONS: Students' preference for patient-centered, relational themes, as well as their tendency to favor the first voice, empathic tone, and willingness to express a range of positive and negative emotions in presenting their projects, suggests that they valued emotional connection with patients and families during the pediatrics clerkship experience.