Providers or professionals: How our conceptions of physician as machine or person lead to burnout.

Physician burnout is a major problem in medicine. Much literature focuses on personal and organizational factors and less on the cultural system underlying medicine. The term health care provider, as opposed to professional, is paradigmatic of how cultural influences have shaped the physician role. This term emphasizes provision that mirrors business and consumer transactions. The pressure to be a provider has been augmented by failures of the medical establishment, which creates a sense of distrust and the need for patients to be proactive in making demands of physicians. This is coupled with shifted expectations of the medical encounter created by technology and the pressure of a bureaucratic system that views physicians primarily as dispensers of services rather than as individual people. These factors create a milieu where physicians both act and feel like machines. While it is important to serve the public good, this idea has become warped and at the cost of physician health. Physicians should instead be understood primarily as professionals, which places the emphasis on the physician as an individual who professes an ethic of patient care that is internally motivated. The language physicians use to describe themselves must portray their humanity and their work in medicine.

Entitlement: The big problem in medical education we will not talk about.

Entitlement is a problem in medical education that has received relatively little attention. First, it is felt by educators, who often feel pressured to conform curricula and evaluations to satisfy learner demands and administrative pressures lest their careers are penalized. Second, entitlement affects the medical system, as entitled physicians are less empathetic and focus more on personal goods rather than patient needs. This shifts the humanistic basis for medicine. Thirdly, entitlement is problematic for learners, as constant accommodations ironically undermine self-reliance and adaptability. Constantly meeting these demands can diminish gratitude and overall happiness. To address this issue, learners must acknowledge the problem and seek remedies to it themselves, as top-down interventions will likely be rebuffed. Rather than focusing solely on the learning environment, solutions should also empower learners to engage their environment in effective and productive ways. This should include correcting cognitive distortions that lead learners to expect administrative interventions in all circumstances perceived as harmful. Other solutions include practicing gratitude and developing work friendships. While certainly not all learners are entitled and some environmental amendments should be made, learners and educators must realize that entitlement is shaping medical culture and collectively take steps to mitigate its negative effects.

The Empathy Tank as a revised model for fostering empathy in medical education.

Empathy has been difficult to sustain and foster in medical training. Based on empirical evidence and intuitive human experience, this paper proposes that empathy can be re-conceptualized as a dynamic reservoir, referred to as an "empathy tank." Physicians and learners who have personally experienced or received much empathy will naturally have a stronger tendency and greater capacity for empathy than others who have experienced little. These instances of empathy that fill the "empathy tank" can take the form of personal experiences, re-experiencing memories, and vicarious experiences. As this reservoir is filled, the empathy therein can more readily be poured out to others. Thus, all trainees should be educated to recognize first and foremost their personal need for empathy that they share with patients and subsequently seek encounters that highlight these empathic experiences. Three practical implications for educational interventions are discussed: (1) Learners and preceptors should recognize instances in training of perceived inadequacy as opportunities to provide empathy, (2) Interventions should target foundational rather than secondary issues in empathy, and (3) Interventions should enable empathy in learners to be self-sustaining.

Opening our eyes to a critical approach to medicine: The humanities in medical education.

This paper examines a recent medical graduate's perspective on how undergraduate education tends to focus on imparting medical knowledge with little reference to the human aspects in clinical medicine. This is problematic because medicine is both about people and practiced by people. Students often have minimal exposure to the humanities prior to and in medical school and are frequently unaware of the societal trends that impact their view of medical practice. Familiarity with the humanities is a crucial means to understanding human nature, recognizing personal sociocultural biases, and practicing patient-centered medicine. This gap in knowledge may be due to the increase in medical information and optimistic ideologies related to medical progress. Philosophical paradigms and historical examples are considered to demonstrate the relevance of both fields in the humanities in understanding the role of moral human agents in applying medical knowledge. Educational changes in the humanities are proposed as a potential solution to our current deficits. Informal changes include mentorship relationships and shifting the general underpinning attitude in medical culture. Formal changes include specific courses teaching a critical approach to medicine. Changes in competency-based education and admissions are also suggested. These amendments are proposed to practice a fuller, truly human medicine.

Physician-hastened death in young children: Getting to underlying assumptions.

Significant changes are occurring in Canada's health care system regarding physician-hastened death (PHD). In the Netherlands, where the Groningen Protocol is in place, euthanasia in now legal for infants and children. The present article considers whether PHD should be applied to young children in Canada and how these paediatric cases differ from adult cases. The discussion analyzes and critiques the underlying assumptions necessary to believe that PHD is good. The role of worldviews in the deliberation of any moral question and the importance of recognizing personal bias are highlighted. The authors present common issues regarding PHD, including suffering, parental autonomy and future quality of life, and examine the basic assumptions on which these arguments are made. Finally, they conclude that the assumptions required are incorrect and that PHD should not be allowed in the case of children. Instead, policies should continue to strive for the protection and promotion of health in all children.

D'importants changements se produisent à l'égard de l'aide médicale à mourir (AMM) au sein du système de santé canadien. Aux Pays-Bas, où le protocole de Groningen est en vigueur, l'euthanasie est désormais légale pour les nourrissons et les enfants. Le présent article évalue si l'AMM devrait s'appliquer aux jeunes enfants du Canada et en quoi les cas d'âge pédiatriques diffèrent de ceux des adultes. L'exposé contient une analyse et une critique des hypothèses sous-jacentes nécessaires pour trouver l'AMM positive. Il souligne le rôle des diverses visions du monde dans les délibérations sur des questions morales et l'importance d'admettre les préjugés personnels. Les auteurs présentent des enjeux courants liés à l'AMM, y compris la souffrance, l'autonomie parentale et la future qualité de vie, et ils examinent les hypothèses fondamentales sur lesquelles reposent ces arguments. Enfin, ils concluent que les hypothèses nécessaires sont fausses et que l'AMM ne devrait pas être autorisée chez les enfants. Les politiques devraient plutôt continuer à privilégier la protection et la promotion de la santé chez tous les enfants.

Sacrifice as a Part of Medical Education: A Reflection on the COVID-19 Pandemic.

The COVID-19 pandemic demanded significant sacrifices from medical learners. We examine the meaning of sacrifice and frame it as a "side effect" of being dedicated to the good of the patient. We contend that sacrifice has played a central role in medicine, even before the pandemic, for professionals and learners alike. We identify three limits to the role of sacrifice in medical education and practice to separate healthy from harmful experiences of sacrifice. Developing an understanding of sacrifice in medical education and practice can help trainees and clinicians know when to marshal resilient responses to healthy sacrifices and reject harmful sacrifices encountered. Maintaining this balance requires a broader reflection on the nature of medical schools and their ability to support virtuous professional identity formation.

Variability in Interpretation of Magnetic Resonance Imaging of the Pediatric Sacroiliac Joint.

OBJECTIVE: Magnetic resonance imaging (MRI) is pivotal in the assessment of early sacroiliitis in children. We aimed to evaluate the agreement between local radiology reports and central imaging reviewers for active inflammation and structural damage at the sacroiliac (SI) joints. METHODS: Eight hospitals each contributed up to 20 cases of consecutively imaged children and adolescents with juvenile idiopathic arthritis and suspected sacroiliitis. Studies were independently reviewed by 3 experienced musculoskeletal pediatric radiologists. Local assessments of global impression and lesions were coded from the local radiology reports by 2 study team members. Test properties of local reports were calculated using the central imaging team's majority as the reference standard. RESULTS: For 120 evaluable subjects, the median age was 14 years, half of the cases were male, and median disease duration at the time of imaging was 0.8 years (interquartile range 0-2). Sensitivity of local reports for inflammation was high, 93.5% (95% confidence interval [95% CI] 78.6-99.2), and specificity was moderate, 69.7% (95% CI 59.0-79.0), but positive predictive value (PPV) was low, 51.8% (95% CI 38.0-65.3). Twenty-seven cases (23%) had active inflammation reported locally but rated normal at the central reading, 19 (70%) with subsequent medication changes. The sensitivity of local reports detecting structural damage was low, 45.7% (95% CI 28.8-63.4), and specificity was high, 88.2% (95% CI 79.4-94.2); PPV was low, 61.5% (95% CI 40.6-79.8). CONCLUSION: Substantial variation exists in the interpretation of inflammatory and structural lesions at the SI joints in children. To reliably identify pathology, additional training in the MRI appearance of the maturing SI joint is greatly needed.

How the humanities shape medical culture: Knowing Wegener and other Nazi eponyms.

This article was migrated. The article was marked as recommended. While the medical humanities have experienced a renaissance, they are still largely a peripheral component of medical education. This is troublesome because the humanities include a number of disciplines that are foundational in understanding medicine and how it should be practiced. Nonetheless, current medical culture makes it difficult to fully incorporate the humanities into curriculum. We therefore propose an incremental approach to shaping the medical culture that can easily be incorporated into daily teaching as opposed to designing additional classes and resources that must be added to existing educational structures. An example of this approach is reviewed here through teaching historical and ethical lessons surrounding Nazi eponyms. The use of names like Wegener provide brief opportunities for sidebars during clinical lectures to remind learners that empirical data do not provide ethical direction and that our medical history has included atrocities that remind us to practice conscientiously. We provide other examples that can be included in daily learning. This approach eschews the burdens associated with large curricular changes, such as student resistance/apathy and logistical barriers, and can be easily implemented. It also enables change to be gradual and through structures that have already been established, allowing learners to see the benefits of insights from the humanities in small, digestible segments. Through this approach, medical culture can be shaped towards a greater appreciation toward the medical humanities.

The physician as person framework: How human nature impacts empathy, depression, burnout, and the practice of medicine.

Troubling trends of depression, burnout, and declines in empathy have been demonstrated amongst residents. I argue that while interventions in medical education are helpful, a new perspective on the issue requires a more fundamental understanding of this problem. Rather than training physicians to act in certain ways, we must first recognize that physicians are first and foremost people. This core principle forms the basis of the framework that educators can use to help learners. Five areas of humanity with implications for physicians are discussed: 1) Physicians and patients share their humanity; 2) People are self-integrated in both personal and professional lives; 3) People are dynamic, thoughtful, and emotional; 4) People are finite; and 5) People are moral beings. Recognizing these can mitigate various factors contributing to current struggles. I also discuss practical implications of this framework to help residents flourish.