Amy Baernstein

Educating for Empathy

AbstractOBJECTIVE: Empathy in the medical setting is appreciation of the patient’s emotions and expression of that awareness to the patient. Named as an essential learning objective by the American Association of Medical Colleges, empathy is believed to significantly influence patient satisfaction, adherence to medical recommendations, clinical outcomes, and professional satisfaction. The objective of this study was to identify effective strategies to enhance empathy in undergraduate medical students. DATA SOURCES: We searched PubMed for studies that address the effectiveness of strategies for teaching empathy to medical students. We identified 13 peer-reviewed, English language, qualitative and quantitative studies reporting primary data on interventions that aim to foster empathy in undergraduate medical students, using Medical Subject Heading terms education, medical, undergraduate or student, medical crossed with empathy. RESULTS: These studies indicate that empathy may be amenable to positive change with a range of interventional strategies. Communication skill workshop addressing the behavioral dimension of empathy show greatest quantitative impact on participants. However, current studies are challenged by varying definitions of empathy, small sample sizes, lack of adequate control groups, and variation among existing empathy measurement instruments. CONCLUSION: Given the methodological limitations of the available studies, and uncertainty about which dimensions of empathy should be addressed, larger studies using validated measurement tools are recommended.

Promoting reflection on professionalism: a comparison trial of educational interventions for medical students.

Purpose To determine whether writing, one-on-one interviews with faculty, or a combination of these interventions effectively elicited reflection on professionalism for medical students. Method The study was a randomized trial conducted in 2001 at Harborview Medical Center, Seattle, Washington, with fourth-year medical students on a four-week clinical clerkship in emergency medicine. Three interventions were evaluated: the critical incident report (CIR), the CIR followed by a one-on-one interview with a faculty member, and one-on-one interview with no CIR. Quality and quantity of professional issues raised were addressed. Results All students (n = 68) agreed to participate; 66 completed the study components. On average, the students addressed significantly more issues of professionalism in their interviews alone than in their CIRs, 15.9 (95% confidence interval [CI] 18.2–13.6) and 7.15 (CI 8.88–5.40) issues respectively (p < .0001). Interviews preceded by CIRs were not significantly different from interviews with no CIR (13.5 versus 15.9 professionalism issues raised, respectively). In-depth explorations, including problem solving and projection to the future, occurred 2.59 times in interviews alone (CI 3.62–1.56) and 0.794 times in CIRs (CI 1.12–0.46) (p < .001). When analyzed as a proportion of total statements, the groups had similar ratios of in-depth statements (11.2% in CIRs and 15.7% in interviews alone). Conclusion Writing did not significantly affect the quantity or quality of reflection in interviews. One-on-one interviews with a faculty mentor most effectively elicited reflection on professionalism. Future studies should examine how reflective exercises such as those evaluated can be used to promote professional development.

Learning professionalism: perspectives of preclinical medical students.

Purpose To identify and examine how students respond to and engage with formal professionalism teaching strategies, and what factors outside the formal curriculum may influence professional development. Method Individual semistructured interviews were conducted with 56 students completing the preclinical curriculum at the University of Washington School of Medicine in 2004 and 2005. Interviews were recorded, transcribed, and analyzed using qualitative methods. Results Students identified role modeling as an important modality for learning professionalism, even during their preclinical years. Role models included classroom faculty and peers, in addition to physicians in clinical settings. Small-group discussions and lectures helped some students identify and analyze the professional behaviors they observed, but they elicited negative responses from others. Students believed their professionalism derived from values, upbringing, and experiences prior to medical school. Some students reflected on their evolving professionalism while working directly with patients. Conclusions Medical schools should ensure that students are exposed to excellent role models—ideally, faculty who can articulate the ideals of professionalism and work with students longitudinally in clinical settings. Lectures about professionalism may alienate rather than inspire students. Students’ premedical experiences and values influencing professionalism should be acknowledged and appreciated. Bedside teaching and reflection on students’ inner experience as they begin to work directly with patients deserve further exploration as opportunities to teach professionalism.

Predictors of Hospitalization for Injection Drug Users Seeking Care for Soft Tissue Infections

BACKGROUNDSoft tissue infections (STIs) from injection drug use are a common cause of Emergency Department visits, hospitalizations, and operating room procedures, yet little is known about factors that may predict the need for these costly medical services.OBJECTIVETo describe a cohort of injection drug users seeking Emergency Department care for STIs and to identify risk factors associated with hospitalization. We hypothesized that participants who delayed seeking care would be hospitalized more often than those who did not.DESIGNCohort study using in-person structured interviews and medical record review. Logistic regression assessed the association between hospital admission and delay in seeking care as well as other demographic, clinical, and psychosocial factors.PARTICIPANTSInjection drug users who sought Emergency Department care for STIs from May 2001 to March 2002.RESULTSOf the 136 participants, 55 (40%) were admitted to the hospital. Delay in seeking care was not associated with hospital admission. Participants admitted for their infection were significantly more likely to be living in a shelter (P = .01) and to report being hospitalized 2 or more times in the past year (P < .01).CONCLUSIONSWe identified a subpopulation of injection drug users, mostly living in shelters, who were hospitalized frequently in the past year and who were more likely to be hospitalized for their current infections compared to others. As members of this subpopulation can be easily identified and located, they may benefit from interventions to reduce the health care utilization resulting from these infections.

Cardiac arrest: a public health perspective.

This article reviews out-of-hospital cardiac arrest from a public health perspective. Case definitions are discussed. Incidence, outcome, and fixed and modifiable risk factors for cardiac arrest are described. There is a large variation in survival between communities that is not explained by patient or community factors. Study of variation in outcome in other related conditions suggest that this is due to differences in organizational culture rather than processes of care. A public health approach to improving outcomes is recommended that includes ongoing monitoring and improvement of processes and outcome of care.

Bringing ethics education to the clinical years: ward ethics sessions at the University of Washington.

Purpose Although most medical schools teach medical ethics during preclinical years, incorporating these ethics into clinical training remains challenging. During clinical rotations, students’ professional behaviors and attitudes are profoundly affected. This project was intended to develop an educational intervention to incorporate medical ethics training as a part of students’ professional development within the context of clinical training. Method “Ward Ethics” is a series of peer discussions guided by clinical faculty mentors trained in fostering issue identification and strategy development. The sessions described here were conducted during medicine and surgery rotations for third-year medical students at the University of Washington School of Medicine from 1998 to 2003. Thirty clinical faculty participated as facilitators. Written evaluations were collected from students and faculty at each session, and faculty interviews were conducted in 2001. Results The data reported are from 24 sessions and 15 faculty interviews from 1999 to 2001. The topics were consistent with prior reports of ethical issues that students encountered. Students reported a variety of learned strategies such as knowing how and when to speak up and transitioning from prioritizing evaluations to focusing on patient care, resulting in their feeling more confident. Faculty reported noticing positive results to their professional development as well. Conclusions Medical students in the clinical years face ethically challenging situations. Some circumstances, if left unexamined, may erode students’ abilities to maintain and develop appropriate professional behaviors. Students participating in this activity agreed that it served as a way to fight isolation, share stories, and exchange ideas for future problem solving.

Where the Rubber Meets the Road: A Cyclist's Guide to Teaching Professionalism

of the profession make it difacult to have entirely unstructured schedules (i.e., the demands of illness, the priority of patient needs), some changes have recently occurred in medical education that reoect improved attention to personal student needs. Some medical schools now make adjustments for the special needs of students (e.g., child care, maternity leaves), and some residency programs accommodate physicians who need more control over their work hours during training. The profession has also implemented new resident work-hour restrictions and the National Resident Matching Program, which matches students to residency sites, allows a spouse’s location to be taken into consideration. Although these changes represent movement toward accommodating a variety of individual priorities, more can and should be done, in part because it would be caring. That said, work hours, paperwork, and the debt burden of medical education have all been increasing. In light of this array of changes, some for the better and others not so, physicians still need to see themselves as part of a profession and to see their work as signiacantly more than a job. Although medical educators have the responsibility and authority to design and implement a curriculum, we are limited in our ability to affect the broader environment of our students’ education. The lessons students learn from their environment are too often at cross-purposes with the values we try to inculcate. Students learn from the faculty and house staff members whom they encounter: These “models” sometimes exemplify the opposite of what we want to nurture. Students learn from institutional policies that might undermine commitment to nonjudgmental regard, caring, and respect: Cost-containment agendas and institutional rewards might not be aligned with standards of professionalism. Students also learn from the physical environment of medical institutions that fail to promote trust: Facilities are understaffed, poorly maintained, and populated by professionals in soiled white coats. In spite of our efforts to educate for professionalism, we have good cause to worry about what our students learn. Perhaps the attention and efforts by medicine’s leaders and learned societies, as well as advocacy by medical educators, will have a signiacant impact on these features of the learning environment and help to vigorously promote medical professionalism. n