Lara Hazelton

Group interventions for patients with cancer and HIV disease. Part I: Effects on psychosocial and functional outcomes at different phases of illness

Abstract Group interventions for individuals facing cancer or HIV disease have drawn considerable attention among researchers and clinicians over the past 20 years. There is growing evidence that group services may be helpful, but which interventions are most effective for participants at which phases in the trajectory of disease has been less clear. Moreover, professionals working in different intervention settings (e.g., primary prevention vs. clinical care) and different disease sites (cancer vs. HIV disease) often have little awareness of relevant advances in other fields. Efforts to integrate findings in the literature may accelerate research and advance the standard of clinical care. The current article, the first in a series of four special reports, critically evaluates the efficacy of group interventions led by professional or trained facilitators for individuals confronted by cancer or HIV, across the spectrum of illness from elevated risk through advanced disease. We examine psychosocial and functional outcomes for different interventions directed toward different patient subgroups, trace common themes, highlight limitations, and offer recommendations for further research.

Group interventions for patients with cancer and HIV disease: Part III. Moderating variables and mechanisms of action.

Abstract Growing evidence supports the value of group interventions for individuals who are at risk for or have developed cancer or HIV disease. However, information is more limited concerning how these services can be delivered in an optimal manner, and what processes contribute to their benefits. Parts I and II of this review examined the efficacy of different interventions for individuals at different phases of illness, ranging from primary prevention to late-stage disease, in both psychosocial and biological domains. The current paper examines some of the factors other than phase of illness that might influence group treatment effects (e.g., intervention parameters, participant characteristics), and explores mechanisms of action.

Group interventions for patients with cancer and HIV disease. Part II: Effects on immune, endocrine, and disease outcomes at different phases of illness

Abstract There has been great interest in the potential impact of group interventions on medical outcomes. This article reviews the effects of professionally-led groups on immune activity, neuroendocrine function, and survival among patients with cancer or HIV disease. We examine findings concerning different types of group services at different phases of illness. Results are mixed, but the most prominent changes in immune and endocrine activity were associated with structured group interventions for patients with early-stage disease. These findings offer provocative illustrations of relevant mind-body interactions, but their clinical importance has yet to be demonstrated empirically. Group interventions have not been tied consistently to improved survival rates for patients with advanced cancer; few studies as yet have focused on survival outcomes among patients with early-stage cancer or HIV disease.

Group Interventions for Patients with Cancer and HIV Disease: Part IV. Clinical and Policy Recommendations

Abstract Group interventions have assumed a growing role in primary prevention and supportive care for cancer and HIV disease. Earlier sections of this Special Report examined empirical findings for these interventions and provided recommendations for future research. The current section offers brief recommendations for service providers, policymakers, and stakeholders. Group services now occupy an increasingly prominent place in primary prevention programs and medical settings. In previous sections of this Special Report (Sherman, Leszcz et al., 2004; Sherman, Mosier et al., 2004a, 2004b) we examined the efficacy of different group interventions at different phases of cancer or HIV disease, considered characteristics of the intervention and the participants that might influence outcomes, and discussed mechanisms of action. Methodological challenges and priorities for future research were highlighted. In this, the final section, we offer brief recommendations for service providers, policymakers, and other stakeholders. We consider some of the barriers that constrain use of empirically-based group interventions and note how these programs might be implemented more widely and effectively.

Understanding, teaching and assessing the elements of the CanMEDS Professional Role: Canadian Program Directors’ views

Abstract Background: Physicians are required to maintain and sustain professional roles during their careers, making the Professional Role an important component of postgraduate education. Despite this, this role remains difficult to define, teach and assess. Objective: To (a) understand what program directors felt were key elements of the CanMEDS Professional Role and (b) identify the teaching and assessment methods they used. Methods: A two-step sequential mixed method design using a survey and semi-structured interviews with Canadian program directors. Results: Forty-six program directors (48% response rate) completed the questionnaire and 10 participated in interviews. Participants rated integrity and honesty as the most important elements of the Role (96%) but most difficult to teach. There was a lack of congruence between elements perceived to be most important and most frequently taught. Role modeling was the most common way of informally teaching professionalism (98%). Assessments were most often through direct feedback from faculty (98%) and feedback from other health professionals and residents (61%). Portfolios (24%) were the least used form of assessment, but they allowed residents to reflect and stimulated self-assessment. Conclusion: Program directors believe elements of the Role are difficult to teach and assess. Providing faculty with skills for teaching/assessing the Role and evaluating effectiveness in changing attitudes/behaviors should be a priority in postgraduate programs.

Changing Concepts of Neuroanatomy Teaching in Medical Education

Background: Anatomy teaching is often described as foundational in the education of physicians, but in recent years there has been increasing pressure on teachers of neuroanatomy to justify its place in the curriculum. Summary: This article examines theoretical assumptions that have traditionally influenced the neuroanatomy curriculum and explains how evolution of thought in the field of medical education has led to a shift in how the pedagogy of neuroanatomy is conceptualized. Conclusions: The widespread adoption of competency-based education, the emphasis on outcome-based objectives, patient- and learner-centered approaches, and a renewed interest in humanistic aspects of medical education have all contributed to a changing educational milieu. These changes have led to a number of curricular innovations. However, questions remain as to what should be taught to medical learners, and how best to teach it.

Exploring the Intersection of Mental Health and Humanities: the Dalhousie Psychiatry Student Writing Competition.

Medical educators have come to recognize the value of reflection in medicine, a process of emotional and cognitive engagement in which experiences are revisited to develop insights and construct personal meaning [1, 2]. The Association for Medical Education in Europe defines reflection as “a metacognitive process that occurs before, during, and after situations with the purpose of developing greater understanding of both the self and the situation so that future encounters with the situation are informed from previous encounters” [3] p. 685. There has been considerable interest in the role of reflection in medical education, with many educators implicitly or explicitly linking reflection to reading narratives or writing them [4, 5]. Many physicians have achieved recognition as writers, and there is a strong connection between medical and literary practice, especially in the elicitation and construction of stories [6, 7]. Recognizing this, numerous organizations have sponsored writing competitions for medical students, offering prizes and opportunities for publication. Some of these emphasize a scientific approach [8], whereas others focus on reflective writing with an effort to promote humanism [9]. Although many journals and websites publish winning entries, there is scant peer-reviewed literature regarding the process and experience of developing and administering these writing contests. Dalhousie University has a strong tradition in the medical humanities [10]. Since 2010, the Dalhousie Department of Psychiatry in Halifax, Nova Scotia, has sponsored an annual writing competition open to medical students and residents across Canada. The goals of this competition are to foster an interest in and awareness of psychiatry among medical learners, and to champion the importance of reflection and the medical humanities within the psychiatric community in Canada. Assumptions underlying the decision to institute a writing competition were that creative activity has intrinsic value, and that reflective writing may help learners make sense of clinical experiences. There was also a belief that psychiatry should recognize and support the contributions of narrative to understanding, witnessing, and interpreting medicine and medical life. To this end, participants are encouraged to submit works which explore the intersection of mental health and the humanities. The Dalhousie Faculty of Medicine Research Ethics Board has determined that the activity described in this article is exempt from ethical review as it does not meet the definition of research as defined in article 2.1 of the Tri-Council Policy Statement Ethical Conduct for Research Involving Humans. The competition is advertised locally and nationally to Dalhousie students and residents through brochures and emails and more broadly through the Canadian Organization for Undergraduate Psychiatry Education and the Canadian Association for Medical Education. Full competition rules are available on the Dalhousie Department of Psychiatry website. There are two categories of entries, one for medical students and the other for postgraduate trainees. Postgraduate trainees do not have to be from psychiatry programs, as mental health is relevant to many areas of medicine. To be eligible, medical students must be enrolled at a Canadian medical school, and postgraduate trainees must have an MD and be pursuing either residency or fellowship training at a Canadian medical school. Students from francophone (French-speaking) medical schools in Canada are eligible to participate, but all contest entries must be written in English. * Lara Hazelton Lara.Hazelton@cdha.nshealth.ca

Cinderology: the Cinderella of academic medicine

Although the study of childrens literature as it applies to medicine has traditionally been the province of the psychoanalytic field,[1][1] authors in other disciplines such as pediatrics have also devoted attention to the subject.[2][2] To our knowledge, however, the extent to which medical

Improving clinical care through the stories we tell

If there is any specialty that should be receptive to the proposition that stories can extend the limits of conventional medicine, it is psychiatry. The work of psychiatrists is inextricably tied to the stories our patients tell us, whether we are listening for diagnostic or therapeutic purposes. The inherent complexity of psychiatric conditions calls for a nuanced approach that is flexible enough to accommodate multiple interpretations of the plots, characters and metaphors that present themselves in the clinical setting. Until the day when we diagnose depression with a brain scan or social phobia with a blood test (a day that will surely never come), psychiatry will remain intertwined with narrative. But if this is the case, why has psychiatry not been more influential within the developing field of narrative medicine? This is one of the questions posed by Dr. Bradley Lewis in this book. Lewis, a psychiatrist and professor of medical humanities and cultural studies at New York University, has previously written books on psychiatry and post-modern philosophy. In Narrative Psychiatry, he argues that efforts to be rigorously scientific and biological have “cut psychiatry off from important humanistic trends in both medicine and psychotherapy” so that we have reached a point when, paradoxically, the rest of medicine is “more open than psychiatry to the human and the storied aspects of clinical work.” The rise of biopsychiatry has been one of the most significant and controversial developments in the short history of psychiatry as a specialty. Often those who criticize biopsychiatry and its connection to the pharmaceutical industry take an antipsychiatry stance. However, Lewis is not one of these. Nor does he restrict himself to purely philosophical considerations such as defining narrative psychiatry. Rather, he takes a clinically oriented approach to the question of how psychiatrists can incorporate the insights of narrative medicine and narrative therapy into their practice, one that does not reject the need for biological treatments when appropriate. Image courtesy of Johns Hopkins University Press A considerable portion of the book is devoted to a detailed analysis of a work of short fiction. Over several chapters, Lewis describes how psychiatrists from different theoretical orientations might formulate the difficulties faced by one of the fictional characters. The purpose is to demonstrate the varied conceptions of the case that are possible; one of the key tenets of narrative theory is that there is not a sole “truth” to be “discovered,” but many possible ways of understanding that each have advantages and disadvantages. The role of the practitioner is to remain curious, tolerant of ambiguity and open to whatever approach the patient will ultimately find most congruent and helpful. This book provides a good summary of the major philosophical shifts in psychiatry, as well as an overview of both narrative medicine and narrative therapy. The use of short fiction to illustrate how different forms of psychotherapy might approach the same case is clear and engaging, and would be a useful teaching resource for psychiatry residents or others learning about schools of psychotherapy for the first time. However, it may not have been necessary for Lewis to spend quite so much time describing multiple therapies for readers to grasp the basic idea that many different interpretations of the same case are possible. Instead, additional examples of narrative psychiatry in practice might have been useful. There is only a single chapter at the end of the book on “Doing narrative psychiatry,” leaving the reader who wishes to change his or her practice without much to go on. If Lewis is correct, then the growing strength of narrative within psychiatry will reduce the tensions within the specialty that arose from an over-reliance on biological models. Narrative Psychiatry is a well-written, timely and engaging book that will appeal to psychiatrists and any others who are interested in how narrative approaches might improve the care we provide to patients.

Smokers in the snow

I sit beside a window in the hospital library, down a hallway from the main desk, among the back issues of medical journals, bound and unbound, on rows of shelves. The only sound is the radiator by my feet blowing warm air up at me. This is one of my favourite places to read. Here at the margins of