Margaret J. Tarpley

Medical Students' Experiences of Moral Distress: Development of a Web-Based Survey

Purpose To develop an instrument for measuring moral distress in medical students, measuring the prevalence of moral distress in a cohort of students, and identifying the situations most likely to cause it. Moral distress, defined as the negative feelings that arise when one knows the morally correct thing to do but cannot act because of constraints or hierarchies, has been documented in nurses but has not been measured in medical students. Method The authors constructed a survey consisting of 55 items describing potentially distressing situations. Responders rated the frequency of these situations and the intensity of distress that they caused. The survey was administered to 106 fourth-year medical students during a three-week period in 2007; the response rate was 60%. Results Each of the situations was experienced by at least some of the 64 respondents, and each created some degree of moral distress. On average, students witnessed almost one-half of the situations at least once, and more than one-third of the situations caused mild-to-moderate distress. The survey measured individual distress (Cronbach alpha = 0.95), which varied among the students. Whereas women witnessed potentially distressing situations significantly more frequently than did men (P = .04), men tended to become more distressed by each event witnessed (P = .057). Conclusions Medical students frequently experience moral distress. Our survey can be used to measure aspects of the learning environment as well as individual responses to the environment. The variation found among student responses warrants further investigation to determine whether students at either extreme of moral distress are at risk of burnout or erosion of professionalism.

Elective Global Surgery Rotations for Residents: A Call for Cooperation and Consortium

BackgroundInternational elective experiences are becoming an increasingly important component of American general surgery education. In 2011, the Residency Review Committee (RRC) approved these electives for credit toward graduation requirements. Previous surveys of general surgery program directors have established strong interest in these electives but have not assessed the feasibility of creating a national and international database aimed at educational standardization. The present study was designed to gain in-depth information from program directors about features of existing international electives at their institution and to ascertain interest in national collaboration.MethodsThis cross-sectional study of 253 United States general surgery program directors was conducted using a web-based questionnaire program.ResultsOf the program directors who responded to the survey, twelve percent had a formal international elective in place at their institution, though 80% of these did not have a formal associated curriculum for the rotation. Sixty percent of respondents reported that informal international electives existed for their residents. The location, length, and characteristics of these electives varied widely. Sixty-eight percent of program directors would like to participate in a national and international database designed to facilitate standardization of electives and educational exchange.ConclusionsIn a world of increasing globalization, international electives are more important than ever to the education of surgery residents. However, a need for standardization of these electives exists. The creation of an educational consortium and database of international electives could improve the academic value of these electives, as well as provide increased opportunities for twinning and bidirectional exchange.

Daily spiritual experiences of older adults with and without arthritis and the relationship to health outcomes

OBJECTIVE Strategies to improve coping with chronic disease are increasingly important, especially with the aging US population. For many, spirituality serves as a source of strength and comfort. However, little is known about the prevalence of daily spiritual experiences (DSE) and how they may relate to physical and mental health. METHODS We surveyed older adults age>50 years with chronic health conditions seen in a primary care setting about their DSE, health perceptions, pain, energy, and depression. RESULTS Of 99 patients, 80% reported DSE most days and many times per day. Women had significantly lower DSE scores than men (reflecting more frequent DSE, mean+/-SD 37.3+/-15.0 versus 45.8+/-17.5; P=0.012). African American women reported the most frequent DSE and white men reported the least frequent DSE (mean+/-SD 35.9+/-13.6 versus 52.2+/-19.1). Frequent DSE were significantly associated with a higher number of comorbid conditions (P=0.003), although not with age, education, or employment status. Persons with arthritis reported significantly more DSE than those without arthritis (mean+/-SD 35.2+/-12.1 versus 47.1+/-18.6; P<0.001). After adjustment for age, race, sex, pain, and comorbid conditions, more frequent DSE were associated with increased energy (P<0.009) and less depression (P<0.007) in patients with arthritis. CONCLUSION DSE are common among older adults, especially those with arthritis. Increased DSE may be associated with more energy and less depression. DSE may represent one pathway through which spirituality influences mental health in older adults.

Spiritual beliefs and barriers among managed care practitioners.

Purpose: Ninety percent of American adults believe in God and 82% pray weekly. A majority wants their physicians to address spirituality during their health care visit. However, clinicians incorporate spiritual discussion in less than 20% of visits. Our objectives were to measure clinician beliefs and identify perceived barriers to integrating spirituality into patient care in a statewide, primary care, managed care group. Methods: Practitioners completed a 30-item survey including demographics and religious involvement (DUREL), spirituality in patient care (SPC), and barriers (BAR). We analyzed data using frequencies, means, standard deviations, and ANOVA. Findings: Clinicians had a range of religious denominations (67% Christian, 14% Jewish, 11% Muslim, Hindu or Buddhist, 8% agnostic), were 57% female and 24% had training in spirituality. Sixty-six percent reported experiencing the divine. Ninety-five percent felt that a patient’s spiritual outlook was important to handling health difficulties and 68% percent agreed that addressing spirituality was part of the physician’s role. Ninety-five percent of our managed care group noted ‘8lack of time’ as an important barrier, ‘lack of training’ was indicated by 69%, and 21% cited ‘fear of response from administration’. Conclusions: Managed care practitioners in a time constrained setting were spiritual themselves and believed this to be important to patients. Respondents indicated barriers of time and training to implementing these beliefs. Comparing responses from our group to those in other published surveys on clinician spirituality, we find similar concerns. Clinician education may overcome these barriers and improve ability to more fully meet their patients’ expressed needs regarding spirituality and beliefs.

Global Surgery Opportunities for U.S. Surgical Residents: An Interim Report

INTRODUCTION In 2011, the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Surgery developed guidelines that allowed time spent and cases performed outside of the United States by surgical residents from ACGME-accredited training programs to be applied toward program completion. We hypothesized that the number of programs with global surgical rotations would have increased after that important development. We also sought to determine the characteristics that led to sustainment of such programs. METHODS An Institutional Review Board-approved electronic survey was sent to all 253 program directors of ACGME-approved general surgery residencies requesting information on international rotations available to residents. Responses were requested from program directors with extant rotations. Survey questions focused on locations, funding, nature of the rotations, faculty involvement, keys to success, and the barriers to overcome during program development and sustainment. RESULTS The survey reported 34 surgery residency programs offering global surgery rotations, up from 23 just 5 years previously. Of these reporting programs, 25 have been approved by the ACGME. Most rotations occur in the postgraduate year 3 or 4 and are primarily clinical rotations. Africa is the main destination. Resident supervision is provided by a mixture of host and home surgeons. A dedicated faculty is considered to be the most important element for success while funding remains a major impediment. CONCLUSIONS The interest in global surgery continues to increase, and general surgical programs will strive to meet the expectations of residents looking for international exposure. Collaboration could facilitate resident opportunities and potentially be more cost-effective.

Early experience in establishing and evaluating an ACGME-approved international general surgery rotation.

BACKGROUND In 2011, the Accreditation Council for Graduate Medical Education Surgery Residency Review Committee first provided guidelines for elective international general surgery rotations. The Vanderbilt general surgery residency program received Surgery Residency Review Committee approval for a fourth-year elective in Kenya beginning in the 2011-2012 academic year. Because this rotation would break ground culturally and geographically, and as an educational partnership, a briefing and debriefing process was developed for this ground-breaking year. OBJECTIVES Our objectives were to prepare residents to maximize the experience without competing for cases with local trainees or overburdening the host institution and to perform continuous quality assessment and improvement as each resident returned back. METHODS Briefing included health protection strategies, a procedures manual containing step-by-step preparation activities, and cultural-sensitivity training. Institutional Review Board exemption approval was obtained to administer a questionnaire created for returning residents concerning educational value, relations with local trainees, physical environment, and personal perceptions that would provide the scaffold for the debriefing conference. RESULTS The questionnaire coupled with the debriefing discussion for the first 9 participants revealed overall satisfaction with the rotation and the briefing process, good health, and no duty hours or days-off issues. Other findings include the following: (1) emotional effect of observing African families weigh cost in medical decision making; (2) satisfactory access to educational resources; (3) significant exposure to specialties such as urology and radiology; and (4) toleration of 4 weeks as a single and expressed need for leisure activity materials such as books, DVDs, or games. The responses triggered adjustments in the briefing sessions and travel preparation. The host institution invited the residents to return for the 2012-2013 year as well as 2013-2014. CONCLUSION Detailed preparation and the follow-up evaluation for assessment and improvement of this nascent international surgery experience are associated with resident satisfaction and the host institution has agreed to continue the rotation.

Spirituality in surgical practice1,2

The role of spirituality in surgical practice has long been recognized as important, but it is only now receiving detailed analysis. In 1910 the British Medical Journal invited Sir William Osler, the premier physician of his day, to editorialize about people who depended on faith and prayer rather than medical professionals for treatment and healing. Osler concluded this editorial with the comment, “. . . the whole subject is of intense interest to me. I feel that our attitude as a profession should not be hostile . . . A group of active, earnest, capable young men are at work on the problem, which is of their generation and for them to solve.” Four generations later the question remains unresolved. Unfortunately, until the last decade or so the academic medical community has expressed little interest in or support of physicians, and especially surgeons, who attempt to shed light on spiritual issues as related to medical outcomes. Arguably the most imaginative and productive surgeon scientist of the early 20th century was Alexis Carrel of France. In 1903 he witnessed and recounted a scientifically unexplainable (miraculous?) healing of a pilgrim in Lourdes. Subsequent to the resultant publicity, surgical superiors at the University of Lyon warned that he would likely fail his final examination; this threat possibly contributed to his leaving France for the United States, where he later received the 1912 Nobel Prize in physiology. His account of the Lourdes experience and a small volume on prayer were both published posthumously. Another surgeon who applied academic scrutiny to the study of spirituality as understood in psychologic terms was Barney Brooks, chairman of surgery at Vanderbilt University Hospital from 1925 to 1951. In the early 1940s Brooks secured funds from the Rockefeller Foundation to assess the psychologic makeup and needs of surgical patients. Brooks reported the findings in his 1943 presidential address, “Psychosomatic Medicine” at the Southern Surgical Association. His colleagues responded negatively when he asserted that mental preparation and the patient’s mindset were on par with surgical skill, so the surgeon was responsible in assisting with this mental preparation. Brooks also addressed the psychologic nature of the surgeon as vital to the patient-physician relationship, deeming some technically skilled but socially deficient people unworthy of the surgical profession. Although Brooks’s study design would never be approved by any institutional review board today, his conclusions asserting the importance of a surgeon’s social interactions with patients were far ahead of his time. Matthew Walker, chairman of surgery at Meharry Medical College from 1944 until 1973, insisted that medical students and physicians needed to be in touch with their own mortality if they were to assist patients and their families in dealing with end-of-life issues. Addressing the role for spirituality in surgical practice involves the historical perspective, definition clarification, public opinion, current practices, funding, communication skills, and even accreditation requirements. Spiritual issues daily influence academic medical centers. Chaplaincy services, while often underused, exist in most medical centers. Hospital food services accommodate Muslim, Jewish, vegetarian, and other dietary restrictions. Scheduling of clinics, procedures, and even staff vacations frequently takes into account religious holy days. Challenges to hospital regulations concerning clothing, hairstyles, and head coverings arise from cultural and faith traditions. Some surgeons have developed special techniques in caring for Jehovah’s Witnesses because of their aversion to blood products. Beliefs about after-death physical wholeness lead some patients and No competing interests declared.

A Randomized Controlled Trial to Assess Effectiveness of a Spiritually-Based Intervention to Help Chronically Ill Adults

Objective: Creative, cost-effective ways are needed to help older adults deal effectively with chronic diseases. Spiritual beliefs and practices are often used to deal with health problems. We evaluated whether a minimal intervention, consisting of a video and workbook encouraging use of patient spiritual coping, would be inoffensive and improve perceived health status. Methods: A randomized clinical trial of 100 older, chronically ill adults were assigned to a Spiritual (SPIRIT) or Educational (EDUC—standard cardiac risk reduction) intervention. Individuals in each group were shown a 28–minute video and given a workbook to complete over 4 weeks. Selected psychosocial and health outcome measures were administered at baseline and 6 weeks later. Results: Participants were mostly female (62%), with a mean age of 65.8 α 9.6 years and had an average of three chronic illnesses. More than 90% were Christian. At baseline, frequent daily spiritual experiences (DSE) were associated with being African American (p < .05) and increased pain (p < .01) and co-morbidities (p < .01). Energy increased significantly (p < .05) in the SPIRIT group and decreased in the EDUC group. Improvements in pain, mood, health perceptions, illness intrusiveness, and self-efficacy were not statistically significant. Conclusions: A minimal intervention encouraging spiritual coping was inoffensive to patients, associated with increased energy, and required no additional clinician time.

Integrating global health into surgery residency in the United States.

Department of Surgery, University of North Carolina, Chapel Hill, North Carolina, Brigham and Women’s Hospital, Center for Surgery and Public Health, Boston, Massachusetts, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, Texas Children’s Hospital, Baylor University, Houston, Texas; and Department of Surgery, Duke University, Durham, North Carolina

The Basics of PowerPoint and Public Speaking in Medical Education

ffective medical education presentations require a working nowledge of computer software such as Microsoft PowerPoint Microsoft Corporation, Redmond, Washington) and skills in ublic speaking. Electronic presentations require readability as ell as worthwhile content; projection before the scheduled resentation is necessary for evaluating layout and color. The ften overwhelming amount of data tempts the educator to rowd slides with graphs, illustrations, or tiny print and then to nnounce, “I know you can’t read this, but . . . .” Constructing ffective slides entails close attention to the number of text lines, ont size, and font style as well as templates and backgrounds to aximize visibility and readability. The medical educator can enefit from discovering and using features of PowerPoint such s the Master Slide for personalized templates, Custom Animaion, Compress, and the spelling and grammar checking softare. Preparation for oral and electronic presentations requires nowledge of the audience, careful choice of words, and timed ractice for clarity and appropriate volume. Medical educators depend on electronic and oral presentaions for didactic teaching, formal lectures, and research foums. Accusations such as “death by PowerPoint,” might be voided if educators, residents, and students acquire basic skills n public speaking as well as PowerPoint. After a discussion of elected features of Microsoft PowerPoint, the general princiles of public speaking will be addressed.