Michael W. Rabow

Professional Formation: Extending Medicine's Lineage of Service Into the Next Century

In his 1910 report on medical education, Flexner emphasized the importance of competency in basic sciences. Less widely recognized is that he also emphasized the necessity of liberal education. On the Flexner Reports 100th anniversary, medicine is challenged to realize Flexners full vision for medical education to ensure that physicians are prepared to lead lives of compassion and service as well as to perform with technical proficiency. To meet the complex medical and social challenges of the next century, medical educators must continue to promote cognitive expertise while concurrently supporting “professional formation”—the moral and professional development of students, their ability to stay true to their personal service values and the core values of the profession, and the integration of their individual maturation with growth in clinical competency. The goal of professional formation is to anchor students to foundational principles while helping them navigate the inevitable moral conflicts in medical practice. The consequences of inadequate support for professional formation are profound, impacting individual learners, patients, the profession, and society at large. Among the many successful professional formation projects nationally, two long-standing programs are described in modest detail to identify common elements that might guide future developments elsewhere. Key elements include experiential and reflective processes, use of personal narratives, integration of self and expertise, and candid discussion within a safe community of learners. Committing to professional formation within medical education will require transformation of formal and informal curricula and will necessitate a rebalancing of attention and financial support within schools of medicine.

Oncologist factors that influence referrals to subspecialty palliative care clinics.

PURPOSE Recent research and professional guidelines support expanded use of outpatient subspecialty palliative care in oncology, but provider referral practices vary widely. We sought to explore oncologist factors that influence referrals to outpatient palliative care. METHODS Multisite, qualitative interview study at three academic cancer centers in the United States with well-established palliative care clinics. Seventy-four medical oncologists participated in semistructured interviews between February and October 2012. The interview guide asked about experiences and decision making regarding outpatient palliative care use. A multidisciplinary team analyzed interview transcripts using constant comparative methods to inductively develop and refine themes related to palliative care referral decisions. RESULTS We identified three main oncologist barriers to subspecialty palliative care referrals at sites with comprehensive palliative care clinics: persistent conceptions of palliative care as an alternative philosophy of care incompatible with cancer therapy, a predominant belief that providing palliative care is an integral part of the oncologists role, and a lack of knowledge about locally available services. Participants described their views of subspecialty palliative care as evolving in response to increasing availability of services and positive referral experiences, but emphasized that views of palliative care as valuable in addition to standard oncology care were not universally shared by oncologists. CONCLUSIONS Improving provision of palliative care in oncology will likely require efforts beyond increasing service availability. Raising awareness of ways in which subspecialty palliative care complements standard oncology care and developing ways for oncologists and palliative care physicians to collaborate and integrate their respective skills may help.

The comprehensive care team: a description of a controlled trial of care at the beginning of the end of life.

OBJECTIVE To describe the characteristics, acceptability, and basic efficacy of an outpatient palliative care consultation service for patients with serious illness continuing to receive treatment for their underlying disease. DESIGN Structured interviews of intervention patients enrolled in a prospective, nonrandomized, controlled trial. SETTING General medicine practice in an urban, academic medical center. PATIENTS Ninety outpatients with cancer, advanced congestive heart failure, or advanced chronic obstructive pulmonary disease. INTERVENTIONS Palliative care consultation to primary care physicians (PCPs); educational and supportive services to patients and their families. OUTCOME MEASURES Physician referrals, program assessment by patients, observations of clinical consultation team members. RESULTS A majority of PCPs (61%) referred patients to the project, which provided an extensive panel of services despite significant financial constraints. Patients reported improved satisfaction with their family (85.7%), PCP (80%), and the medical center at large (65.7%) as a result of these services. Patients found discussing advance care planning difficult (66%), but desired these conversations (66%). Team members observed significant palliative care needs among this population of outpatients, however, PCPs did not implement a significant number of the consultation teams recommendations. CONCLUSIONS Outpatient palliative care consultation and services for patients continuing to pursue treatment of their underlying disease are acceptable and helpful to patients. However, barriers to implementation of palliative care treatments in this population must be explored.

Perceptions of Palliative Care Among Hematologic Malignancy Specialists: A Mixed-Methods Study

PURPOSE Patients with hematologic malignancies are less likely to receive specialist palliative care services than patients with solid tumors. Reasons for this difference are poorly understood. METHODS This was a multisite, mixed-methods study to understand and contrast perceptions of palliative care among hematologic and solid tumor oncologists using surveys assessing referral practices and in-depth semistructured interviews exploring views of palliative care. We compared referral patterns using standard statistical methods. We analyzed qualitative interview data using constant comparative methods to explore reasons for observed differences. RESULTS Among 66 interviewees, 23 oncologists cared exclusively for patients with hematologic malignancies; 43 treated only patients with solid tumors. Seven (30%) of 23 hematologic oncologists reported never referring to palliative care; all solid tumor oncologists had previously referred. In qualitative analyses, most hematologic oncologists viewed palliative care as end-of-life care, whereas most solid tumor oncologists viewed palliative care as a subspecialty that could assist with complex patient cases. Solid tumor oncologists emphasized practical barriers to palliative care referral, such as appointment availability and reimbursement issues. Hematologic oncologists emphasized philosophic concerns about palliative care referrals, including different treatment goals, responsiveness to chemotherapy, and preference for controlling even palliative aspects of patient care. CONCLUSION Most hematologic oncologists view palliative care as end-of-life care, whereas solid tumor oncologists more often view palliative care as a subspecialty for comanaging patients with complex cases. Efforts to integrate palliative care into hematologic malignancy practices will require solutions that address unique barriers to palliative care referral experienced by hematologic malignancy specialists.

Screening the soul: Communication regarding spiritual concerns among primary care physicians and seriously ill patients approaching the end of life

The purpose of this study was to explore the spiritual concerns of seriously ill patients and the spiritual-care practices of primary care physicians (PCPs). Questionnaires were administered to outpatients (n = 65, 90 percent response rate) with end-stage illness and to PCPs (n = 67, 87 percent response rate) in a diverse general medicine practice. Most patients (62 percent) and PCPs (68 percent) considered it important that physicians attend to patients’ spiritual concerns. However, few patients reported receiving such care, and most (62 percent) did not think it was the PCP’s job to talk about spiritual concerns. Although both seriously ill outpatients and PCPs assert the importance of spiritual concerns, PCPs often do not provide spiritual care. Appropriate provision of spiritual care within a diverse population of seriously ill outpatients is complex, necessitating appropriate and attentive screening.

Promise of professionalism: personal mission statements among a national cohort of medical students.

PURPOSE While historic medical oaths and numerous contemporary medical organizations offer guidelines for professionalism, the nature of the professional aspirations, commitments, and values of current medical students is not well known. We sought to provide a thematic catalogue of individual mission statements written by medical students nationally. METHODS In the Healer’s Art elective course, students write a personal mission statement about their highest professional values. In 2006–2007, we randomly selected 100 student mission statements from 10 representative schools nationally. Three researchers coded content using a team-based qualitative approach and categorized the codes into major themes. Student mission statements were compared with classic medical oaths and contemporary professionalism guidelines. RESULTS The mission statements were similar across different schools. Three major themes emerged, comprised of codes identified in 20% or more of the mission statements. The first theme, professional skills, includes dealing with the negatives of training, listening and empathy, growth and development. The second theme, personal qualities, includes wholeness, humility, and constancy/perfectionism. The third theme, scope of professional practice, includes physician relationships, positive emotions, healing, service, spirituality, and balance. Unlike the content of classic oaths and contemporary professionalism statements, the students’ statements dealt with fears, personal-professional balance, love, nonhierachical relationships, self-care, healing, and awe as key to being a physician. CONCLUSIONS In their personal mission statements, this national cohort of medical students described an expanded view of physicianhood that includes such elements as presence, love, and awe. Medical school curricula may require adaptation to support the personal aspirations of those now entering the profession.

Authentic Community as an Educational Strategy for Advancing Professionalism: A National Evaluation of the Healer’s Art Course

BackgroundEfforts to promote medical professionalism often focus on cognitive and technical competencies, rather than professional identity, commitment, and values. The Healer’s Art elective is designed to create a genuine community of inquiry into these foundational elements of professionalism.ObjectiveEvaluations were obtained to characterize course impact and to understand students’ conceptions of professionalism.DesignQualitative analysis of narrative course evaluation responses.ParticipantsHealer’s Art students from U.S. and Canadian medical schools.ApproachAnalysis of common themes identified in response to questions about course learning, insights, and utility.ResultsIn 2003–2004, 25 schools offered the course. Evaluations were obtained from 467 of 582 students (80.2%) from 22 schools participating in the study. From a question about what students learned about the practice of medicine from the Healer’s Art, the most common themes were “definition of professionalism in medicine” and “legitimizing humanism in medicine.” The most common themes produced by a question about the most valuable insights gained in the course were “relationship between physicians and patients” and “creating authentic community.” The most common themes in response to a question about course utility were “creating authentic community” and “filling a curricular gap.”ConclusionsIn legitimizing humanistic elements of professionalism and creating a safe community, the Healer’s Art enabled students to uncover the underlying values and meaning of their work—an opportunity not typically present in required curricula. Attempts to teach professionalism should address issues of emotional safety and authentic community as prerequisites to learning and professional affiliation.

Practices for Embedding an Interpretive Qualitative Approach Within a Randomized Clinical Trial

The embedded approach is a mixed methods design that is most commonly used when qualitative methods are embedded within intervention designs such as randomized clinical trials (RCTs). Scholars have noted challenges associated with embedded procedures and expressed concern that embedded designs undervalue and underutilize interpretive qualitative approaches. This article examines these issues in the context of a study about cancer pain management where qualitative methods were embedded within an RCT design. We describe our practices for stating embedded research questions, designing embedded qualitative data collection within the constraints of the RCT, and developing enriched understandings of the RCT through an interpretive qualitative analysis. These practices provide guidance for intervention researchers planning to embed qualitative components within RCT designs.

Pain Medication Management Processes Used by Oncology Outpatients and Family Caregivers Part II: Home and Lifestyle Contexts

CONTEXT Despite the increasing complexity of medication regimens for persistent cancer pain, little is known about how oncology outpatients and their family caregivers manage pain medications at home. OBJECTIVES To describe the day-to-day management of pain medications from the perspectives of oncology outpatients and their family caregivers who participated in a randomized clinical trial of a psychoeducational intervention called the Pro-Self(©) Plus Pain Control Program. In this article, we focus on pain medication management in the context of highly individualized home environments and lifestyles. METHODS This qualitative study was conducted as part of a randomized clinical trial, in which an embedded mixed methods research design was used. Audio-recorded dialogue among patients, family caregivers, and intervention nurses was analyzed using qualitative research methods. RESULTS Home and lifestyle contexts for managing pain medications included highly individualized home environments, work and recreational activities, personal routines, and family characteristics. Pain medication management processes particularly relevant in these contexts included understanding, organizing, storing, scheduling, remembering, and taking the medications. With the exception of their interactions with the intervention nurses, most study participants had little involvement with clinicians as they worked through these processes. CONCLUSION Pain medication management is an ongoing multidimensional process, each step of which has to be mastered by patients and their family caregivers when cancer treatment and supportive care are provided on an outpatient basis. Realistic patient- and family-centered skill-building interventions are needed to achieve effective and safe pain medication management in the contexts of individual home environments and lifestyles.

The Healer’s Art: Education in meaning and service

he Healer’s Art is a medical school elective developed by Rachel Naomi Remen, MD, of the Institute for the Study of Health and Illness (ISHI) with 4 goals in mind: (1) to provide support for medical students in recognizing, valuing, enhancing and preserving the human dimension of their work; (2) to enable students and physicians to experience and affiliate with the core values of the Hippocratic Oath: compassion, service, harmlessness, love, and justice as a way of life; (3) to enable students and physicians to experience the support of an egalitarian and collegial relationship that is nonjudgmental, noncompetitive, and “harmless”; and (4) to enable students and faculty to explore the concept of healing in Medicine and participate in relationships that promote healing. The Healer’s Art includes five 3-hour experiential and contemplative modules: Discovering and Nurturing Your Wholeness, Sharing Loss and Honoring Grief (2 sessions), Beyond Analysis: Allowing Awe in Medicine, and the Care of the Soul: Service as a Way of Life. These topics are core experiences of professionalism that physicians rarely discuss among themselves. In addition to the original 15-hour course curriculum designed for 1stand 2nd-year medical students, an advanced 6-hour curriculum offered as a day retreat or 2 sequential sessions is now available for 3rdand 4th-year students and residents. The Healer’s Art curriculum is both didactic and experiential—about 10% of course time uses a didactic approach. Noncognitive methodologies such as reflection on life experience or personal values comprise 90% of the course; students successfully participate in such holistic approaches as imagery, ritual, poetry writing, and journal keeping. Each session begins with a “seed talk” in the large group by a faculty member, followed by a guided reflection, and finally the sharing of student and faculty reflections and insights in small groups. Small groups consist of 5 students and a faculty and membership is held constant through each session of the course.