Orit Karnieli-Miller

Physician as partner or salesman? Shared decision-making in real-time encounters

The results of recent research have led to the increased advocacy of shared decision-making regarding medical treatment. Nonetheless, only a limited number of studies have focused on the process of decision-making in real-time encounters. The present paper aims to document and analyze this process. Specifically, we assess whether these decisions are the result of partnership or of persuasive tactics based on power and hierarchical relationships. We will describe and analyze different strategies used by pediatric gastroenterologists in breaking bad news encounters, as well as their consequences. The analysis is based on a multi-method, multi-participant phenomenological study on breaking bad news to adolescents and their families regarding a chronic illness. It included 17 units of analysis (actual encounters and 52 interviews with physicians, parents and adolescents). Data were collected from three hospitals in Northern Israel using observations and audiotapes of diagnosis disclosure encounters and audio-taped interviews with all participants. The analysis identified eight different presentation tactics used in actual encounters during which physicians made various use of language, syntax and different sources of power to persuade patients to agree with their preferred treatment choice. The tactics included various ways of presenting the illness, treatment and side effects; providing examples from other success or failure stories; sharing the decision only concerning technicalities; and using plurals and authority. The findings suggest that shared decision-making may be advocated as a philosophical tenet or a value, but it is not necessarily implemented in actual communication with patients. Rather, treatment decisions tend to be unilaterally made, and a variety of persuasive approaches are used to ensure agreement with the physicians recommendation. The discussion is focused on the complexity of sharing a decision, especially in the initial bad news encounter; and the potentially harmful implications on building a trusting relationship between the physician and the family when a decision is not shared.

Which experiences in the hidden curriculum teach students about professionalism

Purpose To examine the relationship between learner experience in the “hidden curriculum” and student attribution of such experiences to professionalism categories. Method Using the output of a thematic analysis of 272 consecutive narratives recorded by 135 students on a medical clerkship from June through November 2007, the authors describe the frequency of these experiences within and across student-designated Association of American Medical Colleges–National Board of Medical Examiners professionalism categories and employ logistic regression to link varieties of experience to specific professionalism categories. Results Thematic analysis uncovered two main domains of student experience: medical–clinical interaction and teaching-and-learning experiences. From a student perspective the critical incident stories evoked all professionalism categories. Most frequently checked off categories were caring/compassion/communication (77%) and respect (69%). Logistic regression suggested that student experiences within the teaching-and-learning environment were associated with professionalism categories of excellence, leadership, and knowledge and skills, whereas those involving medical–clinical interactions were associated with respect, responsibility and accountability, altruism, and honor and integrity. Experiences of communicating and working within teams had the broadest association with learning about professionalism. Conclusions Student narratives touched on all major professionalism categories as well as illuminating the contexts in which critical experiences emerged. Linked qualitative and quantitative analysis identified those experiences that were associated with learning about particular aspects of professionalism. Experiences of teamwork were especially relevant to student learning about professionalism in action.

Current knowledge and future directions about the disclosure of dementia: A systematic review of the first decade of the 21st century

The disclosure of Alzheimers disease presents a great challenge because it entails emotionally charged communication about a life‐threatening, incurable, and stigmatized disease. Although a broad consensus has evolved regarding the potential benefits of early disclosure of the diagnosis, little is known about how these recommendations are actually implemented, and there is limited published research about the process issues of the disclosure.

Exploring the Meaning of Respect in Medical Student Education: an Analysis of Student Narratives

ABSTRACTBACKGROUNDRespect for others is recognized in the medical literature and society as an essential attribute of the good medical professional. However, the specific meaning of respect varies widely and is underexplored as a lived experience of physicians-in-training.OBJECTIVETo describe third-year medical students’ narratives of respect and disrespect [(dis)respect] during their internal medicine clerkship.DESIGNQualitative thematic analysis of 152 third-year student narratives that ‘taught them something about professionalism,’ focusing on (dis)respect.APPROACHImmersion/crystallization narrative analysis.RESULTSWe reviewed 595 professionalism narratives and found that one in four narratives involved (dis)respect. We then found that 2/3 of these narratives were negative (describing instances of disrespect rather than respect). In the other coded categories, the proportion of negative narratives was significantly lower. In order to better understand these results, we analyzed the content of the (dis)respect narratives and identified six primary themes: (1) content and manner of communication (including, appreciating or belittling, being sensitive or blunt and respecting privacy); (2) conduct: behaviors expressing (dis)respect; (3) patient centeredness: honoring others’ preferences, decisions and needs; (4) treating others as equals; (5) valuing the other and their experience and/or problem; and (6) nurturing students’ learning.CONCLUSIONSFocusing on the lived experience of (dis)respect on wards broadens the concept of respect beyond any one type of act, behavior or attitude. Students perceive respect as a way of being that applies in all settings (private and public), with all participants (patients, family members, nurses, colleagues and students) and under all circumstances (valuing others’ time, needs, preferences, choices, opinions and privacy). Respect seems to entail responding to a need, while disrespect involves ignoring the need or bluntly violating it.

From Patient to Therapatient: Social Work Students Coping With Mental Illness

We explored the experiences of social work students with psychiatric difficulties and focused on their challenges as they went through the different stages of development as health care professionals. We interviewed 12 social work students with psychiatric difficulties and analyzed the data using the immersion/crystallization method. The findings reveal the developmental process they underwent from being patients to being “therapatients” (therapists who are also patients; here, therapists coping with psychiatric difficulties). This process included four stages: an initial exploration of the health care world; questioning the possibility of a patient being a therapist and feeling incompetent; identifying their ability to be professionals; and integrating between their patient and therapist parts to become a therapatient. Understanding this process and finding ways to help students through it is crucial to allowing the patient and therapist parts to “live” together and enrich each other, and to allowing integration of professional knowledge and personal experience.

Cloak of compassion, or evidence of elitism? An empirical analysis of white coat ceremonies

Context  White coat ceremonies (WCCs) are widely prevalent as a celebration of matriculation in medical schools. Critics have questioned whether these ceremonies can successfully combine the themes of professionalism and humanism, as well as whether the white coat is an appropriate symbol.

Understanding Values in a Large Health Care Organization through Work-Life Narratives of High-Performing Employees.

Objective— To understand high-performing frontline employees’ values as reflected in their narratives of day-to-day interactions in a large health care organization. Methods— A total of 150 employees representing various roles within the organization were interviewed and asked to share work-life narratives (WLNs) about value-affirming situations (i.e. situations in which they believed their actions to be fully aligned with their values) and value-challenging situations (i.e. when their actions or the actions of others were not consistent with their values), using methods based on appreciative inquiry. Results— The analysis revealed 10 broad values. Most of the value-affirming WLNs were about the story-teller and team providing care for the patient/family. Half of the value-challenging WLNs were about the story-teller or a patient and barriers created by the organization, supervisor, or physician. Almost half of these focused on “treating others with disrespect/respect”. Only 15% of the value-challenging WLNs contained a resolution reached by the participants, often leaving them describing unresolved and frequently negative feelings. Conclusions— Appreciative inquiry and thematic analysis methods were found to be an effective tool for understanding the important and sometimes competing role personal and institutional values play in day-to-day work. There is remarkable potential in using WLNs as a way to surface and reinforce shared values and, perhaps more importantly, respectfully to identify and discuss conflicting personal and professional values.

Manipulating the Placebo Response in Experimental Pain by Altering Doctor’s Performance Style

Background: Performance is paramount in traditional healing rituals. From a Western perspective, such performative behavior can be understood principally as inducing patients’ faith in the performer’s supernatural healing powers and effecting positive changes through the same mechanisms attributed to the placebo response, which is defined as improvement of clinical outcome in individuals receiving inactive treatment. Here we examined the possibility of using theatrical performance tools, including stage directions and scripting, to reproducibly manipulate the style and content of a simulated doctor–patient encounter and influence the placebo response in experimental pain. Methods: A total of 122 healthy volunteers (18–45 years, 76 men) exposed to experimental pain (the cold pressor test) were assessed for pain threshold and tolerance before and after receiving a placebo cream from a “doctor” impersonated by a trained actor. The actor alternated between two distinct scripts and stage directions, i.e., performance styles created by a theater director/playwright, one emulating a standard doctor–patient encounter (scenario A) and the other emphasizing attentiveness and strong suggestion, elements also present in ritual healing (scenario B). The placebo response size was calculated as the %difference in pain threshold and tolerance after exposure relative to baseline. In addition, subjects demonstrating a ≥30% increase in pain threshold or tolerance relative to baseline were defined as responders. Each encounter was videotaped in its entirety. Results: Inspection of the videotapes confirmed the reproducibility and consistency of the distinct scenarios enacted by the “doctor”-performer. Furthermore, scenario B resulted in a significant increase in pain threshold relative to scenario A. Interestingly, this increase derived from the placebo responder subgroup; as shown by two-way analysis of variance (performance style, F = 4.30; p = 0.040; η2 = 0.035; style × responder status interaction term, F = 5.21; p = 0.024) followed by post hoc analysis showing a ∼60% increase in pain threshold in responders exposed to scenario B (p = 0.020). Conclusion: These results support the hypothesis that structured manipulation of physician’s verbal and non-verbal performance, designed to build rapport and increase faith in treatment, is feasible and may have a significant beneficial effect on the size of the response to placebo analgesia. They also demonstrate that subjects, who are not susceptible to placebo, are also not susceptible to performance style.

Psychiatrists’ Challenges in Considering Disclosure of Schizophrenia Diagnosis in Israel

Doctors’ clear disclosure of diagnoses to patients is fundamental to patient autonomy and patient-centered approaches in health care. Although diagnosis disclosure is common in general health, it is less so in psychiatry. The aim of this study was to explore psychiatrists’ experiences of schizophrenia diagnosis disclosure to patients and/or family members. We conducted in-depth interviews with 14 psychiatrists from hospital and community settings in Israel and used a phenomenological framework to analyze the interviews. Overall, psychiatrists experienced disclosure as problematic, unproductive, and harmful. We identified 10 themes of psychiatrist experiences and concerns conceptualized under three domains: (a) characteristics of schizophrenia, (b) the doctor–patient/family relationship, and (c) psychiatrists’ difficulties with the disclosure task. We discuss the results suggesting a multilayered model of medical, relational, social, and personal disclosure challenges. We suggest that a constructive schizophrenia diagnosis disclosure needs to take into account psychiatrist- and patient-related factors and specify possible directions.

The Impact of Father-to-Mother Aggression on the Structure and Content of Adolescents’ Perceptions of Themselves and their Parents

This study examined the differential influence of the father’s level of aggression toward the mother on adolescents’ perceptions of their parents and of themselves and how these perceptions are interrelated. This study consisted of a probability sample of 1,014 Jewish Israeli youth between the ages of 13 and 18. The findings indicate that in cases in which there was no father-to-mother aggression, adolescents held a coherent image structure of the family members. With the emergence and increase in aggression, the coherence deteriorated. In cases of mild aggression, youths tended to identify with their fathers. As aggression intensified, in cases of severe aggression, the identification with the aggressor was increasingly difficult, and the youths tended to identify with their mother. Theoretical and practical implications of these findings are discussed.