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Ventres WB, Stone LA, Shapiro JF, Haq C, Leão JRB, Nease DE, Grant L, Mercer SW, Gillies JCM, Blasco PG, De Benedetto MAC, Moreto G, Levites MR, DeVoe JE, Phillips WR, Uygur JM, Egnew TR, Stanley CS. Storylines of family medicine V: ways of thinking-honing the therapeutic self. Fam Med Community Health 2024; 12:e002792. [PMID: 38609087 PMCID: PMC11029209 DOI: 10.1136/fmch-2024-002792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024] Open
Abstract
Storylines of Family Medicine is a 12-part series of thematically linked essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'V: ways of thinking-honing the therapeutic self', authors present the following sections: 'Reflective practice in action', 'The doctor as drug-Balint groups', 'Cultivating compassion', 'Towards a humanistic approach to doctoring', 'Intimacy in family medicine', 'The many faces of suffering', 'Transcending suffering' and 'The power of listening to stories.' May readers feel a deeper sense of their own therapeutic agency by reflecting on these essays.
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Affiliation(s)
- William B Ventres
- Family and Preventive Medicine, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas, USA
| | - Leslie A Stone
- Family and Preventive Medicine, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas, USA
| | - Johanna F Shapiro
- Family Medicine, University of California Irvine School of Medicine, Irvine, California, USA
| | - Cynthia Haq
- Family Medicine, University of California Irvine School of Medicine, Irvine, California, USA
| | | | - Donald E Nease
- Family Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, Colorado, USA
| | - Liz Grant
- Usher Institute, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - Stewart W Mercer
- Usher Institute, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - John C M Gillies
- Usher Institute, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | | | | | | | | | - Jennifer E DeVoe
- Family Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - William R Phillips
- Family Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jane M Uygur
- General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Thomas R Egnew
- Family Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Colette S Stanley
- General Internal Medicine, Geriatrics & Palliative Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
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Dowrick C. Medicine as a moral activity. Scand J Prim Health Care 2024; 42:1-2. [PMID: 38006212 PMCID: PMC10851805 DOI: 10.1080/02813432.2023.2285470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
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Epstein RM, Beach MC. "I don't need your pills, I need your attention:" Steps toward deep listening in medical encounters. Curr Opin Psychol 2023; 53:101685. [PMID: 37659284 DOI: 10.1016/j.copsyc.2023.101685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/07/2023] [Accepted: 08/07/2023] [Indexed: 09/04/2023]
Abstract
Patients highly value being listened to, taken seriously, heard, and understood; indeed, listening to patients is essential to alleviate suffering. Yet listening as a clinical skill has been virtually ignored in the training of physicians. In this paper, we synthesize literature related to listening in medicine and explore the internal and external challenges and complexity of listening - including the need to listen with a diagnostic as well as a relational ear to take in physical symptoms, emotions, and contexts - often in chaotic and time-pressured environments. We suggest physicians focus on the development of "deep listening" skills, involving cultivating curiosity, openness, reflective self-questioning, and epistemic reciprocity; we also suggest how to ensure patients know they are being listened to.
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Affiliation(s)
- Ronald M Epstein
- Center for Communication and Disparities Research, Departments of Family Medicine and Medicine (Palliative Care), Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, 1381 South Avenue, Rochester, NY 14620, USA.
| | - Mary Catherine Beach
- Department of Medicine (General Internal Medicine), School of Medicine, Berman Institute of Bioethics, Johns Hopkins University, 2024 East Monument Street, Baltimore, MD 21287, USA
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Lynch JM, van Driel M, Meredith P, Stange KC, Getz L, Reeve J, Miller WL, Dowrick C. The Craft of Generalism clinical skills and attitudes for whole person care. J Eval Clin Pract 2022; 28:1187-1194. [PMID: 34652051 DOI: 10.1111/jep.13624] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/16/2021] [Accepted: 09/12/2021] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Generalists manage a broad range of biomedical and biographical knowledge as part of each clinical encounter, often in multiple encounters over time. The sophistication of this broad integrative work is often misunderstood by those schooled in reductionist or constructivist approaches to evidence. There is a need to describe the practical and philosophically robust ways that understanding about the whole person is formed. In this paper we describe first principles of generalist approaches to knowledge formation in clinical practice. We name the Craft of Generalism. METHODS The newly described methodology of Transdisciplinary Generalism is examined by skilled generalist clinicians and translated into skills and attitudes useful for everyday generalist person-centred practice and research. RESULTS The Craft of Generalism defines the required scope, process, priorities, and knowledge management skills of all generalists seeking to care for the whole person. These principles are Whole Person Scope, Relational Process, Healing Orientation, and Integrative Wisdom. These skills and attitudes are required for whole person care. If any element of these first principles is left out, the resultant knowledge is incomplete and philosophically incoherent. CONCLUSIONS Naming the Craft of Generalism defines the generalist gaze and protects generalism from the colonization of a narrowed medical gaze that excludes all but reductionist evidence or constructivist experience. Defining the Craft of Generalism enables clear teaching of the sophisticated skills and attitudes of the generalist clinician. These philosophically robust principles encourage and defend the use of generalist approaches to knowledge in settings across the community - including health policy, education, and research.
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Affiliation(s)
- Johanna M Lynch
- Primary Care Clinical Unit, The University of Queensland, Brisbane, Queensland, Australia.,Integrate Place at Zest Infusion, Birkdale, Queensland, Australia
| | - Mieke van Driel
- Primary Care Clinical Unit, The University of Queensland, Brisbane, Queensland, Australia
| | - Pamela Meredith
- School of Health, Medical and Applied Sciences, Central Queensland University, Rockhampton, Queensland, Australia
| | - Kurt C Stange
- Center for Community Health Integration, Case Western Reserve University, Cleveland, Ohio, USA
| | - Linn Getz
- Department of Public Health and Nursing, NTNU: Norwegian University of Science and Technology, Trondheim, Norway
| | - Joanne Reeve
- Primary Care Research, Hull York Medical School, Hull, UK
| | - William L Miller
- Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA.,Department of Family Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Christopher Dowrick
- Institute of Population Health Sciences, University of Liverpool, Liverpool, UK
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Epstein RM, Marshall F, Sanders M, Krasner MS. Effect of an Intensive Mindful Practice Workshop on Patient-Centered Compassionate Care, Clinician Well-Being, Work Engagement, and Teamwork. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2022; 42:19-27. [PMID: 34459443 DOI: 10.1097/ceh.0000000000000379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Mindfulness-based interventions for health professionals have been linked to improvements in burnout, well-being, empathy, communication, patient-centered care, and patient safety, but the optimal formats and intensity of training have been difficult to determine because of the paucity of studies and the heterogeneity of programs. A 4-days residential "Mindful Practice" workshop for physicians and medical educators featuring contemplative practices, personal narratives, and appreciative dialogs about challenging experiences may hold promise in improving participants' well-being while also improving compassionate care, job satisfaction, work engagement, and teamwork. METHODS We collected baseline and 2-month follow-up data during four workshops conducted in 2018 to 2019 at conference centers in the United States and Europe. Primary outcomes were burnout, work-related distress, job satisfaction, work engagement, patient-centered compassionate care, and teamwork. RESULTS Eighty-five of 120 participants (71%) completed both surveys (mean age was 49.3 and 68.2% female). There were improvements (P < .01) in two of three burnout components (emotional exhaustion and depersonalization), work-related distress, job satisfaction, patient-centered compassionate care, work engagement and meaning, teamwork, well-being, positive emotion, mindfulness, somatic symptoms, and spirituality. Effect sizes (standardized mean difference of change) ranged from 0.25 to 0.61. With Bonferroni adjustments (P < .0031), teamwork, general well-being, and mindfulness became nonsignificant. DISCUSSION An intensive, multiday, mindfulness-based workshop for physicians had clinically significant positive effects on clinician well-being, quality of interpersonal care and work satisfaction, and meaning and engagement, all important indicators of improved health and sustainability of the health care workforce. Future iterations of the program should increase the focus on teamwork.
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Affiliation(s)
- Ronald M Epstein
- Mr. Epstein: Professor of Family Medicine, Oncology and Medicine (Palliative Care), and American Cancer Society's Clinical Research Professor, Codirector, Center for Communication and Disparities Research, Departments of Family Medicine and Medicine and the Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY. Mr. Marshall: Professor, Department of Neurology, Division of Geriatric Neurology, University of Rochester School of Medicine and Dentistry, Rochester, NY. Mr. Sanders: Senior Instructor, Department of Family Medicine, Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, NY. Mr. Krasner: Professor of Clinical Medicine and Clinical Family Medicine, Departments Medicine and Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
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Lam JTH, Hanson MD, Martimianakis MAT. Exploring the Socialization Experiences of Medical Students From Social Science and Humanities Backgrounds. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:401-410. [PMID: 31348068 DOI: 10.1097/acm.0000000000002901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE To explore the structural, cultural, and interpersonal issues that may contribute to the inadvertent marginalization of medical students with social science and humanities (SSH) backgrounds. METHOD Using the hidden curriculum as an analytic construct, the lead author interviewed 14 medical students with SSH backgrounds at the University of Toronto Faculty of Medicine from February to October 2015. The authors analyzed the interview transcripts for common themes around positive and negative cultural, structural, and interpersonal dimensions of the socialization process. RESULTS Participants reported barriers to applying to medical school: needing to complete prerequisite courses and to do well on an exam geared toward those with a strong science background (the Medical College Admission Test) and lacking an application cohort. Some participants felt they were not ideal candidates for medical school. Participants appreciated how their SSH backgrounds and associated skill sets shaped both their perspectives on patient care and their developing professional identities. However, they perceived that others largely deemed their previous training as irrelevant, and they felt marginalized in medical school by peers, instructors, and the curriculum. These experiences led both to self-censorship, which enabled them to seem to conform to normative behaviors, and to the pursuit of reaffirming elective experiences. CONCLUSIONS The existing hidden curriculum inadvertently marginalizes SSH medical students; their experiences likely reflect the socialization experiences of other students from underrepresented backgrounds. Curricular and institutional reforms are imperative to shift the hidden curriculum toward one of epistemological inclusion that better supports students from nontraditional backgrounds.
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Affiliation(s)
- Justin T H Lam
- J.T.H. Lam is resident physician, Department of Pediatrics, University of Toronto and Hospital for Sick Children, Toronto, Ontario, Canada; ORCID: http://orcid.org/0000-0002-7643-1179. M.D. Hanson is professor, Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; ORCID: http://orcid.org/0000-0002-0820-4521. M.A. Martimianakis is associate professor, Department of Pediatrics, University of Toronto and Hospital for Sick Children, and scientist, The Wilson Centre, University of Toronto and University Health Network, Toronto, Ontario, Canada; ORCID: http://orcid.org/0000-0002-2531-3156
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Tiredness of Life in Older persons: A Qualitative Study on Nurses’ Experiences of Being Confronted With This Growing Phenomenon. THE GERONTOLOGIST 2019; 60:735-744. [DOI: 10.1093/geront/gnz088] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Indexed: 02/03/2023] Open
Abstract
Abstract
Background and Objectives
With worldwide aging it is imperative to understand nurses’ perceptions of tiredness of life (ToL) and their ways of dealing with an increasingly common phenomenon. Most research on ToL relates to older individuals’ experiences. This study aimed to gain insight into nurses’ (a) perceptions of, (b) attitude(s) toward, and (c) ways of dealing with ToL in older patients.
Research Design and Methods
Qualitative study with elements of constructivist grounded theory. Data were collected by means of semi-structured interviews between February 2016 and June 2017 with a purposive sample of 25 nurses working in home care and nursing homes.
Results
A careful consideration indicative of an oscillation between 3 levels (e.g., behavioral, cognitive, and affective) is present. The confrontation with persons having ToL instigates a cognitive process of searching to understand the state a person is in, which on its turn ensues in an emotional balancing between courage and powerlessness and a behavioral approach of action or dialogue.
Discussion and Implications
Our findings indicate that nurses aim to provide good care, sensitive to the older person’s needs, but this process is not without ambiguity. This study provides nurse managers with valuable guidance to (a) support nursing staff in dealing with ToL, and (b) advance opportunities for emotionally sensitive care and (individual- and team-based) reflection. Finally, this study offers suggestions for education programs to incorporate ToL in curricula.
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Rodenbach RA, Norton SA, Wittink MN, Mohile S, Prigerson HG, Duberstein PR, Epstein RM. When chemotherapy fails: Emotionally charged experiences faced by family caregivers of patients with advanced cancer. PATIENT EDUCATION AND COUNSELING 2019; 102:909-915. [PMID: 30579772 PMCID: PMC6491225 DOI: 10.1016/j.pec.2018.12.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 11/23/2018] [Accepted: 12/12/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To explore family caregivers' emotional experiences while caring for patients with advanced cancer and navigating distressing information, awareness of dying, and difficult decisions. METHODS Qualitative descriptive study of semi-structured interviews with 92 bereaved caregivers of patients with advanced cancer. Interviews explored caregivers' experiences as patients transitioned out of active cancer treatment and neared the end of life. RESULTS Included in caregivers' characterization of this transition time were three particularly emotionally charged experiences. The first occurred when caregivers felt jolted into awareness that patients were dying.They were startled to realize that patients would die sooner than expected; some expressed frustration that they had not been adequately warned. In the second, caregivers felt conflicted when involved in decisions that pitted patients' preferences against what caregivers felt patients needed, resulting in ambivalence, guilt, and grief. Thirdly, caregivers who felt they did their best for patients expressed fulfillment and gratitude. CONCLUSION Caregivers of patients with advanced cancer face unique, emotionally charged experiences that can lead to distress and affect care at the end of life. PRACTICE IMPLICATIONS Awareness of these situations may help oncology teams to provide sufficient guidance and support, partner with caregivers to clarify patients' needs, and deliver higher quality care.
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Affiliation(s)
- Rachel A Rodenbach
- University of Pittsburgh Medical Center, 3459 5th Ave, Pittsburgh, PA, 15213, USA; Center for Communication and Disparities Research, 1381 South Ave, Rochester, NY, 14620, USA.
| | - Sally A Norton
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Marsha N Wittink
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Supriya Mohile
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Holly G Prigerson
- Weill Cornell Medicine, 413 E 69th St, New York City, NY, 10021, USA
| | - Paul R Duberstein
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA; Center for Communication and Disparities Research, 1381 South Ave, Rochester, NY, 14620, USA; Rutgers School of Public Health, 683 Hoes Lane West, Piscataway, NJ, 08854, USA
| | - Ronald M Epstein
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA; Center for Communication and Disparities Research, 1381 South Ave, Rochester, NY, 14620, USA
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Roze des Ordons AL, MacIsaac L, Everson J, Hui J, Ellaway RH. A pattern language of compassion in intensive care and palliative care contexts. BMC Palliat Care 2019; 18:15. [PMID: 30710999 PMCID: PMC6359837 DOI: 10.1186/s12904-019-0402-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 01/29/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Compassion has been identified as important for therapeutic relationships in clinical medicine however there have been few empirical studies looking at how compassion is expressed different contexts. The purpose of this study was to explore how context impacts perceptions and expressions of compassion in the intensive care unit and in palliative care. METHODS This was an inductive qualitative study that employed sensitizing concepts from activity theory, realist inquiry, phenomenology and autoethnography. Clinicians working in intensive care units and palliative care services wrote guided field notes on their observations and experiences of how suffering and compassion were expressed in these settings. Data were analyzed using constructivist grounded theory. RESULTS Fifty-eight field notes were generated, along with transcripts from three focus groups. Clinicians conceptualized, observed, and expressed compassion in different ways within different contexts. Patterns of compassion identified were relational, dispositional, activity-focused, and situational. A pattern language of compassion in healthcare was developed based on these findings. CONCLUSIONS Recognizing compassion as shifting patterns of diverse attitudes, behaviours, and relationships raises numerous questions as to how compassion can be developed, supported and recognized in different clinical settings.
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Affiliation(s)
- A. L. Roze des Ordons
- Department of Critical Care Medicine; Division of Palliative Medicine, Department of Oncology; Department of Anesthesiology, Cumming School of Medicine, University of Calgary, South Health Campus ICU, 4448 Front St SE, Calgary, AB T3M 1M4 Canada
| | - L. MacIsaac
- Alberta Health Services, Palliative Care Consult Service, Calgary Zone, Alberta Canada
| | - J. Everson
- Alberta Health Services, Palliative Care Consult Service, Calgary Zone, Alberta Canada
| | - J. Hui
- Department of Family Medicine; Division of Palliative Medicine, Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
| | - R. H. Ellaway
- Department of Community Health Sciences, Office of Health and Medical Education Scholarship, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
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Entwistle VA, Cribb A, Owens J. Why Health and Social Care Support for People with Long-Term Conditions Should be Oriented Towards Enabling Them to Live Well. HEALTH CARE ANALYSIS 2018; 26:48-65. [PMID: 27896539 PMCID: PMC5816130 DOI: 10.1007/s10728-016-0335-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
There are various reasons why efforts to promote “support for self-management” have rarely delivered the kinds of sustainable improvements in healthcare experiences, health and wellbeing that policy leaders internationally have hoped for. This paper explains how the basis of failure is in some respects built into the ideas that underpin many of these efforts. When (the promotion of) support for self-management is narrowly oriented towards educating and motivating patients to adopt the behaviours recommended for disease control, it implicitly reflects and perpetuates limited and somewhat instrumental views of patients. It tends to: restrict the pursuit of respectful and enabling ‘partnership working’; run the risk of undermining patients’ self-evaluative attitudes (and then of failing to notice that as harmful); limit recognition of the supportive value of clinician-patient relationships; and obscure the practical and ethical tensions that clinicians face in the delivery of support for self-management. We suggest that a focus on enabling people to live (and die) well with their long-term conditions is a promising starting point for a more adequate conception of support for self-management. We then outline the theoretical advantages that a capabilities approach to thinking about living well can bring to the development of an account of support for self-management, explaining, for example, how it can accommodate the range of what matters to people (both generally and more specifically) for living well, help keep the importance of disease control in perspective, recognize social influences on people’s values, behaviours and wellbeing, and illuminate more of the rich potential and practical and ethical challenges of supporting self-management in practice.
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Affiliation(s)
- Vikki A Entwistle
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, Scotland, UK.
| | - Alan Cribb
- School of Education, Communication and Society, King's College London, Waterloo Bridge Wing, Franklin-Wilkins Building, Waterloo Road, London, SE1 9NH, UK
| | - John Owens
- School of Education, Communication and Society, King's College London, Waterloo Bridge Wing, Franklin-Wilkins Building, Waterloo Road, London, SE1 9NH, UK
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Abstract
Many clinicians may feel poorly prepared to manage patient suffering resulting from the travails of chronic illness. This essay explores the thesis that chronically and terminally ill patients can be holistically healed by transcending the suffering occasioned by the degradations of their illnesses. Suffering is conveyed as a story and clinicians can encourage healing by co-constructing patients' illness stories. By addressing the inevitable existential conflicts uncovered in patients' narratives and helping them edit their stories to promote acceptance and meaning, suffering can be transcended. This requires that clinicians be skilled in narrative medicine and open to engaging the patient's existential concerns. By helping patients transcend their suffering, clinicians claim their heritage as healers.
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Affiliation(s)
- Thomas R Egnew
- Department of Family Medicine, University of Washington School of Medicine, Seattle, Washington
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Brezis M, Lahat Y, Frankel M, Rubinov A, Bohm D, Cohen MJ, Koslowsky M, Shalomson O, Sprung CL, Perry-Mezare H, Yahalom R, Ziv A. What can we learn from simulation-based training to improve skills for end-of-life care? Insights from a national project in Israel. Isr J Health Policy Res 2017; 6:48. [PMID: 29110738 PMCID: PMC5674237 DOI: 10.1186/s13584-017-0169-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 08/15/2017] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Simulation-based training improves residents' skills for end-of-life (EOL) care. In the field, staff providers play a significant role in handling those situations and in shaping practice by role modeling. We initiated an educational intervention to train healthcare providers for improved communication skills at EOL using simulation of sensitive encounters with patients and families. METHODS Hospital physicians and nurses (n = 1324) attended simulation-based workshops (n = 100) in a national project to improve EOL care. We analyzed perceptions emerging from group discussions following simulations, from questionnaires before and after each workshop, and from video-recorded simulations using a validated coding system. We used the simulation setting as a novel tool for action research. We used a participatory inquiry paradigm, with repetitive cycles of exploring barriers and challenges with participants in an iterative pattern of observation, discussion and reflection - including a description of our own responses and evolution of thought as well as system effects. RESULTS The themes transpiring included lack of training, knowledge and time, technology overuse, uncertainty in decision-making, poor skills for communication and teamwork. Specific scenarios demonstrated lack of experience at eliciting preferences for EOL care and at handling conflicts or dilemmas. Content analysis of simulations showed predominance of cognitive utterances - by an order of magnitude more prevalent than emotional expressions. Providers talked more than actors did and episodes of silence were rare. Workshop participants acknowledged needs to improve listening skills, attention to affect and teamwork. They felt that the simulation-based workshop is likely to ameliorate future handling of EOL situations. We observed unanticipated consequences from our project manifested as a field study of preparedness to EOL in nursing homes, followed by a national survey on quality of care, leading to expansion of palliative care services and demand for EOL care education in various frameworks and professional areas. CONCLUSIONS Reflective simulation exercises show barriers and paths to improvement among staff providers. When facing EOL situations, physicians and nurses use cognitive language far more often than emotions related expressions, active listening, or presence in silence. Training a critical mass of staff providers may be valuable to induce a cultural shift in EOL care.
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Affiliation(s)
- Mayer Brezis
- Center for Quality and Safety, Hadassah Medical Center & Braun School of Public Health, Hebrew University, Jerusalem, Israel.
| | - Yael Lahat
- Clalit Health Services, Tel Aviv, Israel
| | | | - Alan Rubinov
- Hadassah Medical Center & Hebrew University, Jerusalem, Israel
| | - Davina Bohm
- Center for Quality and Safety, Hadassah Medical Center & Braun School of Public Health, Hebrew University, Jerusalem, Israel
| | - Matan J Cohen
- Center for Quality and Safety, Hadassah Medical Center & Braun School of Public Health, Hebrew University, Jerusalem, Israel
| | - Meni Koslowsky
- Department of Psychology, Bar-Ilan University, Ramat Gan, Israel
| | - Orit Shalomson
- Israel Center for Medical Simulation (MSR), Chaim Sheba Medical Center, Tel Hashomer, Israel & Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | | | | | - Amitai Ziv
- Israel Center for Medical Simulation (MSR), Chaim Sheba Medical Center, Tel Hashomer, Israel & Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Abstract
The wonders of high-tech cancer care are best complemented by the humanity of high-touch care. Simple kindnesses can help to diffuse negative emotions that are associated with cancer diagnosis and treatment—and may even help to improve patients’ outcomes. On the basis of our experience in cancer care and research, we propose six types of kindness in cancer care: deep listening , whereby clinicians take the time to truly understand the needs and concerns of patients and their families; empathy for the patient with cancer, expressed by both individual clinicians and the care culture, that seeks to prevent avoidable suffering; generous acts of discretionary effort that go beyond what patients and families expect from a care team; timely care that is delivered by using a variety of tools and systems that reduce stress and anxiety; gentle honesty, whereby the truth is conveyed directly in well-chosen, guiding words; and support for family caregivers, whose physical and mental well-being are vital components of the care their loved ones receive. These mutually reinforcing manifestations of kindness—exhibited by self-aware clinicians who understand that how care is delivered matters—constitute a powerful and practical way to temper the emotional turmoil of cancer for patients, their families, and clinicians themselves.
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Affiliation(s)
- Leonard L. Berry
- Texas A&M University, College Station, TX; Institute for Healthcare Improvement, Cambridge, MA; Henry Ford Health System, Detroit, MI; and Monash University, Melbourne, Victoria, Australia
| | - Tracey S. Danaher
- Texas A&M University, College Station, TX; Institute for Healthcare Improvement, Cambridge, MA; Henry Ford Health System, Detroit, MI; and Monash University, Melbourne, Victoria, Australia
| | - Robert A. Chapman
- Texas A&M University, College Station, TX; Institute for Healthcare Improvement, Cambridge, MA; Henry Ford Health System, Detroit, MI; and Monash University, Melbourne, Victoria, Australia
| | - Rana L.A. Awdish
- Texas A&M University, College Station, TX; Institute for Healthcare Improvement, Cambridge, MA; Henry Ford Health System, Detroit, MI; and Monash University, Melbourne, Victoria, Australia
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Affiliation(s)
- Mark T. Hughes
- Berman Institute of Bioethics, Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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