Cultivating the Inner Life of a Physician Through Written Reflection

Preparing for the End of Life: Medical Students Completing Their Own Advance Directives Described Increased Empathy for Patients

BACKGROUND AND OBJECTIVES

Family medicine offers the opportunity to integrate advance care planning into routine primary care, connecting relationship-centered orientation with thoughtful action before a terminal diagnosis. However, physicians are undertrained in end-of-life counseling and care. To address this educational gap, we had clerkship students complete their own advance directives and submit a written reflection about the experience. The aim of this study was to learn about how students report on the value of completing their own advance directives, according to their written reflections. We hypothesized that self-described empathy, previously defined as understanding patients' emotions and communicating that understanding back to patients, would increase, as reported by students in their reflections.

METHODS

We analyzed 548 written reflections over 3 academic years using a qualitative content analysis approach. An iterative process included open coding, building of themes, and verification with the text by four professionally diverse researchers.

RESULTS

After completing their own advance directives, students reported increased empathy for patients facing end-of-life decisions and discussed the intention to change their future clinical practice regarding helping patients plan for the end of life.

CONCLUSIONS

Using experiential empathy, an approach to teaching and cultivating empathy in which the participants experience the topic first-hand, we directed medical students to consider their own end-of-life wishes. Upon reflection, many noted this process changed their attitudes and clinical approaches to patients' death. This learning experience could be one meaningful component of a longitudinal and comprehensive curriculum to prepare medical school graduates to help patients plan for and face the end of life.

A systematic scoping review of reflective writing in medical education

BACKGROUND

Reflective writing (RW) allows physicians to step back, review their thoughts, goals and actions and recognise how their perspectives, motives and emotions impact their conduct. RW also helps physicians consolidate their learning and boosts their professional and personal development. In the absence of a consistent approach and amidst growing threats to RW's place in medical training, a review of theories of RW in medical education and a review to map regnant practices, programs and assessment methods are proposed.

METHODS

A Systematic Evidence-Based Approach guided Systematic Scoping Review (SSR in SEBA) was adopted to guide and structure the two concurrent reviews. Independent searches were carried out on publications featured between 1st January 2000 and 30th June 2022 in PubMed, Embase, PsychINFO, CINAHL, ERIC, ASSIA, Scopus, Google Scholar, OpenGrey, GreyLit and ProQuest. The Split Approach saw the included articles analysed separately using thematic and content analysis. Like pieces of a jigsaw puzzle, the Jigsaw Perspective combined the themes and categories identified from both reviews. The Funnelling Process saw the themes/categories created compared with the tabulated summaries. The final domains which emerged structured the discussion that followed.

RESULTS

A total of 33,076 abstracts were reviewed, 1826 full-text articles were appraised and 199 articles were included and analysed. The domains identified were theories and models, current methods, benefits and shortcomings, and recommendations.

CONCLUSIONS

This SSR in SEBA suggests that a structured approach to RW shapes the physician's belief system, guides their practice and nurtures their professional identity formation. In advancing a theoretical concept of RW, this SSR in SEBA proffers new insight into the process of RW, and the need for longitudinal, personalised feedback and support.

Components of Successful Spiritual Care

The quantifiable health benefits of spiritual practice and religious community have inspired a movement toward addressing religion within health care and medical education, yet biomedical professionals still often avoid this topic (Giordano and Engebretson in Explore 2(3):216--225, 2006; Post et al. in Ann Intern Med 132(7):578, 2000). This is largely due to a lack of clarity on how to ethically engage with diverse spiritual practices and maintain professional boundaries regarding spiritual care. However, a majority of patients desire increased incorporation of spirituality in medical discussions, indicating a deficit in care that must be addressed (Best et al. in Patient Educ Couns 98(11):1320-1328, 2015; Zaidi in AMA J Ethics 20(7), 2018). In this article, I clarify what constitutes successful spiritual care by identifying its key components and major challenges. I then make recommendations for ethically mindful, comprehensive spiritual care and consider potential next steps including structural changes that prioritize compassion and empathy in medicine.

Interventions to reduce moral distress in clinicians working in intensive care: A systematic review

OBJECTIVE

To evaluate the effectiveness of interventions to mitigate the harmful effects of moral distress experienced by nursing and medical clinicians working in the intensive care setting.

DESIGN

Eligible studies were identified from searches of PubMed, EBSCO (Academic Search Complete, CINAHL and Medline) and Scopus. Included studies were published prior to 20 August 2020.

RESULTS

Twelve studies were included in this review comprising three randomised controlled trials, seven quasi-randomised trials and two observational studies. Nine studies reported interventions targeting only nurses while three included both nurses and doctors. The types of interventions identified included: moral empowerment programs, end-of-life educational programs, reflective exercises through individual narrative writing or group reflective debriefing, multidisciplinary case debriefing meetings integrated into clinical practice and moral resiliency training. Due to the overall low methodological quality and high risk of bias, no single intervention may be considered efficacious in managing moral distress.

CONCLUSIONS

There is weak evidence that some currently available interventions reduce the moral distress experienced by intensive care health care providers. Larger randomised trials involving all intensive healthcare clinicians are required to evaluate multifaceted interventions.

Spirituality and religion in residents and inter-relationships with clinical practice and residency training: a scoping review

OBJECTIVES

With the increased emphasis on personalised, patient-centred care, there is now greater acceptance and expectation for the physician to address issues related to spirituality and religion (SR) during clinical consultations with patients. In light of the clinical need to improve SR-related training in residency, this review sought to examine the extant literature on the attitudes of residents regarding SR during residency training, impact on clinical care and psychological well-being of residents and SR-related curriculum implemented within various residency programmes.

DESIGN

A scoping review was conducted on studies examining the topic of SR within residency training up until July 2020 on PubMed/Medline and Web of Science databases. Keywords for the literature search included: (Spirituality OR Religion) AND (Residen* OR "Postgraduate Medicine" OR "Post-graduate Medicine" OR "Graduate Medical Education").

RESULTS

Overall, 44 studies were included. The majority were conducted in North America (95.5%) predominantly within family medicine (29.5%), psychiatry (29.5%) and internal medicine (25%) residency programmes. While residents held positive attitudes about the role of SR and impact on patient care (such as better therapeutic relationship, treatment adherence and coping with illness), they often lacked the knowledge and skills to address these issues. Better spiritual well-being of residents was associated with greater sense of work accomplishment, overall self-rated health, decreased burnout and depressive symptoms. SR-related curricula varied from standalone workshops to continuous modules across the training years.

CONCLUSIONS

These findings suggest a need to better integrate appropriate SR-related education within residency training. Better engagement of the residents through different pedagogical strategies with supervision, feedback, reflective practice and ongoing faculty and peer support can enhance learning about SR in clinical care. Future studies should identify barriers to SR-related training and evaluate the outcomes of these SR-related curriculum including how they impact the well-being of patients and residents over time.

Mechanisms involved in the formation of professional identity by medical students

BACKGROUND

Despite in-depth discussions regarding professional identity of doctors, there is still a gap in our understanding of how this professional identity actually evolves.

OBJECTIVE

To outline some major mechanisms involved in formation of medical students' professional identity.

METHODS

A qualitative study based on thematic analysis. 296 diary entries, written by eight medical students as part of the three-year course 'Becoming a Physician,' were reviewed. The course, conducted in small groups, gradually exposes students to the clinical field, and emphasizes awareness to marginalized populations, and interpersonal communication skills.

RESULTS

Following the social constructivist learning theory, where learners individually and socially construct meaning attributed to their experiences, we identified three major mechanisms based on students' written reflections. These include linking current experiences to past; comparing different types or aspects of knowledge, doctors or medicine; and future perspective taking.

CONCLUSIONS

This study sheds light on the possible mechanisms used by medical students in forming their professional identity prior to their clinical training. Knowing these mechanisms can help medical educators better understand and support their students in formation of their professional identities. Conducting reflective writing could serve as an effective tool for learners to comprehend the meanings of their experiences.