Assertiveness in physicians' interpersonal professional encounters: A scoping review

PURPOSE

Good relationships between physicians, patients, families and the healthcare team are essential for high-quality care. Medical encounters are sometimes challenging. They may include conflicts, requiring physicians to be assertive: that is to share and protect their needs, rights and values while preserving those of others. Whereas assertiveness has been studied in patients and nursing staff (those with less power in healthcare), physicians' assertiveness, which must be mindful of these power differences, lacks a comprehensive review. Thus, this scoping review focuses on assertive communication in physicians' encounters.

METHODS

A literature search of four online databases: MEDLINE, Embase, PsycINFO and WoS, seeking articles on physicians' assertiveness as a communication style published until February 2022. The Joanna Briggs Institute approach and the Preferred Reporting Items for Systematic Reviews checklist underpinned the review protocol.

RESULTS

We identified 1513 articles relating to assertiveness, reviewed 153 full-text articles and selected 22 for full review, 68% from the last decade. The articles focused mainly on assertive communication and relationships with medical staff, with 54% focusing on bottom-up power relations. In 40% of the articles, no clear definition of assertiveness was included. Definitions included had varied focus: on self, on the other or both. Overall, assertiveness measures varied widely, precluding a methodical comparison.

CONCLUSIONS

Despite the growing interest in physicians' assertiveness, a clearer definition and in-depth exploration of assertiveness are needed alongside development of valid measures of assertiveness appropriate to physicians. Based on the review, we offer a relational definition of assertiveness as the capacity to communicate one's views, concerns, rights and needs while respecting others and preserving therapeutic, collegial and educational professional alliances. This definition may serve to expand research in the field while offering a professional alternative to problematic communication styles-passive and self-denying or paternalistic and aggressive -that obfuscate and thus undermine physician-patient relationships.

The hidden curriculum of breaking bad news: Identification of three dimensions and four communication patterns

OBJECTIVES

To explore students' observations in the hidden curriculum of physicians' breaking bad news interactions and identify dimensions and patterns within them.

METHODS

We qualitatively analyzed 156 written narrative descriptions of bad news encounters in the clinics written by senior medical students.

RESULTS

The analysis identified three dimensions within the encounters: providing information, dealing with emotions, and discussing treatment plans. These dimensions were observed in different proportions, identifying four communication patterns. Half of the encounters focused solely on presenting a treatment plan. Within them, the news was communicated abruptly while neglecting to share information or address emotions.

CONCLUSIONS

Compared to the main literature on breaking bad news that focuses on two dimensions-the present study identified a third, prominent dimension-discussing the treatment plan. Half of the hidden curriculum experiences contradict the taught protocol, paying little/no attention to emotion and information.

PRACTICE IMPLICATIONS

When teaching breaking bad news, it is essential to address the day-to-day practices students' observe. Students exposed to these encounters might misinterpret the physician's reliance on a single dimension as best practice. To mitigate this and help recognize their and others' tendency to focus primarily or solely on one dimension, we suggest a simple reflective prompt.

Burnout in Israeli medical students: a national survey

INTRODUCTION

Professional burnout is characterized by loss of enthusiasm for work, cynicism, and a low sense of personal efficacy. Burnout may adversely affect medical professionalism. Burnout is common in clinicians and varying rates have been reported in medical students. No data exist regarding the prevalence of burnout among Israeli medical students. The aims of this study were to assess the rate of burnout in Israeli medical students and to identify students who were particularly susceptible to burnout.

METHODS

A cross-sectional questionnaire design was employed, gathering data from medical students in all years of study across three medical schools. Burnout was measured using the Maslach Burnout Inventory Student Survey (MBI-SS), translated into Hebrew.

RESULTS

Of the 2160 students in the participating medical schools, 966 (44.7%) completed MBI-SS and demographic questionnaires. The overall burnout rate was 50.6%. Multivariate logistic regression analysis yielded that female gender, age under 25, advanced year of study, studying at a specific medical school and not being a parent are all significantly correlated with higher levels of burnout.

CONCLUSIONS

A high rate of burnout was found. The identification of young women who are not parents during advanced years of studies as being at-risk is important, in order to guide the development of burnout prevention interventions.

More Than Just an Entertainment Show: Identification of Medical Clowns' Communication Skills and Therapeutic Goals

Medical clowns (MCs) are trained professionals who aim to change the hospital environment through humor. Previous studies focused on their positive impact and began identifying their various skills in specific situations. When placed in pediatrics, MCs face various challenges, including approaching frustrated adolescents who are unwilling to cooperate with their care, dealing with their anxious parents, and communicating in a team in the presence of other health professionals. Research that systematically describes MCs' skills and therapeutic goals in meeting these challenges is limited. This article describes a qualitative, immersion/crystallization study, triangulating between 26 video-recorded simulations and 12 in-depth-semi-structured interviews with MCs. Through an iterative consensus-building process we identified 40 different skills, not limited to humor and entertainment. Four main therapeutic goals emerged: building a relationship, dealing with emotions, enhancing a sense of control, caring, and encouragement, and motivating treatment adherence. Mapping MCs' skills and goals enhances the understanding of MCs' role and actions to illustrate their unique caring practices. This clarification may help other healthcare professionals to recognize their practices and the benefits in involving them in care. Furthermore, other health professionals may apply some of the identified skills when faced with these challenges themselves.

Twelve tips to manage a breaking bad news process: Using S-P-w-ICE-S - A revised version of the SPIKES protocol

Breaking bad news (BBN) is a difficult task that requires multiple professional competencies. The way it is managed has implications for all involved in the encounter: the patient, family members, and the news provider. Existing guidelines were developed mainly at the turn of the millennium and require updating based on identification of daily clinical needs and pedagogical challenges while teaching the current protocols. Furthermore, there is a need to provide an overview of BBN encounters as a process, rather than a subdivided event, to help practitioners adopt an approach that might serve them in their daily routines. This twelve tips article summarizes research and practical experience for handling BBN encounters, from their preparation, through delivering the news while attending patients and family members' needs, toward documenting the news, and critically reflecting on the interaction. The tips are structured and explained to serve both practitioners and medical educators.

Position paper: Teaching breaking bad news (BBN) to undergraduate medical students

Sharing new medical information that is perceived as seriously effecting people's lives, i.e., breaking bad news (BBN) is important in caring for patients and relatives and is challenging for healthcare professionals. Optimal BBN requires incorporation and implementation of multiple professional competencies acquired gradually throughout years of training. The BBN encounter has implications for all participants: the patient, family members, their close social environments, and the deliverer of the news. Due to these implications and the accountability involved, medical schools invest educational resources in helping medical students develop this competency. The current paper summarizes literature, research, and teaching experiences while suggesting practical guidelines for designing and teaching a BBN course to undergraduate students. The following principles lie behind the recommendations: stepwise spiral continuity of exposure to and teaching of communication skills in various contexts while focusing on BBN in the advanced clinical years; relating the developing skills to broader humanistic studies; enhancing awareness of self-perspectives and beliefs regarding BBN; connecting to patients' and family members experiences and needs; providing a BBN protocol and opportunities for structured experiential learning followed by reflection and feedback; using observation and reflection to address gaps between theory and real-life practice; and creating continuity of learning about BBN through undergraduate, graduate, and continuing medical education. Applying this learning process can help enhance the management of these difficult conversations to improve patients' care during these difficult, life-changing encounters, and physicians' well-being.

Reflective writing in the teaching of communication skills for medical students-A systematic review

OBJECTIVE

To analyse the use, assessment, and measured outcomes of reflective writing (RW) in teaching communication to medical students.

METHODS

Systematic search of seven electronic databases, focused on using RW in teaching communication skills. Three reviewers selected and prepared the synthesis of the studies. The synthesis was based on thematic analysis using Braun and Clarke's approach.

RESULTS

We identified 1325 studies, reviewed 101 full-text articles, and included 12 articles in the analysis. The four themes identified showed that RW is not a stand-alone practice. RW is blended with other teaching strategies. Through RW, students identified structural, emotional, and relational aspects and challenges of communication. Only a few studies found a positive correlation between reflective ability and communication skills CONCLUSION: RW can be integrated with various teaching methods, at all stages of learning, to stimulate discussion of interpersonal and intrapersonal topics. Through RW, students explore theirs and their patient's emotions, values, behaviours, and needs identifying challenges and practices relevant to communication.

PRACTICE IMPLICATIONS

RW can address different structural, relational, and emotional issues that are relevant to communication learning. Further educational development and high-quality empirical research on the use of RW and unique outcomes are needed to support communication skills learning.

Food-seeking behavior is triggered by skin ultraviolet exposure in males

Sexual dimorphisms are responsible for profound metabolic differences in health and behavior. Whether males and females react differently to environmental cues, such as solar ultraviolet (UV) exposure, is unknown. Here we show that solar exposure induces food-seeking behavior, food intake, and food-seeking behavior and food intake in men, but not in women, through epidemiological evidence of approximately 3,000 individuals throughout the year. In mice, UVB exposure leads to increased food-seeking behavior, food intake and weight gain, with a sexual dimorphism towards males. In both mice and human males, increased appetite is correlated with elevated levels of circulating ghrelin. Specifically, UVB irradiation leads to p53 transcriptional activation of ghrelin in skin adipocytes, while a conditional p53-knockout in mice abolishes UVB-induced ghrelin expression and food-seeking behavior. In females, estrogen interferes with the p53-chromatin interaction on the ghrelin promoter, thus blocking ghrelin and food-seeking behavior in response to UVB exposure. These results identify the skin as a major mediator of energy homeostasis and may lead to therapeutic opportunities for sex-based treatments of endocrine-related diseases.

Time to rise to the challenge of truly implementing patient-centered care and shared decision-making in Israel: The educational and policy mission

Five years ago, Israel was perceived to be on the verge of implementing shared decision making (SDM). However, as presented in this paper, SDM in Israel remains relatively unexplored, is implemented in only few research interventions, and is rarely taught in medical schools or continuing education. Furthermore, policies on patient-centered care and SDM are limited and lack clear regulations and training on how to apply them. This situation is of concern. The paper describes the current state of SDM, identifying higher-level barriers to implementation. They include the need to address healthcare professionals' attitudes regarding patients and relationships; the need to rename and clearly define SDM terminology in Hebrew; the need to place SDM in the larger context and training of PCC; and the call for the development of clear policies, regulations, and training truly to rise to the need for national implementation of PCC and SDM.

Medical Students' and Trainees' Country-By-Gender Profiles: Hofstede's Cultural Dimensions Across Sixteen Diverse Countries

Purpose

The global mobility of medical student and trainee populations has drawn researchers' attention to consider internationalization in medical education. Recently, researchers have focused on cultural diversity, predominately drawing on Hofstede's cross-cultural analysis of cultural dimensions from general population data to explain their findings. However, to date no research has been specifically undertaken to examine cultural dimensions within a medical student or trainee population. This is problematic as within-country differences between gender and professional groups have been identified within these dimensions. We address this gap by drawing on the theoretical concept of national context effects: specifically Hofstede's six-dimensional perspective. In doing so we examine medical students' and trainees' country profiles across dimensions, country-by-gender clustering, and differences between our data and Hofstede's general population data.

Methods

We undertook a cross-cultural online questionnaire study (eight languages) containing Hofstede's 2013 Values Survey. Our questionnaire was live between 1st March to 19th Aug 2018, and December 2018 to mitigate country holiday periods. We recruited undergraduate medical students and trainees with at least 6-months' clinical training using school-specific methods including emails, announcements, and snowballing.

Results

We received 2,529 responses. Sixteen countries were retained for analyses (n = 2,307, 91%): Australia, Chile, China, Hong Kong, India, Indonesia, Ireland, Israel, Japan, Malaysia, New Zealand, Pakistan, South Africa, South Korea, Sri-Lanka, Taiwan. Power distance and masculinity are homogenous across countries. Uncertainty avoidance shows the greatest diversity. We identified four country clusters. Masculinity and uncertainty are uncorrelated with Hofstede's general population data.

Conclusions

Our medical student and trainee data provides medical education researchers with more appropriate cultural dimension profiles than those from general population data. Country cluster profiles stimulate useful hypotheses for further research, especially as patterning between clusters cuts across traditional Eastern-Western divides with national culture being stronger than gendered influences. The Uncertainty dimension with its complex pattern across clusters is a particularly fruitful avenue for further investigation.

Caring for the health and well-being of our learners in medicine as critical actions toward high-quality care

A recent paper has focused on residents' poor lifestyle habits and their potential negative impact on patients' lifestyles. This commentary argues that there are even greater reasons to be concerned about the health and well-being of residents and medical students and the resultant effects on patients throughout the careers of these learners. There is a "hidden curriculum", i.e., customs, rituals and norms of behavior, in medical education and in the training at the healthcare setting, often contradicts the formal curriculum and include messages that neglect the basic needs of the learners as well as the patients. Due to the impact of these messages on the professional identity formation of learners, including a deterioration in their own wellbeing as well as impairment of their ability to empathize with and care for patients, we must align our formal and hidden curricula to show dignity and caring for learners, colleagues, and patients. To do this well, we need to change our approach. We need to add processes for learners to support them in dealing with the stresses of their education and training and allow them to build their families and commit fully to medicine as a vocation, not just a job. We also must add faculty development processes to help align the formal and hidden curricula and help faculty empower and constructively assist their learners to handle challenging situations, e.g., where they see a resident struggling with patient care and day-to-day workload, through empathic feedback. When our learners are treated with kindness and respect they will lead more fulfilling lives and be better able to provide the high-quality care and caring all patients deserve.

Skin exposure to UVB light induces a skin-brain-gonad axis and sexual behavior

Ultraviolet (UV) light affects endocrinological and behavioral aspects of sexuality via an unknown mechanism. Here we discover that ultraviolet B (UVB) exposure enhances the levels of sex-steroid hormones and sexual behavior, which are mediated by the skin. In female mice, UVB exposure increases hypothalamus-pituitary-gonadal axis hormone levels, resulting in larger ovaries; extends estrus days; and increases anti-Mullerian hormone (AMH) expression. UVB exposure also enhances the sexual responsiveness and attractiveness of females and male-female interactions. Conditional knockout of p53 specifically in skin keratinocytes abolishes the effects of UVB. Thus, UVB triggers a skin-brain-gonadal axis through skin p53 activation. In humans, solar exposure enhances romantic passion in both genders and aggressiveness in men, as seen in analysis of individual questionaries, and positively correlates with testosterone level. Our findings suggest opportunities for treatment of sex-steroid-related dysfunctions.

•

UVB exposure increases circulating sex-steroid levels in mice and humans

•

UVB exposure enhances female attractiveness and receptiveness toward males

•

UVB exposure increases females’ estrus phase, HPG axis hormones, and follicle growth

•

Skin p53 regulates UVB-induced sexual behavior and ovarian physiological changes

[THE EXPERIENCE OF OBSTETRICIANS DURING THE FIRST OUTBURST OF COVID-19]

INTRODUCTION

The COVID-19 pandemic posed unique challenges to medical teams in general and in the field of obstetrics in particular, where the provision of medical services could not be postponed. Optimal care during the COVID-19 outburst required rapid adjustment to changes, ensuring staff and patients' safety while maintaining close and direct contact with patients.

OBJECTIVES

To explore obstetricians' experiences during the first outburst, focusing on their challenges, needs and ways of coping.

METHODS

Semi-structured in-depth interviews were conducted online with 13 senior physicians and residents (7 women, 6 men) from four hospitals, who worked in obstetrics. The interviews were analyzed using the Immersion/Crystallization method developed in medicine focused on their experiences.

RESULTS

The findings revealed that alongside the impressive mobilization of the teams during this period, physicians encountered various challenges. These included being overwhelmed with the ever-changing and often conflicting guidelines; a feeling of lack of transparency and loss of trust in the system that did not always protect them nor provided their basic needs; difficulty in maintaining daily needed routines, such as communication within the team; dealing with patients' and their families anxiety; and striving to maintain a positive childbirth atmosphere along with having to set boundaries and keep distance. The teams felt the need for training in dealing with patients' and staff's emotional needs as well as finding ways to maintain a professional-friendly relationship among team members.

CONCLUSIONS

The COVID-19 period forced obstetricians to change procedures and conduct themselves differently. They demonstrated a great commitment to assuring that women have a positive childbirth experience, even within the limitations of COVID. They experienced great difficulty as they themselves were dealing with fears of the virus, distancing from others, and addressing new emerging needs.

DISCUSSION

Reports from around the world and the findings of the current study indicate the importance of developing processes that will enhance physicians' and patients' trust, to allow physicians to feel safe and cared for and to be able to provide high-quality care Identifying the challenges, needs and strengths of the medical teams can help in dealing with this and future pandemics. This requires caring for physicians, as individuals, as family members, as team members, along with provision of training that can help them communicate well to provide high-quality safe care.

Medical students' experiences and needs from written reflective journal feedback

INTRODUCTION

Reflective ability is an important skill for enhancing professionalism and developing communication skills. To improve reflective ability, medical educators encourage use of written reflective journals, for which feedback is important. It is difficult for educators to anticipate how their feedback will be perceived. Therefore, this study examined students' experiences with educators' written feedback on reflective journals.

METHODS

A qualitative, immersion/crystallization analysis of 60 written feedback texts to 15 medical students (30 identified by students as meaningful and 30 as less meaningful) and in-depth semi-structured interviews with these students. We did not define 'meaningful', to leave room for students' own interpretations. We analysed the feedback to identify what it includes (its components) and analysed the interviews to learn about students' experiences of receiving the feedback and the specific components.

RESULTS

Students experienced five components as meaningful: supportive and encouraging statements; legitimisation of their emotions; educators sharing personal-professional experiences; asking questions to enhance reflection; and focusing on the students' main concern. These components enhanced students' willingness to read and learn from the feedback. Three components were experienced as less meaningful: detached, impersonal feedback; negative tone (criticism); and technical issues, for example brevity. These disappointing and hurtful components led students to pay less attention to the feedback or to invest less effort in future written assignments.

CONCLUSIONS

The present study identified components in written reflective journal feedback texts and the experience and needs of students who received them. It showed the complexity of writing reflective feedback because of the need to support students through it, help them deal with emotions, identify and focus on personal content that matters to them, and provide opportunities to develop and enhance their reflective ability, while being mindful of their emotional state. To help educators in this challenging task, a self-assessment mnemonic ('FEEDBACK') for use before sending the initial feedback was developed.

Core experiences of parents of children with autism during the COVID-19 pandemic lockdown

LAY ABSTRACT

The lockdown and home isolation due to the COVID-19 pandemic led to significant transformation in lifestyles. Being a parent in this situation was not easy for anyone, much less for parents of children with special needs. The shutting down of special education systems meant that parents lost a vital support network and had to be the sole full-time caregivers despite often lacking the skills to cope with this new and daunting situation. We interviewed parents and learned that the main difficulties faced by homebound autistic children stemmed from the change in routine, lack of special education services, limited physical space, and food- and sleep-related issues. Some children experienced worsening in behavioral, social, and developmental domains, yet others seemed to not only overcome the challenges of changing conditions but even benefit from them. The children's success or failure was directly related to how their parents coped. The key factors that enabled successful coping were the parents' ability to accommodate to the child's needs, their own creativeness and resourcefulness, and a generally positive outlook. The results of this analysis revealed that the best way to benefit autistic children caught up in drastic changes in their routine lifestyle is to invest in a strong support system for their parents.

The associations between reflective ability and communication skills among medical students

OBJECTIVES

Assess associations between medical students' reflective ability demonstrated in written narratives, and communication skills demonstrated later in simulated-patient breaking bad news interactions.

METHODS

We analyzed 66 medical students' reflective ability, using 'REFLECT' rubric and four newly developed parameters: Noticing Explanations provided to patients, Noticing Emotions, Remoteness/Connectedness in their writing, and mentioning Self-Emotions. 'BAS' and 'SPIKES' questionnaires measured students' communication skills. Spearman and Chi-square tests examined correlations among all variables. Multiple regressions examined associations between reflective ability and demographic variables with communication skills.

RESULTS

Significant positive correlations between students' reflective ability, measured by REFLECT and three of the new parameters, and global communication skill scores. Reflective ability of Noticing Explanations in writing was associated with ability to tailoring information to patients' needs and address emotions.

CONCLUSIONS

High reflective ability may improve communication skills. Specifically, ability to notice explanations to patients may enhance later capability to tailor information to patients and address emotions empathically.

PRACTICE IMPLICATIONS

Encourage educational interventions enhancing reflective ability; specifically observation and detailed writing about how explanations are given to patients and patients' reactions to them. This process may help students develop competency to share and tailor difficult information sensitively-a critical skill when communicating bad news.

The Delivery of Diagnosis by Child Psychiatrists: Process Characteristics and Correlates of Distress

We describe the attitudes of child psychiatrists toward diagnosis delivery (DD) and explore potential stressful factors associated with the process. Eighty Israeli child psychiatrists completed a questionnaire on their perceptions of DD of schizophrenia, autism spectrum disorder (ASD), and attention deficit/hyperactivity disorder (ADHD). We also conducted semi-structured in-depth interviews with 12 child psychiatrists who were asked to share their personal experience with DD. The questionnaire responses revealed that child psychiatrists perceived schizophrenia and ADHD as the most and least severe disorders, respectively, and its treatment as being ineffective and effective, respectively. They expressed negative perceptions toward DD of schizophrenia and positive perceptions toward DD of ADHD. The results of linear regressions revealed that some factors predicted distress accompanying DD in all three diagnoses, such as lack of professional experience, negative perceptions of DD, and the effect of parents' attitudes of opposition to the diagnosis. The interviews revealed that DD was often described by psychiatrists as an emotional experience and that the psychiatrists' age, and whether the psychiatrists identified more with the child or the parent, affected their attitude toward DD. Lastly, the psychiatrists expressed feelings of loneliness in the procedure of DD and their wish to share and reflect on their experiences with others. These findings may contribute to a better understanding of the clinically important topic of DD in child psychiatry that has not been adequately addressed and help deal with psychiatrists' challenges in this task.

Reflective practice in the teaching of communication skills

Reflective practice is encouraged in medical education in general and in teaching communication skills in particular to develop into a reflective practitioner. However, the term is complex to understand and multidimensional thus challenging to grasp, describe and teach. Furthermore, though used frequently little guidance exists on how to promote reflective ability in teaching communication skills. This paper builds on a keynote address delivered at the International Conference of Communication in Healthcare (ICCH 2019) and is based on the vast literature on reflection and the author's personal experience as a researcher and educator. It discusses the components of reflective practice as well as exemplifies the importance of reflective practice to student's capability to learn communication skills.

Students' patient-centered-care attitudes: The contribution of self-efficacy, communication, and empathy

OBJECTIVES

Patient-centered-care (PCC) attitudes are important to enhance PCC behavior, but research on perceptions and attitudes that contribute to PCC attitudes is limited. We tested a new model, assessing whether the association between self-efficacy and PCC attitudes is mediated by communication and empathy attitudes. Furthermore, we assessed medical-school-stage and gender differences in these variables.

METHODS

Medical/dentistry students (N = 653) completed self-reported questionnaires. Analyses were performed using Pearson's-correlations, PROCESS macro, and independent samples t-tests.

RESULTS

The association between communication self-efficacy and PCC attitudes was completely mediated by communication and empathy attitudes. Students in clinical years had more positive attitudes toward PCC and empathy, and higher communication self-efficacy. Females had more positive attitudes toward PCC, communication, and empathy.

CONCLUSIONS

The results emphasize the importance of communication self-efficacy and the mediating role of communication and empathy attitudes in enhancing PCC attitudes. This highlights the need to focus on learners' affective matter (what they feel/think) about their competencies and attitudes.

PRACTICE IMPLICATIONS

Educational interventions should improve understanding of the benefits of applying good communication skills, of learning the importance of empathy and its relevance to patient care, and strengthening students' confidence in applying these skills. Attention to these is important for enhancing students' PCC attitudes.

Shared Decision Making for Psychiatric Rehabilitation Services Before Discharge from Psychiatric Hospitals

Shared decision making (SDM) is an effective health communication model designed to facilitate patient engagement in treatment decision making. In mental health, SDM has been applied and evaluated for medications decision making but less for its contribution to personal recovery and rehabilitation in psychiatric settings. The purpose of this pilot study was to assess the effect of SDM in choosing community psychiatric rehabilitation services before discharge from psychiatric hospitalization. A pre-post non-randomized design with two consecutive inpatient cohorts, SDM intervention (N = 51) and standard care (N = 50), was applied in two psychiatric hospitals in Israel. Participants in the intervention cohort reported greater engagement and knowledge after choosing rehabilitation services and greater services use at 6-to-12-month follow-up than those receiving standard care. No difference was found for rehospitalization rate. Two significant interaction effects indicated greater improvement in personal recovery over time for the SDM cohort. SDM can be applied to psychiatric rehabilitation decision making and can help promote personal recovery as part of the discharge process.

Assessing an Intervention Focused on Enhancing Interpersonal Communication Skills and Humor: A Multi-Method Quasi-Experiential Study Among Medical Students

Teaching and applying interpersonal communication skills (ICS) and humor in medicine is challenging. The present study assessed an innovative course focused on enhancing ICS and humor based on the Four Habits Model and theater concepts. Medical students enrolled in the course (the study group) were assessed pre- and post-intervention, as well as compared with their peers (the control group) using quantitative methods to measure attitudes, self-efficacy, and behaviors. Qualitative methods were used to learn about students' change in perceptions related to ICS and humor following the course, as well as their experiences of developing these skills during the course. Post-intervention study group participants scored significantly higher on all ICS measurements and on humor behavior compared with pre-intervention, and significantly higher on all humor measurements compared with control group participants. Interviews indicated students' increased understanding and difficulties in learning these skills. Analyses showed how framing humor as one possible ICS and focusing on specific parts of the medical encounter can promote patient-centered care.

What you "see" is how you communicate: Medical students' meaning making of a patient's vignette

OBJECTIVES

To examine how medical students notice issues in a vignette and construct their meaning, and how this construction influences their plan to communicate with the patient.

METHODS

Following a breaking bad news course for 112 senior medical students, we qualitatively analyzed the participants' written descriptions of the issues they noticed as requiring special attention, using an Immersion/Crystallization iterative consensus process.

RESULTS

Different students noticed different issues, but no-one noticed all 19 planted issues (Mean of issues noticed by students = 6.77; SD = 2.29). The students wrote about the issues in 46 different ways, representing the diverse meanings they ascribed, ranging from identifying, through inferring, to interpreting while jumping to conclusions. Moreover, for some issues, some students focused on the patient whereas others focused on the physician or the physician-patient relationship. Noticing issues led to preparing for communication with the patient.

CONCLUSIONS

Noticing the issues and the subsequent meaning-making process facilitated the preparation to address them in the envisioned encounter.

PRACTICE IMPLICATIONS

When teaching communication skills, it would be helpful to focus on increasing students' awareness of the issues they notice or fail to notice and their personal meaning-making process. This might reduce bias and enhance their preparation for effective patient-centered communication.

See, reflect, learn more: qualitative analysis of breaking bad news reflective narratives

CONTEXT

Breaking bad news (BBN) is a challenge that requires multiple professional competencies. BBN teaching often includes didactic and group role-playing sessions. Both are useful and important, but exclude another critical component of students' learning: day-to-day role-model observation in the clinics. Given the importance of observation and the potential benefit of reflective writing in teaching, we have incorporated reflective writing into our BBN course. The aim of this study was to enhance our understanding of the learning potential in reflective writing about BBN encounters and the ability to identify components that inhibit this learning.

METHODS

This was a systematic qualitative immersion/crystallization analysis of 166 randomly selected BBN narratives written by 83 senior medical students. We analysed the narratives in an iterative consensus-building process to identify the issues discussed, the lessons learned and the enhanced understanding of BBN.

RESULTS

Having previously been unaware of, not invited to or having avoided BBN encounters, the mandatory assignment led students to search for or ask their mentors to join them in BBN encounters. Observation and reflective writing enhanced students' awareness that 'bad news' is relative and subjective, while shedding light on patients', families', physicians' and their own experiences and needs, revealing the importance of the different components of the BBN protocol. We identified diversity among the narratives and the extent of students' learning.

DISCUSSION

Narrative writing provided students with an opportunity for a deliberative learning process. This led to deeper understanding of BBN encounters, of how to apply the newly taught protocol, or of the need for it. This process connected the formal and informal or hidden curricula. To maximise learning through reflective writing, students should be encouraged to write in detail about a recent observed encounter, analyse it according to the protocol, address different participants' behaviours and emotions, and identify dilemmas and clear lessons learned.

On the verge of shared decision making in Israel: Overview and future directions

Israel has a universal-national healthcare system and a progressive health policy legislation which, together, provide its residents with high-level healthcare services and either free or highly subsidized coverage without any pre-existing conditions. However, it is surprising that shared decision making (SDM) practices and policy are not an integral part of Israel's healthcare system. The purpose of this overview is to describe the gap between the organizational-infrastructure compatibility of Israel's universal healthcare policy and the efforts needed to advance SDM as part of routine healthcare practice. Review of recent research and education initiatives will be described as well as recommendations for policy and clinical practice.

A Qualitative Study Examining Experiences and Dilemmas in Concealment and Disclosure of People Living With Serious Mental Illness

People with mental illnesses face the dilemma of whether to disclose or conceal their diagnosis, but this dilemma was scarcely researched. To gain in-depth understanding of this dilemma, we interviewed 29 individuals with mental illnesses: 16 with major depression/bipolar disorders and 13 with schizophrenia. Using a phenomenological design, we analyzed individuals' experiences, decision-making processes, and views of gains and costs regarding concealment and disclosure of mental illness. We found that participants employed both positive and negative disclosure/concealment practices. Positive practices included enhancing personal recovery, community integration, and/or supporting others. Negative practices occurred in forced, uncontrolled situations. We also identified various influencing factors, including familial norms of sharing, accumulated experiences with disclosure, and ascribed meaning to diagnosis. Based on these findings, we deepen the understanding about decision-making processes and the consequences of disclosing or concealing mental illness. We discuss how these finding can help consumers explore potential benefits and disadvantages of mental illness disclosure/concealment occurrences.

Shared Decision Making During Active Psychiatric Hospitalization: Assessment and Psychometric Properties

Encouraging patients to be involved in their care and enhancing shared decision making (SDM) have been advocated over the past two decades as means to enhance patient-centered care. However, one of the barriers to implementing SDM in medical consultations is the need to adapt this approach to various populations and medical settings, including mental health, and developing reliable and practical methods for measuring and assessing SDM. This article presents the psychometric properties and validity of an adapted scale, SDM-Q-9-Psy, that assesses SDM in routine care among psychiatric inpatients. Psychiatric inpatients were assigned into an SDM intervention cohort (n = 46) or a control cohort (n = 40). The adapted scale was administered after a decision-making process. The scale was subsequently psychometrically tested via factor and reliability analyses. It was also tested for convergent validity and for its ability to distinguish the degree of SDM between the intervention and control groups (construct validity). The SDM-Q-9-Psy scale yielded a Cronbach's α of .94. Convergent and construct validity parameters were good. The SDM-Q-9-Psy scale can be used to evaluate SDM from psychiatric inpatients' perspective and to provide rapid feedback to mental health professionals, enabling them to monitor their decision-making practice in real-time clinical consultations.

"It's in the Cards": The Contribution of Illustrated Metaphor Cards to Exploring Values Within Narratives

In this article, we present the use of illustrated metaphorical cards as a technique to enrich the qualitative narrative interview. We examine the advantages of incorporating a projective tool to assist in constructing and understanding personal narratives of people living with severe mental illness. We interviewed 25 participants-staff and members of a clubhouse in Israel (an international community model of rehabilitation in mental health)-and sought to understand their stories focused on personal and organizational values. The findings revealed that, in most cases, the cards contributed to data collection by enhancing the interviewees' ability for expression and by facilitating richer, more comprehensive stories and descriptions. This in turn enhanced the researcher's ability to understand the messages and stories presented. The research conclusions discuss the cards' potential contribution to improving data collection and analysis. The cards became an additional channel for expressing participants' experiences, emotions, and unique voice.

Medical education in Israel 2016: five medical schools in a period of transition

Abstract

We reviewed the existing programs for basic medical education (BME) in Israel as well as their output, since they are in a phase of reassessment and transition. The transition has been informed, in part, by evaluation in 2014 by an International Review Committee (IRC). The review is followed by an analysis of its implications as well as the emergent roadmap for the future.

The review documents a trend of modernizing, humanizing, and professionalizing Israeli medical education in general, and BME in particular, independently in each of the medical schools. Suggested improvements include an increased emphasis on interactive learner-centered rather than frontal teaching formats, clinical simulation, interprofessional training, and establishment of a national medical training forum for faculty development. In addition, collaboration should be enhanced between medical educators and health care providers, and among the medical schools themselves.

The five schools admitted about 730 Israeli students in 2015, doubling admissions from 2000. In 2014, the number of new licenses, including those awarded to Israeli international medical graduates (IMGs), surpassed for the first time in more than a decade the estimated need for 1100 new physicians annually. About 60 % of the licenses awarded in 2015 were to IMGs.

Conclusions

Israeli BME is undergoing continuous positive changes, was supplied with a roadmap for even further improvement by the IRC, and has doubled its output of graduates. The numbers of both Israeli graduates and IMGs are higher than estimated previously and may address the historically projected physician shortage. However, it is not clear whether the majority of newly licensed physicians, who were trained abroad, have benefited from similar recent improvements in medical education similar to those benefiting graduates of the Israeli medical schools, nor is it certain that they will benefit from the further improvements that have recently been recommended for the Israeli medical schools.

Inspired by the IRC report, this overview of programs and the updated physician manpower data, we hope the synergy between all stakeholders is enhanced to address the combined medical education quality enhancement and output challenge.

Automated Video Analysis of Non-verbal Communication in a Medical Setting

Non-verbal communication plays a significant role in establishing good rapport between physicians and patients and may influence aspects of patient health outcomes. It is therefore important to analyze non-verbal communication in medical settings. Current approaches to measure non-verbal interactions in medicine employ coding by human raters. Such tools are labor intensive and hence limit the scale of possible studies. Here, we present an automated video analysis tool for non-verbal interactions in a medical setting. We test the tool using videos of subjects that interact with an actor portraying a doctor. The actor interviews the subjects performing one of two scripted scenarios of interviewing the subjects: in one scenario the actor showed minimal engagement with the subject. The second scenario included active listening by the doctor and attentiveness to the subject. We analyze the cross correlation in total kinetic energy of the two people in the dyad, and also characterize the frequency spectrum of their motion. We find large differences in interpersonal motion synchrony and entrainment between the two performance scenarios. The active listening scenario shows more synchrony and more symmetric followership than the other scenario. Moreover, the active listening scenario shows more high-frequency motion termed jitter that has been recently suggested to be a marker of followership. The present approach may be useful for analyzing physician-patient interactions in terms of synchrony and dominance in a range of medical settings.

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.

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.

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.

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 role of medical schools in promoting social accountability through shared decision-making

Reducing health inequalities and enhancing the social accountability of medical students and physicians is a challenge acknowledged by medical educators and professionals. It is usually perceived as a macro-level, community type intervention. This commentary suggests a different approach, an interpersonal way to decrease inequality and asymmetry in power relations to improve medical decisions and care. Shared decision-making practices are suggested as a model that requires building partnership, bi-directional sharing of information, empowering patients and enhancing tailored health care decisions. To increase the implementation of shared decision-making practices in Israel, an official policy needs to be established to encourage the investment of resources towards helping educators, researchers, and practitioners translate and integrate it into daily practice. Special efforts should be invested in medical education initiatives to train medical students and residents in SDM practices.

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.

OBJECTIVES

This study aimed to add a process of empirical assessment to the discussion of these criticisms by analysing the content and messages communicated during these ceremonies.

METHODS

Multiple qualitative methods were used to discern the core meanings expressed in a sample of 18 ceremonies through the analysis of artefacts, words, phrases, statements and narratives. Out of a stratified random sample of 25 US schools of medicine conducting WCCs in 2009, 18 schools submitted video, audio and written materials.

RESULTS

All ceremonies followed the same general format, but varied in their content, messages and context. Ceremonies included five principal descriptions of what is symbolised by the white coat, including: commitment to humanistic professional care; a reminder of obligations and privileges; power; the student's need to 'grow', and the white coat as a mantle. Statements about obligations were made three times more frequently than statements about privileges. Key words or phrases in WCCs mapped to four domains: professionalism; morality; humanism, and spirituality. Spoken narratives focused on humility and generosity.

CONCLUSIONS

The WCCs studied did not celebrate the status of an elite class, but marked the beginning of educational, personal and professional formation processes and urged matriculants to develop into doctors 'worthy of trust'. The ceremonies centred on the persons entering the vocation, who were invited to affirm its calling and obligations by donning a symbolic garb, and to join an ancient and modern tradition of healing and immersion in their community. The schools' articulated construct of the white coat situated it as a symbol of humanism. This study's findings may clarify and guide schools' choices in designing their own WCCs.

Are you talking to me?! An exploration of the triadic physician-patient-companion communication within memory clinics encounters

OBJECTIVE

To explore and gain further insight into the nature of the triadic interaction among patients, companions and physicians in first-time diagnostic disclosure encounters of Alzheimer's disease in memory-clinic visits.

METHODS

Twenty-five real-time observations of actual triadic encounters by six different physicians were analyzed. The analysis was accomplished through an innovative combination of grounded theory text analysis and graphics to illustrate the communicational exchanges.

RESULTS

The "triadic" communication was actually a series of alternating dyadic exchanges where the third person tries, with inconsistent degrees of success, to become actively involved. During the initial introduction (phase 1) and summation/disclosure (phase 3), the core dyad shifts from physician-patient to physician-companion.

CONCLUSION

The focus of communication shifts within these encounters: from talking with the patient to talking about him or ignoring him. These shifts may signify an emotionally loaded role transformation from companion to caregiver.

PRACTICE IMPLICATIONS

Effective and empathic management of a triadic communication that avoids unnecessary interruptions and frustrations requires specific communication skills (e.g., explaining the rules and order of the conversation). Professionals need to facilitate the emotionally difficult shift from companion to caregiver and the adjustment of companion and demented patient to this shift.

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.

Sharing qualitative research findings with participants: study experiences of methodological and ethical dilemmas

OBJECTIVE

Sharing qualitative research findings with participants, namely member-check, is perceived as a procedure designed to enhance study credibility and participant involvement. It is rarely used, however, and its methodological usefulness and ethical problems have been questioned. This article explores benefits and risks in applying member-check when studying healthcare topics, questioning the way it should be performed.

METHODS

We discuss researchers' experiences in applying member-check, using four examples from three different studies: healthcare-providers' experiences of working with sexual-abuse survivors; adolescents' exposure to domestic-violence, and delivering and receiving bad news.

RESULTS

Methodological and ethical difficulties can arise when performing member-check, challenging the day-to-day researcher-participant experience, and potentially, the physician-patient relationship.

CONCLUSION

Applying member-check in healthcare settings is complex. Although this strategy has good intentions, it is not necessarily the best method for achieving credibility. Harm can be caused to participants, researchers and the doctor-patient relationship, risking researchers' commitment to ethical principles.

PRACTICE IMPLICATIONS

Because participants' experience regarding member-check is difficult to predict, such a procedure should be undertaken cautiously. Prior to initiating member-check, researchers should ask themselves whether such a procedure is potentially risky for participants; and if anonymity cannot be guaranteed, use alternative procedures when needed.

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.

Exploring the meaning of respect in medical student education: an analysis of student narratives

BACKGROUND

Respect 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.

OBJECTIVE

To describe third-year medical students' narratives of respect and disrespect [(dis)respect] during their internal medicine clerkship.

DESIGN

Qualitative thematic analysis of 152 third-year student narratives that 'taught them something about professionalism,' focusing on (dis)respect.

APPROACH

Immersion/crystallization narrative analysis.

RESULTS

We 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.

CONCLUSIONS

Focusing 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.

Medical students' professionalism narratives: a window on the informal and hidden curriculum

PURPOSE

The aim of this study was to use medical students' critical incident narratives to deepen understanding of the informal and hidden curricula.

METHOD

The authors conducted a thematic analysis of 272 stories of events recorded by 135 third-year medical students that "taught them something about professionalism and professional values." Students wrote these narratives in a "professionalism journal" during their internal medicine clerkships at Indiana University School of Medicine, June through November 2007.

RESULTS

The majority of students' recorded experiences involved witnessing positive embodiment of professional values, rather than breaches. Attending physicians and residents were the central figures in the incidents. Analyses revealed two main thematic categories. The first focused on medical-clinical interactions, especially on persons who were role models interacting with patients, families, coworkers, and colleagues. The second focused on events in the teaching-and-learning environment, particularly on students' experiences as learners in the clinical setting.

CONCLUSIONS

The findings strongly suggest that students' reflective narratives are a rich source of information about the elements of both the informal and hidden curricula, in which medical students learn to become physicians. Experiences with both positive and negative behaviors shaped the students' perceptions of the profession and its values. In particular, interactions that manifest respect and other qualities of good communication with patients, families, and colleagues taught powerfully.

The impact of senior medical students' personal difficulties on their communication patterns in breaking bad news

PURPOSE

To evaluate the possible influence of personal difficulties and barriers that are within the news bearer and his or her self-awareness (SA) of them, on the patterns of communication during encounters involving breaking bad news (BBN).

METHOD

Following an intensive BBN course in 2004, 103 senior medical students at the Sackler School of Medicine, Tel Aviv University, were evaluated for BBN competencies by the analysis of their written descriptions of how they visualized their manner of delivering bad news to a patient described in a challenging vignette. The students were further asked to reflect on their own difficulties and barriers that surfaced in response to reading the narrative presented in the vignette and in delivering the bad news. Using an immersion crystallization narrative analysis method, the authors analyzed the relationship between the students' BBN strategies and their self-perceived barriers and difficulties.

RESULTS

Four types of communicators were identified and related to 45 different personal and professional barriers that the students, through self-reflection, found in themselves. These perceived barriers as well as the ability to self-reflect on them influenced their patterns of communication in their envisioned and written-down encounters, including the level of emotional connectedness, information provided, and the chosen focus-of-care paradigm (physician-centered, patient-centered, or relationship-centered).

CONCLUSIONS

These findings empirically demonstrate that intrapersonal difficulties within the communicator and his or her level of SA about them influenced the manner and content of the communication during the encounter. This finding suggests that enhancing SA and addressing personal and professional difficulties could help physicians' capability to cope with challenging communication tasks. The authors propose a working tool (the Preparatory SPIKES) to facilitate the integration of self-reflection (by identifying personal difficulties) into day-by-day planning and delivery of bad news.

Written notification of test results: meanings, comprehension and implication on patients' health behavior

OBJECTIVE

Mailing test results are frequently used to provide patients with information about their medical condition and enhancing their participation in subsequent management. This study explores patients' experiences of the written notification process and its implications.

METHODS

Telephone interviews were conducted with 128 patients who had undergone endoscopic examinations in two gastroenterology clinics after the received of their mailed biopsies results. The interviews (open and closed questions) focused on patients' perceptions and emotions while waiting, and after reading the reports.

RESULTS

The findings are divided to emotions experienced, comprehension and behavioral implications. The reports arrived 6-33 days later than promised. Many patients were dissatisfied but most did nothing to hasten the process. Over half of them were unable to understand the information in the letters and the future steps needed to be taken. Explanatory covering letters, sent by the hospital clinic, enhanced comprehension and diminished confusion.

CONCLUSIONS

Mailed biopsy reports frequently failed to enhance patient understanding and participation in decisions. Incomprehensibility of written information, and unmet expectations, evoked negative emotional responses.

PRACTICE IMPLICATIONS

Improving readability with simple, non-technical information; and verification of understanding and fulfillment of recommendations using a follow-up call are critical for accomplishing the goals of mailed biopsy reports.

Power relations in qualitative research

This article focuses on the tensions between the commitment to power redistribution of the qualitative paradigm and the ethical and methodological complexity inherent in clinical research. Qualitative inquiry, in general, though there are significant variations between its different paradigms and traditions, proposes to reduce power differences and encourages disclosure and authenticity between researchers and participants. It clearly departs from the traditional conception of quantitative research, whereby the researcher is the ultimate source of authority and promotes the participants' equal participation in the research process. But it is precisely this admirable desire to democratize the research process, and the tendency to question traditional role boundaries, that raises multiple ethical dilemmas and serious methodological challenges. In this article, we offer a conceptual frame for addressing questions of power distribution in qualitative research through a developmental analysis of power relations across the different stages of the research process. We discuss ethical and methodological issues.