"It was haunting...": physicians' descriptions of emotionally powerful patient deaths.

PURPOSE: To understand the emotional experiences of physicians who care for dying patients and to identify educational opportunities for improving patient care and physician well-being. METHOD: Between 1999-2001, physicians at two quaternary care medical centers in Boston, Massachusetts, and Pittsburgh, Pennsylvania, participated in 90-minute, semistructured personal interviews on their most emotionally powerful patient death. Quantitative data was obtained through face-to-face surveys rated on ten-point scales that asked physicians about emotional characteristics of and emotional responses to the death. In the qualitative portion of the survey, physicians were asked to describe the details of the most emotionally powerful patient death, the types and sequence of their emotional reactions, their methods of coping, and subsequent changes in behavior. RESULTS: Physicians had powerful experiences with death during all stages of their careers. Experiences with patient death generally fit into one of three types: "good," "overtreated," or "shocking/unexpected." Housestaff often described coping in isolation with the disturbing emotions generated in the care of dying patients. Physicians learned how to care for and cope with dying patients from their experiences with patients whose deaths were most emotionally powerful and reported changes in their clinical behavior and career paths as a result. CONCLUSIONS: Physicians' emotional reactions to patient death can affect patient care and the personal lives of physicians. Supervising physicians have an opportunity to improve both the care of dying patients and house-staff coping with these deaths by using the "teachable moments" that are present for trainees as they care for the dying.     

Depersonalization,adversity, emotionality,and coping with stressful situations

Depersonalization is defined as persistent or recurrent episodes of feeling detached or estranged from a sense of self and the world. This study addressed the primary question: Do nonclinical individuals who endorse high symptomatic depersonalization have inherently more intense emotional responses, along with more childhood adversity and past trauma? In this IRB approved study, participants who met clinical levels of depersonalization (n = 43, 16.3%) were compared to a group without clinical levels of depersonalization (n = 221, 83.7%). Adverse childhood experiences, adult traumatic events, emotional overexcitability, coping strategies under stress, and anxiety were examined in both groups. The variables to assess depersonalization severity included the Dissociative Experience Scale-II, Cambridge Depersonalization Scale, and Multiscale Dissociation Inventory. The results indicated that clinical levels of depersonalization were identified in 16.3% of the sample. The high depersonalization group had significantly more adverse childhood experiences, in particular, emotional abuse and neglect. They also experienced more adult traumatic events, higher levels of anxiety, more emotional overexcitability, and they employed a less adaptive emotion-oriented coping strategy under stress. It is recommended that treating depersonalization symptoms should include examining childhood adversity, especially emotional abuse and neglect. Based on study findings, emotion regulation skills should be promoted to help individuals with elevated depersonalization manage their emotion-oriented coping strategies, anxiety, and emotional overexcitability.     

Reacting to the diagnosis of prostate cancer: patient learning in a community of practice

The diagnosis of prostate cancer brings with it a number of emotional issues for the patient. These may include: fear of cancer; confronting one's own mortality; quality of life issues such as incontinence and impotence; and the question "why me?" In addition, there is burden of coping with the emotional responses from friends and loved ones which, arising from their concern, can range from fear to seeking to take charge. Added to this is the need to make choices regarding treatment and obtaining information about these. This article is based on a contribution to a symposium on prostate cancer at the Fifth International Conference on Psycho-Oncology and describes a personal experience of confronting these issues. The concept of communities of practice is used to interpret the learning experiences undertaken by the cancer patient.     

Memory and emotions for the september 11, 2001, terrorist attacks in patients with Alzheimer's disease, patients with mild cognitive impairment, and healthy older adults

National traumatic events can produce extremely vivid memories. Using a questionnaire administered during telephone interviews, the authors investigated emotional responses to, and memory for. the September 11, 2001, terrorist attacks in patients with Alzheimer's disease (AD), patients with mild cognitive impairment (MCI), and healthy older adults in the initial weeks following the event and again 3-4 months later. There were several notable findings. First, patients with AD showed less memory than patients with MCI and older adults. Second, patients with AD, but not patients with MCI or older adults, appeared to retain more memory for personal versus factual information. Third, patients with AD and older adults did not differ in the intensity of their reported emotional responses to the attacks, whereas patients with MCI reported relatively less intense emotional responses. Last, distortions of memory for personal information were frequent for all participants but were more common in patients with AD.     

Stressful events,appraisal, coping and recurrent headache

One hundred fourteen headache sufferers recorded their headaches, stressful events, appraisal processes, and coping responses over a 28 day period. Stressful events were found to precede headache attacks more often than periods of headache freedom. Primary appraisals (how much the event mattered), levels of affective regulation coping and ratings of emotional upset were all higher for stressful events that were not associated with subsequent headache. Stressful events occurring during headache were followed by increases in the intensity of the attack. In such instances, avoidance coping was associated with higher ratings of headache intensity following the event and direct coping with lower post-event ratings. It was concluded that stressful events may be causally related to headache and that the ways in which headache sufferers respond to these events may also have implications for the onset and intensity of attacks. © 1998 John Wiley & Sons, Inc. J Clin Psychol 54: 247–256, 1998.     

Stressful events,appraisal, coping and recurrent headache*

One hundred fourteen headache sufferers recorded their headaches, stressful events, appraisal processes, and coping responses over a 28 day period. Stressful events were found to precede headache attacks more often than periods of headache freedom. Primary appraisals (how much the event mattered), levels of affective regulation coping and ratings of emotional upset were all higher for stressful events that were not associated with subsequent headache. Stressful events occurring during headache were followed by increases in the intensity of the attack. In such instances, avoidance coping was associated with higher ratings of headache intensity following the event and direct coping with lower post‐event ratings. It was concluded that stressful events may be causally related to headache and that the ways in which headache sufferers respond to these events may also have implications for the onset and intensity of attacks. © 2003 Wiley Periodicals, Inc. J Clin Psychol, 2003.     

Computers in medical education: information and knowledge management, understanding, and learning

Desktop computers have evolved to permit physicians in practice and/or training to access and manage information to enhance knowledge, understanding, and learning. There are compelling reasons why the personal computer is key to learning and important in medical education. Above all, the computer enhances and amplifies the learning process. Using the desktop computer effectively is relatively easy. We teach our students to research information in books and journals and hope that, as practicing physicians, they do it even more to be current and maintain their competency. Why not a desktop computer to access and manage information, analyze it, and present findings? Computer technology is available to do virtually all of these tasks. Some tools are critical for medical students. For some time, all medical students have needed a black bag and microscope. Now every medical student needs a computer. Ample courseware is available and expanding rapidly for basic sciences and clinical disciplines. The explosion in biomedical information will continue. Finding information is key to understanding and learning rather than depending solely on memory, recall, or library trips for information. The desktop computer will benefit students, faculty, and future physicians and other health professionals as life-long learners.     

7～11岁小学生对学习成功和失败的情绪反应与情绪归因研究

目的:研究7～11岁小学生成功和失败的学习结果的情绪反应和情绪归因特点.方法:采用结构式临床访谈法,访谈了90名7～11岁儿童对成功和失败的学习结果的情绪反应和情绪归因.结果:(1)成功学习情景下的情绪反应强度没有年龄和性别差异,失败的学习情景下的情绪反应强度存在年龄和性别差异.(2)成功和失败的学习情景下的情绪归因没有性别差异,但存在年龄差异.成功和失败的学习情景的情绪归因趋势不一致,成功情景下趋向他人归因,失败情景下倾向于自我归因.(3)成功和失败情景的成绩归因都是自我努力趋向,应对策略也是自我个人努力趋向.结论:儿童对成功和失败的学习结果的情绪反应和情绪归因具有不同的特点.     

Witnessing Clients’ Emotional Transformation: An Emotion‐Focused Therapist's Experience of Providing Therapy

Emotion‐focused therapy (EFT) is an integrative–humanistic, research‐informed, psychological intervention characterized by sustained focus on the client's emotional pain and its transformation. This article discusses the impacts on the therapist when encountering and transforming the client's vulnerability. It is organized around the different phases of the therapy process: meeting a new client, accessing the client's core emotional pain, transforming the client's emotional pain, and ending the therapeutic work. The article also contains personal experiences of the author and provides illustrations of impactful events from therapy sessions. The work, it is suggested, provides significant learning for the therapist on both a personal and a professional level, leading, for example, to the therapist's maturation, better connection with personal hurts and vulnerabilities, greater courage in regard to sharing such feelings, greater kindness toward others and the self, and greater determination to be braver when facing adversity or injustice.     

Information exchange in the NICU: what sources of patient data do physicians prefer to use?

BACKGROUND: There are significant gaps in understanding what sources of patient information physicians utilize in the Neonatal Intensive Care Unit (NICU). OBJECTIVE: We conducted a qualitative study of physicians' self-report of information-seeking behaviors in the NICU of an academic medical center. METHODS: The study used a survey design to assess resident and faculty physicians' perceptions of their utilization of written and verbal sources of patient information. Faculty and resident responses were compared by t-tests to assess how perceptions of information-seeking behavior might differ between these two groups. RESULTS: Of the options listed in our survey, the three most commonly reported information sources were: (1) the bedside flowsheet; (2) conversations with resident physicians; and (3) conversations with nurses. Notes written by physicians-especially resident notes-were the least reported source of patient information. CONCLUSIONS: Physicians' preference to use verbal communication is consistent with prior studies. This study identifies that the bedside flowsheet is also an important source of information, while other written sources-especially resident notes-appear not to be utilized as frequently. Understanding why physicians use or fail to use different sources of patient information may shed light on ways to improve information exchange and reduce medical error in complex settings such as the NICU.     

The influence of the causes and contexts of medical errors on emergency medicine residents' responses to their errors: an exploration.

PURPOSE: To determine emergency medicine residents' emotional and behavioral responses to their medical errors and examine associations between residents' responses to medical error and perceptions of their training. METHOD: In 2003, 55 residents at two U.S. residency programs were asked to complete questionnaires about their errors and responses to their errors in three domains: emotional response, learning behavior, and disclosure. The questions were a mixture of free text, yes/no responses, and some were rated using a five-point Likert scale. Based on a conceptual framework, the authors constructed scales to describe the various domains and associations between the residents' responses to medical error and perceptions of their training were examined using Somers' D. RESULTS: A total of 43 residents returned questionnaires (80%); 40 of these residents described errors. Thirty-three (83%) residents discussed the error with someone; 27 (71%) with the attending and 10 (28%) with the patient/family. Negative emotions were common: 27 (68%) felt remorse, 21 (53%) guilt, 23 (58%) inadequacy, and 22 (55%) frustration. Residents' negative emotional responses were associated with their personal characteristics [26% (95% CI, 5-47%) association with lack of experience] and residents' perceptions of their training environment: 15% association with job overload (95% CI, -8-38%) and 23% association with lack of institutional support (95% CI, 5-41%). While 32 (81%) residents increased attention to detail, only 2 (5%) increased their use of evidence-based medicine. CONCLUSIONS: Errors committed by emergency medicine residents often resulted in negative emotions, limited constructive system-based improvements, and inadequate disclosure. Negative perceptions of the training environment are associated with negative emotional responses.     

Appraisal of the event as a factor in coping with malpractice litigation

The authors designed a study to explore medical malpractice litigation as a stressor, factors that contribute to doctors' appraisal of it, how they actually cope with it, and the potential effects on them and on their mode of practice. We interviewed 51 physicians who had been sued for medical malpractice. Those who identified litigation as their most stressful life event (Group 1, N = 11) experienced significantly more physical and emotional symptoms, especially those suggestive of a major depressive disorder, and used more emotion-focused coping mechanisms than those who identified some other event in life as being most stressful (Group 2, N = 39). The appraisal of litigation as one's most stressful life experience may be a useful predictor of coping response, with previous life experiences as a major contributing factor to this appraisal.     

Perspective: beyond counting hours: the importance of supervision, professionalism, transitions of care, and workload in residency training

The medical education community's conversations about residents' duty hours have long focused solely on the number of those hours. In July 2011, the Accreditation Council for Graduate Medical Education (ACGME) enacted its most recent iteration of standards regarding duty hours. Those standards, as well as a 2008 Institute of Medicine report, look beyond the quantity of duty hours to address their quality as well. Indeed, the majority of the 2011 ACGME standards specify requirements for the qualitative components of residents' working and learning environments, including supervision of residents; professionalism, personal responsibility, and patient safety; transitions of care; and clinical responsibilities (including workload). The authors believe that focusing on these qualitative (rather than quantitative) components of the resident's working and learning environment provides the greatest promise for balancing patient care with resident education, thus optimizing the safety and effectiveness of both. For each of the four qualitative components that the authors discuss (enhancing supervision, nurturing professionalism and personal responsibility, ensuring safe transitions of care, and optimizing workloads and cognitive loads), they offer agendas for faculty development, educational program planning, and research. Thus, the authors call on the medical education community to expand its discussion beyond counting duty hours to focus on these critical issues that ensure quality resident education and patient care and to implement necessary strategies to address them.     

Sharing personal information about anatomical body donors: What first‐year medical students want to know and how it affects emotional responses to dissection

Among educators who teach in the human anatomy laboratory, there has been lively debate about sharing information about anatomical donors. One consideration in this debate is concern about the emotional effect of personalizing donors on the students. The purpose of this study was to evaluate student responses to being exposed to donor information (DI). Three cohorts of first‐year medical students (n = 284) were surveyed at four time points throughout the year. Surveys queried students about positive and negative responses to working in the laboratory, wanting to know specific DI, and if knowing this DI would/did affect their responses to working with donors. Analyses examined the relationships between desire to know DI and indices of the following: positive response index (PRI), negative response index (NRI), avoid‐approach index (AAI), and compassion‐respect index. Across all surveys, a majority of respondents wanted to know some form of DI. At all time points, a majority of respondents felt that knowing all types of DI would increase their positive responses to working with donors. A greater PRI and AAI tended to be associated with wanting to know more personal DI (e.g., names and personal histories). A greater NRI tended to be associated with anticipating that learning personal DI would increase their negative responses before entering the laboratory, which did not persist after dissection began. These data suggest that for a majority of students, knowing personal DI increases their positive response and does not elicit negative responses to dissection or working with anatomical donors. Clin. Anat. 32:1019–1032, 2019. © 2019 Wiley Periodicals, Inc.     

'It gives you an understanding you can't get from any book.' The relationship between medical students' and doctors' personal illness experiences and their performance: a qualitative and quantitative study

Background

Anecdotes abound about doctors' personal illness experiences and the effect they have on their empathy and care of patients. We formally investigated the relationship between doctors' and medical students' personal illness experiences, their examination results, preparedness for clinical practice, learning and professional attitudes and behaviour towards patients.

Methods

Newly-qualified UK doctors in 2005 (n = 2062/4784), and two cohorts of students at one London medical school (n = 640/749) participated in the quantitative arm of the study. 37 Consultants, 1 Specialist Registrar, 2 Clinical Skills Tutors and 25 newly-qualified doctors participated in the qualitative arm. Newly-qualified doctors and medical students reported their personal illness experiences in a questionnaire. Doctors' experiences were correlated with self-reported preparedness for their new clinical jobs. Students' experiences were correlated with their examination results, and self-reported anxiety and depression. Interviews with clinical teachers, newly-qualified doctors and senior doctors qualitatively investigated how personal illness experiences affect learning, professional attitudes, and behaviour.

Results

85.5% of newly-qualified doctors and 54.4% of medical students reported personal illness experiences. Newly-qualified doctors who had been ill felt less prepared for starting work (p < 0.001), but those who had only experienced illness in a relative or friend felt more prepared (p = 0.02). Clinical medical students who had been ill were more anxious (p = 0.01) and had lower examination scores (p = 0.006). Doctors felt their personal illness experiences helped them empathise and communicate with patients. Medical students with more life experience were perceived as more mature, empathetic, and better learners; but illness at medical school was recognised to impede learning.

Conclusion

The majority of the medical students and newly qualified doctors we studied reported personal illness experiences, and these experiences were associated with lower undergraduate examination results, higher anxiety, and lower preparedness. However reflection on such experiences may have improved professional attitudes such as empathy and compassion for patients. Future research is warranted in this area.     

Appraisal of the Event as a Factor in Coping with Malpractice Litigation

Abstract

The authors designed a study to explore medical malpractice litigation as a stressor, factors that contribute to doctors' appraisal of it, how they actually cope with it, and the potential effects on them and on their mode of practice. We interviewed 51 physicians who had been sued for medical malpractice. Those who identified litigation as their most stressful life event (Group 1, N = 11) experienced significantly more physical and emotional symptoms, especially those suggestive of a major depressive disorder, and used more emotion-focused coping mechanisms than those who identified some other event in life as being most stressful (Group 2, N = 39). The appraisal of litigation as one's most stressful life experience may be a useful predictor of coping response, with previous life experiences as a major contributing factor to this appraisal.