Acute empathy decline among resident physician trainees on a hematology-oncology ward: an exploratory analysis of house staff empathy, distress, and patient death exposure

Changes Due to Patient Deaths: Medical Students' Expectations vs. Health Professionals' Experiences

CONTEXT

Preparing healthcare professionals for inevitable encounters with patient deaths is crucial to preventing maladaptive professional bereavement outcomes.

OBJECTIVES

This study aimed to explore the discrepancies between medical students' pre-patient death expectations and healthcare professionals' post-patient death experiences regarding accumulated global changes due to patient deaths (AGC), identify heterogeneous expectation patterns among students, and reveal risk factors for worthy-of-concern expectation patterns.

METHODS

Cross-sectional survey data from 231 professional caregivers and 405 medical and nursing students were used. Independent t tests and analyses of covariance were run for staff-student AGC comparisons. Latent profile analysis (LPA) among students was followed by logistic regression.

RESULTS

The students scored higher than did the staff in two AGC factors: more acceptance of limitations and more death-related anxiety. LPA identified four latent expectation patterns, with the "overoptimistic" (27.8%) group being worthy of concern, as students overestimated positive changes and underestimated negative changes. The overoptimistic pattern was predicted by students' motivations to study medicine, which were driven by "interests," "career opportunities," and "improving medical services in the hometown," rather than "by chance," and higher scores on the death attitude of "neutral acceptance."

CONCLUSION

In general, students tend to overestimate the long-term impacts of patient deaths. However, approximately 1/4 of students hold overly optimistic expectations, which are predicted by motivations to study medicine and death attitudes.

"It's a Heavy Thing to Carry:" Internal Medicine and Pediatric Resident Experiences Caring for Dying Patients

BACKGROUND

Residents often feel unprepared to care for dying patients and may benefit from more training. Little is known about factors in the clinical setting that promote resident learning about end of life (EOL) care.

OBJECTIVES

This qualitative study aimed to characterize the experiences of residents caring for dying patients and elucidate the impact of emotional, cultural, and logistical factors on learning.

METHODS

6 US internal medicine and 8 pediatric residents who had cared for at least 1 dying patient completed a semi-structured one-on-one interview between 2019 and 2020. Residents described an experience caring for a dying patient including their confidence in clinical skills, emotional experience, role within the interdisciplinary team, and perspective on how to improve their education. Interviews were transcribed verbatim and investigators conducted content analysis to generate themes.

RESULTS

3 themes (with subthemes) emerged: (1) experiencing strong emotion or tension (loss of patient personhood, emerging professional identity, emotional dissonance); (2) processing the experience (innate resilience, team support); and (3) recognition of a new perspective or skill (bearing witness, meaning making, recognizing biases, emotional work of doctoring).

CONCLUSIONS

Our data suggests a model for the process by which residents learn affective skills critical to EOL care: residents (1) notice strong emotion, (2) reflect on the meaning of the emotion, and (3) crystallize this reflection into a new perspective or skill. Educators can use this model to develop educational methods that emphasize normalization of physician emotions and space for processing and professional identity formation.

The impact of patient death experiences early in training on resident physicians: a qualitative study

BACKGROUND

Patient death is an inevitability during medical training, with subsequent psychologic distress, decreased empathy and worse learning outcomes. We aimed to explore resident experiences with patient death early in training, including the immediate and delayed impacts of these experiences, preparedness of trainees for these events and coping strategies used, potentially identifying gaps and opportunities to further support trainees during difficult or traumatic events.

METHODS

We performed a qualitative study using phenomenology methodology to understand trainees' personal experiences with patient death. Resident physicians who had completed an internal medicine rotation at McMaster University, Hamilton, Ontario, were invited to participate from December 2020 to April 2021. Semistructured interviews were conducted to understand circumstances, emotional responses, support, coping mechanisms and preparedness regarding the patient death experience. Interviews were transcribed and coded to identify emerging themes with the use of thematic and interpretive analysis.

RESULTS

Eighteen participants were interviewed. On average, the interviews were 40 minutes in length. The participants' mean age was 27 years. The majority of trainees (10 [56%]) were in their first year of residency, with 5 (28%) from family medicine and 4 (22%) from internal medicine. Most participants (13 [72%]) had experienced their first patient death during medical school. Three themes were identified: patient death circumstances, immediate and delayed emotional impact, and preparedness and coping mechanisms. Unexpected death, pronouncing death, cardiopulmonary resuscitation and communicating with families were common challenges. Feelings of guilt, helplessness and grief followed the events. Feeling underprepared contributed to emotional consequences, including difficulties sleeping, intrusive thoughts and emotional distancing; however, these experiences were consistently normalized by participants.

INTERPRETATION

Patient death during medical training can be traumatic for trainees and may perpetuate loss of empathy, changes to practice and residual emotional effects. Educational initiatives to prepare trainees for patient death and teach adaptive coping strategies may help mitigate psychologic trauma and loss of empathy; further research is required to explore these strategies.

Innovation in Resident Core Oncology Education: Switching from an Inpatient Ward Rotation to a Hybrid Model of Inpatient Consultations and Outpatient Clinics

Interest in an oncology career has decreased among internal medicine residents completing an inpatient hematology-oncology rotation. Over years, our institutional data at Indiana University School of Medicine reflected lower satisfaction with the oncology inpatient ward rotation as compared to other rotations. We hypothesized that a switch from an inpatient ward rotation to a hybrid model of inpatient consultations and outpatient clinics would improve resident satisfaction with their educational experience in oncology. Over the 6-month periods preceding and following the change in rotation format, residents were asked to complete anonymous rotation evaluations and rate their experiences on a 5-point Likert scale (poor 1 to excellent 5). Areas assessed included patient load, educational value of patient mix, quality of didactics and teaching, quality of patient care delivery, adequacy of time for reading, and overall rotation quality. The hybrid oncology rotation was rated as significantly superior to the traditional ward format in six out of eight areas including patient load, educational value of patient mix, time for study, teaching quality, relevance of material, and overall rating. Improvements in the perceived quality of patient care delivery (p = 0.139) and quality of didactics (p = 0.058) were also observed without reaching statistical significance. The balance of inpatient and outpatient experiences with the hybrid rotation was highly rated (4.5 ± 0.5). The implementation of a hybrid oncology rotation was associated with perceived improvement in educational value, patient mix, and time for reflection and study without apparent compromise in the quality of patient care delivery.

Empathy among Saudi Residents at a Tertiary Academic Center during the COVID-19 Pandemic and Its Association with Perceived Stress

Background and Objectives: Empathy is an important attribute of a healthy doctor−patient relationship. Although multiple studies have assessed empathy in different countries, little is known about its levels among Saudi residents and its association with perceived stress. Objectives: To assess the levels of empathy and to identify if there is an association with stress in general and across the demographic and training characteristics of residents. Materials and Methods: A cross-sectional questionnaire-based study was carried out from December 2020 to March 2021 among residents training at a tertiary academic center in Riyadh, Saudi Arabia. Empathy and perceived stress were measured using the Jefferson Scale of Empathy (JSE) and the Perceived Stress Scale (PSS). Results: A total of 229 residents participated. The mean JSE score was 105.25 ± 15.35. The mean JSE scores were significantly higher among residents training in pediatrics (mean difference (MD) = 17.35, p < 0.001), family medicine (MD = 12.24, p = 0.007), and medical specialties (MD = 11.11, p = 0.012) when compared with surgical specialties and anesthesia. In addition, residents who worked 1−4 on-calls per month had a higher mean JSE score (MD = 11.23, p = 0.028) compared with those who worked 7 or more on-calls. Lastly, no correlation between empathy and perceived stress was detected in the whole sample (r = −0.007, p = 0.913); however, there was a correlation among residents training in medical specialties (r = −0.245, p = 0.025). Conclusion: Residents in our study had empathy levels comparable with Asian but lower than Western residents. We recommend qualitative studies that explore potential factors that might affect empathy among residents and studying the association between empathy and perceived stress among medical residents. Postgraduate curricula should incorporate interventions that foster a more empathetic doctor−patient relationship.

Predictors of Physician Compassion, Empathy, and Related Constructs: a Systematic Review

BACKGROUND

Compassion in healthcare provides measurable benefits to patients, physicians, and healthcare systems. However, data regarding the factors that predict care (and a lack of care) are scattered. This study systematically reviews biomedical literature within the Transactional Model of Physician Compassion and synthesizes evidence regarding the predictors of physician empathy, compassion, and related constructs (ECRC).

METHODS

A systematic literature search was conducted in CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, AMED, OvidJournals, ProQuest, Web of Science, and Scopus using search terms relating to ECRC and its predictors. Eligible studies included physicians as participants. Methodological quality was assessed based on the Cochrane Handbook, using ROBINS-I risk of bias tool for quantitative and CASP for qualitative studies. Confidence in findings was evaluated according to GRADE-CERQual approach.

RESULTS

One hundred fifty-two included studies (74,866 physicians) highlighted the diversity of influences on compassion in healthcare (54 unique predictors). Physician-related predictors (88%) were gender, experience, values, emotions and coping strategies, quality of life, and burnout. Environmental predictors (38%) were organizational structure, resources, culture, and clinical environment and processes. Patient-related predictors (24%) were communication ease, and physicians' perceptions of patients' motives; compassion was also less forthcoming with lower SES and minority patients. Evidence related to clinical predictors (15%) was scarce; high acuity presentations predicted greater ECRC.

DISCUSSION

The growth of evidence in the recent years reflects ECRC's ongoing importance. However, evidence remains scattered, concentrates on physicians' factors that may not be amenable to interventions, lacks designs permitting causal commentary, and is limited by self-reported outcomes. Inconsistent findings in the direction of the predictors' effects indicate the need to study the relationships among predictors to better understand the mechanisms of ECRCs. The current review can guide future research and interventions.

Understanding moral empathy: A verbatim-theatre supported phenomenological exploration of the empathy imperative

OBJECTIVES

Several studies have measured a decline in empathy during medical training, speculating that factors within the formal, informal and hidden curricula are responsible for this phenomenon. Although the medical education literature describes the moral domain of empathy as most fundamental to the empathic response, most research into the decline has examined the cognitive, affective and behavioural domains. This study distinguishes itself by focusing on how moral empathy is affected through training.

METHODS

Ten medical residents from core education specialties at McMaster University participated in lightly structured interviews concerning their training experiences. Interview transcripts were analysed by way of a descriptive phenomenological approach. Analyses afforded descriptions of the way medical training influences moral empathy. These descriptions were then used to generate a verbatim theatre play that was performed for an audience of residents, educators, learners, researchers and scholars. Following the play, audience participants completed a survey to member-check the descriptions and to glean other reflective experiences in resident training that impact moral empathy. The survey results informed revisions to the codebook that was subsequently used to re-analyse the interview transcripts. This resulted in a final, refined version of the influence of training on learner moral empathy.

RESULTS

The findings suggest that a resident's sense of moral empathy relies upon the notion of an innate capacity for empathy, and is influenced by their clinical and classroom education, and specific experiences with patients during training. Importantly, these factors are rarely experienced as having a direct deleterious impact on residents' moral empathy but rather are experienced as challenges to their ability to act on their moral empathy.

CONCLUSIONS

The study promotes reflection of what it means to experience empathy in the moral domain. The description offers a new perspective from which to view empathic declines that have been previously reported, while also highlighting a moral-behavioural tension that has implications for competency-based assessment and the way empathy is conceptualised in medical education.

Clinician distress in seriously ill patient care: A dimensional analysis

BACKGROUND

Caring for patients with serious illness may severely strain clinicians causing distress and probable poor patient outcomes. Unfortunately, clinician distress and its impact historically has received little attention.

RESEARCH PURPOSE

The purpose of this article was to investigate the nature of clinician distress.

RESEARCH DESIGN

Qualitative inductive dimensional analysis.

PARTICIPANTS AND RESEARCH CONTEXT

After review of 577 articles from health sciences databases, a total of 33 articles were eligible for analysis.

ETHICAL CONSIDERATIONS

This study did not require ethical review and the authors adhered to appropriate academic standards in their analysis.

FINDINGS

A narrative of clinician distress in the hospital clinician in the United States emerged from the analysis. This included clinicians' perceptions and sense of should or the feeling that something is awry in the clinical situation. The explanatory matrix consequence of clinician distress occurred under conditions including: the recognition of conflict, the recognition of emotion, or the recognition of a mismatch; followed by a process of an inability to feel and act according to one's values due to a precipitating event.

DISCUSSION

This study adds three unique contributions to the concept of clinician distress by (1) including the emotional aspects of caring for seriously ill patients, (2) providing a new framework for understanding clinician distress within the clinician's own perceptions, and (3) looking at action outside of a purely moral lens by dimensionalizing data, thereby pulling apart what has been socially constructed.

CONCLUSION

For clinicians, learning to recognize one's perceptions and emotional reactions is the first step in mitigating distress. There is a critical need to understand the full scope of clinician distress and its impact on the quality of patient-centered care in serious illness.

Internal Medicine Residents' Perception of Cancer Prognosis

Cancer is the second leading cause of death in the USA. Many internal medicine physicians feel uncomfortable having to prognosticate; however, oncology patients often ask this of them. The inability to provide an accurate prognosis could lead a patient to make a treatment decision incongruent with their true wishes. We conducted this study to assess resident and attending physicians' knowledge of cancer prognosis and to establish the source of residents' knowledge. We conducted a prospective, cross-sectional study to assess internal medicine resident and attending physician knowledge of median survival for seven different oncologic case scenarios. Correct answers were defined by results of randomized, phase III trials. Residents were asked to identify the source(s) of information that most significantly influenced their choices. All residents and attending physicians affiliated with the University of Hawaii were invited to participate. A total of 67 of 85 surveys (78.8%) were completed, representing 41 residents and 26 attending physicians. Overall, the respondents correctly estimated median survival 42.6% of the time. The respondents underestimated more often than overestimated median survival (46.3% vs. 14.9%, p = 0.0001). Seventy-three percent of residents cited inpatient experience as influencing their oncologic knowledge. Internal medicine residents and attending physicians correctly estimate median survival of cancer patients less than 50% of the time and often underestimate survival. Inpatient rotations, where residents care for the oncologic patients experiencing significant complications of their cancer and treatment, may be giving them an unbalanced perspective on cancer prognosis.

Pediatric Resident Experience Caring for Children at the End of Life in a Children's Hospital

OBJECTIVE

Pediatric residents are expected to be competent in end-of-life (EOL) care. We aimed to quantify pediatric resident exposure to patient deaths, and the context of these exposures.

METHODS

Retrospective chart review of all deceased patients at one children's hospital over 3 years collected patient demographics, time, and location of death. Mode of death was determined after chart review. Each death was cross-referenced with pediatric resident call schedules to determine residents involved within 48 hours of death. Descriptive statistics are presented.

RESULTS

Of 579 patients who died during the study period, 46% had resident involvement. Most deaths occurred in the NICU (30% of all deaths); however, resident exposure to EOL care most commonly occurred in the PICU (52% of resident exposures) and were after withdrawals of life-sustaining therapy (41%), followed by nonescalation (31%) and failed resuscitation (15%). During their postgraduate year (PGY)-1, <1% of residents encountered a patient death. During PGY-2 and PGY-3, 96% and 78%, respectively, of residents encountered at least 1 death. During PGY-2, residents encountered a mean of 3.5 patient deaths (range 0-12); during PGY-3, residents encountered a mean of 1.4 deaths (range 0-5). Residents observed for their full 3-year residency encountered a mean of 5.6 deaths (range 2-10).

CONCLUSIONS

Pediatric residents have limited but variable exposure to EOL care, with most exposures in the ICU after withdrawal of life-sustaining technology. Educators should consider how to optimize EOL education with limited clinical exposure, and design resident support and education with these variable exposures in mind.

Less direct patient care delivered by medical trainees by the end of a hematology-oncology ward rotation: Association with empathy and related factors

OBJECTIVE

The education of trainee physicians in hematology-oncology is challenged by inherent stressors of hematology-oncology. Clinical work load, death and dying, and the known phenomenon of empathy decline during clinical education affect trainees. Time spent with patients or direct patient care time (DPCT) is influenced by many factors, which ultimately affect medical education. Therefore, DPCT may decrease by the end training on a busy hematology-oncology ward rotation.

METHODS

Internal medicine interns and residents (n = 64) rotating on a hematology-oncology ward rotation were consecutively selected to participate. Questionnaires containing Likert scale questions assessing time spent with patients before and after the rotation, empathy/resilience/distress measurements (Interpersonal Reactivity Index [IRI], Connors-Davidson Resilience Scale [CD-RISC], and Impact of Events Scale-Revised [IES-R], respectively), and demographic and situational information were collected at the beginning and end of the rotation RESULTS: DPCT decreased from over 10 to 15 minutes per patient to slightly over 1 to 5 minutes with over half of the trainees spending less than 1 minute per patient per day (P < .001, Cohen's d = 1.05). Empathy scores decreased 2.01 points from 58.9 to 56.8 (P = .018, Cohen's d = 0.33) during the rotation. DPCT decrease was associated mistreatment (P < .001) and lack of support (P = .001) while endorsing external issues (P = .002) and longer rotation time predicted for greater DPCT accounting for 67% of DPCT variance on multivariate analysis.

CONCLUSION

Medical trainees in oncology who feel a lack of social/familial support and feel mistreated by mentors/superiors spend significantly less time with patients. Educational initiatives should replicate and utilize these associations to enhance patient-centric care in oncology.

Honoring Life After Death: Mapping the Spread of the Pause

Background:

Health care is a high-risk environment for clinicians and patients. The risk of burnout increases with increased patient acuity and workload demands. The Pause is a contemplative intervention that has been deployed to foster honor and self-care.

Objective:

We aimed to reveal how clinicians and educators use The Pause and how it changes systems of thinking or practice.

Methods:

Using a modified Delphi method, we interviewed 11 participants who had used The Pause or intend on using it.

Results:

The Pause is being used in 4 continents and many countries. It is most widely learned about by the bedside in practice settings. Participants believe it is malleable and has a powerful systemic effect in fostering a culture of support and honor.

Conclusion:

The Pause should continue to be taught in clinical scenarios to foster a broader humanistic ethos in health care.

Empathy is not in our genes

In academic and public life empathy is seen as a fundamental force of morality - a psychological phenomenon, rooted in biology, with profound effects in law, policy, and international relations. But the roots of empathy are not as firm as we like to think. The matching mechanism that distinguishes empathy from compassion, envy, schadenfreude, and sadism is a product of learning. Here I present a dual system model that distinguishes Empathy¹, an automatic process that catches the feelings of others, from Empathy², controlled processes that interpret those feelings. Research with animals, infants, adults and robots suggests that the mechanism of Empathy¹, emotional contagion, is constructed in the course of development through social interaction. Learned Matching implies that empathy is both agile and fragile. It can be enhanced and redirected by novel experience, and broken by social change.

A Qualitative Study of a Compassion, Presence, and Resilience Training for Oncology Interprofessional Teams

The well-being of health care providers may be challenged by their work, with evidence that oncology health care providers are a high-risk group for burnout. The present qualitative pilot study evaluated a mindfulness-based group intervention, referred to as Compassion, Presence, and Resilience Training (CPR-T), for oncology interprofessional teams. The purpose of this study was to elucidate the subjective experience of oncology health care providers receiving CPR-T and their perceptions of its benefits, risks, or challenges. The CPR-T was delivered to providers from two oncology teams in a large cancer center in Canada. Ten of these providers participated in semistructured interviews 1 to 5 months after completing the CPR-T. The interview transcripts were coded using a thematic analysis strategy. Five benefits of the CPR-T were identified: learning to pause, acquiring a working definition of stress and self-care, becoming fully present, building self-compassion, and receiving organizational acknowledgment and recognition of stress. In addition, two participant-identified challenges were recognized: sharing vulnerability within interprofessional teams and committing to a sitting meditation practice. These findings demonstrate positive transformations as a result of the CPR-T, as well as important challenges, and have important implications for holistic health care practice in oncology. Further research is necessary to validate the findings of this explorative study.

Association between level of exposure to death and dying and professional quality of life among palliative care workers

ABSTRACTBackground:Exposure to the death and dying of others is an anxiety-provoking condition that can contribute to psychological stress. However, the results of empirical studies that evaluated work-related outcomes among physicians and nurses with repeated exposure to dying patients are not consistent.

OBJECTIVE

Our aim was to evaluate whether a high level of exposure to death and dying (LED) can increase the risk for poor professional quality of life (ProQoL) in most healthcare workers, but it can also improve ProQoL in a subset of healthcare workers with specific characteristics.

METHOD

We employed a cross-sectional survey designed to better understand the role of LED as a predictor of ProQoL among healthcare workers.

SETTING AND PARTICIPANTS

Comparison of physicians and nurses with high LED (home-based palliative care units) with a matched group of physicians and nurses with low LED (primary care units) and evaluation of possible interaction effects among LED, death anxiety (DA), and engagement as predictors of ProQoL.

RESULTS

The final sample included 110 questionnaires from the high-LED group (response rate = 39%) and 131 from the low-LED (response rate = 24%) group. Workers with high LED reported an increased level of compassion satisfaction (CS) and low to moderate levels of burnout (BU) and secondary traumatic stress (STS), with no significant differences with respect to other healthcare providers. Although levels of CS, STS, and BU did not differ between groups, a univariate MANOVA revealed that the interaction effect of LED × Engagement reduced levels of CS and that the interaction effect of LED × DA increased STS among workers with high LED.

SIGNIFICANCE OF RESULTS

LED was significantly correlated with ProQoL among healthcare workers with high LED due to the reported interaction effect. These findings imply, for the first time, that there is a possible correlation between engagement and the risk for poor ProQoL among workers with high LED. Further research is essential to gain a better understanding of this issue.