Teaching in relationship: the impact on faculty of teaching "the Healer's Art"

Sources of Joy in Medical Educators as Described by the PERMA Model

Phenomenon: Burnout is prevalent amongst long-practicing physicians. For medical educators, it has deleterious effects not only on the educator themselves, but also the students they are teaching. Though significant research has focused on factors associated with burnout, there is limited understanding of its counter: how physicians, particularly medical educators, derive joy from their work. Approach: This qualitative study included 15 highly-rated clinician educators in Internal Medicine who took part in individual semi-structured interviews. Participants were invited to discuss their sources of professional joy. After transcription, we used thematic content analysis: 50 themes were identified. Themes were then coded using the domains of the PERMA (Positive Emotion, Engagement, Relationships, Meaning, and Accomplishment) model of positive psychology, assigning each theme a best fit domain. Forty-five themes were mapped into the PERMA model. Findings: When describing professional joy, highly-rated clinician educators displayed high levels of overlap with all domains of the PERMA model. Interaction with the learner was a prominent source of professional joy, particularly within Positive Emotion, Engagement, and Relationship domains. Insights: Our findings indicate that the PERMA model appropriately defines the sources of professional joy for these educators. Future research could employ this model to identify targets for interventions aimed at amplifying joy at work for this group.

Where there are challenges, there are opportunities: An undergraduate medical students' teaching concept for mental health in times of COVID-19

COVID-19 had a tremendous effect on medical education. Most teaching sessions had to be shifted online, posing additional stress and potential isolation on medical students. However, it also offered the promotion of innovative digital teaching concepts. In this article, an approach to undergraduate mental health training is presented and evaluated. The curriculum was designed according to Kern's six-step approach and consisted of asynchronous online material as well synchronous digital teaching and was accompanied by a plethora of newly developed teaching material (videos, fact sheets, etc.). Content covered the whole spectrum of diseases seen in a service of psychosomatic medicine and psychotherapy (i.e. anxiety, depression, trauma, somatoform and eating disorders, as well as motivational interviewing). Feedback from participants was collected, and exam results (written and practical) were compared to pre-COVID-19 times using t-tests for dependent and independent samples. Students were highly satisfied with the teaching (rating of 1.3 ± 0.6, n = 139 students). There was no significant difference from course evaluations before COVID-19 (1.5 ± 0.5, p > .05). The teaching also received an award in the students' competition "best digital teaching concept in summer term 2020". In the written exams, there was no significant difference between before COVID-19 (2.4 ± 0.45) and during COVID-19 times (1.6 ± 0.39; p > .05). In the practical objective structured clinical examination (OSCE), there was also no significant difference between students' judgement of the difficulty of the station (1.9 ± 0.22 vs 1.9 ± 0.31; p > .05) or how well-prepared they felt for the exam (2.0 ± 0.24 vs 2.0 ± 0.31; p > .05). However, there was a significant difference in terms of grades, with the pre-COVID-19 grades being significantly better (2.7 ± 0.37 vs 2.0 ± 0.44; p < .05), which reflects the difficulty of transferring practical skills training to an online setting. Students particularly valued the possibility of self-directed learning combined with personal guidance by departmental experts, reflecting the importance of wellbeing-centred medical education. The pandemic triggered overnight challenges for teaching mental health that may also offer the opportunity to think about worldwide teaching standards with easily accessible material and courses online. This may offer the opportunity to enthral medical students to become mental health specialists themselves.

A longitudinal investigation of mental health, perceived learning environment and burdens in a cohort of first-year German medical students' before and during the COVID-19 'new normal'

BACKGROUND

Medical students' propensity to develop mental morbidity has been described for decades but remains unresolved. To assess student mental health person-centred and longitudinally, we have been investigating a cohort of German students since October 2019. After their first semester under 'normal' conditions, rapid changes became necessary due to the COVID-19 situation. In line with the initial aim, we investigated students' change of mental health, perceived learning environment and burdens in the 'new normal'.

METHODS

Students in a newly founded German medical study programme (n = 63) answered a questionnaire each semester (October 2019 = entering medical school; December 2019 = 'old normal'; June 2020 = 'new normal'; December 2020 = 'new normal') on their well-being (FAHW-12), burnout (Maslach Inventory), depression (PHQ-9), perception of the learning environment (DREEM), burdens and protective attitudes in the 'new normal' (items designed for the study).

RESULTS

Friedman tests reveal overall significant differences (all p < .001) in depression and burnout (emotional exhaustion, depersonalisation, personal accomplishment); changes in well-being were identified as just non-significant (p = .05). The effects were explained by a significant increase in burnout and depression identified post-hoc from October 2019 to December 2019. No increase in severity was identified in the 'new normal' semesters. The learning environment was perceived positively even with a significant improvement for June 2020 (repeated measures ANOVA p < .001). Study-related burdens (e.g. procrastination of online-learning material) took on greater relevance than burdens related to physicians' occupation (e.g. potential for students' recruitment to the healthcare system during their studies).

CONCLUSIONS

The 'new' when entering medical school had a greater impact on our students' mental health than the 'new normal'. The readiness for change in the context of a newly designed study programme may have been beneficial with regard to students' positively perceived learning environment during the virtual semesters. Monitoring medical students' mental health longitudinally should be a concern regardless of a pandemic.

Coping with the Practice of Medicine: Religion, Spirituality, and Other Personal Strategies

With the increasing demands on the practice of medicine, this qualitative study asked residents and their faculty (n = 44) to reflect on how they cope with their work. They provided written reflections to questions about successful and disappointing patient experiences, as well as describing their personal, religious, or spiritual practices. Key themes included connecting with family and friends, learning from their mistakes, using cognitive behavioral tools, and engaging with their spirituality and religiosity. One third specifically mentioned they used prayer and/or meditation. We contextualized selected quotes with their level of spiritual well-being, religiosity, and burnout.

Requiring the Healer's Art Curriculum to Promote Professional Identity Formation Among Medical Students

The Healer's Art curriculum (HART) is one of the best-known educational strategies to support medical student professional identity formation. HART has been widely used as an elective curriculum. We evaluated students' experience with HART when the curriculum was required. All one hundred eleven members of the class of 2019 University of New Mexico School of Medicine students were required to enroll in HART. We surveyed the students before and after the course to assess its self-reported impact on key elements of professional identity formation such as empathy towards patients and peers, commitment to service, and burnout. A majority of students (n=53 of 92, 57.6%) reported positive effects of the course on their empathy towards other students. This finding was significantly associated with self-reported willingness to have elected the course had it not been required. One-half of respondents (n=46 of 92, 50.0%) reported positive effects on their empathy towards future patients. At least one-quarter to one-third of respondents reported positive influences on commitment to service, conceptions about being a physician, and self-perceived burnout. Students report benefits on their professional identity formation after participating in a required course on humanism. Empathy-building among peers is one valuable outcome of such curricula.

Optimizing resilience and wellbeing for healthcare professions trainees and healthcare professionals during public health crises - Practical tips for an 'integrative resilience' approach

Public health crises, including pandemics, are associated with significant health risk and concomitant stress, fear, decreased sense of control, and uncertainty. Deleterious impact on both physical and mental health can result, including for healthcare professionals and health professions trainees. Changes in governmental policies and hospital protocols for healthcare professionals as well as disruption of educational formats and requirements for trainees can ensue. Difficult anxiety-provoking realities of public health crises including pandemics which involve caring for many seriously ill patients, moral distress including difficult care decisions, personal health risk, and/or potential risk to one's family can take a dire toll on the mental health of healthcare professionals at all stages of the professional lifecycle. Educational disruptions can create significant anxiety for trainees about completing requirements and achieving competencies. Within this, coping skills may be challenged and strengths may be elucidated as well. Such crises create an imperative for medical educators to support trainees' wellbeing through adaptive flexibility for curriculum innovation and culturally sensitive resilience and wellbeing interventions. Strategies ('tips') to optimize resilience and wellbeing with an integrative resilience approach of individual, learning environment, and organization/systems factors are presented.

A self-report of the Healer's art by junior doctors: does the course have a lasting influence on personal experience of humanism, self-nurturing skills and medical counterculture?

BACKGROUND

Healer's Art (HA) is a voluntary course offered during medical school. The course aims to address the growing loss of meaning and commitment experienced by doctors through the exploration of compassion, empathy and awe in medicine, and early exposure to a supportive community of practice. This project aimed to evaluate the potential influence of HA on junior doctor graduates.

METHODS

Junior doctors who had undertaken HA during their medical studies were interviewed. A thematic analysis was performed on the results of these semi-structured interviews.

RESULTS

Ten junior doctors who had undertaken the HA course participated in interviews. All interviewees described the HA as a positive and enlightening experience in their medical education. The thematic analysis identified four major themes: developing empathy in the doctor-patient journey, self-care and self-awareness, the creation of a supportive community, and coping with the challenging medical culture.

CONCLUSIONS

HA provides experiential learning that enables participants to explore humanistic medicine. Self-selected junior doctors recall the course as a positive experience, and perceive themselves to be continuing to employ the techniques from HA in the healthcare setting. The concepts taught in the HA course appear to have a lasting personal impact on some junior doctors, who identify the course as influencing their self-reported positive patient-doctor relationships and supportive relationships with medical peers.

Views of institutional leaders on maintaining humanism in today's practice

OBJECTIVE

To explore leadership perspectives on how to maintain high quality efficient care that is also person-centered and humanistic.

METHODS

The authors interviewed and collected narrative transcripts from a convenience sample of 32 institutional healthcare leaders at seven U.S. medical schools. The institutional leaders were asked to identify factors that either promoted or inhibited humanistic practice. A subset of authors used the constant comparative method to perform qualitative analysis of the interview transcripts. They reached thematic saturation by consensus on the major themes and illustrative examples after six conference calls.

RESULTS

Institutional healthcare leaders supported vision statements, policies, organized educational and faculty development programs, role modeling including their own, and recognition of informal acts of kindness to promote and maintain humanistic patient-care. These measures were described individually rather than as components of a coordinated plan. Few healthcare leaders mentioned plans for organizational or systems changes to promote humanistic clinician-patient relationships.

CONCLUSIONS

Institutional leaders assisted clinicians in dealing with stressful practices in beneficial ways but fell short of envisaging systems approaches that improve practice organization to encourage humanistic care.

PRACTICE IMPLICATIONS

To preserve humanistic care requires system changes as well as programs to enhance skills and foster humanistic values and attitudes.

Healthcare at the Crossroads: The Need to Shape an Organizational Culture of Humanistic Teaching and Practice

BACKGROUND

Changes in the organization of medical practice have impeded humanistic practice and resulted in widespread physician burnout and dissatisfaction.

OBJECTIVE

To identify organizational factors that promote or inhibit humanistic practice of medicine by faculty physicians.

DESIGN

From January 1, 2015, through December 31, 2016, faculty from eight US medical schools were asked to write reflectively on two open-ended questions regarding institutional-level motivators and impediments to humanistic practice and teaching within their organizations.

PARTICIPANTS

Sixty eight of the 92 (74%) study participants who received the survey provided written responses. All subjects who were sent the survey had participated in a year-long small-group faculty development program to enhance humanistic practice and teaching. As humanistic leaders, subjects should have insights into motivating and inhibiting factors.

APPROACH

Participants' responses were analyzed using the constant comparative method.

KEY RESULTS

Motivators included an organizational culture that enhances humanism, which we judged to be the overarching theme. Related themes included leadership supportive of humanistic practice, responsibility to role model humanism, organized activities that promote humanism, and practice structures that facilitate humanism. Impediments included top down organizational culture that inhibits humanism, along with related themes of non-supportive leadership, time and bureaucratic pressures, and non-facilitative practice structures.

CONCLUSIONS

While healthcare has evolved rapidly, efforts to counteract the negative effects of changes in organizational and practice environments have largely focused on cultivating humanistic attributes in individuals. Our findings suggest that change at the organizational level is at least equally important. Physicians in our study described the characteristics of an organizational culture that supports and embraces humanism. We offer suggestions for organizational change that keep humanistic and compassionate patient care as its central focus.

Addressing Burnout in Oncology: Why Cancer Care Clinicians Are At Risk, What Individuals Can Do, and How Organizations Can Respond

Despite their benevolent care of others, today, more than ever, the cancer care professional who experiences overwhelming feelings of exhaustion, cynicism, and inefficacy is in grave jeopardy of developing burnout. Clinicians are repeatedly physically and emotionally exposed to exceedingly long hours in direct care with seriously ill patients/families, limited autonomy over daily responsibilities, endless electronic documentation, and a shifting medical landscape. The physical and emotional well-being of the cancer care clinician is critical to the impact on quality care, patient satisfaction, and overall success of their organizations. The prevention of burnout as well as targeting established burnout need to be proactively addressed at the individual level and organizational level. In fact, confronting burnout and promoting wellness are the shared responsibility of both oncology clinicians and their organizations. From an individual perspective, oncology clinicians must be empowered to play a crucial role in enhancing their own wellness by identification of burnout symptoms in both themselves and their colleagues, learning resilience strategies (e.g., mindful self-compassion), and cultivating positive relationships with fellow clinician colleagues. At the organizational level, leadership must recognize the importance of oncology clinician well-being; engage leaders and physicians in collaborative action planning, improve overall practice environment, and provide institutional wellness resources to physicians. These effective individual and organizational interventions are crucial for the prevention and improvement of overall clinician wellness and must be widely and systematically integrated into oncology care.

Journeying to the White Coat Ceremony: A description of the people, situations and experiences that inform student visions of the physician they hope to become

Little is known about the experiences that influence entering medical students' internal concepts of themselves as future physicians. During orientation to medical school, students were asked to write stories in response to the cue, "Tell a story about a person or experience that inspired you to consider a career of service in medicine." Qualitative methodology was employed to analyze 190 student stories. Thematic analysis identified descriptive details about content and allowed comparison between the students' and School's expectations. Inspirational settings, contexts, and individuals were identified. Nine different inspirational events were described. Student and School expectations for the kinds of physicians they hoped to become were generally consistent. The study demonstrates that students do indeed bring to medical school visions of the kinds of physicians they hope to become. Linking that vision with medical school activities including the White Coat Ceremony provides a bridge between medical school and students' earlier lives, thus explicitly linking orientation to professional formation.

Insisting on the Healer's Art: The Implications of Required Participation in a Medical School Course on Values and Humanism

THEORY

Elective courses, by definition, allow medical students to self-select for participation in the class. In a small-group learning setting, students uninterested or not ready for a particular learning topic might change the educational experience ("poison the well") for those students most interested in the topic. It is not known how medical students required to take a course in humanism (that they otherwise would not have elected to take) might be impacted by the course or how their presence might affect students originally interested in the course.

HYPOTHESES

Medical students in a required course on humanism and values in medicine will have different experiences based on whether a particular student might have or not have elected to enroll in the course. Students uninterested in taking a course in humanism and values, but required to enroll, will limit the benefit of the course for those students originally interested in participating.

METHOD

In 2012, all 1st-year students at a U.S. medical school were required to take the Healer's Art, an elective on professional values and humanism offered at more than 90 other schools in the United States and internationally. Students completed pre/postcourse surveys assessing emotional exhaustion, work engagement, positive emotions, and cynicism. We analyzed differences between those who would have elected to take the course (Elective students) and those who would not have elected to take it (Required students).

RESULTS

Elective students did not differ from Required students in baseline demographic characteristics, emotional exhaustion, work engagement, or positive emotions. At baseline, Elective students did report feeling safer to talk openly, a greater sense of community, and higher levels of cynicism. Over time, there were no differences in course evaluations or outcomes between Elective and Required students.

CONCLUSIONS

Required students do not differ greatly from those who would have elected to take Healer's Art, and all students appear to have similar experiences in the course.

Professional identity (trans)formation in medical education: reflection, relationship, resilience

A fundamental goal of medical education is the active, constructive, transformative process of professional identity formation (PIF). Medical educators are thus charged with designing standardized and personalized curricula for guiding, supporting, and challenging learners on the developmental professional identity pathway, including the process of socialization. The author of this Commentary provides an overview of foundational principles and key drivers of PIF supporting the being, relating, and doing the work of a compassionate and competent physician. Key elements of PIF including guided reflection, use of personal narratives, integral role of relationships and role modeling, and community of practice are viewed through various lenses of PIF theory and pedagogy. Questions informing the PIF discourse are raised, including interprofessional identity considerations. Central emergent themes of reflective practice, relationships, and resilience are described as supporting and reciprocally enhancing PIF. Overarching lessons include attending to learners' and faculty's PIF within a developmental trajectory of the professional life cycle; process and content within PIF curricula as well as learners' individual and collective voices; curricular/extracurricular factors contributing to socialization, self-awareness, development of core values, and moral leadership; integrating PIF domains within pedagogy; faculty development for skilled mentoring and reflective coaching; and implementing resilience-promoting skill sets as "protective" within PIF. Outcomes assessment including the impact of curricula on learners and on patient-centered care can be challenging, and potential next steps toward this goal are discussed.