What lies beneath? Experiencing emotions and caring in oncology

Parent and oncologist perspectives on prognostic disclosure in advanced childhood cancer: communication pearls and pitfalls

PURPOSE

For children with advanced cancer and their families, communication about prognosis is critical. Unfortunately, data demonstrate that prognostic communication occurs infrequently and inconsistently across advancing illness. Prior to developing an intervention to improve prognostic communication, we aimed to (1) characterize parent and oncologist perspectives on "best" approaches for prognostic communication, and (2) explore similarities and differences between parent and oncologist perspectives.

METHODS

Children with poor-prognosis solid tumors, their parents, and oncologists were followed prospectively for 24 months or until death. Matched semi-structured interviews were conducted with parents and oncologists 0-7 days after medical encounters at timepoints of disease progression or relapse. Reflexive thematic analysis was conducted to describe parent and oncologist impressions of communication quality.

RESULTS

A total of 68 interviews were conducted following serial disease reevaluation encounters involving 13 parents and five oncologists. Nine main themes were identified as "best" approaches: (1) speaking with honesty and clarity, (2) leaving room for hope, (3) leaning into a long-standing relationship, (4) personalizing language, (5) empowering the patient and family, (6) collaborating with the multidisciplinary team, (7) providing anticipatory guidance, (8) setting the scene, and (9) creating a therapeutic space. Parents and oncologists generally agreed on themes related to helpful communication approaches, while parents more explicitly described communication pitfalls.

CONCLUSION

Parents and oncologists described clear recommendations for helpful communication strategies and pitfalls to avoid during difficult prognostic disclosure. Future work should integrate patient perspectives in the design and testing of an intervention to improve prognostic communication in advanced childhood cancer.

Secondary emotional labor: How female nurses respond to the contradictions of caring

Prior research suggests that caring is in tension with a financially incentivized, technologically-driven healthcare system. Nevertheless, employers, the public, and nurses expect nurses to be caring when providing care to patients and families. This article focuses on nurses' emotional labor strategies when managing emotions related to organizationally imposed interference with caring. We analyzed 27 semi-structured interviews with nurses and found that the unsuccessful performance of emotional labor spills over into the women's relationships at and outside of work. We apply Di-Cicco-Bloom and DiCicco-Bloom's concept of secondary emotional labor to examine our findings and how secondary emotional labor further develops the alienation and exploitation concepts of Hochschild's emotional labor theory. We suggest a structural change in nurses' job design that remedies contradictory caring expectations and supports their emotional labor to prioritize a climate of caring for patients.

A Scoping Review on the Concept of Physician Caring

BACKGROUND

Physicians' interest in the health and well-being of their patients is a tenet of medical practice. Physicians' ability to act upon this interest by caring for and about their patients is central to high-quality clinical medicine and may affect burnout. To date, a strong theoretical and empirical understanding of physician caring does not exist. To establish a practical, evidence-based approach to improve health care delivery and potentially address physician burnout, we sought to identify and synthesize existing conceptual models, frameworks, and definitions of physician caring.

METHODS

We performed a scoping review on physician caring. In November 2019 and September 2020, we searched PubMed MEDLINE, Embase, PsycINFO, CINAHL, and CENTRAL Register of Controlled Trials to identify conceptual models, frameworks, and definitions of physician caring. Eligible articles involved discussion or study of care or caring among medical practitioners. We created a content summary and performed thematic analysis of extracted data.

RESULTS

Of 11,776 articles, we reviewed the full text of 297 articles; 61 articles met inclusion criteria. Commonly identified concepts referenced Peabody's "secret of care" and the ethics of care. In bioethics, caring is described as a virtue. Contradictions exist among concepts of caring, such as whether caring is an attitude, emotion, or behavior, and the role of relationship development. Thematic analysis of all concepts and definitions identified six aspects of physician caring: (1) relational aspects, (2) technical aspects, (3) physician attitudes and characteristics, (4) agency, (5) reciprocity, and (6) physician self-care.

DISCUSSION

Caring is instrumental to clinical medicine. However, scientific understanding of what constitutes caring from physicians is limited by contradictions across concepts. A unifying concept of physician caring does not yet exist. This review proposes six aspects of physician caring which can be used to develop evidence-based approaches to improve health care delivery and potentially mitigate physician burnout.

Turning the gaze: Digital patient feedback and the silent pathology of the NHS

Online review and rating sites, where patients can leave feedback on their experience of the health-care encounter, are becoming an increasing feature of primary care in the NHS. Previous research has analysed how digital surveillance is re-shaping the clinical gaze, as health-care professionals are subject to increased public monitoring. Here, we draw on an empirical study of 41 GP practice staff to show how the gaze is turning, not simply from the patient to the health-care provider, but additionally to the body politic of the NHS. Drawing on focus group and interview data conducted in five UK practices, we show how discourses of online reviews and ratings are producing new professional subjectivities among health-care professionals and the extent to which the gaze extends not only to individual health-care interactions but to the health-care service writ large. We identify three counter-discourses characterising the evolving ways in which online reviews and ratings are creating new subjects in primary care practices: victimhood, prosumption versus traditional values and taking control. We show how the ways in which staff speak about online feedback are patterned by the social environment in which they work and the constraints of the NHS they encounter on a day-to-day basis.

Cross-Cultural Validity Study of a Medical Education Leadership Competencies Instrument in Latin American Physicians: A Multinational Study

PURPOSE

Physicians rarely receive formal training in leadership skills. Çitaku and colleagues have identified a set of leadership competencies (LCs) providing validity evidence in North American (NA) and European Union (EU) medical education institutions. We aim to apply this same survey to a sample of Latin American (LA) medical leaders from the oncology community and related areas, compare the results with those of the previous survey, and perform subgroup analyses within the LA cohort.

METHODS

The survey was sent to nearly 8,000 physicians of participating professional organizations. In addition to the 63 questions, we also collected data on the type of institution, country, specialty, sex, age, years of experience in oncology, and leadership position.

RESULTS

The 217 LA respondents placed the highest value on task management competencies (91.37% reported these as important or very important v 87.0% of NA/EU respondents; P < .0001), followed by self-management (87.45% of LA respondents v 87.55% of NA/EU respondents; P = not significant [NS]), social responsibility (86.83% of LA respondents v 87.48% of NA/EU respondents; P = NS), innovation (86.69% of LA respondents v 85.31% of NA/EU respondents; P = NS), and leading others (83.31% of LA respondents v 84.71% of NA/EU respondents; P = NS). Social responsibility, which was first in importance in the NA/EU survey, was only third in the LA survey. Subgroup analyses showed significant variations in the ratings of specific LCs within the LA population.

CONCLUSION

LCs valued by LA leaders somewhat differ from those valued by their NA and EU counterparts, implying that cultural aspects might influence the perception of desired LCs. We also detected variations in the responses within the LA population. Our data indicate that current physician leadership training programs should be tailored to suit specific needs and cultural aspects of each region. Further validity studies of this instrument with other samples and cultures are warranted.

Emotions and Medical Decision-Making

Sociologists have written surprisingly little about the role emotions play in medical decision-making, largely ceding this terrain to psychologists who conceptualize emotional influences on decision-making in primarily cognitive and individualistic terms. In this article, I use ethnographic data gathered from parents and physicians caring for children with life-threatening conditions to illustrate how emotions enter the medical decision-making process in fundamentally interactional ways. Because families and physicians alike often defined emotions as useful information to guide the decision-making process, both parties could leverage them in health care interactions by eliciting or demonstrating emotional investment, strategically deploying emotionally charged symbols, and using emotions as tiebreakers to help themselves and one another make choices in the midst of uncertainty. Constructing emotions as valuable in the decision-making process and effectively marshalling them in these ways offered a number of advantages. It could make decisions easier to arrive at, help people feel more confident in the decisions they made, and reduce interpersonal conflict. By connecting the dynamic role emotions can play in the interactive process through which medical decisions are made to the social advantages they can produce, I point to an underappreciated avenue through which inequalities in health care are perpetuated.

Exploring the impact and experience of fractional work in medicine: a qualitative study of medical oncologists in Australia

OBJECTIVES

Fractional (part-time) appointments are becoming more commonplace in many professions, including medicine. With respect to the contemporary oncological landscape, this highlights a critical moment in the optimisation of employment conditions to enable high-quality service provision given growing patient numbers and treatment volume intensification. Data are drawn from a broader study which aimed to better understand the workforce experiences of medical oncologists in Australia. This paper specifically aims to examine a group of clinicians' views on the consequences of fractional work in oncology.

DESIGN

Qualitative, one-on-one semistructured interviews. Interview transcripts were digitally audio recorded and transcribed verbatim. Data were subject to thematic analysis supported by the framework approach and informed by sociological methods and theory.

SETTING

New South Wales, Australia.

PARTICIPANTS

Medical oncologists (n=22), including 9 female and 13 male participants, at a range of career stages.

RESULTS

Four key themes were derived from the analysis: (1) increasing fractional employment relative to opportunities for full-time positions and uncertainty about future opportunities; (2) tightening in role diversity, including reducing time available for research, mentoring, professional development and administration; (3) emerging flexibility of medical oncology as a specialty and (4) impact of fractional-as-norm on workforce sustainability and quality of care.

CONCLUSION

Fractional appointments are viewed as increasing in oncology and the broader consequences of this major shift in medical labour remain unexamined. Such appointments offer potential for flexible work to better suit the needs of contemporary oncologists; however, fractional work also presents challenges for personal and professional identity and vocational engagement. Fractional appointments are viewed as having a range of consequences related to job satisfaction, burnout and service delivery. Further research is needed to provide a critical examination of the multiple impacts of workforce trends within and beyond oncology.