Which values do attending physicians try to pass on to house officers?

CONTEXT: Professional development in medicine includes the acquisition of values and attitudes which are fundamental to the role of the physician. Little is known about which values and attitudes attending physicians emphasize in their teaching of medical trainees to help them develop professionally. OBJECTIVE: To determine the values and attitudes which attending physicians try to pass on to residents in order to encourage their professional development. DESIGN: Cross-sectional study using a mailed survey. SETTING: Four university-affiliated teaching hospitals. SUBJECTS: Attending physicians with residency-level teaching responsibilities. MEASUREMENTS: The self-reported single value or attitude that attending physicians try to pass on to house officers. RESULTS: Of the 341 attending physicians who returned a completed questionnaire, 265 (78%) shared the single value or attitude they try to pass on to residents. The four main categories into which more than 95% of responses could be categorized were: (i) caring, (ii) respect, (iii) communication and (iv) integrity. There were no statistically significant differences between the responses given by attending physicians who had been named as excellent role models and their colleagues who had not been so named. CONCLUSIONS: Attending physicians attempt to pass on values and attitudes they consider important for the professional development of medical trainees. Future research might focus on optimal ways to teach these qualities to medical learners.

Personal growth in medical faculty: a qualitative study.

BACKGROUND: A physician's effectiveness depends on good communication, and cognitive and technical skills used with wisdom, compassion, and integrity. Attaining the last attributes requires growth in awareness and management of one's feelings, attitudes, beliefs, and life experiences. Yet, little empiric research has been done on physicians' personal growth. OBJECTIVE: To use qualitative methods to understand personal growth in a selected group of medical faculty. DESIGN: Case study, using open-ended survey methods to elicit written descriptions of respondents' personal growth experiences. SETTING: United States and Great Britain. PARTICIPANTS: Facilitators, facilitators-in-training, and members of a personal growth interest group of the American Academy on Physician and Patient, chosen because of their interest, knowledge, and experience in the topic area and their accessibility. MEASUREMENTS: Qualitative analysis of submitted stories included initially identifying and sorting themes, placing themes into categories, applying the categories to the database for verification, and verifying findings by independent reviewers. RESULTS: Of 64 subjects, 32 returned questionnaires containing 42 stories. Respondents and nonrespondents were not significantly different in age, sex, or specialty. The analysis revealed 3 major processes that promoted personal growth: powerful experiences, helping relationships, and introspection. Usually personal growth stories began with a powerful experience or a helping relationship (or both), proceeded to introspection, and ended in a personal growth outcome. Personal growth outcomes included changes in values, goals, or direction; healthier behaviors; improved connectedness with others; improved sense of self; and increased productivity, energy, or creativity. CONCLUSIONS: Powerful experiences, helping relationships, and introspection preceded important personal growth. These findings are consistent with theoretic and empiric adult learning literature and could have implications for medical education and practice. They need to be confirmed in other physician populations.

Teaching resource and information management using an innovative case-based conference.

Physicians play a critical role in controlling resource use in medicine. This paper describes an innovative, interdisciplinary conference that teaches housestaff and medical students about resource and information management in the hospital setting. The objectives are to help foster communication between physicians and other members of the health care team, to improve the understanding of hospital reimbursement, and to influence attitudes toward practicing cost effectiveness. The conference structure includes the following components: case presentation by the treating physician and follow-up information provided by the primary care physician, a review of the itemized hospital bill, discussion of coding issues, discussion of hospital reimbursement comparing case data to institutional and state averages, and a summary of key take-home points and lessons.

Teaching anthropology in the medical curriculum.

Practicing medicine well requires recognizing the breadth of human experience and attending to the psychological and sociocultural dimensions of patients as well as their physical needs. Central to the concerns of anthropology are the shared beliefs and values expressed in social practices and traditions that give meaning to everyday life. The relevance of anthropology for biomedical practice and research is grounded in the discipline's emphasis on contextual meaning and its unique strategies for data gathering. In this article, we briefly review the field of anthropology and the discipline of medical anthropology. We argue for incorporating anthropological concepts and methods in medical training, and summarize anthropology's role in medical education over the past century. Finally, we present ideas for including anthropology in the medical curriculum, proposing curricular goals and content, and teaching settings and techniques. An anthropological orientation can foster trainee self-awareness, help trainees prepare for the diverse perspectives they will encounter in our pluralistic society, and facilitate critical analysis of biomedicine and its systems of care.

Bridging cultural differences in medical practice. The case of discussing negative information with Navajo patients.

BACKGROUND: Cultural differences between doctors and their patients are common and may have important implications for the clinical encounter. For example, some Navajo patients may regard advance care planning discussions to be a violation of their traditional values. OBJECTIVE: To learn from Navajo informants a culturally competent approach for discussing negative information. DESIGN: Focused ethnography. SETTING: Navajo Indian reservation, northeast Arizona. PARTICIPANTS: Thirty-four Navajo informants, including patients, traditional healers, and biomedical health care providers. MEASUREMENT: In-depth interviews. MAIN RESULTS: Strategies for discussing negative information were identified and organized into four stages. Assessment of patients is important because some Navajo patients may be troubled by discussing negative information, and others may be unwilling to have such discussions at all. Preparation entails cultivating a trusting relationship with patients, involving family members, warning patients about the nature of the discussion as well as communicating that no harm is intended, and facilitating the involvement of traditional healers. Communication should proceed in a caring, kind, and respectful manner, consistent with the Navajo concept k'é. Reference to a third party is suggested when discussing negative information, as is respecting the power of language in Navajo culture by framing discussions in a positive way. Follow-through involves continuing to care for patients and fostering hope. CONCLUSIONS: In-depth interviews identified many strategies for discussing negative information with Navajo patients. Future research could evaluate these recommendations. The approach described could be used to facilitate the bridging of cultural differences in other settings.

Western bioethics on the Navajo reservation. Benefit or harm?

OBJECTIVE: To understand the Navajo perspective regarding the discussion of negative information and to consider the limitations of dominant Western bioethical perspectives. DESIGN: Focused ethnography. SETTING: Navajo Indian reservation in northeast Arizona. PARTICIPANTS: Thirty-four Navajo informants, including patients, biomedical health care providers, and traditional healers. RESULTS: Informants explained that patients and providers should think and speak in a positive way and avoid thinking or speaking in a negative way; 86% of those questioned considered advance care planning a dangerous violation of traditional Navajo values. These findings are consistent with hózhó, the most important concept in traditional Navajo culture, which combines the concepts of beauty, goodness, order, harmony, and everything that is positive or ideal. CONCLUSIONS: Discussing negative information conflicts with the Navajo concept hózhó and was viewed as potentially harmful by these Navajo informants. Policies complying with the Patient Self-determination Act, which are intended to expose all hospitalized Navajo patients to advance care planning, are ethically troublesome and warrant reevaluation.

Racial bias in presentation of cases.

To investigate whether medical housestaff report race information differently during case presentations of black patients and white patients, a prospective observational study was performed. Without informing housestaff, a chief resident recorded data during consecutive case presentations over two months. For each presentation, the data included: 1) whether, where, and how often race was identified; 2) whether certain prospectively selected, "possibly unflattering characteristics" were mentioned; and 3) whether any "justifying" diagnoses were considered during presentation or subsequent discussion. Justifying diagnoses were those in which a patient's race was important in considering the likelihood of possible diagnoses. Twenty-three house officers presented 18 black and 35 white patients. A single East Indian patient was excluded from analysis. Race was specified more often during presentations of black than of white patients (16 of 18 for blacks vs. 19 of 36 for whites; p less than 0.01). For two black patients, a justifying diagnosis was considered, but excluding these patients did not change the results. Two other differences did not achieve statistical significance. Race was more often specified prominently and repeatedly during presentations of black patients. Among patients to whom "possibly unflattering" characteristics were attributed, race was more likely to be specified for blacks (10 of 10) than for whites (4 of 9). These case presentations appeared to show a subtle bias.