Storylines of family medicine V: ways of thinking-honing the therapeutic self.

Storylines of Family Medicine is a 12-part series of thematically linked essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'V: ways of thinking-honing the therapeutic self', authors present the following sections: 'Reflective practice in action', 'The doctor as drug-Balint groups', 'Cultivating compassion', 'Towards a humanistic approach to doctoring', 'Intimacy in family medicine', 'The many faces of suffering', 'Transcending suffering' and 'The power of listening to stories.' May readers feel a deeper sense of their own therapeutic agency by reflecting on these essays.

A Comprehensive Clinical Model of Suffering.

Suffering is often a part of the illness experience, and relieving it is a fundamental obligation of medicine. Distress, injury, disease, and loss generate suffering when they threaten meaning in the patient's personal narrative. Family physicians have exceptional opportunities and responsibilities to manage suffering through long-term continuity relationships, demonstrating empathy, and building trust over time and across problems. We propose a new Comprehensive Clinical Model of Suffering (CCMS) founded on the family medicine approach to whole-patient care. Comprehending that suffering can involve every aspect of a patient's life, the CCMS is constructed on 4 axes and 8 domains that form a "Review of Suffering" to help clinicians recognize and manage patient suffering. Applied to clinical care, the CCMS can guide observation and empathetic questioning. Applied to teaching, it can provide a framework for discussions of complex and challenging patients. Barriers to applying the CCMS in practice include clinician training, time with patients, and competing demands. However, by structuring the clinical assessment of suffering, the CCMS may increase the efficiency and effectiveness of clinical encounters and improve patient care and outcomes. The application of the CCMS to patient care, clinical training, and research will require further evaluation.

The Suffering Medical Students Attribute to Their Undergraduate Medical Education.

BACKGROUND AND OBJECTIVES: The purpose of this study was to explore medical student perceptions of their medical school teaching and learning about human suffering and their recommendations for teaching about suffering. During data collection, students also shared their percerptions of personal suffering which they attributed to their medical education. METHODS: In April through May 2015, we conducted focus groups involving a total of 51 students representing all four classes at two US medical schools. RESULTS: Some students in all groups reported suffering that they attributed to the experience of medical school and the culture of medical education. Sources of suffering included isolation, stoicism, confusion about personal/professional identity and role as medical students, and witnessing suffering in patients, families, and colleagues. Students described emotional distress, dehumanization, powerlessness, and disillusionment as negative consequences of their suffering. Reported means of adaptation to their suffering included distraction, emotional suppression, compartmentalization, and reframing. Students also identified activities that promoted well-being: small-group discussions, protected opportunities for venting, and guidance for sharing their experiences. They recommended integration of these strategies longitudinally throughout medical training. CONCLUSIONS: Students reported suffering related to their medical education. They identified common causes of suffering, harmful consequences, and adaptive and supportive approaches to limit and/or ameliorate suffering. Understanding student suffering can complement efforts to reduce medical student distress and support well-being.

A Narrative Approach to Healing Chronic Illness.

Many clinicians may feel poorly prepared to manage patient suffering resulting from the travails of chronic illness. This essay explores the thesis that chronically and terminally ill patients can be holistically healed by transcending the suffering occasioned by the degradations of their illnesses. Suffering is conveyed as a story and clinicians can encourage healing by co-constructing patients' illness stories. By addressing the inevitable existential conflicts uncovered in patients' narratives and helping them edit their stories to promote acceptance and meaning, suffering can be transcended. This requires that clinicians be skilled in narrative medicine and open to engaging the patient's existential concerns. By helping patients transcend their suffering, clinicians claim their heritage as healers.

Medical Student Perceptions of Their Education About Suffering.

BACKGROUND AND OBJECTIVES: To explore student perceptions of their medical school teaching and learning about human suffering and to elicit student recommendations for better approaches to teaching about suffering. METHODS: Qualitative study involving focus groups of students from each class at two US medical schools. RESULTS: Students reported that teaching about human suffering was variable, rarely explicit, and occurred primarily in the pre-clinical curriculum. In the clinical curriculum, addressing patient suffering was neither overtly valued nor evaluated by attending physicians. Students perceived little or no explicit educational attention to the suffering of patients and their families, with the exceptions of specific rotations and attendings. They described little or no teaching of clinical skills to identify and manage suffering and desired such training. Students learned about the clinical management of suffering primarily by ad hoc observation of role models. Some also noted that exposure to patient suffering and the demands of medical education contributed to their own suffering. Students recommended intentional, integrated and longitudinal teaching about suffering, with regular reinforcement and evaluation, across the medical school curriculum. CONCLUSIONS: Students perceived teaching about human suffering as insufficient at the institutions studied and desired to learn clinical skills to identify and help patients manage suffering. Medical educators should explicitly address patient suffering and create longitudinal curricula with improved clinical teaching, faculty role modeling, and student evaluation.

A philosophy for behavioral health integration in primary care.

In response to a call for a philosophy that transcends the professional boundaries that threaten behavioral health integration in primary care, this essay explores the thesis that such a philosophy exists in medicine's core purpose. Drawing on the work of Eric Cassell, a philosophy may be determined that melds the values, themes, and constructs of individual models for behavioral health integration in primary care toward a single, overriding purpose. Effecting such integration challenges current trends in medicine by refocusing medicine on its ethical core. (PsycINFO Database Record

Medical student perceptions of medical school education about suffering: a multicenter pilot study.

BACKGROUND AND OBJECTIVES: Little is known about what students perceive they are taught about suffering in medical school. We sought to explore medical student perceptions of their medical school education about suffering. METHODS: We used an online survey of medical students enrolled in four US medical schools with chi-square analysis of responses by gender and preclinical/clinical status. RESULTS: A total of 1,043 students (38%) responded and indicated that teaching about suffering is occurring in the schools surveyed. Respondents most strongly endorsed statements that their medical school education explicitly teaches that the relief of suffering is an inherent function of being a physician (46.5%) and that most of what they learned about dealing with suffering patients is taught by modeling (46.6%). They reported that their education explicitly teaches about suffering (32.8%), provides a good understanding of suffering (31.7%), and teaches how to interact with suffering patients (31.7%). Students gave the least support to statements that their education prepares them to personally deal with their reactions to the suffering of patients (25.1%) and teaches how to diagnose suffering (15.3%). Responses varied markedly according to gender and clinical status at two of the four schools surveyed. CONCLUSIONS: Teaching about suffering is occurring in the schools surveyed and can be variably experienced according to gender and clinical status. Implied curricular gaps include teaching about how to diagnose suffering and how to personally deal with the feelings that arise when caring for suffering patients. Further research on how students are learning about suffering is warranted to guide curriculum development and implementation.

"I know this must have been a difficult day for you:" personal care in a patient-centered medical home.

In light of calls for a new model of care, family physicians are endeavoring to create a Patient-centered Medical Home. Yet, structures of care in themselves do not make a home; for the medical house to be a home requires physicians to demonstrate a personal touch that communicates caring to the patient. This essay describes one easily accomplished method by which to integrate personal care in a Patient-centered Medical Home.

Role modeling the doctor-patient relationship in the clinical curriculum.

BACKGROUND AND OBJECTIVES: Training in relationship skills relies heavily on role modeling: students observing clinicians at work. This study explored student and faculty perceptions of student learning about relationship skills in hospital and ambulatory settings. METHODS: Qualitative data from focus groups and long interviews were coded by the authors through an iterative dialogic process. Participants were 15 faculty and 35 medical students in clinical training in a New Zealand medical school. RESULTS: Teaching of doctor-patient relationship skills was highly variable, rarely explicit, and heavily dependent on role modeling. Students noted variable focus on relational skills between rotations, incongruity between preclinical training and the behaviors observed in clinical environments, and a need to discern which relational skills were facilitative. Role models who transparently shared their personal experiences of doctoring were more effective in helping students learn relationship skills. CONCLUSIONS: Role modeling alone is insufficient for helping students acquire exemplary doctor-patient relationship skills. Role models must explicitly reflect upon the complex intricacies of interacting with patients to help students understand and incorporate specific skills. Lack of transparency is a barrier to quality role modeling that may be mitigated in ambulatory, primary care settings.

Faculty and medical students' perceptions of teaching and learning about the doctor-patient relationship.

OBJECTIVE: To explore student and faculty perceptions of how students are learning doctor-patient relationship skills in their clinical medical education. METHODS: Exploratory qualitative study involving data from interviews and focus groups with students and interviews with teaching faculty. RESULTS: Respondents reported that pre-clinical relationship skills curricula were not well-coordinated with clinical curricula. Within the clinical curriculum, respondents perceived a disparity between general practice and hospital-based attachments. Teaching of relationship skills on the wards was highly variable, rarely explicit, and primarily dependent on role-modelling. In contrast, general practice runs included explicit teaching with feedback that reinforced skills taught in the pre-clinical curriculum. Respondents recommended increased focus on and assessment of students' interpersonal skills within clinical settings. CONCLUSION: Pre-clinical and clinical relationship skills curricula were not coordinated. The tension between service commitments and student teaching in hospital-based attachments contributed to an insufficient focus on communication and relationship skills acquisition and did not reinforce teaching in pre-clinical and ambulatory clinical settings. PRACTICE IMPLICATIONS: The teaching of doctor-patient relationship skills can be augmented by coordinating pre-clinical and clinical curricula and by requiring observation and structured feedback related to explicit criteria of student skills acquisition across all clinical learning experiences.

Medical trainee perceptions of medical school education about suffering: a pilot study.

BACKGROUND: The relief of suffering is a fundamental goal of medicine, but what medical students are taught about suffering has been largely unexplored. OBJECTIVE: This pilot study explored the perceptions of physicians in postgraduate training of their medical school education about suffering. DESIGN: Survey research involving physicians in postgraduate family medicine training programs. RESULTS: One hundred eighty-four of 304 surveys were returned for a response rate of 61%. Respondents perceived significant gaps in their education about the understanding and diagnosis of suffering and in their preparation to deal with the feelings engendered by caring for suffering patients. Respondents generally perceived that they were prepared to interact with suffering patients and were taught that the relief of suffering is an inherent function of being a physician, but perceived that more explicit teaching about suffering would have better prepared them for residency training. CONCLUSIONS: Perceptions of the teaching about suffering at the medical school level are quite variable with significant curricular gaps in student instruction about suffering and its relief.

Suffering, meaning, and healing: challenges of contemporary medicine.

This essay explores the thesis that changes in contemporary society have transformed the work of doctoring and challenge doctors to be physician-healers. Medical advances in the prevention and management of acute disease have wrought a growing population of chronically ill patients whose care obliges physicians to become holistic healers. Holistic healing involves the transcendence of suffering. Suffering arises from perceptions of a threat to the integrity of person-hood, relates to the meaning patients ascribe to their illness experience, and is conveyed as an intensely personal narrative. Physician-healers use the power of the doctor-patient relationship to help patients discover or create new illness narratives with fresh meanings that reconnect them to the world and to others and thereby transcend suffering and experience healing. Physician-healers equipped with the attitudes, skills, and knowledge to assist patients to transcend suffering are indispensable if contemporary medicine is to maintain its tradition as a healing profession. In the process, physicians may discover meaningful connections with patients that bring new and refreshing perspectives to their work.

The meaning of healing: transcending suffering.

PURPOSE: Medicine is traditionally considered a healing profession, but it has neither an operational definition of healing nor an explanation of its mechanisms beyond the physiological processes related to curing. The objective of this study was to determine a definition of healing that operationalizes its mechanisms and thereby identifies those repeatable actions that reliably assist physicians to promote holistic healing. METHODS: This study was a qualitative inquiry consisting of in-depth, open-ended, semistructured interviews with Drs. Eric J. Cassell, Carl A. Hammerschlag, Thomas S. Inui, Elisabeth Kubler-Ross, Cicely Saunders, Bernard S. Siegel, and G. Gayle Stephens. Their perceptions regarding the definition and mechanisms of healing were subjected to grounded theory content analysis. RESULTS: Healing was associated with themes of wholeness, narrative, and spirituality. Healing is an intensely personal, subjective experience involving a reconciliation of the meaning an individual ascribes to distressing events with his or her perception of wholeness as a person. CONCLUSIONS: Healing may be operationally defined as the personal experience of the transcendence of suffering. Physicians can enhance their abilities as healers by recognizing, diagnosing, minimizing, and relieving suffering, as well as helping patients transcend suffering.

Integrating communication training into a required family medicine clerkship.

Persistent evidence suggests that the communication skills of practicing physicians do not achieve desired goals of enhancing patient satisfaction, strengthening health outcomes and decreasing malpractice litigation. Stronger communication skills training during the clinical years of medical education might make use of an underutilized window of opportunity-students' clinical years-to instill basic and important skills. The authors describe the implementation of a novel curriculum to teach patient-centered communication skills during a required third-year, six-week family medicine clerkship. Curriculum development and implementation across 24 training sites in a five-state region are detailed. A faculty development effort and strategies for embedding the curriculum within a diverse collection of training sites are presented. Student and preceptor feedback are summarized and the lessons learned from the curriculum development and implementation process are discussed.

Issues in end-of-life care: patient, caregiver, and clinician perceptions.

CONTEXT: Review of published research indicates the need to better incorporate patient and caregiver perceptions when providing end-of-life (EOL) care. Although considerable research regarding patient and caregiver experience of EOL has been done, little research has studied patients, caregivers, and clinicians as a connected system. OBJECTIVE: To study the perceptions of patients, caregivers, and physicians who are already connected with one another in an EOL care experience. DESIGN: Qualitative study consisting of in-depth, open-ended, face-to-face interviews and content analysis. SETTING: Community family practice residency programs in rural and urban settings in the Affiliated Family Practice Residency Network of the Department of Family Medicine, University of Washington School of Medicine. PARTICIPANTS: Forty-two patients and 39 caregivers facing EOL were interviewed either alone or together after referral by their physicians. Additionally, results of previously published findings from interviews with 39 family practice faculty were included. OUTCOME MEASURES: Perceptions of participants on EOL issues. RESULTS: Participants identified four primary issues related to their experience of EOL care: awareness of impending death, management/coping with daily living while attempting to maintain the management regimen, relationship fluctuations, and the personal experiences associated with facing EOL. Participants expected their physicians to be competent and to provide a caring relationship. CONCLUSIONS: Awareness of these crucial patient and caregiver EOL issues and expectations and how they differ from clinician perspectives can assist clinicians to appropriately explore and address patient/caregiver concerns and thereby provide better quality EOL care.

Defining effective clinician roles in end-of-life care.

OBJECTIVE: Our goal was to determine primary care clinician perceptions of what is important to the provision of quality end-of-life care. STUDY DESIGN: We used ethnography, a qualitative research method involving the use of open-ended semistructured interviews. POPULATION: We included 38 family practice residency faculty from 9 community residency programs of the Affiliated Family Practice Residency Network, Department of Family Medicine, University of Washington School of Medicine. OUTCOMES MEASURED: The roles described by interviewees when discussing their best practices while delivering end-of-life care were compiled. RESULTS: Primary care clinicians organize their delivery of quality end-of-life care predominantly through their relationships with patients and families. They play 3 roles when providing end-of-life care. As consultants, clinicians provide expert medical advice and treatment. As collaborators, they seek to understand the patient and family experience. Seasoned clinicians act as guides, using their personal intuitive knowledge of patient and family to facilitate everyone's growth when providing end-of-life care. CONCLUSIONS: Shifting clinician focus from skills and knowledge toward relationship, meaning, and roles provides new opportunities to improve end-of-life care for patients, families, and clinicians.