Cultural competency 2.0: exploring the concept of "difference" in engagement with the other.

Cultural competency efforts have received much attention in medical education. Most efforts focus on the acquisition of knowledge and skills about various groups based on race and ethnic identity, national origins, religion, and the like. The authors propose an approach, "Cultural Competency 2.0," that does not reject such efforts but, rather, adds a more critical and expanded focus on learners' attitudes and beliefs toward people unlike themselves. Cultural Competency 2.0 includes learners' examination of the social position of most U.S. medical students, Bourdieu's concept of habitus, and the phenomenon of countertransference to come to new critical insights on learners' attitudes, beliefs, and, ultimately, interactions with all patients. Suggestions are offered for how and where Cultural Competency 2.0 can be used in the curriculum through narrative medicine, particularly through the development of reading practices that unmask illusions of "pure" objectivity often assumed in clinical settings, and that make visible how words and images constrain, manipulate, or empower individuals, groups, ideas, or practices.The authors argue that these educational approaches should be sustained throughout the students' clinical experiences, where they encounter patients of many kinds and see clinicians' varied approaches to these patients. Further, these educational approaches should include assisting students in developing strategies to exercise moral courage within the limitations of their hierarchical learning environments, to strengthen their voices, and, when possible, to develop a sense of fearlessness: to always be advocates for their patients and to do what is right, fair, and good in their care.

Derogatory and cynical humour directed towards patients: views of residents and attending doctors.

CONTEXT: A study of medical students' perspectives on derogatory and cynical humour was published in 2006. The current study examines residents' and attending doctors' perspectives on the same phenomenon in three clinical departments of psychiatry, internal medicine and surgery. METHODS: Two focus groups were conducted in each of the three clinical departments, one with residents and one with attending doctors,during the 2006-07 academic year. Seventy doctors participated, including 49 residents and 21 attendings. The same semi-structured format was used in each group. Questions focused on characterisations of derogatory and cynical humour along with motives and rules for its use.All focus groups were audiotaped and the tapes transcribed. Each transcript was read independently by each researcher as part of an inductive process to discover the categories that describe and explain the uses, motives and effects of such humour. RESULTS: Three categories that appeared in the first study with medical students - locations for humour, the humour game, and not-funny humour - emerged as virtually identical,whereas two others--objects of humour and motives for humour - were more fully elaborated. DISCUSSION: Discussions of derogatory and cynical humour should occur in any department where teaching and role modelling are priorities. In addition, the tenets of appreciative inquiry and the complex responsive process,particularly as they are used at the Indiana University School of Medicine, offer medical educators valuable tools for addressing this phenomenon.

Patients' perspectives on total knee replacement.

OBJECTIVE: Because patients' perspectives on total knee replacement (TKR) surgery have rarely been the topic of research, this study sought to describe their pre- and postoperative experiences. METHODS: Using a qualitative descriptive design, researchers collected data from a convenience sample of 27 patients who were about to undergo or had recently undergone TKR. Preoperative data were obtained in focus group sessions (n = 17); postoperative data were obtained in individual interviews (n = 10). All data-collection sessions were tape-recorded and transcribed, and transcripts were analyzed. The researchers isolated themes by identifying recurrent words and phrases and then sorted the data into thematic categories. RESULTS: Four main themes emerged. First, many participants delayed surgery for months to years, despite increasing pain and limitation. Second, once participants decided to proceed with surgery, they entered a period of waiting and worrying about what would happen during and after surgery. Third, both pre- and postoperative participants struggled with the need for independence, as well as with learning to accept the new knee. And fourth, patients experienced postoperative pain associated with surgery and rehabilitation, yet reported having hope that they'd regain function. CONCLUSIONS: These findings suggest that patients need to be better educated and supported before and after TKR surgery. More research is needed to shed light on how patients' experiences influence their decisions about the surgery and its outcomes.

The association of exposure, risk, and resiliency factors with PTSD among Jews and Arabs exposed to repeated acts of terrorism in Israel.

Israel has faced ongoing terrorism since the beginning of the Al Aqsa Intifada in September 2000. The authors examined risk and resiliency factors associated with posttraumatic stress disorder (PTSD) among 1,117 Jews and 394 Arab adult citizens of Israel during August and September 2004 through telephone interviews. Probable PTSD was found among 6.6% of Jews and 18.0% of Arabs. Predictors of probable PTSD in a multivariate model for Jews were refusal to report income, being traditionally religious, economic and psychosocial resource loss, greater traumatic growth, and lower social support. For Arabs, predictors were low education and economic resource loss among those exposed to terrorism. Findings for only those directly exposed to terrorism were similar to those for the overall national sample.

Rituals of verification: the role of simulation in developing and evaluating empathic communication.

The use of simulation and standardized patients in medical education is firmly established. In this "point-counterpoint" format we debate not their important function but the extent to which they are used to establish "evidence" for trainees' empathic communication skills beyond their surface manifestations. We also question such issues as the power dynamics implicit in simulation when patients are not really worried or dependent but rather students who are under the evaluative surveillance gaze, often relying on formulaic and superficial behaviors associated with good communication. We offer educative experiences in narrative domains as opportunities to develop the habits of thinking and authentic feeling often absent in evaluative-based simulations.

Emergency department visits for suicidality in three hospitals.

The purposes of this study were to describe suicidal persons who come to the emergency department (ED) and to examine the relationship between clinical and health service characteristics and decisions regarding post-ED care. Data were collected from three hospital EDs by means of a retrospective review of records. During the 1-month study period, 163 ED visits were for suicidal ideation (f = 110) or behavior (f = 53). The mean age of the patients was 36.5 years (range = 5-87 years); 51% were female patients. Clinical decisions about post-ED care tended to be cautious, regardless of a patient's level of suicidality, with 71% of patients either transferred for psychiatric evaluation or admitted to the psychiatric unit. Emergency department staff tended to be slightly more conservative than mental health professionals, but the difference in their decisions about disposition was not significant.

Making fun of patients: medical students' perceptions and use of derogatory and cynical humor in clinical settings.

PURPOSE: It has long been known that medical students become more cynical as they move through their training, and at times even exhibit "ethical erosion." This study examines one dimension of this phenomenon: how medical students perceive and use derogatory and cynical humor directed at patients. METHOD: The authors conducted five voluntary focus groups over a three-month period with 58 third- and fourth-year medical students at the Northeastern Ohio Universities College of Medicine in 2005. After transcribing the taped interviews, the authors analyzed the data using qualitative methods and identified themes found across groups. RESULTS: The categories that emerged from the data were (1) categories of patients who are objects of humor, including those deemed "fair game" due to obesity or other conditions perceived as preventable or self-inflicted; (2) locations for humor; (3) the "humor game," including student, resident, and faculty interaction and initiation of humor; (4) not-funny humor; and (5) motives for humor, including coping and stress relief. CONCLUSIONS: The authors offer recommendations for addressing the use of derogatory humor directed at patients that include a more critical, open discussion of these attitudes and behaviors with medical students, residents, and attending physicians, and more vigorous attention to faculty development for residents.