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Cynthia Anderson - Group 3

512 Assignment 4

January 31, 2012

CASE PRESENTATION

 

You have been on night float (7 pm - 7 am) for the past 2 days and are assigned to a  case when you come in on Evening  3.  

 

The patient is a 47 y.o. caucasian male who is scheduled for a C4-5 laminectomy under general anesthesia.  He was originally scheduled for 10 am but, due to an emergency case, was postponed until now.  He was a same day admission and has been in the hospital preop holding area since 1 pm because no hospital room is yet available. 

 

Current medical history:  Pt. has been experiencing increasing neck for the past 3 month.  He has radiating pain in the C-5 root distribution on the right.  It has not improved with physical therapy or pain medications.

 

Social history: The patient is CEO of a biotech business which he started. He works 70-80 hours/week and has a major business trip coming up in a few weeks.  He is married with 3 children. He does not smoke and drinks only socially (wine).  He has been taking vicodin for pain but has had none in the past 24 hours.

 

Past medical history:  None

Past surgical history:  This is his first surgery.

Family history:  Father died during a CABG repair at 48 years of age.  

 

V.S. HR 90 BP 145/85 RR 20 Temp 98 O2 sat. 98

EKG and labwork are unremarkable.

 

You introduce yourself as the anesthesia resident and note that he appears upset and extremely anxious.  

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CURRICULUM

 

 

Step	Description	Comments
Title	“Taking a BATHE”: An empathetic communication technique for patient interviews.	Mneunomic for an empathetic interview style designed adaptable to short interviews (Ref 1,2)
Target Audience	CA-1 residents in first 6 months of training.	Because residents have just finished internship, empathy may have declined. Important to reinforce benefits and issues surrounding as they move forward.
Goal	To provide learners with the knowledge, skills and attitudes to develop a clinical empathetic relationship with patients.	Clinical empathy consists of: Emotive-ability to imagine patients perspectives Moral-MD’s internal motivation to emphasize Cognitive-abiltiy to uderstand patient’s perspectives Behavioral- ability to convey understanding (Ref. 3)
Needs Assessment	Patients Patient satisfaction, compliance to treatment and outcomes improve with empathetic relationship to physicians (Ref 3)   Surgical patients show decreased anxiety and increased satisfaction from empathetic communication with the anesthesiologist. (Ref 4,5) Organizations The ABA identifies empathy toward patients as an essential characteristic for anesthesiologists.(www.theaba.org) Learners Empathy increases physician satisfaction. (Ref. 3, 4, 5)   Empathy declines during medical school and residency. (Ref. 3, 7)
Objectives	By the end of the session the learner will be able to: State the 4 components of clinical empathy and provide examples of each. Discuss the benefits of an empathetic relationship with patients. Describe and demonstrate the BATHE technique and during time-constrained interviews. Discuss factors that cause physician empathy to decline and suggest preventative measures.	BATHE= Background Affect Trouble Handling Empathy   A psychotherapeutic, empathetic communication technique that can be integrated into a 15 minute medical interview.   (Ref. 1,2,6)
Curriculum Description	This is a preparation course for the “Day as a Patient” in which each resident will go through the process of being a surgical patient (preop call, NPO, same day admission, preop holding check in, IV, visit by anesthesia and OR team, transport to OR & monitors/preoxygenation).   Independent Reading:  Ref. 5,6 & 9   Class Session: 90 minutes   Opener- 5 minutes Video of case (as described above) with patient actor & resident actor going through 10 min. script in which resident doesn’t explore patient issues ( patient who is used to control and fears losing it, worries about work, father’s demise during surgery, hunger).    Small Group- 10 minutes Discuss what patient’s issues might be and how they believe interview process could better produce a more trusting relationship.   Presentation of ideas-20 minutes Facilitator should assure that possible impact of resident weariness on night float factors in & explore role of lack in anesthesia continuity of care.   Didactics 20 minutes Use of ARS to review components of empathy, benefits to patients and doctors, BATHE, importance of resident wellness in maintaining empathy.   Small Groups-Role Play- 20 minutes Role play BATHE. Resident take turn being 1)Pt. 2)Anesthesiologist 3) Observer providing critique. Each “patient” will be supplied with a background description of their issues.   Closer - Committment to Act 15 minutes Discuss specifics of their Patient for a Day and ask them to think about BATHE, whether those they interact with utilize this style, and if they experience some of the feelings of the patient in the video. Ask residents to write commitment on how they will maintain empathy through communication and self-care.	Rationale: Studies indicate that effective learning techniques for empathy inlcude: -Incorporation of art/literature -Acting techniques -Patient Navigation techniques (follow or be a patient)
Assessment Techniques	Jefferson Scale of Empathy Pre-Session and Post “Day as Patient”   Resident reflective writing (Committment to Act)   Resident evaluation of the course and experience as a patient.	Rationale: In a systemic review (Ref.8), 6 empathy measuring instruments were found to have internal consistency, vaiidity and reliability.  They distributed into: Self-rated (6) Patient -rated (1)  Observer-rated (1)   The nature of this course lends itself best to a self-rated measurement.  Of the 6 described in the review, the Jefferson Scale was designed specifically for doctors & is the most studied.

 

 

 

REFERENCES

 

1.Stuart MR, Lieberman JA 3d. eds. The fifteen minute hour: applied psychotherapy for the primary care physician. Found at: http://www.fpnotebook.com/psych/exam/BthTchnq.htm

 

2.McCulloch J, Ramesar S. Psychotherapy in Primary Care: the BATHE Technique.  American Fam Physician  1998.  Found at: http://www.aafp.org.

 

3.Stepien K, Baernstein A. Education for Empathy: a review.  JGIM 2006; 21:524-530.

 

4.Rosen S, Svensson M. Calm or not calm: the question of anxiety in the perianesthesia patient.  J Perianesth Nurs 2008; 23(4): 237-46.

 

5.Soltner C, Giquello JA. Continuous care and empathetic anaesthesiologist attitude in the preoperative period: impact on patient anxiety and satisfaction. BJA 2011; 106(5): 680-6.

 

6.DeMaria S, DeMaria AP. Use of BATHE method in the preanesthetic clinic. Anesth Analg. 2011; 113(5):1020-

 

7.Neumann M., Edelhauser F.  Empathy decline and its reasons: a systematic review of studies with medical students and residents.  Acad Med 2011; 86: 996-1009.

 

8. Hemmerdinger J, Stoddart S.  A systematic review of tests of empathy in medicine. BMC Medical Educaton 2007; 7(24): 1-8.

 

9.Switankowsky I.  The importance of empathy in medical practice and some of its difficulties. Humane Medicine: a Journal of the Art and Science of Medicine 2004; 4(24).  Http.//www.humaneealthcare.com

 

 

Andrea Pinnick – Group 3 

ACMD 512 Assgn4 

January 31, 2012 

 

CASE PRESENTATION:  PEDIATRIC DENTISTRY 

You are on your QueensCare + USC Mobile Dental Clinic pediatric dentistry rotation in your 4^th year.  It is one month before graduation and you are behind in operative procedures and need to fulfill your pulpotomy/stainless steel crown graduation requirement. 

The patient is a 7-year-old Hispanic female who presents for her first restorative dentistry procedure.  She had her comprehensive examination and treatment plan completed last week.  Her treatment plan consists of four quadrants of interproximal restorations, including a pulpotomy and stainless steel crown on tooth #B.  Her mother has given written informed consent for dental treatment. 

Current Medical History:  Non-contributory.  Healthy, no medications, NKDA. 

Dental History:  None.  The patient’s first dental visit was last week at the mobile dental clinic for the comprehensive oral examination, radiographic examination, and treatment planning session.   

Behavior:  The patient is slightly apprehensive, but tries her best to cooperate with treatment. 

You go to her classroom to bring her to the dental clinic and she is quiet and you notice watery eyes. 

How do you proceed with treatment today? 

 

CURRICULUM 

 

REFERENCES 

1.       Sherman, Jeffrey, J., Cramer Adam.  Measurement of Changes in Empathy in During Dental School.  Journal Den Educ.  March, 2005.  Vol. 69 (3); 338-345.   

2.       Stepien K, Baernstein A. Education for Empathy: a review.  JGIM 2006; 21:524-530. 

3.        http://www.adea.org/Pages/Professionalism.aspx 

4.        Sarnat H, Arad P, Hanauer D, Shohami E. Communication strategies used during pediatric dental treatment: a pilot study. Pediatr Dent 2001;23(3):337-41. 

5.       Weinstein P, Getz T, Ratener P, Domoto P. Dentists’ responses to fear and non-fear related behaviors in children. J Am Dent Assoc 1982;104:38-40. 

6.       http://www.adea.org 

7.       Hemmerdinger J, Stoddart S.  A systematic review of tests of empathy in medicine. BMC Medical Educaton 2007; 7(24): 1-8.

 

Rickard-Week 3-ACMD512

 

IMPROVING RESIDENT WELLNESS AND COGNITIVE PATIENT EMPATHY IN RESIDENTS AND FELLOWS USING MINDFUL MEDITATION TECHNIQUES – TRAINING AND ASSESSMENT

 

I am particularly interested in this practice as it is currently being promoted in our graduate medical education programs at the University of Washington.  Mindful meditation is founded in Buddhist philosophy of living intentionally from moment to moment being mindful of your thoughts and environment.  Its practice is an intentional approach to how you live in and react to the world around you.  It can involve meditative breathing, body awareness, elements of yoga practice and personal reflection.³

 

Cognitive empathy is more that an emotional response to a patient’s situation but a conscious, mindful if you will, insight into how another’s point of view effects their own experience.¹  Garden specifically describes it as, “to mindfully keep the focus on what the patient is going through.”⁴

 

An eight-week mindful meditation instructional series is offered on a voluntary basis to residents and fellows in all medical specialties on a quarterly basis.  An instructor trained in mindfulness-based stress reduction (MBSR) leads the participants through the development of mindful meditative practices based upon the work of Jon Kabat-Zinn, PhD, founder and director of the Stress Reduction Clinic at the University of Massachusetts Medical Center.³  The focus of the University of Washington program is to improve mental well being to promote better patient care.

 

Assessment 

Shanafelt, et al.¹ in their 2005 JGIM article approach the discussion of resident empathy from a more positive perspective by investigating the impact of positive well being on measured empathetic response.  They cite more than a dozen studies that investigated the impact of negative stress reactions in residents on their ability to perform well clinically, including responding to patients with empathy.  Respondents to their multi-part survey demonstrated a self-reported higher level of well being correlated to higher cognitive empathy scores. There are studies that report differently including Chen, et al.² that found self-reported measures of empathy decreased as the resident progressed through training.  Their article suggests that observed measurements provide a more reliable measurement of empathy.

 

My project would use both forms of evaluation – self-report and objective observation- in a setting that would examine the possible positive effect of stress reduction, and therefore, increased empathy in residents, using the specific technique of mindful meditation.  My assessment design would begin with the Jefferson Scale of Physician Empathy (JSPE) used in the Chen and Hojat studies because they are validated instruments and would provide a basis of comparison for my study.  Participants in the mindful meditation series would complete the JSPE-S (self) survey prior to the first session.  In addition, they would complete a survey of previous and current meditation and stress reduction practices as part of the overall demographics for the group.  The JSPE-S would be repeated at the end of the 8 weeks.  A third JSPE-S would be administered 6 months following completion to determine if 8 weeks of instruction had any lasting effect on the resident’s stress level and empathetic practice.  A similar series of JSPE administrations would be completed by the program directors of the participating trainees.  The results of the trainee’s self-report would be correlated with the PDs evaluation.  It is anticipated that there would be a positive correlation between self-reported improvement in the stress level as a result of the mindful meditative instruction and patient empathy.  These results would have further validation with the positive correlation provided by the objective evaluation by PDs.  There would be low risk in this evaluation method because the results of the PD evaluation would be revealed to the trainee after the completion of the study and would not be included in the summative evaluation.

 

Upon completion of this phase of the study, I would be interested in following trainees throughout their training and into practice to see if they maintained mindful meditative practices and if there would be a correlation with maintained or improved patient empathy.  Do these mindful practices provide the improvement strategies defined by Garden and her mindful focus on the patient?⁴ 

 

Additional investigation questions could include differences between various methods of stress improvement, possible predictive methods for “problem” residents, differences between more clinically-oriented specialties such as internal medicine and those with less direct patient care such as pathology, differences between clinical fields such as nursing and dentistry, differences between evaluation methods.

 

References

1. Shanafelt TD, West C, Zhao X, Novotny P, Kolars J, Habermann T, Sloan J.  Relationship between increased personal well-being and enhanced empathy among internal medicine residents.  J Gen Intern Med. 2005; 20:559-64.
2. Chen DCR, Pahilan ME, Orlander JD. Comparing a self-administered measure of empathy with observed behavior among medical students. J Gen Intern Med. 2009; 25:200-2.
3. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness.  New York: Random House Trade Paperbacks, 2005.
4. Garden R. Expanding clinical empathy: An activist perspective. J Gen Intern Med. 2008; 24:122-5.
5. Hojat M, Mangione S, Nasca TJ, Gonnella JS. Empathy scores in medical school and ratings of empathic behavior in residency training 3 years later. J Soc Psychol. 2005; 145:663-72.

 

Karen Lind - Group 3 

512 Assignment 4 

January 31, 2012 

CASE PRESENTATION 

You are a PGY-1 working in the emergency room during the first few months of the year. You assume the care of an 18 year old male with dizziness. When you walk to the bedside, you are met by the patient, who is laying in the stretcher and the mother, who is standing by the bedside. The patient informs you that he has been having progressively frequent episodes of “the room spinning” for about the past month that sometimes occur with a nonspecific headache. He also reports feeling like he will fall over when he is walking, and his mother mentions that he became unable to use his right arm to make coffee this morning, so he came to the ED.  

Past Medical History: none, no current medications or medication allergies 

Past Surgical history: appendectomy, age 6 

Past Family history: none 

Social history: Smokes ½ ppd for past 1 year, no alcohol or drug use. Lives at home with parents. Works as department store cashier.  

Vitals: T 97.9 orally, HR 67, BP 160/95, RR 16, O2S 99% room air, BGM 147  

After physical exam, you are concerned for intracranial process and a Head CT is ordered as part of initial workup in the ED. The CT reveals a tumor to the cerebellum with early mass effect. You call neurosurgery and order preoperative workup at their request, and then go to the patient’s bedside to discuss the findings with him and his family.  

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CURRICULUM 

Step	Description	Comments
Title	“Empathy at the bedside: A simulation model for ‘breaking bad news’ in the Emergency Department”	The case is intended for PGY-1s, but the lecture/discussion portion may be adapted to other audiences with different case/small group content.
Target Audience	PGY-1 residents in emergency medicine (at our institution, n=16)	This simulated patient/family encounter is designed for the PGY-1 level in terms of expected medical knowledge, communication and systems based practice skills. Higher-level resuscitation and interpersonal difficulties will not be included.
Goal	To improve emergency medicine resident knowledge/skills/attitudes toward empathy in patient encounters, and to provide opportunities for practicing bedside empathy through the use of the SPIKES protocol in a low stakes environment with immediate feedback.	SPIKES protocol was developed by oncologists for breaking bad news to patients. Mnemonic:  S- Setting up the interview (sit down, arrange privacy, have tissues, minimize interruption)  P- assess patient Perception (“what have you been told so far?”)   I  - obtain patient Invitation (“How would you like me to give the information about the test results? Would you like me to give you all the information or sketch out the results and spend more time discussing the treatment plan?”)  K- give Knowledge to patient (use nontechnical words, avoid excessive bluntness, give information in chunks)  E- address Emotions with Empathy  “An empathic response consists of four steps: First, observe for any emotion on the part of the patient. This may be tearfulness, a look of sadness, silence, or shock. Second, identify the emotion experienced by the patient by naming it to oneself. If a patient appears sad but is silent, use open questions to query the patient as to what they are thinking or feeling. Third, identify the reason for the emotion. This is usually connected to the bad news. However, if you are not sure, again, ask the patient. Fourth, after you have given the patient a brief period of time to express his or her feelings, let the patient know that you have connected the emotion with the reason for the emotion by making a connecting statement.”  S- Strategy and Summary (plan for future, sharing decision making)  Above: Ref 1.   SPIKES protocol has been shown to include essentials of breaking bad news according to cancer patients and healthcare professionals in multiple studies (Ref 2).
Needs Assessment	Patients  Empathy is associated with patient satisfaction and, and patients who are more satisfied with communication  have improved understanding of their condition, less anxiety and improved mental functioning. (Ref 3).     Patients often perceive their doctors as lacking warmth. (Ref 5).   Organizations  Accreditation Council for Graduate Emergency Medicine, Society of Academic Emergency Medicine Ethics Committe and the Emergency Medicine Doctrine of Professionalism encourage development of humanistic values such as empathy (Ref 5).   Learners    Empathy tends to decrease during residency training (Ref 3, 5, 7, 10), but can be taught with short interventions and without changing personal style (Ref 3).   Patient encounters with empathic responses may be briefer than those without, and may facilitate patient ability to listen to biomedical responses (Ref 3).  Empathy is associated with patient compliance and higher ratings of interpersonal care, and lack of response to patient concerns is associated with increased complaints. (Ref 3, 6).    Empathy is associated with a personal sense of well-being in residents and a healthy work-life balance (Ref 7).    Decreased empathy may lead to medical errors being made, and is also associated with personal perception of likelihood of future medical errors (Ref 8).
Objectives	By the end of the session the learner will be able to:  Describe the steps of the SPIKES protocol.  Discuss the value of empathy in a healthcare encounter from the patient and provider perspective.   Demonstrate use of empathy with the SPIKES protocol in a simulated patient encounter.	Empathy includes moral, cognitive, behavioral and emotive aspects (Ref 10).     Empathic  phrases can include: “I can imagine how difficult that is,” “Sounds like what you’re telling me is …,” or “It sounds like you were really frightened...”(Ref 3, 4).    “Empathetic  physicians develop an accurate understanding  of patients’ affective  states in the context of a problem-solving  focus, whereas sympathetic  physicians develop a subjective involvement  in patients’ affective  states with the absence of a problem-  solving focus”. (Ref 5).    “Empathy is part of the  critical self-reflection that enables mindful practitioners to listen attentively to patients’ distress, recognize their own errors, refine their technical skills, make evidence-based decisions, and clarify their values so that they can act with compassion, technical competence, presence, and insight.” (Ref 5).
Curriculum Description	Independent Reading:   References 1, 5, 7.  Class Session: 90 minutes for two PGY-1 residents  Opener: 5 minutes. Introduce session and discuss session timetable. Brainstorm importance of empathy and prior experiences in ED or medical school. Brainstorm best/worst scenarios for patient encounters involving empathy.  Didactic:  15 minutes of oral presentation by faculty. Will cover importance of empathy to patients and healthcare providers, history and steps of SPIKES protocol.  Simulation for resident 1: 15 minutes (observed by resident 2)  Feedback for resident 1: 10 minutes (oral and written from faculty and resident 2)  Simulation for resident 2: 15 minutes (observed by resident 1)  Feedback for resident 2: 10 minutes ( oral and written from faculty and resident 2)  Debriefing: 10 minutes. Discuss as small group the impact of the activity and what was learned from it, any unexpected aspects of experience.   Commitment to Change: 10 minutes. Spent in personal reflection and brief written description of impact of activity on the resident and how it will change practice. Explore personal work-life balance.	Rationale:  Our simulation cases are run during weekly resident conference and involve pulling 2 residents per session for about 2 hours for each session. The sessions typically include a simulated case either performed by both residents at once or individually with the other observing. For this session, the residents are given an opportunity to practice and to observe by performing cases separately, although the two could perform the case together as bad news in the ED is often delivered by more than 1 doctor.   “Communication skill workshops addressing the behavioral dimension of empathy show greatest quantitative impact on participants”. (Ref 10)
Assessment Techniques	Oral and written feedback from faculty and resident observer immediately after simulation.   Resident reflection and written commitment to act.  Evaluation of session by residents with suggestions for improvement.	Rationale:  Response to clinical vignettes and surveys may be meaningful surrogate measures of empathy (Ref 7).   Empathy metrics found to be reliable and valid include: self-rated, patient-rated and observer rated (Ref 9).  Written self-evaluation and assessment of interaction by a trained observer are both validated forms of measurement for empathy (Ref 10).

REFERENCES 

1.     Baile W, Buckman R, Lenzi R, Glober G, Beale E. , Kudelka A. “SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer”. The Oncologist August 2000; 5(4): 302-311 http://theoncologist.alphamedpress.org/content/5/4/302.full 

2.     Fisch M, Bruera E. Handbook of Advanced Cancer Care. Anderson Cancer Center. March 2003. P 82.  

3.     Morse DS, Edwardsen EA, Gordon HS. “Missed opportunities for interval empathy in lung cancer communication”. Arch Int Med 2008; 168 (17): 1853-1858 

4.     Coulehan JL, Platt FW, Egener B, et al. “Let me see if I have this right … ”: words that help build empathy. Ann Intern Med 2001;135(3):221–227. 

5.     Seaberg D, Godwin S, Perry S. “Teaching Patient Empathy:  The ED Visit Program”. Acad Emer Med December 2000; 7(12):1433. 

6.     Epstein RM, Hadee D, Carroll J, et al. “Could this be something serious?” Reassurance, uncertainty, and empathy in response to patient’s expressions of worry”. J Gen Intern Med 2007; 22 (12); 1731-1739 http://www.deepdyve.com/lp/springer-journal/could-this-be-something-serious-3suqj4xnSW?key=springer_journal 

7.     Shanafelt TD, West C, Zhao X, et al. “Relationship between increased personal well-being and enhanced empathy among internal medicine residents”. J Gen Int Med 2005; 20 (7): 559-564 

8.     West C, Huschka M et al. “Association of Perceived Medical Errors With Resident Distress and Empathy: A Prospective Longitudinal Study”. JAMA. 2006;296(9):1071-1078. doi: 10.1001/jama.296.9.1071. http://jama.ama-assn.org/content/296/9/1071.short 

9.     Hemmerdinger J, Stoddart S. “A systematic review of tests of empathy in medicine”. BMC Medical Educaton 2007; 7(24): 1-8. 

10.  Stepien K, Baernstein A. “Education for Empathy: a review.” JGIM 2006; 21:524-530.