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ABSTRACT: BACKGROUND AND OBJECTIVES: During medical training, students gain professional competence but may lose elements of personal humanity. Little is known about what personal qualities or values students themselves experience to be at risk or surrendered during medical school. METHODS: Medical students participating in the Healer's Art elective in the United States and internationally during 2008--2009 were asked to reflect, identify, and draw a part of themselves that they were wary about revealing, not comfortable showing, or felt may be diminished in medical school and label this part with a word. Using a team-based qualitative approach, these words were categorized into common themes and the themes analyzed using descriptive and chi-square statistics. RESULTS: Words from 673 students from 31 medical schools were analyzed. Most students were female (58.7%) and in their first year (86.3%). Eleven themes were identified: spirituality, emotional engagement, identity/self-expression, freedom/spontaneity, relationships, self-care, creativity, negative emotions, values, other, and joy/happiness. The most common individual words used were creativity, family, balance, freedom, love, peace, compassion, relationships, and reflection. There were only rare differences in distributions of themes across gender, year in school, school size, or school nationality. CONCLUSIONS: An international cadre of Healer's Art students identified core personal qualities and values that they may not reveal or feel may be diminished in medical school. Medical training involves not only professional formation but exposure to professional deformation as well. Educators must attend to both gains in professional competence and the personal qualities and values that are at risk in the course of professional development.
Family medicine 01/2013; 45(1):13-18. · 1.33 Impact Factor
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Journal of Cancer Education 04/2012; 23(1):65-67. · 0.76 Impact Factor
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ABSTRACT: Hospital-based palliative care is becoming increasingly prevalent. There is growing evidence that it is having a positive impact on patients and their loved ones. In 2008, national data indicated that 58.5% of hospitals with 50 or more beds had a palliative care program. Data from a 2008 survey of California acute care hospitals showed that although 33% of sites had inpatient consultation services, one in five had been operational for only one year. As nascent palliative care programs grow, new issues arise and needs and plans change. Just as palliative care programs benefit from marketing and education plans, they also benefit from a plan to leverage external resources. Largely a missed opportunity, external resources such as organizations, networks, and experts can help palliative care service (PCS) leaders and team members gain information on everything from best practices to funding opportunities, while serving as sources for personal and professional support. The growing number of active PCSs and the increasing availability of support and expertise ensure that new programs no longer have to face challenges alone. Further, the steady increase in the number of new programs has created opportunities for those who are more experienced to serve as mentors for peers who are navigating the challenges of growing and sustaining a clinical service. The authors encourage both mentors and mentees to seek support from or provide support to others in the field. Leveraging the collective expertise and experiences in our field can ensure that palliative care continues to thrive and grow.
Journal of palliative medicine 12/2011; 15(1):25-8. · 1.84 Impact Factor
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ABSTRACT: Patients with gynecologic cancer experience significant symptom burden throughout their disease course and treatment, which negatively impacts their quality of life. The most common symptoms in gynecologic cancer include pain, fatigue, depression and anxiety. Palliative care, including symptom management, focuses on the prevention and relief of suffering and improvement in quality of life, irrespective of prognosis. In a comprehensive cancer care model, palliative care, including symptom management, is offered concurrently with anticancer therapies throughout the disease course, not just at the end of life and not only once curative attempts have been abandoned. Good symptom management begins with routine symptom assessment and use of a standardized screening tool can help identify patients with high symptom burden. Literature regarding epidemiology, assessment and management of pain, fatigue, nausea/vomiting, lymphedema, ascites, depression, anxiety and sexual dysfunction in gynecologic oncology patients will be reviewed in this article.
Expert Review of Anti-infective Therapy 07/2011; 11(7):1077-89. · 2.65 Impact Factor
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ABSTRACT: Although professionalism has emerged as a key competency for today's physicians, there exists little insight into how best to teach medical students the relevant skills or instill in them the commitment required to practice according to the highest professional standards. Ten UCSF medical students were interviewed at three time points (second, third, and fourth years of school). Interviews focused on students' learning and development regarding end-of-life care (EOLC). Students described varying steps in their professional development from their second to fourth years of school, including feeling confused about the definition of professionalism and integrating their personal and professional identities. In addition to professional development, four other themes contributed to the development of medical student understanding of how to provide EOLC as a professional: (1) curricular discordance, (2) role models, (3) the tightrope between trained versus human reactions, and (4) ethical dilemmas. These five themes represent dilemmas that students often learned how to respond to over the course of school. Professional development in EOLC required the acquisition of skills necessary to balance the tension between and navigate conflicting messages present in medical student training.
Journal of Cancer Education 02/2011; 26(3):444-50. · 0.76 Impact Factor
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ABSTRACT: BACKGROUND: To develop and grow most effectively, palliative care programs must consider how best to align their mission with that of their institution. To do so, programs must identify their institutional mission and needs, what palliative care can do to address those needs given available resources, and how the palliative care team can measure and document its value. Such an approach encourages the palliative care team to think strategically and to see themselves and their service as a solution to issues and concerns within the institution. It also helps a palliative care team decide which, among many potential opportunities and possible initiatives, is the one most likely to be supported by the institution and have a recognized and significant impact. SUBJECTS AND METHODS: We present five case studies to demonstrate how successful programs identify and address institutional needs to create opportunities for palliative care program growth. These case studies can serve as models for other programs seeking to develop or expand their palliative care services.
Journal of palliative medicine 10/2010; 13(10):1205-10. · 1.84 Impact Factor
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ABSTRACT: The objective of this paper is to evaluate the educational value of a documentary film about family caregiving for patients with brain tumors. The method used in this study is a pre-post survey among neurosurgeons, neuro-oncologist, and other clinician viewers. Viewers evaluated the film highly and reported an intention to change their practice as a result of watching the film. Following viewing, participants felt more strongly that "all families of patients with brain cancers should meet with a social worker" (P = 0.01) and that "family caregivers greatly impact the health of patients" (P = 0.002), and they were less likely to believe that "supporting family caregivers is primarily someone else's job" (P = 0.009). A documentary film about family caregiving is an effective educational tool to increase awareness among neurosurgery/neuro-oncology clinicians about the importance and needs of family caregivers of patients with brain tumors.
Journal of Cancer Education 03/2010; 25(2):242-6. · 0.76 Impact Factor
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ABSTRACT: In his 1910 report on medical education, Flexner emphasized the importance of competency in basic sciences. Less widely recognized is that he also emphasized the necessity of liberal education. On the Flexner Report's 100th anniversary, medicine is challenged to realize Flexner's full vision for medical education to ensure that physicians are prepared to lead lives of compassion and service as well as to perform with technical proficiency. To meet the complex medical and social challenges of the next century, medical educators must continue to promote cognitive expertise while concurrently supporting "professional formation"-the moral and professional development of students, their ability to stay true to their personal service values and the core values of the profession, and the integration of their individual maturation with growth in clinical competency. The goal of professional formation is to anchor students to foundational principles while helping them navigate the inevitable moral conflicts in medical practice. The consequences of inadequate support for professional formation are profound, impacting individual learners, patients, the profession, and society at large. Among the many successful professional formation projects nationally, two long-standing programs are described in modest detail to identify common elements that might guide future developments elsewhere. Key elements include experiential and reflective processes, use of personal narratives, integration of self and expertise, and candid discussion within a safe community of learners. Committing to professional formation within medical education will require transformation of formal and informal curricula and will necessitate a rebalancing of attention and financial support within schools of medicine.
Academic medicine: journal of the Association of American Medical Colleges 02/2010; 85(2):310-7. · 2.34 Impact Factor
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ABSTRACT: Efforts to promote medical professionalism often focus on cognitive and technical competencies, rather than professional identity, commitment, and values. The Healer's Art elective is designed to create a genuine community of inquiry into these foundational elements of professionalism.
Evaluations were obtained to characterize course impact and to understand students' conceptions of professionalism.
Qualitative analysis of narrative course evaluation responses.
Healer's Art students from U.S. and Canadian medical schools.
Analysis of common themes identified in response to questions about course learning, insights, and utility.
In 2003-2004, 25 schools offered the course. Evaluations were obtained from 467 of 582 students (80.2%) from 22 schools participating in the study. From a question about what students learned about the practice of medicine from the Healer's Art, the most common themes were "definition of professionalism in medicine" and "legitimizing humanism in medicine." The most common themes produced by a question about the most valuable insights gained in the course were "relationship between physicians and patients" and "creating authentic community." The most common themes in response to a question about course utility were "creating authentic community" and "filling a curricular gap."
In legitimizing humanistic elements of professionalism and creating a safe community, the Healer's Art enabled students to uncover the underlying values and meaning of their work--an opportunity not typically present in required curricula. Attempts to teach professionalism should address issues of emotional safety and authentic community as prerequisites to learning and professional affiliation.
Journal of General Internal Medicine 11/2007; 22(10):1422-8. · 2.83 Impact Factor
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ABSTRACT: Inpatient palliative care programs can improve care of patients with serious illness. We developed the California Hospital Initiative in Palliative Services (CHIPS) program to assist hospitals in establishing these programs. CHIPS included an introductory conference followed by 10 months of mentoring with telephone calls, e-mails, on-site consultation at the hospital, and a reunion conference.
To evaluate CHIPS and the factors associated with establishing inpatient palliative care programs, we conducted a cross-sectional telephone survey of leaders from the 38 hospitals that participated in CHIPS. We assessed the number of inpatient palliative care consultation services established by hospitals that participated in CHIPS (success) and hospital characteristics associated with success.
Participants gave CHIPS high ratings. Six hospitals (16%) had a palliative care consultation service at enrollment in CHIPS and 19 hospitals (60%) established one after participation in CHIPS (P<.001). In bivariable comparisons, successful hospitals were more likely to have a hospitalist program (P = .003) or to be located in an urban setting (P = .03).
CHIPS seemed to help many hospitals establish inpatient palliative care programs. Hospitals with hospitalists and those in an urban setting were more likely to succeed in developing palliative care programs. Future studies should focus on the quantity and quality of care provided by these programs.
Archives of Internal Medicine 01/2006; 166(2):227-30. · 11.46 Impact Factor
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Medical Education 12/2005; 39(11):1167-8. · 3.18 Impact Factor
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ABSTRACT: Even for patients receiving complex, intensive medical care for serious and life-threatening illness, family caregiving is typically at the core of what sustains patients at the end of life. The amorphous relationship between physicians and the families of patients at the end of life presents both challenges and opportunities for which physicians may be unprepared. Families play important roles in the practical and emotional aspects of patient care and in decision making at the end of life. At the same time, family members may carry significant burdens as a result of their work. Through the perspectives of the wife, daughter, and home care nurse of a patient who died from pancreatic cancer, we illustrate the range of family caregiver experiences and suggest potentially helpful physician interventions. We describe 5 burdens of family caregiving (time and logistics, physical tasks, financial costs, emotional burdens and mental health risks, and physical health risks) and review the responsibilities of physicians to family caregivers. Based on available evidence, we identify 5 areas of opportunity for physicians to be of service to family members caring for patients at the end of life, including promoting excellent communication with family, encouraging appropriate advance care planning and decision making, supporting home care, demonstrating empathy for family emotions and relationships, and attending to family grief and bereavement. In caring well for family caregivers at the end of life, physicians may not only improve the experiences of patients and family but also find greater sustenance and meaning in their own work.
JAMA The Journal of the American Medical Association 02/2004; 291(4):483-91. · 30.03 Impact Factor
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ABSTRACT: Little is known about the use of palliative care for outpatients who continue to pursue treatment of their underlying disease or whether outpatient palliative medicine consultation teams improve clinical outcomes.
We conducted a year-long controlled trial involving 50 intervention patients and 40 control patients in a general medicine outpatient clinic. Primary care physicians referred patients with advanced congestive heart failure, chronic obstructive pulmonary disease, or cancer who had a prognosis ranging from 1 to 5 years. In the intervention group, the primary care physicians received multiple palliative care team consultations, and patients received advance care planning, psychosocial support, and family caregiver training. Clinical and health care utilization outcomes were assessed at 6 and 12 months.
Groups were similar at baseline. Similar numbers of patients died during the study year (P =.63). After the intervention, intervention group patients had less dyspnea (P =.01) and anxiety (P =.05) and improved sleep quality (P =.05) and spiritual well-being (P =.007), but no change in pain (P =.41), depression (P =.28), quality of life (P =.43), or satisfaction with care (P =.26). Few patients received recommended analgesic or antidepressant medications. Intervention patients had decreased primary care (P =.03) and urgent care visits (P =.04) without an increase in emergency department visits, specialty clinic visits, hospitalizations, or number of days in the hospital. There were no differences in charges (P =.80).
Consultation by a palliative medicine team led to improved patient outcomes in dyspnea, anxiety, and spiritual well-being, but failed to improve pain or depression. Palliative care for seriously ill outpatients can be effective, but barriers to implementation must be explored.
Archives of Internal Medicine 02/2004; 164(1):83-91. · 11.46 Impact Factor
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Michael W Rabow
Medical Education 12/2003; 37(11):1040-1. · 3.18 Impact Factor
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ABSTRACT: Little is known about whether introducing palliative care to seriously ill outpatients continuing to pursue treatment of their disease is acceptable or beneficial to patients. Intervention patients in a trial of outpatient palliative care consultation completed structured exit interviews as part of a qualitative study. Participants had advanced heart or lung disease or cancer, and a life expectancy between 1 to 5 years as estimated by their primary care physician (PCP). Thirty-five of 50 intervention patients (70%) completed the final interview. Twenty-one patients (60%) reported that the team uncovered previously undiagnosed medical problems, 12 patients (34.3%) reported decreased primary care visits, and 8 (22.9%) reported avoiding emergency department visits. Most patients reported improved satisfaction with family caregivers (85.7%), PCPs (80%), and the medical center (65.7%). Most patients (68.6%) would have wanted the intervention even earlier in the course of their illness. Seriously ill outpatients found palliative care acceptable and helpful, reporting increased satisfaction and decreased health care utilization.
Journal of Pain and Symptom Management 12/2003; 26(5):1010-5. · 2.50 Impact Factor
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ABSTRACT: The quantity and quality of end-of-life-care (EOLC) information in commonly used pharmacy textbooks were studied. EOLC content in each of eight best-selling pharmacy textbooks was assigned to 1 of 13 domains; there were a total of 104 possible domains for all eight books. Every mention of EOLC was given a score of 2 for "helpful content present" or 1 for "minimal content present." The quantity of EOLC content was assessed by tabulating the raw number of entries. The average number of EOLC-related entries per book ranged from 1.0 (ethics) to 27.5 (natural history). Eighty-one domains (78%) had fewer than 10 entries, 66 (63%) had 5 or fewer entries, and 28 (27%) had 1 entry or none. The overall quality of content was low, especially in the domains of spiritual issues, ethics, and context of care. The results were consistent with findings for medicine and nursing textbooks. A review of eight commonly used pharmacy textbooks revealed inadequate coverage of EOLC.
American Journal of Health-System Pharmacy 07/2003; 60(12):1246-50. · 1.96 Impact Factor
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ABSTRACT: Prayer and religious ceremonies may help patients near the end of life and their relatives find comfort and discover meaning in their lives. In this paper, we analyze how physicians might respond in two situations regarding prayer and religious ceremonies. First, how should physicians respond when such patients or their families ask physicians to pray for them or with them? Physicians' responses to such requests will depend on their own religious and spiritual beliefs, the congruence of their beliefs with those of the patient and family, and their relationship with the patient. Many physicians may be willing to be present and stand silently while the patient prays. Second, how should physicians respond when such patients and families seek to carry out their religious and spiritual practices in the hospital? Religious ceremonies can provide meaning, hope, and solace to patients and families. Institutional guidelines regarding religious ceremonies should allow as much leeway as is compatible with good care both for the patient for whom the ritual is offered and also for other patients within the facility. Physicians should inquire whether there are religious and spiritual practices that patients and families would like to engage in. However, physicians should be cautious about recommending specific ceremonies or pratices. Physicians can respond to requests and respect patients' spiritual needs in ways that may deepen the therapeutic doctor-patient relationship, without compromising their own religious and spiritual beliefs or professional roles.
Journal of Palliative Medicine 07/2003; 6(3):409-15. · 1.85 Impact Factor
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ABSTRACT: To describe the characteristics, acceptability, and basic efficacy of an outpatient palliative care consultation service for patients with serious illness continuing to receive treatment for their underlying disease.
Structured interviews of intervention patients enrolled in a prospective, nonrandomized, controlled trial.
General medicine practice in an urban, academic medical center.
Ninety outpatients with cancer, advanced congestive heart failure, or advanced chronic obstructive pulmonary disease.
Palliative care consultation to primary care physicians (PCPs); educational and supportive services to patients and their families.
Physician referrals, program assessment by patients, observations of clinical consultation team members.
A majority of PCPs (61%) referred patients to the project, which provided an extensive panel of services despite significant financial constraints. Patients reported improved satisfaction with their family (85.7%), PCP (80%), and the medical center at large (65.7%) as a result of these services. Patients found discussing advance care planning difficult (66%), but desired these conversations (66%). Team members observed significant palliative care needs among this population of outpatients, however, PCPs did not implement a significant number of the consultation team's recommendations.
Outpatient palliative care consultation and services for patients continuing to pursue treatment of their underlying disease are acceptable and helpful to patients. However, barriers to implementation of palliative care treatments in this population must be explored.
Journal of Palliative Medicine 07/2003; 6(3):489-99. · 1.85 Impact Factor
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ABSTRACT: Little is known about the impact on health care students of early end-of-life care (EOLC) education and patient contact. We developed an EOLC course that allowed students to serve as volunteer advocates for patients at the end of life (EOL). We evaluated the course's acceptability to students and its effect on students' attitudes and beliefs.
Journal of Palliative Medicine 11/2002; 5(5):754-5. · 1.85 Impact Factor
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Journal of the American Geriatrics Society 03/2002; 50(2):397. · 3.74 Impact Factor
