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Vulnerability and Professionalism in Healthcare

Authors:
August 2018
A newsletter produced jointly for the Academy for Professionalism
in Health Care and ProfessionalFormation.org
From the Editor - Janet de Groot
Dear Readers,
Summer time and vacations. This year’s conference in Baltimore on resilience and
professionalism highlighted how valuable rejuvenation is. I have rediscovered the ways in
which as colleagues we support one another, through reciprocally providing coverage for
our clinical and academic work. Among the APHC Board, meetings continued through the
summer, but with timeouts for most.
Hiking, walking or activities in new locations encourages curiosity and mindfulness. More
time with friends and family may heighten renewed appreciation of one another. Engaging in writing offers an
opportunity to reflect and rejuvenate. Each of us has different realities and I hope there was and/or is some
time to foster resilience for each of you.
This month we are fortunate to have two articles by first time contributors representing nursing and medicine.
Dr. Janet Delgado Rodriguez elaborates on her recent successful thesis work on vulnerability and
ethics in healthcare. Her article is also an extension of her presentation at the 2018 APHC conference in
Baltimore. Aleesha Shaik’s fascinating work with homeless individuals and a team positioned to
provide healthcare that considers social determinants of health is inspiring. Prior to her final year in
medical school, she has also contributed to policy to end homelessness with the American Medical
Association. Dr. Leann Poston monthly book review is about the provocatively title “The Patient Will
See You Now” is again a fascinating review of a well-researched book.
Soon you will be hearing more about the mid-May APHC 2019 conference in New Orleans. The focus will be
on social justice and professionalism from our various professional perspectives. Aleesha Shaik’s article
anticipates one aspect of the breadth of topics we anticipate discussing. We encourage an international
interprofessional discussion about practice, education and research in social justice and professionalism.
Best regards,
Janet
Janet de Groot, MD, FRCPC, M.Med.Sc.- Founding Editor, APHC-PFO Newsletter
Vulnerability and Professionalism
in Healthcare
by Janet Delgado Rodríguez
All human beings are vulnerable, inescapably and universally, and this inherent vulnerability requires greater
recognition within the healthcare professions (1). We prefer not to recognize our vulnerability. We tend to
believe that we can control what occurs around us. However, we are all vulnerable. Vulnerability is an
unavoidable human condition and is part of us. We experience vulnerability daily; examples of when we feel it
most powerfully is when we lose our job, when we kiss someone for the first time or when we ask someone
for a date, while taking exams, when we apply for a new job and we face an interview, when we feel we are
getting older, when someone fails us, when we have fears…we are vulnerable. We all are embodied beings,
embedded in social relationships and institutions, and inevitably vulnerable (2).
Each of us as individuals are positioned differently. And in the context of our job in healthcare, we are also
vulnerable because of our profession. We witness suffering, pain, death, anxiety, fear, tears daily at work.
Caring for patients and their families, healthcare professionals share and reflect on the gladness and sadness
that accompany these interactions. And in many ways, we are suffering too. These circumstances put the
professionals in a unique position. Professionalism must recognize vulnerability at the core of healthcare
professions (1). There is nothing wrong with us because we are vulnerable in our workplace; it is part of our
profession. There is "a vulnerability that arises out of the experience of others’ vulnerability, and this
vulnerability may require more recognition by the profession” (1).
The problem is that we are rarely taught how to address this huge issue, which is there at the bedside.
Nursing schools and medicals schools have long socialized us to avoid, to hide and not express this
vulnerability. That is, healthcare professionals go out, go to bathrooms to cry, go alone and pretend that their
team and colleagues don´t realize that they are suffering. It has been understood for long time as a
weakness, as a lack, as something that we don´t want. Thus, we try to hide it, to say it doesn´t exist…but it is
there. We question whether we are in error to feel vulnerability. But it is not wrong! We need to recognize it
and not deny it.
It is important to recognize that vulnerability is not necessarily negative, but that it also contains the possibility
of openness, creativity and generativity (1,3,4). There is a positive element associated with its inherent
openness to the world, an opening that is necessary to grow and flourish. In that sense, "allowing ourselves to
be vulnerable," recognizing and accepting our vulnerability, is a precondition for creativity (1). Our
vulnerability presents opportunities for innovation and growth, creativity and fulfillment, since it is what
encourages us to reach out to others and form relationships.
Some qualitative researchers (5,6) have explored extensively how vulnerability can be a strength for
healthcare professionals. Qualitative research can usefully explore and analyze clinical events in which
vulnerability had been experienced and addressed by clinicians in ways that may benefit their patient. In a
focus group study with family physicians, some described that the vulnerability of identifying with the patients’
circumstances or situation, may promote more creative or thoughtful responses to their patients. Another area
of vulnerability was feeling uncertain or having made clinical errors and deciding how best to address it with
patients or learning from errors. These are only a few of the examples gleaned from qualitative research; and
among different health care professionals, in different specialties or even practice locations, no doubt many
more can be explored.
Further, while vulnerability gives strength, it also must be used prudently. On the one hand, it can help
professionals to build patient’s trust, and the patient may feel more understood. On the other hand, if the
clinician’s emotions are exposed primarily for the professional’s needs, the patient may feel unsupported (7).
Overall, recognition of the fact that experiencing vulnerability in the context of healthcare may be a strength,
which can lead healthcare professionals to a deeper understanding of the impact of relationships in
healthcare. A focus on relationships can help professionalism to overcome the fracture between theory and
everyday practice. That is why I propose the turn to a patient relationship centered professionalism.
For more information: Homelessbuthuman.wordpress.com
Janet Delgado Rodríguez, RN, MA, Ph, is a Visiting Scholar at the Vulnerability and Human Condition Initiative, Emory
University, Atlanta, US. Researcher at the Institute of Women´s Studies at the University of La Laguna, Spain.
References
1.Carel, H (2009), “A reply to ‘Towards an understanding of nursing as a response to human vulnerability’ by Derek Sellman: vulnerability
and illness”, Nursing Philosophy (10), 214-219.
2. Fineman, M. A. (2008). The vulnerable subject: Anchoring equality in the human condition. Yale
Journal of Law & Feminism, 20 (1).
3. Fineman, M A (2012), “‘Elderly’ as vulnerable: Rethinking the nature of individual and societal responsibility”, The Elder Law Journal
(20:1), 71-112.
4. Fineman, M A. (2014), “Vulnerability, Resilience, and LGBT Youth”, Temple Political & Civil Rights Law Review (23), 307-
329.
5. Malterud, K & Hollnagel, H (2005), “The doctor who cried: a qualitative study about the doctor's vulnerability”, Annals of Family
Medicine (3:4), 348-352.
6. Malterud, K, Fredriksen, L & Gjerde, M H (2009), “When doctors experience their vulnerability as beneficial for the patients. A focus-
group study from general practice”, Scandinavian Journal of Primary Health Care (27), 85-90.
7.Gjengedal, E, Ekra E M, Hol, H, Kjelsvik, M, Lykkeslet, E, Michaelsen, R et al. (2013), “Vulnerability in health care –
reflections on encounters in every day practice”, Nursing Philosophy (14), 127138.
Lessons in Professionalism
from the Streets
by Aleesha Shaik
“No one wants to be forgotten like an old shoe.”
From Philadelphia to New Orleans to Palo Alto, this sentiment was shared among all of the individuals I
spoke with for my Homeless but Human project.
The Medical Humanities Program at Drexel University College of Medicine provides students with a unique
opportunity to explore disciplines that are often sidelined in medical education. The program, one of the first
of its kind, uses Grand Rounds and electives taught by a wide range of medical professionals to better
prepare future physicians to understand the lived experience and psychosocial impact of illness, identify
social determinants of health and discover a deeper value in medicine particularly important with today’s
focus on physician burnout and resilience.
In order to attain the Medical Humanities Scholar certificate, we also need to complete an independent project
in the field. My idea for Homeless but Human was born the summer after my first year of medical school when
I encountered a homeless man I had walked past many times while in college but had never truly seen.
Without knowing why, this time I decided to chat with him over a meal and our conversation launched me on
a path that re-shaped my vision for my future in medicine.
Inspired by this conversation, I conceptualized a project where I would speak with homeless individuals in
various parts of the country taking advantage of having to travel for several conferences. The goal of the
endeavor was to better appreciate the factors contributing to homelessness, to identify differences in health
services and access between states, and to humanize an oft-overlooked population.
While I believe I accomplished this, what was more impactful for me was seeing the clear effect a simple
conversation had on each of these people, who were so used to being alone and ignored. I couldn’t help the
veteran in New Orleans get surgery on his shoulder nor could I prescribe medications to help my Philadelphia
friend with her depression, but I found that a conversation brought some relief, at least for a few minutes.
Since then, my passion for helping the underserved has led me to help write policy on ending homelessness
for the American Medical Association, to pursue a Master of Public Health degree, to do a rotation with the
Boston Health Care for the Homeless Program (BHCHP) and Drexel’s Health Outreach Program clinics
(HOP), and, ultimately, to pursue a career in preventive medicine and advocacy.
As a result of this project, I am spending more time getting to know the patient as a person and recognizing
and addressing the social determinants that serve as barriers to positive health outcomes. At BHCHP, for
example, free bus tickets and Uber Health are used to ensure that lack of transportation does not prohibit a
patient from picking up medications or making appointments on time. In addition, the physicians I’ve worked
with through BHCHP and HOP are some of the most empathetic and clever physicians I know. They figure
out how to use minimal resources to diagnose and treat patients without compromising care.
At BHCHP, nearly every clinic site has both a physician or nurse practitioner and a case manager present to
assist with every aspect of a patient’s needs. This inter-professional effort is critical to ensuring that patients
receive the care they require. It also serves to uphold several of the professional responsibilities identified in
the 2002 American Board of Internal Medicine’s Medical Professionalism Physician Charter, including
commitments to improving the quality of and access to care.
To ensure that the next generation of physicians maintains the highest level of professionalism, such training
needs to be included in medical education. One of the fundamental principles recognized in the
professionalism charter is that of social justice. Physicians are bound by professionalism to “promote justice
in the health care system” and “to eliminate discrimination in health care.”
As witnessed by my project, integrating the humanities into medical education will aid in the development of
professionalism in our medical students and also encourage them to advocate for more equitable health care.
The process of developing a project promotes thinking about medicine differently, beyond the lab values and
the diagnoses.
At the very least, experiences like mine would remind physicians of the beauty of medicine, the power of
empathy and the importance of professionalism.
Aleesha Shaik is completeing her final year of medical school at Drexel University College of Medicine and is applying
for a residency in Internal Medicine. She received her MPH from the Harvard T.H. Chan School of Public Health and her
Bachelor of Science degree from Johns Hopkins University.
The Patient Will See You Now:
The Future of Medicine Is in
Your Hands
Book Review by Leann Poston
The Patient Will See You Now: The Future of Medicine is in Your Hands by Eric Topol, MD would have
seemed like a science fiction novel before the smartphone. Dr. Topol, a cardiologist and professor of
genomics and director of the Scripps Translational Science Institute in La Jolla, California, compares the
effect of Guttenberg’s printing press on democratizing access to written literature to the ability of the
smartphone to make health care accessible to all and lower costs. Smart phone enabled applications will
allow both healthcare practitioners and patients access to an almost unimaginable number of data points on
their health and fitness due to sensors such as breath monitors, sleep monitors and microscopic blood born
sensors capable of monitoring changes in blood chemistry.
With the advent of direct to consumer genetic testing by companies such as 23 and Me and Ancestry.com,
Dr. Topol feels the focus in healthcare will move to genetic testing for prevention of disease as opposed to
diagnostic testing. He cites the impact Angelina Jolie made when she went public with her BRCA 2 results
and subsequent decision to have a double mastectomy. Genetic testing allowed her to make an informed
decision about how aggressively she wanted to minimize the risk of future disease. According to Dr. Topol,
the internet makes it possible for consumers to research their genetic mutations, read medical and research
journals online and join patient groups for people with similar diagnoses to discuss symptom control and
treatment options. He seems to discount the role of medical professionals in aiding patient synthesis of
information, as well as providing context and verification for accuracy.
Dr. Topol feels that the most significant roadblock to the rapid progression of technology in healthcare is the
paternalistic attitude of many of its practitioners because of their insecurity with technology and with losing
control of medical information. Barriers between the patient and their medical data make it difficult for them to
participate in a meaningful discussion about their health and to be an equal partner in decision making.
However, the ability to accumulate vast amounts of medical data can lead to problems with security and
storage as well as an understanding of who is going to track and evaluate this data. Market forces also
contribute to the delay in integrating technology into healthcare and empowering patients. Medical
practitioners have formulas and requirements for reimbursement and treatment, and many of these new
technology models for healthcare do not easily fit into these models.
With the advent of genomic and precision medicine, large aggregates of genomic data will be needed to
determine the significance, if any, of individual mutations, as well as the interaction between the genome and
modifier genes and proteins. The significance of a mutation is commonly found by reverse genetics in which
case an individual with an unusual disease has their genome sequenced to identify a suspect gene. Familial
genomes are needed for comparison and verification of the mutation, but it cannot stop there. The complexity
of the genome makes it necessary for genomes from unrelated people with and without the mutation in
question to be evaluated. The same argument can be made for pharmaceutical testing. Individual drugs are
suspected to work on approximately 20 percent of the population with efficacy determined by individual
molecular makeup of channels and proteins. Genetic studies are needed to determine which 20 percent of
the treatable population a drug will work for and what modifications can be made to a drug to allow it to work
in others. According to Dr. Topol, pooling genetic data is likely to markedly increase progress in both
diagnosis and treatment of disease.
There are significant risks. Cybersecurity and privacy laws have not progressed at the same rate as
technology use in healthcare. Dr. Topol argues that the White House Consumer Privacy Bill of Rights and the
Do Not Track legislation desperately need to be made law. He advocates for individuals having complete and
unhindered access to their genetic data. He feels it should be illegal for any party to use genetic data or
information obtained from genetic data without the owner’s consent and consent does not mean pushing a
button to access an application after trying to decipher a disclaimer. Dr. Topol concedes that large amounts of
data are needed to look for trends and to advance research, but ultimately the ability to use artificial
intelligence and biomedical and molecular sensors to predict disease is the goal. He ends his well-researched
and thoughtful book by urging large companies to lead the charge towards more autonomous healthcare,
which could negate the need to move their businesses offshore to cut costs.
Topol, E. (2016) The patient will see you now: the future of medicine is in your hands. New York: Basic Book. 393 pages
ISBN 978-0465054749
Leann Poston, MD, is Assistant Dean of Admissions and Career Advancement at WSU-Boonshoft School of Medicine
in Dayton, Ohio.
PFO Update
by Dennis Novack & Kym Montgomery
Year 1 of the Josiah Macy Jr. Foundation grant for ProfessionalFormation.org (PFO) was very successful.
Drexel University Colleges of Medicine and Nursing and Health Professions spearhead the grant for
professionalism and interprofessional education. Thirteen institutions and nearly 50 faculty with over 20
disciplines comprise the pilot program. PFO has 12 comprehensive modules:
1. Personal Growth and Professional Formation
2. Bioethics and Foundations of Professionalism
3. The Hidden Curriculum and Professional Formation
4. The Healthcare Professional’s Role in Regulating Peers and the Profession
5. Social Justice
6. Beyond Recovery: Learning and Growing in the Wake of an Error
7. Interprofessional Teamwork in Healthcare
8. Boundary Issues
9. Moral Distress and Moral Courage
10. Compassion and Resilience
11. Confidentiality
12. Creating Organizational Cultures that Foster Professionalism
During the first year of the grant, leaders from collaborating institutions met periodically to work on revising all
the modules to enable them to be relevant to all healthcare education programs. All 13 participating
institutions are beginning to incorporate PFO into their professionalism and interprofessional education
programs. The goal is that PFO/IPE curricula will be instituted within the upcoming academic year and
continue to grow and thrive in coming years.
PFO has a number of innovative features that are or will be operational very shortly. These include:
The Learning Management System
Module Pre and Post-test surveys so learners can gauge the change in their attitudes and self-
efficacy after interacting with the modules. My Journey page will aggregate all the individual’s
responses.
Dashboard scales that assess learners’ attitudes include: Groningen Reflective Ability Scale, the IRI
Scale for Empathy and the Cohen Perceived Stress Scale, and an innovative values/behavior
concordance scale. The C3 instrument to measure learning environment and the IPEC to assess
attitudes toward interprofessional communication will be available soon. Course leaders will be able to
assign these instruments at predefined intervals as part of their quality control and course evaluation
efforts.
The public-facing website at www.ProfessionalFormation.org currently has seven pages, including
Content, a list of modules; Description; Resources; Editors; Learning Management System; Contact info and
Subscription, which will, eventually, provide information about subscribing to PFO. The website also includes
a private portal to the modules, which are designated for grant participants, initially, and for all institutions,
eventually.
The major goals in Year 2 are to:
Develop PFO IPE curricula for all 13 institutions.
Integrate the PFO IPE curricula across disciplines within institutions.
Utilize PFO’s innovative features.
Begin research projects.
Principle Investigators
Dennis Novack, MD, Drexel University College of Medicine
Kymberlee Montgomery, DrNP, CRNP-BC, CNE, FAANP, FAAN, Drexel University College of Nursing and Health
Professions
Article of Interest - Tackling inequalities to
improve wellbeing in New Zealand
In a world first, Jacinda Ardern's New Zealand Government first budget included measures of
well-being in addition to financial measures. The budget references Te Whare Tapa Whā, a
Māori holistic health and well being model which includes social determinants of health.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31655-
6/fulltext?dgcid=raven_jbs_etoc_email
Listen to the ACH/DocCom Podcast while you're
commuting or exercising
The Academy of Communication in Healthcare and DocCom teamed up to
sponsor a podcast Healthcare Communication: Effective Techniques for
Clinicians. Launched in late January, the 25-minute weekly podcast has over
3,800 downloads on over 30 topical subjects. Check out the list of released
episodes on the link or on your favorite podcast platform
http://bit.ly/ACHDocComPodcast
Professional Formation Newsletter Associate Editors:
Alya Heirali
Babu Krishnamurthy
David Doukas
Hanke Dekker
Janet de Groot
John Spandorfer
Julie Agris
Leann Poston book and film reviews
Lorena Novaes
Marco Filho
Nazia Viceer
Patricia Soares
Patrick Herron
Preston Reynolds biographies
Raul Perez
Rebekah Apple bios and professionalism news
Sally Fortner
Stephen Gambescia interdisciplinary issues
Tyler Gibb ethics, law and professionalism
Virginia Bartlett
Please contact Janet de Groot if you'd like to contribute articles to this newsletter.
If you know someone who would benefit from reading Professional Formation, please pass this
along.
Sign up at http://www.professionalformation.org/Contact Us.
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
The vulnerability of our embodied beings and the messy dependency that often comes in the wake of physical or psychological needs cannot be ignored throughout any individual life and must be central to theories about what constitutes a just and responsive state. The concept of vulnerability reflects the fact that we all are born, live, and die within a fragile materiality that renders all of us constantly susceptible to destructive external forces and internal disintegration. Vulnerability should not be equated with harm any more than age inevitably means loss of capacity. Properly understood, vulnerability is generative and presents opportunities for innovation and growth, as well as creativity and fulfillment. Human beings are vulnerable because as embodied and vulnerable beings, we experience feelings such as love, respect, curiosity, amusement, and desire that make us reach out to others, form relationships, and build institutions. Both the negative and the positive possibilities inherent in vulnerability recognize the inescapable interrelationship and interdependence that mark human existence.
Article
Full-text available
Vulnerability is a human condition and as such a constant human experience. However, patients and professional health care providers may be regarded as more vulnerable than people who do not suffer or witness suffering on a regular basis. Acquiring a deeper understanding of vulnerability would thus be of crucial importance for health care providers. This article takes as its point of departure Derek Sellman's and Havi Carel's discussion on vulnerability in this journal. Through different examples from the authors' research focusing on the interaction between health professionals and patients, existential, contextual, and relational dimensions of vulnerability are illuminated and discussed. Two main strategies in the professionals' interactions with patients are described. The strategy that aims at understanding the patients or families from the professional's own personal perspective oftentimes ends in excess attention to the professional's own reactions, thereby impairing the ability to help. The other strategy attempts to understand the patients or families from the patients' or families' own perspective. This latter strategy seems to make vulnerability bearable or even transform it into strength. Being sensitive to the vulnerability of the other may be a key to acting ethically.
Article
Full-text available
This essay develops the concept of vulnerability in order to argue for a more responsive state and a more egalitarian society. Vulnerability is and should be understood to be universal and constant, inherent in the human condition. The vulnerability approach is an alternative to traditional equal protection analysis; it represents a post-identity inquiry in that it is not focused only on discrimination against defined groups, but concerned with privilege and favor conferred on limited segments of the population by the state and broader society through their institutions. As such, vulnerability analysis concentrates on the institutions and structures our society has and will establish to manage our common vulnerabilities. This approach has the potential to move us beyond the stifling confines of current discrimination-based models toward a more substantive vision of equality.
Article
Full-text available
We wanted to explore those clinical events when doctors had exposed their vulnerability toward patients in a potentially beneficial way. We undertook a qualitative study based on memory work, a structured approach to transform memories into written texts. Study participants were 9 members of a research group who had known each other a couple of years. They were asked in advance to recall a clinical event during which vulnerability was perceived and exposed in a way appreciated positively by the patient. During a group meeting, participants wrote their individual memory stories recalling these events, and the subsequent group discussion was audiotaped, transcribed, and analyzed using a phenomenological approach, applying specific linguistic cues to reveal points of special interest. The main outcome measure was the vulnerability expressed by practitioners. Vulnerability had been experienced and exposed by the participants on several occasions during which the patients had confirmed its potentially beneficial effect. All reported events could be interpreted as different ways of personal disclosure toward the patient. We identified two kinds of disclosure: spontaneously appearing emotions and considered sharing of experiences. A spontaneous exposure of emotions from the doctor may help the patient, and sharing personal experiences may lead to constructive interaction. We need to know more about when and how personal disclosure and other aspects of vulnerability exposed by the doctor are experienced as beneficial by the patient.
Article
To describe events where doctors have experienced that their own sense of vulnerability might have been beneficial for the patient. Qualitative focus group study with data drawn from two group sessions. Analysis was conducted with systematic text condensation. A total of 12 GPs (five men and seven women) aged 30-68 participated. Their clinical experience ranged from one to 39 years. Analysis presented different aspects of participants' experiences of vulnerability experienced as beneficial. The participants generously shared stories about personal and professional vulnerability which they had perceived and sometimes disclosed to the patient. One cluster of stories dealt with situations where the doctors in some way or other had identified with the patient and his or her problem. They felt that their awareness and capacity for interpretation, creative solutions, and compassion had been enhanced through recognition. Another cluster of stories covered events where uncomfortable feelings due to uncertainty or inconsiderate behaviour sharpened the doctors' reflexivity towards their own roles in the interaction. Presenting an excuse or sharing the doubt could break the ice and make a difference. Vulnerability may bring strength, but must be used with caution. Our study opens towards further awareness of the vulnerability of the doctor and how it can benefit the patient in some situations.
Vulnerability, Resilience, and LGBT Youth
  • M A Fineman
Fineman, M A. (2014), "Vulnerability, Resilience, and LGBT Youth", Temple Political & Civil Rights Law Review (23), 307-329.