a first step toward humanism

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I have become rather obsessed lately with how to facilitate the development of professionalism in physicians.

Humanism is important in medical practice, and is included as a component in most definitions of medical professionalism. A healthcare practitioner who acts humanely thinks about the person under his or her care in a holistic manner, and behaves accordingly. Such a practitioner considers multiple perspectives and includes the patient and family in the decision-making process, identifies where the patient's perspectives might conflict with his own, or with societal norms and values, and finally acts in a way that puts the patient's perspectives and values first.

Virginia Tech Carilion School of Medicine

As a life-long medical educator, I am always searching for better ways to encourage self-assessment and individualized learning. As a patient advocate, I see many instances where physicians fail to enter into therapeutic relationships with patients. As a pediatrician, I see examples of physicians facing complex issues, and giving up before they have resolved the issue to the satisfaction of the parent. As a participant in social media, I hear much frustration from people who happen to have complex chronic diseases or undiagnosed symptom complexes. The issue almost always boils down to a failure of communication. Patients, parents, caregivers complain that sometimes their physician doesn't really listen to them. This can happen when we think about our patients as equivalent to the diagnosis or disease they carry, and not as the totality of the person who happens to carry that diagnosis, or have those symptoms. Even if we have no evidence-based therapeutic options for a particular disease or illness, even if we have no name to attach to a myriad of symptoms or complaints, there is still a person who is seeking our assistance to deal with what is bothering them, or worrying their parent, caregiver, spouse, child or friend.

So, although acknowledged as an important part of professionalism in theory, humanism frequently gets lost as health care providers learn to be objective, to follow evidence-based guidelines, and do procedures.

One of the ways most experts believe professionalism in general, and humanism in particular can be facilitated in medical students, residents, fellows and attending physicians, is by using a technique called "critical reflection."

This involves telling stories.

But it goes further than just the story, or the facts of what occurred. In order to be a critical reflection, the writer or teller of the story must identify how the particular event that is related created a change in herself--identify what learning happened as a result of the event. Identification of complex emotions, self assessment of perceived versus demonstrated values by the actor or witness who is relating the event are important to the moral growth of the professional. It is a way to look critically at oneself and emerge a better person. I am working with our new pediatric residents in a "Professionalism in Pediatrics" curriculum. Much of the independent work they will contribute to this curriculum will be developing their ability to reflect on critical incidents in conjunction with certain topics we will be exploring together. So, I thought I would "try it." As I was thinking about the development of humanism in myself, I suddenly saw clearly how that trait had been initiated in myself, and how it withstood multiple attempts made during my own medical education to stifle it. My critical incident happened well before I entered medical school.

I was working in a local general hospital as a "health care career exploration volunteer" during high school. One day I was assigned to the Emergency Department. An ambulance arrived with a gentleman who had suffered a catastrophic event at home, and was in cardiac arrest. Two residents were present and initiated CPR along with the assigned nursing staff, while I stood and watched, undoubtedly with my mouth agape. I remember nothing of the actual events during the attempted resuscitation. All I can remember now was what happened at the end. The residents cleaned themselves up after one had pronounced the man dead. I followed them as they left the resuscitation room, and one said to the other: "Well, you win some, you lose some." And they walked away, leaving the nurses to deal with the family members, who had not even arrived at the hospital yet. And leaving me to deal with what I had just witnessed, on my own.

Standing there, approximately eight years after my own father had been rushed to a hospital emergency department following a severe episode of bleeding into his brain, I was thinking about how my dad might have been treated in the same way. What happened to my mom? Who had been there to comfort her and tell her about his death? I knew that by the time she had arrived at the hospital he had already been pronounced dead. Did anyone at the hospital care, or was he just one of the "lose some?"

Clearly when I was 17 I was not able to reflect intelligently on this incident. Yet I know that this had a profound effect upon me. I identified for myself a desire to not allow strangers to die alone. I felt it was important that somebody actually care about each life they are privileged to care for. This feeling was so strong that it allowed me (well forced me) to care more about my patients as a medical student than my mentors thought I should. The caring part of medical practice became the most important for me. That has made me a patient advocate. That has made me an educator, mentor and friend to my trainees. That may have been why I became a critical care physician.

While I wouldn't wish the experience of losing one's dad at an early age on anyone, nor of witnessing their first patient death at age 17, I am grateful to have had experiences that allowed me to empathize more effectively with patients and families undergoing the stress of actual or impending loss of a loved one. I do believe this experience, along with many others, helped me to develop the credo that I preach whenever a healthcare provider is considering how hard to try or how much to care:

"what would you want for your_______ (child, mother, father, niece, grandparent, etc) in this situation?"

Another part of the critical reflection process that is important, is to get outside input on the reflection.

Do you think I have interpreted this appropriately? Might I just be rationalizing the reason why I still cry at patient bedsides when someone is not getting better?

What do you think about using this modality as a teaching tool?

Recent Comments

Your definition of humanism in the context of healthcare is beautifully articulated. Your blog post embodies the mission of The Arnold P. Gold Foundation...to promote humanism in medicine.

In case you are not aware, we thought you might be interested to know that this year, for the first time, our Gold Humanism Honor Society Biennial Conference is open to non-GHHS members and practicing physicians. It is a unique opportunity to spend a few days in the company of medical students, residents, faculty and practicing doctors all of whom recognize humanism as a core element in the practice of medicine. You can learn more about this Biennial conference, being held Oct. 4-6 2012 in Chicago, at our website, humanism-in-medicine.org.

Thanks for leaving a comment. I am honored the Arnold P. Gold Foundation took the time to read my blog. The conference sounds wonderful. Hope I am able to attend.

That is why we have people such as yourself teaching. Residents/interns/medical students are at times overwhelmed with this type of loss. It is a defense mechanism, and it must be 'trained' out of them. They are still into the 'technical aspects' of how to do CPR. Chief residents are also overwhelmed with duties. Attendings should observe these events and teach to the task at hand...Rare for young trainees to have this talent.

Gary,
Thanks so much for your comment. Residents are often overwhelmed with the tasks they have to check off on their to-do sheets. They are usually unprepared for death and bad outcomes. They are rarely given the time or the guidance to help them to reflect on these issues. It's time we put the compassion and empathy back into health care.

Alice,
Wonderful blog. I can still remember several incidents similar to yours from school and training. I clearly remember a cardiothoracic surgeon in the operating room telling a patient (under anesthesia at the the time) that it was all his fault he was needing a bypass. And he used words that don't bear repeating. Since we don't really know how much people remember from when they are under, I was horrified.
I still cry with my patients. And sometimes get laughed at for it.

Jane, we should never be laughed at for our caring and concern for our patients. Sure, there are those who simply don't understand the emotion, but they need to learn to respect it. And certainly we must be careful not to "cross the line" between humanism and the development of inappropriate relationships with patients and their families. But, given the choice, I would rather have a doctor who genuinely cares about my well-being than one who is the smartest person in the world.
Thanks for taking the time to comment.

This is very encouraging to see that some of my attendings still get emotional and that it is ok. I believe it is the best way to show that you care. I have been told that I get too emotionally involved sometimes (of course nothing inappropriate). Having just lost my daughter 7 months ago, I know no other way to practice than with that "mommy fire" that drives me.

Jacinda, I was told exactly the same thing, over and over again in medical school. Thanks so much for your comment, and for being a part of our training program. We are people, not machines. People come to us for care, and want to be cared for by people. Stay human!

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About Dr. Ackerman

Alice Ackerman, MD, MBA, FAAP, FCCM is the Chair of the Department of Pediatrics at Carilion Clinic and Professor and Founding Chair of Pediatrics at the Virginia Tech Carilion School of Medicine. Dr. Ackerman is recognized nationally as an expert in pediatric critical care.

She has been at Carilion Clinic since June of 2007. Her primary goals are to enhance the health care of children in the Roanoke Valley and Southwest Virginia, and is actively working to do this both as physician in chief of the children's hospital, as well as through involvement with many state-wide initiatives.

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