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Teaching Communications and Professionalism through Writing and Humanities: Reflections of Ten Years of Experience David P. Sklar, MD, David Doezema, MD, Steve McLaughlin, MD, Deborah Helitzer, ScD Abstract Both professionalism and interpersonal communication are core competencies for emergency medicine residents as well as residents from other specialties. The authors describe a weekly, small-group seminar lasting one year for emergency medicine residents that incorporates didactic materials, case studies, narrative expression (stories and poems), and small-group discussion. Examples
of cases and narrative expressions are provided and a rationale for utilizing the format is explained. A theoretical model for evaluation measures is also included. Key words: professionalism; interpersonal communication; core competencies; residents; model. ACADEMIC EMERGENCY MEDICINE 2002; 9:1360–1364.
The Accreditation Council for Graduate Medical Education (ACGME) has recently identified core competencies,1 and the core content for emergency medicine has also been identified in the Model of the Clinical Practice of Emergency Medicine (the Model).2 Both documents specifically identify interpersonal communications and professionalism. The ACGME emphasizes ‘‘interpersonal and communication skills that result in effective information exchange and teaming with patients, families, and other health professionals and professionalism as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.’’1 The Model identifies the core skill ‘‘Professionalism and legal issues—understand and apply principles of professionalism, ethics, and legal concepts pertinent to patient care.’’ Also as part of history and physical, ‘‘communicate effectively to interpret and evaluate the patient’s symptoms and history. . . .’’2 The challenge for residency programs in emergency medicine is to teach those skills and to demonstrate that residents are learning interpersonal and communication skills as well as professionalism and can demonstrate mastery of them by the completion of residency.
At the University of New Mexico, we have been approaching these two important topic areas through small-group faculty-led seminars for second-year emergency medicine residents as part of a one-year-long curriculum with specific readings, case-based discussions, and writing projects. These mandatory seminars occur on a weekly basis with second-year houseofficer residents, who are excused from clinical responsibilities for that hour, and involve the department chair and other faculty from the Department of Emergency Medicine.
From the Department of Emergency Medicine, University of New Mexico Health Sciences Center–School of Medicine, Albuquerque, NM (DPS, DD, SM, DH). Received November 7, 2001; revision received December 11, 2001; accepted January 16, 2002. Address for correspondence and reprints: David P. Sklar, MD, Department of Emergency Medicine, University of New Mexico School of Medicine, Ambulatory Care Center, 4 West, Albuquerque, NM 87131-5233.
PROFESSIONALISM We approach the teaching of professionalism with presentations on ethics and legal issues. The goal of the session is to give residents a framework for approaching difficult ethical and legal dilemmas in the emergency department and to help them behave in a professional and compassionate way with patients. Readings include pertinent journal articles (Table 1). Cases explore medical errors, including system factors, individual factors, environmental factors, and team factors involved in misdiagnosis. Procedural mistakes and drug administration errors, capacity for decision making, and informed consent are also included. Ethics issues, such as death and dying; procedures on the newly dead; and justice and equity and the influence of poverty on the access to emergency and nonemergency care are covered, as are history of the right to emergency care and legislation concerning transfer of patients; racism and health care; and medical malpractice. Because the seminars are small-group discus-
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TABLE 1. Assigned Readings for the Teaching of Professionalism on Legal and Ethical Issues 1. American College of Emergency Physicians. Code of ethics for emergency physicians. Ann Emerg Med. 1997; 30:365–72. 2. Adams J, Schmidt T, Sanders A, et al. Professionalism in emergency medicine. Acad Emerg Med. 1998; 5:1193–9. 3. Blackhall LJ. Must we always use CPR? Sounding board. N Engl J Med. 1987; 317:1281–4. 4. Youngner SJ. Who defines futility? Commentaries. JAMA. 1988; 260:2094–5. 5. Abrams N, Buckner MD, Levin RI. The urban emergency department: the issues of professional responsibility. Ann Emerg Med. 1982; 11:86–90. 6. Veatch RM. Case Studies in Medical Ethics. Cambridge, MA: Harvard University Press, 1977, pp 116–35. 7. Leape LL. Error in medicine. JAMA. 1994; 272:1851–7. 8. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med. 1991; 324:370–6. 9. Brennan TA, Leape LL, Laird NM, et al. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med. 1991; 324:370–6. 10. Todd JS. It is time for universal access, not universal insurance. Sounding board. N Engl J Med. 1989; 321:46–7. 11. Enfield LM, Sklar DP. Patient dumping in the hospital emergency department: renewed interest in an old problem. Am J Law Med. 1988; 13:561–95.
sions, and so that other duties do not interfere, participation is mandatory and based upon required readings. Faculty lead the seminar and receive training in problem-based learning and smallgroup facilitation through the university’s Medical Education Development division in a two-day orientation conducted annually for the School of Medicine faculty. A case is used to begin the discussion and specific questions are addressed at the outset, as advocated by others.3 Case examples are presented in Table 2.
COMMUNICATION—LITERATURE AND HUMANITIES Cases include cross-cultural communications and gender issues, discussion of the emotional impact of errors, power relationships in medicine, stress, illness, and burnout and its effects on physicians and patients. Readings include journal articles, novels, and essays by physician writers: Healing the Wounds,4 Rendezvous with Clouds,5 and The Blood of Strangers,6 are all utilized in part or whole and serve as starting points for discussion. Chapters in Healing the Wounds related to errors and power are assigned to introduce these topics. Rendezvous with Clouds is a book written by an emergency physician who was dying of cancer. Chapters that concern cross-cultural issues and the physician-patient’s
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perspective on illness are utilized. The Blood of Strangers is a memoir by an emergency medicine resident. This book is read in its entirety and introduces the resident to the use of narrative expression to confront stressful, emotional experiences with patients and emphasizes the uniqueness of every patient encounter. The book reminds us that each patient has a past and hopes for a future and that we can learn and grow from our experience and knowledge about them. Readings are assigned weekly and discussed the following week and are intended to take no more than two hours to com-
TABLE 2. Examples of Cases and Questions for Discussion on Professionalism Case I: A 70-year-old man collapsed at home and appeared to stop breathing. His wife called 911 and waited 5 minutes for the paramedics to arrive. She did not begin cardiopulmonary resuscitation (CPR). The paramedics arrived and attempted to resuscitate the patient, although the patient’s wife said, ‘‘He’s dead. Leave him alone. He’s dead.’’ The patient was transported to University of New Mexico Hospital with CPR in progress and was noted to be in ventricular fibrillation when he arrived. Application of two electrical countershocks was not successful and the patient was pronounced dead after 20 minutes of resuscitative efforts in the emergency department. The patient’s wife received a bill for $1,028.00 for the use of emergency department supplies and personnel during the unsuccessful resuscitation. She called the emergency department director complaining about the bill and asking why her husband was not allowed to ‘‘die with dignity.’’ She felt that it was clear from the start that he was dead and all efforts would be futile.
Questions: 1. What is the ‘‘standard of care’’ in our community for response to a 911 call? What is the potential liability for not performing CPR? 2. Can a relative decide for an arrest victim who has not previously expressed his wishes concerning CPR? Case II: A 63-year-old woman presented to the emergency department in severe respiratory distress gasping for air. She was placed in the resuscitation room because cardiac and respiratory arrest appeared imminent. The family (two sons and a husband) grabbed the doctor outside the resuscitation room and said, ‘‘She doesn’t want to be on a respirator. She has severe emphysema. We’ve talked about it before and she doesn’t want to be a vegetable. Don’t put that tube in her lungs.’’ The doctor then entered the room and although the patient was in severe distress he asked her whether she wanted to have a tube put in her throat and be hooked to a breathing machine. The woman nodded yes.
Questions: 1. What should the doctor do? 2. Describe the elements of consent or refusal of consent for treatment. How do you determine whether a patient has capacity to make a decision? 3. What if the patient is put on a ventilator and later wants to be allowed to die?
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plete. Two examples of cases used in the course are presented in Table 3. Residents write about their experiences with patients and demonstrate their own ability to communicate about these issues through writing and discussing each other’s presentations. Some of these presentations have been submitted for publication.6–8 Two examples of writing by residents are presented as sidebars with permission. ‘‘It Began as an Ordinary Shift. . .’’ ‘‘The code was ended and the time of death recorded. Mr. Murphy looked nothing like the man I had seen only minutes before. He was bloated and a grey eerie color. He was covered with blood, his chest cracked open, and a tube stuck out of his neck. I covered him with an already soaked blanket. The end of a code is always a peculiar mix of confusion, shock, and a bizarre sense of camaraderie between the people that shared in the experience. I volunteered to call the family. . . . I felt numb as I began to explain. . . .’’ Lisa Rabinowitz, HO2, Emergency Medicine
‘‘Broad Shoulders’’ I once thought That being an Emergency Physician Meant having broad shoulders To carry those Who can no longer walk. Now I know That it is foolish To think that you can carry Anyone At all. Scott Cameron, HO2, Emergency Medicine
EVALUATION The theoretical model for the relationship between program components, anticipated outcomes, and evaluation measures is displayed in Table 4. In the left column, the program components are listed. The middle column describes the anticipated outcomes that will result from participation in the program, for each program component. The right column describes the evaluation measures that could
TABLE 3. Examples of Cases and Questions for Discussion on Communication Issues Case I: A 30-year-old female patient presents to the emergency department (ED) by emergency medical services. The patient is hearing-impaired and has been in a motor vehicle accident. The patient begins to sign to the physicians in the trauma room. The patient becomes increasingly agitated, as it becomes apparent that no one can understand, and she tries to get out of the cervical spine precautions. Finally, one of the doctors says, ‘‘Lets give her some sux* and intubate her.’’
Question: 1. If you were in charge, how would you handle the situation? Case II: An elder woman from a nursing home presents to the ED with abdominal pain. An intern attempts to ask her questions and the woman appears not to understand. He repeats his questions without effect. He gives up and orders a panel of blood tests and abdominal computed tomography (CT) scan saying, ‘‘this is just veterinary medicine.’’
Questions: 1. How reasonable is his approach? 2. What are the alternatives? 3. Discuss patients who present communication problems and ways to approach them. 4. In the case above, what other sources of information exist? *Sux = succinylcholine.
be used to determine whether the anticipated outcomes have been achieved. A pre–post design would be appropriate and, if possible, the comparison with a group of residents not exposed to the program would be helpful. Assessment of the list of items in the first two columns of the table would comprise a comprehensive evaluation with both process and outcome components. As noted in the theoretical model, attendance at weekly meetings, participation, ability to integrate knowledge during case discussion, and demonstration of interpersonal communication skills in the emergency department are currently evaluated. Other measures are presented that we plan to formally implement in the future. The seminar content is evaluated annually at the end of the seminar by residents and revised annually. Residents are asked to provide an overall rating of the usefulness of the seminar. They fill out a visual analog scale, in which they mark a point between ‘‘useless’’ (0%) and ‘‘could not be more useful’’ (100%). The usefulness rating has increased from 33% to 70% over ten years, as revisions have been made to address specific comments provided by residents.
DISCUSSION We have been conducting these small-group seminars long before the ACGME considered the topics essential for all residents. Our rationale has been
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TABLE 4. Theoretical Model for the Relationship between Program Components, Anticipated Outcomes, and Evaluation Measures Program Theory
Outcomes
Evaluation Measure
Sessions occur once a week
Residents will show up for sessions
• Attendance*
Residents will read cases and present them
Residents will participate actively
• Percent participation* • Improvement in presentation skills
Cases with errors are presented by residents and faculty
Residents will identify and describe the errors, and discuss how to cope with errors, how to get feedback about errors, and how to prevent errors in the future
• Percent of errors identified and described • Knowledge of error prevention measures
Residents will problem-solve a case that covers legal and ethical issues
Residents will be able to analyze an ethical or legal dilemma and make better decisions
• Percent of cases correctly analyzed for legal and ethical issues*
Professional aspects of cases will be discussed
Residents will understand professional responsibilities
• Percent of cases correctly analyzed for professional issues
Residents will be asked to compose narrative expressions of their work
Residents will listen to each other, discuss their emotional issues and reactions, and become more compassionate
• Patient measures of compassion
Residents will submit a story or poem
Residents will communicate more effectively with patients and other physicians
• Physician, nurse, and patient measures of communication*
* Current evaluation includes these measures.
that the topics of professionalism, ethics, legal and cross-cultural issues, communications, gender issues, resident wellness, and medical humanities are critical elements to the successful practice of medicine because they grapple with the relationship between physicians and patients, between physicians and society, and of physicians with themselves. These relationships create a context for the core content topics and procedures emphasized in most professional training programs. The use of small-group facilitator methodology has emphasized the importance of active participation and discussion mentoring by senior faculty, and an opportunity to integrate the daily experience of residency, including mistakes, uncertainty, and interpersonal conflict, into the weekly meetings and discussions with senior faculty. One key to success has been the commitment and continued involvement of the chair and senior faculty. Residents have often experienced unhappiness with having to use an off day to attend the seminar. Without the leadership of the chair, attendance might not be as consistent as it has been. The use of narrative expression both as part of the reading and as a required part of the seminar participation has opened up an entirely new area of rich description of physician experience to interpretation and integration into the developing consciousness of the resident physician. The writing assignments demonstrate the intense emotional
connections between residents and patients during their learning process. As noted by Hunter et al., ‘‘Reading literary texts and writing in narrative genres about patients help students to develop the clinical imagination, the moral imagination, and an empathetic perception of other people and their life situations.’’9 One of the limitations of this pilot program has been the limited use of formal evaluation. As we move into the next phase of compliance with the ACGME core competencies, we intend to link the course with the process and outcome measures outlined in the theoretical model in Table 4. We believe this can be accomplished in the seminar setting as well as in the patient care setting, as described earlier. During our small-group discussions and readings, there have been more expressions of strong emotion, tears, anger, and empathy than at any other time during the residency. The sharing of experience between residents and faculty during the small-group seminars is equally as important as the readings. During the intense clinical experience in the emergency department, there is rarely time to discuss feelings, and in lecture halls such interchange is inhibited by the public nature of a large group and a large place. In the small-group seminar, residents and faculty can share their feelings and concerns that often get buried, and appreciate how critical each one is to the development of the
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References
other. During these interactive sessions, residents and faculty have the opportunity to appreciate the remarkable experiences they share on a daily basis and attempt to make some sense out of the often confusing and chaotic whirl of events that might otherwise blow past unnoticed.
1. 2.
3. 4.
CONCLUSIONS
5.
A small-group, facilitator-led weekly seminar focused on professionalism and communications has been integrated into an emergency medicine residency program utilizing case-based methodology and narrative expression. The format, content, and evaluation measures may be useful in meeting ACGME core competency requirements.
6. 7. 8. 9.
ACGME Outcome Project. Website: www.acgme.org/ outcome/project/outintro㛭fnl1.htm. Hockberger RS, Binder LS, Graber MA, et al. The Model of the Clinical Practice of Emergency Medicine. Ann Emerg Med. 2001; 37:745–70. Fox E, Arnold RM, Brody B. Medical ethics education: past, present and future. Acad Med. 1995; 70:761–9. Hilfiker D. Healing the Wounds. New York: Pantheon Books, 1985. Fleming T. Rendezvous with Clouds. Albuquerque, NM: UNM Press, 1999. Huyler F. The Blood of Strangers. Berkeley, CA: University of California Press, 1999. Navitsky RC. The waiting room. Ann Emerg Med. 2001; 37:547–8. Rasmussen R. Nuts. Change of shift. Ann Emerg Med. 1998; 32:514–6. Hunter KM, Charon R, Connelly JE, et al. The study of literature in medical education. Acad Med. 1995; 70:787–94.
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Where to Find AEM Instructions for Authors For complete instructions for authors, see the January or July issue of Academic Emergency Medicine; visit the SAEM web site at www.saem.org/ inform/autinstr.htm; or contact SAEM via e-mail at
[email protected], via phone at 517-485-5484, or via fax at 517-485-0801.
