1

Teaching tools subgroup John Nessa (Norway) Pavla PIkardova (Czech Republic) Barbora Lukesova (Czech

Republic) Eva Doherty (Ireland) Michael Kaffman(Israel) Lavinia Nanu (Romania)

Steacutephanie DeMaesschalck (Belgium)

A preliminary summary about self-awareness teaching

- What - Why - How - Who - When

WHAT Self-awareness Self-consciousness Self-assessment Mindfulness The various aspects of an individuals ability to direct attention inwardly (ie to an insight or introspection into his or her own thoughts attitudes behavior well-being emotions appearance and competence) are commonly referred to as

- self-consciousness - self-awareness - self-assessment

Self-awareness

- An individuals tendency to pay attention to his or her own emotions attitudes and behavior in response to specific situations In the case of physicians self-awareness is their insight into how their emotional makeup influences patient care

- The ability to conduct oneself as a reflective and accountable practitioner including seeking out sources of informed criticism and valuing reflecting and responding to them appropriately

- Enquiring into own competence and evaluating own capabilities and personal effectiveness

It was developed the Situational Self-Awareness Scale as a psychometric measure of self-awareness

- public self-awareness - private self-awareness

Self-consciousness A permanent personality trait Its psychometric measure is the Self-Consciousness Scale

- private self-consciousness subscale ldquoI am constantly examining my motivesrdquo as it is believed to measure an individuals insight into his or her own feelings memories and motives

2

- public self-consciousness subscale ldquoUsually I worry about making a good impressionrdquo as it is believed to measure a tendency to focus on self-aspects such as behavior and physical appearance that are presented to others

- social anxiety subscale ldquo Large groups make me nervousrdquo that seem to capture a tendency to feel discomfort in the presence of others

Self-assessment ability to assess ones own performance and compare this self-assessment to an external valid and credible source of evaluation of this same performance Self-assessment may be viewed as a specific aspect of public self-awareness

Self reflection

1) knowing-in-actionmdashthe unreflective capacity for performing the majority of routine tasks

2) reflection-in-actionmdashthinking about what one is doing while doing it engaged by and considered critical in situations of uncertainty uniqueness and conflict

3) reflection-on-actionmdashreviewing and thus learning from past experience From a mindfulness perspective reflection-in-action is remarkably similar to the moment-to-moment awareness aspect of mindfulness

Mindfulness in the context of health care is operationally defined as the awareness that emerges through paying attention on purpose in the present moment and non-judgmentally to the unfolding of experience moment by moment As a link between relationship-centered care and evidence-based medicine mindfulness should be considered a characteristic of good clinical practice

Mindful Practice Paying attention on purpose to onersquos own mental and physical processes during everyday tasks to act with clarity and insight hellip leads the mind back from theories attitudes and abstract ions to the experience itself Mindful Practice proposes Attentive observation Critical curiosity Beginnerrsquos mind Presence WHY (A+B) A Demonstrated needs for self-awareness in medical practice

- There are elements of medical errors that can and should be attributed to individual factors These factors are related less commonly to lack of knowledge and skill than to the inability to apply the clinicianrsquos abilities to situations under certain circumstances

- ldquoUninvited Guestsrdquo in Medical Practice ambiguity and uncertainty conflict between the needs of patients and clinicians strong emotions the patientrsquos and onersquos own technical errors witnessing unbearable suffering contradictory evidence unanticipated serious illness impermanence of knowledge illusion of competence lack of control miscommunications and misunderstandings

- Physicians tend to reason tacitly to the extent of consciously perceiving only the tip of the iceberg of their own thinking processes Beneath the surface there are quasi-automatic mental operations that are often useful mental shortcuts

3

however sometimes these same shortcuts can play tricks on reasoning skills Failure to examine the reasoning process led to perpetuation of an error

- Medical judgment is easily derailed by unexamined emotions failure of curiosity low-level heuristics over-concreteness rigidity Inability to reframe the encounter

- Doctors emotional makeups (eg well being fears attitudes and self-assessed level of competence) may affect their patients care

- Physical or mental discomfort whether transient (eg fatigue a recent conflict with another person) or chronic (eg alcoholism depression burnout) may impair clinical judgment and cause distraction and irritability

- Doctors commonly admit that they may lack patience with certain patients however only few are aware that this may lead to discrimination against those patients eg toward elderly and poor patients

- Fear of malpractice litigation may result in avoidance of high risk patients and procedures or in a defensive ordering of diagnostic tests even when clinical judgment deems them to be unnecessary

- A doctor who expects patients to simply obey his or her orders may become intolerant of those who want to be informed about their diseases and to participate in making clinical decisions

- It may be taken for granted that health care professionals should pay attention in both clinical and learning situations However studies on attentiveness show that people are only briefly and unpredictably attentive Attention habitually diverts to unrelated thoughts and feelings leaving any task at hand to be managed on autopilot These studies suggest that mindlessness (mind wandering zoning out task-unrelated thought) is one of the most ubiquitous and pervasive of all cognitive phenomena and that it often occurs unintentionally without awareness occupies a substantial proportion of our day and leads to failures in task performance

B Correlations between Self-Awareness and Clinical performance - One study shows a positive correlation between residents patient-centered

interviewing skills and their progress in self-awareness training - Another study shows direct correlation between self-consciousness as measured

by the self-consciousness scale and medical students assumptions of responsibility for the quality of their relationship with patients as determined by a semi-structured interview

- Another program at the University of Cambridge in the United Kingdom attempts to help students recognize how they resemble or differ from the rest of the student group with respect to their personal history race culture gender sexuality class and personality and to identify what influence this self-awareness might have on their clinical practice15 Students are asked to submit written reports on what they have learned from the exercises emotionally (How did they affect the way you feel) factually (What new information came from them) intellectually (What insights did they yield) and practically (Are there things you will do differently as a result)

- Other programs attempt to help medical students acknowledge and confront prejudices that they may harbor against certain patients One such program is

2

- public self-consciousness subscale ldquoUsually I worry about making a good impressionrdquo as it is believed to measure a tendency to focus on self-aspects such as behavior and physical appearance that are presented to others

- social anxiety subscale ldquo Large groups make me nervousrdquo that seem to capture a tendency to feel discomfort in the presence of others

Self-assessment ability to assess ones own performance and compare this self-assessment to an external valid and credible source of evaluation of this same performance Self-assessment may be viewed as a specific aspect of public self-awareness

Self reflection

1) knowing-in-actionmdashthe unreflective capacity for performing the majority of routine tasks

2) reflection-in-actionmdashthinking about what one is doing while doing it engaged by and considered critical in situations of uncertainty uniqueness and conflict

3) reflection-on-actionmdashreviewing and thus learning from past experience From a mindfulness perspective reflection-in-action is remarkably similar to the moment-to-moment awareness aspect of mindfulness

Mindfulness in the context of health care is operationally defined as the awareness that emerges through paying attention on purpose in the present moment and non-judgmentally to the unfolding of experience moment by moment As a link between relationship-centered care and evidence-based medicine mindfulness should be considered a characteristic of good clinical practice

Mindful Practice Paying attention on purpose to onersquos own mental and physical processes during everyday tasks to act with clarity and insight hellip leads the mind back from theories attitudes and abstract ions to the experience itself Mindful Practice proposes Attentive observation Critical curiosity Beginnerrsquos mind Presence WHY (A+B) A Demonstrated needs for self-awareness in medical practice

- There are elements of medical errors that can and should be attributed to individual factors These factors are related less commonly to lack of knowledge and skill than to the inability to apply the clinicianrsquos abilities to situations under certain circumstances

- ldquoUninvited Guestsrdquo in Medical Practice ambiguity and uncertainty conflict between the needs of patients and clinicians strong emotions the patientrsquos and onersquos own technical errors witnessing unbearable suffering contradictory evidence unanticipated serious illness impermanence of knowledge illusion of competence lack of control miscommunications and misunderstandings

- Physicians tend to reason tacitly to the extent of consciously perceiving only the tip of the iceberg of their own thinking processes Beneath the surface there are quasi-automatic mental operations that are often useful mental shortcuts

3

however sometimes these same shortcuts can play tricks on reasoning skills Failure to examine the reasoning process led to perpetuation of an error

- Medical judgment is easily derailed by unexamined emotions failure of curiosity low-level heuristics over-concreteness rigidity Inability to reframe the encounter

- Doctors emotional makeups (eg well being fears attitudes and self-assessed level of competence) may affect their patients care

- Physical or mental discomfort whether transient (eg fatigue a recent conflict with another person) or chronic (eg alcoholism depression burnout) may impair clinical judgment and cause distraction and irritability

- Doctors commonly admit that they may lack patience with certain patients however only few are aware that this may lead to discrimination against those patients eg toward elderly and poor patients

- Fear of malpractice litigation may result in avoidance of high risk patients and procedures or in a defensive ordering of diagnostic tests even when clinical judgment deems them to be unnecessary

- A doctor who expects patients to simply obey his or her orders may become intolerant of those who want to be informed about their diseases and to participate in making clinical decisions

- It may be taken for granted that health care professionals should pay attention in both clinical and learning situations However studies on attentiveness show that people are only briefly and unpredictably attentive Attention habitually diverts to unrelated thoughts and feelings leaving any task at hand to be managed on autopilot These studies suggest that mindlessness (mind wandering zoning out task-unrelated thought) is one of the most ubiquitous and pervasive of all cognitive phenomena and that it often occurs unintentionally without awareness occupies a substantial proportion of our day and leads to failures in task performance

B Correlations between Self-Awareness and Clinical performance - One study shows a positive correlation between residents patient-centered

interviewing skills and their progress in self-awareness training - Another study shows direct correlation between self-consciousness as measured

by the self-consciousness scale and medical students assumptions of responsibility for the quality of their relationship with patients as determined by a semi-structured interview

- Another program at the University of Cambridge in the United Kingdom attempts to help students recognize how they resemble or differ from the rest of the student group with respect to their personal history race culture gender sexuality class and personality and to identify what influence this self-awareness might have on their clinical practice15 Students are asked to submit written reports on what they have learned from the exercises emotionally (How did they affect the way you feel) factually (What new information came from them) intellectually (What insights did they yield) and practically (Are there things you will do differently as a result)

- Other programs attempt to help medical students acknowledge and confront prejudices that they may harbor against certain patients One such program is

3

however sometimes these same shortcuts can play tricks on reasoning skills Failure to examine the reasoning process led to perpetuation of an error

- Medical judgment is easily derailed by unexamined emotions failure of curiosity low-level heuristics over-concreteness rigidity Inability to reframe the encounter

- Doctors emotional makeups (eg well being fears attitudes and self-assessed level of competence) may affect their patients care

- Physical or mental discomfort whether transient (eg fatigue a recent conflict with another person) or chronic (eg alcoholism depression burnout) may impair clinical judgment and cause distraction and irritability

- Doctors commonly admit that they may lack patience with certain patients however only few are aware that this may lead to discrimination against those patients eg toward elderly and poor patients

- Fear of malpractice litigation may result in avoidance of high risk patients and procedures or in a defensive ordering of diagnostic tests even when clinical judgment deems them to be unnecessary

- A doctor who expects patients to simply obey his or her orders may become intolerant of those who want to be informed about their diseases and to participate in making clinical decisions

- It may be taken for granted that health care professionals should pay attention in both clinical and learning situations However studies on attentiveness show that people are only briefly and unpredictably attentive Attention habitually diverts to unrelated thoughts and feelings leaving any task at hand to be managed on autopilot These studies suggest that mindlessness (mind wandering zoning out task-unrelated thought) is one of the most ubiquitous and pervasive of all cognitive phenomena and that it often occurs unintentionally without awareness occupies a substantial proportion of our day and leads to failures in task performance

B Correlations between Self-Awareness and Clinical performance - One study shows a positive correlation between residents patient-centered

interviewing skills and their progress in self-awareness training - Another study shows direct correlation between self-consciousness as measured

by the self-consciousness scale and medical students assumptions of responsibility for the quality of their relationship with patients as determined by a semi-structured interview

- Another program at the University of Cambridge in the United Kingdom attempts to help students recognize how they resemble or differ from the rest of the student group with respect to their personal history race culture gender sexuality class and personality and to identify what influence this self-awareness might have on their clinical practice15 Students are asked to submit written reports on what they have learned from the exercises emotionally (How did they affect the way you feel) factually (What new information came from them) intellectually (What insights did they yield) and practically (Are there things you will do differently as a result)

- Other programs attempt to help medical students acknowledge and confront prejudices that they may harbor against certain patients One such program is

4

implemented after a week of community medicine experiences (eg visits to an Alcoholics Anonymous meeting a nursing home facility a homeless shelter and an underserved community center) It begins with a short classroom discussion of these experiences and is followed by small-group discussions The points of departure of these discussions is a list of Have you ever questions (eg Have you ever seen a morbidly obese patient and thought that he or she was lazy) The topics cover race culture substance use gender sexual orientation the elderly nurse practitioners and others Students discuss one or more of these topics and then reconvene in order to share with the entire class their conclusions regarding possible prejudice against certain patients

- Participants in direct teaching programs (Balint groups) have reported that the group discussions helped them to deal with their patients in a more competent manner acquire a higher degree of self-awareness and develop higher confidence in dealing with the behavioral aspects of patient care

- Students who participated in (indirect) programs aimed at enhancing their self-assessment skills have reported that the adoption of self-assessment norms improved their motivation and self-awareness and reduced their anxiety before examinations

- - Primary care physicians who participated in an educational program that included

an emphasis on mindful communication reported improvement in personal well-being emotional exhaustion empathy and attitudes associated with patient-centered care according to a study in the September 2330 issue of JAMA a theme issue on medical education

- Improved self-awareness is also perceived by educators to help students and practitioners shed light on their own belief systems (personal perspective and cultural influences) minimize bias in making clinical decisions and reduce counter-transference reactions in dealing with patients who have diverse beliefs values and preferences thus enhancing cultural competence

- A report on a study of reflection on professionalism observed that reflection transforms experience into understanding promoting higher levels of learning

- A review of the research on levels of attentiveness showed as expected that reacting mindlessly leads to failures in task performance

- A qualitative study on the results of a faculty development program found that self-awareness aids effective patient care that it should theoretically prevent errors in clinical practice help maintain professional standards and help prevent ethical drift and was proven to improve clinical teaching

HOW A Approaches to Enhance Self-Awareness Teaching Content Teaching program of self-awareness for physicians consisting of four topics concerning 1 beliefs and attitudes 2 feelings and emotional responses to patient care 3 coping with challenging clinical situations (eg medical errors angry patients

patients with a terminal illness)

5

4 self-care (eg stress management prevention of burnout)

Teaching interventions direct and indirect approaches

Direct approaches teaching programs focusing on students feelings and emotional difficulties that arise in response to various clinical situations

Objectives

To help them recognize how

- their feelings shape their behavior - this behavior affects patients and colleagues - doctors values needs motives and attitudes influence their practice of medicine

To enhance students private self-awareness

Forms of direct approaches

1 Classroom discussions of emotionally challenging clinical situations The program consists of classroom demonstrations of patient interviews by senior clinical instructors These are followed by discussions with psychiatrists of possible emotional responses by the doctor who conducted the interview with the patient and of the degree to which these responses may affect the doctors behavior and decisions An attempt is made to convey the message that all doctors have feelings and impulses that result from their personal experiences with patients and that these feelings can interfere with optimal professional judgment The main weakness of classroom discussions such as those described above is that they cast the students in the role of passive recipients of knowledge which probably limits the effectiveness of this type of teaching

2 Small-group discussions in which the participants share personal experiences (Balint groups Small-group discussions for medical students) In all types of small-group discussions the main task of the tutor is to encourage the participants to express their own thoughts and feelings about what they have heard protect group members from unwelcome intrusions on their privacy and ensure that the presenting participant group members are not unduly hurt by criticism

3 Counseling of individual students

This approach consists of personal feedback after an instructor observes a live or a videotaped student encounter with a patient An attempt is made to analyze the students feelings and help him or her become aware of attitudes that interfere with the patient interview

Indirect approaches

Objectives To draw students attention

6

- to the shortcomings of the medical profession in general - to discrepancies between the optimum treatment given to some patients but not

to others - to how students performance is assessed by themselves and their instructors

Forms of Indirect approaches

4 Analysis of common patient complaints

Examples given by students about poor patient-doctor communication (The doctor was in a hurry did not listen did not understand) inadequate doctors response to patients needs for information (The doctor did not explain did not let me ask questions expected complete obedience) limited insight into the patients state of mind (The doctor embarrassed me appeared not to believe me changed the subject when I spoke about my troubles) or bad manners or prejudice (The doctor did not greet me did not apologize for being late shouted at me discriminated against me because I am) After listing these complaints the instructor quotes published data indicating that the complaints can indeed be traced to doctors behavior For example complaints such as The doctor did not listen to me are consistent with the observation that the average time interval between the onset of patients narratives and their being interrupted by the doctor was only 18 seconds24 Complaints of prejudice are consistent with evidence of doctors tendencies to discriminate against poor and elderly patients and patients belonging to ethnic minorities45 Complaints such as The doctor did not explain are consistent with the finding that doctors attach a lesser importance than their patients to sharing health-related information with them25 As the discussion proceeds the students agree that patients complaints articulate a problem that cannot be dismissed as rare or trivial They recognize that some physicians are indeed arrogant and impatient and even discriminate against some of their patients Students are then asked to trace this behavior to doctors feelings personal life problems and attitudes that may affect the quality of their relations with patients

5 Analysis of the variability in doctors counseling of different patients about their illnesses

This approach has been used previously in teaching counseling skills during the clinical clerkship part of the curriculum17 and is also well suited for teaching self-awareness It consists of a simulated meeting between a patient and his or her attending physician before discharge of the real patient from the hospital For example a young student who has been following the real patient closely in the hospital and who is familiar with the patients case assumes the role of the attending physician while the instructor who is also familiar with the patient plays the role of the patient During the simulation it is assumed that the instructor has the same disease as the real patient However the instructor is obviously different from the real patient (eg has a medical background a good rapport with the students and is respected by them) The fact that the instructor assumes the real patients role motivates the students to do their best in order to meet the instructors expectations for information The medical background of the physician-instructor makes sharing of information easy because unlike what might be the case with real patients in the case of a physician there are no cultural or language barriers

5

4 self-care (eg stress management prevention of burnout)

Teaching interventions direct and indirect approaches

Direct approaches teaching programs focusing on students feelings and emotional difficulties that arise in response to various clinical situations

Objectives

To help them recognize how

- their feelings shape their behavior - this behavior affects patients and colleagues - doctors values needs motives and attitudes influence their practice of medicine

To enhance students private self-awareness

Forms of direct approaches

1 Classroom discussions of emotionally challenging clinical situations The program consists of classroom demonstrations of patient interviews by senior clinical instructors These are followed by discussions with psychiatrists of possible emotional responses by the doctor who conducted the interview with the patient and of the degree to which these responses may affect the doctors behavior and decisions An attempt is made to convey the message that all doctors have feelings and impulses that result from their personal experiences with patients and that these feelings can interfere with optimal professional judgment The main weakness of classroom discussions such as those described above is that they cast the students in the role of passive recipients of knowledge which probably limits the effectiveness of this type of teaching

2 Small-group discussions in which the participants share personal experiences (Balint groups Small-group discussions for medical students) In all types of small-group discussions the main task of the tutor is to encourage the participants to express their own thoughts and feelings about what they have heard protect group members from unwelcome intrusions on their privacy and ensure that the presenting participant group members are not unduly hurt by criticism

3 Counseling of individual students

This approach consists of personal feedback after an instructor observes a live or a videotaped student encounter with a patient An attempt is made to analyze the students feelings and help him or her become aware of attitudes that interfere with the patient interview

Indirect approaches

Objectives To draw students attention

6

- to the shortcomings of the medical profession in general - to discrepancies between the optimum treatment given to some patients but not

to others - to how students performance is assessed by themselves and their instructors

Forms of Indirect approaches

4 Analysis of common patient complaints

Examples given by students about poor patient-doctor communication (The doctor was in a hurry did not listen did not understand) inadequate doctors response to patients needs for information (The doctor did not explain did not let me ask questions expected complete obedience) limited insight into the patients state of mind (The doctor embarrassed me appeared not to believe me changed the subject when I spoke about my troubles) or bad manners or prejudice (The doctor did not greet me did not apologize for being late shouted at me discriminated against me because I am) After listing these complaints the instructor quotes published data indicating that the complaints can indeed be traced to doctors behavior For example complaints such as The doctor did not listen to me are consistent with the observation that the average time interval between the onset of patients narratives and their being interrupted by the doctor was only 18 seconds24 Complaints of prejudice are consistent with evidence of doctors tendencies to discriminate against poor and elderly patients and patients belonging to ethnic minorities45 Complaints such as The doctor did not explain are consistent with the finding that doctors attach a lesser importance than their patients to sharing health-related information with them25 As the discussion proceeds the students agree that patients complaints articulate a problem that cannot be dismissed as rare or trivial They recognize that some physicians are indeed arrogant and impatient and even discriminate against some of their patients Students are then asked to trace this behavior to doctors feelings personal life problems and attitudes that may affect the quality of their relations with patients

5 Analysis of the variability in doctors counseling of different patients about their illnesses

This approach has been used previously in teaching counseling skills during the clinical clerkship part of the curriculum17 and is also well suited for teaching self-awareness It consists of a simulated meeting between a patient and his or her attending physician before discharge of the real patient from the hospital For example a young student who has been following the real patient closely in the hospital and who is familiar with the patients case assumes the role of the attending physician while the instructor who is also familiar with the patient plays the role of the patient During the simulation it is assumed that the instructor has the same disease as the real patient However the instructor is obviously different from the real patient (eg has a medical background a good rapport with the students and is respected by them) The fact that the instructor assumes the real patients role motivates the students to do their best in order to meet the instructors expectations for information The medical background of the physician-instructor makes sharing of information easy because unlike what might be the case with real patients in the case of a physician there are no cultural or language barriers

6

- to the shortcomings of the medical profession in general - to discrepancies between the optimum treatment given to some patients but not

to others - to how students performance is assessed by themselves and their instructors

Forms of Indirect approaches

4 Analysis of common patient complaints

Examples given by students about poor patient-doctor communication (The doctor was in a hurry did not listen did not understand) inadequate doctors response to patients needs for information (The doctor did not explain did not let me ask questions expected complete obedience) limited insight into the patients state of mind (The doctor embarrassed me appeared not to believe me changed the subject when I spoke about my troubles) or bad manners or prejudice (The doctor did not greet me did not apologize for being late shouted at me discriminated against me because I am) After listing these complaints the instructor quotes published data indicating that the complaints can indeed be traced to doctors behavior For example complaints such as The doctor did not listen to me are consistent with the observation that the average time interval between the onset of patients narratives and their being interrupted by the doctor was only 18 seconds24 Complaints of prejudice are consistent with evidence of doctors tendencies to discriminate against poor and elderly patients and patients belonging to ethnic minorities45 Complaints such as The doctor did not explain are consistent with the finding that doctors attach a lesser importance than their patients to sharing health-related information with them25 As the discussion proceeds the students agree that patients complaints articulate a problem that cannot be dismissed as rare or trivial They recognize that some physicians are indeed arrogant and impatient and even discriminate against some of their patients Students are then asked to trace this behavior to doctors feelings personal life problems and attitudes that may affect the quality of their relations with patients

5 Analysis of the variability in doctors counseling of different patients about their illnesses

This approach has been used previously in teaching counseling skills during the clinical clerkship part of the curriculum17 and is also well suited for teaching self-awareness It consists of a simulated meeting between a patient and his or her attending physician before discharge of the real patient from the hospital For example a young student who has been following the real patient closely in the hospital and who is familiar with the patients case assumes the role of the attending physician while the instructor who is also familiar with the patient plays the role of the patient During the simulation it is assumed that the instructor has the same disease as the real patient However the instructor is obviously different from the real patient (eg has a medical background a good rapport with the students and is respected by them) The fact that the instructor assumes the real patients role motivates the students to do their best in order to meet the instructors expectations for information The medical background of the physician-instructor makes sharing of information easy because unlike what might be the case with real patients in the case of a physician there are no cultural or language barriers

7

In such ideal circumstances the student cannot but respond well to the simulated patients needs for information and preferences regarding future management adapt the patients management to his lifestyle and provide optimal counseling As the simulation proceeds the students who are observing the simulation realize that the real patient was almost always not optimally counseled in a similar manner This opens the door to discussions of possible reasons for the detected discrepancies concerning the extent to which the real and simulated patients were listened to and encouraged to ask questions the amount of information they were given and the patients involvement in making clinical decisions Students realize that the simulated patients prerogative for information and respect for her preferences are accepted as obvious when her role is played by a person with the same professional and cultural background as the students However real patients are only rarely given the same consideration even though their needs are similar This double standard makes the students aware that they are not free of prejudice and that stereotyping of patients whether done consciously or subconsciously might affect patient counseling

6 Training students to assess their own performance

Approaches that have been described for improving students self-assessment skills consist of asking each student to first evaluate his or her own performance second compare this self-assessment with the instructors evaluation of the students performance third reflect on the causes of possible differences between these assessments and last make a judgment regarding needs for improvement

Some studies have shown that learners often had difficulties in understanding the purpose of the requirement to assess their own performance31-34 Other difficulties were the requirements for a clear definition of the learning objectives of the teaching program and of the criteria for the evaluation of students performance and the requirements for a large number of teachers for repeated self-assessments and feedback sessions to reconcile the students and teachers assessments B Training mindfulness Through observation of physical sensations thoughts and feelings participants learn that they are more than these components of their experience -- and that they can respond rather than react to lifersquos circumstances --by cultivating a quality of awareness that allows for more discernment in their appraisal of these circumstances Objectives - To understand the principles and applications of mindfulness and mindful

practice - To explore the role of mindfulness training for self-care in medical curricula - To discuss the potential application of mindful practice to participantsrsquo

educational programs - To foster patient safety caring attitudes and professionalism by enhancing

mindful practice in residents and students when encountering challenging situations in clinical medicine

- To foster elements of mindful practice (attentive observation critical curiosity informed flexibility and presence) in trainees at multiple levels

8

WHO

- medical students physicians health professionals patients

WHEN

- During clerkship for medical students - During residency training period for medical residents - Postgraduate Training courses for physicians

Haifa Israel Experience Teaching medical students At the first 3 years of medical school the students experience and work with a tutor in small groups on psyco-social and ethical subjects The course which is called being a doctor- is done by working in small groups dealing with medical issues as well as the personal experience and group processes At the first year the students learn and experience the basic concepts of communication and interview patients physicians and families Small group discussions (dealing with personal and organizational obstacles and the group dynamics as well) and written narratives are the first self-awareness tools At the second year the main issue is medicine in the community (primary care and issues as addiction violence in families etc) They learn communication skills with role plays and real patients-the small group discussions emphasize self reflection They also meet and talk with prisoners battered women drug users and discuss there own feelings and thoughts At the third year the main communication skills are cross cultural and dealing with ethical issues The main self awareness tools are Small group discussions of your own culture and beliefs meeting the others in the group interviewing patients from different backgrounds and eliciting their explanatory model Writing reflective diaries and sharing them with the tutor Separately from this course which is obligatory and evolve in 3 years there is an elective course on Literature and Medicine Through reading stories and poems discussing them and narrating ones experience we facilitate compassion Empathy self reflection and self awareness Sixth year students participate in a communication course of breaking bad news Part of the course deals with the students fears and difficulties dealing with anger and loss It is done by small groups discussions role play and inspecting others Family practice residents methods and courses used to facilitate self awareness

Preceptorship(mentoring)

Balint Groups

Medicine and literature course

Using music art literature cinema in teaching

9

Narrative medicine course (based on writing narrating and close reading)

Family of origin course

Small groups learning of communication which evolve self reflection group and personal proscess Using videos (with real patients) role play of real situations that are brought in

Communication in Palliative care (hands on)

Death grief and bereavement in our life and work Primary care physicians (mostly specialist)

Balint groups (only family Physicians)

Chalenging cases (small groups discussion)

Videotapes- Medical situations with actors (small groups)

Using narrative and working in couples to discuss critical incidents moment

Learning from positive experience What about literature resources Program For Physicians Emphasizing Self-Awareness Associated with Improvemens in Burnout Mood and Patient Emphathy JAMA2009 302(12)1284-93 Richard Smith Thoughts for new medical students at a new medical school Subtitle Giving advice to medical students make doctors think about what is important in what they do BMJ vol 327 20-27 December 2003 Erik Driessen Jan van Tartwijk Tim Dornan The self-critical doctor helping students become more reflective BMJ 200( 336 827-30

Firth-Cozens J Interventions to improve physicians well-being and patient care Soc Sci Med 200152215-22

Shanafelt TD Bradley KA Wipf JE Back AL Burnout and self-reported patient care in an internal medicine residency program Ann Intern Med 2002136358-67

Klein D Najman J Kohman A Munro C Patient characteristics that elicit negative responses from family physicians J Fam Pract 198214881-8

Wetle T Age as a risk factor for inadequate treatment JAMA 1987258516

van Ryn M Burke J The effect of patient race and socio-economic status on physicians perception of patients Soc Sci Med 200050813-28

Cook WR Neff C Attitudes of physicians to medical malpractice litigation in Canada Med Law 199211557-78

Novack DH Suchman AL Clark W Epstein RM Najberg E Kaplan C Calibrating the physician Personal awareness and effective patient care Working Group on promoting Physician Personal Awareness American Academy on Physician and Patient JAMA 1997278502-9

10

Gorlin R Zucker HD Physicians reactions to patients A key to teaching humanistic medicine N Engl J Med 19833081059-63

Fenigstein A Scheier MF Buss AH Public and private self-consciousness Assessment and theory J Consult Clin Psychol 197543522-7

Govern JM Marsch LA Development and validation of the situational self-awareness scale Conscious Cogn 200110366-78

Gordon MJ Self-assessment programs and their implications for health professions training Acad Med 199267672-9

Smith RC Dorsey AM Lyles JS Frankel RM Teaching self-awareness enhances learning about patient-centered interviewing Acad Med 1999741242-8

Jaimovich S How medical students view their relationships with patients the role of private and public self-consciousness J Soc Psychol 19991395-13

Petruccelli E Professionalization and physician self-awareness (2001) lang httpwwwomaorgpcommOMRmar02professionalizmhtmrang Accessed October 2004

Henderson P Johnson MH An innovative approach to developing the reflective skills of medical students (2002) lang httpwwwbiomedcentralcom1472-692024rang Accessed October 2004

Benbassat J Baumal R Teaching doctor patient interviewing skills using an integrated learner and teacher-centered approach Am J Med Sci 2001322349-57

Benbassat J Baumal R A step-wise role-playing approach for teaching patient counseling skills to medical students Patient Educ Couns 200246147-52

Balint M The doctor his patient and the illness Madison International University Press 1964

Merenstein JH Chillag K Balint seminar leaders what do they do Fam Med 199931182-6

Sollner W Maurer G Mark-Stemberger B Wesiack W Besonderheiten und Probleme der Balint-Arbeit mit Medizinstudenten [Characteristics and problems of Balint groups with medical students] Psychother Psychosom Med Psychol 199242302-7

Chou C Lee K Improving residents interviewing skills by group videotape review Acad Med 200277744

Sifri RD Glaser K Witt DK Addressing prejudice in medicine during a third-year family medicine clerkship Acad Med 200176508

9

Narrative medicine course (based on writing narrating and close reading)

Family of origin course

Small groups learning of communication which evolve self reflection group and personal proscess Using videos (with real patients) role play of real situations that are brought in

Communication in Palliative care (hands on)

Death grief and bereavement in our life and work Primary care physicians (mostly specialist)

Balint groups (only family Physicians)

Chalenging cases (small groups discussion)

Videotapes- Medical situations with actors (small groups)

Using narrative and working in couples to discuss critical incidents moment

Learning from positive experience What about literature resources Program For Physicians Emphasizing Self-Awareness Associated with Improvemens in Burnout Mood and Patient Emphathy JAMA2009 302(12)1284-93 Richard Smith Thoughts for new medical students at a new medical school Subtitle Giving advice to medical students make doctors think about what is important in what they do BMJ vol 327 20-27 December 2003 Erik Driessen Jan van Tartwijk Tim Dornan The self-critical doctor helping students become more reflective BMJ 200( 336 827-30

Firth-Cozens J Interventions to improve physicians well-being and patient care Soc Sci Med 200152215-22

Shanafelt TD Bradley KA Wipf JE Back AL Burnout and self-reported patient care in an internal medicine residency program Ann Intern Med 2002136358-67

Klein D Najman J Kohman A Munro C Patient characteristics that elicit negative responses from family physicians J Fam Pract 198214881-8

Wetle T Age as a risk factor for inadequate treatment JAMA 1987258516

van Ryn M Burke J The effect of patient race and socio-economic status on physicians perception of patients Soc Sci Med 200050813-28

Cook WR Neff C Attitudes of physicians to medical malpractice litigation in Canada Med Law 199211557-78

Novack DH Suchman AL Clark W Epstein RM Najberg E Kaplan C Calibrating the physician Personal awareness and effective patient care Working Group on promoting Physician Personal Awareness American Academy on Physician and Patient JAMA 1997278502-9

10

Gorlin R Zucker HD Physicians reactions to patients A key to teaching humanistic medicine N Engl J Med 19833081059-63

Fenigstein A Scheier MF Buss AH Public and private self-consciousness Assessment and theory J Consult Clin Psychol 197543522-7

Govern JM Marsch LA Development and validation of the situational self-awareness scale Conscious Cogn 200110366-78

Gordon MJ Self-assessment programs and their implications for health professions training Acad Med 199267672-9

Smith RC Dorsey AM Lyles JS Frankel RM Teaching self-awareness enhances learning about patient-centered interviewing Acad Med 1999741242-8

Jaimovich S How medical students view their relationships with patients the role of private and public self-consciousness J Soc Psychol 19991395-13

Petruccelli E Professionalization and physician self-awareness (2001) lang httpwwwomaorgpcommOMRmar02professionalizmhtmrang Accessed October 2004

Henderson P Johnson MH An innovative approach to developing the reflective skills of medical students (2002) lang httpwwwbiomedcentralcom1472-692024rang Accessed October 2004

Benbassat J Baumal R Teaching doctor patient interviewing skills using an integrated learner and teacher-centered approach Am J Med Sci 2001322349-57

Benbassat J Baumal R A step-wise role-playing approach for teaching patient counseling skills to medical students Patient Educ Couns 200246147-52

Balint M The doctor his patient and the illness Madison International University Press 1964

Merenstein JH Chillag K Balint seminar leaders what do they do Fam Med 199931182-6

Sollner W Maurer G Mark-Stemberger B Wesiack W Besonderheiten und Probleme der Balint-Arbeit mit Medizinstudenten [Characteristics and problems of Balint groups with medical students] Psychother Psychosom Med Psychol 199242302-7

Chou C Lee K Improving residents interviewing skills by group videotape review Acad Med 200277744

Sifri RD Glaser K Witt DK Addressing prejudice in medicine during a third-year family medicine clerkship Acad Med 200176508

10

Gorlin R Zucker HD Physicians reactions to patients A key to teaching humanistic medicine N Engl J Med 19833081059-63

Fenigstein A Scheier MF Buss AH Public and private self-consciousness Assessment and theory J Consult Clin Psychol 197543522-7

Govern JM Marsch LA Development and validation of the situational self-awareness scale Conscious Cogn 200110366-78

Gordon MJ Self-assessment programs and their implications for health professions training Acad Med 199267672-9

Smith RC Dorsey AM Lyles JS Frankel RM Teaching self-awareness enhances learning about patient-centered interviewing Acad Med 1999741242-8

Jaimovich S How medical students view their relationships with patients the role of private and public self-consciousness J Soc Psychol 19991395-13

Petruccelli E Professionalization and physician self-awareness (2001) lang httpwwwomaorgpcommOMRmar02professionalizmhtmrang Accessed October 2004

Henderson P Johnson MH An innovative approach to developing the reflective skills of medical students (2002) lang httpwwwbiomedcentralcom1472-692024rang Accessed October 2004

Benbassat J Baumal R Teaching doctor patient interviewing skills using an integrated learner and teacher-centered approach Am J Med Sci 2001322349-57

Benbassat J Baumal R A step-wise role-playing approach for teaching patient counseling skills to medical students Patient Educ Couns 200246147-52

Balint M The doctor his patient and the illness Madison International University Press 1964

Merenstein JH Chillag K Balint seminar leaders what do they do Fam Med 199931182-6

Sollner W Maurer G Mark-Stemberger B Wesiack W Besonderheiten und Probleme der Balint-Arbeit mit Medizinstudenten [Characteristics and problems of Balint groups with medical students] Psychother Psychosom Med Psychol 199242302-7

Chou C Lee K Improving residents interviewing skills by group videotape review Acad Med 200277744

Sifri RD Glaser K Witt DK Addressing prejudice in medicine during a third-year family medicine clerkship Acad Med 200176508

11

Jason H Kagan N Werner A Elstein AS Thomas JB New approaches to teaching basic interview skills to medical students Am J Psychiatry 19711271404-7

Beckman HB Frankel RM The effect of physician behavior on the collection of data Ann Intern Med 1984101692-6

Laine C Davidoff F Lewis CE Important elements of outpatient care a comparison of patients and physicians opinions Ann Intern Med 1996125640-5

Fitzgerald JT Gruppen LD White CB The influence of task formats on the accuracy of medical students self-assessments Acad Med 200075737-41

Woolliscroft JO Tenhaken J Smith J Calhoun JG Medical students clinical self-assessments comparisons with external measures of performance and the students self-assessments of overall performance and effort Acad Med 199368285-94

Sullivan ME Hitchcock MA Dunnington GL Peer and self-assessment during problem-based tutorials Am J Surg 1999177266-9

Arnold L Willoughby TL Calkins EV Self-evaluation in undergraduate medical education a longitudinal perspective J Med Educ 19856021-8

Hays RB Jolly BJ Caldon LJM et al Is insight important Measuring capacity to change performance Med Educ 200236965-71

Jelly EC Friedman C An evaluation system for residency training J Fam Pract 19801073-80

Abrams RG Kelley ML Student self-evaluation in a pediatric-operative technique course J Dent Educ 197428385-91

Kennell JH Tempio CR Wile MZ Self-evaluation by first-year medical students in a clinical science programme Br J Med Educ 19737230-8

Adams WR Ham TH Mawardi BH Scali HA Weisman R Research in self-education Dokter HJ Duivenvoorden HJ Verhage F Changes in the attitude of general practitioners as a result of participation in a Balint group Fam Pract 19863155-63

Ireton HR Sherman M Self-ratings of graduate family practice residents psychological medicine abilities Fam Pract Res J 19887236-44

Turner AL Malm RL A preliminary investigation of Balint and non-Balint behavioral medicine training Fam Med 200436114-7

Stackhouse J Furnham A A student-centred approach to the evaluation of clinical skills British Journal of Disorders of Communication 198318171-9

12

Birchwood M Smith J Drury V Healy J Macmillan F Slade M A self-report Insight Scale for psychosis reliability validity and sensitivity to change Acta Psychiatr Scand 19948962-7

Simmond M Fleming J Reliability of the self-awareness of deficits interview for adults with traumatic brain injury Brain Inj 200317325-37

Kerrins KM Comparing the self-image of prepubescent girls before and after four sessions on body awareness J Sch Health 198353541-3

Wegner BS Hartmann AM Geist CR Effect of exposure to photographs of thin models on self-consciousness in female college students Psychol Rep 2000861149- Mindfulness training student self-care and clinical practice ppt Presentation Craig Hassed MD Monash University Melbourne Australia Ron Epstein MD

University of Rochester New York USA

12

Birchwood M Smith J Drury V Healy J Macmillan F Slade M A self-report Insight Scale for psychosis reliability validity and sensitivity to change Acta Psychiatr Scand 19948962-7

Simmond M Fleming J Reliability of the self-awareness of deficits interview for adults with traumatic brain injury Brain Inj 200317325-37

Kerrins KM Comparing the self-image of prepubescent girls before and after four sessions on body awareness J Sch Health 198353541-3

Wegner BS Hartmann AM Geist CR Effect of exposure to photographs of thin models on self-consciousness in female college students Psychol Rep 2000861149- Mindfulness training student self-care and clinical practice ppt Presentation Craig Hassed MD Monash University Melbourne Australia Ron Epstein MD

University of Rochester New York USA