INNOVATIONS IN INTEGRATIVE HEALTHCARE EDUCATION
BRIDGING THE COMPASSION AND EMPATHY GAP IN MEDICAL SCHOOL: THE PHYSICIAN HEALER TRACK AT UTMB-HEALTH |
Cara Geary, MD, PhD, Julie McKee, MD, Catalina Triana, MD, Era Buck, PhD, Scott Walton, BS, MS2, David Valdez, BS, MS2, Victor Sierpina, MD, and Mary Jo Kreitzer, RN, PhD |
“We are what we repeatedly do. Excellence, then, is not an act, but a habit.” —Aristotle Excellence in compassion and empathy require repeated practice. Instead of providing this practice, medical school curriculums emphasize data acquisition and regurgitation, test performance, and competition. Medical students often start their training with a passion to care for and be of service to others. Their training will often acknowledge the importance of humanistic skills but time and energy is rarely within the medical school curriculum to become compassionate and empathic by becoming “what they repeatedly do.” In addition to the lack of attention and actual practice in this realm, a lack of self-care in exchange for test performance is encouraged within the culture. This further erodes compassion and empathy for others as poor self-care contributes to stress and burn-out. As faculty role models trained within this system, it is challenging to rediscover our own empathy and compassion, much less figure out how to change the training for the future. This degradation of compassion and empathy skills is well documented in academic medicine.1–13 While not entirely understood, contributing factors may include any or all of the following: focus on grades and evaluation, competition for residency, long hours, and decreased time and effort for self-care. Other potential culprits are poor faculty role models, medical technology, short office and hospital visits, and lack of long-term relationships with patients.
To address these problems and hopefully prevent so-called “empathy burnout” in students, UTMB-Health (University of Texas Medical Branch, Galveston, TX) has initiated a new track, The Physician Healer Track, for a limited number of students. It is intentionally and mindfully designed to help students maintain their innate compassion and humanity and to grow these personal skills in relation to clinical care. The syllabus description of this new program is as follows: “The Physician Healer Track is designed to mentor students as they develop their professional identity as doctors. The training focuses on self-awareness, self-reflection, interpersonal communication skills, selfcare, and work-life balance. Being a source of healing for the suffering of another is both a responsibility and a privilege. In addition to our technical knowledge and skills, being a healer requires training in equanimity, wisdom and compassion.” (See The Physician Healer Track website for further details.14) UTMB-Health has established a number of “Tracks” in the medical school to provide interested students opportunities to receive expanded learning experiences in areas of interest. Other Tracks include Aerospace Medicine, Bilingual Health, Global Health, Geriatrics, Public Health, Rural Healthcare, and Translational Research.15 Tracks entail five to six months of elective and selective experiences. A variety of configurations with regard to timing are possible. Flexibility allows students to enter a track at multiple points. Programs require a substantial
Innovations in Integrative Healthcare Education
scholarly project and product (e.g., manuscript or oral presentation) for successful completion. Students completing this Physician Healer Track are recognized for their extra commitment in their Dean's letter and at graduation as “Physician Healer” Scholars. Other tracks offer similar recognition. The Physician Healer Track is meant to be highly experiential, fostering mindfulness and self-awareness. To foster these, a variety of small-group, self-study, and clinical experiences are included. Some examples from early sessions in the first year of medical school include self-assessments using the enneagram and self-compassion tests,16 viewing TED and YouTube presentations,17 journaling exercises, selected articles, books,18,19 and other readings. While this is the first year of the program, and it is too early to evaluate its impact, student enthusiasm has been high. We anticipated nine to10 students would sign up for the track and nearly 40 did so. We ultimately limited it to 24 students for the first year (10% of the class). Two second-year students, Scott Walton and David Valdez are integral as actively contributing committee members who are helping guide The Physician Healer Track's planning, implementation, and leadership. Their reflections on the value of this curricular track are as follows: Upon entering medical school, my spirits were high and I was anxious to learn from the professionals in the medical field and perform well in my classes. However, I quickly
EXPLORE May/June 2014, Vol. 10, No. 3 203
learned that gaining the ability to truly heal as a physician required more than a wealth of medical knowledge and A's on all of my tests. I needed to learn how to be present with my patients in order to better alleviate their suffering, especially the suffering that extends beyond the physical. Unfortunately, the stress and rigid structure of medical school curriculums allows too many students to merely pass through without acquiring this skill and their patients suffer because of it. With so much of our medical training focused on the science of medicine, I learned from firsthand experience that too many students, residents, and physicians lack the ability and training necessary to provide a complete healing presence in their clinics. Our first son was diagnosed with an illness that carried with it a poor prognosis. The news turned our lives upside down and the stark contrast between those doctors equipped to provide complete care and those merely there to fill out a chart or complete a task became blatantly obvious. Following this experience, I was introduced to the Physician Healer Track and I am finally receiving the experience and training necessary to learn to fully provide for my patients. The healing aspect of my training is so important to my future and I am grateful that UTMB is beginning to incorporate it actively for all students. Undoubtedly, medical students will confront situations that will pull at their heart strings. The Physician Healer Track will ensure that when students hit the wards, they will be empowered to confront these encounters with confidence and not hide behind the fancy medical jargon that leaves patients to fend for themselves in their vulnerable states. This track will confirm in the hearts and minds of its students that a task to be performed or case to be solved is never more important than a patient to be cared for. (S.W.) I remember being 2 months into the first year of medical school and not being able to keep myself from wondering: where are all the people I was supposed to be helping, who have I helped since I have been
here, and when was the last time I thought about anything other than scheduling my day around lectures, labs, problem-based learning, and assigned readings. I found that my personality and empathy were becoming calloused, and that the flame that once burned so strong to make a difference in people's lives had been redirected toward just learning a massive amount of information and performing on an exam. This continued through the first half of second year and, I admit, although it seemed like the curriculum did try to implement some sort of empathy exposure, it was always minimal and unable to get past the daily strife of being a medical student. Then I heard of a program that was starting which focused on bringing humanity and compassion to medical school. The Physician Healer Track focuses on the elements of being a caregiver that the current medical curriculum fails to adequately address. It not only provides the opportunity for medical students to be engaged in activities focused on combating empathy burn-out but also nurtures students to become well-rounded caregivers trained in more complete patient care. As we all have entered the medical profession to help others, this track acts as a bridge over the traps of a demanding curriculum to help medical students maintain the mindfulness toward care for others that they initially entered with. This track also provides students with the opportunity to learn from passionate physicians who are motivated to serve students by facilitating them in small groups as well as being a visual representation and model of what being a physician healer is all about. Currently the track is only opened to a limited amount of students, but we hope it will soon be available to everyone. Every medical student needs the opportunity to be a physician healer. (D.L.) A number of challenges remain to the implementation of this program. Faculty development is key to expanding our goal of having the key elements of the track available to more students and perhaps the entire class. This will require funding for travel and conferences on mindfulness, mind–body therapies,
204 EXPLORE May/June 2014, Vol. 10, No. 3
communication, and empathy skill development. Food expenses for evening dinner meetings with students has so far been provided from discretionary and endowment funds of generous faculty but eventually need to be budgeted from the School of Medicine. Providing administrative staff support as well as time and effort to lead faculty is crucial to the program's long-term success. We are just starting to realize the need for these structural elements to sustain and grow what promises to be a major innovation in healthcare education. Our success in early recruitment of both students and faculty encourage us to address these challenges and others that inevitably will arise. Stay tuned as we grow and evaluate this program. In the meantime, consider starting one at your own medical or other health professional school. Feel free to adapt our evolving model and so you do not have to reinvent the wheel.14 REFERENCES 1. Dobie S. Viewpoint: reflections on a well-traveled path: self-awareness, mindful practice, and relationship-centered care as foundations for medical education. Acad Med. 2007;82:422–427. 2. Grewal D, Davidson HA. Emotional intelligence and graduate medical education. J Am Med Assoc. 2008;300:1200– 1202. 3. Epstein RM. Mindful practice. J Am Med Assoc. 1999;282:833–839. 4. Shapiro J, Rucker L, Robishek D. Teaching the art of doctoring: an innovative medical student elective. Med Teach. 2006;28:30–35. 5. Karnieli-Miller O, Vu TR, Holtman MC, Clyman SG, Inui TS. Medical students' professionalism narratives: a window on the informal and hidden curriculum. Acad Med. 2010;85:124–133. 6. Coulehan J. Viewpoint: today's professionalism: engaging the mind but not the heart. Acad Med. 2005;80:892–898. 7. Larson EB, Yao X. Clinical empathy as emotional labor in the patient–physician relationship. J Am Med Assoc. 2005;293: 1100–1106. 8. Holm U, Aspergren K. Pedagogical methods and affect tolerance in medical students. Med Educ. 1999;33:14–18. 9. Chen PW. Medical student distress and the risk of doctor suicide. N Y Times 2010. 10. Dyrbye LN, et al. Factors associated with the resilience to and recovery from
Innovations in Integrative Healthcare Education
11.
12.
13.
14. 15. 16.
17.
18.
burnout: a prospective, multi-institutional study of US medical students. Med Educ 2010. Dyrbye LN, et al. Relationship between burnout and professional conduct and attitudes among US medical students. J Am Med Assoc 2010. Thomas MR, et al. How do distress and well-being related to medical student empathy? J Gen Intern Med 2007. Shapiro J. Does medical education promote professional alexithymia? A call for attending to the emotions of patients and self in medical training Acad Med. 2011;86:326–332. http://www.utmb.edu/pedi_ed/PHT/ default.asp. http://www.utmb.edu/oce/Tracks.htm/. http://www.self-compassion.org/tes t-your-self-compassion-level.html http://www.enneagraminstitute.com/. http://www.ted.com/talks/abraham_ver ghese_a_doctor_s_touch.html http:// www.ted.com/talks/brene_brown_on_ vulnerability.html. http://www.amazon.com/s/ ref=nb_sb_noss?url=search-alias% 3Daps&field-keywords=shameless% 20guide%20to%20happiness.
19. MacGregor B. In: Awe of Being Human— A Doctor's Stories From the Edge of Life and Death. Greenbank, WA: Abiding Nowhere Press; 2013.
Cara Geary, MD, PhD, is an Associate Professor of Pediatrics in the Division of Neonatology at the University of Texas Medical Branch in Galveston, Texas. Julie McKee, MD, is a Family Medicine Physician in University of Texas Medical Branch's Department of Family Medicine.
Victor S. Sierpina, MD, is the W.D. and Laura Nell Nicholson Professor of Integrative Medicine, Professor Family Medicine, Director of Medical Student Education, at the University of Texas Medical Branch in Galveston, Texas. He is an associate editor for EXPLORE. Mary Jo Kreitzer, PhD, RN, is the founder and director the Center for Spirituality and Healing and a professor in the School of Nursing at the University of Minnesota, Minneapolis, Minnesota.
Catalina Triana, MD, is a Family Medicine Physician in University of Texas Medical Branch's Department of Family Medicine. Era Buck, PhD, is faculty at the University of Texas Medical Branch in Galveston, Texas. Scott Walton, BS, and David Valdez, BS, are second-year medical students at the University of Texas Medical Branch in Galveston, Texas.
Innovations in Integrative Healthcare Education
EXPLORE May/June 2014, Vol. 10, No. 3 205
BRIDGING THE COMPASSION AND EMPATHY GAP IN MEDICAL SCHOOL: THE PHYSICIAN HEALER TRACK AT UTMB-HEALTH |
Cara Geary, MD, PhD, Julie McKee, MD, Catalina Triana, MD, Era Buck, PhD, Scott Walton, BS, MS2, David Valdez, BS, MS2, Victor Sierpina, MD, and Mary Jo Kreitzer, RN, PhD |
“We are what we repeatedly do. Excellence, then, is not an act, but a habit.” —Aristotle Excellence in compassion and empathy require repeated practice. Instead of providing this practice, medical school curriculums emphasize data acquisition and regurgitation, test performance, and competition. Medical students often start their training with a passion to care for and be of service to others. Their training will often acknowledge the importance of humanistic skills but time and energy is rarely within the medical school curriculum to become compassionate and empathic by becoming “what they repeatedly do.” In addition to the lack of attention and actual practice in this realm, a lack of self-care in exchange for test performance is encouraged within the culture. This further erodes compassion and empathy for others as poor self-care contributes to stress and burn-out. As faculty role models trained within this system, it is challenging to rediscover our own empathy and compassion, much less figure out how to change the training for the future. This degradation of compassion and empathy skills is well documented in academic medicine.1–13 While not entirely understood, contributing factors may include any or all of the following: focus on grades and evaluation, competition for residency, long hours, and decreased time and effort for self-care. Other potential culprits are poor faculty role models, medical technology, short office and hospital visits, and lack of long-term relationships with patients.
To address these problems and hopefully prevent so-called “empathy burnout” in students, UTMB-Health (University of Texas Medical Branch, Galveston, TX) has initiated a new track, The Physician Healer Track, for a limited number of students. It is intentionally and mindfully designed to help students maintain their innate compassion and humanity and to grow these personal skills in relation to clinical care. The syllabus description of this new program is as follows: “The Physician Healer Track is designed to mentor students as they develop their professional identity as doctors. The training focuses on self-awareness, self-reflection, interpersonal communication skills, selfcare, and work-life balance. Being a source of healing for the suffering of another is both a responsibility and a privilege. In addition to our technical knowledge and skills, being a healer requires training in equanimity, wisdom and compassion.” (See The Physician Healer Track website for further details.14) UTMB-Health has established a number of “Tracks” in the medical school to provide interested students opportunities to receive expanded learning experiences in areas of interest. Other Tracks include Aerospace Medicine, Bilingual Health, Global Health, Geriatrics, Public Health, Rural Healthcare, and Translational Research.15 Tracks entail five to six months of elective and selective experiences. A variety of configurations with regard to timing are possible. Flexibility allows students to enter a track at multiple points. Programs require a substantial
Innovations in Integrative Healthcare Education
scholarly project and product (e.g., manuscript or oral presentation) for successful completion. Students completing this Physician Healer Track are recognized for their extra commitment in their Dean's letter and at graduation as “Physician Healer” Scholars. Other tracks offer similar recognition. The Physician Healer Track is meant to be highly experiential, fostering mindfulness and self-awareness. To foster these, a variety of small-group, self-study, and clinical experiences are included. Some examples from early sessions in the first year of medical school include self-assessments using the enneagram and self-compassion tests,16 viewing TED and YouTube presentations,17 journaling exercises, selected articles, books,18,19 and other readings. While this is the first year of the program, and it is too early to evaluate its impact, student enthusiasm has been high. We anticipated nine to10 students would sign up for the track and nearly 40 did so. We ultimately limited it to 24 students for the first year (10% of the class). Two second-year students, Scott Walton and David Valdez are integral as actively contributing committee members who are helping guide The Physician Healer Track's planning, implementation, and leadership. Their reflections on the value of this curricular track are as follows: Upon entering medical school, my spirits were high and I was anxious to learn from the professionals in the medical field and perform well in my classes. However, I quickly
EXPLORE May/June 2014, Vol. 10, No. 3 203
learned that gaining the ability to truly heal as a physician required more than a wealth of medical knowledge and A's on all of my tests. I needed to learn how to be present with my patients in order to better alleviate their suffering, especially the suffering that extends beyond the physical. Unfortunately, the stress and rigid structure of medical school curriculums allows too many students to merely pass through without acquiring this skill and their patients suffer because of it. With so much of our medical training focused on the science of medicine, I learned from firsthand experience that too many students, residents, and physicians lack the ability and training necessary to provide a complete healing presence in their clinics. Our first son was diagnosed with an illness that carried with it a poor prognosis. The news turned our lives upside down and the stark contrast between those doctors equipped to provide complete care and those merely there to fill out a chart or complete a task became blatantly obvious. Following this experience, I was introduced to the Physician Healer Track and I am finally receiving the experience and training necessary to learn to fully provide for my patients. The healing aspect of my training is so important to my future and I am grateful that UTMB is beginning to incorporate it actively for all students. Undoubtedly, medical students will confront situations that will pull at their heart strings. The Physician Healer Track will ensure that when students hit the wards, they will be empowered to confront these encounters with confidence and not hide behind the fancy medical jargon that leaves patients to fend for themselves in their vulnerable states. This track will confirm in the hearts and minds of its students that a task to be performed or case to be solved is never more important than a patient to be cared for. (S.W.) I remember being 2 months into the first year of medical school and not being able to keep myself from wondering: where are all the people I was supposed to be helping, who have I helped since I have been
here, and when was the last time I thought about anything other than scheduling my day around lectures, labs, problem-based learning, and assigned readings. I found that my personality and empathy were becoming calloused, and that the flame that once burned so strong to make a difference in people's lives had been redirected toward just learning a massive amount of information and performing on an exam. This continued through the first half of second year and, I admit, although it seemed like the curriculum did try to implement some sort of empathy exposure, it was always minimal and unable to get past the daily strife of being a medical student. Then I heard of a program that was starting which focused on bringing humanity and compassion to medical school. The Physician Healer Track focuses on the elements of being a caregiver that the current medical curriculum fails to adequately address. It not only provides the opportunity for medical students to be engaged in activities focused on combating empathy burn-out but also nurtures students to become well-rounded caregivers trained in more complete patient care. As we all have entered the medical profession to help others, this track acts as a bridge over the traps of a demanding curriculum to help medical students maintain the mindfulness toward care for others that they initially entered with. This track also provides students with the opportunity to learn from passionate physicians who are motivated to serve students by facilitating them in small groups as well as being a visual representation and model of what being a physician healer is all about. Currently the track is only opened to a limited amount of students, but we hope it will soon be available to everyone. Every medical student needs the opportunity to be a physician healer. (D.L.) A number of challenges remain to the implementation of this program. Faculty development is key to expanding our goal of having the key elements of the track available to more students and perhaps the entire class. This will require funding for travel and conferences on mindfulness, mind–body therapies,
204 EXPLORE May/June 2014, Vol. 10, No. 3
communication, and empathy skill development. Food expenses for evening dinner meetings with students has so far been provided from discretionary and endowment funds of generous faculty but eventually need to be budgeted from the School of Medicine. Providing administrative staff support as well as time and effort to lead faculty is crucial to the program's long-term success. We are just starting to realize the need for these structural elements to sustain and grow what promises to be a major innovation in healthcare education. Our success in early recruitment of both students and faculty encourage us to address these challenges and others that inevitably will arise. Stay tuned as we grow and evaluate this program. In the meantime, consider starting one at your own medical or other health professional school. Feel free to adapt our evolving model and so you do not have to reinvent the wheel.14 REFERENCES 1. Dobie S. Viewpoint: reflections on a well-traveled path: self-awareness, mindful practice, and relationship-centered care as foundations for medical education. Acad Med. 2007;82:422–427. 2. Grewal D, Davidson HA. Emotional intelligence and graduate medical education. J Am Med Assoc. 2008;300:1200– 1202. 3. Epstein RM. Mindful practice. J Am Med Assoc. 1999;282:833–839. 4. Shapiro J, Rucker L, Robishek D. Teaching the art of doctoring: an innovative medical student elective. Med Teach. 2006;28:30–35. 5. Karnieli-Miller O, Vu TR, Holtman MC, Clyman SG, Inui TS. Medical students' professionalism narratives: a window on the informal and hidden curriculum. Acad Med. 2010;85:124–133. 6. Coulehan J. Viewpoint: today's professionalism: engaging the mind but not the heart. Acad Med. 2005;80:892–898. 7. Larson EB, Yao X. Clinical empathy as emotional labor in the patient–physician relationship. J Am Med Assoc. 2005;293: 1100–1106. 8. Holm U, Aspergren K. Pedagogical methods and affect tolerance in medical students. Med Educ. 1999;33:14–18. 9. Chen PW. Medical student distress and the risk of doctor suicide. N Y Times 2010. 10. Dyrbye LN, et al. Factors associated with the resilience to and recovery from
Innovations in Integrative Healthcare Education
11.
12.
13.
14. 15. 16.
17.
18.
burnout: a prospective, multi-institutional study of US medical students. Med Educ 2010. Dyrbye LN, et al. Relationship between burnout and professional conduct and attitudes among US medical students. J Am Med Assoc 2010. Thomas MR, et al. How do distress and well-being related to medical student empathy? J Gen Intern Med 2007. Shapiro J. Does medical education promote professional alexithymia? A call for attending to the emotions of patients and self in medical training Acad Med. 2011;86:326–332. http://www.utmb.edu/pedi_ed/PHT/ default.asp. http://www.utmb.edu/oce/Tracks.htm/. http://www.self-compassion.org/tes t-your-self-compassion-level.html http://www.enneagraminstitute.com/. http://www.ted.com/talks/abraham_ver ghese_a_doctor_s_touch.html http:// www.ted.com/talks/brene_brown_on_ vulnerability.html. http://www.amazon.com/s/ ref=nb_sb_noss?url=search-alias% 3Daps&field-keywords=shameless% 20guide%20to%20happiness.
19. MacGregor B. In: Awe of Being Human— A Doctor's Stories From the Edge of Life and Death. Greenbank, WA: Abiding Nowhere Press; 2013.
Cara Geary, MD, PhD, is an Associate Professor of Pediatrics in the Division of Neonatology at the University of Texas Medical Branch in Galveston, Texas. Julie McKee, MD, is a Family Medicine Physician in University of Texas Medical Branch's Department of Family Medicine.
Victor S. Sierpina, MD, is the W.D. and Laura Nell Nicholson Professor of Integrative Medicine, Professor Family Medicine, Director of Medical Student Education, at the University of Texas Medical Branch in Galveston, Texas. He is an associate editor for EXPLORE. Mary Jo Kreitzer, PhD, RN, is the founder and director the Center for Spirituality and Healing and a professor in the School of Nursing at the University of Minnesota, Minneapolis, Minnesota.
Catalina Triana, MD, is a Family Medicine Physician in University of Texas Medical Branch's Department of Family Medicine. Era Buck, PhD, is faculty at the University of Texas Medical Branch in Galveston, Texas. Scott Walton, BS, and David Valdez, BS, are second-year medical students at the University of Texas Medical Branch in Galveston, Texas.
Innovations in Integrative Healthcare Education
EXPLORE May/June 2014, Vol. 10, No. 3 205
