Credibility and (Dis)Use of Feedback to Inform Teaching : A Qualitative Case Study of Physician-Faculty Perspectives

Tara F. Carr, MD

Guadalupe F. Martinez, PhD

Division of Pulmonary/Critical Care, Sleep and Adult Allergy

Departments of Medicine and Otolaryngology

University of Arizona College of Medicine

Tucson, AZ

Abstract

Evaluation plays a central role in teaching in that physician-faculty theoretically use evaluations from clinical learners to inform their teaching. Knowledge about how physician-faculty access and internalize feedback from learners is sparse and concerning given its importance in medical training. This study aims to broaden our understanding. Using multiple data sources, this cross-sectional qualitative case study conducted in Spring of 2014 explored the internalization of learner feedback among physician-faculty teaching medical students, residents and fellows at a southwest academic medical center. Twelve one-on-one interviews were triangulated with observation notes and a national survey. Thematic and document analysis was conducted. Results revealed that the majority accessed and reviewed evaluations about their teaching. Most admitted not using learner feedback to inform teaching while a quarter did use them. Factors influencing participants use or disuse of learner feedback were the a) reporting metrics and mechanisms, and b) physician-faculty perception of learner credibility. Physician-faculty did not regard learners’ ability to assess and recognize effective teaching skills highly. To refine feedback for one-on-one teaching in the clinical setting, recommendations by study participants include: a) redesigning of evaluation reporting metrics and narrative sections, and b) feedback rubric training for learners.

Introduction

Teaching is at the heart of academic medicine. Evaluation plays a central role in teaching in that clinical teachers, theoretically use evaluations from learners to inform their teaching (1,2) Feedback has been identified as a critical component of evaluation, and by extension, medical education training (3-6). National accreditation agencies emphasize the need for the ongoing meaningful exchange of feedback between learners and physician-faculty (7,8)

The learner perspective has dominated feedback research (9-14). These studies examine how physician-faculty deliver feedback, and how learners absorb the content and delivery of feedback. Physician-faculty also assume the role of learner when medical students and trainees serve as evaluators and provide feedback about physician-faculty teaching. In response, physician-faculty develop perceptions about the quality and context of feedback from learners that shape their receptiveness of that feedback, and teacher self-efficacy (15-18). Yet, only four studies consider context and explore factors that influence feedback receptiveness of physician-faculty (15, 19-21).   Only one study examines how physician-faculty respond to learner feedback to make adjustments to their teaching (15). Previous studies have also uncovered the important idea of “source credibility." (11,14,20,22).  They find that the impetus for both effective learning and teaching adjustment comes from the feedback recipient’s trust in the evaluators’ credibility. A limitation of these studies is the lack of attention to the feedback reporting mechanisms used by their institutions, leaner-teacher contact time, the establishment of relationships, and the various factors that go into trusting or valuing learner feedback. These perceptions play an essential role in how we understand educational exchanges between teacher and learner. As such, the purpose of this study is to recognize physician-faculty perceptions about the feedback process in relationship to their teaching practice.

Knowledge about how physician-faculty access and internalize feedback from learners is sparse (22), much less faculty recommendations for improving the process. This is concerning given the important role feedback plays in clinical training. This study aims at broadening the understanding of how physician-faculty access and internalize written feedback from learners while considering contextual factors that shape the overall feedback experience for physician-faculty. We qualitatively examine if and how learner feedback influences physician-faculty receptivity and incorporation of feedback critiques into their teaching practice. In supporting inquiries, we ask: To what extent do physician-faculty access and use feedback and why (or why not)? What factors shape their decisions to incorporate (or not incorporate) learner feedback into their teaching practice?

Methods

Exempt from human research approval by the site’s Institutional Review Board, this cross-sectional case study explored feedback internalization among medicine physician-faculty at a southwest academic medical center (23). The ethical conduct to maintain anonymity and inhibit coercion was exercised and articulated to participants. Participation was voluntary and without monetary compensation.

Case study research in the social science calls for the use of multiple data sources to gain understanding of an issue using a bounded group (24,25). As such, three data sources were included in analysis and to triangulate findings. First, purposeful selection was used to identify physician-faculty whose lived experiences in the department would assist us in understand the issue (26). Physician-faculty were introduced to the study’s purpose at a routine faculty meeting where voluntary participation was elicited.

Twelve of 15 (80%) full-time medicine subspecialists participated. Sometimes mistaken as a limitation of qualitative case study design is the relative small sample size; our interview numbers not only meet the general qualitative research sample size criterion of five to 30 interviews (27-30) but focuses on obtaining information-richness in the form of quality, length and depth of interview data and supporting evidence from additional sources that answer the research question. (Table 1).

Table 1. Sample Demographics.

Original interview questions were created (Appendix A). Individual semi-structured open ended interviews were conducted during the Spring of 2014. Follow-up interviews on two participants were conducted in early February of 2015 once promoted from mid-level to full professor. The same interview protocol was used to capture changes in perspective from full professors in the effort to expand the insight pool of senior professors.

During the preceding three years, all physician-faculty in the department received e-feedback at the end of rotations from learners that includes evaluation of their individual teaching. E-feedback was designed by the college’s medical education program directors. Forms were 9-point Likert scale with an optional written comments section after each question. To gather information regarding the internalization of feedback, we asked physician-faculty to recollect past e-feedback through their tenure at the study site. Interview questions asked participants to describe their access to evaluations, and internalizations of feedback. Interviews lasted between 30-60 minutes, were audio recorded, and transcribed. Transcripts were de-identified, and demographic information reported was limited. Reporting of narratives was truncated to capture central points and stay within the word count limitation. Participants from outside institutions and departments were not included in this study as evaluation tools may include different reporting mechanisms. Additionally, we wanted to capture and understand the current subculture that exists regarding feedback and teaching that is particular to one local clinical department.

Secondary data were: observation notes, and annual ACGME trainee survey results. Observation notes were taken by the principal investigator to memorialize each interview exchange, physician-faculty education meetings (e.g. faculty meetings, clinical competency committee meetings), and clinic exchanges also during Spring of 2014 (31). Given that the principal investigator is also a physician-faculty member, an insider researcher approach (32) allows the design to include her notations as she is acutely attuned to the daily lived experiences of the participating physician-faculty. The advantage of implementing this approach is that the principal investigator understands the participants’ academic values, current work environment, insider language and cues for accurate and trustworthy behavioral notes. Observation notes were taken to document behavior at education meetings where program evaluation and physician-faculty development was discussed. Disadvantages of being an insider could lead to bias, assumptions about meanings, and overlooking of routine behaviors that could be important. A quasi-outside researcher and non-physician-faculty member in the department served as a collaborator to counter insider researcher assumptions and bias.

Physician-faculty interviewed also partook in the 2013-2014 annual ACGME anonymous online trainee survey in the Spring of 2014. Trainee ratings of physician-faculty commitment to GME programs, and perceived satisfaction the program’s perceived use of evaluations to improve rotations could further validate whether or not physician-faculty use evaluations to inform their teaching. (Appendix B).

Data were analyzed using qualitative software, QSR Nvivo10©. Using a holistic and cross-case analysis approach (25), thematic coding was used to identify patterns in access to feedback, and receptiveness on interview data and observation notes. Axial coding was then used to hone in on specific challenges/strengths in feedback from learners. Once identified, selective coding was conducted to detect themes and redundant assertions so as to ensure that no new information was emerging. Last, document analysis of the ACGME survey results was conducted. Implementing the In-between-triangulation method (33), codes from observation notes and the ACGME survey results were linked through memos to interview data. Member checking between the principal investigator and co-investigator regarding themes, terms, and categorizations occurred to ensure data trustworthiness as defined by Guba (34) (Appendix C).

Results

Access, review, and (dis)use

A significant proportion of physician-faculty accessed and reviewed feedback about them when available (10/12: 83%). The majority of physician-faculty revealed that they do not use learner feedback to make adjustments to their teaching (9/12; 75%). One physician-faculty member summarized the group’s sentiments and disclosed, 

“Not at all. The verbal feedback from my colleagues and boss makes me more cognizant of my behavior and I modify it appropriately; whether it was a success, I’ll let them judge. The written eval[uation]s from [learners] has never changed [my teaching] because they go from horrible to great and they are not useful.”-S11

Only a quarter, all of whom were junior faculty, reported utilizing learner feedback to alter teaching (3/12; 25%). Evidence that the majority of physician-faculty may not be using learner feedback to adjust teaching is broadly, but further corroborated by the ACGME survey data. Although 100% of trainees in this GME program reported having the opportunity to evaluate physician-faculty, less than 70% (which was very close to the national average) reported satisfaction with the program and physician-faculty using learner evaluations to improve. Despite this rating, these learners also reported that physician-faculty were interested in the educational program, and created an environment of inquiry at the rate of 100% (Appendix B). Furthermore, from observation notes taken during daily clinical discussions, it was noted that physician-faculty did not discuss their weaknesses with each other; especially regarding their teaching skills. Finally, when conversations regarding national conferences arose in physician-faculty education meetings or informal social settings, physician-faculty did not dialogue about attending conferences for the specific reason of improving or learning new teaching skills.

Factors influencing (dis)use

Physician-faculty identified several factors shaping their decisions to incorporate learner feedback into their teaching. To begin, just over half (7/12; 58%) reported that the metric used was problematic. When asked what they found valuable or disposable in reporting mechanisms, physician-faculty attested: 

 “A one-to-one evaluation rather than [the software we use] would be more valuable because…the numerical feedback is not very good. They need directed questions. There are non-substantive comments.” - S11

 “The numbers are worthless. I’d rather get comments that say,’ the bedside teaching was excellent, but he should work on his didactic session and change the graphics on that PowerPoint,’ but I never get that.” - S04

Second, differences in the perception of the learners emerged. Observation notes documenting contact time, relationship establishment and perspectives on fellows, specifically, revealed that physician-faculty tended to label learners in “good/bad” categories based on a combination of professional conduct, and medical knowledge base. “Good fellows” were the desired learner in the clinical setting. These learners were discussed and seen frequently in the company of physician-faculty at grand rounds, academic half days and departmental social gatherings. From observation, five physician-faculty had a following of learners who were similar to them in personality traits, interests or career aspirations. These physician-faculty and learners had a relationship, and it was evident at both social and academic gatherings as evident by the quality, duration and topic of verbal engagement, and physical proximity. Not all physician-faculty observed had this type of following and engagement.

Expanding on the observation of categorization and relationship establishment, physician-faculty reflected on their overall experience with learners and reported a general concern with the learners serving as evaluators. As a result, they cited this as a major reason for the disuse of feedback to inform their teaching (9/12; 75%). Concerns were grounded in the context of a) inadequate contact time, b) learners’ teaching fund of knowledge, and c) feedback being foregrounded in whether or not the learner takes a personal liking to the attending. When asked what their visceral reaction was to learner feedback, physician-faculty stated,

“I think you should limit it to somebody who has prolonged exposure to you. Most [learners] are only exposed to you for a few days…I think it’s more about the person doing the eval[uation] than the faculty member’s teaching ability. So I don’t hold learner feedback in high regard.” - S07

“I don’t think they know what a good teacher is….most [learners] just anchor their eval[uation] based on whether they like someone or not, so there’s not a rigorous evaluation of teaching methods.”- S04

These issues relate to physician-faculty skepticism about learners’ abilities to assess the teaching skills of their attending. There was a perception that learners were either: a) not knowledgeable about teaching methods and feedback, or b) scared to give honest feedback to physician-faculty because of the fear of retaliation. Nearly all physician-faculty reporting concerns with learner feedback knowledge recommended they receive a rubric as a tool to not only guide their feedback, but educate them about the evaluation process, and help identify “teaching moments” (7/9; 78%). Physician-faculty remarked,

“They might not know when the teaching is happening… I don’t think they know how that works and what that standard is... they don’t notice it…a lot of the teaching can be seen as unconventional. A rubric for them might be helpful…they need to be educated on evaluation.“- S10

Conversely, only two physician-faculty reported using learner feedback to adjust their teaching (2/9; 22%). They noted,

“[Learners] have been exposed to a lot of teaching and have a sense of what is effective and works for them. So part of our job is to be an effective teacher for different learners so if we’re not an effective teacher for certain learners we need to know about that…in a sense everyone is qualified… It doesn’t mean that one person who says you are not an effective educator is correct. We can’t please everyone, but we can work towards it.”- S11

 “…I try to establish relationships with the residents and fellows, and unfortunately or fortunately, it is easier for me to talk to them that way.”- S01

Learners’ experiences with numerous teachers and styles throughout their physician training were valued by the latter example. They perceived that learners had enough knowledge and experience to provide valid and competent feedback. Additionally, they saw it as their responsibility to adjust teachings and approach the teacher-learner construct as a bidirectional relationship. This is consistent with teacher-learner relationships noted in the observation settings.

Discussion

The implications surrounding learner feedback and how physician-faculty internalize and use feedback to inform their teaching practices are substantial. In sum, physician-faculty in our study did not hold learner feedback in high regard. Extending the work identifying the issue of “source credibility” in feedback (3,11,14,20,22), a key finding that adds dimension to this concept is that physician-faculty in our study use learner feedback to adjust teaching practices based on the specific value they placed on learners’ past education experiences and competency regarding teaching skills and assessment. Results suggested that source credibility is further shaped by communication and existence of a relationship between the two parties given that study participants discussed viewing the dyad as “relationship”. Supporting a recent framework, “educational alliance” introduced by Telio and colleagues (3), this idea of a relationship implies an investment, and value in each other’s roles and contributions. The quality of the relationship and communication matters as it appears to play a role in the development of physician-faculty perceptions about their learner and by extension, receptiveness to learner feedback. If such an alliance is developed, physician-faculty could then draw more informed conclusions about learner credibility that could subsequently shape their use of learner feedback. When considering the context of resident and fellow learners, this underscores the importance of national Resident-as -Teachers programs as the intent of these programs is to build a teaching fund of knowledge for trainees. Research examining their effectiveness from the perspective of seasoned physician-faculty is needed. Additionally, future studies assessing correlations between faculty who place high value on learner feedback and credibility with increased recognition as effective teachers would greatly add to our understanding of this complex issue.

Findings also highlighted the importance of appropriate feedback metrics and mechanisms. Physician-faculty reported dissatisfaction with the metrics of the institution’s online evaluation system, and their corresponding narrative sections. They recommended rubric training for the learners to refine feedback for one-on-one teaching. Looking to our results, we support and propose a feedback rubric that is deployed via a purposeful training. To set the stage for feedback to occur as a process, rubric training could require learners to undergo brief training at their respective orientations on both the use of the rubric and importance of quality narrative feedback for program improvement and physician-faculty development. Rubric for each metric that incorporates rich descriptions could scaffold and improve the critical thinking process involved in writing constructive feedback narratives for learners. Moreover, comment boxes on evaluation reporting mechanisms with either prompts or ideal substantive comment examples could help learners’ better articulate meaningful feedback for physician-faculty and make connections with rubric scoring guides. This approach forces a reconceptualization of the role of learner feedback that is different. With the training and implementation of feedback rubric for learners, this places them in the role of teacher and expert evaluator. This alters the traditional paradigm and forces physician-faculty to expect more of learners and facilitates a system to further train learners in teaching and evaluation skills.

Finally, rubrics could include moderate tailoring to address abbreviated contact time, ensure anonymity, and review institutional safeguards against physician-faculty retaliation against the learner. A limitation of current feedback frameworks (3) is the lack of attention to how limited duration of contact time, and desire for anonymity, could impact quality communication and the establishment of a relationship. Consequently, physician-faculty being evaluated should undergo parallel training to understand context in which learners have been instructed to reflect and formatively evaluate their teaching practices given a varied set of learning/teaching conditions that consider the aforementioned obstacles. We encourage the development and testing of such tools as a next step.

Limitations

A limitation of our study is the restriction to one department and over-representation of junior faculty. Physician-faculty were not asked to disaggregate feedback by the type of learner. Differences between physician-faculty perceptions of medical students versus residents versus fellows may have emerged. Despite these limitations, findings provide critical insight into what gives rise to the receptiveness of learner feedback while providing an honest report on why physician-faculty use or disuse evaluations to inform their teaching.  

Conclusion

Our study evaluates the value physician-faculty place on individual learner feedback about their teaching in the clinical setting. Despite the centrality of feedback in medical education training, physician-faculty predominantly accessed, reviewed, but disused feedback from learners to inform their teaching. This is due to the reporting mechanisms and concern over credibility of the learner; specifically, their ability to assess and recognize effective teaching skills. The introduction of feedback rubric training for learners could advance learning and contribute to sound evaluation as they are important sources of information for identifying and improving teaching and evaluation skills.³⁵ Physician-faculty need to be able to trust and value the feedback they receive. Credible feedback shapes the decisions they make when selecting appropriate professional development opportunities, thus, shaping the quality of our medical training programs.

Acknowledgements

We would like to thank Karen Spear Ellinwood, PhD, JD and Gail T. Pritchard, PhD for the Academy of Medical Education Scholars (AMES) Teaching Scholars Program for providing a platform from which to design and conduct the study. We also wish to thank the faculty members who participated in this study, for their time and candor.

Declaration of Interest

No declarations of interest.

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Reference as: Carr TF, Martinez GF. Credibility and (dis)use of feedback to inform teaching : a qualitative case study of physician-faculty perspectives. Southwest J Pulm Crit Care. 2015;10(6):352-64. doi: http://dx.doi.org/10.13175/swjpcc076-15 PDF

Professionalism: Capacity, Empathy, Humility and Overall Attitude

Robert A. Raschke, MD

Banner Good Samaritan Medical Center

Phoenix, AZ

Recall we have previously defined professionalism and agreed on our primary goal as physicians, and reviewed competing goals that sometimes threaten to distract us. Recall that the Oath of Maimonides brought to mind a few attributes of the good physician that we discuss next. This list is not complete, but a good start. (If you think of others, please comment – I am trying to learn this topic myself in more depth, and would appreciate your thoughts).

Capacity

You have to be cognitively, psychologically and physically healthy to do your best work, but we all have natural tendencies that might need to be overcome in order to optimize our capacity. For instance, I am fundamentally very lazy intellectually (and otherwise). I found I had trouble keeping current with medical literature once I finished fellowship training and went into practice, since I no longer had to worry about being periodically formally tested. But my career choice in medical education helped counteract my laziness. I started a monthly Critical Care journal club within our fellowship, which conveniently fulfills my job duties, but has the personal benefit of forcing me to keep up to date, practice formal rules of critical appraisal, and come to firm conclusions about whether and how each article should impact my patient care. I strongly recommend considering a career in a teaching program as an aspect of your personal professionalism. I’m not implying that doctors in non-teaching positions can’t be highly professional – this clearly isn’t true. But a teaching job emphasizes maintenance of your cognitive capacity and other aspects of professionalism as specific job duties, and protects time for you to work on them.

Teaching also multiplies our ability to bring wellbeing to our patients, through the professional actions of those who have learned from us. I seldom thought about this until just recently – but now it strikes me that we might do more good through the hands of our pupils than through our own.

I have had an interest in hemophagocytic lymphohistiocytosis for about 15 years, and have been made fun-of over the years by some of my partners because of my Don Quixote-like pursuit of that esoteric diagnosis. Persistence paid off though, and I was partially vindicated when I was able to publish a paper describing our experience with HLH in the adult ICU. I also presented our findings in relation to HLH many times to our residents in morning report and Grand rounds.

About a year ago, I received a phone call from one of our graduate residents, who had gone on to open practice in Flagstaff AZ – about a 2-hour car ride north of Phoenix. He was cross-covering a hospital service, and had picked up the care of a hospitalized 21-year old girl with fever of unknown origin, that reminded him of a patient with HLH that I had previously presented in morning report. He correctly diagnosed her with HLH, and was calling to arrange transfer down to Phoenix so that we could take her treatment forward. None of his partners had ever heard of HLH before and therefore had no chance of diagnosing it, and the patient having developed shock and multisystem organ failure would almost certainly have died without specific therapy. After a prolonged ICU stay she survived. Eventually she rehabilitated and returned to finish her college education at Northern Arizona University. My academic interest in HLH, and my role in teaching residents about it, had amplified my professional capacity in a way that I hadn’t expected.  

Happiness in your personal life will reflect on your professional capacity. This can be a very difficult balance, but your job as a physician should not endanger your primary personal relationships. If it does, you might want to look for a different practice, or different specialty within medicine. Enlist your spouse or partner in your work struggles. My wife (of 30 years) Carolyn has been a wonderful blessing to me in this regard. Carolyn is a teacher, but she knows a lot of medicine. She learned it by listening to me vent my work-related frustrations over the past many years. I sometimes bounce cases off her just to ask her what she thinks, having found that her intelligence and keen deductive powers often lead her to the proper course of action, even if she doesn’t know right medical semantics. At times, I feel like I can withstand almost anything that happens in the ICU because I know that Carolyn will be waiting to give me a hug when I get home. Do not sacrifice this blessing for your job, instead make it part of why you are a good doctor.

Physical health will also reflect on your professional capacity. Exercise regularly. Your routine workload ought not to prevent you from working out. If it does, I would recommend you figure out a way to remedy that, because you and your patients will ultimately suffer if your work hours are unhealthy for you. But I think this is rarely the case if you nurture good personal exercise habits. Figure out the physical activities that you enjoy, and make time for them. You ought to be able to get some exercise even during your busiest work weeks. Even a 15-minute work out is better than none at all, especially if you make it habitual over the long course of your life. Whether you enjoy walking your dog, running, yoga, weight-lifting or kayaking, your capacity to do good word will benefit from regular physical activity outside the hospital.

One last thought about capacity: Don’t take a job that would exceed anybody’s capacity to provide good care. I have seen hospitalists with a work list of 40-50 patients for their weekend rounds. No matter how efficient you are, no one can reliably do a good job with that magnitude of workload. As professionals we should set limits on how far we let business people direct our practice of medicine. 

Empathy

I once overheard an intern handing off the care of a patient to another intern, mention that he had ordered the nurse to “throw a Foley in” the patient. I may have been unfair in my quick judgment of the intern’s apparent lack of empathy, but the way he made this statement struck me as nonchalant, with an attitude that the insertion of a Foley catheter was of little consequence one way or another. I had not experienced having a Foley myself at that tender point in my life, but it did strike me that I wouldn’t want one unless absolutely necessary (in fact, it gave me the heeby-geebies just thinking about it).  I have wondered if we should all have to have IVs and Foley’s put in us during medical school, just to help us understand that procedures that seem trivial to doctors can be very stressful to a patient, and should not be undertaken without careful deliberation.

Many physicians relate experiences of personal illnesses to the growth of their own empathy towards their patients. I’ve noticed that as I get older, more and more of my patients are about the same age as my children. It helps me to see my son or daughter in these young patient’s eyes, and helps me appreciate how scared they might be.  But we can’t wait to have children, or to get sick in order to develop empathy. The best I have been able to do is to actively seek empathy at the bedside of my patients. The more you know about your patient, the more likely you are to feel it.  If you don’t particularly feel it, you can at least practice the actions of empathy.  It’s difficult to imagine a physician without empathy attending properly to all aspects of the pain and suffering of their patients.

Depending where you work, the proportion of patients who end up in the unit because of self-destructive behavior can sometimes get overwhelming. There are times when I have estimated that fully two-thirds of the patients on my service were there because of alcohol and drug abuse. It can be challenging to empathize with patients who are morbidly obese, or who are narcotic-seeking.  We have recently seen epidemic proportions of both in our unit. Recently, I was asked to consult on a 45-year-old woman with cellulitis. She had ceased walking 18 months ago because of progressive morbid obesity. She had severe emphysema related to a long history of smoking, and severe obstructive sleep apnea, but refused to use oxygen and BiPAP breathing-assist device that were prescribed by her physician. She had several doubtful unconfirmed diagnoses such as fibromyalgia for which she was addicted to narcotics. The reason I was consulted is that she was having progressive difficulty breathing. But the cause of this seemed pretty obvious to me – she had smoked 3 packs a day for 25 years, and she weighed almost 450 lbs. She was so fat it was amazing she could breathe at all.

She was at rest as I entered her room, but when she awoke to my presence, she suddenly appeared in painful distress. It looked to me like she was faking it. I couldn't get her to give me any useful history. All she wanted to talk about was how much pain she was in - when was her next dose of narcotics due? On examination, she was extremely poorly-kept, smelled bad, and had an abdominal pannus that literally hung down to her knees even while she was laying flat on he back. The chaffed skin underneath was where her cellulitis had blossomed. I have to say in all truthfulness that I was disgusted by her physical appearance, and I judged that her illness was 100% self-inflicted.

I think she might have sensed my unkind thoughts, because I could tell she didn’t like me much. She became very upset with my decision to withhold additional narcotics because they might worsen her breathing. I was relieved when I left her room, but we were clearly adversaries.

Before I came back to see her the next day, I thought about Maimonides prayer – “May I never see in the patient anything but a fellow creature in pain”.  How could I bring myself to sincerely look at this lady as a fellow human being in pain when I had such a judgmental attitude about her? I pondered this as I entered her room to look in on her.  I noted that she had required intubation overnight as I expected she might, but she was not heavily sedated, - in fact, she was actually more alert than she had been on the previous day. Although awake, she couldn’t speak because of the endotracheal tube – this was probably helpful, because it prevented her from riling me by asking for more narcotics. No one else was in the room.

I didn’t have a good plan for how to proceed, but I knew I wanted to make an effort to nurture some empathy for her. Without thinking too much about what I was doing, I took her hand and told her that I knew that everything that had been happening to her over the past few years had been very tough for her, and that I knew she was suffering. I said that she had a tough road ahead as well, but that we had some ideas that could help her (tracheostomy), and that I was going to do my best to get her better so that she could return home as soon as possible. I could feel these words become sincere as I said them. At one point I referred to her as “sister” – not as slang term - but as a way to express to her that I cared about her as a person. This wasn’t a technique – it came out of my mouth in response to kind feelings that I was beginning to have towards her. She listened attentively, and her eyes even got teary. When I was done, she wouldn’t let go of my hand for awhile. I didn’t know what else to say, so I just stood there holding her hand until it seemed like it would be OK to let go.

Another patient who taught me about empathy was a Native American woman who was admitted for an infected stage IV sacral decubitus ulcer. She was in her early-sixties, but she was a wreck. She had a history of noncompliance and had suffered severe sequelae of diabetes, with advanced ischemic heart disease, dialysis-requiring renal failure, blindness, and bilateral above-knee amputations. I remember that when I first heard about her, a very unkind thought entered my mind. Before I ever even met her, I questioned whether it was worth to exert the effort to get her over her acute illness. Her body was so ravaged that I felt that her life wasn’t worth the extensive effort it was going to take to prolong it.

I realized this was a very bad way to think of a patient, so when I met her, I asked her some questions unrelated to her medical history, for the sole purpose of learning more about her – in a search for empathy – in an attempt to understand the value of her life. I asked about her kids, and she told me a story about her youngest son that stuck in my mind. She said she was driving with her husband down a lonely unpaved road on the Indian reservation one day, about ten years previously, when they saw a boy about 12 years old walking off on the dusty shoulder ahead of them – miles from the closest building. She said she knew that boy – had seen him wandering around the reservation - knew he didn’t have parents that cared about him. She said “I wanted that boy”. She told her husband to pull over. Simple as that. The boy got in the car and went home with them.  She raised him as though he was her own son without ever officially adopting him as far as I could tell. He had grown up to be a fine man, and became a teacher. She told me that she had 8 children. Four by birth and four by “adoption”. All of her adult children worked serving others –as teachers, nurses, one as a physical therapist. This information vastly corrected my deficient empathy in the care of this patient. Most patients can provide you with something you can use to connect with them if you seek it out.

I have prejudices that I will probably never overcome. The only advice I can give is to be aware of your prejudices and do your best to find some way to love each of your patients.  You cannot be a good doctor for your patients unless you care about them and are committed to helping reduce their suffering, whether their illness is their fault or not.

Humility

Humility is a characteristic that hangs in the balance with our pride, waxing and waning over the course of our career. We all try to achieve the self-confidence we need to make big decisions under stress, but maintain the humility to recognize and correct our mistakes and accept the help of others. I learned an important lesson about my own pride and lack of humility by observing pride get the best of one of mentors.

When I was a resident in the ICU in the mid 1980s, I was on call under the supervision of my mentor and hero who had been an attending for about 3 years at that time. We got called to the bedside of a patient on mechanical ventilation who was suffering acute shock. We both stood by the bedside trying to figure out what was going on as the nurses got IV fluids and pressors started. The patient continued to deteriorate, and my attending called for a chest X-ray to rule out pneumothorax. As we waited for the radiology tech to arrive, the patient rapidly deteriorated. I suggested that we put a chest tube in without waiting for the x-ray, but my attending said no – we should wait. We waited. The patient continued in a downhill spiral, and coded about 10 minutes later, just after the X-ray finally was taken. He did not survive the code. The CXR showed a pneumothorax.

I don’t know what thoughts are in other’s minds, and I sometimes unfairly project my own tendencies onto others.  But I have interpreted this experience based on my own struggle with pride. I have an immediate tendency to say “No” to any suggestion made by an intern or resident in regards to patient care. I think this tendency comes from an unhealthy pride and desire to always be the one to come up with the smart idea. It’s a little bit humiliating as an attending to have someone in training beat you to the punch. It typically goes like this: intern makes reasonable suggestion; 2) I reject it and verbalize every reason I can think of why it’s a bad idea, (as though I had already considered and discounted it); 3) then I walk off by myself, realize the idea was a good one, and figure out a way to implement it without losing too much face. This last part is usually easier than I think it’s going to be, since the environment in which I work is mostly about doing the right thing for the patient rather than who gets credit. Even though this whole process probably seems ridiculous, it has helped me take advantage of the good advice of others many times over the years.  

The nurses have been a HUGE source of good decision-support for me. But their good advice can only be effectively sought and put to advantage with the proper humility. I once witnessed two attending physicians enter a patient’s room, one right after the other. The first was called to the bedside by a veteran ICU nurse with 25 years of experience because she felt the patient “just didn’t look right”. Objectively though, nothing much seemed to be going on – the patient’s vitals hadn’t changed much, and his morning labs and CXR looked OK. The first attending, a pulmonary critical care specialist, pointed this out, and left the patient’s bedside just as the second attending arrived. Although the second physician shared uncertainty about what was going on, they felt uneasy about leaving the bedside when the nurse felt something bad was brewing. They examined the patient carefully, noting that the legs had mottled. The second physician reordered labs and the CXR, which revealed a tension pneumothorax.  A chest tube was placed, and the patient recovered. Over the years, the nurses have covered for my shortcomings and given me invaluable advice many times. I have also probably missed many opportunities in situations in which nurses didn’t think I would listen to them, and therefore kept their good ideas to themselves. I try to teach my fellows that one of the most important parts of being a good ICU doctor is to treat the nurses with respect and get them in the habit of expressing their opinion by asking for it often. Doesn’t mean you always have to take their advice, but it’s a serious handicap to not at least hear it.  

Overall Attitude

Probably the most important aspect of professionalism is the attitude you take to the patient’s bedside. If you're in Critical Care, or in almost any other field of Medicine, you have potentially the most privileged and fulfilling professions in the world. The most frustrating, user-unfriendly EMR in the world doesn’t change that. So don’t let anyone tell you otherwise. Patients, families, nurses in the hospital want to be able to look up to you. They want you to be the one who can make things better. Can you think of any other profession with more chances to be an angel to someone who is facing one of the toughest days in their lives?

The care you give a patient or their family are likely to be remembered by them for a long time to come. You have incredible leverage to benefit them and a unique opportunity to have a lasting positive effect on their lives. Whether you treat them well or poorly may affect them profoundly, maybe for the rest of their life. I don’t think it’s going too far to think that it even may affect how they treat others, because when people perceive the world as a kind place, it often becomes easier for them to act in kindness to others.

This is the attitude I think we should bring to each workday. 

In any situation that we are faced with, there is good that can be done.

Our job is to find it, and make it happen.

Recently, I’ve seen doctors do a number of things that “weren’t in their job description” – these are the things patients and their families will remember long after they’ve forgotten strictly “medical” aspects of their care. One of my partners took a patient on life support out of the hospital into our lobby courtyard at night to see the stars. Another invited a recovered patient to come with her and give a talk about the importance of nurses to her son’s third grade class. One physician arranged to have a dying patient’s dog snuck-in for a visit, obviously against hospital rules. Another went out to a camper in our parking lot, in which one of our patients wife and daughter were staying, to fix a plumbing leak. Consider yourself as the good guy or gal – this will enrich everyone’s life, starting with your own. One of my mentors keeps a picture of batman in his office to remind him of this.

One more memory about attitude:

Five years ago, I received a call from our transfer coordinator.  I was being asked to assume the care of a patient in transfer who was in a very dismal situation. She was 36 years old, married, the mother of four boys. She was pregnant with a 22-week baby - too young to survive birth. She had recurrent breast cancer with metastases to her lungs and brain. She had lapsed into a coma and was intubated on mechanical ventilation, as edema around her brain tumor increased. 

I covered my face in my hands as I took in this information, and I remember thinking how much I hated certain aspects of my job. There didn't seem to be any reasonable chance for this transfer to turn out anyway but terrible. I resented being put in the position in which I would have to shoulder the emotional burden of bringing her family through their bereavement. If the patient’s family had known what was on my mind, there’s no way they would have allowed me to take care of her.

I went through the motions when the patient arrived, gleaned some more history. Her name was Samantha. Her cancer had recurred at 10 weeks pregnancy. Her oncologist had offered her chemotherapy and hormonal therapy, but warned her that these treatments were risky for the baby. Samantha decided to sacrifice her own treatment for the welfare of her baby. She had been hoping for a girl.

On the fifth hospital day Samantha suffered brain death secondary to cerebral edema, related to her brain metastasis. Her baby was only 23 weeks old – a gestational age with only a 40% survival rate. After consultation with her husband, we carried forth a plan to keep Veronica’s heart beating as long as possible, until her baby could mature enough to survive. Over the next 7 weeks, we maintained Samantha’s blood pressure, gas exchange and temperature. We replaced hormones made by the hypothalamus of the brain and pituitary gland. Fifty days after her mother Samantha's death, healthy baby Samantha was born.

I feel rotten about my initial bad attitude looking back over this case – which turned out to be one of the most fulfilling of my career. That’s one of the great things about critical care. Sometimes the most discouraging beginnings can entail unforeseen potential for you to accomplish good as a physician.  When you have experiences such as this, hang on to the memories (this is one of my selfish reasons for writing this series). Remembering miracles that you are witness to will help you fight discouragement which is the enemy of the proper professional attitude as an intensivist.

Reference as: Raschke RA. Professionalism: capacity, empathy, humility and overall attitude. Southwest J Pulm Crit Care. 2014;9(2):104-14. doi: http://dx.doi.org/10.13175/swjpcc105-14 PDF