Reflective Practice and Leadership in Primary Care Pediatrics: Using CME to Advance Practitioners and Educators Skills
Jan E. Drutz, M.D., Marc Horowitz, M.D. & Ernest Frugé, Ph.D.
Department of Pediatrics, Baylor College of Medicine, Houston, Texas
Introduction
Optimal communication between physicians and patients and, when applicable, members of the patient’s family, is considered by most individuals to represent the ideal professional medical relationship. The expectation of patients and families is that physicians will function in a leadership role.
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Fig. 1. ACGME Core Competencies |
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Acknowledging that specific competency deficiencies have been lacking in the education and training of medical students and postgraduate residency trainees, the Accreditation Council for Graduate Medical Education (ACGME) in recent years has mandated the inclusion of certain core competencies in graduate and postgraduate training (see figure 1). Leading patients and families through difficult circumstances (e.g., delivering “bad news”) is clearly an important aspect of interpersonal and communication skills1 but the perspective and preparation of pediatricians for this aspect of the role has not been well documented.
Statement of the problem and program objectives
Surveys of physicians indicate that delivering bad news is important, yet difficult and frequently stressful. In general, they feel unprepared for this aspect of patient care.2,3 It is not clear what seasoned pediatricians need to know in the area of breaking bad news or what educational strategies are suitable to remedy educational deficits in this area.
• Objective #1: Needs assessment survey of seasoned pediatricians.
• Objective #2: Assess the employment of a reflective practice method in a CME learning experience.
• Objective #3: Extend this method of reflective practice into the role of the clinician as a student and resident educator.
Description of the projects
Project 1 Design: Survey of Seasoned Pediatricians
An 8-item survey on crucial circumstances and aspects of delivering bad news was developed from a combination of literature reviews and focus groups consisting of pediatricians in either academic or community settings. A large convenience sample of experienced community and academic pediatricians used a Likert-type scale to rate the importance of various circumstances and aspects of delivering bad news in their practice experience. In addition, they were asked to rate how adequately their formal medical education had prepared them for this role.
Project 1 Findings:
96 pediatricians attending a Continuing Medical Education (CME) course and 86 pediatricians attending a national academic society meeting completed the survey (See Figure 2). Overall, the group averaged ~15 years postgraduate training. Slightly more than 50% of those attending the CME meeting functioned in a preceptor role, training students, residents or fellows. All those in the academic group identified themselves as “trainers”.
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Fig. 2. Demographics of Sample |
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Baylor Pediatric Postgraduate Symposium 2002 Pediatricians - 86 Average Time in Practice – 16 Years (SD=11) Percentage “Trainer” - 58% Pediatric Academic Societies Meeting 2002 Pediatricians - 96 Average Time in Practice – 14 Years (SD=8) Percentage “Trainer” - 100%
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Results of this survey (Table 1) clearly indicate that seasoned pediatricians, whether in the community or academic setting, think that these circumstances and aspects of delivering bad news are important components of the pediatrician’s role. Results also suggest that pediatricians in general do not think their training has adequately prepared them for this aspect of their professional role.
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Not
Very Very |
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Survey Items |
Average Importance |
Average Preparation |
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Delivering bad news to a parent concerning the sudden/unexpected death of his or her child. |
4.35 sd=.85 |
2.26 sd=1.15
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… to a parent concerning the impending death of his or her child. |
4.41 sd=.82 |
2.39 sd=1.22 |
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… to a child concerning his or her own impending death. |
4.35 sd=.80 |
1.80* sd=1.00 |
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… to a parent or child concerning a severely disabling condition. |
4.59* sd=.67 |
2.37 sd=1.17 |
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… to a parent or child concerning potentially poor treatment outcomes or medical errors. |
4.38 sd=.73 |
2.07 sd=1.08 |
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Conducting a family conference regarding end-of-life decisions (e.g., DNR status, advance directives, withdrawal of life support). |
4.27 sd=.95 |
2.40 sd=1.24 |
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Responding to negative emotions (e.g., hostility) of parents and children to bad news. |
4.40 sd=.69 |
2.15 sd=1.06 |
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Reflecting upon and managing the physician’s (your own) reactions to tragic events and understanding how these may influence role performance and satisfaction. |
4.36 sd=.79 |
1.95 sd=1.07 |
Project 2 Design: Reflective Practice Workshop on Delivering Bad News
Physicians are well trained in using scientific reasoning when formulating a diagnosis and treatment plan based on bio-medical data. They often fail, however, to apply this type of reasoning to other important domains – e.g., psychological, social and emotional factors – the interpersonal dimension. Making suitable adjustments for this type of thinking requires accurate assessment of both external factors (e.g., addressing the emotionally impaired parent in shock) and internal factors (e.g., personal concern regarding iatrogenic error). The more complex and ambiguous the situation, the more important a reflective stance becomes. A 1.5-hour CME workshop was designed for practicing community physicians employing facilitators and various case discussions in a choice of formats: role play of hypothetical cases, open discussion of hypothetical cases, or actual case situations described by individual workshop attendees. Data below represent a number of sample outcomes for physicians attending the workshop.
Project 2 Findings:
The following data (Table 2) represent pre- and post-workshop self-assessment scores for the 19 seasoned pediatricians in attendance. Significant improvements in self-reported knowledge were evident for all 7 types or facets of breaking bad news.
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Table 2: Pre-Post Outcome Measures (10 point scale of knowledge) |
Pre |
Post* |
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I am familiar with the basic principles of how to break bad news to patients, parents and relatives of patients. |
5.74 |
8.05 |
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I know how to break the news to a parent (who I do not know well) concerning the sudden/unexpected death of his or her child. |
5.11 |
7.26 |
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…to a parent (who I know well) that their child had died after years of struggling with a chronic illness. |
5.84 |
7.68 |
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…to a parent that there has been a medical error that has caused serious harm to their child. |
4.05 |
6.05 |
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…to respond to a parent who reacts in a very hostile fashion after receiving bad news concerning their child. |
5.58 |
6.00 |
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…to respond to a parent who is overwhelmed by emotion upon hearing bad news concerning their child. |
5.16 |
7.37 |
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I know the way my own emotional response can effect the way I deliver bad news and I know how to work with these emotions. |
5.63 |
7.26 |
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*t test, p<.00001 on all comparisons |
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Key lessons learned so far and next steps
Pediatricians have an opportunity to play a pivotal role in the health, development, and well-being of children. The vast majority of them, however, are ill-prepared to assume their role in leading patients and families through the most crucial circumstances – where health or life is threatened, permanently diminished or lost. It is our view that these situations are often complex, requiring the physician to adjust to unique and dynamic circumstances (differences in types of illness, prognosis, culture, values, setting, etc.). While guidelines for physician behavior in complex situations, such as delivering bad news or negotiating end-of-life decisions, can be helpful, what actually is required is the ability to appropriately interpret the particulars, reflect in a disciplined manner on the circumstances and potential outcomes, and to take a thoughtful, instead of reactive, leadership role. In our experience, pediatricians convey a keen interest in improving their professionalism and communication skills. Working with colleagues, they find the opportunity to learn through the use of reflective practice a helpful exercise in developing such skills.
Next steps:
1. Additional needs assessment surveys regarding interpersonal/communication skills and professionalism
2. Development of improved outcome measures for our educational methods
3. Pursuit of Objective #3 – Have community pediatricians, with teaching appointments at BCM, employ the reflective practice method in their role as clinician- educators
4. Work with other medical school training programs to broadly distribute this method of education
Questions
1) How can outcome measures be improved? Current measurements employed have some psychometric merit, yet appear prohibitively expensive for wide use. We do not consider it to be an optimal measurement strategy. Standardized responses appear inappropriate to a dynamic situation where non-standardized responses are required.
2) What are good strategies for distribution and what financing is required for other institutions to join the effort?
Literature cited
