|Year : 2013 | Volume
| Issue : 1 | Page : 60-65
Efficiency is not enough; you have to prove that you care: Role modelling of compassionate care in an innovative resident-as-teacher initiative
Maria A Blanco1, Ann Maderer2, Lori Lyn Price3, Scott K Epstein4, Paul Summergrad5
1 Associate Dean for Faculty Development and Assistant Professor of Psychiatry, Tufts University School of Medicine, Boston, Massachusetts, USA
2 Curriculum and Administrative Director, Tufts University School of Medicine, Boston, Massachusetts, USA
3 Instructor of Medicine, Tufts University and Biostatistician, Institute of Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
4 Dean for Educational Affairs and Professor of Medicine, Tufts University School of Medicine and Tufts Medical Center, Boston, Massachusetts, USA
5 Dr. Frances S. Arkin Professor and Chairman Department of Psychiatry, Professor of Medicine, Tufts University School of Medicine, Psychiatrist-in-Chief, Tufts Medical Center, Boston, Massachusetts, USA
|Date of Web Publication||31-May-2013|
Maria A Blanco
145 Harrison Ave, Sackler Building, Room 325 Boston, MA, 02111
Source of Support: The programme was funded by The Arthur Vining Davis Foundations., Conflict of Interest: None
Introduction: The current emphasis on providing holistic competent and efficient healthcare has revealed a need to nurture providers' compassionate and relationship-centred care throughout the continuum of medical education. Methods: Our resident-as-teacher programme trained 41 residents from core clerkships at six clinical sites in the United States of America (USA) to teach and practice compassionate care through role-modelling. The programme focused on resident's demonstrations or failures to demonstrate compassionate care with peers, students and healthcare providers, and engaged residents in disseminating their experience to their colleagues. A mixed-method evaluation assessed short-term outcomes at multiple levels through the collection of resident's: pre- and post-programme scores on empathy scale, performance on standardised patient (SP) exercise, and self-assessment of their performance on relationship-centred care skills; journal reflections; presentations delivered at their site and attendees' evaluation; evaluation of the programme. Quantitative data was analysed calculating descriptive statistics and paired sample t-tests, using SAS. Qualitative data was analysed performing open coding and code frequency counts to identify emergent themes. Results: Residents had empathy scores within the average range, and high scores on SP assessments throughout the programme. The programme had a positive impact on resident's perceptions of their relationship-centred skills. Residents found the programme useful, and emphasised the importance of mindfulness, active presence and slowing down-and were concerned with addressing these needs in daily practice. Eighteen presentations were delivered across sites. Attendees found the presentations useful and necessary in their training. Conclusions: Residents successfully reflected on, embodied and disseminated the programme's core concepts on their rotations. This group required validation of their commitment to compassionate care, and sought strategies to embody their commitment while inspiring other providers, residents and students.
Keywords: Centred care, compassionate, graduate medical education, reflective practice, relationship, role modelling, teaching
|How to cite this article:|
Blanco MA, Maderer A, Price LL, Epstein SK, Summergrad P. Efficiency is not enough; you have to prove that you care: Role modelling of compassionate care in an innovative resident-as-teacher initiative. Educ Health 2013;26:60-5
|How to cite this URL:|
Blanco MA, Maderer A, Price LL, Epstein SK, Summergrad P. Efficiency is not enough; you have to prove that you care: Role modelling of compassionate care in an innovative resident-as-teacher initiative. Educ Health [serial online] 2013 [cited 2021 Feb 26];26:60-5. Available from: https://www.educationforhealth.net/text.asp?2013/26/1/60/112805
| Introduction|| |
In the United Stated of America (USA), the positive impact of providing humanistic care on the patient-clinician relationship and clinical outcomes is well supported by the literature. ,, However, the current emphasis on providing biomedically competent and efficient healthcare has highlighted a need to nurture provider's compassionate care throughout the continuum of medical education.  Furthermore, an erosion of humanistic skills as residents advance in their training is under debate but commonly reported.  Residents are the primary teachers of medical students in the clinical setting; their attitude and behaviour has a significant impact on the development of future physicians. 
The international medical education literature also highlights a need for medical education efforts targeted at increasing trainee's positive attitudes towards patient-centred medicine.  In fact, cross-cultural differences were found in student's attitudes towards patient-centred care with non-American students showing lower attitudinal scores. ,, That trainees are ill-disposed to patient-centred care could be associated with paternalistic models of physician-patient relationship that seem to prevail in these healthcare systems. ,, Therefore, efforts at training medical trainees to practice and teach compassionate, relationship-centred care though role modelling might be informative to a worldwide audience, albeit the existence of cross-cultural contextual differences.
Still, there is paucity of efforts aimed at training medical educators in the teaching of humanistic care.  Efforts to train medical educators, including resident-teachers, in the practice and teaching of compassionate care will address a critical need. Our resident-as-teacher programme trained 41 residents from core clerkships at six clinical sites in the USA to teach and practice compassionate care through role-modelling. The programme focused on resident's monitoring of their demonstrations or failures to demonstrate compassionate care with peers, students and healthcare providers, and engaged residents in the dissemination of their experiences with the programme.
In this brief communication, we describe the programme implementation and main short-term outcomes of our evaluation of the programme. We also address challenges we encountered carrying out the programme.
| Methods|| |
Tufts University School of Medicine (TUSM) is committed to educating, training and supporting healthcare providers in their efforts to compassionately care for their patients. Indeed, that commitment is a tenet upon which the school was founded in 1893. Established by medical students dissatisfied by proprietary schools with minimal bedside teaching, TUSM's very origins are of an institution dedicated to the highest academic and clinical standards, yet deeply committed to instilling in its students the need for compassionate patient care. That tradition continues today, with TUSM proud to have Compassionate Care as one of the nine curricular key themes, meant to be learned, taught and assessed throughout the 4 years of medical school. TUSM is a private institution, located in Boston, Massachusetts, United States of America. The student composition includes: 647 MD students; 132 MD students with dual degrees (MA, MBA, MPH, MSE, PhD); and 494 students from MPH, professional and biomedical research degree programmes.
The goals of the 9-month programme were to (1) train a cadre of residents to teach compassionate care through role-modelling; (2) facilitate residents to apply what they have learned in their daily interactions with students, patients and healthcare providers; (3) ensure residents present what they have learned to their colleagues. The programme was implemented in September 2010, and was funded by The Arthur Vining Davis Foundation.
The programme was communicated to the Academic Deans for five of TUSM teaching hospitals and to the Chair of TUSM's Department of Family Medicine. With their support, the programme was then communicated to Residency Programme Directors at the five hospitals and one Family Medicine teaching site. Programme Directors forwarded the invitation to participate in the programme to their residents; total population of approximately 400 residents. Residents were promised that by participating in the programme they would: be trained in practicing and teaching compassionate, relationship-centred care through role modelling; develop and deliver a scholarly communication about their experience with the programme to their peers at their sites and add this scholarly work to their curriculum vitae; and receive a US$500 honorarium.
The final pool of participants consisted of 41 residents across the six sites, representing seven specialties: Internal Medicine (13); Psychiatry (9); Family Medicine (9); Internal Medicine-Paediatrics (6); Obstetrics and Gynaecology (2); Paediatrics (1); Surgery (1). Of these 41 participants, 22 were second-year residents; 14 were third-year residents; 4 were fourth-year residents (including a first-year fellow); and 1 was a fifth-year resident (a second-year fellow).
Six site faculty teachers were recruited and trained (one per site), three of whom were identified through their past participation in TUSM's Schwartz Compassionate Care Faculty Development Programme, implemented in 2008. A framework for practicing and teaching compassionate, relationship-centred care developed exclusively for the faculty development programme served as the theoretical framework for this initiative.  The framework describes seven relationship-centred care themes with skills, and provides specific communication and educational strategies to perform such skills with both patients (as caregivers) and learners (as teachers).
The programme components were:
We scheduled sessions at each site, and site faculty was charged with monitoring the programme, and serving as the local liaison and support. We also uploaded materials to our school intramural website, administered all evaluation exercises online and created e-lists by site to facilitate continuing communication.
- One half-day core workshop: delivered at each site by one of the principle investigators (PIs) with the assistance of the respective site faculty. Participating residents were introduced to the programme goals, logistics, timeline and theoretical framework, and were engaged in reflective exercises, case discussions and role-plays (See Core Workshop Outline in Appendix 1) [Additional file 1].
- Journal-writing throughout the programme: residents were asked to recall and describe events of their daily practice and teaching in which they: 1) Demonstrated compassionate care to patients; 2) Failed to demonstrate compassionate care to patients; 3) Taught compassionate care to students or peers through role-modelling and 4) Missed an opportunity to teach compassionate care to students or peers through role-modelling. Residents were asked to bring a journal entry to the programme follow-up meetings (See journal entry prompts in Appendix 2) [Additional file 2].
- Four 1-hour, follow-up meetings at each site: residents shared and discussed their experiences applying the programme framework in their daily practice and teaching, their journal entries, and their plans for peer presentations.
- Presentations to peers at sites: residents were asked to design, execute and evaluate a presentation of lessons they learned in the programme to peers and/or other healthcare providers. Residents were given the choice of working on these presentations in groups or individually.
A mixed-method programme evaluation design was developed to assess short-term outcomes at multiple levels. The programme was approved by the Institutional Review Board (IRB) for all participating sites. Data collection included participating residents':
For quantitative analytical purposes, we used a subset of the sample of participating residents based on the number of participants who completed all the questions so that we could calculate total scores. We analysed participant's baseline empathy scores on JSPE and SP exercise, and, based on our programme's conceptual framework, we also developed and analysed resident's self-scores of relationship-centred skills as caregivers and teachers collected from the pre-programme self-assessment questionnaire. We then examined differences between the pre- and post-programme scores performing descriptive statistics and paired sample t-tests using SAS 9.3 (SAS Institute, Inc., Cary, NC).Data with missing points were not considered for the quantitative analysis.
- Pre-/post-programme interpersonal and communication skills performance on a standardised patient (SP) encounter.
- Pre-/post-programme scores on the Jefferson Scale of Physician's Empathy (JSPE). 
- Pre-/post-programme self-assessment of performances of relationship-centred skills as caregivers and teachers taught and practiced in the programme.
- Journal reflections on demonstrations, or failures to demonstrate, skills taught and practiced in the programme at the workplace.
- Presentations delivered at sites and attendees' evaluation of the session.
- Evaluation of the training programme.
Residents were asked to voluntarily submit at least one journal entry at any given point throughout the 9-month programme for research purposes. No punitive action was associated with this request to preserve the formative purpose of this exercise and the research on human subject requirements, respectively. We examined these journal entries to explore how residents apply the programme framework in their daily interactions with patients, students, peers and other healthcare providers at their workplace. We took an inductive approach, consistent with grounded theory, to analyse the data. Data were open coded by two independent researchers and differences were resolved by consensus. Codes were grouped into categories to identify emergent themes. We also performed code frequency counts to identify the most frequently reported themes. The analysis of data was shared with non-participating clinical faculty to incorporate alternative interpretations.
Residents were also asked to seek feedback from peers on their presentation by administering a session evaluation at the end of their presentations. Residents scored the usefulness of each component of the programme on a 5-point scale (very useful-not useful) and provided related open comments via an online programme evaluation administered upon their completion of the programme requirements. Average rating scores were calculated and comments were coded to identify emergent and most frequent themes.
We anticipated that resident's performances on the SP exercises and questionnaires would improve after their participation in the programme. We also expected that journal writing would raise resident's awareness of their demonstrations or failures to demonstrate compassionate, relationship-centred care in their daily practice. Lastly, we hoped that resident's presentations to peers would be well-received, and helped us disseminate our compassionate care educational mission at their clinical sites.
| Results|| |
Before the programme, on average, 40 residents self-scored 68% of the total possible score for the relationship-centred skills as teachers, and 74% of the total possible score for the relationship-centred skills as caregivers. Residents had JSPE scores within the average range of empathy, compared against the normative sample (n=40; Mean=119.60; SD=10.61). SP scores were high (highest possible=30; n=40; Mean=25.98; SD=6.54).
Twenty-nine residents completed both pre-and post-programme questionnaires. Residents self-scores of relationship-centred skills as caregivers and teachers increased significantly post-programme (n=25; SSC median difference=6.00, P=0.001; SST median difference=10.00, P<0.0001). JSPE scores (n=26) increased after the programme by a median of 1.50 points, but this was not statistically significant (P=0.46). SP scores increased after the post-programme (n=28; median increase=1.00); this change was not statistically significant (P=0.42).
Thirty-one residents from six sites voluntarily submitted 145 journal entries-on average, four entries per resident (range, 1-8). Residents' comments suggested that patient, provider and workplace characteristics, for example difficult patients, egocentric providers and overwhelming clinics and problem-solving/task-oriented approaches, interfered with relationship-centred care. Residents also showed awareness of competing roles as healthcare providers and educators, which may have led to missed opportunities to provide and role-model optimal care.
Eighteen presentations were delivered across sites, either by an individual or by groups of residents (1-6 presentations were delivered per site). Audience size varied from 12 to 90 participants. Session venues varied, that is departmental and resident's noon-conferences; faculty and resident's retreats; institutional orientation to new interns; hospital Grand Rounds. Attendees felt that such sessions were vitally important, and were able to identify specific skills to practice at the workplace; this was suggested by attendees' high ratings and comments about strengths of the presentations.
Main outcomes of resident's programme evaluation indicated that all programme components were useful (ratings range: 4.38-3.88 on 5-point scale). The predominant theme that emerged was the importance of mindfulness, active presence and slowing down for themselves, their patients and students. Addressing this in ongoing practice was the resident's primary concern.
| Conclusion|| |
Resident's high initial performance on the empathy scale and SP encounters could be attributed to the recruitment of a self-selected group of trainees who had a commitment to relationship-centred care prior to the programme.
Based on the cohort completing both the pre- and post-surveys, results indicated that the programme had a positive impact on resident's perceptions of their relationship-centred skills as caregivers and teachers taught and practiced in the programme (as determined by resident's higher self-scores after the programme). SP scores also showed a slight improvement in the resident's relationship-centred skills.
Residents' successfully reflected on and embodied the core concepts of compassionate, relationship-centred care during their daily clinical and teaching interactions as journal entries indicated. However, resident's reflections also suggested that humanistic care must be nurtured.
| Challenges|| |
The first challenge we encountered was related to resident's distribution across different sites and departments. To address this, we scheduled sessions at each site with a site faculty monitoring the programme, and serving as liaison and local support. We also uploaded materials to our school intramural website, administered all evaluation exercises online and created e-lists by site to facilitate continuing communication.
Recruiting residents via email might have also presented a problem. Later in the process, we learned that a few non-participating residents disregarded the email announcement. This group of non-participating residents regretted not having considered the email announcement once they learned about their participating peer's experiences with the programme. A brief presentation of the programme plan at general staff meetings may have helped with recruitment and buy-in from all levels of healthcare providers.
Regarding programme weaknesses, it was challenging to have residents complete the programme questionnaires, specifically at the end of the programme. We attributed this challenge to the hectic pace and workload the residents encounter at the workplace and a lack of protected time for mindfulness and reflective practice in the current residency training, which we were not able to overcome. We also noticed that while the e-list we set up was useful, and helped us support the resident's work throughout the programme, the use of our intramural school website was not useful. We could have anticipated this challenge given that our resident-teachers across sites also our intramural school website an obstacle because it requires that they log into a new system (different from their workplace network).
| Educational Implications|| |
This group of residents needed support for and validation of their commitment to compassionate care. Our programme helped participating residents combat the expected erosion of empathy in residency training.  As the literature suggests, promoting patient-centred care is a worldwide need. Our programme experience can inform training efforts around the globe, albeit contextual idiosyncrasies.
| Acknowledgements|| |
The authors are extremely pleased with the enthusiasm for and commitment to the programme among their Site Faculty Teachers and participating residents, whose support made all the difference in accomplishing their programme goals.
The authors thank The Arthur Vining Davis Foundations for the opportunity and resources to reinforce and enhance their teaching and learning commitment to compassionate, relationship-centred care at Tufts, and their primary clinical affiliates.
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