ORIGINAL RESEARCH PAPER
Year : 2011 | Volume
: 24 | Issue : 3 | Page : 490-
Raising medical student awareness of compassionate care through reflection of annotated videotapes of clinical encounters
R Kalish1, M Dawiskiba2, YC Sung1, M Blanco1,
1 Tufts Medica Center, Boston, Massachusetts, USA
2 Cambridge Health Alliance, Cambridge, Massachusetts, USA
Tufts Medica Center, Boston, Massachusetts
Context: With medical training focused on medical knowledge and skills, the nurturing of humanistic care can suffer.
Objectives: We designed and conducted an outpatient rheumatology patient-partner exercise that integrates the assessment of student compassionate care into an outpatient clinical skills training exercise.
Methods: Eleven third-year medical students were videotaped performing a medical history on a patient volunteer. Students, the preceptor and a fourth-year medical student independently observed the videotape, tagged segments demonstrating observed or missed compassionate care opportunities and completed a compassionate care questionnaire. Students also participated in a focus group. Ten patients completed a comparable questionnaire and provided feedback on student encounters.
Findings: Students recognized and reflected on opportunities for compassionate care. The preceptor«SQ»s feedback was reinforced. Students«SQ» ratings of their demonstrations of compassionate care were lower after reviewing videotapes, and were also lower than preceptor ratings. Patients were satisfied with the exercise and highlighted student professionalism.
Conclusions: The exercise proved to be an effective format for promoting student reflection on and self-assessment of
compassionate care. It demonstrated that nurturing compassionate care can be integrated into an outpatient clinical skills exercise.
|How to cite this article:|
Kalish R, Dawiskiba M, Sung Y, Blanco M. Raising medical student awareness of compassionate care through reflection of annotated videotapes of clinical encounters.Educ Health 2011;24:490-490
|How to cite this URL:|
Kalish R, Dawiskiba M, Sung Y, Blanco M. Raising medical student awareness of compassionate care through reflection of annotated videotapes of clinical encounters. Educ Health [serial online] 2011 [cited 2021 Oct 21 ];24:490-490
Available from: https://www.educationforhealth.net/text.asp?2011/24/3/490/101427
ContextCompassionate care has been described as having empathy to understand and be moved by a patient’s emotions, in addition to showing a desire to help relieve patient suffering or distress1-5. Medical educators around the world recognize the need to train competent and compassionate physicians by balancing competency in clinical knowledge and skills with the principles and practice of humanistic care6-10. However, with the rapid expansion of clinical knowledge and skills required in medical training, there is concern that the nurturing of humanism, empathy and compassion has suffered7,11-13. Further, the opportunity to demonstrate and reflect on compassionate care must be provided throughout medical training. This would help avoid potential loss of empathy and selflessness in trainees, an issue currently under discussion in the field2,14-16.A variety of educational approaches have been used to teach compassionate care, including role modeling17, participant observation18, inter-clerkship programs19,20, focused coursework, self-directed learning and standardized patients21,22. Hojat and colleagues also suggests analysis of audio or videotaped encounters with patients, among other approaches15. In order to incorporate the habit of attending to patients’ emotional and spiritual needs as a key component of doctoring23, it may be essential that compassionate care be nurtured together with the acquisition of clinical skills and knowledge in every clinical encounter.ObjectivesOur main objective was to design an educational experience that integrates the recognition and assessment of student compassionate care into a clinical skills exercise with patient-partners, in which students learn specific rheumatologic history-taking and physical exam techniques. This patient-partner exercise has been found to be an effective method of teaching clinical skills, with students benefiting from patient feedback24. Kalish et al. previously explored the use of this exercise to promote reflective learning by videotaping the student-patient encounter and using software that allows students to tag videotaped interactions25,26. They found that videotaping patient-partner encounters provided students with a motivating educational experience and promoted self-awareness of interviewing and interpersonal skills26. Consequently, we describe the patient-partner exercise and report the main outcomes of the exercise related to the recognition and assessment of student compassionate care.MethodsEducational Methods: The goals of the patient-partner exercise were to have students:Recognize opportunities to provide compassionate care.Reflect on their compassionate care interactions. Assess their compassionate care interactions.Put into practice interviewing skills while encountering a rheumatology patient presenting with an unknown diagnosis.Reinforce skills in physical examination of the joints.Receive preceptor feedback on their interviewing, physical exam and compassionate care skills.The theoretical framework that guided the exercise design was based on experiential learning27 and reflective practice28. This framework is consistent with adult learning, and allows learners to go through an educational experience, think back on what occurred and determine how this experience may affect future practice. The components of the exercise are presented in Table 1.
Table 1. Components of the Patient-Partner Exercise
The exercise was implemented at the Tufts Medical Center Rheumatology Clinic from October 2007 through March 2008. All 12 third-year medical students, who were assigned to complete their Internal Medicine core clerkship at this clinical site by Tufts University School of Medicine via a lottery system, were invited to participate. A detailed description of the exercise was sent to the students prior to the start of the rotation. The exercise took place during the ambulatory block of students’ Internal Medicine clerkship at this clinical site.Additionally, the preceptor selected 10 patient-partners from his rheumatologic practice. One of the patients participated twice in the exercise. All of the patients were chosen based on their ability to accurately convey their history, and willingness to participate in the educational exercise. The patient’s primary rheumatologic diagnoses were: three systemic lupus erythematosus; one dermatomyositis (this patient participated twice); two osteoarthritis; one rheumatoid arthritis; one ankylosing spondylitis; one polymyalgia rheumatica; and one fibromyalgia.Research Methods: We designed a mixed-method study to examine the main outcomes related to student compassionate care experiences in the exercise (Goals 1 to 3 and 6 of the exercise). Specific questions that guided the study were:Can student compassionate care be recognized and systematically assessed in a single student patient-partner outpatient exercise?Does videotaping the student-patient encounter provide students with opportunities to engage in self-reflection and self-assessment, and enhance the preceptor’s feedback?The study was approved by the Tufts Medical Center/Tufts University Health Sciences Institutional Review Board.Data Collection; Students: First, tags of video segments on student compassionate care interactions were generated using WebDiver software25. A 'tag' consists of a comment written in a text box that opens adjacent to the videotape frame and is labeled with the time on the tape to which the comment is referring. All comments remain visible as the playing of the tape proceeds. The viewer can click on a text box at any time and the tape will return to the pertinent segment. Tags of all permitted reviewers can be seen together including responses from one reviewer to another reviewer. Students were assigned to tag at least one video segment in which they demonstrated compassionate care and at least one segment in which they missed an opportunity to do so. Second, students completed the student compassionate care interactions questionnaire both prior to and after viewing the videotaped encounter. The tool consisted of 10 items that measured the quality of student compassionate care attributes on a four-point Likert scale (Excellent-Good-Fair-Poor; four points was the highest rating). We designed the questionnaire by combining aspects of physician's humanistic skills mentioned in existing validated tools3,29-36. Table 2 lists the items included in the questionnaire. The tool was pilot-tested with third-year medical students during a clinical exercise before its implementation in our exercise. The questionnaire is available upon request to the corresponding author.
Table 2. Items included in the questionnaire on student compassionate care interactions*
Finally, students participated in a focus group led by one of the researchers. They were asked to share their educational experiences during the course of the exercise. The discussion focused on lessons students learned from observing their clinical performances, including students’ compassionate care interactions and students’ experiences with the feedback they received. Students also commented on strengths of the exercise and shared suggestions for improvement. Data Collection; Preceptor and Fourth-Year Student: In addition to the third-year student tags, a preceptor and a fourth-year student independently tagged video segments after the student tagging. Tags consisted of both responses to the students’ tags and spontaneous tags of interview segments not tagged by students. The questionnaire on student compassionate care interactions was also completed by the preceptor and fourth-year student after viewing the videotapes independently. Both were blinded to the students’ and each other’s questionnaire responses. Data Collection; Patients: Study patients completed a questionnaire to assess student performance and the exercise. The questionnaire consisted of 20 statements on a five-point Likert Scale that asked patients whether they agreed or disagreed with the proposed statement (Strongly Agree-Agree- Undecided-Disagree-Strongly Disagree; five points was the highest rating). Table 3 lists the statements included in the patient-partner questionnaire. Patients were also invited to share their overall impressions of the experience through an open-ended question (Question 21 in Table 3).
Table 3. Patient–Partner Questionnaire*
Data Analysis: We performed the Cronbach’s Alpha Test to measure the reliability of the questionnaire of student compassionate care interactions. We used descriptive statistics and paired-samples t-tests to compare student self-assessment ratings of their compassionate care interactions before and after viewing the videotaped patient-partner encounter. We used descriptive statistics and analysis of variance to compare the student, fourth-year medical student and preceptor post-videotape viewing ratings. The t-test and its extension to more than two groups (F test) is commonly used for comparing group means37,38, as it is effective to control the probability of Type I error (concluding the means are different when they are actually equal). However, we were aware that, in our study, significant results must be considered with caution due to small sample size (n=9). SPSS was used to perform the statistical analysis.The focus group discussion was recorded and transcribed. We independently conducted an inductive content analysis of the discussion through open-coding. Codes were grouped into categories to identify emergent themes39. We discussed coding discrepancies to reach consensus. We also shared analyses with non-participating clinician educators and students to address interpretative validity40.Additionally, we calculated means of the patient responses to the patient-partner questionnaire to analyze trends in patient responses. We also independently conducted an inductive content analysis of patient responses to the open-ended question to identify emergent themes. FindingsEleven students volunteered; four female and seven male. The age range was 23 to 37, with a median age of 25. One student was intimidated by the videotaping component of the exercise and chose not to participate.Ratings of Student Compassionate Care Interactions: The Cronbach’s Alpha coefficient for the 10 items included in the questionnaire of student compassionate care interactions was .75, which indicated high consistency among the attributes measured. The analysis of the student self-assessment ratings of their compassionate care interactions indicated that there was a statistically significant difference at the .05 alpha level between student pre-videotape viewing and post-videotape viewing assessment of their demonstration of a desire to alleviate the patient’s concerns by comforting the patient or offering help (t (8)=2.53; p t (8)=0.55; p Table 4. Paired samples statistics and test for student’s self-assessment ratings of their compassionate care interactions pre- and post-videotape viewing (n=9; one data point cannot be computed)
Analysis of the student, preceptor and fourth-year medical student post-videotape viewing ratings of student compassionate care interactions revealed that ratings were relatively consistent among all raters. However, statistically significant differences were found for ratings related to item 3, student demonstration of a desire to alleviate patient concerns by comforting the patient or offering help (F (2,28)=3.40; pF (2,29)=12.82; p F (2,29)=3.35; pStudent Videotape Tags: Students tagged a total of 21 missed opportunities and 17 fulfilled opportunities to demonstrate compassionate care (mean number of tags = 3.45; range = 1 to 8 tags per student). Seven of the 21 missed opportunities were cited as failure to demonstrate compassionate empathy. Four were noted as missed opportunities to validate a patient’s emotions or perspectives, and three as lack of attentiveness. One student noted that his/her efforts to show compassion seemed 'contrived.' The students did not specify the nature of the deficit in the remaining six video segments that were tagged as missed opportunities. Recognized demonstrations of compassionate care included nine tags for validating a patient’s emotions or perspectives, four tags for words or actions conveying compassionate empathy and one tag for appropriate attentiveness. Three tags did not specify the nature of the compassionate interaction. Examples of student tags of videotape segments are presented in Table 5.
Table 5. Students’ tags of videotaped segments
Student Focus Group: Three major themes emerged from the analysis of the student focus group discussion: nurturing compassionate care through the patient-partner exercise; assessing compassionate care interactions; and compassionate care in the medical school curriculum. In relation to nurturing compassionate care, all students agreed that reviewing the videotape allowed them to 'step back' and recognize demonstrations of compassionate care, as well as interactions in which they missed opportunities to show compassion. Examples cited by students as demonstrations of compassionate care included attentive listening through eye contact and immediately responding to a patient’s verbal or nonverbal expression. Examples of missed opportunities included the absence of an emotional or affective response to difficult emotions and experiences expressed by the patient, and the negative effect of note-taking on demonstrating attentiveness to and respect for the patient. An illustrative comment was: 'I realized at that moment [while reviewing the videotape] that he just made a joke and then laughed at it, and I didn’t laugh at it with him. I’ll have to make sure I do that the next time it comes up.'Students highlighted the recognition of personal biases and approaches through watching their own clinical performances and an enhanced understanding of the preceptor’s feedback as reasons to support videotaping their encounter with the patient-partner. For instance, one student stated: 'It was important to see sometimes that we are so concentrated on ourselves and what we need to get done that we ignore the patient.' And another student related: 'I think the added benefit of the video was that you can actually go back and see what the preceptor’s feedback pertains to.' Four students also mentioned a negative impact of videotaping the student-patient encounter on the legitimacy of the interaction. For instance: 'Even with videotape, you know someone else is watching, and it’s going to affect the interaction, it’s going to take away from it.' While discussing suggestions for improving this exercise, students questioned whether or not reviewing the compassionate care questionnaire prior to the exercise biased their approach to act compassionately. All students, except for one, agreed that the benefits of calling their attention to compassionate care outweighed the risk that their behavior would be altered by the exercise cues. One student summarized: 'I agree it’s artificial and that it may not be the way you normally act in front of a patient, but I think that if you are faced with a similar situation you might remember something you did wrong in this instance.'In terms of the second theme of assessing compassionate care interactions, all students stated that they engaged in reflecting on and self-assessing their compassionate care interactions through this exercise. Students also discussed whether or not a preceptor could provide a valid assessment of student compassionate care interactions. All students, except for one, agreed that an experienced and compassionate preceptor could accurately assess compassionate care interactions. One student said: 'I think that [a preceptor] who has extensive interviewing experience, and who is obviously compassionate, probably can make a decent judgment on compassion.' Students also proposed that the patient’s assessment would be the most valid measure of their compassionate care interactions. For example: 'If the preceptor and the patient disagree, who is going to be right? The patient probably….because it was their experience.'Finally, in relation to compassionate care in the curriculum, students agreed that it should be a component of a medical student’s training. Three students questioned whether or not compassionate care can be taught. One student remarked: 'I think that it’s a step in the right direction [to integrate compassionate care education in the medical school curriculum]… in moving to standardize the way that physician’s [sic] are trained to interact with patients.' Another said: 'The question that this really raises in my head is can you train good bedside manner? Can you train someone to be compassionate?' Patient-Partner Questionnaire: All 10 patients returned their evaluation questionnaires. Overall, patients highly rated student interpersonal skills and compassionate interactions. The highest ratings were related to: student respect for the patient’s views, questions and opinions (mean rating = 4.72); ability to establish a comfortable rapport (4.63); professionalism (4.63); and respect for the patient’s physical comfort while performing the physical examination (4.63). The patients also highly rated the ability of students to conduct the medical history (4.54) and to perform the physical examination with proper respect for the patient’s feelings (4.54). The patients’ lowest ratings were related to student ability to clearly explain his/her role in the session (4.09).The patients strongly agreed that their role as patient-teacher was made clear (4.91) and that the experience was enjoyable (4.72). However, they had varying opinions about whether hiding their diagnosis from the student was difficult (3.27) and interfered with their ability to give their story (3.36). All the patients strongly agreed that they would be willing to consider doing this exercise again for another student (5.00). Regarding videotaping the exercise, the patients strongly agreed that they understood the reason for videotaping the exercise (4.91). They also agreed that they did not feel uncomfortable during the interview or physical examination (4.18).The analysis of the patients’ open-ended responses to the question about their overall impressions of the exercise revealed that the patients found the exercise both enjoyable and gratifying, and they were grateful for being able to participate and contribute to student education. The patients also used the following words and phrases to describe the students interactions: 'respectful,' 'overly cautious' to avoid discomfort, 'thorough in history-taking,' able to 'connect,' 'attentive,' 'concerned,' 'sweet,' 'gentle,' 'compassionate,' 'nice,' 'personable' and 'professional.'DiscussionWe designed an educational experience intended to integrate the recognition and assessment of student compassionate care into a clinical skills exercise. The exercise was driven by our belief that compassionate care must be nurtured as much as possible in student training in ways that offer focused reflection in the context of genuine student-patient interactions. The data from our study showed that students were able to recognize and reflect on opportunities to demonstrate compassionate care. The combined use of two tools was instrumental in achieving this goal. First, the Compassionate Care Questionnaire provided a defined framework that allowed students to recognize compassionate care attributes such as attentive listening and compassionate empathy. Second, the tagged videotape of the student-patient interview provided a vehicle for students to watch and reflect on clinical performance and the preceptor’s feedback. As the student testimonies suggested, both tools promoted reflection, self-assessment and self-directed learning of student compassionate care interactions with patients. Our findings revealed that students tended to rate their compassionate care performance lower after reviewing the videotape, specifically regarding their ability to demonstrate compassionate empathy. Therefore, the videotape seemed to have helped students identify areas for improving their compassionate interactions. Most importantly, students recognized aspects of interpersonal communication that they had not been previously aware of, such as the effect of their note-taking on demonstrations of attentiveness to patients while taking a history. Though the post-video viewing ratings of student compassionate care interactions were quite consistent among raters, the preceptor’s tendency to give students higher ratings could suggest that students and the preceptor had different expectations regarding student demonstration of compassion in this setting – or that students tended to be overly self-critical in assessing their interpersonal demeanor, as has been reported to be the case with physician self-assessment41.The exercise gave students the opportunity to receive feedback from real patients in a safe learning environment42. The students who participated in our study unanimously agreed, as some scholars propose, that patients provide the most valid feedback on the quality and impact of their compassionate interactions because the patient’s perception of compassion or the lack thereof is what ultimately matters43. However, students also highlighted the importance of learning from a clinical teacher who models compassionate and humanistic care, a point well-documented in the literature17.Students also endorsed the teaching and learning of compassionate care in the medical school curriculum. At the same time, they considered the question about whether or not compassionate care can be taught, a question also raised in the literature13,43. Gracey et al. emphasized a five-step methodology for teaching humanistic care in the outpatient setting, which includes: (1) diagnosing the learner; (2) integrating psychosocial issues; (3) debriefing and reflection; (4) feedback; and (5) planning follow-up12. We propose that this exercise is suitable for addressing each of these steps, and serves as a curricular venue for teaching and learning about compassionate and humanistic care.Participating patients enjoyed the exercise and expressed satisfaction with contributing to the professional development of the students. Even though some patients found it challenging to hide their diagnosis from the students, they expressed willingness to participate in this educational effort in the future. The patients also tended to highly rate students’ humanistic skills. We acknowledge that further research on the reliability and validity of untrained patient feedback on medical trainees is needed44.Limitations of our project include that our study occurred in a single school with a single group of students who participated voluntarily with a preceptor who is passionate about the topic. The questionnaire on Student Compassionate Care Interactions was not previously validated or examined for its reliability with other groups. In addition, our evaluation is mainly based on participant reactions, which are considered the lowest level of outcomes in program evaluation45.ConclusionsDespite the above limitations, we believe that medical student compassionate care recognition and skills can be promoted in the context of focused clinical skills exercises. The Compassionate Care Interactions questionnaire, in conjunction with videotaping of medical student-patient interactions that incorporated software that allows tagging of the videotape, can be an effective tool for promoting student reflection and self-assessment and reinforcing the preceptor’s feedback on student compassionate care. This exercise can help students raise their awareness of compassionate care by providing an opportunity to review and receive feedback on their own performance in a specific clinical context. Hojat et al. suggest that we develop 'targeted educational programs' across the medical training continuum to 'prevent extinction' of the 'valuable human quality' of empathy [15: p. 1189]. We believe this exercise is an educational model that can be applied effectively in diverse educational environments and cultures at every level of training, and can help address the need for empathy and patient-centeredness in medical education6-10. We will continue to refine the exercise, evaluate its outcomes and expand it to other clerkship rotations as well as to residency programs to apply it in the continuum of medical education. We hope that our experience will inspire others to adapt these methods in other settings to move towards the goal of nurturing compassionate care skills in all our healthcare providers. AcknowledgementsWe are grateful to David Grogan (of the University Information Technology) for his support with the software tool. We deeply appreciate Dr. Mary Lee and Dr. Scott Epstein's support and thoughtful feedback on the curriculum and manuscript. We are also grateful to Ann Maderer for her skillful assistance with the manuscript editing and preparation. We thank Dr. Joseph Rencic and Gail Doyle for promoting and coordinating medical student participation. References1. Von Dietze E, Orb A. Compassionate care: A moral dimension of nursing. Nursing Inquiry. 2000; 7:166-174.2. Coulehan J, Williams P. Vanquishing Virtues: The impact of medical education. Academic Medicine. 2001; 76(6):598-605.3. Skaff K, Toumey C, Rapp D, Fahringer D. Measuring compassion in physician assistants. Journal of the American Academy of Physician Assistants. 2003; 16(1):31-40.4. Nelson, R. The compassionate clinician: Attending to the spiritual needs of self and others. Critical Care Medicine. 2005; 33(12):2841-2842.5. Sanghavi D. What makes for a compassionate patient-caregiver relationship? Journal on Quality and Patient Safety. 2006; 32(5):283-292.6. General Medical Council. Tomorrow’s doctors. Recommendations on undergraduate medical education. London: General Medical Council; 1993.7. Cooper R, Tauber A. New physicians for a new century. Academic Medicine. 2005; 80(12):1086-1088.8. Boudreau JD, Cassell EJ, Fuks A. A healing curriculum. Medical Education. 2007; 41(12):1193-201. Epub. 2007 Nov 2.9. Ribeiro MM, Krupat E, Amaral CF. Brazilian medical students' attitudes towards patient-centered care. Medical Teacher. 2007; 29(6):e204-208.10. Shiau SJ, Chen CH. Reflection and critical thinking of humanistic care in medical education. Kaohsiung Journal of Medical Sciences. 2008; 24(7):367-372.11. Puchalski C, Larson D. Developing curricula in spirituality and medicine. Academic Medicine 1998; 73(9):970-974.12. Gracey C, Haidet P, Branch W, Weissman P, Kern D, Mitchell G, Frankel R, Inui T. Precepting humanism: Strategies for fostering the human dimensions of care in ambulatory settings. Academic Medicine. 2005; 80(1):21-28.13. Spiro H. Commentary: The practice of empathy. Academic Medicine. 2009; 84(9):1177-1179.14. Newton B, Barber L, Clardy J, Cleveland E, O’Sullivan P. Is there hardening of the heart during medical school? Academic Medicine. 2008; 83(3):244-249.15. Hojat M, Vergare M, Maxwell K, Brainard G, Herrine S, Isenberg G, Veloski J, Gonnella J. The devil is in the third year: A longitudinal study of erosion of empathy in medical school. Academic Medicine. 2009; 84(9):1182-1191.16. Colliver J, Conlee M, Verhulst S, Dorsey K. Reports of the decline of empathy during medical education are greatly exaggerated: A reexamination of the research. Academic Medicine. 2010; 85(4):588-593.17. Weissmann P, Branch W, Gracey C, Haidet P, Frankel R. Role modeling humanistic behavior: Learning bedside manner from the experts. Academic Medicine. 2006; 81(7):661-667.18. McClenon J. The experience of care project: Students as participant observers in the hospital setting. Academic Medicine. 1996; 71:8:923-929.19. Moskowitz E, Veloski J, Fields S, Nash D. Development and evaluation of a 1-day interclerkship program for medical students on medical errors and patient safety. Journal of Medical Quality. 2007; 22(1):13-17.20. Sakowski H, Market R, Jeffried W, Coleman R, Houghton B, Kosoko-Lasaki S, Goodman M, Rich E. Dimensions of clinical medicine: An interclerkship program. Teaching and Learning in Medicine. 2005; 17(4):370-375.21. Wilkes M, Usatine R, Slavin S, Hoffman J. Doctoring: University of California, Los Angeles. Academic Medicine 1998; 73(1):32-40.22. Wilkes M, Hoffman J, Usatine R, Baillie S. An innovative program to augment preceptors' practice and teaching skills. Academic Medicine. 2006; 81(4):332-341.23. Browning DM, Meyer EC, Truog RD, Solomon MZ. Difficult conversations in health care: Cultivating relational learning to address the hidden curriculum. Academic Medicine. 2007; 82:905-913.24. Smith MD, Henry-Edwards S, Shanahan EM, Ahern MJ. Evaluation of patient partners in the teaching of the musculoskeletal examination. Journal of Rheumatology. 2000; 27(6):1533-1537.25. Pea R, Mills M, Rosen J, Dauber K. The diver project: Interactive digital repurposing. IEEE Computer Society. 2004:54-61.26. Kalish RA, Blanco MA, Hafler JP. Providing feedback and promoting reflective learning through observations of a videotaped outpatient rheumatology patient partner experience. AAMC Innovations in Education Session, Poster Presentation. Annual Meeting Washington DC. 2007.27. Kolb D. Experiential learning: Experiences as the source of learning and development. New Jersey: Prentice Hall, 1984.28. Schon D. The Reflective Practitioner. How Professionals Think in Action. USA: Basic Books, 1983.29. Linn L, DiMatteo M, Cope D, Robbins A. Measuring physicians’ humanistic attitudes, values, and behaviors. Medical Care. 1987; 25(6):504-515.30. Hauck F, Zyzanski S, Alemagno S, Medalie J. Patient perceptions of humanism in physicians: Effects on positive health behaviors. Family Medicine. 1990; 22(6):447-452.31. Watson R, Lea A. The caring dimensions inventory (CDI): Content validity, reliability and scaling. Journal of Advanced Nursing. 1997; 25(1):87-94.32. Hojat M, Mangione S, Nasca T, Cohen M, Gonnella J, Erdmann J , Veloski J, Magee M. The Jefferson Scale of Physician Empathy: Development and preliminary psychometric data. Educational and Psychological Measurement. 2001; 61(2):349-365.33. Hojat M, Gonnella JS, Nasca TJ, Mangione S, Vergare M, Magee M. Physician empathy: Definition, components, measurement, and relationship to gender and specialty. American Journal of Psychiatry. 2002; 159(9):1563-1569.34. Hojat M, Gonnella JS, Nasca TJ, Mangione S, Veloksi JJ, Magee M. The Jefferson Scale of Physician Empathy: Further psychometric data and differences by gender and specialty at item level. Academic Medicine. 2002; 77(10 Suppl):S58-S60.35. Leckie J, Bull R, Vrij A. The development of a scale to discover outpatients' perceptions of the relative desirability of different elements of doctors' communication behaviors. Patient Education & Counseling. 2006; 64(1-3):69-77.36. Wu Y, Larrabee JH, Putman HP. Caring Behaviors Inventory: A reduction of the 42-item instrument. Nursing Research. 2006; 55(1):18-25.37. Tan, W. Y. Sampling distributions and robustness of t, F and variance ration of two samples and ANOVA models with respect to departure from normality. Communications in Statistics. 1982; 11:2485-2511.38. Wilcox, R. R. Why can methods for comparing means have relatively low power, and what can you do to correct the problems? Current Directions in Psychological Science. 1992; 1 (3):101-105.39. Strauss AL, Corbin J. Basics of qualitative research: Techniques and procedures for developing grounded theory (2nd ed.). Thousands Oaks, CA: Sage Publications, 1998.40. Maxwell J. Qualitative Research Design: An interactive approach (2nd ed.). Thousands Oaks, CA: Sage Publications, 2005.41. Davis D, Mazmanian P, Fordis M, Van Harrison R, Thorpe K, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence. Journal of the American Medical Association. 2006; 296(9):1094-1102.42. Bokken L, Rethans J, van Heurn L, Duvivier R, Scherpbier A, van der Vleuten C. Students’ views on the use of real patients and simulated patients in undergraduate medical education. Academic Medicine. 2009; 84(7):958-963.43. Wear D, Zarconi J. Can compassion be taught? Let’s ask our students. Journal of General Internal Medicine. 207; 23(7):948-953.44. Berman JR, Lazaro D, Fields T, Bass A, Weinstein E, Putterman C, Dwyer E, Krasnokuitsky S, Paget S, Pillinger MH. The New York City Rheumatology Objective Structured Clinical Examination: Five-year data demonstrates its validity, usefulness as a unique rating tool, objectivity, and sensitivity to change. Arthritis and Rheumatism. 2009; 61(12):1686-1693.45. Kirkpatrick D. Evaluating training programs. The four levels. San Francisco, CA: Berrett-Koehler, 1994.