Keeping Human Stories at the Center of Health Care

M. Bridget Duffy
Harvard Business Review
Originally published October 8, 2018

Here is an excerpt:

A mentor told me early in my career that only 20% of healing involves the high-tech stuff. The remaining 80%, he said, is about the relationships we build with patients, the physical environments we create, and the resources we provide that enable patients to tap into whatever they need for spiritual sustenance. The longer I work in health care, the more I realize just how right he was.

How do we get back to the 80-20 rule? By placing the well-being of patients and care teams at the top of the list for every initiative we undertake and every technology we introduce. Rather than just introducing technology with no thought as to its impact on clinicians — as happened with many rollouts of electronic medical records (EMRs) — we need to establish a way to quantifiably measure whether a new technology actually improves a clinician’s workday and ability to deliver care or simply creates hassles and inefficiency. Let’s develop an up-front “technology ROI” that measures workflow impact, inefficiency, hassle and impact on physician and nurse well-being.

The National Taskforce for Humanity in Healthcare, of which I am a founding member, is piloting a system of metrics for well-being developed by J. Bryan Sexton of Duke University Medical Center. Instead of measuring burnout or how broken health care people are, Dr. Sexton’s metrics focus on emotional thriving and emotional resilience. (The former are how strongly people agree or disagree to these statements: “I have a chance to use my strengths every day at work,” “I feel like I am thriving at my job,” “I feel like I am making a meaningful difference at my job,” and “I often have something that I am very looking forward to at my job.”

The info is here.

Nine risk management lessons for practitioners.

Taube, Daniel O.,Scroppo, Joe,Zelechoski, Amanda D.
Practice Innovations, Oct 04 , 2018

Abstract

Risk management is an essential skill for professionals and is important throughout the course of their careers. Effective risk management blends a utilitarian focus on the potential costs and benefits of particular courses of action, with a solid foundation in ethical principles. Awareness of particularly risk-laden circumstances and practical strategies can promote safer and more effective practice. This article reviews nine situations and their associated lessons, illustrated by case examples. These situations emerged from our experience as risk management consultants who have listened to and assisted many practitioners in addressing the challenges they face on a day-to-day basis. The lessons include a focus on obtaining consent, setting boundaries, flexibility, attention to clinician affect, differentiating the clinician’s own values and needs from those of the client, awareness of the limits of competence, maintaining adequate legal knowledge, keeping good records, and routine consultation. We highlight issues and approaches to consider in these types of cases that minimize risks of adverse outcomes and enhance good practice.

The info is here.

Here is a portion of the article:

Being aware of basic legal parameters can help clinicians to avoid making errors in this complex arena. Yet clinicians are not usually lawyers and tend to have only limited legal knowledge. This gives rise to a risk of assuming more mastery than one may have.

Indeed, research suggests that a range of professionals, including psychotherapists, overestimate their capabilities and competencies, even in areas in which they have received substantial training (Creed, Wolk, Feinberg, Evans, & Beck, 2016; Lipsett, Harris, & Downing, 2011; Mathieson, Barnfield, & Beaumont, 2009; Walfish, McAlister, O’Donnell, & Lambert, 2012).

Cultivating Humility and Diagnostic Openness in Clinical Judgment

John R. Stone
AMA Journal of Ethics. October 2017, Volume 19, Number 10: 970-977.

Abstract
In this case, a physician rejects a patient’s concerns that tainted water is harming the patient and her community. Stereotypes and biases regarding socioeconomic class and race/ethnicity, constraining diagnostic frameworks, and fixed first impressions could skew the physician’s judgment. This paper narratively illustrates how cultivating humility could help the physician truly hear the patient’s suggestions. The discussion builds on the multifaceted concept of cultural humility as a lifelong journey that addresses not only stereotypes and biases but also power inequalities and community inequities. Insurgent multiculturalism is a complementary concept. Through epistemic humility—which includes both intellectual and emotional components—and admitting uncertainty, physicians can enhance patients’ and families’ epistemic authority and health agency.

The article is here.

Competence in chronic mental illness: the relevance of practical wisdom

Guy A M Widdershoven, Andrea Ruissen, Anton J L M van Balkom, & Gerben Meynen
J Med Ethics doi:10.1136/medethics-2014-102575

Abstract

The concept of competence is central to healthcare because informed consent can only be obtained from a competent patient. The standard approach to competence focuses on cognitive abilities. Several authors have challenged this approach by emphasising the role of emotions and values. Combining cognition, emotion and values, we suggest an approach which is based on the notion of practical wisdom. This focuses on knowledge and on determining what is important in a specific situation and finding a balance between various values, which are enacted in an individual's personal life. Our approach is illustrated by two cases of patients with obsessive–compulsive disorder.

The article is here.

Erotic Feelings Toward the Therapist: A Relational Perspective

By Jenny H. Lotterman
Journal of Clinical Psychology
Volume 70, Issue 2, pages 135–146, February 2014

Abstract

This article focuses on the relational treatment of a male patient presenting with sexual and erotic feelings toward the therapist. The use of relational psychotherapy allowed us to collaborate in viewing our therapeutic relationship as a microcosm of other relationships throughout the patient's life. In this way, the patient came to understand his fears of being close to women, his discomfort with his sexuality, and how these feelings impacted his ongoing romantic and sexual experiences. Use of the therapist's reactions to the patient, including conscious and unconscious feelings and behaviors, aided in the conceptualization of this case. Working under a relational model was especially helpful when ruptures occurred, allowing the patient and therapist to address these moments and move toward repair. The patient was successful in making use of his sexual feelings to understand his feelings and behaviors across contexts.

The entire article is here.

Editor's Note: Psychologists do not talk enough about erotic transference and countertransference in psychotherapy.  These emotions happen more frequently than psychologists are willing to admit.

Liberating Reason From the Passions: Overriding Intuitionist Moral Judgments Through Emotion Reappraisal

Matthew Feinberg, Robb Willer, Olga Antonenko and Oliver P. John
Psychological Science, 2012; 23 (7): 788 DOI: 10.1177/0956797611434747

Abstract

A classic problem in moral psychology concerns whether and when moral judgments are driven by intuition versus deliberate reasoning. In this investigation, we explored the role of reappraisal, an emotion-regulation strategy that involves construing an emotion-eliciting situation in a way that diminishes the intensity of the emotional experience. We hypothesized that although emotional reactions evoke initial moral intuitions, reappraisal weakens the influence of these intuitions, leading to more deliberative moral judgments. Three studies of moral judgments in emotionally evocative, disgust-eliciting moral dilemmas supported our hypothesis. A greater tendency to reappraise was related to fewer intuition-based judgments (Study 1). Content analysis of open-ended descriptions of moral-reasoning processes revealed that reappraisal was associated with longer time spent in deliberation and with fewer intuitionist moral judgments (Study 2). Finally, in comparison with participants who simply watched an emotion-inducing film, participants who had been instructed to reappraise their reactions while watching the film subsequently reported less intense emotional reactions to moral dilemmas, and these dampened reactions led, in turn, to fewer intuitionist moral judgments (Study 3).

Avoiding Ethical Missteps

By Alan C. Tjeltveit and Michael Gottlieb
The Monitor on Psychology
April 2012, Vol 43, No. 4, page 68

Psychologists want to contribute to human welfare — and the vast majority of them do. But despite their best intentions, they may find themselves in situations where they unwittingly slip into unethical behaviors.

Most psychologists try to prevent such lapses by, for example, learning the APA Ethics Code and attending risk management workshops to better understand ethical risks. Yet research has shown that such efforts are not enough to keep psychologists from ethical blunders.

How then can psychologists prevent such missteps? We suggest that psychologists at all developmental stages — from student to seasoned professional — are wise to examine and better understand their personal feelings and values and how they can lead to ethical problems. Doing so not only reduces the risk of psychologists drifting into ethical trouble, but also helps move the quality of professional practice from merely adequate to optimal.

The problem and efforts at solutions

Psychology training programs accredited by APA are required to provide ethics education to their students. This helps students and colleagues understand where the “floor” in ethical behavior lies and how the standard of care is commonly interpreted. That usually includes learning the APA Ethics Code, as well as state rules and regulations, relevant state and federal statutes and court decisions, and mastering a particular ethical decisionmaking model.

Unfortunately, research suggests that cognitive strategies alone are not sufficient. Although many psychologists and trainees can accurately describe their ethical responsibilities, they report that they might, in certain situations, act otherwise.

The entire story is here.

Alan Tjeltveit will be The Pennsylvania Psychological Association's Ethics Educator of the Year for 2012.  Nice article and great work over the years educating psychologists in Pennsylvania and across the country.

Oh, and Mike Gottlieb is a great guy too.

Professional Competence in the Face of Life-Threatening Illness

The new issue of *Professional Psychology* includes an article: "Preventing Problems of Professional Competence in the Face of Life-Threatening Illness."

The authors are W. Brad Johnson & Jeffrey E. Barnett.

Psychologists are human. Like our clients, we are nearly certain to encounter difficult life stressors such as relational break-downs, emotional low points, phase-of-life problems, serious medical challenges, or the onset of cognitive decline. Sadly, being a psychologist does little to insulate us from life's tribulations.

At some point during his or her career, nearly every mental health professional will confront a significant health problem. Medical issues may run the gamut from relatively minor (e.g., pneumonia, minor surgery, thyroid dysfunction) to life-threatening (e.g., cardiovascular disease requiring open heart surgery, neuromuscular disorders with a short life-expectancy, various forms of cancer).

Because many psychologists expect to work beyond the typical retirement age, with nearly a fifth reporting that they plan to work until death (Guy, Stark, Poelstra, & Souder, 1987), the probability of life-threatening medical diagnoses occurring during the course of one's career are significant.

But even early career psychologists are vulnerable to life-altering and potentially fatal medical problems (Philip, 1993).

Recent epidemiologic data for U. S. adults between the ages of 45 and 64 indicate that 13% suffer from some form of heart disease and 9.4% have been diagnosed with cancer; between the ages of 65 and 74, these numbers jump to 25.8% for heart disease and 22.5% for cancer (Centers for Disease Control & Prevention, 2010).

Although practitioner emotional health is considered essential and fundamental to the delivery of competent services (Vasquez, 1992), few things may threaten a psychologist's emotional stability more acutely than the diagnosis of a life-threatening illness.

Unfortunately, psychologists are not always effective when it comes to accepting their own vulnerabilities, taking time for self-care, and identifying decrements in their own competence due to either emotional or physical distress (Barnett & Johnson, 2008).

In this article, we direct our focus to the prospect of a life-threatening illness in the psychologist and the subsequent implications for professional competence.

By life-threatening we mean a terminal disease or a progressive medical condition leading to increasing disability and, in most cases, premature death.

Although psychologists are enjoined by the Ethical Principles of Psychologists and Code of Conduct (American Psychological Association; APA, 2010) to ensure their own competence, psychologists struggling with life-altering medical problems may be especially vulnerable to problems in this area.

We highlight how seriously ill and subsequently distressed psychologists may be ineffective at self-assessing and monitoring their professional competence, as well as in making essential decisions about continued clinical practice.

We conclude with numerous recommendations for psychologists designed to both prevent and manage threats to professional competence caused by a life-threatening illness.

Thanks to Ken Pope for this information.