Curricular interventions that impact on medical student empathy, well-being and distress: lessons learned at three medical schools

Transcription

1 ICURAM Curricular interventions that impact on medical student empathy, well-being and distress: lessons learned at three medical schools Diethard Tauschel, Witten/Herdecke University, Witten, Germany Friedrich Edelhäuser, Witten Herdecke University, Witten, Germany Aviad Haramati, Georgetown University School of Medicine, Washington, DC Sian Cotton, University of Cincinnati College of Medicine, Cincinnati, OH CENTILE 2017 Washington DC, October 24, 2017

2 How does a six year integrated Integrative Medicine undergraduate medical curriculum impact on students empathy, distress and well-being? Results from a cross-sectional study on the Integrated Curriculum for Anthroposophic Medicine Witten/Herdecke University Christian Scheffer, Gudrun Roling, Maria Paula Valk-Draad, Melanie Neumann, Gabriele Lutz, Marzellus Hofmann, Dirk Cysarz, Diethard Tauschel & Friedrich Edelhäuser Integrated Curriculum for Anthroposophic Medicine - ICURAM.org in cooperation with students dean s office & medical students' representatives

3 Roadmap 1. Background 2. Setting 3. Objectives, study design, methods 4. Results & discussion 5. Future?

4 Background Self-assessed empathy in medical students significant decrease after year 1 & 3 of medical school Newton BW, Acad Med 2008 associated with clinical phase Neumann M et al., Acad Med 2011 no German data

5 Background Altruistic ideals Burks DJ, Med Educ Cynicism Kopelman L, JAMA 1983 Prevalence of burnout Colin West Prevalence of depression / depressive symptoms prevalence from before to during medical school in longitudinal studies Prevalence of suicidal ideation Rotenstein LS et al., JAMA 2016

6 Background critically endangered endangered near threatened vulnerable least concern

7 Setting Undergraduate medical education in Germany YEAR STRUCTURE Pre-Clinics Clinics 6 Final Year M1 M2 M3

8 Setting X

9 Setting approaching Integrative Medicine in undergraduate medical education (UME) Conventional Medicine Model curriculum Witten/Herdecke University

10 Setting: structure of curriculum WHU & ICURAM YEAR Model Curriculum UWH PBL phys. examination Clinics theory & clinical clerkships Practical year ICURAM Basic study knowledge+basic principles man & nature Clinics skills, relationship & personal development PY responsible action

11 Setting: Integration level YEAR Model Curriculum UWH ICURAM POL knowledge & basic principles Phys. examination man & nature PY Practical responsible year action Basic study Clinics Clinics theory skills, & relationship & clinical rotation personal development level of integration

12 The ESPRI 2 T - Approach a model for patient- and student-centered education Explorative learning Team based learning Integrated learning Integrative approach Reflective practice Supported participation Patient-based Scheffer, C., Tauschel, D., Neumann, M., Lutz, G., Cysarz, D., Heusser, P., & Edelhäuser, F. (2012). Integrative medical education: educational strategies and preliminary evaluation of the Integrated Curriculum for Anthroposophic Medicine (ICURAM). Patient education and counseling, 89(3),

13 The ESPRI 2 T - Approach a model for patient- and student-centered education If we aim for an idividualizied patient centered health-care approach, we have to care for an indiviualizied student centred medical education. Scheffer, C., Tauschel, D., Neumann, M., Lutz, G., Cysarz, D., Heusser, P., & Edelhäuser, F. (2012). Integrative medical education: educational strategies and preliminary evaluation of the Integrated Curriculum for Anthroposophic Medicine (ICURAM). Patient education and counseling, 89(3),

14 Objectives & study design to evaluate empathy, distress and well-being in WHU learning environment medical model curriculum integrated IM Curriculum (ICURAM) cross-sectional study online questionnaire - distress thermometer - WHO -5 well-being - empathy: JSPE-S & IRI

15 Study population & ICURAM participation response rate: 36% (n=185) / female: 62 % (n=108) clinical phase (year 3-6): 58% (n=99) academic year % 19% 6 7% 15% 3 25% 20% % complete n=32 partly n=77 participation in ICURAM 44% 37% no n=64

16 Distress Thermometer Results Are you currently distressed? 55% (n=90) reported being distressed ( 6) no significant correlation distress - participation in ICURAM no significant correlation distress - duration of study

17 WHO-5 Well-Being-Index Results How have you been feeling over the last 2 weeks? score below 13 - depression testing indicated: 25% (n=41) score below 7 - depression disorder likely: 6,6% (n=11)

18 WHO-5 Well-Being-Index Results no signif. correlation well-being - participation in ICURAM Spearman correlation r S =-0.002, p=0.975; Kruskall-Wallis-Test χ , p=0.101

19 WHO-5 Well-Being-Index Results negative correlation well-being - duration of study total group no ICURAM (partly) ICURAM r S =-0.206; p=0.008 r S =-0.141; p=0.286 r S =-0.233; p=0.021

20 Empathy Jefferson Scale Physician Empathy student version Neumann, M. Scheffer, C., Tauschel, D., Lutz, G., Wirtz, M., Edelhäuser, F. (2012).Physician empathy: Definition, outcome-relevance and ist measurement in patient care and medical education. GMS, 29(1), 1-21.

21 Empathy: JSPE Results No significant differences across six years

22 Empathy: JSPE Results Empathy higher with higher participation in ICURAM Spearman r=0.300; p<0.001; Kruskal Wallis (KW-Test) Χ2=19.38; p<0.001

23 Empathy: JSPE Results No significant differences across 6 years total group no ICURAM (partly) ICURAM r S =0.107; p=0.179 r S =0.001; p=0.995 r S =0.093; p=

24 Empathy Interpersonal Reactivity Index (IRI)

25 Empathy: IRI Results No significant decrease across six years

26 Empathy: IRI results - subscales Empathy higher with higher participation in ICURAM KW: Χ2=7.55; p=0.023 KW: Χ2=12.88; p=0.002 KW: Χ2=8.02; p=0.018 Spearman r=0.193; p=0.012 Spearman r=0.257; p=0.001 Spearman r=0.172; p=0.025 Perspective Taking (PT) Empathic Concern (EC) Personal Distress (PD)

27 Empathy: IRI results - subscales Perspective Taking (PT) no significant change across six years Total group no ICURAM: (partly) ICURAM rs=0.011; p=0.887 r S =0.062; p=0.643 r S =-0.030; p=0.770

28 Empathy: IRI results - subscales Empathic Concern (EC) no significant change across six years Total group no ICURAM: (partly) ICURAM r S =-0.080; p=0.311 r S =-0.005; p=0.969 r S =-0.154; p=0.130

29 Summary of quantitative results Distress 55% 6 stays equal for the whole group up- and down-turns along curricular stressors no differences between groups

30 Summary of quantitative results Well-being declines with entering clinical phase ICURAM students significantly lower year 4-6

31 Summary of quantitative results Empathy higher in ICURAM students high in clinical phase, no reduction compared to preclinical phase despite distress decline of well-being

32 Learning Environment Results Sources of distress Physicians disrespectful behaviour towards patients Frustrated & stressed physicians percentage 4% 90% percentage 14% 80% Experienced not scarcely rather very as: stressful stressful stressful stressful Experienced not scarcely rather very as: stressful stressful stressful stressful percentage Economic pressure related to patient treatment time percentage Patients in extreme pain 19% 77% 34% 58% Experienced not scarcely rather very as: stressful stressful stressful stressful Experienced not scarcely rather very as: stressful stressful stressful stressful

33 Discussion no specific courses offered for well-being, destressing, empathy indirect influences content way of involving students protective factors?

34 Where do we stand? Species empathy-decline resistant medical students small population small diffusion rate critically endangered endangered near threatened vulnerable least concern

35 Future prospects How to come to a no concern species? directly addressing well-being and distress!? change of medical anthropology!? systemic change of working environment!? Health-care needs economy, but is not a bussiness!??

36 Thank you for your attention! Diethard Tauschel Friedrich Edelhäuser Integrated Curriculum for Anthroposophic Medicine - Witten/Herdecke University, Faculty of Health

37 Discussion Model medical curriculum WHU selection criteria further perspectives Studium fundamentale, interprofessional personal / professional development student centered / PBL lots of patient contact in clinical phase fostering student engagement

38 Discussion ICURAM augmenting medicine with spiritual perspective / non-reductionistic anthropology student- and patient centeredness ESPRI²T approach perception practice early holistic real patient presentation integrated clerkships Integrative Medicine developmental talks clinical Education Ward Integrative Medicine with supervised hand-over of responsibility for patient care clinical reflexion training

39 ICURAM alumni research qualitative, N=10, 12 mo. of working experience positive impact on - conventional medical training - professional development - personal development Brockhaus J et al.: Idealism became viable, something I can put into practice the meaning of an integrated curriculum for anthroposophic medicine for its graduates. (Diss. / ICCIM, Miami 2014)

40 Conventional medical training - e.g. higher interest and motivation to study with scientific details when put into a more holistic and meaningful context - a more multifaceted medical training through ICURAM Brockhaus J et al.: Idealism became viable, something I can put into practice the meaning of an integrated curriculum for anthroposophic medicine for its graduates. (Diss. / ICCIM, Miami 2014)

41 Professional development - e.g. improved self confidence and ability to understand and deal with difficult situations/pat. - improved ability for empathy - more appreciation for interdisciplinary teamwork through positive teamworking experiences during ICURAM training Brockhaus J et al.: Idealism became viable, something I can put into practice the meaning of an integrated curriculum for anthroposophic medicine for its graduates. (Diss. / ICCIM, Miami 2014)

42 Personal development - improved self-management and self reflection - being enabled to implement own ideals into practice Brockhaus J et al.: Idealism became viable, something I can put into practice the meaning of an integrated curriculum for anthroposophic medicine for its graduates. (Diss. / ICCIM, Miami 2014)

43 Anthroposophic Medicine anthropological concept with four different layers in human being - I(self)-organization - emotional organization - life organization - physical body => addressed in diagnosis and therapy Rudolf Steiner, Ita Wegman: Extending Practical Medicine: Fundamental Principles Based on the Science of the Spirit (1997)

44 How? Spirit Individual organization Soul Emotional organization Life processes life organization Physical body biographic counselling, meditation, Eurythmy Therapy art therapies Rhythmic Massage, natural remedies, Homeopathy drugs, interventions

45 ICURAM Curricular interventions that impact on medical student empathy, well-being and distress Witten/Herdecke University Friedrich Edelhäuser Diethard Tauschel Integrated Curriculum for Anthroposophic Medicine (ICURAM) CENTILE Washington D.C., October 24, 2017