Calibrating the Physician Dennis H. Novack, MD; Anthony L. Suchman, Mt ‘American Academy on Physician and Patient Physicians’ personal characteristics, their past experiences, values, attitudes, and biases can have important effects on communication with patients; being aware of these characteristics can enhance communication. Because medical proach to promoting personal awareness, we propose a “curriculum” of 4 core topics for reflection and discussion. The topics are physicians’ beliefs and at- titudes, physicians’ feelings and emotional responses in patient care, challeng- organized activities that can promote physician personal awareness such as support groups, Balint groups, and discussions of meaningful experiences in medicine. Experience with these activities suggests that through enhancing Personal awareness physicians can improve their clinical care and increase training and continuing education programs rarely undertake an organized ap ing clinical situations, and physician self-care. We present examples of HOWEVER WELL phy earned the science of medicine, they use themselves to practice its art. They ean knowingly use certain skills to elicit a patient's story, work through a diagno- sis, promote rapport, and influence pa- tients’ understanding, decision making complianee, and emotional well-being. Physicians’ effectiveness in using these skills, though, depends on a variety of personal factors." ‘Using their emotional resources and experiences, physicians eonneet with. Fem the Dwaion of Woceal Eavcaton, NEP Hannemann Sonal of Made. legen Uni fly ofthe Hest Setences, Phiagephia, Pa (Or Hoven Univers of Rochestr Senaut Mod (Gre aed Dairy Aechoste, Ny (Ore Suchen Epstan, ena Kanan Assen Resource Cee Midcoatt Mosptl, Bath Me (Or Clr) and Sant Barvoioman’s end ta Roya Lengon Senco (Cettaborn ‘astral patpans inne Working Gown an Fie. ncn Pryecan Persona Antena eed a oe Sachs anc Repiris Deris Novack MD, Orson cl Mace Education, MCP-Hahnemara S2hoo! of Modine, ‘Aloghery Unberiyof te Manin Slane, 2205 ‘Qunen he, Pubaala, Pa tot 502 JAMA, August 13, 1997—Vol 278, No.6 ‘satisfaction with work, relationships, and themselves. asta, 197273502509 patients and support them through myriad distressing situations. Physi- cians’ personalities, personal histories, family and cultural backgrounds, values, biases, attitudes, and emotional “hot buttons" influence their reactions to pa- tients. Unrecognized feelings and atti- tudes can adversely affect physi tient communication: they may interfere with physicians’ abilities to experience and convey accurate empathy®!;may pre- clude or distort meaninggul discussions with patients about dying, sexuality, and other difficult topics; or may lead to underinvelvement or overinvolvement, with certain patients Unacknowledged needs can “leak” inappropriately during the medical encounter and endanger the physician-patient relationship ‘Because physicians use themselvesas instruments of diagnosis and therapy," personal awareness can help them to “calibrate theirinstruments,” using them selves more effectively in these cap: ties. We define physician persanalaware- ness as “insight into how one’s life experiences and emotional make-up af- Personal Awareness and Effective Patient Care iia Clark, MD; Ronald M. Epstein, MD; Eva Najberg, MSc; Craig Kaplan, MD; for the Working Group on Promoting Physician Personal Awareness, fectone'sintoractions withpptions, fai lies, and other professionals.” Physic cians ean increase their personal awareness through a variety of ap- proaches, Most involve reflection aboot past and present experiences, in sol tude or with others, and often require time se aside fromthe usually hetiepace of training or work life. Mental health professionals, whose work demands use of “self” toadsistpa- tients in emotional pain, pertiipate in refletive educational experiences, Ef fective therapists monitor their emo- tional responses toinform the therapeu. tie process for their patients’ benefit, Because medica practitioners routinely ‘work with patients in emotional pai, frequently diseuss sensitive issues, and counsel people experiencing minor and major stressors, it would seem essential that they have similar training. Some writers have stressed the im- portance of activites that promote per- sonal awareness in medical edtcs- tion,®**notingthatimproved awareness fselitates healingrelationships with ps tients" and coping with stress Oth- ers have emphasized the value of sup- port groups in promoting personal and professional growth, as wellagphysiian ‘mental health > Physisians who become moreavareoftheinfluencesof personal factors on their behaviors can better ex- amine how and why they make behay- ioral ehoices. Their ehoiges ean become more informed and potentially more free. Personal awareness ean be a first step in stimulating adaptive attitudinal and behavioral changes. It can also lead toa deeper and more sophisticated un- derstanding of patients behaviors. ‘Yet medical school and residency eur ricula often do nt inelude these sti CCaltrating he Physician —NovacketPhysi- rsonal of ap- n about in soli require pace whose sist pa ipate in ces, Ef erapel benefit. sutinely al pain, ues, and nor and ssential the ine steers clea witha colle of sal and hysan become personal teres *bebat ‘eime east adn soled sted un ties"! Worse, some aspects of medical exlucation promote self-defeating att tudes and behaviors®™ that may hinder the development. of trainee personal swareness. Practicing physicians, frus- trated by certain patients or aspects of ther practices and occasionally stressed to the point of burnout," might benefit from envching their awareness in inter. actions with patients and colleagues However, we know of only a few orga- nized community activities ormedica con ferences witha personalawareness focus, ‘Our interest in physician personal awareness derives fomactviies Since 1883, we have participated in facalty de- velopment courses sponsored by the “American Academy on PhysicianandPa- tient (AAP, formerly the Task Freon the Medical Interview of the Society of General Internal Medicine). The AAPP courses, aimed at improving interper- tonal skills in teaching and practice, include discussion groups on personal awareness, Toensurethesuceessofthese sroups, webavehad expert guidance (see acknowledgments) In adition, we have {nclitated housestaffsupport meetings” and other reflective discussion groups and have observed how inereased per- sonal awareness enhances clinical effec- tiveness and personal satisfaction. Tnthis article, we draw on these expe- riones as well asthe literature to sug. gest a curriculum for physieian personal "arenes, which ncides core topes for reflection and discussion, We also de- soribe a variey of organized discussion groups that can promote physician per- onal awareness. We hope this presenta- tion wil be of interest both to educators ‘who seek to integrate personal aware- ness activities into medical training and to practicing physicians, for whom en- hhanied personal awareness could benefit their patients and themselves. A CORE CURRICULU ‘TOPICS FOR DISCUSSION AND SELF-EXPLORATION In this section we present a core eur~ riculum in personal awareness (Table), issues worthwhile for every clinician to explore. (This ist has been adapted into formal residency eurriculum, which in- cludes guidelines for individual sessions, readings, and audiovisual resources, available from the first author.) We fo- cus on 4 topie areas related to the prac- tice of medicine: physicians’ attitudes and beliefs, their feelings and emotional responses, challenging clinical situa- tions, and self-care. We diseuss the sig- nificance of a variety of issues within these topieareas and pose ideas or ques- tions that might be considered during personal or group reflection. SAOHA, August 18, 1867—Vol 278, No, 6 Physicians’ Beliefs and Attitudes Core Beliefs/Personal Philoso- phy.—People have core beliefs and atti- tudes that are seldom fully articulated and sometimes are organized into aper- sonal philosophy about life.” These be- liefs and attitudes explain why things happen as they do, define right and ‘wrong, and characterize the nature of one’sresponsibilty towardothers. They often contribute to or are defined by ‘one’s spiritual beliefs. Other beliefs are about the intrinsic trustworthiness and goodnessofothers, about how much eon- trol one needs, about expectations of good or bad outcomes of one's actions, and about one’s inherent self-worth, Core. beliefs and attitudes ean pro- founadly affect how physicians listen, n- terpret, and judge patients’ stories and hhow physicians may empathize with ps- tients and counsel them. Physicians also have beliefs about their roles as physi- cians, For example, we have pilot data showing that medical residents who see redieine more as a calling than a job experience less psychological distress (DHN,,T. Bledsoe, MD, W. Rakowsky, ‘MD, unpublished manuscript, 1994).5x- mining core beliefs about medicine can help answer questions such as, “How available do Ineed tobe tomy patients? ‘What are the scope and limits of my re- sponsibilities to patients? Should Itreat psychosocial and mental health prob- lems?” Dysfunctional beliefs may adversely affect patient care. Martin® identified 4 ‘common dysfunctional beliefs of physi- ‘ian limitations in knowledge isa per- ‘sonal faling;responsibilty istobeborne by physicians alone; altruistic devotion towork and denial of selfs desirable; it is “professional” to keep one's unecr- tainties and emotions to oneself. Certain contexts shape physicians beliefs and altitudes, whieh in turn in- fluence patient care. These contexts in- clude one’s family of origin, sex, and so- cfocultural milieu. Family of Origin Influences. —One's attitudes, felings, and behaviors are of ten influenced by patterns in one's fam- ily of or terns may be passed from generation to generation. Examples are atitudes and behaviors concerning intimacy, anger, and conflict resolution. One learns first from one's family about the nature, ben- efits, and pitfalls of caring, about the roles ofthe earegiver, about the balance of giving and receiving, about the com- runicative aspects of iliness, and about hhow to respond to distress. ‘These dy- namics are fundamentally important to the physician-patient relationship. Pa- tients may remind physicians of family Cove Cured or Physician Personal Awarenass Fiysean tect andaminces ‘ote bsokperconal phlesophy Fam tong nvonces ‘Sccceuta ntuenes Pytoare tots rd amatoal responses ‘maton cre ove, eng, atacin, and ounday sting ininosea cae Ccalergig cneal stuatons “Oat pater (Cargo cing patarse Sac mises Pryssanseeare oancog parson! ans prlesonal hes rover andiatagi stesburroulmpsinent ‘members with similar problems or bo- havioral patterns. Unrecognized identi- fleation ofpatientS with family members can elicit feelings including fears of harming the patient, of inadequacy, of loss of eontrol,and of addressing certain difficult topics Useful questions to consider are “What roles did I have in ‘my family? How might I be replicating these roles in my work environment? What lessons did [learn from my family about the nature of relationships, about the nature of caregiving, and about ac- ceptable responses to ‘illness? What kinds of patients might I be likely to as- sociate with family members? Gender Issues.—Sex is a core ele- ment of identity, and sex-role attitudes and expectations affect communication. Sex thus affects professional develop- ment, clinical decisions, and the physi- cian-patient relationship." Women are underrepresented in certain specialties such as surgery® and are promoted more slowly than men. Women phys cians engage in more preventive ser- vices and screen patients at 2 higher rate than men physicians,§*"in part be- cause women physicians have stronger beliefs about the importance of sereen- ing for mammography and cervical can- cerand report more comfort in perform- ing Papanicolaou tests and breast examinations." Female medical stu- dentsmay be moreinterested in psycho- social aspects of medicine than their male peers. A variety of other studies illustrate how attitudes related to sex affect care: In 1 study, physicians read brief case histories said todescribea man or wom- an) with low back pain or epigastric pain. Although these conditions affect both ‘sexes equally in the general population, “female” patients were said to be over” demanding of elinicians’attention, more likely to present with psychosomatic l- nesses, and more likely to have condi- tions in which emotional factors are prominent.® In another study, women Physicians conducted longer’ medical (Catbrateg the Pryscan—Novack ct al 508talked more, and used commu Nication strategies that were more patient-centered and more positive.” Male physicians, in another report, fe- quently: responded to women's ques- tlons with an answer that was less tech- nical than the question, which may have been partially responsible for those ‘women patients’ tendency to ask more ‘questions and to question their doctors? explanations! Differing aspects of psychological de- ‘velopment of men and women fect core altitudes, expectations, and communica tionstyless* Thusiteanbeusefilformen ‘and women students and physicians to cuss their sex-related attitudes. as {hey affet their communication with pa- tients and each other. Usefil questions include, “What messages did I receive from my family and society about sex roles? How havo my attitudes eontrib- Uted to instances of miscommunication With others of the opposite sex? Are there any differences in the way I re- spond tomaleand femalepatients? Inthe ‘way male and female patients respond.to me? Do Irespond dferently to feedback from male or ferale colleagues?” Sociocultural Tnfluences—A.vari- ety of sociocultural influences shape piysician attitudes that affect patient care. For example, physiefantransmis- sion of information to patients is related to characteristics of patients (sex, ed cation, and socal elass) and physicians (Gocial class background and income) Sociocultural norms influence phy: cians? attitudes toward acceptable ness behaviors, obesity, sexual behav- iors, geriatric patients “amily values,” theimportance of work, and many other emotionally charged issues. Moreover, somecontend that medical training eon- stitutesadistine culturethat facilitates socialization into the profession Sociocultural inftences may espe- cially shape physician behaviors when interacting with patients and profesion- als from differen cultures. Inaddition, a substantial number (more than 40% in internal medicinevesidency training pro- rams) of physicians in training are for- gn born and trained. These residents face a number of challenges, including prejudice language problems, and dif feronecsin cultural norms. Forinstance, Pakistani and Indian residents often come othe United States without formal ‘raining in pelvic examinations (or male residents) or testicular examinations (or female residents), beets in their eul tures it would be inappropriate for pa- tients to seek care related to sexual health from physicians of the opposite sex. Its therefore important in edues- tional settings toencourage diseussionof similarities and differences in cultural 504 JAMA, August 13, 1997—VO1278, No.6 norms and assumptions and toprovidea safe, secure atmosphere in which to ex- plore cross-cultural awareness = In exploring sociocultural influences on alitides it can be usefl to ponder tnd diseuss these questions: “To what culture do.T belong and/or with what ealture do identify? What values come toxmind that I particularly like and dis- Tike as T reminisce about my cultural heritage? In reflecting on @ cross- cultural interaction with a patient or colleague, what factors helped me feela sense of ongruence (in syneh’) andlora sense of dissonance Coutofsynch’). How has the ‘ulture’ of medial training af- fected my attitudes? Whatismy institu tionalorpracticecultureandhow doesit respond to my needs?” Physicians’ Feelings and Emotional Responses in Patient Care While medical eare evokes a wide va riety of feelings in physicians that affect their interactions with patients, we fo- us on 2 core emotions: love and anger. Love,Caring, Attraction,andBound- ary Setting in Medical Care—Physi cians’ love and earing for patients con- tribute to patients’ experience of physielan empathy and can be heal- ing?” However, this love and earing are only beneficial ifframed within clear, mu- tually understood boundaries.” Some- times, perhaps because of unmet per- sonal needs, physicians may send ‘unintended messages or became tooemo- tionally investedin certain patients, For physicians in small towns, whose neigh- ‘borsand friendsbecome patients, and for physicians whose family members fallil, setting clear boundaries may be espe- cially difffeult *¥ Also, patients may misinterpret appropriate caring andem- pathy. Because physician-patient rela- Uonships often engender a special in- timacy, there is potential for powerful feelings ofattraction tobe aronsedin both caregiver and patient.© These feelings ‘may induce physiciansto become overly distant, engendering patient and physi- cian dissatisfaction, or to become overly involved emotionally or even sexually, hich willhaveseriouspsychologicaland clinical consequences. Personal aware- ness and understanding of emotional re- actions to patients allows physicians to appropriately set effective boundaries that allow for both objectivity and eon- nectedness with patients." ‘AngeriConflict.—Some fear anger as potentially destructive, some see anger as natural and sometimes helpful in re lationships, and others may weleome and inviteconfiets as away ofdefiningthem- selves and relating to others. Physi- cians who have predominant fears of or attraction toanger and conflict may find that these attitudes affect their pationt care. Physicians vary inthekinds oft. Stions tht wil arouse their anger, and thelrabtiestotachlcertainissuesiay bealfectedby personalassociations They have varying skills in conflict reeohc tion whieh n tur aft their attitudes toward confit. Slt-nowedgeabout the Sources and triggers of one's anger and attitudes andskillsrelatedtoconfctare particulary important because angers Reormmon response tliness suffering, and death, Physicians also must work with diverse members ofa health care team ineluding managed eare adminis: trators whose etloak and behavior my hot maich te physician's expectations Useful questions incude the folowing: "What cortsofpatientselict anangry re actioninme? What worcstuationstsu- ally make me angry and why? What are my usta esponses (omy ownanger end the anger of others (eg, do Toverreact, placate blame others, press my feel Ings, bécome superseasonable?)? What are the underlying feelings when I be- come angry (eg, feeling rejected, humili- Sted, unverthyy? Where aid Tene my responses tanger? Distassingthistopc tvith others and taying out alternative strategies for dealing with anger* can fnrichand deepen one’s understanding. Challenging Clinical Situations Certain common challengesin linia practice best illustrate the importance of understanding one’s attitudes and emotional responses to patients. Difficult Patents. All physicians findsomepatients dificult,” someeven “hateful” Many of these patents have symptoms that elude understand- ingand fallto improve with appropriate therapy, despite high-quality efforts to diagnose and treat disease. Many hav tmajor psychosocial stresses in. their lives and peyehiatrie diagnoses" that dllermine the nature oftheir symptoms and responses to treatment. These pa tientshavemore fnetionalimpairment, health care utilization, and disatisac- tion with care. Physiians’ attitudes about working with patients who have psychosocial and behavioral problems fean determine their clinical effet ness with these patients, Moreover, 8 physician's emotional reactions toa “it ficult” patient can provide limportant elutes to the patient's emotional sate. ‘Whilemestphysiciansmay find certain patents il samo psa be eause of personal biases, may find some patients particularly dificult eg soba Jes, obese people, dependent patients. pochondracs). These biases may prevent Some physiians from acquiring thes toeffecively treat these patients. By ds cussing their thoughts and feelings about Crating the Prypican Novack 8vatient ofsitu: er, and esmay s.They resolt- titudes th care iminis. ations, lowing: iryre- nsusu: hat are tients rstand- opriate forts to iy have a their 1 that nptoms ese pa irment, atisfar titudes no have ~oblems fective- oavdif- portant. stale, icertain ans, be- id some aleoho: nts, hy- prevent he skills .Bydis- geabout vacket fie patients, physiianscan help each ther understand their personal biases, felieve some of the emotional pain that nay be associated with these biases, and tolp each other gain new perspectives in working with various kinds of “difficult” patients, Caring for Dying Patients —Short- comings in physicians’ communications ‘vith dying patients lead toneedilesssuf- fering Few training programs offer sificient attention to communicating with dying patients," even though sach training can improve student atti- fudes* Experiences with death and fears of vulnerability and death pro- foundly influence physicians’ care of chronically land dying pationt,° the giving of bad news to patients and fami- fies," discussion of advance diree- tives, and work with grieving pa- tients and families° Because of their attitudes and beliefs about death or the ‘emotional pain oflosing.a patient, phy cians may become distant or overin- yolved or may undertreat or overtreat the terminally il, Reading literature and poetry about the experience of dy- ing" and physieianaccountsof their own terminal ilinesses!* ean aid personal reflection. It can be useful to diseuss ‘withotherphysiiansperconalattitudes and experiences of eommunicating with ‘grievously ill patients and their families ‘nd tofocus on such questions asthe f lowing: “How have my personal experi- ences with loss and grief affected, en- hanced, or limited my abilities to work with dying patients? What are may oven sititudes and fears of death and vulner- ability and how do they affet my pax tient eare? If] were dying, what would | ‘want and need from my physician?” ‘Medical Mistakes—Physicians at tudes, beliefs, and responses tomistakes can greatly influence patient. care." ‘Though they cognitively understand that it is human to err, many physicians ay nevertheless felthat they ought to be perfect. These physicians will expe- rience excessive guilt and shame if they rmakemistakes, especially mistakes that lead to adverse outcomes. Physicians may be troubled for years after a mis- take, may order excessive diagnostic testing toavoid mistakes, and may inap- propriately. treat. patients. based on overgeneralizing from a mistake. Ph sicians who do not aecept the limitations of their responsibility forall that hap- pens to patients and the limitations of their eraft may defineadverse outcomes aasmistakes (even when most other phy- sieians would havo made similar treat- ‘ment decisions). Many physicians wil not discuss their mistakes with others, taking it ess likely that they willlearn {om their mistakes or heal emotionally. SHOWA, August 13, 1997—Vol 278, No. 6 ‘Many who feel that they made serious nistakes will withhold information or offer misleading information to fami- Tics which may increase their sense of guilt and shame. Those who accept responsibilty fora mistake and discuss it may be more likely to make eonstruc- tive changes in their practices than those who attribute mistakes to job overload.” Patients want physicians to Aiselose mistakes, and patients say they arelesslikely tolitgateafter disclosure than if they discover physieian’s errors by other means." It may be especial beneficial for physicians to disenss their ristakeswithother physicians organiz~ ing their diseussion into 6 topie area ‘Wat was the nature of my mistake? What aremy beliefs about the mistake? What emotions did I experience in the aftermath of the mistake? How di T cope with the mistake? What changes aid T make in my practice asa result of the mistake?” Participants in such discussions can formulate effective ap- proaches for preventing and responding to mistakes, both at the systemic and personal levels. These discussions also promote a callaborative model of train- ing and practice in which physicians? support for each other promotes a eli rate for discussing and learning from nistakes, Physician Self-care Physicians cannot be completely ef- fective in patient eare if they are dis- tracted by distressing personal issues. Reflectionand increasedself-awareness can help maintain a more satisfying bal- ance between personal and professional activities. Physicians ean also monitor their stress levels and formulate adap- tive responses to stress as a way of pre- venting “burnout.” Balancing Personal and Profes- sional Lives—Physicians often com- plain of having “unbalanced lives, with too much time devoted to work. Over dedication to work can lead to profes- sional dissatisfaction, unhappiness at home, physical and emotional problems, and resentment and impatience with normal patient eare demands. Conflict ‘at home may exacerbate this imbalance ‘as physicians further retreat into work, ‘The myriad responsibilities of patient ‘caremay appear toleave physicians with litte control over their time, However, physicians invariably make choices and ‘ay leave certain assumptions unchal- lenged. Bringing these choiees and as- sumptions to light can help physicians relinquish a stance of “victim” and take ‘more responsibility for their choices and their lives. They ean also choose to set asidetime to workonimprovingrelation- ships with signiffeant others, setting sgoals,reading, trying now behaviors, and attending courses that promote” im- proved relationships!" Useful ques- tionstoconsiderinclude, “What wouldbe an ideal distribution of time between ‘work, play, family, and personal growth and development? What are the barriers to achieving balance in my life? In what ‘ways could my assumptions and beliefs boa barvier to change? In what ways is the current imbalance benefiting me and ‘would I be willing to give that up?" Preventing and Managing Stress! Burnout/Impairment—Imbalance in life contributes to physician stress, ‘There are many other stressors, includ ing work overload, administrative and financial pressures, and dealing with pa- tients’ suffering, Some studies find that about, 25% of physicians experience psychiatric morbidity and burnout: Bumout often means impairment, in- lading depression andaleohol and other abuse in training programs as well 288 Physielans for whom patient care satisfies unmet emotional needs, hecause of past deprivations or current personal difficulties, may be es- pecially prone todruguse, maritalinsta- bility, and mental health problems.* Awareness of personal factors that con- tribute to stress and eoping ean lead to adaptive behavioral changes. Enhanced personal awareness could counteract the denialof feelings that promotes mal- adaptive responses to stress, Time set aside fr refletion and discussion fai tates identification of internal and ex- ternal stressors in training and practice, cffectivestrategies ormanagingstress, changes that can be made in attitudes and behaviors, and ways ofunderstand- ing and improving relationships. It is useful for eolleaguestoevaluateand dis- cuss their suceesses and failures in a tendingtotheirprioritiesandtodevelop strategies for rearranging priorities to keep them consistent with personal and professional goals" Using Group Discussion to Promote Physician Personal Awareness A vatiety of group discussion activi- tics in medical training or arganized for practicing physieians ean promote per- sonal awareness. Depending on the depth of exploration desired, some ae- tivities require experienced facilitators to create a supportive atmosphere that ensures safety and confidentiality while encouraging participants to focus on the relevant topies and emotional issues. ‘Theseactivitiesare generally not meant tobe psychotherapeutic in the sense of focusing on self-awareness to treat the ‘emotional distress of individual partic pants, Facilitators usually articulate Catorating the Physician—Novack etal 505cls mits tothe scape and range othe discussion and inquiry, urging partie pantstoshareasmuchoraslitleastheir comfortallows.Forthemast part group dliseussionsfocason personal awareness 4s related to clinical care and profes- sional relationships to enhance partici Pants’ efetivoness as ells and colleagues. Intheprocess, however, pa ticipants may gain useful insights help- {alto their personal lives as well, Key issues listed above can be formally ot informally discussed in many of these activities. Support Groups.—Some medical training programs organize regularly scheduled group sessions to help traine ces establish abalanee between the hi. man and technical aspects of elinieal care. Practicing physicians som times organize support groups in the communities." Although they vary in their eontent and structure, support ‘groups provide opportunities for work ing through the broad range of conflicts that inevitably arse in elnical eare and redical training" At the Rhode Ts- Jan Hospita,a wookly meeting was at- tended by between 5 and 0 hate staf, dependinggonneed:* Forexample, when ‘resident developed a malignaney, vir tually the entire house staff attended. Pressingemotionalissues were often dis. cussed. “One of my patients asked meto ‘tumoffhisrespiratorthismorning. What should I do?” or "The pulmonaty fellow aceused me of murderinghis patient! Did Teal ofthe code too soon?” House staff often faced thei fears and inadequacies and learned from their eolleagues, Sup- Port groups can also beusedin anad hoc fashion, One ofus(CK) suggested anim promptuhousestaffmeeting whena es dent's 4-year-old child died suddenly. House siaff and faculty attended the 2:hour session to relleot on and diseuss the strong feelings that arose fom this incident. Balint Groups—In the 1950s, Mi chaeland Enid Balint suggested that the ‘most frequently used “drug” in medical practice was the physician and proposed studying the properties of this thera- peutic agent.#*"They met regulary with group of general practitioners, who took turns deseribing their interactions with challenging patients and families. Group members worked to understand their attitudes and motivations in their interventions with patients. With the help ofthe Batints and their colleagues, enhanced personal awareness often led to enhanced clinical effectiveness, Since then, Balint groups" have become an important curricular eomponentof many family medicine residencis!™"™ and oc- casional continuing medical education rograms."* Many current Balint groups 506 JAMA, August 13, 1997—Vol278, No.6 use formats distinet from the psychoana- Ite focus of the original group formats, Facilitators represent a broad range of Giseiplines, including. psychiatry, psy- chology, family therapy, and family medi cine, each of which has made eontribu- tions and refinements tothe format." In addition to discussing challenging pa- tients, sessions may also focus on other fssues such as balancing personal and ‘work lives, relationships with colleagues, and ethical dilemmas. ‘The International Balint Federation’ promotes these ae- tivities, Family of Origin Group Discus- sions —Family of origin group diseus- sions are a curricular component of many family medicine resideney pro- grams to help trainees better under- stand their strengths and blind spots when counseling families. Inthese exer- cises, participants construct personal sgenograms and discuss them in facli- tated small group settings. Genograms are family trees that graphically depict the nature of relationships between family members. Conflicts, family roles, strengths, myths, expectations, “trian- gulation,” and other qualities of family dynamics are discussed to the extent that group members feel comfortable. Group members discuss how their fam lies of origin have given them particular strengths and insights. These sessions help participants to place their indi- vidual difficulties in a larger family and social context and toreflecton their own characteristic ways of relating. By adopt- ing an explicit focus on strengths rather than shorteomings, participants canlearn about themselves in an environment of psychological safety and empower- rment.*# Meaningful Experiences Discu: ssions.—In focused workshops at the na- tional meetings ofthe Society of General Internal Medicine and in APP faculty development courses, participants have shared meaningful experiences in their clinieal work."*" Faculty have asked medical students on clinical rotations to write brief narratives about meaningful patients and to reflect on their learn- ing:"™*" Physicians’ and students’ sto- ries are often “critical incidents" that were meaningful because of a sense of connection with patients,” because they substantially changed their inter actions with patients, or changed their perceptions of their caregiving roles, Personal Awareness Groups—Per- sonal awareness groups are an integral feature of AAPP faculty development and practitioner courses and are sched- uled as daily 2-hour sessions during a 2-day to-day course. The “PA” groups areunstructuredat thestart andevolve according to the needs, concerns, and cohesiveness ofthe t 2 patie eg pana etn personal foes that influence rember eletivencesagaliia teachers Wither faiteion gt seasons generate inaghts tate toeueeesfl patient or studentine ee tins and ofr a chance to expen the empathy and support ot gouge tipante. These groups nay dese Usevae payor other ets ose beyond the cogativeand acta ot Hence new behaviors nace antag” Literature in Medicine Discussion Groupee-Perhaps one tied afsmetet schools for Merature in molt courses. Literary works, especially howe that describe patents set Ge Dhysidansand phyigant saieg ee Farce understanding and empsthy fy Datinte experiences ofleroue ey hemeanings and confts of ho ee clan's cling, Literary dieusion tone partipantistingus olen Feowedge from maratve kpowledes Wie logleoscentiicknowledgecane learned fom books or oaines hanes tivelnowiedge demands the seve Ushaton ofthe reader orthe physics Hstening to a patents stone acts partepationconselously ues hitocape Fences, values, memorco and ghar tertealsinaserbingmennng Litera traditions of reading namaste fecting provide an sterativefoutets increase prsonalawarcnessar esa sion group partigpants examine dif dng meanings and interpretation that arise from sharing stories, [Behavioral StienceTaterpersonal Skills Curicula~"Medied st ax resideney behavioral sence cuca mma inca discasson gape and oer experiences tha promot personal are ‘exe, Fucly ue al grup formats malate an discus students’ personal reacionstoa variety aftoplesconmony presented in medical school curricula, ‘such as life cycle issues, sexuality, family Feltonship and porsnaly stl Puc ty sess ite nes nce care, sch exploring patents sel pa ems or working wth dying painter: couraging trainees to share experiences, fete ard rare Tn. reideney interpersonal sk teaning programe is aly review audiotape snd videotapes of rainee Pallet interactions tah singe Interact with patients in “ehallanging patient” case Conferences” Teachers may ask about feelings, cognitions and trotvations, and redone nonverbal Behaviors when interacting wih pe tints. Reaentscanthenbetter under stand why they asked about or avoided certain issusand how ther renconsto pallens might serve as usefldagns Caltrating tre Physcian—Novack etlsants, et on group wsand these rriers terae- p par- ide to ‘move expe. ting. iedical icine ecially | their Henging tic material about patients and about themselves. Students and residents may participate in self-help groups, such as Aleoholies Anonymous, or in actual or role-played “being a’ patient” exer- cises.!™ Subsequent group discussions can increase trainees’ understanding of their own feelings and perspectives on vulnerability, control, and body image asrelated to self-esteem, ‘Thus, physicians wishing to incorpo- rateactivities promoting personalaware- ness nto training or practice have many approaches at their disposal. Although varied in format, each ofthese activities encourages participantstoreflecton their responses to the difficult interpersonal encounters of clinical and teaching set- tings. Sometimes interactions between group diseussions pro- vide material for reflection and diseus- sion. It ean be helpful for participants to review chapters from books that eneour- ageself- reflection *"! Some partici- pants may be encouraged to undertake organized activitiesin theirpersonal ime, suchas PAIRS (Practical Application of Intimate Relationships) programs, which focus on enhancing skills that facilitate intimate relationships.“ COMMENT Dataonthecffectivenessofselfaware- ‘ess programs are searee and often an- ecdotal”**=" Some havedeseribed out- comes of structured approaches, For example, McCue and Sachs" deseribe & stress management workshop for res dents with the goals of (1) learning and practicing interpersonal skills that in- crease the availability of social support; (®) prioritization of personal, work, and educational demands;(8)techniquestoin- crease stamina and attend to self-care reeds; (4) recognition and avoidance of maladaptive responses; and (5) positive outlookskils. Residents in the interven- tion group had significant improvement in measures of physician stress over & control group. Mushin and colleagues!" haveinstituted aresidency eurriculumin professional development that encour ‘agesself reflection, withexcellent eval ations by participants. Clearly, far more research isneeded into the effects of per- ‘sonal awareness activities on physicians snd their pationts. Nevertheless, until better data exist, and because physielan ersonalawarenessiscoimportanttothe Dractice of medicine, it seems sensible to inchideasaregular part of medical train- {ngactivities that allow forreflection and Aiscussion of personal aspeets of clinical ‘are. Theseactivitiescouldbe integrated into existing interpersonal skills and be- vioral science courses™™2! as well as {nto clinical rotations, Because personal ‘awareness and growth are lifelong pro- “AMA, August 13, 1907—Vol 278, No, 6 cesses, it could be useful for practicing physicians to engage in personal reflec: ‘ionand participatein Balint groups, sup- port groups, or other organized activities that promote personal awareness, ‘The process of enhancing personal awareness canals enhance physilanpey- chological well-being. Many lines of philo- sophicalandscientificinguiry suggest that “wellness,” or positive psychological fune- tioning, consists oftheprocessesofsetting and pursuing goals attempting to realize ‘one'spotential experieneingdeepeonnee- tions with others, managing surrounding. demands and opportunities, exercising: self-direction,and possessing pesitiveselt regard.” Trainees and practicing physi- cians who pursue activities that enhance personal awareness in medical practice ‘may also work onimproving these aspects of their personal lives. Enhaneed physi- cian well-being should have benefits for patients as well, Physicians may not fully learn how their values, attitudes, expectations and biasesaffect theircaregivingunlessthey hhave a chanee to explore these issues: protected settings. Too often, physi cians learndificultessonsinsolitaryre- flection or by chance discussions in hall- ways or cafeterias, More unfortunately, they can also learn difficult lessons through professional censure or mal- practice litigation, If medical educators respond to the challenge of instituting. and evaluating activities that promote ppersonalawareness,itcouldhaveimpor- tant consequences for physiciansand pa- tients, Enhanced personal awareness should help trainees and practicing phy- sicians become more effective in thelr care of patients and should inerease pro- fessional satisfaction, perhaps prevent- ing or alleviating burnout."* Those who are more satisfied with thelr practee have more satisfied patients." Physi cians whounderstand theirattitudes to- ward work and toward their profession can make reasonable choices about structuring their work. Those who un- derstand their needs and abilities in re- lation to others ean function more effee- tively as members of health eare teams and as members of families. Including personal awareness as part of medical training may help toestablishadifferent training culture—one that is eoopera- tive rather than competitive, Instead of producing *ironmen” and“ironwomen,” curriculum in personal awareness could help engender cooperation, re- spect, and trust among health profes- sionals. By focusing on enhancing per- sonal awareness in training and in prac- tice, its importance will become widely appreciated asa key tothe effective use of clinical skills and as a basis for medi- cine’s healing art. Other members af the Working Group on Pro- rmotngPhgetclanPersonal Awarenees nbn cont- ted sinifeanty to thie arise: Mary OTe, PhD, Alegheny Unisernity of the Health Sences, hide, Ps; Rosalen Cregg, MEDS, Sain Bartheame’s and the Ral Landon Ssieel of ‘Medicine and Dentistry Landa, Usted Kings, Stuart Green, MSW, HA, Overlak oeitah So rit, NJjand Richard Frankel, PaD, Primary Care Tpsltste, Rochester, NY. “The authors wish othask Mack Lipkin, MD, for introducing peroal swearenese atv ito AAPP coarse: Penny Willamson, SoD, Jalan Bird, MRCP, Deals Cop, BD, aswell a3 Orenne Strode Maloney, Wiliam’ Maney, MD, Sesst Gitreath, PAD, and their ellen Horan Dimeric n Medial Easeaton alle vtom have ‘tebutedenamsously toourandertandigotthe Inportance ofperaonalsarenesiareicl ean Ingand practi Wethane Thomas A Pledeoe MD, who contributed ieasto the original Rho ead Hositalearseaam for house stat spport group Denn Sraby-Blls, Mark Walch and Weaty Levinson whee werkshopsen etre and ony scans’ mistakes cotrbated to creas on thce abject Reteronces 1, Novack DHL Therapeatcsspests of the eel oepuner J Ges Intern Me. ene 2 Eyetetn BM, Campbell ly Coben Cols SA, MeWhinsay TR, Smiestein& Resspetves on pe ent doctareormoniston J Far Prac 1p staan 4, Mengel MB, Physitan ineffectiveness due to aula pin tests, Fam Sat Med 19SIS17S- im. 4. 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