1. Another Elephant in the Consulting Room: Educating Medical Students about Suffering Thomas R. Egnew, EdD, LICSW Tacoma Family Medicine Tacoma, Washington

2. Why is Suffering Important? Four Goals of Medicine* The prevention of disease and injury and the promotion and maintenance of health The relief of pain and suffering caused by maladies The care and cure of those with a malady and the care of those who cannot be cured The avoidance of premature death and the pursuit of a peaceful death * Allert G, Blasszauer B, Boyd K, Callahan D, et al. The goals of medicine: specifying the goals of medicine. Hastings Cent Rep 1996;26;

3. Definitions of Suffering “... an aversive emotional experience characterized by the perception of personal distress that is generated by adverse factors undermining the quality of life.” 1 “... the state of severe distress associated with events that threaten the intactness of the person.” 2 1 Cherny NI, Coyle N, Foley KM. Suffering in the advanced cancer patient: a definition and taxonomy. J Palliat Care 1994;10:57-70. 2 Cassell EJ. The nature of suffering and the goals of medicine. E Engl J Med 1982;306:639-645.

4. Characteristics of Suffering Individual Personal Pertains to the meaning of events May or may not involve pain, but is angst of a differing order than pain Incorporates physical, psychological, social, emotional and spiritual elements

5. “Mechanisms” of Suffering Threat to the integrity of personhood Occurs when an impending destruction of the person is perceived Occurs until the threat of disintegration has passed or until integrity of the person can be restored in some other manner Can occur in relation to any aspect of the person

6. Study Design Survey of a convenience sample of 304 family medicine residents Trichotomous-choice survey of 8 statements based on a review of the literature on medical education and suffering “Suffering” purposely not defined Data analysis by percentages and Chi-square by location of training/gender

7. Survey Statements My medical school education explicitly taught me about suffering as a category of human experience separate from pain My medical school education provided me a good understanding of suffering My medical school education taught me how to diagnose suffering in my patients

8. Survey Statements My medical school education taught me how to interact with patients who are suffering My medical education prepared me to personally deal with my reactions to suffering patients My medical school education taught me that the relief of suffering is an inherent function of being a physician

9. Survey Statements Most of what I learned about dealing with suffering patients in medical school was taught by the modeling I observed with seniors, residents, and attending physicians More explicit attention to and teaching about suffering during the medical school years would have better prepared me for my post- graduate clinical education A section for comments

10. Results 184 surveys returned (61%) Response rates and ages of U.S. and non-U.S. trained physicians were equivalent Graduates from medical schools in 35 states in the U.S. and 18 other countries U.S. graduates perceived more explicit teaching about suffering than non-U.S. graduates (p =.0104) Non-U.S. graduates perceived more learning from modeling than U.S. graduates (p =.0465)

11. Results Explicit teaching about suffering Cohort Agree Disagree Not Sure U.S. Graduates (N = 158) 89 (56%)* 48 (30%) 21 (13%) Non-U.S. Graduates (N = 26) 8 (31%) 9 (35%) 9 (35%) Total Sample (N = 184) 97 (53%) 57 (31%) 30 (16%) Provided good understanding of suffering Cohort Agree Disagree Not Sure U.S. Graduates 84 (53%) 51 (32%) 23 (15%) Non-U.S. Graduates 14 (54%) 5 (19%) 7 (27%) Total Sample 98 (53%) 56 (30%) 30 (16%) *p =.0104

12. Results Taught how to diagnose suffering in patients Cohort Agree Disagree Not Sure U.S. Graduates* 55 (35%) 60 (38%) 42 (27%) Non-U.S. Graduates 10 (38%) 7 (27%) 9 (35%) Total Sample 65 (36%) 67 (37%) 51 (28%) Taught how to interact suffering patients Cohort Agree Disagree Not Sure U.S. Graduates 110 (70%) 36 (23%) 12 (8%) Non-U.S. Graduates 16 (62%) 8 (31%) 2 (8%) Total Sample 126 (68%) 44 (24%) 14 (8%) *One U.S. graduate neglected to answer this question, N = 157

13. Results Prepared to personally deal with suffering Cohort Agree Disagree Not Sure U.S. Graduates 81 (51%) 52 (33%) 25 (16%) Non-U.S. Graduates 11 (42%) 10 (38%) 5 (19%) Total Sample 92 (50%) 62 (34%) 30 (16%) Taught that relief of suffering is an inherent function of being a physician Cohort Agree Disagree Not Sure U.S. Graduates 105 (66%) 34 (22%) 19 (12%) Non-U.S. Graduates 15 (58%) 5 (19%) 6 (23%) Total Sample 120 (65%) 39 (21%) 25 (14%)

14. Results Most learning taught by modeling Cohort Agree Disagree Not Sure U.S. Graduates 96 (61%) 47 (30%) 15 (9%) Non-U.S. Graduates 22 (85%) * 2 (8%) 2 (8%) Total Sample 118 (64%) 49 (27%) 17 (9%) More explicit teaching better preparation for post-graduate education Cohort Agree Disagree Not Sure U.S. Graduates 83 (53%) 42 (27%) 33 (21%) Non-U.S. Graduates 17 (65%) 4 (15%) 5 (19%) Total Sample 100 (54%) 46 (25%) 38 (21%) * p =.0465

15. Limitations Survey not piloted, may not be valid Lack of definition of “suffering” Trichotomous choice not nuanced Study population represents a single specialty Survey used self-report and is subject to recall bias and the outcome measures are not robust

16. Summary May be significant gaps in training about suffering at the medical school level Comments: Little training about suffering in the clinical years of medical school Medical students are not being taught how to diagnose suffering Most teaching about dealing with suffering occurs through modeling

17. Diagnosing Suffering* Ask patient: “Are you suffering?” Cues: Appreciating the sights and sounds of suffering Loss of a sense of connection with patient Empathic identification *Cassell EJ. Recognizing suffering. Hastings Cent Report 1991;21:24-31.

18. Challenges to Diagnosing Suffering Dependent on clinician’s subjective experience Potential for vicarious suffering The mandate to act, to “fix” problems Requires mindfulness Requires narrative competence Requires openness to non-biomedical aspects of the patient’s life

19. Teaching about Suffering Build a conceptual framework Provide role models who actively diagnose suffering at the bedside Reflect issues of suffering in the medical case history Address suffering in care plans Provide time for reflection/teach reflective skills

20. Teaching about Suffering Build a conceptual framework Provide role models who actively diagnose suffering at the bedside Reflect issues of suffering in the medical case history Address suffering in care plans Provide time for reflection/teach reflective skills