The Development of a Physician Vitality Program - Wiley Online Library

Journal of Marital and Family Therapy doi: 10.1111/jmft.12085 October 2015, Vol. 41, No. 4, 443–450

THE DEVELOPMENT OF A PHYSICIAN VITALITY PROGRAM: A BRIEF REPORT Barbara Couden Hernandez and Tamara L. Thomas Loma Linda University School of Medicine

We describe the development of an innovative program to support physician vitality. We provide the context and process of program delivery which includes a number of experimental support programs. We discuss a model for intervention and methods used to enhance physician resilience, support work-life balance, and change the culture to one that explicitly addresses the physician’s biopsychosocial-spiritual needs. Recommendations are given for marriage and family therapists (MFTs) who wish to develop similar support programs for healthcare providers. Marriage and family therapists (MFTs) hold a versatile systemic approach that has been used to augment a variety of settings such as organizational consultation (Distelberg & Castanos, 2012), medical resident1 education (Dankoski, Pais, Zoppi, & Kramer, 2003), veterinary education (Hafen, White, Rush, Reisbig, & McDaniel, 2007), and criminal justice (Lee & Nichols, 2009). However, a clinician whose primary role is to address physician vitality in the work setting has not yet been described in the literature. In this paper we report on the first 3 years of development of an MFT-directed support role to enhance physician vitality at a university medical center.

BACKGROUND Loma Linda University (LLU) and Medical Center (LLUMC) embrace a culture of whole person care (Sorojjakool & Lamberton, 2004). This consists of interactive practices to systematically address biopsychosocial-spiritual needs of patients. Although physicians offer whole person care, they have not always felt that they experience it. Medicine’s relational culture has significant issues that result in diminished resilience, professionalism, general productivity and retention (Pololi, Conrad, Knight, & Carr, 2009). Many physicians are concerned about issues that threaten their vitality which include burnout and difficulty maintaining balance between personal and professional responsibilities (Shanafelt et al., 2012), chronic exposure to suffering (Politi, Clark, Ombao, & Legare, 2010), potential litigation (Kreimer, 2012), difficult patients (Breen & Greenberg, 2010), time constraints and high patient flow (Gunderson, 2001), and difficulty addressing their own mental health concerns (Center et al., 2003). If our physicians’ biopsychosocial-spiritual needs are met, we believe they will be more likely to meet those needs in their patients. A Physician Wholeness and Engagement Taskforce was charged by the President of Loma Linda University Healthcare to address physician engagement and well-being. Physician wellness programs across the country were examined and recommendations sought from consultants regarding potentially effective programs for LLU. The taskforce desired a proactive program that would emerge from the unique biopsychosocial-spiritual needs of our physician population and promote general well-being and vitality. The Taskforce proposed the following goals specific to the new position: (a) conduct a needs assessment, (b) create educational programs to enhance physician wellness and improve interpersonal awareness, (c) develop preventive programs to address problematic behavioral and

Barbara Couden Hernandez, PhD, is Director of Physician Vitality and Professor of Medical Education, Loma Linda University School of Medicine; Tamara Thomas, MD, is Vice Dean for Academic Affairs, and Professor of Emergency Medicine, Loma Linda University School of Medicine. Address correspondence to Barbara Couden Hernandez, Loma Linda University Office of Physician Vitality, 11332 Mountain View Ave., Ste C., Loma Linda, California 92354; E-mail: [email protected]

October 2015

JOURNAL OF MARITAL AND FAMILY THERAPY

443

emotional aspects of work, (d) develop resources to improve work-life balance, (e) provide resources for physicians impaired by substance abuse or other dysfunctional behavior, and (f) coordinate with existing wellness plans. An MFT educator and former intensive care nurse was hired by LLU as the full-time Director of Physician Vitality (DPV) to address the needs of both faculty physicians and residents.

PROGRAM DEVELOPMENT Six months were allocated to explore and initiate effective interventions to address physician needs. The DPV perused websites and spoke with clinicians involved in various physician wellbeing programs across the country in order to clarify her role. Three categories of physician support services included activities and goals that were consistent with the DPV role: behavioral education affiliated with residency programs, ongoing experiential groups for physicians, and physician employee assistance (EAP) programs. The Accreditation Council for Graduate Medical Education (ACGME, 2014) requires all hospitals that offer residency programs to offer behavioral education regarding patient care. This is largely an educational role pertaining to psychosocial elements of patient care, and appropriate diagnosis and management of mentally ill patients. Support may be offered through group facilitation or individual supervision of residents. For example, behavioral health educators in a Pennsylvania residency offer weekly Balint groups (Johnson, Brock, Hamadeh, & Stock, 2001) and reflective group learning activities (Sternlieb, 2008). MFTs head up behavioral education at Indiana University’s family medicine residency program (Dankoski et al., 2003) and the Family Medicine Integrative Collaborative Care program at the University of California, San Diego. Common experiential activities for physicians include Balint groups, Finding Meaning in Medicine groups (Evans, 2006), or participation in Schwartz Center Rounds (Lown & Manning, 2010). These may be offered by behavioral educators or contracted therapist facilitators. For example, two hospitals in the Denver area contract with an East Coast organization to provide monthly experiential events and retreats for their physicians. EAP models provide accessibility and confidential therapy for both faculty physicians and residents. This format is utilized by the University of Washington’s Resident and Fellow Wellness program at the University of Washington Medical Center, and through Physician Support Services at Florida Hospital (Paolini, Bertram, & Hamilton, 2013). These centers offer both counseling and staff enrichment activities. There was a general consensus in the Physician Wholeness and Engagement Taskforce that an EAP program model would not be well utilized by LLU physicians, since an institutional EAP staffed by four MFTs already existed. Scheduling can be a challenge with this model since physician schedules are subject to abrupt change and often necessitate late evening sessions. All of the examined programs made valuable contributions in their respective settings and many offered desirable elements that we eventually decided to incorporate into the DPV role. A needs assessment was conducted and the DPV sought suggestions through intensive interviews with six residents, six faculty physicians, and four administrators in order to help shape the DPV role. We anticipated that while residents and attending physicians would have some overlap in their concerns, the groups were sufficiently different requiring separate program initiatives. Residents described significant time constraints but were interested in brief activities that could improve morale without adding to their fatigue. They desired indications of appreciation for their long hours and hard work. Major life concerns cited included effectively parenting small children, maintaining healthy marriages, and interacting constructively with attending physicians whose evaluations were important to their success as residents. Faculty physicians cited such concerns as diminishing reimbursement and increasing system expectations, high patient flow in their clinics, and lack of time for family life. They desired support for themselves and consultations in their work with residents. Of his need for support, one physician stated, “Sometimes, it’s just the despair of medicine,” referring to his need to talk about the recent spate of patient deaths. Some of the physicians explained that they hesitated to use EAP services because in many cases they did not think their issues of concern arose to a level that required mental health intervention, or that they could spare an hour to discuss these issues with a therapist. 444


October 2015

Several asked the DPV to circulate freely throughout the hospital, clinical areas, and physician lounge in order to form supportive relationships and to be visible and accessible for brief, informal consultations. Referrals to EAP and other mental health services could be provided if warranted. This informal “walk-about” approach appealed to the DPV, as she was interested in building relationships with physicians. While introducing the DPV to the physicians it became apparent that referencing her expertise as a therapist initially created distance rather than encouraged physicians to interact with her. The words therapist and therapy were avoided when describing DPV activities and titles such as consultant, coach, and facilitator held less stigma. She initiated some programmatic initiatives that were therapeutic and systemic in nature which later opened doors for brief direct interventions that more closely resembled traditional therapy. Initiatives Forums were created to make the DPV visible to over 900 employed physicians and residents. A website was constructed and rolled out during the first year. The Physician Vitality portion of the site includes self-administered inventories and questionnaires to identify addictions; links to websites and community agencies for counseling and specialized services; links to videos and articles about issues such as dual physician marriage, parenting, and general relationship enhancement; and a series of videos regarding psychosocial aspects of patient care. Residents are invited to post comments in response to a Question of the Month that features issues such as family responsibilities, physician transparency, meaning making, and other relational topics. The Dr. Mom and Dr. Dad blogs shared helpful tips about effective physician parenting. Also featured were LLU’s Wellness Programs that include smoking cessation, weight control, physical exercise incentives, and diabetes management. Individual physicians were profiled periodically and displayed photographs of their involvement in non-medical pursuits such as marathon races, skiing, dancing, or teaching. We also included interviews about their professional and personal lives. There were over 52,000 page views of our website during the last year alone. We developed a menu of psychoeducational lectures that covered portions of the ACGME Professionalism curriculum. The lectures include such topics as the influence of gender in medicine, how to discuss sexual issues with patients and family members, how to hold family conferences, understanding the family context of ill children, and recognition of common social issues that often confound medical compliance (e.g., inability to pay for medication, neglect of chronic medical conditions in elder abuse, etc.). Evaluations regarding the usefulness of the material, likelihood of incorporating the information in practice, and knowledge of the presenter have consistently been 4.7 on a 1-5 Likert scale, with 5 being high. In addition, residents often initiated conversations with the DPV about personal or professional challenges after these presentations. We also have offered experiential group debriefing to help residents and physicians cope with unexpected patient deaths. A two-hour Collaborative Reflective Training (CRT) on delivering bad news to patients was developed (Hernandez & Kim, 2014), utilizing medical family therapy doctoral interns from LLU in a reflecting team during simulations tailored for each medical specialty. This interdisciplinary approach allows physicians to hear therapists’ impressions and speculations about the relational skills they possess or need to develop in order to sensitively and effectively engage in these difficult conversations with patients and families. Qualitative post-CRT evaluations have demonstrated consistent improvement of physician sensitivity and greater confidence of MFT interns about working with physicians. For example, one critical care resident wrote, “I don’t always know the parents of my patients well, but I know now that every time they tell the story about their daughter who died, I will be part of it. It’s a good reminder to think about how I say, “Your child is dying.” In collaboration with the Physician Professionalism Committee, we developed a peer coach training program. Peer coaches were nominated by their department chairs, given a 2-day training of didactic and experiential exercises that taught them active listening skills and problem-solving and referral protocols. Peers will be matched with physicians experiencing personal or practicerelated difficulties. Quarterly workshops are offered on topics such as the legal and ethical constraints of their role, effective use of questions, and conflict resolution. Peer coaches refer physicians to the DPV for consultation if necessary, resulting in either a follow-up visit with her or October 2015


445

referral to other mental health providers. The DPV serves as both a resource and a facilitator of physician’s skills and tries to support the physician’s sense of ownership for, and investment in, this and other support programs. Several initiatives have afforded greater visibility and collaborative experiences across the healthcare system and university. The DPV coordinates the annual Physician Recognition Award nominations for clinical practices that support the institutional values. Winners receive recognition and a modest monetary gift at an award banquet. One physician wrote, “Thank you for this program. It means a lot to be recognized for excellence and service in front of our peers!” Physician referrals to the DPV have resulted from presentations in departmental meetings annual orientations, and retreats, debriefings after clinical crises, and collegial relationships with nursing staff resulting from facilitating Schwartz Center Rounds. Frequent visits to the medical staff lounge have led to numerous “curbside consultations” about patient deaths, difficult patients, children, and relationship issues. The DPV participates in patient rounds with various groups such as palliative medicine and critical care. Her role includes asking clarifying questions that highlight the needs of patients and experience of doctors, and debriefing difficult end-of-life cases. She provides a meal for the team and incorporates elements of spirituality or poetry to provide soothing or evocative commentary on the experience of assisting patients to achieve a dignified death. Private conversations in the hallways or later, over lunch, often follow these interactions. Home visits for crisis management have been made after catastrophic events such as an unexpected death of a physician’s loved one, diagnosis of a debilitating illness, or the physician being thrust into a caregiving role with a family member. These visits have helped sustain physicians until they have been able to mobilize other resources for ongoing support. The DPV has pursued research studies with medical students and residents that target unique challenges to physicians such as gender differences in medicine, psychosocial practices at end-oflife, or effective programs for physicians in abusive relationships. This has established professional connections, trust, and the DPV’s credibility as a colleague. Quite unexpectedly, the DPV discovered that a number of physicians are excellent photographers and artists. This has led to a rotating photography exhibit in the medical staff lounge. A permanent physician gallery that contains photographs and paintings is being designed in a highly visible area of the hospital. A benefit exhibit at a local art gallery was organized to purchase rocking chairs in the pediatric emergency department. We anticipate that these creative endeavors, which have garnered considerable enthusiasm, will help to offset burnout and enhance physician resilience (Belfiore, 1994). Direct Interventions The vast majority of physicians function remarkably well given their long hours, life and death decision responsibilities, interpersonal challenges with colleagues and ancillary staff, and potential litigation from upset patients. They are required to be in contact with personal, collegial, public, administrative, corporate, and financial entities daily. Academic physicians have additional responsibilities such as research and training of students and residents. The mandate to manage all of these competing responsibilities requires emotional, spiritual, physical, and mental stamina. Intervention Model Review of the literature regarding physician challenges lead to the creation of a model to guide the DPV when interacting in one-to-one consultations, so that a wide variety of physician issues could be addressed. In traditional medical family therapy, the practitioner addresses needs within and between an array of players in the patient system (Rolland, 1994). The DPV developed an intervention model based on Bronfenbrenner’s ecosystemic theory (Bronfenbrenner & Evans, 2000) that accounts for four major categories of contextual elements that influence physicians’ personal and professional lives. These categories include idiosyncratic psychological and spiritual issues (Self), relationships within the physician’s families of origin and creation (Family Socialization), relationships with colleagues, administration, professional affiliations and practices related to third party payers (Professional Context), and personal and professional responses to patients and the clinical setting (Patient Care). 446


October 2015

Some physician concerns in the Self category have pertained to underlying personality constructs such as depression or compulsivity. Such individuals who suffer from untreated anxiety or depression have responded well to several brief encounters that explored situational concerns contributing to their symptoms. The DPV has provided referrals for psychiatric support when appropriate. Family Socialization refers to family of origin norms about what it means to be a physician and a physician who is a family member or spouse. Interventions that target this category include psychoeducational resources to enhance intimate relationships and provide a sense of balance between work and home, exploring meanings associated with being a physician, and strengthening a sense of purpose. Of particular concern to the DPV are the high stress levels of women physicians as they try to balance the demands of small children plus clinical rotations that require overnight call every third night. This can be guilt provoking and highly stressful. One physician mentioned in a casual conversation that she didn’t think she should have gotten married due to her dedication to her patients. This opened a conversation about how to strengthen her relationship with her husband. She gladly took a referral for an MFT specializing couple therapy and later reported positive marital progress and corresponding professional satisfaction. Professional Context refers to the medical socialization received in medical school, residency, and the way physicians have internalized their role as a healthcare provider. It also includes the meaning that medicine has for them and the personal cost of trying to realize their career goals. One physician asked for suggestions about how to console families after death of their loved one, as he had not yet developed a way to do that which was consistent with his culture. We often discuss The Good Resident phenomenon: completing more work than is required in order to influence the attending physician to provide a good evaluation for them as they apply for subspecialty training. These over-functioning behaviors often lead to burnout and strained family relationships. Patient Care concerns include any challenges that pertain to interactions with patients such as demanding or angry patients, providing end-of-life conversations, or offering culturally and spiritually sensitive treatment to a diverse patient population in keeping with our whole person care model. A common concern is Medical futility: medical efforts to keep terminally ill and dying patients alive at the family’s request, sometimes by means that may cause or prolong pain and suffering. The arising ethical and emotional issues can lead to cynicism, abrasive behavior, and emotional exhaustion: symptoms of burnout and compassion fatigue (Maslach & Leiter, 2008). Individual and departmental debriefings have been offered to enhance resilience by diminishing feelings of isolation of those who are involved in difficult clinical situations.

DISCUSSION During the development of the DPV role over the last 3 years, the goals and activities of the DPV were guided by medical literature that underscored the prevalence of physician burnout (Shanafelt et al., 2012), work-life balance challenges (Dyrbye et al., 2014), and the need for physician support services (Paolini, 2009). As an MFT, the DPV has grounded many of her interventions in literature that enhances relational competence (Institute of Medicine, 2001) and that emphasized the value of affective development for doctors (Ofri, 2013). MFT skills and perspectives have strengthened the DPV’s interventions. For example, disagreements between colleagues or organizational entities are often quite similar to family manifestations of triangles, alignments, emotional detours, and functional boundary violations. Understanding the role of hierarchy, power, and gender in relationships has provided helpful lenses to understand medical hierarchies that exist across and within healthcare disciplines, communication and cultural styles across those hierarchies. We have learned that clinical interventions with physicians are different than those in typical family therapy settings. For example, an advertised lecture on power and privilege in the hospital typically would not garner many attendees. But the same lecture can be successfully delivered in the context of a physician social gathering or retreat that offers continuing medical education (CME) for participants. Poor help-seeking practices of physicians are well documented (Hassan, Ahmed, White, & Galbraith, 2009). There is often considerable stigma associated with seeking assistance for mental October 2015


447

health or relational issues, discouraging many physicians from pursuing much needed treatment (Center et al., 2003). The more informal and conversational interactions have been with the DPV and the less therapeutic jargon used, the more approachable she has become. Rather than suggesting a course of therapy for a physician, it has been more productive to recommend a “meeting to create a success plan.” The DPV has rarely engaged in traditional therapy in her role. However, her collegial conversations contain many therapeutic elements such as following curiosity from a not-knowing stance (Hoffman, 2006), maintaining a non-anxious, objective presence (Kerr & Bowen, 1988), highlighting strengths (Blundo, 2010), utilizing circular questioning (Nelson, Fleuridas, & Rosenthal, 1986), creating alternative narratives based on exceptions (Friedman & Combs, 1996), and tracking physician experience across the Gestalt awareness cycle (Clarkson, 1996). Aligning with physicians often means adopting their issue focused language, conversational pace and communication style: critical skills taught in medical family therapy programs (Bischoff, Springer, Reisbig, Lyons, & Likcani, 2012). There are marked differences between the way doctors and therapists approach patients and clients. Medical interventions are based on algorithms and differential diagnoses and offer specific recommendations for treatment in a parsimonious manner. Therapy, on the other hand, offers a lengthier, less clearly proscribed process. When consulting with doctors, it has been useful to offer an algorithmic framework for the consultation to provide a sense of structure and mastery during the conversation. For example, outcomes and dates for follow-up calls fit the medical model and are easily negotiated at the end of a conversation. Physicians are more likely to accept recommendations for psychiatric evaluation or a visit to the employee assistance program after such a meeting if it fits into a mutually established predictable time-limited plan. We have found it important to understand organizational dynamics in order for the DPV to accommodate to the needs of physicians within their larger context. As Distelberg and Castanos (2012) emphasized, when MFTs serve in more than one role in an organization, care must be taken to delineate intentions and limitations in each setting in order to build trust, credibility and to maintain appropriate professional boundaries. Cost analysis of institutional savings by promoting physician wellness has been estimated at $5 million over 2 years (Paolini et al., 2013). Replacing one physician costs an institution roughly $250,000 (AAFPINS, 2013). There are also numerous hidden costs to training programs and society when residents with performance problems are allowed to complete their training program without intervention (Roberts & Williams, 2011). They may communicate poorly, fail to collaborate with other providers, exhibit boundary problems or lapses in professionalism that can jeopardize patient safety or lead to litigation. Another cost that cannot be fully calculated is physician suicide. Given that 300–400 physicians commit suicide every year in this country (Andrew, 2012) screening and intervention can reduce the cost of replacing these physicians as well as the devastating emotional cost to patients, colleagues, and family members. MFTs that present extrapolated potential cost benefits by improving physician engagement and addressing problematic physician behaviors can help justify the cost of creating a physician vitality position and enhance stakeholder buy-in for the role. MFTs who are interested in creating similar roles for themselves would do well to learn about Balint and Finding Meaning in Medicine groups, Schwartz Center Rounds, and ACGME requirements for behavioral health educators in residency programs. It is also helpful to read medical journals and join organizations such as the Collaborative Family Healthcare Association, the Association for the Behavioral Sciences and Medical Education or The Society of Teachers of Family Medicine to understand current medical practices, medical education, and potential roles for MFTs. Networking with physicians, residency educators, and hospital administrators allows MFTs to learn about specific needs and discuss the potential for a physician vitality role in their organizations. Physicians are critical contributors to the meaning and experience of illness. The practical challenges physicians address are immense, as are the psychosocial and relational responsibilities they hold. The culture that depicts doctors as able to overcome any obstacle, defeat death and easily manage unending, crushing stress, must change. If we do not systematically recognize and validate the difficulties that physicians face, we contribute to a “conspiracy of silent neglect” of these health providers (Paolini, 2009, p. 27). 448


October 2015

CONCLUSION The original goals for the DPV have been addressed during the first 3 years in this role. The physician vitality program at LLU includes components of other physician wellness programs, but the final program is unique to the needs and culture at LLU in that it offers biopsychosocial-spiritual care to faculty and resident physicians through formal and informal initiatives. We will adapt and refine effective practices to support physicians and also begin to augment medical school education to support vitality enhancing behaviors in medical education. Program evaluation initiatives in the next year will examine the effectiveness of both the role of DPV and the activities that have been launched during the first 3 years of practice. MFTs are well prepared to address not only the relational needs of physicians but also the systemic elements that impact their personal and professional lives. We hope that this early description of development of goals and initiatives for this new role of Physician Vitality will encourage others to consider the relevance of MFT to this dedicated and hard working population and offer some ideas for both a structure and process to provide them the support they need.

REFERENCES AAFPINS. (2013). The cost of hiring a new doctor. AAFP Insurance Program. Retrieved December 8, 2013, from http://blog. aafpins.com/index.php/the-cost-of-hiring-a-new-doctor/ ACGME. (2014, May 1). Frequently asked questions: Family Medicine. Retrieved March 4, 2014, from http://www. acgme.org/acgmeweb/Portals/0/PDFs/FAQ/120_family_medicine_FAQs_07012014.pdf Andrew, L. B. (2012, March 8). Physician suicide. MedScape, Retrieved January 16, 2014, from http://emedicine. medscape.com/article/806779-overview Belfiore, M. (1994). The group takes care of itself: Art therapy to prevent burnout. The Arts in Psychotherapy, 21, 119–126. Bischoff, R. J., Springer, P. R., Reisbig, A. M. J., Lyons, S., & Likcani, A. (2012). Training for collaboration: Collaborative practice skills for mental health professionals. Journal of Marital and Family Therapy, 38, 199–210. Blundo, R. (2010). Engaging men in clinical practice: A solution-focused and strengths-based model. Families in Society, 91, 307–312. Breen, K. J., & Greenberg, P. B. (2010). Difficult physician-patient encounters. Ethics in medicine: A clinical perspective. Internal Medicine Journal, 40, 682–688. Bronfenbrenner, U., & Evans, G. W. (2000). Developmental science in the 21st century: Emerging questions, theoretical models, research designs and empirical findings. Social Development, 9, 115–125. Center, C., Davis, M., Detre, T., Ford, D. E., Hansbrough, W., Hendin, H., et al. (2003). Confronting depression and suicide in physicians: A consensus statement. Journal of the American Medical Association, 289, 3161–3166. Clarkson, P. (1996). Gestalt counseling in action. Thousand Oaks, CA: Sage. Dankoski, M. E., Pais, S., Zoppi, K. A., & Kramer, J. S. (2003). Popcorn moments. Journal of Feminist Family Therapy, 15, 55–73. Distelberg, B., & Castanos, C. (2012). Levels of interventions for MFTs working with family businesses. Journal of Marital and Family Therapy, 38(Suppl. 1), 72–91. Dyrbye, L. N., Sotile, W., Boone, S., West, C. P., Tan, L., Satele, D., et al. (2014). A survey of U.S. physicians and their partners regarding the impact of work-home conflict. Journal of General Internal Medicine, 29, 155–161. Evans, K. (2006, September 1). Finding meaning in medicine. Greater Good: The Science of a Meaningful Life. University of California, Berkeley. Retrieved March 10, 2014, from http://greatergood.berkeley.edu/article/item/ finding_meaning_in_medicine Friedman, J., & Combs, G. (1996). Narrative therapy: The social construction of preferred realities. New York, NY: W.W. Norton. Gunderson, L. (2001). Physician burnout. Current clinical issues. Annals of Internal Medicine, 35, 145–148. Hafen, M., White, M. B., Rush, B. R., Reisbig, A. M. J., & McDaniel, K. Z. (2007). The role of family therapists in veterinary medicine: Opportunities for clinical services, education, and research. Journal of Marital and Family Therapy, 33, 165–176. Hassan, T. M., Ahmed, S. O., White, A. C., & Galbraith, N. (2009). A postal survey of doctor’s attitudes about becoming mentally ill. Clinical Medicine, 9, 327–332. Hernandez, B. C., & Kim, L. H. (2014). Reflective collaborative training for mental health clinicians and physicians. In R. A. Bean, S. Davis & M. P. Davey, (Eds.), Clinical supervision activities for increasing competence and selfawareness (pp. 135–140). New York: Wiley.

October 2015


449

Hoffman, L. (2006). The art of “withness”: A new bright edge. In H. Anderson & D. Gehart (Eds.), Collaborative therapy: Relationships and conversations that make a difference (pp. 63–79). New York, NY: Taylor & Francis Group. Institute of Medicine (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. Johnson, A., Brock, C., Hamadeh, G., & Stock, R. (2001). The current status of Balint groups in the US family practice residencies: A 10-year follow-up study, 1990–2000. Family Medicine, 33, 672–677. Kerr, M. E., & Bowen, M. (1988). Family evaluation. New York, NY: W.W. Norton. Kreimer, S. (2012). Legal woes. Lawsuits are stressing docs. Hospital & Health Networks, 86(2), 17–18. Lee, R. E., III, & Nichols, W. C. (2009). The doctoral education of professional marriage and family therapists. Journal of Marital and Family Therapy, 36, 259–269. Lown, B. A., & Manning, C. F. (2010). The Schwartz Center Rounds: Evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork, and provider support. Academic Medicine, 85, 1073– 1081. doi:10.1097/ACM. 0b013e3181df741. Maslach, C., & Leiter, M. P. (2008). Early predictors of job burnout and engagement. Journal of Applied Psychology, 93, 498–512. Nelson, T. S., Fleuridas, C., & Rosenthal, D. M. (1986). The evolution of circular questions: Training family therapists. Journal of Marital and Family Therapy, 12, 113–127. Ofri, D. (2013). What doctors feel: How emotions affect the practice of medicine. Boston: Beacon Press. Paolini, H. (2009). Inside the mind of a physician: Illuminating the mystery of how doctors think, what they feel, and why they do the things they do. Orlando: Florida Hospital. Paolini, H. O., Bertram, B., & Hamilton, T. (2013). Antidotes to burnout: Fostering physician resiliency, wellbeing, and holistic development. MedScape. Retrieved March 10, 2014, from http://www.medscape.com/viewarticle/ 782514. Politi, M. C., Clark, M. A., Ombao, H., & Legare, F. (2010). The impact of physicians’ reactions to uncertainty on patients’ decision satisfaction. Journal of Evaluation in Clinical Practice, 17, 575–578. Pololi, L., Conrad, P., Knight, P. S., & Carr, P. A. (2009). The culture of academic medicine: Faculty perceptions of the lack of alignment between individual and institutional values. Journal of General Internal Medicine, 24, 1289–1295. Roberts, N. K., & Williams, R. G. (2011). The hidden costs of failing to fail residents. Journal of Graduate Medical Education, 3, 127–129. Rolland, J. S. (1994). Families, illness, and disability: An integrative treatment model. New York: Basic Books. Shanafelt, T. D., Boone, S., Tan, L., Dyrbye, L. N., Sotile, W., Satele, D., et al. (2012). Burnout and satisfaction with work-life balance among U.S. physicians relative to the general U.S. population. Archives of Internal Medicine, 172, 1377–1385. Sorojjakool, S., & Lamberton, H. (2004). Spirituality, health and wholeness: An introductory guide for health care professionals. New York, NY: Haworth Press. Sternlieb, J. L. (2008). Teaching housekeeping: Learning to manage the emotional impact of patient care. Families, Systems & Health, 26, 356–364.

NOTE 1

Residents are medical school graduates who participate in clinical training in their chosen specialty area for 3–8 years under supervision as part of their medical education requirements.

450


October 2015