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Attitudes and Habits of Highly Humanistic Physicians

Chou, Carol M. MD; Kellom, Katherine; Shea, Judy A. PhD

doi: 10.1097/ACM.0000000000000405
Research Reports

Purpose Humanism is fundamental to excellent patient care and is therefore an essential concept for physicians to teach to learners. However, the factors that help attending physicians to maintain their own humanistic attitudes over time are not well understood. The authors attempted to identify attitudes and habits that highly humanistic physicians perceive allow them to sustain their humanistic approach to patient care.

Method In 2011, the authors polled internal medicine residents at the University of Pennsylvania to identify attending physicians who exemplified humanistic patient care. In this cross-sectional, qualitative study, the authors used a semistructured script to interview the identified attending physicians to determine attitudes and habits that they believed contribute to their sustenance of humanistic patient care.

Results Attitudes for sustaining humanism in this cohort of humanistic physicians included humility, curiosity, and a desire to live up to a standard of behavior. Many of the physicians deliberately worked at maintaining their humanistic attitudes. Habits that humanistic physicians engaged in to sustain their humanism included self-reflection, connecting with patients, teaching and role modeling, and achieving work–life balance. Physicians believed that treating their patients humanistically serves to prevent burnout in themselves.

Conclusions Identification of factors that highly humanistic attending physicians perceive help them to sustain a humanistic outlook over time may inform the design of programs to develop and sustain humanism in teaching faculty.

Dr. Chou is associate professor of clinical medicine, Division of General Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Ms. Kellom is senior research coordinator, Mixed Methods Research Lab, Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania.

Dr. Shea is professor of medicine, associate dean for medical education research, director of evaluation and assessment, and interim chief, Division of General Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Funding/Support: Funding was provided by the Williams fellowship and the Sam Martin Education Pilot Research Award, both at the University of Pennsylvania.

Other disclosures: None reported.

Ethical approval: Ethical approval was obtained through the institutional review board at the University of Pennsylvania.

Previous presentations: Aspects of this work were previously presented at the 35th Annual Society of General Internal Medicine meeting, Orlando, Florida, May 2012; and the Annual American Academy on Communication in Health Care Research and Teaching Forum, Providence, Rhode Island, October 2012.

Correspondence should be addressed to Dr. Chou, 3701 Market St., Suite 741, Philadelphia, PA 19104; telephone: (215) 349-5200; fax: (215) 615-0038; e-mail: cchou@mail.med.upenn.edu.

Humanism in medicine combines scientific knowledge and skills with respectful, compassionate care that is sensitive to the values, autonomy, and cultural backgrounds of patients and their families.1,2 This age-old concept3,4 nevertheless foundered as medicine evolved into an increasingly analytic, biomedically focused field.5 In 1977, to combat dehumanization and disempowerment of patients, George Engel introduced his biopsychosocial model, charging clinicians to attend to psychosocial as well as biological dimensions of illness.6 Since then, studies have shown that humanistic medical care can improve patients’ satisfaction, increase their trust in their doctors,7 and improve health outcomes.8–11 Both the American College of Physicians Charter on Professionalism12 and the Accreditation Council for Graduate Medical Education exhort physicians to both exercise humanism themselves and impart tenets of humanism to resident trainees.13 In an era of proliferating technologies and increasing financial, academic, and productivity pressures, how do physicians maintain their humanistic outlook over time? In this study, we aim to answer this question by identifying factors and habits that highly humanistic academic internal medicine physicians perceive as helping them sustain their own humanistic attitudes.

A previous survey of fourth-year medical students identified factors that contribute to creating a humanistic doctor.14 These include exposure to positive role models and participation in intense experiences, such as caring for dying patients. Other studies have corroborated that role modeling is the predominant means by which residents learn15 and faculty teach2 humanism. Several studies have cited other practical strategies for teaching humanism, including establishing a humanistic learning environment and learning goals and teaching on psychosocial issues.16,17 These studies have all advanced our knowledge regarding how a humanistic physician develops.

Although these studies imply that humanism can be taught and learned, humanistic attitudes still may be difficult to maintain.18,19 To our knowledge, previous studies have not explored what factors and habits are perceived to sustain a faculty member’s practices of humanism. Given the importance of humanism in academic teaching, our goal was to identify (1) personal attitudes that help physicians consistently deliver humanistic patient care and (2) regular habits that help sustain those attitudes. We hoped to identify modifiable attitudes and habits that can be taught and disseminated, with the eventual purpose of informing programs for teaching faculty on sustaining humanism in medical education and patient care. Additionally, knowing what physicians perceive as sustaining their humanism may help inform health systems of conditions conducive to the humanistic delivery of health care.

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Method

Sample selection

To identify the target sample of humanistic physicians, we administered a questionnaire to all 161 internal medicine residents at the University of Pennsylvania in June 2011, asking them to nominate up to three attending physicians who served as excellent role models for the humanistic care of patients. Of those, 119 (74%) responded. Of the 591 Department of Medicine faculty, 92 (15.5%) were nominated at least once.

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Data collection

We invited the most frequently nominated physicians (those receiving 5–21 votes) to participate in one-on-one interviews with one of the investigators (C.M.C.). We designed the interview script (Appendix 1) on the basis of our literature review14,20 and, before the study, pilot-tested it for content and clarity in mock interviews with two physicians. In the semistructured interviews, conducted during August and September 2011, we used open-ended questions to ask physicians to describe factors they felt contribute to sustaining their humanism, including attitudes, habits, behaviors, activities, sources of humanism, role models, and pivotal experiences. We also collected demographic data, including years in practice, training, and subspecialty.

All interviewees provided informed consent and were offered a $100 honorarium for their time. The interview participation rate for the invited faculty was 100%. Interviews lasted approximately 40 to 60 minutes and were audiotaped. We took field notes during the interviews and transcribed the interviews verbatim. We achieved saturation of themes after interviewing 16 faculty members.

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Data management and analysis

We performed multiple readings of the transcripts to identify major ideas or themes revealed in the physicians’ words, phrases, metaphors, and examples. Using NVivo 9 software (QSR International, Melbourne, Australia) to manage coding and analyses, we developed a coding scheme based on initial reading of the early interviews. Thereafter, we took a dialectic, iterative approach to further in-depth readings and analysis to identify themes and subthemes that described our phenomena of inquiry. We resolved discrepancies through team discussion. Ultimately, we identified 5 major themes and 11 subthemes. The institutional review board of the University of Pennsylvania approved the study.

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Results

Table 1 lists the demographics for the 16 participants. We first present results related to our main questions of (1) which attitudes humanistic physicians perceive as helping them maintain their humanism and (2) which habits they use to sustain those attitudes. We then report on three additional themes that emerged: humanism as deliberate practice, the influence of environmental factors on humanism, and the relationship between humanistic practices and burnout (List 1).

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List 1 Themes and Subthemes That 16 Highly Humanistic Internal Medicine Attending Physicians in the University of Pennsylvania Internal Medicine Residency Program Believe Help Sustain Their Humanism, 2011 Cited Here...

  • Attitudes
    • Humility
    • Curiosity
    • Standard of behavior
    • Humanism as medically important for the patient
    • Humanism as important for the physician
    • Role of physician as treating more than just the disease
  • Habits regularly practiced by physicians
    • Self-reflection
    • Seeking connection with patients
    • Teaching/role modeling humanism
    • Striving to achieve balance
    • Mindfulness and spiritual practices
  • Deliberate, intentional work at habits to sustain humanism
  • External/environmental support
  • Humanism as antidote to burnout
Table 1

Table 1

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Attitudes that sustain humanism

Six subthemes represent attitudes that sustain humanism (List 1).

Humility. Most of the physicians described an attitude of humility in their work.

We are very honored that these patients allow us to see them naked in bed, wandering to the bathroom, and then we ask them really in-depth personal questions the first time we meet them. And it’s really an honor that they trust us just because we have this degree behind our name. (#14, General Internal Medicine, female)

This attitude extends to a willingness to learn from patients and learners.

Every single patient can teach you something, whether it’s about yourself, or about them, or about the world. Patients always surprise you. And if you can keep yourself open to that then it just keeps everything really fresh and new and interesting.… (#4, Hematology/Oncology, female)

This humble approach allows these physicians to respect the needs of their patients and be open to continued learning.

Curiosity. The majority of physicians described how being curious about their patients serves to fuel their humanism. They want to understand where the patient is coming from, approaching the patient and family “with a genuine sense of, ‘I want to know your story,’ with real curiosity.”

At the end of the day it really just comes down to being interested in your patients.… I often will try to find something unique or motivational about every patient that I meet. It becomes really important in their care, because you don’t know what their challenges are and you don’t know their fears or concerns.… Understanding what motivates [the patient] helps you be a better doctor. (#4, Hematology/Oncology, female)

Standard of behavior. Many physicians attributed their humanistic behavior to a desire to emulate “the right way to behave,” keeping in mind the “basic values of how people should be cared for,” and “being motivated to do what is correct and proper for the person in front of you.” These physicians recognized that patients “trust that we represent something and I hope that we always represent that there’s a trust and an honor in us to do right by the patient” and that “it’s how I would want to be treated, so I try to treat the patient that way.”

Importance for the patient medically. At least half of the physicians acknowledged that treating a patient humanistically is important for the patient medically. Many felt that treating the patient humanistically “makes a difference in terms of how comfortable patients feel with the care they are getting.” One physician was interested in her patients’ social context not only because the “stories make them more human and less cold” but also because

Caring for the patient isn’t just making sure that they don’t have edema or ascites, but also getting a little deeper than that too.… Do you have the support of your family? How are you getting your meals because … you’re telling me you’re not eating any salt, yet you come in needing a paracentesis every two weeks. (#13, Gastroenterology, female)

Importance for the physician. Half of the physicians commented that acting humanistically is important for them personally; getting to know the patient as a person helps them to invest in the physician–patient relationship. Not only does this help them to be a better doctor to their patients, but “if you don’t know the patient in their context … you’ll never really get to know them, and part of the joy of being a doctor is getting to know a patient … and where they come from.”

The more I know about a patient’s life, the more likely I am to take care of them better and relate to them.… I want to make [the patient care interaction] as full an experience as it can be; knowing more about my patients makes it more enjoyable. (#1, General Internal Medicine, male)

More than just the disease. The majority of physicians agreed that being a doctor means treating more than just the disease. One physician viewed her job as providing a safe place for her patients to talk about life changes and suffering. Another physician stated: “Sure, I give medicine. I give chemo. But I think of myself as a cheerleader. I really am keeping people’s spirits going.” Still another posited:

I realize that it is not just the vent management … [but] also thriving on learning different things about people and entering into their experience.… [My role is] being there with and for the patient. (#15, Pulmonary/Critical Care, male)

These physicians embody a previously expressed belief that one of the functions of physicians is to lend strength to their patients.21

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Habits

Habits that these physicians believed help to sustain their humanistic attitudes can be summarized in five subthemes (List 1).

Self-reflection. Almost all of the interviewed physicians reported actively engaging in self-reflection.

I’ll do this almost on a daily basis. Take that time to step back and think about what’s really happened … what I could have done better and how I could have done things differently.… What have I done right [or] wrong? That’s very much built into my daily routine. (#12, General Internal Medicine, male)

Self-reflection allows many of these physicians the opportunity “to change the way your mind would look at the world around you and to be a lot more compassionate towards others who it might not be as easy to have compassion for.” The capacity for self-reflection therefore extends beyond improving one’s clinical skills to also include how one can be a more humanistic physician.

Connecting with patients. A habit that over half of physicians believed sustains their humanistic attitudes is seeking a connection with patients. Some find this connection to be where the meaning of being a doctor lies. For others, connecting with patients represents something deeper than merely the doctor–patient relationship; finding that connection transcends to a more fundamental person-to-person bond of one human being caring for another.

I think my sustenance … comes from the day-to-day process of being a clinician.… It is an incredible opportunity to learn from different types of patients and families, what is important to them and what they deal with in the context of loss.… And it seems invariably self-sustaining.… (#8, Pulmonary/Critical Care, male)

Teaching/role modeling. Many respondents believed that the habit of teaching and role modeling humanism helps to sustain their humanism. The presence of learners serves as a constant reminder to these physicians of the standard of humanistic care, “knowing that I’m responsible not just for the patients in front of me, but modeling how my students and residents are going to treat their patients.” Other physicians felt similarly.

I do thrive on the interaction with the housestaff … being able to train them and then have them buy into [humanism] and [then] they start quoting you, [then you have] this obligation to live up to what you say. (#15, Pulmonary/Critical Care, male)

Balance. Achieving and maintaining balance was identified by many of the interviewees as an important component of sustaining humanism, whether achiev ing work–life balance or a balance of duties on the job. One physician felt strongly that “I don’t think it’s possible to be a good doctor if you feel that your work–life balance is really skewed, because you just don’t have anything left.” Taking time out for activities such as reading, exercise, and spending time with family and friends; setting limits on schedules; and negotiating control are important factors. One hospitalist strives to achieve work–life balance because, if she finds herself spending too much time at work:

I’m just not centered anymore and it makes it very hard to then function at work. So if I make a point of sort of my life balance of keeping everything together in all my spheres of influence, I feel I do much better and I’m able to do better at work. (#3, General Internal Medicine, female)

Mindfulness and spiritual practices. Some physicians employ regular mindfulness practice as a habit that sustains their humanism. One physician described the practice of being fully present as being “extraordinarily deepening in terms of the connection I feel with my patients.” Others noted the importance of religion and spirituality in sustaining their humanism.

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Intentional work at habits that sustain humanism

Many of these physicians deliberately work at maintaining their humanistic outlook and actively seek out experiences that help them to do so.

I have trained my mind to not think ahead and not be in the past when I’m face-to-face with a person … just fully present… I’ve realized how amazing it has made my ability to connect with people and care for them. (#6, General Internal Medicine, female)

I can sense the part of [the patient] that’s like me, that deserves to be cared for and respected and loved. And so, when I’m the room [with the patient], I’m really striving to feel that part … it’s definitely not random—it’s a conscious choice that I make. (#7, General Internal Medicine, female)

Another physician, who serves primarily as a hospitalist, prioritizes maintaining a practice in an underserved outpatient community clinic because:

It really re-grounds me. It’s practicing medicine for the sake of practicing medicine … just worrying about being a good physician for patients. So that’s a weekly inoculation of what is proper or what is best about being a doctor.… It has to be an ongoing focus. (#12, General Internal Medicine, male)

Two physicians plan medical travel experiences abroad to reground them in humanism. “I need to start planning my next trip abroad to somewhere where I feel like I’m not there just for the doing and for the documentation.… It changes what’s important, experiences like those.”

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Environmental support to sustain humanism

Many physicians cited environmental aspects of their job as being helpful in sustaining their humanism. Three-fourths of the physicians indicated that people in their environment—physician colleagues, nurses, chaplains, and learners—are important in this regard. These people support the physicians’ humanistic practices by assisting in the care of the patient, providing moral support to the physician, and reminding the physician of the standard of humanistic care.

This physician cohort also indicated that positive environmental influences extend beyond merely the people with whom they work. Resources, such as office systems, cancer center counseling services, pain consultants, and social work support, all enhance the care of the patient, “support the patient better,” and allow the physician to achieve balance in life.

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What is the relationship between humanistic practices and burnout?

Half of the interviewees felt that treating patients humanistically, rather than being a cause of burnout, actually is “the antidote” to burnout. One physician said that, even during a busy day when she is tempted to rush through the patients,

If I take it direct and slow and try to connect with each person, I’m going to be happier and less tired at the end of the day, and the patients do better too. (#7, General Internal Medicine, female)

Another physician learned that

You can burn yourself out by just treating the disease.… [However], if you can thrive on other things like getting to know people, helping them negotiate death, or tragedy, or loss, being able to comfort people and just help them, even though you can’t make their loved one better … even if you can somehow find meaning in just being a presence for the family, then every day can be a good day. If you do the relational piece well, not only does it help you enjoy the job and get a sense of purpose about the job, but it’s the best way to engage families and help them. (#15, Pulmonary/Critical Care, male)

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Discussion

To our knowledge, our study is the first to identify attitudes and habits that help highly humanistic academic medicine physicians sustain the humanistic care of their patients. Underlying attitudes that the physicians in our study believed contribute to their humanism include curiosity, humility, and striving to live up to a standard of behavior. Additionally, they intentionally work on sustaining their humanistic attitudes with habits that include self-reflection, striving for work–life balance, role modeling humanism, and focusing on the connection with patients. Furthermore, these physicians felt that support from people and systems in their environment is important for sustaining their humanism.

The importance of sustaining humanistic approaches to patient care, especially for attending physicians who teach humanism to learners, cannot be overemphasized. However, the most humanistic physicians may also be at highest risk for burnout or “compassion fatigue,”22 resulting from the cumulative impact of caring for others at the expense of oneself. Methods to combat burnout have traditionally involved self-care practices outside of work. Many of our findings are indeed consistent with literature on physician well-being, suggesting that care of the self may in turn enhance physicians’ ability to provide compassionate and empathic care to patients.23–28 Specifically, our physicians noted that self-care techniques (such as spending time with friends and family or exercising) and striving for work–life balance are important for maintaining humanism.

Practices that promote well-being may be necessary but still insufficient to sustain humanism—the positive, high-functioning practice of sustaining humanism may involve more than merely avoiding burnout. Our cohort found that their work itself also serves to sustain their humanism. Finding meaning in work has been shown to contribute to job satisfaction and coping with stress.22,25,29–33 Our physicians went a step farther by identifying that finding meaning in work not only contributes to job satisfaction but is a key component of sustaining their humanism. Specifically, the use of self-reflection, role modeling humanistic care, and connecting with patients promote the sustenance of humanism. Given that interactions with patients are the daily work of many physicians, investing in teaching empathy and finding meaning in the connection with patients may help physicians trans form work from a domain of energy expenditure to one of energy renewal.30 Helping to teach and foster this awareness will benefit not only the physicians them selves but also their patients and learners.

A related finding demonstrates that many of our physicians invest active, intentional effort in sustaining their humanistic practices. Making the practice of humanism an “ongoing focus” runs contrary to traditional assumptions that communication skills are innate.34 Instead, it reinforces the idea that humanistic patient care can be not only fostered and developed16 but also made a target of deliberate practice, which in turn is necessary for acquiring expertise.35 Continued deliberate practice to achieve expertise requires the ability to be open to and incorporate ongoing feedback,35 which these humanistic physicians make possible by their attitudes of humility and curiosity. Also necessary for deliberate practice is the presence of discrete skills which can be practiced. Our role model physicians identified such replicable habits, which include self-reflection, mindfulness, and focusing on making the connection with the patient meaningful. Attending physicians who can practice these habits to sustain their own humanism may increase their ability to model humanism for their learners. Furthermore, in searching for methods to retain physicians and promote physician well-being, health systems and physician employers may do well to consider mandating faculty development programs on the basis of these habits that promote the humanistic care of patients.16 Such interventions may improve not only patient care but also faculty well-being.

We have been focusing on the internal work of physicians to maintain their humanism. It should be noted that the physicians also identified the external environment as an important factor in fostering humanism. They cited supportive colleagues and supportive systems, both of which facilitate engagement and connection with their patients. This has implications for institutional policies that could be implemented to improve the delivery of humanistic patient care.29,36,37

Strengths of this study include a high response rate from internal medicine residents and faculty, the breadth of faculty interviewed, and the appreciative focus on positive factors that sustain humanism rather than on barriers to sustaining humanism. Limitations include our focus on only medicine faculty at a single institution, thus limiting the generalizability to other fields outside of medicine and to other institutions. Nominations of the faculty were elicited from medicine residents only, rather than from a 360-degree evaluation. The number of interviewees was low, although we continued interviews until themes reached saturation. Because of the nature of self-report, we were not able to verify whether the behaviors described by these physicians actually occur in the clinical or teaching environment. Also, consistent with a qualitative approach, the focus of this study was on perceptions, not necessarily realities. Our explicit interest was to explore the attitudes and practices that these physicians believe influence their abilities to act in a humanistic manner. Thus, we cannot say how their perceptions are similar to or different from those of physicians who are not viewed similarly by trainees. Nor are we able to make conclusions about actual facilitators and barriers.

In summary, we identified attitudes and habits that academic medicine faculty believe help to sustain their humanism. The fact that these physicians deliberately work to sustain their humanistic habits and feel that their humanistic approach to patients prevents burnout calls for methods to foster humanistic patient care in our teaching physicians and learners. Future investigations may focus on determining whether similar factors and habits sustain humanistic practices in other fields and specialties, as well as evaluating whether faculty development interventions based on fostering attitudes and habits identified here have a positive effect on sustaining humanism in other teaching physicians.

Acknowledgments: The authors would like to thank all of the physicians who participated in the interviews.

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References

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  • What factors do you believe help you to maintain humanistic attitudes toward patients and learners?
  • What activities do you engage in on a regular basis to maintain humanism in your practice?
  • Is there anything else that motivates you to sustain your humanistic attitudes?
  • Do you pay deliberate attention to the teaching of humanism and deliberately model humanistic behavior during your teaching of residents? (Humanistic behavior toward learners and patients)
  • Pivotal experiences or seminal events: What experiences have you had in the past that influence your current humanistic attitudes? These experiences can come from outside of medicine, preclinical (childhood, family upbringing, educational environment, personal or family experiences with illness), or clinical (e.g., med school, residency, or practice) realms.
  • Role models who were most pivotal in development of humanism
  • Previous recognition for humanism or teaching (teaching awards or humanism awards, e.g., institutional or Gold Society)
  • Have you had any formal instruction or training in humanism? Any formal training in teaching, conflict resolution, conflict management, negotiation, or difficult situations?
  • Do you seek out CME or experiences in humanism (e.g., stress management, Balint group, etc.)?
  • What is the most personally satisfying or meaningful aspect of your work?
  • How would you rate your degree of work–life balance/interference? How would you rate your degree of burnout with your job? Do you feel that burnout affects being humanistic and teaching humanism?
  • Based on your experience, what do you feel is the most effective method of teaching humanism? What resources might people benefit from to improve their humanistic teaching? If you were to design a curriculum to teach faculty how to be humanistic, what components would be included?
  • What methods do you think would be effective in increasing the importance of teaching humanism to other faculty?
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Appreciative Interview Script for Faculty Participating in Semistructured Interviews to Investigate Habits of Highly Humanistic Physicians, 2011 Demographics

  • Nature of interaction with residents: input versus output, consult versus ward, mentorship (research or other), didactics; years taught; other learners (e.g., students, fellows) and other teaching situations
  • Role/title in teaching or in health system
  • Age
  • Specialty
  • Years in practice (years since training)
  • Gender
  • Percent research/clinical
  • Academic track
  • Med school, subsequent training (residency, fellowship, other degrees)
  • Ethnicity, religion
  • Marital status; number of children if any; family status/relationship status
  • Full-time/part-time; balance of clinical versus nonclinical time
  • Number of hours spent per week at work
© 2014 by the Association of American Medical Colleges