GHHS Members from AT Still University Travel to the Amazon
by Daniel Ebbs — ATSU GHHS Member
Members of ATSU GHHS Chapter have been working together and with local NGOs (non-governmental organizations) to help add a critical component to the development of sustainable healthcare in regions with little to no health access: sustainable health training. Sustainability is a word that has become popularized and at times is seemingly overused. However, our goals have never been to provide much healthcare at all, but rather to provide a template for community health workers (CHWs) to develop their own training programs. How does this work? If we had to describe this approach with one phrase, it would be ‘train the trainer.’
This methodology has been around for some time and with much documented success in the literature. In fact, many residency programs currently offer rotation sites in developing countries to give residents a chance to develop and help build a capacity to treat patients in their particular specialty. Our goal as medical students is to offer our volunteer services to provide basic life-saving skills, equipment, and medications along with the education in a format that is not only community co-developed, but also where all the training is re-recorded onto tablets by the CHWs after one year. This not only helps with medical education retention but transitions the learning to CHW educators who will then teach other new CHWs who enter the program.
Our chapter currently has members traveling to the Amazon this Thanksgiving to help with the first transition period where CHWs will now be CHW educators, training a dozen new CHWs to provide care and education to nearly 2000 residents in the rural Amazon with limited to no access to any healthcare. Additionally, we have been working with local NGOs in Northern Uganda where there is desperate need for CHW training; we will be assisting with the development of a new training program in June. Our chapter is looking to collaborate with additional health worker training projects both in the United States and abroad. Please contact me if you are interested in developing a similar project of or wish to work with us on a current project in the Peruvian Amazon or Northern Uganda.
Teaching Empathy to Medical Students/Residents while Performing Painful Procedures
by Raghav Govindarajan, MD — GHHS Chapter Advisor for University of Missouri Columbia
John was a 50 year old gentleman who had presented with painful peripheral neuropathy. I had asked my medical student to take a history and do a relevant exam so that I could evaluate her for the clerkship. After taking a thorough history she started the pinprick testing to examine him for sensory disturbances in his feet. Every time she poked John, he would wince with pain. His answers were inconsistent mostly due to the pain. My student persisted to get an accurate answer and his wife had to finally intervene to stop the testing.
Linda was a 60 year old woman who had presented with lower limb weakness to our electromyographic laboratory. My resident started the procedure where a needle is inserted in various muscles to differentiate the good and bad sounds made by muscles. This in turn would tell us where the cause of weakness was. By the time my resident had performed this procedure in three different muscles, Linda was in tears. The nurse in the room intervened to stop the procedure.
In both of these cases the involved student and resident were at the top of their class, very well-liked by their peers and medical staff and considered empathetic in their patient care. While it is very well known that there is a sharp decline in empathy especially among third year medical students, numerous steps have been taken to prevent this erosion. There are now didactics on science of empathy, standardized case simulations, mentoring from patient teachers and an overall strong emphasis on empathy in the medical school curriculum.
Thus while our students were actively showing empathy when interviewing the patient, the same cannot be said while they were performing painful procedures. In my own non-standardized survey of students and residents, I have found that a common roadblock to demonstrating empathy during procedures is that students are ‘so involved in the procedure that they did not realize they were hurting the patient.’ Other reasons that I have heard are that the students persist because they feel they are required to ‘get an answer’ as in the above two cases; are ‘trying to learn the procedure’; have a ‘sense of guilt and shame’ from not having done their job; and sometimes the ‘attending didn’t stop me.’
How can we improve this? There are no easy answers but the onus lies in the clinic mentors to set an example of providing empathetic care, especially during painful procedures. We all want our students and residents to learn procedures and become proficient in their skills but it should not be at the cost of patient discomfort. It is prudent that we not only supervise our trainees but also take over the procedure when we notice that patients are in pain. This might cost the trainees a learning opportunity in a procedural skill but would demonstrate that empathetic patient care trumps all! And with advances in technology our students can become proficient with many procedures on mannequins/simulators before trying them on the patient.
Following these cases, I have used the 5E technique in teaching medical students and residents ‘procedural empathy’ in addition to setting an example by demonstrating it myself. These include:
- Explain the procedure in a simple way so that the patient can understand and answer all questions
- Educate the patient on the discomfort/pain during procedure and tell them to openly report it without any fear of retribution
- Eye contact with the patient periodically during a procedure to make sure he/she is not in pain or hurting
- Empathize actively during the procedure by asking: Am I hurting you? Do you want me to stop? Do you want me to make any changes? Are you in pain?
- Exit the procedure and allow senior staff to take over if you are not able to provide ‘empathetic procedural care’. There is no shame in it!
The Humanism Symposium: A Model for Humanism in Medical Education
When Elizabeth Allan and Ekta Taneja were students at the University of Maryland School of Medicine, they created a for-credit elective course in 2013-2014 on topics of humanism and the medical humanities including contributions drawn from the school’s active GHHS chapter. This student-run course, currently in its third year, is offered to first and second year medical students. They meet approximately once a week throughout the year to discuss topics like communication, gender differences, cultural differences, preventing burn-out, working with “difficult” patients, death and dying. See their poster to learn more