MEdIC Series: The Case of the Backroom Blunder – Expert Review and Curated Commentary

The Case of the Backroom Blunder presented us with an interesting scenario that riveted readers across the globe.  In this case, Trevor the medical student overhears the conversation of two of his senior colleagues discussing and laughing about a recent resuscitation.  The senior members of the team used terms like ‘frequent flyer’, ‘red underpants’, which greatly upsets Trevor.  In his opinion: “A caring doctor would never talk like that. And the slang? That’s just awful.”  What did the ALiEM community think of this case?  Well, read on to gleam the summaries, or go directly to the blog discussion to read what people wrote!

This month Heather Murray (@HeatherM211) and I (@TChanMD) hosted a MEdIC series discussion around this issue with insights from the ALiEM community  We are now proud to present to you the Curated Community Commentary and 2 our two expert opinions. Thank-you to all our participants for contributing to the very rich discussions last week.  Quite frankly, it was a real treat to see the online community really jump on board to make this discussion so vibrant and rich.  We really appreciated the support everyone has given to the MEdIC Series.  (Honestly, I very much enjoyed reading all the comments, all 120 or so of them!)

This follow-up post includes

• The responses of our ‘slang and humour’ experts, Dr. Brian Goldman (@NightShiftMD) of CBC’s White Coat Black Art series, and Ms. Liz Crowe (@LizCrowe2) is an Advanced Clinician Social Worker.
• A summary of insights from the ALiEM community derived from the Twitter and blog discussions
• Freely downloadable PDF versions of the case and expert responses for use in continuing medical education activities

[su_spoiler title=”Expert response 1: Slang and Medical Culture” style=”fancy” icon=”chevron-circle”]

Brian Goldman, MD, FACEP, MCFP(EM), FCFP (@NightShiftMD)
Assistant Professor, Dept. Family And Community Medicine, University of Toronto. Host of White Coat, Black Art on CBC Radio One and author of The Secret Language of Doctors

If Sticks and Stones could Break your bones

The terms ‘red underpants’ and ‘frequent flyer’ are examples of slang – referred more formally by linguists as argot, which is defined by the Merriam-Webster Dictionary as “an often more or less secret vocabulary and idiom peculiar to a particular group.” The purpose of argot is to prevent eavesdropping outsiders from understanding what you’re talking about and to create a bond among colleagues, teammates or friends. Medical argot is simply English augmented with code words that are incomprehensible to all but those in the know.

In general, argot or slang may be used to describe undesirable or frustrating patients. An example used commonly is “frequent flyer,” which refers to patients who return again and again. Some use the term because they believe the repeat patient is gaming the system for benefits such as food, bandages and taxi chits.

There is little published evidence of medical argot. A 1993 survey of American physicians found that slang is learned in the clinical setting and therefore uncommon until the third or fourth year of medical school. That survey found that the use of slang peaks during the first post-graduate year, and begins to decline throughout the residency years, and by 20 years of practice, admitted self-knowledge of slang terms being only marginally higher than that of the preclinical medical student[1].

In researching my book The Secret Language of Doctors, I found a number of anecdotal collections of argot. While I agree that residents are more likely to use argot, there is evidence that slang is also used by some attending physicians[2]. A 2012 study by Reddy and colleagues at the University of Chicago found that 40.3% of hospitalists surveyed admitted to making fun of other physicians, 35.1% made fun of other attendings to colleagues, and 29.8% admitted to making disparaging comments about a patient on rounds[2].

Is there a role for this language?

If slang words are used, then, their use is proof that the language serves a purpose.

Coombs and colleagues wrote that slang helps young doctors overcome anxieties encountered during medical training and practice – those anxieties arising from clinical and diagnostic uncertainty, the difficulty treating fellow human beings, and an attempt to distance oneself from disease and death[1].

The anxiety associated with diagnostic and clinical uncertainty doesn’t get its due in common medical discourse. In her brilliant book Experiment Perilous, Dr. Renee Fox, one of America’s preeminent sociologists, wrote at length about the challenge of dealing with therapeutic uncertainty faced by physicians working in the 1950s at the Medical Research Group in Boston.

“What the physician can do to help a patient, then, is often limited. What he ought to do is frequently not clear. And the consequences of his clinical actions cannot always be accurately predicted. Yet, in the face of these uncertainties and limitations, the physician is expected to institute measures which will facilitate the diagnosis and treatment of the problems the patient presents.”[3] Looking past the use of gender-exclusive pronouns, Fox identified a core anxiety that is as pervasive today as it was back then.

Terms like ;social admission’ or ‘dyscopia’ (i.e. ‘failure to cope’) symbolize the helplessness perceived by residents and attending physicians that a good deal of medical care delivered these days is medically futile. Futility is as often discussed in hospital corridors as it is misunderstood by health professionals[4]. In the same vein, the slang term frequent flyer calls attention to the growing problem of readmissions and repeat visitors to the ED. In my opinion, it is better to acknowledge evident problems in health care than ignore them. The problem with the label frequent flyer is that the term blames the patient, when there’s a growing evidence that repeat visitors are system failures that can be addressed[5].

Although argot may be useful to reduce physician and trainee anxiety, there is no question that slang or argot is often unprofessional[6]. The real issue is what to do when one hears it. Acolytes of medical professionalism might argue that slang should be called out and (if possible) stamped out of hospital discourse. The problem with that strategy is that it drives the use of slang underground. Just because physicians no longer write odious terms such as FLK (funny looking kid) in medical charts does not prove that the term is no longer spoken.

A better approach for medical educators is to notice the slang and – when heard – to ask questions about the frustrations that contribute to its use. Medical educators have a higher obligation to model behavior that is respectful to patients, colleagues and allied health professionals. Pejorative slang tends to be learned avidly by residents and students when the teacher is an attending physician.

Black Humor

Physicians have long used black humour to help cope with anxiety-provoking situations as well as frustration at not being able to cure or even help every patient. Experiment Perilous is replete with examples of what Fox refers to a gallows humour.

There are many suggested purposes to gallows humour. Unlike normal discourse – with its many qualifiers and modifiers that tend to soften the rhetorical blow – gallows humour to the truth in a hurry. Gallows humour often mirrors power relationships. In medicine, it’s considered acceptable for residents to joke about attendings but not the other way around. In that context, gallows humour regarding patients may reflect the powerlessness that physicians feel about treating patients who cannot be helped by modern medicine.

In the past, gallows humour was regarded as therapeutic to health professionals and even necessary to their wellbeing. However, the rise of medical professionalism, has led to re-evaluation and even condemnation of its use. As Katie Watson wrote recently: “Critics of backstage gallows humour who are admirably concerned with empathy for patients sometimes seem curiously devoid of empathy for physicians. Medicine is an odd profession, in which we ask ordinary people to act as if feces and vomit do not smell, unusual bodies are not all that remarkable, and death is not frightening.”[7]

To draw the line between appropriate gallows humour and conduct unbecoming a physician, Watson suggest we think about who is harmed by the joking. Jokes about defenseless patients are off limits; jokes about doctors who are defenseless or ineffective against death, decay and chronic illness are not. If the joke harms the patient’s access to decent care, that’s verboten; so, too, is humour that diverts attention from structural problems in the system by personifying them.

Humor that helps those on the front lines cope with oppressive situations is okay, while humour that mirrors the relationship between bully and victim is not.

How should this case be handled?

Slang and joking that enables physicians to open up about difficult experiences can be therapeutic, while language that cuts them off from their colleagues and themselves does not serve the same purpose. I side with those who believe slang and gallows humour – constructed along the lines just mentioned – serve a therapeutic purpose without harming patients. Used to cope with extraordinary situations such as the one witnessed by Trevor, gallows humour may be in – in the words of Watson – a “psychic survival instinct.” Such displays of humour should take place far away from patients and families.

Trevor’s point of view is extremely valid. Were he to complain to his supervisor or program director about the conversation he overheard between the attending and the resident, there’s a good chance the participants in that conversation would be admonished for modeling unhelpful behavior. Far better if the next time, Trevor is included in the circle, where he can raise his legitimate concerns, where his higher-ups could defend their responses to the failed resuscitation, and where all three of them could reflect upon what happened and how that affected them.

References

[1] Coombs, RH, Chopra S, Schenk DR, Yutan E. Medical slang and its functions. Social Science and Medicine 1993;36:987-98.

[2] Reddy ST, Iwaz JA, Didwania AK, O’Leary KJ, Anderson A, Humphrey HJ, Farnan JM, Wayne DB, Arora VM. Participation in unprofessional behaviors among hospitalists: a multicenter study. J Hosp Med 2012;7:543-50.

[3] Fox RC. Experiment Perilous. Physicians and Patients Facing the Unknown. Transaction Publishers, New Brunswick, USA, 1998, page 238.

[4] Swetz KM, Burkle CM, Berge KH, Lanier WL. Ten common questions (and their answers) on medical futility. Mayo Clin Proc 2014;89:943-59.

[5] Michelen W, Martinez J, Lee A, Wheeler DP. Reducing frequent flyer emergency department visits. J Health Care Poor Underserved 2006;17(1 Suppl) 59-69.

[6] Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136:243-6.

[7] Watson K. Gallows humour in medicine. The Hastings Center Report 2011;41:37-45.

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[su_spoiler title=”Expert response 2:  We don’t cry in critical care, we tend to laugh and joke and be sarcastic…Why?” style=”fancy” icon=”chevron-circle”]

Liz Crowe BSW, PhD(candidate)
Advanced Clinician Social Worker and a PhD Candidate, The University Of Queensland, Brisbane, Queensland, Australia.

The use of humour, swearing and occupation specific language/jargon to cope with dangerous, emotional and traumatic settings is well documented amongst critical care workers [1].   Black or gallows humour was first identified as a phenomenon in the World Wars [2] and is intellectualized as a type of humour that arises in precarious, dangerous or confronting situations as a means to manage negative emotions and consequences to mental health and reduce stress [3]. According to various studies[1,3-7], humour in the critical care context has been identified as a useful tool to:

• Reduce tension, stress and anxiety
• Vent emotions
• Distance oneself from the intense emotions and the confronting nature of the situation
• Re-interpret events and re-frame personal distress
• Distract from the horror and distress
• Ensure individuals continue to perform in the job
• Regroup personal resources
• Create a ‘psychological reset’ to ground people out of their high adrenalin state.
• Build bravado and strength amongst the team in times of crisis.
• Develop group cohesion
• Allow a sense of playfulness amongst the team
• Elicit social support
• Humour, swearing and crassness in critical care bonds teams together forming a psychological defense system against the work.
• May provide a sense of group membership and identity that is quite separate from the individuals’ behavior in their personal lives.

In this case, ensuring that Trevor understands the role that humour may play in various environments may be of value. An awareness of the use of humour in the critical care context would allow individuals to view Dr. Elliott and Jeff’s behavior with a compassionate and understanding framework.

Norms & Explanations

Community expectations of the range of skills that critical professionals will possess are growing. We are all meant to be skilled and clever clinicians who can make death an ‘option’; wonderful educators, counselors and communicators and be able to absorb any situation and mind our own self-care all on top of our long and often exhausting work schedules. These expectations are unfair and unrealistic. Each one of these traits is a skill that needs to be developed, nurtured and mentored over time. When we have students of any occupation in our care it is wise to speak with them early about the many strategies that people will use to distance themselves and survive the often confronting, perverse and tragic environment of critical care. Humour, swearing and crass jargon are part of our ‘armour’ in surviving this work. Providing orientation early for new staff and students can prevent these folks from becoming disillusioned and feeling isolated. For Trevor, this may have been particularly useful, since it may prevent him from feeling isolated from his peers and mentors.

Humour can be an adaptation to stressors or social phenomenon for members of the emergency services, but has also been used by those who work in defense forces, funeral homes and even the sex industry. Humour is often used to incorporate new members to the team. Jokes and stories may be used to educate and orientate new members in a way that is jovial though builds realistic expectations and warns of the work and chaos that will ensue[7].

Humor as an Adaptive Strategy

The nature and culture of the critical care environment means clinicians will often find themselves unable to situate themselves easily on the continuum between empathy and detachment[8]. Context specific variables (mood, previous experiences, personal attachments) will force clinicians to change their location within this spectrum. They will slide up and down this empathy-detachment continuum. At times they will be deeply empathic and connected to patients, families and situations, and then at other times they might detach and distance themselves from the event by using humour and crass language to protect themselves from emotions. At times, this detachment will be adaptive, in that it may allow the provider to move quickly onto the next patient and situation as is the requirement of our work. This is a skill that Dr Elliott has clearly mastered; He is an empathetic and connected attending with his patients; but then adaptively laughs and reframes the situation with colleagues in the backroom.

Similar to our medical student Trevor, people new or external to the critical care context may be easily offended and shocked by the humour used amongst workers with little understanding as to the pressures and tragedy of the job. However, it appears that those who want to emotionally survive the critical care environment will need to share a sense of the absurd and enjoy humour as part of the job in the way that Dr Elliott and Jeff are doing after what was obviously a gruesome and confronting event[9].

References

1. Roe, A and Regehr, C (2010) ‘Whatever Gets You Through Today: An Examination of Cynical Humor Among Emergency Service Professionals’, Journal of Loss and Trauma, 15:448–464.
2. Frankyl, V. (2006) ‘Man’s search for meaning’, Beacon Press, Boston: Mass.
3. Scott, Tricia (2007) ‘Expression of humour by emergency personnel involved in sudden deathwork’, Mortality, 12(4): 350-364.
4. Burchiel, R.N, and King, C.A. (1999) Incorporating fun into the business of serious work: the use of humour in group process; Seminars in Perioperative Nursing, 8(2): 60-70.
5. Moran, C and Massam, M. (1997) ‘An evaluation of humour in emergency work’, Australasian Journal of Disaster and Trauma Studies, 3:10.
6. Olsson H, Backe H, Sorenson S, Kock M (2002) ‘The essence of humour and its effects and functions: a qualitative study’ Journal of Nursing Management, 10:21-26
7. Sanders, T. (2004) Controllable Laughter: Managing Sex Work Through Humor’’, Sociology : the Journal of the British Sociological Association, 38(2): 273.

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[su_spoiler title=”The Case of the Backroom Blunder: Curated from the community” style=”fancy” icon=”chevron-circle”]

Curated by Dr. Heather Murray & Dr. Teresa Chan.

There was a huge online response to this case, and a rich and nuanced discussion occurred, both in the comments section and on Twitter. A number of themes emerged, which are summarized below. In this summary we aimed to highlight issues that are particularly important for practitioners in the emergency department (ED), but the blog comments host a wide breadth of information that is applicable to nearly all healthcare professionals.

Use of slang

Medical slang use was discussed extensively and a few differing perspectives emerged. There seemed to be general agreement that slang that is explicitly derogatory towards patients is inappropriate. However, there were differing perspectives about exactly which terms are “inappropriate.”

Some commenters felt that any slang language in health care is derogatory and as Michelle Gibson stated: “reveals how people really feel about patients.” Others emphasized how language can perpetuate stereotypes or misconceptions, implicitly endorsing certain elements of the healthcare culture.

Jon Bennetson stated that he was appalled by the use of medical slang: “What’s shocking to me is that this kind of patient-denigrating language is seen as so professionally acceptable by doctors that it routinely appears in their publications and medical magazines and no doctors complain about this language.” Specifically he referred to general practice trade journals that use medical slang in their publications.

Others felt that it is not the terms themselves but the intent and tone used that determines the attitude of the physician or care provider. Carolyn Thomas admitted that she has experienced depersonalization as a patient in the hospital setting. However, the slang in the case did not bother her but instead she found the laughter of the caregivers offensive: “High hilarity over a patient’s rectal bleeding … should be as chilling an observation to health care providers as it feels to me.”

Slang terms, however, can be used to convey messages between providers. As Teresa Chan noted, medical slang may parcel information for efficient communication. Loice Swisher agreed:

“Knowing a person is a ‘frequent flyer’ tells me that I likely have information available from prior visits as to what has been tried, tested and offered. It may give me a clue that being the 6^th doctor to see a patient with unexplained abdominal pain that I might not be able to provide an answer and that I need to help the patient get on a new path out of the ED revolving door. It could mean that there are underlying social or financial issues that might have some assistance available…. That doesn’t mean I think less of the patient as a person.”

On of the other hazards of using such terms is that it can affect your decision making. Anand Swaminathan cautioned that the term “frequent flyer” may lead to premature closure and compromise diagnostic reasoning. Similarly, some debated the use of the term ‘acopia’ or ‘failure to cope’, highlighting that this can similarly lead to premature closure around a patient’s particular scenario, as has been suggested in previously in the literature (1).

Black humour: A coping mechanism for stress and trauma

Most commenters agreed that both slang and black humour are methods of creating emotional ‘distance’ from difficult scenarios, which necessarily depersonalize the patient. Participants were split about the merit of this particular coping technique.

Many of the emergency physician commenters pointed out that in the rapid paced ED, the ability to emotionally switch from one patient to another is a survival skill.

As Anne Marie Cunningham stated:

“…the strongest theme emerging from the discussion is that black humour/derogatory language is not a sign of not caring, but a sign that doctors are under pressure. Can they be given time and space for better ways of coping? That seems to be the challenge.”

Kate Bowles shared her experience as a patient:

“From my experience and discussion with other patients, we also hide the humour a bit around staff. There’s a kind of illness professionalism in patients too, weirdly. There isn’t an answer to this; I’m just suggesting that maybe there’s some black humour being used to cope on both sides, that mutual professional courtesy keeps apart.”

Meanwhile, Jon Mendel wrote that he believed power dynamics within a relationship determines the ‘acceptability’ of the use of black humour or slang (i.e. black humour may be fine for patients to use, but not for their doctors).

Table 1 discusses a selection of the pros / cons of medical practitioners using Black Humor as a coping strategy.

Pro	Con
“Black humor is important in all fields of medicine and particularly in EM. We see the worst that society has to offer on a regular basis.Ouisie terrible things happen to good (and bad) people every day.I think depersonalization is critical for us to keep our sanity.” –Anand Swaminathan	“Ultimately, I found that gallows humor and slang were immature coping mechanisms. Becoming cruel and callous would neither shield me from the pain or save me from my own failings… We currently face a most difficult period in medicine. Burnout is at an all-time high, and physician suicide is the topic gracing the pages of our most prominent periodicals. Are coping mechanisms are not working. We must stop making our patients the butt of our grizzly humor.” –Jordan Grumet
“We gradually built our armor of coping/defense mechanisms for our hectic daily work.I would even go further and suggested sometimes when the situations are dire, we “need” to depersonalize so we can focus on tasks and decision-making objectively rather than being swept up in emotions. I think that mechanism of separating illness from the person works well (for say, a pediatric code, a disaster, etc.) that we started using it for other patients as well.” –Stella Yiu	“Some may blow this (laughter) office merely stress releasing, as if it were somehow effective, instead of what it actually is: a symptom of depersonalization that is ultimately the slippery slope to career burnout.” –Carolyn Thomas
“Cruel and inappropriate humor may not always be immature coping mechanisms.However they are often only first line of defense – coping mechanisms that allow individuals to continue with several hours of difficult and busy shifts that lay ahead. However, for many they will then need to unpack their emotions, review their intentions, and work through their emotions and experience of the event. We are all really different” –Liz Crowe	“Dark humor does not help long term and it short-circuits ways of coping and reframing and real support through the dark times when we give our all and the effort is death or destruction.” –Amy Price
	“…Many are themselves uncomfortable with hearing black humor and associated derogatory language and believe it to be immature and indicative of lack of caring.” –John Cosgrove
Table 1. The pros and cons of utilizing black humour as a coping mechanism

For more on Gallows humour, this article by Elizabeth Sullivan in the Psychologist magazine was a suggested reference.

Learners & Black Humor

This case also highlighted the importance of incorporating learners into the discussions around black humour.

Loice Swisher suggested that perhaps what Trevor witnessed was a very unique EM skill set that he was not accustomed to seeing: Emotional Shapeshifting. As Liz Crowe observed, immediate compartmentalization of emotions may be a necessary strategy required of a busy emergency physician so that they can stay sharp, complete their shift and take care of the many other ED patients requiring assistance. Loice states:

“We are trained to rapidly change for one situation to another while making every attempt to have our demeanor match the need. When one observes this shifting to find where the other person is, well, it can be confusing and seem deceiving.”

In the following quote, Stella Yiu eloquently described the insidious nature of how teachers might not be fully self-aware of our practices in this regard, and how this might affect our teaching around such cases:

“It might be such a gradual process and not so explicit to ourselves …that we never see it as such and therefore do not explain it to our learners. We have all thought about patients and cases long after the shift has ended when the full impact of ‘who’ they are hit us – and the learners clearly do not see this (or do not have this explained to them later).”

One medical student (Eve Purdy) stated: “it is desperately uncomfortable when you see superiors making light of a situation that has really shook you. It slams any door shut to debriefing.” Her sentiments are echoed by those previously reported in the literature (2). Medical students have been shown in previous studies to be a very idealistic bunch that desire to be humanistic physicians, able to maintain empathy, ethics and honesty (3), and encounters such as this one may lead to dramatic changes in their perception.

Many participants thoughtfully articulated the treacherous slippery slope that black humour can open up, especially when learners are involved. One brave resident (Sarah Luckett-Gatopoulos) even noted that as she has journeyed up the ranks in medical education she finds herself using terms that she might have found alarming as a medical student. This maps with findings from the nursing literature

Indeed, medical educators and clinical teachers alike need to be cognizant of the impact on their development. Role modeling may be the most potent of teaching strategies, especially in the workplace. (4) As Jonathon Tomlinson highlighted:

“Behaviour is contagious…the importance of role modeling is probably beyond dispute. We learn ways of coping from our peers, gallows humour is one of several ways we cope, but it is a problem if it is the predominant or only way of coping because it is very unlikely to be suitable or sufficient for all the members of a team.”

Participants all seemed to concur that the hidden curriculum may manifest in these scenarios, and if not properly addressed (or debriefed) may lead to changes in learner behaviour. (5,6)

A Call To Action: Finding alternative strategies for fostering resilience

Specifically, studies have shown that emergency medicine trainees are frontline worker that may be particularly susceptible to the stresses of providing clinical care (7).

Time available for debriefing in the ED was explicitly identified as a challenge. Bearing this in mind, participants did make numerous suggestions for how we might better foster resilience in healthcare providers. This is a particular salient issue since there are increasingly high profile instances of PTSD, compassion fatigue leading to burn out and suicide in our healthcare colleagues.

Discussion participants agreed that there is very little formal and informal training in debriefing critical events. Loice Swisher linked an paper which showed that 88% of Peds EM fellows have no debriefing training, despite the majority (90%) wanting to access it (8). Amy Price and Liz Crowe both advocate for more in depth training at all levels in grief management and resilience. Jonathon Tomlinson, like other writers before(9-10), suggested there might also be further opportunities for training in professionalism education:

“Instead of telling doctors and students how they (should) behave we should advocate for humane working conditions and make time for all healthcare professionals to discuss their work through peer supervision, (like the Schwartz rounds other have mentioned) and in ways that give a wider range of opportunities to cope.”

Jonathon Tomplinson points out some studies which support alternate methods for professionalism education including Launer’s narrative-based supervision (11) and Greenhalgh’s educating for complexity (12). He also highlighted the University of Westminster’s Compassion and Resilience in the NHS series (13).

Meanwhile, there may be also a role for expanding the training to include the practice of empathy in the clinical setting (14), since previous studies have shown that clinical exposure alone is not sufficient (15).

All these issues must be kept in mind as we go forward in designing curriculae for our learners. Of note, the origins of cynicism and emotional distance may begin as early as the first clinical exposure for some (i.e. usually third year of medical school) (16).

References

1. Granger, K., Ninan, S., & Stopford, E. (2012). The patient presenting with’Acopia’. Acute medicine, 12(3), 173-177
2. Wear, D., Aultman, J. M., Zarconi, J., & Varley, J. D. (2009). Derogatory and cynical humour directed towards patients: views of residents and attending doctors.Medical education,43(1), 34-41.Hurwitz, S., Kelly, B., Powis, D., Smyth, R., & Lewin, T. (2013). The desirable qualities of future doctors-A study of medical student perceptions. Medical teacher, 35(7), e1332-e1339.
3. Cruess, S. R., Cruess, R. L., & Steinert, Y. (2008). Role modelling—making the most of a powerful teaching strategy. BMJ.336(7646), 718-721.
4. Hendelman, W., & Byszewski, A. (2014). Formation of medical student professional identity: categorizing lapses of professionalism, and the learning environment.BMC medical education,14(1), 139.
5. Kowalczyk L. Empathy gap in medical students. The Boston Globe. March 25, 2013. Accessed on October 1, 2014. Available at: http://goo.gl/IcAGBm.
6. Mills, L. D., & Mills, T. J. (2005). Symptoms of post-traumatic stress disorder among emergency medicine residents. The Journal of emergency medicine,28(1), 1-4.
7. Staple, L. E., O’Connell, K. J., Mullan, P. C., Ryan, L. M., & Wratney, A. T. (2014). National Survey of Pediatric Emergency Medicine Fellows on Debriefing After Medical Resuscitations. Pediatric emergency care.
8. Huddle, T. S. (2005). Viewpoint: Teaching Professionalism: Is Medical Morality a Competency?. Academic Medicine, 80(10), 885-891.
9. Sulmasy, D. P. (2000). Should medical schools be schools for virtue?. Journal of general internal medicine, 15(7), 514-516.
10. Gill, D., Griffin, A., & Launer, J. (2014). Fostering professionalism among doctors: the role of workplace discussion groups. Postgraduate medical journal,90(1068), 565-570.
11. Greenhalgh. Fraser, S. W., & Greenhalgh, T. (2001). Coping with complexity: educating for capability. BMJ, 323(7316), 799-803.
12. University of Westminster’s Compassion and Resilience in the NHS series.
13. Afghan, B., Besimanto, S., Amin, A., & Shapiro, J. (2011). Medical students’ perspectives on clinical empathy training. Education for Health, 24(1), 544.
14. Blumberg, P., & Mellis, L. P. (1985). Medical students’ attitudes toward the obese and the morbidly obese. International Journal of Eating Disorders, 4(2), 169-175.
15. Eikeland, H. L., Ørnes, K., Finset, A., & Pedersen, R. (2014). The physician’s role and empathy–a qualitative study of third year medical students. BMC medical education, 14(1), 165.

Resources that were authored by participants in this discussion

1. Anne Marie Cunningham, Social Media, Black Humour, and Professionals
2. Jonathon Tomlinson:  a.  Do Doctors need to be Kind?  b. Doctors and Empathy
3. Stella Yiu, Loss of Innocence
4. Liz Crowe, Swearing your way out a crisis (by Chris Nickson; the podcast on the page is by Liz)

Other suggested resources

1. Launer J. Conversations inviting change.
2. Schwartz Centre Rounds
3. Attitudes and Habits of Highly Humanistic Physicians
4. Maben, J., Latter, S., & Clark, J. M. (2007). The sustainability of ideals, values and the nursing mandate: evidence from a longitudinal qualitative study.Nursing Inquiry, 14(2), 99-113.
5. EMCases Episode 49, Effective Patient Communication, Patient Centered Care & Satisfaction.
6. Webster F, Rice K, Dainty KN, Zwarenstein M, Durant S, Kuper A. Failure to Cope: The Hidden Curriculum of Emergency Department Wait Times and the Implications for Clinical Training. Academic Medicine. Online first September 30, 2014. doi: 10.1097/ACM.0000000000000499

Videos

1. Dekker S. Just Culture. http://www.youtube.com/watch?v=t81sDiYjKUk&feature=youtu.be
2. Maben J. Care, Compassion and ideals: Nurses’ experience of nursing
3. http://www.youtube.com/watch?v=0zR7gJo5fak&feature=youtu.be
4. University of Westminster’s Compassion and Resilience in the NHS series.   http://www.westminster.ac.uk/resilience/news/compassion-and-resilience-in-the-nhs-lecture-series

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