HOLD YOUR BREATH: Teaching Points

Hold Your Breath: Facilitator’s Guide

Adapted from “Worlds Apart” Facilitator’s Guide

Film directed by: Maren Grainger-Monsen, MD

Purpose

· Provide a semi-structured and informative guide for facilitators to lead discussions on “Hold Your Breath” film

· Provide examples and discussion topics for “Hot Topics” (Culture of Biomedicine, Dr. Fisher’s role, Understanding the Patient’s Perspective, and Translating to Personal Experience) points to bring up to discuss, and “Other Topics” guidelines for discussion

Goals

· Approach each patient as a unique individual and learn about the importance of understanding the patient’s perspective

· Reflect on how the culture of biomedicine has transformed your thinking and attitude in challenging situations

Small Group Discussion Session Exercise

Facilitators are to start the small group session by asking the students to respond to the first question, followed by the discussion session. Prior to the end of the session, students will then respond to the second question.

Our goal is to at least discuss the following two broad questions:

· What impacted you the most about the film?

· How will this apply to your clinical practice?

SUGGESTIONS FOR DISCUSSION GROUP FACILITATION

1. Introduce yourself and your connection to the session.

2. Participants should introduce themselves (Note: helpful to diagram seating location with names.)

3. State the purpose (goal, theme, etc) of the discussion in a positive framework, (FOR EXAMPLE ) “This film raised many challenges to clinical care. In this discussion session we would like to explore your reactions, prior experiences, and see what you can take away and use in future clinical interactions.”

4. Review Ground rules [N.B. This helps to create the conversational climate and safety for frank and respectful discussion]:

a. One person speaks a time.

b. Listen – should state explicit goal on “wait time,” to respect diversity in response time

c. Respect each other.

d. What is “my role” as facilitator

5. It is helpful to think of the discussion as consisting of three parts: the theme (purpose/goal), the group, and the individual. Our first theme/framing question is:

a. What impacted you the most about the film?

b. Give 2-3 minutes for each participant to write his or her responses to this query. (Participants should use 5X7 cards or paper?)

6. After the participants are done writing, open the discussion by asking someone to share what they’ve written down. Then, guide the group through the discussion.

7. There will probably be one to three students who take a lot of airtime right away, which of ok to a point. The point is usually obvious by the silence of other members.

8. You can move the discussion back to the group when just a few students are dominating the discussion with transitional comments such as “ How do others feel, think, agree, share, this view?” Another strategy is to say, “Let’s here from someone else now; what other things to people write down?”

9. If a person is particularly silent, you can engage him/her with a comment such as, “…what do you think about (topic, thought, suggestion); or “…has this been your experience in clinics?

10. In guiding the discussion, consider the triangle below, trying to move from theme to individual to group; as one component seems to dominate, move to another.

11. Wrap up: 2nd theme/framing question is “Based on what we’ve discussed today, what new perspectives or actions will you incorporate into your daily practice?”

a. Have participants write down their goals on the other side of the card

b. Time permitting, have each (or some) participant share their personal goal

c. Ask to collect the cards; state that we plan to look at the cards only to understand the kind of issues and impact the film and discussion raised. If participants want their card back, ask that they put their name on it and state that we will return.

HOT Topics: Questions for the Facilitator

The Culture of Biomedicine

Discuss the term “biomedical culture” as it relates to belief or faith in genetics and science. Discuss how an individual’s cultural influences are broader than just his or her ethnicity, nationality, or religion. Profession can be a major source of cultural influence, which can help shape beliefs, values, and behaviors. In this case, the culture of medicine shapes how physicians and other health professionals talk and think about patients and their diseases.

· What does the film allow you to see about the culture of biomedicine?

· What role does a physician’s cultural background play in a biomedical setting?

· How do physicians remedy differences in their cultural background with expectations of the role as physician?

· What is the role of a secular physician during an encounter with a seemingly religious patient?

· How should physicians resolve religious objections? How should negotiation be approached in similar situation?

· Suppose someone has an (stated or unstated) religious objection, is the correct response “hands off”? What is the correct response?

Opportunity to discuss personal and medical “explanatory models” of illness and treatment that are health beliefs and associated meanings of a particular illness:

· Consider the concepts of “Illness” and “Disease”. Are they clashing belief systems, and how can physicians use both belief systems to treat patients?

· Reflect on the dynamics and hierarchy of the Tumor Board. What is the role of the patient and shared/informed decision making in that setting?

· Consider Dr. Fisher’s statement: “now we are going to treat symptoms” and the relevance related to Mr. Kochi’s understanding that the symptoms are directly related to his illness.

Dr. Fisher’s Role

Dr. Fisher and his willingness to delve into the situation, even with limitations, is an excellent example of the life-long learning process that all physicians encounter in their clinical practice. In the film, Dr. Fisher faces a challenge in a less-than-ideal situation with language barriers, miscommunication, differing health beliefs.

· Consider how Dr. Fisher deals with this situation and reflects on the challenges that he faces. What concepts of mentoring/role modeling

· Reflect on Dr. Fisher’s statement: “I was so concerned with translation of issues that I didn’t get to ask those open ended questions, the bigger maybe more important questions in his care.” How pressing is the sense of obligation to document the presentation of all the information, compared with creating rapport with patient and family members?

· What use of language during interviews, by all providers in the film, do you think create or breakdown barriers?

o Example of create: “Presented hospice, adamantly refused”

o Example of create: “family declined specific intervention”

· Relating to a quote about how the family thought that the surgery “got it all”, is this quote misleading for the family and their understanding of the illness?

Understanding the Patient’s Perspective

An important aspect of care is treating the patient as a person. Medical education primarily focuses on the learning about the disease, and this is often perceived to be the most important aspect of a clinician’s role. But if you ask patients, this is only part of what is important to them. They value health care professionals who listen to them, understand their perspective, explain things to them, and treat them as individuals. Essentially, they value clinicians who understand the illness as they do.

· What are definitions of respect in a doctor-patient relationship?

· In what ways does a physician communicate respect?

· Under what circumstances does a patient feel disrespected?

· Describe any differences in Mr. Kochi’s sore throat and his treatment expectations and Dr. Fisher’s suggested treatment plan.

o What are the key elements of the differing treatment expectations?

· What caretaking expectations did you observe when Mr. Kochi is waiting for his CT scan? What concerns or respect expectations are implied during his questioning of why others’ trauma is more urgent, particularly when he believes that he is in an urgent situation?

· In many settings, the reality of hospitals losing x-rays is standard; however, Mr. Kochi’s expectations and apprehensions regarding the lost x-rays are apparent throughout the film. In what ways can this situation be remedied?

· In approaching each patient as a person towards understanding their perspective, what are key phrases that are helpful in creating rapport and trust with patient? What is realistic in a clinical encounter?

o Example: “What concerns you the most?”

o Example: “Is there anything that you are worried about?”

o Example: “What do you think caused your illness?”

o Example: “How has your illness impacted your life?”

o Example: “What kind of treatment do you hope to receive?”

Translate to Personal Experience

· How do you relate to this film?

· What type of interactions have you experienced that have been challenging?

· What do you bring to the clinical encounter?

Medicine and communication is a lifelong learning process, there are opportunities to grow throughout a medical career.