Making space for empathy: supporting doctors in the emotional labour of clinical care

BACKGROUND: The academic and medical literature highlights the positive effects of empathy for patient care. Yet, very little attention has been given to the impact of the requirement for empathy on the physicians themselves and on their emotional wellbeing. DISCUSSION: The medical profession requires doctors to be both clinically competent and empathetic towards the patients. In practice, accommodating both requirements can be difficult for physicians. The image of the technically skilful, rational, and emotionally detached doctor dominates the profession, and inhibits physicians from engaging emotionally with their patients and their own feelings, which forms the basis for empathy. This inhibition has a negative impact not only on the patients but also on the physicians. The expression of emotions in medical practice is perceived as unprofessional and many doctors learn to supress and ignore their feelings. When facing stressful situations, these physicians are more likely to suffer from depression and burnout than those who engage with and reflect on their feelings. Physicians should be supported in their emotional work, which will help them develop empathy. Methods could include questionnaires that aid self-reflection, and discussion groups with peers and supervisors on emotional experiences. Yet, in order for these methods to work, the negative image associated with the expression of emotions should be questioned. Also, the work conditions of physicians should improve to allow them to make use of these tools. SUMMARY: Empathy should not only be expected from doctors but should be actively promoted, assisted and cultivated in the medical profession

Enhancing & Mobilizing the POtential for Wellness & Emotional Resilience (EMPOWER) among Surrogate Decision-Makers of ICU Patients: study protocol for a randomized controlled trial

Background Critical illness increases the risk for poor mental health outcomes among both patients and their informal caregivers, especially their surrogate decision-makers. Surrogates who must make life-and-death medical decisions on behalf of incapacitated patients may experience additional distress. EMPOWER (Enhancing & Mobilizing the POtential for Wellness & Emotional Resilience) is a novel cognitive-behavioral, acceptance-based intervention delivered in the intensive care unit (ICU) setting to surrogate decision-makers designed to improve both patients’ quality of life and death and dying as well as surrogates’ mental health. Methods Clinician stakeholder and surrogate participant feedback (n = 15), as well as results from an open trial (n = 10), will be used to refine the intervention, which will then be evaluated through a multisite randomized controlled trial (RCT) (n = 60) to examine clinical superiority to usual care. Feasibility, tolerability, and acceptability of the intervention will be evaluated through self-report assessments. Hierarchical linear modeling will be used to adjust for clustering within interventionists to determine the effect of EMPOWER on surrogate differences in the primary outcome, peritraumatic stress. Secondary outcomes will include symptoms of post-traumatic stress disorder, prolonged grief disorder, and experiential avoidance. Exploratory outcomes will include symptoms of anxiety, depression, and decision regret, all measured at 1 and 3 months from post-intervention assessment. Linear regression models will examine the effects of assignment to EMPOWER versus the enhanced usual care group on patient quality of life or quality of death and intensity of care the patient received during the indexed ICU stay assessed at the time of the post-intervention assessment. Participant exit interviews will be conducted at the 3-month assessment time point and will be analyzed using qualitative thematic data analysis methods. Discussion The EMPOWER study is unique in its application of evidence-based psychotherapy targeting peritraumatic stress to improve patient and caregiver outcomes in the setting of critical illness. The experimental intervention will be strengthened through the input of a variety of ICU stakeholders, including behavioral health clinicians, physicians, bereaved informal caregivers, and open trial participants. Results of the RCT will be submitted for publication in a peer-reviewed journal and serve as preliminary data for a larger, multisite RCT grant application

Call to action for global access to and harmonization of quality information of individual earth science datasets

Knowledge about the quality of data and metadata is important to support informed decisions on the (re)use of individual datasets and is an essential part of the ecosystem that supports open science. Quality assessments reflect the reliability and usability of data. They need to be consistently curated, fully traceable, and adequately documented, as these are crucial for sound decision- and policy-making efforts that rely on data. Quality assessments also need to be consistently represented and readily integrated across systems and tools to allow for improved sharing of information on quality at the dataset level for individual quality attribute or dimension. Although the need for assessing the quality of data and associated information is well recognized, methodologies for an evaluation framework and presentation of resultant quality information to end users may not have been comprehensively addressed within and across disciplines. Global interdisciplinary domain experts have come together to systematically explore needs, challenges and impacts of consistently curating and representing quality information through the entire lifecycle of a dataset. This paper describes the findings of that effort, argues the importance of sharing dataset quality information, calls for community action to develop practical guidelines, and outlines community recommendations for developing such guidelines. Practical guidelines will allow for global access to and harmonization of quality information at the level of individual Earth science datasets, which in turn will support open science

SNCA Triplication Parkinson's Patient's iPSC-derived DA Neurons Accumulate α-Synuclein and Are Susceptible to Oxidative Stress

Parkinson's disease (PD) is an incurable age-related neurodegenerative disorder affecting both the central and peripheral nervous systems. Although common, the etiology of PD remains poorly understood. Genetic studies infer that the disease results from a complex interaction between genetics and environment and there is growing evidence that PD may represent a constellation of diseases with overlapping yet distinct underlying mechanisms. Novel clinical approaches will require a better understanding of the mechanisms at work within an individual as well as methods to identify the specific array of mechanisms that have contributed to the disease. Induced pluripotent stem cell (iPSC) strategies provide an opportunity to directly study the affected neuronal subtypes in a given patient. Here we report the generation of iPSC-derived midbrain dopaminergic neurons from a patient with a triplication in the α-synuclein gene (SNCA). We observed that the iPSCs readily differentiated into functional neurons. Importantly, the PD-affected line exhibited disease-related phenotypes in culture: accumulation of α-synuclein, inherent overexpression of markers of oxidative stress, and sensitivity to peroxide induced oxidative stress. These findings show that the dominantly-acting PD mutation is intrinsically capable of perturbing normal cell function in culture and confirm that these features reflect, at least in part, a cell autonomous disease process that is independent of exposure to the entire complexity of the diseased brain

Clinical reactivity and immunogenicity of hemagglutinin influenza vaccine

Subjects aged 3–6, 16–17 and 27–50 years were vaccinated with one dose of hemagglutinin influenza virus vaccine. Clinical reactions, hemagglutination-inhibiting (HI) and strain- and type-specific complement-fixing (CF-V and CF-S) antibodies were determined in sera taken before and four weeks after vaccine administration. The results indicated that the reactogenicity of the vaccine was very low. The HI antibody response differed with the age of the vaccinees, apparently being conditioned by prior exposure to the various influenza virus subtypes. The results of CF tests using strain-specific V antigens corresponded in general with HI tests, with two marked exceptions. In the youngest group nearly half of the subjects developed CF antibody to V-Swine, while all of them remained without antibody detectable in the HI test. However, when V antigen was used instead of intact virus as hemagglutinin, the post-vaccination sera of these subjects also reacted positively in the HI test. Secondly, a number of prevaccination sera from persons aged 27–50 years possessed CF antibody to A/PR 8 in the absence of homologous HI antibody. Among these subjects the antibody response to both A/PR 8 and Swine was more marked in the CF test than in the HI test. After vaccine administration most of the subjects developed antibody or responded by an antibody increase to the S antigens of both influenza A and B. No significant differences were found after intradermal (0.1 ml) and subcutaneous (0.5 ml) administration of one dose of vaccine.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/41682/1/705_2005_Article_BF01250294.pd

Fashioning Entitlements: A Comparative Law and Economic Analysis of the Judicial Role in Environmental Centralization in the U.S. and Europe

This paper identifies and evaluates, from an economic point of view, the role of the judiciary the steady shift of environmental regulatory authority to higher, more centralized levels of government in both the U.S. and Europe. We supply both a positive analysis of how the decisions made by judges have affected the incentives of both private and public actors to pollute the natural environment, and normative answers to the question of whether judges have acted so as to create incentives that move levels of pollution in an efficient direction, toward their optimal, cost-minimizing (or net-benefit-maximizing) levels. Highlights of the analysis include the following points: 1) Industrial-era local (state or national) legislation awarding entitlements to pollute was almost certainly inefficient due to a fundamental economic obstacle faced by those who suffer harm from the over-pollution of publicly owned natural resources: the inability to monetize and credibly commit to repay the future economic value of reducing pollution. 2) When industrial era pollution spilled across state lines in the US, the federal courts, in particular the Supreme Court, fashioned a federal common law of interstate nuisance that set up essentially the same sort of blurry, uncertain entitlements to pollute or be free of pollution that had been created by the state courts in resolving local pollution disputes. We argue that for the typical pollution problem, a legal regime of blurry interstate entitlements - with neither jurisdiction having a clear right either to pollute or be free of pollution from the other - is likely to generate efficient incentives for interjursidictional bargaining, even despite the public choice problems besetting majority-rule government. Interestingly, a very similar system of de facto entitlements arose and often stimulated interjursidictional bargaining in Europe as well as in the U.S. 3) The US federal courts have generally interpreted the federal environmental statutes in ways that give clear primacy to federal regulators. Through such judicial interpretation, state and local regulators face a continuing risk of having their decisions overridden by federal regulators. This reduces the incentives for regulatory innovation at the state and local level. Judicial authorization of federal overrides has thus weakened the economic rationale for cooperative federalism suggested by economic models of principal-agent relationships. As a result of the principle of attribution, there is less risk in Europe that (like in the US) courts would enlarge the federal purview and thereby limit the powers of the Member States. Despite this principle, the power of the European bureaucracy (that is, the European Commission) has steadily increased and led to a steady shift of environmental regulatory competencies to the European level. This shift is only sometimes normatively desirable, and yet there is little that the ECJ can or will do to slow it

Call to action for global access to and harmonization of quality information of individual earth science datasets

Knowledge about the quality of data and metadata is important to support informed decisions on the (re)use of individual datasets and is an essential part of the ecosystem that supports open science. Quality assessments reflect the reliability and usability of data. They need to be consistently curated, fully traceable, and adequately documented, as these are crucial for sound decision-and policy-making efforts that rely on data. Quality assessments also need to be consistently represented and readily integrated across systems and tools to allow for improved sharing of information on quality at the dataset level for individual quality attribute or dimension. Although the need for assessing the quality of data and associated information is well recognized, methodologies for an evaluation framework and presentation of resultant quality information to end users may not have been comprehensively addressed within and across disciplines. Global interdisciplinary domain experts have come together to systematically explore needs, challenges and impacts of consistently curating and representing quality information through the entire lifecycle of a dataset. This paper describes the findings of that effort, argues the importance of sharing dataset quality information, calls for community action to develop practical guidelines, and outlines community recommendations for developing such guidelines. Practical guidelines will allow for global access to and harmonization of quality information at the level of individual Earth science datasets, which in turn will support open science