The Wound Man: From Textbook to Emblem and Hollywood

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If you think you’re having a bad day just remember The Wound Man. Stabbed, bludgeoned and shot yet still standing tall it’s safe to say that his image has been on a journey over more than half a millennium to becoming truly iconic. This journey has taken him from the pages of a medieval textbook to Hollywood via James Bond and the Royal College of Emergency Medicine.

Gunpowder made its way to Europe during the 14th century, probably along the Silk Road trade route with Asia. This meant that as well as the traditional war wounds from blades and arrows doctors were also seeing the effects of cannon and shrapnel. Doctors needed some form of reference to help with the myriad new forms of trauma they might encounter.

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Along came Johannes de Ketham/von Kirchheim, a German physician living and working in 15th century Italy. In 1491 he published Fasciculus Medicinae (the little bundle of Medicine) in Venice; basically the Oxford Handbook of Medicine of its time complying medical knowledge as it was. Written in Latin, the original edition consisted of six illustrations with accompanying text. The world’s first ‘Wound Man’ was one of these illustrations. The illustrations and sections were as follows (diagrams are from the 1495 edition):

Urine and blood letting

  • Urine section: the ‘little bundle’ starts immediately with a section on how a physician could use the colour and smell of a patient’s urine to diagnose their condition

  • Bloodletting/phlebotomy section: a full male figure showing arteries and veins and where the patient could be bled

  • Zodiac figure’: another full male figure annotated with when blood can be taken from certain areas of the body depending on the time of year

‘Zodiac Man’

Obstetrics and Gynaecology

  • Gynaecology and obstetrics: including a pregnant anatomical female figure, and texts related to sexuality, generation, and disorders particular to women

  • ‘Wound Man’: this section illustrated various specific injuries and how to treat them

The original ‘Wound Man’

‘Disease Man’

  • ‘Disease Man’: labelled with various diseases and illnesses

The Fasciculus Medicinae was published again in 1495, 1500, 1509, 1513 and 1522 by which time its information was outdated and it was replaced as a prominent textbook. However, the concept of the ‘Wound Man’ continued with new injuries matching the advancements of military technology.

Possibly the most famous example of a ‘Wound Man’ was included in Feldbuch der Wundarznei (Fieldbook of Surgery), written by the Austrian field surgeon Hans von Gersdorff in 1531.

‘Wound Men’ continued to be used in textbooks until the 17th century, their forms changing with the artistic fashions of the day.

‘Wound Man’ from Feldbuch der Wundarznei (Fieldbook of Surgery), written by Hans von Gersdorff in 1531

The iconography of the ‘Wound Man’ led to its inclusion in the official blazon for the Royal College of Emergency Medicine, adopted on January 24, 1997. Used on the dexter side, it was chosen to show the injured patient in contrast to the healthy man on the sinister side. He represents how emergency medics are trained to treat patients with all kinds of injuries and injury mechanisms as well as the sheer variety seen in trauma patients.

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‘Wound Men’ have been potent icons in fiction as well. ‘The Wound Man’ was a potential title for Ian Fleming’s James Bond novel ‘Dr No’, published in 1958, rejected partly because of the possibility people would mispronounce it as ‘wound up’ rather than a wounded man. In the 1981 novel Red Dragon by Thomas Harris the serial killer Hannibal Lector murders a patient and displays them with multiple injuries similar to a ‘Wound Man’ illustration in one of his books. This was also included in NBC’s television series Hannibal.

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It’s safe to say that Medicine is full of symbols. ‘Wound Men’ are one of the most enduring as symbols of education, traumatic injury and an example of Medicine’s roots over the centuries.

Thanks for reading

- Jamie

How Saline Earned its Salt

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The other day in Resus as I was putting up a bag of fluids for a patient I wondered how long it was we’d been using what seems an incredibly simple but important intervention for our patients. “Putting up a bag of fluids” is a core part of the resuscitation of an unwell patient to the extent it just rolls off the tongue.

Turns out the history of IV saline goes back to Victorian Britain and the cholera pandemics. The Industrial Revolution brought unprecedented numbers of people to the cities, especially London where the population trebled between 1815 and 1860. In many places sewage disposal was not much changed from Tudor days and so struggled to cope. By and large the response was simply to tip the waste into cesspits or into the nearest river hence ‘The Great Stink’ of 1858 which brought the city of London and even Parliament to a standstill.

These conditions were perfect for cholera, a disease brought to Britain from the Indian subcontinent in 1832. A secretory diarrhoea spread via the faeco-oral route it ‘enjoyed’ 5 pandemics between 1817 and 1896. Cholera presents with ‘rice water’ diarrhoea (up to a litre an hour) with a mortality rate up to 70% in untreated patients largely due to extreme dehydration.

Cholera challenged medics at the time and inspired some great work such as that of John Snow on Broad Street in 1854 who rejected the miasmic theory of spread and instead proposed there was a causative agent and that contaminated water was the source. In the same year the causative agent was identified by Filippo Pacini in Italy and was first grown in culture in 1884 by Robert Koch working in Egypt and India. Fluid replacement with intravenous fluid was another such innovation.

By 1832 the work of Dr W B O’Shaughnessy had concluded that the blood of cholera patients had lost most of its water as well as its saline contents and the Lancet recommended “the injection into the veins of tepid water, holding a solution of the normal salts of the blood.” That same year Thomas Latta, a physician working in Leith, Scotland attempted to treat a patient with cholera doing just this.

He first tried treating patients with fluids inserted rectally but found that not only did it not work it actually seemed to make their vomiting and diarrhoea worse. So then he tried intravenous injection. He wrote describing how over half an hour he injected 6 pints (3.4 litres) of fluid in the basilic vein of an elderly lady with cholera: “soon the sharpened features, and sunken eye, and fallen jaw, pale and cold, bearing the manifest imprint of death’s signet, began to glow with returning animation; the pulse returned to the wrist…” Sadly he left the patient in the hands of the house surgeon who did not repeat the treatment as the patient deteriorated again and so she died 5 hours later.

That same year Dr Robert Christison wrote to the Dutch government advising them on this new treatment. He described 37 cases treated with intravenous fluids of whom 12 survived. He mentioned certain risks including air embolus, phlebitis and the potential risks of introducing so much fluid to a patient but generally recommended the treatment. Looking back there were probably other risks too such as secondary infections from unsterile injections they wouldn’t have been aware of.

In these early days there was no standardisation of what the fluid should contain with some physicians using egg whites with their fluid and some adding albumin. It wasn’t until Dr Sydney Ringer’s work in the 1880s that an optimum physiological solution was found. The dangers of potential fluid overload were identified quite early on as well with S.K. Mujumbar of Port Blair, India writing in 1916 of the need to identify cholera patients who actually need fluids so as not to cause “an extra amount of work on the already weakened and embarrassed heart”.

0.9% Saline has since become a staple of modern medicine and is included on the World Health Organisation’s list of essential medicines last published in 2017.

Further pandemics of cholera occurred in 1899-1923 and 1961-1975 by which time advances in public health medicine meant Western Europe was unaffected. The last outbreak in the USA took place in 1910-1911. Cholera remains endemic in many countries in Africa and has continued to re-surface whenever sanitation is affected such as in Haiti following Hurricane Matthew. Diarrhoeal disease is the second highest cause of mortality and leading cause of malnutrition in the under-fives worldwide. The WHO describes diarrhoea as “preventable and treatable”. Re-hydration whether orally or intravenously remains the mainstay of treatment.

So whenever we are putting up a bag of fluid for a patient we are continuing a tradition first started by Thomas Latta injecting 6 pints of fluid into the basilic vein of his patient in Leith.

Thanks for reading

- Jamie

Don't Just Sit There: Audience Participation in Simulation

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In my last blog I talked a bit about setting the audience up for a simulation. In this blog I wanted to explore this more. Students who volunteer first to simulate are often in the minority but it’s important that the audience don’t feel like it’s an easy ride and just sit there.

The standard lay out when I run a simulation session is like this:

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One of the audience members becomes the scribe, recording the clinical history and the story as in unfolds. This provides a point of reference for the students in the simulation as well as helping discussion during debrief. As these example show it also lets students be a bit creative:

We’ve often given students in the audience a checklist and asked them to record proceedings as well as part of student to student feedback.

If you’re giving the students in the simulation information such as an ECG or blood gas, make sure the audience can either see it or get a copy too to involve them. Later on reflect on their conclusions: are they different from those in the simulation?

In the previous blog I mentioned lifelines such as ‘Ask the Audience’. I find reminding the audience that at any moment the students in the simulation might turn round and ask your opinion inspires them to keep paying attention!"

‘Tag Team Simulation’ is something I’ve thought about but not done yet but would be another way to keep the audience engaged - I’d be interested to hear how this works if anyone has done it.

Managing audience members is a key part of the simulation session. If nothing else their engagement is a sign of respect for the students actually doing the simulation and helps create a positive learning atmosphere for everyone.

Thanks for reading

- Jamie

Setting the Stage: The Pre-Brief

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Simulation is an indelible part of medical education as well as the training of other healthcare professionals. At DREEAM I’m lucky to be able to work with the great cohort of simulated patients trained by my colleague Ali Whitfield. Working with real human beings rather than mannequins adds another layer of realism and has become a firm fixture in the training we offer at DREEAM.

However, being ‘on stage’ in a simulation remains a very divisive issue for learners. From my experience half of students will feed back how much they love simulation and want more with the other half hating every moment. That’s usually due to previous bad experiences or pre-conceived notions.

As I’ve worked more with simulation as a facilitator I’ve put more emphasis at the beginning; the pre-brief or ‘setting the stage’ partly due to these pre-conceived notions but also as not every student has the same experiences with simulation. Much as an actor wouldn’t expect to just walk onto a stage so a novice student shouldn’t be expected to just perform without some clear guidance.

My pre-briefs usually follow the same pattern:

  • Introduce the session and why we are using simulation - it’s not being arbitrarily used to scare but instead with very clear objectives with definite relevance

  • The setting (ward, A&E, GP practice whatever) their role (you’re a student/doctor/nurse) and the expectations of the behaviours expected - act as you would as a doctor, treat the simulated patient as a real patient etc. How do referrals work in this scenario? Also, what is expected from the audience? I regularly get one member to act as a scribe on a flip-chart for the learners in the simulation to refer to. Encourage the audience to be active observers

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  • Orientate the students around the environment and the equipment. Highlight any potential sources of confusion such as differences between the patient’s palpable pulse rate and what is on the monitor. Will there be blood results available? Are we running in real time? This helps keep the scenarios running later on

  • Acknowledge simulation can be challenging and where possible allay fears - if you’ve set the scenario up so that any mistakes made will be corrected and death is not an outcome then tell them! In my experience the biggest apprehension toward simulation from students is that we’re trying to catch them out and they’ll kill the patient. If that won’t happen let them know. If it might happen then also let them know and reassure that it’s a safe environment allowing for these mistakes

  • Lifelines - the timeout is a common theme in any simulation and it’s important to reassure students about this. I go further and add lifelines similar to ‘Who Wants to be a Millionaire?’ Students can ‘Ask the Audience’ - turn to the learner watching and ask their opinion or ‘Phone a Friend’ - ask the facilitator a closed, focused question; “I think it’s aortic dissection what’s the best imaging for this?” If it’s not going great we can always time-out and take a break; this is fine and should be used if needed

  • Is there a specific aspect of simulation they’d like you to look out for? Giving useful feedback can be challenging. Students may have apprehensions about one particular skill or part of simulation such as cannulation or delivering a useful referral based on previous experiences. If they can tell you this beforehand it helps observation and providing feedback the student can use

  • Give them appropriate information beforehand. Most of the simulations I do with students are based in the Emergency Department. One is with a patient presenting with chest pain who turns out to have a pulmonary embolus. In real life there would be an ECG. I provide this ECG and give them a moment to read it. I ask what the students are thinking and why. They usually say Acute Coronary Syndrome. At the end after diagnosing PE during the feedback I then ask them to take us through the process of how they ended up changing their mind from ACS to PE (usually because the patient complains of calf pain). I reinforce how important it is to always consider ACS but also what aspects should make us think PE (yes calf pain is important but the patient had oxygen saturations of 90% with no lung history, a clear chest and her ECG shows AF.) - this shows the nature of a true ‘working diagnosis’ as well as helping us understanding each others thought processes

Ultimately the pre-brief is about you and your learners finding out about each other. Standardise as much as you can. Students who go first may resent being ‘the example’ so think about making a video to show everyone what is expected at the beginning. This is then easier for you later on. I think pre-brief is an investment in your simulation sessions. The more and better you do at the beginning the bigger and more rewarding your session will be.

Thanks for reading

Jamie

We Need to Talk About Kevin: Is Kevin McCallister a Psychopath?

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It’s Christmas time, there’s no need to be afraid. At Christmas time we let in light and we banish shade. And usually sit down to watch a number of Christmas films including one or both of Home Alone (1990) or Home Alone 2: Lost in New York (1992)*. Both films were written and produced by John Hughes and directed by Chris Colombus and star Macaulay Culkin as Kevin McCallister as a young boy left home at Christmas in the first film and who ends up in New York in the second. In both he has to defend himself against a couple of bumbling burglars ‘The Wet Bandits’, Harry (Joe Pesci) and Marv (Daniel Stern). Home Alone remains the highest grossing live action comedy in the US and only lost the worldwide title in 2011 to The Hangover II. Both films are firm fixtures for Christmas watching.

Yet, on a recent viewing the other day there was an easy question in my mind. Not the sad decline of Macaulay Culkin from childhood star to example for any child who becomes famous or even the fact that the McCallister family would clearly have social services swarming over them. No, this question was about the character of Kevin himself. Beyond all the jokes and slapstick, is Kevin McCallister a psychopath?

I’m not a psychiatrist so I first had to look up the criteria to make a diagnosis. Turns out psychopathy doesn’t really exist anymore as a diagnosis and has been largely replaced by anti-social personality disorder (ASPD). So this changed my question for this musing immediately; does Kevin McCallister fulfil the criteria for ASPD?

As Kevin McCallister is American it seemed right to base any diagnosis against the criteria of the American Psychiatric Association. Fortunately, they publish their diagnostic criteria in the Diagnostic and Statistical Manual of Psychiatric Disorders (DSM) now in its 5th iteration published in 2013. The DSM defines the essential features of a personality disorder as “impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits.” The DSM 5 details very clear criteria to make a diagnosis of ASPD.

First there needs to be significant impairments in self functioning AND in interpersonal functioning.

DSM defines impairments in self functioning as either identity or self-direction:

a.Identity: Ego-centrism; self-esteem derived from personal gain, power, or pleasure.

b.Self-direction: Goal-setting based on personal gratification; absence of prosocial internal standards associated with failure to conform to lawful or culturally normative ethical behaviour.

Kevin certainly has high self-esteem. In Home Alone he genuinely believes that through his own power he has made his own family disappear. A belief that prompts celebration:

In terms of conforming to legal or ethical behaviour at no point in either film does he seek to tell the police or authorities that he’s home alone or at risk of the Wet Bandits. Indeed, he shop lifts albeit inadvertently in the first film and uses his father’s credit card to book into a luxury hotel in the second. He certainly uses his freedom for personal gratification spending $967 ($1,742.98 in today’s money) on room service alone in Home Alone 2.

So far it seems like he’s ticking the boxes without us even mentioning the vigilante justice. More of that violence later.

On to interpersonal functioning, defined by the DSM as either in empathy or intimacy:

a.Empathy: Lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another.

b.Intimacy: Incapacity for mutually intimate relationships, as exploitation is a primary means of relating to others, including by deceit and coercion; use of dominance or intimidation to control others.

Speaking as a doctor in Emergency Medicine let’s get this straight: Kevin would have killed the Wet Bandits several times over. Especially in the second film where to start he throws four bricks on Marv’s head from height. Marv would be dead. No question. Kevin McCallister is attempting murder:

Later on, he sets up elaborate traps and stays around rather than running away (like most would do) merely to supervise Marv getting electrocuted and Harry setting fire to his head:

At no stage does he show any remorse and actually celebrates what he’s doing. Prior to meeting Kevin the Wet Bandits were cartoon villains, non-violent and stupid. Did they deserve to die? Kevin obviously felt it was worth risking it and enjoyed it.

He does form friendships in both films with people he previously feared; Old Man Marley and the Pigeon Lady. He inspires the former to re-connect with his family and gives the latter a present. This does suggest that he can form bonds with people. However, both were useful to him by helping him escape the Wet Bandits so it could be argued he was exploiting and rewarding them for his own benefit. This bit is open to debate but for the benefit of the blog lets assume this was Machiavellian manipulation and move on.

The patient then needs to have pathological personality traits in antagonism and disinhibition.

The DSM defines antagonism as:

a.Manipulativeness: Frequent use of subterfuge to influence or control others; use of seduction, charm, glibness, or ingratiation to achieve one„s ends.

b.Deceitfulness: Dishonesty and fraudulence; misrepresentation of self; embellishment or fabrication when relating events.

c. Callousness: Lack of concern for feelings or problems of others; lack of guilt or remorse about the negative or harmful effects of one’s actions on others; aggression; sadism.

d. Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults; mean, nasty, or vengeful behaviour.

We’ve already looked at Kevin’s violence and cruelty. He’s also certainly a master of deception. Throughout both films he is adept at speaking to adults and painting stories with great ease. Lying comes very easily to him as does using props and music whether to pretend to be his dad in the shower, a gangster with a gun or even a house full of celebrating people:

This is a crafty kid who is willing to lie and smile while doing it.

Disinhibition is defined by the DSM as:

a. Irresponsibility: Disregard for – and failure to honor – financial and other obligations or commitments; lack of respect for – and lack of follow through on – agreements and promises.

b. Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing and following plans.

c.Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard for consequences; boredom proneness and thoughtless initiation of activities to counter boredom; lack of concern for one’s limitations and denial of the reality of personal danger

In both films Kevin shows poor regard for his own safety, whether climbing down a rope soaked in kerosine, zip-lining from the roof of his house or climbing his brother’s shelves:

Early on in both films he is shown impulsively lashing out in anger when he feels frustrated at having his pizza eaten or embarrassed in public during his choir solo. Kevin is not inhibited:

And violence is clearly natural to him. So far…seems to be meeting all the criteria.

Finally these factors must be consistent across time and place. They must not be due to intoxication or head injury.

As Kevin behaves the same in Home Alone (1990, set in Chicago) and Home Alone 2 (1992, set in New York) we can assume his behaviour is consistent to time and place. At no point is he seen taking drugs or drinking alcohol so we can rule those out as a cause. He does hit his head slipping on ice in Home Alone 2 but that’s very late on and isn’t shown to effect his behaviour in any way. Once again he’s meeting criteria.

They must not be better understood as “normative for the individual’s developmental stage or socio- cultural environment.”

Kevin is a remarkable child acting in a way we wouldn’t expect of a boy his age. He definitely has, at best, a chaotic family and there’s no doubt that after Home Alone 2 social services would have come down on the McCallister family like a tonne of bricks:

However, the house is pristine and all the children look well nourished and dressed. While there’s plenty of questions about what kind of job the McCallisters must do in order to fund this lifestyle there’s no indication that this is a family where violence is the norm. Box ticked again.

Finally, the individual is at least age 18 years.

Ah, here it falls down right at the last. Kevin is 8 in Home Alone and so well below the age where we can diagnose ASPD. NICE does have a Quality Standard (QS59) first published in 2014 aimed at identifying children at risk of ASPD. This includes interventions for the whole family. But in no way can a conclusive diagnosis be made in a child.

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So is Kevin McCallister a psychopath? By the DSM diagnostic criteria the answer is no. Does he show some traits that might set off alarm bells? The answer is yes. However, there is a debate about whether ‘psychopathy’ is an evolved trait which has been able to survive through natural selection as it has benefited human society to have individuals without morals prepared to do whatever it takes to achieve their goals (Glenn, Kurzban and Raine, 2011). Maybe we should celebrate Kevin’s innate traits as he uses them to defend himself and his family. After all, it means the bad guys get caught and it wouldn’t really make good films if he just rang the police like a good citizen.

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Time to be serious now. This blog does highlight a big issue I find with mental health. Almost ahead of any other profession people are all too willing to play ‘keyboard psychiatrist’ and diagnose public figures such as Donald Trump with a mental illness. Whilst this blog is meant as a bit of fun it shows how mental health has very clear diagnostic criteria to be met before we use loaded terms such as ‘psychopath’. That can be my Christmas message: before you make a stigmatising diagnosis make sure you know what you’re talking about. In fact in general: research first, speak later. Let’s be nice people.

Merry Christmas, you filthy animals

*Yes, I am aware there is a ‘Home Alone 3’ and even somethings called Home Alone 4: Taking Back the House and Home Alone: The Holiday Heist. I just choose to ignore them as we all should.

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REFERENCES:

Glenn, A., Kurzban, R. and Raine, A. (2011). Evolutionary theory and psychopathy. Aggression and Violent Behavior, 16(5), pp.371-380.

Hopwood, C. J., Thomas, K. M., Markon, K. E., Wright, A. G., & Krueger, R. F. (2012). DSM-5 personality traits and DSM-IV personality disorders. Journal of abnormal psychology121(2), 424-32.

Pitch Perfect: Delivering a Short Talk

Earlier this year I submitted an abstract to the Association for Simulated Practice in Healthcare (ASPiH) conference about my work on the application for medical students in the Emergency Department.

On 3rd August I received an email back informing me I’d been accepted for a poster presentation. Joy was then met with not a small amount of trepidation as I read further “You should plan to speak for 3 minutes with an additional 2 minutes for questions.”

3 minutes?

180 tiny seconds of time to talk about my project, my baby?

I’d presented for 10 minutes before but this was something else in terms of brevity. So I tried to have a process. This is my process, I’m not saying it’s perfect and there’s still things I’d want to change but it’s an example of how to approach the problem of getting your message across in a short period of time.

The idea of any talk is to engage, inspire and inform, That ratio can be changed around; the longer your talk you more you can inform about at the risk of losing engagement and inspiration. Obviously with only 3 minutes I was going to have to cut on the informing and focus on engagement and inspiring. I needed another way of informing the audience.

So, I wrote a blog. This step helped me know the subject and clarify the key points along the way. What’s the killer and what’s filler? What is nice to know but what is absolutely essential about your message? By doing this I realised I had three (always a good number) key points I wanted to highlight: the app was easy to make, it flipped the classroom and blended learning and that students value opportunities to practice digital literacy in simulation.

My talk would therefore be used to get those three points across and hopefully inspire my audience to look for the blog to read more.

Once the blog was written (and that took a long time) and I’d realised what the purpose of my talk would be I decided to see this as an ‘elevator pitch’ similar to those used in business as a format of engaging potential employers/investors in your project. Essentially you imagine you’re in the lift with the person you want to impress and you’ve got the time it takes to go from the ground floor to the top to sell yourself or your product.

With that in my mind I did a few Google searches to find what advice is our there to create an elevator pitch. Unsurprisingly, they’ve made an industry out of this so there’s a lot of information but very little I found useful without needing to pay money. However, I found this blog very useful by Alyssa Gregory. She breaks the process down into stages:

  1. Define who you are are

  2. Describe what you do

  3. Identify ideal audience

  4. Explain what’s unique and different about you

  5. State what you want to happen next

  6. Create an attention-grabbing hook

  7. Put it all together (start with 6)

So I did this. I wrote it out.

And I read it out loud. Slowly and clearly. It came in at 2 minutes 45 seconds. Great! But on reading it out loud it felt flat. And weird. I realised while it was a useful tactic to plan a bit like an elevator pitch the key difference was I wasn’t selling anything. So I did the next step. I practised. With an audience.

This seems perfunctory but it’s key. Only on performing in front of colleagues who I knew would be productive in their criticism did I start to get a sense of what it was like to hear about the application. They could tell me about the ebb and flow and how easy it was to follow my three key messages. There was a rewrite. And another.

Finally, I was lucky in that my poster was on the third day of ASPiH so on the second I was able to watch a poster session and get a feel for the room and see what works and what doesn’t. Clear, slow speech was vital. A bit of humour if possible. Don’t distract with your body language. Look at the audience and not your poster.

There was another slight rewrite and then a lot more practising.

This is what I came up with.

As I said before it’s not perfect but I was happy with it and it seemed to be well received.

I hope this is useful to you and helps if you’ve got a very short presentation to make. Any of your own tips? Anything you don’t agree with? Let me know!

Medical Education - There's An App For That

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Third year medical students at the University of Nottingham on clinical attachment at the Queens Medical Centre spend one week with us in DREEAM and the Emergency Department. Emergency Medicine can be daunting for experienced students let alone those right at the beginning of the clinical phase of the course. Also, as students arrive in the spring their week is often shortened due to Bank Holidays and other commitments such as core teaching. I wanted to find a way to give the students as much information as possible about the working of the department and its protocols as well as a way of increasing contact time to make the most of their attachment. A smartphone application seemed a practical solution.

IT’S EASY

The thought of creating an application might bring to mind Matrix-style screens of numbers and formulas indecipherable to anyone except hackers and programmers. The truth is it has never been easier to create your own application thanks to a number of websites which require no coding experience. A simple Google search reveals just what a crowded market the app building industry has become so I recommend a bit of research to find the platform that works best for you. Most of them work along the lines of choosing a template and then picking functionality such as social media links to add literally in a ‘drag and drop’ style. I chose AppMakr due to its ease of use and because the app also works as a website allowing students to access it on their computers and laptops as well.

The whole process is based on simply picking what functionality you want (say a calendar) and dragging it across. Each function is based on an RSS feed so you link your calendar to a Google calendar or your podcast icon to a SoundCloud feed. In order for the app to have our department’s Initial Assessment Tools (IATs) I created a Google Drive folder containing the guidelines as PDF files and used the shareable link. This meant clicking on the IATs button opened the IATs up for the students to use.

Backgrounds can be played around with. I tried importing pictures but found the resolution and sizes difficult; I think this had more to do with the images I was trying to bring in rather than the website itself.

You can pay to create your app and submit it to iTunes for consideration (it will need to be very good to get approved) or AppMakr will create a mobile website for free. The mobile website for this application can be found here. All students need to do is set the website to the home screen of their mobile or tablet and there, instant application. It was that simple.


Simply pressing on the green cross brings up the list of functions. The green cross acts as a kind of home button.

Using Google Drive links the presentation buttons bring up the slides for each session. The IATs function works the same. The calendar links to a Google Calendar account created especially for this application.

External resources were linked to the application as well. Certain Free Open Access Medical Education (FOAM) resources were linked as well as dedicated Social Media, Podcast and YouTube resources to help the students during the attachment. Unlike other apps this worked without internet connection which helps in the concrete basement of our Emergency Department!

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Finally, a forum was created into which students and educators could log in and communicate. This helped share resources and further discussions. This brings me on to my next point:

FLIPS THE CLASSROOM AND BLENDS YOUR CURRICULUM

The flipped classroom describes students being given learning resources before a teaching session. The teaching session is then used to explore the material in greater detail (Heacademy.ac.uk, 2018). The role of the teacher in the flipped classroom has been described as a facilitator and coach or ‘guide on the side’ (Baker 2000). This notion resonates within suggested theories in medical education regarding the exponential growth as well as the shortening half life of knowledge such as connectivism (Siemens 2005) or navigationism (Brown 2006). The growth of Web 2.0 resources such as blogs and podcasts further facilitates this.

Using the application it was possible via the forum and word of mouth to point the students to a particular resource (say a podcast on Abdominal Pain) and advise them to listen to it before their session on Abdominal Pain. By flipping the classroom we can establish a set level of prior knowledge the traditional session can then build on. This maximises the time together. There’s a number of resources aimed at helping educators set up a flipped classroom programme such as this one from the Flipped Learning Network.


The forum allowed further discussions around cases (anonymised) or other subjects that couldn’t be covered in the timetabled sessions. These discussions were held between 1700-1900 in the evening and all students were encouraged to participate. This use of online resources alongside traditional sessions is called blended learning (Heacademy.ac.uk, 2018). The point was that the sessions would lead onto online discussion which would then be referred back to in the next face-to-face session which takes some time to get used to but is rewarding. The Higher Education Academy has a great page on blended learning here.

REAL LIFE PRACTICE IN SIMULATION

In all 18 students ‘downloaded’ the application. There was an orientation session at the beginning as well as clear guidance on professional online behaviour; so called ‘netiquette’ (Webroot.com, 2018).

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All sessions were designed to integrate the application either through guideline reference in simulation or signposted online resources during seminar sessions. All students used the application in at least one session with 11 students (61%) using the application in every session.

The forum transcription was analysed for any emergent themes. As I already discussed the forum was a key part of the ‘flipped classroom’ and improving communication before educators and students. This resulted in logistical messages communicating session changes or short term information such as interesting patients:

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There was signposting to resources to consolidate sessions or for prior learning before teaching:

There were also online discussions instigated around investigations or clinical questions:

The reason(s) for students using the application during simulation was assessed. By far and away the most common reason was to look up departmental guidelines (13) followed by looking up national guidelines (4), looking up free open access resources (2) and to look back on a presentation (1).

Students were asked to rate the application on a Likert scale. All students rated the application positively (4 or 5) with 14 (78%) rating the application 5/5.

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Finally, students were given a free text box for further feedback. As the diagram below shows this feedback focused on themes of reference and reflecting real life practice:

This suggests that medical students appreciate the role of guidelines and technology in clinical practice. The importance of digital literacy and navigating resources for expedient care is well documented with the Royal College of Nursing and Health Education England launching programmes to improve and formalise skills in this area (The Royal College of Nursing, 2018 and Health Education England, 2018). Studies have looked at promoting digital literacy amongst medical students (Mesko, Győrffy and Kollár, 2015). Perhaps with the rise of connectivism and/or navigationism as a learning paradigm we will see even more work into this area with digital literacy becoming a key skill alongside clinical acumen. Anecdotally speaking to the students the biggest barrier to using the application was familiarity. Once this was overcome they felt comfortable using it and contributing on the forum.

Students value innovation from educators but this requires careful design of the curriculum and resources to ensure feasibility and compatibility.  The project suggests that application design is feasible for educators with limited coding experience and the results indicate that students engage well with a blended curriculum.  Engagement with the application was related to student confidence and perceived relevance.  Mobile learning tailored with simulation offers students a realistic experience.  Resource design may become a crucial part of educator development.  Students require guidance with new resources when presented to them.

Reference

Baker, J. W. (2000) The “Classroom Flip”: Using Web Course Management Tools to Become the Guide on the Side. In: the 11th International Conference on College Teaching and Learning: Jacksonville, Florida.

Brown, T. (2006) "Beyond constructivism: navigationism in the knowledge era", On the Horizon, Vol. 14 Issue: 3, pp.108-120, https://doi.org/10.1108/10748120610690681

Flipped Learning Network (FLN). (2014) The Four Pillars of F-L-I-P™

Heacademy.ac.uk. (2018). Blended learning | Higher Education Academy. [online] Available at: https://www.heacademy.ac.uk/knowledge-hub/blended-learning-0 [Accessed 19 Oct. 2018].

Heacademy.ac.uk. (2018). Flipped learning | Higher Education Academy. [online] Available at: https://www.heacademy.ac.uk/knowledge-hub/flipped-learning-0 [Accessed 19 Oct. 2018].

Health Education England. (2018). Digital literacy. [online] Available at: https://www.hee.nhs.uk/our-work/digital-literacy [Accessed 29 Oct. 2018].

Mesko, B., Győrffy, Z. and Kollár, J. (2015). Digital Literacy in the Medical Curriculum: A Course With Social Media Tools and Gamification. JMIR Medical Education, 1(2), p.e6.

Siemens, G. (2005). Connectivism: A learning theory for the digital age.International Journal of Instructional Technology and Distance Learning2(1), 3-10.

The Royal College of Nursing. (2018). Improving Digital Literacy | Royal College of Nursing. [online] Available at: https://www.rcn.org.uk/professional-development/publications/pub-006129 [Accessed 29 Oct. 2018].

Webroot.com. (2018). What is Netiquette? A Guide to Online. [online] Available at: https://www.webroot.com/hk/en/resources/tips-articles/netiquette-and-online-ethics-what-are-they [Accessed 29 Oct. 2018].

Heart or Head - Can We Teach Empathy?

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First, I want you to read the descriptions of these four patients and imagine, really imagine, them in front of you as if this is their triage and you're just about to see them:

  • A teenager with leukaemia on chemotherapy who's presenting with a fever, shortness of breath and a productive cough

  • An elderly lady who has tripped on the pavement whilst collecting for charity and is presenting with right hip pain and shortening and external rotation of her right leg

  • An intravenous drug user who presents with left groin pain and swelling with fever two days after injecting there

  • A middle aged man in police custody after being arrested at a far right rally for smashing a window brought to you with a laceration to his right arm who's being racially abusive

You're probably already making working diagnoses based on these statements: possible neutropenic sepsis, right neck of femur fracture, groin abscess, laceration needing sutures.  But how do you feel reading them?  Sure, you're going to do your best and you'll be professional but how would you be inside as you see these hypothetical patients?  Would you feel compassion? Sympathy?  How about empathy?

Empathy has been an important factor in the reflections all healthcare professionals underwent following the Mid Staffs scandal:

“food and drinks were left out of reach of patients…the standards of hygiene were at times awful with families forced to remove used bandages and dressings from public areas…people…suffered horrific experiences that will haunt them and their loved ones for the rest of their lives” (Campbell, 2018).

The Francis Report identified empathy as one of the main professional attributes that enable compassionate care (Webarchive.nationalarchives.gov.uk, 2018). The Department of Health and NHS Commissioning Board 2012 recommended that, “care is given through relationships based on empathy, respect and dignity” (Webarchive.nationalarchives.gov.uk, 2018). This leads us to the obvious question:

WHAT IS EMPATHY?

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I think it's fair to say that empathy's meaning can get lost in translation.  A straw poll of colleagues on a certain shift led to a number of different suggestions, "it's when you feel sorry for someone", "it's when you show you care", "it's when you can put yourself in their shoes".

Empathy is defined by Merriam-webster.com (2018) as:

  1. the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner; also the capacity for this

  2. the imaginative projection of a subjective state into an object so that the object appears to be infused with it

I like this line from Harper Lee's 'To Kill a Mockingbird' - 

"You never really understand another person until you consider things from his point of view - until you climb inside of his skin and walk around in it."

First things first: empathy is not about feeling sorry - that's sympathy.  But let's look at the above definition from Merriam-Webster.  "Understanding, being aware of, being sensitive to" - all sound very appropriate for the caring professional.  But "vicariously experiencing the feelings, thought and experience of another...the capacity for the imaginative projection" - is this necessary?  Is it healthy for healthcare professionals exposed to challenging environments every day to be put through such an emotional wringer?

THE BIOLOGY OF EMPATHY

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We certainly know that empathy has a biological framework. Empathy has a proven genetic basis (Knafo, 2008) acting as an evolutionary advantage by promoting altruism and other prosocial behaviours (de Waal, 2008). Displaying empathy is linked to known neuronal pathways such as those involved in facial mimicry (Sonnby-Borgstrom et al, 2003) and imitation (Field et al, 1982 and Fornan et al, 2004) as well as the mirror neuron (Iacoboni, 2008) and limbic systems (Carr el al, 2003, Iacoboni and Dapretto, 2006 and Preston and de Waal, 2002). In contrast deficits in empathy are particularly evident after focal prefrontal cortex damage with poor empathic development seen in children with early damage to their frontal lobes (Eslinger, 1998). Further evidence of the innateness of empathy has been reproduced in several studies showing how children as young as 18-hours-old are distressed at other’s crying (Martin and Clark, 1982, Sagi and Hoffmann, 1976 and Simner, 1971).

Behavioural psychologists have hypothesised that everyone falls somewhere on a spectrum of emphasising and tendency towards system creation (empathy-systemising theory) (Baron-Cohen, 2009). 

EMPATHY AS BEHAVIOUR - THE CHECKLIST APPROACH

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If we accept empathy as behaviour we can focus on the prosocial behaviours in a simulated environment with our students. Kahn’s Etiquette Based Medicine (EBM) (Kahn, 2008) is an interesting development in this area.  He looked at clinical checklists such as Pronovost’s checklist for inserting central lines (Thelancet.com, 2018) and used the same principle for empathetic behaviour in a potentially simulated environment giving the following example:

1. Ask permission to enter the room; wait for an answer.

2. Introduce yourself, showing ID badge.

3. Shake hands (wear glove if needed).

4. Sit down. Smile if appropriate.

5. Briefly explain your role on the team.

6. Ask the patient how he or she is feeling about being in the hospital.

Let’s imagine designing a simulation where this could be assessed.  Our students could cycle through simulated patients with a variety of different diagnosis: a patient in pain, a patient with substance abuse, a patient with mental health issues.  The simulation could also look at the standard A-E and diagnostic approach but also include this empathic assessment just as prominently.  The simulated patient would be very useful  in feedback:

“When I mentioned that my husband had died it was nice that you held my hand.”

or

“You didn’t always look me in the eye which made me feel like you were talking over me sometimes.”

Those observing the simulation can also give similar feedback based on their third person observations in a purely objective format: we saw or heard this therefore it appeared as this.  It would be useful to include fellow students as part of this audience to help learn from each other. Further studies have expanded on Kahn's initial checklist to include suggestions for a second meeting with a patient (Castelnuovo, 2013).

Kahn accepts the pedagogical limitations here; this is behaviour not feeling.  But he argues that this is a useful first step for students to start to develop empathy.  This reminds me of the ‘Hello my name is...’ campaign, an incredibly successful movement based on a very simple premise.  As Kahn himself argues, it is easier to change behaviour than attitude.

We already use simulation and observed exercises as the basis of teaching and assessing communication skills.  A student could in theory pass without issue on a station marked communication skills when they know that is being assessed before forgetting communication skills when it comes to further stations.  The current move towards more holistic and OSCE assessment partially recognises this possibility; a station is no longer marked for one particular topic but instead assesses focused examination, investigation interpretation and communication skills.  We have to make sure that empathy is consider in all observed real and simulated patient encounters both assessed and not.

EMPATHY - REFLECTING AND REPORTING

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Experiential attempts to foster empathy in students have focused on immersion and realism such as ageing simulation (Through Their Eyes Project, 2018) and reflection and simulation (Counseling.org, 2018).  These are time and resource heavy. The Jefferson Scale of Physician Empathy offers a psychometric assessment of students and practitioners and has a growing evidence base (Tavakol, Dennick and Tavakol, 2011). The JSPE is based on self-reporting via a questionnaire. This suggests that a reflective model can be encouraged either via simulation and immersion or through qualitative questioning of subjects. This obviously relies on resources and honesty.

So can empathy be taught? The truth is this depends on how you view empathy, as a skill or a behaviour. Even then, some of the greats of education have been unable to agree and have changed their minds.

In 1951 humanist Carl Rogers wrote that empathy was a skill that can be taught (Rogers, 1951) but by 1975 changed his opinion and argued that it wasn’t a skill but behaviour that had to be willingly displayed (Rogers, 1975). This definition sounds closer to behaviourism but still includes the element of free will. Fellow humanist Martin Buber disagreed arguing that feeling empathy was a passive event that had to be allowed to happen (Buber, 1955).

However, some have argued that empathy cannot be taught. The philosopher Edith Stein repeated Buber’s idea of empathy only being noticed ‘post-event’. However she disagreed with Rogers arguing that what they called empathy was in fact ‘self-transposal’ – a person actively listening to another – and that empathy was only achieved after crossing-over to the other’s viewpoint before returning back. She believed that empathy was a ‘happening’ not behaviour and as such was impossible to teach (Stein, 1970). Davis agreed with Stein believing that self-transposal could be taught as it is cognitive process but as a behaviour empathy cannot be taught as a skill (Davis, 1990). She did however argue that through experiential learning, humanism and reflection empathy could be facilitated (Davis, 1989).

So we have a dictionary definition of empathy and we know there are checklists and questionnaires we can use as well as immersive simulation to help foster, if not teach, empathy in our students even if we can’t agree if that is a skill or a behaviour we are fostering. This brings me to my next question: Is empathy even that useful? Could it even be harmful?

Although some authors have concluded that empathy makes for better clinicians (Quince et al, 2016) the evidence and models used to make these conclusions is sketchy at the best.  One study Quince (2016) referred to concluded that clinicians can improve their ability to recognise emphatic moments in clinic not that it made them better at their job (Levinson, 2000).  I can think of medical students so caught up in feeling for patients they'd seen in a trauma call they reported not concentrating well afterwards to the detriment of their studies.  Previous studies have shown how empathy actually declines with experience until a "minimum level of empathy" is found which is all that's needed "to benefit from the positive aspects of professional quality of life in medicine" (Gleichgerrcht and Decety, 2014). 

EMPATHY AND DECISION MAKING

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Paul Bloom wrote a very interesting article in the New Yorker called The Baby in the Well (Bloom et al., 2018) explaining how individuals actually make bad assessments of situations based on empathy.  He cites several studies where empathy skews our emotional response and decision making disproportionately.  In one such study participants were given the choice between donating to save the life of one named individual with a photograph and back story or a group of 8 nameless individuals.  Participants consistently gave more money to save that one individual whose name they knew and who they could empathise to even though money to the other group would have saved more lives (Kogut and Ritov, 2005).

This means we could be liable to make bad decisions for the patients we feel more empathetic toward. Never mind the potential risks of counter-transference that inexperienced practitioner or student may not be aware of when they first encounter patients. So if empathy might be risky what else should we encourage?

EMPATHY OR COMPASSION?

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According to Singer and Klimecki (2014) whenever we meet a person in distress we are inspired to feel either compassion or empathic distress. The two pathways have two distinct basis in neurobiology. First, the empathy training activated motion in the insula (linked to emotion and self-awareness) and motion in the anterior cingulate cortex (linked to emotion and consciousness), as well as pain registering). The compassion group, however, stimulated activity in the medial orbitofrontal cortex (connected to learning and reward in decision making) as well as activity in the ventral striatum (also connected to the reward system). The two types of training led to very different emotions and attitudes toward action. The empathy-trained group actually found empathy uncomfortable and troublesome. The compassion group, on the other hand, created positivity in the minds of the group members. The compassion group ended up feeling kinder and more eager to help others than those in the empathy group.

From Singer and Klimecki (2014)

This suggests there is an importance to encourage healthcare workers towards the positive outcomes and to encourage compassion rather than empathy. The Loving Kindness Meditation model of mindfulness has been shown to foster positive emotions (Fredrickson et al., 2008).

In debating whether empathy testing could be introduced to medical school applications Schwartzstein (2015) suggested the following four stage model for supporting compassion development at medical school:

APPROACHES TO SUSTAINING COMPASSION AND COMMUNICATION SKILLS IN MEDICAL SCHOOL

  • Implement curricular changes that support students' idealism, kindness, and focus on patients, such as providing earlier clinical experiences or requiring participation in student-directed clinics.

  • Select clinical faculty for their ability to support the desired values.

  • Refine measures and instruments for assessing interpersonal skills, support faculty in completing these assessments, and prohibit students deficient in the necessary skills from advancing in their training.

  • Advocate for financial and logistic systems that enable doctors to spend more time with patients.

I find this model fascinating as it suggests a complete overhaul of a medical education facility based purely on compassion and communication. Would it work? It’s too early to tell and it will be interesting to see if it gets any mileage.

Back to our hypothetical patients.  Would attempting to place ourselves in the shoes of a fascist be helpful?  Obviously we have to be professional and ignore fundamental-attribution bias but what about empathy? Empathy has been shown to motivate an individual to help another person based purely on altruism - the 'empathy-altruism hypothesis' - rather than any gain to the individual (Batson et al, 1991).  If a healthcare professional is doing their best for their patient does it matter if it is empathy or professional duty motivating their actions?  Is it better to teach our students the behaviours and values of treating our patients with compassion and respect rather than obsessing about empathy?  Use feedback from patients both real and simulated to reflect on clinical behaviour and encourage the actions which make others feel respected and listened to regardless of motivation.  Make students aware they are entering an emotionally challenging profession and that they should expect complex feelings.  Encourage them to reflect and support them if they don't feel empathy, support them if they do and support them if they feel too much.

This is obviously a massive topic and it’s impossible to cover everything. Let me know what you think, I’d love to continue this debate.

- Jamie (@mcdreeamie)

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References

Baron-Cohen S, Autism: The Empathizing–Systemizing (E-S) Theory, Year in Cognitive Neuroscience 2009: Ann. N.Y. Acad. Sci. 1156: 68–80 (2009).

Batson, C. D., Batson, J. G., Slingsby, J. K., Harrell, K. L., Peekna, H. M., & Todd, R. M. (1991). Empathic joy and the empathy-altruism hypothesis. Journal of Personality and Social Psychology, 61(3), 413-426. http://dx.doi.org/10.1037/0022-3514.61.3.413

Bloom, P., Cassidy, J., Parker, I., Thurman, J., Gessen, M. and Murakami, H. (2018). The Baby in the Well. [online] The New Yorker. Available at: https://www.newyorker.com/magazine/2013/05/20/the-baby-in-the-well [Accessed 28 Aug. 2018].

Buber M (1955), Between Man and Man Boston, Mass: Beacon Press; 1955.

Campbell, D. (2018). Mid Staffs hospital scandal: the essential guide. [online] the Guardian. Available at: https://www.theguardian.com/society/2013/feb/06/mid-staffs-hospital-scandal-guide [Accessed 26 Sep. 2018].

Carr L et al 2003, “Neural mechanisms of empathy in humans: A relay from neural systems for imitation to limbic areas.” In J. T. Cacioppo, and G. G. Berntson (eds.). Social neuroscience: Key readings, New York: Psychology Press, pp. 143-152.

Castelnuovo, G. (2013). 5 years after the Kahn's etiquette-based medicine: a brief checklist proposal for a functional second meeting with the patient. Frontiers in Psychology, 4.

Counseling.org. (2018). [online] Available at: https://www.counseling.org/docs/vistas/a-researched-based-experiential-model-for-teaching-a-required-addictive-behaviours-course-to-clinical-counseling-students.pdf?sfvrsn=4 [Accessed 28 Aug. 2018].

Davis CM (1989) Patient practitioner interaction: an experiential manual for developing the art of healthcare Thorofare, NJ: Slack Inc: 1989.

Davis CM (1990), What is empathy and can empathy be taught? PHYS THER, 1990; 70: 707-711.

Eslinger PJ 1998, Neurological and neurophysiological bases of empathy, Eur Neurol 1998;39:193–199

Field TM et al 1982, “Discrimination and imitation of facial expressions by neonates.” Science 218: 179-181.

Fornan DR et al 2004, “Toddlers’ responsive imitation predicts preschool-age conscience.” Psychological Science 15: 699-704.

Fredrickson, B., Cohn, M., Coffey, K., Pek, J. and Finkel, S. (2008). Open hearts build lives: Positive emotions, induced through loving-kindness meditation, build consequential personal resources. Journal of Personality and Social Psychology, 95(5), pp.1045-1062.

Gleichgerrcht, E. and Decety, J. (2014). The relationship between different facets of empathy, pain perception and compassion fatigue among physicians. Frontiers in Behavioral Neuroscience, 8.

Iacoboni, M., and M. Dapretto. 2006. “The mirror neuron system and the consequences of its dysfunction.” Nature Reviews Neuroscience 7: 942-951.

Iacoboni, M. 2008. Mirroring people: The new science of how we connect with others. New York: Farrar, Straus and Giroux.

Kahn, M. (2008). Etiquette-Based Medicine. New England Journal of Medicine, 358(19), pp.1988-1989.

Knafo, A., C. Zahn-Waxler, C. Van Hulle, J. L. Robinson, and S. H. Rhee. 2008. “The developmental origins of a disposition toward empathy: Genetic and environmental contributions.” Emotion 8: 737-752.

Kogut, T. and Ritov, I. (2005). The “identified victim” effect: an identified group, or just a single individual?. Journal of Behavioral Decision Making, 18(3), pp.157-167.

Lee, H. (1960). To kill a mockingbird. Harlow: Longman.

Martin, G. B., and R. D. Clark. 1982. “Distress crying in neonates: Species and peer specificity.” Developmental Psychology 18: 3-9.

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Preston, S. D., and F B. M. de Waal. 2002. “Empathy: Its ultimate and proximate bases.” Behavioral and Brain Sciences 25: 1-72

Quince, T., Thiemann, P., Benson, J., & Hyde, S. (2016). Undergraduate medical students’ empathy: current perspectives. Advances in Medical Education and Practice7, 443–455. http://doi.org/10.2147/AMEP.S76800

Rogers CR (1951) Client Centred Therapy Boston, Mass: Houghton Mifflin Co.

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Schwartzstein, R. (2015). Getting the Right Medical Students — Nature versus Nurture. New England Journal of Medicine, 372(17), pp.1586-1587.

Simner, M. L. 1971. “Newborn's response to the cry of another infant.” Developmental Psychology 5: 136-150.

Singer, T. and Klimecki, O. (2014). Empathy and compassion. Current Biology, 24(18), pp.R875-R878.

Sonnby-Borgstom M et al 2003, . “Emotional empathy as related to mimicry reactions at different levels of information processing.” Journal of Nonverbal Behavior 27: 3-23.

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Tavakol, S., Dennick, R. and Tavakol, M. (2011). Psychometric properties and confirmatory factor analysis of the Jefferson Scale of Physician Empathy. BMC Medical Education, 11(1).

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