Wisdom in Medicine: the path through

adversityMargaret Plews-Ogan MD

Natalie May PhDJustine Owens PhD

The Wisdom in Medicine Project• Co-investigators Justine Owens PhD and Natalie May PhD

• Collaborators Jo Shapiro, Sigall Bell, Tom Gallagher, Wendy Levinson, Lawrence Calhoun (Post-traumatic growth), Monica Ardelt (wisdom)

• 3 year project to investigate how people cope positively with difficult circumstance, how they change, and whether those changes resemble how wisdom is described

• 2 populations: – physicians who have made a serious medical error

– patients who have chronic pain

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Wisdom in Medicine Project

• Mixed quantitative/qualitative design• In depth interviews combined with

questionnaires on: – Wisdom (Ardelt 3D wisdom scale)– Post-traumatic growth (Calhoun)– Personality (NEO)– Forgiveness (Fetzer)– Gratitude– Spirituality (Fetzer)

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Study Aims• To describe the positive changes that occur in response to

adversity and investigate whether these changes resemble how wisdom is described

• To investigate whether wisdom exemplars score higher on quantitative measures of wisdom, PTG, gratitude, forgiveness, and personality measures of positive emotions (NEO)

• To delineate the important elements in the path people take through adversity to wisdom

• To describe what helps and what hinders positive growth

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Wisdom Definition: Ardelt’s 3D wisdom model

• Cognitive: the capacity to comprehend the significance and deeper meaning of things, tolerating ambiguity and uncertainty, knowing the limits of knowing

• Affective: the capacity for compassion and empathy

• Reflective: the capacity to see things from many different perspectives, to avoid blame and subjectivity

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Methods• Physician participants recruited through word of mouth and

advertisement through malpractice insurance companies• 3 regions: NE, SE and West• Each participant completed a series of questionnaires (NEO,

gratitude, forgiveness, spirituality, 3D wisdom scale, PTG scale), and a 1 hour long semi-structured interview using a standardized interview guide

• Interview guide was constructed using AI, PTG as theoretical framework

• Interviews were audiotaped and transcribed verbatim• Coding was done in nVIVO 8. Once coding structure was

established through iterative coding process, two separate coders coded same 10% of interviews to establish reliability (kappa 0.88-0.97)

• Interviews were scored on wisdom by separate interviewers (kappa 0.7, adjudicated through discussion to 100%)

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Interview guide questions• Tell us the story of a medical error in which you were

involved? • Reflecting on that experience, has it changed you in a

positive way as a physician? As a person? Tell me about that.

• What helped you in this process? What made it more difficult?

• What advice would you have for others?• How might your colleagues or institution support you?• Do you think that this experience gave you wisdom? If

so, what does that mean to you?

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Qualitative Analysis• Coding structure developed through iterative process of

extracting themes, combining, further coding until no new themes emerging. PTG and wisdom constructs served as background theoretical framework. Researchers also coded specifically for disclosure, forgiveness, whether training prepared, advice, participant’s wisdom wisdom definition, change nodes of turning points, stepping stones and use of metaphor

• Path elements (process elements) derived from coded material subthemes as well as direct re-examination of the material with the path elements in mind.

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Descriptive Statistics

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• Total number: 61 physicians• Gender: M (54%) F (46%)• Mean Age: 48• Specialty: Internal Medicine (32%) FM (10%)Peds (10%)

OBGYN (7%), Surgery (10%), Anesthesia (5%), Emergency Medicine (5%), Other (pathology, orthopedics, PM&R, Psychiatry, neurosurgery)

• Practice Setting: Academic 67% Private Practice 33%• Lawsuit: Yes (18%) No (82%)• Disclosure: Yes (61%) No(39%)• Did training prepare you? Yes (6%) No (94%)

Summary of Findings• Wisdom exemplars had significantly higher scores on

scales of wisdom, gratitude, spirituality, forgiveness and positive emotions. PTG was non-significant, but in the expected direction

• When people describe the positive changes that resulted from their experience of adversity they use the language of wisdom. (increased compassion, forgiveness, understanding the limits of knowing, seeing things from many perspectives, seeing the deeper meaning of things)

• Important elements in the path through adversity included acceptance, stepping in, integration, new narrative, and wisdom.

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Summary of findings

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• What helped included: – Talking about it– Disclosure/ apology– Forgiveness– Spirituality (in the broadest sense) and/or

professional code of honor “doing the right thing”– Learning (becoming an expert) and making

positive changes– Teaching about it

Important Pathelements and subthemes

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Acceptance Stepping in Integration New narrative Wisdom

Seeing things as they are

Taking it in

Taking responsibility

Disclosure and apology

Learning what happened

Doing the right thing (going into the room every day)

Dealing with imperfection

Forgiveness without forgetting

Experimenting with new ways of doing things

Finding or creating meaning

The imperfect (but good) doctor

Changing the work to enhance meaning (revaluing relationship, teams)

Becoming an expert combined with humility

Reconnecting

Compassion/empathy “other-centeredness”

Self reflection

Balancing humility with decisiveness

Seeing the bigger picture

Teaching/Sharing stories

Acceptance• “Like any other big event in your life, you don’t immediately fix it,

you can’t gloss it over, you know, being able to recognize, ok, I am just going to feel wrong about this no matter what and I am not going to be able to fix it”

• “The slowest part was the quiet recognition that, you know, the buck does stop here, and you are going to make wrong decisions frequently and the job is to really make sure to truly just own that as a part of the passions for your job.”

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Stepping in• “It took everything I had to go into that room every day, to continue

to care for him”

• “it was definitely a hard place to go. I felt like whatever I got, I would deserve. But I stood there. I stood there.”

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IntegrationDealing with imperfection• “I never thought I was perfect, but boy this brought it up big time, and

then trying to slowly work through that fact…”

Forgiveness without forgetting• “I think it honors the memory of those patients if you share these things, if

you are wiling to carry them with you and never forget. So I like to say I carry a little graveyard in my head of all the patients that have passed and of all the people I wish I had done things differently for”

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New Narrative• “It’s made me more willing to stand up and cut against the grain a little

bit, more willing to be the one to say the emperor has no clothes.”• “it’s kind of like what I was talking about when I say icon versus what’s real.

To be a good doctor is not to be made of crystal or something, you know, this sort of flawless being. It’s not about perfection. It’s just a different vision of what it means to be excellent I guess, and a more real vision of that.

• “I really changed the way that I worked by saying ‘I’m not going to do this multitasking. I’m going to spend time on things. I’m going to see patients at a slower pace.’ And it’s not been a negative thing for me ever, having made that decision. And, um, I’m not really great at negotiating things for myself, but that I was really, like, firm on. And because of that spending enough time, some incredible encounters with patients, you know, incredible conversations that could never have happened. And, you know, until this moment I hadn’t really put together that this is why I’ve done this. But it is why (crying). So, it’s a really good thing to have come from this.

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WisdomHumility• “I’ve been getting humble, if that is good. Because you never want to

think that you are hot stuff that can’t make a mistake, that can’t listen to other possible diagnoses, can’t learn from other physicians, that can’t learn from the patients, what they are going through and so you need to be humble.

Understanding the deeper meaning of things• “Well, it made me feel vulnerable…. it continually informs me about what

it means to be alive and what it means to be a human being and what it means to die. So in some sense those traumatic mistakes are part of that ongoing learning.”

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Wisdom (cont.)Seeing the bigger picture and putting things in perspective• “And so just seeing the importance of the relationship in practicing. I

think it made me even more aware of how fragile things are and how one small thing can make a world of difference.”

Tolerating ambiguity• “..the understanding of how imperfect all of this is, you know. We still do

too much of a job of the public and even students and residents…that (medicine) is an exact science, that if we just do it right it will all come out right and that’s just not the case. So I do think I am a lot more tolerant of uncertainty because you realize that you can’t fix it all.”

Increased compassion, empathy, forgiving• With patients I think I have developed a much better sense of compassion

and empathy. You know, where I used to be ashamed or afraid to talk about any personal experience, I have no problems doing that now, and that’s been incredibly empowering to me.”

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Wisdom (cont.)

Capacity for self-reflection, collective awareness• “Paying attention…being more aware that there are different

presentations and that your common goal is healing.”• “I had never really appreciated up until that point how we really all

can, if we work together and work together well, then we can help fix each other’s failings little bits at a time. Having a team, a real team that all works together…we have the opportunity to back each other up when somebody misses something.”

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http://www.youtube.com/user/UVaWisdomInMedicine

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For those interested

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• Training DVD for physicians on coping positively with error is available.

• DVD on coping positively with chronic pain for clinicians who treat patients with chronic pain or patients self help groups

• Contact Peggy Plews-Ogan MD (mp5k@virginia.edu)

More details for those interested

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Quantitative Analysis• Narratives were scored by two separate

researchers as wisdom exemplars or non-exemplars (72% agreement). Disagreement was resolved through discussion.

• Hypothesis 1: wisdom exemplars will score significantly higher than non-exemplars on measures of wisdom, post-traumatic growth, gratitude, forgiveness, spirituality and positive emotions

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Results: Group Statistics

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Exemplar groups N Mean

Std. Deviation

Std. Error Mean

wisdom non-exemplar 15 3.679 0.20317 0.05246

wisdom exemplar 41 3.8913 0.32743 0.05114

forgiving non-exemplar 13 19.2308 2.58695 0.71749

wisdom exemplar 37 22.0541 2.58141 0.42438

dailyspirit non-exemplar 14 24 12.78822 3.41779

wisdom exemplar 39 38.1795 16.1504 2.58613

gratitude non-exemplar 14 34.2143 5.39485 1.44183

wisdom exemplar 41 39.6098 3.22396 0.5035

E6positiveemotions

non-exemplar 14 47.5 12.972 3.467

wisdom exemplar 42 56.12 11.156 1.721

Results: Independent Samples Test

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Equal variancesassumed/

not assumed

Levene's Test for Equality of

Variancest-test for Equality of Means

F Sig. t dfSig.

(2-tailed)Mean

DifferenceStd. Error

Difference

95% Confidence Interval of the Difference

Lower Upper

wisdom assumed 3.763 0.058 -2.345 54 0.023 -0.21238 0.09058 -0.39399 -0.03077

not assumed

-2.899 40.46 0.006 -0.21238 0.07326 -0.36038 -0.06437

forgiving assumed 0.152 0.699 -3.39 48 0.001 -2.82328 0.83273 -4.49759 -1.14898

not assumed

-3.387 21.008 0.003 -2.82328 0.8336 -4.55681 -1.08976

dailyspirit assumed 3.405 0.071 -2.962 51 0.005 -14.17949 4.78662 -23.78903 -4.56994

not assumed

-3.308 28.906 0.003 -14.17949 4.28595 -22.94649 -5.41249

gratitude assumed 9.123 0.004 -4.503 53 0 -5.39547 1.1982 -7.79875 -2.99219

not assumed

-3.533 16.285 0.003 -5.39547 1.52722 -8.62843 -2.16251

E6positiveemotions

assumed 1.144 0.29 -2.404 54 0.02 -8.619 3.586 -15.808 -1.43

not assumed

-2.227 19.818 0.038 -8.619 3.871 -16.698 -0.54

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Non-Exemplar Wisdom Exemplar3.55

3.6

3.65

3.7

3.75

3.8

3.85

3.9

3.95

Wisdom Exemplars and Non-Exemplars: 3 D Wisdom Scale

Exemplar Groups

Mea

n W

isd

om

Error Bars: 95% Cl t=2.345, p=0.023

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Non-Exemplar Wisdom Exemplar17.5

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18.5

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19.5

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20.5

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21.5

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22.5

Wisdom Exemplars and Non-Exemplars: Forgiving Scale

Exemplar Groups

Mea

n F

org

ivin

g

Error Bars: 95% Cl t=3.39, p=0.001

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Non-Exemplar Wisdom Exemplar0

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15

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35

40

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Wisdom Exemplars and Non-Exemplars: DailySpirit Scale

Exemplar Groups

Mea

n D

aily

Sp

irit

Error Bars: 95% Cl t=2.962, p=0.005

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Non-Exemplar Wisdom Exemplar31

32

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Wisdom Exemplars and Non-Exemplars: Gratitude Scale

Exemplar Groups

Mea

n G

rati

tud

e

Error Bars: 95% Cl t=3.533, p=0.003

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Non-Exemplar Wisdom Exemplar31

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Wisdom Exemplars and Non-Exemplars:NEO positive emotions Scale

Exemplar Groups

Mea

n E

6po

siti

veem

oti

on

s

Error Bars: 95% Cl t=2.404, p=0.02