Background. Qualitative research explores complex phenomena encountered by clinicians, health care providers, policy makers and consumers. Although partial checklists are available, no consolidated reporting framework exists for any type of qualitative design. Objective. To develop a checklist for explicit and comprehensive reporting of qualitative studies (indepth interviews and focus groups). Methods. We performed a comprehensive search in Cochrane and Campbell Protocols, Medline, CINAHL, systematic reviews of qualitative studies, author or reviewer guidelines of major medical journals and reference lists of relevant publications for existing checklists used to assess qualitative studies. Seventy-six items from 22 checklists were compiled into a comprehensive list. All items were grouped into three domains: (i) research team and reflexivity, (ii) study design and (iii) data analysis and reporting. Duplicate items and those that were ambiguous, too broadly defined and impractical to assess were removed. Results. Items most frequently included in the checklists related to sampling method, setting for data collection, method of data collection, respondent validation of findings, method of recording data, description of the derivation of themes and inclusion of supporting quotations. We grouped all items into three domains: (i) research team and reflexivity, (ii) study design and (iii) data analysis and reporting. Conclusions. The criteria included in COREQ, a 32-item checklist, can help researchers to report important aspects of the research team, study methods, context of the study, findings, analysis and interpretations.

Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups

Basics of qualitative research: Grounded theory procedures and techniques

Experience and Educationis the best concise statement on education ever published by John Dewey, the man acknowledged to be the pre-eminent educational theorist of the twentieth century. Written more than two decades after Democracy and Education(Dewey's most comprehensive statement of his position in educational philosophy), this book demonstrates how Dewey reformulated his ideas as a result of his intervening experience with the progressive schools and in the light of the criticisms his theories had received. Analysing both "traditional" and "progressive" education, Dr. Dewey here insists that neither the old nor the new education is adequate and that each is miseducative because neither of them applies the principles of a carefully developed philosophy of experience. Many pages of this volume illustrate Dr. Dewey's ideas for a philosophy of experience and its relation to education. He particularly urges that all teachers and educators looking for a new movement in education should think in terms of the deeped and larger issues of education rather than in terms of some divisive "ism" about education, even such an "ism" as "progressivism." His philosophy, here expressed in its most essential, most readable form, predicates an American educational system that respects all sources of experience, on that offers a true learning situation that is both historical and social, both orderly and dynamic.

经验与教育 = Experience and education

According to W. Edwards Deming, American companies require nothing less than a transformation of management style and of governmental relations with industry. In Out of the Crisis, originally published in 1982, Deming offers a theory of management based on his famous 14 Points for Management. Management's failure to plan for the future, he claims, brings about loss of market, which brings about loss of jobs. Management must be judged not only by the quarterly dividend, but by innovative plans to stay in business, protect investment, ensure future dividends, and provide more jobs through improved product and service. In simple, direct language, he explains the principles of management transformation and how to apply them.

Out of the Crisis

Lincoln, Yvonna, and Egon Guba, "Postpositivism and the Naturalist Paradigm," pp. 14-46 in Yvonna Lincoln and Egon Guba, Naturalistic Inquiry . Beverly Hills, CA: Sage, 1985.*

ability Coherence and quality of associations VI. Higher cognitive functioning A. Memory B. Attention and concentration C. General information D. Calculation E. Intelligence F. Abstraction G. Judgment

https://www.springer.com/cda/content/document/productFlyer/productFlyer-WEST_978-1-4612-7559-6.pdf?SGWID=0-0-1297-174561716-bookseller

The Medical Interview

Junior faculty wishing to achieve successful careers in academic medicine face many challenges. To facilitate faculty in their career development, the authors implemented and evaluated an innovative collaborative, or peer-group, mentoring program at their medical school. Based on Rogerian and adult learning principles, the program incorporated development of skills in key areas for career development, a structured values-based approach to career planning, and instruction in scholarly writing. The 80-hour program has so far been conducted twice over two academic years (1999-2001) with 18 faculty (50% women). Quantitative and qualitative methods were used in the evaluation. Program attendance was 89%. All participants completed a written academic development plan, an exercise they rated as valuable. They also completed an average of one to three manuscripts for publication. Evaluation data highlighted the critical nature of a supportive learning environment and the reasons participants chose to attend the program consistently. Key meaningful outcomes for most participants were: (1) identification of their core values; (2) a structured process of short- and long-term career planning based on these core values; (3) the development of close, collaborative relationships; (4) development of skills in such areas as gender and power issues, negotiation and conflict management, scholarly writing, and oral presentation, and (5) improved satisfaction linked to participants' decisions to remain in academic medicine. Participants developed a sense of personal transformation and empowerment. The authors conclude that collaborative mentoring offers a new approach to faculty development that addresses limitations of traditional approaches in a satisfying and cost-effective way.

Helping medical school faculty realize their dreams: an innovative, collaborative mentoring program.

Consider these two physicianpatient dialogues: 1. Patient: You know, when you discover a lump in your breast, you kind of feelwell, kind of(her speech tapers off; she looks down; tears form in her eyes). Dr. A: When did you actually discover the lump? Patient: (absently) I don't know. It's been a while. 2. Patient: (same as above) Dr. B: That sounds frightening. Patient: Well, yeah, sort of. Dr. B: Sort of frightening? Patient: Yeah and I guess I'm feeling like my life is over. Dr. B: I see. Worried and sad too. Patient: That's it, Doctor. Dr. A's patient may well go home feeling unheard and misunderstood. Dr. B's patient, while equally distressed about the possibility of having breast cancer, may leave the office believing that her doctor understands her. One of the most widespread and persistent complaints of patients today is that their physicians don't listen. For their part, physicians complain that they no longer have sufficient time to spend with patients, and they often blame economic pressures imposed by managed care (1, 2). Nonetheless, they acknowledge that personal encounters with patients constitute the most satisfying aspect of their professional lives. They recognize that empathy, the ability to connect with patientsin a deep sense, to listen, to pay attentionlies at the heart of medical practice (1, 3, 4). In clinical medicine, empathy is the ability to understand the patient's situation, perspective, and feelings and to communicate that understanding to the patient. The effective use of empathy promotes diagnostic accuracy, therapeutic adherence, and patient satisfaction, while remaining time-efficient (5-11). Empathy also enhances physician satisfaction (12). As with any other tool, clinical empathy requires systematic practice to achieve mastery (13, 14). Certain well-timed words and sentences facilitate empathy during the clinical encounter. These words that work are the subject of this paper. Empathy in Theory Tichener coined the term empathy in 1909 from two Greek roots, em and pathos (feeling into) (15). For some 50 years thereafter, empathy was discussed in the psychological and psychoanalytic literature as a type of vicarious emotional response (16-23). For example, Katz (24) wrote when we experience empathy, [it is] as if we were experiencing someone else's feelings as our own. We see, we feel, we respond, and we understand as if we were, in fact, the other person. Lief and Fox (25) diluted this strong sense of identification when they used the word to designate the vector for detached concern. They wrote that empathy involves an emotional understanding of the patient, while maintaining sufficient separation so that expert medical skills can be rationally applied to the patient's problem (25). In practice, emotional understanding has to be tested by checking back with the patient, and its accuracy is enhanced through iteration. The concept of empathy has three important implications. First, empathy has a cognitive focus. The clinician enters into the perspective and experience of the other person by using verbal and nonverbal cues, but she neither loses her own perspective nor collapses clinical distance. Second, empathy also has an affective or emotional focus. The clinician's ability to put herself in the patient's placeor walk a mile in his moccasinsrequires the experience of surrogate or resonant feelings (26). Finally, the definition requires that clinical empathy have an action component. One cannot know without feedback. The practitioner communicates understanding by checking back with the patient, using, for example, statements such as Let me see if I have this right or I want to be sure I understand what you mean. This gives the patient opportunities to correct or modulate the physician's formulation. At the same time it expresses the physician's desire to listen deeply, thereby reinforcing a bond or connection between clinician and patient. Empathy is sometimes confused with sympathy, or emotional identification with the patient's plight. Sympathetic responses include a physician's feeling sad and becoming teary eyed when his patient starts crying, or a physician's experiencing righteous anger when her patient recounts an injustice. Sympathy also applies to feelings of loss that people experience in response to another's loss. When present, sympathy often contributes to the physicianpatient relationship, yet physicians may not always exhibit sympathy because some patients are disagreeable, culpable, or unlikable. Empathy, by contrast, does not depend on having congruent feelings and thus may be more versatile. A physician can be empathic even when he or she cannot be sympathetic (27, 28). Numerous investigators have demonstrated the importance of empathy in the medical encounter. Empathy allows the patient to feel understood, respected, and validated. This promotes patient satisfaction, enhances the quantity and quality of clinical data, improves adherence, and generates a more therapeutic physicianpatient relationship (5-11, 29-31). To achieve these goals, medical educators conceptualized empathy as a set of teachable and learnable skills and developed a new focus on communication skills in the medical curriculum (13, 14, 32-36). More recently, some educators have explored the roles of narrative and literature in teaching clinical empathy (37-39), and others have emphasized the importance of reflection and self-awareness in maintaining one's empathic skills (40-44). Empathy in Practice Clinical empathy can be visualized as a positive feedback loop, or a neurologic track with afferent and efferent components (45, 46). The afferent arm includes verbal and nonverbal cues that lead to the practitioner's initial appraisal or understanding of the patient's message. The efferent arm includes the practitioner's responsesqueries such as Tell me more or statements such as I can imagine how difficult it is. Such responses elicit additional information. While it is impossible for the clinician to understand exactly how the patient feels, in clinical empathy successive cycles may lead to a clearer, more accurate fix on the patient's perspective and feelings. Thus, empathic communication includes the following components. Active Listening This requires nonverbal and paralanguage skills, such as appropriate position and posture; good eye contact; mirroring of facial expression; and facilitative responses, such as nodding and minimal expressions (for example, Hmmm and Uh-huh). It also demands that the physician remain silent and focus her attention on the patient's story (47, 48). Framing or Sign Posting Clinicians often initiate an empathic response when they pick up a suggestion or indication that the patient is experiencing concern, conflict, or emotion. Because accurate understanding is not commonly attempted in ordinary conversation, patients may be unaccustomed to empathic responses. Clinicians may need to disclose their intent, providing a frame or signpost for the patient (35). Lengthy warning may be inefficient and exhausting, so we usually abbreviate it in these ways: Let's see if I have this right. Sounds like what you're telling me is Or simply Sounds like Reflecting the Content An empathic response accurately identifies the factual content of the patient's statement, as well as the nature and intensity of the patient's feelings, concerns, or quandaries. A reflection of content (symptoms or ideas) might sound like the following: So you were fine until this morning when you woke up with pain in your belly, and it's been growing more severe ever since. Sounds like you think that you have appendicitis and that you might need to go into the hospital. The physician may also mirror the patient's interests and values: So, if I'm hearing you right, what you really enjoy is going out at night with your friends and having a few drinks. Identifying and Calibrating the Emotion Clinical empathy often entails responding to the patients' expressed (or suggested) feelings. This means identifying the emotion and calibrating its intensity. Sometimes emotional content is evident, but the nature of the emotion is unclear. In such cases the patient will often reveal the feeling, if given an opportunity. Tell me how you're feeling about this. I have the sense that you feel strongly, but I'm not sure I understand exactly what the feeling is. Can you tell me? The following are examples of empathic responses to patient statements that express sadness, fear, anger, distrust, and ambivalence. Sadness: That must have been a pretty painful experience for you, you sound like it was very sad. Fear: Sounds like you were really frightened when you discovered that lump. Anger: That situation really got to you, didn't it? I can imagine how angry I'd feel if that happened to me. Distrust: It seems you're not sure whether you should trust me further after I didn't get that test result back to you last week. Ambivalence: It seems to me that you're caught in a bind about whether to stop smoking or not. Feelings vary markedly in intensity; often, clinicians tend to sanitize or dilute them. Consider this example: Patient: Most days the pain is so terrible that I just want to stay in bed. I just stare at the ceiling what's the point of it all? Doctor: So you're frustrated about the pain? In this case, the physician identified an emotion (frustration) but failed to capture the patient's profound sense of helplessness. Weak affective words such as bother, annoy, upset, uneasy, and apprehensive are sometimes appropriate. At other times, red-blooded adjectives such as infuriated, enraged, tormented, overwhelmed, and terrified are more in order. This patient feels so depressed and helpless that he asks, What's the point of it all? By hearing only annoyance or frustration in the statement, the physician missed a diagnostic cue and perhaps a useful path of inquiry and has distanced herself from the patient. An alternative an

Let me see if I have this right...

Medical interviewing is the foundation of medical care and is the clinician's most important activity. A growing body of evidence suggests that clinicians use distinctive, describable behaviors to conduct medical interviews. This article describes four patterns of behavior that we term Habits and reviews the research evidence that links each Habit with both biomedical and functional outcomes of care. The Four Habits are: Invest in the Beginning, Elicit the Patient's Perspective, Demonstrate Empathy, and Invest in the End. Each Habit refers to a family of skills. In addition, the Habits bear a sequential relationship to one another and are thus interdependent. The Four Habits approach offers an efficient and practical framework for organizing the flow of medical visits. It is unique because it concentrates on families of interviewing skills and on their inter-relationships.

Richard M. Frankel

Papers

The Medical Interview

Helping medical school faculty realize their dreams: an innovative, collaborative mentoring program.

Let me see if I have this right...

Getting the most out of the clinical encounter: the four habits model.

The Four Habits Coding Scheme: validation of an instrument to assess clinicians' communication behavior.