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Policy PointsThe meaning of health in health care remains poorly defined, defaulting to a narrow, biomedical disease model. A national dialogue could create a consensus regarding a holistic and humanized definition of health that promotes health care transformation and health equity.Key steps for operationalizing a holistic meaning of health in health care include national leadership by federal agencies, intersectoral collaborations that include diverse communities, organizational and cultural change in medical education, and implementation of high‐quality primary care.The 2023 report by the National Academies of Sciences, Engineering, and Medicine on achieving whole health offers recommendations for action. [ABSTRACT FROM AUTHOR]

Background: Disagreements between patients and caregivers about treatment benefits, care decisions, and patients' health are associated with increased patient depression as well as increased caregiver anxiety, distress, depression, and burden. Understanding the factors associated with disagreement may inform interventions to improve the aforementioned outcomes. Methods: For this analysis, baseline data were obtained from a cluster‐randomized geriatric assessment trial that recruited patients aged ≥70 years who had incurable cancer from community oncology practices (University of Rochester Cancer Center 13070; Supriya G. Mohile, principal investigator). Patient and caregiver dyads were asked to estimate the patient's prognosis. Response options were 0 to 6 months, 7 to 12 months, 1 to 2 years, 2 to 5 years, and >5 years. The dependent variable was categorized as exact agreement (reference), patient‐reported longer estimate, or caregiver‐reported longer estimate. The authors used generalized estimating equations with multinomial distribution to examine the factors associated with patient‐caregiver prognostic estimates. Independent variables were selected using the purposeful selection method. Results: Among 354 dyads (89% of screened patients were enrolled), 26% and 22% of patients and caregivers, respectively, reported a longer estimate. Compared with dyads that were in agreement, patients were more likely to report a longer estimate when they screened positive for polypharmacy (β = 0.81; P =.001), and caregivers reported greater distress (β = 0.12; P =.03). Compared with dyads that were in agreement, caregivers were more likely to report a longer estimate when patients screened positive for polypharmacy (β = 0.82; P =.005) and had lower perceived self‐efficacy in interacting with physicians (β = −0.10; P =.008). Conclusions: Several patient and caregiver factors were associated with patient‐caregiver disagreement about prognostic estimates. Future studies should examine the effects of prognostic disagreement on patient and caregiver outcomes. Nearly one‐half (48%) of older patients and caregivers disagree with each other about the patient's prognosis; specifically, 26% of patients and 22% of caregivers report a longer estimate of the patient's prognosis. Caregiver distress, patient communication self‐efficacy, polypharmacy, and oncologist sex are associated with patient‐caregiver agreement about prognostic estimates. [ABSTRACT FROM AUTHOR]

Objectives: The well‐being of doctors is at risk, as evidenced by high burnout rates amongst doctors around the world. Alarmingly, burned‐out doctors are more likely to exhibit low levels of professionalism and provide suboptimal patient care. Research suggests that burnout and the well‐being of doctors can be improved by mindfulness‐based interventions (MBIs). Furthermore, MBIs may improve doctors' performance (eg in empathy). However, there are no published systematic reviews that clarify the effects of MBIs on doctor well‐being or performance to inform future research and professional development programmes. We therefore systematically reviewed and narratively synthesised findings on the impacts of MBIs on doctors' well‐being and performance. Methods: We searched PubMed and PsycINFO from inception to 9 May 2018 and independently reviewed studies investigating the effects of MBIs on doctor well‐being or performance. We systematically extracted data and assessed study quality according to the Medical Education Research Study Quality Instrument (MERSQI), and narratively reported study findings. Results: We retrieved a total of 934 articles, of which 24 studies met our criteria; these included randomised, (un)controlled or qualitative studies of average quality. Effects varied across MBIs with different training contents or formats: MBIs including essential mindfulness training elements, or employing group‐based training, mostly showed positive effects on the well‐being or performance of doctors across different educational and hospital settings. Doctors perceived both benefits (enhanced self‐ and other‐understanding) and challenges (time limitations and feasibility) associated with MBIs. Findings were subject to the methodological limitations of studies (eg the use of self‐selected participants, lack of placebo interventions, use of self‐reported outcomes). Conclusions: This review indicates that doctors can perceive positive impacts of MBIs on their well‐being and performance. However, the evidence was subject to methodological limitations and does not yet support the standardisation of MBIs in professional development programmes. Rather, health care organisations could consider including group‐based MBIs as voluntary modules for doctors with specific well‐being needs or ambitions regarding professional development. Mindfulness is often promoted as a means to facilitate well‐being and performance. This review offers guidance regarding the essential interventional elements that determine perceptions of impact. [ABSTRACT FROM AUTHOR]

Background: Disagreements between patients and caregivers about treatment benefits, care decisions, and patients' health are associated with increased patient depression as well as increased caregiver anxiety, distress, depression, and burden. Understanding the factors associated with disagreement may inform interventions to improve the aforementioned outcomes.Methods: For this analysis, baseline data were obtained from a cluster-randomized geriatric assessment trial that recruited patients aged ≥70 years who had incurable cancer from community oncology practices (University of Rochester Cancer Center 13070; Supriya G. Mohile, principal investigator). Patient and caregiver dyads were asked to estimate the patient's prognosis. Response options were 0 to 6 months, 7 to 12 months, 1 to 2 years, 2 to 5 years, and >5 years. The dependent variable was categorized as exact agreement (reference), patient-reported longer estimate, or caregiver-reported longer estimate. The authors used generalized estimating equations with multinomial distribution to examine the factors associated with patient-caregiver prognostic estimates. Independent variables were selected using the purposeful selection method.Results: Among 354 dyads (89% of screened patients were enrolled), 26% and 22% of patients and caregivers, respectively, reported a longer estimate. Compared with dyads that were in agreement, patients were more likely to report a longer estimate when they screened positive for polypharmacy (β = 0.81; P = .001), and caregivers reported greater distress (β = 0.12; P = .03). Compared with dyads that were in agreement, caregivers were more likely to report a longer estimate when patients screened positive for polypharmacy (β = 0.82; P = .005) and had lower perceived self-efficacy in interacting with physicians (β = -0.10; P = .008).Conclusions: Several patient and caregiver factors were associated with patient-caregiver disagreement about prognostic estimates. Future studies should examine the effects of prognostic disagreement on patient and caregiver outcomes. [ABSTRACT FROM AUTHOR]

Background: Patients with advanced, incurable cancer who understand their illness is incurable are more likely to prefer hospice care at the end of life compared with patients who believe their illness is curable. To the authors' knowledge, it is unclear whether patient-caregiver agreement regarding perceived prognosis is associated with hospice enrollment.Methods: The current study examined the prospective relationship between patient-caregiver agreement concerning perceived prognosis and hospice enrollment in the last 30 days of life. Data were collected during a cluster randomized controlled trial examining a communication intervention for oncologists and patients with advanced cancer and their caregivers. At the time of study entry, patients and caregivers (141 dyads) were categorized as endorsing a "good" prognosis if they: 1) reported a >50% chance of surviving ≥2 years; or if they 2) predicted that the patient's quality of life 3 months into the future would be ≥7 on an 11-point scale.Results: Approximately one-fifth of dyads agreed on a poor prognosis whereas approximately one-half disagreed regarding prognosis. In approximately one-third of dyads, patients and caregivers both believed the patient's future quality of life would be good (34%) and that the patient would live for ≥2 years (30%). Patients in these dyads were less likely to enroll in hospice compared with patients in dyads who disagreed and those who agreed on a shorter life expectancy and poor future quality of life.Conclusions: Dyadic understanding of patients' projected life expectancy and future quality of life appears to be predictive of care received at the end of life. Improving rates of hospice enrollment may be best achieved with dyadic interventions. [ABSTRACT FROM AUTHOR]

Background: In caring for patients with advanced cancer, accurate estimation of survival is important for clinical decision making. The purpose of this study was to assess the accuracy of 2-year survival probabilities estimated by oncologists, patients, and caregivers and to identify demographic and clinical factors associated with prognostic accuracy.Methods: This was a secondary observational analysis of data obtained from a cluster randomized controlled trial. Participants included 38 oncologists, 263 patients with advanced nonhematologic cancer, and 193 of their caregivers from clinics in Sacramento and Western New York. Discrimination within each group (oncologists, patients, caregivers) was evaluated using the C statistic, whereas calibration was assessed by comparing observed to predicted 2-year mortality using the chi-square statistic.Results: The median survival from study entry was 18 months, and 41.8% of patients survived for 2 years. C statistics for oncologists, patients, and caregivers were 0.81 (95% CI, 0.76-0.86), 0.62 (95% CI, 0.55-0.68), and 0.72 (95% CI, 0.65-0.78), respectively; oncologists' predictions were better than the predictions of both patients (P = .001) and caregivers (P = .03). Oncologists also had superior calibration: their predictions of 2-year survival were similar to actual survival (P = .17), whereas patients' (P = .0001) and caregivers' (P = .003) predictions diverged significantly from actual survival. Although most oncologists' predictions were classified as realistic (62.0%), approximately one-half of patients' and caregivers' predictions (50.0% and 46.0%, respectively) were unduly optimistic. Among patients, nonwhite race and higher levels of social well-being predicted undue optimism (P < .05).Conclusions: Compared with oncologists, patients and caregivers displayed inferior prognostic discrimination, and their predictions were poorly calibrated, primarily because of overoptimism. [ABSTRACT FROM AUTHOR]

Background: Older patients with advanced cancer who are 100% certain they will be cured pose unique challenges for clinical decision making, but to the authors' knowledge, the prevalence and correlates of absolute certainty about curability (ACC) are unknown.Methods: Cross-sectional data were collected in a geriatric assessment trial. ACC was assessed by asking patients, "What do you believe are the chances that your cancer will go away and never come back with treatment?" Response options were 100% (coded as ACC), >50%, 50/50, <50%, 0%, and uncertain. The willingness to bear adversity in exchange for longevity was assessed by asking patients to consider trade-offs between survival and 2 clinical outcomes that varied in abstractness: 1) maintaining quality of life (QOL; an abstract outcome); and 2) specific treatment-related toxicities (eg, nausea/vomiting, worsening memory). Logistic regression was used to assess the independent associations between willingness to bear adversity and ACC.Results: Of the 524 patients aged 70 to 96 years, approximately 5.3% reported that there was a 100% chance that their cancer would be cured (ACC). ACC was not found to be significantly associated with willingness to bear treatment-related toxicities, but was more common among patients who were willing to trade QOL for survival (adjusted odds ratio, 4.08; 95% CI, 1.17-14.26).Conclusions: Patients who were more willing to bear adversity in the form of an abstract state, namely decreased QOL, were more likely to demonstrate ACC. Although conversations regarding prognosis should be conducted with all patients, those who are willing to trade QOL for survival may especially benefit from conversations that focus on values and emotions. [ABSTRACT FROM AUTHOR]

Objective: To identify predictors of participation of patients with advanced cancer in clinical encounters with oncologists and to assess the impact of patient and caregiver participation on perceptions of physician support.Methods: This is a secondary data analysis from the Values and Options in Cancer Care study, a cluster randomized clinical trial of a patient-centered communication intervention. Patients and caregivers completed pre-visit and post-visit health and communication measures. Audio recorded patient-caregiver (when present)-physician encounters were coded for active patient/caregiver participation behaviors (eg, question asking, expressing concern) and for physicians' facilitative communication (eg, partnership-building, support). Mixed linear regression models were used to identify patient, physician, and situational factors predicting patient and patient plus caregiver communication behaviors and post-visit outcomes.Results: Physician partnership building predicted greater expressions of concern and more assertive responses from patients and patient-caregiver pairs. Patients' perceptions of greater connectedness with their physician predicted fewer patient expressions of concern. Patient perceptions of physician respect for their autonomy were lower among patients accompanied by caregivers. Caregiver perceptions of physician respect for patient autonomy decreased with increasing patient age and varied by site.Conclusions: In advanced cancer care, patient and caregiver communication is affected by ecological factors within their consultations. Physicians can support greater patient participation in clinical encounters through facilitative communication such as partnership-building and supportive talk. The presence of a caregiver complicates this environment, but partnership building techniques may help promote patient and caregiver participation during these visits. [ABSTRACT FROM AUTHOR]

Objective: To test the feasibility and assess the uptake and acceptability of implementing a consumer questions programme, AskShareKnow, to encourage consumers to use the questions ‘1. What are my options; 2. What are the possible benefits and harms of those options; 3. How likely are each of those benefits and harms to happen to me?’ These three questions have previously shown important effects in improving the quality of information provided during consultations and in facilitating patient involvement. Methods: This single‐arm intervention study invited participants attending a reproductive and sexual health‐care clinic to view a 4‐min video‐clip in the waiting room. Participants completed three questionnaires: (T1) prior to viewing the intervention; (T2) immediately after their consultation; and (T3) two weeks later. Results: A total of 121 (78%) participants viewed the video‐clip before their consultation. Eighty‐four (69%) participants asked one or more questions, and 35 (29%) participants asked all three questions. For those making a decision, 55 (87%) participants asked one or more questions, while 27 (43%) participants asked all three questions. Eighty‐seven (72%) participants recommended the questions. After two weeks, 47 (49%) of the participants recalled the questions. Conclusions: Enabling patients to view a short video‐clip before an appointment to improve information and involvement in health‐care consultations is feasible and led to a high uptake of question asking in consultations. Practice Implications: This AskShareKnow programme is a simple and feasible method of training patients to use a brief consumer‐targeted intervention that has previously shown important effects in improving the quality of information provided during consultations and in facilitating patient involvement and use of evidence‐based questions. [ABSTRACT FROM AUTHOR]

Background: Compassion has been extolled as a virtue in the physician–patient relationship as a response to patient suffering. However, there are few studies that systematically document the behavioural features of physician compassion and the ways in which physicians communicate compassion to patients. Objective: To develop a taxonomy of compassionate behaviours and statements expressed by the physician that can be discerned by an outside observer. Design: Qualitative analysis of audio‐recorded office visits between oncologists and patients with advanced cancer. Setting and Participants: Oncologists (n = 23) and their patients with advanced cancer (n = 49) were recruited in the greater Rochester, New York, area. The physicians and patients were surveyed and had office visits audio recorded. Main Outcome Measures: Audio recordings were listened to for qualitative assessment of communication skills. Results: Our sensitizing framework was oriented around three elements of compassion: recognition of the patient's suffering, emotional resonance and movement towards addressing suffering. Statements of compassion included direct statements, paralinguistic expressions and performative comments. Compassion frequently unfolded over the course of a conversation rather than being a single discrete event. Additionally, non‐verbal linguistic elements (e.g. silence) were frequently employed to communicate emotional resonance. Discussion and Conclusions: This study is the first to systematically catalogue instances of compassionate communication in physician‐patient dialogues. Further refinement and validation of this preliminary taxonomy can guide future education and training interventions to facilitate compassion in physician–patient interactions. [ABSTRACT FROM AUTHOR]

Objective: Discussing end-of-life (EOL) care is challenging when death is not imminent, contributing to poor decision-making and EOL quality-of-life. A communication support program (CSP) targeting these issues may facilitate discussions. We aimed to qualitatively explore responses to a nurse-led CSP, incorporating a question prompt list (QPL—booklet of questions patients/caregivers can ask clinicians), promoting life expectancy and EOL-care discussions. Methods: Participants met a nurse-facilitator to explore an EOL-focussed QPL. Prognosis and advance care planning (ACP) QPL content was highlighted. Thirty-one transcribed meetings were analysed using thematic text analysis before reaching data saturation. Results: Thirty-one advanced cancer patients (life expectancy <12 months) and 11 family caregivers were recruited from six medical oncology clinics in Sydney, Australia. Intent to use the QPL related to information needs, involvement in care and readiness to discuss EOL issues. Many participants did not want life expectancy estimates, citing unreliable estimates, unknown treatment outcomes, or coping by not looking ahead. Most displayed interest in ACP, often motivated by a loved one's EOL experiences, clear treatment preferences, concerns about caregivers or recognition that ACP is valuable regardless of life expectancy. Timing emerged as a reason not to discuss EOL issues; many maintaining it was too early. Conclusion: Patients and caregivers appear ambivalent about acknowledging approaching death by discussing life expectancy but value ACP. Given heterogeneity in responses, individualised approaches are required to guide EOL discussion conduct and content. Further exploration of the role of prognostic discussion in ACP is warranted. [ABSTRACT FROM AUTHOR]

Medical Education 2011:: 663-668 For doctors, curiosity is fundamental to understanding each patient's unique experience of illness, building respectful relationships with patients, deepening self-awareness, supporting clinical reasoning, avoiding premature closure and encouraging lifelong learning. Yet, curiosity has received limited attention in medical education and research, and studies from the fields of cognitive psychology and education suggest that common practices in medical education may inadvertently suppress curiosity. This study aimed to identify common barriers to and facilitators of curiosity and related habits of mind in the education of doctors. We conducted a theory-driven conceptual exploration and qualitative review of the literature. Curiosity is related to inquisitiveness, reflection and mindfulness. Instructional practices can suppress curiosity by confusing haste with efficiency, neglecting negative emotions, promoting overconfidence and using teaching approaches that encourage passive learning. Curiosity tends to flourish in educational environments that promote the student's responsibility for his or her own learning, multiple perspectives and mindful reflection on both the subject and the learning process. Specific educational strategies that can support curiosity in classroom and clinical settings include the mindful pacing of teaching, modelling effective management of emotions, confronting uncertainty and overconfidence, using inquiry-based learning, helping students see familiar situations as novel, simultaneously considering multiple perspectives, and maximising the value of small-group discussions. Instructor attributes that contribute to the development of student curiosity include patience, a habit of inquiry, emotional candour, intellectual humility, transparency and recognition of the benefits to be gained in learning from peers. Curiosity, inquisitiveness and related habits of mind can be supported in medical education through specific, evidence-based instructional approaches. Medical educators should balance the teaching of facts, techniques and protocols with approaches that help students cultivate and sustain curiosity and wonder in the context-rich, often ambiguous world of clinical medicine. [ABSTRACT FROM AUTHOR]

Context Subjective rating scales for communication skills may yield more personally meaningful responses than more standardised rating schemes. It is unclear, however, whether such evaluations may be overly biased by respondents’ rating styles, which may lead to unreliable measurement of examinees’ communication skills. Methods Our study involved 212 students from the classes of 2005 and 2006 at the University of Rochester School of Medicine and Dentistry. All students were rated by actors depicting standardised patients (SPs) on the same seven cases using the 19-item Rochester Communication Rating Scale (RCRS). Different students were assigned to different actors playing the same SP. We assessed the extent to which actors’ personal rating styles influenced the scores they assigned to students. Main outcome measures were: between-actor variability in responses; the degree to which actors’ response styles contribute to overall scores, and improvements in reliability achieved by standardising actors’ ratings. Results There were statistically significant differences between actors in their mean assigned scores. Scores aggregated over 18 separate SP cases have an expected generalisability coefficient of 0.79. If raw RCRS scores are used, a total of 27 replications of the RCRS are required to achieve a Cronbach’s alpha of 0.8; standardisation reduces this number to 18. Conclusions Although actors are variable in their use of a standardised subjective scale of communication, such differences contribute to an acceptably small proportion of the total variance if scores are combined across a large number of cases. Reliability can be markedly improved by standardising scores across raters. [ABSTRACT FROM AUTHOR]

There have been several studies evaluating psychotherapeutic interventions for reducing death anxiety in patients,[12] and mindfulness-based approaches may mitigate human tendencies to avoid or become defensive when death is more proximal.[[14]] Components of these approaches might be adapted for physicians. Why many oncologists fail to share accurate prognoses: they care deeply for their patients. Effect of a patient-centered communication intervention on oncologist-patient communication, quality of life, and health care utilization in advanced cancer: the VOICE randomized clinical trial. [Extracted from the article]

Context Although peer-assessment appears promising as a method to assess interpersonal skills among medical students, results may be biased by method of peer selection, particularly if different kinds of classmates are assigned systematically by different methods. It is also unclear whether students with lower interpersonal skills may be more negative towards their classmates than students with higher levels of interpersonal skills and, if so, how much bias this may introduce into the results of peer assessment. It is also unclear whether low-rated students are more likely to ask to rate one another. Design, Setting, and Participants Participants were 296 medical students from the classes of 2004, 2005 and 2006 at the University of Rochester School of Medicine and Dentistry. All participants were evaluated by between 6 and 12 classmates near the end of both their second and third years. In some classes peer-raters were assigned from class lists, while in other classes students were asked to recommend classmates to rate and be rated by. Main outcome measures Mean numerical ratings of interpersonal-attributes scores received from peers, compared with mean scores simultaneously assigned to peers. We also examined students' selection of peer-raters, as well as scores received by their peer-raters. Results For all 3 classes in both second and third years, students in the lowest quartile of received scores were significantly more likely to simultaneously assign lower scores to their peers. Among third-year students, such low-scoring students were significantly more likely to ask to rate and be rated by other low-scoring students. Among third-year students, low-rated students were more likely to rate and be rated by other low-rated students, irrespective of how rater assignments are made. Most students who were originally in the lowest quartile of received scores remained so after removing the scores assigned by low-rated raters. Among pre-clinical second-year students, however, low-rated students were no more likely than high-rated students to be rated by other low-rated students. Conclusion Students with low levels of peer-assessed interpersonal attributes are more negative in their judgements of classmates. Third-year medical students with low levels of interpersonal attributes are more likely to be rated by other students with low levels of interpersonal attributes, irrespective of method of rater assignment. This effect was not seen in the second year of medical school. Biases in selection of raters among third-year students, however, do not appear to affect the results of peer assessment. Thus, medical schools that choose to institute peer assessment can select the method of peer-rater assignment based on practicality and logistical considerations. Students' affiliations with one another in the third year appear to be related to peer-assessed interpersonal attributes. [ABSTRACT FROM AUTHOR]

Context Peer assessment has been increasingly recommended as a way to evaluate the professional competencies of medical trainees. Prior studies have only assessed single groups measured at a single timepoint. Thus, neither the longitudinal stability of such ratings nor differences between groups using the same peer-assessment instrument have been reported previously. Methods Participants were all members of 2 consecutive classes of medical students ( n = 77 and n = 85) at the University of Rochester School of Medicine and Dentistry who completed Years 2 and 3 of medical school consecutively. All participants were evaluated by 6−12 classmates near the end of both Years 2 and 3. Main outcome measures were mean numerical ratings on peer-assessed scales of professional work habits (WH) and interpersonal attributes (IA). Results Both scales had high internal consistencies in both years (Cronbach's α 0.84–0.94). The IA and WH scales were moderately correlated with one another ( r = 0.36 in Year 2, r = 0.28 in Year 3). Year 2 scores were predictive of Year 3 scores for both scales (WH: r = 0.64; IA; r = 0.62). Generalisability and decision analyses revealed that 1 class was consistently more discriminating with the WH scale, while the other was more discriminating with of the IA scale. Depending on the class, year and scale, the number of raters needed to achieve a reasonable reliability ranged between 7 and 28. Conclusions Although Year 3 peer ratings were consistently higher than Year 2 peer ratings for both WH and IA, individual scores were highly correlated across the 2 years, despite the fact that different individuals were chosen as peer raters. Abilities appear to be stable between Years 2 and 3 of medical school. Groups may differ in their ability to discriminate different kinds of skills. Generalisability analysis can be used to discover these patterns within groups. [ABSTRACT FROM AUTHOR]

Current assessment formats for medical students reliably test core knowledge and basic skills. Methods for assessing other important domains of competence, such as interpersonal skills, humanism and teamwork skills, are less well developed. This study describes the development, implementation and results of peer assessment as a measure of professional competence of medical students to be used for formative purposes. Year 2 medical students assessed the professional competence of their peers using an online assessment instrument. Fifteen randomly selected classmates were assigned to assess each student. The responses were analysed to determine the reliability and validity of the scores and to explore relationships between peer assessments and other assessment measures. Factor analyses suggest a 2-dimensional conceptualisation of professional competence: 1 factor represents Work Habits, such as preparedness and initiative, and the other factor represents Interpersonal Habits, including respect and trustworthiness. The Work Habits factor had moderate, yet statistically significant correlations ranging from 0.21 to 0.53 with all other performance measures that were part of a comprehensive assessment of professional competence. Approximately 6 peer raters were needed to achieve a generalisability coefficient of 0.70. Our findings suggest that it is possible to introduce peer assessment for formative purposes in an undergraduate medical school programme that provides multiple opportunities to interact with and observe peers. [ABSTRACT FROM AUTHOR]

A simple question to caregivers such as, "what are your thoughts on this information" may be adequate for identifying gaps in caregiver prognostic understanding and discrepancies between patients and caregivers. Consistent with our hypotheses, patients in dyads who disagreed on prognosis had significantly higher rates of hospice enrollment compared with patients in dyads who agreed on a good prognosis. Oncology care teams could improve rates of timely hospice enrollment by assessing caregiver prognostic understanding and including caregivers in prognostic discussions, thereby improving end-of-life care. [Extracted from the article]

The article discusses how reflection promotes adaptive expertise and practical wisdom. It states that reflective groups, reflective narratives and reflective practice sessions have evolved to provide self-knowledge and a corrective to the natural human tendency to self-deceive. It concludes that reflection demands the development of specific skills, involves the brain and the mind, requires attention to high-quality feedback and is subject to scientific investigation and understanding.