title: Conflicts in Learning to Care for Critically Ill Newborns: "It Makes Me Question My Own Morals".
abstract: Caring for critically ill and dying patients often triggers both professional and personal growth for physician trainees. In pediatrics, the neonatal intensive care unit (NICU) is among the most distressing settings for trainees. We used longitudinal narrative writing to gain insight into how physician trainees are challenged by and make sense of repetitive, ongoing conflicts experienced as part of caring for very sick and dying babies. The study took place in a 45-bed, university-based NICU in an urban setting in the United States. From November 2009 to June 2010 we enrolled pediatric residents and neonatology fellows at the beginning of their NICU rotations. Participants were asked to engage in individual, longitudinal narrative writing about their "experience in the NICU." Thematic narrative analysis was performed. Thirty-seven physician trainees participated in the study. The mean number of narratives per trainee was 12; a total of 441 narratives were available for analysis. Conflict was the most pervasive theme in the narratives. Trainees experienced conflicts with families and conflicts with other clinicians. Trainees also described multiple conflicts of identity as members of the neonatology team, as members of the medical profession, as members of their own families, and as members of society. Physician trainees experience significant conflict and distress while learning to care for critically ill and dying infants. These conflicts often led them to question their own morals and their role in the medical profession. Physician trainees should be educated to expect various types of distress during intensive care rotations, encouraged to identify their own sources of distress, and supported in mitigating their effects.
authors: Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine and Berman Institute of Bioethics, 1809 Ashland Avenue, Baltimore, MD, 21205, USA. rboss1@jhmi.edu.
authors: Renee D
authors: RD
authors: Boss
authors: Johns Hopkins University School of Medicine, Berman Institute of Bioethics, Baltimore, MD, 21205, USA.
authors: Gail
authors: G
authors: Geller
authors: Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA.|Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA.
authors: Pamela K
authors: PK
authors: Donohue
mesh_terms: D001291:Attitude of Health Personnel; D003220:Conflict, Psychological; D003422:Critical Care; D016638:Critical Illness; D034462:Dissent and Disputes; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal; D007396:Internship and Residency; D008297:Male; D009014:Morals; D033262:Narration; D010817:Physician-Patient Relations; D013315:Stress, Psychological; D014481:United States; D014495:Universities; D014956:Writing
keywords: Ethical conflicts; Narrative writing; Neonatal intensive care; Physician trainee; United States
references: Acad Med. 2010 Jan;85(1):124-33
references: 20042838
references: Ambul Pediatr. 2008 Mar-Apr;8(2):86
references: 18355735
references: Acad Med. 2011 Mar;86(3):369-77
references: 21248599
references: Health Commun. 2009 Dec;24(8):683-91
references: 20183377
references: Obstet Gynecol. 2008 Jul;112(1):29-34
references: 18591304
references: JAMA. 1999 Sep 1;282(9):833-9
references: 10478689
references: J Med Philos. 1998 Apr;23(2):131-52
references: 9638566
references: Acad Med. 2002 Apr;77(4):271-7
references: 11953289
references: J Perinatol. 2007 Aug;27(8):510-6
references: 17443196
references: Genet Med. 2010 May;12(5):289-97
references: 20386316
references: Acad Med. 2009 Jul;84(7):844-50
references: 19550174
references: Acad Med. 2002 Apr;77(4):299-304
references: 11953294
references: J Med Philos. 1998 Apr;23(2):170-89
references: 9638568
references: JAMA. 2009 Sep 23;302(12):1284-93
references: 19773563
references: BMJ Qual Saf. 2011 Apr;20 Suppl 1:i62-6
references: 21450775
references: J Gen Intern Med. 2007 Oct;22(10):1434-8
references: 17653807
references: Acad Med. 2002 Oct;77(10 Suppl):S58-60
references: 12377706
references: Patient Educ Couns. 2001 Oct;45(1):13-22
references: 11602364
references: JAMA. 1997 Aug 13;278(6):502-9
references: 9256226
references: Patient Educ Couns. 2009 May;75(2):149-54
references: 19013048
references: Pediatrics. 2008 Sep;122(3):583-9
references: 18762529
references: Pediatrics. 2008 Apr;121(4):e731-7
references: 18346988
references: Acad Med. 2009 May;84(5):587-96
references: 19704191
references: J Palliat Med. 2006 Feb;9(1):70-81
references: 16430347
references: JAMA. 2001 Oct 17;286(15):1897-902
references: 11597295
references: Acad Med. 2012 Jan;87(1):41-50
references: 22104060
references: Clin Genet. 2010 May;77(5):421-9
references: 20447149
references: BMJ. 2003 Jul 26;327(7408):185
references: 12881257
references: J Appl Philos. 2003;20(1):17-29
references: 14552296
references: Genet Med. 2009 Jul;11(7):527-35
references: 19444128
references: J Surg Educ. 2008 Mar-Apr;65(2):99-100
references: 18439528
references: Acad Med. 2008 Jul;83(7):653-8
references: 18580082
references: Med Educ. 2007 Oct;41(10):942-6
references: 17908112
references: Narrat Inq Bioeth. 2013 Fall;3(2):89-93
references: 24407071
references: Acad Med. 2011 Aug;86(8):996-1009
references: 21670661
references: Acad Med. 2010 Nov;85(11):1709-16
references: 20881818
references: Hastings Cent Rep. 2004 Nov-Dec;34(6):31-8
references: 15666893
references: Assessment. 2008 Sep;15(3):329-42
references: 18310597
references: Qual Saf Health Care. 2010 Dec;19(6):479-83
references: 21127108