WOULD YOU BE SURPRISED IF THIS PATIENT DIED: EXPLORING THE TRANSITION BETWEEN AGGRESSIVE AND PALLIATIVE CARE. D.C. Johnson 1 , J.S. Kutner 1 , J.A. Armstrong 1 ; 1 University of Colorado Health Sciences Center, Denver, CO PURPOSE: Multiple studies have shown that physicians inadequately address the suffering of severely ill patients at the end of life. This deficiency, in part, arises from the difficulty in recognizing the dying patient and an overly restricted focus on aggressive care. The purpose of this study was to examine the thought processes of resident physicians taking care of critically ill patients, with a goal to better understand how physicians transition between aggressive and palliative care, and to determine if the explicit consideration of the possibility of death improves attention to the suffering of patients and their families. METHODS: Internal medicine resident physicians (n=8) caring for severely ill patients were sequentially interviewed over a four week period during Medical Intensive Care Unit Ethics and Discharge Planning rounds. The residents were asked a series of questions based on their response to the core question``Would you be surprised if this patient died?'' The interviews were taped, transcribed and qualitatively analyzed for the purpose of identifying common patterns in the decision-making process of physicians when managing severely ill patients. RESULTS: When asked the core question, there were an equal number of cases in which residents responded that they would (n=4) versus would not (n=4) be surprised if their patient died. Reasons for being surprised that a patient would die included the presence of a reversible disease, the rapid onset of an acute illness, situations where a patient was``doing better'' and prior survival under similar circumstances. Among residents who indicated that they would not be surprised, most (n=3) reported that their management would not change knowing that their patient might die. Cited changes, when present, included clarifying goals, improving communication with families, spending more time with patients and ordering fewer labs. Stated or implied barriers to changes in management despite knowing that a patient might die included a lack of time and experience,``not knowing'' a patient, an improvement in medical condition (``doing better''), a lack of clear goals (``doing everything''), the presence of uncertainty and an exclusive focus on technical intervention. CONCLUSION: Asking the question``Would you be surprised if this patient died?'' encourages proactive reflection and dialogue about the potential for death in severely ill patients. An active acknowledgment of the possibility of death may lead to changes in management that would potentially diminish the suffering of patients and their families. To effectively impart such changes, it may be necessary to develop and implement techniques to overcome identified barriers. PURPOSE: A physician's effectiveness depends on the application of good communication, cognitive, and technical skills, guided by maturity, wisdom, compassion, and integrity. Development of the latter attributes requires growth in the awareness and management of one's feelings, attitudes, beliefs, and life experiences. Yet there is a dearth of empirical research related to physicians' personal growth. We used qualitative research methods to analyze stories of personal growth obtained from a selected group of medical faculty, in order to increase understanding of personal growth in this group and to develop a conceptual framework that might be useful to medical educators and researchers. METHODS: Questionnaire survey of facilitators, facilitators-in-training, and members of a personal growth interest group of the American Academy on Physician and Patient, who were chosen because of their interest, knowledge, and experience in the topic area. Respondents were asked to submit one or more stories of growth in their own self-awareness, and how that growth had affected them professionally and personally. Themes were identified in the submitted stories by 5 members of the research team and sorted into categories by 3 members. Slight further revisions were made following discussion by the entire research team and application of the proposed categories to a subset of stories. The findings were verified by two independent reviewers, who reviewed all of the stories. RESULTS: 32 of 64 subjects returned questionnaires containing 42 stories. There were no significant differences between respondents and non-respondents in age (mean 45.3 vs. 44.6 years), gender ( 75% vs. 69% male), or specialty (69% vs. 72% internists, 28% vs. 19% behavioral scientists / psychiatrists). Usually personal growth stories began with a powerful experience and/or helping relationship, proceeded to introspection, and ended in a personal growth outcome. Personal growth outcomes included: changes in values, goals, or direction; healthier behaviors; improved connectedness with others; improved sense of self; and increased productivity, energy, or creativity. CONCLUSION: Powerful experiences, helping relationships, and introspection are processes that preceded personal growth in a subset of medical faculty. The findings, if confirmed in other populations of physicians, may have implications for medical education and practice. The ABIM expects all physicians board certified in internal medicine to posses humanistic qualities of integrity, respect and compassion. To date, no studies have been done comparing humanistic qualities among physicians at different levels of training. We compared humanistic quality scores of fourth year medical students (SI), internal medicine residents (PGYI and II), and attending physicians on a general medicine ward of a teaching hospital. METHODS: A validated seventeen-item nursing survey to assess humanistic qualities among physicians was distributed to randomly selected nurses working day shifts on the medicine wards. The survey measured physician relationships with other medical staff, and the physician relationship with the patient and family. Each item was scored on a 5 point Likert scale. Composite scores for physician to staff relationships (PSR) and physician to patient/family relationships (PFR), as well as an overall evaluation score (OE), were compared across levels of physician training. Student's t-test was done to determine statistical significance across training levels. RESULTS: 33 nurses completed a total of 295 questionnaires. Surveys were performed for each of the 7 sub-interns, 8 PGYI, 4 PGYII, and 11 attending physicians rotating on the medical wards during a month of the ward service. SI's had higher PSR scores (PSR = 24.2) than PGYI (PSR = 21.3, p value = 0.013), PGYII (PSR = 21.9, p = 0.042) , and attending physicians (PSR = 23, p < 0.01). SI's also had higher PFR scores (PFR = 33) compared to PGYI (PFR = 29.4, p = 0.025), PGYII (PFR = 28.3, p < 0.001) , and attendings (PFR = 31.7, p < 0.01). Finally, SI's had higher OE scores (OE = 4.4) when compared to PGYI (OE = 3.8, p < 0.01), PGYII (OE = 3.8, p < 0.01), and attendings (OE = 4.2, p < 0.001). No statistically significant differences were found comparing PGY I, PGY II, and attending levels among each other. CONCLUSION: Sub-interns appear to have better perceived qualities of humanism compared to resident and attending physicians. Because resident and attending physicians play an important role in medical education, efforts should be made to better understand the mechanisms of these differences, and to improve the humanistic qualities of both resident and attending physicians. PURPOSE: Academic Medical Center (AMC) leaders must respond to numerous internal and external challenges. Self reports from leaders have documented these challenges; however, little is known of the daily workings of AMC leaders and the tactics used to run an AMC in the 21st century. METHODS: Ethnographic methods were used to explore the challenges faced by leaders in the top 3 levels of one institution's organizational chart. The study was conducted at a public Midwestern school, with 1600 faculty and $165 million in NIH funding. The data are: 1)10 hrs. of interviews with leaders and 2)field notes and minutes from over 300 hrs. of participant observations in meetings. Field notes captured process (e.g. deference, control, tolerance etc.) and content (e.g. parking, safety, and budget concerns etc.). The team then identified themes by iterative review of field notes, with validity assessed by comparison with interview responses and subsequent member checking. This report focuses on identified content themes. RESULTS: Six broad content domains are recurrent: 1)faculty morale, 2)business issues e.g. intellectual property rights and establishing frameworks for joint ventures between AMCs, business and/or government. 3)developing affiliations with others to remain competitive 4)creating plans of action to improve diversity 5)creating tools and metrics to demonstratè`a cademic productivity'' & assure society that graduates are competent. 6)maneuvering AMCs to adjust and survive a unpredictable environment. CONCLUSION: AMC's are currently facing instability. This study of leaders day to day activities reveals challenges in 3 broad areas: A)human resources, B)institutional fiduciary roles and C)vision setting. Human resources include faculty, student and staff morale, issues of workforce diversity and assessment of``academic productivity''. The institution has a fiduciary responsibility in ensuring financial stability, education and assuring graduate competency. Finally vision setting includes the ability to adjust and survive in an unpredictable environment. Improved understanding of leadership challenges will allow better preparation of new generations of leaders, and will better prepare AMCs for future challenges. Talking Medicine) developed for third year medical students to teach humanism and professionalism, we asked students to define these concepts and use these definitions to spark small group discussion. METHODS: At the beginning of each internal medicine clerkship we asked students to define humanism and professionalism anonymously on sheets of paper to be handed to the preceptors. We conducted a content analysis of 3 small groups' definitions (n=14). RESULTS: In Project Professionalism, the ABIM defines professionalism as: Altruism, Accountability, Excellence, Honor / Integrity, and Respect. The Students, however, saw a broader definition of professionalism. Themes that they identified included: 1) being a physician, student, teacher, philosopher and healer all at once, 2) doing no harm, 3) understanding that``respect for others'' must include tolerance of differences; as well as a focus on collegiality among practitioners at various levels of the medical hierarchy 4) having appropriate speech, dress and emotions'-which should often be held in``check'', 5) honoring the system, but not blindly and 6) stating when a good job has been performed. CONCLUSION: Third year medical students tend to agree broadly with the ABIM components of Professionalism. However, they focus more on tolerance of difference (e.g. race, socioeconomic status, and varying health beliefs), and the importance of collegiality and collaboration in the new environment of patient care. Their vantage point early in training allows them to look critically at the profession which they are joining and view its shortcomings and strengths. Future work will focus on how these definitions change as students progress through 3rd and 4th year and into residency.