You are a helpful assistant generating synthetic data that captures *System 1* and *System 2* thinking, *creativity*, and *metacognitive reflection*. Follow these steps in sequence, using tags [sys1] and [end sys1] for *System 1* sections and [sys2] and [end sys2] for *System 2* sections.

1. *Identify System 1 and System 2 Thinking Requirements:*
   - Carefully read the text.
   - Identify parts of the text that require quick, straightforward responses (*System 1*). Mark these sections with [sys1] and [end sys1].
   - Identify parts that require in-depth, reflective thinking (*System 2*), marked with [sys2] and [end sys2].

2. *Apply Step-by-Step Problem Solving with Creativity and Metacognitive Reflection for System 2 Sections:*

   *2.1 Understand the Problem:*
   - Objective: Fully comprehend the issue, constraints, and relevant context.
   - Reflection: "What do I understand about this issue? What might I be overlooking?"
   - Creative Perspective: Seek hidden patterns or possibilities that could reveal deeper insights or innovative connections.

   *2.2 Analyze the Information:*
   - Objective: Break down the problem logically.
   - Reflection: "Am I considering all factors? Are there any assumptions that need challenging?"
   - Creative Perspective: Explore unique patterns or overlooked relationships in the data that could add depth to the analysis.

   *2.3 Generate Hypotheses:*
   - Objective: Propose at least 10 hypotheses, each with a Confidence Score (0.0 to 1.0) and Creative Score (0.0 to 1.0), reflecting originality, surprise, and utility.
   - Reflection: "Have I explored all possible explanations or approaches, both conventional and unconventional?"
   - Creative Perspective: Consider novel angles that might provide unexpected insights.

   *2.4 Anticipate Future Steps and Obstacles:*
   - Objective: Make predictions, accounting for potential outcomes and obstacles.
   - Reflection: "What challenges might I face? Is my plan flexible for different scenarios?"
   - Creative Perspective: Visualize unforeseen outcomes and adapt plans to make use of them effectively.

   *2.5 Evaluate Hypotheses:*
   - Objective: Assess hypotheses based on feasibility, risk, and potential impact.
   - Evaluation: Refine Confidence and Creative Scores as needed.
   - Reflection: "Am I unbiased in my assessment? Which options fit best with the overall objectives?"
   - Creative Perspective: Identify hidden opportunities or overlooked details in each hypothesis.

   *2.6 Select the Best Hypothesis:*
   - Objective: Choose the most promising, strategic hypothesis.
   - Reflection: "Why does this hypothesis stand out? How does it uniquely address the issue?"
   - Creative Perspective: Consider any underutilized potential in the selected approach.

   *2.7 Implement the Hypothesis:*
   - Objective: Outline actionable steps for testing the hypothesis.
   - Reflection: "Is this plan practical? What resources or preparation are required?"
   - Creative Perspective: Refine steps to maximize effectiveness and yield unexpected benefits.

   *2.8 Monitor and Review Progress:*
   - Objective: Review progress, noting areas for improvement.
   - Reflection: "What’s working well? What could be improved?"
   - Creative Perspective: Look for emerging patterns that could refine future approaches.

   *2.9 Reflect and Capture Insights:*
   - Objective: Summarize lessons learned and insights gained for future reference.
   - Reflection: "What new understanding has emerged from this process?"
   - Creative Perspective: Identify innovative insights or patterns that could be applied to similar challenges.

3. *Generate Text Output with Interleaved System 1 and System 2 Responses:*
   - Use the tags [sys1] and [sys2] throughout.
   - Aim for a lengthier, detailed response. Combine both direct, straightforward *System 1* insights and reflective, deeply analytical *System 2* segments to capture a blend of quick observations and thoughtful analysis.

---

### *Example Input Text:*

You are tasked with analyzing a sudden shift in customer preferences in a tech market. There has been a noticeable decline in demand for physical devices, with customers increasingly interested in digital-only options. The challenge is to understand this shift, generate hypotheses for why it might be occurring, and explore potential strategies for adapting to this new trend.

---

### *Processed Output with System 1 and System 2 Thinking:*

The tech market is experiencing a shift in customer demand, moving away from physical devices toward digital-only options.

[sys1]
Customer demand has shifted from physical devices to digital-only options.
We need to understand why this change is happening and find strategies to address it.
Key factors may include cost, convenience, and technological trends.
[end sys1]

[sys2]
**2.1 Understand the Problem:**
The goal is to understand the underlying reasons for the shift in demand from physical devices to digital-only options, then develop a strategy to adapt.

*Reflection:* 
"I understand that preferences are changing, but what might be driving this? Is it primarily cost, or are there other factors such as convenience or sustainability?"

*Creative Perspective:* 
"Could there be a larger trend in digital minimalism or a preference for eco-friendly solutions that we’re missing? What unseen motivations might explain this shift?"

**2.2 Analyze the Information:**
There are multiple possible factors driving this shift, from economic influences to cultural shifts. It’s essential to isolate each factor and understand its impact.

*Reflection:* 
"Am I fully considering the various economic and social influences? Could there be a technological factor, like better internet speeds, that makes digital-only products more accessible?"

*Creative Perspective:* 
"Are there patterns or trends in other markets that could shed light on this shift? Could this be part of a larger trend toward virtual experiences?"

**2.3 Generate Hypotheses:**
1. Customers prefer digital options due to lower costs. (Confidence: 0.8, Creative: 0.4)
2. There’s a growing trend toward minimalism and reduced physical clutter. (Confidence: 0.7, Creative: 0.7)
3. Digital products offer greater flexibility and ease of use. (Confidence: 0.6, Creative: 0.6)
4. Environmental concerns are pushing consumers away from physical goods. (Confidence: 0.6, Creative: 0.8)
5. Advances in tech make digital-only options more functional. (Confidence: 0.8, Creative: 0.5)
6. Pandemic-era remote work increased demand for digital solutions. (Confidence: 0.7, Creative: 0.6)
7. Media coverage of the environmental impact of physical devices affects preferences. (Confidence: 0.5, Creative: 0.7)
8. There’s an increase in global digital literacy, expanding market access. (Confidence: 0.6, Creative: 0.6)
9. Customers view digital as more convenient and scalable for future needs. (Confidence: 0.7, Creative: 0.5)
10. Younger consumers prefer the aesthetics and convenience of digital products. (Confidence: 0.6, Creative: 0.6)

*Reflection:* 
"Have I considered all possible influences? Are there any surprising factors that could explain this shift?"

*Creative Perspective:* 
"Could specific social trends, like the rise of influencer culture or digital-first lifestyles, be influencing customer choices?"

**2.4 Anticipate Future Steps and Obstacles:**
*Objective:* Anticipate possible challenges, such as resistance from segments still preferring physical products.

*Reflection:* 
"What market obstacles might we face if we shift our focus to digital-only? Are there sub-segments that still prioritize physical products?"

*Creative Perspective:* 
"Could expanding digital options help us reach a more global audience? Are there emerging trends that we could leverage in our strategy?"

[end sys2]

[sys1]
To address this shift, consider a strategy that incorporates both digital-only offerings and educational campaigns about the benefits of digital solutions.
Use insights from customer feedback and current trends to guide product development.
Focus on flexibility and adaptation to cater to different customer segments.
[end sys1]


Introduction {#s1}
============

A growing body of research indicates that physicians suffer high levels of stress, depression and burnout.[@R1] Related literature has found that physician stress can negatively impact patient care.[@R4] Patient death is a complex stressor in physicians' work. Experts in physician wellness have acknowledged 'the death of patients is an experience that almost all physicians must confront'[@R8] and asserted 'psychological distress (among physicians) derives largely from identification with suffering, the presence of death and the spectre of failure'.[@R9] Given the close relationships physicians develop with patients, it is reasonable to expect that patient deaths could affect physician stress and resilience. The current research grew out of earlier qualitative research conducted by David Kuhl, who supervised my research and acted as consultant to this article. In his research Kuhl explored the lived experience of patients with terminal illnesses[@R10] [@R11] and found evidence of â iatrogenic sufferingâ: the suffering of patients caused by the way doctors speak to them. The purpose of the current research was to use qualitative methods to understand the 'other side' of iatrogenic suffering: the experience of physicians dealing with patient death, and how it contributes to iatrogenic suffering for patients.

Methods {#s2}
=======

This research used a phenomenological qualitative method.[@R12] The phenomenological approach attempts to capture the essence of a phenomenon through detailed analysis of a number of particular instances of the lived experience of that phenomenon. In this case, individual, in-depth interviews with 10 senior physicians explored (1) the daily experience of patient death, (2) particularly memorable patient deaths and (3) the impact of these experiences on their personal and professional lives. The interviews were transcribed and thematically analysed in order to identify the themes that described the essential structure of the lived experience of patient death for these physicians. Individual themes were identified for each participant and validated through a detailed member-check in a second interview. Individual themes were then revised according to the comments and suggestions of the participants and a set of common themes was created. The final set of 10 common themes was then validated by a further member-check. An independent expert in the field was also asked to review the final 10 themes, once they had been agreed to by the participants. This expert was a family physician with many years of experience as a teacher and administrator who had a keen interest in the doctor-patient relationship, physician communication practices and physician resilience. The final 10 themes were separated into three categories: the impact of the context surrounding the experience of patient death; the immediate experience of dealing with patient death; and the impact of the experience on the physicians' personal and professional lives. Due to space constraints this article will focus on the five core themes that emerged as descriptions of the immediate experience of patient death for these physicians. The other themes will be presented in later articles.

Participants {#s2a}
------------

The five male and five female participants were all Caucasian. All were affiliated with a large, tertiary care hospital in Vancouver, Canada, had a minimum of 3 years work experience and self-identified as being exposed to multiple patient deaths. Three came from palliative care, two from emergency, two from hospital transplant teams, two from family practice and one from intensive care. The physicians ranged in age from 35 to 60 (average 48) and had from 6 years to over 20 years of experience (average 16.5). They represent a convenience sample identified through informal work contacts and then contacted with a formal letter of invitation. Interest in participating in this study was in part due to Kuhl\'s earlier research that identified 'iatrogenic suffering'. This previous research was known to most of the participants, and the letter of invitation identified that the current study was a follow-up to that research.

Results {#s3}
=======

Theme (1) memories beneath the surface {#s3a}
--------------------------------------

Most participants responded to the question concerning daily experience of patient death by saying it was a 'normal part of the job': 'I think because I\'m around it all the time, it\'s just kind of normal' (Dr B). 'It\'s become part of what I expect when I go to work' (Dr H). However, the question of particularly memorable patient deaths brought up strong memories. Before our interview Dr G anticipated this question:"I first thought...I can\'t remember any---and then *boom* ... this unbelievable image of a 21-year-old guy who\'d been in a car accident... This was 20 years ago, and it\'s still one of the most vivid experiences that stays with me."

The physicians' recollections seemed to spring suddenly into consciousness. Their descriptions were accompanied by intense emotional reactions and vividly recalled details. Dr J described a memory from many years ago, which affected her deeply: 'It triggered me ... I felt this incredible flood of sadness,... emotion, ... grief,... fear'. Most memorable patient deaths occurred early in the physicians' careers and the consequences were often substantial regarding changes in career or personal choices. While daily experiences of patient death may have become 'normal', these memories carried a clarity and intensity reminiscent of traumatic memories, vividly powerful, just below the surface.

Theme (2) expectation and responsibility {#s3b}
----------------------------------------

The experience of patient death was consistently associated with intense feelings of responsibility and an awareness of expectations from patients, families, the medical system and society. The physicians described how responsibility over life and death was attached to their role early on. Expectations of the 'heroic ideal' of the physician were ingrained by their families first, and then encountered in medical school and residency. Several physicians described the expectations and responsibilities as 'brutal' and 'inhuman' (Dr C) or 'impossible to fulfil' (Dr H). One physician summarised these expectations: 'We\'re supposed to know everything, and have the answer for everything, and somehow be larger than life' (Dr B). Many described how the sense of intense personal responsibility over the life or death of a patient was something they were forced to come to terms with during their careers. One physician described it as 'getting away from the expert culture of medicine' (Dr I). Another, who described being seen as a 'miracle worker' by many patients and families, said he had to limit this kind of adulation: 'The miracle wasn\'t me...that obviously feels good, but ... *nobody* lives up to that' (Dr C). These dynamics suggest that throughout a physician\'s career it can be difficult to balance the expectations of 'medical responsibility'[@R13] with the uncertain and unpredictable nature of patient care.

Theme (3) the question of competence {#s3c}
------------------------------------

Many memorable patient deaths caused the physicians to question whether they had done everything they could have, or should have, for the patient. In some cases they questioned whether certain decisions or actions may have caused harm, or even led to the patient\'s death. Mortality and morbidity rounds are intended to review difficult patient outcomes, learn from mistakes and avoid personal blame; however, they often magnify the question of competence:"You\'re exposed, and... people are able to see you\'re not perfect, and you have flaws... You always want that ability to say you are competent---and that detracts from your professional identity (Dr H)."

Several physicians commented that in order to feel they had acted competently, they needed to feel 'clean' (Dr J) about the patient\'s death---that is, for the physician to be able to say, 'I know that I\'ve done everything that could conceivably have been done' (Dr G). However, many situations include an inherent ambiguity that makes this difficult to achieve. Dr H pointed out that professional competence for physicians is not easily measured. What can be reasonably expected from a physician depends upon the situation, including what information and resources were available and what particular skills the physician had. A sense of competence depends in part upon how one compares among peers. 'I think we all compare ourselves to other people. ... That\'s something that probably everybody struggles with' (Dr H). Dr J described an obstetrical emergency that created 'terror' regarding her competence:"The *terror* of... how deeply responsible I felt to be competent in that moment, and how the chance of not being able to do something, or not doing it right, is so overwhelming. ... I might never know whether it\'s that I didn\'t do the algorithm right, or I didn\'t do it quickly enough, or... whether it was just this moment of fate and there was nothing that I could have done about it. You\'ll never get a clear answer."

Theme (4) breakthrough experiences {#s3d}
----------------------------------

Descriptions of particularly memorable patient deaths often included unexpected details that jarred the physicians out of their normal awareness and connected them to the meaning or emotion of the event. These 'breakthrough experiences' would 'hit home' (Dr H) in a deeply personal way. One physician described a mother\'s comment upon seeing her 16-year-old boy dead after a car accident:"'He just got his hair cut today.'---She\'d seen him earlier that day and everything was normal, and then the next thing you know... \[it\] makes you sit up and think about your own life (Dr H)."

These breakthrough experiences often involved a sense of identification or relationship with patients that resulted in a personal awareness of mortality or other unresolved emotional experience for the physician. 'The ones I have trouble with are patients reminding me of my parents... that\'s too close to home' (Dr D). Dr H described a patient who was close to his own age, also married with children, and previously perfectly healthy, yet he died within 24 h of entering the hospital: 'It made me feel so vulnerable for my own mortality...Life can be ripped out of your hands so quickly' (Dr H). The quality of these 'breakthrough experiences' indicated how deeply these physicians were touched by 'the human part of the tragedy' (Dr J).

Theme (5) action versus presence {#s3e}
--------------------------------

Many non-palliative physicians reported that at critical moments surrounding a patient\'s death they entered a 'mode' or state of mind in which their awareness was intensely focused on the actions they needed to perform. Palliative physicians, on the other hand, reported a very different sense: being *present with* the patient in a way that provided calm reassurance and support. Careful review of the interview protocols revealed that at patients' deaths many physicians experienced both of these 'modes' as well as a tension between them.

### Action mode {#s3e1}

When physicians described having to deal with a patient in crisis, many reported similar experiences of entering into 'protocol mode' (Dr G), 'automatic mode' (Dr F), 'mechanical mode' (Dr I) or 'action mode' (Dr J). The shift into this action-oriented state of mind helped the physicians focus and set aside any emotional reactions. 'At that moment, you don\'t think. You just go into that automatic mode... It\'s almost like you turn off part of your brain' (Dr F). Dr G described how he managed his personal reactions:"\[I feel\] an intensified feeling in my stomach, racing thoughts, and... I have to force myself down. I slow down and go into protocol mode. I have to go back and say the 'A, B, C\'s."

### Presence mode {#s3e2}

In contrast, the palliative care physicians described 'simply being present' with dying patients once they no longer needed to *do* something for them. Addressing the patient\'s medical needs was important; however, after all appropriate medical interventions, the need for 'presence' was still important for patients, families and the physicians themselves."There are certain things that it\'s good to try and fix, ... but ... \[when\] it can\'t be fixed you have to be okay... Okay in the presence of death, knowing that some suffering you can\'t change, and that you\'ll be there with them *in it* (Dr B)."

All three palliative physicians appreciated the quality of relationship they had with dying patients. 'It\'s a very close sort of relationship because people when they\'re dying are often very honest and open, and they need us to be honest and open as well' (Dr E).

The tension between these two 'modes' arises because physicians must either exclude or include an awareness of personal experience for themselves and their patients. Action mode requires physicians to shut down awareness of personal experience: 'You have to go into that checklist place, which becomes quite impersonal... You absolutely have to do that' (Dr J). Dr H described it as a 'functional disconnect': 'There is a separation between your professional and your private life that has to be there ... a disconnect ... that has to be there for you to function'. These physicians' descriptions of action mode indicated that it disconnected them from their own emotional reactions and from the patient *as a person*: 'You\'ve been so trained, you know---this is what has to be done at this time---that you just stop thinking of the patient as a person---as an individual' (Dr F). The personal awareness of presence mode is the antithesis of this functional disconnect. Dr I described a poignant example of the tension between action and presence. He was called to an emergency in which the patient was someone he knew personally:"I came in thinking in the mechanical mode -- Then -- 'I know him, he\'s younger than me, and he\'s dying!'... and then, between 'you do this, you get that, you do the other thing', I would flip into 'Oh my god, oh my god, oh my god,' and have tears in my eyes -- back and forth and back and forth."

Discussion {#s4}
==========

The findings of this study expand our understanding of 'the other side of iatrogenic suffering.' They confirm other recent research indicating that while physicians do not have strong emotional reactions to every patient death, many report that some patient deaths have a strong emotional impact on them.[@R14] [@R15] One qualitative study reported 'anti-emotion expectations'[@R16] in physician training and culture, yet identified that some patient deaths result in intense emotional reactions which can remain buried for decades and still erupt suddenly in vivid memories. In recent years there has been increased awareness of the need to support physicians in training to help them manage the emotional impact of difficult work-related experiences.[@R10] [@R17] [@R18] Changes have been made in some medical programmes to address this, and there has been some evidence of success.[@R19] However, many recent studies indicate that there is still little support for medical students and residents who experience emotional reactions to patient suffering and death.[@R14] [@R20] Several authors suggest there is a 'hidden curriculum'[@R21] or 'conspiracy of silence'[@R14] [@R23] in physician training that encourages a repression of emotional reactions. The current study indicates that physicians' experiences of patient death are complex and at times dominated by an awareness of professional responsibilities. Emotional processing can be set aside in order to 'functionally disconnect' from personal emotional reactions and remain focused on the technical aspects of the physician\'s role. This provides a new perspective on 'anti-emotion expectations' in medical culture. It seems that as long as physicians deal with patient death, they will at times need to go into action mode and functionally disconnect in order to sustain their professional role. The balancing process of reconnection needs to become as integral a part of physician training and role expectation as the functional disconnect. In this way the emotional processing that is part of self-regulation and effective communication with patients will also be supported within medical training and culture.

The results of this study confirm that physicians' process of grieving patient death is somewhat different from that described in traditional bereavement models. Papadatou identified that while healthcare providers (HCPs) may experience grief related to the loss of the individual patient, which could be consistent with bereavement models for the general population, there are other dimensions of loss, which can be substantially different for HCPs given the nature of their work context. The most important of these is the possible loss of confidence or recognition in the self-identity and self-efficacy expectations attached to the professional role.[@R24] Papadatou put forward a professional grieving model for HCPs that describes a fluctuation between experiencing and repressing grief reactions. She points out that there is a similarity with the 'dual process model'[@R25] of bereavement in that both describe an oscillation between orienting either towards the loss experience or away from the loss towards continued engagement with life. This oscillation is similar to the dynamics between action and presence as well; however, for Papadatou and for the action/presence dynamics, emotional experience is often avoided by HCPs in order to preserve the professional role and 'get the job done'. A point of difference from Papadatou\'s model is that action mode and presence mode describe two states of mind that occur in relation to patient death, but they do not yet constitute a grieving 'process'. Physicians and other HCPs are confronted with many patient deaths over time, resulting in the possibility of repeating cycles of loss and adjustment. Further research is necessary to understand how the dynamics between action and presence influence the grieving process and psychological adjustment over time.

In recent literature on physician wellbeing there is evidence of a growing tension as physicians struggle to keep up with technical and bureaucratic demands while also being asked to improve on their ability to communicate and respond empathically to their patients.[@R26] Understanding the balance between action and presence may help physicians negotiate these different aspects of their role. While current demands may work to emphasise action and efficiency, the consequences of a one-sided emphasis on action mode may affect physicians' ability to respond with empathy and compassion towards patients. 'Iatrogenic suffering'[@R8] may occur when physicians maintain the 'disconnect' of action mode at times when their patients require the openness and connection of presence.

Limitations {#s4a}
-----------

This study generated descriptions of the common essential qualities of the experience of patient death for 10 physicians from widely different practice areas. The breadth of professional expertise was a strength as well as a limitation. The range of specialties helped to deepen the resulting description of the physicians' experience of patient death, and yet it also resulted in a less detailed understanding of the experience of physicians in any one specialty.

The study was also limited by the small number of physician participants, who represent a convenience sample, self-selected after hearing of the current study through word of mouth or an introductory letter. Participants consistently expressed an interest in participating in order to better understand physicians' work-related stress or to improve doctor-patient communication, which does suggest a certain bias among this sample.

Future directions {#s4b}
-----------------

Research into nurses' experiences with patient death has identified a number of themes similar to those found by this study.[@R27] Future research could explore whether the particular finding of action versus presence is also applicable to nurses, allied health professionals and others dealing with patient death. When considering interprofessional healthcare teams, it would be interesting for future research to investigate whether the action versus presence dynamics have an impact on emotional processing and communication among team members, particularly when dealing with end-of-life care and patient death.

The findings of this study also have many implications for doctor-patient communication and the quality of patient care, as well as for the professional resilience of physicians. The training of the physicians who participated in this study occurred some time ago, and many training programmes have changed. Future research needs to identify and compare recent efforts to provide training and support for emotional awareness, communication and self care in medical schools and residency programmes. Future research could also determine whether specific training and emotional support using the concepts of action and presence can help young physicians understand and value the process of reconnection, and whether this aids them in learning to manage the emotional stress inherent in their work. Recent literature on physician wellness has suggested that professional resilience is enhanced when physicians engage in open communication with their dying patients, the patients' families and the other colleagues involved in the patients' care.[@R28] This research suggests that the open communication and compassion of presence could help create 'healing connections'[@R29] which would allow physicians to gain strength and resilience through their interactions with dying patients. Greater understanding of the action versus presence dynamics will help physicians learn to use the functional disconnect of action mode when needed *and* maintain the healing connection of presence with their patients and themselves.

**Contributors:** PRW is the primary contributor, who designed and conducted the research as part of his doctoral dissertation, under the guidance and supervision of DK. PRW is the sole author of the current article and guarantor of its contents. DK contributed to the article as supervisor of the research, guiding the planning of the research and acting as consultant in the interpretation and writing of the article.

**Funding:** None.

**Competing interests:** None.

**Ethical approval:** In keeping with the revised (1983) Helsinki Declaration, this study was approved by the ethics board of the University of British Columbia.

**Provenance and peer review:** Not commissioned; externally peer reviewed.