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More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
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Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
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Eating disorders, which are well known as a substantial mental health problem in society, can come across all ages, but anorexia nervosa and avoidant-restrictive food intake are more common in childhood and adolescents, while bulimia nervosa and binge eating disorder are less prevalent in pediatric patients, but also with significant functional impairment [1].
Recently, a systematic review analyzed the lifetime prevalence of eating disorders and found for anorexia nervosa a prevalence of 1.4% for women and 0.2% for men. Bulimia nervosa had higher prevalence scores 1.9% for women and 0.6% for men. Binge eating disorder had the highest prevalence percentage with 2.8% in women and 1% in men. The prevalence for avoidant-restrictive food intake disorder was investigated and was found to be 0.3% [2, 3]. All these results must be cautiously taken into consideration because the real community incidence of eating and feeding disorders is unknown. Other studies found an increasing number of cases diagnosed with bulimia nervosa or binge eating disorder [4, 5]. In the young women’s population, anorexia nervosa seems to be the most predominant form of feeding and eating disorders, while binge eating disorder is more common in men [6]. Overall, studies show a higher prevalence of eating disorders among females and the young population [7].
Genetic predisposition is associated with the diagnosis of anorexia nervosa. Studies demonstrated that it is also a vulnerability inherited for anxiety and obsessiveness, by examining the family members of patients suffering from eating disorders and identifying anxiety disorders, obsessive compulsive disorder and autistic spectrum disorders diagnosed in the family members. The families with eating disorders have higher levels of academic achievement, traits of perfectionism and sensitivity, being above the average [8]. On the other hand, some studies explained the onset of anorexic episodes in the context of nonspecific triggers such as puberty, changes of schools or home, exams, conflicts with friends, family members, being bullied and bereavement. The anorexic behavior becomes a mechanism that manifest’s in discomfort situations rather than confronting them [9]. A report showed that bulimia and binge eating disorders are being influenced by environmental factors, but theses play also a part in the onset and evolution of anorexia nervosa. In the same study it was mentioned that 17–18 years old was the peak age onset for bulimia and binge eating disorders [10].
Typical symptoms describing patients with anorexia nervosa are an obsessive fear of gaining weight, body dysmorphia, voluntary and deliberate purging and over exercising. Purging is a voluntary action, characterized by putting the fingers down the throat to induce vomiting. Because of this repeated action on the knuckles of the right hand appear calluses, known as Russell sign, caused by the repeated pressure from the teeth during purging. In time purging becomes a reflex and patients can vomit without effort, quickly, within seconds. Due to the gastric acidity after vomiting, teeth may become denuded of enamel and the parotid gland becomes enlarged. As a consequence of many hours of physical exercise joint problems can be precipitated and, on the long term, osteoporosis can develop caused by malnutrition and endocrine abnormalities [11, 12].
Specific behaviors usually used by patients in order to lose more weight are represented by avoidance of calorie intake such as a restrictive diet, consuming vegan food, hiding or disposing the food that is served by offering to pets or friends, chewing gum or smoking just to feel the mouth full with something, trying to mimic the feel of fullness by drinking water or diet drinks, always calculating the amount of calories intake by reading all food labels or avoiding medication that can lead to weight gain. Another way to maintain or reduce weight is to overcome the calorie intake by inducing vomiting, using laxatives in excessive doses, exposing the body to cold just for burning more calories, doing exhausting physical exercises, administering pain killers to release pain in order to be able to over exercise, using and buying substances for losing weight. Also, compulsive behaviors of rechecking ones weight, examining oneself in mirrors for hours, seeking to feel their bones through skin, comparing their body to magazines or online pictures can be present [13].
To define compulsive exercises we must assume any form of physical activity that cannot be stopped or cut down even in the presence of detrimental effects on health status [14, 15]. For persons who associate excessive physical exercises, this behavior usually started for healthy issues, prior to the presence of eating symptoms, and patients describe themselves as having greater levels of physical activity than their friends during childhood, or even being athletes during that period [16, 17]. For normal subjects, usually these activities come unplanned and are done in a spontaneous manner, with joy in participating, but for patients with eating disorders activities become carefully planned and self-conscious. A possible explanation of this behavior comes from ancient times, as an evolutionary adaptation; despite weight loss individuals are able to search food in wider areas [18]. Also, a strong emotional involvement is attached to physical activities [19, 20], and it is considered to be the last symptom that resolves [21]. Examples of such exercises are: swimming, running, cycling, all of this done in privet and solitude; go up and down the stairs more than it is required for a task, getting of public transport for walking long distances, standing on feet for longer than it is required or pacing all the time. Studies connect the over activity that is still present after discharge with a more chronic evolution, earlier relapse rates and longer periods of time spent in hospital admissions [22, 23].
Gastrointestinal functional symptoms can also associate in the course evolution of an eating disorder. Patients with anorexia nervosa reported postprandial fullness, abdominal distension and unspecific abdominal pain. On the other hand, for bulimia nervosa more frequent were reported bloating, flatulence and constipation as gastrointestinal functional symptoms [24]. If these symptoms are severe enough and require more investigations, for patients that are malnourished, invasive investigations of the gut such as colonoscopy or upper gastrointestinal endoscopy, could lead to important risks. Patients diagnosed with anorexia nervosa have the gut much thinner than well-nourished patients, and so the risk of tear or perforation is much higher, therefore, less invasive investigation are considered to be safer, such as CT scanning or barium passage [25].
Osteopenia represents a consequence of bone loss after a long period of low weight and sex steroid suppression. This effect may become irreversible in patients with severe anorexia nervosa, and implies a high risk for bone fracture even in young old patients [26].
One of the most important phases in physical examination consists in determining the body mass index, which expresses weight in kilograms reported to height in squared meters (height is greater early in the morning). It is a simple formula to measure the nutritional risk but always needs to be interpreted in the clinical context. Sometimes based on this measurement, the case management plan can be influenced in determining which patient needs the most to be admitted and which can be treated in the community [27]. A so-called normal BMI is considered between the interval of 20–25 kg/m2, but if this parameter keeps falling as a consequence of inappropriate restriction of food intake, this has to be taken into consideration. Measuring the physical resilience of the patient with a simple screening test can be done by telling the patient to sit up, squat and stand, or by using handgrip for measuring strength [28]. Another important step is measuring pulse, blood pressure, and ECG for investigating the risk of prolonged QTc interval (over 450 ms) that can indicate electrolyte disturbances (hypokalemia, hypomagnesaemia, and hypocalcemia), heart disease (myocardial ischemia and cardiomyopathies), and improper use of drugs such as antipsychotics, antidepressants, antihistamines, antibiotics, and antiarrhythmics. Commonly anorexic patients present cardiovascular instability as bradycardia, showing a pulse under 50 bpm, or resting tachycardia with a pulse over 100 bpm suggesting infection or dehydration [29]. Also, basic screening is necessary. A full blood cell count has to be done, biochemical assays such as transaminase to evaluate liver function, creatinine and urea for determining renal function. Electrolytes abnormalities are common and need to be measured to exclude hyponatremia after an excessive water intake, hypokalemia in the context of excessive purging, or hypocalcaemia, hypomagnesaemia that can indicate the improper use of laxatives. Thyroid function should be checked together with plasma ferritin, folate, and B12 vitamin [30].
Body temperature frequently drops under 36°C in anorexic patients, who voluntary induce hypothermia in order to start shivering, consume energy and lose some more weight. Fever in a patient with low BMI is always significant and can indicate infection, with negative consequences because even minor episodes of sepsis can have a fatal outcome. Other signs present could be pale conjunctives, dry tongue and teguments, muscular weakness, peripheral edema in the context of low-level albumin, hand calluses after self-induced vomiting. It is not uncommon that patients present constipation, as a paradox effect of withdrawing the laxatives that were used for long periods of time in very high doses [31].
The ICD-11 restructured the chapter of feeding and eating disorders guided by the principles of more clinical utility and relevance around the world, after 25 years of research and evidence based knowledge. The disorders included in this chapter are not better explained by other health problems, developmentally conditions or cultural context. Moreover, two previous distinct conditions were united in one single block named feeding and eating disorders that combines abnormal eating patterns associated with fear of gaining weight, body image and feeding behaviors that imply limited food intake, eating non-edible substances, or voluntary regurgitation of foods that have been eaten. We could say that this grouping decision enhances the clinical importance of feeding problems during infancy and childhood [32].
The ICD-11 guidelines for Pica have not been changed in a substantial way from the previous version of ICD. Pica is still characterized by a frequent and regular ingestion of non-nutritive substances, like different objects or materials, to a persistent and severe degree that requires special clinical attention, in a subject capable to distinguish between substances that can and cannot be eaten. This type of behavior has severe risks on the health and functioning system of an individual [31, 32].
For the rumination and regurgitation disorder the ICD-11 guidelines are almost the same as in the ICD-10. The main symptoms of the disorder need to be frequent as several times per week and present over a sustained period of at least several weeks. Characteristic symptoms that appear in an individual that reached the age of 2 are represented by regurgitation of food that was previous swallowed or the food that was brought up in the mouth could be re-chewed, re-swallowed or spat out [33].
A new ICD-11 diagnosis is avoidant-restrictive food intake disorder, characterized by a very low and insufficient amount or variety of food in order to supply an adequate level of energy or demands. This course of restriction causes weight loss and nutritional deficiencies but without a preoccupation of body weight and shape [33].
For Anorexia nervosa, the major features of the disorder remained unchanged in the ICD-11, such as a low body weight for an individual’s height, age and developmental phase without a better explanation of another condition. The low weight is defined by a body mass index under 18.5 km/m2 or less than the fifth percentile in children or adolescents, but these should be used as general aspects of reference permitting in some circumstance to diagnose anorexia nervosa at higher levels of weight. A detailed specification was added to anorexia as a severity qualifier indicating that the level of underweight status can influence the prognosis by other health complications determining a high mortality risk or a poorer outcome. This classification consists in significantly low body weight; defined as a BMI between 18.5 and 14.0 kg/m2 for adult subjects and between the fifth percentile and the 0.3 percentile in children. The next severity step is named as dangerously low body weight and requires a BMI below 14.0 kg/m2 for adults and for children less than 0.3 percentile. Another important aspect in the ICD-11 is the qualifier anorexia nervosa in recovery with normal body weight, providing a solution for those patients that have regained weight but still need special attention and care. Despite the DSM-5 classifications, ICD-11 emphasizes the behavior patterns (restricting pattern and binge-purge pattern) that are weight related and used by patients in order to lose more weight. In both classification systems, physical symptoms such as amenorrhea, osteopenia are frequent consequences of food restriction, they still occur but they are no longer considered as one of the main criteria for diagnosis. Also, the ICD-11 and DSM-5 do not include as mandatory the presence of a reported fear about gaining weight, considering this symptom as a more culturally based belief. On the other hand, there is a need of modified normal behavior in order to prevent loss weight so that anorexia nervosa diagnosis can be confirmed [32, 33, 34].
Bulimia nervosa in the ICD-11 remains characterized by binge eating episodes and compensatory behaviors to prevent weight gain but, different from anorexia nervosa, the patient is not underweight even if they are preoccupied by body shape image. A change in the frequency of the binge eating episodes was made by reducing them to once a week or more over a period of at least 1 month. Also, the time criteria have been shortened admitting the importance of receiving clinical care without any further delay. In parallel, for DSM-5 the time criteria include a period of at least 3 months. A binge eating episode represents a distinct period when an individual has no control over the eating or the amount of food intake. The common type of bulimia is the one without purging but with severe fasting or physical exercises and can be difficult to differentiate from binge eating disorder based solely on the regular compensatory behaviors [35].
A new diagnosis was added to ICD-11, named binge eating disorder, separated by the other eating disorders as a disturbance characterized by recurrent binge eating episodes accompanied by negative emotions and severe distress, without compensatory behaviors to prevent weight gain. This category was previously described in the Appendix of DSM-IV and now forms a new diagnosis in the DSM-5. To assume a correct diagnosis according to DSM-5, 3 out of 5 additional features have to be present, like: eating faster than normal; eating even if the patient does not feel hungry; eating until he feels uncomfortably full; the food intake is done in solitude; and negative emotions such as guilt, disgust or depression can follow the overeating. An important aspect is that ICD-11 guidelines do not require for the binge eating episodes an objective evaluation of the amount of food eaten but suggests the importance of the subjective experience of losing control over eating rather the quantity ingested [36].
While both bulimia nervosa and binge eating disorder associate marked distress in the ICD-11 criteria, the DSM-5 requires marked distress just for binge eating disorder and not in the case of bulimia nervosa. A possible explanation for these differences between the two diagnostic categories would be the presence of the weight-compensatory behaviors that we can assume to reflect severe distress. In ICD-11 disturbances in body shape are required for anorexia and bulimia nervosa; self-body image concerns can be present in the binge eating disorder or avoidant-restrictive food intake disorder but are not necessary criteria. All in all, the new changes have the purpose to broaden the diagnostic process and facilitate clinical practice with the disadvantage of over diagnosing but also with respect to the course of life evolution [37].
If the criteria of behavior frequency are not fulfilled or other symptoms are considered sub-threshold, those eating disorders are classified in the DSM-5 as unspecified feeding and eating disorders, and in the ICD-11 as poorly specified other feeding and eating disorder [34, 37].
Eating disorders must be medically assessed in order to establish if present physical conditions are consequences of the mental illness or different somatic health problems. This strategy allows developing an integrated management plan, because both problems need proper evaluation and treatment and can impact recovery or the quality of life [38].
The most common symptoms in anorexia nervosa are the fear of gaining weight and the excessive preoccupation of being overweight or fat. Despite the fact that they are malnourished, patients try to lose even more weight. In contrast, many gastrointestinal illnesses have as a central symptom the weight loss and in this situation the patient is worried about the loss and tries to regain weight. The main two illnesses with this symptomatology are coeliac disease and inflammatory bowel disease. More family members can be affected by these diseases, but such family predisposition can be present for eating disorders too [39].
On the other hand, functional gastrointestinal disorders cam mimic an eating disorder, but usually they do not associate weight loss and have a long past evolution in the patient’s history. Such frequently reported diseases are the irritable bowel syndrome and the non-ulcer dyspepsia, also common in patients with diagnose of eating disorder. Food intolerance and allergies can simultaneously be present in a patient with eating disorders, but in this scenario it is more difficult to precisely discriminate between the two conditions [40]. The loss of appetite is a very common symptom, but nonspecific, in both mental and physical disorders. It can associate with weight lost and needs more investigating. In eating disorders, patients do not lose their appetite, the restriction from food intake has a voluntary component, that is not present in organic disorders, were the loss of appetite is without effort and involuntary. On the other hand, compulsive eating with an increased level of appetite can be present in Prader-Willi syndrome, craniopharyngioma, tumors of the hypothalamus or recovery from acute illnesses. This symptom is characteristic in bulimia nervosa or the binge purge subtype of anorexia [41]. Dysphagia is considered an alarming symptom in old age patients, and needs endoscopy or barium passage, malignancy strictures or achalasia are usually suspected. Other gastrointestinal symptoms that are commonly present include odynophagia, nausea, vomiting, hematemesis or melena, abdominal pain, constipation, diarrhea. Odynophagia described as pain when swallowing can be present in a reflux esophagitis or esophageal candida. Vomiting is a very unspecific symptom usually associated with nausea that can have different causes such as inflammatory bowel disease, side effects of different drugs, a high intracranial pressure, pyloric stenosis, gastro-paresis, but in these circumstances a voluntary control is not present as in eating disorders and it is not hidden [42]. Hematemesis or melena can represent a medical emergency, but frequently represent a consequence of purging and vomiting, with the development of Mallory Weiss tears. For the abdominal pain the doctor should establish the level of intensity, quality and localization of the pain in order to differentiate a peptic ulcer, gallstones, pancreatitis or appendicitis. Constipation, diarrhea, and rectal bleeding are symptoms that need to be integrated with other factors and the most important aspect is the change in bowel habit that can imply Crohn’s disease or ulcerative colitis [43].
The age of onset can be a very important clue. Usually, organic conditions, in special malignant illnesses that can manifest with weight loss, become more frequent with old age. If symptoms appear over 50 years, appropriate investigations are required. Moreover, the onset of eating disorders is identified in the teenage years or early adulthood [43].
In order to establish a diagnosis of an eating disorder the patient should be physically examined, the mental state evaluation should be done, all of these supported by a detailed medical history, family history and social context. All symptoms must be placed in a chronological order.
International guidelines recommend psycho-behavior therapy for all eating disorders, which can be applied in a form of outpatient care, when the treatment is accepted and the patient accepts to cooperate, with major beneficial effects, being more cost-effective, reducing hospitalizations, making patients feel more secure in their own environment, maintaining social contact with friends and family members, being able to perform other pleasant activities and making the rehabilitation phase much easier. Patients with a BMI over 16 kg/m2, with bulimia nervosa or binge purge syndrome are usually treated in outpatient or day care units because the risks are less serious on physical harm and this form of outpatient context has been proved to be highly effective [44]. On the other hand, for more severe forms, when patients’ symptoms are not improving with home treatment or the patients’ physical status is unstable (weight is rapidly diminishing, the BMI is under 14 kg/m2, low pulse, blood pressure, body temperature decreasing or fever being present, difficulty in performing the basic test of physical strength) more restrictive measures must be taken in a partial or day admission, or even a compulsory treatment would be necessary in order for the patient to improve physical and mentally but also, to limit potential harm behavior [45]. Anorexic patients in general do not want to die, but it is needed to understand the psychological drive of an anorexic patient who has an extreme fear of gaining weight, who is unable to rationally see that their physical state has become critical, and if the weight will continue to drop the result will lead to death [44].
It is highly recommended for these patients to be treated by a multi-disciplinary team with a minimum of a psychological therapist and a family doctor, but in hospital care additional support is required as a registered dietician, specialist physician, psychiatrist, nurses, physiotherapist, occupational therapist and social worker [46]. Nurses and other medical staff represent a key element in the management treatment approach by limiting mobility, imposing bed rest, monitoring fluid balance and physical symptoms (pulse, blood pressure, temperature), supervising mealtimes (observation for at least 1 h after eating), showers, toilets (patients being alone can consider a perfect opportunity to engage in behaviors such as purging, excessive physical exercises or water loading for a false weight gain). Even with the risk of some saying these rules are unethical; protocols like this can avoid numerous unwanted behaviors done by patients in the purpose of resisting the weight gain and destroying the process of recovery. In the context of bed resting for an easier and closer observation it is important to start prophylaxis for deep vein thrombosis with low molecular weight heparin [47]. Also, clothes need to be checked because they can represent means for falsifying weight or transport regurgitated food. Dieticians are also important for the safe management of patients with eating disorders. They need to be consulted for the risk of re-feeding syndrome, must establish a meal plan for proper nutritional requirements, to include all nutrients, carbohydrates, proteins, fats, vitamins and all kinds of minerals, to use supplements if the case imposes, and monitor weight gaining in a correct pace, and also, on the long term, to provide proper education for a balanced nutrition plan and teach patients how to prepare their meals and eat adequately in social situations [46].
The management of over activity can be treated firstly by providing psychoeducation about the advantages and disadvantages of this behavior and to discourage exercise. Also, relaxation and distractions techniques can be helpful, the use of wheelchairs to reduce the level of energy spent, administer Olanzapine with a good effect on the compulsive behavior, providing a calm and warm environment, with a permanent supervision from medical staff [48].
Treatment goals address numerous aspects such as nutritional, physical, social and mental health comorbidities. Some studies were made on healthy subjects, who voluntarily agreed to be starved, and the effect of this demonstrated that even in normal subjects thought processes were slowed, executive functions were impaired, with decision making disturbances, and personality traits accentuated in a manner that persons were more paranoid, depressed or became psychotic. The majority of these symptoms were reversed by re-feeding treatment in normal individuals and similarities were observed for anorexic patients, who had an improvement in thinking, mood stability and improved the engagement level for psychotherapy [49].
For malnourished patients re-feeding may represent the only solution for surviving. It has to be initiated promptly with benefits on the physical strength, cerebral function. It restores the reduced size of internal organs, heart, gut and their functions, offers a better functioning of the immune system, patients being less susceptible for infections. All of these outcomes appear after a slow process, because the body needs to readapt to the increased availability of calories and nutrients [50]. If the patients have a very low BMI, under 16 kg/m2, or had a rapid loss weight within the last 3–6 months of over 15% of the body weight, had little nutritional intake for more than 10 days or have low levels of potassium, phosphate, magnesium prior to the re-feeding, they are at risk of developing a re-feeding syndrome, according to the NICE guidelines [51]. The re-feeding syndrome can be defined as a consequence of trying to re-establish the normal weight of a very malnourished patient. During this phase, the maximal risk is within 72 h and implies potentially fatal shifts in fluids and electrolytes. The characteristic biochemical abnormality is the hypophosphatemia, but hypokalemia and hypomagnesaemia can also occur. NICE recommends starting re-feeding process at 5 kcal/kg/24 h for those with severe anorexia nervosa, through a nasogastric re-feeding tube and progressively increasing the rate of re-feeding to the target calorie intake over the next 4–7 days. Other studies showed that higher initial re-feeding rates can be applied such as 15 or 20 kcal/kg/ 24 h, with or without the association of re-feeding syndrome [52].
In order to avoid this kind of situations the patient has to be admitted in special medical units with experience in re-feeding syndrome, to monitor the blood chemistry twice a day, start with caution and increase quickly if the patient tolerates well. A particular aspect is to start giving thiamine before feeding starts, and to continue with it at least 10 days in order to overcome the development of Wernicke’s encephalopathy or Korsakoff syndrome. Hypophosphatemia can have fatal effect through numerous clinical features such as cardiac failure, arrhythmias, seizures, tremor, rhabdomyolysis, and respiratory failure. Hypomagnesaemia can also occur and complicate the feeding treatment by cardiac arrhythmia, hypertension crises, tremor, tetany, confusion, seizures and abdominal pain. Hypokalemia can appear as a consequence of staring to feed the anorexic patient, but more common it is present in patients with binge-purge subtype because of vomiting or induced laxative diarrhea. All of these electrolyte deficiencies must be treated properly to offer a safe outcome. Other complications that can occur during re-feeding are elevated transaminase levels with liver failure, coagulation problems, acute tubular renal necrosis, tubular renal nephritis, cardiac Torsade du Pointes, arrhythmias, prolonged QTc, cardiomyopathy [53, 54].
If the patients is in a severe state for the re-feeding process doctors have to decide if an enteral tube feeding is required. For this intervention training and experience is need, because the gut wall in malnourished patients is extremely thin and there is the risk of rupture, a lethal complication. Also after passing the tube, the safety position must be checked before it is used. In order to confirm the placement of the tube, gastric fluid can be aspirated, and the level of acidity can be determined, or an X-ray might be required. Gastrostomy tubes are not advisable to use, they need an endoscopic or radiologic approach, with the risk of peritonitis or other infections. Feeding through a tube is just a temporary solution, as part of an integrated plan, and patients need to be responsible and slowly introduce a full oral intake [55].
For osteopenia the recommended treatment is weight restoration and a normalization of the endocrine hormones. Also hormones substitution with transdermal estrogen, analogue of parathyroid hormone, bisphosphonates, raloxifene and denosumab drugs can be prescribed in this case [56].
Psychotherapy should be the treatment of choice for all eating disorders. The number of sessions required is different in each eating disorder type. In the case of anorexia nervosa no specific psychotherapy has shown clear superiority, but the number of sessions required is the highest, with an average of 40. Adolescents with anorexia nervosa have better outcomes after family therapy. For bulimia nervosa and binge eating disorder psychotherapy should be offered as a first line treatment, especially cognitive behavior therapy, or as an alternative interpersonal psychotherapy, psychodynamic, or family-based therapy in children and adolescent with bulimia nervosa. Usually the number of sessions required is less for bulimia and binge eating disorder, with a medium of 20 weeks [57, 58].
Pharmacological therapies with positive results in controlled trials in eating disorders are second generation of antipsychotics and antidepressants. For anorexia nervosa olanzapine had the most beneficial effects, in the case of bulimia nervosa and binge eating disorder Fluoxetine showed a good outcome, with a small effect from Lisdexamfetamine for binge eating disorder and Mirtazapine for avoidant restrictive eating disorder [59, 60].
Eating disorders characterized by low weight associate high morbidity and mortality rates. A follow-up study which monitored hospitalized patients with anorexia nervosa reported an average life expectancy of 39 years. Studies showed that 1/3 of patients suffering from anorexia nervosa tend to have a full recovery, in same percentage patients have just a partial recovery, and approximately 1/3 will have a chronic evolution or die. On a more optimistic point of view, a full recovery has been shown to be possible but with early intervention plan and sustained treatment over a medium of almost 7 to 9 years [61].
In general the prognosis for bulimia nervosa is good with treatment and assistance, but if the patient associate low self-esteem or different forms of personality disorders these aspects can affect the outcome. Little is known about the prognosis in binge eating disorders or other eating and feeding disorders [62].
For all eating disorders, poor prognostic factors can be considered as: late onset, anxiety in the presence of others when eating, severe weight loss, association of other chronic disorders, difficulties in childhood for social adjustment, being a male, having conflicts with parents or friends, being present binge and purge behaviors, low motivational for change, shame or not having enough money for engaging in psychotherapies sessions, association of concomitant depressed mood and obsessive body imagine preoccupation. Better evolutions have been identified in adolescents than adults, but only in association with family psychotherapy making the majority of these patients partially recovered, with less episodes of relapse. Also, in the young group distribution an onset in adolescents have a much better prognosis than one in early childhood [62].
There is now a general agreement that insight is not an all-or-none phenomenon, but rather a complex, multidimensional concept in psychiatric disorders. It includes different components, like the ability of a patient to recognize the presence of a mental illness, the capacity to accept that some symptoms are pathological and are determined by a mental disorder, the awareness of illness’s consequences and compliance with treatment [63].
Lack of insight has been largely demonstrated in schizophrenia, other psychoses and bipolar disorder [64, 65, 66, 67]. DSM-5 included an “insight” specifier in OCD, body dysmorphic and hoarding disorder. Also, different levels of lack of insight, from good to absent, have been found in other psychiatric disorders, like depressive and anxiety disorders, specific and social phobias, Alzheimer disease and other neurocognitive disorders, eating disorders [68, 69, 70, 71].
Patients with anorexia nervosa (AN) commonly lack insight, at least in the early stages of illness. This element will determine important difficulties in assessment, lack of compliance or avoidance of treatment, frequent relapses and also may limit the identification of eating disorders. These patients have distorted cognitions about body weight and shape and also, they are ambivalent regarding motivation to recover [72]. On the other hand, patients with bulimia nervosa (BN) have typically a bigger level of motivation to recover.
Until now there is not a disorder-specific scale for the assessment of insight in patients with eating disorders. Many researchers use SAI-ED (the Schedule for the Assessment of Insight for EDs), a short self-report questionnaire, which has only seven items. Even if the SAI-ED has not been fully validated, has a significant level of internal consistency [72].
In their study evaluating the clinical insight in 193 patients with anorexia nervosa, Gorwood et al. observed that 88% of patients (171) had a high level of insight (SAI-ED total score > 4) and 12% of patients (22) had a poor insight (SAI-ED < 4).
The authors drew three important conclusions:
Insight was not improved in a vast majority of patients, even if they followed 4 months of specialized care and all clinical and cognitive markers improved.
In this study, the only factor that has been demonstrated improving insight was minimum BMI.
Premorbid IQ was highly associated with the level of baseline insight.
Other studies revealed other factors correlated with insight (cognitive functions - memory and executive functions), psychiatric and addictive comorbidities, associated personality disorders prescribed psychotropic drugs, social cognitions, use of psychotherapy [72, 73, 74, 75, 76].
Beside comorbid somatic conditions of eating disorders (anemia, arteriosclerosis, hypertension, high cholesterol, high triglycerides, myocardial infarction, lung problems, stomach ulcer, Bowel problems, liver diseases, fibromyalgia, stroke, epilepsy or seizures, cancer, arthritis, osteoporosis, sleep problems), all three EDs (eating disorders) are associated with other psychiatric conditions, especially mood disorders, anxiety disorders, posttraumatic stress disorder, substance use disorder and personality or conduct disorder [77].
Regarding mood disorders, most common associated with EDs are major depressive disorder, persistent depression, bipolar I [78]. Affective disorders, substance use disorders and anxiety disorders represent the most common predictive factors for suicide. Researchers have reported also that eating disorders are associated with suicide. The meta-analysis of Smith et al. [78], which included 2611 longitudinal studies, concluded that ED diagnosis is significantly associated with an increased risk for suicide attempt (SA) although the rate of SA varied considerably across studies [78]. In the group of patients with anorexia nervosa (AN), the rate of SA was between 3 and 20% [79]; in bulimia nervosa patients (BN), the rate ranged between 25 and 35% [79]; and in BED patients, the rate was 12.5% [78] and 20.8% when combining all EDs [80]. In the study of Udo et al., which included 36,171 respondents in the Third National Epidemiological Survey on Alcohol and Related Conditions (NESARC-III), the prevalence of suicide attempts was 24.8% for AN, 15.5% for anorexia nervosa-restricted type (AN-R), 44.1% for anorexia nervosa binge/purge type (AN-BP), 31.4% for bulimia nervosa, and 22.9% for binge-eating disorder (BID) [77].
Regarding anxiety disorders, most common associated with eating disorders are panic disorder, social anxiety disorder, specific phobias and general anxiety disorder [78]. The association between social anxiety and EDs could be a part of a wider socio-emotional phenotype which it is considered to contribute to the development and maintenance of EDs. SA may be a risk factor for ED, or SA may be secondary to the ED, as a consequence of ED psychopathology or malnutrition [81].
Abuse of substances is common in EDs, the lifetime prevalence being estimated between 23 and 37% [82]. Tobacco, caffeine and alcohol were the most prevalent SUD in the study of Bahji et al., being followed by cannabis and cocaine [83, 84].
Between axis II DSM diagnoses, most common comorbidities in ED are antisocial, borderline and schizotypal personality disorders and conduct disorders [78].
The authors declare that they have no conflict of interest.
Provider-patient interactions constitute a foundation upon which a durable therapeutic relationship can be built. The same is inherently true for trainee-patient interactions. Beyond some of the more superficial factors, patient-provider relationship (PPR) has profound implications on numerous domains, from clinical outcomes to treatment adherence and patient satisfaction [1, 2, 3, 4]. In this chapter, we will review existing evidence in this increasingly prominent area of leadership development, focusing on PPR in the context of graduate medical education (GME) and advanced practice (AP) training. More specifically, we will explore how the interplay between professional (e.g., mutual respect, tone of voice, body language); personal (e.g., mutual empathy, focus on wellness); and leadership (e.g., flexibility, proactivity, setting positive example) traits becomes central to optimal clinical outcomes, patient satisfaction, and high quality of care [3, 4, 5, 6, 7, 8, 9]. Additional focus will be placed on the importance of wellness, both on the part of providers/trainees and patients. For the reader’s convenience, general themes from this chapter are summarized inFigure 1.
Word cloud depicting relative weights and frequencies of key terms reflecting the current chapter’s focus.
Research pertinent to this manuscript was performed via a comprehensive literature search. Internet-based search platforms used during the preparation of this manuscript included Google ™ Scholar, PubMed, and Bioline International. Specific search terms included, but were not limited to, “advanced practice,” “graduate medical education,” “provider-patient relationship,” “care effectiveness,” “care optimization,” “leadership,” “relationship,” and “wellness.” Out of a total of 11,434,570 initial search results, we narrowed down our reference list to approximately 1,520 results highly specific to our intended area of focus. Out of that list, we selected our current reference list of 134 literature sources.
Active listening — The practice of listening to a speaker while providing feedback and conveying that one sees the speaker’s point of view and understands him or her [10].
Adaptive leadership – Based on the idea that leadership is a personal characteristic independent of one’s position in a hierarchy, adaptive leadership entails the work that practitioners do to initiate and sustain the patient’s own initiative in maintaining well-being, therapeutic compliance and adherence [11, 12].
Adherence — The extent to which a patient continues an agreed-on mode of treatment without close supervision [13].
Advanced practice providers – A group of medical professionals that include physician assistants and advanced practice registered nurses [14, 15].
Body language — The expression of thoughts and feelings by means of nonverbal bodily movements, for example, gestures or facial expressions [16].
Empathy — A term that describes a process wherein a provider/trainee tries to understand what the patient is feeling and experiencing, physically and emotionally, and communicates that understanding to patient [17].
Graduate medical education – Also known as GME, is a system of postgraduate medical training whereby medical school graduates participate in a step-wise, long-term program to transition into practice within their intended specialties and subspecialties [18].
Leadership-based partnership — A partnership that engages all stakeholders as co-leaders to achieve a common goal or a set of common goals. It is distinct from the more traditional patient-provider partnerships, which tend to be more paternalistic in nature.
Motivational interviewing — A technique in which a person becomes a helper in the change process and expresses acceptance of his/her client; a style of counseling that can help resolve the ambivalence that prevents clients from realizing personal goals [19, 20].
Patient-centric approaches — Approaches that emphasize patient needs and priorities within the overall context of a therapeutic relationship and the healthcare system.
Patient satisfaction — Indicator or set of indicators for measuring the quality in health-care, including the overall performance of doctors and hospitals [3, 21]. More recently this has been evolving toward a more comprehensive term ‘patient experience’ which encompasses a much broader set of variables and provides a much broader context [22].
Servant leadership - Servant leadership is a leadership philosophy in which the main goal of the leader is to serve, with focus on empathy, positive reinforcement, selflessness, awareness, foresight and stewardship [23, 24].
Social determinants of health - Conditions in the places where people live, learn, work, and socially interact affect a wide range of health risks and outcomes [25].
Telemedicine — The use of telecommunication in the delivery of health services to enable provider–patient and provider–provider consultation despite geographical separation [26, 27].
Thorough approach — The doctor/provider/ trainee is conscientious and persistent [17].
Tone of voice — The quality of someone’s voice which expresses a mood or emotion [28].
Long-established as a positive modulator of health-care quality and effectiveness, the importance of developing and sustaining a constructive and PPR cannot be overstated [29, 30]. The PPR itself is a relatively complex and multi-factorial concept, with contributing inputs from various closely inter-related domains, including effective communication, mutual respect, empathy, good listening ability, body language, tone of voice, leadership skills, cultural awareness, conceptual openness and joint decision-making, in addition to clear evidence of professional/technical competency [5, 31, 32, 33, 34]. It is therefore not surprising that, over time, PPR became a key component and focus of medical school, GME, and AP training curricula [35, 36, 37, 38, 39, 40]. In the subsequent sections of this chapter, we will discuss various nuances and aspects of the PPR, focusing specifically on the importance of adaptive leadership in the overall framework of therapeutic effectiveness, long-term sustainability, and LBP [11, 38, 41].
During a health-care visit, whether with physician, trainee, or AP provider, it is important for the patient to feel comfortable, respected and listened to [42]. The focus should be on developing and sustaining a PPR that is based on mutual trust and the ability to relate with one another, utilizing primarily patient-centric approaches (PCAs) [43, 44, 45]. This helps facilitate the development of interpersonal respect and a bond (also known as a rapport) between the individuals involved [45], optimally resulting in the emergence of a LBP.
It is well known that a first impression, or the intuitive opinion of another person, can be formed in a matter of minutes based on appearance, body language, and tone of voice [17, 46]. Although it is not always accurate or correct, it nonetheless creates a basis for further interaction and relationship growth. The first essential tool is body language, which can be defined as “the expression of thoughts and feelings by nonverbal bodily movements” [16]. The second is tone of voice, including word choice, defined as the quality of someone’s voice with which one expresses a mood or emotion [28]. As a whole, nonverbal and verbal characteristics are key to successful PPR, mainly because a negative first impression is difficult to overcome [47].
There are certain techniques trainees in particular are encouraged to learn and embrace in order to optimize the odds of a positive first impression. First, and perhaps most fundamentally, they should study the patient’s medical records and be aware of his/her name and reason for the visit. In doing so, the provider/trainee can confidently enter the room properly addressing the patient, introducing themselves with a first and last name, and making good eye contact with a firm handshake (of course with a consideration of specific scenarios where such well-meant gestures may not be culturally acceptable) [17]. Before asking the patient to explain their reason for the appointment, the provider/trainee may consider inquiring about other aspects of his/her life [17]. In addition to promoting openness and trust, such questions may bring out important details about social determinants of health (SDH) [48]. Omission of these simple and effective measures may cause the patient to experience discomfort and distrust, causing them to neglect to share important information with the HCP. After moving to address the patient’s chief complaint, the provider/trainee should follow-up with increasingly more specific inquiries, appropriately moving from broader to more focused questions that follow a logical process. Appropriate expectations should be set along the way. This helps reduce any misunderstandings and ensures that information is communicated and processed in a controlled fashion. Taken together, the above approach helps facilitate the relationship-building process and inherently promotes the impression of a health-care visit as being both successful and meaningful.
It has been said that effective communication between a patient and a provider is “the heart and art of medicine” when building a therapeutic PPR [49]. At all times, providers should be aware of, and pay close attention to, their verbal expressions and word choices. Even though they have an extensive vocabulary of complex clinical terms, it is possible to confuse and even scare the patient depending on how medical information is delivered [50]. For example, when talking about having a surgery to remove an anatomic structure, using the word “excise” or “resect” can be easily misunderstood and using the phrase “cutting it out” sounds pain inflicting [17]. Consequently, using the term “removing” could be less stressful for the patient while still conveying the main point of treatment. Also, during consultations, it is important to take note of the general tone of the conversation (i.e., friendly and engaged versus tense and business-like). Patients may perceive the interaction more positively if the HCP has a more constructive and approachable demeanor about the visit as a whole, including polite greetings and farewells and conversing about non-medical details [51]. On the other hand, the emergence of tension during a conversation can cause negative effects on patient satisfaction compared to a more light-hearted but professional tone. Of course, the context of a conversation must be respected, with matters of great impact being discussed at an appropriately more formal but equally empathetic and sympathetic level. Thus, if a provider communicates difficult diagnostic findings or therapeutic options through careful language selection, a patient may still report a more positive experience [51].
In addition to the importance of different ‘verbal behaviors’ within the overall PPR framework, ‘non-verbal behaviors’ may be just as important. For a provider/trainee, noticing a patient’s non-verbal behavior can help better understand carefully hidden emotions, such as anxiety and/or fear [17]. For example, fidgeting can reveal that the patient is anxious or may feel overwhelmed. Catering to his/her needs via word choice by the HCP guides the patient to feel sufficiently secure to calmly talk about their condition or other concerns. For patients, noticing that the HCP has their arms crossed, frowns, or makes faces may indicate disinterest and cause the patient to be equally closed off [52, 53, 54]. An HCP should incorporate eye contact, attentiveness, body movements, and time conscientiousness in order to make the patient feel as though he/she can be open while building the overall relationship [17, 55]. Gaining positive feedback from patients and doctors/trainees in non-verbal behaviors (i.e., attitudes, gestures, expressions, etc.) is vital in order to avoid confusion and misinterpretation which ultimately damages the rapport [55].
Finally, one must remember that good first impressions should not be taken for granted and must be sustained [56, 57]. This often entails a considerable effort over time. Consequently, PPR needs to be fostered with the long-term in mind, including focused and ongoing efforts by the entire HCT to maintain appropriate levels of communication, respect and trust. Most importantly, once a bad impression emerges, it is much more difficult to overcome when compared to the efforts required in maintaining an ongoing and sustained positive relationship (and thus mutual impression) [47].
Within the past few decades, the idea has gained traction that maintaining a strong PPR requires both the provider and patient to be empathetic and play equal roles as co-leaders within the overall, multi-dimensional therapeutic interaction [58, 59]. Empathy entails the consideration of combined cognitive and affective components – both very important aspects of a provider’s and a patient’s well-being [60, 61]. When demonstrating cognitive empathy, HCPs should be able to recognize, reflect, and consider a patient’s emotions, while affective empathy allows them to support a patient’s mental state when they undergo similar feelings themselves [62, 63]. HCPs do not need vast experience nor introspection about a patient’s emotions to truly relate; previous studies have shown that empathy is a skill which can be both taught and/or enhanced through specific interventions [63, 64, 65]. The latter is especially important in the setting of medical, GME and AP education [66]. In fact, approximately two-thirds of medical schools have been teaching these skills, in some form, since the mid-2000’s [67]. Empathetic communication skills are a vital part of provider education, and are powerful tools that enhance the understanding of the patient’s point-of-view, and over time help build a robust LBP between the stakeholders.
It is important to recognize that effective empathy in clinical care is best facilitated in settings where the provider is neither overwhelmed nor affected by burnout. The ability to adequately reflect and identify oneself with another person’s feelings requires one to ‘slow down and take a deep breath.’ Stress from excessive workload, antisocial behavior, unappreciated gender/cultural/racial differences, failure to meet the patient face-to-face, and time constraints can manifest externally as lack of empathy, even if not intentional [67]. While there is no quantitative way to measure empathy, certain actions will help psychologically improve patients’ perception of their healthcare experience and the overall provider quality. The Accreditation Council for Graduate Medical Education (ACGME) recommends that through effective listening, thorough explanations and counseling, and decisions considering a patient’s information and choice, physicians (with emphasis on trainees) will enhance the patient’s perception of the overall care process, experience, and will help create and maintain mutual trust [67]. By avoiding apathy and any artificial barriers to patient-provider communication, HCPs are not only showing active personal and professional leadership, but also facilitate the growth and development of patient leadership, including the ability and the initiative to maintain interest in self-care and long-term health prevention [68].
Providers and trainees utilizing consistent communications and fostering overall patient comfort are more likely to achieve positive medical outcomes, including patient satisfaction [68, 69]. Data show that physicians with high empathy scores are more likely to have patients with good clinical outcomes, fewer complications, and symptomatic improvement [70, 71]. In one study, researchers studied how physician empathy affects diabetic patients using the Jefferson Scale of Empathy (JSE), an instrument measuring empathy through a physician’s understanding of the patient’s pain and apprehension, and a willingness to help. The results showed that patients whose practitioners had higher JSE scores were more likely to have an improved hemoglobin A1c and cholesterol level [72]. Another study suggested that patients with the common cold who highly rated their physicians’ empathy scores, experienced overall ‘milder symptoms’ and were more satisfied with therapy [73].
Empathy can have direct positive influence on patients’ health and their perception of HCP support [74, 75]. In one study, patients and physicians completed a questionnaire assessing their perceived emotional skills and quality of life. Results showed that even when highly empathetic doctors share negative results, patients with lower emotional skills experienced a primarily unfavorable impressions and feelings [76]. Of note, patients with high emotional skills reported greater perceived benefit from HCP empathy when hearing ‘bad news’ and not necessarily in a follow-up consultation [76]. Accordingly, interventions to provide additional patient support may be beneficial in cases where significant mismatch in emotional coping skills exist within a particular PPR.
In cases where patient-perceived HCP empathy helps enhance overall stakeholder experience and satisfaction, the therapeutic adherence also appears to be positively impacted. In one study, more than 500 outpatients participated in a questionnaire demonstrating that “information exchange, perceived expertise, interpersonal trust, and partnership” were among factors greatly affecting their compliance [77]. This, in turn, allows the HCP to actively enhance patient healthcare experience and associated outcomes, and do so in a relatively shorter period of time [77]. Being aware of the patients’ fears and emotions, as well as the practice of self-reflection has been seen as a core competency for physicians and advanced practitioners, especially those who are in training. Within this dynamic, patients will also play a critical role in seeking help and following through on what is asked of them. Meanwhile, it is very important that providers strive to avoid misplacement within their patients’ emotional milieu [78]. This approach, known as ‘clinical empathy’, has been suggested as an optimal way for physicians to maintain an emotionally healthy and balanced PPR [78]. By trying to understand the inner experiences of a patient and seeing ‘an individual’ rather than ‘a case,’ HCPs are taking on an active leadership role by making empathy a key instrument for therapeutic effectiveness.
While the information regarding HCP empathy as it relates to patient outcomes continues to be somewhat limited, studies have shown that medical empathy is important to improve patient satisfaction, compliance, and level of anxiety/distress [79, 80]. Simple word choices displaying empathy can have tremendous impact on the perceived quality of communication. It is essential that HCPs maintain compassionate care during consultations, with active awareness of the positive power of empathy, its ability to foster a meaningful connection, and a number of other potentially beneficial effects.
The first step in becoming an effective leader is taking the initiative [23]. To some extent, patients assume a leadership role when they choose to seek medical care, with preventive and long-term maintenance interventions being most impactful manifestations of ‘patient as a leader’ [81, 82, 83]. Furthermore, shared decision making between patients and their providers is critical to the effectiveness of any PCA [84, 85]. In one example, a recent study examined the involvement of patients in clinical research, with an objective to foster greater patient involvement during pre-study, intra-study, and post-study activities. Data were gathered based on a set of priorities that consider the needs of patients during research related activities, defining an engaged patient as an ‘expert’ participant [86]. The importance of active patient involvement and self-directed leadership is most critical in the setting of oncology clinical trials, with significant missed opportunities due to poor overall patient enrollment or participation [87]. This is especially striking when one considers that the proportion of patients partaking in clinical trials typically does not exceed 5% of those with a diagnosis of cancer [88]. Consequently, encouraging patient leadership and initiative is important to improving clinical trials participation and potentially improving outcomes related to lack of active patient engagement.
Within the broader context of LBP, both patients and HCPs must remember that only relationships based on mutual trust can be successful in the long run [89]. Such leadership-based approaches and considerations are especially important when dealing with chronic health conditions and increasingly complex HCTs [90, 91]. It has been said that “the best follower is a leader-in-the-making,” and within the long-term PPR these words become especially relevant [92]. Consequently, it is important to persistently and consistently promote leadership qualities and behaviors within each and every PPR.
The self-management of a patient’s health and well-being is a complex and multifactorial issue [93, 94]. HCTs should approach medicine with a clear focus on PCAs. In addition, it is important to maintain a holistic approach, with considerations given to factors well beyond topics such as ‘medication compliance’ or ‘long-term follow-up’ [95]. It is therefore critical that pharmacologic therapies appropriately balance biophysiological needs with highly individualized patient quality-of-life considerations to achieve sustainably healthy lifestyle and long-term well-being [96]. Finally, adequate self-reflection, deliberate mindfulness, focus on mental health/hygiene, and non-judgmental approaches are required to achieve optimal outcomes in this important domain [97, 98, 99, 100]. HCPs should be well-versed with the above issues and topics, and there should be ample time devoted to patient wellness as a core element of medical school, advanced practice training, and graduate medical education curricula [101, 102].
HCPs and trainees are inherently attentive to the signs and symptoms of their patients, yet they often fail to properly tend to their own well-being [103]. Workaholism is all-too-prevalent among HCPs and is closely tied to burnout and various associated adverse secondary health sequelae [104, 105, 106]. Consequently, doctors and other members of HCTs should strive to preserve their own well-being, thus ensuring that quality of patient care is not negatively affected by provider burnout [107, 108]. The statistics of burnout in healthcare are staggering, with reported incidence of 30–68%, depending on the area of professional training/specialization [107].
From definitional perspective, burnout is characterized by the presence of 3 distinct manifestations: Emotional exhaustion (e.g., loss of enthusiasm for work or feeling drained); Depersonalization (e.g., manifest as cynicism or a callous approach toward others); and “Low sense of personal accomplishment” (e.g., a perception of clinical ineffectiveness and a feeling that the work is no longer meaningful) [109]. Medical students and trainees are among the most severely affected groups, but no one in the healthcare industry is truly spared [109, 110, 111]. Among physicians, high scores on the “Emotional exhaustion” and “Depersonalization” scales are seen more frequently [112]. Within the established core competencies, the ACGME places emphasis on professionalism, stating that residents must demonstrate a “responsiveness to patient needs that supersedes self-interest” [113]. Medical providers who feel emotionally or physically ‘drained’ or are unable to effectively recuperate outside of the workplace are less likely to achieve adequate (and sufficient) personal fulfillment and well-being. Self-sacrifice prevails as a part of professional identity as it applies to medical students and graduate medical education trainees [114, 115]. In one randomized study, data was collected from 74 practicing physicians in an attempt to learn more about burnout reduction and associated interventions consisting of a facilitated small-group curriculum. The authors concluded that physicians felt more empowered and engaged at work following the implementation of such targeted intervention(s) [113].
Body language, tone of voice, empathy, and the ability to perform patient tasks/procedures competently are all critically important projections in regard to patient interactions. The question arises as to whether such important concepts can be taught and understood through simulation based medical education (SBME). The answer is “yes” in the case of most HCPs [116, 117, 118, 119, 120, 121, 122]. The next question then arises as to which is better, immersive or non-immersive simulation.
From definitional perspective, simulation generally refers to “noting or relating to digital technology or images that actually engage one’s senses and may create an altered mental state [123].” For the sake of this discussion, we will not include the interviewing of standardized patients or the use of manikins, but confine ourselves to digital technology. It must be acknowledged, though, that working directly with a patient is the true, most valuable, real world experience [124]. The rapidly changing world of SBME allows the opportunity to use digital technology in order to create an environment where much can be learned and experienced in order to minimize the chance for medical error or culturally inappropriate behaviors, to name only two of many possible use cases. More specifically, we will address the use of immersive technology that uses virtual reality (VR), a ‘360-degree experience’ vs. images on a desktop computer, while noting that VR is clearly preferred to using a desktop simulation. In a way of pre-simulation caution, instructors must be aware that immersive VR technology can result in disorientation, nausea, headaches, and difficulties with vision (i.e., cybersickness) [125].
Body language, tone of voice, taskings/procedures, and empathy can be taught using both methods. However, considerable evidence is emerging that immersive digital VR architecture works best [126, 127, 128, 129]. At the same time, it is evident that desktop non-immersive simulation can work better than regular lecture formats [130]. Tanvir et al. found that VR-based simulation of patients with disability allowed learners to perform better when compared to learners using a desktop model (e.g., non-immersive simulation) as reflected by information recall regarding the patient and the reduction in implicit bias [129]. Ventura, et al., performed a memory assessment of participants in an immersive vs. non-immersive environment to explore memory assessment and found the data supported the use of ‘360-degree’ technology in the evaluation of cognitive function [128]. Additionally, even behavioral counseling for primary care providers can be enhanced through the use of VR as a learning tool [127]. Everson, et al., believe that cultural empathy is an antecedent to cultural competence, and found that a 3D simulation experience impacted empathy in a positive manner among nursing students who dealt with a culturally and linguistically diverse population [126].
Any simulation, whether it is immersive, non-immersive, or real face-to-face meetings with actual humans, that puts a learner in the “patient’s shoes” warrants a dedicated educational effort [131, 132]. The exciting aspect of medical simulation, whether with standardized patients, manikins, immersive VR, or non-immersion desktop modeling, is that the instructor can mitigate the risks of anything ‘going wrong’ when learners are actively engaged in a real-world situation. Immersive VR, in particular, can be used in the pre-clinical arena to teach not only facts and procedures, but also reduce implicit bias thereby increasing empathy; cultural, physical, or otherwise. Finally, simulation may be a way to help providers maintain readiness, especially in the setting of patient volume fluctuations where procedures (e.g., cardiac catheterization) and protocols (e.g., trauma resuscitation) require ongoing provider competency [133, 134].
Literature provides significant insight into the workings of physician-patient interactions and PPR. In this chapter, key aspects of PPR and associated patterns of interaction were described. It is well established that tone of voice, body language, empathy, empowering patients to co-lead, encouraging patient wellness, and fostering physician wellness can all positively affect the PPR, resulting in improved patient satisfaction, adherence, and even clinical outcomes. While these aspects of HCP-patient interaction were explored and documented, there still remain opportunities to study other factors, such as patient education and engagement of caretakers and family members. To summarize, the authors of this chapter emphasize that LBP can be a versatile tool in building a sustainable, long-term, positive, and therapeutically effective PPR.
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