‘ <i>Involve me and I learn</i>’: an experiential teaching approach to improve dyspnea awareness in medical residents

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ABSTRACT

Background

Dyspnea is a frightening and debilitating experience. It attracts less attention than pain (‘dyspnea invisibility’), possibly because of its non-universal nature. We tested the impact of self-induced experimental dyspnea on medical residents.

Materials and Methods

During a teaching session following the principles of experiential learning, emergency medicine residents were taught about dyspnea theoretically, observed experimental dyspnea in their teacher, and personally experienced self-induced dyspnea. The corresponding psychophysiological reactions were described. Immediate and 1-year evaluations were conducted to assess course satisfaction (overall 0–20 grade) and the effect on the understanding of what dyspnea represents for patients.

Results

Overall, 55 emergency medicine residents participated in the study (26 men, median age 26 years). They were moderately satisfied with previous dyspnea teaching (6 [5–7] on a 0–10 numerical rating scale [NRS]) and expressed a desire for an improvement in the teaching (8 [7–9]). Immediately after the course they reported improved understanding of patients’ experience (7 [6–8]), which persisted at 1 year (8 [7–9], 28 respondents). Overall course grade was 17/20 [15–18], and there were significant correlations with experimental dyspnea ratings (intensity: r = 0.318 [0.001–0.576], p = 0.043; unpleasantness: r = 0.492 [0.208–0.699], p = 0.001). In multivariate analysis, the only factor independently associated with the overall course grade was ‘experiential understanding’ (the experimental dyspnea-related improvement in the understanding of dyspneic patients’ experience). A separate similar experiment conducted in 50 respiratory medicine residents yielded identical results.

Conclusions

This study suggests that, in advanced medical residents, the personal discovery of dyspnea can have a positive impact on the understanding of what dyspnea represents for patients. This could help fight dyspnea invisibility.

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Most cited references 34

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An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea.

Mark B Parshall, Richard Schwartzstein, Lewis Adams … (2012)

Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been enormous growth in knowledge about the neurophysiology of dyspnea and increasing interest in dyspnea as a patient-reported outcome. The purpose of this document is to update the 1999 ATS Consensus Statement on dyspnea. An interdisciplinary committee of experts representing ATS assemblies on Nursing, Clinical Problems, Sleep and Respiratory Neurobiology, Pulmonary Rehabilitation, and Behavioral Science determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant expertise. The final content of this statement was agreed upon by all members. Progress has been made in clarifying mechanisms underlying several qualitatively and mechanistically distinct breathing sensations. Brain imaging studies have consistently shown dyspnea stimuli to be correlated with activation of cortico-limbic areas involved with interoception and nociception. Endogenous and exogenous opioids may modulate perception of dyspnea. Instruments for measuring dyspnea are often poorly characterized; a framework is proposed for more consistent identification of measurement domains. Progress in treatment of dyspnea has not matched progress in elucidating underlying mechanisms. There is a critical need for interdisciplinary translational research to connect dyspnea mechanisms with clinical treatment and to validate dyspnea measures as patient-reported outcomes for clinical trials.

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Is a specialist breathlessness service more effective and cost-effective for patients with advanced cancer and their carers than standard care? Findings of a mixed-method randomised controlled trial

Morag Farquhar, A. Prevost, Paul McCrone … (2014)

Background Breathlessness is common in advanced cancer. The Breathlessness Intervention Service (BIS) is a multi-disciplinary complex intervention theoretically underpinned by a palliative care approach, utilising evidence-based non-pharmacological and pharmacological interventions to support patients with advanced disease. We sought to establish whether BIS was more effective, and cost-effective, for patients with advanced cancer and their carers than standard care. Methods A single-centre Phase III fast-track single-blind mixed-method randomised controlled trial (RCT) of BIS versus standard care was conducted. Participants were randomised to one of two groups (randomly permuted blocks). A total of 67 patients referred to BIS were randomised (intervention arm n = 35; control arm n = 32 received BIS after a two-week wait); 54 completed to the key outcome measurement. The primary outcome measure was a 0 to 10 numerical rating scale for patient distress due to breathlessness at two-weeks. Secondary outcomes were evaluated using the Chronic Respiratory Questionnaire, Hospital Anxiety and Depression Scale, Client Services Receipt Inventory, EQ-5D and topic-guided interviews. Results BIS reduced patient distress due to breathlessness (primary outcome: −1.29; 95% CI −2.57 to −0.005; P = 0.049) significantly more than the control group; 94% of respondents reported a positive impact (51/53). BIS reduced fear and worry, and increased confidence in managing breathlessness. Patients and carers consistently identified specific and repeatable aspects of the BIS model and interventions that helped. How interventions were delivered was important. BIS legitimised breathlessness and increased knowledge whilst making patients and carers feel ‘not alone’. BIS had a 66% likelihood of better outcomes in terms of reduced distress due to breathlessness at lower health/social care costs than standard care (81% with informal care costs included). Conclusions BIS appears to be more effective and cost-effective in advanced cancer than standard care. Trial registration RCT registration at ClinicalTrials.gov NCT00678405 (May 2008) and Current Controlled Trials ISRCTN04119516 (December 2008). Electronic supplementary material The online version of this article (doi:10.1186/s12916-014-0194-2) contains supplementary material, which is available to authorized users.

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The affective dimension of laboratory dyspnea: air hunger is more unpleasant than work/effort.

Robert Banzett, Richard Schwartzstein, Robert Lansing … (2008)

It is hypothesized that the affective dimension of dyspnea (unpleasantness, emotional response) is not strictly dependent on the intensity of dyspnea. We tested the hypothesis that the ratio of immediate unpleasantness (A(1)) to sensory intensity (SI) varies depending on the type of dyspnea. Twelve healthy subjects experienced three stimuli: stimulus 1: maximal eucapnic voluntary hyperpnea against inspiratory resistance, requiring 15 times the work of resting breathing; stimulus 2: Pet(CO(2)) 6.1 mm Hg above resting with ventilation restricted to less than spontaneous breathing; stimulus 3: Pet(CO(2)) 7.7 mm Hg above resting with ventilation further restricted. After each trial, subjects rated SI, A(1), and qualities of dyspnea on the Multidimensional Dyspnea Profile (MDP), a comprehensive instrument tested here for the first time. Stimulus 1 was always limited by subjects failing to meet a higher ventilation target; none signaled severe discomfort. This evoked work and effort sensations, with relatively low unpleasantness (mean A(1)/SI = 0.64). Stimulus 2, titrated to produce dyspnea ratings similar to those subjects gave during stimulus 1, evoked air hunger and produced significantly greater unpleasantness (mean A(1)/SI = 0.95). Stimulus 3, increased until air hunger was intolerable, evoked the highest intensity and unpleasantness ratings and high unpleasantness ratio (mean A(1)/SI = 1.09). When asked which they would prefer to repeat, all subjects chose stimulus 1. (1) Maximal respiratory work is less unpleasant than moderately intense air hunger in this brief test; (2) unpleasantness of dyspnea can vary independently from perceived intensity, consistent with the prevailing model of pain; (3) separate dimensions of dyspnea can be measured with the MDP.

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Author and article information

Journal

Journal ID (nlm-ta): Med Educ Online

Journal ID (iso-abbrev): Med Educ Online

Title: Medical Education Online

Publisher: Taylor & Francis

ISSN (Electronic): 1087-2981

Publication date (Electronic, pub): 11 October 2022

Publication date (Electronic, collection): 2022

Publication date PMC-release: 11 October 2022

Volume: 27

Issue: 1

Electronic Location Identifier: 2133588

Affiliations

[a ]Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique; , Paris, France

[b ]AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive, Réanimation, Département R3S; , Paris, France

[c ]AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Unité Mobile de Soins Palliatifs; , Paris, France

[d ]AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Laboratoire de parasitologie-mycologie; , Paris, France

[e ]AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département R3S; , Paris, France

[f ]AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service d’accueil des urgences; , Paris, France

[g ]Sorbonne Université, INSERM, UMRS 1166, IHU ICAN; , Paris, France

[h ]AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Tenon, Service de médecine interne; , Paris, France

[i ]Sorbonne Université, INSERM, UMRS 1142 LIMICS; , Paris, France

[j ]AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Pneumologie, Département R3S; , Paris, France

Author notes

CONTACT Thomas Similowski thomas.similowski@ 123456upmc.fr Département R3S, Hôpital Pitié-Salpêtrière; , 47-83 boulevard de l’Hôpital, Paris 75013 France

[*]

Maxens Decavèle and Laure Serresse are co-first authors

[#]

Capucine Morélot-Panzini and Thomas Similowski are co-last authors

Article

Publisher ID: 2133588

DOI: 10.1080/10872981.2022.2133588

PMC ID: 9559048

PubMed ID: 36218180

SO-VID: 781e2b5b-75e5-415f-84b9-d23ac8d941ac

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

‘ Involve me and I learn’: an experiential teaching approach to improve dyspnea awareness in medical residents

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ABSTRACT

Background

Materials and Methods

Results

Conclusions

Related collections

Teaching and learning evolution

Most cited references 34

An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea.

Is a specialist breathlessness service more effective and cost-effective for patients with advanced cancer and their carers than standard care? Findings of a mixed-method randomised controlled trial

The affective dimension of laboratory dyspnea: air hunger is more unpleasant than work/effort.

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