A total of six PGY4/5 students from the Adult and Paediatric Endocrinology and Metabolism program participated in the study. We identified four major subthemes as follows (representative quotes in Table 1):
1. The curriculum accurately reflected and addressed issues in real world medical practice Participants were asked to describe their perspective on empathy in residency and beyond, as well as to outline previous empathy training.
(a) Level of empathy
All participants identified a desire to practice in an empathic manner. A few felt empathy levels remained largely unchanged, while many were conscious of burnout. Some participants attributed this to progression through their training, weighing the satisfaction of increased independence with the stress of added responsibility, work hours, and competing priorities. One participant noted “There’s just so much added responsibility and it increases as you go along in your training, obviously there’s a lot in terms of work hours, and how busy you are, and different projects you’re working on… it goes without saying that quality of life definitely takes a hit, and burnout goes up”. Some residents noted that empathy levels fluctuated as their quality of life ebbed and flowed. They also acknowledged that residents are less time constrained than staff and anticipated a challenge in maintaining empathy and effective communication under the pressure of independent practice.
(b) Other humanities/communications training
Participants described several examples of previous empathy and communications training. These included interviews with standardized patients, traditional didactic lecture, and formal courses in their undergraduate medical training. Participants also noted that role models played a large role in helping them develop empathy and communication skills.
In summary, residents largely felt that their level of empathy declined during medical training and anticipated a further decline upon graduation. Most residents had received some formal empathy training prior, and also described the importance of role models in developing a communication style.
2. The comics curriculum facilitated holistic development
Participants were polled on the impact the comics curriculum had on their development as medical practitioners. This included their role as medical learners, medical teachers, and burgeoning physicians. They were asked to discuss the impact the curriculum had on them outside of their medical training.
(a) Demonstration of institutional commitment to wellness
Participants voiced an appreciation for the curriculum as medical learners. They saw the curriculum as an institutional commitment to humanism and appreciated the course as a safe environment for them to share and normalize difficult experiences. As one participant noted “having a forum for that and having a curriculum for that where it shows that the program actually cares about that as well is very important.”
(b) Provided techniques to practice patient-centered approach
Residents were mixed on the impact of the curriculum on their development as physicians. Some felt the curriculum had limited impact on their practice, or that it did not provide skills applicable outside of patients with diabetes. Some felt that while they did not learn any new techniques, they appreciated the course as a refresher of previous knowledge. Others felt the curriculum helped them better understand the perspective of patients with diabetes and highlighted the importance of physician-patient communication. Many felt the curriculum provided techniques to practice a patient-centered approach, especially in challenging situations. Participants also noted that seeing the patient’s perspective helped maintain their empathy when dealing with difficult clinical experiences.
(c) Fostered resilience
Participants felt that the group discussions normalized the experience of burnout and helped to build a sense of comradery and resilience amongst the participants.
(d) Provided tools to help students tackle challenging situations
One participant stated the course helped them as an educator. They felt it was a reminder of the student perspective, and that it helped them better see the impact of physician-patient interactions on observing medical learners. They also felt they gained techniques to teach students how to tackle challenging situations. They found that the focus on empathy and resilience also served as a reminder for them to check in on the wellbeing of junior learners.
Overall, participants found the curriculum to be impactful. As students, they found it to be a safe space for them to share difficult experiences. As growing physicians, participants appreciated the techniques provided by the course, and found it helpful in illustrating the patient perspective. One participant felt the course served as a reminder of the importance of remaining cognisant of learner well-being. Outside of medical education, participants appreciated the course as a way to normalize burnout and build relationships with their peers.
3. Participant appreciated the comics as an educational medium
Participants were asked for their feedback on the content of the comics, their effectiveness as an educational medium, and suggestions for improvement.
(a) Positive aspects of comics
Feedback on the comics was largely positive. Participants enjoyed the uniqueness of the medium and believed it made the material more engaging. They felt the comics clearly communicated broad themes of compassion and empathy in a way that facilitated further discussion. As residents in the Adult and Paediatric Endocrinology and Metabolism program, they felt that the scenarios in the comics were practical depictions of issues they might face.
(b) As an educational medium
Participants felt the comics were a unique and interactive way to present material. While they almost universally favoured comics over textbooks, they were ambivalent about the relative benefits of comics over mediums like movies or video clips, pointing out individuals have their own preferences. It was also noted that comics presented material in a brief but powerful way, as one participant noted “it’s a visual message as well, which is a lovely way of doing it…you can say a lot in a picture which could take a chapter of a textbook and get that message across really quickly. And I think that’s the real power of it”. Participants found the comics to be an effective way to teach foundational concepts, and to act as a springboard for further discussion.
(c) Refinement of material
Some participants appreciated the non-skills based focus of the course; however others suggested the comics could be improved by presenting more techniques and frameworks for communication skills. While there was some ambivalence regarding the complexity of the comics, it was suggested that incorporating more complex clinical scenarios could be beneficial for senior learners. As one participant noted “maybe they should just be refined to a more fellow level. To have more subtleties, like more things we might..see or hear on a day-to-day basis”. Some suggested topics included situations with more realistic barriers to communication and handling uncomfortable interactions.
In summary, participants largely appreciated the content of the comics. They also appreciated the comics as a unique and educational medium. Feedback on the comics was mixed, with some participants suggesting more complicated subject matter given their level of training, while others appreciating the greater focus on themes of empathy rather than clinical complexity.
4. Participant feedback on the curriculum
Participants were polled on the relative importance of each aspect of the curriculum. They were also asked their opinion on the relevance of the curriculum to their overall training. Finally, participants were asked to discuss the logistical implementation of the curriculum.
(a) Value of reflective exercises and discussion
Participants were divided on whether the reflective exercises or the group discussion were most beneficial. Most felt the group discussions were an appropriate environment to share experiences and seek advice. Participants largely felt that hearing and sharing experiences was important in promoting self-reflection on challenging situations. One participant felt the reflective exercises played a key role as an intersessional reminder of the topics from previous modules.
(b) Relevance of Curriculum
Participants were ambivalent on the educational relevance of the curriculum. Some felt that undergraduate medical education sufficiently covered communications training. Others appreciated the course as a reminder of fundamental principles of empathy. Participants described hearing patient complaints of poor physician interactions and noted that such physicians may have benefited from more formalized communications training. One participant appreciated the shift away from a skills-based approach, while others felt the course would be improved by providing more specific techniques to handle challenging scenarios. Participants appreciated the course as their only formalized opportunity for reflection and empathy training. Some felt the focus on diabetes to be overly specific to their program, while others believed the concepts were broadly applicable.
(c) Facilitator of curriculum integration
Hosting the session on an academic half-day was preferable as residents felt they could easily disengage from their clinical responsibilities. Participants largely felt the number of sessions were appropriate. They appreciated that the course was interactive and non-didactic, praising its “informal” style. One participant felt the workload outside of the course was appropriate, and that more work could become burdensome.
Overall, feedback on the curriculum was variable. Opinions were mixed on which specific components were most important, though almost all appreciated the opportunity to safely share negative experiences. Opinion on curriculum relevance was also mixed, with some believing they had sufficient exposure from previous training, and others appreciating the course as the sole opportunity for empathy education in their post-graduate education. Participants felt the course to be appropriate in terms of workload and time commitment.