Training Methods for Delivering Difficult News in Genetic Counseling and Genetics Residency Training Programs

Genetic counselors and clinical geneticists are often in the position of delivering difficult news (DDN) to patients and families. Many studies show that healthcare providers require major improvement in the skills needed in DDN in a manner that is satisfactory to their patients. The purpose of this study was to assess the amount and methodology of DDN training received by genetic counselors and medical genetics residents in their training programs, such as observations of DDN or attending didactic lectures. To our knowledge, there is no previous assessment or study of DDN training in genetic counselor and medical genetics residency programs; therefore, we aim to both assess and compare the training in DDN received by genetic counselors and by genetics residents and determine whether there is a desire for recommendations on DDN training. We invited genetic counseling (GC) and genetics residency program directors to participate in an online survey designed to assess coursework, clinical experiences, and directors’ attitudes toward teaching DDN. Response rate was 85% (28/33) for GC program directors and 26% (14/53) for genetics residency program directors. One hundred percent of GC and genetics residency directors who responded to the survey agreed that it is important for genetic counselors and medical geneticists to be able to deliver difficult news effectively and that training programs should formally teach students how to deliver difficult news. Six of the eight common teaching methods are used by at least 75% of GC programs while two of eight are used by at least 75% of genetics residency programs. Seventy-nine percent of GC and 93% of genetics residency program directors agree that there should be recommendations on how to teach students to deliver this news. Our results show that techniques for DDN are integrated more fully into GC program curricula than genetics residency curricula. Directors of both types of programs desire recommendations and more standardized education for training students to deliver difficult news.     

Understanding Continuity to Recognize Discontinuity

In this paper the author comments on the contribution by António P. Ribeiro and Miguel M. Gonçalves (in this journal) that offer a creative and unique perspective on maintenance and transformation of problematic self-narrative. From here the author contributes to the topic through the exploration of some issues: a) the relation, in the dialogical process of self-narrative construction, between semiotic processes that give voice to the semantic opposition and semiotic processes that give voice to the contradictory; b) the relation between sameness and ipseity in the self-narrative process; c) the role of a pathemic axis of meaning in the generation process of self-narratives. A final reflection is done on narrative as a device of clinical intervention in which the author makes a distinction between methods based on the recognition and extension of variability and methods based on the recognition of permanency so to get to variability.     

Pre-arrest diversion of people with mental illness: Literature review and international survey

Mental health diversion is a process where alternatives to criminal sanctions are made available to persons with mental illness (PMI) who have come into contact with the law. One form of mental health diversion is pre-arrest, in which the police use their discretion in laying charges. Concomitant with the growth of pre-arrest diversion programs is a growing body of research devoted to the phenomenon. The purpose of this paper is to review the existing literature of pre-arrest diversion, and to report the results of an international survey of pre-arrest diversion programs we conducted to identify evidence-based practices. On the basis of our review and survey, we note that successful pre-trial programs appear to integrate relevant mental health, substance abuse and criminal justice agencies by having regular meetings between key personnel from the various agencies. Often, a liaison person with a mandate to effect strong leadership plays a key role in the coordination of various agencies. Streamlining services through the creation of an emergency drop-off center with a no-refusal policy for police cases is seen as crucial. While there is some indication that mentally ill offenders benefit from their participation in this form of diversion, the evaluative literature has not yet achieved the "critical mass" necessary to create generalizable, evidence-based knowledge. The absence of generally agreed-upon outcomes could lead to the inequitable application of basic principles of diversion. We suggest that indicators, benchmarks, and outcomes must be agreed upon if a comprehensive understanding of pre-arrest programs is to emerge.     

On the limits of infants' quantification of small object arrays

Recent work suggests that infants rely on mechanisms of object-based attention and short-term memory to represent small numbers of objects. Such work shows that infants discriminate arrays containing 1, 2, or 3 objects, but fail with arrays greater than 3 [Feigenson, L., & Carey, S. (2003). Tracking individuals via object-files: Evidence from infants' manual search. Developmental Science, 6, 568-584; Feigenson, L., Carey, S., & Hauser, M. (2002). The representations underlying infants' choice of more: Object files versus analog magnitudes. Psychological Science, 13(2), 150-156]. However, little is known about how infants represent arrays exceeding the 3-item limit of parallel representation. We explored possible formats by which infants might represent a 4-object array. Experiment 1 used a manual search paradigm to show that infants successfully discriminated between arrays of 1 vs. 2, 2 vs. 3, and 1 vs. 3 objects. However, infants failed to discriminate 1 vs. 4 despite the highly discriminable ratio, providing the strongest evidence to date for object-file representations underlying performance in this task. Experiment 2 replicated this dramatic failure to discriminate 1 from 4 in a second paradigm, a cracker choice task. We then showed that infants in the choice task succeeded at choosing the larger quantity with 0 vs. 4 crackers and with 1 small vs. 4 large crackers. These results suggest that while infants failed to represent 4 as “exactly 4”, “approximately 4”, “3”, or as even as “a plurality”, they did represent information about the array, including the existence of a cracker or cracker-material and the size of the individual objects in the array.     

Never getting to zero: Elementary school students' understanding of the infinite divisibility of number and matter

Clinical interviews administered to third- to sixth-graders explored children's conceptualizations of rational number and of certain extensive physical quantities. We found within child consistency in reasoning about diverse aspects of rational number. Children's spontaneous acknowledgement of the existence of numbers between 0 and 1 was strongly related to their induction that numbers are infinitely divisible in the sense that they can be repeatedly divided without ever getting to zero. Their conceptualizing number as infinitely divisible was strongly related to their having a model of fraction notation based on division and to their successful judgment of the relative magnitudes of fractions and decimals. In addition, their understanding number as infinitely divisible was strongly related to their understanding physical quantities as infinitely divisible. These results support a conceptual change account of knowledge acquisition, involving two-way mappings between the domains of number and physical quantity.     

Looking forward to looking backward: the misprediction of regret

Decisions are powerfully affected by anticipated regret, and people anticipate feeling more regret when they lose by a narrow margin than when they lose by a wide margin. But research suggests that people are remarkably good at avoiding self-blame, and hence they may be better at avoiding regret than they realize. Four studies measured people's anticipations and experiences of regret and self-blame. In Study 1, students overestimated how much more regret they would feel when they "nearly won" than when they "clearly lost" a contest. In Studies 2, 3a, and 3b, subway riders overestimated how much more regret and self-blame they would feel if they "nearly caught" their trains than if they "clearly missed" their trains. These results suggest that people are less susceptible to regret than they imagine, and that decision makers who pay to avoid future regrets may be buying emotional insurance that they do not actually need.     

Spatial coupling affects both homologous and non-homologous limbs

The present study examined the interaction between limb movements in space. The amount of interaction was measured by how much moving one limb affected the movement of another limb. Participants were 24 right-handed university students (19 female, mean age=19 years). The task was to draw lines with the right hand while moving another limb in lines or circles of different sizes. Significant coupling effects were found between both homologous and non-homologous limbs. Movement of the right hand was most strongly affected by the left hand, less by the right foot, and least by the left foot, consistent with the functional cerebral distance model. This effect of limb was observed only in the major dimension along which movement was not restrained. Both the limb and dimension effects were reduced when the trajectory of motion decreased in size.     

Sense of coherence, negative life events and appraisal of physical health among university students

We examined the stress-buffering effects of the ‘sense of coherence' among 116 undergraduates (70 females and 46 males) with a mean age of 18.6 years. Self-reported physical well-being and psychological distress were assessed on two occasions separated by two months. Assessment of the sense of coherence occurred at time-one, whereas assessment of negative life-events for the past year occurred at time-two. Sense of coherence correlated negatively with negative life events and reported psychological symptoms of both occasions, and negative life events correlated positively with both assessments of psychological distress. Negative life events correlated positively with physical ailments reported for both occasions only among students low in sense of coherence; this significant correlation persisted after accounting for the relationship between psychological and physical symptoms. We discuss the possible salubrious effects of a sense of coherence on the health appraisals of young adults experiencing stress.