Utilizing an Audience Response System to Teach Countertransference to Pediatric Residents

Resident psychiatrists have a unique trainee environment compared with residents in other medical training programs. In psychiatry training programs, the use of self-reflection to recognize and manage countertransference reactions is an expected aspect of the curriculum (1), while there are fewer opportunities for self-reflection in other medical specialties (2, 3). Countertransference can be defined as feelings, conscious or unconscious, about the patient that may be underrecognized by the physician or student; these feelings naturally occur in each of us and "do not signify that something is wrong with the doctor" (4). Recognizing when countertransference occurs and skillfully using this knowledge in one's clinical work is considered a key to clinical competence for psychiatrists (3), because countertransference helps us to diagnose and assess patients, guides our interventions and treatment, and helps us to learn more about ourselves as clinicians (5). It has also been hypothesized that physicians from other specialties could benefit from this knowledge (6), with evidence suggesting that it could help physicians better recognize errors, improve decision making, and resolve conflict (7).

To bridge the self-reflection gap between the psychiatric community and other medical communities, we developed a novel workshop to teach countertransference to pediatric residents. The model relied on an audience response system as a mechanism to encourage participation around an emotionally charged topic. An audience response system allows groups to vote on a topic or answer a question, with the option of making anonymized answers available to the audience in real time. We hypothesized that a nonpsychiatric training program would benefit from the anonymity and collaboration conferred by this system.

There is a small but increasing literature on the role of the audience response system in medical education. In one study, radiology residents who were taught with an audience response system demonstrated better comprehension of the material and better retention at a 3-month follow-up compared with residents who were taught with didactic lectures. Additionally, residents indicated a strong preference for teaching that integrated the system (8). Incorporating an audience response system into preparation for the Psychiatry Resident-In-Training Examination led to success both in terms of increasing scores and with regard to subjective reporting of enjoying this method of teaching compared with traditional methods (9). Overall, audience response systems have been shown to increase learner engagement and participation, although findings showing increased knowledge-retention are inconsistent (10).

Methods

We were invited to present on the topic of countertransference at a lunchtime conference for pediatric residents. On the basis of informal count and tabulated audience response system responses, approximately 20 individuals were in attendance. This included medical students, interns, residents, and one attending physician. In this study, we utilized Poll Everywhere, a web-based audience response system that allows for anonymous audience response via text message or the web, with real-time response aggregation.

We began the didactic with a task designed to demonstrate the functionality of the audience response system to the audience, to show that responses would be anonymous, and to emotionally prime the audience. This first task asked the audience to rate their present mood using a scale of different cartoon emoticon faces. The next task was free-response, asking the audience to describe their emotional response to two different pictures of a puppy (the first happy, the second sad). The responses generated are summarized in Table 1.

Next, we flashed an array of words and acronyms on the screen: "Chronic Lyme," "ARFID" (avoidant/restrictive food intake disorder), "PANDAS" (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections), "POTS" (postural orthostatic tachycardia syndrome), "SI" (suicidal ideation), and "Psych boarder," and we asked the audience to text the emotions that they generated. These phrases were chosen to provoke emotional reactions, because patients and families who hear these words often present unique challenges and require extra clinical time. As shown in Table 1, this generated significant negative emotions. At this time, participants were asked to verbally elaborate on their experiences working with "difficult" patients and families, and a group discussion ensued.

We then presented the case of a teenager with a history of chronic Lyme disease, formerly diagnosed as PANDAS, who presented with acute and chronic abdominal pain, nausea, vomiting, and poor oral intake. We asked the audience several questions via the audience response system regarding how they would feel about being involved in the care of this patient. As presented in Table 1, their responses were fairly homogenous, demonstrating frustration with the patient's multitude of vague and subjective symptoms, anger toward other clinicians, and even dread at the prospect of caring for the patient. We asked questions to elicit how challenging patient cases affect a resident's identity. The responses focused on negative self-talk and feelings of inadequacy and guilt (see Table 1). In addition, we asked questions to elicit ways in which difficult cases affect residents' lives outside of the hospital, when they return home from work. As shown in Table 1, responses varied: some residents reported good ability to compartmentalize between home and work, others used humor to cope, while others noted a direct negative impact on their home life.

In the next portion of the workshop, the audience was asked to rate their confidence in accurately defining countertransference and to respond to the question, "Can you define countertransference?" None of the participants responded "yes," eight reported "somewhat," and five reported "not at all." We then offered a broad definition of countertransference as the sum of their feelings toward a patient, discussed specific nuances about what this means, and reviewed the potential benefits of acknowledging and understanding residents' feelings about patients.

Lastly, we asked participants to consider the impact that an awareness of countertransference might have on their clinical care. Strategies to improve patient care, after acknowledging countertransference toward a patient, were brainstormed among participants as a group, with participants offering ideas that included practicing mindfulness prior to entering patients' rooms, debriefing with other team members when angry or upset, and sharing the burden of challenging conversations among various team members.

Results

To gauge the impact of this workshop, we devised a postworkshop anonymous questionnaire that assessed learner satisfaction and learning objectives. We obtained 17 completed surveys, and all course evaluation comments were positive and indicated improved awareness of and appreciation for the subject matter. Results of our postworkshop survey (see Table 2) indicated significantly improved confidence in defining countertransference. Additionally, participants reported an increase in their level of comfort working with challenging patients and families because of their participation in the workshop. In terms of the open-ended feedback (Table 2), all submitted comments were positive and commended various aspects of the curriculum. Four respondents specifically referenced the audience response system as being a positive addition to the experience. Others indicated that it was "good to know [that] other people feel the same [way they do]" and that the workshop "was great, especially for interns this time of year."

Discussion

Overall, the workshop feedback supported the idea that the psychiatric principle of countertransference was an undertaught and underutilized resource for trainees in nonpsychiatric specialties. The emotional depth of the responses, in addition to the praise received in the feedback, indicates that use of an audience response system deepened discussion of sensitive subject matters and helped to create the space for increased emotional vulnerability among participants. By providing an opportunity for participants to share negative countertransference reactions toward patients, our aim was to demonstrate that the normalization of these emotions and subsequent potential reduction of shame would reduce their propensity to unconsciously act on these thoughts by, for example, decreasing time spent with or avoiding particular patients or families, becoming outwardly angry or frustrated, allowing negative feelings to impair clinical judgment, or developing feelings of helplessness or incompetence, all of which further contribute to burnout. Learners also expressed gratitude for the skill-based nature of the workshop, validating the decision to include practical tips for what to do with countertransference reactions.

One limitation of this study was time constraint—with more time for discussion, responses may have been more varied or in depth. Another limitation was that participants comprised a small group of individuals who personally knew some of the presenters, which may have fostered comfort. On the other hand, some participants might have been less likely to be open about negative feelings with closer colleagues. Likewise, the small group format may have made participants feel intimidated and unwilling to engage fully. Furthermore, given the time of the presentation during the lunch hour, some audience members came and went freely over the course of the presentation, which may have been disruptive for some participants. Finally, the concept of being a pediatrician not wanting to help or feeling frustrated by a sick child introduces complicated and possibly conflicting emotions that may remain unconscious for some individuals.

The feedback that we received from participants in this workshop session indicated that this was a well-received exercise that most of the participants would recommend to others. We feel that most trainees across a wide spectrum of specialties would benefit from understanding and processing their countertransference. In addition, we believe that this was a successful application of an audience response system, and our findings suggest that such system should be used when teaching similar therapeutic principles in the future, such as enhancing learner self-compassion, destigmatizing burnout among practitioners, and sharing defensive reactions to feedback.

Key Points/Clinical Pearls