Jeffrey Silver Humanism in Healthcare Research Roundup – April 2019

The Jeffrey Silver Humanism in Healthcare Research Roundup features summaries of recently published studies on humanism in healthcare. To receive email notification of new studies once per month, enter your information here and select “Jeffrey Silver Research Roundup” from the checkboxes at the bottom. See previous posts in this series.

Publications from Gold Foundation-Affiliated Authors

 “I cannot take this any more!”: Preparing interns to identify and help a struggling colleague.     Zabar S, Hanley K, Horlick M, Cocks P, Altshuler L, Watsula-Morley A, Berman R, Hochberg M, Phillips D, Kalet A, Gillespie C. J Gen Intern Med. 2019 Apr 16.
Dr. Adina Kalet is a Mapping the Landscape grantee.
Residency can be a grueling experience for young physicians, especially the first year (intern year). Studies show that the incidence of depression and thoughts of death increase significantly during the first three months. To help address this issue and empower learners to assist struggling colleagues, Dr. Zabar and colleagues created an Objective Structured Clinical Exam (OSCE) scenario within the internal medicine, orthopedic surgery, and surgery residency programs at New York University Langone Medical Center. In this OSCE, they used a standardized health professional (SHP) as a stand-in for a colleague who was in a distressed state, and observed how the 145 first-year resident physicians reacted. Although two out of three residents checked in on their colleague’s emotional state, fewer than a third screened for depression using a two-question screen and fewer than 1 in 20 asked about additional symptoms of depression. Only a third screened for suicidal ideation. Not surprisingly, those who screened for depression were twice as likely to direct their colleague for help. Altogether, Zabar and colleagues provide a new tool to help interns assess a struggling colleague and bring the issue of mental health among interns to the forefront.

A qualitative study of New York medical student views on implicit bias instruction: implications for curriculum development.     Gonzalez CM, Deno ML, Kintzer E, Marantz PR, Lypson ML, McKee MD. J Gen Intern Med. 2019 Apr 16.
Dr. Cristina Gonzalez is a Mapping the Landscape grantee.
In recent years, there has been an increased awareness of how implicit bias, that is, the unconscious attribution of particular qualities to a certain social group, impacts the quality of care of patients. But because these biases are so deeply embedded, it is often difficult to teach medical students about these implicit biases and how to deal with them. This is the objective of a qualitative study by Dr. Gonzalez and colleagues at Albert Einstein College of Medicine. They asked 11 focus groups, composed of a total of 56 medical students, a set of open-ended questions about their implicit biases and used the race Implicit Association Test (IAT) as a tool to generate discussion. They found four themes: (1) resistance to the presence of bias within themselves, (2) shame and hesitation to divulge implicit biases, (3) the negative role of the “hidden curriculum” (e.g. faculty role-modeling biased behavior), and (4) structural barriers to student engagement, such as the lack of diversity and formal facilitator training. These insights can help educators build better curricula that more directly address these concerns and overcome these challenges.

Differences in narrative language in evaluations of medical students by gender and under-represented minority status.     Rojek AE, Khanna R, Yim JWL, Gardner R, Lisker S, Hauer KE, Lucey C, Sarkar U. J Gen Intern Med. 2019 Apr 16.
Dr. Catherine Lucey is a Mapping the Landscape grantee.
Throughout clerkships, the wording of medical student evaluations and assessments is extremely important, not only because these comments guide trainee growth and development but also because language from assessments often go into the Medical Student Performance Evaluation (Dean’s Letter) and letters of recommendation. At the University of California San Francisco, Ms. Rojek and colleagues looked at nearly 90,000 evaluations from two schools (totaling 14 years between them) and self-identified ethnicity and gender. Through a sophisticated algorithm, they identified the frequencies of words and categorized them according to their descriptions of personal attributes or competencies.  What they found was that “common, important words were used with similar frequency across gender and underrepresented minority status.” While cautiously optimistic, the authors note that there were differences in the frequency of specific words that may signal biases. They conclude by suggesting that it may be time to rethink narrative clerkship evaluations to emphasize competency-based evaluations and reduce bias in evaluations.

Why do women leave surgical training? A qualitative and feminist studyFree full text  Liang R, Dornan T, Nestel D. Lancet. 2019 Feb 9;393(10171):541-549.
Dr. Tim Dornan is a Mapping the Landscape grantee.
Despite immense strides, women remain under-represented in surgical fields. In fact, in the UK and Australasia, only 1 out of 9 surgeons is a woman. The reasons for this are unclear, but dropout from training programs is a major concern. Dr. Liang and colleagues explore this from a qualitative perspective, trying to understand what factors lead to women leaving surgical training. Further, they use feminist and participatory research methods in order to better capture the voices of women who have left the field. In total, they interviewed 12 women from Australia and New Zealand. This method enabled the investigators to identify six new factors: unavailability of leave, distinction between valid and invalid reasons for leave, poor mental health, absence of interactions with social supports, fear of repercussion, and lack of pathways for independent and specific support. This is in addition to previously identified obstacles, such as long working hours, insufficient role models, discrimination and harassment. While the study’s size limits the generalizability of results, the findings help build a base from which to address this pressing problem.

Pre-medical majors in the humanities and social sciences: impact on communication skills and specialty choice.     Hirshfield LE, Yudkowsky R, Park YS. Med Educ.2019 Apr;53(4):408-416.
Dr. Laura Hirshfield is a Mapping the Landscape grantee.
Communication and interpersonal skills (CIS) are important characteristics of physician performance. These, in turn, are guided by physician background and experiences that come into play long before the first day of medical school. Two-time MTL grantee Dr. Hirschfield and her colleagues examine how pre-medical backgrounds in the humanities and social sciences are associated with CIS, as well as licensure examination results and postgraduate specialty choice. To do this, they looked at the med school applications, graduation competency examination CIS scores, standardized scores, and postgraduate training placement data of 465 medical students from the classes of 2014-2016 at the University of Illinois at Chicago. They found that CIS scores were higher in humanities and social sciences majors compared to their science major peers. Additionally, to the surprise of the investigators, CIS performance did not significantly predict the likelihood of picking primary care over subspecialty training. Overall, the authors suggest that humanities and social science majors may be better communicators, and that admissions committees should consider selecting cohorts of students who have more diverse pre-medical backgrounds.

The timing of family meetings in the medical intensive care unit.  Piscitello GM, Parham WM 3rd, Huber MT, Siegler M, Parker WF. Am J Hosp Palliat Care. 2019 Apr 14.
Dr. Mark Siegler served on the Gold Foundation Research Institute Advisory Board.
As any patient or healthcare professional who has been through the Medical Intensive Care Unit (MICU) can attest, family meetings are an important aspect of caring for the critically ill. Such meetings help to improve communication, reduce family distress, and align the values of patient’s family with those of the healthcare team. Yet family meetings are often underutilized. To understand this phenomenon, Dr. Piscitello and colleagues looked at the timing of family meetings for 131 patients in the MICU at the University of Chicago. In 46% of cases, there was a family meeting within 72 hours of MICU admission. While this may sound like good news, the timing of these meetings coincided with a 30-fold greater risk of patient death within the subsequent 72 hours. In the remainder of patients, family meetings tended to be held more inconsistently and beyond day 5. This troubling pattern suggests that family meetings are often used to negotiate withdrawal of life support rather than to learn about values. The authors conclude that there are ample opportunities to improve communication skills training for clinicians in the ICU to help maximize the role of family meetings.

Other Publications

 The crossroads of posttraumatic stress disorder and physician burnout: a national review of United States trauma and nontrauma surgeons.     Jackson TN, Morgan JP, Jackson DL, Cook TR, McLean K, Agrawal V, Taubman KE, Truitt MS. Am Surg. 2019 Feb 1;85(2):127-135.
Burnout is a major and widespread problem that affects a wide spectrum of people working in healthcare. Surgeons, in particular, appear to be at a higher risk for burnout. The reasons are unclear, but it may be partly linked to the risk of PTSD (Post-Traumatic Stress Disorder).  After all, PTSD, a stress-based syndrome defined as “the pathologic state of persistently re-experiencing a traumatic event causing distress and functional impairment,” is about three times higher in trauma physicians and surgical residents than in the general population. Dr. Jackson and colleagues took a closer look at this, by distributing a survey on burnout and PTSD to nearly 7,000 physicians. About 350 responded (15%). Although PTSD and burnout were high in both trauma and nontrauma physicians, overwhelming work responsibilities, bad outcomes/malpractice, and work-life discord were the three most common contributing stressors. Interestingly, care for the critically injured and bullying by colleagues were the least common stressors. While the cross-sectional nature of this one-time survey limits broader conclusions, the findings suggest that wellness among surgeons needs to be addressed in a manner that aligns with their stressors and concerns.

Healthcare provider compassion is associated with lower PTSD symptoms among patients with life-threatening medical emergencies: a prospective cohort study.     Moss J, Roberts MB, Shea L, Jones CW, Kilgannon H, Edmondson DE, Trzeciak S, Roberts BW. Intensive Care Med. 2019 Mar 25.
For those touched by critical illness, symptoms of post-traumatic stress disorder (PTSD) are fairly common. In fact, one in four intensive care unit (ICU) survivors suffer from PTSD symptoms, such as re-experiencing distressful symptoms, effortful avoidance of reminders, and physiologic hyperarousal.  It has been speculated that compassionate care by providers may help to reduce the risk of subsequent PTSD symptoms. To explore this possible relationship, Ms. Moss and colleagues looked at 113 critically ill patients one month after an ED visit and used validated measures of provider compassion (Consultation and Relational Empathy [CARE]) and PTSD (checklist of 20 symptoms) to find a possible association. What they found was that about a quarter had PTSD symptoms and that patients who perceived greater provider compassion were more likely to have lower PTSD symptoms. The investigators caution that this correlation does not imply a direct cause-and-effect relationship, but it does further emphasize that compassionate care for patients may be associated with some very tangible health benefits.

Assessment of inpatient time allocation among first-year internal medicine residents using time-motion observations    Free full text Chaiyachati K, Shea JA, Asch DA, Liu M, Bellini LM, Dine CJ, Sternberg AL, Gitelman Y, Yeager AM, Asch JM, Desai SV.  JAMA Intern Med. 2019 Apr 15.
Resident physicians play an important role in delivering care to hospitalized patients, as they learn how to become independent physicians. However, there is incomplete information about how exactly they deliver care. To better quantify what they do, Dr. Chaiyachati and colleagues recorded over 2,173 hours of activity performed by 80 internal medicine interns (first-year residents) from 6 mid-Atlantic training programs. They found that 43% of time was spent on the electronic medical record, while only 13% was spent in direct patient care and 7% on education. Even there, about a quarter of all direct patient care and educational activities were spent in multitasking with indirect patient care tasks. Compared to the 1990s, there is a decline in direct patient care from 25% to 13%, but, given the changes in healthcare delivery, the authors caution that it is unclear whether this change is necessarily good or bad. Regardless, this provides a new baseline against which to measure future efforts to improve workday structures and experiences of internal medicine trainees.

Bharat Kumar, MD

Humanism in Research Assistant Editor

Updates the staff, databases, and social media about new studies around humanism in healthcare; curates and compiles the monthly Jeffrey Silver Humanism in Healthcare Research Roundup.