Jeffrey Silver Humanism in Healthcare Research Roundup – April 2020

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-Affiliated Authors<

  “I wish they had asked”: a qualitative study of emotional distress and peer support during internship  Moore KA, O’Brien BC, Thomas LR. J Gen Intern Med. 2020 Mar 30. doi: 10.1007/s11606-020-05803-4. Dr. Colleen O’Brien is a CHA-Gold Innovation Fellow.
Internship, that is, the first year of residency, can be a challenging time for new physicians who are coping with new responsibilities, duties, and identities. If not properly supported, this can lead to emotional distress, deterioration of well-being, and burnout. To understand the contributors to emotional distress, Kendra Moore and colleagues conducted a qualitative study of 11 second-year internal medicine residents at the University of California San Francisco. Analysis of the transcripts from semi-structured interviews demonstrated five themes: (1) distress was a pervasive experience, (2) participants grappled with identity reconciliation, (3) clinical competency reinforced self-efficacy, (4) resident support was ad hoc, and (5) intern experiences shaped supervisory style. Through these insights, they were able to synthesize a model to illustrate how near-peers can make an impact in reducing intern distress. The authors seek to use this model to create a formalized peer support skill-building curriculum for senior residents.  

The views and experiences of clinicians sharing medical record notes with patients DesRoches CM, Leveille S, Bell SK, Dong ZJ, Elmore JG, Fernandez L, Harcourt K, Fitzgerald P, Payne TH, Stametz R, Delbanco T, Walker J. JAMA Netw Open. 2020 Mar 2;3(3):e201753. Free full text  Dr. Sigall Bell is a Gold Professor and a Mapping the Landscape grantee. 
Over the past decade, the idea of “open notes” that both practitioners and patients can see has become mainstream. But how do clinicians view this development?  Catherine DesRoches and colleagues examined this through a large web-based survey sent to 6,064 clinicians affiliated with three large healthcare systems across multiple specialties. 1,628 (27%) responded between May and August 2018. Nearly 3 out of 4 clinicians agreed that open notes were a good idea, and about 3 out of 5 would recommend the practice to colleagues. At the same time, approximately 1 out of 3 reported spending more time on documentation, including avoiding language that may be perceived as critical to the patient. Overall, the authors conclude that open notes “may help clinicians, patients, and families improve care by moving toward more open communication and partnership.”  

Mindful opportunity to reflect on experience: interdisciplinary mind-body medicine skills training for health-care professionals Barnhill JL, Gerkin JS, Moura VL, Weil AB. Glob Adv Health Med. 2020 Feb 14;9:2164956120907876.  Free full text Dr. Amy Weil has served on the Gold Humanism Honor Society Advisory Council. 
Multiple lines of evidence suggest that mindfulness can improve the well-being of health practitioners, and, in so doing, may help improve patient care, staff engagement and reduce burnout. But can mindfulness be taught and learned?  Jessica Barnhill and colleagues investigated this by implementing an abbreviated version of the mind-body medicine skills training program at the University of North Carolina. They compared scores of the Freiburg Mindfulness Inventory (FMI) survey and Perceived Stress Scale (PSS) before and after the training for 13 participants. They found a statistically significant increase in mindfulness and decrease in stress. The response to the course was positive, and participants stated that they would utilize their learned skills in the future. While the authors caution that the small size, lack of randomization, and short time frame limit the generalizability of results, this study opens avenues for further research.  

From stigma to validation: A qualitative assessment of a novel national program to improve retention of physician-scientists with caregiving responsibilities Jones RD, Miller J, Vitous CA, Krenz C, Brady KT, Brown AJ, Daumit GL, Drake AF, Fraser VJ, Hartmann KE, Hochman JS, Girdler S, Kalet AL, Libby AM, Mangurian C, Regensteiner JG, Yonkers K, Jagsi R. J Womens Health (Larchmt). 2020 Apr 15Dr. Adina Kalet is a Mapping the Landscape grantee and a Gold Professor.
Physician-scientists represent a unique subset of practitioners who unite scientific inquiry with clinical knowledge. Their roles are essential in providing healthcare and advancing scientific progress. Yet the numbers of physician-scientists are decreasing, in part due to gender imbalances, disillusionment over salary caps, and lack of interest by medical students. To remedy this, the Doris Duke’s Charitable Foundation established the Fund to Retain Clinician Scientists (FRCS) and conducted a prospective program evaluation to understand the challenges of clinician scientists. They interviewed 28 FRCS program participants and used thematic analysis to identify overarching themes, one of which (time as a limited and valuable resource) was examined in an earlier paper. Two themes related to the responsibilities of caregiving were examined in this paper: (1) a culture of stigma and (2) a culture of validation. (93% of those interviewed had childcare needs.) Participants shared that FRCS and similar programs help validate them as both scientists and caregivers. These insights may help to craft approaches to shift from stigma around family responsibilities toward validation of work-life integration.  

Clinical teachers’ perceptions of their role in professional identity formation Sternszus R, Boudreau JD, Cruess RL, Cruess SR, Macdonald ME, Steinert Y. Acad Med. 2020 Mar 31. Dr. Richard Cruess is the Chairman of the Board of Gold Foundation for Humanistic Healthcare, Canada. Drs. J. Donald Boudreau and Yvonne Steinert are Mapping the Landscape grantees. Professional identity formation is “a developmental process whereby the characteristics, values, and norms of the profession are internalized as medical students and residents learn to think, act, and feel like physicians.”  Clinical teachers are essential in this process, but little research has been undertaken to understand their perceptions. To analyze this, Robert Rternszus and colleagues conducted 16 semistructured interviews and developed coding schemes to synthesize four main findings: (1) clinical teachers need prompting to be able to describe professional identity formation, (2) a physician’s professional identity is integrated with a personal identity, (3) a physician’s professional identity is forged through caring for patients, and (4) clinical teachers believe they influence learners’ professional identity formation but they cannot discern the magnitude of their influence. These results support prior findings around medical students and residents and show that clinical teachers have important influences through role modeling, providing graded autonomy, and engaging learners in challenging conversations. This study indicates that to support learners best in their professional identity formation, clinical teachers need to space and encouragement to explicitly reflect on their own identities and formation.  

Fostering empathy, implicit bias mitigation, and compassionate behavior in a medical humanities course Schwartz BD, Horst A, Fisher JA, Michels N, Van Winkle LJ. Int J Environ Res Public Health. 2020 Mar 25;17(7). Drs. Brian D. Schwartz and Nicole Michels are Mapping the Landscape grantees.  Free full text
In the United States, many physicians start off as pre-medical students in college. These pre-med students undergo various experiences to inform the humanism that they eventually demonstrate as physicians. To foster compassion among these students, Rocky Vista University developed a Medical Humanities course characterized by team service-learning projects. Brian Schwartz and colleagues then sought to determine if this course would foster compassion through a mixed-methods approach combining qualitative and quantitative techniques. Thirty-two patients enrolled and completed the Reflective Practice Questionnaire and the Jefferson Scale of Empathy before and after the course. They found that there was a statistically significant increase in their scores. Additionally, written minutes and reflections after each meeting were examined for evidence of self-examination and dissonance. They identified that virtually all participants had dissonance leading to self-examination. These results suggest that a Medical Humanities course with team service-learning projects may be helpful in fostering empathy among pre-medical students.  

Other Publications

The mediating role of psychological capital on the relation between distress and empathy of medical residents: a cross-sectional survey Jin J, Li H, Song W, Jiang N, Zhao W, Wen D. Med Educ Online. 2020 Dec;25(1):1710326.  Free full text
Psychological capital (PsyCap) is “the positive psychological state of a person in the process of growth and development, which goes beyond human capital and social capital, and is a psychological resource to promote personal growth and performance improvement.” Those with higher PsyCap tend to have better work performance, job satisfaction, and well-being. So what is the PsyCap of resident physicians?  Jing Jinn ad colleagues surveyed 620 first-year residents in China using the Jefferson Scale of Physician Empathy and the Psychological Capital Questionnaire. Among the 537 who completed the survey, they found a negative association between measured levels of empathy and distress, but that this negative association was less when accounting for the effect of PsyCap. They conclude that PsyCap may be a mediating variable and that higher PsyCap may be protective for first-year residents.  

Coaching in undergraduate medical education: a national survey Wolff M, Hammoud M, Santen S, Deiorio N, Fix M. Med Educ Online. 2020 Dec;25(1):1699765.   Free full text
Coaching is an important aspect of professional identity formation in several high-performance fields, but how does coaching impact undergraduate medical education?  Margaret Wolff and colleagues examined this through a survey developed by the American Medical Association (AMA) of 32 medical schools in the United States. They identified that the majority of schools either currently had coaching programs (53%) or were in the process of developing one (44%). The majority of these programs appeared to be relatively recent, and provided some compensation to coaches for their time and effort. The main foci of these coaching programs appeared to be professional identity formation (80%) and professionalism (76%).  However, the vast majority of coaches (84%) did not formally assess students in any domain or directly observe students clinically (76%). Based on these results, the authors to conclude that while coaching is becoming more popular in undergraduate medical education, there remain important questions about how best to further develop and encourage coaching programs.  

Building ‘a compassionate armour’: The journey to develop strength and self-compassion in a group treatment for complex post-traumatic stress disorder Ashfield E, Chan C, Lee D. Psychol Psychother. 2020 Apr 19.
Post-Traumatic Stress Disorder (PTSD) is a condition in which there is “heightened psychological distress following exposure to a threatening or catastrophic event.”  One modality of treatment is group therapy. But how does group therapy lead to changes in experiencing PTSD?  Emily Ashfield and colleagues investigated this through a qualitative study of 11 individuals. Using semi-structured interviews and a constructivist grounded theory, they developed an explanatory theoretical model. Specifically, they identified three essential aspects of the group that brought about change: (1) the group itself, where relationships were formed, (2) understanding themselves and difficulties, and (3) experiencing their emotions and compassion from others. These mechanisms help to explain how group therapy may aid those with PTSD and bring about personal changes.  

Novel peer-facilitated method to decrease burnout and enhance professional development: the READ-SG prospective cohort study Abrams M, Cromer S, Faye A, Cogan J, Brown T, Chong D, Granieri E. Postgrad Med J. 2020 Mar 5. pii: postgradmedj-2019-137361. doi: 10.1136/postgradmedj-2019-137361.
Burnout remains a challenging problem, and group sessions have been suggested as a way to combat it.  However, group sessions for resident physicians have not yet shown efficacy in decreasing burnout.  Mark Abrams and colleagues hypothesized that peer-led groups may be more effective. They used the READ-SG (Reflect, Empathize, Analyze, and Discuss in Small Groups) method to develop peer-facilitated groups. 137 postgraduate trainees at NewYork Presbyterian Hospital/Columbia University Irving Medical Center were enrolled and encouraged to attend monthly READing group sessions (10 in total). Participants took the Maslach-Burnout Inventory-Human Services Survey (MBI-HSS) and a self-developed survey, the READ-SGSS, before and after the 1-year study period.  The study found that more session attendance correlated with improved burnout scores and that the sessions improved symptoms of burnout.  While results are preliminary, because the READ-SG method is easy to learn and implement, it suggests that peer-led groups may indeed help to combat burnout among resident physicians.

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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.