Jeffrey Silver Humanism in Healthcare Research Roundup – April 2021

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.

Validity evidence for a novel instrument assessing medical student attitudes toward instruction in implicit bias recognition and management Gonzalez CM, Grochowalski JH, Garba RJ, Bonner S, Marantz PR. BMC Med Educ. 2021 Apr 12;21(1):205. doi: 10.1186/s12909-021-02640-9. PMID: 33845830; PMCID: PMC8040240.        Free full text Dr. Cristina Gonzalez has been a Gold Foundation grantee.
Implicit bias, that is, “the unconscious, unintentional mental associations we make based on social identity groups,” continues to influence practitioner communication patterns and clinical decision-making, and contributes to health disparities as a whole. Recognizing implicit bias remains a challenge, especially in the context of medical education, where proper assessment of learner attitudes may inform curriculum development and optimize learner engagement. To address this need, Dr. Gonzalez and colleagues developed the Attitude Towards Implicit Bias Instrument (ATIBI). Using an interprofessional team of experts, they initially developed 27 items as part of this instrument. They then used results from seven cohorts of medical students (n=1072) to refine the instrument and determine the instrument’s internal consistency. They ultimately synthesized an 18-item instrument that had a high internal consistency (α=0.90). These results suggest that the ATIBI produces valid and reliable scores “to measure medical students’ attitudes toward acceptance of implicit bias, implicit bias instruction, and its relevance to clinical care.”

How are the arts and humanities used in medical education? Results of a scoping review Moniz T, Golafshani M, Gaspar CM, Adams NE, Haidet P, Sukhera J, Volpe RL, de Boer C, Lingard L. Acad Med. 2021 Apr 6. doi: 10.1097/ACM.0000000000004118. Epub ahead of print. PMID: 33830951. Drs. Tracy Moniz, Paul Haidet, Nancy E. Adams, Javeed Sukhera, Rebecca Volpe, and Lorelei Lingard have been Gold Foundation grantees.
Medical educators are increasingly recognizing the importance of arts and humanities in teaching about medicine, but how and why are they being used to educate physician and interprofessional learners across the continuum of medication education?  To answer this question, Dr. Moniz and colleagues conducted a scoping review of seven databases, identifying 21,985 citations. Through application of inclusion and exclusion criteria, they narrowed their analysis to 769 records. A majority describe either conceptual works that critically engage arts and humanities approach or call for their use(n=294), or describe programs with such an emphasis (n=255). The literary arts were the most common (n=197), and there tended to be a focus on undergraduate medical education (n=245). Major gaps were noted with regards to interprofessional education, program evaluation, and learner assessment. Similarly, the voices of those who contribute to the arts and other practitioners from outside medicine were lacking. These results suggest multiple opportunities to further incorporate arts and humanities into medical education. Namely, the authors cite three major areas for improvement: (1) building knowledge across subfields, (2) substantively engaging theory, and (3) including the voices of artist-practitioners alongside medical educators.

What is the state of compassion education? A systematic review of compassion training in health care Sinclair S, Kondejewski J, Jaggi P, Dennett L, L Roze des Ordons A, Hack TF. Acad Med. 2021 Apr 6. doi: 10.1097/ACM.0000000000004114. Epub ahead of print. PMID: 33830949.
Compassion, that is, “a virtuous and intentional response to know a person, to discern their needs and ameliorate their suffering through relational understanding and action,” is recognized as an essential feature of high-quality humanistic healthcare. Toward that end, there has been a growing focus on incorporating compassion training programs into medical education. But what is the current state and quality of these interventions?  Dr. Sinclair and colleagues conducted a systematic review, and then mapped the components of each intervention onto the Patient Compassion Model. Among the 103 interventions identified in 108 manuscripts, the majority of these mapped to the “virtuous response” domain of the Patient Compassion Model, and very few mapped to “relational communication,” “seeking to understand,” “attending to needs,” and “relational space” domains. The vast majority had a high or unclear risk of bias, since they included small numbers of learners, had no comparator/control groups, used only self-reported outcome measures, or had little to no long-term follow-up. Based on these results, the authors provide the following suggestions for educators seeking to develop compassion education interventions: (1) adopt a competency-based approach, (2) employ multimodal teaching methods that address the requisite attitudes, skills, behaviors, and knowledge within multiple domains of compassion; (3) evaluate learning over time; and (4) include patient, preceptor, and peer evaluations as outcome measures.

Effective goals-of-care conversations: From skills training to bedside Nagpal V, Philbin M, Yazdani M, Veerreddy P, Fish D, Reidy J. MedEdPORTAL. 2021 Mar 10;17:11122. doi: 10.15766/mep_2374-8265.11122. PMID: 33768153; PMCID: PMC7970639.        Free full text Dr. Jennifer Reidy has been a Gold Foundation grantee.
Goals-of-care (GOC) conversations are vital to understanding the perspectives of patients with chronic and severe illnesses. However, studies demonstrate that clinicians often feel unprepared to engage in GOC conversations. At the University of Massachusetts Memorial Hospital, Dr. Nagpal and colleagues developed a 3-hour simulation session during which teams of two learners interacted with standardized patients. A Mini-Clinical Evaluation Exercise (Mini-CEX) was performed to identify changes in outcomes. Among the 84 Internal Medicine residents, there were increases in self-perceptions regarding preparedness in conducting GOC conversations (from 42% to 90%). Mini-CEX scores also showed improvement in 70% of resident physicians in ensuring patients’ comfort, displaying empathy, and recognizing and responding to emotion. The authors intend to use this data to determine long-term retention of these skills and to identify better ways to measure the patients’ and families’ experiences of these conversations.

Gaming and anxiety in the nursing simulation lab: A pilot study of an escape room Reed JM, Ferdig RE. J Prof Nurs. 2021 Mar-Apr;37(2):298-305. doi: 10.1016/j.profnurs.2021.01.006. Epub 2021 Jan 20. PMID: 33867084.
Simulation is a key tool in nursing education and has been shown to increase the competency, teamwork, safety, and self-confidence. However, nursing students also describe significant anxiety that may impede the learning process. Therefore, nursing faculty are tasked with figuring out ways to reduce anxiety while maintaining fidelity to the simulation. Janet Reed and Dr. Richard Ferdig propose a novel approach: using an escape room. Escape rooms are “team-based games where live players perform actions such as finding clues, solving puzzles, and accomplishing tasks to escape from the room in a limited amount of time.”  Using a quasi-experimental design, they assessed the anxiety and enjoyment of 14 nursing students participating in an escape room, simulating a case of a patient with pneumonia, through the STAI (State Trait Anxiety Inventory) and the EGameFlow scale, respectively. They found that student anxiety levels decreased significantly by the end of the exercise; they also enjoyed the exercise, including the competition aspect. This pilot data is encouraging to educators who would like to implement escape rooms as teaching methods “to promote active learning and problem solving under time pressure, skills which are essential for 21st century nurses.”

Association of race/ethnicity with likeliness of COVID-19 vaccine uptake among health workers and the general population in the San Francisco Bay Area Grumbach K, Judson T, Desai M, Jain V, Lindan C, Doernberg SB, Holubar M. JAMA Intern Med. 2021 Mar 30:e211445. doi: 10.1001/jamainternmed.2021.1445. Epub ahead of print. PMID: 33783471; PMCID: PMC8010643.        Free full text Dr. Timothy Judson has been a Gold Foundation grantee.
During the ongoing COVID-19 pandemic, people from Black, Latinx, Asian, and Native American communities have been disproportionately affected. The advent of multiple safe and effective vaccines holds the potential of reducing the burden, but a long history of structural racism and distrust of the medical establishment may lead to suboptimal vaccination rates. In the San Francisco Bay Area, Dr. Kevin Grumbach and colleagues surveyed 1803 medical center employees and 3161 members of the general population to determine patterns in vaccine uptake. Interestingly, while healthcare professionals were more likely to take the vaccine, there remained disparities in vaccination intentions. According to the authors, “Asian individuals and multiracial individuals, and those of other races were more similar to Black and Latinx individuals than White individuals in their likeliness of vaccine uptake.” The authors highlight these results to demonstrate the importance of reaching out to historically marginalized populations, including in healthcare occupations.

Veterans’ reported comfort in disclosing sexual orientation and gender identity Ruben MA, Kauth MR, Meterko M, Norton AM, Matza AR, Shipherd JC. Med Care. 2021 Apr 1. doi: 10.1097/MLR.0000000000001543. Epub ahead of print. PMID: 33797509. Dr. Mollie A Ruben has been a Gold Foundation grantee.
Sexual and gender minority (SGM) populations comprise a diverse group that includes, but is not limited to, lesbian, gay, bisexual, asexual, transgender, Two-spirit, queer, and/or intersex individuals. SGM populations have less access to healthcare and are subject to greater healthcare disparities in large part due to social exclusion and concealment of identity. This is particularly so among veterans, where, until relatively recently, policies prohibited disclosure among active-duty personnel. But are current veterans comfortable disclosing their sexual and gender identity (SOGI)?  Dr. Mollie Ruben and colleagues surveyed 806 veterans with a confidential survey, which included questions on sexual orientation, gender identity, birth sex, race/ethnicity, as well as comfort with the ability to discuss with a Veterans Health Administration practitioner about these four identities. 7.15% endorsed a sexual or gender minority identity, which is higher than the 4.5% in the general population. Both cisgender and heterosexual veterans were more comfortable in disclosing their identities on the form and to their practitioners. The authors caution that, while routine SOGI data collection is encouraged, it is vital to reduce barriers for veteran disclosure of SOGI by keeping such data secure, up-to-date, and inclusive of options for self-report. This information provides the basis for further research, including identification of best practices so that the Veterans Health Administration can be more responsive to SGM veterans.

Psychological and occupational impact of the COVID-19 pandemic on UK surgeons: a qualitative investigation Al-Ghunaim TA, Johnson J, Biyani CS, O’Connor D. BMJ Open. 2021 Apr 1;11(4):e045699. doi: 10.1136/bmjopen-2020-045699. PMID: 33795311; PMCID: PMC8024056.        Free full text
The ongoing COVID-19 global pandemic has dramatically upended life for entire populations, including healthcare practitioners such as surgeons, for whom COVID-19 infection represents an additional occupational risk. But how exactly have surgeons been affected by COVID-19?  Between May and July 2020, Dr. Tmam Abdulaziz Al-Ghunaim and colleagues interviewed 141 British surgeons with two open-ended questions: (1) “What challenges are the COVID-19 crisis currently presenting to you in your work and home life?” and (2) “How is this stress affecting you personally?” They then used thematic analysis to identify four themes: (1) changing and challenging work environment as a result of COVID-19, (2) challenges to professional life and development, (3) management of change and loss in the respondents’ personal lives, and (4) emotional and psychological impacts. 85.8% reported that they were generally negatively affected, and, among these, 7.8% were affected in a strongly negative manner. These insights highlight important target areas for workplace support and mental health interventions, as we continue to endure the COVID-19 pandemic.

Nursing’s leaky pipeline: Barriers to a diverse nursing workforce Bennett MP, Lovan S, Smith M, Elllis-Griffith C. J Prof Nurs. 2021 Mar-Apr;37(2):441-450. doi: 10.1016/j.profnurs.2020.05.002. Epub 2020 May 11. PMID: 33867103.
Maintaining and increasing the diversity of the nursing workforce is a major priority, but recruiting and retaining individuals from underrepresented minorities remains a major challenge. Dr. Mary P. Bennett and colleagues examined the effects of student losses over time on nursing program diversity. They examined how 2,498 pre-nursing majors at Western Kentucky University School of Nursing from 2012 to 2016 tracked over seven key checkpoints. They identified that 57% of students were lost by the end of their second year, before application to nursing school. In fact, losses were highest during the Anatomy and Physiology course during freshman level, a key requirement for enrollment in nursing school. This disproportionately affected minority students (70%), those requiring remedial coursework (65%), and first-generation students (62%). On the contrary, those with a prior degree, older students, and those who started in another major were more likely to continue. This information is important because it can empower supportive interventions for nursing students early in their educational careers to potentially improve diversity in the applicant pool and in future nurses.

Voices from the front lines: An analysis of physicians’ reflective narratives about flaws with the ‘system’ Moniz T, Pack R, Lingard L, Watling C. J Med Humanit. 2021 Apr 6:1–16. doi: 10.1007/s10912-021-09690-6. Epub ahead of print. PMID: 33822310; PMCID: PMC8021932.       Free full text Drs. Tracy Moniz, Lorelei Lingard, and Christopher J. Watling have been Gold Foundation grantees.
Physicians’ written narratives are important sources of data to understand self-expression of experiences and concerns. So what do physicians think about flaws in the system?  Through content and narrative analysis, Dr. Tracy Moniz and colleagues explored 87 articles within four major medical journals that dealt primarily with systems flaws and physicians’ orientation to the flawed system. They found seven recurring system flaws, five of which centered on medical culture: (1) failures of communication, (2) erosive impact of the hidden curriculum, (3) inadequate health advocacy, (4) frenzied pace of work, (5) experience of stigma, (6) limited and disparate healthcare resources, and (7) restrictive institutional practices as impeding patient-centered care. In response to these challenges, physicians voice tension between elements outside of their control and those within their agency of control. Since narratives tended to focus on system flaws within medical culture, the authors note that this study “points to the culture of medicine (and specific aspects of culture) as creating a situation of tension for 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.