Jeffrey Silver Humanism in Healthcare Research Roundup – April 2022

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.


Emotional harm in the radiology department: analysis of an underrecognized preventable error Siewert B, Swedeen S, Brook OR, Eisenberg RL, Sokol-Hessner L, Kruskal JB. Radiology. 2022 Mar;302(3):613-619. doi: 10.1148/radiol.2021211846. Epub 2021 Nov 23. PMID: 34812668 Dr. Lauge Sokol-Hessner has been a Gold Foundation grantee.
Emotional harm constitutes about 70% of preventable harm in primary care settings and has a tremendous impact, comparable to physical injury. At Beth Israel Deaconess Medical Center, Dr. Bettina Siewert and colleagues examined adverse events between December 2014 and December 2020 to identify radiology-related submissions related to emotional harm. Among the 3032 submissions, 37 were related to 43 “dignity and respect” incidents. These included incidents involving a failure to be patient centered (23), disrespectful communication (16), privacy violations (2), minimizations of patient concerns (1) and loss of property (1). 41 of these were due to a failure to be patient-centered and disrespectful communication. Root cause analysis identified that in 22 incidents (52%), emotional harm stemmed from a lack of listening to a preference in care voiced by the patient. The investigators estimate that 34 (79%) of incidents can be potentially prevented by “individual feedback, staff communication training focusing on active listening, asking the patient’s preference, and closed-loop communication.”  Even so, these statistics may have underestimated emotional harm, since poor communication, a vital contributor to potential emotional harm, was reported in a different category and constituted an additional 7% of complaints. Regardless, the investigators highlight the importance of healthcare team members to engage in perspective-taking in order to support respectful and dignified patient-centered care.

Clinicians’ perceptions of the health status of formerly detained immigrants Hampton K, Mishori R, Griffin M, Hillier C, Pirrotta E, Wang NE. BMC Public Health. 2022 Mar 23;22(1):575. doi: 10.1186/s12889-022-12967-7. PMID: 35321680; PMCID: PMC8941369. Free full text Dr. Ranit Mishori has been a Gold Foundation grantee.
The United States immigration detention system has detained more than 30,000 people per day over the past decade. These centers are characterized by overcrowding, poor hygiene and sanitation, and poor and delayed medical care. To better understand the adverse health impacts of immigration detention centers, Dr. Kathryn Hampton and colleagues surveyed healthcare team members identified through snowball sampling, ultimately receiving 150 responses. 85 clinicians reported observing, in total, an estimated 1,300 patients with medical issues attributed to detention. Thematic analysis of free-text responses showed four major themes: (1) lack of access to medications, (2) abuse and mental health conditions, (3) inability to access healthcare after release from detention, and (4) lack of clinician knowledge of practices regarding reporting to government authorities. While the survey is not a nationally representative sample, it helps to highlight health issues of those who have been recently released from immigration detention centers, particularly mental health issues stemming from the trauma of detention and neglect. The authors conclude by noting that this information can “help inform policy discussions specifically surrounding systematic changes to the delivery of healthcare in detention, quality assurance and transparent reporting.”

What do rheumatology patients want in an after-visit summary? A Kano analysis of patient preferences Kumar B, Zahn C, Seeman L, Levins L, Davis B, Swee M. J Clin Rheumatol. 2022 Jan 21. doi: 10.1097/RHU.0000000000001817. Epub ahead of print. PMID: 35067509. Dr. Bharat Kumar has been a Gold Foundation grantee.
After-visit summaries (AVS) are patient-specific documents created by clinicians for patients to communicate important healthcare-related information at the end of a clinical encounter. They have become more commonplace due to incentives from the Affordable Care Act in 2009. But what do patients really want in their AVS? Dr. Bharat Kumar and colleagues evaluated the preferences of patients at a large Midwestern Veterans Affairs rheumatology clinic to develop a clinic-specific AVS template. First, the quality improvement team interviewed patients and clinical staff to identify potentially important features for inclusion. Then a Kano-style questionnaire was drafted, soliciting patient preferences regarding each of the 15 potential features. For each item, two questions were asked: one for how inclusion would drive satisfaction, and one for how exclusion would drive dissatisfaction. After distribution to 50 patients, results were analyzed to determine which features to prioritize. Ultimately, 9 features were identified that drive satisfaction: a photo of the clinician’s face, color text and images, large font-size, contact information, single-page length, prescribed medications, follow-up information, and directions to lab/x-rays. After creation of the AVS and implementation in clinic, post-intervention surveys assessing AVS content, visual appeal, and readability showed high levels of satisfaction (4.3, 4.6, and 4.4 out of 5). The authors conclude that the Kano analysis is a feasible way to solicit patient preferences and that shorter, clearer presentations of information in AVS may drive higher satisfaction.

Primary care physician gender and electronic health record workload Rittenberg E, Liebman JB, Rexrode KM. J Gen Intern Med. 2022 Jan 6. doi: 10.1007/s11606-021-07298-z. Epub ahead of print. PMID: 34993875.
Primary care physicians spend more time in the electronic health record (EHR) than in face-to-face encounters. Worse still, data suggests that female physicians spend more time in the EHR than male physicians, and that this may be contributing to higher levels of burnout among female physicians. To identify potential causes for these differences, Dr. Eva Rittenberg and colleagues examined gender differences in EHR usage among primary care physicians at Brigham and Women’s Hospital. Specifically, they looked at time spent in patient charts for messages, orders, clinical review, and notes, and matched these based on administrative data, including gender, panel size, clinical workload, and panel gender composition. They discovered that female PCPs receive more messages from patients and staff members than male physicians, suggesting different expectations in communication styles based on gender. However, with orders and clinical review, there were no significant gender differences, highlighting that female physicians are not “slower at doing the equivalent work as their male colleagues.”  These results point to practical solutions to reducing gender differences, such as increasing compensation, developing support systems, and promoting team-based care. The investigators also outline future directions for research, including correlating patterns of EHR inbasket use with physician burnout and identifying the impact of interventions to decrease EHR inbasket message volume.

Normalising disclosure or reinforcing heroism? An exploratory critical discourse analysis of mental health stigma in medical education Sukhera J, Poleksic J, Zaheer J, Pack R. Med Educ. 2022 Mar 5. doi: 10.1111/medu.14790. Epub ahead of print. PMID: 35246993. Dr. Javeed Sukhera has been a Gold Foundation grantee.
Despite better recognition of the need to support learner well-being, significant barriers continue to exist, including stigma. Using Foucauldian Critical Discourse Analysis (CDA), Dr. Javeed Sukhera and colleagues first examined tweets and news articles to examine the nature of discourses on mental health stigma at the public level. They then complemented the textual analysis by recruiting semi-structured interviews with 12 medical students, residents, and faculty. Stigma was constructed as being rooted within the structural power of the medical education system and society at large. Two conflicting dominant discourses were identified: (1) disclosure and normalization of help seeking can reduce stigma, and (2) attempts to reduce stigma through disclosure would be challenging within a culture that rewards perfection and lauds heroism. Because these are in tension with one another, it suggests that any initiatives designed to improve learner or faculty well-being must examine if the approach perpetuates or dismantles stigma. Heroic disclosures by themselves are unlikely to resolve stigma. Rather, because stigma is deeply rooted in the medical education system, solutions likely require transformative structural changes.

Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2020 Shanafelt TD, West CP, Sinsky C, Trockel M, Tutty M, Wang H, Carlasare LE, Dyrbye LN. Mayo Clin Proc. 2022 Mar;97(3):491-506. doi: 10.1016/j.mayocp.2021.11.021. PMID: 35246286. Drs. Tait Shanafelt, Colin P West, and Lotte N Dyrbye have been Gold Foundation grantees.
Satisfaction with Work Life Integration (WLI) is an important aspect of well-being and may help to prevent or address burnout. In order to understand trends in WLI, Dr. Tait Shanafelt and colleagues examined data from a series of longitudinal surveys regarding well-being conducted in 2011, 2014, 2017, and 2020. There were approximately 7,510 responders in 2020, which demographically correlated with the population of physicians in the United States as a whole. Burnout, emotional exhaustion, depersonalization, and WLI scores improved in 2020 compared to 2011, 2014, and 2017. The authors caution that the study was not designed to provide explanations for this trend, although possible reasons include pandemic-related changes in delivery of care (such as virtual care, relaxation of documentation and regulatory requirements, better team-based care), greater emphasis on well-being by organizations, and systems-based organizational interventions to improve well-being. Additionally, physicians still have a 40% higher risk for burnout and are 30% less likely to be satisfied with WLI, compared to others in the workforce. The authors conclude that more work is needed to address the elevated rates of burnout in physicians, as well as its effects on patient care.

The impact of the work environment on the health-related quality of life of Licensed Practical Nurses: a cross-sectional survey in four work environments Phillips LA, de Los Santos N, Ntanda H, Jackson J. Health Qual Life Outcomes. 2022 Mar 19;20(1):44. doi: 10.1186/s12955-022-01951-9. PMID: 35305650; PMCID: PMC8934126. Free full text
Nursing can be a challenging profession that can impact physical and mental health. In fact, studies show higher rates of injury among nurses than workers in agriculture, mining or construction. Yet little is known about the health-related quality of life (HRQOL) of nurses and how the work environment impacts HRQOL. Dr. Leah Adeline Phillips and colleagues sought to answer these questions by conducting a cross-sectional survey of 15,860 Licensed Practical Nurses (LPNs) in Alberta, Canada. They used the SF-36, a previously validated instrument to assess HRQOL, along with questions regarding perceptions of work environment and resilience. Among the 4,425 LPNs who responded, nurses had lower scores than Canadians of the same age group (35-44). LPNs who reported higher-quality workplaces were likely to have higher HRQOL, suggesting that work environment can impact nurse health outcomes. Based on these results, the authors suggest that systems-level interventions to support high-quality work environments, such as having adequate access to staffing and equipment, encouraging team collaborations, and ensuring participatory decision-making by nursing staff, may have a role in improving the self-reported health of nurses.

College complaints against resident physicians in Canada: a retrospective analysis of Canadian Medical Protective Association data from 2013 to 2017 Crosbie C, McDougall A, Pangli H, Abu-Laban RB, Calder LA. CMAJ Open. 2022 Jan 18;10(1):E35-E42. doi: 10.9778/cmajo.20210026. PMID: 35042693; PMCID: PMC8920540. Free full text
Understanding and learning from patient complaints is an important priority for physician regulatory bodies (or colleges, in the Canadian system) because analysis can help to guide interventions to support patient safety and professionalism. Dr. Charlotte Crosbie and colleagues conducted a retrospective analysis of regulatory college complaints between 2008 and 2017 using records from the Canadian Medical Protective Association. They identified 142 cases involving 145 patients through that 10-year period. Descriptive analysis of cases from 2013 to 2017 demonstrated that the top contributor to complaints was deficient patient assessment (69/142, or 48.6%). Most cases involved clinical problems (65%), relationship problems (58.3%), or professionalism issues (41.1%). The vast majority (97.9%) did not result in severe physician sanctions. While the yearly rate of complaints increased from 5.4 to 7.9 per 1,000 between 2008 and 2017, the rate of increase was still slower than that of non-resident physicians. From these data, the authors recommend targeted interventions to increase awareness of the importance of communication, documentation, and professionalism within residency programs.

Physicians, emotion, and the clinical encounter: A survey of physicians’ experiences Schwartz R, Osterberg LG, Hall JA. Patient Educ Couns. 2022 Mar 5:S0738-3991(22)00094-5. doi: 10.1016/j.pec.2022.03.001. Epub ahead of print. PMID: 35287992. Dr. Judith Hall has been a Gold Foundation grantee.
Rationality has historically been prioritized over emotion within the culture of medicine, despite the fact that emotions, both positive and negative, are inextricable parts of clinical encounters. To understand the challenges that physicians encounter in managing emotions, Dr. Rachel Schwartz and colleagues designed a survey consisting of 16 multiple-choice questions and 6 free-text prompts and sent it to 103 physicians in internal medicine (27%), neurology (25%), emergency medicine (23%) and family medicine (24%). Results showed that fewer than 10% received emotion management training. Those who had received such training had greater comfort in dealing with patient emotions and were more likely to engage in teaching on emotion. Qualitative analysis revealed three central themes regarding challenges: (1) need for strategies in response to emotionally aroused patients, (2) need for management strategies when medical judgment clashes with patient desires, and (3) need for skills for navigating system barriers. Five themes were identified for successfully managing emotions: (1) acknowledging, honoring, and naming the emotion present, (2) self-identification/relating to the patient, (3) using nonverbal approaches, such as holding hands, (4) engaging in pragmatic problem-solving for the patient, (5) acknowledging system barriers and shared frustrations. Participants responded with interest in further research on emotion management, and these responses were classified into five themes: (1) physician wellness, (2) emotion management skills, (3) communication training, (4) forum for sharing strategies needed, and (5) system issues. While the authors acknowledge that these results may not be generalizable, these results suggest that greater emotional management training is necessary.

Time-specific differences in stated preferences for health in the United States Law EH, Pickard AS, Walton SM, Xie F, Lee TA, Schwartz A. Med Care. 2022 Mar 22. doi: 10.1097/MLR.0000000000001714. Epub ahead of print. PMID: 35315380. Dr. Alan Schwartz has been a Gold Foundation grantee.
To optimize allocation of limited resources within healthcare systems, decision makers often rely upon economic assessments of health consequences. Valuation studies, such as EQ-5D-3L, are periodically undertaken to understand preferences for health, and results of these studies go into the determination of quality-adjusted life years (QALY), which is roughly a common currency. However, these preferences change over time, which may in turn, mean changes in the determination of QALY’s. To determine how health preferences have changed from 2002 to 2017, Dr. Ernest H. Law and colleagues conducted a rigorous set of quantitative analyses of data from U.S. EQ-5D-3L studies. Overall, they found that individuals in 2017 were generally less willing to trade quantity of life for quality of life, compared to those from 2002. Additionally, the authors note that demographic changes, which were controlled for the purposes of this study, may mean that there are even more changes in health preferences.

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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.