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.

Association of Marginalized Identities With Alpha Omega Alpha Honor Society and Gold Humanism Honor Society Membership Among Medical Students Hill KA, Desai MM, Chaudhry SI, Nguyen M, McDade W, Xu Y, Li F, Fancher T, Hajduk AM, Westervelt MJ, Boatright D. JAMA Netw Open. 2022 Sep 1;5(9):e2229062. doi: 10.1001/jamanetworkopen.2022.29062. PMID: 36069984. Free full text
Alpha Omega Alpha (AOA) and The Gold Humanism Honor Society (GHHS) are exclusive medical student honor societies that confer benefits to members including increased likelihood to match into residency, mentorship and networking opportunities. (Disclosure: GHHS is a program of the Gold Foundation.) These benefits are particularly relevant for marginalized groups who, through the course of their medical education, frequently report being denied opportunities based on aspects of their identities. To determine whether AOA and GHHS membership is associated with (1) student race and ethnicity, (2) sex, (3) sexual orientation, (4) childhood family income, and (5) intersection of different identities, Katherine A. Hill and colleagues analyzed data from the Graduation Questionnaire filled out by students who graduated from Liaison Committee on Medical Education (LCME)-accredited US medical schools from 2016 to 2019. Among the 50,384 students, the researchers determined that there were significant membership disparities. Specifically, in AOA but not in GHHS, there was underrepresentation of racial and ethnic minoritized groups and a cumulative effect of marginalized identities that further lowered students’ likelihood of being an AOA member. In fact, students with no marginalized identity (White, male, heterosexual, non-low-income) were more than 4 times more likely to be AOA members than students with four marginalized identities (non-White, female, LGB [Lesbian, Gay, Bisexual], low-income). In both AOA and GHHS, Asian students and students from low-income backgrounds were underrepresented. In contrast, women and LGB students were overrepresented in GHHS but not AOA. The authors suggest that differences between the two honor societies may be in part due to selection processes: AOA tends to use academic rank as a cutoff for eligibility while GHHS uses student peer nomination. Regardless, the authors note that sources of bias are likely multifactorial and that both AOA and GHHS “may consider taking evidence-based steps to minimize bias by deliberative bodies.”

To learn more, read a Gold Foundation interview with lead author Katherine Hill and senior author Dr. Dowin Boatright.

Assessment of the Relationship Between an Adverse Impact of Work on Physicians’ Personal Relationships and Unsolicited Patient Complaints Trockel J, Bohman B, Wang H, Cooper W, Welle D, Shanafelt TD. Mayo Clin Proc. 2022 Sep;97(9):1680-1691. doi: 10.1016/j.mayocp.2022.03.005. PMID: 36058580. Free full text Dr. Tait Shanafelt has been a Gold Foundation grantee.
In recent years, there has been increasing awareness that physician well-being, particularly work-life integration, has an important effect on the quality of patient care. However, no study yet, according to the researchers, has looked at how the impact of work on personal relationships (IWPR), a specific dimension of work-life integration may be associated with patient care. Joshua Trockel and colleagues examined this through linking physician wellness survey results from 429 physicians with data from the Patient Advocacy Reporting System (PARS), an index of patient care quality based on unsolicited patient complaints. In 2013, the investigators distributed a survey consisting of the Professional Fulfillment Index (PFI), Patient-Reported Outcomes and Measurement Information System (PROMIS) and IWPR Scale to 2,384 physicians at Stanford University. Ultimately, 831 returned surveys (34.9%), and 429 of those doctors consented to link their responses to their respective PARS scores. The researchers then generated a multivariate model that adjusted for gender and specialty category. They found that for each 1-point increment in IWPR score (from 0-10, 10 being the worst, measuring how much their work has made it harder to sustain personal relationships), there was a 19% greater odds of being in the higher PARS tercile. Given that a higher PARS score is associated with a greater risk of adverse clinical outcomes and malpractice litigation the authors consider this to be a significant finding. They encourage organizations to undertake efforts to mitigate IWPR through improving efficiency in the practice environment, reducing after-hours electronic health records task burden, and optimizing inbox management. The authors are careful to note that the study cannot determine causality or potential direction of effect, and that this was conducted at a single-site in a large academic health system. Nevertheless, they conclude that “work conditions that require physicians to sacrifice personal relationships to meet professional demands could hinder physicians’ ability to provide optimal clinical care.”

Professional Coaching and Surgeon Well-Being. A Randomized Controlled Trial Dyrbye LN, Gill PR, Satele DV, West CP. Ann Surg. 2022 Aug 24. doi: 10.1097/SLA.0000000000005678. Epub ahead of print. PMID: 36000783. Drs. Liselotte Dyrbye and Colin West have been Gold Foundation grantees.
The prevalence of burnout among surgeons is estimated to be about 39-48%, depending on surgical specialty and practice setting. This high prevalence is worrisome, especially since burnout is associated with higher rates of medical error, malpractice litigation, lower professional satisfaction, turnover, suicidal ideation, and substance abuse. Professional coaching may be one part of the solution since professional coaching “allows individuals to identify opportunities, generate goals, and take action related to professional needs, such as influencing change, dealing with conflict, addressing detrimental aspects of work, improving career fit, and improving work-life integration.” At the Mayo Clinic, Dr. Liselotte N. Dyrbye and colleagues conducted a randomized controlled trial of 80 surgeons to evaluate the impact of 6 monthly professional coaching sessions on burnout, quality of life, and resilience. Participants were randomized to either an immediate coaching or control group (who also received coaching but only after 6 months). At baseline, 6 months, and 12 months, participating surgeons completed the Maslach Burnout Inventory, a one-item Quality of Life question, and the Connor-Davidson Resilience Scale. The researchers found that during the six-month intervention, burnout decreased (2.5% in the intervention compared to an increase in 2.5% in control group) and resilience increased in the intervention group compared to controls. However, six months after completion of the coaching period, burnout returned to near baseline levels while resilience continued to improve. Based on these results, the authors suggest that professional coaching may be a viable component of a strategy to reduce burnout.

The Association of Limited English Proficiency With Morbidity and Mortality After Trauma Castro MRH, Schwartz H, Hernandez S, Calthorpe L, Fernández A, Stein D, Mackersie RC, Menza R, Bongiovanni T. J Surg Res. 2022 Aug 25;280:326-332. doi: 10.1016/j.jss.2022.07.044. Epub ahead of print. PMID: 36030609. Dr. Alicia Fernandez is a Gold Professor.
Traumatic injury is a leading cause of death for adults in the United States, and following trauma, studies have shown disparities in multiple groups, including Black, Latinx, and uninsured patients. What has not been deeply studied is whether there is an association between limited English proficiency (LEP) and outcomes after trauma. To examine this, Maria R. H. Castro and colleagues conducted a retrospective cohort study at the Zuckerberg San Francisco General Hospital of adult trauma patients admitted from 2012 to 2018. The researchers compared morbidity and in-hospital mortality rates of 10,960 English-proficient patients to 2,144 LEP patients using univariate and multi-variable logistic and generalized linear models. They discovered that LEP patients had significantly longer hospital stays and shorter time in the intensive care unit, and were more often discharged to home with home health services or to skilled nursing facility/rehabilitation. The in-hospital mortality rate was 7% for patients who had limited English proficiency vs. 4% for English-proficient patients. While the authors caution that this single-center retrospective study may not necessarily be generalizable, further studies on the drivers of such disparities are necessary, as well as potential approaches to remediate them.

Effects of a Curriculum Addressing Racism on Pediatric Residents’ Racial Biases and Empathy Jindal M, Thornton RLJ, McRae A, Unaka N, Johnson TJ, Mistry KB. J Grad Med Educ. 2022 Aug;14(4):407-413. doi: 10.4300/JGME-D-21-01048.1. PMID: 35991090; PMCID: PMC9380619. Free full text
In recent years, there has been greater awareness of the role of interpersonal racism in exacerbating healthcare disparities. In response, numerous educational approaches have been proposed and studied. However, the role of empathy within the context of racism has not yet been investigated. Dr. Monique Jindal and colleagues evaluated how a longitudinal discussion-based curriculum addressing racism impacts pediatric residents’ racial biases and empathy. Components of the curriculum included 1-hour small group sessions, perspective-taking exercises, and reflective discussion revolving around (1) self-reflection on implicit bias, (2) historical trauma, and (3) structural racism. To measure changes in bias and empathy, the investigators used the Implicit Association Test and the Interpersonal Reactivity Index, respectively. Among the 65 pediatric resident physicians at Johns Hopkins University and Cincinnati Children’s Hospital who completed the post-survey (out of 111, 59%), they found statistically significant shifts in the IAT from baseline pro-white or pro-Black biases to “no preference.” At the same time, there was an unexpected modest decrease in mean empathy among all resident physicians, which the authors believe may not be clinically significant. This data empowers investigators to engage in further research, including studying longer-term impacts and engaging in qualitative methods to provide deeper context.

The relationship between empathy and the quality of the educational environment in Canadian emergency medicine residents Maniuk T, Cheung WJ, Fischer L, Nemnom MJ, Eagles D. CJEM. 2022 Aug;24(5):493-497. doi: 10.1007/s43678-022-00297-x. Epub 2022 Apr 29. PMID: 35486367; PMCID: PMC9051016. Free full text
Globally, as many as half of all medical trainees are experiencing burnout, leading to a number of profound negative impacts. Prior studies have shown that empathy and educational environment have an inverse relationship with burnout, but little is known about how educational environments affect empathy. Dr. Tetyana Maniuk and colleagues explored this among Canadian Emergency Medicine residents through a cross-sectional email survey. The investigators coupled the Toronto Empathy Questionnaire (TEQ) and Scan of Postgraduate Educational Environment Domains (SPEED) with demographic questions to identify any relationships between the perceived quality of educational environment and empathy. Among the responses of the 138 participants (out of 364 total, 38%), there was no statistically significant association between TEQ scores and mean SPEED score. Of note, a third of resident physicians had low levels of empathy which the authors noted was “a red flag for medical education leaders.”  The authors conclude that “further research is needed to elucidate modifiable factors contributing to the development of low empathy in emergency medicine residents.”

Identity and uncertainty: art-mediated medical student reflections in a time of transition. Robledo-Gil T, Ryznar E, Chisolm MS, Balhara KS. Med Educ Online. 2022 Dec;27(1):2120946. doi: 10.1080/10872981.2022.2120946. PMID: 36066076. Free full text Dr. Margaret Chisolm has been a Gold Foundation grantee.
Medical education is punctuated by many transitions that can be challenging, especially in the age of the COVID-19 pandemic. Reflection using arts-mediated approaches has been posited as one way to facilitate such transitions. To explore this, Dr. Talia Robledo-Gil and colleagues conducted a qualitative study of a virtual art gallery curated by medical students transitioning to their clerkship years. Among 213 students, 55 consented to having their responses included in this study. Through a constructivist approach, the investigative team identified three overlapping schemas of self-understanding: (1) the personal self, (2) the professional self, and (3) the social self. Subthemes included uncertainty and concerns focusing on medical training and knowledge, the sense of hope and value inherent to their social connections, critiques of the culture of medical education, and reflections on complicity and responsibility in racial injustice. Altogether, the authors note that “students often linked their hopes and concerns for their new clinical roles with the evolution of their own identities.”  While the authors caution that this was a single-site study over only two months and that responses may be biased due to self-selection, it nevertheless provides insights into how medical students reflect on transitions and empowers further research on how students operationalize identity.

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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.