Jeffrey Silver Humanism in Healthcare Research Roundup – August 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-Affiliated Authors

Parenthood during graduate medical education: a scoping review Stack SW, Eurich KE, Kaplan EA, Ball AL, Mookherjee S, Best JA.  Acad Med. 2019 Aug 13.
This study was funded in part by the Gold Foundation. Drs. Shobha Stack, Andrea Ball, Somnath Mookherjee, and Jennifer Best are Mapping the Landscape grantees.
In recent years, there has been an increased interest in understanding the relationship between parenthood and graduate medical education training. After all, the average age of entering medical students is 24 and the average age of a physician mother at her first birth is 30. Dr. Shobha Stack and colleagues performed a scoping review, examining 2,341 articles and ultimately including 90 studies in their aim of understanding how parenthood impacts graduate medical education training. From these articles, they were able to construct a framework based on six themes: (1) policy, (2) program preparation, (3) relationships, (4) others’ perceptions, (5) maternal health, and (5) well-being. However, their review points out that there remain several unanswered questions, especially how resident-parents should be supported after re-entering training and how resident parenthood affects patient care. The authors call upon researchers to conduct scholarly work on this often-overlooked topic and suggest national associations and specialty societies/boards together develop and implement “accessible, clear, and detailed parental policies” that include non-traditional families.

 Effect of a professional coaching intervention on the well-being and distress of physicians: a pilot randomized clinical trial Dyrbye LN, Shanafelt TD, Gill PR, Satele DV, West CP.  JAMA Intern Med. 2019 Aug 5.
Drs. Lotte Dyrbye, Tait Shanafelt, and Colin West are Mapping the Landscape grantees.
Burnout is a serious problem among physicians, affecting quality and safety, patient-physician relationships, productivity, and turnover. One approach to reduce burnout is professional coaching, which has already been broadly associated with improved retention, job satisfaction, and communication skills, among other contributors to well-being. To better examine the effectiveness of this approach on physicians, Dr. Lotte Dyrbye and colleagues conducted a randomized clinical trial at four Mayo Clinic sites. They recruited 88 physicians, who underwent baseline testing via the Maslach Burnout Inventory, Physician Job Satisfaction Scale, Utrecht Work Engagement Scale, and Empowerment at Work Scale. Forty-four were then were enrolled in a 6-month professional coaching program. Among the 41 who received coaching and completed follow-up surveys, there were decreases in emotional exhaustion and overall burnout and increases in quality of life and resiliency scores. The authors caution that this is only a pilot trial that did not study long-term durability and generalizability to other settings. However, their findings suggest that this intervention may be a complementary strategy to improving system-level drivers of work-related stressors.

The patient experience debrief interview: how conversations with hospitalized families influence medical student learning and reflection. Chua IS, Bogetz AL, Bhansali P, Long M, Holbreich R, Kind T, Ottolini M, Park YS, Lineberry M, Hirshfield LE.  Acad Med. 2019 Jul 30.
Dr. Laura Hirshfield is a Mapping the Landscape grantee.
Medical students learn from a variety of sources, including professors, textbooks and journal articles, but the most lasting influences may be from patients and their families. Indeed, reflective practice focusing on how healthcare practitioners impact patient and caregiver emotional experiences and well-being may foster professional growth and combat empathic decline, burnout, and acculturation. Dr. Ian Chua and colleagues looked at this through a multi-institutional, mixed-methods, cluster randomized trial among pediatric clerkship students. They asked 199 students to write essays based on a memorable patient encounter. 100 of these had completed a patient experience debrief interview beforehand, while 88 students served as controls without such an interview. Three blinded authors then used the 4-level REFLECT rubric to determine their depth of reflection. They found that 31% of the intervention group attained critical reflection, the highest level of reflection, compared to 2% in the control group. Patient-centered themes were also more common in the intervention group. These findings suggest a unique approach to deepen self-reflection and maximize opportunities for reflective practice.

Perceived bullying among internal medicine residents Ayyala MS, Rios R, Wright SM.  JAMA. 2019 Aug 13;322(6):576-578.
Dr. Scott Wright is a Gold Professor. He will be presenting at the Gold Humanism Summit in October 2019 about the CLOSLER initiative.
Bullying is something we often think of as occurring on the playground, but how often does it happen during the training of physicians?  Dr. Manasa Ayyala and colleagues sought to answer this, using data from the 2016 Internal Medicine In-Training Examination supplementary survey. They found that among the 24,104 residents who completed the survey, 13.6% (2,876) answered affirmatively to the question “During your time at your residency program, were you ever bullied?”  80% of those who reported bullying noted verbal harassment, followed by “other,” physical, and sexual harassment (25%, 5.3, and 3.6% respectively). Of those who reported feeling bullied, 31% sought help. Factors associated with bullying included a native language other than English, higher postgraduate year level, being an international medical graduate, and having lower in-training examination scores. This has important implications because 57%, 39%, and 27% of respondents reported burnout, worsened performance, and depression, respectively, as consequences of being bullied. The authors conclude that further research is needed and that programs should take strong steps to eliminate bullying.

Interprofessional learning to improve communication in challenging healthcare conversations: what clinicians learn from each other Bell SK, Langer T, Luff D, Rider EA, Brandano J, Meyer EC.  J Contin Educ Health Prof. 2019 Jul 12. Drs. Elaine C. Meyer and Sigall Bell are Mapping the Landscape grantees. Dr. Bell is also a Gold Professor.
Conversations between practitioners and patients can often be challenging. For physicians and other clinicians, learning about how to go about these conversations is critical. Unfortunately, most of this education is uni-disciplinary. Dr. Sigall Bell and colleagues took a closer look at opportunities for interprofessional learning through a prospective study at Boston Children’s Hospital. Specifically, they enrolled 783 participants in 46 communication workshops over two years. These participants received pre-, post-, and 3-month followup questionnaires that focused on experiences learning with practitioners of varying professions. They found that 96% of those who completed the surveys (722) reported that interprofessional interactions improved their learning. After 3 months, 64% reported that the workshops made interactions with interprofessional colleagues more collaborative. Additionally, they described five themes: (1) stronger teamwork, (2) patient-centered focus, (3) specific communication skills, (4) content-specific knowledge, and (5) shared global values. The authors conclude that interprofessional workups may serve an important role in fostering better communication between practitioners and their patients, as well as improving coordination among interprofessional healthcare teams.  

Other Publications

Maladaptive perfectionism, impostorism, and cognitive distortions: threats to the mental health of pre-clinical medical students Hu KS, Chibnall JT, Slavin SJ.  Acad Psychiatry. 2019 Aug;43(4):381-385.
Medical school is a stressful time that can take a devastating toll on mental well-being. Since medical students are used to sustaining high levels of academic performance, they are particularly susceptible to maladaptive perfectionism (a striving for flawlessness) and imposter syndrome (a persistent fear of being discovered as a fraud). Dr. Katherine Hu and colleagues wanted to learn more about these stressors, so they surveyed 169 first-year St. Louis University medical students, using validated instruments including the Center for Epidemiologic Studies-Depression scale, the State-Trait Anxiety Inventory, the Almost Perfect Scale-Revised, and Clance Imposter Phenomenon Scale. Among the 169 students, 25.4% met criteria for maladaptive perfectionism, 31.9% had high or intense impostor phenomenon scores, and 9.5% reported having a moderate or great deal of shame and/or embarrassment related to academic performance in medical school. These findings are instructive because they can inform efforts early in medical school to support mental health needs. The authors suggest considering screening for maladaptive perfectionism and impostor phenomenon, and, if necessary, providing group or individual cognitive behavioral therapy sessions.

How does medical education affect empathy and compassion in medical students? A meta-ethnography: BEME Guide No. 57. Krishnasamy C, Ong SY, Loo ME, Thistlethwaite J. Med Teach. 2019 Aug 7:1-12.
Empathy is critical for physicians for many different reasons, including improved patient satisfaction, better diagnostic and clinical outcomes, and enhanced patient enablement. Fortunately, literature demonstrates that empathy and compassion can be developed and shaped through education and practice. In order to understand how empathy can be better incorporated into medical curricula, Dr. Charmaine Krishnasamy and colleagues examined this further and asked two critical questions: How does medical education affect empathy and compassion in medical students?  And how is this perceived by medical students, educators, and patients?  By searching through 1,454 articles in several databases, they found 33 relevant qualitative studies. Four main themes were derived: (1) seeing the patient as a person, (2) appreciating the elements of empathy and compassion, (3) navigating the training environment, and (4) being guided by ideals. These themes informed the development of a conceptual framework that may help to guide educators toward better incorporation of empathy and compassion into medical education.

Learning medical professionalism – the application of appreciative inquiry and social media  Free full text  Hsieh JG, Kuo LC, Wang YW.  Med Educ Online. 2019 Dec;24(1):1586507.
Professionalism has long been considered a cornerstone of medical practice, but conceptions of professionalism evolve over time with changes in society and technology. In this age of social media, how can medical educators incorporate social media to teach about medical professionalism?  Dr. Jyh-Gang Hsieh and colleagues at Hzu Chi University in Taiwan explored this through the creation of a curriculum for medical students in their first clinical year. They created a Facebook group and encouraged medical students to write posts on positive behaviors observed during clinical practice. Other students and instructors responded to the content to better explore the attributes of medical professionalism. In total, 103 students posted 435 instances of positive role modeling. Passion about teaching, compassion, and competence were the most commonly mentioned topics, seen in 23%, 17.2%, and 9.6% of posts. Interestingly, medical students tended to emphasize what the authors call “traditional oriental medicine” values like “treating patients like family” and mentor-apprentice type relationships over “Western medicine” traditions like integrity and honesty, and respect for patient dignity and autonomy. The authors conclude that “daily discussion of positive role models [on social media]” may be an effective way to teach professionalism.

Compassion fatigue among oncologists: the role of grief, sense of failure, and exposure to suffering and death  Laor-Maayany R, Goldzweig G, Hasson-Ohayon I, Bar-Sela G, Engler-Gross A, Braun M.  Support Care Cancer. 2019 Aug 8.
Compassion fatigue is a phenomenon in which witnessing high levels of suffering and death over time may lead to reduced capacity and interest in being empathetic to the suffering of others. Not surprisingly, compassion fatigue may contribute to burnout and secondary traumatic stress. Because they deal with cancer, oncologists are particularly susceptible to this phenomenon. To understand compassion fatigue, Dr. Rony Laor-Maayany surveyed 74 oncologists in Israel using the Professional Quality of Life Questionnaire (PRoQOL) and the Texas Revised Inventory of Grief (TRIG)-Present Scale. Surprisingly, they found no association between exposure to suffering and death and compassion fatigue. Rather, it was grief and sense of failure that predicted compassion fatigue, burnout, and secondary traumatic stress. Altogether, the authors suggest that the subjective experience elicited by the exposure, e.g. grief, may be more important than the exposure itself. This provides insight into potential interventions focusing on perceptions and experiences to prevent compassion fatigue and consequent burnout.

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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.