Jeffrey Silver Humanism in Healthcare Research Roundup – December 2020-January 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.

Association of physician burnout with suicidal ideation and medical errors Menon NK, Shanafelt TD, Sinsky CA, Linzer M, Carlasare L, Brady KJS, Stillman MJ, Trockel MT. JAMA Netw Open. 2020 Dec 1;3(12):e2028780. doi: 10.1001/jamanetworkopen.2020.28780. PMID: 33295977; PMCID: PMC7726631.  Free full text Dr. Tait Shanafelt has been a Gold Foundation grantee.
Suicidal ideation is prevalent among physicians, with 1 in 10 medical students, 1 in 4 interns, and 1 in 16 practicing physicians reporting some degree of suicidal ideation. Burnout has been associated with both depression and suicide in physicians, but the exact relationship between these three remains unclear. Nikitha Menon and colleagues examined this through a cross-sectional online survey of 1354 practicing physicians. To quantify burnout, suicidal ideation, and depression, they utilized subscales of the Stanford Professional Fulfillment Index (PFI), Maslach Burnout Inventory-Human Services Survey for Medical Personnel, Mini-Z burnout survey, and Patient-Reported Outcomes Measurement Information System (PROMIS) depression Short Form. Ultimately, they discovered that depression was directly associated with suicidal ideation but not burnout. For each increase in standard deviation in the PROMIS scale for depression, there was a two-fold increased odds of suicidal ideation. Interestingly, burnout was independently associated with self-reported medical errors. These results provide insights into the nature of burnout and suicidal ideation, but major limitations apply: a low response rate, self-reported measures, and a low number of physicians in the sample reporting suicidal ideation (75 out of 1,354) hamper making wide-scale generalizations. Nevertheless, this study sheds light on the complex relationship among burnout, depression, and suicidal ideation.

Speaking up about patient-perceived serious visit note errors: patient and family experiences and recommendations Lam BD, Bourgeois F, Dong ZJ, Bell SK. J Am Med Inform Assoc. 2020 Dec 23:ocaa293. doi: 10.1093/jamia/ocaa293. Epub ahead of print. PMID: 33367831. Dr. Sigall K. Bell, a Gold Professor, has been a Gold Foundation grantee.
In line with recent trends toward greater transparency in the patient-physician relationship, “open notes,” that is, notes shared by physicians to patients on patient portals, are becoming more common. These allow patients to engage with physicians, with the benefits of possibly promoting better medication adherence, shared decision-making, and a culture of safety, including identifying errors in documentation. Dr. Barbara Lam and colleagues examined how patients deal with documentation errors through a mixed-methods study of 6,913 adult and 3,672 pediatric families in two Northeast U.S. academic medical centers. Among the 8,648 participants, 1,434 (17%) perceived at least one mistake. In this group, 627 (44%) reported that the mistake was serious and 342 of them (56%) contacted the healthcare center. Participants who self-identified as Black or African American, Asian, “other” or “multiple” race(s) were 42% less likely to speak up (odds ratio: 0.58). The most common reasons for not speaking up included not knowing how to report a mistake (61%) and avoiding perception as a troublemaker (34%). Respondents strongly preferred online, asynchronous communications for reporting. The investigators conclude that there is “a ripe environment for innovation and patient partnership at a time when such engagement is prioritized.”

How do we assess resilience and grit among internal medicine residents at the Mayo Clinic? A longitudinal validity study including correlations with medical knowledge, professionalism and clinical performance. Alahdab F, Halvorsen AJ, Mandrekar JN, Vaa BE, Montori VM, West CP, Murad MH, Beckman TJ. BMJ Open. 2020 Dec 15;10(12):e040699. doi: 10.1136/bmjopen-2020-040699. PMID: 33323437; PMCID: PMC7745331.  Free full text Dr. Colin West and Dr. Victor Montori have been Gold Foundation grantees.
Resilience is described as “adapting effectively to stressors such as relationship problems, serious health issues, or workplace and financial challenges.” It is inextricably linked to well-being and is protective for burnout. But how can we measure resilience, and the closely related concept of grit (perseverance and passion for long-term goals) among physicians? Dr. Fares Alahdab and colleagues examined this through validation of two scores, the Connor-Davidson Resilience Scale (CD-RISC 10) and Short Grit Scale (Grit-S), among 213 Internal Medicine resident physicians at the Mayo Clinic over four years. They compared them with percentiles in In-Training Examination Scores, Mini-Clinical Evaluation Examination (Mini-CEX) scores, conference attendance, and evaluation completion. They identified a high degree of reliability within both the CD-RISC 10 and Grit-S, suggesting that it may adequately measure resiliency and grit among Internal Medicine resident physicians. There was also a negative correlation between CD-RISC 10 scores and ITE percentiles as well as with mini-CEX scores. Conversely, GRIT-S scores were positively correlated with evaluation completion and conference attendance. Altogether, these suggest that residents “demonstrated resilience within a competitive training environment despite less favorable test performance and grittiness that was manifested by completing tasks.”  The investigators suggest that future research should focus on the associations among resilience, grit, burnout, and well-being.

Building longitudinal relationships into a traditional block clerkship model: a mixed-methods study Atalay AJ, Osman NY, Krupat E, Alexander EK. Acad Med. 2020 Oct 27. doi: 10.1097/ACM.0000000000003810. Epub ahead of print. PMID: 33116060. Dr. Edward Krupat has served on the strategic planning committee of the Gold Foundation Research Institute.
Even though continuity in patient-physician relationships has become an essential educational principle, most medical schools continue to utilize sequential block clerkships that may impede continuity. At Harvard Medical School and Brigham and Women’s Hospital, a Longitudinal Clinical Experiences with Patients (LCEP) curriculum was integrated into a block clerkship model. This created an infrastructure around which students could identify and follow patients longitudinally. Dr. Alev Atalay and colleagues utilized an electronic survey and periodic confidential live interviews to track the curriculum for 52 students and characterize how it impacted their educational experiences. They found that students followed 3.3 LCEP patients over the clerkship year, and 94% of them followed two or more patients longitudinally. Students overall voiced that they had a deeper understanding of the patient experience, the health care system, and disease progression. However, they also noted competing priorities between block clerkship responsibilities and longitudinal opportunities. The authors concluded that it is feasible to promote longitudinal patient relationships within a traditional block-clerkship model and that hybridization in the program promotes patient-centeredness.

Mindful ethical practice and resilience academy: equipping nurses to address ethical challenges Rushton CH, Swoboda SM, Reller N, Skarupski KA, Prizzi M, Young PD, Hanson GC. Am J Crit Care. 2021 Jan 1;30(1):e1-e11. doi: 10.4037/ajcc2021359. PMID: 33385208. Dr. Cynda Rushton has been a Gold Foundation grantee.
Nurses often confront ethical challenges in their day-to-day work, which, when combined with other job-related stresses and workload fatigue, may contribute to moral distress and injury. Mindfulness, the practice of being aware of what is happening in the present moment, may help to prevent such moral distress. Dr. Cynda Hylton Rushton and colleagues examined if MEPRA (Mindful Ethical Practice and Resilience Academy), a longitudinal, experiential educational curriculum, can enhance mindfulness, resilience, confidence, and competence in dealing with ethical challenges. To do so, they utilized 11 distinct scales to compare the outcomes in 192 participants in the curriculum with 223 in a comparison group. They identified that mindfulness, ethical confidence, ethical competence, work engagement, and resilience increased significantly in those who completed MEPRA, while turnover intention and symptoms of depression and anger declined. This research helps to build a foundation for further investigation, including how educational curricula can be individualized and tailored to specific work environments in a sustainable manner.

Social networks of older patients with advanced cancer: potential contributions of an integrated mixed methods network analysis Yousefi Nooraie R, Mohile SG, Yilmaz S, Bauer J, Epstein RM. J Geriatr Oncol. 2020 Dec 17:S1879-4068(20)30507-5. doi: 10.1016/j.jgo.2020.12.005. Epub ahead of print. PMID: 33342721. Dr. Ronald Epstein has been a Gold Foundation grantee and a recipient of the Arnold P. Gold Humanism in Medicine Award given by The Society of Teachers of Medicine. He is also the Co-Founder of Mindful Practice, which collaborates with the Gold Foundation to offer programs to healthcare professionals.
Health decisions are rarely made in isolation; rather, they occur as a result of dynamic processes between the patient, healthcare professionals, and social networks. Dr. Reza Yousefi Nooraie and colleagues examined these social networks in elderly patients with cancer by employing a technique called Mixed-Methods Social Network Analysis (MMSNA). MMSNA addresses structures in a dynamic manner that is both quantitative and qualitative. By interviewing 16 patients, they identified three “thematic structural dimensions, corresponding to: a) segregated clusters, b) start-shaped, and c) existence of core.” Healthcare professionals were rarely included in these networks, which may help to explain hesitancy by older patients to “understand, accept, or heed information that they receive from clinicians.” The authors concluded that MMSNAs can help provide insights into the richness of personal stories about illnesses, perspectives about their health, and determinants of quality of life.

How physician compensation and education debt impacts financial stress and burnout: a survey study of women in physical medicine and rehabilitation Verduzco-Gutierrez M, Larson AR, Capizzi AN, Bean AC, Zafonte RD, Odonkor CA, Bosques G, Silver JK. PM R. 2020 Dec 10. doi: 10.1002/pmrj.12534. Epub ahead of print. PMID: 33301648. Dr. Allison Bean, Dr. Ross Zafonte, and Dr. Julie Silver have been Gold Foundation grantees.
Physician educational debt is a major problem facing the workforce, with prior literature showing its association with burnout, suboptimal quality of life, and choice of specialization towards higher-paying fields. Female physicians are even more subject to financial stress, given the gender-related disparities that increase throughout their careers. Dr. Monica Verduzco-Gutierrez and colleagues examined the relationship between perceptions of financial stress by female physicians who specialized in Physical Medicine & Rehabilitation and their well-being. They sent a survey of 51 questions to members of the “Women Physiatrists” Facebook group and received 245 responses. Among them, 222 (about 9 in 10) reported ever having education debt, and 162 (about 2 in 3) reported current debt. Overwhelming majorities agreed that they would have fewer burnout symptoms “if they were able to do more work that is core to their professional mission” and that “feeling undervalued at work is linked to physiatrists’ burnout symptoms” (about 9 in 10, for each). Statistically significant correlations were noted between greater debt and self-identification as Black/African American, fewer years out of training, practice in general physiatry, and both inpatient and outpatient responsibilities. Similarly, greater current debt had a significant relationship with personal life dissatisfaction, career regret, and burnout. The authors caution that the survey was only completed by a small sample on Facebook at one point in time, which may introduce selection and sampling biases. Nevertheless, these results shine a light on gender bias and the role of financial stress in the well-being of female physiatrists.

Establishing trust within interprofessional teams with a novel simulation activity in the pediatric clerkship Huth K, Growdon AS, Stockman LS, Brett-Fleegler M, Shannon MT, Taylor M, Hundert ES, Kesselheim JC. J Interprof Care. 2020 Dec 8:1-6. doi: 10.1080/13561820.2020.1840338. Epub ahead of print. PMID: 33290114. Dr. Jennifer Kesselheim is a Gold Professor.
Interprofessional trust is foundational to effective collaboration between diverse members of the healthcare team. So how can we teach this to medical students? Dr. Kathleen Huth and colleagues at Boston Children’s Hospital developed a novel simulation activity involving interprofessional conflict. The investigators adapted the VALUE mnemonic to align simulation objectives (renamed as VALUED). 214 students attended the simulation session, and then completed a written evaluation self-assessing confidence in resolving conflict and perceived effectiveness of the activity. They identified three “student phenotypes” describing student common behaviors: deferential, aggressive, and collaborative. They also identified three themes related to anticipated changes in practice: (1) developing a shared mental model, (2) establishing a shared goal, and (3) developing a role on the interprofessional team. These results suggest that simulation-based learning may be an effective method to teaching interprofessional trust to medical students. They intend to expand the simulation activities and explore whether it changes clinician and patient experience.

Gender effects in assessment of clinical teaching: does concordance matter? Stroud L, Freeman R, Kulasegaram K, Cil TD, Ginsburg S. J Grad Med Educ. 2020 Dec;12(6):710-716. doi: 10.4300/JGME-D-20-00145.1. Epub 2020 Dec 2. PMID: 33391595; PMCID: PMC7771598.
Despite the popularity of learner assessments of faculty teaching performance, literature demonstrates that there are significant biases that may lead to higher scores for male teachers, thereby putting female faculty physicians at a disadvantage when it comes to performance reviews, merit pay, and promotion. Dr. Lynfa Stroud and colleagues examined phenomenon, specifically to find out whether this gender bias is influenced by the gender of the learner as well as its extent into different specialties. At the University of Toronto, they looked at residents’ ratings of faculty in Internal Medicine (IM), Family Medicine (FM), and Surgery. They then categorized ratings based on the dyadic relationship between resident learner (male or female) and faculty teacher (male or female). Looking at the average ratings, they found that male faculty received significantly higher scores than female faculty in Surgery and Family Medicine. In Surgery, this was driven by male resident ratings, whereas in Family Medicine, the resident’s gender did not play a significant role. These results suggest that gender bias exists and may be driven by the learner’s gender, but effects are small and may not be universal across specialties and departments.

Clinical implications of removing race from estimates of kidney function Diao JA, Wu GJ, Taylor HA, Tucker JK, Powe NR, Kohane IS, Manrai AK. JAMA. 2020 Dec 2:e2022124. doi: 10.1001/jama.2020.22124. Epub ahead of print. PMID: 33263721; PMCID: PMC7711563.
Racial disparities exist in the care of patients with chronic kidney disease, with Black adults being diagnosed at later stages and having higher morbidity and mortality. In recent years, there has been increasing attention to how chronic kidney disease is defined and how race adjustments figures into these definitions and consequently the health disparities. James Diao and colleagues examined this through the records of 9,522 nonpregnant, non-Hispanic Black adults in the National Health and Nutrition Examination Survey (NHANES). They calculated the estimated Glomerular Filtration Rate (eGFR), a marker of kidney function, using the CKD-EPI equation (Chronic Kidney Disease Epidemiology Collaboration), both with and without the race coefficient. They found that nearly 1 in 3 (29.1%) of Black adults with existing CKD would be reclassified into more severe stage of disease; 3.5% of Black adults would be classified as having CKD Stage 3b or higher, up from 2.3%. This change would impact prescription of medications, medical nutrition therapy, referral to specialists, and eligibility for kidney transplant. As the authors note, given the “historical misuse of race as a biological variable,” the use of race as an adjustment variable in calculating chronic kidney disease ought to be re-examined.

Empathic and listening styles of first year undergraduate nursing students: A cross-sectional study McKenna L, Brown T, Williams B, Lau R. J Prof Nurs. 2020 Nov-Dec;36(6):611-615. doi: 10.1016/j.profnurs.2020.08.013. Epub 2020 Aug 21. PMID: 33308562.
Empathic communication underpinned by attentive, nonjudgmental, and respectful listening and response between nurses and patients is essential for upholding high-quality nursing and ensuring patient dignity. But little is known about how nursing students approach empathic communication, and how to develop these skills. Lisa McKenna and colleagues performed a cross-sectional study of 135 first-year Bachelor of Nursing (BN) students at an Australian University. Participants completed the Listening Styles Profile (LSP) and Active-Empathic Listening Scale (AELS) to quantify their self-perceived listening and responding styles. They identified that a people-oriented LSP was correlated with the three stages of AELS, namely sensing, processing, and responding. In contrast, content-oriented LSP was correlated with processing and responding AELS, and action-oriented LSP was strongly correlated with processing AELS. The authors concluded that there is considerable variety in empathic communication styles even early in the early stages of a nursing career, and that more specific educational strategies are needed to facilitate development of these skills.

Effect of a patient-led educational session on pre-clerkship students’ learning of professional values and on their professional development Butani L, Sweeney C, Plant J. Med Educ Online. 2020 Dec;25(1):1801174. doi: 10.1080/10872981.2020.1801174. PMID: 32730189; PMCID: PMC7482741.  Free full text
Patients and their families play vital roles in the education and professional identity development of physicians. However, formalized curricula incorporating family, and studies evaluating the effectiveness of this approach, remain scarce. Dr. Lavjay Butani and colleagues examined this through the implementation of a pediatric patient and family-led educational session during a molecular medicine course for first-year medical students. They then had students submit a written reflection on what they had learned, and conducted content analysis of these submissions. Among 99 written narratives, they found two major themes: (1) becoming legitimate participants in caring for patients, and (2) variable personal reactions. The investigators also used Arnold and Stern’s framework for professionalism to identify experiences comporting with the four aspirational professional values of altruism, accountability, humanism and excellence. They concluded by noting the value of incorporating patients and family members as part of early exposures in the pre-clinical years of medical school.

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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.