Jeffrey Silver Humanism in Healthcare Research Roundup – February 2020

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

Humanistic medicine in anaesthesiology: development and assessment of a curriculum in humanism for postgraduate anaesthesiology trainees Canales C, Strom S, Anderson CT, Fortier MA, Cannesson M, Rinehart JB, Kain ZN, Perret D. Br J Anaesth. 2019 Dec;123(6):887-897. This study was funded in part by a Picker Gold GME Challenge Grant awarded to Dr. Danielle Perret and University of California, Irvine.
Despite the importance of humanism in healthcare, formal humanism curricula are fairly rare in anesthesiology residency programs. The greater incorporation of technology and increasing pressures toward dehumanized care make it especially important. At the University of California, Irvine, investigators utilized funds from a Picker Gold GME Challenge Grant to develop the “Humanism in the Perioperative Medicine” curriculum. This curriculum centered on creating five “always” events: (1) determine patients’ view of the perioperative experience, (2) use empathetic communication in all patient interactions, (3) identify and mitigate each patient’s level of anxiety, (4) pay close attention to pain and anxiety, and (5) communicate empathically and clearly with family and friends. These were incorporated into a yearlong series of workshops and feedback sessions. The team examined how this curricula impacted residents (n=10) and patients (n=30 before, and n=30 afterwards). They found that resident self-assessment of empathy (through the Jefferson Scale of Patient Perceptions of Physician Empathy) increased; patients’ perceptions of physician empathy and physician professionalism, overall satisfaction, anxiety, and pain also improved. The authors conclude that this curriculum has benefits for both learners and patients.

‘What do we do, doctor?’ Transitions of identity and responsibility: a narrative analysis Yardley S, Kinston R, Lefroy J, Gay S, McKinley RK. Adv Health Sci Educ Theory Pract. 2020 Jan 20. Dr. Sarah Yardley is a Mapping the Landscape grantee.
For new physicians, the transition from medical student to doctor is a huge adjustment, entailing major changes in both identity and responsibility. But how exactly does this transition take place?  Dr. Sarah Yardley and colleagues examined this qualitatively through logbooks, audio-diaries, audio-recorded interviews, and focus groups of 32 final-year medical students in 17 different UK medical schools. They then utilized thematic analysis framed by Labov’s six stages of a story. They found that the complex relationship between responsibility and identity spans the entire process of transition. Three major themes were identified: (1) anticipating and preparing for responsibility, (2) the importance of decision making and acting with autonomy, and (3) the impact of identity on responsibility. The authors note that these findings “highlight the need to integrate greater responsibilities into undergraduate learning” and advocate for a more predictable process of adopting responsibilities.

Interventions to improve patient comprehension in informed consent for medical and surgical procedures: an updated systematic review Glaser J, Nouri S, Fernandez A, Sudore RL, Schillinger D, Klein-Fedyshin M, Schenker Y. Med Decis Making. 2020 Jan 16:272989X19896348. Dr. Alicia Fernandez is a Gold professor.
Obtaining informed consent is an ethical and legal priority before any invasive medical or surgical procedure. Yet, in vulnerable populations, there’s often a gap in comprehension that poses a major barrier to the exchange of vital information. Dr. Johanna Glaser and colleagues examined ways to reduce this barrier through a systematic review. After searching through 1850 unique citations in literature, they identified 60 interventions from 52 studies. While these studies were too heterogeneous for quantitative synthesis, they did identify some strategies to improve patient comprehension: test/feedback or teach-back strategies (3 of 3 trials, or 100%, showed improvement), interactive digital interventions (11/13 studies, 85%), audiovisual interventions (15/27 studies, 56%), and written interventions (6/14 studies, 43%). However, the absence of reporting on educational levels and health literacy prevented more definitive conclusions.

The Society of Gynecologic Oncology wellness curriculum pilot: a groundbreaking initiative for fellowship training Turner TB, Kushner DM, Winkel AF, McGwin G Jr, Blank SV, Fowler JM, Kim KH; SGO Wellness Taskforce. Gynecol Oncol. 2020 Jan 3. pii: S0090-8258(19)31797-4. doi: 10.1016/j.ygyno.2019.12.005. Dr. Abigail Winkel is a Mapping the Landscape grantee.
Burnout continues to be a major problem, especially among gynecologic oncology fellows where rates are as high as 87.5%. To help address this, the Society for Gynecologic Oncology convened a Wellness Taskforce and designed a four-module curriculum spanning four months. They then piloted this curriculum at 15 sites with 74 fellows. These modules included reflective writing, guided discussion, and multimedia presentations. Through pre- and post-surveys, they identified increases in (1) comfort level in talking about symptoms of burnout from 63% to 74% and (2) identifying symptoms of burnout and psychosocial distress, from 75% to 90%. At the same time, there was no statistically significant decrease in perceived stress scale (PSS) scores before and after the intervention, and 27% felt the curriculum probably did not benefit their personal well-being. Nevertheless, the authors emphasize that this pilot shows promise and will continue to be adapted so that it can be implemented nationwide.

Associations between residents’ personal behaviors and wellness: A national survey of obstetrics and gynecology residents Winkel AF, Woodland MB, Nguyen AT, Morgan HK. J Surg Educ. 2020 Jan – Feb;77(1):40-44. Dr. Abigail Winkel is a Mapping the Landscape grantee.
Physicians often counsel patients on healthy behaviors such as health maintenance, nutrition, exercise, and sleep. However, physicians themselves often fail to adhere to these behaviors and many engage in maladaptive coping responses contributing to poor well-being and burnout. To better understand personal behaviors and physician wellness, Dr. Abigail Winkel and colleagues conducted a survey of 4,999 obstetrics/gynecology residents. They found that 61.3% reported at least one wellness issue. When correlating behaviors to well-being, only regular exercise was positively correlated with wellness, and alcohol use was correlated with burnout or mental health problems. The authors acknowledge that the brief nature of the self-assessment and the absence of associated demographic information make generalization difficult. Yet these results provide a base for future studies and help shine a light on potential interventions.

Association of open communication and the emotional and behavioural impact of medical error on patients and families: state-wide cross-sectional survey Prentice JC, Bell SK, Thomas EJ, Schneider EC, Weingart SN, Weissman JS, Schlesinger MJ. BMJ Qual Saf. 2020 Jan 20. Dr. Sigall Bell is a Gold professor and Mapping the Landscape grantee.
Approximately one in four Americans report experiencing (either themselves or by someone close to them) a medical error within the past five years. These errors are associated with significant emotional, financial, physical, and sociobehavioral impacts, so it is important to minimize these harms. Dr. Julia Prentice and colleagues examined the impact of open communication – that is, disclosure by providers and invitation for discussion – on their emotions, including feelings of distrust, anger, sadness, depression, and abandonment. To do this, they conducted a cross-sectional recontact survey among Massachusetts residents in 2018 (through random digit dialing) who may have experienced a medical error in 2017. They discovered that 34% reported no communication while 24% reported greater than 5 elements of open communication. More open communication was associated with lower odds of persisting sadness, depression, and feeling abandoned/betrayed as well as lower doctor/facility avoidance. However, open communication was not associated with medical care avoidance and healthcare trust. Altogether, these results suggest that healthcare practitioners and systems could implement programs for open communication to help mitigate harms of medical errors.

A snapshot of underrepresented physicians 15 years after medical school Krupat E, Camargo CA, Espinola JA, Fleenor TJ, Strewler GJ, Dienstag JL. Adv Health Sci Educ Theory Pract. 2020 Jan 25. Dr. Edward Krupat has served on the strategic planning committee of the Gold Foundation Research Institute.
Despite concerted efforts to improve diversity in the healthcare field, there remain significant barriers for underrepresented minorities in medicine (URiM) that range from outright discrimination to more subtle discouragement. To better understand their experiences, Dr. Edward Krupat and colleagues looked at MD recipients from Harvard Medical School between 1996 and 1999. They then sent an online survey to the 547 identified participants, of whom 56 belonged to a URiM group. They then compared the two groups (URiM vs. non-URiM). The URiM respondents were more likely to have greater debt and come from families with lower educational attainment. As medical students, they also were more sensitive to stereotype threat (feeling at risk of confirming a negative stereotype of one’s group) and sought to avoid a career that places them under constant pressure. Unfortunately, they also are more likely to currently feel a lower level of satisfaction with their career progress. These data suggest that URiM medical students have unique needs, and may be discouraged by negative student experiences in medical school, a lack of mentor encouragement, and financial pressures.

Homelessness, cancer, and health literacy: A scoping review Lawrie K, Charow R, Giuliani M, Papadakos J. J Health Care Poor Underserved. 2020;31(1):81-104. Drs. Meredith Giuliani and Janet Papadakos are Mapping the Landscape grantees.
There are an estimated 2.5 million to 3 million homeless individuals in the United States, comprising a vulnerable population with decreased access to healthcare and decreased levels of health literacy. This is particularly true in regards to cancer, which is the leading cause of death  among the homeless aged 45 years or older. To better explore this health disparity, Dr. Karen Lawrie and colleagues performed a scoping review on 1,120 articles, ultimately narrowing down to 33 articles on which they performed thematic analysis. These 33 articles focused on different aspects, including screening, prevention, treatment, and end-of-life care for different types of cancers. Among the three themes were (1) access to and utilization of healthcare, (2) patient-provider interaction, and (3) self-care. Low health literacy is intimately tied to all three themes, and the authors conclude that, in order to reduce barriers for this population, health literacy universal precautions should be considered.

Empowering medical students as agents of curricular change: a value-added approach to student engagement in medical education Geraghty JR, Young AN, Berkel TDM, Wallbruch E, Mann J, Park YS, Hirshfield LE, Hyderi A. Perspect Med Educ. 2020 Feb;9(1):60-65. Dr. Laura Hirschfield is a Mapping the Landscape grantee.
Medical students are often considered passive recipients of education, but newer research is upholding that active student engagement into structuring medical curricula can lead to a better and more valuable educational experience. Starting in 2012, the University of Illinois College of Medicine-Chicago developed a Student Curricular Board (SCB) to incorporate these student voices into curricular changes. Dr. Joseph Geraghty explored the impact of the SCB by surveying 753 medical students across all levels of training. 563 (74.8%) responded, of whom 96% agreed that opportunities for involvement in curriculum were important and 71% stated that the SCB improved the student experience. 1,257 comments were also categorized into 11 key themes about strengths and areas for improvement. Although this study was conducted in one center, the authors conclude that incorporation of students into medical curriculum design can be replicable to other places and lead to sustained improvements.

Other Publications

Self-compassion, trauma, and posttraumatic stress disorder: A systematic review Winders SJ, Murphy O, Looney K, O’Reilly G. Clin Psychol Psychother. 2020 Jan 27. doi: 10.1002/cpp.2429.
Post-traumatic stress disorder (PTSD) is an anxiety disorder in which “distinct symptom clusters of re-experiencing, avoidance, and numbing and arousal [persist] for more than one month after trauma.”  It is a devastating condition that may be mitigated by self-compassion, in which an individual “treat[s] oneself with the same kindness and compassion as one would treat others in the same situation.”  Dr. Sarah-Jane Winders and colleagues sought to summarize the relationship between these two concepts by conducting a systematic review. They identified 35 papers; among these, 11 used self-compassion as a form of intervention. These studies support the idea that self-compassion can be helpful in treating PTSD but there were notable limitations. Only two papers compared those with PTSD with those without PTSD, many papers used the now outdated DSM-IV criteria, and there was significant heterogeneity with regards to the trauma, form of intervention, and demographic characteristics of participants. These lead the authors to conclude that more research is needed to explore how exactly self-compassion can mitigate PTSD.

Compassion in pediatric healthcare: a scoping review Sinclair S, Kondejewski J, Schulte F, Letourneau N, Kuhn S, Raffin-Bouchal S, Guilcher GMT, Strother D. J Pediatr Nurs. 2020 Jan 2;51:57-66.
Compassion can be conceptualized as “an attitude, feeling, trait, or state that arises in witnessing the suffering of another.” It is a central construct for humanistic healthcare. But what are the associated concepts, facilitators, and barriers to compassion in the field of pediatrics? To answer these questions, Dr. Shane Sinclair and colleagues conducted a scoping review. They identified 28 studies that broadly related to compassion or compassionate care. Key facilitators included continuity of care, communication, and coordination of care. Conversely, barriers included burnout and secondary traumatic stress and poor communication. Altogether, the authors note that there is “a critical need to establish a comprehensive evidence-based understanding of the construct of compassion in pediatric healthcare to enhance the clinical practice and strengthen future research.”

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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.