Jeffrey Silver Humanism in Healthcare Research Roundup – February 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.

From burnout to wholehearted engagement: a qualitative exploration of psychiatry residents’ experience of stress Corgan S, Winkel AF, Sugarman R, Young JQ. Acad Med. 2021 Jan 5;Publish Ahead of Print. doi: 10.1097/ACM.0000000000003912. Epub ahead of print. PMID: 33410608. Dr. Abigail Winkel has been a Gold Foundation grantee.
Approximately 2 out of every 5 psychiatry resident physicians today meet criteria for burnout, a condition in which stress levels surpass a physician’s capacity to maintain empathy, personal connection to work, and sense of accomplishment. This has major adverse effects on personal and professional development and threatens the psychiatry workforce as a whole. To tackle this, Dr. Sondra Corgan and colleagues conducted a qualitative investigation to develop an exploratory framework for psychiatry residents’ experiences of stress. They interviewed 14 resident physicians from all four years of training at Zucker Hillside Hospital in Glen Oaks, New York. Through grounded theory, they identified three themes for how residents cope with stress: (1) self-care, (2) work relationships, and (3) meaning making. From these themes, they suggested strategies for residency programs, including “creating spaces to promote peer connection; providing training in addressing conflict across authority, experience, and professional gradients; and facilitating engagement in meaning-making activities, such as personal psychotherapy.”

Effects of the COVID-19 pandemic on medical students: a multicenter quantitative study Harries AJ, Lee C, Jones L, Rodriguez RM, Davis JA, Boysen-Osborn M, Kashima KJ, Krane NK, Rae G, Kman N, Langsfeld JM, Juarez M. BMC Med Educ. 2021 Jan 6;21(1):14. doi: 10.1186/s12909-020-02462-1. PMID: 33407422; PMCID: PMC7786337.  Free full text Dr. Kathleen Kashima is a former Chair of the Gold Humanism Honor Society Advisory Council.
In response to the COVID-19 pandemic, in March 2020, the Association of American Medical Colleges (AAMC) released guidance recommending that medical students immediately pause all clinical rotations. This had important educational and psychological effects on US medical students. Dr. Aaron Harries and colleagues examined these through a cross-sectional survey sent by e-mail to students in their clinical years at six medical schools. They discovered that, among the 741 students who responded, there were mixed feelings. Approximately 75% agreed that the pandemic had significantly disrupted their medical education, and 60% believed that they should continue with normal clinical rotations during the pandemic. About 80% reported they would accept the risk of infection if returning to the clinical setting. 75% indicated they thought they would contract COVID-19 at some point, regardless of contact with the clinical environment.) Somewhat paradoxically, 75% felt that removing them from clinical rotations was appropriate, but approximately a third felt guilty, a third felt disappointed, and a quarter felt relieved. 84% of students felt at least somewhat anxious; a little over half felt that adequate personal protective equipment would help relieve this sense of anxiety in returning to clinical rotations. This survey has limitations, notably a relatively low response rate of 29.5%. However, these results provide a valuable snapshot of medical student concerns and anxieties during the pandemic.

Does medical students’ high expression of empathy correlate with their choice of primary care residencies? Park J, Blatt B, Greenberg L. South Med J. 2021 Jan;114(1):8-12. doi: 10.14423/SMJ.0000000000001192. PMID: 33398353. Dr. Benjamin Blatt has been a Gold Foundation grantee.
Primary care specialties, like Internal Medicine and Family Medicine, have traditionally been perceived as people-oriented and as characterized by empathy. But do more empathic medical students go into these fields? Dr. Joseph Park and colleagues explored this among 593 third-year medical students at George Washington University from 2008 to 2011. Participants completed the perspective-taking and empathy subscales of the Interpersonal Reactivity Index (IRI), which researchers then sought to correlate with their choice of matched specialty. They found that there were not significant correlations between medical students expressing high empathy and those choosing patient-oriented residencies. The authors note that this negative result raises some interesting questions. They suggest that generational and gender differences may help to explain the absence of a correlation. Women, who, as a subgroup, express higher empathy in these scales according to previous studies, are choosing previously male-dominated non-primary care subspecialties, and millennials are considering lifestyle and life-work balance in their choice of specialization. The authors speculated that these factors may reduce the impact of high expressions of empathy on the subsequent choice of residency.

Racial differences in patient perception of interactions with providers are associated with health outcomes in type II diabetes Reid HW, Lin OM, Fabbro RL, Johnson KS, Svetkey LP, Olsen MK, Matsouaka RA, Chung ST, Batch BC. Patient Educ Couns. 2021 Jan 29:S0738-3991(21)00058-6. doi: 10.1016/j.pec.2021.01.031. Epub ahead of print. PMID: 33579569. Dr. Helen Reid has been a Gold Foundation grantee.
Type 2 Diabetes Mellitus is a highly prevalent chronic condition in which there exist healthcare disparities between non-Hispanic Black (NHB) patients and non-Hispanic White (NHW) patients. Even when controlling for access to care, insurance status, and adherence to processes of care, glycemic control remains worse among NHB patients. Patient-practitioner interactions may be an important contributor to this disparity. To explore this, Dr. Hadley W. Reid and colleagues conducted a cross-sectional survey among 221 patients in the Duke University Health System. Among the 115 NHB participants, there was a positive association between perceptions that their practitioner always explained results and medications and better glycemic control. This association was not found among the 106 NHW participants. Similarly, among NHB participants, never perceiving discrimination from providers was associated with a decrease in the probability of missing an appointment. For all patients (that is, both NHW and NHB), never perceiving disrespect from office staff was associated with an increase in medication adherence. Based on these findings, the authors conclude that particular aspects of communication may contribute to racial disparities and that better training may lead to improved patient-centered care, especially for NHB patients.

Assessment of the inclusion of racial/ethnic minority, female, and older individuals in vaccine clinical trials Flores LE, Frontera WR, Andrasik MP, Del Rio C, Mondríguez-González A, Price SA, Krantz EM, Pergam SA, Silver JK. JAMA Netw Open. 2021 Feb 1;4(2):e2037640. doi: 10.1001/jamanetworkopen.2020.37640. PMID: 33606033.  Free full text Dr. Julie Silver has been a Gold Foundation grantee.
Mass vaccination is a critical factor in preventing and combating infectious disease threats, as we are learning with the COVID19 pandemic. However, a long history of excluding members of racial/ethnic minority groups, women, and older individuals, has contributed to inequities in assessing and providing accessibility to these vaccines. Laura Flores and colleagues examined the extent to which racial/ethnic minority groups, women, and older adults are represented in vaccine clinical trials. To do so, they examined data from from 2011 to 2020. They found 230 U.S.-based trials with 219,555 total participants. In these, white individuals were overrepresented (77.9%) while Black/African American and American Indian or Alaska Native individuals were underrepresented (10.6 and 0.4%, respectively). Representation of Latino/Hispanic individuals was also low (11.6%), but fewer studies reported ethnicity. Adult trials had more female participants (56%) compared to male participants. Enrollment of participants ages 65 and above was also low (12.1%). This information helps illuminate the current landscape and thus aid in ensuring equitable enrollment in future vaccine trials. Indeed, increasing access to vaccine trials to populations at higher risk, including racial/ethnic minorities and older individuals, may help to counter safety concerns and hesitancy in these communities.

Qualitative analysis of medical student reflections on the implicit association test Gonzalez CM, Noah YS, Correa N, Archer-Dyer H, Weingarten-Arams J, Sukhera J. Med Educ. 2021 Feb 5. doi: 10.1111/medu.14468. Epub ahead of print. PMID: 33544914. Drs. Cristina Gonzalez and Javeed Sukhera have been Gold Foundation grantees.
Implicit bias refers to “the unconscious, unintentional mental associations we make about various social groups (e.g. race, gender, and sexual orientation).”  Recent evidence suggests that physicians, like other professionals and the general population, exhibit implicit bias and that this implicit bias may lead to diagnostic errors. The IAT (Implicit Association Test) has been one widely used tool for research and education to prompt insight and self-reflection. But how exactly do medical students reflect on other experiences with the IAT?  Dr. Christina Gonzalez and colleagues examine this, through analysis of 180 written reflections from clerkship students who had taken the IAT. They found three major themes: (1) reacting to the IAT, (2) accepting bias yet struggling to identify strategies, and (3) self-identifying a range of strategies. In their analysis, they found that even though there were deep emotional reactions, students rarely chose to identify a strategy. Even those that did identify a strategy often did not articulate a nuanced approach. This discordance provides insight for educators on how to move forward, by not only incorporating approaches to identify implicit bias but also expanding instruction to active learning exercises for skill development and practice. That way, we can, as the authors state, “bridge the chasm between this acceptance to reach skill development in management of bias.”

Faculty disclosure of personal mental health history and resident physician perceptions of stigma surrounding mental illness Vaa Stelling BE, West CP. Acad Med. 2021 Jan 25. doi: 10.1097/ACM.0000000000003941. Epub ahead of print. PMID: 33496429. Dr. Colin P. West has been a Gold Foundation grantee.
Nearly half of physician trainees experience depression or depressive symptoms at some point during their training, which can lead to increased medical errors, decreased quality of life, unprofessional conduct, and suicidal ideation. This is exacerbated by a strong stigma surrounding mental illness and seeking help. Drs. Brianna Vaa Stelling and Colin West examine one approach to erasing this stigma: adding faculty disclosure of mental health issues to confidential 1-hour “noon conferences,” part of the core curriculum for internal medicine residents at the Mayo Clinic Rochester. To do so, they surveyed 69 resident physicians who attended a noon conference in December 2016. Among the 39 who responded, 39 (100%) enjoyed the session, 38 (97.4%) stated that faculty members sharing personal struggles destigmatizes mental health issues, 25 (89.7%) agreed that their knowledge of available mental health resources increased, and 33 (84.6%) agreed they were more likely to pursue mental health resources after attending the conference. The authors conclude that such an approach is feasible and meaningful but further study of longer-term outcomes and actual help-seeking behaviors is warranted.

Medical students’ perspectives on empathy: a systematic review and metasynthesis Costa-Drolon E, Verneuil L, Manolios E, Revah-Levy A, Sibeoni J. Acad Med. 2021 Jan 1;96(1):142-154. doi: 10.1097/ACM.0000000000003655. PMID: 32769475.
Physician empathy is an important facet of professional identity and is associated with several benefits to both practitioners and to patients. But how do we conceptualize empathy, particularly at the medical student level where professional identity begins to take shape?  And how can their perspectives generate new insights into the teaching of empathy?  Dr. Emmanuel Costa-Drolon and colleagues conducted a systematic review and meta-ethnography to answer these questions. They identified 35 articles from 4 databases that provided data from more than 1,700 medical students, interns and residents. Four themes emerged from their analysis: (1) defining empathy, (2) teaching empathy, (3) willingness to be an empathetic doctor, and (4) evolution of empathy during medical school. Overall, these revealed conflicting thoughts and ambivalence about what constitutes empathy, how to best teach empathy, and what benefits come from teaching empathy. Based on these insights, the authors suggest that “a physician’s empathy must be an end – not a means.” Additionally, given this ambiguity, the authors suggest that empathy education should be “structured around clearer concepts, such as listening to patients.” This meta-ethnography provides a base from which to frame larger questions about how empathy can be better integrated at all levels of undergraduate medical education.

Experiences and management of physician psychological symptoms during infectious disease outbreaks: a rapid review Fiest KM, Parsons Leigh J, Krewulak KD, Plotnikoff KM, Kemp LG, Ng-Kamstra J, Stelfox HT. BMC Psychiatry. 2021 Feb 10;21(1):91. doi: 10.1186/s12888-021-03090-9. PMID: 33568141; PMCID: PMC7875435.  Free full text
The COVID-19 pandemic continues to be a significant threat to the global healthcare system. Physicians, nurses, and other individuals involved in healthcare have been at the front lines, battling not only the virus itself but also the associated moral distress, long shifts, and difficult triage decisions. These contribute to anxiety, depression, and other psychological symptoms, but how prevalent are these symptoms?  Dr. Kirsten M. Fiest reviewed the literature and found 193 studies, covering 90,000 physicians, that pertained to physician psychological symptoms during infectious disease outbreaks, including Influenza H1N1, H5N1, and H7N9, MERS (Middle Eastern Respiratory Syndrome), Ebola, and COVID-19. Anxiety and post-traumatic stress disorder were particularly high, seen in as many as 92.3% and 75.2% of respondents. Those at higher risk included women, younger physicians, more junior physicians, and those who have more direct contact with infected patients. Concerns about the availability and use of personal protective equipment and worry about families were common themes. Responses by physicians were also quite variable, and included self-isolation, following protocols, and receiving emotional support from family members. These results suggest the need for healthcare systems to prioritize the psychological needs of physicians and other healthcare practitioners. As COVID-19 continues to exact its toll worldwide, the authors suggest that healthcare systems can take steps such as providing options for appropriate accommodation away from family members and accessible training and ensuring access to personal protective equipment.

Characterizing the community collaborations of a community-based student-run clinic Pennington K, Harwood E, Sick B. J Prim Care Community Health. 2020 Jan-Dec;11:2150132720984400. doi: 10.1177/2150132720984400. PMID: 33356798; PMCID: PMC7768577.  Free full text Dr. Brian Sick has been a Gold Foundation grantee.
Student-run clinics (SRCs) are important sites for service-learning and shape health professional students’ understanding of health care disparities. They also benefit communities directly by providing an access point for underserved populations. Yet little is known about the nature of these community collaborations. and colleagues examine the community collaborations behind the Phillips Neighborhood Clinic (PNC) in South Minneapolis, where more than 400 students from 13 professional programs volunteer each year. Specifically, they interviewed 20 student volunteers and 2 community members. Through analysis of interview transcripts, they identified three themes: (1) perceptions of community outreach, (2) perceptions of the community advisory board, and (3) recommendations for advancing health on a community level. These insights have powered a redesign of the community advisory board so that the student-run clinic can better cater to community needs. The authors conclude by calling for more research to determine how SRCs can more meaningfully engage communities and how the characteristics of these relationships can be operationalized.

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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.