Jeffrey Silver Humanism in Healthcare Research Roundup – February-March 2022

Nurse reading

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.

Meeting the challenge of teaching bioethics: a successful residency curricula utilizing Team-Based Learning. Spencer SP, Lauden S, Wilson S, Philip A, Kasick R, Mahan JD, Fernandes AK. Ann Med. 2022 Dec;54(1):359-368. doi: 10.1080/07853890.2021.2013523. PMID: 35114873; PMCID: PMC8820793. Free full text Dr. Ashley K. Fernandes has received multiple Gold Foundation grants, including a Mapping the Landscape award and a Picker Gold Graduate Medical Education Challenge Grant. This study was partly funded by the Gold Foundation.
Bioethical principles are essential to humanistic practice, yet the majority of pediatric residency programs lack formal assessment of clinical ethics knowledge and skills. Seeing this gap, Dr. Sandra Spencer and colleagues developed a residency curriculum using the principles of team-based learning (TBL). Using L. Dee Fink’s principles of Significant Learning and Jonsen, et al’s Four-Box Method of ethical analysis, the authors created content for 10 TBL sessions and implemented them as part of a 3-year longitudinal residency curriculum at Nationwide Children’s Hospital, the first curriculum of its kind. As part of their evaluation, the authors looked at individual and group readiness assessment tests (iRAT/gRAT), pre-work completion, and satisfaction with sessions among the 348 resident encounters. They found that there was significant improvement in iRAT/gRAT scores and high rates of satisfaction (4.42 out of 5 on a Likert scale), although pre-work completion was low (28%). They attribute the success to multiple factors, including the engaging format, adherence to established principles of curricular design and ethical analysis. The authors report that the curriculum can be easily modified for different specialties and formats. They intend to build upon this success through a grant from The Arnold P. Gold Foundation to expand the curriculum’s reach and scope.

Patients’ perspectives on medical students’ professionalism: Blind spots and opportunities. Haney S, Rowland P, Ginsburg S. Med Educ. 2022 Jan 30. doi: 10.1111/medu.14735. Epub ahead of print. PMID: 35098573. Dr. Paula Rowland has been a Gold Foundation grantee.
Professionalism is a key part of medical education and is routinely evaluated by preceptors, but what are the patients’ perspectives? Simon Haney and colleagues examined this question through a qualitative study of 19 patients at a hospital in Toronto, Canada. Each participant watched five video scenarios depicting professionally challenging situations and were asked to discuss what behaviors by the medical student would be appropriate or inappropriate to do from the perspective of the patient and the perspective of the medical student. These interviews were recorded and analyzed using a constructivist grounded theory approach. While most principles were previously described in literature, there were four new themes. Two of the new themes focused on what the medical student should do: hide dissension within the healthcare team and respect patients’ privacy/be respectful to patients. Surprisingly, the other two new themes focused on guidance for patients: advocate for yourself and trust in the system. The authors considered these four areas “blind spots” and thus opportunities to include in future curricula updates. In particular, the authors suggest greater instruction on “how to minimize barriers to patient self-advocacy, how to communicate respectfully and honor the trust patients place in the medical education and care systems.”

Men and Women Pursue Nonlinear Career Paths, but Impacts Differ: a Cross-Sectional Study of Academic Hospitalists. Defoe MV, Cameron KA, Burden M, Mazurek SR, Updike JA, Keniston A, O’Leary KJ, Best JA. J Gen Intern Med. 2022 Jan 28:1–8. doi: 10.1007/s11606-022-07402-x. Epub ahead of print. PMID: 35091922; PMCID: PMC8796748. Free full text Dr. Jennifer A. Best has been a Gold Foundation grantee.
Nonlinear career paths are becoming increasingly common among physicians, in part due to concerns about work-life balance. Such nonlinear paths include extended leave (EL) and non-traditional work arrangements (NTWA). Prior literature suggests that women and men have different experiences with these nonlinear career paths, but little is known about how these two types of non-career paths impact hospitalists’ personal lives and careers. Dr. Maya Defoe and colleagues sent an electronic survey to 272 hospitalists in three academic medical centers. Among the 141 hospitalists who responded, 37 had had extended leave and 78 had had an NTWA experience. Women were more likely to have taken EL and for longer periods, but taking NTWA to address burnout or childbirth/adoption were surprisingly comparable for men and women. A qualitative analysis of survey responses showed differing negative impacts of EL based on gender. While men predominantly described negative impacts on career, women additionally reported negative impacts on personal life, career, well-being, and work-life integration. With respect to NTWA, men and women described positive impacts overall. According to authors, these results suggest that nonlinear career paths “may be a double-edged sword for women.”  While these career paths advance representation of women, they can have negative impacts that are more specific for women than men. Regardless, increased support is necessary to prevent burnout among hospitalists and maintain a balanced work-life balance, especially among female hospitalists.

The impact of COVID-19 on professional identity. Byram JN, Frankel RM, Isaacson JH, Mehta N. Clin Teach. 2022 Feb 10. doi: 10.1111/tct.13467. Epub ahead of print. PMID: 35142075. Free full text Dr. Richard Frankel and Dr. Harry Isaacson have been Gold Foundation grantees.
The ongoing COVID-19 pandemic has impacted medical education at all levels, and, in so doing, has impacted the professional identity formation (PIF) of medical students. To characterize these effects, Dr. Jessica N. Byram and colleagues invited medical students at the University of Indiana to submit reflections using the following prompt: “How has the [COVID-19] pandemic impacted the way(s) you think about your medical education and your professional identity as a physician in training?”  26 students (approximately 20% of invited students) submitted their reflections. Three themes were identified: (1) changing conceptions of the role and image of a physician, (2) views about medical education, and (3) the role of medical students in a pandemic. Of note, PIF was impacted by “heroic physicians” who served as exemplars for them. For some students, being removed from clinical settings represented a barrier to advancing PIF. The authors emphasize that this research is important because it adds to the body of literature about the utility of self-reflections in PIF as well as showing how the pandemic has affected conceptions of professionalism among trainees.

Preparing Doctors in Training for Health Activist Roles: A Cross-Institutional Community Organizing Workshop for Incoming Medical Residents. Emery EH, Shaffer JD, McCormick D, Zeidman J, Geffen SR, Stojicic P, Ganz M, Basu G. MedEdPORTAL. 2022 Jan 18;18:11208. doi: 10.15766/mep_2374-8265.11208. PMID: 35106380; PMCID: PMC8763867. Free full text Dr. Gaurab Basu and Danny McCormick have been Gold Foundation grantees
There is increasing recognition that health outcomes are strongly associated with social risk factors and structural forces and that physicians can play important roles as activists to address these. Yet formal programs to teach physicians how to become community leaders are largely missing. Dr. Eleanor Emery and colleagues developed a 3-hour educational workshop to familiarize resident physicians about community organizing and public narrative. 51 participants from 13 residency programs attended the workshop in June 2019. Surveys demonstrated that participants found the workshop valuable and agreed that the workshop achieved its learning objectives. In their comments, participants also indicated that workshop prompted interest in public narrative and community organizing. The authors intend to develop virtual modules focused on other community organizing leadership skills and conduct longer-term evaluations to determine how these interventions impact the knowledge and skill of participants.

Analysis of Depressive Symptoms and Perceived Impairment Among Physicians Across Intern Year. Meeks LM, Cleary J, Horwitz A, Pereira-Lima K, Zhao Z, Fang Y, Sen S. JAMA Netw Open. 2022 Jan 4;5(1):e2144919. doi: 10.1001/jamanetworkopen.2021.44919. PMID: 35076705; PMCID: PMC8790665. Free full text Dr. Karina Pereira-Lima and Dr. Srijan Sen have been Gold Foundation grantees.
The first year of residency, termed internship, can often be a difficult one, especially since there has historically been a normalization of depressive symptoms during training. Worse yet, this can skew residents’ perceptions of their own functioning, leading to potential risks for both physician trainees and for patients. But what is the degree of this association between depressive symptoms and perceived impairment? Dr. Lisa M. Meeks and colleagues examined this through analyzing data from 15,566 residents in the Intern Health Study. They correlated results from the Patient Health Questionnaire-9 (PHQ-9) Score, a validated self-report of depression symptoms, with self-perceived impairment both before and during intern year. They found that the mean severity of depressive symptoms viewed as functionally impairing increased during intern year, compared to immediately prior at all levels of self-perceived impairment. The authors suggest that this may be associated with “a rising bar,” i.e. “symptoms previously described as very impairing is normalized after entering internship as being somewhat impairing.”  This normalization of depressive symptoms has important implications for self-care of trainees as well as for maintaining high-quality patient care. The authors conclude by urging more research in this area, especially in investigating the basis of this link and in developing potential interventions to support mental health during the internship year.

Does Perceived Racism Affect Prostate Cancer Screening Rates and Patient-Provider Shared Discussions Among Black and White Men? Crittendon DR, LaNoue M, George B. J Health Care Poor Underserved. 2022;33(1):5-19. doi: 10.1353/hpu.2022.0003. PMID: 35153202. Dr. Marianna LaNoue has been a Gold Foundation grantee.
Prostate cancer is a leading cause of death for men living in the United States, and the burden of disease disproportionately affects Black men. Indeed, Black men are more likely to present with more aggressive cancer types, cancer at more advanced stages, and greater variation in their treatment compared to white men. The precise reasons are unclear, but disparate rates of screening using Prostate-Specific Antigen (PSA) may be a major contributor. To assess how perceived racism may be linked to prostate screening rates and shared medical discussions, Denine R. Crittendon and colleagues examined data from the Behavioral Risk Factor Surveillance System survey. They used propensity matching to compare populations of white men and Black men among the 63000 total respondents to yield a sample size of 18,918 men ages 45 to 65+; from that pool, the authors created a matched sample of 334 men in each group. Interestingly, screening rates between Black men and white men were statistically comparable, but Black men were significantly less likely than white men to receive shared decision-making conversations around the advantages and disadvantages of screenings. And although Black men reported greater perceived racism, there was no statistically significant effect on screening outcomes. The authors caution that there are limitations to these results; most notably, among the 18,918 respondents in the unmatched sample, there were only 641 Black men. Nevertheless, the difference in shared decision-making is an important result and one that needs further exploration as a target in interventions to advance equity in prostate cancer outcomes.

What’s Playing in Your Waiting Room? Patient and Provider Stress and the Impact of Waiting Room Media. Fryburg DA. J Patient Exp. 2021 Nov 29;8:23743735211049880. doi: 10.1177/23743735211049880. PMID: 34869835; PMCID: PMC8641118. Free full text
The healthcare environment can be a stressful place for both patients and healthcare team members. This stress can adversely affect the nature of relationships between patients and their healthcare team members. One widely used strategy to reduce such stress is to include televisions to distract viewers, particularly in waiting rooms. But not all media is the same. Dr. Fryburg discusses the need for positive media to reduce stress in the healthcare environment. In contrast to negative media, like news media, or neutral programming such as home and garden shows, positive media can decrease stress and anxiety and positively affect mood. Nature media, for example, has been shown to induce several physiological responses associated with relaxation, including heart rate, blood pressure, and facial tension. Kindness media, which demonstrates compassion, can also create a more positive mood and promote a sense of community. Dr. Fryburg concludes by noting the enormous potential of positive media to potentially heighten patient activation and engagement, along with improve clinician satisfaction and morale.

Virtue and care ethics & humanism in medical education: a scoping review. Doukas DJ, Ozar DT, Darragh M, de Groot JM, Carter BS, Stout N. BMC Med Educ. 2022 Feb 26;22(1):131. doi: 10.1186/s12909-021-03051-6. PMID: 35219311; PMCID: PMC8881825. Free full text  Dr. David Doukas, Dr. David Ozar, Martina Darragh, Dr. Janet de Groot, and Brian S. Carter have been Gold Foundation grantees. This study was funded in part by the Gold Foundation.
Medical ethics is central to humanistic healthcare, professionalism, and medical education. Virtue and care ethics are complementary subsets of medical ethics that are very closely tied to humanism. While virtue ethics focuses on how optimizing aspects of moral character predispose one to behaving in an ethical manner, care ethics is more relational, dealing with how moral reasoning occurs within the context of relationships. Despite the centrality of virtue and care ethics to humanism, it is unclear how virtue and care ethics has been implemented in medical curricula and how is it related to learner humanism in medical literature. To examine this, Dr. David Doukas and colleagues conducted a scoping review of 8 databases, identifying 811 records pertaining to these questions and ultimately including 25 for analysis. Among these 25, 8 detailed the full implementation of curricula. They identified nine distinctive themes and four side issues. They also identified three aspirational metaphors (“habits of the heart,” “a beacon on a map,” “learning to drive on the edge of tires”) and four detractive metaphors (“heroes vs. villains,” “ailing culture,” “bludgeon of ethics,” and “medical monasticism”). The authors hope that this manuscript serves “as a foundation for sound curriculum related to humanism” and that implementation will promote humanism among physicians.

Internal Medicine Residents’ Experience Performing Routine Assessment of What Matters Most to Patients Upon Hospital Admission. Burstein DS, Chretien KC, Puchalski C, Teufel K, Aivaz M, Kaboff A, Tuck MG. Teach Learn Med. 2022 Jan 22:1-12. doi: 10.1080/10401334.2021.2018696. Epub ahead of print. PMID: 35067146.
Soliciting patients’ values, goals, and priorities are extremely important in the promotion of patient-centered care, yet resident physicians often report difficulty incorporating these into their practice.  To understand how internal medicine residents approach taking these elements of the history, Dr. David S. Burstein and colleagues conducted an exploratory investigation and interviewed eligible residents about their experiences after completing their general wards rotations. Prior to and during their rotations, the resident physicians were encouraged to take a “personal history” from patients upon hospital admission, which focused on their values, goals, and priorities. Transcripts of interviews were then coded and analyzed. They found four themes: (1) taking a personal history had value, (2) situational and relational factors created barriers, (3) variability in buy-in with the proposed intervention affected effort, and (4) meaningful personal history taking could be an adaptive and longitudinal process. Overall, the resident physicians responded positively to the intervention. The authors conclude that taking patients’ personal history is feasible and that it may positively affect patient care.

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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.