Jeffrey Silver Humanism in Healthcare Research Roundup – July 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

Shared medical appointments and patient-centered experience: a mixed-methods systematic review      Free full text Wadsworth KH, Archibald TG, Payne AE, Cleary AK, Haney BL, Hoverman AS. BMC Fam Pract. 2019 Jul 8;20(1):97. Drs. Kim Wadsworth, Trevor Archibald, Allison Payne, Anita Cleary, Byron L. Haney, and Adam Hoverman are Mapping the Landscape grantees. Shared medical appointments (SMAs), or group visits, are an innovative healthcare delivery method that may be more responsive to patient needs. But what is the evidence to support their use and their impact on patient-centered care?  Dr. Kim Wadsworth and colleagues examined this question through a systematic review of over 1,632 articles. Collectively, they found 13 controlled trials, 11 qualitative papers, and two mixed method studies. They found that SMAs are highly variable, and factors like the quality of facilitative leadership, patient seating design, and degree of interprofessional involvement may drive improvements in efficacy and feasibility. As a whole, compared to usual care, the authors note that SMAs have “a greater ability to engage and empower patients as active participants.”  However, they caution that the lack of uniform satisfaction measures prevents overarching conclusions.

Transdisciplinary strategies for physician wellness: qualitative insights from diverse fields 

Schwartz R, Haverfield MC, Brown-Johnson C, Maitra A, Tierney A, Bharadwaj S, Shaw JG, Azimpour F, Thadaney Israni S, Verghese A, Zulman DM.   J Gen Intern Med. 2019 Jul;34(7):1251-1257. Dr. Abraham Verghese is a former Gold Foundation Trustee and gave both the 2011 and 2005 Jordan J. Cohen Humanism in Medicine Lecture at the AAMC. Burnout is a widespread and pressing problem among healthcare practitioners that has been associated with increased medical errors, job attrition, and physician distress. However, it is not unique to healthcare practitioners. What can we learn from how other professions deal with burnout and well-being?  Dr. Rachel Schwartz and colleagues examined this through a qualitative study of 30 professionals from outside the field of medicine. Through one-on-one interviews and analysis by an interdisciplinary team of physicians and health services researchers, they drew certain conclusions with relevance to healthcare practitioners. Among them were the importance of engagement by leadership, development of self-care practices, and promotion of meaningful engagement. The authors particularly highlight two novel strategies that have not yet been explored in the medical realm: (1) “emotional distancing strategies” that allow for emotional self-protection and (2) “bidirectional exchange” to emphasize moments of meaningful connection to patients. Further multidisciplinary research, according to the authors, may help to address this need further.

Promoting shared decision-making behaviors during inpatient rounds: a multimodal educational intervention Harman SM, Blankenburg R, Satterfield JM, Monash B, Rennke S, Yuan P, Sakai DS, Huynh E, Chua I, Hilton JF; Patient Engagement Project. Acad Med. 2019 Jul;94(7):1010-1018. Dr. Stephanie Harman is a Gold Professor. Shared decision-making (SDM), the process by which a patient and a physician make decisions together based on patient values and best clinical evidence, is associated with increased treatment adherence, lower healthcare expenditures, and decreased disease severity. However, translating these ideals into practice is often challenging. Dr. Harman and colleagues illustrate how to overcome them through an 8-week multimodal educational intervention within the inpatient hospitalist teaching programs at two academic centers. They used workshops, campaign messaging, report cards, and coaching to learn whether there were changes in the behaviors of 49 hospitalists. In order to identify improvements in SDM, they used the Rochester Participatory Decision-Making Scale (RPAD), a validated scale measuring SDM that ranges from 0 to 9 points. They found that after the intervention there was a mean increase of 1.68 points. While future research on the more long-lasting and more systemic impacts of such interventions are needed, this study provides a demonstration that educational interventions can prompt the adoption of SDM behaviors in the inpatient setting.

Pre-clerkship medical students’ perceptions of medical professionalism      Free full text Reimer D, Russell R, Khallouq BB, Kauffman C, Hernandez C, Cendán J, Castiglioni A.   BMC Med Educ. 2019 Jul 1;19(1):239. Drs. Caridad Hernandez, Juan Cendán, and Analia Castiglioni are Mapping the Landscape grantees. Professional identity formation (PIF) is a complex process by which a student integrates knowledge, skills, beliefs, values, and experiences to transform herself or himself into a physician with a set of unique core values, morals, ethical principles, and self-awareness. This process starts early in medical school, but how exactly this occurs remains poorly understood. Dr. Danielle Reimer and colleagues examined this process through a two-phase mixed-methods study. Specifically, they conducted four nominal group technique sessions with first- and second-year medical students to identify 27 professionalism attributes. They then employed a card-sorting exercise among 100 medical students to group them into seven professional domains. These seven include: (1) proficiency and lifelong learning, (2) image, (3) integrity, (4) self-management and patient-centeredness, (5) ethics and professional reputation, (6) self-awareness and self-improvement, and (7) dependability. While most student-identified domains were similar between M1’s and M2’s, M1’s had a greater focus on patient-centered care while M2’s focused more on advancement of the field. Although the authors note that this was only at one institution and had a limited number of participants, this provides a methodology and a starting point to better understand PIF among other groups of medical students.

Communicating uncertainty: a narrative review and framework for future research  Simpkin AL, Armstrong KA.  J Gen Intern Med. 2019 Jun 13. Dr. Arabella Simpkin is a Mapping the Landscape grantee. Despite major advances in medicine, there remains a lot of uncertainty in answering some basic questions. In an age of personalized healthcare and shared decision-making, how can this uncertainty be adequately characterized and communicated?  A narrative review by Drs. Arabella Simpkin and Katrina Armstrong describe uncertainty in the medical context and strategies to effectively communicate uncertainty. One challenge they note is that there are two types of uncertainty: aleatoric uncertainty (or chance, due to random variability) and epistemic uncertainty (due to incomplete knowledge). Distinguishing and communicating the subtleties of the two can help physicians select an appropriate clinical approach. While there is little published evidence about uncertainty, the authors group current approaches into four primary domains: (1) assessing patient preferences, (2) risk and ambiguity communication, (3) providing emotional support, and (4) clarification of contingency plans. They conclude by noting that discussion and reflection about uncertainty, although often uncomfortable, are essential for further exploration of the topic.

Physician Workforce Disparities and Patient Care: A Narrative Review      Free full text Silver JK, Bean AC, Slocum C, Poorman JA, Tenforde A, Blauwet CA, Kirch RA, Parekh R, Amonoo HL, Zafonte R, Osterbur D.   Health Equity. 2019 Jul 1;3(1):360-377. Drs. Julie Silver, Allison Bean, Chloe Slocum, Adam Tenforde, Cheri Blauwet, Rebecca Kirch, and Ranna Parekh are Mapping the Landscape grantees. Despite advances in increasing the diversity of the physician workforce over the past few decades, there still remain challenges for physicians from underrepresented minority groups, such as women, racial and ethnic minorities, sexual and gender minorities, and people with disabilities.  Not only are they are underrepresented in the field, but are also at increased risk for burnout and mental health issues as well as for reduced career duration.  A narrative review by Dr. Julie Silver and colleagues explores and characterizes these disparities and potential solutions.  Through a rigorous search methodology, they identified 199 relevant studies.  These studies document the specific challenges that each group faces, as well as potential solutions to help mitigate these disparities.  By providing a comprehensive list of possible targeted interventions, the authors call on organizations and institutions to further examine inequities and implement compensatory strategies.

Other Publications

Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients Cooper WO, Spain DA, Guillamondegui O, Kelz RR, Domenico HJ, Hopkins J, Sullivan P, Moore IN, Pichert JW, Catron TF, Webb LE, Dmochowski RR, Hickson GB.   JAMA Surg. 2019 Jun 19. Surgery is often compared to a team sport, with numerous healthcare team members coordinating with each other to improve patient outcomes and the surgeon serving as a leader to uphold professional behavior. To understand how such professionalism impacts postoperative complications, Dr. William Cooper and colleagues looked at 13,653 patients undergoing surgery in two academic medical centers participating the National Surgery Quality Improvement Program (NSQIP). They found that patients whose surgeons had more coworker reports were much more likely to have complications. Those with 1-3 reports had a 14.3% increased risk and those with 4 or more reports had a nearly 12% greater risk. Altogether, these findings suggest that addressing unprofessional behavior by surgeons may help optimize patient outcomes.

Burnout, and fulfillment, in the profession of critical care medicine  Mikkelsen ME, Anderson BJ, Bellini L, Schweickert WD, Fuchs BD, Prasad Kerlin M; Section of Medical Critical Care.   Am J Respir Crit Care Med. 2019 Jun 25. Among critical care physicians, burnout is a major problem, with as many as 45% of intensivists experiencing burnout. Long, often sleepless, hours and higher acuity of care are considered major contributors. To help address this, the Critical Care Societies Collaborative has suggested reducing the length of critical care rotations from 14 days to 7 days. To examine the potential effects of such a change, Dr. Mark Mikkelsen and colleagues at the University of Pennsylvania conducted a cross-sectional study of 29 physicians over the course of 9 months. They used the Stanford Professional Fulfillment Index (SPFI) and Well-Being Index (WBI) to document patterns in burnout and well-being throughout the 9 months, and compared burnout in those who had 14-day rotations with those who had 7-day rotations. They found that the odds of burnout for 14-day rotations was 5.5-fold higher than with 7-day rotations. Additionally, fulfillment and burnout varied considerably by rotation, suggesting that there are a lot of individual factors, both on rotations and outside rotations, that contribute to burnout and fulfillment. Altogether, the authors’ findings uphold the Critical Care Societies Collaborative’s hypothesis that longer rotations lead to more burnout.

Association between primary care practitioner empathy and risk of cardiovascular events and all-cause mortality among patients with type 2 diabetes: a population-based prospective cohort study      Free full text Dambha-Miller H, Feldman AL, Kinmonth AL, Griffin SJ.   Ann Fam Med. 2019 Jul;17(4):311-318. Much literature suggests empathic patient-centered care is associated with greater patient activation, empowerment, self-management, and treatment adherence. But can empathic patient care also improve outcomes in patients with such chronic diseases as type 2 diabetes?  Dr. Hajira Dambha-Miller and colleagues investigated whether practitioner empathy is associated with a lower incidence of cardiovascular disease events, like heart attacks, and all-cause mortality in those with type 2 diabetes mellitus. Specifically, they looked at data from the ADDITION-Cambridge Trial, which enrolled 867 individuals with type 2 diabetes and followed them up over 10 years to track long-term outcomes. These patients were also administered the Consultation and Relational Empathy (CARE) measure questionnaire, which assessed the degree of practitioner empathy. They found that positive patient experiences of practitioner empathy were associated with a 0.5-fold lower risk of all-cause mortality. There was also a trend toward a lower risk of cardiovascular events, but it did not reach statistical significance. While the authors caution that correlation does not prove causation, they do suggest that empathic healthcare can complement advances in genomics, metabolomics, proteomics, and technology in order to improve outcomes in chronic diseases like type 2 diabetes.

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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.