Jeffrey Silver Humanism in Healthcare Research Roundup – July 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

Designing Well-Being: Using Design Thinking to Engage Residents in Developing Well-Being Interventions Thomas LR, Nguyen R, Teherani A, Lucey CR, Harleman E. Acad Med. 2020 Jul;95(7):1038-1042. doi: 10.1097/ACM.0000000000003243. Drs. Larissa Thomas and Catherine Lucey are Mapping the Landscape grantees.
Design thinking (DT), also known as human-centered design, is a participatory approach to problem-solving that focuses on understanding emotions and human dynamics. Although it has been employed in other fields for decades, it has, so far, only rarely been used in medical education. Larissa Thomas and colleagues used design thinking to help develop approaches to support well-being among resident physicians at the University of California San Francisco.  To do so, they created an 8-month program that included 2-hour facilitated workshops every other month in line with a 5-step process articulated by the Institute of Design at Stanford University.  Empathy interviews were conducted with stakeholders to foster discussion and generate ideas for further sessions. Through this process, they identified four design principles: time for fun in everyday work, integrating resident needs and input, communities for peer support, and interventions at the right time and place.  These in turn led to major changes in the residency program: first, a near-peer community structure, which evolved into new resident peer support programs. Moreover, the authors interviewed 17 of the 18 resident physicians who participated in the design thinking program.  They found three overarching themes: the promotion of creative thinking for well-being, enhancement of trust in the residency program, and challenges with project work.  The authors conclude by stating that design thinking may be a suitable method for developing interventions in other spheres of medical education.  

Centering Patients, Revealing Structures: The Health Humanities Portrait Approach Sufian S, Blackie M, Michel J, Garden R. J Med Humanit. 2020 Jul 11. doi: 10.1007/s10912-020-09640-8. Drs. Sandy Sufian and Michael Blackie are Mapping the Landscape grantees.
It is fair to say that patients’ lives are extremely complex and that there is a lot of depth and breadth to the human and social dimensions of their lives.  But how can we teach health professions learners to examine these social issues?  Sandy Sufian and colleagues introduce the Health Humanities Portrait Approach as a means to incorporate this facet of humanism into curricula.  Borrowing from the fields of art, photography, and literature, the authors articulate five tenets that underlie Critical Portraiture, namely (1) texture, (2) perspective-taking, (3) centering the subject, (4) critical composition, and (5) tonality. They additionally introduce the Health Humanities Portrait (HHP), which is the pedagogical tool to advance educational delivery of such concepts. Unlike clinical cases, HHP uses patient-created stories to build contextual skills and structural competency to understand illness from a larger perspective. The HHP has been piloted at the University of Illinois-Chicago, through 9 HHPs, showing the feasibility of incorporating this into curricula. The authors hope to develop more portraits and to apply them into new settings and new audiences.

The DISCuSS model: Creating connections between community and curriculum – A new lens for curricular development in support of social accountability Goez H, Lai H, Rodger J, Brett-MacLean P, Hillier T. Med Teach. 2020 Jul 1:1-7. doi: 10.1080/0142159X.2020.1779919. Drs. Pamela Brett-MacLean and Tracey Hillier are Mapping the Landscape grantees.
There is increasing recognition in academic medicine that physicians have critical roles in reducing health inequities and addressing barriers to healthcare. To support this social accountability mission within the medical school curriculum, Helly Goez and colleagues at the University of Alberta created the DISCuSS model.  The DISCuSS model is composed of five steps to uphold the Diversity mandate: Identify gaps, Search literature, Create modules, Sustainability, Social accountability.  Over the past five years, they have developed nine curricular modules for medical students.  Data from the AFMC (Association of Faculties of Medicine of Canada Graduation) Questionnaire suggest that students have greater perception of preparedness to care for the underserved.  The authors conclude that this five-step model is a practical approach to addressing academic medicine’s social accountability mandate.

Childbearing Decisions in Residency: A Multicenter Survey of Female Residents Stack SW, Jagsi R, Biermann JS, Lundberg GP, Law KL, Milne CK, Williams SG, Burton TC, Larison CL, Best JA. Acad Med. 2020 Jun 16. doi: 10.1097/ACM.0000000000003549. Free full text   Drs. Shobha Stack and Jennifer Best are Mapping the Landscape grantees.
Residency is an exciting and busy time for physicians, where individuals are bridged between medical school and independent practice.  But for many, the busy pace of residency impacts decisions about personal and family life, specifically the decision to have children.  Shobha Stack and colleagues examine resident decision-making regarding childbearing through a survey of 804 female resident physicians in 78 graduate medical education programs and 25 specialties. They discovered that, among the 447 that were partnered or married, 61% decided to delay childbearing.  Being younger, not currently a parent, in a specialty with an uncontrollable lifestyle, or in a large program were statistically significantly correlated with this decision to delay childbearing. The overwhelming majority (93%) of these stated a busy work schedule played an important role in making this decision, and significant percentages cited a desire not to extend residency training (53%), lack of access to childcare (46%), financial concerns (42%), fear of burdening colleagues (35%), and concern for pregnancy complications (27%).  Regardless, only 38% were satisfied with this decision. Based on these data, the authors support initiatives to normalize parenthood in residency and taking a holistic approach to parenthood rather than focusing on pregnancy and childbirth as a sex-specific issue.

Pediatric Trainees’ Speaking Up about Unprofessional Behavior and Traditional Patient Safety Threats Kesselheim JC, Shelburne JT, Bell SK, Etchegaray JM, Lehmann LS, Thomas EJ, Martinez W. Acad Pediatr. 2020 Jul 13. pii: S1876-2859(20)30435-6. doi: 10.1016/j.acap.2020.07.014. Dr. Sigall Bell is a Gold Professor and a Mapping the Landscape grantee.
Physicians are expected to be professional in their behavior, and professionalism is recognized as an important pillar for patient safety.  But what happens when unprofessional behavior is observed?  Jennifer Kesselheim and colleagues examined pediatric trainees views on speaking up about unprofessional behavior and patient safety threats through a survey of 512 pediatric trainees at two large US academic children’s hospitals.  They found that, among the 223 (44%) who responded to the survey, unprofessional behavior was observed more frequently than traditional safety threats (57% vs. 34%). However, of those who observed such behavior, speaking up about unprofessional behavior was much lower than speaking out about safety threats (48% vs. 79%). In vignettes provided to participants, only one in 10 pediatric trainees was likely to speak up to an attending physician using assertive language; even when there was high perceived potential for patient harm, only one in five voiced that they would speak up assertively in such a scenario. The investigators attribute this to a fear of conflict, which may be addressed through policy and leadership commitments to promoting, normalizing, and protecting speaking up.

The Role of Power in Health Care Conflict: Recommendations for Shifting Toward Constructive Approaches Bochatay N, Kuna Á, Csupor É, Pintér JN, Muller-Juge V, Hudelson P, Nendaz MR, Csabai M, Bajwa NM, Kim S. Acad Med. 2020 Jul 14. doi: 10.1097/ACM.0000000000003604. Free full text Dr. Sara Kim is a Mapping the Landscape grantee.
In recent decades, there has been a movement toward engaging healthcare professionals from multiple specialties and backgrounds in team-based care.  However, conflicts may arise among teams, and stem from the distribution and display of power.  Naike Bochatay and colleagues conducted semistructured interviews with 249 healthcare professionals in the United States, Switzerland, and Hungary to understand conflict through the prism of the six social bases of power (positional, expert, informational, reward, coercive, referent).  They determined that social bases of power, particularly positional, expert, and coercive, were comparable across the sites. However, rigid hierarchies contributed to negative experiences in conflicts, particularly in Hungary, where 97% of conflict stories involved power struggles.  Compounding the problem was the presence of an audience, which made addressing conflict in a timely manner much more difficult. Based on these findings, the authors suggest greater leverage of referent power (representing “charisma and the ability to inspire,” such as modeling positive behavior) to help resolve conflict, and addressing conflict in a more private backstage manner.

Public Perceptions of Advance Care Planning, Palliative Care, and Hospice: A Scoping Review Grant MS, Back AL, Dettmar NS. J Palliat Med. 2020 Jul 2. doi: 10.1089/jpm.2020.0111. Dr. Anthony Back is a Mapping the Landscape grantee.
Advance care planning (ACP), palliative care, and hospice care are important elements of healthcare infrastructure and help patients to have better quality of life during serious, life-threatening illnesses.  However, the public at large is often unfamiliar with ACP, palliative care, and hospice, leading to perceptions that may differ from clinicians. Marian Grant and colleagues conducted a scoping review to describe these public perceptions, ultimately finding 12 studies with 9,800 participants meeting their inclusion criteria. About 80-90% and 86% were aware of ACP and hospice, respectively, but, in regards to palliative care, 66 to 71% reported no awareness. However, when prompted with a definition, 95% had favorable attitudes of palliative care.  For hospice, 70-91% considered it favorable, but 37% had significant misconceptions. And despite high public awareness of ACP, studies show most people have not been moved to name a healthcare proxy decision maker or complete a written directive. The authors conclude that ACP, palliative care, and hospice care have very different levels of awareness, perceptions of importance, and reports of action taking, and therefore have distinct challenges in reaching the public. They note that such research is critical in developing a successful public messaging campaign, and suggest that the COVID-19 pandemic may shift perceptions and require further research.

Palliative Care’s Role Managing Cancer Pain During the Opioid Crisis: A Qualitative Study of Patients, Caregivers, and Clinicians Brooks JV, Poague C, Formagini T, Roberts AW, Sinclair CT, Keirns CC. J Pain Symptom Manage. 2020 Jul 6. pii: S0885-3924(20)30583-2. doi: 10.1016/j.jpainsymman.2020.06.039. Dr. Carla Keirns is a Mapping the Landscape grantee.
Adequate management of pain in cancer patients is often difficult, leading to reduced quality of life. Fortunately, the specialty of palliative care (PC) is expanding its role in symptom management, but many questions remain about perceptions and experiences of cancer pain, especially with regards to opioid use.  To answer this gap in knowledge, Joanna Brooks and colleagues conducted 44 interviews with patients, caregivers, and non-palliative care healthcare professionals. Transcripts of these interviews were then analyzed using grounded theory. Overall, they found that PC facilitated appropriate pain management and destigmatized opioid use, including fear of addiction. These findings suggest that PC may have a broad role in collaborating with patients and other healthcare practitioners in delivering effective pain relief.

Bedside Education in the Art of Medicine (BEAM): an Arts and Humanities Web-Based Clinical Teaching Resource Zhang CM, Kelly-Hedrick M, Lehmann SW, Gelgoot EN, Taylor AK, Chisolm MS. Acad Psychiatry. 2020 Jun 30. doi: 10.1007/s40596-020-01270-5. Dr. Margaret Chisholm is a Mapping the Landscape grantee.
It has been suggested that greater incorporation of the arts and humanities into clinical practice may help to further reflection of the human aspects of caring for patients. But arts and humanities have only rarely been integrated into bedside clinical teaching. To help facilitate that, Christiana Zhang and colleagues developed the Bedside Education in the Art of Medicine (BEAM) app, a free, open-access arts- and humanities-based mobile app. The app allows the user to find pieces of art tagged to particular theme (such as suffering or joy) in order to prompt discussion and reflection. In a pilot study of 15 resident physicians and 7 medical students among four inpatient teaching teams, they found that using the BEAM app deepened connections between the patient and practitioner, led to appreciation of a dedicated time and space to discuss the patient as a person, and upheld effectiveness of using art to foster discussion and dialogue. The makers of BEAM hope to expand the use of their app to encourage conversations about humanism in other contexts worldwide.

The ‘exotic other’ in medical curricula: Rethinking cultural diversity in course manuals Zanting A, Meershoek A, Frambach JM, Krumeich A. Med Teach. 2020 Mar 11:1-8. Free full text   Dr. Janneke Frambach is a Mapping the Landscape grantee.
Teaching medical students about cultural diversity is an important priority, but it is often understated in curricula.  Albertine Zanting and colleagues performed an exploratory, qualitative content analysis on three curricula in the Dutch and English languages.  They synthesized an overarching theme, that culture is an exotic problematic “other,” as compared to an implicit Dutch or Western standard.  This theme was mediated by four mechanisms: culture is (not) relevant, patients and strangers, static stereotypes, and correlation or causation.  The authors conclude by suggesting greater incorporation of pertinent and non-stereotypical cultural trainings to contribute to equitable healthcare.

Addressing Patient Bias Toward Health Care Workers: Recommendations for Medical Centers Paul-Emile K, Critchfield JM, Wheeler M, de Bourmont S, Fernandez A. Ann Intern Med. 2020 Jul 14. doi: 10.7326/M20-0176. Dr. Alicia Fernandez is a Gold professor.
Unfortunately, more than half of physicians, nurse practitioners, and registered nurses have encountered identity-based patient bias. These situations lead to uncomfortable questions about the ethically correct way to resolve such situations. To address such problems, Kimani Paul-Emile and colleagues recommend systematic institutional approaches to responding to biased patients. These recommendations include, among others, writing policies that explicitly address situations of patient bias, establishing procedures that account for clinical roles and services, establishing trainee-specific procedures, and creating mechanisms for reporting patient bias toward healthcare workers and support for persons within the organization to use it.  They exhort the medical profession to expand awareness at all levels of practice and training about the problem, and highlight that instituting such policies upholds the well-being of both practitioners and patients.

Other Publications 

The little things: Exploring perceptions and experiences of client and family-centred care through photovoice Nizzer S, Ryan S, McKay SM. Patient Experience Journal: Vol. 7 : Iss. 1 , Article 6. doi: 10.35680/2372-0247.1368.   Free full text
In recent years, there has been increased focus on client-and-family-centered care (CFCC), a paradigm that prioritizes patients and their families at the center of healthcare.  However, there’s little known about CFCC in the context of children with complex care.  Sonia Nizzer and colleagues performed a qualitative study using photovoice to explore this further.  They identified seven caregivers and instructed them to take photographs to understand their perspectives.  They then interviewed them to examine the photographs in more detail.  They found seven themes: (1) provider qualities and relationship, (2) beyond the care plan, (3) consistency, (4) communication, (5) respect our home, (6) human dignity, and (7) put yourself in our shoes.  The investigators referred to these themes by the colloquial phrase “the little things,” noting that they encapsulate small, non-clinical practical gestures and may more truly reflect CFCC.  They hope that arts-based tools may help in transforming healthcare environments to better incorporate CFCC.

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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.