Jeffrey Silver Humanism in Healthcare Research Roundup – July 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.

Tell Me More®: A medical student focused humanistic communication model to enhance student professional identity formation through meaningful patient encounters Bhuiya T, Zhong X, Pollack G, Fornari A, Ahuja TK. Patient Educ Couns. 2021 Jul 6:S0738-3991(21)00430-4. doi: 10.1016/j.pec.2021.06.031. Epub ahead of print. PMID: 34281722. Drs. Alice Fornari and Taranjeet Ahuja are Gold partners in implementing Tell Me More®, a program of the Gold Foundation.
Professional Identity Formation (PIF) refers to the ways in which “medical education is a multifaceted, individualized process in which medical students develop new ways of being as they are becoming physicians.”  A major aspect of PIF is fostering compassionate communication skills that enhance the patient-practitioner relationship. To that end, The Arnold P. Gold Foundation in collaboration with the Icahn School of Medicine at Mount Sinai developed the Tell More More (TMM)® program in 2014. The TMM program provides a template for guided interviews to help capture patients’ stories outside of their medical symptoms and then display them on a poster. Tanzim Bhuiya and colleagues collected 63 reflections from 14 students enrolled in the TMM® program from throughout the Northwell Health system, and then used content analysis to identify underlying themes. They ultimately found 6 themes: (1) Connection, (2) Humanism, (3) Discovery, (4) Impact, (5) Privilege, and (6) Perspective. Altogether, they found that TMM® is a replicable and low-resource program that can provide educational opportunities to support PIF by medical students.

A review of nursing position statements on racism following the murder of George Floyd and other Black Americans Knopf A, Budhwani H, Logie CH, Oruche U, Wyatt E, Draucker CB. J Assoc Nurses AIDS Care. 2021 Jul-Aug 01;32(4):453-466. doi: 10.1097/JNC.0000000000000270. PMID: 34171884.
The killing of unarmed Black Americans in 2020, including Ahmaud Arbery, Breonna Taylor, and George Floyd, prompted a national outcry against racism and police brutality. In response, three major professional nursing organizations, the American Academy of Nursing, the American Association of Colleges of Nursing, and the American Nurses Association, issued their own position statements in June 2020. Dr. Amelia Knopf and colleagues conducted a thematic analysis for “identifying, interpreting, naming, and describing recurrent patterns” within these texts. They then examined position statements from 18 leading nursing schools to determine the presence of these themes. They found six themes: (1) condemnation of police brutality, (2) acknowledgment of the effects of racism on health, (3) calls to combat racism, (4) calls to end systemic racism, (5) calls to stand by or support those working against racism or discrimination, and (6) calls for respect for all persons. These themes were highly prevalent among the nursing school position statements, although the specific wording may differ. These results suggest that positions statements between leading nursing schools align with those of national professional organizations, a necessary step in advancing anti-racist health care reforms. This alignment, the authors conclude, can help “train the next generation of nurses to combat the toxic effects of racism in health care.”

Can sharing clinic notes improve communication and promote self-management? A qualitative study of patients with COPD Fisher KA, Kennedy K, Bloomstone S, Fukunaga MI, Bell SK, Mazor KM. Patient Educ Couns. 2021 Jun 8:S0738-3991(21)00402-X. doi: 10.1016/j.pec.2021.06.004. Epub ahead of print. PMID: 34175167. Dr. Sigall K. Bell, a Gold Professor, has been a Gold Foundation grantee.
“Open notes,” that is, clinic notes that are shared between patients and their practitioners so that patients can review them, hold the promise of improving communication and promoting patient engagement. However, little is known about how open notes impact patients with chronic illnesses. Dr. Kimberly Fisher and colleagues examined how open notes impact communication and self-management among patients with chronic obstructive pulmonary disease (COPD). To do so, they (1) provided patients with their prior clinic visit note and asked them to “think aloud” about their impressions, (2) administered a 14-item questionnaire regarding health literacy, and (3) abstracted their pulmonary function test results from the health record. In the 30 patients, they found that open notes supported four functions of the six-function communication framework: (1) exchanging information, (2) enabling self-management, (3) fostering the relationship, and (4) managing uncertainty. Altogether, by enhancing these functions, it may be possible to reduce COPD exacerbations and hospitalizations as well as improve health-related quality of life. The authors concluded by advocating for more research to ensure notes are written in ways that optimize communication while fulfilling other functions of clinical documentation.

How do children and adolescents experience healthcare professionals? Scoping review and interpretive synthesis Davison G, Kelly MA, Conn R, Thompson A, Dornan T. BMJ Open. 2021 Jul 9;11(7):e054368. doi: 10.1136/bmjopen-2021-054368. PMID: 34244289. Free full text Drs. Martina Ann Kelly and Tim Dornan have been a Gold Foundation grantees.
Currently, children and adolescents (CAD) largely experience healthcare as part of a family unit. But with a move toward children-centered care (CCC), there is greater emphasis on understanding the experiences and perspectives of sick children and adolescents. To that end, Dr. Gail Davison and colleagues conducted a scoping review of 99 included studies to gather evidence on CADs’ experiences of healthcare practitioners (HCPs). They then used these results to conduct two focus groups for further consolidation and elaboration of an interpretive synthesis. Favorable experiences were of forming trusting relationships and being involved in healthcare discussions and decisions; less favorable experiences included not relating to or being unable to trust HCPs and/or being excluded from conversations about them. HCPS can form trusting relationships by being “personable, wise, sincere, and relatable” and including CADs in conversations, explaining medical information, and listening to wider needs and preferences. The authors concluded that, in order to achieve the vision of CCC, there remains a pressing need for “communication strategies, training, assessments, and feedback (from CADs, specifically) at both the undergraduate and postgraduate levels of health professions education.”

“We can’t just have a casual conversation”: An institutional ethnography-informed study of work in labour and birth Brydges R, Nemoy L, Campbell DM, Meffe F, Moscovitch L, Fella S, Chandrasekaran N, Bishop C, Khodadoust N, Ng SL. Soc Sci Med. 2021 Jun;279:113975. doi: 10.1016/j.socscimed.2021.113975. Epub 2021 Apr 29. PMID: 33964590.
Labor and delivery units have increasingly become interprofessional, with obstetrics, nursing, and midwifery practices coexisting in the care of pregnant patients. However, these interactions may also generate considerable conflict. To examine this dynamic, Dr. Ryan Brydges and colleagues engaged in change-oriented inquiry informed by institutional ethnography (IE) at an urban academic hospital in Toronto, Canada. They used critical incident analysis reports to document issues regarding transfers of care and consultation and contextualized them through interviews with relevant participants, analysis of everyday/every night work processes, and correlation with local and national texts. This methodology helped to uncover otherwise hidden links between the work of practitioners and their social organizations. They found three work processes regarding consultation that presented interprofessional challenges. In each, there were discordances and subjectivities in “textual coordinators” like regulatory practice protocols, local ruling policies, and cultural expectations that became drivers and limiters in how professionals provide care. Although social organizations vary considerably, this approach to uncover the dynamics of interprofessional conflict may be useful in prompting informed and sustained change.

A longitudinal study exploring learning environment culture and subsequent risk of burnout among resident physicians overall and by gender Dyrbye LN, West CP, Herrin J, Dovidio J, Cunningham B, Yeazel M, Lam V, Onyeador IN, Wittlin NM, Burke SE, Hayes SN, Phelan SM, van Ryn M. Mayo Clin Proc. 2021 Jul 1:S0025-6196(21)00067-7. doi: 10.1016/j.mayocp.2020.12.036. Epub ahead of print. PMID: 34218879. Drs. Liselotte N. Dyrbye and Colin P. West have been Gold Foundation grantees.
Burnout symptoms are highly prevalent among resident physicians and lead to a variety of negative outcomes, including suboptimal professional behaviors, medical errors, lower scores on national in-training examinations, and regrets about career and specialty choice. Studies have demonstrated that female residents are more likely than male residents to experience burnout, but little is known about how learning environments contribute to this disparity. To examine this, Dr. Liselotte Dyrbye and colleagues administered a survey to 4,696 resident physicians which included items on interpersonal experiences, psychological safety and bias, inclusion, respect, and justice, unfair treatment, and two items from the Maslach Burnout Inventory. Using data from 2,888 resident physicians that answered in both their second and third years of residency, they identified a few trends. Women reported more negative interpersonal experiences and unfair treatment than men in their second year of residency, and, in their third year, women were more likely than men. Additionally, second-year residents who reported more negative interpersonal experiences were more likely to have burnout in their third year. Interestingly, these factors did not vary in effect magnitude by gender. Altogether, the authors conclude that “the differences in burnout were due to level of exposure rather than differential impact of an exposure between men and women.”  This also reinforces the need for “system-level interventions that improve psychological safety, eliminate bias, address inclusion and respect, and ensure justice for all learners.”

Recent trends in faculty promotion in U.S. medical schools: Implications for recruitment, retention, and diversity and inclusion Xierali IM, Nivet MA, Syed ZA, Shakil A, Schneider FD. Acad Med. 2021 Jun 1. doi: 10.1097/ACM.0000000000004188. Epub ahead of print. PMID: 34074899. Dr. Marc Nivet is a former Gold Foundation Board member.
Increasing diversity and inclusion among medical school faculty is a major priority among academic departments. However, little is known about patterns of faculty promotion with respect to gender, race/ethnicity, department, tenure status, and degree type. Dr. Imam M. Xierali and colleagues sought to examine these patterns using the Association of American Medical Colleges (AAMC) Faculty Roster. They looked at promotion status for full-time assistant and full-time associate professors who started between 2000 and 2009 and followed them for the following decade. They then used bivariate analyses to identify correlations by sex, race/ethnicity, department, tenure status, and degree type. Among the 52,126 assistant professors and 23,103 associate professors, they found a promotion rate of 37.1% in clinical science departments, 44.3% in basic science departments, and 33.6% in other departments. At the assistant professor level, women (36.3%), minorities underrepresented in medicine (31%), nontenured (32.5%), and those holding degrees other than MD, DO, OHD, or PhD (20.6%) had lower levels of promotion. At the associate professor level, disparities were less pronounced and women were promoted at equivalent rates to men. The authors emphasize the need for further research into the drivers of these disparities and interventions to address them.

Remote shared decision making through telemedicine: A systematic review of the literature Hartasanchez SA, Heen AF, Kunneman M, García-Bautista A, Hargraves IG, Prokop LJ, May CR, Montori VM.Patient Educ Couns. 2021 Jun 11:S0738-3991(21)00411-0. doi: 10.1016/j.pec.2021.06.012. Epub ahead of print. PMID: 34147314. Drs. Marleen Kunneman, Victor Montori, and Ian Hargraves have been Gold Foundation grantees.
The COVID-19 pandemic has accelerated the adoption of telemedicine, but with this change comes important questions about how telemedicine can uphold humanistic care. More specifically, how can telemedicine uphold shared decision-making between clinicians and patients to co-produce evidence-based, sensible, and feasible responses to the problematic situation of the patient?  To answer this, Dr. Sandra Hartasanchez and colleagues conducted a systematic review of remote shared decision-making. They identified 12 eligible articles. Themes from the articles included practical issues, technology and communication quality, satisfaction, and empowerment. Unfortunately, the literature on remote SDM remains sparse and heterogeneous when it comes to outcomes. Based on this, the authors propose a research agenda and advocate for “innovation, design, implementation, and effectiveness research to advance remote SDM.”

Do I belong here? Confronting imposter syndrome at an individual, peer, and institutional level in health professionals Rivera N, Feldman EA, Augustin DA, Cacares W, Gans HA, Blankenburg R. MedEdPORTAL. 2021 Jul 6. doi: 10.15766/mep_2374-8265.11166.  Free full text
Imposter syndrome is “the internalized feeling of self-doubt and not belonging in a particular group that can lead to the fear of being discovered as a fraud.”  It is common among physicians, particularly among underrepresented minority groups. Dr. Nancy Rivera and colleagues designed a 75-minute interactive workshop, composed of small-group case discussions, large-group instruction, and individual reflection, to help participants reflect on and address imposter syndrome. Participants also received an 8-item postworkshop evaluation form to assess the efficacy of the workshop. Among the 90 participants, 92% felt that it met objectives, with equivalent percentages expressing that “the workshop was a valuable use of my time,” “handouts include useful resources” and “I will apply information learned today to develop a workshop in the future.”  While longer-term outcomes on practice changes are still forthcoming, the authors concluded that the workshop is helpful for learners to recognize and address imposter syndrome.

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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.