Jeffrey Silver Humanism in Healthcare Research Roundup – June 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  

Adverse Childhood Experiences in Trainees and Physicians With Professionalism Lapses: Implications for Medical Education and Remediation Williams BW, Welindt D, Hafferty FW, Stumps A, Flanders P, Williams MV. Acad Med. 2020 Jun 9. Frederic Hafferty is a Mapping the Landscape grantee.      About 20% to 50% of medical students and resident physicians report having at least one adverse childhood experience (ACE), such as exposure to physical or sexual abuse, neglect, or loss of a parent. These adverse childhood experiences are strongly correlated with medical and mental health issues, but little is known about how ACEs impact professionalism. To understand this, Betsy Williams and colleagues looked at 123 cases of U.S. physicians and trainees referred to a Midwestern center for assessment and remediation of unprofessionalism. Each participant answered the ACE questionnaire to quantify ACE exposure and completed a psychosocial developmental interview to explore both the ACEs and unprofessional behavior. They found that 70% (n=86) of individuals had at least 1 ACE, and 22% (n=27) reported 4 or more. Physical or sexual abuse, feeling unwanted or unloved, witnessing abuse of their mother or stepmother, or caretaker substance abuse were ACEs that particularly predicted reasons for referral. To help these physicians and trainees, the authors advocate beginning from a “position of compassion and one that seeks data and understanding.” They also recommend faculty apply principles of trauma-informed medical education (TIME), a paradigm of medical education that embraces “sensitivity, collaboration, rapport building, and fostering a sense of choice and control.”

The Relationship Between Residents’ Perceptions of Residency Program Leadership Team Behaviors and Resident Burnout and Satisfaction Dyrbye LN, Leep Hunderfund AN, Winters RC, Moeschler SM, Vaa Stelling BE, Dozois EJ, Satele DV, West CP. Acad Med. 2020 Jun 9. Colin West and Liselotte Dyrbye are Mapping the Landscape grantees. Burnout during residency remains a major problem and contributes to adverse outcomes for well-being, patient care, and professional development. Because many risk factors for burnout are systemic and organizational in nature, Lotte Dyrbye and colleagues hypothesized that less favorable leadership behaviors by program directors and associate program directors are associated with burnout and decreased satisfaction. In order to test this hypothesis, they sent surveys to 1,146 resident physicians within the 77 graduate medical education training programs run by the Mayo Clinic. They used the Mayo Clinic Leadership Survey, two questions from the Maslach Burnout Inventory, and a single question on satisfaction to create a composite residency leadership team scale. From the data of 762 residents who responded (66.5%), they determined that for every 1-point gain in the composite leadership team score, there were 9% lower odds of burnout, 20% higher odds of program satisfaction, and 19% higher odds of satisfaction with the organization. Based on these data, the authors recommend studying whether leadership training could be a viable approach to improve resident well-being and satisfaction.

How Do Standardized Patients Form Their Complex Identities? The Impact of Interactions With Medical Students Starr SA, Plack MM, Lewis KL, Blatt B. Simul Healthc. 2020 May 27. Benjamin Blatt is a Gold Foundation grantee. Standardized Patients (SPs) have been used for more than a half-century to help evaluate and provide feedback for students in simulated clinical encounters. But SPs are more than just educational instruments; these individuals have complex identities that inform their ability to educate medical students effectively. Samantha Starr and colleagues examined this through a set of semi-structured focus group interviews with 18 SPs. They utilized content analysis to synthesize four major themes: (1) identity transformation toward a new professional identity, (2) self-actualization toward maximal potential, (3) judgmental reactions to medical student behaviors, and (4) simulation-reality interaction between their simulated and real selves. Overall, through their interactions and experiences with medical students, SPs develop a complex identity with multiple roles. These lead to a newfound sense of purpose and fulfillment associated with challenges of navigating between their “real selves” and “simulated selves.” The authors offer recommendations to SP educators related to each of the four themes, actions that may help in training, recruiting, and retaining SPs.

A Faculty Development Graduate Medical Education Retreat to Teach and Address Social Determinants of Health Martinez J, Fornari A, VanHuse V, Fried E, Uwemedimo OT, Kim EJ, Conigliaro J, Yacht AC. J Med Educ Curric Dev. 2020 May 15;7:2382120520915495. Alice Fornari is a Gold Foundation grantee and presented at the 2019 Gold Humanism Summit.
Social determinants of health (SDH) refer to social, economic, and environmental factors impacting health and well-being. They account for 60% of health outcomes, but education about SDH, especially at the graduate medical education (GME) level seems to be lagging. Johanna Martinez and colleagues at the Donald and Barbara Zucker School of Medicine at Hofstra /Northwell sought to address this by creating a one-day retreat for clinician-educator faculty. The retreat, titled “Social Determinants of Health: Walking in Your Patients’ Shoes,” was designed to promote reflection about SDHs and develop feelings of empowerment with regards to SDH. They evaluated the efficacy of the curriculum through electronic surveys immediately after and 3 months after the retreat. Among the 134 respondents, nearly 90% planned to enhance SDH training in their GME programs and 97% reported making a change to their curriculum or clinical workflows within 3 months. The authors conclude by stating that this can “serve as a model to the GME community on how to start to develop ‘physician-citizens.’”

Reconceptualizing Ethics through Morbidity and Mortality Rounds Snelgrove R, Ng SL, Devon K. J Am Coll Surg. 2020 May 29. Stella Ng is a Gold Foundation grantee.
Surgeons often encounter difficult situations that require complex ethical reasoning, yet surgical education largely focuses on technical knowledge and clinical judgment. One reason that has been suggested for this lack of emphasis on ethics in formal education may be a lack of training or familiarity. To remedy this, the Division of General Surgery at the University of Toronto instituted monthly Ethics Morbidity and Mortality (M&M) rounds. These rounds focused on integrating ethical reasoning with examination of physiological complications by dedicating at least 30 minutes to the ethical complications of care. They conducted semi-structured interviews with 21 participants (9 resident physicians and 12 faculty members) to examine the perspectives of participants. They discovered that participants saw ethics principles as learnable and a transformable part of identity, and that ethics is integral to surgical practice. The authors note that by incorporating ethics into an “engaging and valuable” educational conference, they were able to shift attitudes about ethics and prompt integration of ethical principles into professional identity.

Burnout among Academic Clinicians as It Correlates with Workload and Demographic Variables Nassar AK, Reid S, Kahnamoui K, Tuma F, Waheed A, McConnell M. Behav Sci (Basel). 2020 May 27;10(6). Megan McConnell is a Mapping the Landscape grantee.
Burnout is a psychological state resulting from prolonged exposure to job stressors. It is commonly characterized as having three dimensions: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). But what are the specific risk factors associated with each of these dimensions? Aussama Nassar and colleagues surveyed 326 faculty members at McMaster University to identify these risk factors. They used a modified version of the Maslach Burnout Inventory that asked questions about how three categories of burnout sources (trainees, patients, and administration) related to the three dimensions of burnout. They then correlated demographic data with these results. They found that younger age, female gender, surgical specialty, low academic rank, academic main practice, numerous night shifts, living alone, and higher patient volume were associated with higher EE and DP scores. These insights may help to craft better interventions, especially at the administrative level, for higher risk groups, e.g. surgeons, females, and younger staff members.

Applying the Theory of Gendered Organizations to the Lived Experience of Women with Established Careers in Academic Medicine Balmer DF, Courts KA, Dougherty B, Tuton LW, Abbuhl S, Hirshfield LE. Teach Learn Med. 2020 May 27:1-10. Laura E. Hirshfield is a Mapping the Landscape grantee.
Despite nearly 20 years of parity between the number of women and men entering the medical field, there remain significant gender inequities that impact the quality of professional life for women. Dorene Balmer and colleagues used the Theory of Gendered Organizations to understand how these inequities manifest themselves and lead to effects on women. At the University of Pennsylvania, they interviewed 30 participants and performed content analysis on the transcripts. Through this analysis, they found that informal workplace interactions misaligned with formal expectations, particularly with regards to faculty promotion and salary. Participants recognized gender inequity as embedded within the organization and, as a result, advocated for themselves and for junior women faculty. The authors conclude by stating that “to be successful [in addressing gender inequity], change strategies must resonate with women’s experiences.”

Mental Health of Young Physicians in China During the Novel Coronavirus Disease 2019 Outbreak Li W, Frank E, Zhao Z, Chen L, Wang Z, Burmeister M, Sen S. JAMA Netw Open. 2020 Jun 1;3(6):e2010705. Srijan Sen is a Mapping the Landscape grantee.   Free full text
COVID-19 continues to be a growing worldwide public health challenge that is adversely affecting the physical and mental well-being of physicians and other healthcare personnel. Weidong Li and colleagues were conducting a longitudinal survey of resident physicians in China when the COVID-19 outbreak started, and so were able to document how the outbreak impacted anxiety, depression, and workplace violence. More specifically, they surveyed 726 Chinese residents 2 weeks before starting residency and 3 months afterwards (before the outbreak) and then 6 months after starting residency (during the outbreak), using the Generalized Anxiety Disorder-7 (GAD-7) scale, Patient Health Questionnaire-9 (PHQ-9), and additional questions about workplace violence. They determined that there was a statistically significant increase in symptoms of anxiety and depression as well as fear of violence, observed violence, and experienced violence. These results highlight the need to provide support and access to mental health services as the pandemic continues its course.

Ethnic and Racial Diversity in Academic PM&R Compared to All Other Medical Specialties Sanchez AN, Martinez CI, Stampas A, Pedroza C, Escalon MX, Silver JK, Frontera J, Verduzco-Gutierrez M. Am J Phys Med Rehabil. 2020 Jun 1.  Julie K. Silver is a Mapping the Landscape grantee.     
Diversity within healthcare is important in creating an environment in which different opinions and ideas are represented and reflected. Indeed, as Ashley Sanchez and colleagues note, “Physician diversity drives medical excellence and positively impacts academia, creating an atmosphere where different thoughts and opinions can be freely expressed and refined through collaboration”. There is data which suggests that patients look for physicians who look like them, share their experiences, and/or speak their native language. In turn, diversity among physician trainees and within the workforce may lead to improved patient experience and outcomes as well as having the potential to help to address health inequities. This diversity is not only driven by recruitment of diverse applicants but also retention with faculty promotion. Sanchez and colleagues looked at ethnic and racial diversity within academic medicine and found that it was significantly disproportionate, a trend that was also present within Physical Medicine & Rehabilitation (PM&R) programs in the United States. They found that, compared to Whites of comparable academic rank, there was a 89%, 90% and 62% decreased odds of being African American, Hispanic, or Asian. This disparity was worst for full professors, where the odds of being African American, Hispanic, or Asian decreased to 99%, 96%, and 90%, respectively. The magnitude of these results, and their implications suggests the pressing need to implement more robust initiatives to recruit, promote, and retain underrepresented racial and ethnic minorities at all levels of training and practice within the PM&R community.

Leadership training programs in graduate medical education: a systematic review Kumar B, Swee ML, Suneja M. BMC Med Educ. 2020 Jun 2;20(1):175. Bharat Kumar and Manish Suneja are Mapping the Landscape grantees. The study was funded in part by the Gold Foundation.  Free full text
As the healthcare profession and society at large adapts to changing societal standards and technology, high-quality leadership becomes increasingly important. But how can we develop effective physician leaders? Bharat Kumar and colleagues conducted a systematic review to examine leadership development programs in graduate medical education, specifically focusing on their efficacy and their methodological rigor. They found 15 studies, but the vast majority of these studies only tracked participants for short periods of time and for knowledge, rather than pragmatic application of skills. The authors stress the need for better structured interventions that more transparently document how leadership training programs can empower physicians to lead change.

Other Publications

Disparities In Outcomes Among COVID-19 Patients In A Large Health Care System In California Azar KMJ, Shen Z, Romanelli RJ, Lockhart SH, Smits K, Robinson S, Brown S, Pressman AR. Health Aff (Millwood). 2020;101377hlthaff202000598. Free full text
As COVID-19 infections continue to rise within the United States, disturbing patterns have begun to emerge regarding health disparities. Indeed, racial and ethnic minorities as well as socioeconomically disadvantaged groups are bearing a disproportionate burden of illness and death. Kristen Azar and colleagues examined 1,052 confirmed COVID19 cases between January and April 2020 at Sutter Health, a large not-for-profit integrated health system in northern California. They linked the presence and suspected presence of disease to demographic variables such as race/ethnicity, sex, age, and socioeconomic variables. They found that non-Hispanic African American patients were 2.7 times more likely to be hospitalized compared to their non-Hispanic white counterparts, even when controlled for age, sex, comorbidities, and income. Additionally, they found that men were twice as likely to require hospital admission as women, and that congestive heart failure, type 2 diabetes, and hypertension were all independently associated with an increased risk of hospitalization. As the authors noted, “The experience of Sutter Health highlights the fact that race and ethnicity play a pivotal role in determining how and when care is accessed, and what the outcome is. Our findings suggest that the greatest risk, in terms of hospitalization, is borne by African Americans. The COVID-19 pandemic offers the opportunity to identify and quantify these inequities and to seek solutions. Health systems have an ethical obligation to ensure that all patients receive the right care at the right time, especially in times of crisis.”

Feeling let down: An investigation of breastfeeding expectations, appreciation of body functionality, self-compassion, and depression symptoms  Rosenbaum DL, Gillen MM, Markey CH. Appetite. 2020 Jun 9:104756.
The American Academy of Pediatrics recommends exclusive breastfeeding for the first six months of life and continuation of breastfeeding until their infant is at least 12 months old. However, up to 72% of women may not be able to breastfeed exclusively, leading to psychological distress. Diane Rosenbaum and colleagues surveyed 536 new mothers regarding body image, appreciation of body functionality, self-compassion, and depressive symptoms. They determined that women who were unable to exclusively breastfeed had lower appreciation of body functionality. In this group, those with low self-compassion had even lower appreciation of body functionality and subsequently had higher depressive scores. Altogether, the authors highlight the importance of balancing initiatives to increase breastfeeding while promoting body positivity and self-compassion.

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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.