Jeffrey Silver Humanism in Healthcare Research Roundup – June 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.

Postgraduate ethics training programs: a systematic scoping review Hong DZ, Goh JL, Ong ZY, Ting JJQ, Wong MK, Wu J, Tan XH, Toh RQE, Chiang CLL, Ng CWH, Ng JCK, Ong YT, Cheong CWS, Tay KT, Tan LHS, Phua GLG, Fong W, Wijaya L, Neo SHS, Lee ASI, Chiam M, Chin AMC, Krishna LKR. BMC Med Educ. 2021 Jun 9;21(1):338. doi: 10.1186/s12909-021-02644-5. PMID: 34107935; PMCID: PMC8188952. Free full text
Ethics education among physicians is a major priority to ensure that physicians can resolve dilemmas in a humanistic manner. But little is known about how ethics is taught in the postgraduate setting. Dr. Daniel Zhihao Hong and colleagues conducted a systematic review, ultimately conducting two searches that included 66 and 29 articles, respectively. Five themes were identified: (1) goals and objectives, (2) content, (3) pedagogy, (4) enabling and limiting factors of teaching ethics, and (5) assessment modalities used. Ethics training programs varied considerably, in part due to the diverse settings, approaches, content, and quality assessments. The authors conclude by noting the importance of enhancing communication skills and professionalism and call for establishing Entrustable Professional Activities in ethics to better assess knowledge and practice.

Structural distress: experiences of moral distress related to structural stigma during the COVID-19 pandemic Sukhera J, Kulkarni C, Taylor T. Perspect Med Educ. 2021 Apr 29:1–8. doi: 10.1007/s40037-021-00663-y. Epub ahead of print. PMID: 33914288; PMCID: PMC8082743. Free full text Dr. Javeed Sukhera has been a Gold Humanism Scholar at the Havard Macy Institute and a Gold Foundation grantee.
The ongoing COVID-19 pandemic has had significant negative effects on patients and physicians. It has disproportionately affected those who are subject to structural stigma, that is, “discrimination towards certain groups [that] is enacted through policy and practice.” It has also exposed moral distress, a concept that originated in nursing literature to describe an individual’s reaction “when they believe they know the right thing to do but are unable to do it.” To examine the interaction between these concepts, Dr. Javeed Sukhera and colleagues conducted semi-structured interviews with 22 Canadian physicians. Using constructivist grounded theory, they then analyzed the transcripts to derive an explanatory theory: structural distress. In structural distress, resident physicians experience powerlessness, leading them to “go above and beyond the call of duty, potentially worsening their psychological well-being.” Faculty physicians can have a buffering role in mitigating this structural distress through role modeling vulnerability, enhancing resident physicians’ agency, and involving resident physicians in policy decisions. The authors conclude by encouraging further research on the experiences of structural distress among all levels of medical learners.

Using ethnographic methods to classify the human experience in medicine: a case study of the presence ontology Maitra A, Kamdar MR, Zulman DM, Haverfield MC, Brown-Johnson C, Schwartz R, Israni ST, Verghese A, Musen MA. J Am Med Inform Assoc. 2021 Jun 21:ocab091. doi: 10.1093/jamia/ocab091. Epub ahead of print. PMID: 34151988. Dr. Abraham Verghese is a former Gold Foundation Trustee and gave both the 2012 and 2005 Jordan J. Cohen Humanism in Medicine Lecture at the AAMC.
Presence is an emerging medical discourse referring to “the purposeful practice of awareness, focus, and attention within the intent to understand and connect with patients.”  Despite the importance of physician presence, a conceptual framework remains elusive, which had made capturing the components of presence “incomplete, vague, and subjective.” Defining and elaborating presence is especially important in light of new healthcare technology and devices that may impact interpersonal connections. Dr. Amrapali Maitra and colleagues sought to answer this need by creating a new model, Presence Ontology. The authors conducted a systematic review of over 20,000 articles, followed by relational ethnography of 27 clinical encounters, and then interviews about relational work with 40 professionals. Among other features of Presence Ontology, there are 8 upper-level class entities (Person, Characteristic, Encounter, Action, Object, Factor, Quality, Emotion). This complex model can be applied to help with ethnographic data mining, documentation of practice, and development of clinical instruments for practice that encourage greater presence with patients.

Exposure to workplace trauma and posttraumatic stress disorder among intern physicians Vance MC, Mash HBH, Ursano RJ, Zhao Z, Miller JT, Clarion MJD, West JC, Morganstein JC, Iqbal A, Sen S. JAMA Netw Open. 2021 Jun 1;4(6):e2112837. doi: 10.1001/jamanetworkopen.2021.12837. PMID: 34100937; PMCID: PMC8188264. Free full text Dr. Srijan Sen has been a Gold Foundation grantee.
Posttraumatic Stress Disorder (PTSD) is “a potentially debilitating condition characterized by intrusive memories, avoidance, negative alterations in mood and cognition, and hyperarousal after experience to a traumatic stressor.”  Physicians are at risk for work-related trauma, but there little is known about PTSD among physicians-in-training. To determine its prevalence, Dr. Mary Vance and colleagues conducted a cohort study among 1,134 interns over 12 months. More than half (56.4%) reported work-related trauma exposure. Using the Primary Care PTSD Screen (PC-PTSD-5), they determined that 10.8% of interns screened positive for PTSD. This is three times higher than the prevalence rate in the general population. Risk factors associated with trauma exposure included non-Hispanic White race/ethnicity, more hours worked, early family environment, and stressful life experiences at baseline. Similarly, risk factors associated with PTSD included being unmarried, non-Hispanic White race/ethnicity, concern about medical errors, stressful life experiences during internship, depression at month 12 of internship, and anxiety at month 12 of internship. Given the high prevalence of PTSD and its risk factors, the authors highlight the urgent need for interventions to reduce trauma exposure and treat PTSD symptoms among intern physicians.

Occupational and personal consequences of the COVID-19 pandemic on US oncologist burnout and well-Being: a study from the ASCO clinician well-being task force Hlubocky FJ, Back AL, Shanafelt TD, Gallagher CM, Burke JM, Kamal AH, Paice JA, Page RD, Spence R, McGinnis M, McFarland DC, Srivastava P. JCO Oncol Pract. 2021 Jun 21:OP2100147. doi: 10.1200/OP.21.00147. Epub ahead of print. PMID: 34152789. Drs. Anthony Back, Tait Shanafelt and Arif Kamal have been Gold Foundation grantees.
The COVID-19 pandemic continues to impact the delivery of healthcare services, including cancer care. But how exactly has it impacted well-being of cancer specialists?  Dr. Hlubocky and colleagues examined this through four virtual focus groups of 25 oncologists during September-November 2020. Through thematic analysis, they identified five consequences: (1) impact of pre-COVID-19 burnout, (2) occupational or professional limitations and adaptations, (3) personal implications, (4) concern for the future of cancer care and the workforce, and (5) recommendations for physician well-being interventions. Disruptions in care, education, research, financial practice health, and telemedicine were a few of many stressors. Oncologists also reported significant personal impact, including loss of social supports and fear of personal, familial, friend, and colleague viral exposure or transmission. However, there were also opportunities for personal growth and fostering greater resilience, including support resources, flexible time-off, development of care guidelines, well-being resources, and mental health advocacy. Altogether, the authors see a mixed picture, in which oncologists are facing many stressors but also embracing ingenuity to find new ways of supporting their practices.

Burnout and moral resilience in interdisciplinary healthcare professionals Antonsdottir I, Rushton CH, Nelson KE, Heinze KE, Swoboda SM, Hanson GC. J Clin Nurs. 2021 Jun 17. doi: 10.1111/jocn.15896. Epub ahead of print. PMID: 34145678. Dr. Cynda Rushton has been a Gold Foundation grantee.
Moral resilience, “the ability to preserve or restore integrity in response to moral adversity,” is believed to be a mitigating factor for burnout. But how exactly are these related?  Inga Antonsdottir and colleagues conducted a cross-sectional study of 639 healthcare professionals. They surveyed demographic factors as well as burnout and resiliency via the Maslach Burnout Inventory Human Services Survey and the Rushton Moral Resilience Scale. They determined that higher moral resilience is related to lower burnout and turnover intention. More specifically, through multiple linear stepwise regression, moral resilience factors explain 34%, 30%, and 29% of variance for depersonalization, emotional exhaustion, and reduced personal accomplishment, three factors associated with burnout. While the authors caution that this was not a randomized national sample, they do note that this represents an important step in understanding how moral resilience impacts burnout.

Implicit bias recognition and management: tailored instruction for faculty Rodriguez N, Kintzer E, List J, Lypson M, Grochowalski JH, Marantz PR, Gonzalez CM. J Natl Med Assoc. 2021 Jun 14:S0027-9684(21)00074-2. doi: 10.1016/j.jnma.2021.05.003. Epub ahead of print. PMID: 34140145. Dr. Cristina Gonzalez was a Gold Humanism Scholar at the Harvard Macy Institute.
Implicit biases are unconscious mental associations that individuals make about various social groups that can impact understanding and actions. In recent years, there has been increasing recognition that implicit bias contributes to health disparities, and numerous programs have been established for physicians to recognize and debrief implicit bias during clinical encounters. But not much is known about how these programs impact confidence and comfort in recognizing implicit bias. Natalia Rodriguez and colleagues delivered five departmental/divisional grand rounds about the topic. Pre- and post-intervention surveys were distributed, which included 12 items and free-text areas to describe strategies for recognizing and managing potentially biased events, yielding 116 completed surveys. Participants reported increases in confidence and competence after a single session. Qualitative analysis of free-text responses demonstrated three themes: (1) looking inward, (2) looking outward, and (3) taking action at individual and institutional levels. These results suggest that a 60- to 90-minute session on implicit bias may help to achieve its educational goals. However, further research to see longer-term outcomes and effects on behavior are needed.

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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.