Jeffrey Silver Humanism in Healthcare Research Roundup – June 2022

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.

A graphic transformation: A qualitative study of transformative learning in medical trainees during COVID-19 using comics as data presentation Vipler B, Green M, McCall-Hosenfeld J, Haidet P, Tisdell E. Teach Learn Med. 2022 May 13:1-16. doi: 10.1080/10401334.2022.2062362. Epub ahead of print. PMID: 35567316. Drs.Michael Green and Paul Haidet have been Gold Foundation grantees.
The ongoing COVID-19 pandemic has dramatically disrupted medical education programs and altered how trainees are educated. Yet these disruptions also provide opportunities for transformative learning. To understand this, Dr. Benjamin Vipler and colleagues interviewed six resident and fellow physicians at a mid-Atlantic academic health system who cared for COVID-positive patients, directly or indirectly, during the initial peak of the pandemic in March-May 2022. They examined the trainee physicians’ responses through the lens of transformative learning theory. The investigators then drafted comics to depict interviewees’ experiences. Transformative learning theory describes the process by which “individuals construct new or revised interpretations of the meaning or an experience.”  They identified three themes: (1) a sense of guilt (comparing their experiences to those with higher COVID-19 case volume), (2) the impact on training, and (3) venues and processes for reflection. Based on this analysis, the authors had three major takeaways. First, removal of trainees from direct COVID-19 care was not benign and may have led to considerable guilt. Second, trainees may benefit from structured reflection, especially during stressful times. And finally, comics may be used as a methodology for presenting qualitative research. Their comics are available through the link above.

Evolution of investigating informed assent discussions about CPR in seriously ill patients Stapleton RD, Ford DW, Sterba KR, Nadig NR, Ades S, Back AL, Carson SS, Cheung KL, Ely J, Kross EK, Macauley RC, Maguire JM, Marcy TW, McEntee JJ, Menon PR, Overstreet A, Ritchie CS, Wendlandt B, Ardren SS, Balassone M, Burns S, Choudhury S, Diehl S, McCown E, Nielsen EL, Paul SR, Rice C, Taylor KK, Engelberg RA. J Pain Symptom Manage. 2022 Jun;63(6):e621-e632. doi: 10.1016/j.jpainsymman.2022.03.009. PMID: 35595375. Dr. Anthony L. Back has been a Gold Foundation grantee.
Cardiopulmonary resuscitation (CPR) is an emergency procedure to preserve intact brain function and restore spontaneous blood circulation. Despite advances in CPR, the one-year survival of CPR is 13.4% and falls to less than 2% in certain advanced chronic disease states. In addition, CPR can lead to situations that may be unexpected by the patient or family members, such as broken ribs, intubation, or an extended life in a coma. Therefore, discussions between clinicians and patients or family members about Do Not Resuscitate (DNR) orders are important as part of shared decision-making. One such approach to facilitate discussions is Informed Assent (IA), a framework “whereby patients extremely unlikely to benefit from CPR are informed that unless they disagree, CPR will not be performed because it will not help achieve their goals.” To understand the utility of IA, Dr. Renee D. Stapleton and colleagues conducted a three-stage mixed-methods investigation. First, they conducted focus groups with 30 patients with advanced COPD or malignancy along with 20 family members and 15 physicians in order to identify the acceptability of IA. They determined that participants accepted the approach and appreciated “honesty, empathy, trust, and choice.”  Based on these findings, they then conducted a pilot randomized control trial among outpatients, comparing 12 receiving the IA intervention with 15 receiving usual care. They found that those receiving IA were less likely to want CPR at a two-week subsequent assessment. These results empowered the third stage, which is an ongoing, larger inpatient randomized control trial. While the results are still forthcoming, preliminary observations by authors suggest that clinical context and care settings (i.e. outpatient in stage 2 vs. inpatient settings in stage 3) are highly relevant to the application of IA. In conclusion, the authors state that IA may be an acceptable way to negotiate ethical dilemmas in the ICU regarding resuscitation.

From distress to detachment: Exploring how providing care for stigmatized patients influences the moral development of medical trainees Liu LX, Goldszmidt M, Calvert S, Burm S, Torti J, Cristancho S, Sukhera J. Adv Health Sci Educ Theory Pract. 2022 May 29:1–17. doi: 10.1007/s10459-022-10125-7. Epub ahead of print. PMID: 35643994; PMCID: PMC9148414. Free full text Dr. Mark Goldszmidt has been a Gold Foundation grantee, and Dr. Javeed Sukhera has been Gold Foundation grantee and a Gold Humanism Scholar at the Harvard Macy Institute.
Trainees are often challenged with the task of caring for those from stigmatized patient populations, such as people who inject drugs. These challenges may influence the long-term moral development of medical trainees. To shed light on the under-explored topic of moral development in medical education, Dr. Lisa X. Liu and colleagues conducted a qualitative study of 48 medical trainees at two urban Canadian teaching hospitals. Through examination of field notes, interviews, and medical documentation, the authors identified four themes: (1) cycles of frustration and moral tension, (2) disconnection and mistrust, (3) material pressures and influences, and (4) adapting and adjusting. The investigators found that caring for people who inject drugs triggered frustration among trainees, which in turn, often perpetuated a sense of futility and avoidance. Importantly, role-modelling alone cannot fully explain trainees’ struggles with maintaining empathy; “the dynamic and uncertain nature of care” is also a contributory factor. Altogether, structural and institutional changes are needed to improve care for people who inject drugs and other stigmatized populations.

Evaluation of health behaviors and overall quality of life in younger adult African American cancer survivors Trendowski MR, Kyko JM, Lusk CM, Ruterbusch JJ, Hastert TA, Harper FWK, Thompson H, Beebe-Dimmer JL, Schwartz AG. Cancer Med. 2022 Jun 2. doi: 10.1002/cam4.4855. Epub ahead of print. PMID: 35655423. Free full text
Increasing lines of evidence demonstrate that African-Americans experience notable health disparities in a variety of fields. This includes cancer survivorship, where younger adult African Americans have a 5-year survival rate of 74.3%, compared to younger white adults at 83.5%. The root causes of this are likely very complex and rooted in socioeconomic determinants of health. To determine these, Dr. Matthew Trendowski and colleagues surveyed 517 African-American patients who were diagnosed with any cancer between the ages of 20 and 49 as part of the Detroit Research of Cancer Survivors (ROCS) study. Quality of life, clinical characteristics, and health behaviors were assessed through the FACT-G (Functional Assessment of Cancer Therapy-General), FACT-Cog (Functional Assessment of Cancer Therapy-Cognition), and PROMIS (Patient Reported Outcome Measurement Information System) Anxiety and Depression scores. These were correlated with sociodemographic information and health characteristics. The investigators found that perceived discrimination and the number of discriminatory events were significantly associated with reductions in overall quality of life, cognitive functioning, anxiety, and depression. Multiple comorbidities were also associated with poorer mental and overall health. The authors conclude by emphasizing the importance of educating clinicians about the unique needs of younger African-American cancer survivors as well as the development of community-informed interventions.

The role of moral distress on physician burnout during COVID-19 Powell CAJ, Butler JP. Int J Environ Res Public Health 2022 May 17;19(10):6066. doi: 10.3390/ijerph19106066. PMID: 35627603; PMCID: PMC9142098. Free full text
The ongoing COVID-19 pandemic has impacted physician well-being in many ways. One such way is prompting moral distress, the “discomfort or internal conflict that is caused when professionals feel as though they cannot carry out the appropriate or ethical course of action that they believe to be right.”  But how prevalent is this, and how does it relate to burnout?  Drs. Caitlin Powell and John Butler conducted an online survey of 479 physicians through physician Facebook groups to identify links between moral distress and burnout. Through complex statistical analysis, they found that moral distress was a significant mediator in explaining how perceived organization support, medical specialization, and emotional labor impacts burnout. These results provide insights about how to reduce burnout, including improving organizational support, promoting problem-faced coping skills, and engaging in deep emotional labor. The authors do note limitations to the generalizability of the study, including the changing nature of the pandemic, non-randomized sampling techniques, and female predominance among responders. Nevertheless, this shed greater light on how moral distress has impacted physician burnout through the pandemic.

A novel narrative medicine approach to DEI training for medical school faculty Holdren S, Iwai Y, Lenze NR, Weil AB, Randolph AM. Teach Learn Med. 2022 May 24:1-10. doi: 10.1080/10401334.2022.2067165. Epub ahead of print. PMID: 35608161. Dr. Amy Weil has been a member of the Gold Humanism Honor Society Advisory Council.
In recent years, there has been an increasing recognition of the need for longitudinal, self-reflective, and pedagogically focused programming to help medical school faculty explore concepts related to anti-racism and social justice. In response, Dr. Sarah Holdren and colleagues at the University of North Carolina developed a four-session anti-racism program using the principles of Narrative Medicine. Because Narrative Medicine promotes critical self-reflection through reading of a creative text, extemporaneous writing activity, and discussion, it seemed appropriate to apply this as a method of DEI training. More specifically, the investigators created four 60-minute virtual sessions focusing on (1) Narrative Medicine in Medical Education and Clinical Practice, (2) Phenomenology of Race in Medicine, (3) Narrative Medicine & Anti-Racism in the Interprofessional Medical Education Classroom, and (4) Narrative Medicine as Anti-Racist Praxis. Over the course of year, 32 medical school faculty participated, of which 19 completed pre- and post-intervention surveys. From the qualitative analysis of survey responses, five themes emerged: (1) value of longitudinal narrative reflection in a small-group setting for DEI work, (2) desire to commit more time to DEI, anti-racist, and social justice work while balancing busy teaching and clinical schedules, (3) the value of storytelling in DEI and anti-racism programming, (4) an understanding of deconstructive and reconstructive work of anti-racism in medicine, and (5) an increased ability to educate and enact change through teaching, activism, and institutional cultural and policy changes. This was consistent with survey results showing that 68.4% felt “somewhat more” or “more” comfortable engaging in concepts of race. Based on these encouraging results, the authors “hope this structure may inspire faculty to reconsider traditional modes of teaching and caring, and lead them to more just models for our medical education and health systems.”

Discrimination exposure based on race, gender, and sexual orientation of Veterans Affairs Health Administration patients Berke DS, Ruben MA, Liautaud MM, Meterko M, Kauth MR, Shipherd JC. J Health Care Poor Underserved. 2022;33(2):714-725. doi: 10.1353/hpu.2022.0058. PMID: 35574871. Dr. Mollie A. Ruben has been a Gold Foundation grantee.
Unfortunately, identity-based discrimination is pervasive throughout the United States healthcare system and is associated with a variety of adverse health outcomes. Dr. Danielle Berke and colleagues examined this within the largest integrated healthcare system, the Veterans Affairs Health Administration (VHA). Using data from the VHA Survey of Healthcare Experiences of Patients, the authors sought to determine the prevalence of exposure to healthcare discrimination among sociodemographic groups. Approximately 12% of the 806 respondents experienced discrimination, while another 9% witnessed discrimination. Women and racial/ethnic minoritized patients were more likely to experience and witness discrimination compared to men and non-Hispanic white patients. Interestingly, those who witnessed discrimination were also more likely to report poorer health. Because the primary source of such discrimination was the VHA clinical staff, results of the survey strongly suggest a need for targeted interventions to reduce instances of discrimination. The authors note that while the results of their study bring to light the magnitude and effects of identity-based discrimination within the VHA, more research is needed to clarify our understanding of discrimination-linked health disparities. The standard inclusion of questions about discrimination would be an important step toward that end.

Legacy of the role of medicine and nursing in the Holocaust: An educational intervention to support nursing student professional identity formation and ethical conduct Kruse JA, Wald HS. Nurs Educ Perspect. 2022 May 17. doi: 10.1097/01.NEP.0000000000000996. Epub ahead of print. PMID: 35584013. Dr. Hedy Wald has been a Gold Humanism Scholar at the Harvard Macy Institute and a facilitator/content contributor to the Humanism in Health and Healthcare course at
History records how nurses and physicians were intimately involved in the many atrocities of the Holocaust. Confronting and learning about this legacy constitute an important medical imperative. Drs. Julie A. Kruse and Hedy S. Wald describes how an invited seminar presentation and colloquium affected professional identity formation (PIF) among 73 undergraduate community nursing students. Among the 60 who attended both program components, 38 completed the optional post-program evaluation survey, of which 14 students responded to an “additional comments” query with free text. This was the basis for qualitative analysis, which demonstrated four themes: (1) increased awareness and knowledge of the role of nursing in the Holocaust, (2) nurse as patient advocate/judicious obedience, (3) importance of adhering to ethics and values, and (4) use of art and reflective writing for processing experience. Their experience suggests that teaching the legacy of nurses during the Holocaust can indeed prompt critical reflection and serve as a “powerful platform for scaffolding PIF and ethical conduct.”

Medical students’ perceptions of learning and working on the COVID-19 frontlines: ‘… a confirmation that I am in the right place professionally’ Klasen JM, Schoenbaechler Z, Bogie BJM, Meienberg A, Nickel C, Bingisser R, LaDonna K. Med Educ Online. 2022 Dec;27(1):2082265. doi: 10.1080/10872981.2022.2082265. PMID: 35638171. Free full text
The ongoing COVID-19 pandemic has had a pervasive impact on medical education throughout the world, with decreased opportunities for hands-on experiential learning. In Basel, Switzerland, students were offered the opportunity to work at the Triage Test Centre, which enabled them to retain clinical exposure, under appropriate supervision by senior healthcare workers and safety protocols. To characterize their experiences, Dr. Jennifer M. Klasen and colleagues conducted semi-structured interviews with 21 medical students. They then used constructivist grounded theory to identify three themes: (1) learning, adapting, and improving skills, (2) interactions and flattened hierarchy, and (3) development of professional identity. Overall, working on the pandemic frontlines enabled students “to feel like legitimate healthcare providers” and advanced their development of professional identity. While the authors note that this small study may not necessarily be generalizable, they conclude by drawing contrasts between medical student experiences in Basel and those in other areas where training was continued “from behind a computer screen.”

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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.