Jeffrey Silver Humanism in Healthcare Research Roundup – March 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.

Effect of clear vs standard covered masks on communication with patients during surgical clinic encounters: a randomized clinical trial Kratzke IM, Rosenbaum ME, Cox C, Ollila DW, Kapadia MR. JAMA Surg. 2021 Mar 11. doi: 10.1001/jamasurg.2021.0836. Epub ahead of print. PMID: 33704389.
Effective communication is an important part of the physician-patient relationship, including nonverbal communication. Masks, although extremely important for their protective benefits, obscure parts of the face and thus may hinder facial recognition and communication. Dr. Ian M. Kratzke and colleagues examined how face masks impact communication with patients by conducting a randomized control trial. They split 200 patients from 15 surgeons’ clinics in 7 subspecialties into two groups: a standard mask group and a clear mask group. (The clear masks were ASTM level 3, equal in protection to standard surgical masks; high-risk patients whose physicians were recommended to wear an N95 respirator were excluded from the study.) The investigators then assessed surgeon communication and trust in surgeons via the Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey and other questions. A qualitative assessment of patient comments was also conducted, using thematic analysis to examine patient preferences. They found that patients preferred clear masks. Patients who were cared for with surgeons wearing clear masks rated them higher for (1) providing understandable explanations, (2) demonstrating empathy, and (3) building trust. However, the majority of surgeons preferred standard masks, citing concerns about comfort, mask fit, mask fogging, and perceived level of protection. The authors conclude by emphasizing “purposeful attention to communication” to balance the many benefits of mask-wearing with its inadvertent effects on hindering communication.

Experiences of Latinx individuals hospitalized for COVID-19: A qualitative study Cervantes L, Martin M, Frank MG, Farfan JF, Kearns M, Rubio LA, Tong A, Matus Gonzalez A, Camacho C, Collings A, Mundo W, Powe NR, Fernandez A. JAMA Netw Open. 2021 Mar 1;4(3):e210684. doi: 10.1001/jamanetworkopen.2021.0684. PMID: 33704475   Free full text Dr. Alicia Fernandez is a Gold Professor.

The COVID-19 pandemic has disproportionately affected Latinx populations. Data show that Latinx individuals are more likely to become infected, hospitalized and die from COVID-19 compared with their white counterparts. While many have speculated on possible factors, how did Latinx patients themselves perceive the situation? Dr. Lilia Cervantes and colleagues conducted semistructured phone interviews of 60 Latinx COVID-19 survivors from public hospitals in San Francisco and Denver. Analysis of the transcripts yielded five themes: (1) COVID-19 was a distant and secondary threat (seen as unlikely, exaggerated, or fake) (2) COVID-19 was a compounder of disadvantage, (3) reluctance to seek medical care, (4) health care system interactions (including isolation, gratitude for compassionate and Spanish-speaking clinicians, and discharge with insufficient information or resources) (5) faith and community resiliency. Economic anxiety – including fear of losing wages/employment, costs of care, and immigration repercussions – was present throughout the five themes. Additionally, the investigators identified a need for more effective, culturally specific and language-concordant public health messaging regarding testing, contact tracing, and when to seek medical care. Since isolation, mistrust, and confusion were common experiences, hospitals ought to leverage technology and other services to link patients to support systems, including spiritual care. The authors also suggested that Latinx COVID-19 survivors can become “ambassadors within the community.”  On a larger scale, the investigators concluded by highlighting “the need for economic and housing policies that support Latinx individuals’ ability to isolate and protect the safety of essential workers and also the broader community.”

Assessment of the association of leadership behaviors of supervising physicians with personal-organizational values alignment among staff physicians Shanafelt TD, Wang H, Leonard M, Hawn M, McKenna Q, Majzun R, Minor L, Trockel M. JAMA Netw Open. 2021 Feb 1;4(2):e2035622. doi: 10.1001/jamanetworkopen.2020.35622. PMID: 33560424; PMCID: PMC7873777   Free full text Dr. Tait Shanafelt has been a Gold Foundation grantee.
As physicians have become increasingly employed by large organizations, concern has arisen around how the values of these organizations align with physicians’ professional values, especially as such misalignment is associated physician burnout. To learn more about contributing organizational factors, Dr. Tait Shanafelt and colleagues sent surveys to 1,924 physicians at Stanford University assessing perceived personal-organizational values alignment, professional fulfillment, and burnout. They also evaluated leadership behaviors of their immediate supervisor. Among the 1,285 who responded (67% response rate), they found that personal-organization value alignment was positively correlated with professional fulfillment and negatively correlated with burnout. Aggregate leader behavior scores were associated with a 21.6% variation in personal-organizational values alignment score. In fact, for each 1-point increase in leadership score, there was a 0.56 increase in the personal-organizational values alignment score. Altogether, this study suggests a need to develop first-line physician leaders so that there is better alignment of values and consequently higher physician fulfillment and lower burnout.

Persistent impostor phenomenon is associated with distress in medical students Rosenthal S, Schlussel Y, Yaden MB, DeSantis J, Trayes K, Pohl C, Hojat M. Fam Med. 2021 Feb;53(2):118-122. doi: 10.22454/FamMed.2021.799997. PMID: 33566346. Dr. Charles Pohl is a former Gold Trustee and Chair of the Gold Humanism Honor Society Advisory Council.
Imposter Phenomenon (IP) is “a personality construct associated with emotional distress in some high-achieving individuals who are unable to internalize their achievements or take ownership of their success.”  As many as 50% of entering medical students have evidence of Imposter Phenomenon. But little is known about its links to other personality traits and how IP changes over the course of medical school. At Thomas Jefferson University, Dr. Susan Rosenthal and colleagues surveyed 257 medical students using the Clance Impostor Phenomenon Scale (CIPS), Jefferson Scale of Empathy, Self-Compassion Scale, and Zuckerman-Kuhlman Personality Questionnaire at the start of their first year. They followed up with 182 of these students again at the end of their first year. 87% of entering students had high or very high levels of IP. Women tended to have higher scores than men. Among those with high levels of IP, there was lower self-compassion, sociability self-esteem, and “getting along with peers” scores. Conversely, lower IP scores were associated with lower levels of anxiety and loneliness. At the end of their first year, scores were even higher. The reasons for these trends are unclear, but the investigators suspect that intense pressure and competition for admission are important factors. Moreover, because IP is believed to be “responsive to intervention, supportive feedback and collaborative learning,” the investigators assert that IP can be addressed in the early stages of medical education. In turn, because of IP’s association with depression and anxiety, the investigators hope that timely interventions can prevent distress and burnout among medical students.

Investigation of work-life integration on burnout symptoms in women physician runners: a cross-sectional survey study Uhlig-Reche H, Larson AR, Silver JK, Tenforde A, McQueen A, Verduzco-Gutierrez M. BMJ Open Sport Exerc Med. 2021 Feb 19;7(1):e001028. doi: 10.1136/bmjsem-2020-001028. PMID: 33680501; PMCID: PMC7898857   Free full text Drs. Julie K. Silver and Adam Tenforde have been Gold Foundation grantees.
Burnout, a work-related syndrome consisting of emotional exhaustion, depersonalization, and a reduced sense of personal efficacy or accomplishment, is highly prevalent among physicians. Physical activity has been proposed as means of countering burnout, with studies showing that exercise lowers the risk of burnout. To examine this phenomenon, Dr. Hannah Uhlig-Reche and colleagues surveyed 369 self-declared physically active female physicians in the United States. They used a 60-item questionnaire to determine demographics, compensation, debt, and domestic responsibilities and sought to correlate these variables with burnout via the Mini-Z Burnout Survey. In this population, which tended to be white (74.5%) and at least 6 years out from training (85.9%), there was a statistically significant correlation between greater burnout and two variables: (1) working more hours per week and (2) being responsible for a greater percentage of domestic duties. These findings suggest that exercise alone may not be sufficient to control burnout. Rather, the investigators highlight the necessity of addressing these two causes of burnout as a means of prevent burnout, especially in female physicians.

Patient characteristics associated with and changes over time in trust in inpatient physicians Prochaska MT, Zhang H, Meltzer DO, Arora VM J Gen Intern Med. 2021 Feb 25. doi: 10.1007/s11606-021-06649-0. Epub ahead of print. PMID: 33634381. Dr. Vineet Arora has been a Gold Foundation grantee.
While physicians have long been ranked one of the most trusted professions in the United States, trust in the medical profession has eroded over recent years. The causes of this erosion are unclear, but potential contributors include discontinuity of inpatient care and persistent racial disparities. Dr. Micah T. Prochaska and colleagues examined clinical and demographic factors associated with patient trust of inpatient physicians and how they have changed over time. Records of 37,116 patients from an ongoing study of hospital care between 2006 and 2018 were analyzed. Age, gender, race, insurance status, length of stay, the Charlson Comorbidity Score, and year of admission were solicited, as well as patient trust of their inpatient physician. The investigators determined that older age, privately insured patients, and men were more trusting; interestingly, non-white women were more trusting than their white counterparts. In this population, trust did not significantly change over time. However, increases in trust were temporally associated with institutional expansions in access to care. Although only conducted in one large urban hospital, the investigators’ experiences provide insights into how the larger healthcare community can improve trust in inpatient physicians.

“Walking in Their Shoes”: The effects of an immersive digital story intervention on empathy in nursing students Yu J, Parsons GS, Lancastle D, Tonkin ET, Ganesh S. Nurs Open. 2021 Mar 20. doi: 10.1002/nop2.860. Epub ahead of print. PMID: 33743185   Free full text
Empathy and compassion among nurses and other heathcare staff are vital to dignified, safe, person-centered care. But how can empathy be taught? Dr. Juping Yu and colleagues conducted a randomized-control trial to determine the effect of novel immersive digital story intervention, titled “Walking in Their Shoes.” Using principles from the Theory of the Mind model, which posits that understanding a person’s thoughts or feelings is essential to predicting their response (and thus, their needs), the investigators developed a simulation based on a real patient’s experience with bowel cancer. 238 second-year nursing students were recruited and completed the Jefferson Scale of Empathy at baseline, immediately after the trial, and then 8-12 weeks thereafter. Compared to the control group, the group that experienced the digital story intervention had an increase in empathy scores, from a common baseline, immediately after the intervention. However, at follow-up, there was no longer any difference in scores. The investigators consider this data to be encouraging but also point out that reinforcement strategies and other approaches are likely necessary to sustain improvements in empathy scores.

“We All Really Need to just Take a Breath”: Composite narratives of hospital doctors’ well-being during the COVID-19 pandemic Creese J, Byrne JP, Conway E, Barrett E, Prihodova L, Humphries N. Int J Environ Res Public Health. 2021 Feb 19;18(4):2051. doi: 10.3390/ijerph18042051. PMID: 33669828; PMCID: PMC7921910. Free full text
The COVID-19 pandemic continues to pose a direct threat to the physical and mental health of large swathes of first responders, including healthcare professionals, such as physicians. But how exactly has it affected physician well-being?  Dr. Jennifer Creese and colleagues conducted 48 semi-structured interviews with doctors from Ireland to conceptualize their well-being during the first wave of the pandemic (March-May 2020). They found a very complex interplay of factors that affected their well-being, including (1) time and space for well-being, (2) the emotions of working in the context of COVID-19, (3) lockdown and life beyond the hospital, and (4) supporting and protecting hospital doctors. Oddly, many saw improvements in their physical well-being, but emotional exhaustion, guilt, isolation, and poor support contributed to declines in mental well-being. This investigation provides practical insights into how to better support doctors both during and after the pandemic.

Representation of women on National Institutes of Health study sections Volerman A, Arora VM, Cursio JF, Wei H, Press VG. JAMA Netw Open. 2021 Feb 1;4(2):e2037346. doi: 10.1001/jamanetworkopen.2020.37346. PMID: 33587131; PMCID: PMC7885038   Free full text Drs. Vineet Arora and Valerie Press have been Gold Foundation grantees.
National Institutes of Health study sections are important committees that determine grant awards and scientific agendas. Therefore, diverse representation on the study sections of these 25 institutes is of vital importance. Dr. Anna Volerman and colleagues investigated the gender makeup of these study sections. Using publicly available information on study sections during one review cycle in 2019, they extracted data on gender representation based on names and pictures, as well as markers of research productivity and career progression. They determined that 38.9% of reviewers were women and less than half of study sections had a female scientific research officer or chair. Female reviewers were more likely to hold lower academic ranks and were more likely to be temporary members. Women were less likely to be reviewers among institutes with higher total funding and higher number of research grant awards. Interestingly, study sections chaired by women were less likely to have women as reviewers, but, in institutes with a chairwoman, women were more likely to be reviewers. Although the investigation was not intended to directly link one to the other, the authors conclude that this that underrepresentation may “partially explain gender bias in peer review and differences in funding and promotion.”

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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.