Jeffrey Silver Humanism in Healthcare Research Roundup – March-April 2023

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.

The art of seeing: The impact of a visual arts course on medical student wellbeing. Noorily AR, Willieme A, Belsky M, Grogan K. Med Teach. 2023 Mar 2:1-6. PMID: 36862139. doi: 10.1080/0142159X.2023.2184675. Epub ahead of print. Dr. Katie Grogan has been a Gold Foundation grantee.
Approximately half of all medical students suffer from burnout, a quarter experience depressive symptoms, and a tenth express suicidal ideation. It has been suggested that greater integration of the arts and humanities may help to support well-being among medical students. Dr. Ariella R. Noorily and colleagues examined how the “Art of Seeing” visual arts elective at NYU Grossman School of Medicine has impacted the mindfulness, self-awareness, and stress of 40 students who took this course between 2019 and 2021. Among these 40 students, 15 took the course in-person prior to the pandemic, and 25 students participated virtually during the pandemic. They surveyed students before and after the course using the mindful attention awareness scale (MAAS), situational self-awareness scale (SSAS), and perceived stress questionnaire (PSQ). They found significant improvements on all three scales. These trends were present in both the in-person and the virtual versions of the class. Additionally, the authors examined open-ended responses by participants to works of art as part of the post-test. They found that students demonstrated increased focus on the present moment, emotional awareness, and creative expression in the post-test free responses. The authors conclude that “in addition to improving the skills of observation, communication, empathy, and comfort with ambiguity, visual arts can be used as a tool to enhance wellbeing and mitigate burnout in this vulnerable population.”

Psychological Determinants of Physician Variation in End-of-Life Treatment Intensity: A Systematic Review and Meta-Synthesis. George LS, Epstein RM, Akincigil A, Saraiya B, Trevino KM, Kuziemski A, Pushparaj L, Policano E, Prigerson HG, Godwin K, Duberstein P. J Gen Intern Med. 2023 Feb 2. PMID: 36732436. Doi: 10.1007/s11606-022-08011-4. Dr. Ronald Epstein, co-founder of Mindful Practice, has been a Gold Foundation grantee.
Discussing and managing end-of-life care is a challenging task for many physicians because it demands balancing individualization of care with evidence-based practice. In fact, about 35% of end-of-life care spending is associated with physician beliefs and treatment preferences not evidence-based practice. To understand how physician psychological propensities determine variability in end-of-life care, Dr. Login S. George and colleagues conducted a systematic review that initially encompassed 5,623 references and resulted in a meta-synthesis of 28 articles. They identified seven psychological propensities influencing physician judgments: (1) professional identity as someone who extends lifespan, (2) mortality aversion, (3) communication avoidance, (4) conflict avoidance, (5) personal values favoring life extension, (6) decisional avoidance, and (7) over-optimism. These results may help guide further research on how to reduce unwarranted variability while upholding individualization of care. Behavioral “nudges,” skill provision, and peer group sessions may be promising approaches. Mindfulness and self-awareness-based interventions may also enhance physician well-being and attitudes towards patient care. Altogether, the authors concluded that since end-of-life care intensity is a major source of low-value expenditure, “further work is needed on leveraging psychological propensities to reduce physician-attributed variation in end-of-life intensity.”

Endured and prevailed: a phenomenological study of doctors’ first year of clinical practice. Coakley N, O’Leary P, Bennett D. BMC Med Educ. 2023 Feb 13;23(1):109. PMID: 36782187; PMCID: PMC9923928. Doi: 10.1186/s12909-023-04059-w. Free full text Dr. Deirdre Bennett has been a Gold Foundation grantee.
The transition from medical student to doctor can be difficult, with multiple lines of evidence showing that new physicians sometimes lack confidence, feel anxious in their new roles, and experience a negative impact to their mental health and well-being. To help understand these lived experiences, Dr. Niamh Coakley and colleagues conducted an interpretative phenomenological analysis (IPA) of 12 participants. A “double hermeneutic” approach was undertaken, in which the participant provides an account of how they make sense of their experience and the researcher interprets this account further. The researchers identified four overlapping temporal stages of the transition experience: adjustment, development, adversity, and rationalization. Anxiety and self-doubt characterizes the earlier phases while survival, transformation, and learning from adversity are seen more in the later phases. These insights have practical implications. Experience-based learning, increased support, and overlapping of responsibilities are organizational approaches to mitigate the challenges of this transition. The authors noted that this was a single-center study from Ireland and may not necessarily be generalizable to other settings. Nevertheless, it explores the experience of transition through a novel methodological approach and highlights the need for greater support and understanding during a potentially tough time.

Physician resistance to injustice: A scoping review. Wyatt TR, Ma TL, Ellaway RH. Soc Sci Med. 2023 Mar;320:115727. PMID: 36736054. Doi: 10.1016/j.socscimed.2023.115727. Dr. Rachel Ellaway has been a Gold Foundation grantee.
Physicians are in a privileged position in society, in which they have the capacity to engage in resistance to systems of harm and injustice, which threaten humanism in healthcare. However, resistance seems to have little legitimate place in physician professionalism. To explore this dichotomy, Dr. Tasha R. Wyatt and colleagues performed a scoping review to understand how often and in what contexts physicians have engaged in resistance. Out of 2123 papers, 60 were selected for full-text review. Four themes were identified: (1) professional responsibility to resist, (2) legitimate resistance, (3) resistance to perceived threats, and (4) resistance as moral agency. Of note, 95% of studies were from the United States, suggesting an area for further research in global health settings. Their results also suggest that physicians engage in resistance when they feel that their personal or professional interests are threatened. The authors conclude that “physician resistance, of whatever kind and for whatever reasons, is of critical concern therefore and needs to be better understood. This study contributes to that understanding and to a necessary conversation within and beyond the profession.”

Analyzing interprofessional teamwork in the operating room: An exploratory observational study using conventional and alternative approaches. Boet S, Burns JK, Brehaut J, Britton M, Grantcharov T, Grimshaw J, McConnell M, Posner G, Raiche I, Singh S, Trbovich P, Etherington C. J Interprof Care. 2023 Feb 5:1-10. PMID: 36739535. Doi: 10.1080/13561820.2023.2171373. Epub ahead of print.
Intraoperative teamwork, between surgeons, nurses, and other individuals in the operating room, is critical for patient safety and quality of care. Providing feedback to improve teamwork is vital, but how can this be done? Dr. Sylvain Boet and colleagues examined three tools for understanding teamwork processes and identification of teamwork behaviors: NOTECHS (Operating Theatre Team Non-Technical Skills Assessment Tool), TEAM (Team Emergency Assessment Measure), and SEIPS (modified Systems Engineering Initiative for Patient Safety model). Using the OR Black Box®, they recorded 50 consecutive surgical cases. Trained raters used these three tools to analyze the behaviors. They found that NOTECHS and TEAM provided pattern descriptions and summative assessments while SEIPS helped uncover deeper dynamics within teamwork processes. The authors note that combined methods of assessment “may offer maximum insight when feasible, drawing on the strengths of each approach.”

Advance Care Planning for Spanish-Language Speakers: Patient, Family, and Interpreter Perspectives. Puerto G, Chiriboga G, DeSanto-Madeya S, Duodu V, Cruz-Oliver DM, Tjia J. J Appl Gerontol. 2023 Feb 16:7334648231156864. PMID: 36794526. Doi: 10.1177/07334648231156864. Epub ahead of print. Dr. Jennifer Tjia has been a Gold Foundation grantee.
Advanced care planning (ACP) supports the delivery of future medical care based on patients’ personal values and life goals. While ACP is a vital component to person-centered healthcare, language access to ACP materials remains a challenge. To explore the challenges and facilitators of ACP with respect to Spanish-language translation of ACP resources, Geraldine Puerto and colleagues conducted focus groups with 29 Spanish-speaking persons who had experiences with ACP as a patient, family member, and/or medical interpreter. Using thematic analysis, they found four themes: (1) ACP translations are confusing; (2) ACP understanding is affected by country of origin; (3) ACP understanding is affected by local healthcare provider culture and practice; and (4) ACP needs to be normalized into local communities. Altogether, the results strongly suggest that cultural adaptation can enhance language translation and that medical interpreters can further add cultural insights. The authors conclude that “high-quality translation of ACP resources alone are insufficient to bridge cultural gaps. Efforts to improve ACP uptake need to address both language translation and cultural nuances to increase patient and family understanding.”

Patients Are the People Who Teach Me the Most”: Exploring the Development of Communication Skills During Internal Medicine Residency. Burke G, Melvin L, Ginsburg S. J Grad Med Educ. 2023 Feb;15(1):59-66. PMID: 36817542; PMCID: PMC9934842. Doi: 10.4300/JGME-D-22-00433.1. Free full text
High-quality physician-patient communication is a hallmark of humanistic care, but how do physicians learn how to communicate with patients? Dr. Gabriel Burke and colleagues examined this question through interviewing 15 Internal Medicine residents at the University of Toronto. Through extensive analysis using constructivist grounded theory, they concluded that the majority of skills development occurs during unsupervised interactions with patients without guidance from an attending physician: “How I learn is from actually having conversation with real patients.” Although attendings were important in role modeling and providing feedback after observations, some resident physicians felt that they altered their communication styles when observed so that they will be judged favorably. Other barriers included prioritization of efficiency over patient-centeredness and generically positive feedback lacking in constructive features. The authors concluded that “overreliance on observation by attendings and examiners … may fail to unearth the authentic and largely self-taught communication behaviors of residents.”

Problem-based shared decision-making in diabetes care: a secondary analysis of video-recorded encounters. Ruissen MM, Montori VM, Hargraves IG, Branda ME, León García M, de Koning EJ, Kunneman M. BMJ Evid Based Med. 2023 Mar 2:bmjebm-2022-112067. PMID: 36868578. doi: 10.1136/bmjebm-2022-112067. Epub ahead of print. Free full text Dr. Victor Montori, Dr. Ian Hargraves, Dr. Marleen Kunneman, and Megan Branda have been Gold Foundation grantees
Shared decision-making (SDM) is a stepwise, collaborative process, often described as weighing the pros and cons of multiple options. However, there are different forms of SDM depending on the situation (‘purposeful SDM framework”). Four forms of SDM have been articulated: (1) weighing treatment alternatives, (2) negotiating conflicting desires, (3) solving problematic situations and (4) developing existential insight. Dr. Merel M. Ruissen and colleagues examined how these different forms of SDM were used in a random sample of 100 video-recorded clinical encounters of patients with type 2 diabetes in primary care. They found that 86 of 100 encounters had at least one instance of SDM. 36% used one form of SDM (29% and 35% used 2 or >3 forms of SDM, respectively). This was particularly common when discussing options for switching medications. Among the four forms of SDM, weighing alternatives, negotiating conflicting desires, and problem-solving were similarly prevalent (33%, 30%, and 36% overall). Only 1% of instances were observed to be in the developing existential insight’ category. From this analysis, the authors affirm that different forms of SDM are commonly used, even in the same encounter, and that SDM goes well beyond only weighing alternatives.

Natural Language Processing of Learners’ Evaluations of Attendings to Identify Professionalism Lapses. Heath JK, Clancy CB, Pluta W, Weissman GE, Anderson U, Kogan JR, Dine CJ, Shea JA. Eval Health Prof. 2023 Feb 24:1632787231158128. PMID: 36826805. doi: 10.1177/01632787231158128. Epub ahead of print. Free full text Dr. Jennifer Kogan has been a Gold Foundation grantee
An important role of faculty physicians is to foster a safe, positive learning environment and continually display respectful interactions. Formal reporting systems do not capture all  lapses in professional behavior by faculty members; narrative faculty evaluations provide an additional potential source, but manually reviewing this large amount of data is a time- and resource-intensive endeavor. Dr. Janae Heath and colleagues explored whether using natural language processing (NLP) can facilitate this process. They looked at 15,432 narrative evaluations of medical faculty by medical trainees at the University of Pennsylvania. An NLP-model using sentiment analysis in combination with negation terms and key words yielded a positive predictive value of 49%. In other words, 49% of professional lapses identified by the NLP were confirmed by a manual review to be actual professional lapses. The authors noted that generalizability may be limited since the NLP was calibrated at only one center and that language used to describe professionalism is highly heterogeneous and is subject to cultural shifts. Nevertheless, this study shows the viability of NLP as a “scalable, automated strategy for screening narrative evaluations of faculty to identify professionalism lapses.”

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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.