Jeffrey Silver Humanism in Healthcare Research Roundup – March-April 2024

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.

Physician empathy and chronic pain outcomes Licciardone JC, Tran Y, Ngo K, Toledo D, Peddireddy N, Aryal S. JAMA Netw Open. 2024 Apr 1;7(4):e246026. doi: 10.1001/jamanetworkopen.2024.6026. PMID: 38602675; PMCID: PMC11009829. Free full text
The patient-physician relationship is essential to humanism in medicine and is heavily influenced by physician empathy. Studies have shown links between physician empathy and patient satisfaction, as well as, over 3 months, a connection between increased physician empathy and better outcomes and quality of life for patients attending pain clinic. Would physician empathy be associated with improved outcomes for chronic pain over a longer time span? To investigate this, Dr. John Licciardone and colleagues aimed to assess the impact of patient-reported physician empathy on outcomes in patients with chronic low back pain over 12 months. Analyzing data from 1,470 participants in the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation (PRECISION) cohort, the research focused on patients ages 21 to 79 with CLBP. Patients self-reported data using the Consultation and Relational Empathy (CARE) measure to gauge physician empathy and completed follow-ups quarterly to evaluate pain, function, and health-related quality of life (HRQOL). Researchers found that patients with physicians who were considered very empathic had lower levels of pain intensity, less back-related disability, and fewer HRQOL deficits, compared to patients with physicians who were slightly empathic. In addition, the outcomes associated with having a very empathetic physician were better than the outcomes associated with nonpharmacological treatments, opioid therapy, and lumbar spine surgery. Based on the data, the authors concluded that “Physician empathy is an important aspect of the patient-physician relationship among those with chronic pain. Greater efforts to cultivate and improve physician empathy appear warranted in this population.”

Associations between organizational communication and patients’ experience of prolonged emotional impact following medical errors Sokol-Hessner L, Dechen T, Folcarelli P, McGaffigan P, Stevens JP, Thomas EJ, Bell S. Jt Comm J Qual Patient Saf. 2024 Mar 7:S1553-7250(24)00071-0. doi: 10.1016/j.jcjq.2024.03.002. Epub ahead of print. PMID: 38565471. Drs. Lauge Sokol-Hessner, Patricia Folcarelli, Eric J. Thomas, and Sigal Bell have been Gold Foundation grantees.
Medical errors frequently affect patients’ physical as well as emotional health, leading to enduring negative effects such as suffering, reduced trust, and reluctance to return for care. To explore these emotional impacts further, Dr. Lauge Sokol-Hessner and colleagues conducted a subanalysis of the 2017 National Patient Safety Foundation (now Institute for Healthcare Improvement) survey to investigate the frequency and factors influencing prolonged emotional impacts after medical errors in a sample of 2,536 American adults. The investigators found that 22% (559) of respondents had experienced a medical error, with 451 forming the study sample after exclusions based on the recency of the error and known duration of emotional impact. The study focused on examining prolonged emotional impacts categorized by duration (>1 month and >1 year) and on analyzing patient characteristics, the nature of the medical errors, and how organizational communication post-error affected emotional outcomes. The investigators discovered that despite similar types of medical errors experienced by patients, prolonged emotional impacts were significantly influenced by how healthcare organizations communicated with the patients post-error and whether communication aligned with national disclosure guidelines, including someone speaking openly and directly about the error or someone apologizing and taking responsibility. Prolonged physical impact was the most strongly associated factor for prolonged emotional impact. Additionally, patients with an annual household income of less than $50,000, women, and individuals with less formal education were twice as likely as their counterparts to report emotional impact lasting longer than a year. The researchers concluded that “organizations should emphasize communication consistent with national guidelines and consider longer surveillance and support for patients after safety events, particularly those at potential risk of health care disparities.”

Associations of health care utilization and therapeutic alliance in patients with advanced cancer Bell SG, Althouse AD, Belin SC, Arnold RM, Smith KJ, White DB, Chu E, Schenker Y, Thomas TH. J Palliat Med. 2024 Apr;27(4):515-520. doi: 10.1089/jpm.2023.0559. PMID: 38574330. Dr. Robert M. Arnold has been a Gold Foundation grantee.
The therapeutic alliance (TA) refers to the mutual understanding, caring, and trust between patients and their oncologists. Recent literature demonstrates that TA impacts treatment adherence and quality of life. To further explore this association, Dr. Sarah G. Bell and colleagues conducted a secondary analysis of the CONNECT study, a cluster randomized clinical trial involving 672 advanced cancer patients. The investigators used the Human Connection (THC) scale to measure TA and analyzed how it influenced emergency department (ED) visits within 30 days of death and hospice enrollment rates. They found that patients with higher TA scores were significantly less likely to visit the ED in their final days, suggesting that strong patient-oncologist relationships might help manage end-of-life issues more proactively, leading to fewer crisis-driven hospital visits. However, contrary to their hypotheses, higher TA did not correlate with increased hospice enrollment, indicating that even strong patient-provider relationships might not influence the decision to enter hospice care. This study highlights the potential of enhancing therapeutic alliances to reduce emergency interventions at the end of life, though it did not establish a connection between TA and hospice enrollment decisions.

Decision-making for hospitalized incarcerated patients lacking decisional capacity Batbold S, Duke JD, Riggan KA, DeMartino ES. JAMA Intern Med. 2024 Jan 1;184(1):28-35. doi: 10.1001/jamainternmed.2023.5794. PMID: 38048093; PMCID: PMC10696514.
The U.S. criminal legal system has a growing, aging incarcerated population with higher rates of chronic illnesses compared to the general population. Incarcerated individuals whose medical needs exceed prison capabilities are cared for in nearby clinics and hospitals, but such care may be complicated by policies or uncertainty by the healthcare team of the patient’s rights and the role of prison employees – especially in cases when incarcerated patients do not have the capacity to make their own medical decisions. To investigate this, Sarah Batbold and colleagues undertook a retrospective qualitative study of incarcerated patients transferred from a federal medical center operated by the Federal Bureau of Prisons to a tertiary care center over a 20-year period. The researchers reviewed medical records of all incarcerated individuals admitted for at least 24 hours to the Mayo Clinic between 1999 and 2019. They identified 967 admissions involving 462 patients, with 131 admissions involving a loss of decisional capacity and 43 requiring surrogate decision-making. Notably, prison employees were documented as being present or participating in medical decisions for half of all the admissions. Thematic analysis revealed five major themes: (1) uncertainty and misinformation about patient rights, (2) role of prison employees in medical decision-making, (3) privacy violations, (4) deference to prison officials, and (5) estrangement from family and friends outside of the prison. The authors highlight the need for improved training in carceral healthcare and stricter adherence to legal and ethical standards, and provide suggestions for clinicians to advance humanistic care of incarcerated patients. They also note that hospitals with “high volumes of incarcerated patients should review formal policies with hospital staff or conduct joint training sessions with correctional employees.”

Physician coaching by professionally trained peers for burnout and well-being: a randomized clinical trial Kiser SB, Sterns JD, Lai PY, Horick NK, Palamara K. JAMA Netw Open. 2024 Apr 1;7(4):e245645. doi: 10.1001/jamanetworkopen.2024.5645. PMID: 38607628; PMCID: PMC11015346. Free full text
Physician burnout is an epidemic characterized by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment, which significantly impacts patient care and physician well-being. Despite various personal and systemic contributors, burnout has been exacerbated by the COVID-19 pandemic, increasing clinicians’ emotional and psychological stress. To explore this further, Dr. Stephanie B. Kiser and colleagues at Massachusetts General Physicians Organization conducted a randomized clinical trial to assess the effectiveness of a peer-to-peer professional coaching program designed to improve physician well-being, increase workplace satisfaction, and reduce burnout. The study, involving 138 physicians, compared outcomes between a group receiving coaching (n=67) and a delayed intervention control group over three months (n=71). Physicians in the coaching group selected their peer coaches from a trained pool and participated in six structured coaching sessions. The sessions aimed to establish and pursue professional and personal goals, fostering an environment of supportive accountability and growth. Compared with the group with no intervention, statistically significant improvements in burnout (-21.6% vs. +2.5% in controls), interpersonal disengagement (-30.1% vs. +4.1%), professional fulfillment (+10.7% vs. no change), and work engagement (+6.3% vs. -2.2%) were observed after 3 months of coaching. These positive changes suggest that peer coaching could be a valuable strategy for mitigating burnout and enhancing physician satisfaction and efficacy. Results of this study underscore the potential of internal peer coaching as a cost-effective and impactful intervention to address burnout and improve overall physician well-being. This approach not only aids in immediate stress reduction but also contributes to a more supportive and engaged professional environment. Future research will determine the long-term benefits of such interventions and their broader applicability across different healthcare settings.

Perceived stress from social isolation or loneliness among clinical and non-clinical healthcare workers during COVID-19 Meese KA, Boitet LM, Sweeney KL, Rogers DA. BMC Public Health. 2024 Apr 11;24(1):1010. doi: 10.1186/s12889-024-18363-7. PMID: 38605388; PMCID: PMC11010423.
Loneliness and social isolation are conditions where an individual’s social needs are unmet, which has been linked to higher burnout, lower job satisfaction, and physical and mental health issues, such as hypertension, cardiovascular disease, depression, and earlier mortality. These conditions were particularly exacerbated among healthcare workers during the COVID-19 pandemic due to heightened job demands and reduced social interactions. To explore this further across interprofessional teams, Dr. Katherine A. Meese and colleagues conducted a study across three consecutive years (2020-2022) at a large academic medical center in the southeastern United States, focusing on the impact of social isolation and loneliness on healthcare workers. The study utilized annual cross-sectional surveys completed by 6,310 healthcare employees who reported on stressors, including loneliness and social isolation. Analysis of the data revealed significant job role-related disparities, with trainees and physician scientists reporting the highest levels of loneliness as a major stressor. Workplace settings such as hospital-based ICUs showed higher rates of loneliness compared to other locations. Demographic factors like age and gender identity also influenced the experience of loneliness, with younger employees and those identifying as non-binary or using self-described gender identity options reporting higher levels. Overall, people who identified as Hispanic/LatinX reported the highest levels of loneliness, followed by other/self-identify race categories and white; people who identified as Asian or Pacific Islander reported the second-highest level in 2020, which was a spike from the other years. The study provides valuable insights into where targeted interventions and support systems within healthcare institutions are most needed to address and mitigate these stressors, thereby improving overall worker mental health and well-being.

Racial and ethnic bias in letters of recommendation in academic medicine: a systematic review Deshpande SR, Lepore G, Wieland L, Kogan JR. Acad Med. 2024 Mar 8. doi: 10.1097/ACM.0000000000005688. Epub ahead of print. PMID: 38466619. Dr. Jennifer R. Kogan has been a Gold Foundation grantee.
Letters of recommendation (LORs) are crucial for applications across medical education and academic medicine and have become even more significant after the Step 1 exam transitioned to pass/fail scoring. Recent studies highlight persistent gender and racial biases in LORs, such as the use of different adjectives for men and women, and racial disparities in letter content and length. Structured Letters of Recommendation (SLORs) have been introduced to counteract these biases by standardizing evaluations. To better understand this, Dr. Saarang R. Deshpande and colleagues conducted a systematic review to analyze the impact of racial, ethnic, and UIM biases in both traditional and structured LORs. Through a comprehensive search across several databases, leading to the inclusion of 23 studies that assessed LORs for a total of 19,012 applicants and 41,925 letters. The findings revealed that racial and ethnic biases persist in the length and language of LORs, with UIM applicants often receiving letters that differ in language intensity and content focus compared to their peers. For instance, UIM candidates frequently received shorter LORs and were described with fewer standout adjectives and more grindstone language. Moreover, SLORs, while proposed to be objective, still demonstrated racial and ethnic biases, albeit at a potentially reduced level compared to traditional LORs. The systematic review underscores the ongoing issues of bias in LORs within medical education, highlighting the need for further research and improvement in how LORs and SLORs address and reflect the diverse backgrounds of applicants. This study calls for enhanced mechanisms to mitigate bias and ensure fairness and equity in professional evaluations and advancements in the medical field.

Predicting primary care physician burnout from electronic health record use measures Tawfik D, Bayati M, Liu J, Nguyen L, Sinha A, Kannampallil T, Shanafelt T, Profit J. Mayo Clin Proc. 2024 Apr 3:S0025-6196(24)00037-5. doi: 10.1016/j.mayocp.2024.01.005. Epub ahead of print. PMID: 38573301. Tait Shanafelt has been a Gold Foundation grantee. Free full text
The electronic health record (EHR) has had dual effects on both increasing quality monitoring, records archiving, and research capacities as well as greater administrative burden and clinician burnout. Because of the large amounts of recorded data in EHRs and its contributions to burnout, it may be possible to quantify the risk of burnout through EHR metadata. Burnout is currently assessed exclusively by surveys, but this leads to survey burden, response biases, and delays in diagnosis. To investigate the use of EHR metadata as a tool to predict burnout, Dr. Daniel Tawfik and colleagues conducted a retrospective longitudinal cohort study at a large academic center and its affiliated community primary care clinics, involving 233 primary care physicians over two years. The study analyzed EHR use data and well-being surveys, including the Stanford Professional Fulfillment Index, to develop a predictive model of burnout. The model incorporated a wide array of EHR-related metrics, such as time spent on various EHR tasks, and personal well-being scores from the surveys. The study found that the predictive power of the EHR-derived model was limited, with the best-performing models achieving only modest success in predicting individual physician burnout. However, the models showed some potential in predicting which clinics might have higher levels of physician burnout, suggesting that EHR data could be useful at a broader organizational level to identify areas in need of intervention. The findings underline the complex nature of burnout, influenced by various factors beyond measurable EHR interactions, pointing to the need for comprehensive approaches to address the issue at both the individual and system levels.

Critical care nurses’ moral resilience, moral injury, institutional betrayal, and traumatic stress after COVID-19 Weissinger GM, Swavely D, Holtz H, Brewer KC, Alderfer M, Lynn L, Yoder A, Adil T, Wasser T, Cifra D, Rushton C. Am J Crit Care. 2024 Mar 1;33(2):105-114. doi: 10.4037/ajcc2024481. PMID: 38424022. Dr. Cynda Rushton has been a Gold Foundation grantee.
Critical care nurses frequently encounter stressful and ethically challenging situations which contribute significantly to professional and psychological strain. The COVID-19 pandemic exacerbated these challenges, leading to widespread burnout, a high intent to leave the profession, and significant psychological impacts such as traumatic stress and moral injury. This has raised concerns about the sustainability of the workforce and patient safety. Dr. Guy M. Weissinger and colleagues addressed these issues by conducting a study to examine the psychological impacts of traumatic stress, moral injury, moral resilience, and institutional betrayal among critical care nurses and their relationships to burnout. From January to March 2022, the investigative team sent an online survey to 121 critical care nurses who worked during the COVID-19 pandemic. The research aimed to analyze the extent to which moral injury symptoms and traumatic stress relate to moral resilience, institutional betrayal, and patient-related burnout. The findings revealed a high prevalence (71.5%) of significant traumatic stress and moral injury symptoms among the participants, linked strongly to feelings of institutional betrayal and burnout. Despite the psychological challenges, the study identified moral resilience as a potential protective factor, suggesting that enhancing moral resilience could help mitigate the adverse effects of traumatic and morally injurious experiences. The study underscores the importance of addressing systemic issues and how “Interventions must be tailored to their actual needs and timely to support individual growth and needed system-level changes.”

Hospitalizations and transgender patients in the United States Khanijow K, Wright S, Hedian H, Harris C. J Hosp Med. 2024 Apr 16. doi: 10.1002/jhm.13368. Epub ahead of print. PMID: 38623767. Dr. Scott Wright has been a Gold Professor.
Transgender adults in the U.S. often experience social and legal discrimination, which negatively impacts their health and leads to increased health issues and hospitalizations. Research has shown that transgender patients face inequities and discrimination in outpatient settings; what about inpatient care? In this study analyzing data from the National Inpatient Sample (NIS) from 2018 to 2019, Dr. Keshav Khanijow and colleagues examined the hospitalization rates, mortality, and resource utilization among 28,310 hospitalized transgender individuals (4,870 for medical diagnoses and 10,245 for psychiatric diagnoses), comparing these metrics against 16,617,979 cisgender patients with similar medical and psychiatric conditions. The study employed multivariable regression models to adjust for potential confounders in evaluating outcomes such as length of stay (LOS) and total hospital charges, with a focus on understanding if the disparities observed in outpatient settings were also present during hospital stays. The investigators found that transgender patients had fairly similar in-hospital mortality and resource utilization rates as cisgender patients when hospitalized for the same conditions. Transgender patients were on average younger and had lower Elixhauser comorbidity scores. The authors note that there are inpatient experiences not accounted for by these metrics, including patient satisfaction, and that while these inpatient care metrics are comparable, the equity of care and experiences could still be substantially different. The authors suggest that future work could explore inpatient experience and other outcomes, such as readmission rates. They conclude by emphasizing the importance of healthcare equity and the need to ensure that “transgender patients feel safe comfortable within our nation’s hospitals.”

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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.