Jeffrey Silver Humanism in Healthcare Research Roundup – May 2020

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.

  Publications from Gold-Affiliated Authors  

Effects of a communication intervention randomized controlled trial to enable goals-of-care discussions Bickell NA, Back AL, Adelson K, Gonsky JP, Egorova N, Pintova S, Lin JJ, Kozuch P, Bagiella E, Smith CB. JCO Oncol Pract. 2020 May 6:OP2000040. Dr. Anthony Back is a Mapping the Landscape grantee.
Goals-of-care (GoC) discussions between cancer patients and their practitioners are extremely important to maintain a high quality of life in the advanced stages of disease. However, data suggest that, when they do occur, they occur within the last 2 months of life and frequently do not involve the primary oncologist. To help remedy this situation, Nina Bickell and colleagues examined whether a 2-hour communication skills training course and four coaching sessions would help improve the prevalence and quality of GoC communications, as rated by 265 patients with newly diagnosed advanced cancer. They enrolled 11 oncologists into this intervention, and compared their communication skills to 11 oncologists who did not receive the intervention. They found that the intervention improved the oncologists’ skill in eliciting patient values, but did not lead to statistically significant increases in the prevalence or quality of GoC communications. Additionally, there was no difference in deaths, hospitalizations, ICU admissions, or chemotherapy. The authors conclude that results of this study demonstrate the viability of a coaching intervention to improve communication skills and that further work is needed to teach oncologists how to better align treatment recommendations with patient values.

The views and experiences of clinicians sharing medical record notes with patients DesRoches CM, Leveille S, Bell SK, Dong ZJ, Elmore JG, Fernandez L, Harcourt K, Fitzgerald P, Payne TH, Stametz R, Delbanco T, Walker J. JAMA Netw Open. 2020 Mar 2;3(3):e201753. Free full text  Dr. Sigall Bell is a Gold Professor and a Mapping the Landscape grantee.
Over the past decade, the idea of “open notes” that both practitioners and patients can see has become mainstream. But how do clinicians view this development?  Catherine DesRoches and colleagues examined this through a large web-based survey sent to 6,064 clinicians affiliated with three large healthcare systems across multiple specialties. 1,628 (27%) responded between May and August 2018. Nearly 3 out of 4 clinicians agreed that open notes were a good idea, and about 3 out of 5 would recommend the practice to colleagues. At the same time, approximately 1 out of 3 reported spending more time on documentation, including avoiding language that may be perceived as critical to the patient. Overall, the authors conclude that open notes “may help clinicians, patients, and families improve care by moving toward more open communication and partnership.”

Being vulnerable: A qualitative inquiry of physician touch in medical education Kelly M, Nixon L, Rosenal T, Crowshoe L, Harvey A, Tink W, Dornan T. Acad Med. 2020 May 5. Drs. Martina Kelly, Lara Nixon, Tom Rosenal and Tim Dornan are Mapping the Landscape grantees. Dr. Rosenal is also a reviewer for the Gold Foundation’s Hope Babette Tang Humanism in Healthcare Essay Contest.
Touch is a very important form of nonverbal communication that impacts the quality of humanistic care. Yet there is little data about how physicians view and experience touch. Martina Kelly and colleagues examined this through the qualitative lens of collaborative inquiry. They enrolled six experienced physician-educators from the University of Calgary, and, through meeting transcripts, narrative accounts, and role-playing exercises, identified two overarching themes. The first, touch as presence, allowed physicians to acknowledge patients as vulnerable and demonstrate their own humanity. The second, touch as risk, acknowledged the subjective and intimate nature of touch as being potentially unwelcome. They also discussed possible ways to broaden teaching around touch, focusing in particular on the development of a safe learning environment for learners to adapt and adopt appropriate skills for clinical practice. The authors mention that, since touch is such a ubiquitous aspect of nonverbal communication, further research on patient perspectives is needed.

The transition from medical student to resident: A qualitative study of new residents’ perspectives Chang LY, Eliasz KL, Cacciatore DT, Winkel AF. Acad Med. 2020 Apr 28. Abigail Winkel is a Mapping the Landscape grantee.
The transition between medical school and residency can be daunting, with new responsibilities, expectations, and duties. Lucy Chang and colleagues looked at the experiences of 10 first-year residents at New York University Grossman School of Medicine transitioning from medical school. Through one-on-one telephone interviews and a grounded theory methodology, they synthesized a conceptual model based on cell biology, where individual aspects of professional identity and growth comprise a nucleus while environmental aspects constitute a cytoplasm. Five broad themes emerged: “the abrupt change in educational environment, an immersive experience of learning as a resident, ambivalence and tensions around the new role, navigation of professional relationships, and balance and integration of working in medicine with personal lives and goals.” The authors conclude by stating that the most effective efforts to improve the transition to residency likely focus on the interface between the nucleus and cytoplasm, whereby “new residents adapt to working and learning within the context of their environment.”

Original research: An investigation of career choice regret among American nurses Dyrbye L, West C, Johnson P, Cipriano P, Peterson C, Beatty D, Major-Elechi B, Shanafelt T. Am J Nurs. 2020 Apr;120(4):24-33. Lotte Dyrbye and Tait Shanafelt  are Mapping the Landscape grantees.
Studies have shown that burnout is strongly associated with career choice regret for U.S. physicians, but does the same association hold true for nurses? To help understand the prevalence of career choice regret and factors associated with this regret for nurses, Lotte Drybye and colleagues analyzed online survey responses from 6,933 nurses nationwide. The survey questions included the Maslach Burnout Inventory-Human Services Survey for Medical Personnel (MBI-HSS[MP]) and several questions on career regret. They found that 15% experienced this regret, and that this regret was independently correlated with burnout, unplanned/mandatory overtime, being male, and having a higher academic degree. Among these, burnout was the most strongly associated (odds ratio: 4.39). These results suggest that burnout needs to be addressed among nurses to ensure satisfaction with career choice. However, the authors acknowledge several caveats: a low response rate of 9.9% prevents generalizability, and this survey did not include members who were not members of the American Nurses Association (ANA), thereby potentially introducing bias.

Relationship between faculty characteristics and emotional exhaustion in a large academic medical center Zivin K, Brower KJ, Sen S, Fowler R, Gold KJ. J Occup Environ Med. 2020 May 12. Srijan Sen is a Mapping the Landscape grantee.
Burnout is an occupational syndrome that is characterized by emotional exhaustion (EE), depersonalization, and decreased personal accomplishment at work. Kara Zivin and colleagues took a closer look at the EE contribution to burnout among medical school faculty. They did so by using the Physician Worklife Study and Healthy Work Place Study as part of a survey of 1,401 individuals. They found that 42% of respondents experienced EE. Faculty who had more clinical effort, more workplace stress, less reliance, less personal time, and more depressive symptoms were more likely to have EE compared with others. Interestingly, female gender, mid-career stage, and coping skills were not associated with levels of EE after accounting for other variables. Through these results, the authors surmise that coping skills may not necessarily mitigate EE, and, by extension, burnout, so long as there remain significant time and mental health burdens.

Becoming a clinician: Trainee identity formation within the GP supervisory relationship Brown J, Reid H, Dornan T, Nestel D. Med Educ. 2020 Apr 29. Helen Reid and Tim Dornan are Mapping the Landscape grantees.
Part of becoming a physician involves working in a supervisory relationship with a senior physician who helps to guide identity formation. But little is known about these supervisory relationships. James Brown and colleagues examined this using a critical realist approach with paired General Practitioner interns and supervisors in Victoria, Australia. They collected audio recordings of weekly supervisory encounters and reflections of these encounters, as well as four sequential recorded semi-structured interviews with each supervisor and trainee. They identified three social discourses: (i) clinical responsibility, (ii) ownership of clinical knowledge, and (iii) measures of trainee competency. These were then utilized to categorize four social relationships: (a) junior learner/expert clinician, (b) apprentice assistant/master coach, (c) co-clinicians, and (d) lean clinician/advisor. Regardless of the type of relationship, these seemed to be reciprocal identities and required a degree of invitation by supervisors for learners to enter those roles. The authors conclude by noting that supervisors and trainees must be explicit about their relationships, and can use language provided by the model to foster clarity in communication.  

Humanistic education in surgery: a “patient as teacher” program for surgical clerkship Simpson J, Ng S, Kangasjarvi E, Kalocsai C, Hindle A, Kumagai A, Cil T, Fenech D, Ahmed N, Rotstein O. Can J Surg. 2020 May 13;63(3):E257-E260. Arno Kumagai is a Mapping the Landscape grantee, and Stella Ng is a Gold Foundation grantee.
Surgeons can be seen as cold, uncompassionate, and autonomous. The authors note that surgical clerkships could offer an opportunity for medical students to consider the humanistic aspects of surgery in addition to its technical, science-oriented nature and “counter the dehumanizing effects of the hidden curriculum of surgery.” To highlight these humanistic aspects, Jory Simpson and colleagues at the University of Toronto piloted a “patient as teacher” program, which prior research has shown to be effective way to reach medical students and residents. Within the 8-week surgical clerkship, they incorporated three workshops. The first two focused on breast cancer survivors who shared their stories and reflections on their experience with surgeons, while the third prompted students to produce an arts-based reflection piece. Medical students reported gaining a greater appreciation for the surgeon-patient therapeutic alliance and shared decision-making, as well as the role of a surgeon in longitudinal care. Patients-as-teachers reported the sessions to be therapeutic and empowering and were willing to participate again. Evaluation into the program and its outcomes is ongoing.

Implementing inter-professional patient-family centered plan of care meetings on an inpatient hospital unit Hernandez N, Fornari A, Rose S, Tortez L. Patient Experience Journal. 2020; 7(1): 84-91. Alice Fornari is a Gold Foundation grantee and spoke at the 2019 Gold Humanism Summit.   Free full text
Inpatient plan of care meetings have been promoted in recent decades as ways to help improve person-centered care in the inpatient setting. However, implementation is often problematic. At a community hospital within Northwell Health-Hofstra University, Nicolas Hernandez and colleagues implemented formalized clinician and patient and family plan of care meetings. They used the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores before and after the intervention to determine if there was improvement in communication and care transitions. They also conducted interviews with patients to identify areas for improvement. The investigators determined that there indeed was improvement in patient/family communication with doctors and there were positive attitudes toward plan of care meetings. However, there was a lack of direct feedback from patients and family members and concerns about redundancy when sharing information during sessions. Overall, the authors consider this to be a baseline for identifying ways to facilitate further improvement and for scaling up the pilot in other settings.

Other Publications

Finding common threads: How patients, physicians and nurses perceive the patient gown Lucas CM, Dellasega C. Patient Experience Journal. 2020; 7(8): 51-64.   Free full text
Patient gowns have long been used in healthcare, but little research has been conducted about how patients perceive these gowns. Some data do suggest that current gowns may contribute to dehumanization and discouragement; Christy Lucas and Cheryl Dellasega explore this further among patients, nurses, and physicians. They interviewed 10 patients, 10 nurses, and 10 physicians, and utilized thematic analysis of interviews to understand perspectives and consider alternative designs. Altogether, they found negative first impressions of the gown and ideas for improvement, including individualization of designs, and barriers to change. Practitioners and patients diverged on certain topics, including expectations of wearing gowns in hospitals. Based on these results, the authors call for changes to attire to “humanize and dignify patients in the eyes of providers.”

Patient education in the hospital-at-home care context Vaartio-Rajalin H, Nyholm L, Fagerstrom L. Patient Experience Journal. 2020; 7(8): 65-74.   Free full text
Hospital-at-home (HAH) care is an emerging model where patients receive hospital-level care in their own homes. This requires education from family caregivers, who can serve as informal coworkers to physicians and other medical staff. Heli Vaartio-Rajalin and colleagues conducted a qualitative study among 27 adult non-palliative patients and 18 family caregivers in Finland. Through paired telephone interviews and thematic content analysis, they identified six themes, namely (i) feeling empowered, (ii) feeling served, (iii) feeling confused, (iv) feeling insecure, (v) facing uncertainty, and (vi) feeling dismissed. Holistically, they conclude that HAH staff provided patient education that met patient and family giver actual knowledge expectations, but dialog and comprehension checking were lacking, leading to assumptions about client needs. While the authors note that their results cannot be generalized, they conclude by advocating that “patient education should … be made the systematic, explicit, and visible core of advanced nursing care.”

To receive an email update when next month’s Research Roundup is published, please sign up here and check the box for Research Roundup.

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.