Jeffrey Silver Humanism in Healthcare Research Roundup – May 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.

Mistreatment Experiences, Protective Workplace Systems, and Occupational Distress in Physicians Rowe SG, Stewart MT, Van Horne S, Pierre C, Wang H, Manukyan M, Bair-Merritt M, Lee-Parritz A, Rowe MP, Shanafelt T, Trockel M. JAMA Netw Open. 2022 May 2;5(5):e2210768. doi: 10.1001/jamanetworkopen.2022.10768. PMID: 35522279. Free full text Dr. Tait D. Shanafelt has been a Gold Foundation grantee.
Research on workplace mistreatment has found it to be common for medical trainees, but there is little data on how often practicing physicians experience mistreatment and what the sources might be. Mistreatment is associated with increased burnout, worse job performance, and depression, and may be experienced more frequently by women and physicians of color. To better explore this, Dr. Susannah G. Rowe and colleagues conducted a survey of 1,909 medical staff at Stanford University in September and October 2020. The survey consisted of three sections: (1) the Mistreatment, Protection, and Respect (MPR) Measure, a 7-item measure devised by the authors, (2) the Professional Fulfillment Index, and (3) a demographic questionnaire for gender, race, age, and specialty. Among the 1,505 who completed the survey (78.8%), 1,397 respondents answered questions about mistreatment. 327 (23.4%) reported experiencing mistreatment in the last 12 months, with patients and visitors being the most common source of mistreatment. The perception of mistreatment was associated with a 1.13-point increase in burnout and 0.99-point decrease in professional fulfillment on scales of 0 to 10. For respondents who reported that their workplace system has no protections, the impact was even greater: 2.41-point increase in burnout and 2.81-decrease in professional fulfillment. Worse still, women were twice as likely to experience mistreatment. While non-white physicians also seemed to experience more mistreatment, the small numbers of non-white respondents precluded further analysis. Regardless, this study suggests that there is a high prevalence of workplace mistreatment of physicians, particularly by patients and visitors. Based on these findings, the authors conclude that there is an “urgent need for organizations to put systems in place to reduce the incidence of mistreatment.”

Finding Meaning in Medicine: Pediatric Residents’ Perspectives on Humanism Pu H, Bachrach LK, Blankenburg R. Acad Pediatr. 2022 May-Jun;22(4):680-688. doi: 10.1016/j.acap.2021.12.007. Epub 2021 Dec 11. PMID: 34902564.
Because humanism is a core component of physician professionalism, several interventions have been introduced at early stages of training to foster humanism and promote wellness. However, the perspectives of resident physicians on how humanism impacts the formation of their professional identity remains largely unknown. To describe this development, Dr. Helen Pu and colleagues interviewed 32 pediatric residents at Stanford University. Through analysis of transcripts via grounded theory, they uncovered five themes: (1) Empathy, compassion and respect are foundational elements of humanism; (2) Each resident had a unique view of humanism derived from personal values; (3) Residents felt that the terms excellence and resilience (from the Gold Foundation IECARES model) did not fit their own definitions; (4) Residents felt that humanism is a central part of their practice and training; and (5) The demands, structure, and culture of residency were often in conflict with promoting humanism in residents. They also developed a new framework to conceptualize humanism identity formation during pediatrics residency that emphasizes the increased power of the healthcare system and unconscious acquisition on humanism formation in residency. The authors highlight that this framework can be applied in residency programs as a means to analyze specific needs of residents and programs as well as to address factors impacting socialization and identity formation.

A Formative Mixed-Methods Study of Emotional Responsiveness in Telepalliative Care Hutchinson RN, Anderson EC, Ruben MA, Manning N, John L, Daruvala A, Rizzo DM, Eppstein MJ, Gramling R, Han PKJ. J Palliat Med. 2022 Apr 12. doi: 10.1089/jpm.2021.0589. Epub ahead of print. PMID: 35417249. Dr. Mollie A. Ruben has been a Gold Foundation grantee.
Palliative care (PC) has been shown to improve quality of life for people with serious illnesses. Telepalliative (tele-PC) service shows promise in expanding access, but can tele-PC services support emotionally responsive patient-clinician interactions?  Dr. Rebecca N. Hutchinson and colleagues conducted a mixed-methods study to assess clinicians’ emotional responsiveness. They used data from questionnaires, qualitative interviews, and video coding of 11 tele-PC consultations in Maine and Vermont. Quantitatively, all patients rated tele-PC as equal to, or better than, in-person PC in providing emotional support. This was backed by qualitative analysis, which showed a tendency toward higher positive emotions and lower negative emotions following consultation. In video coding, there were 114 instances of patients expressing emotions, of which clinicians detected and responded 98% of the time. Altogether, their data provides multiple lines of evidence that tele-PC appears to support emotionally responsive patient-clinician interactions. Based on this, the authors advocate for further dissemination, implementation, and evaluation of tele-PC services.

Multiple symptoms and health anxiety in primary care: a qualitative study of tensions and collaboration between patients and family physicians Le TL, Mylopoulos M, Bearss E, Geist R, Maunder R. BMJ Open. 2022 Apr 15;12(4):e050716. doi: 10.1136/bmjopen-2021-050716. PMID: 35428616; PMCID: PMC9014049. Free full text
Physicians often encounter patients with multiple, persistent, and challenging symptoms. These patients often have health anxiety, poorer health outcomes, and higher utilization of health resources. These dynamics can make it challenging to foster and maintain the therapeutic alliance. To understand the interpersonal processes influencing this relationship, Dr. Thao Lan Le and colleagues conducted semi-structured interviews with 18 patients with high physical symptom severity and/or high health anxiety, and 7 family physicians in the same clinic at a large teaching hospital. Through grounded theory, they synthesized a model of interpersonal tension and collaboration. Central to this is how physicians’ helpful attitudes and actions, such as spending time, active listening, open-mindedness, compassion, managing expectations, and managing one’s own feelings, can facilitate discussion of troublesome topics (e.g. testing and referrals, medications, psychological factors and stress, concerns over missing something serious) to identify and then resolve crucial dilemmas. The authors acknowledge that lessons from this single-center study may not necessarily be transferable, but it does nevertheless shed light on important relationships. It also provides practical advice to clinicians in the field facing such dilemmas: Shift the focus away from the content of troublesome topics and toward the process of building trusting relationships with patients.

Exploring reasons for MD-PhD trainees’ experiences of impostor phenomenon Chakraverty D, Cavazos JE, Jeffe DB. BMC Med Educ. 2022 Apr 30;22(1):333. doi: 10.1186/s12909-022-03396-6. PMID: 35490228; PMCID: PMC9055705. Free full text
Students in MD-PhD programs have to undergo rigorous training to obtain both of their degrees, including prolonged periods of training, multiple transitions between patient care and research, and heightened expectations of academic research and productivity. Because of these, trainees often experience imposter phenomenon, an experience in which high-achieving successful individuals believe that their successes are not a product of effort and competence but rather luck. This has practical implications because imposter phenomenon is associated with lower perceived wellness, greater anxiety, distress, burnout, and perfectionism. Yet little is known about imposter phenomenon in MD-PhD trainees. To characterize this experience, Dr. Devasmita Chakraverty and colleagues first conducted a survey containing the Clancy Impostor Phenomenon Scale (CIPS) to identify MD-PhD trainees with Imposter Syndrome. They then interviewed participants and analyzed transcripts to derive themes. Out of 959 respondents, 13 were identified as MD-PhD students and residents; 9 went on to complete interviews. All 9 experienced moderate-to-intense imposter phenomenon. Four themes emerged from their analysis: (1) professional identity formation, (2) fear of evaluation, (3) minority status, and (4) program-transition experiences. Findings from this research point to strategies to reduce imposter phenomenon, including early discussions during orientation, building supportive communities and networks of mentors and peers, re-immersion program to smooth transitions, and leadership training workshops. The authors caution that the small sample and cross-sectional design may limit generalizability, but the study points to new directions in research, including longitudinal studies and assessment of potential interventions.

Interprofessional model on speaking up behaviour in healthcare professionals: a qualitative study Umoren R, Kim S, Gray MM, Best JA, Robins L. BMJ Lead. 2022 Mar;6(1):15-19. doi: 10.1136/leader-2020-000407. Epub 2021 Apr 26. PMID: 35537012. Drs. Jennifer A. Best and Sara Kim have been Gold Foundation grantees.
Speaking up to express concerns about patient safety is an important component of safety culture and contributes to psychologically safe environments. However, prior literature suggests that cultural, interpersonal, and personal factors may hinder speaking up. Dr. Rachel Umoren and colleagues examined the barriers and facilitators of speaking up through 12 focus groups and two interviews with 62 nurses, advanced practice providers, and physicians at three healthcare facilities. They identified two recurring themes: (1) the predominantly hierarchical culture of medicine as a barrier and (2) institutional, interpersonal, and individual factors can modulate the impact of medicine’s hierarchical culture. This suggests the key role of establishing psychological safety through greater leader inclusivity, simulation training, and safety practices such as procedural safety checklists or code debriefing. Larger reform of institutional structures to support and reinforce individuals speaking up may also be helpful, including formalized training and rewarding of team leaders for establishing safety culture.

From ‘spectating’ to ‘spect-acting’: medical students’ lived experiences of online Forum Theatre training in consulting with domestic abuse victims McGrath D, Gormley GJ, Reid H, Murphy P. Adv Simul (Lond). 2022 Apr 15;7(1):11. doi: 10.1186/s41077-022-00208-1. PMID: 35428361; PMCID: PMC9012059. Free full text Dr. Helen Reid has been a Gold Foundation grantee.
Domestic abuse remains highly prevalent around the world, with 27% of women aged 15 to 49 years who have been in a relationship experiencing physical and/or sexual violence by their intimate partner. Healthcare practitioners have an important role in recognizing features of domestic abuse and intervening to prevent further harm. Mr. Daire McGrath and colleagues studied how an online forum training exercise impacts how medical students approach domestic abuse. They adopted the methodology of Forum Theatre (FT), which permits an experiential and immersive learning experience, to craft a simulated consultation between a general practitioner and a domestic abuse victim. They then interviewed 11 participants and used template analysis to structure the phenomenological interpretation. Five themes were developed: (1) “Almost being there…but not quite”: the realistic experience of forum theatre, (2) “Taken on an emotional journey”, (3) “Opening and controlling a privileged space”, (4) “Small things matter…”: cultivating and maintain rapport, and (5) Critically reflecting on future professional self. This analysis supports the potential role of FT to teach students about domestic abuse since it elicits a meaningful and emotive response among participants. Moreover, it may help to improve consultation skills, including “observational awareness of a patient’s body language and signs of physical abuse.”  The authors conclude by noting that further research is necessary to determine how FT can be implemented in other settings and to explore the impact of such activity on learners’ empathic skills.

Social Support, Social Isolation, and Burnout: Cross-Sectional Study of U.S. Residents Exploring Associations With Individual, Interpersonal, Program, and Work-Related Factors Leep Hunderfund AN, West CP, Rackley SJ, Dozois EJ, Moeschler SM, Stelling BEV, Winters RC, Satele DV, Dyrbye LN. Acad Med. 2022 Apr 20. doi: 10.1097/ACM.0000000000004709. Epub ahead of print. PMID: 35442910. Drs. Colin West and Liselotte Dyrbye have been Gold Foundation grantees.
Social support is believed to be an important contributor to resilience and well-being, but very little is understood about how social support contributes to the well-being of resident and fellow physicians. To understand how social support and isolation are associated with burnout, program satisfaction, and organizational satisfaction, Dr. Andrea Leep Hunderfund and colleagues conducted a cross-sectional survey, focusing on social support/isolation, burnout, program satisfaction, and organization satisfaction, of all resident physicians at the Mayo Clinic’s four graduate medical education training sites. They also collected data about duty hours, call burden, elective time, and vacation days from institutional administrative records and interviews from program coordinators and/or directors. With this data, they conducted multivariable regression to examine the strength of relationships among variables. 762 residents (out of 1,146 surveyed) ultimately responded. Results demonstrated higher emotional and tangible support were strongly associated with lower odds of burnout and higher odds of program and organization satisfaction. Conversely, higher social isolation scores were associated with lower odds of program satisfaction and organization satisfaction. More specifically, the odds of burnout decreased by 45% and 18% for each 1-point increase (out of 5 points) in the emotional and tangible support scores, respectively. Interestingly, they also found that personal and professional relationships, satisfaction with autonomy, and vacation days correlate with social support, rather than the structure of programs. These findings suggest important roles for cultivating and improving workplace relationships, prioritizing leadership and faculty development, providing graded resident responsibility, and staggering breaks from training in combating burnout.

Lessons learned from academic medical centers’ response to the COVID-19 pandemic in partnership with the Navajo Nation Bongiovanni T, Shamasunder S, Brown W 3rd, Rivera Carpenter C, Pantell M, Ghali B, Harrison JD. PLoS One. 2022 Apr 5;17(4):e0265945. doi: 10.1371/journal.pone.0265945. PMID: 35381019; PMCID: PMC8982841. Free full text Dr. Sriram Shamasunder has been a Gold Foundation grantee.
The ongoing COVID-19 pandemic has uncovered and exacerbated pre-existing healthcare inequities in the United States, including those affecting Native American populations. To help address this, in 2020-2021, the University of California San Francisco (UCSF) and Health Equity, Action, Leadership (HEAL) Initiative jointly sent volunteer teams of nurses and doctors to serve in Navajo Nation hospitals. To explore the perspectives of these volunteers, Dr. Tasce Bongiovanni and colleagues conducted semi-structured interviews of 37 clinicians and hospital administrators. Through thematic analysis of transcripts, they identified 4 themes: (1) Mission and values, (2) Workforce preparation, (3) Coordination, and (4) Solidarity and trust. Each theme had four subthemes, yielding 16 subthemes total. For each subtheme, the authors articulated corresponding recommendations to help guide further initiatives. The authors concluded that academic medical centers can indeed interact with vulnerable populations to develop “deep, meaningful, longstanding partnerships,” which can help to address healthcare inequalities.

Human-Caused Sound Distractors and their Impact on Operating Room Team Function Brommelsiek M, Krishnan T, Rudy P, Viswanathan N, Sutkin G. World J Surg. 2022 Jun;46(6):1376-1382. doi: 10.1007/s00268-022-06526-9. Epub 2022 Mar 28. PMID: 35347392. Dr. Margaret Brommelsiek has been a Gold Foundation grantee.
The Operating Room (OR) is often loud and noisy with the various machine- and human-caused sounds that can interfere with communication and undermine safety. Dr. Margaret Brommelsiek and colleagues examined the variety and acoustic intensity of these sounds through spectral analysis of 59 surgeries, along with their impact on team communication through a survey of 60 surgical team members. 93% of participants indicated that OR noise, particularly irrelevant conversations, interfere with team communication. The researchers also found that human-caused sounds were comparable to machine-based sounds, but were rated as more interfering with surgical team function. Spectral analysis confirmed that both the machine- and human-caused sounds obscure surgeon instructions. The authors use these findings to call for reduced avoidable sounds in the OR in order to reduce the likelihood of miscommunications. They also seek to conduct more research on the topic by “observing episodes of communication breakdowns and documenting contributions of OR sound sources responsible for those backgrounds.”

Leveraging Machine Learning to Understand How Emotions Influence Equity Related Education: Quasi-Experimental Study Sukhera J, Ahmed H. JMIR Med Educ. 2022 Mar 30;8(1):e33934. doi: 10.2196/33934. PMID: 35353048; PMCID: PMC9008524. Free full text Dr. Javeed Sukhera has been a Gold Foundation grantee.
Addressing bias is an important aspect of promoting health equity. However, teaching and learning about bias is often challenging because of the emotional component of bias-related discourse. After all, emotions play an important role in mediating the relationship between self-concept and learning. When discussing biases, learners may feel threatened, feel negative emotions, and then avoid processing of learning. To understand the role of emotions, Dr. Javeed Sukhera and Mr. Hasan Ahmed conducted a two-stage quasi-experimental study. They first developed a sentiment analysis (SA) of bias-related dialogue using a pre-existing archive of interviews with health professionals. They then applied the SA to an archive of social media discourse on Twitter that contained equity-related hashtags. The SA algorithm that was developed was quite accurate (83% matched human scoring of sentiment). When comparing 555 tweets by health professionals to 6,680 tweets from the general population, they found that health professionals are more likely to show and convey emotions regarding equity-related issues. The authors note that this study “provides an example and template for future researchers” to glean better insights into the emotionally charged nature of teaching and learning about bias. This can inform approaches that educators take to incorporate and accommodate learner emotions in discussing bias.

An Interactive Game with Virtual Reality Immersion to Improve Cultural Sensitivity in Health Care Hershberger PJ, Pei Y, Crawford TN, Neeley SM, Wischgoll T, Patel DB, Vasoya MM, Castle A, Mishra S, Surapaneni L, Pogaku AA, Bositty A, Pavlack T. Health Equity. 2022 Mar 3;6(1):189-197. doi: 10.1089/heq.2021.0128. PMID: 35402778; PMCID: PMC8985530. Free full text Dr. Sabrina Neeley has been a Gold Humanism Scholar at the Harvard Macy Institute Program for Educators.
Healthcare professionals are as susceptible to implicit and explicit biases as those in the general population, which may exacerbate healthcare disparities. Prior literature suggests that training to enhance awareness of individual perspectives and experiences may help to mitigate these biases. Along those lines, Dr. Paul J. Hershberger and colleagues created an online training simulation that includes the interactive life course experience of two characters, a Syrian refugee with limited English proficiency and a Black pregnant woman with a history of opioid use disorder. The simulation highlighted socioeconomic determinants of health using virtual reality immersion. 364 clinical and nonclinical health professionals completed the simulation, of which 158 also completed pre- and post-simulation questions. Compared to before playing the game, participants had increased feelings of compassion toward the patient and decreased expectations about how difficult future encounters with the patient would be. Participants were also less inclined to view the patient as responsible for their situation. The authors note that, while training simulations cannot fully replace real-life experiences, tools like these can help to provide practice necessary for consistent behavior change.Their simulation is available online at

Transition Needs Compassion: a Thematic Analysis of an Online Compassion-Focused Therapy Group in a Gender Service Pipkin A, Smith A, Shearn C. Mindfulness (N Y). 2022 May 4:1-11. doi: 10.1007/s12671-022-01893-9. Epub ahead of print. PMID: 35529521; PMCID: PMC9067548. Free full text
Studies demonstrate that transgender and gender non-conforming people experience greater rates of shame and self-criticism, which, in turn can lead to considerable psychological distress. One way to help address this is through the promotion of self-compassion and compassion-focused therapy. Dr. Alastair Pipkin and colleagues explored this through semi-structured interviews of six transgender people who attended an 8-week compassion-focused therapy group in the United Kingdom. Through inductive thematic analysis, they identified four themes: (1) transition needs compassion, (2) acceptability of compassion-focused approach, (3) being in a group with other transgender people, and (4) online delivery works despite its challenges. Overall, the compassion-focused framework appeared to benefit participants and was an appropriate and helpful way of understanding the experiences of stigma. The authors noted that these findings can empower further quantitative and qualitative evaluation of clinical outcomes.

Clinician End-of-Life Experiences With Pediatric Muslim Patients at a US Quaternary Care Center Kolmar A, Kamal AH, Steinhauser KE. J Pain Symptom Manage. 2022 May;63(5):673-679. doi: 10.1016/j.jpainsymman.2022.01.005. Epub 2022 Jan 12. PMID: 35032621 Drs. Karen Steinhauser and Arif H. Kamal have been Gold Foundation grantees.
Recognizing spiritual and cultural differences is critical for culturally sensitive End-of-life (EOL) care. Given the large population of Muslim Americans, understanding clinician experiences when encountering Muslim patients obtaining EOL care is an important priority. Dr. Amanda Kolmar and colleagues examined this in the pediatric context through thematic analysis of interviews with 16 nurses, physicians, and social workers at Duke University Medical Center. Three major themes emerged: (1) barriers to rapport, (2) barriers to clinician neutrality, and (3) barriers to decision-making. Some barriers are generalizable to other minority groups, such as language and cultural barriers, while other barriers are more specific, such as “concepts of death being in God’s hands.”  Many clinicians voiced concern that the complex interplay between religion and culture may put Muslim patients at risk for lesser care. Complicating matters further, moral distress may exist when patients and clinicians have divergent views based on their own backgrounds, particularly with regards to gender roles. The authors caution that there is significant diversity within Islam and that these interactions may not necessarily be representative. However, this does shed light on disparities and provides directions for how to overcome barriers in delivering culturally competent EOL care to Muslim patients.

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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.