Jeffrey Silver Humanism in Healthcare Research Roundup – November-December 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.

What are the care needs of families experiencing sudden cardiac arrest? A survivor- and family-performed systematic review, qualitative meta-synthesis, and clinical practice recommendations Douma MJ, Myhre C, Ali S, Graham TAD, Ruether K, Brindley PG, Dainty KN, Smith KE, Montgomery CL, Dennet L, Picard C, Frazer K, Kroll T. J Emerg Nurs. 2023 Nov;49(6):912-950. doi: 10.1016/j.jen.2023.07.001. Epub 2023 Sep 21. Erratum in: J Emerg Nurs. 2023 Dec 6;: PMID: 37737785 Free full text Dr. Katherine E. Smith has been a Gold Foundation grantee.
The traumatic experience of sudden cardiac arrest (SCA) extends beyond the patient, profoundly affecting families as well. Recognizing this, Matthew Douma and colleagues conducted a systematic analysis and qualitative meta-synthesis focusing on the care needs of families who have experienced a family member’s SCA. They analyzed data from 39 studies involving 215 survivors and 418 family participants. The studies included were diverse, covering experiences from different countries and healthcare systems. Five major analytical themes were identified: (1) When the crisis begins we must respond; (2) Anguish from uncertainty, we need to understand — the family’s information needs are wide-ranging and long-lasting; (3) Partnering in care, we have much to offer — assigning one person to offer information and emotional support to families is “essential”; I(4) The crisis surrounding the victim, ignore us, the family, no longer. — “There is a near-universal desire of families to be acknowledged and respected and to have their experience and distress recognized and addressed openly”; (5) Our family’s emergency is not over, now is when we need help the most — “Families want follow-up to address unanswered questions, process grief, and transition to a new normal—whether bereaved or caregiver to a survivor.” Based on these insights, the study emphasized the importance of comprehensive care strategies. The authors concluded with recommendations, including (1) improved recognition and rapid response, (2) adoption of formal systems for improving information provision for families, (3) facilitation of effective communication between clinicians and families, (4) support for family presence and participation or support for family absence from resuscitation and (5) provision of meaningful psychological aftercare.

Partnering with patients and families to improve diagnostic safety through the OurDX tool: Effects of race, ethnicity, and language preference Bourgeois FC, Hart NJ, Dong Z, Ngo LH, DesRoches CM, Thomas EJ, Bell SK. Appl Clin Inform. 2023 Oct;14(5):903-912. doi: 10.1055/s-0043-1776055. Epub 2023 Nov 15. PMID: 37967936; PMCID: PMC10651368 Free full text Drs. Eric Thomas and Sigall K. Bell have been Gold Foundation grantees. Dr. Sigall K. Bell is also a Gold Professor.
Diagnostic errors and delays are major causes of healthcare complications, and evidence suggests that individuals from marginalized and minoritized groups may be more vulnerable to these diagnostic errors. In order to understand how diagnostic errors impact those at risk, Dr. Fabienne Bourgeois and colleagues developed and evaluated the OurDX tool, an electronic previsit tool designed to involve patients and families more directly in the diagnostic process and report diagnostic concerns to their clinicians. They conducted a cross-sectional study involving a cohort of 5,731 patients and families, and focused on how such factors as race, ethnicity, and language preference influence engagement with the OurDX tool. Results revealed that patients from non-English speaking backgrounds and patients self-identifying as Black were more likely to report a diagnostic concern than English-preferring patients and patients self-identifying as white, respectively. Interestingly, there were no statistically significant differences in physician-verified diagnostic concerns or in integration of patient contributions into the note, based on race, ethnicity, or language presence. The authors concluded by emphasizing the importance of including patients’ perspectives in healthcare settings in identifying potential diagnostic delays and errors, especially in patients who are at higher risk of healthcare disparities.

The Lancet Commission on medicine, Nazism, and the Holocaust: Historical evidence, implications for today, teaching for tomorrow Czech H, Hildebrandt S, Reis SP, Chelouche T, Fox M, González-López E, Lepicard E, Ley A, Offer M, Ohry A, Rotzoll M, Sachse C, Siegel SJ, Šimůnek M, Teicher A, Uzarczyk K, von Villiez A, Wald HS, Wynia MK, Roelcke V. Lancet. 2023 Nov 18;402(10415):1867-1940. doi: 10.1016/S0140-6736(23)01845-7. Epub 2023 Nov 8. PMID: 37951225 Dr. Hedy Wald has been a Gold Humanism Scholar at the Harvard Macy Institute and Dr. Matthew Wynia has been a Gold Foundation grantee.
The Holocaust was a systematic, state-sponsored persecution and murder of 6 million Jews by the Nazi regime and its collaborators, largely between 1939 and 1945. Health professionals during that time contributed to the Holocaust, and confronting their crimes has been a foundation of health professional ethics after World War II. The Lancet Commission on Medicine, Nazism, and the Holocaust aims to learn from and reflect on this history. Dr. Herwig Czech and colleagues published their findings with the aim of “supporting the development of morally conscious and self-critical, yet courageous and resilient health professionals.”  As part of the Commission’s report, they call for the introduction of teaching about the history of medicine, Nazism, and the Holocaust in all healthcare education settings. In doing so, they hope to foster history-informed professional identity formation and shape the social roles and responsibilities of the medical profession as a whole. Full recommendations can be found in their article.

Detour or new direction: The impact of the COVID-19 pandemic on the professional identity formation of postgraduate residents Cupido N, Diamond L, Kulasegaram K, Martimianakis MA, Forte M. Acad Med. 2023 Nov 1;98(11S):S24-S31. doi: 10.1097/ACM.0000000000005359. Epub 2023 Jul 28. PMID: 37983393 Dr. Tina Martimianakis has been a Gold Foundation grantee.
The COVID-19 pandemic has brought unprecedented challenges to healthcare, significantly impacting the professional identity formation (PIF) of postgraduate medical residents. To explore this further, Nathan Cupido and colleagues conducted a qualitative study involving 22 family medicine residents at the University of Toronto. Through symbolic interactionism as a theoretical framework, the study uncovered meanings that residents attributed to disruptions and subsequent reconfigurations of their postgraduate training resulting from the pandemic. Specifically, they identified 3 themes: (1) the impact of disruptions to residents’ postgraduate training on their learning and provision of care as family physicians; (2) the impact on their membership, agency, and relationships in their profession; and (3) the blurring of boundaries between their personal and professional identities. The study highlights the pandemic’s dual impact: It has been a catalyst for growth in professional identity for some, but for others, it has introduced significant struggles and reevaluations of career paths. These findings underscore the need for supportive structures within medical training programs to aid residents in navigating the complexities of PIF during times of crisis.

Embedding interprofessional education in clinical settings: Medical and dental student perceptions of a patient interview-storytelling experience Miller KA, Keeney T, Singh TA, Tolchin DW, Kesselheim JC, Farrell SE. Acad Med. 2023 Nov 17. doi: 10.1097/ACM.0000000000005523. Epub ahead of print. PMID: 37976381 Dr. Jennifer C. Kesselheim is a Gold Professor.
Interprofessional Education (IPE) is an important aspect of humanistic healthcare training to promote inclusiveness and equity among healthcare team members, but it can be challenging to deliver IPE in practice. Dr. Kelsey A. Miller and colleagues conducted a qualitative study to help evaluate a curricular intervention at Harvard Medical School regarding patient interview-storytelling experience. As part of this intervention, 161 first-year medical and 34 first-year dental students conducted a brief semi-structured patient interview. They were instructed to transcribe stories and provide reflections on the interview card. The authors then employed “a pragmatic qualitative research approach” similar to thematic analysis and synthesized three major themes: (1) students value patient-centered holistic care as the goal of interprofessional collaboration, (2) students reflect emerging professional and interprofessional identities in relating to patients, teams, and systems, and (3) students appreciate interprofessional care is complex and challenging, requiring sustained effort and commitment. The study suggested that while there is enthusiasm and recognition of the importance of IPE, effective integration requires adaptation to support conversations among healthcare team members. The authors concluded that this curricular intervention focusing on interviewing and storytelling is effective in delivering IPE.

Assessment of adverse childhood experiences, Adverse professional experiences, depression, and burnout in US physicians Trockel MT, West CP, Dyrbye LN, Sinsky CA, Tutty M, Wang H, Carlasare LE, Menon NK, Shanafelt TD. Mayo Clin Proc. 2023 Dec;98(12):1785-1796. doi: 10.1016/j.mayocp.2023.03.021. PMID: 38043996 Drs. Colin P. West, Liselotte Dyrbye, and Tait Shanafelt have been Gold Foundation grantees.
Multiple lines of evidence suggest that adverse childhood experiences (ACEs) and adverse professional experiences (APEs) may represent identifiable risk factors for both depression and burnout in physicians. To explore this among U.S. physicians, Dr. Mickey A. Trockel and colleagues conducted a secondary analysis of data from the American Medical Association Physician Masterfile. The study assessed the relationship between ACEs, APEs related to COVID-19, and the prevalence of depression and burnout. The analysis involved responses from 7,360 physicians who completed either a mailed survey (1,125 out of 3,671 total) or an electronic survey (6,235 out of 90,000 total). The findings revealed that 25% of physicians had experienced at least one of the two ACEs assessed (“emotional abuse during childhood” and “living with a household member with problematic substance abuse”), and 54.6% had encountered at least one of the two adverse COVID-19 experiences evaluated (“provided care to COVID-19-infected patients while not having adequate PPE” and “experienced disruptive economic consequences due to the COVID-19 pandemic”). This study highlights the significant prevalence of these adversities among physicians and their association with depression and burnout. The authors emphasize that screening for the ACEs and APEs included in the study, followed by the administration of the PROMIS depression scale, could help detect 23 physicians with mild to severe depression symptoms out of every 100. The authors concluded that there is a pressing need for targeted interventions and support systems within the medical community to address these adversities and improve the mental health and well-being of physicians.

Professional identity struggle and ideology: A qualitative study of residents’ experiences Sawatsky AP, Matchett CL, Hafferty FW, Cristancho S, Ilgen JS, Bynum WE 4th, Varpio L. Med Educ. 2023 Nov;57(11):1092-1101. doi: 10.1111/medu.15142. Epub 2023 Jun 3. PMID: 37269251; PMCID: PMC10592531 Dr. Adam Sawatsky and Dr. Frederic W Hafferty have been Gold Foundation grantees.
Professional identity formation (PIF), that is, “learning the ways of thinking, acting and feeling of the groups to which we belong and internalizing them as our own,” is a critical part of training and is shaped by ideology, the system of ideas and representations that dominate the minds of individuals or social groups. To investigate how PIF and ideology intersect, Dr. Adam P. Sawatsky and his team conducted a qualitative study with 12 resident physicians from the Mayo Clinic (n=7), the University of Washington (n=3), and Duke University (n=2). Employing a methodology that combined rich picture drawings and one-on-one interviews, the authors analyzed the data using a constructivist orientation and guidance from Althusser’s theory of ideology. The findings highlighted three major areas of struggle: the intense demands and expectations of perfectionism in their work, the tension between evolving professional identities and existing personal identities, and the dissonance between their envisioned professional identity and the realities of medical practice. These insights shed light on the inner conflicts and challenges faced by medical residents, offering a window into their professional and personal growth journey. These findings suggest that there is no single “true” explanation of PIF and that the process of PIF is highly individualized. The authors conclude that “learners, educators, and institutions can play a meaningful role in supporting identity development in medical learners through dismantling and rebuilding its damaging elements.”

Reluctant heroes: New doctors negotiating their identities dialogically on social media Dornan T, Armour D, Bennett D, Gillespie H, Reid H. Med Educ. 2023 Nov;57(11):1079-1091. doi: 10.1111/medu.15109. Epub 2023 May 22. PMID: 37218311 Drs. Tim Dornan, Deirdre Bennet, and Helen Reid have been Gold Foundation grantees.
The transition from medical student to doctors can be a challenge, especially in negotiating tensions between individual agency and the influence of institutions. Dr. Tim Dornan and colleagues delved into how new doctors navigate their professional identities using social media. Employing a dialogic qualitative analysis informed by Bakhtin’s cultural-historical theory, the team scrutinized 182 tweets to understand the dynamics of identity formation among interns. This novel approach revealed a distinct gradient of power and effect in the social media discourse. Institutional representatives often portrayed new doctors as heroes, while the interns themselves expressed feelings of incapability, vulnerability, and fear. In contrast, senior doctors exhibited a more ambivalent stance. This study highlights the nuanced ways in which new doctors adopt and resist various professional identities, influenced by hierarchical structures within the medical field. The authors concluded that these dialectic tensions, rooted in hierarchical dynamics, may not only cause emotional distress to interns but also limit the benefits to patients. They suggest that fostering dialogue among patients, physicians, and institutional representatives could alleviate these tensions, supporting a more harmonious transition for interns into their professional roles and potentially enhancing patient care.

From skillful to empathic: Evaluating shifts in medical students’ perceptions of surgeons through a combined patient as teacher and arts-based reflection program Gill GK, Ng SL, Kangasjarvi E, Crukley J, Kumagai A, Simpson JS. Can Med Educ J. 2023 Nov 8;14(5):14-21. doi: 10.36834/cmej.76536. PMID: 38045079; PMCID: PMC10690007 Free full text Drs. Stella Ng and Arno Kumagai have been Gold Foundation grantees.
In recent years, there has been greater recognition of the need for more humanistic approaches to health professions education. Patient-as-teacher (PAT) and arts-based reflection (ABR) programs are two validated methods that have individually shown benefit in fostering patient-centered humanistic care. To further explore the potential to synergize PAT and ABR approaches, Dr. Gurjot K. Gill and colleagues conducted a study exploring the impact of a combined PAT and ABR program on third-year medical students’ perceptions of surgeons. This study, conducted at the University of Toronto, involved 52 out of 296 students who completed their surgery clerkship. Using a novel one-item survey, students were asked to “list the top five attributes of a surgeon in order of perceived importance,” both before and after their clerkship. The results showed a significant shift in students’ perspectives, with a 17% increase in the predicted probability of ranking a humanistic characteristic (such as compassion, patience, patient advocate) as the most important and a 21% increase of ranking a humanistic characteristic among the top three attributes. These results indicate a growing appreciation for the value of humanism in surgical practice among medical students. The authors conclude that the combination of patients teaching medical students, followed by student reflection through art, was an effective intervention in shifting student perspectives toward recognizing the importance of humanistic characteristics in surgeons.

Anticipation or avoidance: Internal Medicine resident experiences performing invasive bedside procedures Louis AS, Lee C, Page AV, Ginsburg S. Can Med Educ J. 2023 Nov 8;14(5):5-13. doi: 10.36834/cmej.73122. PMID: 38045067; PMCID: PMC10689992 Free full text
Internal Medicine resident physicians’ proficiency in performing invasive bedside procedures, such as lumbar puncture and paracentesis, is crucial for patient care and training requirements. In acquiring these skills, there is a delicate interplay between emerging competence and persistent doubts and anxiety surrounding self-confidence. To better understand these experiences and potential empathic approaches to support procedural training, Dr. Alyssa S. Louis and her team conducted a qualitative study that included five semi-structured interviews and one focus group with seven IM residents (12 IM residents in total). The study aimed to identify barriers and facilitators affecting residents’ ability to perform essential procedures during their postgraduate years 1-3 of residency. Through thematic analysis, four key themes emerged: 1) Patient-specific factors such as body habitus and procedure urgency, (2) Systems factors like time constraints and accessibility of materials, (3) Faculty factors, including availability for supervision, comfort level, and referral preferences, and (4) Resident-specific factors, particularly preparation, prior experiences, and confidence. These findings highlight the complex interplay of various factors impacting residents’ procedural competence and confidence. Insights from this study could pave the way for identifying residents who develop an aversion to procedures and for developing effective strategies to support them in overcoming these hurdles and achieving success in their procedural skills. The authors concluded by noting that this research provides a foundation for future interventions aimed at enhancing the procedural competence of IM residents.

Hope and illness expectations: A cross-sectional study in patients with advanced cancer Loučka M, Althouse AD, Arnold RM, Smith TJ, Smith KJ, White DB, Rosenzweig MQ, Schenker Y. Palliat Med. 2023 Dec 12:2692163231214422. doi: 10.1177/02692163231214422. Epub ahead of print. PMID: 38087831 Dr. Robert M. Arnold has been a Gold Foundation grantee.
Hope, a vital coping mechanism for individuals with advanced disease, is an intricate psychological phenomenon. Sometimes clinicians can withhold serious news or prognosis because they do not want to take hope away, yet unrealistic expectations can complicate decisions and end-of-life care. Dr. Martin Loučka and his team sought to explore this complexity through a cross-sectional secondary analysis of the CONNECT trial, which focused on oncology clinic nurse-led primary palliative care interventions. The study included 672 patients from 17 oncology clinics and employed the Herth Hope Index, a validated 12-item survey, to measure hope. Additionally, the researchers assessed illness expectations by evaluating patients’ understanding of their treatment goals, life expectancy, and acknowledgment of terminal illness, performing multivariable regression and adjusting for demographic and clinical confounders. The results of this study suggest that hope can be maintained amidst both realistic and unrealistic illness expectations. The findings highlight the nuanced relationship between patients’ understanding of their illness and their sense of hope, implying that communication about serious news should not only focus on clarifying expectations but also on supporting individuals’ hopes. The authors emphasized the need for further studies to understand the impact of various confounding variables on hope, the association between objective hope and illness expectations, and to explore effective methods for clarifying people’s expectations. This research underscores the importance of balancing honesty and empathy in clinical communication, particularly for patients with advanced cancer.

“It’s what we can do right now”: Professional identity formation among Internal Medicine residents during the COVID-19 pandemic Madrazo L, Zhang G, Bishop KA, Appleton A, Joneja M, Goldszmidt M. Acad Med. 2023 Dec 1;98(12):1428-1433. doi: 10.1097/ACM.0000000000005452. Epub 2023 Sep 4. PMID: 37683270 Dr. Mark Goldszmidt has been a Gold Foundation grantee.
Professional identity formation (PIF) during medical training is influenced by a myriad of factors, including personal experiences, the learning environment, and moments of disruption, like the COVID-19 pandemic. Dr. Lorenzo Madrazo and his colleagues conducted semi-structured group interviews with 24 Internal Medicine residents to explore how the pandemic influenced PIF. The study employed constructivist grounded theory for data analysis. The investigation highlighted how residents’ actions and resignation in the face of patient care challenges during the pandemic shaped their professional identity. The pandemic exacerbated system constraints, heightening residents’ awareness of the dissonance between their personal values and those demonstrated by the healthcare system. For example, some residents discussed advocating for patients and being told “no” because of the pandemic restrictions, such as limits on visitors. This struggle between the individual physician and the “system” was further amplified by restrictive institutional policies, leading to a sense of being an “outsider” within the system. The study suggests that residents’ professional identities are continually influenced by their perceptions and responses to various challenges. The conclusions drawn from the study emphasize the pandemic’s role in providing opportunities that influence PIF. Supervisory individuals play a crucial role in this process through role modeling and empowering practices that align with the core aspects of physician identity. The authors concluded that understanding and adapting to these influences is key to shaping medical training that supports positive aspects of PIF while mitigating its detrimental effects.


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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.