Jeffrey Silver Humanism in Healthcare Research Roundup – October & November 2019

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  

What is clinician presence? A qualitative interview study comparing physician and non-physician insights about practices of human connection Brown-Johnson C, Schwartz R, Maitra A, Haverfield MC, Tierney A, Shaw JG, Zionts DL, Safaeinili N, Thadaney Israni S, Verghese A, Zulman DM. BMJ Open. 2019 Nov 3;9(11):e030831. Dr. Abraham Verghese is a former Gold Foundation Trustee and gave both the 2011 and 2005 Jordan J. Cohen Humanism in Medicine Lecture at the AAMC
Clinician presence is a concept that describes a “purposeful practice of awareness, focus, and attention with the intent to understand and connect with individuals and patients.”   It’s a powerful concept that contrasts against the depersonalization that is seen in burnout. But what allows a clinician to be present?  Cati Brown-Johnson and colleagues explored this in a qualitative study of 10 physicians and 30 non-medical professionals. They found that presence has three requirements: (1) purposeful intention to connect, (2) conscious navigation of time, and (3) awareness of the physical environment. In order to support clinician presence, the authors make several suggestions, including sharing the screen to integrate the electronic health record, integrating caregivers, friends, and family to clinic visits, and incorporating mindfulness in clinical interactions. They conclude by noting that “while challenging to cultivate, this connection offers some of the greatest rewards for practicing physicians.”  

Identifying intangible assets in interprofessional healthcare organizations: feasibility of an asset inventory Rider EA, Comeau M, Truog RD, Boyer K, Meyer EC. J Interprof Care. 2019 Sep-Oct;33(5):583-586. Drs. Elizabeth Rider and Elaine Meyer are Mapping the Landscape grantees.
Healthcare systems are increasingly reliant on business models that focus on tangible assets like facilities and profits. But what about intangible assets, like values, partnerships, and human capital?  Rider and colleagues examined if it is possible to develop an asset inventory to better help understand what intangible assets contribute to an organization’s growth and success. Using the KJ method, a bottom-up problem-solving tool that facilitates the organization of gathered data, and an appreciative inquiry perspective on 28 participants involved in healthcare, including 8 physicians, they identified and categorized a host of assets, including philosophy and mission, human capital, scholarship/research productivity, partnerships, and practice and practical strategies. The authors caution that is a pilot study at a single institution, so its generalizability is still unclear. However, they plan on repeating this periodically to understand evolving benchmarks and strengths to better guide strategic growth.  

Caregiver experiences of care coordination for recently discharged patients: a qualitative metasynthesis Callister C, Jones J, Schroeder S, Breathett K, Dollar B, Sanghvi UJ, Harnke B, Lum HD, Jones CD. West J Nurs Res. 2019 Oct 4:193945919880183. Dr. Steven Schroeder and Mr. Ben Harnke are Mapping the Landscape grantees.
Despite being frequently involved in patient care after hospital discharge, informal caregivers are often overlooked in the discharge process. To better understand their perspectives and identify opportunities for improving the discharge process, Callister and colleagues performed a qualitative metasynthesis of 12 English-language articles published in the United States since 2000. They identified five key themes: (1) suboptimal access to clinicians after discharge, (2) overwhelming responsibilities to manage appointments and medications, (3) need for information and training at discharge, (4) feeling disregarded by clinicians, and (5) need for emotional support for caregivers. The authors note that these conclusions are tempered by the absence of clinician perspectives and the inability to access the original qualitative data for each study. Nevertheless, these insights can help health care systems to craft specific improvements to better focus on the needs of informal caregivers in the post-discharge period.  

Physician and trainee experiences with patient bias Wheeler M, de Bourmont S, Paul-Emile K, Pfeffinger A, McMullen A, Critchfield JM, Fernandez A. JAMA Intern Med. 2019 Oct 28. Dr. Alicia Fernandez is a Gold Professor.
The clinical workforce is becoming more diverse, with 28% being foreign-born, 50% being nonwhite, and 34% being women. This increasing diversity may lead to conflict with patients who reject or demean such physicians based on their social characteristics. Margaret Wheeler and colleagues examined this through a set of 13 focus groups containing 50 participants from southern California. The experiences varied broadly from microaggressions to outright refusal of care, and participants described consequences on their sense of well-being, including avoidance behaviors and moral distress from not knowing how to protect colleagues. Team support was crucial in transforming these painful experiences into learning moments. The authors suggest strategies such as setting limits, appropriate deflection, team plans, debriefings, support for the offended clinicians or students, and faculty development. The authors conclude that addressing this problem requires “concerted effort from medical schools and hospital leadership to create an environment that respects the diversity of patients and physicians alike.”  

Evidence relating health care provider burnout and quality of care: a systematic review and meta-analysis Tawfik DS, Scheid A, Profit J, Shanafelt T, Trockel M, Adair KC, Sexton JB, Ioannidis JPA. Ann Intern Med. 2019 Oct 8. Dr. Tait Shanafelt is a Mapping the Landscape grantee.
Burnout is a devastating condition for physicians that has been linked to suicidality, broken relationships, increased employee turnover, and decreased productivity, but how does burnout impact quality of care delivered to patients?  Daniel Tawfik and colleagues examined this through a systematic review and meta-analysis of 123 publications, encompassing 241,533 health care practitioners. They identified five categories of quality of care outcomes: best practices, communication, medical errors, patient outcomes, and quality and safety.  Results of the analysis were quite variable. 58 studies indicated burnout was related to poor-quality care while 50 showed no significant effect (6 actually showed a relationship to high-quality of care). Relationships between burnout and quality of care were highly heterogeneous and excess significance was observed suggesting potential bias.  This excess significance was most prominent for retrospective studies examining adherence to best practice guidelines and for quality and safety metrics, likely because studies on existing data sets may predispose to selective outcome and analysis reporting. Altogether, this leads the authors to conclude that “Whether curtailing burnout improves quality of care, or whether improving quality of care reduces burnout, is not yet known, and adequately powered and designed randomized trials will be indispensable in answering these questions.”  

Compassion in the clinical context: constrained, distributed, and adaptive Roze des Ordons AL, MacIsaac L, Hui J, Everson J, Ellaway RH. J Gen Intern Med. 2019 Oct 21. Dr. Rachel Ellaway is a Mapping the Landscape grantee.
Compassion is a cornerstone of humanistic health care, but there are often many constraining and enabling factors that influence how compassion is expressed and perceived. Amanda Roze des Ordons and colleagues explore these factors using a qualitative approach. Specifically, five clinicians within critical care and palliative care settings in Calgary, Alberta, Canada were prompted to record their experiences and observations of witnessing or participating in clinical encounters involving compassion. They were then invited to share their reflections through a focus group or semi-structed interview. They identified four key phenomena: individual gaps and lapses in compassion (such as inattention, intention vs. perception, personal capacity, and personal toll), relational challenges (i.e. receptivity, fragmentation, and lack of shared understanding), contextual constraints on compassion (i.e. situational pressures, the clinical environment, gaps in education, and organizational culture), and distributed compassion (how teams adapt behaviors in response to perceived needs). Their findings highlight that compassion is dependent on the particular context and that teams can identify and respond to gaps in compassion.  

Maternity leave in residency: a multicenter study of determinants and wellness outcomes Stack SW, Jagsi R, Biermann JS, Lundberg GP, Law KL, Milne CK, Williams SG, Burton TC, Larison CL, Best JA. Acad Med. 2019 Nov;94(11):1738-1745. Drs. Jennifer Best and Shobha Stack are Mapping the Landscape grantees.
Residency training is a long period of time following medical school in which physicians gain practical skills to become independent practitioners. During this time, it is not uncommon for resident physicians to become pregnant. To better understand the determinants and effects of maternity leave, Shobha Stack and colleagues developed a survey and sent it to 1537 female residents through 6 institutions within the United States, of which 804 responded (52%). Of the 126 respondents who were mothers, 63 had their first child during residency. Additionally, most mothers took 6 weeks of maternity leave, although the duration ranged from 2 to 40 weeks. The desire not to extend residency training was a major determinant for this duration; longer breastfeeding duration and perceptions of logistical support from program administration were also associated with longer maternal leave. Unfortunately, burnout affected half of mothers regardless of leave length. These findings highlight the need for “clear, consistent, transparent, and easily accessible policies that support the many women already attempting to integrate GME (graduate medical education) and motherhood.”  

Communication with older patients with cancer using geriatric assessment: a cluster-randomized clinical trial from the National Cancer Institute Community Oncology Research Program Mohile SG, Epstein RM, Hurria A, Heckler CE, Canin B, Culakova E, Duberstein P, Gilmore N, Xu H, Plumb S, Wells M, Lowenstein LM, Flannery MA, Janelsins M, Magnuson A, Loh KP, Kleckner AS, Mustian KM, Hopkins JO, Liu JJ, Geer J, Gorawara-Bhat R, Morrow GR, Dale W. JAMA Oncol. 2019 Nov 7:1-9. Dr. Ronald Epstein is a Mapping the Landscape grantee and a Gold Humanism in Medicine Specialty Society honoree.
Patient-centered communication that is informative, participatory, and responsive is vital towards the humanistic practice of medicine. This is particularly true with regards to cancer and aging, two conditions that are often difficult for practitioners and patients to discuss openly. Supriya Mohile and colleagues examined the Geriatric Assessment (GA) as an intervention to improve the quality of communications between oncologists and older patients with cancer. The Geriatric Assessment is a validated instrument to capture patient-reported and objective measures important to older adults. Supriya Mohile enrolled 541 participants over the age of 70 from 31 community practices as part of a cluster-randomized controlled trial. They employed the GA in 17 centers and compared patient satisfaction, caregiver satisfaction, quality of life measures, and number of aging-related concerns in conversations to the 14 centers that had no intervention. They found the GA was associated with greater satisfaction, although quality of life outcomes did not differ between the groups. This study suggests that the GA is practical, convenient, and associated with improvements in patient- satisfaction.  

How culture is understood in faculty development in the health professions: a scoping review Lewis LD, Steinert Y. Acad Med. 2019 Oct 8. Dr. Yvonne Steinert is a Mapping the Landscape grantee.
Faculty development is a vital part of practitioner education once formal training is over. This faculty development, in turn, is informed by culture. But what does this culture mean and how does it relate to faculty development?  Lerona Lewis and Yvonne Steinert sought to answer this question through a systematic review of 955 articles, of which 70 were selected for full review. Descriptive analysis found that only one article explicitly evaluated the cultural relevance of a faculty development program. A thematic analysis revealed three themes: (1) culture was frequently mentioned but not explicated, (2) culture centered on issues of diversity, aiming to promote institutional change, and (3) cultural consideration was not routinely described in international faculty development. These findings highlight the need to better define and explore culture in the context of faculty development, especially as the world is becoming more globalized.  

Other Publications  

Curricula for empathy and compassion training in medical education: A systematic review Patel S, Pelletier-Bui A, Smith S, Roberts MB, Kilgannon H, Trzeciak S, Roberts BW. PLoS One. 2019 Aug 22;14(8):e0221412. Free full text
Empathy and compassion are core elements of health care quality, but can they be taught?  Sundip Patel and colleagues examined this through a systematic review looking at 52 peer-reviewed articles. There was a wide variety of curricula that ranged from brief hour-long interventions to three-year programs. Self-assessed empathy or compassion was the most common outcome measure, but 25 of the 52 used a third-party observer to measure empathy or compassion. Ultimately, they found five effective behaviors that led to increases in real patient perception of compassion: (1) sitting during the interview, (2) detecting non-verbal cues of emotion, (3) recognizing and responding to opportunities for compassion, (4) nonverbal communication of caring, and (5) verbal statements of acknowledgment, validation and support. While promising, the authors caution that these studies were highly heterogeneous, did not study long-term effects beyond 12 months, and may be subject to bias, according to the Cochrane Collaboration’s tool for assessing the risk of bias in clinical trials. Nevertheless, this systematic review affirms that training can enhance physician empathy and compassion.  

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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.