Jeffrey Silver Humanism in Healthcare Research Roundup – October-November 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

Patient-centered communication and outcomes in heart failure Fabbri M, Finney Rutten LJ, Manemann SM, Boyd C, Wolff J, Chamberlain AM, Weston SA, Yost KJ, Griffin JM, Killian JM, Roger VL. Am J Manag Care. 2020 Oct;26(10):425-430. doi: 10.37765/ajmc.2020.88500. PMID: 33094937. Dr. Kathleen Yost is a Mapping The Landscape grantee.
Patient-centered communication, which acknowledges patients’ needs, preferences, and experiences, is vital to a healthy patient-provider relationship. It may also help improve outcomes for people living with chronic disease, though the study authors note its impact has not been previously studied in people who have heart failure. To do so, Dr. Matteo Fabbri and colleagues analyzed surveys from 2,398 residents in southeast Minnesota, correlating scores from the Chronic Illness Resources Survey (CIRS), a previously validated 15-point scale, to death and hospitalization rates. They found that heart failure patients with excellent patient-centered communication experienced lower risks of death (Hazard Ratio: 0.7), compared to those with fair patient-centered communication. There was no statistically significant correlation between patient-centered communication and hospitalization. There are some limitations: a 45% response rate (though in line with lower national response rates), an observational study design, and a data set of mostly Caucasian individuals means that further validation of these results is needed. However, this opens the door for using CIRS as a way to identify patient who have communication barriers and for providing tailored interventions to improve the quality of care.  

Perceptions of equity and inclusion in acute care surgery: from the #EAST4ALL survey Tseng ES, Zakrison TL, Williams B, Bernard AC, Martin MJ, Zebib L, Soklaridis S, Kaafarani HM, Zarzaur BL, Crandall M, Seamon MJ, Winfield RD, Bruns B; and the Equity, Quality, and Inclusion in Trauma Surgery Practice Ad Hoc Task Force of the Eastern Association for the Surgery of Trauma. Ann Surg. 2020 Oct 15. doi: 10.1097/SLA.0000000000004435. Epub ahead of print. PMID: 33065637. Dr. Sophie Soklaridis is a Mapping The Landscape grantee.
Over the past decade, there has been increasing recognition among surgeons about the importance of equality and inclusion within the profession. Yet there is little data about how acute care surgeons (from the fields of trauma surgery, surgical critical care, and emergency general surgery) view the problems of inequality and exclusion. To understand their views, Dr. Esther Tseng and colleagues conducted a mixed-methods online survey within the Eastern Association for Surgery of Trauma (EAST).  Among 306 respondents, they found that 57.5% of females witnessed or experienced sexual harassment and 48.6% of surgeons of color witnessed or experienced racial/ethnic discrimination. Female surgeons and surgeons of color were more likely to report unfair treatment in the workplace. An important limitation is the low response rate (13%), which hampers generalizability. Nevertheless, it provides an important glimpse into a problem among acute care surgery with regards to inclusion and equality, and highlights the need to remove barriers to help attract and retain a talented and diverse acute care surgery workforce.  

Help-seeking behaviors of transition-aged youth for mental health concerns: qualitative study Stunden C, Zasada J, VanHeerwaarden N, Hollenberg E, Abi-Jaoudé A, Chaim G, Cleverley K, Henderson J, Johnson A, Levinson A, Lo B, Robb J, Shi J, Voineskos A, Wiljer D. J Med Internet Res. 2020 Oct 5;22(10):e18514. doi: 10.2196/18514. PMID: 33016882.  Free full text  Dr. Andrew Johnson is a Mapping The Landscape grantee.
The transition from adolescence to adulthood is often challenging. Little is known about what factors determine whether this population seeks help for mental health issues. Dr. Chelsea Stunden and colleagues examined this through 12 semi-structured focus groups with 73 transition-aged youth in Canada.  Through transcript analysis and coding, they identified four themes: “(1) the influence of formal service providers (accessibility and experiences), (2) the influence of social factors (system navigation and stigma), (3) the influence of health literacy (symptom recognition, acting on symptoms, digital tools and the internet, and mental health awareness campaigns), and (4) the influence of low-intensity sources of support, namely, self-help.” Based on these findings, they suggest ways to reduce barriers, including using family physicians as resources in the help-seeking process and employing digital help-seeking tools.  These findings also highlight the need to research the effectiveness and unique features of low-intensity supports such as web or mobile apps.  

“If your feelings were hurt, I’m sorry…”: how third-year medical students observe, learn from, and engage in apologies Fischer IC, Frankel RM. J Gen Intern Med. 2020 Oct 6. doi: 10.1007/s11606-020-06263-6. Epub ahead of print. PMID: 33034017. Dr. Richard Frankel is a  Gold grantee, including a Mapping The Landscape grantee.
Apologies play an important role in medical care, especially at the intersections of professionalism, patient safety, and medicolegal malpractice risk. But what are medical students learning about apologies? In this study, Drs. Ian Fischer and Richard Frankel characterized the experiences of third-year medical students in observing and engaging in apologies. They drew upon 238 third-year student professionalism narratives that pertained to apology over the past 15 years at Indiana University School of Medicine. They then looked at whether these statements contained the four key elements of genuine apologies: (1) acknowledgement, (2) explanation, (3) regret/remorse, and (4) reparation. Only 17% of apologies were complete with all four elements, and over 40% were coded as “non-apologies,” with only an acknowledgement and explanation. Most (70%) of student experiences were positive, with apology completeness having a significant effect. About 1 in 5 were coded as negative, and about 1 in 4 students reported being embarrassed by the actions of their colleagues or supervisors. Overall, the authors note the importance of role-modeling apologetic behavior and developing formal instruction to highlight greater awareness of the importance of apologies.

Physician task load and the risk of burnout among US physicians in a national survey Harry E, Sinsky C, Dyrbye LN, Makowski MS, Trockel M, Tutty M, Carlasare LE, West CP, Shanafelt TD. Jt Comm J Qual Patient Saf. 2020 Oct 4:S1553-7250(20)30246-4. doi: 10.1016/j.jcjq.2020.09.011. Epub ahead of print. PMID: 33168367. Drs. Colin West, Lotte Dyrbye, and Tait Shanafelt are Mapping The Landscape grantees.
A physician’s day-to-day work is growing increasingly complex for a number of different reasons, leading to a greater cognitive load on physicians. Is this heavier cognitive load contributing to burnout? Dr. Elizabeth Harry and colleagues examine this relationship in a large national study of U.S. physicians. Specifically, they examined how the NASA Task Load Index, a measure of physician task load (PTL), was correlated with the Emotional Exhaustion and Depersonalization scales of the Maslach Burnout Inventory (MBI).  4,517 individuals answered from a range of different subspecialties. The researchers determined that physician task load was strongly related to burnout, independent of age, gender, practice setting, specialty, and hours worked per week. For every 10% decrease in PTL, there was a 33% lower odds of experiencing burnout. This is particularly important for fields with high PTL, which in this study included emergency medicine, urology, anesthesiology, and radiology, as well as general surgery and internal medicine subspecialties. These results lay the groundwork for further study, including identifying what aspects of PTL are more likely to contribute to burnout and whether initiatives to reduce PTL also reduce burnout.  

The physician healer track: educating the hearts and the minds of future physicians Buck E, Billingsley T, McKee J, Richardson G, Geary C. Med Educ Online. 2021 Dec;26(1):1844394. doi: 10.1080/10872981.2020.1844394. PMID: 33167822.   Free full text Dr. Era Buck is a Mapping The Landscape grantee.
Medical school is a vital time in which future physicians develop their professional identity, and, as such, provides ample opportunities to promote the humanistic roles of physicians as healers.  At the University of Texas Medical Branch, Dr. Era Buck and colleagues developed a four-year longitudinal curriculum, The Physician Healer Track, to promote such values.  The track focuses on the curricular themes of awareness and attention, balance and wellness, communication and connection, integration and acculturation, and reflection. It is structured longitudinally with monthly dinner meetings with faculty, a two-month preceptorship in year 1, a fourth-year immersion course, and an elective.  258 students have enrolled over the first 6 years, comprising 20-26% of each medical school class, and there is less than 1% attrition after the first year. The authors intend on more systemic evaluation in the future, but note that, based on summative evaluation, there has been incremental and holistic growth in students as they progress through the program.  They also hope to expand this further to better understand how it can be applied elsewhere.  

Feasibility and acceptability of digital legacy-making: an innovative story-telling intervention for adults with cancer DeSanto-Madeya S, Tjia J, Fitch C, Wachholtz A. Am J Hosp Palliat Care. 2020 Nov 10:1049909120971569. doi: 10.1177/1049909120971569. Epub ahead of print. PMID: 33167669. Drs. Jennifer Tjia and Amy Wachholtz are Mapping The Landscape grantees.
The diagnosis of advanced cancer evokes existential questions that get to the heart of the human experience.  As part of patient-centered care, understanding this psycho-emotional and existential suffering is imperative. Dr. Susan DeSanto-Mandeya and colleagues took an innovative approach to exploring this, through a pilot study whose intervention was the creation of a digital video legacy-making interview.  They enrolled 16 adults with an advanced or life-limiting cancer diagnosis, and measured their quality of life both before and after the intervention. While the pilot study was not powered to detect changes, they did see improvements in their quality of life. Moreover, they found that the creation of such videos was a feasible and acceptable way to “provide the individuals with the personal space and time to reflect upon, find meaning in, and leave a lasting legacy of their life.” 

Influences on and characteristics of the professional identity formation of clinician educators: a qualitative analysis Triemstra JD, Iyer MS, Hurtubise L, Poeppelman RS, Turner TL, Dewey C, Karani R, Fromme HB. Acad Med. 2020 Nov 10. doi: 10.1097/ACM.0000000000003843. Epub ahead of print. PMID: 33177319.    Free full text Dr. Reena Karani is a Mapping The Landscape grantee.
Despite the increasing prevalence of clinician educator pathways in academic medical centers, there remains a lack of understanding about how exactly clinician educators develop their educator identity (EID). Dr. Justin Triemstra and colleagues used 6 focus groups, with 93 individuals in total, to help answer this question. Through thematic analysis, they identified 5 overarching domains: (1) a community supportive of medical education, (2) a culture of their institution or training, (3) personal characteristics, such as aptitude or affinity for teaching, (4) facilitators of entry into educator roles, and (5) the professionalization of medical education. The authors conclude that these themes can be used to better understand how communities of practice influence EID and to design faculty development programs for clinician educators.  

Reading the self: medical students’ experience of reflecting on their writing over time Cunningham H, Taylor DS, Desai UA, Ender KL, Glickstein J, Krishnan US, Richards BF, Charon R, Balmer DF. Acad Med. 2020 Nov 3. doi: 10.1097/ACM.0000000000003814. Epub ahead of print. PMID: 33149084.   Free full text Dr. Rita Charon is a Mapping The Landscape grantee.
Writing is an important means by which medical students can reflect upon their growth.  But how exactly do they grow over their time in medical school?  At Columbia University Vagelos College of Physicians and Surgeons, a Portfolio curriculum provides repeated opportunities for students to build reflective capacity, termed Signature Reflections. Dr. Hetty Cunningham and colleagues conducted five focus groups with 18 third-year students to examine their experiences with these Signature Reflections. Through thematic analysis, they identified three core themes: (1) safe space, (2) narrative experience, and (3) mirror of self, as well as one overarching theme, moving through time. Based on this analysis, the authors believe that reflective writing exercises can fill an unmet need to promote the education of physicians who are self-aware, trusting, and empathetic.

Other Publications

Hostility, compassion and role reversal in West Virginia’s long opioid overdose emergency Ondocsin J, Mars SG, Howe M, Ciccarone D. Harm Reduct J. 2020 Oct 12;17(1):74. doi: 10.1186/s12954-020-00416-w. PMID: 33046092; PMCID: PMC7549084.       Free full text
The United States continues to have an opioid overdose epidemic, and West Virginia, a rural state in Appalachia, has the highest fatality rate, at 51.5 deaths out of 100,000 in 2018. Public health experts have been working on ways to reduce harm, but little is known about the risk that environment contributes to drug-related loss of life. Dr. Jeff Ondocsin and colleagues conduced semi-structured interviews (n=21) and observation and video recordings of injection sequences (n=5) with people who inject heroin/fentanyl (PWIH) in southern West Virginia, as well as telephone interviews (n=2) with individuals who provide care for PWIH.  They then analyzed interviews, field notes, and video recordings to derive five thematic categories: (1) the long shadow of prescription opioids, (2) lack of compassion from law and emergency services, (3) barriers to prevention services, (4) low levels of knowledge about safe injection practices, and (5) role reversal by family members. These results provide context for potential interventions that address misinformation and associated stigma for people who are affected by high-risk patterns of drug use.  

Investigating the relation between self-assessment and patients’ assessments of physicians-in-training empathy: a multicentric, observational, cross-sectional study in three teaching hospitals in Brazil Bernardo MO, Cecilio-Fernandes D, Lima ARA, Silva JF, Ceccato HD, Costa MJ, de Carvalho-Filho MA. BMJ Open. 2019 Jun 25;9(6):e029356. doi: 10.1136/bmjopen-2019-029356. PMID: 31243037; PMCID: PMC6597646.       Free full text
Physician empathy is a core element of humanistic care. It enhances professional fulfillment, diminishes burnout, and correlates positively with clinician competence.  The mainstay of assessing physician empathy has been self-assessments, but literature suggests that self-perceptions by physicians may be different than perceptions by patients. Dr. Monica Oliveira Bernando and colleagues examined the correlation in three public teaching hospitals in Brazil.  86 physicians-in-training answered the Jefferson Scale of Physician Empathy (JSE) and Interpersonal Reactivity Index, while 566 patients answered the Jefferson Scale of Patient’s Perceptions of Physician Empathy and the Consultation and Relational Empathy Scale.  They found that there was poor correlation between scores, with the possible exception of a weak correlation between compassionate care subscores.  This study adds to literature suggesting that self-assessment of empathy is insufficient in measuring physician empathy and that it is important to incorporate patients when assessing physician empathy.  

Professional identity formation: a role for patients as mentors Kline CC, Park SE, Godolphin WJ, Towle A. Acad Med. 2020 Oct;95(10):1578-1586. doi: 10.1097/ACM.0000000000003561. PMID: 32618605.
Professional identity formation is a complex, iterative process by which students become physicians. While a lot of scholarly work has focused on how communities of practice among physicians impact professional identity formation, what role can patients have in this process? At the University of British Columbia, there is an Interprofessional Health Mentors Program (HMP), which is a longitudinal preclinical elective where patients act as mentors for medical students to educate them about the lived experiences of chronic conditions and disability.  Dr. Cathy Kline and colleagues interviewed 18 students in that program and conducted thematic analysis to gain insight into patient roles in PIF.  They identified seven themes: (1) patient as more than disease, (2) patient as autonomous, (3) patient as expert, (4) doctor as partner, (5) doctor as collaborator, (6) self-aware doctor, and (7) empathic doctor. Overall, carefully selected health mentors can help preclinical medical students construct their professional identity by facilitating discussions and prompting self-reflection.

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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.