Jeffrey Silver Humanism in Healthcare Research Roundup – August-September 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

Introduction to health systems science: experiential learning through patient interviews in the emergency department Sawyer NT, Danielson A, Johl Karnjit, Williams DM. AEM Educ Train. 2020 Jul 23. doi: 10.1002/aet2.10512.  Drs. Nicolas Sawyer and Donna Williams were supported by The Arnold P. Gold Foundation in the development of this project as Gold Humanism Scholars at  the Harvard Macy Institute Program for Educators in Health Professions.
In recent years, there’s been an understanding that, in addition to basic and clinical science, medical students must learn about health systems science (HSS), a broad term describing the structure and function of the U.S. healthcare delivery system.  To increase the amount and quality of HSS education among second-year medical students, Nicolas Sawyer and colleagues developed UNITED (Understanding Needs in the Emergency Department).  As part of the UNITED Experience, medical students interviewed patients in the Emergency Department under the supervision of an attending physician and a social worker; they then debriefed the results of those interviews with their classmates and wrote a reflection paper.  As part of this pilot program, students submitted 15 reflections, which were then subject to qualitative analysis.  Three primary themes were identified among 98 codes: (1) Medical students question their understanding of the healthcare system after listening to patients’ stories, (2) focused patient interviews about the healthcare system provide a unique perspective of the patient experience not found elsewhere in the preclinical curriculum, and (3) discussing the realities of being a patient in the U.S. healthcare system is an emotional experience for students.  Overall, the investigators found that students going through experiential HSS education have greater emotional activation and desire to improve care delivery.  

Toward a bias-free and inclusive medical curriculum: development and implementation of student-initiated guidelines and monitoring mechanisms at one institution Benoit LJ, Travis C, Swan Sein A, Quiah SC, Amiel J, Gowda D. Acad Med. 2020 Sep 1. doi: 10.1097/ACM.0000000000003701. Dr. Jonathan Amiel is a Mapping the Landscape grantee, a member of the Gold Humanism Honor Society Advisory Council, and a Gold Humanism Scholar at the Harvard Macy Institute Program for Educators in Health Professions.
There is increasing recognition of the high prevalence in medical curricula of implicit bias, a term describing “unconscious but learned beliefs that lead to negative associations regarding a person or group based on irrelevant characteristics of that person or group.”  At Columbia University Vagelos College of Physicians and Surgeons, a task force initiated by students and convened by faculty developed and disseminated guidelines for educators to reduce bias in the curriculum, and created a feedback portal to allow for ongoing discussion and adaptation of curricular materials.  Six guidelines were developed: (1) be inclusive in representations of healthy/normal, (2) be inclusive in representations of pathology, (3) avoid stereotypes in representations of pathology, (4) acknowledge limitations of reaction, (5) explore differences in health outcomes and responses to treatment, and (6) consider informal attitudes and behaviors.  As part of bias monitoring, they encouraged students to report incidents of bias via formal course evaluations, the learning environmental portal, and a bias portal.  They found 245 comments, of which 106 related to bias.  These incidents were then relayed to the senior associate dean of curricular affairs and then to the appropriate faculty member.  The investigators plan on updating and reviewing the guidelines periodically, and hope that their set of guidelines can be a useful tool for others to identify and remedy implicit bias.  

Supporting inclusive learning environments and professional development in medical education through an identity and inclusion initiative Woodruff JN, Vela MB, Zayyad Z, Johnson TA, Kyalwazi B, Amegashie C, Silverman R, Levinson D, Blythe K, Lee WW, Thomas S, Parrish W, Humphrey HJ. Acad Med. 2020 Sep 1. doi: 10.1097/ACM.0000000000003689. Dr. Wei Wei Lee is a Mapping the Landscape grantee.
Medical schools are increasingly addressing sociopolitical issues as a way for students to understand the challenges of future clinical practice.  The University of Chicago Pritzker School of Medicine (PSOM) demonstrates one way in which these can be addressed.  PSOM convened an Identity and Inclusion (i2i) Steering Committee charged with “providing ongoing direction for programs and/or curricula at Pritzker that support an inclusive learning environment and promote respectful and effective communication with diverse patients and colleagues around issues of identity.”  The i2i committee has facilitated continuous quality improvement through three principles: (1) clarity around a well-defined set of values, (2) an iterative and engaged approach responsive to the learning community’s needs, and (3) promotion of meaningful discourse across all areas of the school. Through institutional climate surveys as well as the Association of American Medical Colleges (AAMC) Medical School Year Two Questionnaire and Graduation Questionnaire, they determined that, compared to their peers in other medical schools, students voice greater “knowledge of opinion influenced by perspectives from different backgrounds,” “diversity in school enhanced training,” and “tools for interacting with people with different identity groups.”  Through this experience, the authors conclude that medical school leaders should “actively work on the qualitative aspects of an inclusive and welcoming learning environment.”  

Implementing an intensive care unit (ICU) diary program at a large academic medical center: Results from a randomized control trial evaluating psychological morbidity associated with critical illness Sayde GE, Stefanescu A, Conrad E, Nielsen N, Hammer R. Gen Hosp Psychiatry. 2020 Sep-Oct;66:96-102. doi: 10.1016/j.genhosppsych.2020.06.017. Epub 2020 Jul 2. Free full text This research project was supported by the Gold Humanism Honor Society.
Post-intensive Care Syndrome (PICS) is a relatively new disorder associated with the psychological sequela of being in the Intensive Care Unit.  Post-traumatic stress disorder (PTSD), depression, and anxiety are all important components of PICS, and contribute to decreased quality of life beyond discharge.  Because patients exhibiting the most severe PTSD symptoms often have no factual recall of their ICU stay, diaries have been proposed as tools to better record events during the ICU stays. George Sayde and colleagues examined this through a randomized control trial at a large, public Level One trauma center, comparing ICU diary use with PTSD education alone at the bedside.  Patients and family members were encouraged to note events in everyday language as well as subjective responses to the experience of being in the ICU.  Upon discharge, at weeks 1,4, and 12, participants were given the Revised Impact of Events Scales (IES-R), Patient Health Questionnaire (PHQ-8), Hospital Anxiety and Depression Scale (HADS), and Generalized Anxiety Disorder 7-item (GAD-7).  Ultimately, 35 patients completed post-discharge followup, of which 18 were in the arm with ICU diary + PTSD education and 17 were in the arm with PTSD education only.  They found no benefit in ICU diaries vs. PTSD bedside education alone.  The high attrition rate (originally 60 patients were enrolled) and absence of long-term follow-up may help to explain the lack of a statistical difference.  However, this program did promote a culture of compassion, collaboration, and humanism, and, subjectively, the ICU diaries aided in the recovery process for patients and families.  

Cultivating empathy through virtual reality: advancing conversations about racism, inequity, and climate in medicine. Roswell RO, Cogburn CD, Tocco J, Martinez J, Bangeranye C, Bailenson JN, Wright M, Mieres JH, Smith L. Acad Med. 2020 Jul 21. doi: 10.1097/ACM.0000000000003615. Epub ahead of print. Dr. Lawrence G. Smith, Founding Dean of the Zucker School of Medicine and Executive Vice President/Physician-in-Chief at Northwell Health, is a Board Trustee at The Arnold P. Gold Foundation.
With the growing recognition that racism and bias are central to health inequities, medical schools are trying to better understand how to educate faculty and students about these topics.  At Zucker School of Medicine and Northwell Health, Robert Boswell and colleagues implemented a Virtual Reality (VR) racism module as a component of professional development for faculty members.  Sessions were composed of three components: a 60-minute interactive large group session on microaggressions followed by a 20-minute VR module and then group reflection and debriefing.  76 of the 112 faculty and staff who participated in the workshop completed a post-session survey.  90.8% reported feeling engaged, 94.7% agreed that it was an effective tool for enhancing empathy, and 85.5% stated the at the session enhanced their own empathy for racial minorities.  The authors conclude that this pilot was successful in demonstrating the potential use of VR for enhancing diversity and equity initiatives.  They also intend to assess and build scalability of the VR module and apply the module for learners.  

Group mentorship for undergraduate medical students-a systematic review Skjevik EP, Boudreau JD, Ringberg U, Schei E, Stenfors T, Kvernenes M, Ofstad EH. Perspect Med Educ. 2020 Aug 20. doi: 10.1007/s40037-020-00610-3. Dr. J. Donald Boudreau is a Gold Professor and a Mapping the Landscape grantee.
Mentoring is “a process whereby an experienced, highly regarded, empathetic person (the mentor) guides another (usually younger) individual (the mentee) in the development and re-examination of their own ideas, learning, and personal and professional development.” Group-based mentorship has become popular as a way to provide different perspectives and resources. But are these useful? Elise Skjevik and colleagues looked at 20 articles describing 17 different group mentorship programs. Using the Medical Education Research Study Quality Instrument (MERSQI), they appraised the quality of these studies and their outcomes.  They found that most studies were single-group cross-sectional studies at a single institution.  Despite the absence of high-quality studies and low response rates, group mentorship is a promising intervention in medical education.  Group mentorship programs that are longitudinal and mandatory seem to be the most helpful, but further research with higher quality study design is necessary for more definitive conclusions.  

Burnout, depression, career satisfaction, and work-life integration by physician race/ethnicity Garcia LC, Shanafelt TD, West CP, Sinsky CA, Trockel MT, Nedelec L, Maldonado YA, Tutty M, Dyrbye LN, Fassiotto M. JAMA Netw Open. 2020 Aug 3;3(8):e2012762. doi: 10.1001/jamanetworkopen.2020.12762. Free full text   Drs. Tait Shanafelt, Colin West, and Liselotte Dyrbye are Mapping the Landscape grantees.   
Burnout continues to be a major occupational problem for physicians.  However, little is known about the variations in experiences of burnout by physician race and city. Luis C. Garcia and colleagues conducted a secondary analysis of data from a national study of 4,424 physicians, as part of the first nationwide study to examine occupational burnout by race/ethnicity.  Among the variables recorded, they looked at race/ethnicity, sex, age, clinical specialty, hours worked per week, primary practice setting, and relationship status; physicians with a high depersonalization or emotional exhaustion score on the Maslach Burnout Inventory were classified as having burnout.  They determined that, holding other variables constant, physicians in minority racial/ethnic groups were less likely to report burnout compared with non-Hispanic white physicians.  Also, Black Non-Hispanic physicians were more likely to report work-life integration satisfaction than white non-Hispanic physicians. The reasons for this are unclear, and the authors urge future research in “assessing rates of occupational burnout among physicians in minority racial/ethnic groups, including instrument validation, stigma and cultural response bias.”  

Clinician experiences of care provision in the correctional setting: a scoping review Simon L, Beckmann D, Stone M, Williams R, Cohen M, Tobey M. J Correct Health Care. 2020 Sep 2:1078345820953154. doi: 10.1177/1078345820953154. Drs. Lisa Simon and David Beckmann are Mapping the Landscape grantees
There are more than 11 million people worldwide who are currently incarcerated.  These individuals are vulnerable and often do not have routine access to healthcare, leading to poorer health outcomes.  At the same time, practitioners caring for these patients are at greater risk for burnout.  Lisa Simon and colleagues examine the experiences of clinicians who take care of the incarcerated through a scoping review of 4467 unique citations in multiple databases.  They ultimately found 25 studies, and synthesized three major themes: (1) correctional healthcare as a distinct clinical setting, (2) ethical dilemmas in correctional healthcare, and (3) burnout and safety concerns.  The authors conclude that literature regarding this topic is “severely limited” and that there is “great potential for future research.”  

Effect of a brief mindfulness-based program on stress in health care professionals at a US biomedical research hospital: a randomized clinical trial Ameli R, Sinaii N, West CP, Luna MJ, Panahi S, Zoosman M, Rusch HL, Berger A. JAMA Netw Open. 2020 Aug 3;3(8):e2013424.  Free full text  Dr. Colin P. West is a Mapping the Landscape grantee.    
Mindfulness, that is, “paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of moment-by-moment experiences,” has long been considered an intervention to help reduce physician stress.  But is it a feasible approach that can reduce stress compared to conservative measures?  At the National Institutes of Health, Rezvan Ameli and colleagues implemented a mindfulness-based self-care (MSBC) intervention composed of five weekly 1.5-hour in-class mindfulness practice sessions.  They then randomized 82 participants and compared 43 in this group to 35 who had no such intervention (4 others did not follow up).  They compared stress level, based on the Perceived Stress Scale 10-Item version at baseline, week 5, and week 13.  They discovered over 13 weeks that in the mindfulness group, stress and anxiety scores were lower, and trait mindfulness and state mindfulness scores were higher.  Burnout, positive affect, and mindful self-care gains were not maintained.  This randomized trial shows the feasibility of mindfulness interventions and their ability to sustain changes over time.  

Patients as teachers and arts-based reflection in surgical clerkship: A preliminary exploration Kangasjarvi E, Ng SL, Friesen F, Simpson JS. Med Teach. 2020 Aug 26:1-7. doi: 10.1080/0142159X.2020.1807482. Dr. Stella Ng is a Mapping the Landscape grantee. The “Patients-as-teachers” (PAT) is an appealing method to teach medical students that upholds humanistic values.  Not only are patients experts in their own right, but patients may be more empowered knowing that they are contributing to the future of healthcare.  Emilia Kangasjarvi and colleagues sought to apply principles of PAT in their surgery clerkship for third-year medical students. The PAT program consisted of three interactive workshops and the creation of an arts-based reflection piece.  Patient teachers were encouraged to discuss their experiences with illness, and sessions were facilitated by a social worker.  To evaluate this program, five patient teachers were invited to participate in one-on-one interviews and 46 students were invited to participate in focus groups at the end of the program.  Thematic analysis was then applied, identifying two major themes: (1) what students/patient teachers valued about the PAT program, and (2) what they perceived as learned.  Both students and patient teachers appreciated the opportunity to share in the stories.  The authors note that this preliminary exploration provides the basis for further intervention and research, particularly focusing on how learning occurs and its long-term impacts.  

It can be done! A skills-based elective in implicit bias recognition and management for preclinical medical students Gonzalez CA, Walker SA, Rodriguez N, Karp E, Marantz PR. Acad Med. 2020 Sep 1. doi: 10.1097/ACM.0000000000003697. Dr. Cristina Gonzalez is a Mapping the Landscape grantee.
Medical students often encounter bias in their learning environment but have little formal training in specifically identifying implicit bias and addressing it in a proactive manner.  At Albert Einstein College of Medicine, Cristina Gonzalez and colleagues sought to address this problem by creating a skills-based elective for 15 first-year medical students.  They developed nine 90-minute sessions that used transformative learning theory to inform instructional design.  Through role-play exercises, they assessed whether students retained and applied lessons from the sessions.  The investigators then conducted focus groups and performed thematic analysis to better understand student perspectives.  The investigators identified three major themes: (1) student engagement can be enhanced, (2) instruction is empowering, and (3) addressing bias in one’s own and witnessed encounters can be done.  The authors hope to adapt this course to develop novel, skills-based curricula relevant to other learners in healthcare.  

Other Publications

Advance Care Planning Among Users of a Patient Portal During the COVID-19 Pandemic: Retrospective Observational StudyPortz JD, Brungardt A, Shanbhag P, Staton EW, Bose-Brill S, Lin CT, Kutner JS, Lum HD. J Med Internet Res. 2020 Aug 11;22(8):e21385. doi: 10.2196/21385.
As the COVID-19 pandemic continues to challenge healthcare systems worldwide, there is a pressing need to deliver healthcare in lines with humanistic principles, such ensuring patient autonomy.  In the critically ill, this means discussing goals of care, ideally before the critical illness prevents adequate discussion.  At the University of Colorado, Jennifer Portz and colleagues implemented a set of web-based tools for patients to learn about advance care planning, including a way to legally appoint a medical decision maker via the designation of a medical durable power of attorney (MDPOA).  From January to May 2020, they monitored use of this advance care planning tool.  They determined that monthly use increased from 418 users in January to 815 in May.  The issuance of a stay-at-home order on March 26,2020, in particular led to a 2.4-fold increase in MDPOA forms submitted per week.  Additionally, women were more likely to complete an MDPOA (67%) and that the mean age of portal users was 47.7 years.  Over 50% of those completing an MDPOA did not have a prior agent listed.  This data validates the important role of web portals to facilitate the designation of MDPOA’s, particularly during this epidemic.

Anxiety, mental illness, learning disabilities, and learning accommodation use: A cross-sectional study Brown J, McDonald M, Besse C, Manson P, McDonald R, Rohatinsky N, Singh M.  J Prof Nurs. 2020 Aug 10. doi: 10.1016/j.profnurs.2020.08.007 Anxiety, mental illness, and learning disabilities are major challenges to students in the healthcare professions.  Indeed, students with anxiety, mental illness, or learning disabilities may have lower levels of well-being stemming from concerns about struggling and being in danger of dismissal.  Additionally, these students require other resources, such as learning accommodations, so that they can take maximal advantage of their learning opportunities.  Janine Brown and colleagues examined the prevalence of these three conditions among 1,327 first-year nursing students in Saskatchewan, Canada, through the Academic Success Inventory for College Students (ASICS) tool.  They identified that, among entering students, 21% have been diagnosed with anxiety, 16% with mental illness, and 2% with a learning disability.  Among fourth-year students, 23%, 22%, and 8% were diagnosed with anxiety, mental illness, and a learning disability, respectively.  The percentage of those utilizing learning accommodations increased from 6% to 13%.  These results suggest an important role for identifying and addressing anxiety, mental illness, and learning disabilities among nursing students so that they can thrive throughout their education.

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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.