In observance of YomHaShoah – Holocaust Remembrance Day – the Berman Institute cohosted a webinar on April 8, 2021, “Bias, Structural Racism, and Health Professionals: Lessons for Today from Nazi Medicine,” presented by Sheldon Rubenfeld, clinical professor of medicine, Baylor College of Medicine executive director of The Center for Medicine after the Holocaust.
Analysis of Medical Records Finds Physicians Are More Likely to Doubt Black Patients
With the implementation of the 21st Century Cures Act on April 5, healthcare providers are now required to give their patients free access to all the health information in their electronic medical records. Black patients are much more likely than white patients to discover language in those records that indicates they are not believed by their physicians, according to a new study by Johns Hopkins faculty published in the Journal of General Internal Medicine.
“We set out to see if we could identify linguistic mechanisms through which physicians communicate disbelief of patients in medical records and, if so, to explore racial and gender differences in the use of such language,” said Mary Catherine Beach, a faculty member in JHU’s schools of medicine and public health, and its bioethics institute. “Our analysis of medical record language suggests Black patients are less likely to be believed by physicians. The bias reflected in those medical records may in turn affect care from future clinicians.”
Beach and her Hopkins Medicine colleague Somnath Saha first noticed in the medical records of patients with sickle cell disease that doctors and nurses were signaling disbelief in their patients’ reports of pain. They began examining additional records to see if this phenomenon extended to patients receiving treatment for other conditions. Working with a linguist and a computer scientist they identified three aspects of language in clinic notes by which physicians communicate disbelief of patients:
- Quotation marks around patients’ words (e.g., had a “reaction” to the medication)
- Specific “judgment” words that suggest doubt (e.g., ‘claims’ or ‘insists’)
- Evidentials, a sentence construction in which patients’ symptoms or experience is reported as hearsay.
“We evaluated the prevalence of these features in over 9000 notes in one clinic, then tested differences by race and gender. We found all 3 of these forms of language more often in the records of Black patients than white patients. Women’s records were somewhat more likely than men’s to have quotes, but not judgment words or evidentials,” said Saha. “Some of this language reflects how clinicians are taught to document things, and there are reasons to use quotes and evidentials that don’t necessarily cast doubt on what patients are saying. But if it’s just benign word use, why would we see a difference in their application by patients’ race and gender? That’s what makes such language so insidious.”
Beach and Saha note that the prevalence of electronic medical records means that one clinician’s notes will follow a patient wherever they go in the healthcare system and could adversely impact the patient’s care moving forward. According to Beach, Hopkins Medicine has been extremely receptive to addressing the impact of biased language on patient care, asking her to speak at Grand Rounds, to residents, and to all current medical students about her and Saha’s research.
“Clinicians know that patients are sometimes mistaken or even deceptive,” said Beach. “But if we also know there is racial bias in the way patients’ credibility gets assessed, we must revisit the certainty we have in our own impressions. We have to question ourselves before we question the statements of others.”
Recapping the Berman Institute at ASBH 2020
The Berman Institute will be well represented at the 22nd annual meeting of the American Society for Bioethics and Humanities (ASBH), with a group of faculty, fellows, and students scheduled to present online.
View the full schedule and summaries of all Berman Institute presentations.
 |
You can also follow us on Twitter: #ASBH19, featuring our @bermaninstitute, @aregenberg, @kahnethx, @tnrethx, @DiStefano_MJ, and more. |
Special Events
Plenary: Social Justice and Bioethics through the Lens of the Story of Henrietta Lacks
October 15, 2020
1:15-2:30 p.m.
Join Jeff Kahn, Ruth Faden, Jeri Lacks (granddaughter of Henrietta Lacks), and Patricia King for a panel discussion examining social justice and bioethics through the lens of issues and challenges raised by the story of Henrietta Lacks and the HeLa cell line derived from her cells.
Antigone in Ferguson: Free Online Zoom Performance
October 17, 2020
6- 8:30 p.m.
A groundbreaking project that fuses dramatic readings by acclaimed actors of Sophocles’ Antigone with live choral music culminating in a powerful, healing discussion that will foreground the perspectives of people in Baltimore whose lives have been impacted by racialized police violence and health inequity
Employing Greek Tragedy to Help Medical Professionals Cope with COVID
Frontline medical workers continue to confront unprecedented professional and personal challenges of the COVID-19 pandemic. From their own inadequate access to personal protective equipment to facing impossible decisions about allocating limited lifesaving resources among their patients, clinicians have experienced feelings of betrayal, anger, and fear.
Now, by combining one of the pandemic’s newest forms of communication – the Zoom webinar – with the ancient art of Greek tragedy, an innovative project is reaching frontline medical workers who may be struggling in isolation, providing them the opportunity to name and communalize their experiences, connect with colleagues, and access available resources.
Theater of War for Frontline Medical Providers – developed by Theater of War Productions, the Johns Hopkins Berman Institute of Bioethics, and the Johns Hopkins Program in Arts, Humanities & Health – presents dramatic readings by acclaimed actors of scenes from ancient Greek plays for audiences of frontline medical providers to open up powerful dialogue about difficult subjects. In a paper published by The Lancet on July 23, the project’s organizers write “we have found that presenting scenes from ancient tragedies about complex ethical situations for frontline medical providers generates an open, non-threatening space in which health personnel can begin to process, interrogate, share, and bear witness to experiences of loss, betrayal, grief, and other forms of moral suffering during the COVID-19 pandemic.”
Theater of War for Frontline Medical Providers events begin with a live reading of scenes carefully curated to address themes and issues that medical providers may be facing during the pandemic, such as personal risk, abandonment, deferred grief, deviation from standards of care, helplessness, and complicity in creating suffering. After the performance, the actors are replaced by four panelists—a diverse group of front-line medical providers—who respond to what they heard in the plays that resonated with their own experiences of caring for patients during the pandemic. After the panelists’ remarks, a skilled facilitator prompts the audience to join the discussion with a series of questions encouraging reflection and dialogue about themes raised by the plays. The discussion provides an opportunity for the medical workers in the audience to take center stage, sharing the impact of COVID-19 on their lives and finding solace in the community of their peers.
The project premiered on May 24, with 417 clinicians from the Baltimore area logging onto Zoom for a performance featuring Frances McDormand, Jesse Eisenberg, David Strathairn, and Frankie Faison. In a post-performance evaluation, 93% of respondents reported that the program offered new insights about their experience during COVID; 92% said the program made it easier to talk about difficult subjects related to COVID. Following that success, the Arts in Health Initiative of the Laurie M Tisch Illumination Fund provided a grant to fund 10 performances of the project in New York City.
The first of these performances, focusing on the EMS/first responder community in NYC will take place Thursday, July 30, at 7 p.m. While focusing on EMS professionals, this first performance will be open to the general public. To register, please visit: www.towems.eventbrite.com. Cast members will include: Anthony Almojera, Vice President of New York City’s Uniformed EMS Officers Union; Amy Ryan, whose credits include “The Office,” “Birdman,” and “Gone Baby Gone;” and Chad Coleman from “The Wire” and “The Walking Dead,” among other credits.
Other actors confirmed to participate in upcoming performances include McDormand, Strathairn, Faison, Eisenberg, and David Zayas. The next two performances will be:
August 19, noon-2 p.m.
Lincoln Medical Center, Bronx
Featuring Frances McDormand, Jesse Eisenberg, David Zayas, Frankie Faison
September 16, noon-2 p.m.
Lenox Hill Hospital
Manhattan Eye, Ear, and Throat
Lenox Health Greenwich Village
Cast TBA
“Ancient tragedies provide a new entry point for clinicians to process moral suffering generated by the pandemic,” wrote Theater of War Artistic Director Bryan Doerries and Berman Institute faculty Cynda Rushton, Jeremy Greene and Gail Geller in The Lancet. “While individual cognitive reframing can be helpful in the treatment of traumatic disorders, there is also a role for collective social interventions in responding to collective trauma. Ancient Greek plays about chronic and terminal illness, moral distress, the challenges of witnessing suffering, and end-of-life care can be used to forge a common vocabulary for openly engaging doctors, nurses, students, and other health-care professionals in creating constructive dialogue, fostering understanding, compassion, and a renewed sense of community.”
Formation of the Physician
A Physician’s Open Letter to Hospital Visitors
Dear Visitors:
We love you, but for now we have to show it from a distance.
“Physical distancing,” staying away from each other and avoiding groups of people, is absolutely necessary to help fight COVID-19. This is most important in our hospitals, where the risk of catching and spreading the virus is highest. Patients still need to come to the hospital for care, but for now they can’t bring anyone with them. This can go two ways—it can make us more distant, or it can make us closer than ever.
Having a loved one in the hospital is never easy, and we know this policy makes it harder. It hurts when you can’t be there for loved ones when they need it most—even though we know it’s best for patients, healthcare providers and our community. We believe this pain of separation is proof that we need each other. Our shared discomfort with rules that keep people apart can also be the glue that helps us stick together.
The fight against COVID-19 is changing the world as we know it, and we expect even more changes in coming days, weeks and months. We’re all doing our best to cope, but many of us are feeling scared and alone. It’s natural to be mad and blame others, and to want to take as much as we can for ourselves. Yet, there has never been a time in history when the common ground that connects all people has been easier to see.
COVID-19 is a deadly virus that threatens everyone—all ages, colors and genders. Just as it affects all of us, we all have the power to help defeat it.
We’re in this together. We care deeply for our patients, and we love those who want to be here with us to support them. For now, we ask that you kindly show your love by going home!
Sincerely,
Dr. Marielle Gross
Marielle S. Gross completed her residency in Gynecology & Obstetrics at Johns Hopkins University School of Medicine in 2018. She is a Hecht-Levi Fellow at the Berman Institute of Bioethics. This summer, she will join the faculty at the University of Pittsburgh’s School of Medicine.
Resources for Frontline Clinicians
In Fight Against COVID-19, Nurses Face High-Stakes Decisions
As the number of confirmed COVID-19 cases accelerates in the United States, nurses on the front lines of the health care response have found themselves in unprecedented positions, making high-stakes decisions for patients and their own personal lives.
“We in uncharted territory in response to the magnitude of the pandemic,” says Cynda Rushton, a professor at the Johns Hopkins School of Nursing and Berman Institute of Bioethics known as an international leader in nursing ethics. “It’s a time of great stress and uncertainty, and nurses are rising to the challenge.”
Two weeks ago, Rushton—author and editor of Moral Resilience: Transforming Moral Suffering in Healthcare (Oxford University Press, 2018)—helped create the Frontline Nurses Wikiwisdom Forum, a virtual safe space where nurses can share their challenges and experiences during COVID-19.
“We know that nurses are the backbone of American health care, and often its heart and soul,” the site says. “The COVID-19 pandemic is testing all of us, but nurses are on the front lines. This space will be available 24/7 until America exits this crisis. Join us. Share your knowledge, experience, and challenges about working on the front lines of a pandemic. We know you are overworked, understaffed, possibly heartbroken and anxious, but always courageous. Feeling part of a community, even a virtual one, can help.”
In a wide-ranging Q&A with the JHU Hub, Professor Rushton discusses the pandemic’s impact on the nursing profession, the ethical challenges it poses, and reasons for hope among the turmoil.
Read the full story here.
Clinical Decision Making
The Ventilator Nurse Training (VeNT) Program
Raising Children with Medical Complexity: Issues in Housing and Household Expenses
Q&A with Cynda Hylton Rushton: Examining Clinician Burnout
By Danielle Kress
Published courtesy of Johns Hopkins School of Nursing
In Fall 2019 the National Academy of Medicine released a new report, Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being.
Cynda Hylton Rushton, PhD, RN, FAAN, the Anne and George L. Bunting Professor of Clinical Ethics in the Johns Hopkins Berman Institute of Bioethics and the School of Nursing, was one of only two nurses selected to serve on the committee preparing the report. As a forerunner in helping nurses overcome the burden of burnout, Rushton played a key role in bringing forth evidence-based recommendations for addressing this problem in the future.
Rushton shares some inside perspective into burnout, the committee’s findings, and what this means going forward.
Why was a committee needed to explore burnout among health professionals, which the committee defined as physicians, nurses, pharmacists, dentists, nurse practitioners, and physician assistants?
Burnout, a state of emotional exhaustion, cynicism and decreased personal accomplishment, remains a significant problem for clinicians across the country. On a daily basis, clinicians are struggling to balance the needs of an increased number of sick or injured patients and populations dealing with comorbidities and severe illnesses, the intersection of patient care and technology, documentation requirements and mounting pressure to do more with less. When these factors collide, there becomes a gap between the way clinicians want to practice and the way they actually are. These threats to integrity can result in moral distress and lead to burnout.
Overall, clinicians are drained physically, mentally, and emotionally and their well-being degraded. The committee was charged with examining the scientific evidence regarding the causes and consequences of burnout and identifying evidence-based systemic solutions.
How much is burnout really affecting clinicians?
Among nurses, 35-45 percent experience some form of burnout, with comparable rates among other providers and higher rates among physicians. It’s important to note that burnout has been viewed as an occupational hazard rather than a mental health diagnosis. It is not a few days or even weeks of depletion or exhaustion. It is the cumulative, long-term distress and suffering that is slowly eroding the workforce and leading to significant job dissatisfaction and many leaving their professions. In some instances, serious health concerns and suicide can result.
What about the impact on patients?
Patient care can suffer when clinicians withdraw or are not fully engaged in their work. Moral distress, long hours, negative work environments, or organizational inefficiencies can all impact a clinician’s ability to provide what they feel is quality, safe patient care. Likewise, patients are impacted when health care organizations are unable to attract and retain competent and compassionate clinicians.
What does this mean for nurses?
As the largest sector of the health care professions, nurses have the most patient interaction and are at the center of the health care team. Nurses are integral to helping patients to holistically respond to their health conditions, illness or injury. If nurses are suffering from burnout and moral distress, the whole care team and the patient, will experience serious consequences when nurses’ capacities to adapt to the organizational and external pressures are eventually exceeded.
What is one of the most important takeaways from the NAM report on burnout?
Burnout is a complex and pervasive problem that impacts all members of the health care team, health care organizations, and the public. Bold and comprehensive reforms are needed to stem the tide of burnout. No longer is it justified for individual clinicians to be responsible for remediating the serious systemic contributors to burnout that undermine clinical practice.
The consensus report calls for a systems approach to clinician wellbeing that engages point-of-care clinicians, key stakeholders, professional societies and organizations, regulatory bodies, insurers, and policy makers to design comprehensive solutions. Reforms that impact the structure, organization, and culture of health care are urgently needed.
What can be done to address this widespread problem?
To effect sustainable change, strategic actions and organizational changes that address the underlying contributors to burnout must be developed, implemented, and evaluated. That includes health system leadership, dismantling systemic barriers to providing safe and quality care, and supporting the resiliency and integrity of frontline clinicians and learners in the health professions.
Increased investment in a comprehensive research agenda is vital to understanding the effectiveness and impact of systemic solutions. We need to look at the health care team in its entirety and understand that strengthening each part will improve job performance and patient care and satisfaction and contribute to healthier work environments.
How has your MEPRA program been innovative in this area?
At Johns Hopkins, I have led the development and implementation of the Mindful Ethical Practice and Resilience Academy (MEPRA). The Academy includes a foundational curriculum, community of practice, retreats, and unit-based Champion initiative. The goal is to build moral resilience among frontline nurses who face ethical challenges from issues related to resource allocation and ineffective communication to patient suffering and care coordination within the organization, and to foster systemic solutions.
The results have been substantial so far. The Academy is truly resonating with frontline nurses and giving them renewed confidence in what they do and why they do it. We’re witnessing a ripple effect, seeing how newly enabled nurses are speaking up and helping others on the health care team with some of the tools and skills they learned through the program. The academy goes beyond individual skills to engage frontline nurses in designing solutions to cultivate a culture of ethical practice in health care.
**
Additional Resources: