Wonderings to research questions: Engaging patients in long COVID research prioritization within a learning health system.

Background: An integral component of research within a learning health system is patient engagement at all stages of the research process. While there are well-defined best practices for engaging with patients on predetermined research questions, there is little specific methodology for engaging patients at the stage of research question formation and prioritization. Further, with an emerging disease such as Long COVID, population-specific strategies for meaningful engagement have not been characterized. Methods: The COVID-19 Focused Virtual Patient Engagement Studio (CoVIP studio) was a virtual panel created to facilitate patient-centered studies surrounding the effects of long-term COVID ("Long COVID") also known as post-acute SARS-CoV-2 syndrome (PASC). A diverse group of panelists was recruited and trained in several different areas of knowledge, competencies, and abilities regarding research and Long COVID. A three-step approach was developed that consisted of recording panelists' broad wonderings to generate patient-specific research questions. Results: The "wonderings" discussed in panelists' training sessions were analyzed to identify specific populations, interventions, comparators, outcomes, and timeframes (PICOT) elements, which were then used to create a survey to identify the elements of greatest importance to the panel. Based on the findings, 10 research questions were formulated using the PICOT format. The panelists then ranked the questions on perceived order of importance and distributed one million fictional grant dollars between the five chosen questions in the second survey. Through this stepwise prioritization process, the project team successfully translated panelists' research wonderings into investigable research questions. Conclusion: This methodology has implications for the advancement of patient-engaged prioritization both within the scope of Long COVID research and in research on other rare or emerging diseases.

"I realized I was not alone": A mixed-methods investigation of the implementation of Ubuntu groups to reduce burnout and social isolation in an allopathic medical School in the Southeastern United States.

PURPOSE/BACKGROUND: Healthcare providers experience higher rates of workplace burnout, a reality highlighted by the COVID-19 pandemic. In response, small groups, inspired by South African philosophy, Ubuntu, were introduced to decrease burnout and social isolation and build community and belonging. This study examines how participation in these groups can impact these measures. METHODS: In this mixed-methods study, trained facilitators led small groups that utilized story-sharing to foster connections within the group and broader community. Quantitative and qualitative data were analyzed separately and merged to identify convergence. RESULTS: Three main qualitative themes emerged: 1) seeking and building connections and community, 2) curiosity, learning, and growing, and 3) open-hearted and thriving. These themes were linked to quantitative outcomes, showing a statistically significant decrease in social isolation among staff/faculty and students. Furthermore, faculty/staff exhibited reduced burnout compared to students, while students reported increased feelings of belonging. CONCLUSION: Participation in Ubuntu groups positively influenced students' sense of belonging, reduced faculty/staff burnout, and alleviated social isolation for all participants. Future research should explore the potential of this intervention to further promote wellness on medical campuses. Programs emphasizing the well-being of individuals, including faculty, staff, and students, are crucial for supporting the overall health of medical communities and the wider society.

Patient and Care Team Perspectives on Social Determinants of Health Screening in Primary Care: A Qualitative Study.

Importance: Health systems in the US are increasingly screening for social determinants of health (SDOH). However, guidance incorporating stakeholder feedback is limited. Objective: To examine patient and care team experiences in early implementation of SDOH screening in primary care. Design, Setting, and Participants: This qualitative study included cross-sectional analysis of SDOH screenings during primary care visits from February 22 to May 10, 2022, primary care team member interviews from July 6, 2022, to March 8, 2023, and patient stakeholder engagement on June 30, 2022. The setting was a large southeastern US health care system. Eligible patients were aged 18 years or older with completed visits in primary care. Exposure: Screening for SDOH in primary care. Main outcomes and Measures: Multivariable logistic regression evaluated patient (eg, age, race and ethnicity) and care team characteristics (eg, practice type), and screening completeness. Interviews contextualized the quantitative analysis. Results: There were 78 928 visits in practices conducting any SDOH screening. The population with visits had a mean (SD) age of 57.6 (18.1) years; 48 086 (60.9%) were female, 12 569 (15.9%) Black, 60 578 (76.8%) White, and 3088 (3.9%) Hispanic. A total of 54 611 visits (69.2%) were with a doctor of medicine and 13 035 (16.5%) with a nurse practitioner. Most had no SDOH questions answered (75 298 [95.4%]) followed by all questions (2976 [3.77%]). Logistic regression analysis found that clinician type, patient race, and primary payer were associated with screening likelihood: for clinician type, nurse practitioner (odds ratio [OR], 0.13; 95% CI, 0.03-0.62; P = .01) and physician assistant (OR, 3.11; 95% CI, 1.19-8.10; P = .02); for patient race, Asian (OR, 1.69; 95% CI, 1.25-2.28; P = .001); Black (OR, 1.49; 95% CI, 1.10-2.01; P = .009); or 2 or more races (OR, 1.48; 95% CI, 1.12-1.94; P = .006); and for primary payer, Medicaid (OR, 0.62; 95% CI, 0.48-0.80; P < .001); managed care (OR, 1.17; 95% CI, 1.07-1.29; P = .001); uninsured or with Access Health (OR, 0.26; 95% CI, 0.10-0.67; P = .005), and Tricare (OR, 0.71; 95% CI, 0.55-0.92; P = .01). Interview themes included barriers (patient hesitancy, time and resources for screening and referrals, and number of questions/content overlap) and facilitators (communication, practice champions, and support for patient needs). Conclusions and Relevance: This qualitative study presents potential guidance regarding factors that could improve SDOH screening within busy clinical workflows.

Massage therapy in palliative care populations: a narrative review of literature from 2012 to 2022.

BACKGROUND AND OBJECTIVE: Patients living with serious illness are often eligible for palliative care and experience physical symptoms including pain or dyspnea and psychological distress that negatively impacts health-related quality of life and other outcomes. Such patients often benefit from massage therapy to reduce symptom burden and improve quality of life when such treatment is available. At present, no synthesis or review exists exploring massage therapy specifically provided with palliative care patient populations. This review is needed because those with serious illness are a growing and important vulnerable population. Massage therapy is used frequently and in many healthcare delivery contexts, but the body of research has not led to its systematic integration or broad acceptance. METHODS: PubMed search for clinical research focused on massage therapy for palliative care-eligible populations from 2012 and 2022. Search terms included keywords: massage, massage therapy, serious illness, advanced illness, and palliative care. KEY CONTENT AND FINDINGS: Thirteen unique articles were identified through the PubMed database search and from a manual review of references. Study designs of included articles were one pilot, one quasi-experimental single-arm study, one mixed-methods study, two qualitative (both with hospital-based palliative care populations), seven randomized controlled trials, and one retrospective cohort analysis in a major Veterans Health Administration health care facility. CONCLUSIONS: Variability was found in study design, scope, sample size, and outcomes for related articles published in the last ten years. Few eligible interventions reflected real-world massage therapy delivery suggesting more clinical research is needed to examine massage provided by massage therapists trained to work with palliative care populations. Gaps in the current body of existing evidence supports the need for this review and recommendations for the direction of future related research.

"I Don't Want to Go to Work": A Mixed-Methods Analysis of Healthcare Worker Experiences from the Front- and Side-Lines of COVID-19.

During the COVID-19 pandemic, healthcare workers (HCW) were categorized as "essential" and "non-essential", creating a division where some were "locked-in" a system with little ability to prepare for or control the oncoming crisis. Others were "locked-out" regardless of whether their skills might be useful. The purpose of this study was to systematically gather data over the course of the COVID-19 pandemic from HCW through an interprofessional lens to examine experiences of locked-out HCW. This convergent parallel mixed-methods study captured perspectives representing nearly two dozen professions through a survey, administered via social media, and video blogs. Analysis included logistic regression models of differences in outcome measures by professional category and Rapid Identification of Themes from Audio recordings (RITA) of video blogs. We collected 1299 baseline responses from 15 April 2020 to 16 March 2021. Of those responses, 12.1% reported no signs of burnout, while 21.9% reported four or more signs. Qualitative analysis identified four themes: (1) professional identity, (2) intrinsic stressors, (3) extrinsic factors, and (4) coping strategies. There are some differences in the experiences of locked-in and locked-out HCW. This did not always lead to differing reports of moral distress and burnout, and both groups struggled to cope with the realities of the pandemic.

Patient Goals for Living with Rheumatoid Arthritis: A Qualitative Study.

Rheumatoid arthritis is highly individualized in terms of its flare ups and periods of remission. Each patient's unique experience requires a high level of personalization in terms of treatment making it necessary to understand what their goals for living are. This study explores patient perceptions on how the burden of RA shapes patients' goals for living and their preferences for symptom and side-effect management within the United States. Fifteen patients diagnosed with RA with varying lengths of diagnosis were interviewed. A thematic analysis was conducted to construct a conceptual framework. Emerging themes identified disease burdens as: (1) inability to perform essential needs, (2) negative feelings about disease, and (3) its influence on relationships. These burdens shaped desired goals for living which guided the symptom and side-effect priorities the patient wanted managed. Practitioners should consider patient goals and preferences in conjunction with disease progression when engaging in treatment decisions.

Determining massage dose-response to improve cancer-related symptom cluster of pain, fatigue, and sleep disturbance: A 7-arm randomized trial in palliative cancer care.

BACKGROUND: The efficacy of various massage doses in palliative cancer care settings is still debated, and no specific protocol is available. AIM: Evaluating response to various massage doses for symptom cluster of pain-fatigue-sleep. DESIGN: A 7-arm randomized-controlled trial with weekly massage for 4 weeks depending on the prescribed dose (15-, 30-, or 60-min; 2× or 3×/week) and a 4-week follow-up. The intensities of pain, fatigue, and sleep disturbance were measured using a 0-10 scale at nine-timepoint; baseline, weekly during the intervention, and the follow-up period. Then, the mean scores of the three symptoms were calculated as the symptom cluster intensity at each timepoint. IRCT.ir IRCT20150302021307N5. SETTING/PARTICIPANTS: Adults with cancer (n = 273) who reported all three symptoms at three oncology centers in Iran. RESULTS: The odds of clinical improvement (at least 30% reduction in symptom cluster intensity from baseline) increased with dose-escalation significantly [(OR = 17.37; 95% CI = 3.87-77.90 for 60-min doses); (OR = 11.71; 95% CI = 2.60-52.69, for 30-min doses); (OR = 4.36; 95% CI = 0.94-20.32, for 15-min doses)]. The effect durability was significantly shorter at 15-min doses compared to 30- and 60-min doses. The odds of improvement for doses 3×/week was not significant compared to doses 2×/week (OR = 12.27 vs OR = 8.34); however, the effect durability for doses 3×/week was significantly higher. CONCLUSIONS: The findings indicated that dose-escalation increases the efficacy of massage for the pain-fatigue-sleep symptom cluster. Although the 60-min doses were found to be more effective, the 30-min doses can be considered more practical because they are less costly and time-consuming. Our findings can be helpful to develop massage guidelines in palliative care settings. TRIAL REGISTRATION: Iranian Registry of Clinical Trials, IRCT20150302021307N5.

Mobile Health Apps for Patient-Centered Care: Review of United States Rheumatoid Arthritis Apps for Engagement and Activation.

BACKGROUND: Rheumatoid arthritis (RA) is a highly dynamic and individualized disease in terms of its patterns of symptomatic flare-ups and periods of remission. Patient-centered care (PCC) aligns patients' lifestyle goals with their preferences for managing symptoms and side effects through the selection of therapies appropriate for disease management. Mobile health (mHealth) apps have the potential to engage and activate patients in PCC. mHealth apps can provide features that increase disease knowledge, collect patient-generated health indicators and behavioral metrics, and highlight goals for disease management. However, little evidence-based guidance exists as to which apps contain functionality essential for supporting the delivery of PCC. OBJECTIVE: The objective of this study was to evaluate the patient-centeredness of United States-based rheumatoid arthritis mobile apps in terms of patient engagement and activation. METHODS: A search of mobile apps on 2 major United States app stores (Apple App Store and Google Play) was conducted from June 2020 to July 2021 to identify apps designed for use by patients with RA by adapting the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines for mobile health app screening based on the literature. Reviewers conducted a content analysis of mobile app features to evaluate their functionality for patient engagement and activation. Engagement and activation were assessed using the Mobile Application Rating Scale (MARS) and social cognitive theory, respectively. Apps were ranked by their ability to facilitate PCC care along 2 dimensions: engagement and activation. RESULTS: A total of 202 mobile apps were initially identified, and 20 remained after screening. Two apps emerged with the greatest ability to facilitate PCC. Both apps were scored as having acceptable or good patient engagement according to the MARS. These 2 apps also had high patient activation according to social cognitive theory, with many features within those apps representing theoretical constructs such as knowledge, perceived self-efficacy, and expectations about outcomes that support behavioral management of RA. CONCLUSIONS: We found very few mobile apps available within the United States that have functionality that both engages and activates the patient to facilitate PCC. As the prevalence of mobile apps expands, the design of mobile apps needs to integrate patients to ensure that their functionality promotes engagement and activation. More research is needed to understand how mobile app use impacts patient engagement and activation, and ultimately, treatment decisions and disease trajectory.

COVID-19 and Massage Therapy Education Impact and Future Implications.

Massage therapy education processes, practices, and research are rarely described in the scientific literature, and the Covid-19 pandemic may have caused dramatic shifts in how massage therapists were being educated. To date, findings of the impact of the pandemic pivot on massage therapy education have yet to be reported. This editorial explores the trends in hands-on education of other professions during the pandemic and relates these trends to massage therapy education. Currently, it is unknown how institutions supported massage therapy educators in preparation for the shift to online and hybrid learning.

Evaluating a Global Assessment Measure Created by Standardized Patients for the Multiple Mini Interview in Medical School Admissions: Mixed Methods Study.

BACKGROUND: Standardized patients (SPs) are essential stakeholders in the multiple mini interviews (MMIs) that are increasingly used to assess medical school applicants' interpersonal skills. However, there is little evidence for their inclusion in the development of instruments. OBJECTIVE: This study aimed to describe the process and evaluate the impact of having SPs co-design and cocreate a global measurement question that assesses medical school applicants' readiness for medical school and acceptance status. METHODS: This study used an exploratory, sequential, and mixed methods study design. First, we evaluated the initial MMI program and determined the next quality improvement steps. Second, we held a collaborative workshop with SPs to codevelop the assessment question and response options. Third, we evaluated the created question and the additional MMI rubric items through statistical tests based on 1084 applicants' data from 3 cohorts of applicants starting in the 2018-2019 academic year. The internal reliability of the MMI was measured using a Cronbach α test, and its prediction of admission status was tested using a forward stepwise binary logistic regression. RESULTS: Program evaluation indicated the need for an additional quantitative question to assess applicant readiness for medical school. In total, 3 simulation specialists, 2 researchers, and 21 SPs participated in a workshop leading to a final global assessment question and responses. The Cronbach α's were >0.8 overall and in each cohort year. The final stepwise logistic model for all cohorts combined was statistically significant (P<.001), explained 9.2% (R2) of the variance in acceptance status, and correctly classified 65.5% (637/972) of cases. The final model consisted of 3 variables: empathy, rank of readiness, and opening the encounter. CONCLUSIONS: The collaborative nature of this project between stakeholders, including nonacademics and researchers, was vital for the success of this project. The SP-created question had a significant impact on the final model predicting acceptance to medical school. This finding indicates that SPs bring a critical perspective that can improve the process of evaluating medical school applicants.

Neglecting physician desires to teach at an academic medical facility: A mixed method investigation of the consequences.

PURPOSE: Recent findings have suggested that physicians who spend more time participating in their most meaningful job activities (e.g. teaching) are less likely to experience burnout. The current study aimed to expound upon this finding, focusing specifically on the role of teaching in promoting meaning and preventing burnout. METHOD: A total of 428 physicians at a large academic healthcare institution completed an online survey that included measures of burnout and other relevant variables. In the second part of this study, 20 physicians participated in interviews with the aim of expounding upon and contextualizing the findings from Part 1. RESULTS: Results from Part 1 suggested that although meaningfulness derived from teaching was associated with reduced burnout, this association was only true for those who indicated that clinical teaching was among the most meaningful parts of being a physician. In addition, physicians were less likely to spend time working on their most meaningful job activity when it was teaching. Part 2 illustrated why teaching in the clinical environment can be so meaningful and protective against burnout. CONCLUSIONS: Many physicians are unable to teach due to the increasing demands of medical institutions, which may contribute to the increasing levels of burnout in healthcare providers.

A Year in Review for the IJTMB.

Yearly review and evaluation of the journal metrics and processes help to understand the value, worth, and impact of the Journal. In this editorial, the yearly review includes discussions on the current statistics of journal submissions and publication, updates to the IJTMB website, current social media impact, as well as the current peer review process and metrics. Additionally, the peer reviewers for the past year are thanked and acknowledged for their efforts and service to the Journal.

Chronicling moral distress among healthcare providers during the COVID-19 pandemic: A longitudinal analysis of mental health strain, burnout, and maladaptive coping behaviours.

The COVID-19 pandemic has presented many novel situations that have amplified the presence of moral distress in healthcare. With limited resources to protect themselves against the virus and strict safety regulations that alter the way they work, healthcare providers have felt forced to engage in work behaviours that conflicted with their professional and personal sense of right and wrong. Although many providers have experienced moral distress while being physically in the workplace, others suffered while at home. Some healthcare providers worked in facilities that were unable to open during the pandemic due to restrictions, which could contribute to a sense of powerlessness and guilt. The current study assessed whether the ability to see patients each week impacted the relationship between an employee's moral distress and their mental health strain, burnout, and maladaptive coping. A total of 378 healthcare providers responded to weekly surveys over the course of 7 months (April 2020-December 2020). Hierarchical linear modeling techniques were used to examine the study variables over time. Results showed that moral distress predicted an individual's mental health strain and burnout, even after controlling for the prior week. However, moral distress was not a significant predictor of maladaptive coping. Interestingly, there was not a significant difference between the average ratings of moral distress between those who were able, and those who were not able to see patients, meaning that both groups experienced symptoms of moral distress. However, cross-level moderation results indicated that the ability to see patients magnified the relationships between moral distress and mental health strain and burnout over time. Implications of the results and recommendations for how moral distress should be addressed among healthcare providers are discussed.

The Journey of a Massage Therapist's Experience After Receiving a Formal Complaint.

Discussions of professionalism and conflict within practice are an important area of enquiry as massage therapy practice continues to be recognized within the health care realm. The scientific literature has paid little attention to these massage therapy professional and ethical dilemmas. Herein, we explore one such area of conflict between a client and therapist in regard to communication and complaints. An interview was conducted to gain further insight to the situation and is structured based upon the following interview guide: description of the instance, how the therapist handled this situation, reflection on how the therapist's actions contributed to the situation, brief discussion of how other professions handled these types of situations, and reflection on what could have been done differently.

Trends of Publication in the Education and Practice Sections of the IJTMB: a Call to Action.

The scope of the IJTMB includes not only publishing scientific research studies, but also to publish education innovation and practice-oriented approaches for all allied health providers whose practice include manually applied therapeutic massage and bodywork. The aims of the Practice and Education sections of the Journal are described in this editorial. The Education section covers topics including curriculum and competencies development, instructional design and delivery, instructional technology, distance learning, and testing/evaluative procedures for both initial education as well as continuing education. Planning, organization, marketing, and management of a successful practice, the incorporation of new scientific findings and methods into clinical practice, new clinical approaches to prevention and treatment of specific health conditions, and ethical issues are included in the Practice section. In an effort to increase publication within these sections we have put forth this call to action. We invite educators and practitioners to submit manuscripts discussing innovations in massage therapy education, how schools and students dealt with the Covid-19 pandemic, practitioners and clients adapted to the pandemic, investigations of the massage therapy profession and about massage therapists, as well as interesting case studies.

Enhancing the practice of medicine with embedded multi-disciplinary researchers in a model of change.

Successfully embedding researchers in a health care setting brings unique challenges and opportunities. Through a joint clinical and academic partnership, we have developed a novel approach to problem-solving in the health care context, by employing a model for leading through change to embed researchers in transformative initiatives. Using the model, we have been able to leverage our local environment and resources to engage multi-disciplinary researchers in solving complex issues. An example is our initiative, Enhancing the Practice of Medicine, to address burnout among health care providers. Through this work, we have identified 3 primary factors critical to the successful deployment of embedded researchers. First and foremost, a multi-disciplinary team with diverse expertise is necessary to truly understand the root causes and potential solutions for complex issues. Second, this diverse team of embedded researchers must be involved from the initial stages of project design and have a voice throughout all phases of planning and assessing the initiative. Finally, embedded researchers will be most successful when they are supported to build relationships, navigate the system, and conduct research as part of an integrated and comprehensive effort that aligns with health system priorities.

Attitudes, beliefs and behaviors of religiosity, spirituality, and cultural competence in the medical profession: A cross-sectional survey study.

INTRODUCTION: Religion and spirituality play important roles in the lives of many, including healthcare providers and their patients. The purpose of this study was to examine the relationships between religion, spirituality, and cultural competence of healthcare providers. METHODS: Physicians, residents, and medical students were recruited through social platforms to complete an electronically delivered survey, gathering data regarding demographics, cultural competency, religiosity, and spirituality. Four composite variables were created to categorize cultural competency: Patient Care Knowledge, Patient Care Skills/Abilities, Professional Interactions, and Systems Level Interactions. Study participants (n = 144) were grouped as Christian (n = 95)/non-Christian (n = 49) and highly religious (n = 62)/not highly religious (n = 82); each group received a score in the four categories. Wilcoxon rank sum and Chi-square tests were used for analysis of continuous and discrete variables. RESULTS: A total of 144 individuals completed the survey with the majority having completed medical school (n = 87), identifying as women (n = 108), white (n = 85), Christian (n = 95), and not highly religious (n = 82). There were no significant differences amongst Christian versus non-Christian groups or highly religious versus not highly religious groups when comparing their patient care knowledge (p = .563, p = .457), skills/abilities (p = .423, p = .51), professional interactions (p = .191, p = .439), or systems level interaction scores (p = .809, p = .078). Nevertheless, participants reported decreased knowledge of different healing traditions (90%) and decreased skills inquiring about religious/spiritual and cultural beliefs that may affect patient care (91% and 88%). Providers also reported rarely referring patients to religious services (86%). CONCLUSIONS: Although this study demonstrated no significant impact of healthcare providers' religious/spiritual beliefs on the ability to deliver culturally competent care, it did reveal gaps around how religion and spirituality interact with health and healthcare. This suggests a need for improved cultural competence education.