Risks

AEM Educ Train. 2022;6:e10772.  | 1 of 9 https://doi.org/10.1002/aet2.10772

wileyonlinelibrary.com/journal/aet2

Received: 10 April 2022  | Revised: 23 May 2022  | Accepted: 24 May 2022 DOI: 10.1002/aet2.10772

O R I G I N A L C O N T R I B U T I O N

“A sorely neglected field”: A multisite study of self- reported humanities exposure among emergency medicine residents

Kamna S. Balhara MD, MA1  | Nathan Irvin MD, MSHPR1 | Korie L. Zink MD, MS1 | Sanjay Mohan MD2 | Adriana S. Olson MD, MA.Ed3  | Sean Tackett MD, MPH4,5 | Emergency Medicine Education Research Alliance (EMERA)† | Linda Regan MD, MEd1

1Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA 2Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York, USA 3Section of Emergency Medicine, Department of Medicine, University of Chicago, Chicago, Illinois, USA 4Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA 5Biostatistics Epidemiology and Data Management Core, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

Correspondence Kamna S. Balhara, MD, MA, Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument St, Suite 6- 100, Baltimore, MD 21287, USA. Email: [email protected]

Abstract Background: The Association of American Medical Colleges has identified the hu- manities as fundamental to medical education across all specialties. Evidence from un- dergraduate medical education (UME) demonstrates the humanities' positive impacts on outcomes that could be relevant to patient care and trainee well- being in emer- gency medicine (EM) residency training. However, less is known about the humanities' role in graduate medical education (GME). Objectives: The objectives were to describe EM residents' self- reported exposure to the humanities and its relationship with their empathy, tolerance of ambiguity, and patient- centeredness, and to assess their attitudes toward the humanities in GME. Methods: This cross- sectional survey- based study was conducted at six U.S. EM resi- dency programs in 2018– 2019. Quantitative analyses included linear regressions test- ing for trends between humanities exposures and outcomes, adjusted for sex, year in training, and clustering within programs; adjunct analysis of free- text responses was performed using an exploratory constructivist approach to identify themes about views on the humanities' role in medicine. Results: Response rate was 54.8% (153/279). A total of 65% of respondents were male and 28.1% of respondents had a preceding humanities degree. Preceding humani- ties degree and current self- reported humanities exposure were positively associated with performance on empathy subscales (p = 0.02). Seventy- five percent (n = 114) of respondents agreed humanities are important in GME; free- text responses revealed perceived positive impacts of humanities on generating well- rounded clinicians and enhancing patient care. Conclusions: Engagement with the humanities may be associated with empathy among EM residents. Although the magnitude of associations was smaller than that

© 2022 Society for Academic Emergency Medicine.

†The Emergency Medicine Education Research Alliance (EMERA) is a consortium of graduates of the Northwestern Emergency Medicine Residency Program who collaborate to produce high- quality education research. Website: http://emera netwo rk.org/

Was scheduled to be presented at the Society for Academic Emergency Medicine Annual Meeting, Denver, CO, May 2020, though not presented due to COVID- 19 pandemic.

Supervising Editor: Dr. Stephen Cico.

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EXPOSURE AMONG EMERGENCY MEDICINE RESIDENTS

INTRODUC TION

A growing body of evidence suggests the humanities may positively impact health professions learners across multiple domains, includ- ing skills- based outcomes (e.g., observation), relational outcomes (e.g., empathy, communication), and transformational outcomes (e.g., professional identity formation, resilience).1– 4 The Association of American Medical Colleges (AAMC) and the National Academies of Sciences, Engineering and Medicine (NASEM) have identified the humanities as fundamental to medical education across the training continuum.4,5

Though the humanities are gaining some traction within emer- gency medicine (EM), humanities- based curricula specifically tar- geting EM residents are largely lacking.6 While over 70% of North American medical schools offer humanities- based curricula in under- graduate medical education (UME), only 17% of arts and humanities programming target residents. Less is known about the prevalence and impact of the humanities in graduate medical education (GME), including in EM.3,4,7

Studies in UME have demonstrated correlations between hu- manities exposure and positive medical student attributes, includ- ing empathy, tolerance of ambiguity (TA), and communication.4 The impacts of humanities- based curricula seen in UME, if continued into GME, could have even greater salience for residents providing clinical care, since attributes such as empathy and TA are associ- ated with residents' resilience and the quality of care patients re- ceive.8– 10 EM residents frequently encounter threats to empathy and patient- centeredness due to burnout and compassion fatigue and routinely contend with ambiguity, in the form of “undifferen- tiated” patients and high- stakes decision making with limited infor- mation.11– 13 As such, the enhancement of trainees' TA, empathy, and patient- centered care through the humanities could represent an im- portant benefit to EM residents' training. Additionally, the core func- tions of the humanities in medical education identified by a recent scoping review, including perspective taking, personal insight, and social advocacy, correspond directly with specific elements of the most recent Accreditation Council for Graduate Medical Education (ACGME) EM milestones, including understanding patients' per- spectives (ICS1), self- awareness and reflection (ICS1, PROF3), and patient and community advocacy (SBP3, SBP4).14,15 Moreover, the humanities have the potential to be valuable pedagogical adjuncts for specific components of (i) the EM Model of Practice, such as those listed in “Other Core Competencies for the Practice of Emergency Medicine” (including well- being and resilience, ethical principles, and social determinants of health) and (ii) the ACGME Common Program

Requirements, including adherence to ethical requirements, re- spect and responsiveness to diverse patient populations, ability to recognize and develop a plan for one's own personal and profes- sional well- being, communication, and advocacy.16,17 Despite these potential benefits and occupational considerations, to the best of our knowledge, there are no multisite studies that have investigated residents' engagement with the humanities in EM or how it might relate to favorable outcomes. Given the lack of formal humanities curricula across EM residencies, we elected to explore residents' self- reported engagement with the humanities as a surrogate mea- sure for humanities exposure. Specifically, the goals of our multi- site study were to (i) assess self- reported engagement with the human- ities amongst EM residents in six programs across the United States and examine whether exposure to the humanities related to EM res- idents' empathy, TA, and patient- centeredness and (ii) capture EM residents' attitudes towards the humanities in medical education.

METHODS

Study design, setting, and population

This was a cross- sectional survey- based study of EM residents at six ACGME- accredited EM residency programs in 2018– 2019 in the Northeast, Mid- Atlantic, Midwest, Southeast, and Southwest United States. Two programs were 4- year programs; the remainder were 3- year programs. Programs were selected to represent both geographic and programmatic diversity to increase generalizability. Surveys were conducted over an 8- month period and were admin- istered electronically at four sites, on paper at one site, and a mix of on paper and online at another. A hybrid collection technique was utilized to increase survey completion rates and to make accessing the survey easiest for the learners being surveyed at their respec- tive institutions. All residents at each site were eligible for inclusion.

Study measures and outcomes

The survey was based on a previous study that developed a ques- tionnaire to measure medical students' self- reported exposure to humanities, and content validity was assessed by a team of EM clinician- educators with experience in humanities education and as- sessment and evaluation1 (Supplemental Material).

This anonymous survey collected information on basic de- mographics and preceding training in the humanities. The survey

seen in UME, this study demonstrates resident interest in humanities and suggests that extracurricular engagement with the humanities may be insufficient to prolong positive impacts seen in UME. Further research is needed to explore how to sus- tain these benefits through integration or addition of the humanities in existing GME curricula.

    |  3 of 9BALHARA et al.

defined humanities as the study of human society and culture, in- cluding, but not limited to, languages, literature, art, music, philoso- phy, history and geography, religion, and ethics.18 Given the absence of standardized humanities curricula in EM residency education, we measured humanities exposure via residents' self- reported en- gagement with humanities using a scale modeled on Mangione et al.1 Participants were asked how often they participated in 10 humanities- related activities on a 7- point scale of frequency (ranging from 1 [never] to 7 [daily]), with subsequent calculation of a human- ities exposure score with a possible range of 10 to 70.

TA was assessed using Geller's 7- item scale, which has been ap- plied in other studies of health care professionals.19– 21 Response op- tions were provided on a 6- point Likert scale from “strongly agree” to “strongly disagree,” with no neutral option. Scores were reported as scale totals (possible range of 7– 42). Higher scores reflected greater TA.

The Interpersonal Reactivity Index (IRI) questionnaire, which characterizes empathy as a multidimensional cognitive and affective construct, was used to evaluate empathy.22 The IRI has 28 items with 5- point Likert scale response options ranging from “does not describe me well” to “describes me very well.”23 Each response was scaled from 0 to 4. The IRI encompasses four factors of seven items each: perspec- tive taking (ability to spontaneously see others' perspectives), fantasy (ability to put oneself in the situation of another), empathic concern (“other- oriented” feelings of sympathy and concern for unfortunate others), and personal distress (“self- oriented” negative personal re- sponse to others' distress). Domain scores were reported as summed totals of each item's score. Higher scores reflected greater perspective- taking ability, ability to put oneself in the situation of others, empathic concern, and personal distress, respectively.

Patient- centeredness was assessed via the Patient– Practitioner Orientation Scale (PPOS), an 18- item scale widely used in medical education and applied cross- culturally. Response options consisted of a 6- point Likert scale from “strongly agree” to “strongly disagree” with no neutral option. Scores were reported as item- means scaled 1– 6. Higher scores reflected greater patient- centeredness.24– 26 Attitudes about the inclusion of humanities in medical education were measured on 5- point Likert scales, as well as open- ended questioning.

Data analysis

Quantitative

We calculated descriptive statistics and performed bivariate analy- ses with parametric and nonparametric tests. Simple linear regres- sions were used to test for trends between self- reported humanities exposure and performance on self- reported measures. For each sim- ple linear regression, linear regressions that adjusted for individual sex and year in training were performed, accounting for clustering within programs. Stata 13 (Stata Statistical Software, Release 13, 2013) was used for data analysis.

Adjunct analysis

Free- text responses to the open- ended question on the role of the humanities in medicine were coded iteratively by two study team members (ASO and KSB) with a third (NI) available for resolution of discrepancies. This was an adjunct analysis to supplement quantita- tive survey findings, as recommended by LaDonna et al.27 An ex- ploratory approach was utilized, applying a constructivist paradigm to identify common themes in residents' perceptions of the humani- ties' role in medicine. Responses were also systematically coded for valence (positive or negative). Each site's institutional review board deemed the study protocol exempt.

RESULTS

The survey response rate was 54.8% (153/279; Table 1). Participants were represented across all years in training with relatively few PGY- 4 respondents given fewer participating 4- year programs. A total of 28.1% of respondents (n = 43) reported a preceding humani- ties degree. A total of 65% of respondents were male.

Residents' self- reported humanities exposure

The mean current humanities exposure score for respondents was 33.4 (range 10– 70; Table 1). There were no significant differences between programs, year in training, or gender in self- reported expo- sure to the humanities. Participants with previous humanities train- ing had increased current self- reported humanities exposure during residency (mean ± SD 36.6 ± 5.75 vs. 32.2 ± 7.00; p < 0.01]).

There was no significant difference between year in training in performance on TA, IRI, and PPOS scales. Respondents who identi- fied as female had higher mean scores on patient- centeredness and empathy measures. (Table 1).

Frequency of current exposure to specific humanities- related activities is detailed in Table 2. Almost all respondents reported lis- tening to music at least once a month and more than half read for pleasure at least once a month. While up to 70% reported attending a concert or visiting a museum at least once a year, active participa- tion in the creation of art was reported less frequently.

Humanities exposure and empathy, TA, and patient- centeredness

After adjusting for year in training, gender, and clustering within pro- grams, participants with preceding degrees in a humanities discipline scored lower on the IRI personal distress subscale, which measures “self- oriented” feelings of personal anxiety and unease in tense in- terpersonal settings (mean ± SD 5.3 ± 3.1 vs. 7.0 ± 4.3; p = 0.02). Current humanities exposure was associated with increased scores on the IRI fantasy subscale, which represents the ability to put

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EXPOSURE AMONG EMERGENCY MEDICINE RESIDENTS

TA B

LE 1   C ha ra ct er is tic s of 1 53 E M re si de nt s fr om s ix p ro gr am s su rv ey ed o n hu m an iti es e xp os ur e, p at ie nt - c en te re dn es s, T A , a nd e m pa th y in 2 01 8– 20 19

PG Y

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de r

A ll

1 2

3 4

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m al

eb p-

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15 3 (1 00 )

57 (3 7)

41 (2 7)

46 (3 0)

9 (6 )

N /A

99 (6 5)

53 (3 5)

N /A

H um an iti es e xp os ur e sc al e to ta l

33 .4 (± 6. 9)

33 .8 (± 6. 9)

31 .9 (± 7. 1)

34 .2 (± 7)

32 .9 (± 6. 1)

0. 46 8

32 .8 (± 7)

34 .4 (± 6. 8)

0. 21

0

Pa tie nt - c en te re dn es s (P PO S)

O ve

ra ll

4. 5 (± 0. 5)

4. 5 (± 0. 4)

4. 5 (± 0. 5)

4. 4 (± 0. 5)

4. 7 (± 0. 5)

0. 30 4

4. 4 (± 0. 5)

4. 6 (± 0. 5)

0. 04 2

Sh ar

in g

4. 4 (± 0. 6)

4. 4 (± 0. 6)

4. 5 (± 0. 7)

4. 3 (± 0. 6)

4. 5 (± 0. 5)

0. 41 4

4. 3 (± 0. 6)

4. 5 (± 0. 7)

0. 02

5

C ar

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4. 6 (± 0. 5)

4. 7 (± 0. 5)

4. 5 (± 0. 5)

4. 5 (± 0. 5)

4. 8 (± 0. 6)

0. 09 2

4. 6 (± 0. 5)

4. 7 (± 0. 5)

0. 13 2

TA 25 .8 (± 6. 7)

25 .7

(± 6. 9)

26 .1

(± 6. 8)

25 .2

(± 6. 6)

26 .8 (± 6. 3)

0. 92 9

25 .6

(± 6. 7)

26 .0

(± 6. 8)

0. 71

1

Em pa th y (IR I)

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pe ct

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ng 20

.1 (± 4. 5)

20 .7

(± 4. 4)

19 .5 (± 5. 6)

20 .2

(± 3. 6)

18 .1 (± 5. 1)

0. 38 4

20 .1

(± 4. 3)

20 .2

(± 5. 0)

0. 96 6

Fa nt as y

17 .0

(± 5. 6)

17 .8 (± 5. 1)

17 .1

(± 6. 4)

15 .8 (± 5. 9)

16 .1

(± 4. 0)

0. 42 0

15 .8 (± 5. 4)

19 .2 (± 5. 4)

0. 00

1

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th ic

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20 .1

(± 4. 3)

20 .5

(± 4. 2)

20 .3 (± 5. 4)

19 .6 (± 3. 9)

19 .9 (± 2. 8)

0. 82 7

19 .0 (± 4. 3)

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N ot

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a s

n (% ) o r m ea n (± SD ). H um an iti es s ca le s co re d as s um m ed to ta l o f 1 0 ite m s w ith 7 - p oi nt re sp on se o pt io ns b as ed o n in cr ea si ng fr eq ue nc y of e ng ag em en t, fo r a ra ng e of 1 0– 70 .

PP O S to ta ls a nd d om ai n ar e m ea ns /i te m , r an ge o f 1 – 6 . T A is to ta l f or s ca le , r an ge 7 – 4 2. IR I i s re po rt ed a s su m o f i te m s in s ca le w ith ra ng e of 0 – 2 8 fo r e ac h do m ai n.

A bb re vi at io ns : I RI , I nt er pe rs on al R ea ct iv ity In de x; P PO S, P at ie nt – P ra ct iti on er O rie nt at io n Sc al e; T A , t ol er an ce fo r a m bi gu ity .

a p- va lu es c or re sp on d to A N O VA te st c om pa rin g PG Y m ea ns .

b D at a fo r s ex d o no t a dd u p to 1 53 d ue to m is si ng d at a.

c p- va lu es c or re sp on d to t- te st c om pa rin g m ea ns fo r m al es a nd fe m al es .

    |  5 of 9BALHARA et al.

oneself in others' shoes (Table 3). No other attributes were signifi- cantly associated with preceding or current exposure to humanities.

Role of the humanities in medicine and medical education

Respondents perceived the humanities to be important across all levels of medical education, with 74.5% (n = 114) of respondents agreeing or strongly agreeing that humanities have an important role in UME, 64.9% (n = 98) for GME, and 60.3% (n = 91) for con- tinuing faculty development. Thirty respondents (19.6%) provided

free- text responses on their thoughts on the role of the humanities in medicine. Similar to all respondents, 39% of this subset identi- fied as female and 35% reported previous humanities training, with a similar distribution of year in training (45% PGY- 1, 23% PGY- - 2, 29% PG- Y3, and 3% PGY4). Themes and representative quotes are described in Table 4. Most (28/30, 93%) expressed positive views on the humanities' role in medicine; benefits described included (i) generating more well- rounded physicians, (ii) humanizing patients and physicians, (iii) positive impacts on patient care and communica- tion, and (iv) personal enrichment. Some advocated for a larger role for the humanities within medical education. Barriers noted included lack of time or competing responsibilities in residency, in contrast to

Never or every few years

Once a year to every few months

Monthly or more

Listen to music 0 (0.0) 2 (1.3) 149 (98.7)

Read for pleasure 15 (10.0) 51 (34.0) 84 (56.0)

Sing or play instrument 84 (56.8) 28 (18.9) 36 (24.3)

Attend concerts 26 (17.3) 102 (68.0) 22 (14.7)

Visit museums or galleries 24 (16.0) 105 (70.0) 21 (14.0)

Write for pleasure 92 (60.9) 41 (27.2) 18 (11.9)

Paint, draw, sculpt, craft, etc. 91 (60.3) 43 (28.5) 17 (11.3)

Attend theater/visual arts performances

57 (37.8) 86 (57.0) 8 (5.3)

Attend talks/lectures about arts, literature, ethics, etc.

74 (49.3) 70 (46.7) 6 (4.0)

Perform in theater or visual arts performances

137 (91.3) 10 (6.7) 3 (2.0)

Note: Data are reported as n (%).

TA B L E 2 Frequencies of use of each type of humanities across all respondents

TA B L E 3 Patient- centeredness, TA, and empathy by quartile of humanities scale totals

Quartile p- value

1 2 3 4 Unadjusteda Adjustedb

Humanities scale total 24.6 (±2.9) 31.0 (±1.5) 36.1 (±1.8) 42.9 (±3.1) N/A N/A

PPOS

Overall 4.4 (±0.4) 4.5 (±0.4) 4.6 (±0.5) 4.5 (±0.6) 0.362 0.458

Sharing 4.2 (±0.5) 4.4 (±0.5) 4.5 (±0.7) 4.3 (±0.7) 0.638 0.924

Caring 4.5 (±0.5) 4.6 (±0.5) 4.7 (±0.5) 4.6 (±0.5) 0.290 0.088

Tolerance for ambiguity

23.6 (±7.0) 25.5 (±6.3) 26.3 (±6.4) 27.7 (±6.6) 0.044 0.131

IRI

Perspective taking 18.5 (±4.3) 21.4 (±4.5) 21.4 (±4.4) 19.2 (±4.6) 0.399 0.452

Fantasy 14.3 (±5.6) 17.6 (±5.5) 18.8 (±5.1) 17.2 (±5.9) 0.006 0.017

Empathic concern 19.4 (±5.1) 20.6 (±4.5) 20.1 (±4.5) 20.7 (±3.5) 0.217 0.422

Personal distress 7.5 (±4.4) 5.1 (±3.5) 6.3 (±4.1) 6.8 (±4.3) 0.627 0.703

Note: Data are reported as mean (±SD). Humanities scale scored as summed total of 10 items with 7- point response options based on increasing frequency of engagement, for a range of 10– 70. PPOS totals and domain are means/item, range of 1– 6. TA is total for scale, range 7– 42. IRI is reported as sum of items in scale with range of 0– 28 for each domain. Abbreviations: IRI, Interpersonal Reactivity Index; PPOS, Patient- Practitioner Orientation Scale; TA, tolerance for ambiguity. ap- values correspond to simple linear regression. bp- values correspond to multiple regressions that adjust for individual residency year and sex and account for clustering within programs.

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increased availability of humanities curricula in UME. Even among those who expressed positive views of humanities in medicine, many respondents conceptualized the humanities as in some way external to or separate from medical education or practice as evidenced by descriptions of it being a link to the world “outside of medicine” or as “a counterbalance to our more scientific focus as doctors.”

DISCUSSION

This multisite study of EM residents describes existing patterns of resident engagement with humanities, examines correlations be- tween self- reported humanities exposure and specific resident at- tributes, and indicates largely positive resident attitudes toward inclusion of humanities in GME. Our results demonstrate that pre- ceding humanities training and current humanities exposure are both associated with higher performance on empathy subscales, though no other associations were noted.

Empathy is an important attribute for physicians. Clinician em- pathy is associated with improved patient satisfaction and increased adherence to treatment, and trainee empathy has the potential to directly impact care and resident well- being, resilience, and burn- out.8,10,28 However, empathy can be a challenging skill to teach or fa- cilitate. Given the current intersecting crises of COVID- 19 and social upheaval, those working in “safety- net” settings such as emergency

departments are particularly at risk for compassion fatigue and burnout, and our results suggest that the humanities could be ex- plored further as a means by which to foster resilience and improved patient care through empathic connection.28

Reading and listening to music were the most frequently reported modalities of self- reported engagement with humanities. Streaming music platforms and availability of reading materials on mobile devices likely make activities such as reading or listening to music more ac- cessible to residents with demanding schedules. While it is premature to recommend any specific modality that would make the humanities more accessible in GME, and while the impacts of the humanities in GME are not fully established, EM educators seeking to explore humanities- based education could consider incorporating music into their curricula, given the frequency of engagement with music reported by residents. Music has, for instance, been applied toward engaging medical trainees in discussions of psychiatric illness.29,30Reading- and writing- based sessions, often grounded in narrative medicine, have been used to inspire reflective practice, enhancement of bedside patient discussions, or engagement with patient experiences.31– 33 Though fewer respondents reported self- initiated visual arts engage- ment, there are also reports in the literature of the feasibility of vi- sual arts– based GME curricula, including museum visits, engagement with community art, and multimedia longitudinal curricula applied toward learning objectives as diverse as improving observation skills, resilience, and bias awareness.34– 38 Further research is necessary to

TA B L E 4 Common themes and representative quotations from adjunct analysis of written responses on role of humanities in medicine

Themes/subthemes Representative quotations

Benefits to residents

Resident well- being or enjoyment “I'm aware of a number of benefits— from mental health and wellness perspectives.” “Life/medicine would have very little meaning if not for the pleasure that the humanities

provide us.”

Helps be more well- rounded “Humanities are important in order to be a well- rounded human.”

Benefits to clinical practice

Humanizing patients and/or physicians “Sometimes physicians forget that there is a world outside of medicine and that there is more to the human experience than their chronic medical conditions.”

“I think they help … allow us to feel like real humans, and in that way they are critical.”

Improved patient care and communication “I think this is a regrettably neglected part of medicine that I think would make people better caretakers.”

“Humanities exposure helps us to communicate with and understand our patients better.”

Compassion “Humanities are incredibly important and I believe play a crucial role in shaping a … compassionate physician.”

Understanding impacts of culture on health “The humanities provide perspectives on society and culture's view of our body and health. It is good to understand the background and stay in touch with these perspectives.”

Humanities in medical education

Should have larger role in GME “I think this is a sorely neglected field in medicine.” “Would love to have more of this incorporated in our training.” “My medical school had many rich humanities experiences available and I miss that all the

time in residency.”

External to science in medicine “Some humanities exposure in life is enjoyable, in addition to providing a counterbalance to our more scientific focus as doctors.”

Obstacles to inclusion “With the increasing burden of responsibilities on physicians, additional training or requirements are always challenging to address.”

Abbreviation: GME, graduate medical education.

    |  7 of 9BALHARA et al.

understand which practices may be most beneficial in fostering empa- thy or other potential benefits of humanities engagement.

Respondents expressed positive attitudes toward the role of the humanities in medicine and medical education, with adjunct analysis preliminarily suggesting perceived impacts on personal well- being, com- passionate practice, interprofessional communication, and patient care. Respondents also identified the humanities as a link to social and cultural concepts that impact health. Indeed, humanities- based approaches have been applied in health professions curricula addressing bias, health eq- uity, and social determinants of health. As educators move to meet the urgent need to address issues of social inequity in health, humanities- based approaches may also be relevant to other topics that are challeng- ing to teach, including antiracism and inclusivity.36– 40

While additional research is needed into the integration of the humanities into GME, many GME faculty members, understand- ably, might feel ill- equipped to integrate humanities into residency curricula; ideally, such activities should be pursued by those with formal training in the humanities and its pedagogical frameworks.4 Recognizing that not all medical educators will have such training, this presents an opportunity for collaboration. Currently, there are 60 partnerships between museums and medical schools that pro- vide collaborative arts- based educational programming for medical students.41There has been exponential growth in health humanities programs offered by undergraduate institutions, and many medical schools feature centers or institutions for the medical humanities, which also offer nexuses for partnership in developing curricula.42 Curricular repositories and training programs also exist.43– 47

Our results do not reveal the magnitude of associations that might have been expected based on findings in UME. This may be due to rel- atively limited extracurricular engagement with humanities in GME as a result of competing time pressures and responsibilities during residency as well as the lack of formal humanities curricula in EM residency training. Our study suggests that extracurricular self- initiated engagement with humanities during residency may be insufficient to prolong positive im- pacts seen from formal humanities curricula among medical students, and residents may not experience the same degree of benefit, potentially as a factor of dose or lack of structured engagement. Medical students and residents also represent different populations of learners. As such, the attributes studied may not evolve with similar trajectories. For instance, TA has been shown to decrease as medical students gain more training, but studies of residents demonstrate increased TA with additional clin- ical training.48 Empathy, TA, and patient- centeredness also bear a com- plex relationship with other attributes, such as moral injury and burnout, which residents face at higher levels than medical students.49,50As such, a “one- size- fits- all” approach may be inadequate. Future research focused on understanding how best to leverage the humanities in EM residency training will be helpful in illuminating these critical issues.

LIMITATIONS

Our study was subject to limitations common to survey- based re- search. While we believe our survey response rate of greater than

50% is relatively robust, we did not capture all eligible respondents, subjecting our data to nonresponse, selection, and self- perception bias. Our survey instrument, though based on published work in UME, may not have asked participants about the entire scope of ac- tivities that could fall under the umbrella of the humanities. A total of 28.1% of our respondents reported preceding experience in the humanities. Though higher than the 13% of medical school matricu- lants with undergraduate humanities majors, “preceding experience” in our study also additionally captured those with undergraduate minors or graduate degrees.51 Though smaller in number, those who provided free- text comments were reflective of the distribution of the larger sample in terms of training year, gender, and preced- ing humanities training. There are also limitations to the qualitative analysis of free- text survey responses; however, given that there are little existing data on GME learners' attitudes toward the humani- ties, we believe the free- text responses represented new, unique data that may inform future directions of inquiry on an infrequently explored topic.27 Additionally, we sampled 3- and 4- year programs at academic and community sites across a variety of locations with a gender distribution and training duration similar to the broader EM residency population, but generalizability to all EM programs may be limited. Given the cross- sectional study design, we were only able to infer association and not causation. The relationship and direc- tionality of the relationship between humanities exposure and spe- cific resident attributes represents an important future direction of study; it is, for instance, possible that there are certain preexisting personal attributes that generate a predilection for engaging in the humanities. However, since there are no consistent humanities cur- ricula across EM residencies, a cross- sectional survey represented the most feasible preliminary approach to examining relationships between humanities and specific resident attributes. Future re- search is needed to investigate the mechanisms by which humanities exposure may influence these attributes, the duration of impacts, and what impacts translate to patient care.

CONCLUSION

Though the magnitude of associations was smaller than that seen among medical students, this multisite study of emergency medi- cine residents demonstrates resident interest in the humanities in medical education and an association between humanities exposure and empathy. Additionally, residents perceived the humanities as important to generating well- rounded clinicians and improving pa- tient care. Implementation and evaluation of humanities curricula tailored to the unique needs of emergency medicine residents may be needed to better understand how to translate the benefits of the humanities from undergraduate medical education to emergency medicine residency training.

AUTHOR CONTRIBUTIONS Kamna S. Balhara, Adriana S. Olson, Linda Regan, and EMERA made substantial contributions to concept and design. Kamna S.

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EXPOSURE AMONG EMERGENCY MEDICINE RESIDENTS

Balhara, Sanjay Mohan, Adriana S. Olson, EMERA and Linda Regan made substantial contributions to acquisition of the data. Kamna S. Balhara, Korie L. Zink, Sanjay Mohan, Nathan Irvin, Adriana S. Olson, Sean Tackett, and Linda Regan made substantial contribu- tions to analysis and interpretation of the data. Kamna S. Balhara, Korie L. Zink, Sanjay Mohan, Sean Tackett, and Nathan Irvin made substantial contributions to drafting of the manuscript. All authors contributed to critical revision of the manuscript for important in- tellectual content. Nathan Irvin and Sean Tackett provided statis- tical expertise.

CONFLIC T OF INTERE S T Korie L. Zink, Sanjay Mohan, and Linda Regan report no conflicts of interests. Kamna S. Balhara reports grant funding received by her institution from the Association of American Medical Colleges, the Josiah H. Macy Foundation, the Agency for Healthcare Research and Quality, the National Institutes of Health, and EMF/CORD to conduct investigator- initiated research on the humanities and health equity, antiracism and the humanities, machine learning, artificial intelligence, and patient safety. Nathan Irvin reports grant funding received by his institution from the Association of American Medical Colleges, the Josiah H. Macy Foundation, and the Stavros Niarchos Foundation to conduct investigator- initiated research on the humanities and health equity, anti- racism and the humanities, and community trauma response. Adriana S. Olson re- ports grant funding received by her institution from EMF/CORD to conduct investigator- initiated research on simulation and pa- tient safety. Sean Tackett reports grant money to Johns Hopkins University School of Medicine to conduct research conceived and written by Sean Tackett from National Institutes of Health and Kern Institute and contract funding from Osmosis for investigator- initiated research.

E THIC S S TATEMENT Ethical approval was granted by the institutional review board at each participating institution.

ORCID Kamna S. Balhara https://orcid.org/0000-0001-6302-3355 Adriana S. Olson https://orcid.org/0000-0002-2585-0971

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SUPPORTING INFORMATION Additional supporting information may be found in the online version of the article at the publisher’s website.

How to cite this article: Balhara KS, Irvin N, Zink KL, et al.. “A sorely neglected field”: A multisite study of self- reported humanities exposure among emergency medicine residents. AEM Educ Train. 2022;6:e10772. doi: 10.1002/aet2.10772