Humanism, Empathy, Social Justice, and Global Health Symposium

Introduction: International medical graduates (IMG) account for 46.5% of all internal medicine residency matches in 2022 and up to 25% of practicing licensed doctors. They face unique challenges, among which communication was noted by both trainees and program directors. Patient-centered communication (PCC) is a method of clinician-patient interaction that has been shown to improve patient outcomes and satisfaction. Short trainings have been shown to improve knowledge and confidence while producing enduring effects of patient-centeredness for the learner. However, little has been described in the literature about designing PCC curricula for IMGs.

Objective: To demonstrate the process of creating a multimodal PCC curriculum for an internal medicine residency program with a high proportion of IMGs

Methods: Kern’s Six Steps of Curriculum Development was performed for an Internal Medicine Residency Program. Survey-based needs assessments identified gaps in communication skills. Pedagogical interventions included communication workshops, flipped classroom didactics, clinical observation tools, and associated faculty development. Immediate and delayed post-surveys were administered.

Results: Residents were least prepared for encounters involving sexual history, chronic pain, and substance use, with IMGs less prepared for sexual concerns (p=0.023), substance use (p=0.049), eliciting emotional context (p=0.012), and medication non-adherence (p=0.024). IMGs reported significantly less communication skills training time (p=0.002) and skills practice (p=0.008) before residency than non-IMGs. English proficiency and cultural differences were not statistically significant barriers. Didactics significantly increased preparedness in substance use (p=0.001), sexual histories (p=0.002), and chronic pain (p=0.011). Delayed posttest was performed at the end of the academic year. Residents felt that the QEC didactics had a positive impact on their future patient interactions: 44% of residents rated “a great deal”, and 52% rated “a moderate amount”. There was no statistically significant difference between IMGs and non-IMGs. Compared to last year, 65.5% of residents reported that their PCC skills have improved, 17.2% greatly improved, and 17.2% slightly improved. There was no statistically significant difference between IMGs and non-IMGs. There was no statistically significant improvement in all communication themes (p>0.05): agenda setting, eliciting emotional context, adherence, shared decision-making, lifestyle modification, health literacy, chronic pain, sexual concerns, and substance use. This is likely due to residents’ overestimation of their communication skills at baseline whereas training increased awareness of areas for improvement.

Conclusion: Effective communication is one of the unique challenges faced by IMGs. With the development of a multimodal communication curriculum, significant improvements in knowledge and skill can be achieved for both IMGs and US medical graduates. This not only improves patient outcomes but helps to reduce education inequities.

Desired Impact: The goal of this project is to increase local awareness and skill in evidence-based patient-centered and relationship-centered communication skills, and thereby improve the quality of patient-centeredness and humanistic care in our health system. In particular, IMGs comprise a valuable and significant portion of the US healthcare workforce, and innovative multi-pronged curricula are needed to reduce the disparity of communication skills training for this group.

Key Words: Patient-centered communication, IMG, Curriculum Development

Introduction: Burnout is a healthcare crisis affecting ~50% of physicians, impairing physician health and well-being, and patient care and safety. It is important to identify the optimal survey to measure burnout. The Maslach Burnout Inventory (MBI) (20-items) measures emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA). The Mayo Well-Being Index (WBI) measures 6 dimensions of distress (9-items). While MBI is the gold standard and most robust, WBI is popular for its brevity.

Objectives: 1) Test the feasibility of on-line survey platforms to deliver physician burnout surveys; 2) Determine preferences for MBI vs. WBI to guide implementation of a system-wide burnout assessment.

Methods: All physicians participating in a cooking demonstration at The Queen’s Medical Center wellness event completed on-line versions of MBI, WBI and a survey assessing respondents’ attitudes towards burnout surveys. Data were collected and analyzed anonymously.

Results: Fifty-one (24 male; 27 female) physicians participated. WBI: 62% exceeded the burnout threshold. MBI: 51% met burnout threshold for EE, 31% for DP and 18% for PA; overall, 57% met burnout threshold for at least 1 of the 3 MBI domains, with women reporting more burnout than men (63% vs. 50%), particularly DP and PA. Although respondents took longer to complete MBI vs. WBI (7.5±4.0 vs. 4.2±2.6 min), physicians felt that both were of acceptable length (100% vs. 94%) and that it was reasonable to be asked to complete either survey annually (96% vs 98%). Only ~55% felt that their survey responses would remain confidential and anonymous.

Conclusion: Burnout among our physicians is similar to our mainland counterparts at >55%. While WBI is favored for its brevity, physicians found both WBI and MBI acceptable if administered annually. Given its robustness and results that may be more actionable, we will likely administer the MBI to our medical staff for burnout assessment.

Desired Impact (brief statement, not in the word count):
Obtaining physician feedback about burnout surveys will optimize our ability to monitor and characterize physician burnout and design interventions to improve physician well-being.

The last two iterations of the Humanism, Empathy, Social Justice, and Global Health Symposia were coordinated by Gregory Maskarinec, cultural anthropologist and University of Hawaiʻi (UH) John A. Burns School of Medicine (JABSOM)’s Director of the Office of Global Health and International Medicine at the time. Paul Farmer joined us remotely from Rwanda for the February 2022 Symposium, delivering two talks in two days. Paul died four days after his second talk – an incalculable loss for the world. Gregory had been ill since 2020, and was not expected to live much longer after the February 2022 symposium. Paul had expressed his sadness at Gregory’s impending demise, but ironically he died ahead of Gregory, who passed away in June 2022. Another incalculable loss.

For this essay, I have drawn on the conversations, correspondence, their writings, and an article that I wrote together with Gregory and Paul. I am led to believe that at the current juncture, Gregory and Paul would have spoken out against the genocidal assault on the Palestinian people.

Introduction:
Historical events such as US thermonuclear weapon testing within their home lands left many Compacts of Free Association (COFA) citizens, including those of Chuukese, Marshallese, Pohnpeian, Yapese, and Kosraean descent, with poor health and educational outcomes that led to their migration to Hawai’i.

Objectives:
Perform clinic needs assessments and address disparities with a patient navigation program.

Methods:
A retrospective case-control study was conducted to quantify the severity of health disparities among COFA-affiliated populations receiving primary care in a hospital-embedded teaching clinic in Honolulu, HI by evaluating prevalence of chronic, noncommunicable diseases.
The Wayfinder Program was established to address the relative health burden. Medical students were given didactics on patient-centered communication skills, cultural humility, and COFA-specific issues. The students utilized telephone interpreter services to connect with patients and address their gaps in care.

Results:
In comparison to the age- and sex-matched control group, patients with ethnolinguistic backgrounds from COFA nations have diabetes prevalence twofold greater (54.1%), chronic kidney disease 1.8 times greater (24.3%), and history of stroke two times greater (13.0%). Prevalence of uncontrolled diabetes in the studied population was more than three times higher (16.1%), and end stage renal disease 3.9 times higher (10.2%) than that of the control group.
After finding that one of the two telephone interpreter agencies used had fewer wait times (average wait time 8 mins vs 24 mins), a clinic policy change was implemented for preference of interpreter companies.Following one year of the program, key exemplary case studies were reviewed, highlighting the benefit of the program for the migrant patient population.

Conclusion:
To address chronic disease disparities in COFA migrants, medical students work as patient navigators through the Wayfinder program and are continuing to evaluate and improve the program for this patient population.

Desired Impact:
Evaluate the relative burden of chronic, noncommunicable diseases (e.g. diabetes, chronic kidney disease) among patients with ethnolinguistic backgrounds from COFA nations within a primary care practice in Hawai’i.
Assess the importance of using interpreter services for rare languages of the Pacific in patient care delivery, while appraising differences in access between two language service agencies.
Translate a model of medical students as patient navigators to the novel context of COFA-associated patient populations in Hawai’i.

Introduction: Chuuk, the largest state within the Federated States of Micronesia, has one of the highest burdens of tuberculosis in the Pacific. In May 2023, members of the University of Hawaii Department of Family Medicine participated in TB Free Chuuk, which is a multi-organization (CDC, WHO, Chuuk state TB program among others), multidisciplinary public health initiative to decrease the burden of TB and Hansen’s disease in Chuuk by conducting nation-wide TB screening and treatment.

Objectives: To screen 21,000 Chuukese residents and treat all cases of active and latent TB. To conduct screening for Hansen’s disease for all adults and children, and to screen all adults for diabetes. To describe the efforts to decrease the burden of TB and Hansen’s disease in Chuuk.

Methods: Data were collected and organized by team epidemiologists, with analysis in progress.

Results: As of October 5, 2023, teams have completed TB screening for 12,194 people, with 176 people referred for treatment of active TB. 2,170 people (18%) found to have latent TB, and 2,053 of these began their TB prevention 3-HP regimen with local community health outreach workers (CHOWs) continuing to administer treatment. 7,969 people have taken medication to prevent leprosy. Over 1000 individuals tested positive for diabetes and 400 were newly diagnosed cases referred for treatment.

Conclusion: To maximize the effectiveness of the mass screening and treatment, collaboration with the Public Health teams in Chuuk is vital in order to include the entire community. Continued planning and screening are necessary to provide screening to the Mortlock and NorthWest islands in Chuuk.

Desired Impact: The mass screening and treatment in Chuuk works to provide lasting positive health impacts in Chuuk State by decreasing the burden of TB and Hansen’s disease, building healthier communities for the present and future generations in Chuuk.

Introduction:  A physician’s ability to establish an empathic understanding of patients is essential to the development of a therapeutic relationship. Educating students to become empathic physicians is an important learning objective in medical education. In the backdrop of a physician burnout epidemic and efforts to deliver patient-centered care, clinical empathy remains variably defined and incompletely understood.

Objectives:  We performed a scoping review to explore the current understanding of clinical empathy and assess approaches to teach empathy to medical students.

Methods:  We used standard methodology and performed PubMed searches “empathy”, “clinical”, “education”, and “teaching” from 2010-23. Articles were screened and reviewed, with common concepts and findings identified and aggregated by consensus.

Results:  Clinical empathy most commonly includes two categories. “Cognitive empathy” is the ability to identify and understand another’s feelings and perspective, without invoking an emotional response. Felt to be an active skill that may be acquired and developed, cognitive empathy is aligned with historical Western medical culture of emotional detachment and objectivity. “Affective empathy” is the ability to subjectively experience and share in another’s psychological state or feelings. Longstanding beliefs on the merits of cognitive empathy and risks of affective empathy, particularly vis-à-vis burnout, have been increasingly challenged, with evidence that both are needed in balance. A third component, “compassionate empathy” is also now recognized as the ability to respond to another’s emotions with verbal or non-verbal communication, including tone of voice, facial expressions and body posture. Medical school programs to teach empathy vary widely, including didactics, skills training, experiential training, with moderate impact on quantitative empathy scores. Few were designed to specifically address one of the three components of empathy.

Conclusion: Clinical empathy remains variably defined and incompletely understood. Teaching empathy to medical students is moderately impactful. Further work is needed to define the best approaches.

Desired Impact: Programs to teach clinical empathy to medical students are moderately effective and generally are not intentionally and specifically designed to address one or more of the three clinical empathy components. Best practice approaches to teach clinical empathy to medical students need to be developed.

Introduction: Multiple barriers exist in the enrollment of racial and ethnic minority groups into breast cancer screening and clinical trials. Such barriers include the lack of knowledge, mistrust, and access. To increase participation of rural-dwelling Native Hawaiian/Pacific Islanders (NHPI) and other underserved minority groups in breast cancer screening and clinical trials, a pilot project was developed to augment community engagement, provide education, and gain insights into the cancer screening/clinical trial process.

Objective: Engage rural Oahuʻs underserved communities in breast cancer screening and facilitate enrollment into the Digital Tomosynthesis Mammography and Digital Mammography in Screening Patients of Breast Cancer Trial (TMIST) utilizing a team comprising of a cultural congruent and gender concordant Community Health Educator (CHE) and medical oncology health care provider.

Methods: We reviewed the community activities over the course of a year. The CHE facilitated outreach by speaking at numerous church events and other community gatherings.

Results: Participants did not respond favorably to surveys on social determinants of health. Common reasons for their reluctance included lack of perceived importance and medical mistrust. When discussing verbiage that was intimidating or confusing such as clinical trial protocol consent language, TMIST study participants conveyed a strong sense of dehumanization.

Conclusion: A total of 92 women were screened for the TMIST clinical trial. Of those, 12 were enrolled in TMIST and 32 participants received mammograms. Participant insight highlighted the importance of education using culturally sensitive language and community engagement to combat the lack of knowledge and mistrust. Continued development of education materials centered around community involvement will improve the accrual of NHPI participation in breast cancer screening/clinical trials.

Desired Impact: We hope this project established a basis for equity in communities with low breast cancer screening and clinical trial participation rates. We intend to build upon the community partnerships forged during this pilot project.

Introduction: The houseless simulation exercise (HSE) is an innovative interprofessional education (IPE) online activity developed for health professional students to build awareness and empathy for persons experiencing houselessness, and to develop skills to provide effective and compassionate care for this vulnerable population.

Objectives: To create a learning environment for students to explore personal assumptions and implicit biases about houselessness; discuss impacts of social determinants of health (SDOH) on people experiencing houselessness; perform decision-making in difficult situations; and collaborate with an interprofessional team.

Methods: Faculty from the schools of nursing, medicine, pharmacy, social work and public health developed and conducted the HSE over two years with the support of subject matter experts. Students assumed the role of a single parent facing challenges related to houselessness in a scripted activity. In Year 1, debriefing sessions focused on uncovering assumptions and implicit biases. In Year 2, debriefing expanded to include discussions about the impacts of SDOH, and an interprofessional teamwork activity regarding potential interventions, including policy initiatives.

Results: Using a retrospective pre-post format, students’ self-assessment on the Interprofessional Collaboration Competency Attainment Survey showed improvements in all 20 questions and 6 domains (all p<0.0001). Students rated the exercise well (mean scores 3.8-4.4 on a 5-point Likert scale). The design and delivery of the simulation was rated highly (4.1-4.5). Student scores indicated improvements in awareness of challenges faced by houseless people related to SDOH, including financial pressures to meet basic needs, challenges in escaping houselessness, emotional stress and frustration, and health outcomes (all p<0.0001).

Conclusion: Results support the HSE as an effective strategy for helping students to uncover personal biases, to identify the impacts of SDOH on people experiencing houselessness, and to gain skills as a working member of an interprofessional team. Desired Impact: Educational experiences building awareness and empathy for houseless persons are essential for the development of a healthcare workforce capable of caring for this vulnerable population.

Sun Safety Education for Elementary School Students in Hawaiʻi
By Heather Zimmerman, BS, BSN, University of Hawaiʻi John A. Burns School of Medicine, and Kevin Cassel, DrPH, MPH, University of Hawaiʻi Cancer Center

As global temperatures rise, sun safety measures are increasingly warranted. Although populations in Hawaiʻi experience an average ultraviolet index of 9 (very high), we found that some schools' curricula lacked sun safety educational programs. Implementing preventive sun safety education is necessary to ensure that rates of disease related damage from ultraviolet radiation (UVR) do not continue to rise with the next generation.

This pilot program aimed to prepare and evaluate a 1-hour educational presentation for fourth-grade students on the island of Oʻahu. Utilizing culturally diverse images, we compiled a PowerPoint presentation illustrating the long-term health effects of UVR damage, and the proper use of UV- protective measures such as sunscreen, hats, sunglasses, clothing, and shade-seeking behavior.

The first presentation was delivered on December 1st, 2023, to 70 4th-graders at an elementary school in Honolulu, Hawaiʻi. Interactivity was stressed, and presenters observed students' responses to questions using a raise of hands. Although we did not officially measure, patterns were evident. For example, in pre-teaching, up to five students raised their hand to each question, with an accuracy of fifty percent at most. After reviewing appropriate protective gear, we again prompted students to identify which type of protective gear was missing in subsequent images. Post-teaching, an estimated seventy-five percent of the students raised their hands for each question, with an observed accuracy of one hundred percent when randomly selected to identify the missing protective gear.

Throughout the presentation, students were engaged; however, participation notably increased post-teaching, and by the end of the presentation, every student selected successfully identified the missing article of protective gear.

Based on these outcomes, we contend that sun safety education is potentially effective when delivered to fourth-grade students in Hawai’i via an interactive, representative PowerPoint, and a formal survey-based study is warranted to validate these observations.

DESIRED IMPACT: This educational series is intended to improve sun safety awareness and practice amongst elementary school students in Hawaiʻi, using materials reflective of the diverse cultures of this region.

[Title]
"Bridging Access: Expanding Service Dog Integration in Japan and the United States"

[Authors]
Emi Saegusa-Beecroft, M.D., Ph.D.1,2
Tomoko Takayanagi, M.D., Ph.D.3
Junji B. Machi, M.D., Ph.D., FACS1,2

1. Office of Global Health and International Medicine, John A. Burns School of Medicine, University of Hawai’i
2. Department of Surgery, John A. Burns School of Medicine, University of Hawai’i
3. Chairperson, Japan Service Dog Association, Kanagawa, Japan

[Introduction]
This comparative study highlights disparities in service animal integration for individuals with disabilities, in Japan and the United States.

[Objective]
To advocate for a policy reform to enhance inclusivity of service animals in Japan.

[Methods]
A comparative analysis was conducted, focusing on legislation, service dog team statistics, and the operational practices of service dog organizations in both countries.

[Results]
In Japan, only 58 mobility service dogs exist for fewer than 0.4% of an estimated 15,000 potential beneficiaries. Conversely, the U.S. supports fewer than 1% of 61 million adults with disabilities, with 7,911 service dog teams.
In the U.S., the Americans with Disabilities Act (ADA) advocates for a wide range of disabilities, allowing service animals, including those for physical, PTSD, autism, epilepsy, and mental illnesses, provided they perform specific tasks.
This contrasts with Japan's limited recognition, which, despite the “Act on Assistance Dogs for Physically Disabled Persons,” acknowledges only Guide Dogs, Mobility Service Dogs, and Hearing Dogs as Assistance Dogs.
Amidst this disparity, the Japan Service Dog Association (JSDA) and "Cynthia's Hill” mobility service dog training facility, one of just ten in Japan, signify progress. JSDA's recent Assistance Dogs International accreditation and emphasis on personalized training regimens, along with Cynthia's Hill's rigorous matching and aftercare, confront the challenges of low public awareness and the substantial cost; approximately $21,000 USD in Japan versus over $40,000 USD in the U.S., per service dog.

[Conclusion]
The study calls for a global dialogue for reevaluating Japan's policies to parallel the more inclusive ADA standards of the U.S. Promoting understanding and acceptance of assistance dogs aims to build an empathetic, inclusive, and equitable society. By aligning policies with the intricate needs of people living with disabilities, the goal is to integrate assistance dogs fully into public life, enhancing independence and dignity for all.

[Desired Impact]
To catalyze policy advancements in Japan towards a more inclusive service dog system, mirroring the ADA's broader recognition of disabilities, thereby ensuring service dogs are accessible to all who need them, enhancing the quality of life for people living with disabilities globally.

[Key Words]
Service dogs, disability inclusivity policy, cross-cultural analysis (Japan - U.S.).