Artists on the Research Team: An Interdisciplinary Approach to Team Science, Research Rigor, and Creative Dialogue.

In an arts in public health research team, artists may be undervalued as key research collaborators because of the difficulties in skillful integration of experts who possess not only different bodies of knowledge but also different ways of examining and valuing the world. Under the stewardship of two Rhode Island state agencies, an innovative research-driven enterprise, comprising researchers, clinicians, and community artists, was brought together to integrate arts-based interventions into statewide public health policy and practice. Here, we examine our work with the Rhode Island Arts and Health Advisory Group as a case study to illuminate our experiences in collaborating with artists on public health policy and practice research. Using existing frameworks from the literature, we define the attributes of, and challenges to, successful research collaborations and identify from our work how these apply to interdisciplinary collaborations between artists and public health practitioners. To support others working at the nexus of arts in public health, we include key experiences that were specific to the engagement of artists in research teams.

Community-engaged Evidence Synthesis to Inform Public Health Policy and Clinical Practice: A Case Study.

BACKGROUND: This case study documents the work of the Rhode Island Arts and Health Advisory Group, which convened in 2016 to develop a set of policy, clinical practice, and research recommendations for implementation by the Rhode Island Department of Health, The Rhode Island State Council on the Arts, and partners. Comprised of artists, clinicians, community members, and patients, the group partnered with researchers to complete an evidence synthesis project of arts-based health care interventions. METHODS: The group took a community-engaged approach to evidence synthesis, featuring the use of online, and in-person training materials to facilitate the codesign and coexecution of the evidence synthesis protocol. The final evidence map was translated into an online evidence map to facilitate analysis and discussion on arts-based interventions in health care. RESULTS: The evidence map informed the development of recommendations for advancing the integration of arts and health in the state. The project evaluation indicated that our community-engaged approach to evidence synthesis promoted engagement as defined by the PCORI Engagement Strategy Rubric (ie, reciprocal relationships, partnership, colearning, transparency, honesty, and trust). Participation also improved community research partners confidence in engaging with the health care system, developed greater empathy and understanding of others in the community, and increased interest in using science or research in advocacy efforts. CONCLUSIONS: Engaging community partners in evidence synthesis promotes community dialogue and engagement in research, specifically towards: (1) elucidating outcomes of import to patients and communities that are not represented in the medical literature; and (2) identifying comparisons among interventions that resonate with patients and communities.

Opioids and pain in the emergency department: a narrative crisis.

The opioid crisis poses challenges to patients who come to the emergency department (ED) in pain and the clinicians who have a duty to offer relief. In search of help, patients often find suspicion. But clinicians have reasons to be concerned about feeding addiction and its lethal consequences. This article discusses the narrative challenges facing many clinicians in the ED tasked with caring for complex patients in pain. It will discuss the many ways our brains are influenced by story, and how this susceptibility is often beyond our grasp. And yet, narrative and story skills present great opportunities for improving pain management, not only when it comes to opioids, but by returning the focus back to the patient in pain.

Benefit Paradox.

I could have been more understanding, especially when police brought a man I'll call Mr. Atkins to the emergency room for depression and suicidal ideation. But it was 3:00 a.m. and the ER was a carnival of disease and discontent, a parade of drunk drivers and folks who practiced conflict resolution with knives and bullets. A patient well known for her drug abuse wasn't done yelling at me for refusing to write her a narcotic script when a nurse tweaked at my elbow to please come speak with Mr. Atkins, who was making a case to walk out.

Decision Aids, Doorknob Moments, and Physician-Patient Solidarity in EDs.

Potential benefits of decision aids and technology, such as artificial intelligence, used at the bedside are many and significant. Like any tools, they must be used appropriately for specific tasks, since even validated decision aids have limited utility when they are misapplied, overly relied upon, or used as a substitute for thinking carefully about clinically and ethically relevant questions. Patients are more than data points in human form, as they come to emergency departments with stories. As technology casts ever-lengthening shadows over patient-clinician interactions, a key question is: How should clinicians cultivate relationships with technology so it functions in solidarity with patients?

Examining the Constructs of Burnout, Compassion Fatigue, Secondary Traumatic Stress in Physicians Using Factor Analyses.

Background: Adverse affective experiences have been well-documented in healthcare providers. Research describes them under a variety of terms, including burnout, secondary traumatic stress (STS), and compassion fatigue (CF). The present study evaluates conflicting models of STS, CF, and burnout constructs in physicians. Methods: Surveys were mailed to all allopathic physicians with active Rhode Island medical licenses. Three hundred and seventy-five complete responses were received. The survey included common measures of STS, CF, and burnout. Confirmatory Factor Analysis (CFA) was used to evaluate discriminant validity of the three constructs and test 5 a priori (1-, 2-, and 3-factor) theoretical models, and Exploratory Factor Analysis (EFA) was planned assess underlying factor structure in the case that CFA did not provide evidence supporting any existing model. Results: By CFA, all five a priori models of burnout, CF, and STS fail to demonstrate adequate model fit (Standardized Root Mean Square Residual >0.10, Tucker-Lewis Index <0.90). EFA with parallel analysis extracts four factors underlying the three burnout, STS, and CF measures. The four factors describe 54.3% of variance and can be described as (1) depressive mood; (2) primary traumatic stress-like symptoms; (3) responses to patients' trauma; and (4) sleep disturbances. Conclusion: In spite of abundant discussion surrounding burnout, CF, and STS in physicians, measures of these constructs did not uphold their theoretical factor structures in the present study. Future research might explore other constructs and measures that may describe adverse affective physician experiences.

What Are the Right Tools for Studying Arts in Health Interventions?

The arts can touch places that are difficult to recognize and understand, capture in words, or measure by numbers-whether you're an artist, a patient, or an educator. This ineffability presents a dilemma for practitioners and researchers in arts in health when questions of legitimacy, efficacy, program implementation, and research funding are tied to outcomes-based research. Ethical tensions arise when traditional public health and clinical research methods are the wrong tools for capturing what's vital about the arts. This article argues that being a responsible arts in health researcher requires interrogating what counts as evidence, especially when the insistence on rigor risks oversimplifying and diminishing the power of the arts. It further argues for equity in arts in health research, including equity in investigative strategies that value both the arts and the research.

Stories in the Time of COVID-19.

The time of COVID-19 is the time of storytelling-stories of chaos, loss, and despair, but also of victories large and small, acts of kindness, and deep connections. Stories are a way to pass on meaning from one person to another, among communities, and across generations. COVID-19 stories are being used in the education of physicians, but for whose benefit and to what end? What if the "heroic" frontline worker is experiencing burnout or working out of necessity rather than by choice? What if the battle against an invisible enemy does not end triumphantly but becomes an interminable war of attrition? It is important not only to propose new questions but also to create spaces for stories that do not fit conveniently into standard narratives. Stories help foster the energy and drive to write about what is next and to act as physicians in the service of human beings and their lives.

What Cy Twombly's Art Can Teach Us About Patients' Stories.

Some patients' stories can be hard to tell and hard to listen to, especially in pressured, time-pinched clinical environments. This difficulty, however, doesn't absolve clinicians from a duty to try to understand patients' stories, interpret their meanings, and respond with care. Such efforts require clinical creativity, full engagement, and the recognition that emotions and personal feelings leak into the space between storyteller and story listener. Art objects are complex bodies of information that can challenge clinicians and trainees to become more comfortable with messy narratives as well as with ethical and aesthetic ambiguity. By slowing down and observing art, trainees can reflect on how clinicians make sense of stories that contain information that appears random and lacks coherence-and, more importantly, how clinicians draw on these stories to respond to patients' needs.

Why Won't My Patient Act Like a Jerk?

I'm avoiding Mr. G's room. I shouldn't have read the emergency room notes from the other hospital, where this middle-aged man raised a stink about the wait. What type of person calls the triage nurse a bitch? From the timestamps on the electronic medical record notes, he stormed from that ER and drove his abdominal pain, vomiting, diarrhea, and discontent directly across town to us. I'm reminded of this oft-quoted aphorism from Sir William Osler: "The good physician treats the disease; the great physician treats the patient who has the disease." It's cited by medical educators as an invocation to never forget the humanistic heart at the center of clinical care. But what if the patient is a jerk? That I haven't met Mr. G, only read briefly about him, doesn't stop these ugly feelings from surfacing.

The Weight of Pain: What Does a 10 on the Pain Scale Mean? An Innovative Use of Art in Medical Education to Enhance Pain Management.

CONTEXT: Art and museum spaces offer a novel educational platform for exploring the subjective elements inherent to the understanding and treatment of pain. Physicians and museum educators collaborated on an educational model using art to explore the metacognitive dimensions of pain management. OBJECTIVES: Sessions used inquiry-based strategies to increase clinician awareness of implicit biases and build clinically applicable metacognitive skills that might influence how clinicians respond to patients in pain. METHODS: Two sessions led by museum educators and physician facilitators were held at the Museum of Art, Rhode Island School of Design. Through exercises that used works of art as the basis for guided discussions rooted in constructivist learning theory, participants explored how personal experiences, communication, and tolerance for uncertainty shape their interpretations. These sessions created unique, nonjudgmental opportunities for clinicians to make connections between their experience and how they perceive, interpret, and respond to the subjective experiences of patients in pain. Optional surveys were distributed. RESULTS: Participants at both sessions noted the event impacted how they think about making observations and communication-elements of practice inherent to pain management. The majority reported the experience could lead to a change in their practice. At the first session, 100% were interested in future sessions and 100% at the second would recommend it. CONCLUSIONS: Facilitated, reflective experiences with works of art have the capacity to challenge clinicians to become aware of their implicit biases, thought processes, and communication with potential importance for improving pain management and providing more compassionate care.

Fight or flight: the ethics of emergency physician disaster response.

Most disaster plans depend on using emergency physicians, nurses, emergency department support staff, and out-of-hospital personnel to maintain the health care system's front line during crises that involve personal risk to themselves or their families. Planners automatically assume that emergency health care workers will respond. However, we need to ask: Should they, and will they, work rather than flee? The answer involves basic moral and personal issues. This article identifies and examines the factors that influence health care workers' decisions in these situations. After reviewing physicians' response to past disasters and epidemics, we evaluate how much danger they actually faced. Next, we examine guidelines from medical professional organizations about physicians' duty to provide care despite personal risks, although we acknowledge that individuals will interpret and apply professional expectations and norms according to their own situation and values. The article goes on to articulate moral arguments for a duty to treat during disasters and social crises, as well as moral reasons that may limit or override such a duty. How fear influences behavior is examined, as are the institutional and social measures that can be taken to control fear and to encourage health professionals to provide treatment in crisis situations. Finally, the article emphasizes the importance of effective risk communication in enabling health care professionals and the public to make informed and defensible decisions during disasters. We conclude that the decision to stay or leave will ultimately depend on individuals' risk assessment and their value systems. Preparations for the next pandemic or disaster should include policies that encourage emergency physicians, who are inevitably among those at highest risk, to "stay and fight."

The Duty of Mind: Ethical Capacity in a Time of Crisis.

In a disaster, physicians are forced to make challenging and heartbreaking ethical decisions under conditions of physical and emotional exhaustion. Evidence shows that the conditions of stress that mark disasters can undermine the process of ethical decision-making. This results in biased allocation of scarce resources, fewer utilitarian and altruistic decisions, and a wider variation in decisions. Stress also predisposes clinicians to decision strategy errors, such as premature closure, that lead to poor outcomes. The very ability to make sound and ethical decisions is thus a scarce resource. Ethical frameworks underpinning disaster protocols enumerate many physician obligations, but seldom articulate the risk posed by having decisions made ad hoc by decision-makers who are compromised by the stress of the concurrent crisis. We propose, therefore, that a "duty of mind"-the obligation to make critical decisions under the clearest possible state of thought-be added to ethical frameworks for disaster response. Adding the duty of mind to the pillars on which planning is based would force attention to a moral imperative to include decision support tools in disaster planning. By moving the consideration of possible choices to a moment when time and consultation facilitate clear and considered thought, the duty of mind is upheld. (Disaster Med Public Health Preparedness. 2018;12:657-662).

Doctors as Makers.

Traditional skills and expertise are not enough to prepare future physicians for the complexity, instability, and uncertainty of clinical practice. Responding and making meaning from ill-defined or unusual problems calls for, even demands, creativity. In this article, the author suggests expanding the traditional role of doctor as science-using, evidence-based practitioner to include that of doctor as a "maker" (creator) and artist. Such a reimagining requires a shift in how we view medical knowledge and patients' stories, as well as a new appreciation for "not-knowing" as a generative, creative space in medicine. Creative thinking deserves a central place in the training of doctors, driven by a reconceptualization of the traditional educational model to include medical disciplines, humanities scholars, artists, and designers.