Author Archives: STFM News

Virtual Recruitment for Community-Engaged Qualitative Research During COVID-19

Marie Balfour, BA, Medical College of Wisconsin 
Karna Baraboo, BA, Medical College of Wisconsin

Elise Kahn, BS, Medical College of Wisconsin 
William Mead-Davies, BS, Medical College of Wisconsin

Annie Tuman, BA, Medical College of Wisconsin 
Benjamin Wrucke, BS, Medical College of Wisconsin (Equal Contribution)

Rebecca Bernstein, MD, MS Department of Family and Community Medicine, Medical College of Wisconsin b

Corresponding Author:  Marie Balfour, BA 

INTRODUCTION

The COVID-19 pandemic has highlighted health disparities across many communities in
the United States, and the call for community-engaged research has never been greater [1,2].
However, the minimization of in-person interaction has forced medical researchers to adjust their
methods of engagement significantly [3]. As a group of community-engaged medical student
researchers, we encountered several challenges and developed solutions as we adjusted to virtual
recruitment of research participants for qualitative research.

  
Challenge 1: BUILDING TRUST  

One barrier to virtual recruitment was establishing trust with research participants. Our
studies involved sensitive topics such as weight, aging, food insecurity, addiction and finances.
Originally, many of us planned to spend time in clinics, homeless shelters, and other community
sites to engage with potential participants and develop a sense of familiarity. Without this
opportunity, most participants did not see our faces until the virtual interview which may have
affected who was willing to participate. 


Solutions implemented: To compensate for the loss of in-person recruitment, many of us
utilized intermediaries such as physicians, mentors, caseworkers, school administrators, and
clinical administrators to communicate with potential participants. This strategy helped to
generate participant trust. In one project that recruited medical professionals, participant
invitations that did not include an intermediary led to a 40 percent participation rate, while
invitations including a faculty mentor or previous participant recommendation yielded
participation rates of 64 and 80 percent, respectively.  We noted that trust and familiarity gained
by introductions and recommendations from intermediaries led to an increased likelihood of
participation.  


Although effective, this strategy also presented challenges. Relying on intermediaries for
recruitment placed a greater burden on our community partners, who were asked to complete
additional tasks. This also may have slowed the research process because the schedule of the
intermediary dictated recruitment. Finally, trust was placed on the intermediary to recruit a
representative sample which may have introduced sampling bias.


Recommendations: 
● All community engagement projects should have a network of intermediaries who have
established trust with participants prior to beginning research. 
● Community engagement projects conducted during COVID-19 require enhanced
relationships with these networks in order to increase participation rates and create more
natural interactions. 

Challenge 2: LEVERAGING RECRUITMENT TECHNOLOGY  
At the outset of many of our projects, we used a common outreach method (such as
email) for all subjects. Due to virtual recruitment constraints and variable subject familiarity with
technology, many of us found that personalizing outreach methods led to more successful
participant engagement and recruitment.  

Solutions Implemented: Virtual recruitment proved to be increasingly population-
dependent and customized. Those in academic settings were more active on email and were
familiar with online meeting platforms. In contrast, working parents and senior groups were

more receptive to phone calls. The likelihood of phone pick-up was improved by masking
unfamiliar phone numbers and displaying familiar clinic numbers with a telephone number
masking application (e.g. Doximity Dialer). In one study, school administrators sent study
recruitment information through a specialized school-specific parent interface, allowing
recruitment materials to reach just over 1,800 families. Without utilizing these population-
specific avenues, recruitment and resource dissemination would have been significantly
impacted.  

Adding new strategies to improve virtual recruitment outcomes came with significant
challenges.  Submitting IRB amendments specifying recruitment protocol changes delayed
project benchmarks. Additionally, we recognize the choice of recruitment technology might
influence the study population. For example, benefits of online meeting platforms were most
apparent when the recruitment pool consisted of educated professionals frequently using these
platforms. Email-based recruitment methods also could have altered study outcomes, by limiting
participants to those with access to the Internet. 

 Recommendations:  
● Personalize outreach methods to a study population. 
● Administer communication preferences survey during recruitment in order to confirm
preferred communication method. 
● Begin recruitment using multiple methods in order to efficiently eliminate unsuccessful
methods. 
   

CONCLUSION  

Future research conducted remotely should be guided by themes of building trust and
leveraging recruitment technologies. While we focused on recruitment, it is important to
acknowledge the impact that COVID-19 will have on project outcomes. Given that our studies
included interviews, participants’ responses typically reflected their current situation, many of
which had been altered by COVID-19.  
   

ACKNOWLEDGEMENTS

We are grateful for the support of Dr. Leslie Ruffalo and Dr. Bryan Johnston from the
Department of Family and Community Medicine at Medical College of Wisconsin. Research
reported in this publication was supported by the National Institute On Aging of the National
Institutes of Health under Award Number T35AG029793, the Department of Family and
Community Medicine at MCW, and the Wisconsin Medical Society. The content is solely the
responsibility of the authors and does not necessarily represent the official views of these
entities. 
 

REFERENCES 

  1. Tapp, Hazel. The Changing Face of Primary Care Research and Practice-Based Research
    Networks (PBRNs) in Light of the COVID-19 Pandemic. J Am Board Fam Med. 2020;33(5)645-
    649 
  2. Krouse, Helene J. COVID-19 and the Widening Gap in Health Inequity. Otolaryngol.
    Head Neck Surg. 2020;163(1)65-66 
  3. Ratneswaren, Anenta. The importance of community and patient involvement in COVID-
    19 research. Clin Med (Lond). 2020;20(4)120-122

Fairly Well

A 94-year-old woman wrote this poem about her time isolated in room 139 of her assisted living facility during the early stages of the pandemic. With vaccine distribution finally taking place, it seems like a good day to look back at the experience of one of our most vulnerable.

1-3-9: A Pandemic Poem

I am inmate 1-3-9
Alone in a lonely cell.
Although it’s quite confining,
I’m faring fairly well.

My books are my companions.
My TV a faithful friend.
My bed a cozy refuge
When the daylight ends.

Many days have come and gone
Since I landed in this jail.
And though it’s inconvenient,
I’m faring fairly well.

Betty Isaac Smith, age 94

What’s in a Title? Establishing Clear Expectations and Professional Culture Through How We Address Our Colleagues.

What’s in a Title? Establishing Clear Expectations and Professional Culture Through How We Address Our Colleagues

Kelly M. Roberts, PhD, LMFT; P.K. Grafton, DO; Jaspreet Kaur, DO

“Bye, Doctor [male intern last name]. Bye, [female resident first name],” said the male attending physician as the residents left the continuity clinic.

“What’s in a name?” wondered the female resident, having been casually addressed with her first name multiple times, in comparison to colleagues addressed with their professional titles. 

This interaction, however, was particularly unsettling for her and raised multiple internalized questions. Was this the attending’s attempt to encourage the intern to use his newly earned title and foster professional development, or was this an attempt to demean her? Was it intentional or unintentional? Conscious or subconscious? Did the matter warrant further attention and discussion? Would failure to contend with the issue affect her performance or growth?

This wasn’t the first instance of title imbalance; multiple versions of this same scenario had been raised by residents over the course of two years, yet our program wasn’t realizing lasting change. Meetings were held based upon this particular instance, and since that time everyone involved has reflected on multidimensional aspects related to title utilization.

As a debriefing exercise, we are sharing combined administrator and resident perspectives covering a few title utilization conceptual areas such as identity formation, power differentials, programmatic culture, and clarity of expectations

Identity Formation

Becoming a physician involves more than acquiring medical knowledge and developing clinical skills. Physicians also need to develop professional identities—physician, community leader, medical board member, etc. These identities start long before medical school but must be cultivated during school, residency, fellowships, and throughout attending practice. Students and residents establish evolve their identities through social experiences, patient encounters, and educational time spent with attending physicians and mentors. Helping students and residents form their professional identities, and function appropriately within them, is a critical component of the medical education system. The title of “doctor” is one that a student will need guidance and education growing into and maintaining.

Power Differentials and Hierarchies

Physician burnout and well-being is a current hot topic. Many studies discuss the use of Maslow’s hierarchy of human needs as the potential framework for addressing wellness. Part of this hierarchy is esteem. A physician’s esteem is tied to multiple internal and external factors. Especially during residency training, external factors play a large role in physician esteem. After working through undergraduate, medical school, and then additional years of residency, achieving the title “doctor” has significant and powerful meaning. Hearing patients, attendings, and nurses refer to you as “doctor X” is empowering. While on the flip side, being addressed without your title by a superior can leave you questioning their respect and opinion of you as a physician.

Professional Culture

Residents are encouraged to use their titles in lieu of first name when introducing themselves to patients or nurses at most training programs. The formality of titles is generally lax when residents are amongst their colleagues in resident work areas, call rooms, and table rounds. However, the title strategically finds its place during bedside rounds, a formal setting involving patient care. Deciphering between the appropriate use and setting for casual versus formal communication is foundational in building trust and respect, and is unique to training programs. A 2017 study examined the likelihood of professional titles usage during introductions at internal medicine grand rounds and found females introduced male speakers with formal titles 95% of the time in comparison to 49% male introducing female speakers. Female introducers in general were more likely to use professional titles when introducing any gender speaker in comparison to male introducers.

Clarity of Expectations

The possibly unintentional variation in formality may undermine the expertise of female physicians and impact their professional growth. In a training environment, it is imperative to follow a unified, though not necessarily formalized process for addressing resident physicians—male and female—as they advance in their professional roles. Establishing the appropriateness of casual versus formal communication is unique to institutions given its multifactorial nature; although universally clarifying expectations could enhance sensitivity and potentially mitigate existing gender bias in medicine.

Our Own Process

One exercise that assisted with defining a few of these elements was the decision to deploy an STFM CONNECT post over this topic. The following quotes pulled from that post demonstrate the diversity of perspectives offered at the time:

…Lopsided use of titles is arrogant to my ear. My ego and confidence as a physician are not wrapped up in a title.

…This is something that physicians in a larger community, such as where I practice now, rarely have to consider.  But in small towns, physicians interact with their staff and their patients in a host of very close ways that would be quite avoidable – and even considered of questionable ethics – in regions of higher population density.  The use of the title allows us to take a step back and be more “objective” while continuing to address health issues of those for whom we care (care, in every sense of the word).

…I call residents “Doctor” so the patients, nurses, others, and they themselves know who they are and their role, especially important for URM and women. They are not expected to be the patient’s friend, nurse, pal, aide, etc. They are expected to be each patient’s physician.

Attendings hold immeasurable power to propitiate, or stunt, resident growth on a daily basis. As members of STFM, externalizing your own questions will undoubtedly prevent residents from internalized struggles about their own identity, helping them own, with all the rights and responsibilities, the true and noble title of doctor.