Search

Importance: The emergence and promise of generative artificial intelligence (AI) represent a turning point for health care. Rigorous evaluation of generative AI deployment in clinical practice is needed to inform strategic decision-making., Objective: To evaluate the implementation of a large language model used to draft responses to patient messages in the electronic inbox., Design, Setting, and Participants: A 5-week, prospective, single-group quality improvement study was conducted from July 10 through August 13, 2023, at a single academic medical center (Stanford Health Care). All attending physicians, advanced practice practitioners, clinic nurses, and clinical pharmacists from the Divisions of Primary Care and Gastroenterology and Hepatology were enrolled in the pilot., Intervention: Draft replies to patient portal messages generated by a Health Insurance Portability and Accountability Act-compliant electronic health record-integrated large language model., Main Outcomes and Measures: The primary outcome was AI-generated draft reply utilization as a percentage of total patient message replies. Secondary outcomes included changes in time measures and clinician experience as assessed by survey., Results: A total of 197 clinicians were enrolled in the pilot; 35 clinicians who were prepilot beta users, out of office, or not tied to a specific ambulatory clinic were excluded, leaving 162 clinicians included in the analysis. The survey analysis cohort consisted of 73 participants (45.1%) who completed both the presurvey and postsurvey. In gastroenterology and hepatology, there were 58 physicians and APPs and 10 nurses. In primary care, there were 83 physicians and APPs, 4 nurses, and 8 clinical pharmacists. The mean AI-generated draft response utilization rate across clinicians was 20%. There was no change in reply action time, write time, or read time between the prepilot and pilot periods. There were statistically significant reductions in the 4-item physician task load score derivative (mean [SD], 61.31 [17.23] presurvey vs 47.26 [17.11] postsurvey; paired difference, -13.87; 95% CI, -17.38 to -9.50; P < .001) and work exhaustion scores (mean [SD], 1.95 [0.79] presurvey vs 1.62 [0.68] postsurvey; paired difference, -0.33; 95% CI, -0.50 to -0.17; P < .001)., Conclusions and Relevance: In this quality improvement study of an early implementation of generative AI, there was notable adoption, usability, and improvement in assessments of burden and burnout. There was no improvement in time. Further code-to-bedside testing is needed to guide future development and organizational strategy.

Goal: The objective of this study was to evaluate satisfaction with work-life integration (WLI), social isolation, and the impact of work on personal relationships (IWPR) among senior healthcare operational leaders., Methods: Between June 7 and June 30, 2021, we performed a national survey of CEOs and other senior healthcare operational leaders in the United States to evaluate their personal work experience. Satisfaction with WLI, social isolation, and IWPR were assessed using standardized instruments. Burnout and professional fulfillment were also assessed using standardized scales., Principal Findings: The mean IWPR score on the 0-10 scale was 4.39 (standard deviation was 2.36; higher scores were unfavorable). On multivariable analysis to identify demographic and professional factors associated with the IWPR score, each additional hour worked per week decreased the likelihood of a favorable IWPR score. The IWPR, feeling isolated, and satisfaction with WLI were independently associated with burnout after adjusting for other personal and professional factors. On multivariable analysis, healthcare administrators were more likely than U.S. workers in other fields to indicate work had adversely impacted personal relationships in response to the item "In the past year, my job has contributed to me feeling more isolated and detached from the people who are most important to me.", Practical Applications: Experiencing an adverse IWPR is common among U.S. healthcare administrators, who are more likely than the general U.S. working population to indicate their job contributes to isolation and detachment from the people most important to them. Problems with WLI, isolation, and an adverse IWPR are associated with increased burnout and lower professional fulfillment. Intentional efforts by both organizations and administrative leaders are necessary to address the work characteristics and professional norms that erode WLI and result in work adversely impacting personal relationships., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Foundation of the American College of Healthcare Executives.)

Background: Washing red blood cell (RBC) units mitigates severe allergic transfusion reactions. However, washing reduces the time to expiration and the effective dose. Automated washing is time- and labor-intensive. A shortage of cell processor tubing sets prompted review of medical necessity for washed RBC for patients previously thought to require washing., Study Design and Methods: A single-center, retrospective study investigated discontinuing wash RBC protocols in chronically transfused adults. In select patients with prior requirements for washing, due to a history of allergic transfusion reactions, trials of unwashed transfusions were performed. Patient demographic, clinical, laboratory, and transfusion data were compiled. The per-unit washing cost was the sum of the tubing set, saline, and technical labor costs., Results: Fifteen patients (median age 34 years interquartile range [IQR] 23-53 years, 46.7% female) were evaluated. These patients had been transfused with a median of 531 washed RBC units (IQR 244-1066) per patient over 12 years (IQR 5-18 years), most commonly for recurrent, non-severe allergic reactions. There were no transfusion reactions with unwashed RBCs aside from one patient with one episode of pruritus and another with recurrent pruritus, which was typical even with washed RBC. We decreased the mean number of washed RBC units per month by 72.9% (104 ± 10 vs. 28.2 ± 25.2; p < .0001) and saved US $100.25 per RBC unit., Conclusion: Washing of RBCs may be safely reconsidered in chronically transfused patients without a history of anaphylaxis. Washing should be implemented judiciously due to potential lack of necessity and logistical/operational challenges., (© 2023 AABB.)

Objectives: Dentists' well-being is being challenged today by many factors. However, effective screening tools to assess their distress and well-being are yet to be validated. The present study aims to evaluate the ability of the Well-Being Index (WBI) to identify distress and stratify dentists' well-being and their likelihood for adverse professional consequences., Method and Materials: A convenience sample of dentists completed a web-based 9-item WBI survey along with other instruments that measured quality of life (QOL), fatigue, burnout, and questions about suicidal ideation, recent dental error, and intent to leave their current job., Results: A total of 597 dentists completed the survey. The overall mean WBI score was 2.3. The mean WBI score was significantly greater in dentists with low QOL than among dentists without low QOL (4.1 vs 1.6, p < 0.001). Dentists with extreme fatigue, burnout, and suicidal ideation had significantly higher mean WBI score than those without distress (all p < 0.001). WBI score stratified the dentists' likelihood of reporting a recent dental error and intent to leave their current job., Conclusion: The WBI may be a useful screening tool to assess well-being among dentists and identify those in distress and at risk for adverse professional consequences., (© 2024. The Author(s).)

Physicians spend a large amount of time with the electronic health record (EHR), which the majority believe contributes to their burnout. However, there are limitedstandardized measures of physician EHR time. Vendor-derived metrics are standardized but may underestimate real-world EHR experience. Investigator-derived metrics may be more reliable but not standardized, particularly with regard to timeout thresholds defining inactivity. This study aimed to enable standardized investigator-derived metrics using conversion factors between raw event log-derived metrics and Signal (Epic System's standardized metric) for primary care physicians. This was an observational, retrospective longitudinal study of EHR raw event logs and Signal data from a quaternary academic medical center and its community affiliates in California, over a 6-month period. The study evaluated 242 physicians over 1370 physician-months, comparing 53.7 million event logs to 6850 Signal metrics, in five different time based metrics. Results show that inactivity thresholds for event log metric derivation that most closely approximate Signal metrics ranged from 90 seconds (Visit Navigator) to 360 seconds ("Pajama time") depending on the metric. Based on this data, conversion factors for investigator-derived metrics across a wide range of inactivity thresholds, via comparison with Signal metrics, are provided which may allow researchers to consistently quantify EHR experience., (©2023 AMIA - All rights reserved.)

The purpose of this paper is to present an argument for why there is a need to re-envision the underlying culture of undergraduate biology education to ensure the success, retention, and matriculation of Black students. The basis of this argument is the continued noted challenges with retaining Black students in the biological sciences coupled with existing research that implicates science contexts (i.e., the cultural norms, values, and beliefs manifesting through policies and practices) as being the primary source of the challenges experienced by Black students that lead to their attrition. In presenting this argument, we introduce the Re-Envisioning Culture Network, a multigenerational, interdisciplinary network comprised of higher education administrators, faculty, staff, Black undergraduate students majoring in biology, Black cultural artists, community leaders, and STEM professionals to work together to curate and generate resources and tools that will facilitate change. In introducing the REC Network and disseminating its mission and ongoing endeavors, we generate a clarion call for educators, researchers, STEM professionals, students, and the broader community to join us in this endeavor in fostering transformative change.

Background: Incarcerated trans women experience significant victimization, mistreatment, barriers to gender-affirming care, and human rights violations, conferring high risk for trauma, psychological distress, self-harm, and suicide. Across the globe, most carceral settings are segregated by sex assigned at birth and governed by housing policies that restrict gender expression-elevating 'safety and security' above the housing preferences of incarcerated people., Aim/methods: Drawing upon the lived experiences of 24 formerly incarcerated trans women in Australia and the United States and employing Elizabeth Freeman's notion of chrononormativity , Rae Rosenberg's concept of heteronormative time , and Kadji Amin's use of queer temporality, this paper explores trans women's carceral housing preferences and contextual experiences, including how housing preferences challenge governing chrononormative and reformist carceral housing systems., Findings: Participants freely discussed their perspectives regarding housing options which through thematic analysis generated four options for housing: 1) men's carceral settings; 2) women's carceral settings; 3) trans- and gay-specific housing blocks; and 4) being housed in protective custody or other settings. There appeared to be a relationship between the number of times the person had been incarcerated, the duration of their incarceration, and where they preferred to be housed., Conclusions: This analysis contributes to richer understandings regarding trans women's experiences while incarcerated. This paper also informs the complexities and nuances surrounding housing preferences from the perspectives of trans women themselves and considers possible opportunities to enhance human rights, health and wellbeing when engaging in transformative approaches to incarceration., Competing Interests: The authors report there are no competing interests to declare., (© 2023 The Author(s). Published with license by Taylor & Francis Group, LLC.)

Background: Trans people are incarcerated at disproportionately high rates relative to cisgender people and are at increased risk of negative experiences while incarcerated, including poor mental health, violence, sexual abuse, dismissal of self-identity, including poor access to healthcare. Aims: This scoping review sought to identify what is known about the knowledge, attitudes, and behaviors of correctional staff toward incarcerated trans people within the adult and juvenile justice systems. Method: This scoping review was conducted in accordance with the five-stage iterative process developed by Arksey and O'Malley (2005), utilizing the PRISMA guidelines and checklist for scoping reviews and included an appraisal of included papers. A range of databases and grey literature was included. Literature was assessed against predetermined inclusion and exclusion criteria, with included studies written in English, online full text availability, and reported data relevant to the research question. Results: Seven studies were included with four using qualitative methodologies, one quantitative, and two studies employing a mixed methods approach. These studies provided insights into the systemic lack of knowledge and experience of correctional staff working with trans people, including staff reporting trans issues are not a carceral concern, and carceral settings not offering trans-affirming training to their staff. Within a reform-based approach these findings could be interpreted as passive ignorance and oversights stressing the importance of organizational policies and leadership needing to set standards for promoting the health and wellbeing of incarcerated trans persons. Conclusions: From a transformational lens, findings from this study highlight the urgent need to address the underlying structural, systemic, and organizational factors that impact upon the knowledge, attitudes, and behaviors staff have and hold in correctional, and other health and community settings to meaningfully and sustainably improve health, wellbeing, and gender-affirming treatment and care for trans communities, including make possible alternative methods of accountability for those who do harms., Competing Interests: The authors report there are no competing interests to declare., (© 2023 The Author(s). Published with license by Taylor & Francis Group, LLC.)

Purpose: The COVID-19 pandemic has had deleterious effects on oncologist professional and personal well-being, the optimal delivery of quality cancer care, and the future cancer care workforce, with many departing the field. Hence, the identification of evidence-based approaches to sustain oncologists is essential to promote well-being., Materials and Methods: We developed a brief, oncologist-centered, virtual group peer support program and tested its feasibility, acceptability, and preliminary impact on well-being. Trained facilitators provided support to peers on the basis of burnout research in oncology with available resources to enhance oncologist resilience. Peers completed pre- and postsurvey assessment of well-being and satisfaction., Results: From April to May 2022, 11 of 15 (73%) oncologists participated in its entirety: mean age 51.1 years (range, 33-70), 55% female, 81.8% Ca, 82% medical oncologists, 63.6% trained ≥15 years, average 30.3 patients/wk (range, 5-60), and 90.9% employed in hospital/health system practice. There was a statistically significant difference in pre- and postintervention well-being (7.0 ± 3.6 v 8.2 ± 3.0, P = .03) with high satisfaction with postgroup experience (9.1 ± 2.5). These quantitative improvements were affirmed by qualitative feedback. These themes included (1) an enhanced understanding of burnout in oncology, (2) shared experience in practice of oncology, and (3) fostering connections with diverse colleagues. Future recommendations proposed included (1) restructuring group format and (2) tailoring groups according to practice setting (academic v community)., Conclusion: Preliminary results suggest that a brief, innovative oncologist-tailored group peer support program is feasible, acceptable, and beneficial for enhancing well-being dimensions including burnout, engagement, and satisfaction. Additional study is required to refine program components (optimal timing, format) to support oncologist well-being, now during the pandemic and well into recovery.

Most incarceration settings around the world are governed by strong cisnormative policies, architectures, and social expectations that segregate according to a person's legal gender (i.e. male or female). This paper draws on the lived experiences of 24 formerly incarcerated trans women in Australia and the U.S. to elucidate the way in which the prison functions according to Lucas Crawford's theory of trans architecture, alongside Jacques Derrida's notion of archive fever. The paper displays how the cisnormative archive of the justice system and its architectural constructs impact trans women in men's incarceration settings, including how trans women entering the incarceration setting are able to embody gender in a way that is not reified by the insistences of those normative structures. In light of this, this paper advances a theoretical understanding of the prison as an archive and as an architectural construct, providing a new means of understanding how incarcerated trans persons may use and perform gender to survive carceral violence., Competing Interests: Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Importance: Understanding of the interplay between the electronic health record (EHR), health care team relations, and physician well-being is currently lacking. Approaches to cultivate interpersonal interactions may be necessary to complement advancements in health information technology with high-quality team function., Objective: To examine ways in which the EHR, health care team functioning, and physician well-being intersect and interact., Design, Setting, and Participants: Secondary qualitative analysis of semistructured interview data from 2 studies used keyword-in-context approaches to identify excerpts related to teams. Thematic analysis was conducted using pattern coding, then organized using the relationship-centered organization model. Two health care organizations in California from March 16 to October 13, 2017, and February 28 to April 21, 2022, participated, with respondents including attending and resident physicians., Main Outcome and Measures: Across data sets, themes centered around the interactions between the EHR, health care team functioning, and physician well-being. The first study data focused on EHR-related distressing events and their role in attending physician and resident physician emotions and actions. The second study focused on EHR use and daily EHR irritants., Results: The 73 respondents included attending physicians (53 [73%]) and resident physicians (20 [27%]). Demographic data were not collected. Participants worked in ambulatory specialties (33 [45%]), hospital medicine (10 [14%]), and surgery (10 [14%]). The EHR was reported to be the dominant communication modality among all teams. Interviewees indicated that the EHR facilitates task-related communication and is well suited to completing simple, uncomplicated tasks. However, EHR-based communication limited the rich communication and social connection required for building relationships and navigating conflict. The EHR was found to negatively impact team function by promoting disagreement and introducing areas of conflict into team relationships related to medical-legal pressures, role confusion, and undefined norms around EHR-related communication. In addition, interviewees expressed that physician EHR-related distress affects interactions within the team, eroding team well-being., Conclusions and Relevance: In this study, the EHR supported task-oriented and efficient communication among team members to get work done and care for patients; however, participants felt that the technology shifts attention away from the human needs of the care team that are necessary for developing relationships, building trust, and resolving conflicts. Interventions to cultivate interpersonal interactions and team function are necessary to complement the efficiency benefits of health information technology.

Detransition, a relatively recent phenomenon within academic discourse and mainstream media, refers to individuals who transition from the gender they transitioned into. Experiences of detransition, including those shared on social media, are poorly understood. Drawing upon narratives of gender detransition as shared on a global social media site, this analysis explores and seeks to better understand how detransition experiences are shared; and the effect of detransition narratives on gendered embodiment and belonging. Employing Butler's (Undoing gender. Routledge, 2004) notion of livable lives and Crawford's (Seattle J Soc Justice 8(2):515-539, 2010) conception of trans architecture, this analysis theoretically extends trans conversations to include discourses and narratives of detransition. A total of 130 archival posts by 36 contributors relating to detransition were collected from a popular global social media site where the engagement of reflexive thematic analysis contributed to the development of three themes: Contemplating transformation; Experiences of detransition; and Prominent discourses for detransition. Study findings suggest that detransition narratives expressed on this social media site demonstrate the multifaceted and complex ways in which non-normative gendered lives are rendered unlivable. In response, this analysis problematizes gender by conceptualizing detransition as a transformation toward a trans space outside a cisnormative frame contributing to making gendered lives more livable., (© 2023. The Author(s).)

High mobility group A1 (HMGA1) chromatin regulators are upregulated in diverse tumors where they portend adverse outcomes, although how they function in cancer remains unclear. Pancreatic ductal adenocarcinomas (PDACs) are highly lethal tumors characterized by dense desmoplastic stroma composed predominantly of cancer-associated fibroblasts and fibrotic tissue. Here, we uncover an epigenetic program whereby HMGA1 upregulates FGF19 during tumor progression and stroma formation. HMGA1 deficiency disrupts oncogenic properties in vitro while impairing tumor inception and progression in KPC mice and subcutaneous or orthotopic models of PDAC. RNA sequencing revealed HMGA1 transcriptional networks governing proliferation and tumor-stroma interactions, including the FGF19 gene. HMGA1 directly induces FGF19 expression and increases its protein secretion by recruiting active histone marks (H3K4me3, H3K27Ac). Surprisingly, disrupting FGF19 via gene silencing or the FGFR4 inhibitor BLU9931 recapitulates most phenotypes observed with HMGA1 deficiency, decreasing tumor growth and formation of a desmoplastic stroma in mouse models of PDAC. In human PDAC, overexpression of HMGA1 and FGF19 defines a subset of tumors with extremely poor outcomes. Our results reveal what we believe is a new paradigm whereby HMGA1 and FGF19 drive tumor progression and stroma formation, thus illuminating FGF19 as a rational therapeutic target for a molecularly defined PDAC subtype.

Undergraduate science, technology, engineering, and mathematics (STEM) classrooms are not race-neutral spaces, and instructors have the power to center racial equity and inclusion in their instructional practices. Yet how instructors think about race and racism can impact whether and how they adopt inclusive practices. We examined how 39 undergraduate STEM instructors noticed anti-Black racialized events that were experienced by students in classroom narratives. We created narrative cases that described multiple common, harmful anti-Black racialized experiences based on extant research and guidance from an expert advisory board. Instructors responded to cases by describing the problems they noticed. Using frameworks of racial noticing and color-evasive racial ideology, we conducted qualitative content analysis of instructor responses. Color-evasive racial ideology was pervasive, with most responses (54%) avoiding any discussion of race, and few responses acknowledging race or racism in more than one event (10%). We characterized six forms of color-evasiveness. This study adds to a growing body of literature indicating that color-evasion is pervasive in STEM culture. Instructors would benefit from professional development that specifically aims to counter color-evasiveness and anti-Blackness in teaching. Furthermore, STEM disciplines must pursue systemic change so that our organizations value, expect, promote, and reward the development and enactment of a critical racial consciousness.

Importance: The ability to attract and retain university hospital faculty staff is in jeopardy because of the high levels of mental symptoms in this professional group., Objective: To examine the prevalence and determinants of symptoms of severe burnout, job strain, and suicidal ideation in tenured associate and full professors in university hospitals., Design, Setting, and Participants: This nationwide cross-sectional study offered online surveys to 5332 tenured university hospital faculty members in France from October 25, 2021, to December 20, 2021., Exposures: Burnout and job strain., Main Outcomes and Measures: Participants completed the 22-item Maslach Burnout Inventory and a 12-item job strain assessment tool, reported suicidal ideation, and used visual analog scales to evaluate unidimensional parameters. The primary outcome was presence of severe burnout symptoms. Factors associated with mental health symptoms were identified by multivariable logistic regression., Results: Completed questionnaires were returned by 2390 of 5332 faculty members (response rate, 45%; range, 43%-46%). Tenured associate professors were a median of 40 (IQR, 37-45) years old with a sex ratio of 1:1, whereas tenured full professors were a median of 53 (IQR, 46-60) years old with a sex ratio of 1:5. Of 2390 respondents, 952 (40%) reported symptoms of severe burnout. Symptoms of job strain (296 professors [12%]) and suicidal ideation (343 professors [14%]) were also reported. Compared with full professors, significantly more associate professors reported feeling overwhelmed at work (496 [73%] vs 972 [57%]; P < .001), considering resignation (365 [54%] vs 834 [49%]; P = .004), or considering a career change (277 [41%] vs 496 [29%]; P < .001). Factors independently associated with less burnout were a longer time being a professor (adjusted odds ratio [aOR], 0.97; 95% CI, 0.96-0.98 per year of age), sleeping well (aOR, 0.88; 95% CI, 0.83-0.92), feeling valued by colleagues (aOR, 0.91; 95% CI, 0.86-0.95 per visual analog scale point) or the public (aOR, 0.92; 95% CI, 0.88-0.96 per visual analog scale point), and accepting more tasks (aOR, 0.82; 95% CI, 0.72-0.93). Factors independently associated with more burnout were having a nonclinical position (OR, 2.48; 95% CI, 1.96-3.16), reporting work encroachment on private life (OR, 1.17; 95% CI, 1.10-1.25), feeling the need to constantly put on a brave face (OR, 1.82; 95% CI, 1.32-2.52), considering a career change (OR, 1.53; 95% CI, 1.22-1.92), and having experienced harassment (OR, 1.52; 95% CI, 1.22-1.88)., Conclusions and Relevance: These findings suggest that the psychological burden on tenured university hospital faculty staff in France is considerable. Hospital administrators and health care authorities should urgently develop strategies for burden prevention and alleviation and for attraction of the next generation.

Trans women incarcerated throughout the world have been described as "vulnerable populations" due to significant victimization, mistreatment, lack of gender-affirming care, and human rights violations, which confers greater risk of trauma, self-harm, and suicide compared with the general incarcerated population. Most incarceration settings around the world are segregated by the person's sex characteristics (i.e., male or female) and governed by strong cis and gender normative paradigms. This analysis seeks to better understand and appreciate how the "instructions" and the "authorities" that regulate trans women's corporeal representation, housing options and sense of self-determination implicate and affect their agency and actions in handling intimacies related to their personal life. Drawing upon lived incarcerated experiences of 24 trans women in Australia and the United States, and employing Ken Plummer's notion of intimate citizenship , this analysis explores how trans women navigate choices and ways "to do" gender, identities, bodies, emotions, desires and relationships while incarcerated in men's prisons and governed by cis and gender normative paradigms. This critical analysis contributes to understanding how incarcerated trans women through grit, resilience, and ingenuity still navigate ways to embody, express and enact their intimate citizenship in innovative and unique ways., Competing Interests: Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/ or publication of this article.

Objectives: This psychobiography focuses on the advocacy work of Natasha Keating, a trans woman incarcerated in two male prisons in Australia between 2000 and 2007. Incarcerated trans women are a vulnerable group who experience high levels of victimization and discrimination. However, Natasha advocated for her rights while incarcerated and this advocacy contributed to substantial changes in the carceral system. This psychobiography uses psychological understandings of resilience as well as the Transgender Resilience Intervention Model (TRIM) to investigate the factors that enabled this advocacy., Method: Data consisted of an archive of letters written by Natasha and interviews with individuals who knew her well. This psychobiography was guided by du Plessis' (2017) 12-step approach and included the identification of psychological saliencies and the construction of a Multilayered Chronological Chart., Results: Natasha's life is presented in four chapters, with each chapter including a discussion of resilience based on the TRIM., Conclusions: The TRIM suggests that during incarceration, Natasha was able to access more group-level resilience factors than at any other time in her life. This, combined with individual resilience factors, enabled her advocacy. This finding has implications for advocacy in general as it highlights the importance of both individual- and group-level factors in enabling individuals to effectively advocate for change in their environments., (© 2022 The Authors. Journal of Personality published by Wiley Periodicals LLC.)

Trans women are disproportionately incarcerated in the United States and Australia relative to the general population. Stark racial and ethnic disparities in incarceration rates mean that Black American and First Nations Australian trans women are overrepresented in incarceration relative to White and non-Indigenous cisgender and trans people. Informed by the Intersectionality Research for Transgender Health Justice (IRTHJ) framework, the current study drew upon lived experiences of Black American and First Nations Australian trans women to develop a conceptual model demonstrating how interlocking forces of oppression inform, maintain, and exacerbate pathways to incarceration and postrelease experiences. Using a flexible, iterative, and reflexive thematic analytic approach, we analyzed qualitative data from 12 semistructured interviews with formerly incarcerated trans women who had been incarcerated in sex-segregated male facilities. Three primary domains-pathways to incarceration, experiences during incarceration, and postrelease experiences-were used to develop the "oppression-to-incarceration cycle." This study represents a novel application of the IRTHJ framework that seeks to name intersecting power relations, disrupt the status quo, and center embodied knowledge in the lived realities of formerly incarcerated Black American and First Nations Australian trans women.

Severe burns on the posterior trunk present a treatment challenge in that these surfaces bear the major portion of body weight, with shearing forces exerted when changing the patient from supine to prone position. In their high-volume center at Burn and Reconstructive Centers of America, the authors developed protocols for use of cultured epidermal autografts (CEAs) for coverage of large burns, including those specific to posterior burns. This paper describes techniques and approaches, including milestone timelines, to treat and manage these patients. Key factors for successful treatment begin with early development of a detailed surgical plan. Members of the trained team participate in the plan and understand standard procedures and any deviation. Patients are identified early for treatment with CEA so that a full thickness skin biopsy can be sent to the manufacturer for processing. Patients with >30% total body surface area (TBSA) burns are considered for CEA burn wound coverage due to the potential for conversion of superficial partial thickness to deep partial thickness or full thickness burns over hospitalization time. We also present the outcomes in patients with posterior trunk burns treated with CEA from 2016 to 2019 in three participating centers within our network. Data in 40 patients with mean TBSA of 56% demonstrated a high rate of successful CEA engraftment (83%), and overall survival rate (90%) following one or two applications with CEA and/or CEA + split thickness skin graft (STSG). Development of standard treatment protocols and surgical plans has enabled positive outcomes with CEA in severe burns including posterior burns., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Transgender and gender diverse (TGD) people are disproportionately incarcerated in the United States relative to the general population. A dearth of quantitative research has explored victimization as a risk factor for incarceration as well as the victimization experiences of formerly incarcerated TGD populations. Methods : In 2019, 574 TGD adults completed an online survey assessing sociodemographics, victimization across settings, and incarceration history. Latent class analysis was used to identify two sets of latent subgroups based on respondent's victimization experiences: 1) lifetime victimization (low; moderate; and high) and 2) classes of victimization while incarcerated (low; moderate; and high). Bivariate and multivariable logistic regression analyses examined sociodemographic, mental health, and lifetime victimization experiences associated with lifetime incarceration (Outcome 1). Among those with incarceration histories, bivariate hierarchical logistic regression analyses also explored the association between gender identity, race/ethnicity, HIV status, visual gender non-conformity, and class of victimization during incarceration (Outcome 2) . Results: Participants' mean age was 31.4 ( SD = 11.2), 43.4% had a non-binary gender identity, 81.5% were White, non-Hispanic, 2.1% were living with HIV, and 13.2% had been incarcerated. In the multivariable model for Outcome 1, high levels of victimization, age, being a racial/ethnic minority, being a trans woman, living with HIV, and past-12-month polysubstance use were all associated with increased odds of lifetime incarceration ( p -values < 0.05). In the bivariate hierarchical logistic regression analyses for Outcome 2, living with HIV and having a visually gender non-conforming expression were significantly associated with elevated odds of experiencing high levels of victimization while incarcerated ( p -values < 0.05). Conclusion: Findings document the relationships between victimization and incarceration among TGD people as well as identify the subpopulations at greater risk for incarceration and experiencing victimization while incarcerated. Efforts are needed to prevent victimization across the life course, including while incarcerated and support TGD individuals in coping with the negative sequelae of victimization and incarceration experiences.

Young women remain underrepresented among engineering bachelor's degree holders. While there is a relatively large body of extant research on the many factors that curtail young women's interest in pursuing engineering, less is known about high school girls who are on an engineering pathway. Therefore, this study focuses on a select group of precollege young women who express a strong interest in engineering. Specifically, informed by theories of gender as a social system and previous empirical research, this mixed-methods study explores the constellation of significant actors within the daily lives of these young women, to understand from whom and how they are supported in pursuing this gender-atypical field, and simultaneously, from whom and how they are discouraged. To do so, the researchers analyzed survey and interview data from a sample of diverse high school girls who participate in the Society of Women Engineers' (SWE) SWENext programme. Quantitative results indicate that young women report high levels of encouragement from most sources, including parents, teachers, and other young women. However, across various peer contexts, they receive much more support from other young women than from young men. Qualitative results further reveal that parents and teachers stand out in young women's recollections of encouragement, often through advocating their participation in engineering activities or providing mentoring support. In contrast, young men in engineering spaces were recalled as particularly discouraging of their engineering participation, by socially or physically excluding them or refusing to provide recognition. Implications for future research and practice are discussed., Competing Interests: CONFLICTS OF INTEREST The authors declare no conflicts of interest.

Goal: The objective of this study was to evaluate the prevalence of burnout and professional fulfillment among healthcare administrative leaders and examine the association between burnout and professional fulfillment and personal and professional characteristics., Methods: Between June 7 and June 30, 2021, we performed a national survey of CEOs and other senior operational leaders to evaluate their personal work experience. Burnout and professional fulfillment-as well as a sleep-related impairment and self-valuation-were assessed using standardized instruments., Principle Findings: Of the 5,994 members of the American College of Healthcare Executives who were sent an invitation to participate, 1,269 (21.2%), including 279 CEOs, submitted usable responses. The mean overall burnout score was 2.71 (range: 0-10), and 33% of participants had burnout scores that fell in the high range (unfavorable). Mean professional fulfillment score was 7.29 (range: 0-10), with 56.6% scoring in the high range (favorable). Burnout and professional fulfillment scores varied by role. On multivariable analysis, sleep-related impairment (OR for each 1-point increase = 1.29, 95% CI [1.19-1.41]; p < .001) and self-valuation (OR for each 1-point increase = 0.63, 95% CI [0.57-0.68]; p < .001) were independently associated with burnout after adjusting for all other variables., Applications to Practice: Results of this study suggest that healthcare leaders had lower burnout and professional fulfillment scores than clinicians. Nonetheless, one third of healthcare leaders had burnout scores that fell in the high range. At the individual level, improved sleep health and self-valuation appear to reduce risk of burnout and promote professional fulfillment., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Foundation of the American College of Healthcare Executives.)

Paradoxical reactions are immune-mediated disease exacerbations that can occur in Mycobacterium tuberculosis (TB) following initiation of treatment. They are rare, challenging to manage and often fatal. We present a case of neurotuberculosis in a young woman, complicated by a paradoxical reaction in which infliximab was trialled without success. This case demonstrates the severity of presentation that can occur in neurotuberculosis, and the complications that paradoxical reactions can present. It also highlights the difficulty of delivering palliative care within the context of communicable disease with challenges posed by both TB and the COVID-19 pandemic., Competing Interests: Nil., (© PMA.)

Objectives: To investigate relationships between load tolerance of single leg isometric knee extension and athlete reported knee pain location and severity during the single leg decline squat., Design: Cross-sectional study., Methods: 175 college basketball athletes (99 women, 76 men) in Alberta, Canada participated at the start of the 2018-19 season. Knee pain location (dichotomized into focal/diffuse pain), and severity (numerical rating scale 0-10) were collected during the single leg decline squat. Athletes completed a standardized single leg isometric knee extension to determine load tolerance (defined by pain or reduced form). A quantile regression model was used to examine the association between load tolerance and pain location adjusting for sex, years played, body mass index and team., Results: Athletes with diffuse pain had a significantly lower median load tolerance (-0.89 kg) than athletes without pain (95% confidence interval [-1.49, -0.29]; p = 0.003). Athletes with focal pain tolerated similar median loads (-0.42 kg) to those without pain (95% confidence interval [-1.17, 0.33]; p = 0.26). Higher knee pain severity was associated with a non-linear but consistent reduction in load tolerance (p < 0.001)., Conclusions: Athlete-reported knee pain location during the single leg decline squat influenced load tolerance to isometric knee extension. Athletes with focal pain tolerated similar isometric loads to their pain free teammates. Clinicians should consider load selection of isometric knee extension for athletes with diffuse pain given their lower load tolerance. Future research should consider reporting pain location in addition to pain severity to differentiate clinical presentations and response to exercise., (Copyright © 2022 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

This case study provides a critical discourse analysis of 121 letters of complaint and self-advocacy authored by Natasha Keating, a trans woman incarcerated in two Australian male correctional facilities from 2000 to 2007. During her incarceration, Natasha experienced victimization, misgendering, microaggression, and institutional discrimination. Despite this, Natasha embodied and "fought" against the injustices she experienced, whilst seeking to speak for other trans incarcerated persons also silenced and treated with indifference, contributing to changes in the carceral system. This original case study analyzes the discursive strategies Natasha employed to construct and reclaim an affirming self-identity through a deliberate campaign to effect social change and policy concessions within a system designed to curtail self-determination. Through her empathic and impassioned letter-writing approach, leveraging a military metaphor , this novel analysis showcases the significant implications her activism/agentism and determination had in naming and seeking to dismantle the systems of oppression trans incarcerated women experience., Competing Interests: Conflict of interests The authors declared no potential conflicts of interest with respect to research, authorship, or publication of this article.

Objective: To examine how perceived leadership behaviours affect burnout, professional fulfilment and intent to leave the organisation among physicians., Design: Anonymous cross-sectional survey study from November 2016 to October 2018., Setting: 12 036 attending and resident physicians at 11 healthcare organisations participating in the Physician Wellness Academic Consortium (PWAC) were surveyed to assess burnout and professional fulfilment and their drivers., Participants: A sample of 5416 attending physicians with complete data on gender, specialty, leadership, burnout and professional fulfilment., Main Outcomes and Measures: The leadership behaviour of each physician's supervisor was assessed using the Mayo Clinic Participatory Management Leadership Index and categorised in tertiles. Multivariable logistic regression analyses examined the effect of leadership behaviour rating of each physician's supervisor on burnout, professional fulfilment and intent to leave controlling for gender and specialty., Results: The response rate was 45% across 11 institutions. Half of the respondents were female. Professional fulfilment increased with increasing tertiles of leadership behaviour rating (19%, 34%, 47%, p<0.001). The odds of professional fulfilment were 5.8 times higher (OR=5.8, 95% CI: 5.1 to 6.59) for physicians in the top tertile compared with those in the lowest tertile. Physicians in the top tertile were also 48% less likely to be burned out (OR=0.52, 95% CI: 0.45 to 0.61) and reported 66% lower intent to leave (OR=0.34, 95% CI: 0.26 to 0.44). Individuals who rated their supervisor's leadership in upper tertiles relative to lower tertiles exhibited lower levels of burnout (18% vs 35% vs 47%, p<0.001), and intent to leave (16% vs 24% vs 50% p<0.001)., Conclusion: Perceived leadership behaviours have a strong relationship with burnout, professional fulfilment and intent to leave among physicians. Organisations should consider leadership development as a potential vehicle to improve physician wellness and prevent costly physician departures., Competing Interests: Competing interests: TS is coinventor of the Mayo Clinic Participatory Management Leadership Index and Well-being Index Instruments (Physician Well-being Index, Medical Student Well-being Index, Nurse Well-being Index, Well-being Index). Mayo Clinic holds the copyright to these instruments and has licensed them for use outside of Mayo Clinic. TS receives a portion of any royalties paid to Mayo Clinic. TS reported receiving honoraria from grand rounds or keynote lecture presentations and advising for health care organisations outside the submitted work. Other authors report no conflict of interest., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Reducing physician occupational distress requires understanding workplace mistreatment, its relationship to occupational well-being, and how mistreatment differentially impacts physicians of diverse identities., Objectives: To assess the prevalence and sources of mistreatment among physicians and associations between mistreatment, occupational well-being, and physicians' perceptions of protective workplace systems., Design, Setting, and Participants: This survey study was administered in September and October 2020 to physicians at a large academic medical center. Statistical analysis was performed from May 2021 to February 2022., Main Outcomes and Measures: Primary measures were the Professional Fulfillment Index, a measure of intent to leave, and the Mistreatment, Protection, and Respect Measure (MPR). Main outcomes were the prevalence and sources of mistreatment. Secondary outcomes were the associations of mistreatment and perceptions of protective workplace systems with occupational well-being., Results: Of 1909 medical staff invited, 1505 (78.8%) completed the survey. Among respondents, 735 (48.8%) were women, 627 (47.1%) were men, and 143 (9.5%) did not share gender identity or chose "other"; 12 (0.8%) identified as African American or Black, 392 (26%) as Asian, 10 (0.7%) as multiracial, 736 (48.9%) as White, 63 (4.2%) as other, and 292 (19.4%) did not share race or ethnicity. Of the 1397 respondents who answered mistreatment questions, 327 (23.4%) reported experiencing mistreatment in the last 12 months. Patients and visitors were the most common source of mistreatment, reported by 232 physicians (16.6%). Women were more than twice as likely as men to experience mistreatment (31% [224 women] vs 15% [92 men]). On a scale of 0 to 10, mistreatment was associated with a 1.13 point increase in burnout (95% CI, 0.89 to 1.36), a 0.99-point decrease in professional fulfillment (95% CI, -1.24 to -0.73), and 129% higher odds of moderate or greater intent to leave (odds ratio, 2.29; 95% CI, 1.75 to 2.99). When compared with a perception that protective workplace systems are in place "to a very great extent," a perception that there are no protective workplace systems was associated with a 2.41-point increase in burnout (95% CI, 1.80 to 3.02), a 2.81-point lower professional fulfillment score (95% CI, -3.44 to -2.18), and 711% higher odds of intending to leave (odds ratio, 8.11; 95% CI, 3.67 to 18.35)., Conclusions and Relevance: This survey study found that mistreatment was common among physicians, varied by gender, and was associated with occupational distress. Patients and visitors were the most frequent source, and perceptions of protective workplace systems were associated with better occupational well-being. These findings suggest that health care organizations should prioritize reducing workplace mistreatment.

Importance: Burnout is common among physicians and is associated with suboptimal patient outcomes. Little is known about how experiences with patients, families, and visitors differ by physician characteristics or contribute to the risk of burnout., Objective: To examine the occurrence of mistreatment and discrimination by patients, families, and visitors by physician characteristics and the association between such interactions and experiencing burnout., Design, Setting, and Participants: This cross-sectional survey was conducted from November 20, 2020, to March 23, 2021, among US physicians., Exposures: Mistreatment and discrimination were measured using items adapted from the Association of American Medical College's Graduation Questionnaire with an additional item querying respondents about refusal of care because of the physicians' personal attributes; higher score indicated greater exposure to mistreatment and discrimination., Main Outcomes and Measures: Burnout as measured by the Maslach Burnout Inventory., Results: Of 6512 responding physicians, 2450 (39.4%) were female, and 369 (7.2%) were Hispanic; 681 (13.3%) were non-Hispanic Asian, Native Hawaiian, or Pacific Islander; and 3633 (70.5%) were non-Hispanic White individuals. Being subjected to racially or ethnically offensive remarks (1849 [29.4%]), offensive sexist remarks (1810 [28.7%]), or unwanted sexual advances (1291 [20.5%]) by patients, families, or visitors at least once in the previous year were common experiences. Approximately 1 in 5 physicians (1359 [21.6%]) had experienced a patient or their family refusing to allow them to provide care because of the physician's personal attributes at least once in the previous year. On multivariable analyses, female physicians (OR, 2.33; 95% CI, 2.02-2.69) and ethnic and racial minority physicians (eg, Black or African American: OR, 1.59; 95% CI, 1.13-2.23) were more likely to report mistreatment or discrimination in the previous year. Experience of mistreatment or discrimination was independently associated with higher odds of burnout (vs score of 0 [no mistreatment], score of 1: OR, 1.27; 95% CI, 1.04-1.55; score of 2: OR, 1.70; 95% CI, 1.38-2.08; score of 3: OR, 2.20; 95% CI, 1.89-2.57). There was no difference in the odds of burnout by gender after controlling for experiencing mistreatment and discrimination score and other demographic factors, specialty, practice setting, work hours, and frequency of overnight call., Conclusions and Relevance: In this study, mistreatment and discrimination by patients, families, and visitors were common, especially for female and racial and ethnic minority physicians, and associated with burnout. Efforts to mitigate physician burnout should include attention to patient and visitor conduct.

Context: Causes of anterior knee pain (AKP) in jumping athletes include patellofemoral pain and patellar tendinopathy. The differential diagnosis of AKP is challenging, with variations in clinical presentations. No previous research has used pain location to describe AKP in basketball players., Objective: To (1) describe the prevalence and pain distribution of AKP in collegiate basketball players and (2) report the prevalence of focal inferior pole pain using 2 outcome measures., Design: Cross-sectional study., Setting: University and collegiate basketball facilities in Alberta, Canada., Patients or Other Participants: A total of 242 collegiate basketball athletes (138 women, 104 men)., Main Outcome Measure(s): The single-legged decline squat test (SLDS) was used to capture pain location via pain mapping (dichotomized as focal or diffuse) and pain severity (numeric rating scale). The Oslo Sports Trauma Research Centre Knee questionnaire (OSTRC-Knee) and adapted version for patellar tendinopathy (OSTRC-Patellar Tendinopathy Questionnaire [OSTRC-P]) were used to report the prevalence of AKP and patellar tendinopathy, respectively. Focal inferior pole pain during the SLDS was used to classify patellar tendinopathy., Results: Of the 242 players, 146 (60%) reported pain with the SLDS (unilateral = 64 [26%]; bilateral = 82 [34%]). A total of 101 (43%) described knee pain using the OSTRC-Knee. Pain mapping captured the variability in pain locations. Diffuse pain was more prevalent (left, 70%; right, 72%) than focal pain (left, 30%; right, 28%). Low prevalence of patellar tendinopathy was noted using the OSTRC-P (n = 21, 8.7%) and inferior pole pain during the SLDS (n = 25, 10.3%)., Conclusions: Diffuse AKP was common in Canadian basketball players; however, pain mapped to the inferior pole of the patella was not common. Few players reported tendinopathy using the OSTRC-P, suggesting that patellar tendinopathy was not a primary knee pain presentation in this jumping cohort. Pain location, rather than the presence or severity of pain alone, may better describe the clinical presentation of AKP in jumping athletes., (© by the National Athletic Trainers' Association, Inc.)

Competing Interests: One of the authors, Dr. Tait Shanafelt has the following disclosure: Dr Shanafelt is co-inventor of the Well-being Index instruments (Physician Well-being Index, Nurse Well-being Index, Medical Student Well-being Index, the Well-being Index) and the Participatory Management Leadership Index. Mayo Clinic holds the copyright for these instruments and has licensed them for use outside of Mayo Clinic. Mayo Clinic pays Dr. Shanafelt receives a portion of any royalties received. As an expert on the well-being of healthcare providers, Dr. Shanafelt frequently gives grand rounds/key note lecture presentations and provides advising for healthcare organizations. He receives honoraria for some of these activities. All other authors have no conflicts of interest.

TP53 aberrations [del(17p) or TP53 mutation] predict poor survival with chemoimmunotherapy in patients with chronic lymphocytic leukaemia (CLL). We evaluated long-term efficacy and safety of first-line ibrutinib-based therapy in patients with CLL bearing TP53 aberrations in a pooled analysis across four studies: PCYC-1122e, RESONATE-2 (PCYC-1115/16), iLLUMINATE (PCYC-1130) and ECOG-ACRIN E1912. The pooled analysis included 89 patients with TP53 aberrations receiving first-line treatment with single-agent ibrutinib (n = 45) or ibrutinib in combination with an anti-CD20 antibody (n = 44). All 89 patients had del(17p) (53% of 89 patients) and/or TP53 mutation (91% of 58 patients with TP53 sequencing results available). With a median follow-up of 49·8 months (range, 0·1-95·9), median progression-free survival was not reached. Progression-free survival rate and overall survival rate estimates at four years were 79% and 88%, respectively. Overall response rate was 93%, including complete response in 39% of patients. No new safety signals were identified in this analysis. Forty-six percent of patients remained on ibrutinib treatment at last follow-up. With median follow-up of four years (up to eight years), results from this large, pooled, multi-study data set suggest promising long-term outcomes of first-line ibrutinib-based therapy in patients with TP53 aberrations. Registered at ClinicalTrials.gov (NCT01500733, NCT01722487, NCT02264574 and NCT02048813)., (© 2021 The Authors. British Journal of Haematology published by British Society for Haematology and John Wiley & Sons Ltd.)

Since opportunities to conduct experiments in space are scarce, various microgravity simulators and analogs have been widely used in space biology ground studies. Even though microgravity simulators do not produce all of the biological effects observed in the true microgravity environment, they provide alternative test platforms that are effective, affordable, and readily available to facilitate microgravity research. The Microgravity Simulation Support Facility (MSSF) at the National Aeronautics and Space Administration (NASA) John F. Kennedy Space Center (KSC) has been established for conducting short duration experiments, typically less than 1 month, utilizing a variety of microgravity simulation devices for research at different gravity levels. The simulators include, but are not limited to, 2D Clinostats, 3D Clinostats, Random Positioning Machines, and Rotating Wall Vessels. In this chapter, we will discuss current MSSF capabilities, development concepts, and the physical characteristics of these microgravity simulators., (© 2022. Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Provider well-being has become the fourth pillar of the quadruple aim for providing quality care. Exacerbated by the global COVID-19 pandemic, provider well-being has become a critical issue for health care systems worldwide. We describe the prevalence and key system-level drivers of burnout in oncologists in Ontario, Canada., Methods: This is a cross-sectional survey study conducted in November-December 2019 of practicing cancer care physicians (surgical, medical, radiation, gynecologic oncology, and hematology) in Ontario, Canada. Ontario is Canada's largest province (with a population of 14.5 million), and has a single-payer publicly funded cancer system. The primary outcome was burnout experience assessed through the Maslach Burnout Inventory., Results: A total of 418 physicians completed the questionnaire (response rate was 44% among confirmed oncologists). Seventy-three percent (n = 264 of 362) of oncologists had symptoms of burnout (high emotional exhaustion and/or depersonalization scores). Significant drivers of burnout identified in multivariable regression modeling included working in a hectic or chaotic atmosphere (odds ratio [OR] = 15.5; 95% CI, 3.4 to 71.5; P < .001), feeling unappreciated on the job (OR = 7.9; 95% CI, 2.9 to 21.3; P < .001), reporting poor or marginal control over workload (OR = 7.9; 95% CI, 2.9 to 21.3; P < .001), and not being comfortable talking to peers about workplace stress (OR = 3.0; 95% CI, 1.1 to 7.9; P < .001). Older age (≥ 56 years) was associated with lower odds of burnout (OR = 0.16; 95% CI, 0.1 to 0.4; P < .001)., Conclusion: Nearly three quarters of participants met predefined standardized criteria for burnout. This number is striking, given the known impact of burnout on provider mental health, patient safety, and quality of care, and suggests Oncologists in Ontario may be a vulnerable group that warrants attention. Health care changes being driven by the COVID-19 pandemic provide an opportunity to rebuild new systems that address drivers of burnout. Creating richer peer-to-peer and leadership engagement opportunities among early- to mid-career individuals may be a worthwhile organizational strategy., Competing Interests: Simron SinghEmployment: Sanofi (I), AstraZeneca (I)Honoraria: Novartis, IpsenResearch Funding: Novartis Brett NichollsEmployment: McKesson Canada Andrea EisenOther Relationship: Cancer Care Ontario Conrad B. FalksonStock and Other Ownership Interests: AllScripts Maureen TrudeauStock and Other Ownership Interests: RNA DiagnosticsResearch Funding: Roche Canada, Novartis, Pfizer, Eisai, AstraZeneca, Astellas Pharma, Genomic Health Tait ShanafeltHonoraria: Multiple Healthcare OrganizationsResearch Funding: Pharmacyclics, GlaxoSmithKline, Genentech, Celgene, Hospira, Cephalon, Polyphenon E InternationalPatents, Royalties, Other Intellectual Property: Dr Shanafelt is coinventor of the Well-being Index Instruments (Physician Well-being Index; Nurse Well-being Index; Medical Student Well-being Index; Well-being Index) and the Mayo Clinic Participatory Management Leadership Index. Mayo Clinic holds the copyright to these instruments and has licensed them for use outside Mayo Clinic. Mayo Clinic pays Dr Shanafelt receives a portion of any royalties it receivesOther Relationship: Medical CentersOpen Payments Link: https://openpaymentsdata.cms.gov/physician/429217 Glenn BaumanHonoraria: BayerResearch Funding: SiemensNo other potential conflicts of interest were reported.

Purpose: Although previous studies have revealed professional consequences of burnout among nurses, less is known about the potential personal consequences. This study investigated the prevalence of suicidal ideation and attitudes toward help seeking among U.S. nurses relative to other workers, and the extent to which personal and professional factors, including burnout, were related to suicidal ideation., Methods: In November 2017, a cross-sectional survey was sent to 86,858 nurses who were members of the American Nurses Association and to a probability-based sample of 5,198 U.S. workers. The survey included questions regarding suicidal ideation, burnout, symptoms of depression, individual and professional characteristics, and willingness to seek professional help if a serious emotional problem arose. Multivariable logistic regression analyses were conducted to identify factors associated with suicidal ideation after controlling for other factors., Results: Among the 7,378 nurse respondents, 403 (5.5%) reported having suicidal ideation within the past year. Most nurses (84.2%) indicated willingness to seek professional help for a serious emotional problem. Yet nurses with suicidal ideation were less likely to report that they'd seek such help (72.6%) than nurses without suicidal ideation (85%). In a multivariable analysis of nurses' data, after controlling for other personal and professional characteristics, we found that burnout was strongly associated with suicidal ideation. Adjusted combined multivariable analyses showed that nurses were more likely than other workers to have suicidal ideation. Both nurses and other workers who reported suicidal ideation were less likely to seek help than were those who did not report such ideation., Conclusions: Compared with other U.S. workers, nurses are at higher risk for suicidal ideation, and nurses with such ideation are more reluctant to seek help than those without it. Burnout contributes to the risk of suicidal ideation. These issues warrant greater attention. Systems- and practice-level interventions must be identified and implemented, both to address the higher prevalences of burnout and suicidal ideation in nurses and to mitigate the stigma about mental health problems and other barriers to seeking help., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Prior work has shown that burnout among breast surgeons is prevalent and highest in those earlier in their clinical practice career. Therefore, we sought to better understand and identify specific contributors to early-career breast surgeon burnout., Methods: We analyzed data from our 2017 survey of members of the American Society of Breast Surgeons. The 16-items of the Professional Fulfillment Index were used in determining overall burnout and professional fulfillment scores. Multivariable regressions were performed to evaluate factors related to overall burnout and professional fulfillment., Results: The mean overall burnout score was 1.23 (0-4 scale; higher score unfavorable) for surgeons in practice < 5 years, compared with 1.39 for surgeons in practice 5-9 years and 1.22 for those in practice ≥ 10 years. The mean professional fulfillment score was 2.71 (0-4 scale; higher score favorable) for surgeons in practice < 5 years, 2.66 for surgeons in practice 5-9 years, and 2.67 for surgeons in practice ≥ 10 years. Multivariable analysis showed that burnout was positively correlated with ≥ 60 work hours per week in the group practicing for < 5 years, and dedicating less than full time to breast surgery in the group in practice 5-9 years. Professional fulfillment was negatively associated with single relationship status in surgeons practicing < 5 years, and dedicating less than full time to breast surgery for those in practice 5-9 years., Conclusion: Our study suggests that breast surgeons who have been in practice for 5-9 years have particularly high overall burnout rates and additional support focused on this group of breast surgeons may be needed., (© 2021. Society of Surgical Oncology.)

Health care professionals and the institutions in which they work are being stretched to their limits amidst the current COVID-19 pandemic. At the same time, a second longstanding pandemic has been brought to the fore: the entrenched system of racial injustice and oppression. The first pandemic is new, and to date, substantial resources have been allocated to urgently addressing its mitigation; the second has a long history with inconsistent attention and resources but has recently been spotlighted more intensely than at any time in the nation's recent past. The authors contend that these 2 simultaneous pandemics have brought forth the need for institutions in the United States to make a renewed commitment to respect, wellness, diversity, and inclusion. While investment and leadership in these domains have always been essential, these have largely been viewed as a "nice-to-have" option. The events of much of 2020 (most notably) have illustrated that committing to and investing in policies, programs, centers, and leadership to drive change in these domains are essential and a "need-to-have" measure. The authors outline the necessity of investing in the promotion of cultures of inclusive excellence at both individual and organizational levels to coordinate a united response to the simultaneous pandemics. It is in the interests of health care systems to consider the wellness of the workforce to overcome the longer-term economic, systemic, and social trauma that will likely occur for years to come at both the individual and institutional levels. Maintaining or augmenting investment is necessary despite the economic challenges the nation faces. Now is the time to cultivate resilience and wellness through a renewed commitment to cultures of respect, diversity, and inclusion. This commitment is urgently needed to support and sustain the health care workforce and maintain outstanding health care systems for future generations., (Copyright © 2020 by the Association of American Medical Colleges.)

This study utilizes interviews from 22 young female engineers from diverse racial/ethnic backgrounds as they first entered the White and male-dominated engineering labor force with the goal of examining: (1) how these women endorsed a gender-blind frame that characterizes their workplaces as fundamentally meritocratic, and alternatively, (2) how they named gender as relevant or salient to experiences and interactions at work. Drawing on the insights of intersectional scholars to answer the previous questions, the study calls attention to how the invocation of these frames differed for women of color compared to their majority White female peers. Results revealed that most respondents strongly endorsed the idea that engineering workplaces are meritocratic and that their gender is not relevant. However, there is also evidence of racial divergence in the themes expressed. For example, some White women expressed a narrative contradictory to meritocracy, discussing their workplaces as like family, while in contrast, women of color often expressed uncomfortable experiences of standing out. Overall, the results suggest that female engineers' tendency to disavow, either explicitly or implicitly, that discrimination and bias occurs in their workplaces, likely contributes to continued gender and racial inequality; subsequently, programs and interventions to facilitate awareness of inequality are critically needed., Competing Interests: Declarations Conflicts of Interest The authors declare no competing of conflict of interests.

The acute consequences of the COVID-19 pandemic have impacted wellness strategies aimed at mitigating the pre-existing epidemic of burnout in radiology. Specifically, safety measures including social distancing requirements, effective communications, supporting remote and distributed work teams, and newly exposed employment and treatment inequities have challenged many major efforts at fostering professional fulfillment. To get our wellness efforts back on track and to achieve a new and perhaps even a better "normal" will require refocusing and reconsidering ways to foster and build a culture of wellness, implementing practices that improve work efficiencies, and supporting personal health, wellness behaviors, and resilience. Optimizing meaning in work is also critical for well-being and professional fulfillment. In addition to these earlier approaches, organizations and leaders will need to reprioritize efforts to build high-functioning cohesive and connected teams; to train, implement, and manage peer-support practices; and to support posttraumatic growth. This growth represents the positive psychological changes that can occur after highly challenging life circumstances and, when successful, allows individuals to achieve a higher level of functioning by addressing and learning from the precipitating event. Our practices can support this growth through education, emotional regulation, and disclosure, by developing a narrative that reimagines a hoped-for better future and by finding meaning through services that benefit others., (Copyright © 2021 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Objective: To compare physicians with workers in other fields on measures of self-valuation (SV) and determine the effect of adjusting for SV on the relationship between being a physician and risk for burnout., Patients and Methods: A random sample of physicians from the American Medical Association Physician Masterfile and a probability sample from the general US population were used. Data were collected for this cross-sectional study between October 12, 2017 and March 15, 2018. Burnout was indicated by a score of 27 or higher on Emotional Exhaustion or 10 or higher on Depersonalization, using the Maslach Burnout Inventory. Self-valuation was measured with Self-valuation Scale items., Results: Physicians (248/832=29.8%) more than workers in other fields (1036/5182=20.0%) "often" or "always" felt more self-condemnation than self-encouragement to learn from the experience when they made a mistake. Physicians (435/832=52.3%) more than workers in other fields (771/5182=14.9%) "often" or "always" put off taking care of their own health due to time pressure. Physicians had greater odds of burnout before (odds ratio [OR], 1.51; 95% CI, 1.30 to 1.76) but not after adjusting for SV responses (OR, 0.93; 95% CI, 0.78 to 1.11). After adjustment for SV, work hours, sex, and age, physicians had lower odds of burnout than workers in other fields (OR, 0.82; 95% CI, 0.68 to 0.99)., Conclusion: Self-valuation is lower in physicians compared with workers in other fields and adjusting for SV eliminated the association between being a physician and higher risk for burnout. Experimental design research is needed to determine whether the association of SV with burnout is causal and the degree to which SV is malleable to intervention at individual, organization, and professional culture levels., (Copyright © 2021. Published by Elsevier Inc.)

Objectives: To measure nurse-perceived electronic health records (EHR) usability with a standardized metric of technology usability and evaluate its association with professional burnout., Methods: A cross-sectional survey of a random sample of US nurses was conducted in November 2017. EHR usability was measured with the System Usability Scale (SUS; range 0-100) and burnout with the Maslach Burnout Inventory., Results: Among the 86 858 nurses who were invited, 8638 (9.9%) completed the survey. The mean nurse-rated EHR SUS score was 57.6 (SD 16.3). A score of 57.6 is in the bottom 24% of scores across previous studies and categorized with a grade of "F." On multivariable analysis adjusting for age, gender, race, ethnicity, relationship status, children, highest nursing-related degree, mean hours worked per week, years of nursing experience, advanced certification, and practice setting, nurse-rated EHR usability was associated with burnout with each 1 point more favorable SUS score and associated with a 2% lower odds of burnout (OR 0.98; 95% CI, 0.97-0.99; P < .001)., Conclusions: Nurses rated the usability of their current EHR in the low marginal range of acceptability using a standardized metric of technology usability. EHR usability and the odds of burnout were strongly associated with a dose-response relationship., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: To investigate the association of personal accomplishment (PA) with the other subscales, assess its association with well-being outcomes, and evaluate drivers of PA by resident level., Background: Most studies investigating physician burnout focus on the emotional exhaustion (EE) and depersonalization (DP) subscales, neglecting PA. Therefore, the role of PA is not well understood., Methods: General surgery residents were surveyed following the 2019 American Board of Surgery In-Training Examination regarding their learning environment. Pearson correlations of PA with EE and DP were assessed. Multivariable logistic regression models assessed the association of PA with attrition, job satisfaction, and suicidality and identified factors associated with PA by PGY., Results: Residents from 301 programs were surveyed (85.6% response rate, N = 6956). Overall, 89.4% reported high PA, which varied by PGY-level (PGY1: 91.0%, PGY2/3: 87.7%, PGY4/5: 90.2%; P = 0.02). PA was not significantly correlated with EE (r = -0.01) or DP (r = -0.08). After adjusting for EE and DP, PA was associated with attrition (OR 0.60, 95%CI 0.46-0.78) and job satisfaction (OR 3.04, 95%CI 2.45-3.76) but not suicidality (OR 0.72, 95%CI 0.48-1.09). Although the only factor significantly associated with PA for interns was resident cooperation, time in operating room and clinical autonomy were significantly associated with PA for PGY2/3. For PGY4/5s, PA was associated with time for patient care, resident cooperation, and mentorship., Conclusion: PA is a distinct metric of resident well-being, associated with job satisfaction and attrition. Drivers of PA differ by PGY level and may be targets for intervention to promote resident wellness and engagement., Competing Interests: The authors declare no conflict of interests., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Physician burnout has been linked to medical errors, decreased patient satisfaction, and decreased career longevity. In light of the increasing prevalence of cardiovascular disease, vascular surgeon burnout presents a legitimate public health concern owing to the impact on the adequacy of the vascular surgery workforce. The aims of this study were to define the prevalence of burnout among practicing vascular surgeons and identify factors that contribute to burnout to facilitate future Society for Vascular Surgery (SVS) initiatives to mitigate this crisis., Methods: In 2018, active SVS members were surveyed electronically and confidentially using the Maslach Burnout Inventory. The survey was tailored to explore specialty-specific issues, and to capture demographic and practice-related characteristics. Emotional exhaustion (EE) and depersonalization (DP) were analyzed as dimensions of burnout. Consistent with convention, surgeons with a high score on the DP and/or EE subscales of the Maslach Burnout Inventory were considered to have at least one manifestation of professional burnout. Risk factors associated with symptoms of burnout were identified using bivariate analyses (χ 2 , Kruskal-Wallis). Multivariate logistic regression models were developed to identify independent risk factors for burnout., Results: Of 2905 active SVS members, 960 responded to the survey (34% participation rate). After excluding retired surgeons and incomplete submissions, responses from 872 practicing vascular surgeons were analyzed. The mean age was 49.7 ± 11.0 years; the majority of respondents (81%) were male. Primary practice settings were academic (40%), community practice (41%), veteran's hospital (3.3%), active military practice (1.5%), or other. Years in practice averaged 15.7 ± 11.7. Overall, 41% of respondents had at least one symptoms of burnout (ie, high EE and/or high DP), 37% endorsed symptoms of depression in the past month, and 8% indicated they had considered suicide in the last 12 months. In unadjusted analysis, factors significantly associated with burnout (P < .05) included clinical work hours, on-call frequency, electronic medical record and documentation requirements, work-home conflict, and work-related physical pain. On multivariate analysis, age, work-related physical pain and work-home conflict were independent predictors for burnout., Conclusions: Symptoms of burnout and depression are common among vascular surgeons. Advancing age, work-related physical pain, and work-home conflict are independent predictors for burnout among vascular surgeons. Efforts to promote vascular surgeon well-being must address specialty-specific challenges, including the high prevalence of work-home conflict and occupational factors that contribute to work-related pain., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To understand the relationships between burnout, job satisfaction, and career plans among physician assistants in the United States., Methods: The authors surveyed PAs in 2016. The survey included the Maslach Burnout Inventory and items on job satisfaction and career plans., Results: Overall 82.7% of PAs were satisfied with their job, 32.2% indicated intent to leave their current position, and 19.5% reported intent to reduce work hours. On multivariate analysis, burnout increased the odds of job dissatisfaction, intent to reduce work hours within the next year, and intent to leave the current practice in the next 2 years., Conclusions: About a third of PAs indicated intent to leave their current practice and one in five indicated intent to reduce their clinical hours. Burnout was an independent predictor of job satisfaction and career plans., (Copyright © 2021 American Academy of Physician Assistants.)