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The US physician workforce is aging, prompting concerns regarding clinical performance of senior physicians. Pediatric emergency medicine (PEM) is a high-acuity, multitasking, diagnostically complex and procedurally demanding specialty. Aging's impact on clinical performance in PEM has not been examined. We aimed to assess PEM physician's' perceptions of peers' clinical performance over career span.We surveyed 478 PEM physician members of the American Academy of Pediatrics' Section on Emergency Medicine survey study list-serve in 2020. The survey was designed by the investigators with iterative input from colleagues. Respondents rated, using a 5-point Likert scale, the average performance of 4 age categories of PEM physicians in 9 clinical competencies. Additional items included concerns about colleague's performance and preferences for age of physician managing a critically ill child family member.We received 232 surveys with responses to core initial items (adjusted response rate, 49%). Most respondents were 36 to 49 (34.9%) or 50 to 64 (47.0%) years old. Fifty-three percent reported ever having concern about a colleague's performance. For critical care-related competencies, fewer respondents rated the ≥65-year age group as very good or excellent compared with midcareer physicians (36-49 or 50-64 years old). The ratings for difficult communications with families were better for those 65 years or older than those 35 years or younger. Among 129 of 224 respondents (58%) indicating a preferred age category for a colleague managing a critically ill child relative, most (69%) preferred a 36 to 49-year-old colleague.Pediatric emergency medicine physicians' perceptions of peers' clinical performance demonstrated differences by peer age group. Physicians 65 years or older were perceived to perform less well than those 36 to 64 years old in procedural and multitasking skills. However, senior physicians were perceived as performing as well if not better than younger peers in communication skills. Further study of age-related PEM clinical performance with objective measures is warranted.

Critical illness confers a significant risk of psychological distress, both during and after intensive care unit (ICU) admission. The Patient Dignity Inventory is a 25-item instrument initially designed to measure psychosocial, existential and symptom-related distress in terminally ill patients.This study was conducted to validate the inventory as a means of identifying distress in inpatient critical care settings.Single-center prospective cohort study of adult patients admitted to one of five ICUs within the University of Pennsylvania Health System for greater than 48 hours from January 2019 to February 2020. Patients completed the inventory in addition to the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-seven questionnaires.The tool's internal structure was assessed via principal components analysis. 155 participants consented, completed the surveys and were included for analysis. Scores on the inventory showed evidence of internal consistency when used in critical care settings (Cronbach's α=0.95). Moreover, principal components analysis elucidated four themes prevalent in critically-ill patients: Illness-related Concerns, Interactions with Others, Peace of Mind and Dependency. Construct validity was assessed through correlational analysis with depression and anxiety questionnaires. Scores on the inventory appear to be valid for assessing dignity-related psychological concerns in the critical care setting although there is overlap among components and with anxiety and depression scores.This study demonstrates that the inventory can be used to assess patient distress in critical care settings. Further research may elucidate the role of dignity-based interventions in treating and preventing post-intensive care psychological symptoms.

Background The 2020–2021 residency application cycle was altered to reduce COVID-19 transmission, with moves to all virtual interviews and no away rotations for medical students. These changes may have affected how students ranked residency programs, such as choosing programs near their medical schools. Objective To determine if a larger percentage of medical students matched to residency programs in the same state as their medical schools in 2021 vs 2018–2020. Methods We searched the webpages or emailed student affairs deans of the 155 Liaison Committee on Medical Education accredited MD programs to attain medical school match lists. Differences in the percentage of students matching to residency programs in the same US state as their medical schools in 2021 vs 2018–2020 were compared using chi-square tests. Results We recorded 36 021 of 79 406 (45%) National Resident Matching Program, 759 of 1720 (44%) ophthalmology, and 586 urology MD residency matches between 2018 and 2021. The percentage of students matching to residency programs in the same state as their medical schools was 35.9% in 2021 versus 34.3% in 2018–2020 (P=.005). Students were more likely to match to programs in the same state as their medical schools in 2021 if they attended a public medical school (40.3% vs 38.5%, P=.009) or applied into specialties where ≥50% of students traditionally perform away rotations (32.2% vs 30.2%, P=.031). Conclusions There was a small difference in the percentage of medical students matching to residency programs in the same state as their medical schools in 2021 vs 2018–2020.

Background Pre-transplant evaluation is mandated by Centers for Medicare and Medicaid Services, but there is wide institutional variation in implementation, and the family experience of the process is incompletely understood. Current literature largely focuses on adult transplant recipients. Methods This qualitative study begins to fill the knowledge gap about family experience of the pre-transplant evaluation for children through interviews with caregivers at a large pediatric transplant center. Results Prominent themes heard from caregivers include (1) the pre-transplant evaluation is overwhelming and emotional, (2) prior experiences and background knowledge frame the evaluation experience, and (3) frustration with communication among teams is common. Conclusions These findings are relevant to efforts by transplant centers to optimize information delivery, minimize concrete barriers, and address healthcare systems issues. Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information Supplementary Information The online version contains supplementary material available at 10.1007/s00467-021-05354-8.

To date, education about health equity for early-stage healthcare trainees is largely situated outside of surgical disciplines. This study aims to evaluate the effectiveness of a surgical equity curriculum offered to a voluntary group of medical and graduate students.Mixed-methods cohort study from January to June 2021. Pre- and post-course surveys measured domains of attitudes, self-reported confidence, and knowledge via 5-point Likert scale and multiple-choice questions. Paired t tests were used to analyze quantitative responses. Qualitative responses were studied via iterative thematic analysis.At the University of Pennsylvania in Philadelphia, PA which provides tertiary level, institutional care, 10, interdisciplinary 1.5-hour sessions were held over 1 semester, teaching surgical equity topics that spanned the peri-operative continuum.Twenty-four medical and graduate students from across the University of Pennsylvania enrolled. Twenty completed both surveys.From pre- to post-course, students improved across all domains. Students improved in their self-rated ability to identify strategies to talk about sensitive health topics with patients (pre: 20%, post: 90%) and identify strategies to address healthcare disparities in surgery (pre: 10%, post: 90%). Qualitatively, from pre- to post-course, more students could articulate the role of bias and identify opportunities for surgeons to engage in surgical equity. The course strengthened any pre-existing interest in surgical equity, and for 1 student, created interest in a surgical career where it had not previously existed. Many also expressed greater resolve to provide patient-centric care.Formal curricula can improve students' ability to advocate for surgical equity. A similar framework may fill a need for medical students interested in health equity and surgical careers at other institutions.

Clinical pathways are evidence-based guidelines adapted to local settings. They have been shown to improve patient outcomes and reduce resource utilization. However, it is unknown how physicians integrate clinical pathways into their clinical reasoning.We conducted a single-center qualitative study involving one-on-one semi-structured interviews of pediatric residents and pediatric hospitalist attendings between August 2021 and March 2022. Interviews were audio-recorded and professionally transcribed. We utilized a qualitative descriptive framework to code data and identify themes.We interviewed 15 pediatric residents and 12 pediatric hospitalists. Thematic analysis of interview transcripts revealed four themes related to physician utilization of and experience with clinical pathways: (1) utility as a tool, (2) means of standardizing care, (3) reflection of institutional culture, and (4) element of the dynamic relationship with the clinician diagnostic process. These themes were generally common to both residents and attending physicians; however, some differences existed and are noted when they occurred.Clinical pathways are part of many clinicians' diagnostic processes. Pathways can standardize care, influence the diagnostic process, and express local institutional culture. Further research is required to ascertain the optimal clinical pathway design to augment and not inhibit the clinician's diagnostic process.

Background The COVID-19 pandemic forced numerous unprecedented systemic changes within residency programs and hospital systems. Objective We explored how the COVID-19 pandemic, and associated changes in clinical and educational experiences, were related to internal medicine residents' well-being in the early months of the pandemic. Methods Across 4 internal medicine residency programs in the Northeast United States that have previously participated in the iCOMPARE study, all 394 residents were invited to participate in a study with open-ended survey prompts about well-being approximately every 2 weeks in academic year 2019–2020. In March and April 2020, survey prompts were refocused to COVID-19. Content analysis revealed themes in residents' open-ended responses to 4 prompts. Results One hundred and eighty-six residents expressed interest, and 88 were randomly selected (47%). There were 4 main themes: (1) in early days of the pandemic, internal medicine residents reported fear and anxiety about uncertainty and lack of personal protective equipment; (2) residents adapted and soon were able to reflect, rest, and pursue personal wellness; (3) communication from programs and health systems was inconsistent early in the pandemic but improved in clarity and frequency; (4) residents appreciated the changes programs had made, including shorter shifts, removal of pre-rounding, and telemedicine. Conclusions COVID-19 introduced many challenges to internal medicine residency programs and to resident well-being. Programs made structural changes to clinical schedules, educational/conference options, and communication that boosted resident well-being. Many residents hoped these changes would continue regardless of the pandemic's course.

Biosimilar therapies and their naming conventions are both relatively new to the drug development market and in clinical practice. We studied the use of the four-letter naming convention in practice and the knowledge, perceptions, and preferences of US health care providers. A survey was distributed among health care professionals with a history of utilizing biosimilars in clinical practice to measure key knowledge and the presence of discernable naming trends. Differences in responses across pre-hypothesized subgroups were tested for statistical significance. Of the 506 surveys emailed, 83 (16%) people responded. Overall, there was poor knowledge about the key concepts surrounding biosimilars. For example, only 52% of respondents correctly identified that biosimilars were not the same as the generic drug; however, frequent use correlated with superior knowledge across all groups. In reference to naming preferences, 67% of all respondents indicated that they commonly use the brand name to distinguish biosimilars in clinical practice and a majority of them (85%) indicated that the brand name was easier to remember than the nonproprietary name with the four-letter suffix. An unexpected number of neutral responses was documented. Notably, more than half of respondents (68%) indicated a neutral response when asked if the four-letter suffix promoted medical errors. There remains a knowledge gap with regard to biosimilars, and lack of consensus on how the naming convention is and should be utilized in clinical practice. The data also suggest that effective biosimilar education could aid in promoting familiarity with the naming convention among health care providers.

Little is known about national practices and use of in‐person outreach clinics and telemedicine in transplantation. We initially aimed to assess contemporary use of in‐person outreach and telemedicine in liver and intestinal transplantation in the U.S. We conducted a national survey of liver and intestinal transplant programs to assess use of outreach and telemedicine from January to March of 2019. Given the coronavirus disease 2019 (COVID‐19) pandemic, we distributed a second survey wave in April 2020 to assess changes in telemedicine use. Of the 143 programs surveyed, the initial response rate was 51% (n=73) representing all 11 Organ Procurement and Transplantation Network (OPTN) regions and 29 states. Pre‐COVID‐19, a total of 42 (59%) surveyed programs had in‐person outreach clinics only while 12 (16%) programs in only 6 states used telemedicine. Centers with higher median MELD at transplant were more likely to utilize telemedicine (p=0.02). During the COVID‐19 pandemic, among 55 of the 73 original responding programs (75%) from all 11 OPTN regions, telemedicine use increased from 16% to 98% and was used throughout all phases of transplant care. Telemedicine utilization was very low prior to COVID‐19 and has increased rapidly across all phases of transplant care presenting an opportunity to advocate for sustained future use.

Aim of the study Since over 80% of sudden cardiac arrests occur in the home, cardiopulmonary resuscitation (CPR) training for family members of high-risk cardiac patients represents a promising intervention. The use of mobile application-based (mApp) CPR training may facilitate this approach, but evidence regarding its efficacy is lacking. Methods We conducted a multicenter, pragmatic, cluster-randomized trial assessing CPR training for family members of cardiac patients. The interventions were mApp (video, no manikin) and VSI (video + manikin). CPR skills were evaluated 6-months post-training. We hypothesized that chest compression (CC) rate from training with an mApp would be no worse than 5 compressions per minute (CPM) lower compared to VSI. Results From 01/2016 to 01/2018, we enrolled 1325 eligible participants (mean age 51.6 years, 68.2% female and 59.4% white). CPR skills were evaluated 6-months post-training in 541 participants (275 VSI, 266 mApp). Mean rate was 84.6 CPM (95% CI: 80.4, 88.6) in VSI, compared to 82.7 CPM (95% CI: 76.2, 89.1) in the mApp, and mean depth was 42.1 mm (95% CI: 40.3, 43.8) in VSI, compared to 38.9 mm (95% CI: 36.2, 41.6) in the mApp. After adjustment, the mean difference in CC rate was −2.3 CPM (95% CI −9.4, 4.8, p = 0.25, non-inferiority) and CC depth was −3.2 mm (95% CI −5.9, 0.1, p = 0.056). Conclusion In this large prospective trial of CPR skill retention for family members of cardiac patients, mApp training was associated with lower CC quality. Future work is required to understand additional approaches to improve CPR skill retention. Clinical Trial Registration URL: ClinicalTrials.gov, Identifier: NCT02548793 .

Objective Our study completes the development and estimates the psychometric properties of a novel, ventral hernia-specific patient reported outcomes (PRO) tool-the Abdominal Hernia-Q (AHQ). Summary background data A standardized method for measuring hernia-related PRO has not been identified. There remains a need for a broadly applicable, hernia-specific tool that incorporates patient viewpoints and offers pre- and postoperative forms. Methods Concept elicitation interviews, focus groups, and cognitive debriefing interviews were completed to define content. The preoperative AHQ was administered to patients scheduled to have a ventral hernia repair (VHR). The postoperative AHQ was administered to patients within 24 months post-VHR. The SF-12 and HerQLes were concurrently administered. Psychometric evaluation was performed. Subsequently, the AHQ (pre: 8 items; post: 16 items) underwent prospective testing. Results Cross-sectional evaluations of patient responses to the AHQ (pre n = 104; post n = 261) demonstrated high internal consistency (Cronbach α pre = 0.86; post = 0.90) and moderate disattenuated correlations with the HerQLes (pre r = -0.71 and post r = -0.70) and the SF-12 domains (pre and post r ≥ 0.5 for 7 of 8 domains). Principal components analyses produced 2 factors preoperatively and 3 factors postoperatively. In prospective testing (n = 67), the AHQ scores replicated the cross-sectional psychometric results and suggested sensitivity to clinical outcomes. Conclusions Through patient involvement and rigorous, iterative psychometric evaluation, we have produced substantial data to suggest the validity and reliability of AHQ scores in measuring hernia-specific PRO. The AHQ advances the clinical management and treatment of patients with abdominal hernias by providing a more complete understanding of patient-defined outcomes.

BackgroundVision loss may be a risk factor for hallucinations, but this has not been studied at the population level.MethodsTo determine the association between self-reported vision loss and hallucinations in a large community-based sample of older adults, we performed a cross-sectional and longitudinal analysis of two large, nationally representative US health surveys: the National Health and Aging Trends Study (NHATS) and the Health and Retirement Study (HRS). Visual impairment and hallucinations were self- or proxy-reported. Multivariate single and mixed effects logistic regression models were built to examine whether visual impairment and history of cataract surgery were associated with hallucinations.ResultsIn NHATS (n = 1520), hallucinations were more prevalent in those who reported difficulty reading newspaper print (OR 1.77, 95% confidence interval (CI): 1.32–2.39) or recognising someone across the street (OR 2.48, 95% CI: 1.86–3.31) after adjusting for confounders. In HRS (n = 3682), a similar association was observed for overall (OR 1.32, 95% CI: 1.08–1.60), distance (OR 1.61, 95% CI: 1.32–1.96) and near eyesight difficulties (OR 1.52, 95% CI: 1.25–1.85). In neither sample was there a significant association between cataract surgery and hallucinations after adjusting for covariates.ConclusionsVisual dysfunction is associated with increased odds of hallucinations in the older US adult population. This suggests that the prevention and treatment of vision loss may potentially reduce the prevalence of hallucinations in older adults.

BACKGROUND: Why physicians use surveillance imaging for asymptomatic cancer survivors despite recommendations against this is not known. METHODS: Physicians surveilling head and neck cancer survivors were surveyed to determine relationships among attitudes, beliefs, guideline familiarity, and self-reported surveillance positron-emission-tomography/computed-tomography use. RESULTS: Among 459 responses, 79% reported using PET/CT on some asymptomatic patients; 39% reported using PET/CT on more than half of patients. Among attitudes/beliefs, perceived value of surveillance imaging (O.R. 3.57, C.I. 2.42–5.27, P =

Substance use disorder is a common cause of morbidity and mortality in the United States. Comprehensive harm reduction programs have emerged as a public health strategy to help those with substance use disorder. At this time little is known about the population of people who use comprehensive harm reduction programs. To address this gap in knowledge we examined health needs and priorities among people who utilize a comprehensive harm reduction program. We conducted in depth semi-structured interviews with 29 people who access services at a harm reduction program. Themes from the qualitative interviews revealed priorities included improving housing stability, sobriety, and reunification with children. Lack of trust of the health care system was often reported as a barrier to optimal medical care. Comprehensive harm reduction programs are in a position to offer services that can help improve physical health and social determinants of health for people with substance use disorder.

PURPOSE: Most of what is known about resident burnout and wellness comes from cross-sectional snapshot surveys. The purpose of this study was to elicit qualitative perspectives on wellness from a cohort of internal residents over time using ecological momentary assessment. METHOD: Drawing on principles of ecological momentary assessment, 13 different open-ended survey prompts were delivered between October and March during the 2019–2020 academic year. Participants were 88 randomly selected internal medicine residents from 4 internal medicine training programs in the Northeast. RESULTS: The response rate was 95%. Three main themes regarding wellness were self, program/education environment, and medical/structural system. A fourth theme, the desire to provide quality patient care, cut across all other themes. The patient care theme repeatedly stressed residents’ desire to spend more time with patients. The self theme primarily reflected messages about personal emotions and the need for work–life balance and wellness. The program/education environment theme reflected the value of learning, teamwork and community, and program culture. The medical/structural system theme showed that residents’ experiences were shaped by the efficiency of their days, and largely a product of their schedules and administrative support. Closing advice to future trainees was optimistic and reassuring. CONCLUSIONS: While findings support much of what has been learned via single-occasion survey snapshots, an ecological momentary assessment design allowed a deeper dive into contextual associations. The results affirm the primacy of patient care and also highlight the value of teamwork and culture. Peers and program leaders are heavily influential in setting the tone for the learning experience, whether for the day or with a more enduring message of respect and support. There is opportunity to maximize high- or higher-value learning experiences for residents and find solutions to reduce and reframe the perceived “low-value administrative work” that is part of care coordination.

The purpose of this study was to evaluate barriers and facilitators to glycemic control and diabetes shared medical appointment (SMA) engagement in underserved patients with type 2 diabetes.Semi-structured focus groups were conducted in 50 patients using an interview script guided by a social determinants of health (SDOH) conceptual framework.Patients positively perceived the social support and access to care benefits of the SMA. While barriers related to self-care behaviors (particularly diet), financial issues, and unreliable transportation were common, notable differences among the four groups existed. Controlled patients were motivated by fear of diabetic complications. Poorly-controlled patients discussed comorbidities and negative influence of family as barriers to glycemic control. Diabetes distress and fatalism were endorsed by poorlycontrolled, non-engaged patients.Overcoming SDOH including transportation barriers, food insecurity, and diabetes distress and fatalism are promising areas of intervention for SMA models to improve care for underserved populations.

Unprofessional faculty behaviors negatively impact the well-being of trainees yet are infrequently reported through established reporting systems. Manual review of narrative faculty evaluations provides an additional avenue for identifying unprofessional behavior but is time- and resource-intensive, and therefore of limited value for identifying and remediating faculty with professionalism concerns. Natural language processing (NLP) techniques may provide a mechanism for streamlining manual review processes to identify faculty professionalism lapses. In this retrospective cohort study of 15,432 narrative evaluations of medical faculty by medical trainees, we identified professionalism lapses using automated analysis of the text of faculty evaluations. We used multiple NLP approaches to develop and validate several classification models, which were evaluated primarily based on the positive predictive value (PPV) and secondarily by their calibration. A NLP-model using sentiment analysis (quantifying subjectivity of the text) in combination with key words (using the ensemble technique) had the best performance overall with a PPV of 49% (CI 38%-59%). These findings highlight how NLP can be used to screen narrative evaluations of faculty to identify unprofessional faculty behaviors. Incorporation of NLP into faculty review workflows enables a more focused manual review of comments, providing a supplemental mechanism to identify faculty professionalism lapses.

Introduction:In the absence of evidence-based guidelines, paediatric cardiologists monitor patients in the ambulatory care setting largely according to personal, patient, institutional, and/or financial dictates, all of which likely contribute to practice variability. Minimising practice variability may optimise quality of care while incurring lower costs. We sought to describe self-reported practice patterns and physician attitudes about factors influencing their testing strategies using vignettes describing common scenarios in the care of asymptomatic patients with tetralogy of Fallot and d-transposition of the great arteries.Methods:We conducted a cross-sectional survey of paediatric cardiologists attending a Continuing Medical Educational conference and at our centre. The survey elicited physician characteristics, self-reported testing strategies, and reactions to factors that might influence their decision to order an echocardiogram.Results:Of 267 eligible paediatric cardiologists, 110 completed the survey. The majority reported performing an annual physical examination (66–82%), electrocardiogram (74–79%), and echocardiogram (56–76%) regardless of patient age or severity of disease. Other tests (i.e. Holter monitors, exercise stress tests or cardiac MRIs) were ordered less frequently and less consistently. We observed within physician consistency in frequency of test ordering. In vignettes of younger children with mild disease, higher frequency testers were younger than lower frequency testers.Conclusions:These results suggest potential practice pattern variability, which needs to be further explored in real-life settings. If clinical outcomes for patients followed by low frequency testers match that of high frequency testers, then room to modify practice patterns and lower costs without compromising quality of care may exist.

BACKGROUND: Biosimilar therapies and their naming conventions are both relatively new to the drug development market and in clinical practice. We studied the use of the four-letter naming convention in practice and the knowledge, perceptions, and preferences of US health care providers. METHODS: A survey was distributed among health care professionals with a history of utilizing biosimilars in clinical practice to measure key knowledge and the presence of discernable naming trends. Differences in responses across pre-hypothesized subgroups were tested for statistical significance. RESULTS: Of the 506 surveys emailed, 83 (16%) people responded. Overall, there was poor knowledge about the key concepts surrounding biosimilars. For example, only 52% of respondents correctly identified that biosimilars were not the same as the generic drug; however, frequent use correlated with superior knowledge across all groups. In reference to naming preferences, 67% of all respondents indicated that they commonly use the brand name to distinguish biosimilars in clinical practice and a majority of them (85%) indicated that the brand name was easier to remember than the nonproprietary name with the four-letter suffix. An unexpected number of neutral responses was documented. Notably, more than half of respondents (68%) indicated a neutral response when asked if the four-letter suffix promoted medical errors. CONCLUSIONS: There remains a knowledge gap with regard to biosimilars, and lack of consensus on how the naming convention is and should be utilized in clinical practice. The data also suggest that effective biosimilar education could aid in promoting familiarity with the naming convention among health care providers.

Background Medical interns are at risk for sleep deprivation from long and often rotating work schedules. However, the effects of specific rotations on sleep are less clear. Objective To examine differences in sleep duration and alertness among internal medicine interns during inpatient intensive care unit (ICU) compared to general medicine (GM) rotations. Methods This secondary analysis compared interns during a GM or ICU rotation from a randomized trial (2015–2016) of 12 internal medicine residency programs assigned to different work hour limit policies (standard 16-hour shifts or no shift-length limits). The primary outcome was sleep duration/24-hour using continuous wrist actigraphy over a 13-day period. Secondary outcomes assessed each morning during the concomitant actigraphy period were sleepiness (Karolinska Sleepiness Scale [KSS]), alertness (number of Brief Psychomotor Vigilance Test [PVT-B] lapses), and self-report of excessive sleepiness over past 24 hours. Linear mixed-effect models with random program intercept determined associations between each outcome by rotation, controlling for age, sex, and work hour policy followed. Results Of 398 interns, 386 were included (n = 261 GM, n = 125 ICU). Average sleep duration was 7.00±0.08h and 6.84±0.10h, and number of PVT lapses were 5.5±0.5 and 5.7±0.7 for GM and ICU, respectively (all P > .05). KSS was 4.8±0.1 for both rotations. Compared to GM, ICU interns reported more days of excessive sleepiness from 12am–6am (2.6 vs 1.7, P < .001) and 6am–12pm (2.6 vs 1.9, P = .013) and had higher percent of days with sleep duration < 6 hours (27.6% vs 23.4%, P < .001). GM interns reported more days with no excessive sleepiness (5.3 vs 3.7, P < .001). Conclusions Despite ICU interns reporting more excessive sleepiness in morning hours and more days of insufficient sleep (

Two large national studies of resident duty hours incidentally revealed surgical and medical resident dissatisfaction with residency training. Aiming for an inclusive and democratic approach to improve graduate medical education, we conducted a national innovation tournament--reaching out to the program directors of all 474 US internal medicine residency programs to invite them and their residents and associate program directors to participate. Participants could submit multiple ideas as individuals or teams in four domains: [1] resident well-being and personal and professional development; [2] resident education and clinical preparedness; [3] resident sleep and alertness; and [4] patient safety. Residents and program directors were reinvited to rate ideas, whether they had submitted ideas themselves or not. We used a schedule of lottery-based prizes to stimulate the submission and rating of ideas and encourage engagement. 164 residents and program directors from 51 different programs submitted 328 ideas. 153 residents and program directors from 48 different programs submitted 15,345 ratings of ideas. Winning ideas aimed to reduce residents' work burden or improve their mental health, sleep, eating, or relaxation or reflected technical fixes to the operations of residency, such as changing vacation schedules and the timing of pay. The results of this tournament provided actionable suggestions to improve residency training now being tested in our own residency programs. Innovation tournaments drive engagement and generate value by their opportunities for inclusion and by shifting problem solving to the end user.

Recent literature has suggested racial disparities in Alpha Omega Alpha Honor Medical Society (AΩA) selection and raised concerns about its effects on the learning environment. Internal reviews at multiple institutions have led to changes in selection practices or suspension of student chapters; in October 2020, the national AΩA organization provided guidance to address these concerns.This study aimed to better understand student opinions of AΩA.An anonymous survey using both multiple response option and free response questions.Medical students at the Perelman School of Medicine at the University of Pennsylvania.Descriptive statistics and logistic regressions were used to examine predictors of student opinion towards AΩA. Free responses were analyzed by two independent coders to identify key themes.In total, 70% of the student body (n = 547) completed the survey. Sixty-three percent had a negative opinion of AΩA, and 57% felt AΩA should not exist at the student level. Thirteen percent believed AΩA membership appropriately reflects the student body; 8% thought selection processes were fair. On multivariate analysis, negative predictors of a student's preference to continue AΩA at the student level included belief that AΩA membership does not currently mirror class composition (OR: 0.45, [95% CI: 0.23-0.89]) and that AΩA selection processes were unfair (OR: 0.20 [0.08-0.47]). Self-perception as not competitive for AΩA selection was also a negative predictor (OR: 0.44 [0.22-0.88]). Major qualitative themes included equity, impact on the learning environment, transparency, and positive aspects of AΩA.This single-institution survey demonstrated significant student concerns regarding AΩA selection fairness and effects on the learning environment. Many critiques extended beyond AΩA itself, instead focusing on the perceived magnification of existing disparities in the learning environment. As the national conversation about AΩA continues, engaging student voices in the discussion is critical.

Purpose The purpose of this study was to explore the mentor-mentee relationship in veterans with type 2 diabetes and gain insight into successful pairings. Methods Qualitative semistructured interviews were conducted as part of a peer mentoring randomized controlled trial to understand participants’ experiences, their relationship with their partner, and how the intervention affected self-care behaviors. Purposive sampling was done to ensure adequate representation of mentees who made large strides in reaching their glycemic targets, those who made marginal improvements toward their glycemic goals, and those who got worse. All interviews were audio-recorded, transcribed, and analyzed for salient themes. Results The intervention was well received, with most participants describing it as valuable. Participants perceived the intervention to have a number of benefits, including accessible support, enhanced self-confidence, increased accountability, better self-efficacy, improved glycemic management, and a fulfilled sense of altruism. Participants did encounter barriers, including logistical, interpersonal, and individual obstacles. The more successful mentees tended to be more effusive in their description of their mentors, endorsed a stronger sense of connection to their mentor, described a more structured interaction with their mentor, and tended to be more complimentary of the intervention. Conclusions Large peer support programs are appealing and well received. These programs can be optimized by selecting naturally inclined mentors, providing additional training to introduce more structure into mentorship interactions, and targeting mentees who are not struggling with overwhelming comorbidities.

Objective Our objective was to explore knowledge, attitudes and beliefs about pregnancy and contraceptive decision-making among reproductive-aged women with cystic fibrosis. Study design In this qualitative study, we used purposive sampling of reproductive age women enrolled in the Adult Cystic Fibrosis program at Penn Medicine. We conducted semistructured one-on-one interviews lasting 30–60 min. Interviews were audio-recorded and transcribed verbatim. Data were analyzed using thematic analysis. Results We interviewed 24 women. Participants described shortened life span, personal health status and impact of cystic fibrosis on a potential child as three factors that were central to family planning. Future pregnancy intentions, perception of fertility including misconceptions and provider counseling influenced related contraception utilization. Conclusions Women with cystic fibrosis described thoughtful considerations about desired pregnancies to be planned during times of optimal health. Gaps in knowledge may limit a woman’s ability to make the most informed family planning decisions. Implications Having cystic fibrosis directly affects women’s decisions around pregnancy and family planning. Understanding what motivates women with cystic fibrosis to use or not to use contraception can improve family planning care delivery to this population.

Background The Pediatric Heart Network Collaborative Learning Study (PHN CLS) increased early extubation after infant tetralogy of Fallot (TOF) and coarctation repair overall at participating sites through implementing a clinical practice guideline (CPG). We evaluated variability across sites in CPG implementation and outcomes. Methods Patient characteristics and outcomes (time to extubation, length of stay [LOS]) were compared across sites, including pre-CPB to post-CPG changes. Semistructured interviews were analyzed to assess similarities and differences in implementation strategies across sites. Results A total of 322 patients were included (4 active sites, 1 model site). Patient characteristics were similar across active sites, whereas pre-CPG median time to extubation varied from 15.4 to 35.5 hours. All active sites had a significant post-CPG decline (p Conclusions All PHN CLS sites successfully reduced time to extubation. The magnitude of change varied and may be partly explained by different CPG implementation strategies. These data can guide CPG dissemination and design of future improvement projects.

We aimed to discover barriers and facilitators of HIV pre-exposure prophylaxis (PrEP) adherence in young men and transgender women of color who have sex with men (YMSM/TW). Short-term and sustained adherence were measured by urine tenofovir concentration and pharmacy refills, respectively. Optimal adherence was defined as having both urine tenofovir concentration consistent with dose ingestion within 48 hours and pharmacy refills consistent with ≥4 doses per week use. Participants completed semi-structured interviews exploring adherence barriers and facilitators. Participants (n=31) were primarily African-American (68%), mean age 22 years (SD: 1.8), and 48% had optimal adherence. Adherence barriers included stigma, health systems inaccessibility, side effects, competing stressors, and low HIV risk perception. Facilitators included social support, health system accessibility, reminders/routines, high HIV risk perception, and personal agency. Our findings identify targets for intervention to improve PrEP adherence in these populations, including augmenting health activation and improving accuracy of HIV risk perception.

BACKGROUND: Concern persists that extended shifts in medical residency programs may adversely affect patient safety. METHODS: We conducted a cluster-randomized noninferiority trial in 63 internal-medicine residency programs during the 2015–2016 academic year. Programs underwent randomization to a group with standard duty hours, as adopted by the Accreditation Council for Graduate Medical Education (ACGME) in July 2011, or to a group with more flexible duty-hour rules that did not specify limits on shift length or mandatory time off between shifts. The primary outcome for each program was the change in unadjusted 30-day mortality from the pretrial year to the trial year, as ascertained from Medicare claims. We hypothesized that the change in 30-day mortality in the flexible programs would not be worse than the change in the standard programs (difference-in-difference analysis) by more than 1 percentage point (noninferiority margin). Secondary outcomes were changes in five other patient safety measures and risk-adjusted outcomes for all measures. RESULTS: The change in 30-day mortality (primary outcome) among the patients in the flexible programs (12.5% in the trial year vs. 12.6% in the pretrial year) was noninferior to that in the standard programs (12.2% in the trial year vs. 12.7% in the pretrial year). The test for noninferiority was significant (P = 0.03), with an estimate of the upper limit of the one-sided 95% confidence interval (0.93%) for a between-group difference in the change in mortality that was less than the prespecified noninferiority margin of 1 percentage point. Differences in changes between the flexible programs and the standard programs in the unadjusted rate of readmission at 7 days, patient safety indicators, and Medicare payments were also below 1 percentage point; the noninferiority criterion was not met for 30-day readmissions or prolonged length of hospital stay. Risk-adjusted measures generally showed similar findings. CONCLUSIONS: Allowing program directors flexibility in adjusting duty-hour schedules for trainees did not adversely affect 30-day mortality or several other measured outcomes of patient safety. (Funded by the National Heart, Lung, and Blood Institute and Accreditation Council for Graduate Medical Education; iCOMPARE ClinicalTrials.gov number, NCT02274818.)

BACKGROUND: A purpose of duty-hour regulations is to reduce sleep deprivation in medical trainees, but their effects on sleep, sleepiness, and alertness are largely unknown. METHODS: We randomly assigned 63 internal-medicine residency programs in the United States to follow either standard 2011 duty-hour policies or flexible policies that maintained an 80-hour workweek without limits on shift length or mandatory time off between shifts. Sleep duration and morning sleepiness and alertness were compared between the two groups by means of a noninferiority design, with outcome measures including sleep duration measured with actigraphy, the Karolinska Sleepiness Scale (with scores ranging from 1 [extremely alert] to 9 [extremely sleepy, fighting sleep]), and a brief computerized Psychomotor Vigilance Test (PVT-B), with long response times (lapses) indicating reduced alertness. RESULTS: Data were obtained over a period of 14 days for 205 interns at six flexible programs and 193 interns at six standard programs. The average sleep time per 24 hours was 6.85 hours (95% confidence interval [CI], 6.61 to 7.10) among those in flexible programs and 7.03 hours (95% CI, 6.78 to 7.27) among those in standard programs. Sleep duration in flexible programs was noninferior to that in standard programs (between-group difference, −0.17 hours per 24 hours; one-sided lower limit of the 95% confidence interval, −0.45 hours; noninferiority margin, −0.5 hours; P = 0.02 for noninferiority), as was the score on the Karolinska Sleepiness Scale (between-group difference, 0.12 points; one-sided upper limit of the 95% confidence interval, 0.31 points; non-inferiority margin, 1 point; P

Background: Little is understood about the different ways patients complete advance directives (ADs), which is most commonly through lawyers and increasingly using websites. Objective: To understand patients’ perspectives on different approaches to facilitating AD completion, the value of legal regulation of ADs, and the use of a web-based platform to create an AD. Design: Semi-structured interviews with patients. Setting/Participants: We purposively sampled 25 patients at least 70 years of age or with a chronic disease from 2 internal medicine clinics. Measurements: Interviews focused on experiences and perspectives creating ADs, including facilitation by lawyers, health-care professionals, and websites. Feedback on a website prototype was also obtained. Responses were analyzed with modified grounded theory until thematic saturation was achieved. Results: Although a majority of participants with ADs had used lawyers, participants were ambivalent about the benefits of lawyer facilitation. Most valued both the medical perspective of a health-care professional and a lawyer’s attention to legal requirements for AD validity. Participants had positive impressions of the web platform, but some were concerned about privacy with online storage. Trust emerged as an overarching theme, and participants valued legal regulation of ADs to ensure document authenticity and delivery of preference-concordant care. Conclusion: Efforts to improve documentation of care planning need to address the disparate methods by which participants complete ADs. Creating options that combine the perceived benefits of a legal approach with greater health professional involvement could appeal to participants. Privacy concerns may limit web use by some patients.

Background: In 2019, nearly two decades after metformin approval, liraglutide became the third medication approved by the U.S. FDA for pediatric type 2 diabetes (T2D). However, successful uptake of liraglutide in practice depends on prescribers’ perceptions of acceptability and appropriateness of use in this population. Objective: We explored pediatric diabetes prescribers’ perceptions on ordering liraglutide, including facilitators and barriers, for youth with T2D at a single, large academic center. Methods: We conducted semi-structured interviews with diabetes attending physicians (A), fellow physicians (F), and nurse practitioners (NP) supplemented with a patient vignette, chart-stimulated recall (CSR), and review of a clinical practice guideline (CPG). Interviews were audio-recorded, transcribed, and analyzed using modified grounded theory by three coders with constant comparison techniques. Results: Nineteen physicians (15 A, 4 F) and 6 NPs with a median experience of 7 years (1.5- 40) participated. Themes identified included 1) primary drivers of use: desire to promote weight loss/maintenance or to avoid/reduce insulin use; 2) acceptance by patients and families: highest for those with familiarity with the medication class and interest in weight benefits; and 3) primary barriers to prescribing: patients’ dislike of injections or prescriber hesitancy due to lack of experience with the drug, concerns about adherence, or issues with insurance coverage. Although most responders recommended liraglutide when presented with a patient vignette, they recalled prescribing barriers in actual practice during CSR. The CPG was endorsed as a facilitator to prescribing, but additional dissemination and use strategies were recommended. Conclusions: Although liraglutide adds to the toolbox for pediatric T2D, our findings highlight the challenges of introducing new therapeutics and provide insights that may guide implementation efforts in pediatric diabetes clinics. Disclosure T. A. Hitt: None. S. Vazquez diaz: None. Y. Sanchez-kleinberg: None. J. A. Shea: None. L. E. Katz: None. M. Vajravelu: None. Funding National Institutes of Health (5T32DK063688-17, K23DK125719-01); University of Pennsylvania

BackgroundCardiovascular disease (CVD) remains a leading cause of morbidity and mortality worldwide, conferring a disparate burden on low-income and middle-income countries (LMICs). Haiti represents a resource-constrained setting, limited by a paucity of resources and trained cardiovascular professionals equipped to address the increasing burden of CVD.ObjectiveHere, we describe the creation of a comprehensive cardiology curriculum delivered through a virtual classroom. The curriculum was created to augment cardiovascular education in LMICs such as Haiti.MethodsOver one academic year (May 2019–2020), International Cardiology Curriculum Accessible by Remote Distance Learning-Haiti consisted of biweekly, live-streamed, synchronous didactic lectures, seminars and case presentations broadcasted to 16 internal medicine (IM) residents at Hôpital Universitaire de Mirebalais, one of only four IM training programmes in Haiti. The virtual classroom was created using commercially available videoconferencing and data-sharing platforms. Prelecture and postlecture surveys and an end of the year survey were administered to assess the impact of the curriculum.ResultsParticipant performance analysis revealed that 80% of the curriculum demonstrated a positive trend in knowledge acquisition postintervention. Based on the end of the year evaluation, 94% of participants reported that the curriculum was educational and relevant to medical practice in Haiti and 100% reported that the curriculum was good to excellent. Additionally, the curriculum was cited as an effective means of maintaining trainee education during the COVID-19 pandemic.ConclusionThis international medical education pilot study demonstrates the feasibility of augmenting cardiology education in LMICs by creating a virtual curriculum made possible by local partnerships, internet access and technology.

Objectives Blood cultures are fundamental in evaluating for sepsis, but excessive cultures can lead to false-positive results and unnecessary antibiotics. Our objective was to create consensus recommendations focusing on when to safely avoid blood cultures in PICU patients. Design A panel of 29 multidisciplinary experts engaged in a two-part modified Delphi process. Round 1 consisted of a literature summary and an electronic survey sent to invited participants. In the survey, participants rated a series of recommendations about when to avoid blood cultures on five-point Likert scale. Consensus was achieved for the recommendation(s) if 75% of respondents chose a score of 4 or 5, and these were included in the final recommendations. Any recommendations that did not meet these a priori criteria for consensus were discussed during the in-person expert panel review (Round 2). Round 2 was facilitated by an independent expert in consensus methodology. After a review of the survey results, comments from round 1, and group discussion, the panelists voted on these recommendations in real-time. Setting Experts' institutions; in-person discussion in Baltimore, MD. Subjects Experts in pediatric critical care, infectious diseases, nephrology, oncology, and laboratory medicine. Interventions None. Measurements and main results Of the 27 original recommendations, 18 met criteria for achieving consensus in Round 1; some were modified for clarity or condensed from multiple into single recommendations during Round 2. The remaining nine recommendations were discussed and modified until consensus was achieved during Round 2, which had 26 real-time voting participants. The final document contains 19 recommendations. Conclusions Using a modified Delphi process, we created consensus recommendations on when to avoid blood cultures and prevent overuse in the PICU. These recommendations are a critical step in disseminating diagnostic stewardship on a wider scale in critically ill children.