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Background: This paper aimed to describe the airway practices of intensive care units (ICUs) in Australia and New Zealand specific to patients presenting with COVID-19 and to inform whether consistent clinical practice was achieved. Specific clinical airway guidelines were endorsed in March 2020 by the Australian and New Zealand Intensive Care Society (ANZICS) and College of Intensive Care Medicine (CICM)., Methods and Findings: Prospective, structured questionnaire for all ICU directors in Australia and New Zealand was completed by 69 ICU directors after email invitation from ANZICS. The online questionnaire was accessible for three weeks during September 2020 and analysed by cloud-based software. Basic ICU demographics (private or public, metropolitan or rural) and location, purchasing, airway management practices, guideline uptake, checklist and cognitive aid use and staff training relevant to airway management during the COVID-19 pandemic were the main outcome measures. The 69 ICU directors reported significant simulation-based inter-professional airway training of staff (97%), and use of video laryngoscopy (94%), intubation checklists (94%), cognitive aids (83%) and PPE "spotters" (89%) during the airway management of patients with COVID-19. Tracheal intubation was almost always performed by a Specialist (97% of ICUs), who was more likely to be an intensivist than an anaesthetist (61% vs 36%). There was a more frequent adoption of specific airway guidelines for the management of COVID-19 patients in public ICUs (94% vs 71%) and reliance on specialist intensivists to perform intubations in private ICUs (92% vs 53%)., Conclusion: There was a high uptake of a standardised approach to airway management in COVID-19 patients in ICUs in Australia and New Zealand, likely due to endorsement of national guidelines., Competing Interests: Four authors were authors of The Safe Airway Society of Australia and New Zealand consensus statement on airway management and tracheal intubation specific to the COVID-19 adult patient group. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: The neurosurgery match is among the most competitive across all specialties. As a result, numerical Step U.S. Medical Licensing Examination Step 1 scores have historically played a major role in selecting applicants for interviews. With the anticipated change in Step 1 scoring to pass/fail will come significant ramifications for how program directors (PDs) screen and select applicants. The present study characterized the responses of PDs to the change in U.S. Medical Licensing Examination Step 1 scoring and its consequences on medical students applying to neurosurgery., Methods: After receipt of an institutional review board exemption, a validated 19-item survey was electronically distributed to 99 PDs of neurosurgery training programs as a part of a national study across 30 residency specialties. Descriptive statistical analyses were performed, and statistical significance was determined by nonoverlapping 95% confidence intervals., Results: A total of 48 responses were obtained (48.5%). Most PDs were men, with a mean age of 52 years, and, on average, had served 7.4 years as a PD. Most PDs (79%) disagreed with binary Step 1 scoring. Most (85%) believed the change will make objective comparison of applicants more difficult, and 83% reported they will begin to require Step 2 clinical knowledge scores with application submission. More than one half (71%) believed medical school reputation will become more important in resident selection. Only 15% believed that pass/fail Step 1 scoring will improve medical student well-being., Conclusion: Binary Step 1 scoring represents a significant change in medical student evaluations, with consequences for the neurosurgery residency application process. The results from the present study might help guide PD practices and prepare medical students for the anticipated changes to the application process., (Published by Elsevier Inc.)

Study Objectives: To quantify the readiness of individual academic emergency departments (EDs) in the United States for an outbreak of pandemic influenza. Methods, design, and setting: Cross-sectional assessment of influenza pandemic preparedness level of EDs in the United States via survey of medical directors and department chairs from the 135 academic emergency medicine departments in the United States. Preparedness assessed using a novel score of 15 critical preparedness indicators. Data analysis consisted of summary statistics, χ 2 , and ANOVA., Participants: ED medical directors and department chairs., Results: One hundred and thirty academic emergency medicine departments contacted; 66 (50.4 percent) responded. Approximately half (56.0 percent) stated their ED had a written plan for pandemic influenza response. Mean preparedness score was 7.2 (SD = 4.0) out of 15 (48.0 percent); only one program (1.5 percent) achieved a perfect score. Respondents from programs with larger EDs (=30 beds) were more likely to have a higher preparedness score (p < 0.035), an ED pandemic preparedness plan (p = 0.004) and a hospital pandemic preparedness plan (p = 0.007). Respondents from programs with larger EDs were more likely to feel that their ED was prepared for a pandemic or other major disease outbreak (p = 0.01). Only one-third (34.0 percent) felt their ED was prepared for a major disease outbreak, and only 27 percent felt their hospital was prepared to respond to a major disease outbreak., Conclusions: Significant deficits in preparedness for pandemic influenza and other disease outbreaks exist in US EDs, relative to HHS guidelines, which appear to be related in part to ED size. Further study should be undertaken to determine the barriers to appropriate pandemic preparedness, as well as to develop and validate preparedness metrics.

Summary: Small surgical residency programs like plastic surgery can be challenging environments to accommodate parental leave. This study aimed to report the experiences, attitudes and perceived support of Canadian plastic surgery residents, recent graduates and staff surgeons with respect to pregnancy and parenting during training. Residents and staff surgeons were invited via email to participate in an online survey. The results presented here explore experiences of pregnancy and parental leave of current plastic surgery residents and staff surgeons. Residents' and staff surgeons' perceptions of program director support, policies, negative comments and the impact of parental leave on the workload of others were also explored. Although the findings suggest that there may be improvements in the support of program directors, there continues to be a negative attitude in surgical culture toward pregnancy during residency. The perceived confusion of respondents with respect to programspecific policies emphasizes the need for open conversations and standardization of parental leave.

Clinical teaching is the primary educational tool use to train learners from day one of medical school all the way to the completion of fellowship. However, concerns over time constraints and patient census have led to a decline in bedside teaching. This paper provides a critical review of the literature on clinical teaching with a focus on instructor teaching strategies, clinical teaching models, and suggestions for incorporating technology. Recommendations for instructor-related teaching factors include adequate preparation, awareness of effective teacher attributes, using evidence-based-knowledge dissemination strategies, ensuring good communication, and consideration of environmental factors. Proposed recommendations for potential teaching strategies include the Socratic method, the One-Minute Preceptor model, SNAPPS, ED STAT, teaching scripts, and bedside presentation rounds. Additionally, this article will suggest approaches to incorporating technology into clinical teaching, including just-in-time training, simulation, and telemedical teaching. This paper provides readers with strategies and techniques for improving clinical teaching effectiveness.

Emergency medicine residency programs around the country develop didactic conferences to prepare residents for board exams and independent practice. To our knowledge, there is not currently an evidence-based set of guidelines for programs to follow to ensure maximal benefit of didactics for learners. This paper offers expert guidelines for didactic instruction from members of the Council of Emergency Medicine Residency Directors Best Practices Subcommittee, based on best available evidence. Programs can use these recommendations to further optimize their resident conference structure and content. Recommendations in this manuscript include best practices in formatting didactics, selection of facilitators and instructors, and duration of individual sessions. Authors also recommend following the Model of Clinical Practice of Emergency Medicine when developing content, while incorporating sessions dedicated to morbidity and mortality, research methodology, journal article review, administration, wellness, and professionalism.

Background: The process of entrustment-placing trust in a trainee to independently execute a task-has been proposed as a complementary metric to assess competence. However, entrustment decision-making by trainee supervisors is not well understood in surgical training. We aim to explore processes underlying entrustment decision-making (EDM) by general surgery program directors., Materials and Methods: Purposive sampling was used to recruit 20 program directors from Accreditation Council for Graduate Medical Education-accredited general surgery training programs to participate in a one-hour semistructured interview. We analyzed interviews using an iterative and inductive approach to identify novel themes associated with the process of trainee entrustment., Results: Qualitative analysis identified that program directors rely on a network of faculty to make entrustment decisions regarding trainees. Perceived trainee competence to perform independent clinical tasks varies significantly in and out of the operating room (OR), with a strong emphasis on entrustment for technical competencies to the exclusion of cognitive competencies. In the OR, entrustment is informed by an attending's reflexive trust and physical presence, trainee labels, and presumed discernment. Outside of the OR, trainee labels, presumed discernment, and transference of competence were identified as critical themes., Conclusions: Modifiable components of entrustment are equally dependent on trainee and faculty behavior. Entrustment is more heavily informed by trainee performance in the OR, despite program directors uniformly stating that judgment outside of the OR is the most critical component of resident training. The inclusion of EDM to evaluate trainee progression should be considered as an important adjunct to established Accreditation Council for Graduate Medical Education milestones., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective This study gathered information from public hospital chief medical officers to better understand underlying mechanisms through which public reporting affects institutional behavioural change and decision making towards quality improvement. Methods This qualitative study used thematic analysis of 17 semistructured, in-depth interviews among a peak group of medical directors representing 26 health services in Victoria, Australia. Results The medical directors indicated a high level of in-principle support for public reporting of identifiable, individual clinician-level data. However, they also described varying conceptual understanding of what public reporting of performance data is. Overall, they considered public reporting of individual clinicians' performance data a means to improve health care quality, increase transparency and inform consumer healthcare decision making. Most identified caveats that would need to be met before such data should be publicly released, in particular the need to resolve issues around data quality and timeliness, context and interpretation and ethics. Acknowledgement of the public's right to access individual clinician-level data was at odds with some medical directors' belief that such reporting may diminish trust between clinicians and their employers, thus eroding rather than motivating quality improvement. Conclusions Public reporting of identifiable individual healthcare clinicians' performance data is an issue that merits robust research and debate given the effects such reporting may have on doctors and on hospital quality and safety. What is known about the topic? The public reporting of individual clinician-level data is a mechanism used in some countries, but not in Australia, for increasing health care transparency and quality. Clinician-level public reporting of doctors' performance attracts contention and debate in Australia. What does this paper add? This paper informs debate around the public reporting of individual clinician-level performance data. Among a discrete cohort of senior hospital administrators in Victoria, Australia, there was strong in-principle support for such public reporting as a means to improve hospital quality and safety. What are the implications for practitioners? Before public reporting of individual clinician performance data could occur in Australia, resolution of issues would be required relating to legality and ethics, data context and interpretation, data quality and timeliness.

Background: The culture at a medical school and the positive experiences in primary care clerkships influence student specialty choice. This choice is significant if the demand for primary care physicians is to be met. The aim of this study was to examine family medicine clerkship directors' perceptions of the medical school environment., Methods: Data were collected as part of the 2015 Council of Academic Family Medicine Educational Research Alliance Family Medicine Clerkship Director survey. Questions asked included how clerkship directors perceived the environment of their medical school towards family medicine, has the environment towards family medicine changed between 2010 and 2015, do they take action to influence student attitudes towards family medicine and whether faculty members in other departments make negative comments about family medicine., Results: The response rate was 79.4%. While most respondents indicated the environment of their medical school has become more positive towards family medicine, a majority of clerkship directors perceived the environment to be either very much against, slightly against or indifferent towards family medicine. Nearly one-half (41.4%) of the clerkship directors were notified more than once a year that a faculty member of another department made a negative comment about family medicine. Results varied among regions of the USA and between schools located in the USA and Canada., Conclusion: Family medicine clerkship directors often perceived negativity towards family medicine, a finding that may limit the effectiveness of academic health centres in their mission to better serve their community and profession., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Importance: Many rural and agricultural communities experience hardship from a shortage of clinicians. The aging of the clinician population threatens future supply in these areas. Developing policies to build a sustainable workforce requires the understanding of experiences from those currently in medical practice. Previous research about rural clinicians has primarily sampled non-Latinx white men, and to a lesser extent, non-Latinx white women; to date, no study has examined differences by race/ethnicity, sexual orientation, or gender identity., Objective: To describe the professional experiences of a diverse group of primary care clinicians and clinic directors in an underserved rural and agricultural region of California., Design, Setting, and Participants: In this qualitative study, semistructured in-depth qualitative interviews were performed with clinicians and clinic directors from December 1, 2017, to December 31, 2018, with a present or recent medical practice in the central San Joaquin Valley region of California. Participants (N = 26) consisted of physicians, nurse practitioners, and clinic directors practicing in primary care settings. Settings included solo and group private practice, academic training programs, community health centers, and rural health clinics., Main Outcomes and Measures: Personal experiences as primary care clinicians and clinic directors, and perceived associations with gender, race/ethnicity, sexual orientation, and gender identity., Results: Of 26 primary care clinicians and clinic directors interviewed, 16 (62%) identified as female, 12 (46%) identified as non-Latinx white, and 3 (12%) identified as a member of a sexual and gender minority group. Participants who self-identified as female, nonwhite, and of certain sexual orientation and gender identity minority groups described burnout from bias, harassment, and hostility in their professional relationships with colleagues and health care staff. These experiences intensified their feelings of community isolation and professional isolation. Harassment and institutional discrimination were factors in the decision of participants to change practices or exit the region entirely. Discriminatory acts against members of sexual and gender minority groups were the most severe, including threats to licensure and denial of hospital admitting privileges. In contrast to the minority group participants, the remaining participants expressed little to no awareness of these negative experiences, or the association between these experiences and retention., Conclusions and Relevance: Professional harassment and discrimination may hamper efforts to improve clinician and clinic director recruitment and retention in underserved rural and agricultural areas and may pose barriers to addressing health disparities within those communities. Additional investigation appears to be needed to assess the extent to which professional harassment and discrimination affect clinicians and clinic directors in similar communities across the United States.

Background: Chair of the Department of Surgery, sometimes known as the Chief, holds a title that has significant historical connotations. Our goal was to assess a group of objectively measurable characteristics that unify these individuals as a group., Methods: Utilizing publicly available data for all US teaching hospitals, demographic information was accumulated for the named chiefs/chairs of surgery. Information collected included location of their program, their medical/surgical training history, their surgical specialty, previous chair/chief titles held, and academic productivity., Results: Of the 259 programs listed, data were available on 244 individuals who were trained in 19 different specialties. The top three specialties of these practitioners are General Surgery (40, 16.3%), Surgical Oncology (38, 15.5%), and Vascular Surgery (33, 13.5%). There were only 14 female chairs (5.7%) and only one chair with a doctor of osteopathic medicine degree. The majority (62.3%) had been a previous chief of a surgical subdivision with only 26% having been a previous chair/chief of the surgical department. The average chair had 72 peer-reviewed manuscripts with 28 published book chapters. Chair's at academic institutions with university affiliation had a significantly higher number of peer-reviewed manuscripts (P < 0.0001) as well as were more likely to be trained at academic institutions (P = 0.013)., Conclusions: There are no set characteristics that define the Chair of a Department of Surgery. By understanding a group of baseline characteristics that unify these surgical leaders, young faculty and trainees with leadership aspirations may begin to understand what is necessary to fill these roles in the future., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The American College of Surgeons' Trauma Quality Improvement Program (TQIP) provides trauma centres with performance reports on their processes and outcomes of care relative to their peers. This study explored how performance reports are used by trauma centre leaders to engage in performance improvement and perceived barriers to use., Study Design: Qualitative focus group study with trauma medical directors (TMDs) and trauma programme managers (TPMs) in US trauma centres. Consistent with qualitative descriptive analysis, data collection and interpretation were inductively and iteratively completed. Major themes were derived using a constant comparative technique., Results: Six focus groups were conducted involving 22 TMDs and 22 TPMs. Three major themes were captured: (1) technical uses of performance reports; (2) cultural uses of performance reports; (3) opportunities to enhance the role and value of TQIP. First, technical uses included using reports to assess data collection procedures, data quality and areas of poor performance relative to peers. In this domain, barriers to report use included not trusting others' data quality and challenges with report interpretation. Second, reports were used to influence practice change by fostering inter-specialty discussions, leveraging resources for quality improvement, community engagement and regional collaboratives. Perceived lack of specialist engagement was viewed as an impediment in this domain. Lastly, identified opportunities for TQIP to support report use involved clarifying the relationship between verification and performance reports, and increasing partnerships with nursing associations., Conclusion: Trauma centre improvement leaders indicated practical and social uses of performance reports that can affect intention and ability to change. Recommendations to optimise programme participation include a focus on data quality, adequate resource provision and enhanced support for regional collaboratives., Competing Interests: Competing interests: AN is Medical Director of the American College of Surgeons’ trauma quality programmes. CH is Manager of Data and Report Operations at American College of Surgeons. MN is Program Manager, Trauma Quality Improvement Program at American College of Surgeons., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Little is known about the level of burnout among program administrators (PAs) working in graduate medical education., Objective: We created a national database with baseline burnout data for PAs from residency and fellowship programs, including intention to leave their current positions., Methods: A cross-sectional study was conducted in July 2017 to assess levels of burnout in a national cohort of PAs, who were largely members of online specialty forums. The Copenhagen Burnout Inventory (CBI) was used to measure burnout. Univariate analysis produced descriptive statistics for CBI. We performed a 2-sample t test to measure differences in average burnout scores for those who had thoughts of resigning from their positions and those who had not., Results: Of the approximately 10 205 national PAs, we sampled 1126 (11%). Of the 1126 individuals who received the study information, 931 (83%) completed the baseline survey. Total mean scores for all subscales were elevated (personal: 53.7, SD 21.4; work-related: 52.0, SD 22; and client-related: 30.6, SD 20.8; each scale ranged from 0, low, to 100, high). Burnout scores differed between those contemplating leaving their jobs and those who were not, across all subscales of CBI, including personal (64.2 versus 42.4, -24.18 to -19.44 confidence interval [CI]), work-related (63.5 versus 39.7, -26.12 to -21.35 CI), and client-related (36.6 versus 24.2, -14.95 to -9.84 CI; P < .0001 for all)., Conclusions: In this national survey of PAs, burnout scores measured by the CBI were higher among those who had considered leaving their positions., Competing Interests: Conflict of interest: The authors declare they have no competing interests.

Background: There is an increasing number of pediatric urgent care centers that are largely staffed by pediatric residency graduates. It is unclear if pediatric residency adequately prepares a physician to fully and successfully provide care in an urgent care setting. The goal of this study is to conduct an assessment of urgent care directors' perceptions of recent pediatric residency graduates' preparedness to successfully provide pediatric urgent care after graduation., Methods: This is a 2018 cross-sectional survey of all pediatric emergency medicine division chiefs in the United States and all pediatric urgent care directors who are members of the Society for Pediatric Urgent Care. An electronic survey was distributed consisting of eight multiple choice questions regarding perceived preparedness and knowledge gaps of recent pediatric residency graduates for independent practice in urgent care. Descriptive statistics were used to analyze results and qualitative data were analyzed via an inductive thematic approach., Results: Forty-two percent (65/154) of surveys were completed. No respondents believed that a recent pediatric residency graduate would be adequately prepared to independently practice in a pediatric urgent care and 81% of respondents recommended some additional training. Most respondents described this training as important (46%) or very important (35%). Most respondents recommended between 6 months and 1 year as the appropriate amount of time to achieve competency., Conclusions: Despite the growing number pediatric residency graduates staffing pediatric urgent care centers, the majority of surveyed pediatric emergency medicine division chiefs and pediatric urgent care directors do not think that pediatric residency adequately prepares graduates to successfully provide urgent care to pediatric patients. We recommend further exploration of gaps in knowledge of recent pediatric residency graduates as a next step towards developing systems for further training for pediatric residency graduates to gain competency in urgent care management.

Purpose of Review: Against the background of increasing healthcare costs and diminishing budgets, this review aims to present clinicians with ethically viable options to overcome budgetary restraints when seeking to introduce novel products., Recent Findings: Healthcare administrators and primary healthcare providers are not unlikely to have different opinions when discussing the introduction of novel products. However, rather than taking a 'no' for an answer, doctors may be able to argue for a change - even if this may seem to come at a higher cost. The recent introduction of the reversal agent sugammadex may provide a timely example for the possibility of success 'against all financial odds'., Summary: Health professionals have the responsibility to deliver high-quality care while acknowledging the financial budget constraints. However, evidence (vs. perception) for outcome benefits of novel drugs or devices should stimulate a robust desire for their timely introduction. Demonstrating actual benefits understandable to administrators, seeking alliances with other medical specialties or patient groups, as well as negotiations with the healthcare industry may all represent viable options. Simply waiting for patents to expire should remain a measure of last resort.

Purpose: The purpose of this paper is to gain a better understanding of the difficulties encountered in the hybrid roles of physician-managers (P-Ms), examine the impact of organizational constraints on the role conflicts experienced by P-Ms and explore the different ways their two roles are integrated., Design/methodology/approach: A qualitative approach was adopted, using six focus groups made up of clinical co-managers, medical directors and P-Ms. In all, 43 different people were interviewed to obtain their perceptions of the day-to-day realities of the role of the P-M. The data collected were subsequently validated., Findings: Although the expectations of the different groups involved regarding the role of P-Ms are well understood and shared, there are significant organizational constraints affecting what P-Ms are able to do in their day-to-day activities, and these constraints can result in role conflicts for the people involved. Such constraints also affect the ways P-Ms integrate the two roles. The authors identify three role hybridization profiles., Practical Implications: The results afford a better understanding of how organizational constraints might be used as levers of organizational change to achieve a better hybridization of the dual roles of P-Ms., Originality/value: This paper seeks to reach beyond a simple identification of constraints affecting the dual roles of P-Ms by analyzing how such constraints impact on these professionals' day-to-day activities. Results also enable us to further refine Katz and Kahn's (1966) role model, in addition to identifying hybridization profiles.

Objective:: To determine attitudes of residents and program directors towards research during residency training., Study Design:: Survey of current otolaryngology residents and program directors., Setting:: Otolaryngology residency programs., Methods:: An anonymous web-based survey ( www.surveymonkey.com ) was sent to 106 program directors (PDs) and 115 program coordinators. The program coordinators subsequently sent it to residents. Fisher exact tests and correlations were used to determine statistically significant differences., Results:: Overall, 178 residents and 31 PDs responded to our surveys. All residents surveyed reported some research experience prior to residency. Residents who reported a previous first-author manuscript publication prior to residency were more likely than residents who had no previous first-author publication to report a first-author publication during residency (58.44% vs 27.27%, P < .0001); 33% of the residents reported academics as a desired future career setting after residency. The most significant barrier to research perceived by the residents was time constraint due to residency duties and personal commitments (93% and 74%, respectively). The second and third most common barriers to research were lack of statistical knowledge at 52% and lack of interest in research at 43.6%., Conclusions:: Research is a required component of otolaryngology residency training. The most significant barrier in our survey was the lack of protected research time, followed by lack of biostatistical knowledge and interest. Program directors may need to implement structured research rotations tailored to individual residents' research interests and integrate training in research methodology and biostatistics.

Background: Management by Objectives (MbO) has been shown to establish efficient team work in both industry and medicine. Its most important prerequisite for success is target agreements between managers and medical professionals on equal footing. In medicine, lump-sum financing urges the delivery of a health care service with minimal effort. Consequently, daily clinical life changed, with economic goals seeming to become priority over medical principles., Objective: To determine how well MbO can still be practiced in hospitals with lumped treatment prices., Methods: We used an anonymized questionnaire for already retired physician executives who completed their active leadership positions between 2010 and 2015 in Saxony (Germany). We asked various type of target agreements that had been used in order to achieve medical or economic targets., Results and Conclusions: Out of 111 former executives, the questionnaires of 25 respondents could be analysed. Eight respondents confirmed target agreements that were mostly set by managing directors. If used, most targets had not been adapted to the infrastructure and personnel strength, nor were they coordinated with neighbouring departments. Four respondents received financial incentives. Most medical executives were unsatisfied and preferred to abandon further goal setting. Due to the low number of cases, the representativeness of the study is limited. Nevertheless, it might be questioned if a flat-rate remuneration system facilitates the change into an authoritarian leadership concept.

Background: Behavioral economics is a field of economics that draws on insights from psychology to understand and identify patterns of decision making. Cognitive biases are psychological tendencies to process information in predictable patterns that result in deviations from rational decision making. Previous research has not evaluated the influence of cognitive biases on decision making in a managed care setting., Objective: To assess the presence of cognitive biases in formulary decision making., Methods: An online survey was conducted with a panel of U.S. pharmacy and medical directors who worked at managed care organizations and served on pharmacy and therapeutics committees. Survey questions assessed 4 cognitive biases: relative versus absolute framing effect, risk aversion, zero-risk bias, and delay discounting. Simulated data were presented in various scenarios related to adverse event profiles, drug safety and efficacy, and drug pricing for new hypothetical oncology products. Survey questions prompted participants to select a preferred drug based on the information provided. Survey answers were analyzed to identify decision patterns that could be explained by the cognitive biases. Likelihood of bias was analyzed via chi-square tests for framing effect, risk aversion, and zero-risk bias. The delay discounting section used a published algorithm to characterize discounting patterns., Results: A total of 35 pharmacy directors and 19 medical directors completed the survey. In the framing effect section, 80% of participants selected the suboptimal choice in the relative risk frame, compared with 38.9% in the absolute risk frame (P < 0.0001). When assessing risk aversion, 42.6% and 61.1% of participants displayed risk aversion in the cost- and efficacy-based scenarios, respectively, but these were not statistically significant (P = 0.27 and P = 0.10, respectively). In the zero-risk bias section, results from each scenario diverged. In the first zero-risk bias scenario, 90.7% of participants selected the drug with zero risk (P < 0.001), but in the second scenario, only 32.1% chose the zero-risk option (P < 0.01). In the section assessing delay discounting, 54% of survey participants favored a larger delayed rebate over a smaller immediate discount. A shallow delay discounting curve was produced, which indicated participants discounted delayed rewards to a minimal degree., Conclusions: Pharmacy and medical directors, like other decision makers, appear to be susceptible to some cognitive biases. Directors demonstrated a tendency to underestimate risks when they were presented in relative risk terms but made more accurate appraisals when information was presented in absolute risk terms. Delay discounting also may be applicable to directors when choosing immediate discounts over delayed rebates. However, directors neither displayed a statistically significant bias for risk aversion when assessing scenarios related to drug pricing or clinical efficacy nor were there significant conclusions for zero-risk biases. Further research with larger samples using real-world health care decisions is necessary to validate these findings., Disclosures: This research was funded by Xcenda. Mezzio, Nguyen, and O'Day are employees of Xcenda. Kiselica was employed by Xcenda at the time the study was conducted. The authors have nothing to disclose. A portion of the preliminary data was presented as posters at the 2017 AMCP Managed Care & Specialty Pharmacy Annual Meeting; March 27-30, 2017; in Denver, CO, and the 2017 International Society for Pharmacoeconomics and Outcomes Research 22nd Annual International Meeting; May 20-24, 2017; in Boston, MA.

PurposeTo assess perceptions and attitudes toward disasters and disaster planning among outpatient primary care leaders., Methods: Written surveys and semi-structured interviews of non-physician clinical managers and physician medical directors were conducted using the 2009 H1N1 pandemic as a case-based scenario at 5 university-affiliated family medicine clinics. Domains assessed included perceived pandemic threat; value, existence, and barriers to creating personal disaster plans; staff absenteeism estimates; barriers to work attendance. Quantitative and qualitative data were analyzed using descriptive statistics and content analysis with identification and coding of common themes, respectively., Results: All 12 invited leaders participated and believed a personal disaster plan was important but only 2 had plans. None had ever discussed with their staff the importance of having a personal disaster plan. Two common barriers in creating a plan were low threat perception level and never considering the possibility of pandemic influenza. Only half of respondents could list common barriers preventing staff from working. Staff were confident employees would come to work during a disaster., Conclusion: Outpatient primary care leaders may hold misconceptions regarding future disasters, underestimate their potential impact on clinics, and lack personal preparedness. Further investigation and interventions are needed to ensure clinics can be prepared so they can function and help hospital and emergency services when disasters strike. (Disaster Med Public Health Preparedness. 2018;12:644-648).

Purpose This study aims to explore the structural aspects (roles, responsibilities and reporting) of dyad leadership in one health-care organization (HCO). Design/methodology/approach The perceptions of 32 leaders (17 physician leaders and 15 dyad co-leaders) in formal leadership positions (six first-level with formal authority limited to teams or divisions, 23 middle-level with wider departmental or program responsibility and three senior-level with institution-wide authority) were obtained through focus groups and surveys. In addition, five senior leaders were interviewed. Descriptive statistics was used for quantitative data, and qualitative data were analyzed for themes by coding and categorization. Findings There are a large number of shared responsibilities in the hybrid model, as most activities in HCOs bridge administrative and professional spheres. These span the leadership (e.g. global performance and quality improvement) and management (e.g. human resources, budgets and education delivery) domains. The individual responsibilities, except for staff and physician engagement are in the management domain (e.g. operations and patient care). Both partners are responsible for joint decision-making, projecting a united front and joint reporting through a quadrat format. The mutual relationship and joint accountability are key characteristics and are critical to addressing potential conflicts and contradictions and achieving coherence. Practical implications Clarity of role will assist development of standardized job descriptions and required competencies, recruitment and leadership development. Originality/value This is an original empirical study presenting an integrated view of dyad leaders and senior leadership, meaningful expansion of shared responsibilities including academic functions and developing mutual relationship and emphasizing the central role of stability generating management functions.

Recently, a student-initiated movement to end the United States Medical Licensing Examination Step 2 Clinical Skills and the Comprehensive Osteopathic Medical Licensing Examination Level 2-Performance Evaluation has gained momentum. These are the only national licensing examinations designed to assess clinical skills competence in the stepwise process through which physicians gain licensure and certification. Therefore, the movement to end these examinations and the ensuing debate merit careful consideration. The authors, elected representatives of the Directors of Clinical Skills Courses, an organization comprising clinical skills educators in the United States and beyond, believe abolishing the national clinical skills examinations would have a major negative impact on the clinical skills training of medical students, and that forfeiting a national clinical skills competency standard has the potential to diminish the quality of care provided to patients. In this Perspective, the authors offer important additional background information, outline key concerns regarding the consequences of ending these national clinical skills examinations, and provide recommendations for moving forward: reducing the costs for students, exploring alternatives, increasing the value and transparency of the current examinations, recognizing and enhancing the strengths of the current examinations, and engaging in a national dialogue about the issue.

Background and Objective: To determine whether family medicine program directors (PDs) experienced moral distress due to obstacles to Hepatitis C virus (HCV) treatment, and to explore whether they found those obstacles to be unethical., Design: An omnibus survey by the Council of Academic Family Medicine's Educational Research Alliance was administered to 452 and completed by 273 US-based PDs. The survey gauged attitudes and opinions regarding ethical dilemmas in patient access to HCV treatment., Results: Most of the respondents were male. Sixty-four percent of respondents believed that treatment should be an option for all patients regardless of cost. Forty-one percent believed that it was unethical to deny treatment based on past or current substance use, and 38% believed treatment should be offered to patients who were substance abusers. Moral distress was reported by 61% (score >3) of participants when they were unable to offer treatment to patients due to the patient's failure to meet eligibility criteria. In addition, PDs reporting moderate-to-high levels of moral distress were also likely to report the following opinions: 1) treatment should be offered regardless of cost, 2) it is unethical to deny treatment based on past behavior, 3) substance abusers should be offered treatment, 4) it is unethical for medicine to be prohibitively expensive, and 5) Medicaid policy that limits treatment will worsen racial and ethnic disparities., Conclusions: Currently, important ethical dilemmas exist in the access and delivery of HCV therapy. Although a diversity of opinions is noted, a significant proportion of PDs are concerned about patients' inability to avail equitable care and experience distress. In some cases, this moral distress is in response to, and in conflict with, current guidelines., Competing Interests: Conflict of interest: AS, CMW, RP, NRK, and PJV conceived the study. CMW, AS, and RP analyzed the data. CMW, AS, NRK, PJV, and RP drafted and edited the manuscript. All authors reviewed and approved the final manuscript. AS had full access to all the study data and takes responsibility for the integrity and accuracy of the data and data analysis. No competing interests exist for any of the authors., (© Copyright 2018 by the American Board of Family Medicine.)

Objective: The primary purpose of this study was to determine the prevalence of burnout among Psychiatry clerkship directors., Methods: Psychiatry clerkship directors were solicited via email to complete an electronic version of the Maslach Burnout Inventory-General Survey and the Respondent Information Form., Results: Fifty-four out of 110 surveys (49%) were completed. Fourteen percent of respondents scored in the "high exhaustion" category, 21.6% scored in the "low professional efficacy" category, 20.4% scored in the "high cynicism" category, and 15.1% of respondents met threshold for at least two of the three categories. Those who scored in the "low professional efficacy" category reported higher levels of salary support for research, while those who scored in the "high cynicism" category reported lower levels of salary support at a trend level. Those who scored in the "high cynicism" category were younger., Conclusions: Approximately 14-22 percent of psychiatry clerkship directors reported some level of burnout depending on the subscale used. Future studies should aim to better identify those clerkship directors who are at greatest risk for becoming burned out by their educational role and to clarify the link between salary support for research, age, and burnout.

Background and Objectives: Nearly one-half (46%) of physicians report at least one symptom of burnout. Family medicine residency program directors may have similar and potentially unique levels of burnout as well as resiliency. The primary aims of this study were to examine burnout and resiliency among family medicine residency directors and characterize associated factors., Methods: The questions used were part of a larger omnibus survey conducted by the Council of Academic Family Medicine (CAFM) Educational Research Alliance (CERA) in 2016. Program and director-specific characteristics were obtained. Symptoms of burnout were assessed using two single-item measures adapted from the full Maslach Burnout Inventory, and level of resiliency was assessed using the Brief Resilience Scale., Results: The overall response rate for the survey was 53.7% (245/465). Symptoms of high emotional exhaustion or high depersonalization were reported in 27.3% and 15.8% of program directors, respectively. More than two-thirds of program directors indicated that they associated themselves with characteristics of resiliency. Emotional exhaustion and depersonalization were significantly correlated with never having personal time, an unhealthy work-life balance, and the inability to stop thinking about work. The presence of financial stress was significantly correlated with higher levels of emotional exhaustion and depersonalization. In contrast, the level of resiliency reported was directly correlated with having a moderate to great amount of personal time, healthy work-life balance, and ability to stop thinking about work, and negatively correlated with the presence of financial stress., Conclusions: Levels of emotional exhaustion, depersonalization, and resiliency are significantly related to personal characteristics of program directors rather than characteristics of their program.

Objectives: to explore clinicians vision on hospital discharge records in order to identify useful elements to foster a more accurate compiling., Design: qualitative research with phenomenological approach., Setting and Participants: participants were selected through purposive sampling among clinicians of two hospitals located in Sardinia; the sample included 76 people (32 medical directors and 44 doctors in training)., Main Outcome Measures: identified codes for themes under investigation: vision of accurate compiling, difficulties, and proposals., Results: collected data highlighted two prevailing visions, respectively focused on the importance of an accurate compiling and on the burden of such activity. The accurate compiling is hindered by the lack of motivation and training, by the limits of the registration system and the information technology, by the distortions induced by the prominent role of the hospital discharge records in the evaluation processes. Training, timely updating of the information system accompanied by a proper cross-cultural validation process, improvement of the computer system, and activation of support services could promote more accurate compiling., Conclusions: the implementation of services, unconnected with evaluation and control processes, dedicated to training and support in the compiling of the hospital discharge records and in the conduction of related epidemiological studies would facilitate the compliance to the compilation. Such services will make tangible the benefits obtainable from this registration system, increasing skills, motivation, ownership, and facilitating greater accuracy in compiling.

Aim: The aim of this study was to describe the process of how nurse and physician managers in formalized dyads work together to address clinical management issues in the surgical division of one hospital setting., Background: Nurse and physician managers are uniquely positioned to co-lead and transform healthcare delivery. However, little is known about how this management dyad functions in the healthcare setting., Design: A constructivist grounded theory approach was used to investigate the process of how nurse and physician managers work together in formalized dyads in an urban Canadian university affiliated teaching hospital., Methods: Data collection occurred from September 2013-August 2014. Data included participant observation (n = 142 hours) and intensive interviews (n = 36) with nurse-physician manager dyads (12 nurses, 9 physicians) collected in a surgical department. Theoretical sampling was used to elaborate on properties of emerging concepts and categories., Results/findings: A substantive theory on 'intentional partnering' was generated. Nurses' and physicians' professional agendas, which included their interests and purposes for working with each other served as the starting point of 'intentional partnering'. The theory explains how nurse and physician managers align their professional agendas through the processes of 'accepting mutual necessity', 'daring to risk (together)' and 'constructing a shared responsibility'. Being credible, earning trust and safeguarding respect were fundamental to communicating effectively., Conclusion: Intentional partnering elucidates the relational components of working together and the strategizing that occurs as each partner deliberates on what he or she is willing to accept, risk and put into place to reap the benefits of collaborating., (© 2017 John Wiley & Sons Ltd.)

Background: Desirable candidate characteristics for aesthetic surgery fellowship applicants remain unknown because of a lack of data in the literature., Objectives: This study aims to identify the criteria used to select applicants for aesthetic surgery fellowship in the United States., Methods: A 38-question survey was sent in April 2015 to all directors of fellowships endorsed by the American Society for Aesthetic Plastic Surgery (n = 20) in the United States. The survey investigated various factors including residency training and fellowship interview. A 5-point Likert scale was used to grade 33 influential factors from 1 ("not at all important") to 5 ("essential"); a separate 5-point Likert scale was used for 5 controversial factors from 1 ("very negative impact") to 5 ("very positive impact")., Results: Sixty-five percent (13 out of 20) of directors responsed. The most important factors were letters of recommendation by well-established plastic surgeons (4.6 ± 0.7), interpersonal skills (4.5 ± 0.8), overall interview performance (4.5 ± 0.7), professionalism and ethics (4.4 ± 1.0), and letters of recommendation by aesthetic surgeons (4.4 ± 1.2). The least important factors were Alpha Omega Alpha Honor Medical Society membership (1.8 ± 0.6), postgraduate degrees (1.9 ± 0.9), US Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge (CK)/Comprehensive Osteopathic Medical Licensing Examination (COMLEX) Level 2 Cognitive Evaluation and USMLE/COMLEX Step 3 score (1.9 ± 0.9), and research fellowships (2.0 ± 0.6)., Conclusions: This study provides data on the aesthetic surgery fellowship directors' perceptions about the criteria important for applicant selection. We trust that fellowship directors, residency programs, and applicants find this data useful as they prepare for the aesthetic surgery fellowship match., (© 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com)

Background: This is the third survey exploring the quality of cosmetic training in plastic surgery residency. We focused on determining: (1) the applied modalities and extent of resident exposure; and (2) resident confidence in performing variable cosmetic procedures., Objectives: To analyze trends in resident exposure and confidence in aesthetic plastic surgery procedures from the standpoint of program directors (PDs) and residents., Methods: The survey was developed and e-mailed to 424 residents enrolled in the ASAPS Residents Program and 95 PDs. Both independent and integrated programs were included. The questions were posed in a five-point ranking format. Univariate statistical analysis was used to examine all aspects. The results were analyzed in relation to our previous surveys in 2008 and 2011., Results: Thirty-three PDs (34.7%) and 224 (52.8%) residents responded. Residents felt most confident with abdominoplasty, breast reduction, and augmentation-mammaplasty. Facial aesthetic procedures, especially rhinoplasty and facelift, were perceived as "challenging." The three most preferred modalities of aesthetic education were, in descending order, residents' clinic, staff cosmetic patients, and cadaver dissections. Both residents and PDs felt a need for more training especially in facial procedures. Only 31.5% of residents who planned to focus on cosmetic surgery felt ideally prepared integrating cosmetic surgery into their practice (compared to 50% in previous surveys)., Conclusions: Despite improvements observed from 2008 to 2011 published surveys, there are still challenges to be met especially in facial cosmetic procedures. It is suggested that resident clinics and cadaver courses be universally adopted by all training programs., (© 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com)

Background: Since 2013, the National Resident Matching Program (NRMP) has asked all programs to declare themselves to be "all in" or "all out" for the NRMP. Before this rule was enacted, program directors who were surveyed expressed concerns about what they anticipated with the change, including resources for increased applications and potential delays with residency start times., Objective: This study investigated the positive and negative effects of the rule change on recruiting seen from the perspective of internal medicine (IM) program directors., Methods: In this mixed model cross-sectional survey, Accreditation Council for Graduate Medical Education-accredited IM program directors were surveyed regarding their impressions of the impact of the policy change. Data were aggregated using constant comparative analysis., Results: A total of 127 of 396 (32%) IM program directors responded, and 122 of 127 (96%) identified their program as "all in." A total of 110 respondents expressed impressions of the rule change, with 48% (53 of 111) reporting positive responses, 28% (31 of 111) neutral responses, and 24% (27 of 111) negative responses. Programs with higher percentages of visa-holding residents had lower positive responses (37% [22 of 60] versus 61% [31 of 51]). Resident quality was felt to be unchanged or improved by most program directors (93%, 103 of 111), yet 24% (27 of 112) reported increases in delayed start times for visa-holding residents. Qualitative analysis identified increased fairness, at the expense of an increase in program resources as a result of the change., Conclusions: A slight majority of residency programs reported a neutral or negative impression of the rule change. Since the rule change, program directors noted increased application volume and delayed residency starts for visa-holding residents., Competing Interests: Conflict of interest: The authors declare they have no competing interests.

Introduction: Senior medical students frequently rotate at orthopaedic residency programs away from their home medical schools. However, to our knowledge, the perspective of program directors (PDs) and applicants on the value, objectives, and costs of these rotations has not been studied., Methods: Surveys evaluating the frequency, costs, benefits, and objectives of away rotations were distributed to all orthopaedic residency PDs in the United States and applicants in the 2014-2015 Match cycle. Data analysis was conducted to perform inferential and descriptive statistics; comparisons were made between and among PD and applicant groups using two-tailed means Student t-test and analysis of variance., Results: A total of 74 PD (46.0%) and 524 applicant (49.3%) responses were obtained from a national distribution. Applicants completed an average of 2.4 away rotations, with an average cost of $2,799. When stratified on self-reported likelihood of Matching, there were no substantial differences in the total number of rotations performed. The only marked differences between these groups were the United States Medical Licensing Examination Step 1 score and the number of applications to residency programs. PDs reported that significantly fewer rotations should be allowed, whereas applicants suggested higher limits (2.42 rotations versus 6.24, P < 0.001). PDs and applicants had similar perspectives on the value of away rotations; both groups reported more value in finding a "good fit" and making a good impression at the program and placed less value on the educational impact., Discussion: The value of orthopaedic away rotations appears more utilitarian than educational for both PDs and applicants. Rotations are performed regardless of perceived likelihood of Matching and are used by students and programs to identify a "good fit." Therefore, given the portion of an academic year that is spent on orthopaedic rotations, findings showing perceived low educational value and marked discrepancies between the expected number of rotations by PDs and applicants indicate that the current structure of away rotations may not be well aligned with the mission of undergraduate medical education., Level of Evidence: V.

This study examines "identity work" among hybrid doctor-managers (DMs) in the Spanish National Health System to make sense of their managerial roles. In particular, the meanings underlying DMs experience of their hybrid role are investigated using a Grounded Theory methodology, exposing distinctions in role-meanings. Our findings provide evidence that using different social sources of comparison (senior managers or clinicians) to construct the meaning of managerial roles leads to different role-meanings and role identities, which are the source of the two established types of DM in the literature, the reluctant and the enthusiast. The contribution is twofold: our findings lead us to theorize DMs' identity work processes by adding an overlooked role-meaning dimension to identity work; and raise practical reflections for those who wish to develop enthusiast doctor managers., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: The physician manager role in the health care system is invaluable as they serve as role models and quality setters. The requirements from physician managers have become more demanding and the role less prestigious; yet burnout and its prevention in this group have received little attention. Physician leadership development programmes have generally dealt directly with skill and knowledge acquisition. The aim of this research was to evaluate an intensive workshop designed to modify attitudes and improve skills of physician-managers of community clinics, through focus on personal well-being and empowerment., Methods: Two hundred fifty six physicians affiliated with Clalit Health Services, the largest health maintenance organization in Israel, participated in 16 IMPACT courses during the years 2013-2015. The programme comprised five full days during a two-week period, including an overnight and follow-up meetings three and six weeks later. Theoretical knowledge, experiential learning, practical tools, deep personal exercises, and simulations were conveyed through individual and group work. Topics included: models of self-awareness, outcome thinking, determining a personal and organizational vision, and creating a personal approach to leadership. At the end of each course, and by email at 6 or more months after completion of the course, participants were asked to anonymously respond to closed questions (on a scale of 1-6) and an open question., Results: Mean scores for the contribution of IMPACT to participants' role of physician manager were 5.3 at the end of the course, and 4.7 at 6 or more months later. Mean scores at 6 or more months were 5.0 regarding the contribution of the programme to personal development, 4.4 regarding satisfaction in the role of physician manager, and 4.6 regarding their coping with managerial dilemmas., Conclusion: A workshop that focused on personal growth and self-awareness increased physicians' job satisfaction and their sense of managerial capability, coping with managerial dilemmas, and belonging to the organization.

Background: The concept of leadership has been studied in various disciplines and from different theoretical approaches. It is a dynamic concept that evolves over time. There are few studies in our field on managers' self-perception of their leadership style. There are no pure styles, but one or another style is generally favoured to a greater or lesser degree. In the primary health care (PHC) setting, managers' leadership style is defined as a set of attitudes, behaviours, beliefs and values. The objectives of this study were to describe and learn about the self-perception of behaviours and leadership styles among PHC managers; to determine the influence of the leadership style on job satisfaction, efficiency, and willingness to work in a team; and to determine the relationship between transformational and transactional styles according age, gender, profession, type of manager years of management experience, and the type of organization., Methods: To describe leadership styles as perceived by PHC managers, a cross sectional study was performed using an 82 items-self-administered Multifactor Leadership Questionnaire (MLQ). This questionnaire measures leadership styles, attitudes and behaviour of managers. The items are grouped into three first order variables (transformational, transactional and laissez-faire) and ten second order variables (which discriminate leader behaviours). Additionally, the questionnaire evaluates organizational consequences such as extra-effort, efficiency and satisfaction., Results: One hundred forty responses from 258 managers of 133 PHC teams in the Barcelona Health Area (response rate: 54.26 %). Most participants were nurses (61.4 %), average age was 49 years and the gender predominantly female (75 %). Globally, managers assessed themselves as equally transactional and transformational leaders (average: 3.30 points). Grouped by profession, nurses (28.57 % of participants) showed a higher transactional leadership style, over transformational leadership style, compared to physicians (3.38 points, p < 0.003). Considering gender, men obtained the lowest results in transactional style (p < 0.015). Both transactional and transformational styles correlate with efficiency and job satisfaction (r = 0.724 and r = 0.710, respectively)., Conclusions: PHC managers' self-perception of their leadership style was transactional, focused on the maintenance of the status quo, although there was a trend in some scores towards the transformational style, mainly among nurse managers. Both styles correlate with satisfaction and willingness to strive to work better.

As you strive to develop your craft as a leader, some fundamental elements have the potential to deliver a huge impact on your effectiveness. Here are three: 1. An integrated leadership philosophy. 2. An understanding of what really drives the people in your organization. 3. An overarching responsibility to connect the threads.

Background and Objectives: In the current interferon-free era, family medicine is in a unique position to deliver hepatitis C (HCV) treatment with adequate training. Little is known about attitudes of family medicine program directors (PDs) toward capacity building within their residency programs. We report the results of a nationwide survey of family medicine PDs to examine these attitudes., Methods: This study was part of a CERA (Council of Academic Family Medicine Educational Research Alliance) omnibus survey administered to family medicine PDs between February 2015 and March 2015. Attitudes were assessed using a Likert scale ranging from 1=strongly disagree to 6=strongly agree., Results: We surveyed 452 physicians, with 273 responses (response rate 61%). The majority of PDs (78%) believed that chronic HCV represented a significant problem for primary care, and 61.9% believed their program should take steps to build capacity in HCV treatment. There was no effect of regional HCV prevalence, residency program context, or PD characteristics on intent to build capacity., Conclusions: This is the first report to examine PDs intent to build capacity in HCV treatment in this interferon-free, direct antiviral era. Our findings highlight a historic opportunity to train family physicians and position them on the frontline as HCV treatment providers.

Objective: The 2014 Ebola virus disease (EVD) outbreak in West Africa remains the most deadly in history. Emergency departments (EDs) are more likely to come into contact with potential EVD patients. It is important for EDs to be prepared to care for suspected EVD patients. Our objective was to understand the perceived challenges experienced by Washington State ED medical directors in EVD preparedness., Methods: An anonymous, electronic survey was sent to a convenience sample of ED medical directors across Washington State between November and February of 2014-2015. The perceived challenges of and attitudes toward EVD preparations were assessed and reported as stratified proportions., Results: Of 85 medical directors contacted, 59 responses (69%) were received. This included EDs with annual patient volumes of 60,000 (12 hospitals, 20%). Among the perceived challenges in EVD preparations were spatial modifications (eg, building an anteroom for donning and doffing of personal protective equipment) and waste management planning. Ninety-five percent of respondents moderately or strongly agreed that it is important to have a predesignated hospital to care for EVD patients., Conclusions: Washington State ED medical directors have faced significant challenges in ensuring their EDs are prepared to safely care for suspected EVD patients. Attitudes toward EVD preparations are mixed. Varying levels of perceived importance may represent an additional barrier to statewide EVD preparedness. (Disaster Med Public Health Preparedness. 2016;10:662-668).

Background: Patients with end-stage renal disease report infrequent end-of-life discussions, and nephrology trainees report feeling unprepared for end-of-life decision making, but the views of dialysis medical directors have not been studied., Aim: Our objective is to understand dialysis medical directors' views and practice patterns on end-of-life decision making for patients with ESRD., Design: We administered questionnaires to dialysis medical directors during medical director meetings of three different dialysis organizations in 2013. Survey questions corresponded to recommendations from the Renal Physicians Association clinical practice guidelines on initiation and withdrawal of dialysis., Setting/participants: There were 121 medical director respondents from 28 states., Results: The majority of respondents felt "very prepared" (66%) or "somewhat prepared" (29%) to participate in end-of-life decisions and most (80%) endorsed a model of shared decision making. If asked to do so, 70% of the respondents provided prognostic information "often" or "nearly always." For patients with a poor prognosis, 36% of respondents would offer a time-limited trial of dialysis "often" or "nearly always", while 56% of respondents would suggest withdrawal from dialysis "often" or "nearly always" for those with a poor prognosis currently receiving dialysis therapy. Patient resistance and fear of taking away hope were the most commonly cited barriers to end-of-life discussions., Conclusion: Views and reported practice patterns of medical directors are consistent with clinical practice guidelines for end-of-life decision making for patients with end-stage renal disease but inconsistent with patient perceptions., (© The Author(s) 2016.)

Rationale and Objectives: The Association of Program Directors in Radiology regularly surveys its members regarding issues of importance to support radiology residency programs and their directors., Materials and Methods: This is an observational cross-sectional study using two Web-based surveys posed to the Association of Program Directors in Radiology membership in the fall of 2014 (49 items) and the spring of 2015 (46 items) on the subjects of importance to the members, including the Accreditation Council on Graduate Medical Education Milestones, the Non-Interpretative Skills Curriculum, the American Board of Radiology Core Examination, the effect of the new resident testing and program accreditation paradigms on training outcomes, the 2015 Residency Match, the Interventional Radiology/Diagnostic Radiology (IR/DR) Residency, and Program Director (PD)/Program Coordinator resources., Results: Responses were collected electronically, results were tallied using SurveyMonkey software, and qualitative responses were tabulated or summarized as comments. Findings were reported during the 63rd annual meeting of the Association of University Radiologists. The maximal response rate was 33% in the fall of 2014 and 36% in the spring of 2015., Conclusions: PDs believed that the radiology Milestones, now largely implemented, did not affect overall resident evaluation, was not reflective of resident experience, and actually made evaluation of residents more difficult. PDs also felt that although the American Board of Radiology oral examination had been a better test for clinical practice preparedness, their new residents knew at least as much as before. There was little evidence of recall reemergence. The radiology training community saw a drop in residency applicant quality as demonstrated by the United States Medical Licensing Examination scores and clinical rotation grades. Because the new IR/DR Residency positions were to be funded at the expense of the traditional DR positions, the majority of PDs expected a negative effect of the impending IR/DR match on their DR recruitment. PDs were in favor of a unified clinical radiology curriculum similar to the Radiological Society of North America online physics modules., (Copyright © 2016 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Purpose - Physicians are commonly promoted into administrative and managerial roles in US hospitals on the basis of clinical expertise and often lack the skills, training or inclination to lead. Several studies have sought to identify factors associated with effective physician leadership, yet we know little about how physician leaders themselves construe their roles. The paper aims to discuss these issues. Design/methodology/approach - Phenomenological interviews were performed with 25 physicians at three organizational levels with physicians affiliated or employed by four hospitals within one health care organization in the USA between August and September 2010. A rigorous comparative methodology of data collection and analysis was employed, including the construction of analytic codes for the data and its categorization based on emergent ideas and themes that are not preconceived and logically deduced hypotheses, which is characteristic of grounded theory. Findings - These interviews reveal differences in how part- vs full-time physician leaders understand and value leadership roles vs clinical roles, claim leadership status, and identify as physician leaders on individual, relational and organizational basis. Research limitations/implications - Although the physicians in the sample were affiliated with four community hospitals, all of them were part of a single not-for-profit health care system in one geographical locale. Practical implications - These findings may be of interest to hospital administrators and boards seeking deeper commitment and higher performance from physician leaders, as well as assist physicians in transitioning into a leadership role. Social implications - This work points to a broader and more fundamental need - a modified mindset about the nature and value of physician leadership. Originality/value - This study is unique in the exploration of the nature of physician leadership from the perspective of the physician on an individual, peer and organizational level in the creation of their own leadership identity.

Purpose - The purpose of this paper is to explore how healthcare managers construct the manager role in relation to the medical profession in their organisations. Design/methodology/approach - In total, 18 of Sweden's 20 healthcare chief executive officers (CEOs) and 20 clinical department managers (CDMs) were interviewed about their views on management of physicians. Interviews were performed in the context of one aspect of healthcare management; i.e., management of physicians' sickness certification practice. A discourse analysis approach was used for data analysis. Findings - Few managers used a management-based discourse to construct the manager role. Instead, a profession-based discourse dominated and managers frequently used the attributes "physician" or "non-physician" to categorise themselves or other managers in their managerial roles. Some managers, both CEOs and CDMs, shifted between the management- and profession-based discourses, resulting in a kind of "yes, but […]" approach to management in the organisations. The dominating profession-based discourse served to reproduce the power and status of physicians within the organisation, thereby rendering the manager role weaker than the medical profession for both physician and non-physician managers. Research limitations/implications - Further studies are needed to explore the impact of gender, managerial level, and basic profession on how managers construct the manager role in relation to physicians. Practical implications - The results suggest that there is a need to address the organisational conditions for managers' role taking in healthcare organisations. Originality/value - Despite the general strengthening of the manager position in healthcare through political reforms during the last decades, this study shows that a profession-based discourse clearly dominated in how the managers constructed the manager role in relation to the medical profession on the workplace level in their organisations.

Background and Objectives: Eating during hemodialysis treatment remains a controversial topic. It is perceived that more restrictive practices in the United States contribute to poorer nutritional status and elevated mortality compared with some other parts of the world. However, in-center food practices in the United States have not been previously described., Design, Setting, Participants, & Measurements: In 2011, we conducted a survey of clinic practices and clinician (dietitian, facility administrator, and medical director) opinions related to in-center food consumption within a large dialysis organization. After the initial survey, we provided clinicians with educational materials about eating during treatment. In 2014, we performed a follow-up survey. Differences in practices and opinions were analyzed using chi-squared tests and logistic regression., Results: In 2011, 343 of 1199 clinics (28.6%) did not allow eating during treatment, 222 clinics (18.2%) did not allow drinking during treatment, and 19 clinics (1.6%) did not allow eating at the facility before or after treatment. In 2014, the proportion of clinics that did not allow eating during treatment had declined to 22.6% (321 of 1422 clinics), a significant shift in practice (P<0.001). Among the 178 (6.8%) clinics that self-reported that eating was "more allowed" in 2014, the main reason for this shift was an increased focus on nutritional status. Among clinicians, a higher percentage encouraged eating during treatment (53.1% versus 37.4%; P<0.05), and facility administrators and medical directors were less concerned about the seven reasons commonly cited for restricting eating during treatment in 2014 compared with 2011 (P<0.05 for all)., Conclusions: We found that 28.6% and 22.6% of hemodialysis clinics within the United States restricted eating during treatment in 2011 and 2014, respectively, a rate more than double that found in an international cohort on which we previously published. However, practices and clinician opinions are shifting toward allowing patients to eat. Additional research is warranted to understand the effect that these practices have on patient outcomes and outline best practices., (Copyright © 2016 by the American Society of Nephrology.)