Academic Medicine

Humanizing the Morbidity and Mortality Conference Morbidity and mortality conferences (MMCs) are a long-held legacy institution in academic medicine that enable medical providers and hospital administrators to learn from systemic and individual errors, thereby leading to improved medical care. Originally this forum had 1 major role—education. The MMC evolved and a second key role was added: quality improvement. In the wake of the 2020 COVID-19 pandemic, a second evolution—one that will humanize the MMC—is required. The pandemic emphasizes the need to use MMCs not only as a place to discuss errors but also as a place for medical providers to reflect on lives lost. The authors' review of the literature regarding MMCs indicates that most studies focus on enabling MMCs to become a forum for quality improvement, while none have emphasized the need to humanize MMCs to decrease medical provider burnout and improve patient satisfaction. Permitting clinicians to be human on the job requires restructuring the MMC to provide a space for reflection and, ultimately, defining a new purpose and charge for the MMC. The authors have 3 main recommendations. First, principles of humanism such as compassion, empathy, and respect, in particular, should be incorporated into traditional MMCs. Second, shorter gatherings devoted to giving clinicians the opportunity to focus on their humanity could be arranged. Third, an MMC focused entirely on the human aspects of medical care could be periodically arranged to provide an outlet for storytelling, artistic expression, and reflection. Humanizing the MMC—a core symposium in clinical medicine worldwide—could be the first step in revitalizing the spirit at the heart of medicine, one dedicated to health and healing. This spirit, which has been eroding as the field of medicine becomes increasingly corporate in structure and mission, is as essential during peaceful times in health care as during a pandemic. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimers: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. Correspondence should be addressed to Haider J. Warraich, 4B-132, 1400 VFW Parkway, Boston VA Healthcare System, Boston, MA 02132; telephone: (617) 323-7700; email: hwarraich@partners.org; Twitter: @haiderwarraich. Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a "work of the United States Government" for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government. © 2020 by the Association of American Medical Colleges

Perceptual Facilitators for and Barriers to Career Progression: A Qualitative Study With Female Early Stage Investigators in Health Sciences Purpose: Despite efforts to increase the representation of women in the national scientific workforce, results still lag. While women's representation in health-related sciences has increased substantially, women remain underrepresented in senior leadership roles. This study was conducted to elucidate influences at the individual, interpersonal, organizational, and societal levels that present as barriers to and facilitators for advancement in research careers for women, with the goal of promoting and retaining a more diverse leadership. Method: The authors conducted individual, 1-hour, in-depth, semistructured interviews with 15 female early stage investigators pursuing careers in health sciences research at a large minority-serving institution in Florida in 2018. Interview guides were designed by using a social ecological framework in order to understand the influence of multilevel systems. Employing a qualitative approach, drawing from a phenomenological orientation, 2 researchers independently coded transcripts and synthesized codes into broad themes. Results: Barriers and facilitators were reported at all ecological levels explored. Illustrative quotations reflect the unequal distribution of familial responsibilities that compete with career advancement, family members' lack of understanding of the demands of a research career, the importance of female mentors, perceived differences in the roles and expectations of female and male faculty at institutions, and normative upheld values that influence early career progression. Conclusions: Achieving pervasive and sustained changes that move toward gender equity in research requires solutions that address multilevel, explicit and implicit influences on women's advancement in science. Suggestions include shifting familial and institutional norms, creating support systems for women with female mentors, and enforcing consistent policies regarding the roles and expectations of faculty. Findings shed light on the influence of gender on career progression by providing context for the experiences of women and underscore the importance of addressing pervasive societal and structural systems that maintain inequities hindering women's progress in the scientific workforce. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/B57. Acknowledgments: The authors would like to thank the participants who took part in the study, without whom this work would not be possible. Funding/Support: This research was supported in part by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under award NIMHD U54MD012393, Florida International University Research Center in Minority Institutions. Other disclosures: None reported. Ethical approval: This study was approved by the institutional review board for the study site located in South Florida, as recorded in application IRB-18-0268, reference number 106877. Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Previous presentations: This work was presented at the RCMI (Research Centers in Minority Institutions) Translational Science Conference, Capacity Building and Investigator Development track; December 2019; Bethesda, Maryland. Correspondence should be addressed to Sofia B. Fernandez, 11200 SW 8th Street, AHC4-328, Miami, FL 33199; telephone: (305) 348-0365; fax: (305) 348-5801; email: sofernan@fiu.edu. © 2020 by the Association of American Medical Colleges

Hispanic Identity and Its Inclusion in the Race Discrimination Discourse in the United States As protests against racism occur all over the United States and medical institutions face calls to incorporate antiracism and health equity curricula into professional training and patient care, the antiracism discourse has largely occurred through a Black/African American and White lens. Hispanics, an umbrella category created by the U.S. government to include all people of Spanish-speaking descent, are the largest minority group in the country. Hispanics are considered an ethnic rather than a racial group, although some Hispanics self-identify their race in terms of their ethnicity and/or country of origin while other Hispanics self-identify with any of the 5 racial categories used by the U.S. government (White, Black or African American, American Indian or Alaska Native, Asian, or Native Hawaiian or Other Pacific Islander). Expanding the antiracism discourse in medicine to include Hispanic perspectives and the diversity of histories and health outcomes among Hispanic groups is crucial to addressing inequities and disparities in health and medical training. A lack of inclusion of Hispanics has contributed to a growing shortage of Hispanic physicians and medical school faculty in the United States as well as discrimination against Hispanic physicians, trainees, and patients. To reverse this negative trend and advance a health care equity and antiracist agenda, the authors offer steps that medical schools, academic medical centers, and medical accreditation and licensing bodies must take to increase the representation of Hispanics and foster their engagement in this evolving antiracism discourse. Acknowledgments: The authors wish to acknowledge the work of the Latino Medical Student Association, the National Hispanic Medical Association, and all organizations representing Hispanics in medicine, both past and present. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Cristina R. Fernández, Department of Pediatrics, Columbia University Irving Medical Center, 630 West 168th Street, PH-17 Room 201-I, New York, NY 10032; telephone: (212) 342-1758; email: crf2101@cumc.columbia.edu; Twitter: @DrCFernandez. © 2020 by the Association of American Medical Colleges

Everyday Heroism: Maintaining Organizational Cultures of Wellness and Inclusive Excellence Amid Simultaneous Pandemics Health care professionals and the institutions in which they work are being stretched to their limits amidst the current COVID-19 pandemic. At the same time, a second longstanding pandemic has been brought to the fore: the entrenched system of racial injustice and oppression. The first pandemic is new and to date substantial resources have been allocated to urgently addressing its mitigation; the second has a long history with inconsistent attention and resources but has recently been spotlighted more intensely than at any time in the nation's recent past. The authors of this article contend that these 2 simultaneous pandemics have brought forth the need for institutions in the United States to make a renewed commitment to respect, wellness, diversity, and inclusion. While investment and leadership in these domains have always been essential, these have largely been viewed as a "nice-to-have" option. The events of much of 2020 (most notably) have illustrated that committing to and investing in policies, programs, centers, and leadership to drive change in these domains are essential and a "need-to-have" measure. The authors outline the necessity of investing in the promotion of cultures of inclusive excellence at both individual and organizational levels to coordinate a united response to the simultaneous pandemics. It is in the interests of health care systems to consider the wellness of the workforce to overcome the longer term economic, systemic, and social trauma that will likely occur for years to come at both the individual and institutional levels. Maintaining or augmenting investment is necessary despite the economic challenges the nation faces. Now is the time to cultivate resilience and wellness through a renewed commitment to cultures of respect, diversity, and inclusion. This commitment is urgently needed to support and sustain the health care workforce and maintain outstanding health care systems for future generations. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Magali Fassiotto, PhD, Stanford University School of Medicine, Stanford, CA, 94305; telephone: (650) 723-6078; email: magali.fassiotto@stanford.edu; twitter: @StanfordMedOFDD. © 2020 by the Association of American Medical Colleges

Novel Prescriptions From Medical Schools for Physician–Scientist Training and Engagement in the Twenty-First Century Physicians engaged in biomedical research are well positioned to directly focus the discovery process on human biology. However, the relative proportion of investigators engaged in both caring for patients and conducting research is decreasing. To address the dwindling numbers of physician–scientists nationally, the Burroughs Wellcome Fund (BWF) created the Physician-Scientist Institutional Awards Program by dedicating 25 million dollars to new initiatives at 10 degree-granting, accredited medical schools in North America, awarded on the basis of institutions' proposals. The perceived barriers to physician–scientist training, program initiatives, and commitment to training a diverse group of future researchers were articulated in each application. In all, the BWF review committee considered 136 distinct proposals from 83 medical schools, representing 54% of all accredited medical schools in North America. Barriers identified by more than one-third of the applicant institutions included the absence of both mentors and role models, student indebtedness, institutional cultures that valued clinical care delivery above the discovery process, limited prior relevant research experience, and structural barriers that limited scheduling flexibility during training. Awards were granted to institutions with programs designed to be sustainable and overcome critical, prospectively identified barriers to training and retention of physician–scientists. Potential solutions from the 10 funded programs were focused on different stages of the training experience. Though a determination about the relative success of each of the initiatives will take many years, careful consideration of the barriers identified and more general application of specific program component may be beneficial in increasing the numbers of physicians actively involved in biomedical research. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to John E. Burris, Burroughs Wellcome Fund, 21 T.W. Alexander Drive, P.O. Box 13901, Research Triangle Park, NC 27709-3901; email: jburris@bwfund.org. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2020 by the Association of American Medical Colleges

Recognizing Cross-Institutional Fiscal and Administrative Barriers and Facilitators to Conducting Community-Engaged Clinical and Translational Research Purpose: This qualitative study examined fiscal and administrative (i.e., pre- and post-award grants process) barriers and facilitators to community-engaged research among stakeholders across 4 Clinical and Translational Science Awards (CTSA) institutions. Method: A purposive sample of 24 key informants from 3 stakeholder groups—community partners, academic researchers, and research administrators—from the CTSA institutions at the University of North Carolina at Chapel Hill, Medical University of South Carolina, Vanderbilt University Medical Center, and Yale University participated. Semistructured interviews were conducted in March–July 2018, including questions about perceived challenges and best practices in fiscal and administrative processes in community-engaged research. Transcribed interviews were independently reviewed and analyzed using the Rapid Assessment Process to facilitate key theme and quote identification. Results: Community partners were predominantly Black, academic researchers and research administrators were predominantly White, and women made up two-thirds of the overall sample. Five key themes were identified: level of partnership equity, partnership collaboration and communication, institutional policies and procedures, level of familiarity with varying fiscal and administrative processes, and financial management expectations. No stakeholders reported best practices for the institutional policies and procedures theme. Cross-cutting challenges included communication gaps between stakeholder groups, lack of or limits in supporting community partners' fiscal capacity, and lack of collective awareness of each stakeholder group's processes, procedures, and needs. Cross-cutting best practices centered on shared decision-making and early and timely communication between all stakeholder groups in both pre- and post-award processes. Conclusions: Findings highlight the importance of equitable processes, triangulated communication, transparency, and recognizing and respecting different financial management cultures within community-engaged research. This work can be a springboard used by CTSA institutions to build on available resources that facilitate co-learning and discussions between community partners, academic researchers, and research administrators on fiscal readiness and administrative processes for improved community-engaged research partnerships. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/B55. Acknowledgments: Adina Black and Elisa D. Quarles served as reviewers in the Rapid Assessment Process. Adina Black provided administrative support in developing this manuscript. Jennifer Teixeira, director of research administration in the Office of Sponsored Research at University of North Carolina at Chapel Hill, contributed to the conceptualization of this project. The authors thank the stakeholders—community partners, academic researchers, and research administrators—for participating in this study. Funding/Support: This work was supported, in part, by the Clinical and Translational Science Awards Program, funded by the National Center for Advancing Translational Sciences of the National Institutes of Health: grants #UL1TR002489 (University of North Carolina at Chapel Hill), #UL1TR001450 (Medical University of South Carolina), #UL1TR002243 (Vanderbilt University Medical Center), and #UL1TR001863 (Yale University). Other disclosures: None reported. Ethical approval: The University of North Carolina at Chapel Hill Institutional Review Board approved this study on September 8, 2017 (IRB#15-0849). Disclaimers: The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Correspondence should be addressed to Lori Carter-Edwards, University of North Carolina at Chapel Hill, Campus Box 7064, 160 N. Medical Dr., Chapel Hill, NC 27599; telephone: (919) 966-5305; email: lori_carter-edwards@unc.edu; Twitter: @NCTraCS. This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2020 by the Association of American Medical Colleges

Effect of Continuing Professional Development on Health Professionals' Performance and Patient Outcomes: A Scoping Review of Knowledge Syntheses Purpose: Continuing professional development (CPD) programs, which aim to enhance health professionals' practice and improve patient outcomes, are offered to practitioners across the spectrum of health professions through both formal and informal learning activities. Various knowledge syntheses (or reviews) have attempted to summarize the CPD literature; however, these have primarily focused on continuing medical education or formal learning activities. Through this scoping review, the authors seek to answer the question, What is the current landscape of knowledge syntheses focused on the impact of CPD on health professionals' performance defined as behavior change and/or patient outcomes? Method: In September 2019, the authors searched PubMed, Embase, CINAHL, Scopus, ERIC, and PsycINFO for knowledge syntheses published between 2008 and 2019 that focused on independently practicing health professionals and reported outcomes at Kirkpatrick's levels 3 and/or 4. Result: Of the 7,157 citations retrieved from databases, 63 satisfied the inclusion criteria. Of these 63 syntheses, 38 (60%) included multicomponent approaches, and 27 (43%) incorporated eLearning interventions – either stand-alone or in combination with other interventions. While a majority of syntheses (n = 42 [67%]) reported outcomes affecting health care practitioners' behavior change and/or patient outcomes, most of the findings reported at Kirkpatrick level 4 were not statistically significant. Ten of the syntheses (16%) mentioned the cost of interventions though this was not their primary focus. Conclusions: Across health professions CPD is an umbrella term incorporating formal and informal approaches in a multi-component approach. eLearning is increasing in popularity but remains an emerging technology. Several of the knowledge syntheses highlighted concerns regarding both the financial and human costs of CPD offerings, and such costs are being increasingly addressed in the CPD literature. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/B56. Acknowledgments: The authors would like to thank Rhonda Allard, a medical librarian at Uniformed Services University of the Health Sciences, for helping design, refine, and conduct the searches for this study. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimer: The opinions and assertions expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Uniformed Services University of the Health Sciences or the Department of Defense or the Henry M. Jackson Foundation for Military Medicine. Correspondence should be addressed to Anita Samuel, Uniformed Services University of the Health Sciences, Department of Medicine, Graduate Programs in Health Professions Education, 4301 Jones Bridge Road, Bethesda, MD 20814; telephone: (301) 295-9539; email: anita.samuel.ctr@usuhs.edu. Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a "work of the United States Government" for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government. © 2020 by the Association of American Medical Colleges

Personalized Graduate Medical Education and the Global Surgeon: Training for Resource-Limited Settings Problem: The World Health Organization and the World Bank have identified improvement in access to surgical care as an urgent global health challenge and a cost-effective investment in public health. However, trainees in standard U.S. general surgery programs do not have adequate exposure to the procedures, technical skills, and foundational knowledge essential for providing surgical care in resource-limited settings. Approach: The Michael E. DeBakey Department of Surgery at Baylor College of Medicine (BCM) created a 7-year global surgery track within its general surgery residency in 2014. Individualized rotations equip residents with the necessary skills, knowledge, and experience to operate in regions with low surgeon density and develop sustainable surgical infrastructures. BCM provides a formal, integrated global surgery curriculum—including 2 years dedicated to global surgery—with surgical specialty rotations in domestic and international settings. Residents tailor their individual experience to the needs of their future clinical practice, region of interest, and surgical specialty. Outcomes: There have been 4 major outcomes of the BCM global surgery track: (1) increased exposure for trainees to a broad range of surgeries critical in resource-limited settings, (2) meaningful international partnerships, (3) contributions to global surgery scholarship, and (4) establishment of sustainable global surgery activities. Next Steps: To better facilitate access to safe, timely, and affordable surgical care worldwide, global surgeons should pursue expertise in topics not currently included in U.S. general surgical curricula, such as setting-specific technical skills, capacity building, and organizational collaboration. Future evaluations of the BCM global surgery track will assess the effect of individualized education on trainees' professional identities, clinical practices, academic pursuits, global surgery leadership preparedness, and comfort with technical skills not encompassed in general surgery programs. Increasing availability of quality global surgery training programs would provide a critical next step towards contributing to the delivery of safe surgical care worldwide. Acknowledgements: The authors wish to thank Miriam King, MEd, Scott LeMaire, MD, Chad Wilson, MD, MPH, C. Anne Morrison, MD, MPH, Walter Johnson, MD, MPH, MBA, Neema Kaseje, MD, MPH, Nader Masserweh, MD, MPH, Josephine Koller, BBA, Sydney Webster, MEd, Jaye Chambers, Allyson Bremer, Woods McCormack, MA, Bip Nandi, MBBChir, Heather Vasser, MD, Kathryn Gunter, MD, Michael Coburn, MD, Michael Belfort, MBBCH, DA (SA), MD, PhD, Jeffrey Wilkinson, MD, Rachel Pope, MD, MPH, Kelli Barbour, MD, Candy Wilburn, Etan Weinstock, MD, Peter Hotez, MD, PhD, John Dawson, MD, Christopher Perkins, MD, MS, Adam Gibson, JD, Taylor Napier, MA, Hisashi Nikaidoh, MD, Lynn Nikaidoh, Craig Brown, Sue Smith, JD, and John Collier, MDiv, MA. Funding/Support: Funding and support for the creation of the global surgery residency track were received from the Baylor College of Medicine Michael E. DeBakey Department of Surgery, Hitoshi Nikaidoh Memorial Endowment, George A. Robinson IV Foundation, Craig and Galen T. Brown Foundation, CHRISTUS Foundation for HealthCare, Caring Friends in Deed, and the Bridget L. Harrison, MD International Education Support Fund. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Rachel W. Davis, Baylor College of Medicine, 1 Baylor Plaza, MS390, Houston, TX, 77030; telephone: (713) 798-6078; email: rachelwdavis@bcm.edu; Twitter: @RachelWDavis. © 2020 by the Association of American Medical Colleges

Discharge Communication: A Multi-Institutional Survey of Internal Medicine Residents' Education and Practices Purpose: To characterize residents' practices around hospital discharge communication and their exposure to transitions-of-care instruction in graduate medical education (GME). Method: In spring 2019, internal medicine residents at 7 academic medical centers completed a cross-sectional survey reporting the types of transitions-of-care instruction they experienced during their GME training and the frequency with which they performed 6 key discharge communication practices. The authors calculated a mean discharge communication score for each resident and, using multiple logistic regression, they analyzed the relationship between exposure to types of educational experiences and the discharge communication practices that residents reported to perform frequently (> 60% of time). The authors also used content analysis to explore factors that motivated residents to change their discharge practices. Results: The response rate was 63.5% (613/966). Resident discharge communication practices varied. Notably, only 17.0% (n = 104) reported routinely asking patients to "teach-back" or explain their understanding of the discharge plans. The odds of frequently performing key discharge communication practices were greater if residents received instruction based on observation of and feedback regarding their communication with patients at discharge (adjusted odds ratio [OR] 1.73; 95% confidence interval [CI], 1.07-2.81), or if they received explicit on-rounds teaching (adjusted OR 1.46; 95% CI, 1.04-2.230). In open-ended comments, residents reported that experiencing adverse patient events at some point in the post-discharge continuum was a major impetus for practice change. Conclusions: This study exposes gaps in hospital discharge communication with patients, highlights the benefits of workplace-based instruction on discharge communication skills, and reveals the influence of adverse events as a source of hidden curricula. The results suggest that developing faculty to incorporate transitions-of-care instruction in their rounds teaching and integrating experiences across the post-discharge continuum into residents' education may foster physicians-in-training who are champions of effective transitions of care within the fragmented healthcare system. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/B54. Acknowledgements: The authors would like to thank Shreya Singhal and Megan Sutter, PhD, for statistical assistance, as well as Amy Ou, MD, Masha Slavin, MD, Bilal Alqam, MD, Marina Baskharoun, MD, Nick Gowen, MD, Paul Williams, MD, and Derek Hupp, MD, for help distributing the survey. Funding/Support: Dr. Shreya P. Trivedi's time was supported by Health Resources and Services Administration-T32 grant (T32HP22238). Other disclosures: None reported. Ethical approval: Ethical approval was received from each participating institution. Previous presentations: The findings of this study were presented as a virtual oral presentation for the Lipkin Finalist Award for the Society of General Internal Medicine On-Demand 2020 National Conference. Data: The data for this study were not collected from outside sources. Correspondences should be addressed to Shreya Trivedi, Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, Massachusetts 02215; telephone: (215) 527-9238; email: strived1@bidmc.harvard.edu; Twitter: @ShreyaTrivediMD. © 2020 by the Association of American Medical Colleges

Sin-Eaters No abstract available

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

Telephone consultation 11855 int 1193,