Undergraduate College Pathway Programs Designed to Attract and Matriculate Students from Underrepresented Groups into Medicine.

OBJECTIVES: Undergraduate college pathway (or pipeline) programs support students' interests as they explore advanced degree and career pathways. Many programs aim to diversify the medical workforce by reducing barriers that may have otherwise prevented desired academic and career goals; however, variability in structure, expectations, benefits, and outcome data exist. This systematic review was conducted to identify and evaluate undergraduate college pathway programs designed to increase the diversity of medical school matriculants. METHODS: We searched Ovid Medline, PsycInfo, Scopus, and the Education Resources Information Center for peer-reviewed, original research publications (1996-2019) describing US pathway/pipeline programs designed for undergraduate-level college students from underrepresented groups to apply and enter medical school. Data extraction included application processes, participant demographics, curricular components, social support systems, mentorship, funding, and program/participant outcomes. We reviewed the journal impact factor to inform us about where articles are being published. RESULTS: Our full-text review included 137 articles; 25 articles met the inclusion criteria. All of the papers were descriptive, requiring an application, minimum grade point average, letters of recommendation, and personal statements. All of the programs aimed to diversify medicine, yet some could not request identification of race/ethnicity because of changes in affirmative action or legal restrictions when reporting demographics. Women represented the majority of enrollees. The program length varied; all reported having one or a combination of academic enrichment, research, field observation/experience, and mentorship. All of the programs included career development and various supplemental social supports. Only two programs provided comparison data; four reported no outcomes. CONCLUSIONS: Pathway programs support the acquisition and enhancement of professional skills. Lacking longitudinal or comparison data leads to questions of the long-term impact on diversifying the medical workforce. This article highlights a need for rigorous data collection methods and transparent reporting of participant outcomes to inform programmatic efficacy.

Racial Diversity Among American Cardiologists: Implications for the Past, Present, and Future.

In the United States, race-based disparities in cardiovascular disease care have proven to be pervasive, deadly, and expensive. African American/Black, Hispanic/Latinx, and Native/Indigenous American individuals are at an increased risk of cardiovascular disease and are less likely to receive high-quality, evidence-based medical care as compared with their White American counterparts. Although the United States population is diverse, the cardiovascular workforce that provides its much-needed care lacks diversity. The available data show that care provided by physicians from racially diverse backgrounds is associated with better quality, both for minoritized patients and for majority patients. Not only is cardiovascular workforce diversity associated with improvements in health care quality, but racial diversity among academic teams and research scientists is linked with research quality. We outline documented barriers to achieving workforce diversity and suggest evidence-based strategies to overcome these barriers. Key strategies to enhance racial diversity in cardiology include improving recruitment and retention of racially diverse members of the cardiology workforce and focusing on cardiovascular health equity for patients. This review draws attention to academic institutions, but the implications should be considered relevant for nonacademic and community settings as well.

Mentorship of Underrepresented Physicians and Trainees in Academic Medicine: a Systematic Review.

BACKGROUND: Though the USA is becoming increasingly diverse, the physician workforce contains a disproportionately low number of physicians from racial and ethnic groups that are described as underrepresented in medicine (URiM). Mentorship has been proposed as one way to improve the retention and experiences of URiM physicians and trainees. The objective of this systematic review was to identify and describe mentoring programs for URiM physicians in academic medicine and to describe important themes from existing literature that can aid in the development of URiM mentorship programs. METHODS: The authors searched PubMed, PsycINFO, ERIC, and Cochrane databases, and included original publications that described a US mentorship program involving academic medical doctors at the faculty or trainee level and were created for physicians who are URiM or provided results stratified by race/ethnicity. RESULTS: Our search yielded 4,548 unique citations and 31 publications met our inclusion criteria. Frequently cited objectives of these programs were to improve research skills, to diversify representation in specific fields, and to recruit and retain URiM participants. Subjective outcomes were primarily participant satisfaction with the program and/or work climate. The dyad model of mentoring was the most common, though several novel models were also described. Program evaluations were primarily subjective and reported high satisfaction, although some reported objective outcomes including publications, retention, and promotion. All showed satisfactory outcomes for the mentorship programs. DISCUSSION: This review describes a range of successful mentoring programs for URiM physicians. Our recommendations based on our review include the importance of institutional support for diversity, tailoring programs to local needs and resources, training mentors, and utilizing URiM and non-URiM mentors.

Mentorship of US Medical Students: a Systematic Review.

BACKGROUND: Mentoring of medical students remains a core pillar of medical education, yet the changing landscape of medicine has called for new and innovative mentoring models to guide students in professional development, career placement, and overall student well-being. The objective of this review is to identify and describe models of mentorship for US medical students. METHODS: We searched PubMed, PsycINFO, Education Resources Information Center, and Cochrane Databases of Systematic Reviews following PRISMA guidelines. We included original, English-language studies of any research design including descriptive studies that described a mentorship program at a US medical school designed for medical students. RESULTS: Our search yielded 3743 unique citations. Thirty articles met our inclusion criteria. There was significant diversity of the identified programs with regard to program objectives and size. The traditional dyad model of mentorship was the most frequently cited model, with a combination of models (dyad and group mentorship) cited as the second most common. Outcome measures of the programs were largely survey based, with satisfaction being the most measured outcome. Overall, satisfaction was highly rated throughout all the measured mentoring programs. Seven programs provided objective outcomes measures, including improved residency match data and increased scholarly productivity. The programs with objective outcomes measures were smaller, and 6/7 of them focused on a specific clinical area. Five of these programs relied on the traditional dyad model of mentorship. Cost and faculty time were the most frequently cited barriers to these programs. DISCUSSION: Our review demonstrates that mentoring programs for medical students can positively improve medical school satisfaction and career development. These results underscore the need for continued innovative mentoring programs to foster optimal student development in the setting of the increasingly competitive residency match process, growing expectations about student research productivity, and the national focus for overall student wellness.

Mentorship of Women in Academic Medicine: a Systematic Review.

BACKGROUND: Women remain underrepresented in academic medicine, particularly in leadership positions. This lack of women in leadership has been shown to have negative implications for both patient care and educational outcomes. Similarly, the literature demonstrates that female physicians are less likely to have mentors, despite the proven benefits of mentorship for career advancement. The objective of this review is to identify and describe models of mentorship for women in academic medicine. METHODS: We searched PubMed, PsycINFO, Education Resources Information Center, and Cochrane Databases of Systematic Reviews following PRISMA guidelines in June 2017. We included original English language studies that described a mentorship program in the USA that involved academic medical doctorates and that were created for women or provided results stratified by gender. RESULTS: Our search returned 3625 results; 3309 references remained after removal of duplicates. Twenty articles met inclusion criteria. The majority of the programs were designed for junior faculty and used the dyad model of mentoring (i.e., one mentor/one mentee). Frequently cited objectives of these programs were to improve scholarship, promotion, and retention of female faculty. Program evaluations were primarily survey-based, with participant-reported satisfaction being the most frequent measured outcome. Most results showed very high satisfaction. Gender concordance between mentor and mentee did not impact satisfaction. Eight articles reported objective outcomes, including publications, retention, and promotion, and each of these demonstrated an improvement after program implementation. DISCUSSION: Our review suggests that mentorship programs designed for women, regardless of the model, are met with high satisfaction and can help promote and retain women in academic medicine. No clear best practices for mentorship emerged in the literature. Institutions, therefore, can individualize their mentorship programs and models to available resources and goals. These results demonstrate the importance of more widespread implementation of mentorship programs to more effectively facilitate professional development and success of women in academic medicine.

Characteristics differentiating problem representation synthesis between novices and experts.

BACKGROUND: Formulating a thoughtful problem representation (PR) is fundamental to sound clinical reasoning and an essential component of medical education. Aside from basic structural recommendations, little consensus exists on what characterizes high-quality PRs. OBJECTIVES: To elucidate characteristics that distinguish PRs created by experts and novices. METHODS: Early internal medicine residents (novices) and inpatient teaching faculty (experts) from two academic medical centers were given two written clinical vignettes and were instructed to write a PR and three-item differential diagnosis for each. Deductive content analysis described the characteristics comprising PRs. An initial codebook of characteristics was refined iteratively. The primary outcome was differences in characteristic frequencies between groups. The secondary outcome was characteristics correlating with diagnostic accuracy. Mixed-effects regression with random effects modeling compared case-level outcomes by group. RESULTS: Overall, 167 PRs were analyzed from 30 novices and 54 experts. Experts included 0.8 fewer comorbidities (p < .01) and 0.6 more examination findings (p = .01) than novices on average. Experts were less likely to include irrelevant comorbidities (odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.2-0.8) or a diagnosis (OR = 0.3, 95% CI = 0.1-0.8) compared with novices. Experts encapsulated clinical data into higher-order terms (e.g., sepsis) than novices (p < .01) while including similar numbers of semantic qualifiers (SQs). Regardless of expertise level, PRs following a three-part structure (e.g., demographics, temporal course, and clinical syndrome) and including temporal SQs were associated with diagnostic accuracy (p < .01). CONCLUSIONS: Compared with novices, expert PRs include less irrelevant data and synthesize information into higher-order concepts. Future studies should determine whether targeted educational interventions for PRs improve diagnostic accuracy.

Sphingosine-1-phosphate lyase deficiency produces a pro-inflammatory response while impairing neutrophil trafficking.

Sphingosine-1-phosphate (S1P) lyase catalyzes the degradation of S1P, a potent signaling lysosphingolipid. Mice with an inactive S1P lyase gene are impaired in the capacity to degrade S1P, resulting in highly elevated S1P levels. These S1P lyase-deficient mice have low numbers of lymphocytes and high numbers of neutrophils in their blood. We found that the S1P lyase-deficient mice exhibited features of an inflammatory response including elevated levels of pro-inflammatory cytokines and an increased expression of genes in liver associated with an acute-phase response. However, the recruitment of their neutrophils into inflamed tissues was impaired and their neutrophils were defective in migration to chemotactic stimulus. The IL-23/IL-17/granulocyte-colony stimulating factor (G-CSF) cytokine-controlled loop regulating neutrophil homeostasis, which is dependent on neutrophil trafficking to tissues, was disturbed in S1P lyase-deficient mice. Deletion of the S1P4 receptor partially decreased the neutrophilia and inflammation in S1P lyase-deficient mice, implicating S1P receptor signaling in the phenotype. Thus, a genetic block in S1P degradation elicits a pro-inflammatory response but impairs neutrophil migration from blood into tissues.

The use of podcasts as a tool to teach clinical reasoning: a pseudorandomized and controlled study.

OBJECTIVES: Podcasts have emerged as an efficient method for widespread delivery of educational clinical reasoning (CR) content. However, the impact of such podcasts on CR skills has not been established. We set out to determine whether exposure to expert reasoning in a podcast format leads to enhanced CR skills. METHODS: This is a pseudo-randomized study of third-year medical students (MS3) to either a control group (n=22) of pre-established online CR modules, or intervention group (n=26) with both the online modules and novel CR podcasts. The podcasts were developed from four "clinical unknown" cases presented to expert clinician educators. After completing these assignments in weeks 1-2, weekly history and physical (H&P) notes were collected and graded according to the validated IDEA rubric between weeks 3-7. A longitudinal regression model was used to compare the H&P IDEA scores over time. Usage and perception of the podcasts was also assessed via survey data. RESULTS: Ninety control and 128 intervention H&Ps were scored. There was no statistical difference in the change of average IDEA scores between intervention (0.92, p=0.35) and control groups (-0.33, p=0.83). Intervention participants positively received the podcasts and noted increased discussion of CR principles from both their ward (3.1 vs. 2.4, p=0.08) and teaching (3.2 vs. 2.5, p=0.05) attendings. CONCLUSIONS: This is the first objective, pseudo-randomized assessment of CR podcasts in undergraduate medical education. While we did not demonstrate significant improvement in IDEA scores, our data show that podcasts are a well-received tool that can prime learners to recognize CR principles.

Implementation of a clinical reasoning curriculum for clerkship-level medical students: a pseudo-randomized and controlled study.

Background The National Academies of Sciences report Improving Diagnosis in Healthcare highlighted the need for better training in medical decision-making, but most medical schools lack formal education in clinical reasoning. Methods We conducted a pseudo-randomized and controlled study to evaluate the impact of a clinical reasoning curriculum in an internal medicine clerkship. Students in the intervention group completed six interactive online modules focused on reasoning concepts and a skills-based workshop. We assessed the impact of the curriculum on clinical reasoning knowledge and skills and perception of education by evaluating: (1) performance on a clinical reasoning concept quiz, (2) demonstration of reasoning in hospital admission notes, and (3) awareness of attending physician utilization of clinical reasoning concepts. Results Students in the intervention group demonstrated superior performance on the clinical reasoning knowledge quiz (67% vs. 54%, p < 0.001). Students in the intervention group demonstrated superior written reasoning skills in the data synthesis (2.3 vs. 2.0, p = 0.02) and diagnostic reasoning (2.2 vs. 1.9, p = 0.02) portions of their admission notes, and reported more discussion of clinical reasoning by their attending physicians. Conclusions Exposure to a clinical reasoning curriculum was associated with superior reasoning knowledge and superior written demonstration of clinical reasoning skills by third-year medical students on an internal medicine clerkship.

Effect of Lactation on Maternal Hypertension: A Systematic Review.

INTRODUCTION: Hypertension is relatively common in pregnancy, and pregnancy may unmask hypertension among women who are predisposed to it. Lactation may be a means through which to mitigate pregnancy-related vascular risk. The impact of lactation on maternal blood pressure, and the duration of any effect, remains unclear. This study aimed at systematically reviewing the literature evaluating the impact of lactation on the development of hypertension. MATERIALS AND METHODS: We searched PubMed, including EMBASE and MEDLINE, for studies that reported on the association between breastfeeding and maternal risk of hypertension that were published in a peer-reviewed source. The quality of the studies included was assessed by using the Newcastle-Ottawa Scale. RESULTS: Nineteen studies met all inclusion criteria for this review. Of the four studies with short-term follow-up, 50% showed a protective association. The fifteen studies with longer-term follow-up were stratified by outcome assessed. Sixty-seven percent of the studies that evaluated for elevated blood pressure and 100% of the studies evaluating for an outcome of hypertension showed a protective association. The minimum duration of lactation associated with a benefit was 1 month. This association was demonstrated in follow-up periods as long as two to three decades. Studies that showed a protective association had overall higher quality ratings. DISCUSSION: Lactation is associated with a beneficial effect on maternal blood pressure that persists for decades. These results add to the growing body of literature demonstrating the protective association of lactation on maternal cardiovascular risk. Providers may incorporate the decreased risk of hypertension into their counseling on the maternal benefits of lactation.

S1P1 receptor directs the release of immature B cells from bone marrow into blood.

S1P1 receptor expression is required for the egress of newly formed T cells from the thymus and exit of mature T and B cells from secondary lymphoid organs. In this study, we deleted the expression of the S1P1 receptor gene (S1pr1) in developing B cells in the bone marrow. Although B cell maturation within the bone marrow was largely normal in the B cell-specific S1pr1 knockout (B-S1pr1KO) mice, their newly generated immature B cells appeared in the blood at abnormally low numbers as compared with control mice. In the bone marrow of B-S1pr1KO mice, immature B cells in contact with the vascular compartment displayed increased apoptosis as compared with control mice. Forced expression of CD69, a negative regulator of S1P1 receptor expression, in developing bone marrow B cells also reduced the number of immature B cells in the blood. Attenuation of CXCR4 signaling, which is required for the proper retention of developing B cells in bone marrow, did not release immature B cells into the blood of B-S1pr1KO mice as effectively as in control mice. Our results indicate that the S1P1 receptor provides a signal necessary for the efficient transfer of newly generated immature B cells from the bone marrow to the blood.