Residents' Reflections on Cost-Conscious Care after International Health Electives: A Single-Center Qualitative Study.

BACKGROUND: Estimates suggest 30% of health care expenditures are wasteful. This has led to increased educational interventions in graduate medical education (GME) training aimed to prepare residents for high value, cost-conscious practice. International health electives (IHE) are widely available in GME training and may be provide trainees a unique perspective on principles related to high value, cost-conscious care (HVCCC). OBJECTIVE: The purpose of this study was to explore how trainee reflections on IHE experiences offer insight into HVCCC. DESIGN: The authors conducted an applied thematic analysis of narrative reflective reports of GME trainees' IHE experiences to characterize their perceptions of HVCCC. PARTICIPANTS: The Mayo International Health Program (MIHP) supports residents and fellows from all specialties across all Mayo Clinic sites. We included 546 MIHP participants from 2001 to 2020. APPROACH: The authors collected post-elective narrative reports from all MIHP participants. Reflections were coded and themes were organized into model for transformative learning during IHEs, focusing on HVCCC. KEY RESULTS: GME trainees across 24 different medical specialties participated in IHEs in 73 different countries. Three components of transformative learning were identified: disorienting dilemma, critical reflection, and commitment to behavior change. Within the component of critical reflection, three topics related to HVCCC were identified: cost transparency, resource stewardship, and reduced fear of litigation. Transformation was demonstrated through reflection on future behavioral change, including cost-aware practice, stepwise approach to health care, and greater reliance on clinical skills. CONCLUSIONS: IHEs provide rich experiences for transformative learning and reflection on HVCCC. These experiences may help shape trainees' ideology of and commitment to HVCCC practices.

Autonomy and professional identity formation in residency training: A qualitative study.

CONTEXT: Professional identity formation (PIF) involves the development of professional values, actions and aspirations and is central to medical education. Current understanding of PIF is informed by psychological and sociological theories. One ideal of medicine is responsibility to the patient; the development of this ideal is related to learner autonomy. The purpose of this study was to further theorise the relationships between the individual and contextual aspects of PIF through exploring the associations amongst autonomy, making decisions and responsibility for patients during residency training. METHODS: Using constructivist grounded theory, we conducted 23 semi-structured interviews with internal medicine residents at an academic medical centre. Interview transcripts were de-identified and processed through open coding and analytic memo writing. During data collection and analysis, we identified social cognitive theory (SCT), specifically reciprocal determinism, or the triadic and reciprocal relationship between context, person and behaviour, as a useful theoretical lens through which to illuminate the relationship between autonomy and PIF. Using SCT to guide analysis, we organised themes, identified relationships amongst themes, and refined them through group discussion and constant comparison with new data. RESULTS: Residents discussed three main themes: autonomy; making decisions, and responsibility for patient care. Autonomy allowed residents to feel personally responsible for patient care, and build confidence and trust. Autonomy allowed residents to feel engaged in making 'real decisions' for patient care. By displaying confidence in their decision making, residents were granted more autonomy. Lack of autonomy led to disengagement and lack of ownership over patient care. CONCLUSIONS: This study highlighted the role of autonomy in the PIF of learners. Exploring the tension between autonomy and supervision through the lens of SCT highlighted the interconnectedness of context, behaviour and identity in PIF. To ensure optimal learning environments for PIF, educators should weigh the need for autonomy against the demands for supervision and patient safety.

Graduate medical education competencies for international health electives: A qualitative study.

BACKGROUND: Residency programs offer international health electives (IHEs), providing multiple educational benefits. This study aimed to identify how IHEs fulfill the Accreditation Council for Graduate Medical Education (ACGME) core competencies. METHODS: We conducted a thematic analysis of post-rotation reflective reports from residents who participated in IHEs through the Mayo International Health Program. We coded reports using a codebook created from the ACGME competencies. Using a constant comparative method, we identified significant themes within each competency. RESULTS: Residents from 40 specialties participated in 377 IHEs in 56 countries from 2001 to 2014. Multiple themes were identified within each of the six ACGME core competencies: Patient Care and Procedural Skills (4), Medical Knowledge (5), Practice-Based Learning and Improvement (3), Interpersonal and Communication Skills (5), Professionalism (4), and Systems-Based Practice and Improvement (3). Themes included improving physical exam and procedural skills, providing care in resource-limited setting, gaining knowledge of tropical and non-tropical diseases, identifying socioeconomic determinants of health, engaging in the education of others, and increasing communication across cultures and multidisciplinary teams. CONCLUSIONS: Through IHEs, residents advanced their knowledge, skills, and attitudes in each of the six ACGME competencies. These data can be used for development of IHE competencies and milestones for resident assessment.

Gender and Professional Title Use in Internal Medicine Resident Narrative Assessments.

Background: Residency is a time of personal and professional growth. Resident assessment and feedback are an integral part of that process. However, assessment may be influenced by various types of bias, including gender bias. Women are less likely than men to be identified by their professional titles in many settings. The use of professional titles for residents in written assessments is unknown and may be a marker of bias. Objective: To assess for differences and trends regarding the use of professional and personal titles in formal resident assessments related to gender-based resident-faculty pairs. Methods: Electronic assessments of postgraduate year 1 (PGY1) internal medicine residents from the 2019-2020 academic year were used. Professional title use was analyzed, as it relates to resident-faculty gendered dyads, among other variables. The primary outcome of professional title usage was split into a binary variable by professional versus other titles and analyzed using logistic regression and random-effects model. Results: We analyzed 1,363 unique electronic assessments (37.8% from female faculty). Female residents were more likely to be addressed by a professional title than their male colleagues (odds ratio [OR], 1.7; confidence interval [CI], 1.2-2.4; p = 0.02). We found no difference in professional title usage based on resident-faculty gendered dyads. After adjusting for repeated faculty and resident encounters with random-effects model, secondary analysis found no significant difference in evaluation of word count between gendered dyads. Conclusions: The analysis found no significant difference in professional title usage based on resident-faculty dyads. In our analysis, female residents were significantly more likely to have their professional title used on assessments than male residents.

Association between obesity and female sexual dysfunction: a review.

INTRODUCTION: Obesity is a global health crisis that has been growing over the past few decades. The economic burden associated with obesity is substantial as it is associated with multiple disabling chronic diseases, such as cardiovascular disease, certain cancers, osteoarthritis, chronic pain, and mental illness. Obesity is known to be a risk factor for sexual dysfunction in men, but this association is less well understood in women. AIMS: To provide a narrative review of the available literature on the relationship between overweight/obesity and female sexual dysfunction, elaborate on the possible mechanisms explaining this association, and discuss the effects of weight loss on sexual function in those with obesity. METHODS: A search of the medical literature was carried out in PubMed and Medline, focusing on original research and systematic reviews of original research on obesity and sexual function in women. RESULTS: The relationship between obesity and female sexual function is not consistent across studies. While women with obesity are more likely to have worse sexual function and avoid sexual activity, many studies have failed to identify these associations. Lifestyle changes resulting in weight loss lead to better sexual function, and bariatric surgery has been shown to improve sexual function in the first couple of years following the procedure; yet, the long-term effects of weight loss and bariatric surgery are still uncertain. CONCLUSIONS: The evidence on the relationship between obesity and female sexual function is mixed. Nevertheless, weight loss has been shown to improve sexual function in women with obesity. The impact of weight loss medications and the long-term effect of bariatric surgery on female sexual function require further study.

Fitting In While Standing Out: Professional Identity Formation, Imposter Syndrome, and Burnout in Early-Career Faculty Physicians.

PURPOSE: Professional identity formation (PIF) is a dynamic process by which an individual internalizes the core values and beliefs of a specific profession. Within medical education, PIF begins in medical school and continues throughout training and practice. Transitions affect PIF, with a critical transition occurring between medical training and unsupervised practice. This study aims to characterize PIF during the transition from resident to early-career faculty physician and explores the relationship between PIF and burnout during this transition. METHOD: The authors conducted a qualitative study using constructivist grounded theory. They conducted semistructured interviews with early-career faculty physicians (defined as practicing for ≤ 5 years) from the Department of Medicine, Mayo Clinic. Deidentified interview transcripts were processed through open and axial coding. The authors organized themes and identified relationships between themes that were refined through discussion and constant comparison with newly collected data. During data analysis, the authors identified self-determination theory, with the concepts of autonomy, competence, and relatedness, as a framework to support the organization and analysis of the data. RESULTS: Eleven early-career faculty physicians participated in the interviews. Their PIF was characterized by the dual desires to fit in and stand out. Striving for these desires was characterized by imposter syndrome, driving physicians to question their decision making and overall competence. Participants associated imposter syndrome and academic pressures with burnout. Autonomy support by the institution to pursue opportunities important for career development helped mitigate burnout and support PIF. CONCLUSIONS: Early-career faculty physicians face identity challenges when transitioning from training to unsupervised practice, including striving to fit in and stand out. They link this tension to imposter syndrome, which they associated with burnout. Institutional awareness and support, including addressing structural and cultural contributors to imposter syndrome, are paramount as new faculty explore their identities and navigate new challenges.

A Clinical Review on Paroxetine and Emerging Therapies for the Treatment of Vasomotor Symptoms.

Most women experience vasomotor symptoms (VMS) during their menopausal transition. Menopausal hormone therapy (HT) is the most effective treatment for VMS, but some women choose not to use HT or have contraindications to using HT. Non-hormonal treatment options should be offered to these symptomatic menopausal women. Multiple large randomized controlled trials have demonstrated statistically significant reductions in hot flash severity and/or frequency with the use of selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs). To date, paroxetine mesylate remains the only non-hormonal treatment that has been approved by the United States Food and Drug Administration (FDA) for the management of moderate to severe postmenopausal vasomotor symptoms. Lower doses are needed to reduce VMS than those used to treat anxiety or depression, which is beneficial since side effects are typically dose dependent. The recommended dosage is 7.5 mg once daily at bedtime. Dose dependent side effects include nausea, fatigue, and dizziness. Knowing potential medication interactions is critical such as with medications that can lead to serotonin syndrome, concomitant use with monoamine oxidase inhibitors and being aware of p450 drug metabolism is essential for patients taking drugs that utilize the CYP2D6 enzyme for metabolism including tamoxifen. This review discusses in detail the available data supporting the use of paroxetine for the treatment of VMS, including side effects and considerations regarding prescribing. A discussion of other emerging treatments is included as well, including estetrol, oxybutynin and neurokinin 3 (NK3) receptor antagonists.

Reframing professional identity through navigating tensions during residency: A qualitative study.

INTRODUCTION: Professional identity formation (PIF) is the internalization of characteristics, values, and norms of the medical profession. An individual's identity formation has both psychological and sociological influences. Social psychology may be useful to explore the interactions between the psychological and sociological aspects of PIF. In this study, we explored how resident physicians navigated tensions between professional ideals and the reality of medical practice to characterize PIF during residency training. METHODS: Using constructivist grounded theory, the authors conducted 23 semi-structured interviews with internal medicine residents. Interview transcripts were processed through open coding and analytic memo writing. During data gathering and analysis, the authors utilized Social Cognitive Theory, specifically the bidirectional influence between person, behavior, and context, to analyze relationships among themes. Theoretical insights were refined through group discussion and constant comparison with newly collected data. RESULTS: Residents described tensions experienced during residency between pre-existing ideals of "a good doctor" and the realities of medical practice, often challenging residents to reframe their ideals. The authors provide evidence for the presence of dynamic, bidirectional influences between identity (person), behavior, and environment (context), and demonstrate how PIF is informed by a complex interplay between these elements. The authors present two examples to demonstrate how residents reframed their ideals during residency training. DISCUSSION: The complex bidirectional influences between person, behavior, and context, informed by SCT, helps illuminate the process of PIF in residency training. This study highlights the effects of the context of residency training on the development of residents' professional identities.

COVID-19 Gender Disparities and Mitigation Recommendations: A Narrative Review.

The coronavirus disease 2019 (COVID-19) pandemic has rapidly created widespread impacts on global health and the economy. Data suggest that women are less susceptible to severe illness. However, sex-disaggregated data are incomplete, leaving room for misinterpretation, and focusing only on biologic sex underestimates the gendered impact of the pandemic on women. This narrative review summarizes what is known about gender disparities during the COVID-19 pandemic and the economic, domestic, and health burdens along with overlapping vulnerabilities related to the pandemic. In addition, this review outlines recommended strategies that advocacy groups, community leaders, and policymakers should implement to mitigate the widening gender disparities related to COVID-19.

Dealing With Patient Death on International Health Electives: A Qualitative Study of Residents' Experiences.

PURPOSE: International health electives (IHEs) provide numerous educational benefits; potential harms are less well understood. One potential harm is trainee distress associated with increased patient death during IHEs. The purpose of this study was to explore residents' and fellows' IHE experiences with patient death. METHOD: The authors used applied thematic analysis to explore residents' and fellows' IHE experiences with patient death. The Mayo International Health Program supports IHEs from all specialties across three Mayo Clinic sites. Data were collected and analyzed in two steps. First the authors collected, coded, and analyzed narrative reflections from 43 postrotation reports gathered in 2001-2017 and identified themes relating to experiences with patient death. Second, in 2016-2017 the authors conducted semistructured interviews with six previous participants to refine thematic analysis. RESULTS: Participants described impacts of experiencing increased patient death and identified themes in two domains: difficult experiences with patient death and potential interventions to help residents process their experiences. They identified four themes illustrating why these experiences were difficult: lack of preparation for increased exposure to death, lack of closure, consequences of limited resources, and differences in cultural beliefs regarding death. While pretrip preparation for dealing with death was viewed as important, trainees identified support during and debriefing after IHEs as additional important interventions. CONCLUSIONS: Given the popularity of IHEs, residency programs should consider the effect on trainees of increased exposure to patient death. Study findings can inform IHE preparation, support, and debriefing to minimize distress associated with witnessing patient deaths on IHEs.

Transformative Learning and Professional Identity Formation During International Health Electives: A Qualitative Study Using Grounded Theory.

PURPOSE: International health electives (IHEs) are widely available during residency and provide unique experiences for trainees. Theoretical models of professional identity formation and transformative learning may provide insight into residents' experiences during IHEs. The purpose of this study was to explore transformative learning and professional identity formation during resident IHEs and characterize the relationship between transformative learning and professional identity formation. METHOD: The authors used a constructivist grounded theory approach, with the sensitizing concepts of transformative learning and professional identity formation to analyze narrative reflective reports of residents' IHEs. The Mayo International Health Program supports residents from all specialties across three Mayo Clinic sites. In 2015, the authors collected narrative reflective reports from 377 IHE participants dating from 2001 to 2014. Reflections were coded and themes were organized into a model for transformative learning during IHEs, focusing on professional identity. RESULTS: Five components of transformative learning were identified during IHEs: a disorienting experience; an emotional response; critical reflection; perspective change; and a commitment to future action. Within the component of critical reflection, three domains relating to professional identity were identified: making a difference; the doctor-patient relationship; and medicine in its "purest form." Transformation was demonstrated through perspective change and a commitment to future action, including continued service, education, and development. CONCLUSIONS: IHEs provide rich experiences for transformative learning and professional identity formation. Understanding the components of transformative learning may provide insight into the interaction between learner, experiences, and the influence of mentors in the process of professional identity formation.