Factors Associated with Medical Students' Attitudes About Cost-Conscious Care: A Mixed-Methods Multi-school Study.

BACKGROUND: Because physician practices contribute to national healthcare expenditures, initiatives aimed at educating physicians about high-value cost-conscious care (HVCCC) are important. Prior studies suggest that the training environment influences physician attitudes and behaviors towards HVCCC. OBJECTIVE: To explore the relationship between medical student experiences and HVCCC attitudes. DESIGN: Quantitative and qualitative analysis of a multi-institutional survey. PARTICIPANTS: Medical students from nine US medical schools. APPROACH: A 44-item survey that included the Maastricht HVCCC Attitudes Questionnaire, a validated tool for assessing HVCCC attitudes, was administered electronically. Attitudinal domains of high-value care (HVC), cost incorporation (CI), and perceived drawbacks (PD) were compared using one-way ANOVA among students with a range of exposures. Open text responses inviting participants to reflect on their attitudes were analyzed using classical content analysis. KEY RESULTS: A total of 740 students completed the survey (response rate 15%). Students pursuing a "continuity-oriented" specialty held more favorable attitudes towards HVCCC than those pursuing "technique-oriented" specialties (HVC sub-score = 3.20 vs. 3.06; p = 0.005, CI sub-score = 2.83 vs. 2.74; p < 0.001). Qualitative analyses revealed personal, educational, and professional experiences shape students' HVCCC attitudes, with similar experiences interpreted differently leading to both more and less favorable attitudes. CONCLUSION: Students pursuing specialties with longitudinal patient contact may be more enthusiastic about practicing high-value care. Life experiences before and during medical school shape these attitudes, and complex interactions between these forces drive student perceptions of HVCCC.

A Longitudinal Assessment of Resident and New Graduate Well-Being According to Length of Training: A Report From the Length of Training Pilot in Family Medicine.

Background & Objectives: No prior studies have examined how length of training may influence wellness. As part of the Length of Training Pilot (LoTP), we explored resident and new graduate well-being according to program year and length of training in 3- and 4-year family medicine residency training programs. METHODS: Two surveys captured data included in these analyses. One was a resident survey that included the Mayo Clinic physician-expanded Well-Being Index (eWBI) administered annually during the In-Training Examination (2014-2019). The second was administered to graduates 1 year after completion of training between 2016 and 2022 and included the same well-being questions. Response rates ranged between 77.7% and 96.8%. RESULTS: The eWBI summary scores for burnout were highest in postgraduate year 1 (PGY1) and did not differ statistically according to length of training (PGY1: 2.02 in 3-year [3YR] programs vs 1.93 in 4-year [4YR] programs, P=.55; postgraduate year 2 [PGY2]: 2.42 in 3YR programs vs 2.38 in 4YR programs, P=.83; postgraduate year 3 [PGY3]: 2.18 in 3YR programs vs 2.28 in 4YR programs, P=.59; and 2.34 in postgraduate year 4 [PGY4] for those in 4YR programs), though some statistical differences were noted for three items. New graduates' eWBI summary scores before the COVID-19 pandemic were 1.77 among 3YR graduates and 1.66 among 4YR graduates (P=.59). These scores were higher during COVID-19 at 1.89 for 3YR graduates and 2.02 for 4YR graduates (P=.62). Length of training was not associated with differences in well-being before or during COVID-19. CONCLUSIONS: We found no associations between length of training and physician well-being during training or among new graduates before or during COVID-19.

Postresidency Practice Setting and Clinical Care Features According to 3 Versus 4 Years of Training in Family Medicine: A Length of Training Pilot Study.

BACKGROUND AND OBJECTIVES: Factors associated with physician practice choice include residency location, training experiences, and financial incentives. How length of training affects practice setting and clinical care features postgraduation is unknown. METHODS: In this Length of Training Pilot (LoTP) study, we surveyed 366 graduates of 3-year (3YR) and 434 graduates of 4-year (4YR) programs 1 year after completion of training between 2013 and 2021. Variables assessed included reasons for practice setting choice, practice type, location, practice and community size, specialty mix, and clinical care delivery features (eg, integrated behavioral health, risk stratified care management). We compared different length of training models using χ2 or Fisher's exact tests for categorical variables and independent samples, and t test (unequal variances) for continuous variables. RESULTS: Response rates ranged from 50% to 88% for 3YR graduates and 68% to 95% for 4YR graduates. Scope of practice was a predominant reason for graduates choosing their eventual practice, and salary was a less likely reason for those completing 4 years versus 3 years of training (scope, 72% vs 55%, P=.001; salary, 15% vs 22%, P=.028). Community size, practice size, practice type, specialty mix, and practice in a federally designated underserved site did not differ between the two groups. We found no differences in patient-centered medical home features when comparing the practices of 3YR to 4YR graduates. CONCLUSIONS: Training length did not affect practice setting or practice features for graduates of LoTP programs. Future LoTP analyses will examine how length of training affects scope of practice and clinical preparedness, which may elucidate other elements associated with practice choice.

An Analysis of Workplace-Based Assessments for Core Entrustable Professional Activities for Entering Residency: Does Type of Clinical Assessor Influence Level of Supervision Ratings?

PURPOSE: The authors describe use of the workplace-based assessment (WBA) coactivity scale according to entrustable professional activities (EPAs) and assessor type to examine how diverse assessors rate medical students using WBAs. METHOD: A WBA data collection system was launched at Oregon Health and Science University to visualize learner competency in various clinical settings to foster EPA assessment. WBA data from January 14 to June 18, 2021, for medical students (all years) were analyzed. The outcome variable was level of supervisor involvement in each EPA, and the independent variable was assessor type. RESULTS: A total of 7,809 WBAs were included. Most fourth-, third-, and second-year students were assessed by residents or fellows (755 [49.5%], 1,686 [48.5%], and 918 [49.9%], respectively) and first-year students by attending physicians (803 [83.0%]; P < .001). Attendings were least likely to use the highest rating of 4 (1 was available just in case; 2,148 [56.7%] vs 2,368 [67.7%] for residents; P < .001). Learners more commonly sought WBAs from attendings for EPA 2 (prioritize differential diagnosis), EPA 5 (document clinical encounter), EPA 6 (provide oral presentation), EPA 7 (form clinical questions and retrieve evidence-based medicine), and EPA 12 (perform general procedures of a physician). Residents and fellows were more likely to assess students on EPA 3 (recommend and interpret diagnostic and screening tests), EPA 4 (enter and discuss orders and prescriptions), EPA 8 (give and receive patient handover for transitions in care), EPA 9 (collaborate as member of interprofessional team), EPA 10 (recognize and manage patient in need of urgent care), and EPA 11 (obtain informed consent). CONCLUSIONS: Learners preferentially sought resident vs attending supervisors for different EPA assessments. Future research should investigate why learners seek different assessors more frequently for various EPAs and if assessor type variability in WBA levels holds true across institutions.

Primary Care and Community-Based Partnerships to Enhance HPV Vaccine Delivery.

INTRODUCTION/OBJECTIVES: With growing vaccination misinformation and mistrust, strategies to improve vaccination communication across community-based settings are needed. METHODS: The Rural Adolescent Vaccine Enterprise (RAVE), a 5-year (2018-2022) stepped-wedge cluster randomized study, tested a clinic-based practice facilitation intervention designed to improve HPV vaccination. An exploratory aim sought to explore the use of partnerships between primary care clinics and a community partner of their choosing, to implement a social marketing campaign related to HPV immunization. We assessed perceptions about the value and success of the partnership, and barriers and facilitators to its implementation using a 29-item community partner survey, key informant interviews, and field notes from practice facilitators. RESULTS: Of the initial 45 clinics participating in RAVE, 9 were unable to either start or complete the study, and 36 participants (80.0%) were actively engaged. Of these, 16/36 clinics (44.4%) reported establishing successful partnerships, 10 reported attempting to develop partnerships (27.8%), and another 10 reported not developing a partnership (27.8%), which were often caused by the COVID-19 pandemic. The most common partnership was with public health departments at 27.3%. Other partnerships involved libraries, school districts, and local businesses. More than half (63.7%) reported that creating messages regarding getting HPV vaccination was moderately to very challenging. Just under half reported (45.5%) that messaging was hard because of a lack of understanding about the seriousness of diseases caused by HPV, parents being against vaccines because of safety concerns, and religious values that result in a lack of openness to HPV vaccines. Community partners' health priorities changed as a result of RAVE, with 80% prioritizing childhood immunizations as a result of the RAVE partnership. CONCLUSIONS: Community groups want to partner with primary care organizations to serve their patients and populations. More research is needed on how best to bring these groups together.

Resident Involvement in Curricular and Clinical Practice Change and Satisfaction With Training According to Length of Training in Family Medicine.

BACKGROUND AND OBJECTIVES: Most research in residency training has focused on quality improvement within a single program. We explored resident involvement in curricular and clinical practice change, the learning environment, and resident satisfaction in 3-year family medicine residencies compared to matched 4-year residencies. METHODS: We used two surveys to capture data. One was for program directors, which assessed the level of resident involvement in curricular and practice transformation. The second was a resident survey, which asked residents to rate their involvement in curricular change and practice transformation, the learning environment, and satisfaction with training. Both were administered annually between 2013 and 2019. Response rates ranged from 84.6% to 100%. RESULTS: Findings revealed no overall difference in resident involvement in curricular change, but the program director survey findings indicated that a higher proportion of residents in 4-year programs were using a broader diversity of approaches to working on quality improvement (QI) projects compared to those in 3-year programs. We also found statistical differences in the number of QI projects completed per year, with 34.1% completing three or more in 4-year programs compared to 13.3% in 3-year programs (P<.001). We found a positive correlation between resident involvement, learning environment, and satisfaction with training for both 3-year (range 0.489-0.666; P=.001) and 4-year residents (range 0.441-0.529; P=.001). CONCLUSIONS: Four-year residents were involved in a greater number of quality improvement projects and had a more diverse profile of involvement than those in 3-year residency programs. Involvement in practice and curricular change and the learning environment were associated with greater levels of resident satisfaction with training in both 3-year and 4-year programs.

Measuring Clinical Preparedness After Residency Training: Development of a New Instrument.

BACKGROUND AND OBJECTIVES: Research on preparedness for independent clinical practice typically uses surveys of residents and program directors near graduation, which can be affected by several biases. We developed a novel approach to assess new graduates more objectively using physician and staff member assessors 3 months after graduates started their first job. METHODS: We conducted a literature review and key informant interviews with physicians from varying practice types and geographic regions in the United States to identify features that indicate a lack of preparedness for independent clinical practice. We then held a Clinical Preparedness Measurement Summit, engaging measurement experts and family medicine education leaders, to build consensus on key indicators of readiness for independent clinical practice and survey development strategies. The 2015 entrustable professional activities for family medicine end-of-residency training provided the framework for assessment of clinical preparedness by physician assessors. Sixteen published variables assessing interpersonal communication skills and processes of care delivery were identified for staff assessors. We assessed frequencies and compared survey findings between physician and staff assessors in 2016 to assist with survey validation. RESULTS: The assessment of frequencies demonstrated a range of responses, supporting the instrument's ability to distinguish readiness for independent practice of recent graduate hires. No statistical differences occurred between the physician and staff assessors for the same physician they were evaluating, indicating internal consistency. CONCLUSIONS: To learn about the possible impact of length of training, we developed a novel approach to assess preparedness for independent clinical practice of family medicine residency graduates.

Resident Assessment of Clinician Educators According to Core ACGME Competencies.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) requires faculty to pursue annual development to enhance their teaching skills. Few studies exist on how to identify and improve the quality of teaching provided by faculty educators. Understanding the correlation between numeric scores assigned to faculty educators and their tangible, practical teaching skills would be beneficial. OBJECTIVE: This study aimed to identify and describe qualities that differentiate numerically highly rated and low-rated physician educators. DESIGN: This observational mixed-methods study evaluated attending physician educators between July 1, 2015, and June 30, 2021. Quantitative analysis involved descriptive statistics, normalization of scores, and stratification of faculty into tertiles based on a summary score. We compared the highest and lowest tertiles during qualitative analyses of residents' comments. PARTICIPANTS: Twenty-five attending physicians and 111 residents in an internal medicine residency program. MAIN MEASURES: Resident evaluations of faculty educators, including 724 individual assessments of faculty educators on 15 variables related to the ACGME core competencies. KEY RESULTS: Quantitative analyses revealed variation in attending physician educators' performance across the ACGME core competencies. The highest-rated teaching qualities were interpersonal and communication skills, medical knowledge, and professionalism, while the lowest-rated teaching quality was systems-based practice. Qualitative analyses identified themes distinguishing high-quality from low-quality attending physician educators, such as balancing autonomy and supervision, role modeling, engagement, availability, compassion, and excellent teaching. CONCLUSIONS: This study provides insights into areas where attending physicians' educational strategies can be improved, emphasizing the importance of role modeling and effective communication. Ongoing efforts are needed to enhance the quality of faculty educators and resident education in internal medicine residency programs.

Development and Pilot Testing of a Programmatic System for Competency Assessment in US Anesthesiology Residency Training.

BACKGROUND: In 2018, a set of entrustable professional activities (EPAs) and procedural skills assessments were developed for anesthesiology training, but they did not assess all the Accreditation Council for Graduate Medical Education (ACGME) milestones. The aims of this study were to (1) remap the 2018 EPA and procedural skills assessments to the revised ACGME Anesthesiology Milestones 2.0, (2) develop new assessments that combined with the original assessments to create a system of assessment that addresses all level 1 to 4 milestones, and (3) provide evidence for the validity of the assessments. METHODS: Using a modified Delphi process, a panel of anesthesiology education experts remapped the original assessments developed in 2018 to the Anesthesiology Milestones 2.0 and developed new assessments to create a system that assessed all level 1 through 4 milestones. Following a 24-month pilot at 7 institutions, the number of EPA and procedural skill assessments and mean scores were computed at the end of the academic year. Milestone achievement and subcompetency data for assessments from a single institution were compared to scores assigned by the institution's clinical competency committee (CCC). RESULTS: New assessment development, 2 months of testing and feedback, and revisions resulted in 5 new EPAs, 11 nontechnical skills assessments (NTSAs), and 6 objective structured clinical examinations (OSCEs). Combined with the original 20 EPAs and procedural skills assessments, the new system of assessment addresses 99% of level 1 to 4 Anesthesiology Milestones 2.0. During the 24-month pilot, aggregate mean EPA and procedural skill scores significantly increased with year in training. System subcompetency scores correlated significantly with 15 of 23 (65.2%) corresponding CCC scores at a single institution, but 8 correlations (36.4%) were <30.0, illustrating poor correlation. CONCLUSIONS: A panel of experts developed a set of EPAs, procedural skill assessment, NTSAs, and OSCEs to form a programmatic system of assessment for anesthesiology residency training in the United States. The method used to develop and pilot test the assessments, the progression of assessment scores with time in training, and the correlation of assessment scores with CCC scoring of milestone achievement provide evidence for the validity of the assessments.

A Scoping Literature Review on Evidence-Based Strategies to Increase Cervical Cancer Screening.

Previous reviews of strategies to increase cervical cancer screening are more than 10 years old, the U.S. continues to fall short of the Healthy People 2030 cervical cancer screening goal, and guidelines were revised in 2018, therefore an updated review of the existing literature is needed. We conducted a scoping review using electronic databases PubMed, Scopus, and Ovid Medline that included publication dates between 2012 and 2021 to answer the question, "Which strategies implemented in U.S. primary care settings have been most successful in increasing rates of cervical cancer screening since the 2012 US Preventative Services Task Force cervical cancer screening guidelines were published?" We mapped findings to pre-specified implementation strategy categories. After initially identifying 399 articles, we excluded 350 due to duplicates or not meeting review criteria, leaving 49 articles for full review. We excluded 37 of these during full-text review and identified 2 additional articles from the manual search of reference lists for a total of 14 studies for abstraction. Eleven articles reported on strategies resulting in increased cervical cancer screening, and 3 did not. Clinic workflow re-design strategies showed the greatest promise in improving cervical cancer screening rates, education strategies for patients had mixed results, and quality management strategies were not effective. These findings suggest clinical workflow re-structures and patient education strategies can increase cervical cancer screening in primary care settings. Results are particularly important in settings that care for underserved populations, as these settings may need additional implementation strategies to decrease cervical cancer screening disparities.

An Exploratory Study of Rural Parents' Knowledge and Attitudes About HPV Vaccination Following a Healthcare Visit With Their Child's Primary Care Provider.

INTRODUCTION/OBJECTIVES: Annually, HPV infections result in $775 million in direct medical costs and approximately 46 000 new cases of HPV-associated cancers. Safe and highly effective vaccines have been available to prevent HPV for children/adolescents since 2006. Vaccination rates remain low, especially in rural areas. Parental attitudes and beliefs affect HPV vaccination rates. METHODS: We developed, tested, and administered a survey that asked how parents and healthcare providers interacted about the HPV vaccine following a healthcare visit with an age-eligible child, as part of a multicomponent randomized controlled trial designed to improve HPV vaccination rates in rural Oregon. The 21-item survey assessed parents' information-seeking behavior, knowledge about HPV cancer risk reduction, the HPV vaccine series, and their vaccine confidence. RESULTS: Forty-three participants (59.7%) were in the intervention group; 29 (40.3%) were controls. Over 90% of healthcare visits were illness, injury, sports physical, or well-child visits (n = 67 or 93.1%), and 6.9% of visits were vaccine-specific. No statistically significant differences were found between study groups for healthcare visits. Over half the parents reported having discussions about HPV and the HPV vaccine (54.5%) with their care providers, 31.3% had recently learned about HPV, HPV risks, and the HPV vaccine prior to the visit, 83.1% were knowledgeable about cancers associated with HPV, and 79.2% were considering vaccinating their child(ren), which did not differ between study groups. CONCLUSIONS: Knowledge about HPV-related cancers and consideration for vaccinating children was higher than expected, but not associated with the intervention tested.

Funding Opportunities Designed to Promote Antiracist Change Across a Health Sciences University.

Importance: As health professionals acknowledge the historic and current influences racism has on patient care and health outcomes, leaders must develop antiracist activities to disrupt current narratives. Objective: To examine the outcomes of antiracism funding opportunities for development, implementation, and evaluation of initiatives across a multi-health professions academic university. Design, Setting, and Participants: This mixed-methods cohort study involved the evaluation of 17 antiracism projects conducted at a midsize single academic university in the Pacific Northwest with schools of dentistry, medicine, nursing, pharmacy, and public health. Projects were designed by students, faculty, staff, and community members, many of whom were from diverse backgrounds. Data collection and analyses were conducted between January and December 2022. Main Outcomes and Measures: Influence and reach of institutionally funded antiracist projects and best practices for funding them. Key metrics included project types, allocation of funds, level of community engagement, number of individuals engaged, demographic characteristics of project leaders, and project facilitators and barriers. Results: Forty-two proposals were submitted, and 17 were selected for funding, representing 3 of 5 health profession schools. Study teams included women (15 of 19 [79%]), gender queer (1 [5%]), Asian American (5 [26%]), Black or African American (2 [11%]), Hispanic or Latinx (1 [5%]), Middle Eastern, North African, or biracial (4 [21%]) and White (7 [37%]) individuals. Four of 17 teams (24%) returned funds because their proposed projects exceeded their workload. Eight projects (47%) were fully implemented, most in the School of Medicine. Community engagement surveys were completed by 10 projects (59%), and 1741 participants engaged in 1 or more funded events. Two focus groups were attended by 7 of 17 projects (41%), which reflected diversity among grantees. Participants noted that facilitators of antiracist activities included strong community engagement, improved well-being, and sense of support by both the community and the institution. Barriers to advancing antiracist initiatives included restrictive timelines, being unprepared for the time needed for their efforts, distrust from community members due to previous experiences with diversity and inclusion projects, and difficulties navigating complex institutional systems and processes. Conclusions and Relevance: The findings of this study suggest that efforts needed to implement antiracist change should not be underestimated. Engagement should be inclusive across academic health centers and communities. Future efforts need to support innovator full-time equivalent support, individual mentorship, and institutional sponsorship.

A comparison of electronic health records and the Oregon state immunization registry for human papilloma virus vaccine delivery (2005-2022).

INTRODUCTION: Immunization Information Systems (IIS) play an important information-sharing role at the point of care, and provide vital vaccination data for research studies and policy-makers. Previous validation studies comparing the accuracy of state registry data to health records have had mixed results. METHODS: We conducted a retrospective review of EHR vaccination data for 9-17 year-old patients from 10 Oregon primary care clinics who had at least one ambulatory care visit in the past 3 years from the date of validation data collection. Data on 100 age eligible youth were captured per clinic. We compared HPV and Tdap vaccinations captured in the EHR to the Oregon ALERT IIS. All clinics were located in rural areas with both family medicine (n = 7) and pediatric (n = 3) primary care clinics. RESULTS: Overall agreement for HPV vaccination between EHR and ALERT IIS was 89.4 % (k = 0.83; p < 0.05). For Tdap vaccination overall agreement was 80.8 % (k = 0.60; p < 0.05). Pediatric clinics showed a higher overall vaccine agreement for both HPV at 93.3 % (k = 0.89; p < 0.05) and Tdap at 95.3 % (k = 0.90; p < 0.05). Among clinics that used bidirectional data exchange (only family medicine clinics), HPV agreement was higher at 91 % (k = 0.85) versus 88 % (k = 0.81; p < 0.05) and was lower for Tdap 75 % with bidirectional data exchange (k = 0.50) versus 86 % without bidirectional data exchange (k = 0.70; p < 0.05). When the EHR and ALERT IIS disagreed, ALERT ISS usually had additional vaccines. CONCLUSIONS: ALERT IIS data provides more accurate data than EHRs can provide when measuring vaccine delivery among adolescents in rural Oregon.

Optimizing Survey Response Rates in Graduate Medical Education Research Studies.

BACKGROUND AND OBJECTIVE: Survey response rates of 70% or higher are needed if findings are to be considered generalizable. Unfortunately, survey studies of health professionals have declining response rates. We have conducted survey research with residents and residency directors for over 13 years. Here we describe the strategies we used to obtain optimal response rates in residency training research collaboratives. METHODS: We administered over 6,000 surveys between 2007 and 2019 to evaluate the Preparing the Personal Physician for Practice and Length of Training Pilot studies, both of which involved redesigning residency training. Survey recipients included program directors, clinic managers, residents, graduates, as well as supervising physicians and clinic staff members. We logged and analyzed survey administration efforts and approaches to optimize strategies. RESULTS: Overall, we obtained response rates of 100% for program director surveys, 98% for resident surveys, 97% for continuity clinic surveys, 81% for graduates surveys, and 48% for the supervising physician and 43% for the clinic staff. Response rates were highest when the relationships between the evaluation team and survey recipients were closest. Strategies for optimizing response rates included (1) building relationships with all participants whenever possible, (2) sensitivity to survey timing and fatigue, and (3) using creative and persistent follow-up measures to encourage survey completion. CONCLUSION: High response rates are achievable, though they require an investment in time, resources, and ingenuity in connecting with study populations. Investigators conducting survey research must consider administrative efforts needed to achieve target response rates, including planning for funds accordingly.

Resident Visit Productivity and Attitudes About Continuity According to 3 Versus 4 Years of Training in Family Medicine: A Length of Training Study.

BACKGROUND AND OBJECTIVES: Training models in the Length of Training Pilot (LOTP) vary. How innovations in training length affect patient visits and resident perceptions of continuity is unknown. METHODS: We analyzed resident in-person patient encounters (2013-2014 through 2018-2019) for each postgraduate year (PGY) and total visits at graduation derived from the Accreditation Council for Graduate Medical Education reports for each LOTP program. We collected data on residents' perceptions of continuity from annual surveys (2015-2019). We analyzed continuous variables using independent samples t tests with unequal variance and categorical variables using χ2 tests in comparing 3-year (3YR) versus 4-year (4YR) programs. RESULTS: PGY-1 and PGY-2 residents in 4YR programs saw statistically more patients than their counterparts in 3YR programs. In PGY3, 3YR program residents had statistically higher visit volume compared to 4YR program residents. Visits conducted in PGY4 ranged from 832 to 884. The additional year of training resulted in approximately 1,000 more total patient visits. Most residents in 3YR and 4YR programs rated their continuity clinic experience as somewhat or very adequate (range 86.3% to 93.7%), which did not statistically differ according to length of training. CONCLUSIONS: Resident visits were significantly different at each PGY level when comparing 3YR and 4YR programs in the LOTP and the additional year of training resulted in about 1,000 more total visits. Resident perspectives on the adequacy of their continuity clinic experience appeared to not be affected by length of training. Future research should explore how the volume of patient visits performed in residency affects scope of practice and clinical preparedness.

An Exploratory Study of Primary Care Clinicians' Perspectives on 2021 New and Updated Cancer Screening Guidelines.

BACKGROUND AND OBJECTIVE: Cancer screening rates remain low in rural, racial and ethnic minority, low-income, and uninsured populations. Prior studies showed that cancer screening recommendations vary based on clinicians' factors. We conducted an exploratory study on primary care clinicians' beliefs about new or updated cancer screening guidelines according to clinician demographics. METHODS: This cross-sectional study involved administering a web-based survey in July and August of 2021 to primary care clinicians practicing in diverse ambulatory settings in the Pacific Northwest belonging to the same health system. The survey assessed clinician demographics, attitudes about the impact of cancer screening on mortality, and how clinicians stay up-to-date with guidelines. RESULTS: Of the 191 clinicians, 81 responded (42.4%), after removing 13 incomplete surveys, we analyzed 68 (35.6%). The majority agreed/strongly agreed that breast (76.1%), colorectal (95.5%), and cervical (90.9%) cancer screening, and HPV vaccination (85.1%) prevent early cancer mortality: there were no differences according to clinician gender or years in practice. Female compared to male clinicians were more likely to agree/strongly agree that tobacco smoking cessation (female: 100% vs male: 86.4%, P = .01) prevents early cancer mortality, whereas male compared to female clinicians were more likely to agree/strongly agree that lung cancer screening (male: 86.4% vs female: 57.8%, P = .04) prevents early cancer mortality. One-third (33.3%) of clinicians were unaware of the 2021 update on lung cancer screening and females were more likely than males to say they did not know about this change (females: 43.2% vs males: 13.6%, P = .02). CONCLUSIONS: This study suggests that clinicians' attitudes are not likely the primary factor affecting low cancer screening rates in some populations and that few differences exist in beliefs based on gender, and none based on years in practice.

The Association Between Length of Training and Family Medicine Residents' Clinical Knowledge: A Report From the Length of Training Pilot Study.

BACKGROUND AND OBJECTIVE: The associations between training length and clinical knowledge are unknown. We compared family medicine in-training examination (ITE) scores among residents who trained in 3- versus 4-year programs and to national averages over time. METHODS: In this prospective case-control study, we compared the ITE scores of 318 consenting residents in 3-year programs to 243 who completed 4 years of training between 2013 through 2019. We obtained scores from the American Board of Family Medicine. The primary analyses involved comparing scores within each academic year according to length of training. We used multivariable linear mixed effects regression models adjusted for covariates. We performed simulation models to predict ITE scores after 4 years of training among residents who underwent only 3 years of training. RESULTS: At baseline postgraduate year-1 (PGY1), the estimated mean ITE scores were 408.5 for 4-year programs and 386.5 for 3-year programs, a 21.9 point difference (95% CI=10.1-33.8). At PGY2 and PGY3, 4-year programs scored 15.0 points higher and 15.6 points higher, respectively. When extrapolating an estimated mean ITE score for 3-year programs, 4-year programs would still score 29.4 points higher (95% CI=15.0-43.8). Our trend analysis revealed those in 4-year programs had a slightly lesser slope increase compared to 3-year programs in the first 2 years. Their drop-off in ITE scores is less steep in later years, though these differences were not statistically significant. CONCLUSIONS: While we found significantly higher absolute ITE scores in 4 versus 3-year programs, these increases in PGY2, PGY3 and PGY4 may be due to initial differences in PGY1 scores. Additional research is needed to support a decision to change the length of family medicine training.