COVID-19 Impact on Family Medicine Residents Exam Performance.

BACKGROUND AND OBJECTIVES: The COVID-19 pandemic began interrupting family medicine residency training in spring 2020. While a decline in scores on the American Board of Family Medicine In-Training Examination (ITE) has been observed, whether this decline has translated into the high-stakes Family Medicine Certification Examination (FMCE) is unclear. The goal of this study was to systematically assess the magnitude of COVID-19 impact on medical knowledge acquisition during residency, as measured by the ITE and FMCE. METHODS: A total of 19,101 initial certification candidates from 2017 to 2022 were included in this study. Annual ITE scores and FMCE scores were reported on the same scale (200-800) and served as the outcome measure. We conducted multilevel regression analysis to determine ITE score growth and FMCE scores compared to cohorts prior to COVID-19. RESULTS: During COVID-19, the increase in ITE scores from postgraduate year 2 (PGY-2) to PGY-3 was 25.5 points less, representing a 57.6% relative decrease; and from PGY-3 ITE to FMCE, it was 8.6 points less, a 12.7% relative decrease, compared with cohorts prior to COVID-19. FMCE scores were 6.6 points less during COVID-19, representing a 1.2% relative decline from the average FMCE score prior to COVID-19. CONCLUSIONS: This study found nonsubstantive COVID-19 impact on FMCE scores, but a considerable knowledge acquisition decline during residency, especially during the PGY-2 to PGY-3 period. While COVID-19 impacted learning, our findings indicated that residencies were largely able to remediate knowledge deficits before residents took the FMCE.

The FLRT3-UNC5B checkpoint pathway inhibits T cell-based cancer immunotherapies.

Cancers exploit coinhibitory receptors on T cells to escape tumor immunity, and targeting such mechanisms has shown remarkable clinical benefit, but in a limited subset of patients. We hypothesized that cancer cells mimic noncanonical mechanisms of early development such as axon guidance pathways to evade T cell immunity. Using gain-of-function genetic screens, we profiled axon guidance proteins on human T cells and their cognate ligands and identified fibronectin leucine-rich transmembrane protein 3 (FLRT3) as a ligand that inhibits T cell activity. We demonstrated that FLRT3 inhibits T cells through UNC5B, an axon guidance receptor that is up-regulated on activated human T cells. FLRT3 expressed in human cancers favored tumor growth and inhibited CAR-T and BiTE + T cell killing and infiltration in humanized cancer models. An FLRT3 monoclonal antibody that blocked FLRT3-UNC5B interactions reversed these effects in an immune-dependent manner. This study supports the concept that axon guidance proteins mimic T cell checkpoints and can be targeted for cancer immunotherapy.

Differences in Physician Performance and Self-rated Confidence on High- and Low-Stakes Knowledge Assessments in Board Certification.

INTRODUCTION: Evidence links assessment to optimal learning, affirming that physicians are more likely to study, learn, and practice skills when some form of consequence ("stakes") may result from an assessment. We lack evidence, however, on how physicians' confidence in their knowledge relates to performance on assessments, and whether this varies based on the stakes of the assessment. METHODS: Our retrospective repeated-measures design compared differences in patterns of physician answer accuracy and answer confidence among physicians participating in both a high-stakes and a low-stakes longitudinal assessment of the American Board of Family Medicine. RESULTS: After 1 and 2 years, participants were more often correct but less confident in their accuracy on a higher-stakes longitudinal knowledge assessment compared with a lower-stakes assessment. There were no differences in question difficulty between the two platforms. Variation existed between platforms in time spent answering questions, use of resources to answer questions, and perceived question relevance to practice. DISCUSSION: This novel study of physician certification suggests that the accuracy of physician performance increases with higher stakes, even as self-reported confidence in their knowledge declines. It suggests that physicians may be more engaged in higher-stakes compared with lower-stakes assessments. With medical knowledge growing exponentially, these analyses provide an example of the complementary roles of higher- and lower-stakes knowledge assessment in supporting physician learning during continuing specialty board certification.

Exposure to endocrine-disrupting plasticisers and lung function in children and adolescents: A systematic review and meta-analysis.

Exposure to endocrine-disrupting plasticisers (EDPs), such as phthalates and bisphenols, has been associated with reduced lung function in children and adolescents. However, the existing literature yields conflicting results. This systematic review and meta-analysis aimed to assess the epidemiologic evidence investigating the association between EDP exposure and lung function in children and adolescents. A comprehensive search of five databases identified 25 relevant studies. We employed a random-effects meta-analysis on spirometry measures. The effect size of interest was the change in lung function in standard deviation (SD) units resulting from a two-fold increase in exposure levels. We found that certain phthalates marginally reduced lung function in children. Forced expiratory volume in 1 s (FEV1) was reduced by a two-fold increase in mono-benzyl phthalate (MBzP) (ß = -0.025 SD, 95%CI: 0.042, -0.008), mono-ethyl-oxo-hexyl phthalate (MEOHP) (ß = -0.035 SD, 95%CI: 0.057, -0.014) and mono-carboxy-nonyl phthalate (MCNP) (ß = -0.024 SD, 95%CI: 0.05, -0.003). Forced vital capacity (FVC) was decreased by a two-fold increase in MBzP (ß = -0.022 SD, 95%CI: 0.036, -0.008) and MEOHP (ß = -0.035 SD, 95%CI: 0.057, -0.014) levels. A two-fold increase in MCNP levels was associated with lower FEV1/FVC (ß = -0.023 SD, 95%CI: 0.045, -0.001). Furthermore, a two-fold increase in MEOHP levels reduced forced mid-expiratory flow (FEF25-75) (ß = -0.030 SD, 95%CI: 0.055, -0.005) and peak expiratory flow (PEF) (ß = -0.056 SD, 95%CI: 0.098, -0.014). Notably, associations were more pronounced in males. Given the potential for reverse causation bias, the association between childhood exposure to EDPs and lung function remains uncertain. Overall, our meta-analysis showed small reductions in lung function with higher phthalate exposure. However, future studies are warranted in younger age groups.

Unrestrained cleavage of Roquin-1 by MALT1 induces spontaneous T cell activation and the development of autoimmunity.

Constitutive activation of the MALT1 paracaspase in conventional T cells of Malt1TBM/TBM (TRAF6 Binding Mutant = TBM) mice causes fatal inflammation and autoimmunity, but the involved targets and underlying molecular mechanisms are unknown. We genetically rendered a single MALT1 substrate, the RNA-binding protein (RBP) Roquin-1, insensitive to MALT1 cleavage. These Rc3h1Mins/Mins mice showed normal immune homeostasis. Combining Rc3h1Mins/Mins alleles with those encoding for constitutively active MALT1 (TBM) prevented spontaneous T cell activation and restored viability of Malt1TBM/TBM mice. Mechanistically, we show how antigen/MHC recognition is translated by MALT1 into Roquin cleavage and derepression of Roquin targets. Increasing T cell receptor (TCR) signals inactivated Roquin more effectively, and only high TCR strength enabled derepression of high-affinity targets to promote Th17 differentiation. Induction of experimental autoimmune encephalomyelitis (EAE) revealed increased cleavage of Roquin-1 in disease-associated Th17 compared to Th1 cells in the CNS. T cells from Rc3h1Mins/Mins mice did not efficiently induce the high-affinity Roquin-1 target IκBNS in response to TCR stimulation, showed reduced Th17 differentiation, and Rc3h1Mins/Mins mice were protected from EAE. These data demonstrate how TCR signaling and MALT1 activation utilize graded cleavage of Roquin to differentially regulate target mRNAs that control T cell activation and differentiation as well as the development of autoimmunity.

Factors Associated With Maintenance of an Improved Ejection Fraction: An Echocardiogram-Based Registry Study.

Background Heart failure with improved ejection fraction (EF) is increasingly recognized as a sizable and distinct entity. While the features associated with improvedEF have been explored and new guidelines have emerged, factors associated with sustaining an improved EF over time have not been defined. We aimed to assess factors associated with maintenance of an improved EF in a large real-world patient cohort. Methods and Results A total of 7070 participants with heart failure with improved EF and a subsequent echocardiogram performed after at least 9 months of follow-up were included in a retrospective cohort study conducted at the Cleveland Clinic in Cleveland, Ohio. Multiple logistic regression models, adjusted for demographics, comorbidities, and medications were built to identify characteristics and therapeutic interventions associated with maintaining an improved EF. Mean age (SD) was 64.9 (13.8) years, 62.7% were men, and 75.1% were White participants. White race and the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or angiotensin receptor-neprilysin inhibitors were associated with maintaining the EF at least 9 months after EF improvement. In contrast, male sex or having atrial fibrillation/flutter, coronary artery disease, history of myocardial infarction, presence of an implanted cardioverter-defibrillator, and use of loop diuretics were associated with a decline in EF after previously documented improvement. Conclusions Continued use of renin-angiotensin-aldosterone system inhibitors was associated with maintaining the EF beyond the initial improvement phase.

Should employees be required to return to the office?

Expectations for where and when work should take place changed radically for workers through the COVID-19 global pandemic. Now that COVID-19 no longer poses a significant safety threat for the typical worker, executives at many organizations are now expecting their employees to return to the office. The issues seem to revolve around perceived barriers to culture, collaboration, and innovation when employees are not present together in the office. Yet, many employees strongly resist a return to the office. They have experienced well-being, productivity, and autonomy benefits from a remote and hybrid work arrangement. Rigid return to office rules feel outdated, manipulative, and controlling to many employees. In the current article we explore expert opinion on the issues of culture, collaboration, and innovation. Specifically, we ask whether a return to office will improve these aspects of organizational functioning and we outline evidence that leads us to provide an answer these questions. Executives and managers may find these expert opinions useful in their consideration of workplace policies and guidelines for the use of remote, hybrid, and in office work arrangements in their organizations.

Function and targeting of MALT1 paracaspase in cancer.

The paracaspase MALT1 has emerged as a key regulator of immune signaling, which also promotes tumor development by both cancer cell-intrinsic and -extrinsic mechanisms. As an integral subunit of the CARD11-BCL10-MALT1 (CBM) signaling complex, MALT1 has an intriguing dual function in lymphocytes. MALT1 acts as a scaffolding protein to drive activation of NF-κB transcription factors and as a protease to modulate signaling and immune activation by cleavage of distinct substrates. Aberrant MALT1 activity is critical for NF-κB-dependent survival and proliferation of malignant cancer cells, which is fostered by paracaspase-catalyzed inactivation of negative regulators of the canonical NF-κB pathway like A20, CYLD and RelB. Specifically, B cell receptor-addicted lymphomas rely strongly on this cancer cell-intrinsic MALT1 protease function, but also survival, proliferation and metastasis of certain solid cancers is sensitive to MALT1 inhibition. Beyond this, MALT1 protease exercises a cancer cell-extrinsic role by maintaining the immune-suppressive function of regulatory T (Treg) cells in the tumor microenvironment (TME). MALT1 inhibition is able to convert immune-suppressive to pro-inflammatory Treg cells in the TME of solid cancers, thereby eliciting a robust anti-tumor immunity that can augment the effects of checkpoint inhibitors. Therefore, the cancer cell-intrinsic and -extrinsic tumor promoting MALT1 protease functions offer unique therapeutic opportunities, which has motivated the development of potent and selective MALT1 inhibitors currently under pre-clinical and clinical evaluation.

TRAF6 controls T cell homeostasis by maintaining the equilibrium of MALT1 scaffolding and protease functions.

MALT1 is a core component of the CARD11-BCL10-MALT1 (CBM) signalosome, in which it acts as a scaffold and a protease to bridge T cell receptor (TCR) ligation to immune activation. As a scaffold, MALT1 binds to TRAF6, and T cell-specific TRAF6 ablation or destruction of MALT1-TRAF6 interaction provokes activation of conventional T (Tconv) effector cells. In contrast, MALT1 protease activity controls the development and suppressive function of regulatory T (Treg) cells in a T cell-intrinsic manner. Thus, complete loss of TRAF6 or selective inactivation of MALT1 catalytic function in mice skews the immune system towards autoimmune inflammation, but distinct mechanisms are responsible for these immune disorders. Here we demonstrate that TRAF6 deletion or MALT1 paracaspase inactivation are highly interdependent in causing the distinct immune pathologies. We crossed mice with T cell-specific TRAF6 ablation (Traf6-ΔT) and mice with a mutation rendering the MALT1 paracaspase dead in T cells (Malt1 PD-T) to yield Traf6-ΔT;Malt1 PD-T double mutant mice. These mice reveal that the autoimmune inflammation caused by TRAF6-ablation relies strictly on the function of the MALT1 protease to drive the activation of Tconv cells. Vice versa, despite the complete loss of Treg cells in Traf6-ΔT;Malt1 PD-T double mutant mice, inactivation of the MALT1 protease is unable to cause autoinflammation, because the Tconv effector cells are not activated in the absence of TRAF6. Consequentially, combined MALT1 paracaspase inactivation and TRAF6 deficiency in T cells mirrors the immunodeficiency seen upon T cell-specific MALT1 ablation.

The burden of respiratory syncytial virus in healthy term-born infants in Europe: a prospective birth cohort study.

BACKGROUND: Respiratory syncytial virus (RSV) is a major cause of hospitalisation in infants. The burden of RSV infection in healthy term infants has not yet been established. Accurate health-care burden data in healthy infants are necessary to determine RSV immunisation policy when RSV immunisation becomes available. METHODS: We performed a multicentre, prospective, observational birth cohort study in healthy term-born infants (≥37 weeks of gestation) in five sites located in different European countries to determine the health-care burden of RSV. The incidence of RSV-associated hospitalisations in the first year of life was determined by parental questionnaires and hospital chart reviews. We performed active RSV surveillance in a nested cohort to determine the incidence of medically attended RSV infections. The study is registered with ClinicalTrials.gov, NCT03627572. FINDINGS: In total, 9154 infants born between July 1, 2017, and April 1, 2020, were followed up during the first year of life and 993 participated in the nested active surveillance cohort. The incidence of RSV-associated hospitalisations in the total cohort was 1·8% (95% CI 1·6-2·1). There were eight paediatric intensive care unit admissions, corresponding to 5·5% of 145 RSV-associated hospitalisations and 0·09% of the total cohort. Incidence of RSV infection in the active surveillance cohort confirmed by any diagnostic assay was 26·2% (24·0-28·6) and that of medically attended RSV infection was 14·1% (12·3-16·0). INTERPRETATION: RSV-associated acute respiratory infection causes substantial morbidity, leading to the hospitalisation of one in every 56 healthy term-born infants in high-income settings. Immunisation of pregnant women or healthy term-born infants during their first winter season could have a major effect on the health-care burden caused by RSV infections. FUNDING: Innovative Medicines Initiative 2 Joint Undertaking, with support from the EU's Horizon 2020 research and innovation programme and European Federation of Pharmaceutical Industries and Associations.

Interprofessional clinical event debriefing-does it make a difference? Attitudes of emergency department care providers to INFO clinical event debriefings.

BACKGROUND: Debriefing is increasingly used in clinical environments. Surveys indicate staff support for debriefing clinical events, but little is known about the specific effects of debriefing on healthcare workers in the workplace. INFO (Immediate, Not for personal assessment, Fast facilitated feedback, and Opportunity to support and ask questions) is a charge nurse facilitated clinical event debriefing program implemented in 2016 and currently used in five Emergency Departments (ED) in Calgary, Alberta, Canada. There have been more than 840 documented INFO debriefings. METHODS: Thirty interprofessional ED healthcare workers were recruited through posters and email to take part in voluntary one-on-one interviews using a standardized question script that asked participants about their experience with INFO debriefing assessments. Specifically, participants were asked to provide demographic information, give feedback about their involvement in INFO clinical debriefings, impact of debriefings on their clinical practice, stress levels and wellbeing. Interviews were transcribed and analysed using NVivo software. RESULTS: Forty-five healthcare workers replied to the initial recruitment methods with fifteen not responding to follow-up communication. Overall, staff satisfaction with INFO debriefing was highly rated. A qualitative thematic analysis to saturation approach was used to analyse the data. Five main themes were identified: 1.Effect of debriefing on clinical practice and patient care. 2. Psychological safety and teamwork. 3. Emotional acknowledgment after critical events. 4. Managing work stress in the ED. 5. Barriers to debriefing. CONCLUSIONS: In this study, debriefing in the ED helped interprofessional healthcare workers manage stress, provide improved patient care and teamwork while acknowledging emotions. This study specifically involved INFO, however, there are similarities that make our findings applicable to other clinical event debriefing programs. We believe this study provides further evidence supporting debriefing in clinical care areas.

RéSUMé: CONTEXTE: Le débriefing est de plus en plus utilisé dans les environnements cliniques. Les enquêtes indiquent que le personnel est favorable au débriefing des événements cliniques, mais on sait peu de choses sur les effets spécifiques du débriefing sur les travailleurs de la santé sur le lieu de travail. INFO (Immediate, Not for personal assessment, Fast facilitated feedback, and Opportunity to support and ask questions) est un programme de débriefing d'événements cliniques animé par l'infirmière en chef, mis en œuvre en 2016 et actuellement utilisé dans cinq services d'urgence (SU) à Calgary, Alberta, Canada. Il y a eu plus de 840 débriefings INFO documentés. MéTHODES: Trente travailleurs interprofessionnels des services d'urgence ont été recrutés par le biais d'affiches et de courriels pour participer à des entretiens individuels volontaires à l'aide d'un script de questions standardisé qui demandait aux participants de parler de leur expérience des évaluations de débriefing INFO. Plus précisément, les participants ont été invités à fournir des informations démographiques, à donner leur avis sur leur participation aux débriefings cliniques INFO, sur l'impact des débriefings sur leur pratique clinique, sur leur niveau de stress et sur leur bien-être. Les entretiens ont été transcrits et analysés à l'aide du logiciel NVivo. RéSULTATS: Quarante-cinq travailleurs de la santé ont répondu aux méthodes de recrutement initiales, quinze n'ont pas répondu à la communication de suivi. Dans l'ensemble, la satisfaction du personnel à l'égard du compte rendu d'INFO a été très bonne. Une analyse thématique qualitative jusqu'à saturation a été utilisée pour analyser les données. Cinq thèmes principaux ont été identifiés : 1. l'effet du débriefing sur la pratique clinique et les soins aux patients. 2. La sécurité psychologique et le travail en équipe. 3. Reconnaissance émotionnelle après des événements critiques. 4. Gestion du stress au travail dans les services d'urgence. 5. Obstacles au débriefing. CONCLUSIONS: Dans cette étude, le débriefing aux urgences a aidé les travailleurs de la santé interprofessionnels à gérer le stress, à améliorer les soins aux patients et le travail d'équipe tout en reconnaissant les émotions. Cette étude a porté spécifiquement sur INFO, mais il existe des similitudes qui rendent nos résultats applicables à d'autres programmes de débriefing d'événements cliniques. Nous pensons que cette étude apporte des preuves supplémentaires en faveur du débriefing dans les domaines des soins cliniques.

Optimized CRISPR-Cas9-based Strategy for Complex Gene Targeting in Murine Embryonic Stem Cells for Germline Transmission.

Although CRISPR-Cas9 genome editing can be performed directly in single-cell mouse zygotes, the targeting efficiency for more complex modifications such as the insertion of two loxP sites, multiple mutations in cis, or the precise insertion or deletion of longer DNA sequences often remains low (Cohen, 2016). Thus, targeting and validation of correct genomic modification in murine embryonic stem cells (ESCs) with subsequent injection into early-stage mouse embryos may still be preferable, allowing for large-scale screening in vitro before transfer of thoroughly characterized and genetically defined ESC clones into the germline. This procedure can result in a reduction of animal numbers with cost effectiveness and compliance with the 3R principle of animal welfare regulations. Here, we demonstrate that after transfection of homology templates and PX458 CRISPR-Cas9 plasmids, EGFP-positive ESCs can be sorted with a flow cytometer for the enrichment of CRISPR-Cas9-expressing cells. Cell sorting obviates antibiotic selection and therefore allows for more gentle culture conditions and faster outgrowth of ESC clones, which are then screened by qPCR for correct genomic modifications. qPCR screening is more convenient and less time-consuming compared to analyzing PCR samples on agarose gels. Positive ESC clones are validated by PCR analysis and sequencing and can serve for injection into early-stage mouse embryos for the generation of chimeric mice with germline transmission. Therefore, we describe here a simple and straightforward protocol for CRISPR-Cas9-directed gene targeting in ESCs. Graphical abstract.

Oxacillin plus ertapenem rapidly clears persistent left ventricular assist device-related methicillin-susceptible Staphylococcus aureus bacteremia.

There is an increasing use of left ventricular assist devices (LVADs) as bridge to transplantation or permanent destination therapy in the heart failure patient population. Infection remains a common complication in LVADs, with Gram-positive skin flora as predominant pathogens implicated, including Staphylococcus aureus. While there is emerging evidence for synergistic antibiotic combinations with methicillin resistant S. aureus, there remains a significant gap in the literature for persistent methicillin susceptible S. aureus bacteremia. In this article, we describe the first successful treatment of persistent LVAD-related bacteremia with salvage oxacillin plus ertapenem. The salvage therapy described here must be balanced by the risks for toxicity, impact on resistance, microbiota disruption, drug shortages, and patient costs. This combination warrants further evaluation in the clinical setting to better establish its role in our expanding patient population.

Racial/Ethnic Group Trajectory Differences in Exam Performance Among US Family Medicine Residents.

BACKGROUND AND OBJECTIVES: Racial/ethnic score disparities on standardized tests are well documented. Such differences on the American Board of Family Medicine (ABFM) certification examination have not been previously reported. If such differences exist, it could be due to differences in knowledge at the beginning of residency or due to variations in the rate of knowledge acquisition during residency. Our objective was to examine the residents' mean initial scores and score trajectories using the In-Training Examination (ITE) and certification examination. METHODS: A total of 17,275 certification candidates from 2014 to 2019 were included in this study. Annual ITE scores and certification examination scores are reported on the same scale and serve as the outcome. We conducted multilevel longitudinal regression to determine initial knowledge and growth in knowledge acquisition during residency by race/ethnicity categories. RESULTS: The mean postgraduate year 1 (PGY-1) ITE score was 393.3, with minority residents scoring 16.2 to 36.0 points lower compared to White residents. The mean increase per year in exam performance from PGY-1 ITE to the certification exam was 39.9 points (95% CI, 38.7, 41.1) with additional change among race/ethnicity categories per year of -3.2 to 1.9 points. CONCLUSIONS: This study found that there were initial score disparities across race/ethnicity groups in PGY-1, and these disparities continued at the same rate throughout residency training, suggesting equality in acquisition of knowledge during family medicine residency training but with a persistent gap throughout training.

Racial/Ethnic Representation Among American Board of Family Medicine Certification Candidates from 1970 to 2020.

BACKGROUND: Because improved patient outcomes and experiences have been associated with health care workforce diversity, efforts to create a diverse family physician workforce have increased. However, a metric that could properly measure family physician representation in various contexts has seldom been studied. OBJECTIVE: The goal of this study is to propose a new metric logRQ and use it to examine the diversification progress of American Board of Family Medicine (ABFM) certification candidates relative to national, state, and historic populations, as well as medical school matriculants. METHODS: We obtained race/ethnicity for certification candidates from the 2014 to 2020 ABFM Certification Examination Registration questionnaire and examined racial/ethnic representation relative to various populations via logRQs. RESULTS: The total sample comprised 26,368 initial certification candidates and 55,347 continuing certification candidates. Asian, Hispanic, and Black's logRQ increased by 0.51, 0.42, and 0.41, respectively, in initial certification candidates compared with continuing certification candidates. In addition, logRQ standard deviation ranged from 0.19 to 0.87 across States, indicating state-level variation. Although Black and Hispanic remained underrepresented, the degree of underrepresentation had improved substantially across the past 5 decades, with logRQ increasing from -2.12 (Black) and -1.16 (Hispanic) in the 1970s to -0.46 (Black) and -0.68 (Hispanic) in the 2010s. The race/ethnicity logRQs of 2020 initial certification candidates relative to 2013 to 2014 medical school matriculants were all near 0, reflecting equitable representation. CONCLUSION: We utilized the proposed metric logRQ to quantify the advancement in representation among ABFM certification candidates in different contexts. The proposed logRQ may serve as a useful tool to monitor representation progress systematically.

The American Board of Family Medicine's 8 Years of Experience with Differential Item Functioning.

INTRODUCTION: Differential item functioning (DIF) procedures flag examination questions in which examinees from different subpopulations who are of equal ability do not have the same probability of answering it correctly. Few medical certification boards employ DIF procedures because they do not collect the needed data on the examinee's race or ethnicity. This article summarizes the American Board of Family Medicine's (ABFM) combined use of DIF procedures and an expert panel to review certification questions for bias. METHODS: ABFM certification examination data from 2013 to 2020 were analyzed using a DIF procedure to flag questions with possible ethnic or racial bias. The flagged questions were reviewed by a racially and ethnically diverse panel of content experts. If the panel judged the source of the DIF was not clinically relevant for the practice of family medicine, the question was removed from the examination. RESULTS: Out of the 3487 questions analyzed, 374 unique questions (11%) were flagged by DIF procedures as potentially biased. Of the flagged questions, the review panel felt 4 should be removed for fairness. DISCUSSION: Using DIF procedures and panel review can improve the quality of the board certification questions and demonstrate the organization's commitment to avoid racial or ethnic bias.

Human-Autonomy Teaming: A Review and Analysis of the Empirical Literature.

OBJECTIVE: We define human-autonomy teaming and offer a synthesis of the existing empirical research on the topic. Specifically, we identify the research environments, dependent variables, themes representing the key findings, and critical future research directions. BACKGROUND: Whereas a burgeoning literature on high-performance teamwork identifies the factors critical to success, much less is known about how human-autonomy teams (HATs) achieve success. Human-autonomy teamwork involves humans working interdependently toward a common goal along with autonomous agents. Autonomous agents involve a degree of self-government and self-directed behavior (agency), and autonomous agents take on a unique role or set of tasks and work interdependently with human team members to achieve a shared objective. METHOD: We searched the literature on human-autonomy teaming. To meet our criteria for inclusion, the paper needed to involve empirical research and meet our definition of human-autonomy teaming. We found 76 articles that met our criteria for inclusion. RESULTS: We report on research environments and we find that the key independent variables involve autonomous agent characteristics, team composition, task characteristics, human individual differences, training, and communication. We identify themes for each of these and discuss the future research needs. CONCLUSION: There are areas where research findings are clear and consistent, but there are many opportunities for future research. Particularly important will be research that identifies mechanisms linking team input to team output variables.