Relationship Between Gender and Academic and Military Achievement Among USU Medical School Graduates.

INTRODUCTION: Despite increases in the number of female matriculants in medical school, civilian data demonstrate that women still struggle to reach parity in attainment of leadership positions. In military medicine, we have seen a major increase in the number of women graduating from the USU. Yet, we still know little about the representation of female military physicians in leadership positions. The aim of this study is to examine the relationship between gender and academic and military achievement among USU School of Medicine graduates. METHODS: Utilizing the USU alumni survey sent to graduates from the classes of 1980 to 2017, items of interest, such as highest military rank, leadership positions held, academic rank, and time in service, were used to evaluate the relationship between gender and academic and military achievement. Contingency table statistical analysis was conducted to compare the gender distribution on the survey items of interest. RESULTS: Pairwise comparison demonstrated significant differences between gender in the O-4 (P = .003) and O-6 (P = .0002) groups, with females having a higher-than-expected number of O-4 officers and males having a higher-than-expected number of O-6 officers. These differences persisted in a subsample analysis that excluded those who separated from active duty prior to 20 years of service. There was a significant association between gender and holding the position of commanding officer (χ2(1) = 6.61, P < .05) with fewer females than expected. In addition, there was a significant association between gender and the highest academic rank achieved (χ2(3) = 9.48, P < 0.05) with lower-than-expected number of females reaching the level of full professor, in contrast to males who exceed the expected number. CONCLUSIONS: This study suggests that female graduates of USU School of Medicine have not achieved promotion to the highest levels of rank, military, or academic leadership at the projected rate. Efforts to explore what barriers may impact military medicine's desire to have more equal representation of women in higher ranks and positions should be undertaken with specific attention to what drives retention versus separation of medical officers and if systematic changes are needed to help promote equity for women in military medicine.

Inflammation-induced PELP1 expression promotes tumorigenesis by activating GM-CSF paracrine secretion in the tumor microenvironment.

The inflammatory tumor microenvironment has been implicated as a major player fueling tumor progression and an enabling characteristic of cancer, proline, glutamic acid, and leucine-rich protein 1 (PELP1) is a novel nuclear receptor coregulator that signals across diverse signaling networks, and its expression is altered in several cancers. However, investigations to find the role of PELP1 in inflammation-driven oncogenesis are limited. Molecular studies here, utilizing macrophage cell lines and animal models upon stimulation with lipopolysaccharide (LPS) or necrotic cells, showed that PELP1 is an inflammation-inducible gene. Studies on the PELP1 promoter and its mutant identified potential binding of c-Rel, an NF-κB transcription factor subunit, to PELP1 promoter upon LPS stimulation in macrophages. Recruitment of c-Rel onto the PELP1 promoter was validated by chromatin immunoprecipitation, further confirming LPS mediated PELP1 expression through c-Rel-specific transcriptional regulation. Macrophages that overexpress PELP1 induces granulocyte-macrophage colony-stimulating factor secretion, which mediates cancer progression in a paracrine manner. Results from preclinical studies with normal-inflammatory-tumor progression models demonstrated a progressive increase in the PELP1 expression, supporting this link between inflammation and cancer. In addition, animal studies demonstrated the connection of PELP1 in inflammation-directed cancer progression. Taken together, our findings provide the first report on c-Rel-specific transcriptional regulation of PELP1 in inflammation and possible granulocyte-macrophage colony-stimulating factor-mediated transformation potential of activated macrophages on epithelial cells in the inflammatory tumor microenvironment, reiterating the link between PELP1 and inflammation-induced oncogenesis. Understanding the regulatory mechanisms of PELP1 may help in designing better therapeutics to cure various inflammation-associated malignancies.

Effects of live and video simulation on clinical reasoning performance and reflection.

INTRODUCTION: In recent years, researchers have recognized the need to examine the relative effectiveness of different simulation approaches and the experiences of physicians operating within such environments. The current study experimentally examined the reflective judgments, cognitive processing, and clinical reasoning performance of physicians across live and video simulation environments. METHODS: Thirty-eight physicians were randomly assigned to a live scenario or video case condition. Both conditions encompassed two components: (a) patient encounter and (b) video reflection activity. Following the condition-specific patient encounter (i.e., live scenario or video), the participants completed a Post Encounter Form (PEF), microanalytic questions, and a mental effort question. Participants were then instructed to re-watch the video (i.e., video condition) or a video recording of their live patient encounter (i.e., live scenario) while thinking aloud about how they came to the diagnosis and management plan. RESULTS: Although significant differences did not emerge across all measures, physicians in the live scenario condition exhibited superior performance in clinical reasoning (i.e., PEF) and a distinct profile of reflective judgments and cognitive processing. Generally, the live condition participants focused more attention on aspects of the clinical reasoning process and demonstrated higher level cognitive processing than the video group. CONCLUSIONS: The current study sheds light on the differential effects of live scenario and video simulation approaches. Physicians who engaged in live scenario simulations outperformed and showed a distinct pattern of cognitive reactions and judgments compared to physicians who practiced their clinical reasoning via video simulation. Additionally, the current study points to the potential advantages of video self-reflection following live scenarios while also shedding some light on the debate regarding whether video-guided reflection, specifically, is advantageous. The utility of context-specific, micro-level assessments that incorporate multiple methods as physicians complete different parts of clinical tasks is also discussed.

Challenges in mitigating context specificity in clinical reasoning: a report and reflection.

Objectives Diagnostic error is a growing concern in U.S. healthcare. There is mounting evidence that errors may not always be due to knowledge gaps, but also to context specificity: a physician seeing two identical patient presentations from a content perspective (e.g., history, labs) yet arriving at two distinct diagnoses. This study used the lens of situated cognition theory - which views clinical reasoning as interconnected with surrounding contextual factors - to design and test an instructional module to mitigate the negative effects of context specificity. We hypothesized that experimental participants would perform better on the outcome measure than those in the control group. Methods This study divided 39 resident and attending physicians into an experimental group receiving an interactive computer training and "think-aloud" exercise and a control group, comparing their clinical reasoning. Clinical reasoning performance in a simulated unstable angina case with contextual factors (i.e., diagnostic suggestion) was determined using performance on a post-encounter form (PEF) as the outcome measure. The participants who received the training and did the reflection were compared to those who did not using descriptive statistics and a multivariate analysis of covariance (MANCOVA). Results Descriptive statistics suggested slightly better performance for the experimental group, but MANCOVA results revealed no statistically significant differences (Pillai's Trace=0.20, F=1.9, df=[4, 29], p=0.15). Conclusions While differences were not statistically significant, this study suggests the potential utility of strategies that provide education and awareness of contextual factors and space for reflective practice.

Examining the patterns of uncertainty across clinical reasoning tasks: effects of contextual factors on the clinical reasoning process.

Objectives Uncertainty is common in clinical reasoning given the dynamic processes required to come to a diagnosis. Though some uncertainty is expected during clinical encounters, it can have detrimental effects on clinical reasoning. Likewise, evidence has established the potentially detrimental effects of the presence of distracting contextual factors (i.e., factors other than case content needed to establish a diagnosis) in a clinical encounter on clinical reasoning. The purpose of this study was to examine how linguistic markers of uncertainty overlap with different clinical reasoning tasks and how distracting contextual factors might affect physicians' clinical reasoning process. Methods In this descriptive exploratory study, physicians participated in a live or video recorded simulated clinical encounter depicting a patient with unstable angina with and without contextual factors. Transcribed think-aloud reflections were coded using Goldszmidt's clinical reasoning task typology (26 tasks encompassing the domains of framing, diagnosis, management, and reflection) and then those coded categories were examined using linguistic markers of uncertainty (e.g., probably, possibly, etc.). Results Thirty physicians with varying levels of experience participated. Consistent with expectations, descriptive analysis revealed that physicians expressed more uncertainty in cases with distracting contextual factors compared to those without. Across the four domains of reasoning tasks, physicians expressed the most uncertainty in diagnosis and least in reflection. Conclusions These results highlight how linguistic markers of uncertainty can shed light on the role contextual factors might play in uncertainty which can lead to error and why it is essential to find ways of managing it.

Understanding context specificity: the effect of contextual factors on clinical reasoning.

Background Situated cognition theory argues that thinking is inextricably situated in a context. In clinical reasoning, this can lead to context specificity: a physician arriving at two different diagnoses for two patients with the same symptoms, findings, and diagnosis but different contextual factors (something beyond case content potentially influencing reasoning). This paper experimentally investigates the presence of and mechanisms behind context specificity by measuring differences in clinical reasoning performance in cases with and without contextual factors. Methods An experimental study was conducted in 2018-2019 with 39 resident and attending physicians in internal medicine. Participants viewed two outpatient clinic video cases (unstable angina and diabetes mellitus), one with distracting contextual factors and one without. After viewing each case, participants responded to six open-ended diagnostic items (e.g. problem list, leading diagnosis) and rated their cognitive load. Results Multivariate analysis of covariance (MANCOVA) results revealed significant differences in angina case performance with and without contextual factors [Pillai's trace = 0.72, F = 12.4, df =(6, 29), p < 0.001, η p 2 = 0.72 $\eta _{\rm p}^2 = 0.72$ ], with follow-up univariate analyses indicating that participants performed statistically significantly worse in cases with contextual factors on five of six items. There were no significant differences in diabetes cases between conditions. There was no statistically significant difference in cognitive load between conditions. Conclusions Using typical presentations of common diagnoses, and contextual factors typical for clinical practice, we provide ecologically valid evidence for the theoretically predicted negative effects of context specificity (i.e. for the angina case), with large effect sizes, offering insight into the persistence of diagnostic error.

The Linguistic Effects of Context Specificity: Exploring Affect, Cognitive Processing, and Agency in Physicians' Think-Aloud Reflections.

Background The literature suggests that affect, higher-level cognitive processes (e.g. decision-making), and agency (the capacity to produce an effect) are important for reasoning; however, we do not know how these factors respond to context. Using situated cognition theory as a framework, and linguistic tools as a method, we explored the effects of context specificity [a physician seeing two patients with identical presentations (symptoms and findings), but coming to two different diagnoses], hypothesizing more linguistic markers of cognitive load in the presence of contextual factors (e.g. incorrect diagnostic suggestion). Methods In this comparative and exploratory study, 64 physicians each completed one case with contextual factors and one without. Transcribed think-aloud reflections were coded by Linguistic Inquiry and Word Count (LIWC) software for markers of affect, cognitive processes, and first-person pronouns. A repeated-measures multivariate analysis of variance was used to inferentially compare these LIWC categories between cases with and without contextual factors. This was followed by exploratory descriptive analysis of subcategories. Results As hypothesized, participants used more affective and cognitive process markers in cases with contextual factors and more I/me pronouns in cases without. These differences were statistically significant for cognitive processing words but not affective and pronominal words. Exploratory analysis revealed more negative emotions, cognitive processes of insight, and third-person pronouns in cases with contextual factors. Conclusions This study exposes linguistic differences arising from context specificity. These results demonstrate the value of a situated cognition view of patient encounters and reveal the utility of linguistic tools for examining clinical reasoning.

Sequence matters: patterns in task-based clinical reasoning.

Background The cognitive pathways that lead to an accurate diagnosis and efficient management plan can touch on various clinical reasoning tasks (1). These tasks can be employed at any point during the clinical reasoning process and though the four distinct categories of framing, diagnosis, management, and reflection provide some insight into how these tasks map onto clinical reasoning, much is still unknown about the task-based clinical reasoning process. For example, when and how are these tasks typically used? And more importantly, do these clinical reasoning task processes evolve when patient encounters become complex and/or challenging (i.e. with contextual factors)? Methods We examine these questions through the lens of situated cognition, context specificity, and cognitive load theory. Sixty think-aloud transcripts from 30 physicians who participated in two separate cases - one with a contextual factor and one without - were coded for 26 clinical reasoning tasks (1). These tasks were organized temporally, i.e. when they emerged in their think-aloud process. Frequencies of each of the 26 tasks were aggregated, categorized, and visualized in order to analyze task category sequences. Results We found that (a) as expected, clinical tasks follow a general sequence, (b) contextual factors can distort this emerging sequence, and (c) the presence of contextual factors prompts more experienced physicians to clinically reason similar to that of less experienced physicians. Conclusions These findings add to the existing literature on context specificity in clinical reasoning and can be used to strengthen teaching and assessment of clinical reasoning.

It Totally Possibly Could Be: How a Group of Military Physicians Reflect on Their Clinical Reasoning in the Presence of Contextual Factors.

INTRODUCTION: Contextual factors (eg, diagnostic suggestion and burnout) can affect physician clinical reasoning performance, leading to diagnostic error. Yet, contextual factors have only recently been studied and none of that work focused on how physicians appraise (ie, evaluate) the clinical situation as they reason. The purpose of this qualitative study was to use appraisal to describe the effect of contextual factors on clinical reasoning. MATERIALS AND METHODS: Physicians (n = 25) either viewed two video cases or participated in two live scenarios, one with contextual factors and one without. Afterwards, they completed a "think-aloud" reflection while reviewing the cases. Transcribed think-alouds were coded for appraisal markers, comparing cases with and without contextual factors. RESULTS: When contextual factors were present, participants expressed more emotional evaluation and uncertainty about those emotions. Across all types of cases, participants expressed uncertainty about the case and assessed what "could" or "would" have gone differently. CONCLUSIONS: This study suggests that one major effect of contextual factors may be that they induce emotions, which may affect the process of clinical reasoning and diagnostic error. It also suggests that uncertainty may be common in clinical practice, and we should thus further explore its impact.

An Exploratory Assessment of Sleep Patterns, Burnout and Perceived Stress of a Cohort of Active Duty Military Physicians.

This article was migrated. The article was marked as recommended. Introduction: Physician well-being is crucial and has the potential to impact patient safety. Many physicians across different stages of their careers experience stress, burnout, and/or decreased sleep. These factors can negatively affect physician well-being and performance and contribute to medical errors. The purpose of this study is to further understand physician well-being by examining a single cohort for patterns of sleep, burnout, and perceived stress across gender, training level, and specialty. Materials and methods: A cohort of 32 practicing military physicians ranging from first-year residents to experienced attendings continuously wore an actigraphy watch for a duration of at least 5 days to capture baseline sleep patterns. On the last day of data collection, participants completed a self-reported assessment of their daytime sleepiness using the Epworth Sleepiness Scale (ESS), a two-item burnout scale adapted from the Maslach Burnout Inventory, and a 10-item perceived stress questionnaire. Data for the entire cohort were descriptively analyzed. Results: The cohort had a mean sleep duration of 6.69 hours across the 5 days, with a maximum mean sleep duration of 7.90 hours, and a minimum mean sleep duration of 5.69 hours per day. Analysis stratified by gender and level of training revealed an average sleep duration of at least 6 hours across these groups. Overall, the cohort reported low perceived stress levels, low daytime sleepiness, and low burnout. Conclusion: The cohort of physicians examined in the present study did not show signs of significant sleep deprivation, feelings of perceived stress, or burnout. This may be due to military culture and the structure of military training facilities that emphasize duty hour regulations. In addition, these findings may be related to the fact that military health professionals are salaried, as opposed to being on a fee-for-service schedule, and military facilities offer well-being programs.

Clinical Reasoning in the Ward Setting: A Rapid Response Scenario for Residents and Attendings.

Introduction: There is a need for educational resources supporting the practice and assessment of the complex processes of clinical reasoning in the inpatient setting along a continuum of physician experience levels. Methods: Using participatory design, we created a scenario-based simulation integrating diagnostic ambiguity, contextual factors, and rising patient acuity to increase complexity. Resources include an open-ended written exercise and think-aloud reflection protocol to elicit diagnostic and management reasoning and reflection on that reasoning. Descriptive statistics were used to analyze the initial implementation evaluation results. Results: Twenty physicians from multiple training stages and specialties (interns, residents, attendings, family physicians, internists, surgeons) underwent the simulated scenario. Participants engaged in clinical reasoning processes consistent with the design, considering a total of 19 differential diagnoses. Ten participants provided the correct leading diagnosis, tension pneumothorax, with an additional eight providing pneumothorax and all participants offering relevant supporting evidence. There was also good evidence of management reasoning, with all participants either performing an intervention or calling for assistance and reflecting on management plans in the think-aloud. The scenario was a reasonable approximation of clinical practice, with a mean authenticity rating of 4.15 out of 5. Finally, the scenario presented adequate challenge, with interns and residents rating it as only slightly more challenging (means of 7.83 and 7.17, respectively) than attendings (mean of 6.63 out of 10). Discussion: Despite the challenges of scenario complexity, evaluation results indicate that this resource supports the observation and analysis of diagnostic and management reasoning of diverse specialties from interns through attendings.

Why health professions education needs functional linguistics: the power of 'stealth words'.

CONTEXT: Language is one of the primary modalities for teaching and learning in the health professions in contexts ranging from the more formal teaching relationships of medical school to the guided practice of trainees through continuing education and the deliberate practice of lifelong learning. Yet linguistic analysis, with the possible exception of discourse analysis, has not become a core methodological tool in the field of health professions education (HPE). The purpose of this paper is to argue for the more widespread adoption of one particular approach to linguistics, one that examines less of what learners and instructors say and looks more at how they say it: functional linguistics. FUNCTIONAL LINGUISTICS: THE POWER OF 'STEALTH WORDS': This approach theorises and structures the functions of language, regularly focusing attention on 'stealth words' such as I, but and was. Drawing on a rich body of literature in linguistics, psychology, the learning sciences and some early work in HPE, we demonstrate how functional linguistic tools can be applied to better understand learners' and instructors' beliefs, reasoning processes, values and emotions. FUNCTIONAL LINGUISTICS AND REFLECTION: AN APPLICATION OF STEALTH WORDS: A brief qualitative analysis of one tool - analysis of the generic use of 'you' to mean 'one' or 'anyone' - demonstrates how functional linguistics can offer insight into physicians' bids for credibility and alignment as they think aloud about their clinical reasoning. FUNCTIONAL LINGUISTICS AND HPE: FUTURE DIRECTIONS: Finally, we offer suggestions for how functional linguistic tools might address questions and gaps in four active research areas in HPE: reflection; emotion and reasoning; learning in simulated contexts, and self-regulated learning. CONCLUSIONS: We argue that the words used by learners, instructors and practitioners in the health professions as they move through undergraduate and graduate training into practice can offer clues that will help researchers, instructors and colleagues to better support them.

Clinical Reasoning in the Primary Care Setting: Two Scenario-Based Simulations for Residents and Attendings.

Introduction: We describe the development and implementation of tools medical educators or researchers can use for developing or analyzing residents' through attending physicians' clinical reasoning in an outpatient clinic setting. The resource includes two scenario-based simulations (i.e., diabetes, angina), implementation support materials, an open-ended postencounter form, and a think-aloud reflection protocol. Method: We designed two scenarios with potential case ambiguity and contextual factors to add complexity for studying clinical reasoning. The scenarios are designed to be used prior to an open-ended written exercise and a think-aloud reflection to elicit reasoning and reflection. We report on their implementation in a research context but developed them to be used in both educational and research settings. Results: Twelve physicians (five interns, three residents, and four attendings) considered between three and six differential diagnoses (M = 4.0) for the diabetes scenario and between three and nine differentials (M = 4.3) for angina. In think-aloud reflections, participants reconsidered their thinking between zero and 14 times (M = 3.5) for diabetes and zero and 11 times (M = 3.3) for angina. Cognitive load scores ranged from 4 to 8 (out of 10; M = 6.2) for diabetes and 5 to 8 (M = 6.6) for angina. Participants rated scenario authenticity between 4 and 5 (out of 5). Discussion: The potential case content ambiguity, along with the contextual factors (e.g., patient suggesting alternative diagnoses), provides a complex environment in which to explore or teach clinical reasoning.