Contributors to Independent Research Funding Success from the Perspective of K12 BIRCWH Program Directors.

INTRODUCTION: Faculty training awards are an important means of advancing early career faculty in research. The National Institutes of Health (NIH) Building Interdisciplinary Research Careers in Women's Health (BIRCWH) is a long-running K12 career development program and has been integral in promoting the research success of faculty nationally. We surveyed BIRCWH program directors to understand factors likely to influence long-term research careers and funding success. MATERIALS AND METHODS: We developed an online survey containing open-ended questions about individual and programmatic attributes and activities that promote success in achieving independent research funding. Domains of interest included: 1) strategies for funding success; 2) traits for predicting success; 3) groups considered vulnerable to attrition; and 4) existing resources and means of support. RESULTS: Fifteen institutions (75%) were included in the final analysis. Passion for research, persistence, resilience, and strong mentorship relationships were identified by all directors as factors important to scholar success. Responses also revealed an important pattern: program directors attributed attrition either to individual or organizational characteristics. This distinction has meaningful consequences for framing efforts to diminish attrition. Faculty who were clinicians, women, parents and underrepresented minorities were identified as vulnerable to attrition from the research careers. Common perceived challenges in these groups included isolation/feeling alienated, juggling numerous priorities, inadequate research time, lack of role models, and work-life balance issues. CONCLUSION: K12 BIRCWH directors identified persistence and resilience and developing community, networks, and other support opportunities as elements of scholar success. Programs and mentors can help early career faculty by teaching skills and providing tools they can use to maximize the value of these opportunities and expand their mentees' research relationships. Our study also highlights the importance of social factors, particularly isolation, on clinicians, women, and minoritized scholars on career success.

Program Directors Survey on Diversity in Cardiovascular Training Programs.

BACKGROUND: Women and minorities are under-represented in cardiovascular disease (CVD) specialties. It remains unknown how characteristics of the CVD learning environment affect diversity and how program directors (PDs) approach these critical issues. OBJECTIVES: The second annual Cardiovascular PD Survey aimed to investigate characteristics of the CVD learning environment that may affect diversity and strategies PDs use to approach these issues. METHODS: The survey contained 20 questions examining U.S.-based CVD PD perceptions of diversity in CVD and related characteristics of the CVD fellowship learning environment. RESULTS: In total, 58% of PDs completed the survey. Responding programs demonstrated geographic diversity. The majority were university-based or -affiliated. A total of 86% of PDs felt diversity in CVD as a field needs to increase, and 70% agreed that training programs could play a significant role in this. In total, 89% of PDs have attempted to increase diversity in fellowship recruitment. The specific strategies used were associated with PD sex and the presence of under-represented minority trainees in the program. PDs identified lack of qualified candidates and overall culture of cardiology as the 2 most significant barriers to augmenting diversity. A majority of programs have support systems in place for minority fellows or specific gender groups, including procedures to report issues of harassment or an unsafe learning environment. PDs identified shared best practices for recruitment and implicit bias training, among others, as important resources in their efforts to support diversity in CVD training. CONCLUSIONS: Diversity is important to CVD PDs. They are striving to increase it in their programs through recruitment and strategies directed toward the fellowship learning environment. The CVD community has opportunities to standardize strategies and provide national resources to support PDs in these critical efforts.

Embryo transfer training in fellowship: national and institutional data.

OBJECTIVE: To evaluate current national practices in embryo transfer (ET) training in United States reproductive endocrinology and infertility (REI) fellowship programs and live birth rates after ET performed by fellows versus attending physicians. DESIGN: Cross-sectional survey of U.S. fellowship program directors and fellows in 2019 and retrospective cohort study of IVF cycle outcomes after ET performed by fellows versus attending physicians. SETTING: Not applicable. PATIENT(S): Fellowship program directors and fellows completed a survey. Embryo transfers from 2015-2018 were analyzed. INTERVENTION(S): A survey assessed experiences with ET training. Cycle outcomes were analyzed. MAIN OUTCOME MEASURE(S): Proportion of fellows performing ET during training, and live birth rate following fellow and faculty ETs. RESULT(S): Anonymous surveys were sent to 51 REI fellowship program directors and 142 fellows. Twenty-one percent (15/73) reported that no ETs were performed by fellows. Forty-four percent of third-year fellows had performed fewer than ten ETs during fellowship training. Retrospective review of 940 blastocyst ETs revealed no difference in live birth rates between fellows and attending physicians: 51.6% (131/254) versus 49.4% (339/686), respectively. CONCLUSION(S): This study revealed striking differences between fellowship programs regarding the adequacy of ET training; nearly one-half of third-year fellows had performed fewer than ten ETs. With appropriate supervision, there is no difference in live birth rate between ETs performed by fellows and attending physicians. Efforts should be made to address barriers and set minimums for the number of transfers performed during fellowship.

International electives in neurological surgery training: a survey of program directors from Accreditation Council for Graduate Medical Education-approved neurological surgery programs.

OBJECTIVE: The burden of neurosurgical disease in low- and middle-income countries (LMICs) has emerged as a significant factor in global health. Additionally, calls have been growing for first-world neurosurgeons to find ways to help address the international need. Allowing residents to pursue international elective opportunities in LMICs can help alleviate the burden while also providing unique educational opportunities. However, pursuing international work while in residency requires overcoming significant logistical and regulatory barriers. To better understand the general perspectives, perceived barriers, and current availability of international rotations, a survey was sent out to program directors at Accreditation Council for Graduate Medical Education (ACGME)-approved residencies. METHODS: An anonymous survey was sent to all program directors at ACGME-approved residencies. The survey included branch points designed to separate programs into program directors with an existing international rotation, those interested in starting an international rotation, and those not interested in starting an international rotation. All participants were asked about the perceived value of international training and whether residents should be encouraged to train internationally on a 5-point Likert scale. The survey ended with open-response fields, encouraging thoughts on international rotations and overcoming barriers. RESULTS: Forty-four percent of recipients (50/113) responded; of the 50 programs, 13 had an established international elective. Of programs without a rotation, 54% (20/37) noted that they were interested in starting an international elective. Key barriers to starting international training included funding, the Residency Review Committee approval process, call conflicts, and the establishment of international partners. Perceived learning opportunities included cultural awareness, unique pathology, ingenuity, physical examination skills, and diagnosis skills. The majority of respondents thought that international rotations were valuable (74%, 37/50) and that residents should be encouraged to pursue international educational opportunities (70%, 35/50). Program directors who maintained an existing international rotation or were interested in starting an international elective were more likely to perceive international rotations as valuable. CONCLUSIONS: Recent calls from The Lancet Commission on Global Surgery for increased surgical interventions in the developing world have been expanded by neurosurgical leadership to include neurosurgical diseases. Resident involvement in international electives represents an opportunity to increase treatment of neurosurgical disease in LMICs and develop the next generation of international neurosurgeons. To increase opportunities for residents at international sites, attention should be focused on overcoming the practical and regulatory barriers at a local and national level.

Gender disparities in academic vascular surgeons.

OBJECTIVE: Previous studies have identified significant gender discrepancies in grant funding, leadership positions, and publication impact in surgical subspecialties. We investigated whether these discrepancies were also present in academic vascular surgery. METHODS: Academic websites from institutions with vascular surgery training programs were queried to identify academic faculty, and leadership positions were noted. H-index, number of citations, and total number of publications were obtained from Scopus and PubMed. Grant funding amounts and awards data were obtained from the National Institutes of Health (NIH) and Society for Vascular Surgery websites. Industry funding amount was obtained from the Centers for Medicare and Medicaid Services website. Nonsurgical physicians and support staff were excluded from this analysis. RESULTS: We identified 177 female faculty (18.6%) and 774 male faculty (81.4%). A total of 41 (23.2%) female surgeons held leadership positions within their institutions compared with 254 (32.9%) male surgeons (P = .009). Female surgeons held the rank of assistant professor 50.3% of the time in contrast to 33.9% of men (P < .001). The rank of associate professor was held at similar rates, 25.4% vs 20.7% (P = .187), respectively. Fewer women than men held the full professor rank, 10.7% compared with 26.2% (P < .001). Similarly, women held leadership positions less often than men, including division chief (6.8% vs 13.7%; P < .012) and vice chair of surgery (0% vs 2.2%; P < .047), but held more positions as vice dean of surgery (0.6% vs 0%; P < .037) and chief executive officer (0.6% vs 0%; P < .037). Scientific contributions based on the number of each surgeon's publications were found to be statistically different between men and women. Women had an average of 42.3 publications compared with 64.8 for men (P < .001). Female vascular surgeons were cited an average of 655.2 times, less than half the average citations of their male counterparts with 1387 citations (P < .001). The average H-index was 9.5 for female vascular surgeons compared with 13.7 for male vascular surgeons (P < .001). Correcting for years since initial board certification, women had a higher H-index per year in practice (1.32 vs 1.02; P = .005). Female vascular surgeons were more likely to have received NIH grants than their male colleagues (9.6% vs 4.0%; P = .017). Although substantial, the average value of NIH grants awarded was not statistically significant between men and women, with men on average receiving $915,590.74 ($199,119.00-$2,910,600.00) and women receiving $707,205.35 ($61,612.00-$4,857,220.00; P = .416). There was no difference in the distribution of Society for Vascular Surgery seed grants to women and men since 2007. Industry payments made publicly available according to the Sunshine Act for the year 2018 were also compared, and female vascular surgeons received an average of $2155.28 compared with their male counterparts, who received almost four times as much at $8452.43 (P < .001). CONCLUSIONS: Although there is certainly improved representation of women in vascular surgery compared with several decades ago, a discrepancy still persists. Women tend to have more grants than men and receive less in industry payments, but they hold fewer leadership positions, do not publish as frequently, and are cited less than their male counterparts. Further investigation should be aimed at identifying the causes of gender disparity and systemic barriers to gender equity in academic vascular surgery.

The effect of orthopaedic surgeons' and interventional radiologists' availability on the priority treatment sequence for hemodynamically unstable pelvic fractures: a survey of US Level I trauma centers.

BACKGROUND: Most guidelines recommend both pelvic packing (PP) and angioembolization for hemodynamically unstable pelvic fractures, however their sequence varies. Some argue to use PP first because orthopaedic surgeons are more available than interventional radiologists; however, there is no data confirming this. METHODS: This cross-sectional survey of 158 trauma medical directors at US Level I trauma centers collected the availability of orthopaedic surgeons and interventional radiologists, the number of orthopaedic trauma surgeons trained to manage pelvic fractures, and priority treatment sequence for hemodynamically unstable pelvic fractures. The study objective was to compare the availability of orthopaedic surgeons to interventional radiologists and describe how the availability of orthopaedic surgeons and interventional radiologists affects the treatment sequence for hemodynamically unstable pelvic fractures. Fisher's exact, chi-squared, and Kruskal-Wallis tests were used, alpha = 0.05. RESULTS: The response rate was 25% (40/158). Orthopaedic surgeons (86%) were on-site more often than interventional radiologists (54%), p = 0.003. Orthopaedic surgeons were faster to arrive 39% of the time, and interventional radiologists were faster to arrive 6% of the time. There was a higher proportion of participants who prioritized PP before angioembolization at centers with above the average number (> 3) of orthopaedic trauma surgeons trained to manage pelvic fractures, as among centers with equal to or below average, p = 0.02. Arrival times for orthopaedic surgeons did not significantly predict prioritization of angioembolization or PP. CONCLUSIONS: Our results provide evidence that orthopaedic surgeons typically are more available than interventional radiologists but contrary to anecdotal evidence most participants used angioembolization first. Familiarity with the availability of orthopaedic surgeons and interventional radiologists may contribute to individual trauma center's treatment sequence.

Forward Feeding in Graduate Medical Education: Results of a National Survey.

BACKGROUND AND OBJECTIVES: "Forward feeding" is defined as the sharing of information regarding learner behaviors and performance outside of formal institutional committee structures. The purpose of this study was to establish baseline opinions and policies of forward feeding in family medicine residency programs. METHODS: Data for this study were obtained as part of the 2015 CERA Program Directors Fall Survey. Program directors indicated whether they felt that faculty should and do engage in forward feeding. Respondents were asked to rate the importance of various types of information about learners (academic performance, clinical performance, professionalism, physical health, and mental health), reasons for promoting, and concerns regarding forward feeding on a 5-point Likert scale. RESULTS: The overall response rate was 49% (227/461). Most agreed that faculty should (87%) and do (83%) engage in forward feeding. Concerns regarding professionalism and clinical performance were reported as most important to share. The most important reason identified for forward feeding was the early identification of struggling residents, followed by the ability to direct teaching to the resident's specific needs, and improving the quality of feedback. Fear of creating bias was the most commonly cited concern for engaging in forward feeding, followed by fear of violating confidentiality and difficulty maintaining confidentiality. Fear of litigation was the least common concern. CONCLUSIONS: Despite concerns, the majority of program directors feel that faculty should and do engage in forward feeding. Our study confirms the importance of clinical performance and professionalism as two important themes of information shared by attendings about residents.

Family Medicine Program Director Tenure: 2011 Through 2017.

BACKGROUND AND OBJECTIVES: The program director (PD) position is challenging. PDs are faced with many competing priorities and risk of burnout. Short PD tenure may contribute to training program challenges. The tenure of family medicine residency directors has not been rigorously studied. Our objective was to study family medicine program director tenure and change in tenure over time, and compare these to available Accreditation Council for Graduate Medical Education (ACGME) data. METHODS: We analyzed the 11 Council of Academic Family Medicine Educational Research Alliance PD surveys from 2011 through 2017. We calculated mean and median responses to the question "How long have you been program director at your current program?" We compared these results to data from the ACGME Data Resource Book for all specialty programs. RESULTS: Of 2,577 responses in 11 PD surveys over 7 years, mean family medicine PD tenure was 6.5 years and median tenure was 4.5 years. Tenure did not change significantly from 2011-2017, and 30.5% of PDs have been in their position 0, 1, or 2 years. The right skew in our data (ie, median substantially less than mean), is similar to that seen in other specialties. CONCLUSIONS: Mean family medicine PD tenure is 6.5 years and median tenure is 4.5 years. The short tenure and large number of new PDs annually may impact program quality and suggests more resources and support may be needed for PDs new in their position.

A National Survey of Internal Medicine Primary Care Residency Program Directors.

BACKGROUND: The United States is facing a primary care physician shortage. Internal medicine (IM) primary care residency programs have expanded substantially in the past several decades, but there is a paucity of literature on their characteristics and graduate outcomes. OBJECTIVE: We aimed to characterize the current US IM primary care residency landscape, assess graduate outcomes, and identify unique programmatic or curricular factors that may be associated with a high proportion of graduates pursuing primary care careers. DESIGN: Cross-sectional study PARTICIPANTS: Seventy out of 100 (70%) IM primary care program directors completed the survey. MAIN MEASURES: Descriptive analyses of program characteristics, educational curricula, clinical training experiences, and graduate outcomes were performed. Bivariate and multivariate logistic regression analyses were used to determine the association between ≥ 50% of graduates in 2016 and 2017 entering a primary care career and program characteristics, educational curricula, and clinical training experiences. KEY RESULTS: Over half of IM primary care program graduates in 2016 and 2017 pursued a primary care career upon residency graduation. The majority of program, curricular, and clinical training factors assessed were not associated with programs that have a majority of their graduates pursuing a primary care career path. However, programs with a majority of program graduates entering a primary care career were less likely to have X + Y scheduling compared to the other programs. CONCLUSIONS: IM primary care residency programs are generally succeeding in their mission in that the majority of graduates are heading into primary care careers.

Recent Trends in Publications of US and European Directors in Vascular Surgery.

BACKGROUND: We hypothesized that there may be significant differences between academic productivity of the vascular training programs in the United States (US) and Europe. In an effort to explore this theory, we reviewed the number of vascular publications listed in PubMed from 2010 to 2015 for US and European directors in vascular surgery. METHODS: The list of program directors from the Association of Program Directors in Vascular Surgery (APDVS) and the European Union of Medical Specialists (EUMS) were queried for the names of the directors of vascular surgical training programs at the end of 2015. PubMed listed 5,474 citations published from 2010 to 2015. Three thousand five hundred sixty-one were from Europe while 1,912 were from the US. UK and German programs did not list their directors' names in the EUMS website and were thus not included in the European data. RESULTS: The average number of citations in PubMed per program director was 2.36 per year. In Europe, each of the 273 program directors averaged 2.17 publications per year, whereas each of the 114 US program directors averaged 2.80 publications per year (P = 0.37). Journal of Vascular Surgery (JVS) publications made up 24.0% (12.7% in Europe and 45.0% in the US). In the US, the top third produced 69% of the publications and 77% of the JVS publications, whereas in Europe, the top third produced 87% of the publications and 98% of the JVS publications. In the US, 5 program directors (4.4%) had no publications and 21 (18.4%) had no JVS publications. In Europe, 82 program directors (30.0%) had no publications, whereas 180 (65.9%) had no JVS publications. Abstracts were categorized by topic for comparison. CONCLUSIONS: In both Europe and the US, the top third produced more than two-thirds of the publications, with the disparity being even more pronounced in Europe where the top third produced almost 90% of the total publications. Comparing the topics of the publications from Europe and the US, it was found that the US program directors published a great deal more on Endovenous Lower Extremity, Open Lower Extremity, Education, thoracic endovascular aortic repair, Open Carotid, and Endo Venous, whereas their European counterparts published more in the areas of Vascular Medicine, Replies, and Not Vascular.

Recent trends in publications of US vascular surgery program directors.

Objective In order to examine the academic productivity of US vascular surgery program directors, the number of vascular publications listed in PubMed from 2001 to 2015 for US vascular surgery program directors was reviewed. We suggest that this can be used as a benchmark for academic productivity. Methods The names of the program directors were taken from the Accreditation Council for Graduate Medical Education (ACGME) website at two time points: December 2009 (Independent Programs) and December 2015 (Independent + Integrated). This was used to query PubMed, which listed 5196 publications: 3284 from 2001 to 2009 and 1912 from 2010 to 2015. Results There were 104 program directors (2001-2009) and 114 program directors (2010-2015) with average number of publications in PubMed per program director as 3.68/year (SD ± 2.31) and 2.80/year (SD ± 2.73), respectively ( P = .01). From 2001 to 2009, 1215 (37%) and in 2010 to 2015, 860 (45%) of the publications were from Journal of vascular surgery. The top third produced 67% and 69% of publications in the two time-points. No statistical difference was ascertained regionally: northeast, southeast, midwest and west ( P = .46). The numbers of publications/year decreased by 17% compared to first 10 years. From 2001 to 2009, there were no programs with no publications which increased to five and three with no Journal of Vascular Surgery publications which increased to 21 in 2010-2015. The independent and integrated program directors published average of 2.85 (SD ± 2.69) and 3.47 (SD ± 3.1) total publications; 1.25 (SD ± 1.4) and 3.47 (SD ± 1.7) Journal of Vascular Surgery papers/year, respectively ( P = .28, P = .23). Changes in the study subject were noted by percentage of total publications: endovascular lower extremity arterial (4.7% to 8.9%), Thoracic Endovascular Aortic Repair (TEVAR) (4.5% to 9.9%), Arterio-Venous (AV) access (0.0% to 3.0%), basic science (14.7% to 6.8%), open thoracic (3.0% to 0.6%). Conclusion There seems to be a significant decline in the number of publications over the last 15 years. Yet, the subject of the publications has progressed from Open to TEVAR with an increase in endovascular publications. However, basic science publications reduced by half.

What do emergency physicians in charge do? A qualitative observational study.

INTRODUCTION: The emergency physician in charge role has developed in many large EDs to assist with patient flow. We aimed to describe and classify the problem-solving actions that this role requires. METHODS: We interviewed senior emergency physicians and performed iterative, qualitative observations, using continuous reflective inquiry, in a single centre. We reviewed and classified these approaches by consensus. RESULTS: Nine different problem-solving approaches were identified. These are deflecting, front loading, placing, plucking, flooding, targeting, chasing, guiding and juggling. These are useful for training and developing our understanding of how to manage an ED. CONCLUSIONS: Emergency physicians in charge have a number of problem-solving approaches that can be readily defined. We have described and categorised these. These results are potentially useful for developing decision support software.

Perspectives of Family Medicine Clerkship Directors Regarding Forward Feeding: A CERA Study.

BACKGROUND AND OBJECTIVES: Forward feeding signifies sharing information about learners for purposes of professional and academic advancement, and promotes progression toward a competency-based educational continuum. The aim of this study is to assess reasons for difficulty or failure of the family medicine clerkship and investigate utilization and methods of forward feeding. Reasons behind medical school policies regarding forward feeding are also evaluated. METHODS: Data were collected through the 2013 Council of Academic Family Medicine (CAFM) Educational Research Alliance (CERA) Family Medicine Clerkship Director survey. Directors rated reasons for clerkship difficulty or failure on a 6-point Likert scale. They also reported if they utilized forward feeding, to whom, and the communication method used. Finally, they were asked about factors influencing institutional policy toward forward feeding, including threats of litigation. RESULTS were compared between public and private schools, and based on tenure as clerkship director. Analyses were performed using chi-square or Fisher's exact test. RESULTS: Knowledge deficits were the most common reason for clerkship difficulty and failure, followed by professionalism difficulties. Over half of respondents engage in forward feeding, and almost all pass this information to other clerkship directors. Concern for student privacy and faculty bias were noted as two important factors influencing school policy. While almost half of respondents felt that litigation fears influenced their school's approach to forward feeding, few were aware of any related litigation. CONCLUSIONS: Forward feeding is only utilized by half of clerkship directors. More studies regarding the potential impacts of this practice are warranted.

Medical management and leadership: a time of transition?

Perspectives on medical management and leadership are in a time of transition, but there is much we still need to understand better. This paper explores some of the tensions and dilemmas inherent in understandings of medical management and leadership.