Faculty Physician and Trainee Experiences with Micro- and Macroaggressions: a Qualitative Study.

BACKGROUND: Micro- and macroaggressions are often stereotype threats that can have detrimental effects on the recipients. Survey data shows that these aggressions are happening. However, there are few qualitative studies on trainees and faculty physicians' experiences with such aggressions and their impact. OBJECTIVE: Explore how micro- and macroaggressions impact physician trainees and faculty. DESIGN, SETTING, PARTICIPANTS: Virtual, one-on-one, semi-structured interviews were conducted between February and September 2021, among 14 physicians and trainees (medical students, residents, fellows, and faculty) at a tertiary, urban, US academic medical center and its associated hospitals. Participants shared their experiences with micro- and macroaggressions in training and the workplace, as well as their thoughts on intervention and education. APPROACH: Qualitative interviews; grounded theory approach KEY RESULTS: A total of 14 physicians and trainees (5 faculty, 2 fellows, 5 residents, 2 students; 11 [79%] women) participated. Four themes with multiple subthemes surfaced: definition, the moment an aggression is experienced, aftereffect of an aggression, and education and training. While general definitions of micro- and macroaggressions were similar among participants, some may have overlooked the inclusion of a marginalized group as central to each term. Both types of aggressions had a range of effects on participants, with faculty noting a cumulative effect. Institutional diversity was identified as a key source of support. Ideas on how to combat such acts included mandatory educational programs and policies, with the acknowledgment that much effort and time are necessary to change mindset and culture. CONCLUSIONS: Faculty physicians and medical trainees shared their personal experiences with micro- and macroaggressions during work and training. Participants described various emotions in the moment but also noted that these aggressions often had lasting impacts. They recognized the challenges of finding a solution to micro- and macroaggressions. Institution-wide education was favored by many as a first step.

Preparing Residents to Respond to Incidences of Gender Discrimination and Sexual Harassment: An Interactive Workshop.

OBJECTIVES: Gender discrimination and sexual harassment are common in academic medicine. There are limited data on how to prepare medical trainees to respond to these incidents. The objective of this work was to understand the experience of residents with sexual harassment and to evaluate the impact of a low-cost educational intervention to better prepare residents to respond to incidents of gender discrimination and sexual harassment. METHODS: We adapted a national faculty development workshop to be given to Internal Medicine residents. The workshop had three components: an introduction to the problem of sexual harassment, cases for guided practice, and review of Title IX. The workshop was presented to residents during protected academic time and assessed with pre-/post- surveys. RESULTS: The majority (65, 73.0%) of residents reported at least one incident of gender discrimination or sexual harassment in the prior 6 months; 62 (69.7%) residents reported an incident of gender harassment, 26 (29.6%) reported unwanted sexual attention, and 2 (2.3%) reported an incident of sexual coercion. The majority of residents (53, 62.4%) reported previous training, but only 28 (32.6%) felt well trained. Compared with before the workshop, residents reported more comfort (mean 2.88 vs 3.39, P = 0.0304) with and confidence (mean 3.47 vs 3.88, P = 0.0284) in responding to incidents of harassment. After the workshop, residents were more likely to use active responses, including express discomfort (15.0% vs 51.0%), express a preference (15.0% vs 53.1%), and debrief (13.3% vs 63.3%) and less likely to ignore the incident (56.7% vs 34.7%). CONCLUSIONS: This workshop offers one potential solution by better preparing residents to actively respond to incidents of gender discrimination and sexual harassment.

Implementation of a patient-collected audio recording audit & feedback quality improvement program to prevent contextual error: stakeholder perspective.

BACKGROUND: Using patient audio recordings of medical visits to provide clinicians with feedback on their attention to patient life context in care planning can improve health care delivery and outcomes, and reduce costs. However, such an initiative can raise concerns across stakeholders about surveillance, intrusiveness and merit. This study examined the perspectives of patients, physicians and other clinical staff, and facility leaders over 3 years at six sites during the implementation of a patient-collected audio quality improvement program designed to improve patient-centered care in a non-threatening manner and with minimal effort required of patients and clinicians. METHODS: Patients were invited during the first and third year to complete exit surveys when they returned their audio recorders following visits, and clinicians to complete surveys annually. Clinicians were invited to participate in focus groups in the first and third years. Facility leaders were interviewed individually during the last 6 months of the study. RESULTS: There were a total of 12 focus groups with 89 participants, and 30 leadership interviews. Two hundred fourteen clinicians and 800 patients completed surveys. In a qualitative analysis of focus group data employing NVivo, clinicians initially expressed concerns that the program could be disruptive and/or burdensome, but these diminished with program exposure and were substantially replaced by an appreciation for the value of low stakes constructive feedback. They were also significantly more confident in the value of the intervention in the final year (p = .008), more likely to agree that leadership supports continuous improvement of patient care and gives feedback on outcomes (p = .02), and at a time that is convenient (p = .04). Patients who volunteered sometimes expressed concerns they were "spying" on their doctors, but most saw it as an opportunity to improve care. Leaders were supportive of the program but not yet prepared to commit to funding it exclusively with facility resources. CONCLUSIONS: A patient-collected audio program can be implemented when it is perceived as safe, not disruptive or burdensome, and as contributing to better health care.

Does Provider Gender Affect the Quality of Primary Care?

BACKGROUND: Women providers have a more patient-centered communication style than men, and some studies have found women primary care providers are more likely to meet quality performance measures. OBJECTIVE: To explore gender differences in the quality of primary care process and outcome measures. DESIGN: Retrospective analysis of primary care performance data from 1 year (2018-2019). PARTICIPANTS: A total of 586 primary care providers (311 women and 275 men) who cared for 241,428 primary care patients at 96 primary care clinics at 8 Veterans Affairs (VA) medical centers. MAIN MEASURES: Our primary outcome was a composite quality measure that averaged all thirty-four primary care performance measures that assessed performance in cancer screening, diabetes care, cardiovascular care, tobacco counseling, risky alcohol screening, immunizations, HIV testing, opiate care, and continuity. Our secondary outcomes were performance on each of the 34 measures. KEY RESULTS: There was no difference in the average performance on our composite measure between men and women (75.8% vs. 76.6%, p = 0.17). Among the 34 primary care quality measures collected, there was no difference between male and female providers' performance. Using a more conservative cut-point, women were more likely to screen at-risk diabetic patients for hypoglycemia and document follow-up on risky alcohol behavior noted during patient check-in. These differences were clinically small and likely due to chance, given the multiple measures evaluated in this study. CONCLUSIONS: We found little evidence of difference in the performance on primary care quality measures between male and female providers.

Sexual Harassment of Female Providers by Patients: a Qualitative Study.

BACKGROUND: Sexual harassment of women is a pervasive problem. Prior studies found that sexual harassment of female providers by patients is common, but guidance on addressing this problem is limited. OBJECTIVE: To understand the experiences of female providers with sexual harassment by patients with a focus on how practicing providers address these events. DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS: Twenty female, internal medicine providers, including resident physicians, staff physicians, and nurse practitioners at a large, urban, academic hospital in the USA. APPROACH: Interviews were analyzed for themes. KEY RESULTS: Two themes were explored: first, the experiences with sexual harassment and, second, the strategies to address sexual harassment. We coded four sub-themes regarding participant experiences: (1) their descriptions of the types of harassment, (2) the context of the event, (3) the impact of the harassment, and (4) their preparation to address the harassment. We coded seven sub-themes on strategies used by participants: (1) indirect strategies, (2) confrontation, (3) modifying the clinical encounter, (4) modifying self, (5) alerting others, (6) debrief, and (7) report. CONCLUSION: Our qualitative study found that sexual harassment of female providers by patients is an ongoing problem, disruptive to the patient-provider relationship, and a possible threat to the well-being of both provider and patient. Formal training on how to address this problem was lacking, but all providers had developed or adapted strategies based on personal experiences or role modeling. Educating providers on strategies is an important next step to addressing this problem.

The Experience of Male Physicians with Sexual and Gender-Based Harassment: a Qualitative Study.

BACKGROUND: Sexual harassment and gender-based harassment are common in medicine; however, there is little in the literature regarding men's experience with gender-based and sexual harassment. OBJECTIVE: The objective of this study was to better understand the experience men have with sexual and gender-based harassment in medicine. DESIGN: We developed and piloted an interview guide based on a review of the literature and conducted semi-structured interviews of male physicians, from trainees to attendings, at a tertiary care facility. Participants were recruited via email between April and August of 2019. These interviews were transcribed verbatim and, using an iterative coding approach based in grounded theory, were coded and analyzed for themes. MAIN RESULTS: We conducted a total of 16 interviews. Five major themes were identified: (1) personal experiences of harassment, (2) witnessed harassment, (3) characterization of harassment, (4) impact of harassment, and (5) strategies for responding to harassment. The men reported experiences with sexual and gender-based harassment but were hesitant to define these encounters as such. They had minimal emotional distress from these encounters but worried about their professional reputation and lacked training for how to respond to these encounters. Many had also witnessed their female colleagues being harassed by both male patients and colleagues but did not respond to or stop the harassment when it originated from a colleague. CONCLUSION: We found that men experience sexual harassment differently from women. Most notably, men report less emotional distress from these encounters and often do not define these events as harassment. However, similar to women, men feel unprepared to respond to episodes of harassment against themselves or others. Whether to deter sexual harassment against themselves, or, more commonly, against a female colleague, men can gain the tools to speak up and be part of the solution to sexual harassment in medicine.

A mixed-methods needs assessment of adult diabetes mellitus (type II) and hypertension care in Toledo, Belize.

BACKGROUND: Non-communicable diseases, including diabetes mellitus and hypertension, continue to disproportionately burden low- and middle-income countries. However, little research has been done to establish current practices and management of chronic disease in these settings. The objective of this study was to examine current clinical management and identify potential gaps in care of patients with diabetes mellitus and hypertension in the district of Toledo, Belize. METHODS: The study used a mixed methodology to assess current practices and identify gaps in diabetes mellitus and hypertension care. One hundred and twenty charts of the general clinic population were reviewed to establish disease epidemiology. One hundred and seventy-eight diabetic and hypertensive charts were reviewed to assess current practices. Twenty providers completed questionnaires regarding diabetes mellitus and hypertension management. Twenty-five individuals with diabetes mellitus and/or hypertension answered a questionnaire and in-depth interview. RESULTS: The prevalence of diabetes mellitus and hypertension was 12%. Approximately 51% (n = 43) of patients with hypertension were at blood pressure goal and 26% (n = 21) diabetic patients were at glycemic goal based on current guidelines. Of the patients with uncontrolled diabetes, 49% (n = 29) were on two oral agents and only 10% (n = 6) were on insulin. Providers stated that barriers to appropriate management include concerns prescribing insulin and patient health literacy. Patients demonstrated a general understanding of the concept of chronic illness, however lacked specific knowledge regarding disease processes and self-management strategies. CONCLUSIONS: This study provides an initial overview of diabetes mellitus and hypertension management in a diverse patient population in rural Belize. Results indicate areas for future investigation and possible intervention, including barriers to insulin use and opportunities for lifestyle-specific disease education for patients.

Helping Residents Excel in Team-Based Care: An Interactive Case-Based Interprofessional Education Curriculum.

INTRODUCTION: Communication and collaboration with an interprofessional team is vital for patient care, yet teaching these skills to resident physicians faces multiple challenges. METHODS: We developed an interactive, case-based curriculum on interprofessional communication and collaboration and implemented it at a large Veterans Affairs hospital. A pre/post survey study design was used to evaluate the curriculum, with 31 residents completing both surveys (100% response rate). RESULTS: After the curriculum, there was improvement in the residents' knowledge, comfort, and satisfaction in communicating and collaborating with the interprofessional team. Satisfaction scores with clinic also improved in all measures. DISCUSSION/CONCLUSIONS: Overall, a curriculum aimed at teaching interprofessional communication and collaboration improved residents' comfort and satisfaction in this realm and may help them achieve competence in these challenging-to-teach skills.

A Medication Hiccup: Chlorpromazine-Induced Agranulocytosis in a 72-Year-Old Male.

INTRODUCTION: Agranulocytosis, a severe decrease or absence of neutrophils, is a side effect of several medications, including chlorpromazine. If not promptly recognized, it can lead to overwhelming infection, sepsis, and death. CASE PRESENTATION: A 72-year-old man with adenocarcinoma of the lung status-post recent lobectomy was admitted for postsurgical pain and electrolyte derangement. During his admission, he had intractable hiccups and was started on chlorpromazine 25 mg by mouth 3 times a day. Within a week, he developed pneumonia, type 1 respiratory failure, and a progressive neutropenia. Chlorpromazine-induced agranulocytosis was suspected and chlorpromazine was discontinued; however, the patient expired, with postmortem findings of aspergillus bronchopneumonia as cause of death. DISCUSSION: Chlorpromazine is a well-studied cause of agranulocytosis. This case is novel in its rapid time course of less than 1 week; most cases report the resultant agranulocytosis on the order of weeks rather than days. CONCLUSION: This case highlights an important need to recognize this medication side effect early so the offending agent may be stopped and the patient properly supported, so as to avoid the severe risk of neutropenic infection, sepsis, and death.

Evaluation of a Patient-Collected Audio Audit and Feedback Quality Improvement Program on Clinician Attention to Patient Life Context and Health Care Costs in the Veterans Affairs Health Care System.

Importance: Evidence-based care plans can fail when they do not consider relevant patient life circumstances, termed contextual factors, such as a loss of social support or financial hardship. Preventing these contextual errors can reduce obstacles to effective care. Objective: To evaluate the effectiveness of a quality improvement program in which clinicians receive ongoing feedback on their attention to patient contextual factors. Design, Setting, and Participants: In this quality improvement study, patients at 6 Department of Veterans Affairs outpatient facilities audio recorded their primary care visits from May 2017 to May 2019. Encounters were analyzed using the Content Coding for Contextualization of Care (4C) method. A feedback intervention based on the 4C coded analysis was introduced using a stepped wedge design. In the 4C coding schema, clues that patients are struggling with contextual factors are termed contextual red flags (eg, sudden loss of control of a chronic condition), and a positive outcome is prospectively defined for each encounter as a quantifiable improvement of the contextual red flag. Data analysis was performed from May to October 2019. Interventions: Clinicians received feedback at 2 intensity levels on their attention to patient contextual factors and on predefined patient outcomes at 4 to 6 months. Main Outcomes and Measures: Contextual error rates, patient outcomes, and hospitalization rates and costs were measured. Results: The patients (mean age, 62.0 years; 92% male) recorded 4496 encounters with 666 clinicians. At baseline, clinicians addressed 413 of 618 contextual factors in their care plans (67%). After either standard or enhanced feedback, they addressed 1707 of 2367 contextual factors (72%), a significant difference (odds ratio, 1.3; 95% CI, 1.1-1.6; P = .01). In a mixed-effects logistic regression model, contextualized care planning was associated with a greater likelihood of improved outcomes (adjusted odds ratio, 2.5; 95% CI, 1.5-4.1; P < .001). In a budget analysis, estimated savings from avoided hospitalizations were $25.2 million (95% CI, $23.9-$26.6 million), at a cost of $337 242 for the intervention. Conclusions and Relevance: These findings suggest that patient-collected audio recordings of the medical encounter with feedback may enhance clinician attention to contextual factors, improve outcomes, and reduce hospitalizations. In addition, the intervention is associated with substantial cost savings.

Evaluation of phospholipid and liposomal S-adenosyl methionine for the treatment of liver injury in a murine model.

We have used a murine model of Acetaminophen induced hepatoxicity to determine if S-adenosyl methionine 1,4 butanedisulfonate (SD4) in liposomes can prevent liver injury when administered immediately prior to acetaminophen, as judged by serum aspartate aminotransferase and alanine aminotransferase levels, and histological evidence of liver necrosis. No protection was observed when mice received 1 g/kg unencapsulated SD4. Partial protection was observed with 5 or 0.5 mg/kg SD4 in unextruded distearoylphosphatidylglycerol (DSPG) liposomes. Protection comparable to that seen in mice receiving encapsulated SD4 is achieved when mice received lipid alone in equivalent amounts, suggesting that the contribution of encapsulated SD4 to the efficacy of the liposomes may be minimal. Unextruded distearoylphosphatidylcholine (DSPC) liposomes show only slight effects even at 50 mg/kg SD4. This is likely caused by the size of unextruded DSPC lipsomes, because extruded DSPC liposomes, whose size is smaller, are of comparable efficacy to unextruded DSPG liposomes.