Hospital Physicians' Perspectives on Occupational Stress During COVID-19: a Qualitative Analysis from Two US Cities.

BACKGROUND: US physicians are at risk for high rates of occupational stress and burnout, which the COVID-19 pandemic has intensified. As approaches targeting physicians' individual resilience have fallen short, researchers are increasingly calling for studies that investigate organizational drivers of stress and burnout. OBJECTIVE: To understand the multi-dimensional systems factors shaping hospital physicians' occupational stress during the pandemic. DESIGN: Qualitative, semi-structured interviews conducted in February-October 2021. SETTING: Hospitals in New York City and New Orleans. PARTICIPANTS: A purposive snowball sample of attending physicians and fellows in hospital medicine, emergency medicine, pulmonary critical care, and palliative care who spent at least 4 weeks providing inpatient COVID-19 care beginning in March 2020 was selected. The sample included 40 physicians from 14 hospitals in New York City and 39 physicians from nine hospitals in New Orleans. APPROACH: Descriptive analysis of participants' self-reported perceptions of occupational stress. KEY RESULTS: Participants identified multiple factors shaping their occupational stress including individual-level factors such as age, work experience, and life stage; institutional-level factors such as resource disparities, institutional type and size, and policies; professional-level factors such as informal rationing and medical uncertainty; and societal-level factors such as the federal response, COVID politics, and social inequalities. Stressors within and across these four levels worked in combination to shape physicians' perceptions of occupational stress at the individual level. CONCLUSIONS: This article contributes to an emergent literature on systems-based approaches to occupational stress and burnout among physicians by demonstrating the intersections among societal conditions, professional cultures, institutional work environments, and individual stress. Findings from semi-structured interviews suggest that interventions to reduce physician stress and burnout may be more effective if they target systems factors and stressors at multiple levels.

Moral Stress and Moral Distress: Confronting Challenges in Healthcare Systems under Pressure.

Stresses on healthcare systems and moral distress among clinicians are urgent, intertwined bioethical problems in contemporary healthcare. Yet conceptualizations of moral distress in bioethical inquiry often overlook a range of routine threats to professional integrity in healthcare work. Using examples from our research on frontline physicians working during the COVID-19 pandemic, this article clarifies conceptual distinctions between moral distress, moral injury, and moral stress and illustrates how these concepts operate together in healthcare work. Drawing from the philosophy of healthcare, we explain how moral stress results from the normal operations of overstressed systems; unlike moral distress and moral injury, it may not involve a sense of powerlessness concerning patient care. The analysis of moral stress directs attention beyond the individual, to stress-generating systemic factors. We conclude by reflecting on how and why this conceptual clarity matters for improving clinicians' professional wellbeing, and offer preliminary pathways for intervention.

Multidimensional stressors and protective factors shaping physicians' work environments and work-related well-being in two large US cities during COVID-19.

INTRODUCTION: Clinician burnout and poor work-related well-being reached a critical inflection point during the COVID-19 pandemic. This article applies a novel conceptual model informed by the Total Worker Health® approach to identify and describe multilevel stressors and protective factors that affected frontline physicians' work environments and work-related well-being. METHODS: We conducted a qualitative study of hospital-based physicians from multiple hospital types in Los Angeles and Miami who cared for COVID-19 patients. Semistructured interviews lasting 60-90 min were conducted over Zoom. Interview transcripts were thematically coded using Dedoose qualitative software. RESULTS: The final sample of 66 physicians worked in 20 hospitals. Stressors in the social, political, and economic environment included dealing with the politicization of COVID-19, including vaccine hesitancy; state and federal governmental COVID-19 policies and messaging; and shifting CDC guidance. Employment and labor pattern stressors included the national nursing shortage, different policies for paid time off, furloughs, reduced pay, and layoffs. Organizational-level stressors included institutional policies, staffing constraints and high patient volume (i.e., increased number of cases and longer lengths of stay), and perceived poor leadership. At the individual worker level, stressors included concerns about viral transmission to family, strained personal relationships, and work-life fit, particularly for those with young children. Respondents identified promising protective factors at multiple levels, including responsive state leadership, job security, concrete opportunities to provide input into institutional policy, strong leadership and communication, and feeling cared for by one's institution. CONCLUSION: Findings support a multi-level strategy that acknowledges internal organizational and external factors shaping clinicians' work-related well-being, consistent with the Total Worker Health® approach.

Promoting scientific literacy in evolution through citizen science.

Evolutionary understanding is central to biology. It is also an essential prerequisite to understanding and making informed decisions about societal issues such as climate change. Yet, evolution is generally poorly understood by civil society and many misconceptions exist. Citizen science, which has been increasing in popularity as a means to gather new data and promote scientific literacy, is one strategy through which people could learn about evolution. However, despite the potential for citizen science to promote evolution learning opportunities, very few projects implement them. In this paper, we make the case for incorporating evolution education into citizen science, define key learning goals, and suggest opportunities for designing and evaluating projects in order to promote scientific literacy in evolution.

Protecting Practitioners in Stressed Systems: Translational Bioethics and the COVID-19 Pandemic.

COVID-19 revealed health-care systems in crisis. Intersecting crises of stress, overwork, and poor working conditions have led to workforce strain, under-staffing, and high rates of job turnover. Bioethics researchers have responded to these conditions by investigating the ethical challenges of pandemic response for individuals, institutions, and health systems. This essay draws on pandemic findings to explore how empirical bioethics can inform post-pandemic translational bioethics. Borrowing from the concept of translational science in medicine, this essay proposes that translational bioethics should communicate knowledge about ethical challenges in health-care work to support health systems change. The authors draw from their experience with the Study to Examine Physicians' Pandemic Stress (STEPPS), an interdisciplinary research project that investigates physicians' experiences at the front lines of the COVID-19 pandemic. Using STEPPS as an example of empirical bioethics with potential for translation, the authors review their research and discuss the ongoing process for translating their findings, focusing on how bioethics research and practice can contribute to supporting the health-care workforce.

Separate but Equal? The Sorting of USMDs and Non-USMDs in Internal Medicine Residency Programs.

BACKGROUND: The US internal medicine workforce relies on international and osteopathic medical graduates to fill gaps in residency. Little is known about the distribution and impact of IMGs, DOs, and USMDs concentrating in different types of IM programs. OBJECTIVE: Determining the extent to which USMDs, DOs, and IMGs concentrate in different types of IM programs and comparing Board pass rates by program concentration. DESIGN, SETTINGS, AND PARTICIPANTS: This survey study used data from the AMA's FREIDA database for 476 non-military IM programs in 2017-2018, and 2016-2018 ABIM exam pass rates for 388 accredited programs. MEASUREMENTS: Outcomes were (1) program concentration based on percentage of residents who were USMDs, IMGs, and DOs in 2017-2018 and (2) 2016-2018 program ABIM pass rates as proxies for program quality. Key independent variables were hospital type (community-based, community-based university-affiliated, or university-based) when program concentration was the outcome, and program concentration when Board pass rates were the outcome. RESULTS: Twenty-five percent of programs were "USMD-dominated," 17% were "DO-dominated," 42% were "IMG dominated," and 16% were "integrated." The chances that a university hospital was USMD-dominated were 32 percentage points higher than that for a community hospital (AME = 0.32, baseline probability = 0.11, 95% CI, 0.17-0.46, P < .001). USMD-dominated programs also had significantly higher pass rates by 4.0 percentage points (AME = 0.04, baseline proportion = 0.90, 95% CI, 0.02-0.06, P < .001) than integrated programs, while DO-dominated programs had significantly lower pass rates (AME = - 0.1, baseline proportion = 0.90, 95% CI, - 0.15 to - 0.04, P < .001). CONCLUSION: USMDs and non-USMDs systematically cluster in certain types of residency programs and their training may not be equal, as measured by board pass rates.

Avian malaria and bird humoral immune response.

BACKGROUND: Plasmodium parasites are known to impose fitness costs on their vertebrate hosts. Some of these costs are due to the activation of the immune response, which may divert resources away from self-maintenance. Plasmodium parasites may also immuno-deplete their hosts. Thus, infected individuals may be less able to mount an immune response to a new pathogen than uninfected ones. However, this has been poorly investigated. METHODS: The effect of Plasmodium infection on bird humoral immune response when encountering a novel antigen was tested. A laboratory experiment was conducted on canaries (Serinus canaria) experimentally infected with Plasmodium relictum (lineage SGS1) under controlled conditions. Birds were immune challenged with an intra-pectoral injection of a novel non-pathogenic antigen (keyhole limpet haemocyanin, KLH). One week later they were challenged again. The immune responses to the primary and to the secondary contacts were quantified as anti-KLH antibody production via enzyme-linked immunosorbent assay (ELISA). RESULTS: There was no significant difference in antibody production between uninfected and Plasmodium infected birds at both primary and secondary contact. However, Plasmodium parasite intensity in the blood increased after the primary contact with the antigen. CONCLUSIONS: There was no effect of Plasmodium infection on the magnitude of the humoral immune response. However, there was a cost of mounting an immune response in infected individuals as parasitaemia increased after the immune challenge, suggesting a trade-off between current control of chronic Plasmodium infection and investment against a new immune challenge.

Stressing the journey: using life stories to study medical student wellbeing.

While previous studies have considered medical student burnout and resilience at discrete points in students' training, few studies examine how stressors and resilience-building factors can emerge before, and during, medical school. Our study focuses on students' life stories to comprehensively identify factors contributing to student wellbeing. We performed a secondary analysis of life-story interviews with graduating fourth year medical students. These interviews were originally conducted in 2012 as part of the Project on the Good Physician, and then re-analyzed, focusing on student wellbeing. Respondents were encouraged to identify turning points in their life stories. De-identified transcripts were then coded using a consensus-based iterative process. 17 of 21 respondents reported feeling burned out at least once during medical school. Students identified three major stressors: negative role models, difficult rotations, and the United States Medical Licensing Examination Step 1. Two "motivational stressors"-financial concerns and personal life events-emerged as sources of stress that also motivated students to persevere. Finally, students identified four factors-positive role models, support networks, faith and spirituality, and passion-that helped them reframe stressors, making the struggle seem more worthwhile. These findings suggest that a life-story approach can add granularity to current understandings of medical student wellbeing. Initiatives to reduce stress and burnout should extend beyond the immediate medical school context and consider how past challenges might become future sources of resilience. This study also provides an example of secondary analysis of qualitative data, an approach which could be useful to future research in medical education.

Host shift and cospeciation rate estimation from co-phylogenies.

Host shifts can cause novel infectious diseases, and is a key process in diversification. Disentangling the effects of host shift vs. those of cospeciation is non-trivial as both can result in phylogenic congruence. We develop a new framework based on network analysis and Approximate Bayesian Computation to quantify host shift and cospeciation rates in host-parasite systems. Our method enables estimation of the expected time to the next host shift or cospeciation event. We then apply it to avian haemosporidian parasite systems and to the pocket gophers-chewing lice system, and demonstrate that both host shift and cospeciation can be reliably estimated by our method. We confirm that host shifts have shaped the evolutionary history of avian haemosporidian parasites and have played a minor role in the gopher-chewing lice system. Our method is promising for predicting the rate of potential host shifts and thus the emergence of novel infectious diseases.

Plasmodium infection and oxidative status in breeding great tits, Parus major.

BACKGROUND: Plasmodium parasites may affect the oxidative status of their hosts, defined as the balance of pro-oxidant compounds and antioxidant defences in an organism. An increased energy requirement, the activation of immune functions or the parasite itself may lead to a higher production of pro-oxidants and/or an antioxidant depletion resulting in a higher oxidative stress and associated damage in infected individuals. Relatively little is known about the mechanisms underlying oxidative processes at play during host-Plasmodium interaction in the wild. METHODS: The effect of Plasmodium infection on host oxidative status was investigated in wild populations of breeding great tits, Parus major, naturally infected by Plasmodium spp. When chicks were 14 days old, the parents were blood-sampled to measure four complementary oxidative status markers: pro-oxidant production as mitochondrial superoxide production in red blood cells (RBC), antioxidant defences as plasma antioxidant capacity and oxidative damage as reactive oxygen metabolites in the plasma and RBC membrane resistance to oxidative attack. RESULTS: Plasmodium-infected individuals produced more pro-oxidants compared to uninfected ones and pro-oxidant production positively correlated to infection intensity. There was also a conditional effect of reproductive effort on oxidative damage depending on Plasmodium infection status. There was no direct effect of infection on oxidative damage and no effect on antioxidant defences. CONCLUSIONS: The results suggest that Plasmodium parasites may impose a cost in terms of increased oxidative stress possibly mediated via a higher energy requirement in infected hosts. This further suggests that Plasmodium parasites may modify host life history traits via an induction of oxidative stress. This study highlights that measuring several complementary oxidative status markers may enable to capture oxidative processes at play during host-Plasmodium interactions.

Experimental plant communities develop phylogenetically overdispersed abundance distributions during assembly.

The importance of competition between similar species in driving community assembly is much debated. Recently, phylogenetic patterns in species composition have been investigated to help resolve this question: phylogenetic clustering is taken to imply environmental filtering, and phylogenetic overdispersion to indicate limiting similarity between species. We used experimental plant communities with random species compositions and initially even abundance distributions to examine the development of phylogenetic pattern in species abundance distributions. Where composition was held constant by weeding, abundance distributions became overdispersed through time, but only in communities that contained distantly related clades, some with several species (i.e., a mix of closely and distantly related species). Phylogenetic pattern in composition therefore constrained the development of overdispersed abundance distributions, and this might indicate limiting similarity between close relatives and facilitation/complementarity between distant relatives. Comparing the phylogenetic patterns in these communities with those expected from the monoculture abundances of the constituent species revealed that interspecific competition caused the phylogenetic patterns. Opening experimental communities to colonization by all species in the species pool led to convergence in phylogenetic diversity. At convergence, communities were composed of several distantly related but species-rich clades and had overdispersed abundance distributions. This suggests that limiting similarity processes determine which species dominate a community but not which species occur in a community. Crucially, as our study was carried out in experimental communities, we could rule out local evolutionary or dispersal explanations for the patterns and identify ecological processes as the driving force, underlining the advantages of studying these processes in experimental communities. Our results show that phylogenetic relations between species provide a good guide to understanding community structure and add a new perspective to the evidence that niche complementarity is critical in driving community assembly.

Functionally and phylogenetically diverse plant communities key to soil biota.

Recent studies assessing the role of biological diversity for ecosystem functioning indicate that the diversity of functional traits and the evolutionary history of species in a community, not the number of taxonomic units, ultimately drives the biodiversity--ecosystem-function relationship. Here, we simultaneously assessed the importance of plant functional trait and phylogenetic diversity as predictors of major trophic groups of soil biota (abundance and diversity), six years from the onset of a grassland biodiversity experiment. Plant functional and phylogenetic diversity were generally better predictors of soil biota than the traditionally used species or functional group richness. Functional diversity was a reliable predictor for most biota, with the exception of soil microorganisms, which were better predicted by phylogenetic diversity. These results provide empirical support for the idea that the diversity of plant functional traits and the diversity of evolutionary lineages in a community are important for maintaining higher abundances and diversity of soil communities.

Sex, gender, genetics, and health.

This article addresses 2 questions. First, to what extent are sex and gender incorporated into research on genetics and health? Second, how might social science understandings of sex and gender, and gender differences in health, become more integrated into scholarship in this area? We review articles on genetics and health published in selected peer-reviewed journals. Although sex is included frequently as a control or stratifying variable, few articles articulate a conceptual frame or methodological justification for conducting research in this way, and most are not motivated by sex or gender differences in health. Gender differences in health are persistent, unexplained, and shaped by multilevel social factors. Future scholarship on genetics and health needs to incorporate more systematic attention to sex and gender, gender as an environment, and the intertwining of social and biological variation over the life course. Such integration will advance understandings of gender differences in health, and may yield insight regarding the processes and circumstances that make genomic variation relevant for health and well-being.

Physicians as shock absorbers: The system of structural factors driving burnout and dissatisfaction in medicine.

American physicians disproportionately suffer from burnout. Despite calls for systemic solutions, however, few studies have actually examined how 'the system' works-i.e. how structural factors intersect in real-time as a system to shape wellbeing. I borrow a systems theoretical approach, which explicitly recognizes the dynamic relationships and interdependencies between different actors and factors in healthcare, to examine how structural factors work together to shape physicians' wellbeing. Drawing on an eight-month ethnography in a pediatrics clinic, I show how respondents experienced pressures from multiple structural levels: societal (including broader social inequality and changing doctor-patient relationships); organizational (centralized decision-making, economic pressures, and unresponsive leadership); and professional (specialty cultures and unhealthy norms). I find that individual physicians effectively served as shock absorbers, routinely absorbing countless, interconnected structural demands ("shocks") and converting them into competent medical care, at significant cost to their mental health. In so doing, I intervene in sociological debates about the broader fate of the medical profession and conclude that if medicine remains resilient against threats to its dominance, it may well be at the expense of individual physicians' mental wellbeing.

The impact of health inequities on physicians' occupational well-being during COVID-19: A qualitative analysis from four US cities.

OBJECTIVE: The aim of this study is to describe frontline physicians' perceptions of the impact of racial-ethnic and socioeconomic disparities in COVID-19 infection and mortality on their occupational well-being. METHODS: One hundred and forty-five qualitative, semistructured interviews were conducted between February 2021 and June 2022 with hospital medicine, emergency medicine, pulmonary/critical care, and palliative care physicians caring for hospitalized COVID-19 patients in four US cities. RESULTS: Physicians reported encountering COVID-related health disparities and inequities at the societal, organizational, and individual levels. Encountering these inequities, in turn, contributed to stress among frontline physicians, whose concerns revealed how structural conditions both shaped COVID disparities and constrained their ability to protect populations at risk from poor outcomes. Physicians reported feeling complicit in the perpetuation of inequities or helpless to mitigate observed inequities and experienced feelings of grief, guilt, moral distress, and burnout. CONCLUSIONS: Health inequities are an under-acknowledged source of physicians' occupational stress that requires solutions beyond the clinical context.

Assessing barriers to health insurance and threats to equity in comparative perspective: the Health Insurance Access Database.

BACKGROUND: Typologies traditionally used for international comparisons of health systems often conflate many system characteristics. To capture policy changes over time and by service in health systems regulation of public and private insurance, we propose a database containing explicit, standardized indicators of policy instruments. METHODS: The Health Insurance Access Database (HIAD) will collect policy information for ten OECD countries, over a range of eight health services, from 1990-2010. Policy indicators were selected through a comprehensive literature review which identified policy instruments most likely to constitute barriers to health insurance, thus potentially posing a threat to equity. As data collection is still underway, we present here the theoretical bases and methodology adopted, with a focus on the rationale underpinning the study instruments. RESULTS: These harmonized data will allow the capture of policy changes in health systems regulation of public and private insurance over time and by service. The standardization process will permit international comparisons of systems' performance with regards to health insurance access and equity. CONCLUSION: This research will inform and feed the current debate on the future of health care in developed countries and on the role of the private sector in these changes.

Biogeography of avian blood parasites (Leucocytozoon spp.) in two resident hosts across Europe: phylogeographic structuring or the abundance-occupancy relationship?

Relationships between hosts and parasites represent complex co-evolving systems that can vary both temporally and spatially. This variation may result in different phylogeographic outcomes, ranging from highly geographically structured parasite populations comprised of specialist lineages that are locally abundant but have restricted global occupancy to geographically unstructured parasite populations consisting of widespread parasites. Here, we present results from a large biogeographic study of the Leucocytozoon blood parasites of two nonmigrant bird species, conducted at nine sites across Europe. The aim was to determine whether the parasite lineages of the two hosts were phylogeographically structured across Europe. Employing molecular methods, we found a large diversity of parasites, and although overall prevalence varied greatly, the parasites were not genetically structured. Several measures of local parasite abundance were associated with the number of sites that the lineage occurred in, which is consistent with the macroecological phenomenon of the abundance-occupancy relationship. Taken together, our results show that parasite dispersal is somewhat uncoupled to that of the host in this system: we suggest that broad host and/or vector preference may play an important role in determining the distribution of these parasites and in affecting host-parasite coevolution in this system.

The Resurgence of Medical Education in Sociology: A Return to Our Roots and an Agenda for the Future.

From 1940 to 1980, studies of medical education were foundational to sociology, but attention shifted away from medical training in the late 1980s. Recently, there has been a marked return to this once pivotal topic, reflecting new questions and stakes. This article traces this resurgence by reviewing recent substantive research trends and setting the agenda for future research. We summarize four current research foci that reflect and critically map onto earlier projects in this subfield while driving theoretical development elsewhere in the larger discipline: (1) professional socialization, (2) knowledge regimes, (3) stratification within the profession, and (4) sociology of the field of medical education. We then offer six potential future directions where more research is needed: (1) inequalities in medical education, (2) socialization across the life course and new institutional forms of gatekeeping, (3) provider well-being, (4) globalization, (5) medical education as knowledge-based work, and (6) effects of the COVID-19 pandemic.

Specialty and Lifestyle Preference Changes during Medical School.

PURPOSE: Medical student specialty choices have significant downstream effects on the availability of physicians and, ultimately, the effectiveness of health systems. This study investigated how medical student specialty preferences change over time in relation to their demographics and lifestyle preferences. METHOD: Students from ten medical schools were surveyed at matriculation (2012) and graduation (2016). The two surveys included questions about specialty and lifestyle preferences, demographics, educational background, and indebtedness. Student data from 2012 to 2016 were paired together and grouped into those whose specialty preferences remained constant or switched. RESULTS: Response rates in 2012 and 2016 were 65% (997/1530) and 50% (788/1575), respectively. Fourth-year students ranked "enjoying the type of work I am doing" as less important to a good physician lifestyle than did first-year students (from 59.6 to 39.7%). The lifestyle factors "having control of work schedule" and "having enough time off work" were ranked as more important to fourth-year students than first-year students (from 15.6 to 18.2% and 14.8 to 31.9%, respectively). The paired dataset included 19% of eligible students (237/1226). Demographic and lifestyle factors were not significantly associated with specialty preference switching. Additionally, no significant association existed between changing lifestyle preferences and switching specialty preference (p = 0.85). CONCLUSIONS: During the course of medical school, lifestyle preferences became more focused on day-to-day factors and less on deeper motivational factors. Neither demographics nor lifestyle preferences appear to relate to a student's decision to switch specialty preference during medical school. These findings represent an important step in uncovering causes of specialty preference trends.

Patients, practitioners, and paradoxes: responses to the Cuban health crisis of the 1990s.

Twenty-one respondents in Havana, Cuba, were interviewed for the purpose of understanding the challenges facing the Cuban health care system since the 1990s and the individual solutions that have been proposed to these challenges. Three major shortages were identified: a lack of medication, a lack of medical supplies, and a lack of medical professionals. Consequently, informal coping mechanisms, such as the black market and using personal connections, were a common way of overcoming the difficulties associated with these shortages. Beyond this, however, Cuban health care has experienced a unique fusion of medical traditions, such that now biomedicine and complementary and alternative medicine not only coexist in Cuban society but actively collude together to respond to the increasing demands for health services in light of waning supplies of medication and medical supplies. As a result, Cuba has managed to survive its most difficult health crisis since the beginning of the Revolution.