Community-Based, Cluster-Randomized Pilot Trial of a Cardiovascular Mobile Health Intervention: Preliminary Findings of the FAITH! Trial.

BACKGROUND: African Americans continue to have suboptimal cardiovascular health (CVH) based on the American Heart Association Life's Simple 7 (LS7), 7 health-promoting behaviors and biological risk factors (eg, physical activity, blood pressure). Innovative, community-level interventions in partnership with trusted institutions such as African American churches are potential means to improve CVH in this population. METHODS: Using a community-based participatory research approach, the FAITH! Trial (Fostering African American Improvement in Total Health) rigorously assessed the feasibility and preliminary efficacy of a refined, community-informed, mobile health intervention (FAITH! App) for promoting CVH among African Americans in faith communities using a cluster randomized controlled trial. Participants from 16 churches in Rochester and Minneapolis-St Paul, MN, were randomized to receive the FAITH! App (immediate intervention) or were assigned to a delayed intervention comparator group. The 10-week intervention core features included culturally relevant and LS7-focused education modules, diet/physical activity self-monitoring, and a group sharing board. Data were collected via electronic surveys and health assessments. Primary outcomes were average change in mean LS7 score (continuous measure of CVH ranging from poor to ideal [0-14 points]) from baseline to 6 months post-intervention (using generalized estimating equations) and app engagement/usability (by the Health Information Technology Usability Evaluation Scale; range, 0-5). RESULTS: Of 85 enrolled participants (randomized to immediate [N=41] and delayed [control] intervention [N=44] groups), 76 and 68 completed surveys/health assessments at baseline and 6 months post-intervention, respectively (80% retention rate with assessments at both baseline and 6-month time points); immediate intervention [N=30] and control [N=38] groups). At baseline, the majority of participants (mean age [SD], 54.2 [12.3] years, 71% female) had <4-year college education level (39/66, 59%) and poor CVH (44% in poor category; mean LS7 score [SD], 6.8 [1.9]). The mean LS7 score of the intervention group increased by 1.9 (SD 1.9) points compared with 0.7 (SD 1.7) point in the control group (both P<0.0001) at 6 months. The estimated difference of this increase between the groups was 1.1 (95% CI, 0.6-1.7; P<0.0001). App engagement/usability was overall high (100% connection to app; >75% completed weekly diet/physical activity tracking; Health Information Technology Usability Evaluation Scale, mean [SD], 4.2 [0.7]). CONCLUSIONS: On the basis of preliminary findings, the refined FAITH! App appears to be an efficacious mobile health tool to promote ideal CVH among African Americans. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03777709.

Community-based, cluster-randomized pilot trial of a cardiovascular mHealth intervention: Rationale, design, and baseline findings of the FAITH! Trial.

BACKGROUND: Compared to whites, African-Americans have lower prevalence of ideal cardiovascular health (CVH) based on the American Heart Association Life's Simple 7 (LS7). These CVH inequities have worsened during the COVID-19 pandemic. Ideal LS7 health-promoting behaviors and biological risk factors (eg, diet, blood pressure) are associated with improved CVH outcomes. The FAITH! (Fostering African-American Improvement in Total Health) App, a community-informed, mobile health (mHealth) intervention, previously demonstrated significant improvements in LS7 components among African-Americans, suggesting that mHealth interventions may be effective in improving CVH. This paper presents the FAITH! Trial design, baseline findings, and pandemic-related lessons learned. METHODS: Utilizing a community-based participatory research approach, this study assessed the feasibility/preliminary efficacy of a refined FAITH! App for promoting LS7 among African-Americans in faith communities using a cluster, randomized controlled trial. Participants received the FAITH! App (immediate intervention) or were assigned to a delayed intervention comparator group. Baseline data were collected via electronic surveys and health assessments. Primary outcomes are change in LS7 score from baseline to 6-months post-intervention and app engagement/usability. RESULTS: Of 85 enrolled individuals, 76 completed baseline surveys/health assessments, for a participation rate of 89% (N = 34 randomized to the immediate intervention, N = 42 to delayed intervention). At baseline, participants were predominantly female (54/76, 71%), employed (56/76, 78%) and of high cardiometabolic risk (72/76, 95% with hypertension and/or overweight/obesity) with mean LS7 scores in the poor range (6.8, SD = 1.9). CONCLUSIONS: The FAITH! Trial recruitment was feasible, and its results may inform the use of mHealth tools to increase ideal CVH among African-Americans.

Older Patients with Advanced Chronic Kidney Disease and Their Perspectives on Prognostic Information: a Qualitative Study.

BACKGROUND: Prognostic information is key to shared decision-making, particularly in life-limiting illness like advanced chronic kidney disease (CKD). OBJECTIVE: To understand the prognostic information preferences expressed by older patients with CKD. DESIGN AND PARTICIPANTS: Qualitative study of 28 consecutively enrolled patients over 65 years of age with non-dialysis dependent CKD stages 3b-5, receiving care in a multi-disciplinary CKD clinic. APPROACH: Semi-structured telephone or in-person interviews to explore patients' preference for and perceived value of individualized prognostic information. Interviews were analyzed using inductive content analysis. KEY RESULTS: We completed interviews with 28 patients (77.7 ± SD 6.8 years, 69% men). Patients varied in their preference for prognostic information and more were interested in their risk of progression to end-stage kidney disease (ESKD) than in life expectancy. Many conflated ESKD risk with risk of death, perceiving a binary choice between dialysis and quick decline and death. Patients expressed that prognostic information would allow them to plan, take care of important business, and think about their treatment options. Patients were accepting of prognostic uncertainty and imagined leveraging it to nurture hope or motivate them to better manage risk factors. They endorsed the desire to receive prognosis of life expectancy even though it may be hard to accept or difficult to talk about but worried it could create helplessness for other patients in their situation. CONCLUSION: Most, but not all, patients were interested in prognostic information and could see its value in motivating behavior change and allowing planning. Some patients expressed concern that information on life expectancy might cause depression and hopelessness. Therefore, prognostic information is most appropriate as part of a clinical conversation that fosters shared decision-making and helps patients consider treatment risks, benefits, and burdens in context of their lives.

Exploring Patients' Values and Preferences for Initial Atrial Fibrillation Education.

BACKGROUND: People with a new diagnosis of atrial fibrillation (AF) require knowledge to build skills and confidence to engage in decision making for AF treatment and prevention of AF-related complications. Data to guide development of content and approaches that enable acquisition of knowledge to support effective self-management are lacking. OBJECTIVE: The aim of this study was to explore patients' values concerning the content of initial AF education, describe how providers delivered education, and identify patients' preferences for approaches to education. METHODS: We used a qualitative inductive approach. Twenty-five participants given a diagnosis of AF within 18 months of enrollment were recruited from midwest US healthcare system clinics. Data were collected using a semistructured interview guide and were analyzed using qualitative content analysis. RESULTS: Themes emerging were as follows: (1) important to know, (2) recollections of the how and what of education, and (3) preferences for educational resources. Participants highly valued providers' explanations that AF was not immediately life-threatening and did not require limitations to usual activities. This reassurance from providers decreased fear and then enabled participants to learn about AF management. Verbal explanations were the primary approach to delivering education, but participants consistently expressed preferences for receiving written information and videos to supplement verbal explanations. CONCLUSIONS: Addressing emotional and quality of life concerns at the time of AF diagnosis reduced fear and was critical for enabling participants to attend to discussions about treatment and self-management. The value participants placed on written and video resources as an adjunct to verbal explanation suggests that providers should consider educational approaches beyond verbal explanations.

A Multicenter Comparison of Complementary and Alternative Medicine (CAM) Discussions in Oncology Care: The Role of Time, Patient-Centeredness, and Practice Context.

BACKGROUND: Little is known about how complementary and alternative medicine (CAM) is discussed in cancer care across varied settings in the U.S. METHODS: In two practices affiliated with one academic medical center in southern California (SoCal), and one in the upper Midwest (UM), we audio-recorded patient-clinician interactions in medical oncology outpatient practices. We counted the frequency and duration of CAM-related conversations. We coded recordings using the Roter Interaction Analysis System. We used chi-square tests for bivariate analysis of categorical variables and generalized linear models for continuous variables to examine associations between dialogue characteristics, practice setting, and population characteristics with the occurrence of CAM discussion in each setting followed by multivariate models adjusting for clinician clustering. RESULTS: Sixty-one clinicians and 529 patients participated. Sixty-two of 529 (12%) interactions included CAM discussions, with significantly more observed in the SoCal university practice than in the other settings. Visits that included CAM were on average 6 minutes longer, with CAM content lasting an average of 78 seconds. In bivariate tests of association, conversations containing CAM included more psychosocial statements from both clinicians and patients, higher patient-centeredness, more positive patient and clinician affect, and greater patient engagement. In a multivariable model including significant bivariate terms, conversations containing CAM were independently associated with higher patient-centeredness, slightly longer visits, and being at the SoCal university site. CONCLUSION: The frequency of CAM-related discussion in oncology varied substantially across sites. Visits that included CAM discussion were longer and more patient centered. IMPLICATIONS FOR PRACTICE: The Institute of Medicine and the American Society of Clinical Oncology have called for more open discussions of complementary and alternative medicine (CAM). But little is known about the role population characteristics and care contexts may play in the frequency and nature of those discussions. The present data characterizing actual conversations in practice complements a much larger literature based on patient and clinician self-report about CAM disclosure and use. It was found that CAM discussions in academic oncology visits varied significantly by practice context, that the majority were initiated by the patient, and that they may occur more when visit time exists for lifestyle, self-care, and psychosocial concerns.

Evaluation of Community Programs for Early Childhood Development: Parental Perspectives and Recommendations.

Objectives Optimal early childhood development is crucial for promoting positive child health outcomes. Community programs supporting child development are available throughout the United States but general parental perceptions of such programs are not well understood. This study aimed to examine parental perceptions of community programs for early childhood development in a semi-urban city of the US. Methods Data were collected from focus groups (n = 4) composed of English-fluent parents from the local community with at least one child aged 0-5 years. After generation of verbatim transcripts, data were analyzed by two independent coders in order to identify themes. Results Parental perceptions were categorized into four areas: (1) Utilization of community services, (2) Helpful aspects of community services, (3) Negative aspects of community services and (4) Parental recommendations for improved resource utilization. Helpful aspects identified included social and economic support, provision of parental education, and developmental screening and medical support. Negative aspects included utilization of standardized assessment tools, awareness of agencies and resources, and access to services. In order to improve resource utilization, parents suggested improved communication with parents and the child's medical home, transparency, and translation of program information into other languages. Conclusions For Practice Overall, participants felt that community programs that support early childhood development and parenting were helpful. However, community agencies can improve on communication with parents and medical providers as well as translation of program information.

Was a decision made? An assessment of patient-clinician discordance in medical oncology encounters.

BACKGROUND: Shared decision making is promoted to improve cancer care quality. Patients and clinicians may have different ideas about what constitutes a cancer care decision, which may limit the validity of self-reported measures of shared decision making. We sought to estimate the extent to which patients and clinicians agree on whether a cancer care decision was made during an outpatient encounter. METHODS: We surveyed patients and clinicians immediately after an oncology encounter at a large, tertiary medical centre and calculated agreement in response to the single-item question, 'Was a specific decision about cancer care made during the appointment today?' Answer options were 'yes' and 'no'. Participants were 315 oncology patients, with any solid tumour malignancy and at any stage of management, and their clinicians (22 staff oncologists, nine senior fellows and five nurse practitioners). RESULTS: Patients and clinicians reported having made a cancer care decision in 184 (58%) and 174 (55%) of encounters, respectively. They agreed on whether a cancer care decision was made in 213 (68%) of encounters (chance-adjusted agreement was 0.34); in 56 of the 102 discordant encounters, the patient reported making a decision while the clinician did not. We found no significant correlates with discordance. CONCLUSIONS: Patients and clinicians do not always agree on whether a cancer care decision was made. As such, measures that ask patients and/or clinicians to evaluate a decision-making process or outcome may be methodologically insufficient when they do not explicitly orient respondents towards the thing they are being asked to assess.

Comparative analysis of online health queries originating from personal computers and smart devices on a consumer health information portal.

BACKGROUND: The number of people using the Internet and mobile/smart devices for health information seeking is increasing rapidly. Although the user experience for online health information seeking varies with the device used, for example, smart devices (SDs) like smartphones/tablets versus personal computers (PCs) like desktops/laptops, very few studies have investigated how online health information seeking behavior (OHISB) may differ by device. OBJECTIVE: The objective of this study is to examine differences in OHISB between PCs and SDs through a comparative analysis of large-scale health search queries submitted through Web search engines from both types of devices. METHODS: Using the Web analytics tool, IBM NetInsight OnDemand, and based on the type of devices used (PCs or SDs), we obtained the most frequent health search queries between June 2011 and May 2013 that were submitted on Web search engines and directed users to the Mayo Clinic's consumer health information website. We performed analyses on "Queries with considering repetition counts (QwR)" and "Queries without considering repetition counts (QwoR)". The dataset contains (1) 2.74 million and 3.94 million QwoR, respectively for PCs and SDs, and (2) more than 100 million QwR for both PCs and SDs. We analyzed structural properties of the queries (length of the search queries, usage of query operators and special characters in health queries), types of search queries (keyword-based, wh-questions, yes/no questions), categorization of the queries based on health categories and information mentioned in the queries (gender, age-groups, temporal references), misspellings in the health queries, and the linguistic structure of the health queries. RESULTS: Query strings used for health information searching via PCs and SDs differ by almost 50%. The most searched health categories are "Symptoms" (1 in 3 search queries), "Causes", and "Treatments & Drugs". The distribution of search queries for different health categories differs with the device used for the search. Health queries tend to be longer and more specific than general search queries. Health queries from SDs are longer and have slightly fewer spelling mistakes than those from PCs. Users specify words related to women and children more often than that of men and any other age group. Most of the health queries are formulated using keywords; the second-most common are wh- and yes/no questions. Users ask more health questions using SDs than PCs. Almost all health queries have at least one noun and health queries from SDs are more descriptive than those from PCs. CONCLUSIONS: This study is a large-scale comparative analysis of health search queries to understand the effects of device type (PCs vs. SDs) used on OHISB. The study indicates that the device used for online health information search plays an important role in shaping how health information searches by consumers and patients are executed.

Evaluating the process of online health information searching: a qualitative approach to exploring consumer perspectives.

BACKGROUND: The Internet is a common resource that patients and consumers use to access health-related information. Multiple practical, cultural, and socioeconomic factors influence why, when, and how people utilize this tool. Improving the delivery of health-related information necessitates a thorough understanding of users' searching-related needs, preferences, and experiences. Although a wide body of quantitative research examining search behavior exists, qualitative approaches have been under-utilized and provide unique perspectives that may prove useful in improving the delivery of health information over the Internet. OBJECTIVE: We conducted this study to gain a deeper understanding of online health-searching behavior in order to inform future developments of personalizing information searching and content delivery. METHODS: We completed three focus groups with adult residents of Olmsted County, Minnesota, which explored perceptions of online health information searching. Participants were recruited through flyers and classifieds advertisements posted throughout the community. We audio-recorded and transcribed all focus groups, and analyzed data using standard qualitative methods. RESULTS: Almost all participants reported using the Internet to gather health information. They described a common experience of searching, filtering, and comparing results in order to obtain information relevant to their intended search target. Information saturation and fatigue were cited as main reasons for terminating searching. This information was often used as a resource to enhance their interactions with health care providers. CONCLUSIONS: Many participants viewed the Internet as a valuable tool for finding health information in order to support their existing health care resources. Although the Internet is a preferred source of health information, challenges persist in streamlining the search process. Content providers should continue to develop new strategies and technologies aimed at accommodating diverse populations, vocabularies, and health information needs.

On becoming a coach: a pilot intervention study with managers in long-term care.

BACKGROUND: Health care leaders have called for the development of communication and leadership skills to improve manager-employee relationships, employee job satisfaction, quality care, and work environments. PURPOSES: The aim of the study reported here was to pilot how a 2-day coaching workshop ("Coaching for Impressive CARE") conducted as a leadership development strategy influenced frontline care managers' coaching practices in residential long-term care (LTC) settings. We had four objectives: (a) to identify managers' perceptions of their role as a coach of employee performance in LTC facilities, (b) to understand managers' intentions to coach employee performance, (c) to examine opportunities and factors that contributed to or challenged implementation of workshop coaching skills in daily leadership/management practice, and (d) to examine managers' reports of using coaching practices and employee responses after the workshop. METHODS: We used an exploratory/descriptive design involving pre-/post-workshop surveys, e-mail reminders, and focus groups to examine participation of 21 LTC managers in a 2-day coaching workshop and their use of coaching practices in the workplace. FINDINGS: Focus group findings provided examples of how participants used their coaching skills in practice (e.g., communicating empathy) and how staff responded. Factors contributing to and challenging implementation of these coaching skills in the workplace were identified. Attitudes and intentions to be a coach increased significantly, and some coaching skills were used more frequently after the workshop, specifically planning for performance change with employees. PRACTICE IMPLICATIONS: The coaching workshop was feasible to implement, well received by participants, influenced their willingness to become coaches, and had some noted impact on their use of coaching behaviors in the workplace. Coaching skills by managers to improve staff performance with residents in LTC facilities can be learned.

Lessons learned from patients' weight-related medical encounters: Results from 34 interviews.

OBJECTIVES: How to best care for larger-bodied patients is a complicated issue in modern medicine. The present study seeks to inform current medical practices to ensure the delivery of high-quality and evidence-based care through the examination of higher-weight patients' experiences with weight-related care. METHODS: Higher-weight patients (N = 34) completed semi-structured interviews about their experiences and recommendations for weight-related care. Interviews were coded by two independent coders and harmonized. Findings were organized into broad domains of 1) negative care experiences and 2) positive care experiences and recommendations. RESULTS: Patients described a range of negative care experiences, including stigmatization from providers (e.g., rude, attacking, or insulting communication about weight), while concurrently expressing insufficient weight management support from providers. Positive care experiences and recommendations included patient-centered care (e.g., physician humility and empathy) and attending to the patient's weight, which conveyed concern for the patient. CONCLUSIONS: Our findings reflect patients' ambivalent attitudes toward weight-related care: while weight-focused provider communication can be highly stigmatizing, patients simultaneously desire more weight-management support from providers. PRACTICE IMPLICATIONS: Providers who wish to move their practices from a weight-loss focus to one targeting healthy living should provide a rationale for these shifts to inform patients' perceptions of high-quality care.

Rationale, design, and participant characteristics of the FAITH! Heart Health+ study: An exploration of the influence of the social determinants of health, stress, and structural racism on African American cardiovascular health.

BACKGROUND: African Americans (AAs) face cardiovascular health (CVH) disparities linked to systemic racism. The 2020 police killing of Mr. George Floyd in Minneapolis, Minnesota, alongside the COVID-19 pandemic, exacerbated adverse psychosocial factors affecting CVH outcomes among AAs. This manuscript describes the study protocol and participant characteristics in an ancillary study exploring the relationship between biopsychosocial factors and CVH among AAs. METHODS: Using a community-based participatory approach, a mixed-methods ancillary study of 58 AA participants from an overarching randomized control trial (RCT) was conducted. Baseline RCT health assessments (November 2020) provided sociodemographic, medical, and clinical data. Subsequent health assessments (February-December 2022) measured sleep quality, psychosocial factors (e.g., high-effort coping), biomarkers (e.g., cortisol), and cardiovascular diagnostics (e.g., cardio-ankle vascular index). CVH was assessed using the American Heart Association Life's Simple 7 (LS7) (range 0 to 14, poor to ideal) and Life's Essential 8 (LE8) scores (range 0 to 100, low to high). Correlations between these scores will be examined. Focus group discussions via videoconferencing (March to April 2022) assessed psychosocial and structural barriers, along with the impact of COVID-19 and George Floyd's killing on daily life. RESULTS: Participants were predominantly female (67%), with a mean age of 54.6 [11.9] years, high cardiometabolic risk (93% had overweight/obesity and 70% hypertension), and moderate LE8 scores (mean 57.4, SD 11.5). CONCLUSION: This study will enhance understanding of the associations between biopsychosocial factors and CVH among AAs in Minnesota. Findings may inform risk estimation, patient care, and healthcare policies to address CVD disparities in marginalized populations.

Listening in on difficult conversations: an observational, multi-center investigation of real-time conversations in medical oncology.

BACKGROUND: The quality of communication in medical care has been shown to influence health outcomes. Cancer patients, a highly diverse population, communicate with their clinical care team in diverse ways over the course of their care trajectory. Whether that communication happens and how effective it is may relate to a variety of factors including the type of cancer and the patient's position on the cancer care continuum. Yet, many of the routine needs of cancer patients after initial cancer treatment are often not addressed adequately. Our goal is to identify areas of strength and areas for improvement in cancer communication by investigating real-time cancer consultations in a cross section of patient-clinician interactions at diverse study sites. METHODS/DESIGN: In this paper we describe the rationale and approach for an ongoing observational study involving three institutions that will utilize quantitative and qualitative methods and employ a short-term longitudinal, prospective follow-up component to investigate decision-making, key topics, and clinician-patient-companion communication dynamics in clinical oncology. DISCUSSION: Through a comprehensive, real-time approach, we hope to provide the fundamental groundwork from which to promote improved patient-centered communication in cancer care.

The Problem and Power of Professionalism: A Critical Analysis of Medical Students' and Residents' Perspectives and Experiences of Professionalism.

PURPOSE: Professionalism has historically been viewed as an honorable code to define core values and behaviors of physicians, but there are growing concerns that professionalism serves to control people who do not align with the majority culture of medicine. This study explored how learners, particularly those from historically marginalized groups, view the purpose of professionalism and how they experience professionalism as both an oppressive and valuable force. METHOD: The authors conducted a qualitative study with a critical orientation. In 2021 and 2022, they interviewed fourth-year medical students and senior residents at 3 institutions about their perceptions and experiences of professionalism. After cataloguing participants' stories, the authors combined critical theory with narrative and thematic analysis to identify mechanisms by which professionalism empowered or disempowered individuals or groups based on identities. RESULTS: Forty-nine trainees (31 medical students and 18 senior residents from multiple specialties) participated in interviews; 17 identified as a race/ethnicity underrepresented in medicine and 15 as people of color not underrepresented in medicine. Their stories, especially those of participants underrepresented in medicine, identified professionalism as an oppressive, homogenizing force that sometimes encoded racism through various mechanisms. These mechanisms included conflating differences with unprofessionalism, enforcing double standards of professionalism, and creating institutional policies that regulated appearance or hindered advocacy. Participants described deleterious consequences of professionalism on their learning and mental health. However, participants also described useful aspects of professionalism as a means of advocating for marginalized groups. Additionally, participants described how they reconceived professionalism to include their own identities and values. CONCLUSIONS: Trainees, especially those from historically marginalized groups, experience professionalism as a restrictive, assimilative force while also finding value in and constructive adaptations for professionalism. Understanding both the destructive and empowering aspects of professionalism on individual and institutional levels can help improve the framing of professionalism in medical education.

Sign of the times: Community engagement to refine a cardiovascular mHealth intervention through a virtual focus group series during the COVID-19 Pandemic.

Background: African-Americans are underrepresented in mobile health intervention research studies which can perpetuate health inequities and the digital divide. A community-based, user-centered approach to designing mobile health interventions may increase their sociocultural relevance and effectiveness, especially with increased smartphone use during the coronavirus disease 2019 pandemic. We aimed to refine an existing mobile health intervention via a virtual focus group series. Methods: African-American community members (n = 15) from churches in Minneapolis-St. Paul and Rochester, Minnesota were enrolled in a virtual (via videoconferencing), three-session focus group series over five months to refine a cardiovascular health-focused mobile health application (FAITH! [Fostering African-American Improvement in Total Health!] App). Participants accessed the app via their smartphones and received a Fitbit synced to the app. Participants engaged with multimedia cardiovascular health-focused education modules, a sharing board for social networking, and diet/physical activity self-monitoring. Participant feedback on app features prompted iterative revisions to the FAITH! App. Primary outcomes were app usability (assessed via Health Information Technology Usability Evaluation Scale range: 0-5) and user satisfaction. Results: Participants (mean age [SD]: 56.9 [12.3] years, 86.7% female) attended a mean 2.8 focus groups (80% attended all sessions). The revised FAITH! App exceeded the goal Health Information Technology Usability Evaluation Scale score threshold of ≥4 (mean: 4.39, range: 3.20-4.95). Participants positively rated updated app content, visual appeal, and use of social incentives to maintain engagement. Increasing user control and refinement of the moderated sharing board were identified as areas for future improvement. Conclusions: Community-partnered, virtual focus groups can optimize usability and increase participant satisfaction of mobile health lifestyle interventions that aim to promote cardiovascular health in African-Americans.

"Finding My Piece in That Puzzle": A Qualitative Study Exploring How Medical Students at Four U.S. Schools Envision Their Future Professional Identity in Relation to Health Systems.

PURPOSE: Health systems science (HSS) curricula equip future physicians to improve patient, population, and health systems outcomes (i.e., to become "systems citizens"), but the degree to which medical students internalize this conception of the physician role remains unclear. This study aimed to explore how students envision their future professional identity in relation to the system and identify experiences relevant to this aspect of identity formation. METHOD: Between December 2018 and September 2019, authors interviewed 48 students at 4 U.S. medical schools with HSS curricula. Semistructured interviews were audiorecorded, transcribed, and analyzed iteratively using inductive thematic analysis. Interview questions explored how students understood the health system, systems-related activities they envisioned as future physicians, and experiences and considerations shaping their perspectives. RESULTS: Most students anticipated enacting one or more systems-related roles as a future physician, categorized as "bottom-up" efforts enacted at a patient or community level (humanist, connector, steward) or "top-down" efforts enacted at a system or policy level (system improver, system scholar, policy advocate). Corresponding activities included attending to social determinants of health or serving medically underserved populations, connecting patients with team members to address systems-related barriers, stewarding health care resources, conducting quality improvement projects, researching/teaching systems topics, and advocating for policy change. Students attributed systems-related aspirations to experiences beyond HSS curricula (e.g., low-income background; work or volunteer experience; undergraduate studies; exposure to systems challenges affecting patients; supportive classmates, faculty, and institutional culture). Students also described future-oriented considerations promoting or undermining identification with systems-related roles (responsibility, affinity, ability, efficacy, priority, reality, consequences). CONCLUSIONS: This study illuminates systems-related roles medical students at 4 schools with HSS curricula envisioned as part of their future physician identity and highlights past/present experiences and future-oriented considerations shaping identification with such roles. These findings inform practical strategies to support professional identity formation inclusive of systems engagement.

Impact of COVID-19 on Hematology-Oncology Fellowship Programs: A Quantitative and Qualitative Survey Assessment of Fellowship Program Directors.

PURPOSE: The COVID-19 pandemic led to unprecedented challenges in medical training, and we sought to assess the specific impact of COVID-19 on hematology-oncology (HO) fellowship programs. METHODS: We conducted a cross-sectional anonymous online survey of 103 HO program directors (PDs) in conjunction with the American Society of Hematology (ASH) and ASCO. We sought to assess the specific impact of COVID-19 on HO fellowship programs' clinical, educational, and research activities, evaluate perceptions regarding PD and trainee emotional and mental health, and identify ways to support programs. Data were analyzed using descriptive statistics, parametric and nonparametric tests, and multivariable logistic regression models. Responses to open-ended questions were analyzed with thematic analysis. RESULTS: Significant changes to fellowship activities included transitioning fellow training from outpatient clinics to telehealth (77.7%), shifting to virtual education (94.2%), and moving to remote research work (63.1%). A minority (21.4%) of PDs reported that their fellows were redeployed to cover non-HO services. Most PDs (54.4%) believed COVID-19 had a slight negative impact on fellowship training. PD self-reported burnout increased significantly from 15.5% prepandemic to 44.7% during the pandemic, and most PDs witnessed minor signs of fellow burnout (52.4%). Common PD concerns included inadequate supervision for telehealth activities, reduced opportunities for fellow advancement and promotion, lack of professional development activities, limited research operations and funding, program financial constraints, and virtual recruitment. CONCLUSION: We encourage institutions and national societies to allocate resources and develop programs that can support fellowships and mitigate the potential negative effects of COVID-19 on trainee and PD career development.

Impact of COVID-19 on Hematology-Oncology Trainees: A Quantitative and Qualitative Assessment.

PURPOSE: Graduate medical and research training has drastically changed during the COVID-19 pandemic, with widespread implementation of virtual learning, redeployment from core rotations to the care of patients with COVID-19, and significant emotional and physical stressors. The specific experience of hematology-oncology (HO) fellows during the COVID-19 pandemic is not known. METHODS: We conducted a mixed-methods study using a survey of Likert-style and open-ended questions to assess the training experience and well-being of HO fellows, including both clinical and postdoctoral trainee members of the American Society of Hematology and ASCO. RESULTS: A total of 2,306 surveys were distributed by e-mail; 548 (23.8%) fellows completed the survey. Nearly 40% of fellows felt that they had not received adequate mental health support during the pandemic, and 22% reported new symptoms of burnout. Pre-existing burnout before the pandemic, COVID-19-related clinical work, and working in a primary research or nonclinical setting were associated with increased burnout on multivariable logistic regression. Qualitative thematic analysis of open-ended responses revealed significant concerns about employment after training completion, perceived variable quality of virtual education and board preparation, loss of clinical opportunities to prepare for independent clinical practice, inadequate grant funding opportunities in part because of shifting research priorities, variable productivity, and mental health or stress during the pandemic. CONCLUSION: HO fellows have been profoundly affected by the pandemic, and our data illustrate multiple avenues for fellowship programs and national organizations to support both clinical and postdoctoral trainees.

Conversations on Cancer Chemotherapy Cessation in Patients With Advanced Cancer: Qualitative Findings From a Multi-Institutional Study.

PURPOSE: As many as 20% of oncology patients receive chemotherapy in the last 14 days of their lives. This study characterized conversations between patients and cancer clinicians on chemotherapy cessation in the setting of advanced cancer. METHODS: This 3-site study captured real-time, audio-recorded interviews between oncology clinicians and patients with cancer during actual clinic visits. Audio-recordings were reviewed for discussion of chemotherapy cessation and were analyzed qualitatively. RESULTS: Among 525 recordings, 14 focused on stopping chemotherapy; 14 patients participated with 11 different clinicians. Two types of nonmutually exclusive conversation elements emerged: direct and specific elements that described an absence of effective therapeutic options and indirect elements. An example of a direct element is as follows: "…You know this is…always really tough…But I-I think that you may need more help…I think we're close to stopping chemotherapy…And hospice is really helpful to have in place…" In contrast, the second conversation element was more convoluted: "…transplant is not an option and surgery is not an option…The options…are taking a pill…It doesn't shrink the tumor…It may help you live a little longer. But I'm worried if [you] had the pill, it's still a therapy and it still has side effects. I [am] worried if I give it to you now, that you're so weak, it will make you worse." No relationship seemed apparent between conversation elements and chemotherapy cessation. CONCLUSIONS: Conversations on chemotherapy cessation are complex; multiple factors appear to drive the decision to stop.