Engaging the community on colorectal cancer screening: Additional factors identified by African Americans as potential barriers during focus groups.

OBJECTIVE: African-Americans have the highest rate of colorectal cancer deaths. Adherence to colorectal cancer screening guidelines can improve outcomes. The objective of this study was to evaluate physician trust and barriers to screening utilizing a unique bi-directional learning focus group involving African-American adults and health care learners. METHODS: A focus group of African-American adults from a community church and university health care learners was conducted to identify colon cancer screening barriers. Health care learners were medical students, resident physicians and gastroenterology fellows. Pre-focus group surveys, including the Wake Forest Physician Trust Scale (WFPTS) and a colon cancer screening knowledge survey, were administered. Audio recording of the focus group was transcribed with subsequent thematic analysis. A post-focus group survey evaluated the colorectal cancer screening barriers identified during the focus group. Analysis of pre- and post- focus group surveys was performed using Fisher Exact test with significance set at p<0.05. RESULTS: The focus group consisted of 18 members (7 African-American community members, 11 non-African American health care learners). WFPTS revealed that 83% (86% community members, 82% health care learners; p = 1.0) strongly agree / agree that their physician would advocate for their health. 77% (86% community members, 73% health care learners; p = 1.0) strongly agree / agree that they trusted their physician. 100% recognized that colon cancer screening is recommended. The focus group identified lack of awareness (81%), colonoscopy preparation (81%), trust in physician (60%), lack of insurance coverage (56%), transportation (56%), colonoscopy wait time (50%), insufficient physician discussion (50%) and fear of procedure or cancer (35%) as screening barriers. Post-focus group surveys revealed that community members more frequently identified racial disparity in health care (p = 0.0474), physician respect toward patients (p = 0.0128) and insufficient physician discussion (p = 0.0006) as screening barriers. CONCLUSIONS: Focus group discussion identified multiple barriers for colorectal cancer screening. Notably, differences in the perceptions of African-American community members and non-African-American health care learners about racial disparity in health care, physician respect toward patients and insufficient physician discussion were revealed. The integration of bi-directional focus group learning can be considered as a potential strategy to assist in the development of focused screening interventions.

Whiteness theory and the (in)visible hierarchy in medical education.

CONTEXT: The theory of whiteness in medical education has largely been ignored, yet its power continues to influence learners within our medical curricula and our patients and trainees within our health systems. Its influence is even more powerful given the fact that society maintains a 'possessive investment' in its presence. In combination, these (in)visible forces create environments that favour White individuals at the exclusion of all others, and as health professions educators and researchers, we have the responsibility to uncover how and why these influences continue to pervade medical education. PROPOSAL: To better understand how whiteness and the possessive investment in its presence create (in)visible hierarchies, we define and explore the origin of whiteness by examining whiteness studies and how we have come to have a possessive investment in its presence. Next, we provide ways in which whiteness can be studied in medical education so that it can be disruptive. CONCLUSION: We encourage health profession educators and researchers to collectively 'make strange' our current hierarchical system by not just recognising the privileges afforded to those who are White but also recognising how these privileges are invested in and maintained. As a community, we must develop and resist established power structures to transform the current hierarchy into a more equitable system that supports everyone, not just those who are White.

Telehealth Policy, Practice, and Education: a Position Statement of the Society of General Internal Medicine.

Telehealth services, specifically telemedicine audio-video and audio-only patient encounters, expanded dramatically during the COVID-19 pandemic through temporary waivers and flexibilities tied to the public health emergency. Early studies demonstrate significant potential to advance the quintuple aim (patient experience, health outcomes, cost, clinician well-being, and equity). Supported well, telemedicine can particularly improve patient satisfaction, health outcomes, and equity. Implemented poorly, telemedicine can facilitate unsafe care, worsen disparities, and waste resources. Without further action from lawmakers and agencies, payment will end for many telemedicine services currently used by millions of Americans at the end of 2024. Policymakers, health systems, clinicians, and educators must decide how to support, implement, and sustain telemedicine, and long-term studies and clinical practice guidelines are emerging to provide direction. In this position statement, we use clinical vignettes to review relevant literature and highlight where key actions are needed. These include areas where telemedicine must be expanded (e.g., to support chronic disease management) and where guidelines are needed (e.g., to prevent inequitable offering of telemedicine services and prevent unsafe or low-value care). We provide policy, clinical practice, and education recommendations for telemedicine on behalf of the Society of General Internal Medicine. Policy recommendations include ending geographic and site restrictions, expanding the definition of telemedicine to include audio-only services, establishing appropriate telemedicine service codes, and expanding broadband access to all Americans. Clinical practice recommendations include ensuring appropriate telemedicine use (for limited acute care situations or in conjunction with in-person services to extend longitudinal care relationships), that the choice of modality be done through patient-clinician shared decision-making, and that health systems design telemedicine services through community partnerships to ensure equitable implementation. Education recommendations include developing telemedicine-specific educational strategies for trainees that align with accreditation body competencies and providing educators with protected time and faculty development resources.

Strategies for Advancing Equity in Frontline Clinical Assessment.

Educational equity in medicine cannot be achieved without addressing assessment bias. Assessment bias in health professions education is prevalent and has extensive implications for learners and, ultimately, the health care system. Medical schools and educators desire to minimize assessment bias, but there is no current consensus on effective approaches. Frontline teaching faculty have the opportunity to mitigate bias in clinical assessment in real time. Based on their experiences as educators, the authors created a case study about a student to illustrate ways bias affects learner assessment. In this paper, the authors use their case study to provide faculty with evidence-based approaches to mitigate bias and promote equity in clinical assessment. They focus on 3 components of equity in assessment: contextual equity, intrinsic equity, and instrumental equity. To address contextual equity, or the environment in which learners are assessed, the authors recommend building a learning environment that promotes equity and psychological safety, understanding the learners' contexts, and undertaking implicit bias training. Intrinsic equity, centered on the tools and practices used during assessment, can be promoted by using competency-based, structured assessment methods and employing frequent, direct observation to assess multiple domains. Instrumental equity, focused on communication and how assessments are used, includes specific, actionable feedback to support growth and use of competency-based narrative descriptors in assessments. Using these strategies, frontline clinical faculty members can actively promote equity in assessment and support the growth of a diverse health care workforce.

Reviewing Internal Medicine Clerkship Grading Through a Proequity Lens: Results of a National Survey.

PURPOSE: Equity in assessment and grading has become imperative across medical education. Although strategies to promote equity exist, there may be variable penetrance across institutions. The objectives of this study were to identify strategies internal medicine (IM) clerkship directors (CDs) use to reduce inequities in assessment and grading and explore IM CDs' perceptions of factors that impede or facilitate the implementation of these strategies. METHOD: From October to December 2021, the Clerkship Directors in Internal Medicine of the Alliance for Academic Internal Medicine conducted its annual survey of IM core CDs at 137 U.S. and U.S. territory-based medical schools. This study is based on 23 questions from the survey about equity in IM clerkship assessment and grading. RESULTS: The survey response rate was 73.0% (100 of 137 medical school CDs). Use of recommended evidence-based strategies to promote equity in clerkship assessment and grading varied among IM clerkships. Only 30 respondents (30.0%) reported that their clerkships had incorporated faculty development on implicit bias for clinical supervisors of students; 31 (31.0%) provided education to faculty on how to write narrative assessments that minimize bias. Forty respondents (40.0%) provided guidance to clerkship graders on how to minimize bias when writing final IM clerkship summaries, and 41 (41.0%) used grading committees to determine IM clerkship grades. Twenty-three CDs (23.0%) received formal education by their institution on how to generate clerkship grades and summaries in a way that minimized bias. CONCLUSIONS: This national survey found variability among medical schools in the application of evidence-based strategies to promote equity in assessment and grading within their IM clerkships. Opportunities exist to adopt and optimize proequity grading strategies, including development of programs that address bias in clerkship assessment and grading, reevaluation of the weight of standardized knowledge exam scores on grades, and implementation of grading committees.

Implicit bias instruction across disciplines related to the social determinants of health: a scoping review.

One criticism of published curricula addressing implicit bias is that few achieve skill development in implicit bias recognition and management (IBRM). To inform the development of skills-based curricula addressing IBRM, we conducted a scoping review of the literature inquiring, "What interventions exist focused on IBRM in professions related to social determinants of health: education, law, social work, and the health professions inclusive of nursing, allied health professions, and medicine?"Authors searched eight databases for articles published from 2000 to 2020. Included studies: (1) described interventions related to implicit bias; and (2) addressed knowledge, attitude and/or skills as outcomes. Excluded were interventions solely focused on reducing/neutralizing implicit bias. Article review for inclusion and data charting occurred independently and in duplicate. Investigators compared characteristics across studies; data charting focused on educational and assessment strategies. Fifty-one full-text articles for data charting and synthesis, with more than 6568 learners, were selected. Educational strategies included provocative/engagement triggers, the Implicit Association Test, reflection and discussion, and various active learning strategies. Most assessments were self-report, with fewer objective measures. Eighteen funded studies utilized federal, foundation, institutional, and private sources. This review adds to the literature by providing tangible examples of curricula to complement existing frameworks, and identifying opportunities for further research in innovative skills-based instruction, learner assessment, and development and validation of outcome metrics. Continued research addressing IBRM would enable learners to develop and practice skills to recognize and manage their implicit biases during clinical encounters, thereby advancing the goal of improved, equitable patient outcomes.

Innovation and Missed Opportunities in Internal Medicine Undergraduate Education During COVID-19: Results from a National Survey.

BACKGROUND: COVID-19 disrupted undergraduate clinical education when medical schools removed students from clinical rotations following AAMC recommendations. Clerkship directors (CDs) had to adapt rapidly and modify clerkship curricula. However, the scope and effects of these modifications are unknown. OBJECTIVE: To examine the effects of the initial phase of COVID-19 on the internal medicine (IM) undergraduate clinical education. DESIGN: A nationally representative web survey. PARTICIPANTS: IM CDs from 137 LCME-accredited US medical schools in 2020. MAIN MEASURES: Items (80) assessed clerkship structure and curriculum, assessment in clerkships, post-clerkship IM clinical experiences, and CD roles and support. The framework of Understanding Crisis Response (Royal Society for Encouragement of Arts, Manufactures, and Commerce) was used to determine whether curricular modifications were "amplified," "restarted," "let go," or "ended." KEY RESULTS: Response rate was 74%. In response to COVID-19, 32% (32/101) of clerkships suspended all clinical activities and 66% (67/101) only in-person. Prior to clinical disruption, students spent a median of 8.0 weeks (IQR: 2) on inpatient and 2.0 weeks (IQR: 4) on ambulatory rotations; during clinical re-entry, students were spending 5.0 (IQR: 3) and 1.0 (IQR: 2) weeks, respectively. Bedside teaching and physical exam instruction were "let go" during the early phase. Students were removed from direct patient care for a median of 85.5 days. The sub-internship curriculum remained largely unaffected. Before the pandemic, 11% of schools were using a pass/fail grading system; at clinical re-entry 47% and during the survey period 23% were using it. Due to the pandemic, 78.2% of CDs assumed new roles or had expanded responsibilities; 51% reported decreased scholarly productivity. CONCLUSIONS: Curricular adaptations occurred in IM clerkships across US medical schools as a result of COVID-19. More research is needed to explore the long-term implications of these changes on medical student education and clinical learning environments.

What Women Need: a Study of Institutional Factors and Women Faculty's Intent to Remain in Academic Medicine.

BACKGROUND: A longstanding gender gap exists in the retention of women in academic medicine. Several strategies have been suggested to promote the retention of women, but there are limited data on impacts of interventions. OBJECTIVE: To identify what institutional factors, if any, impact women faculty's intent to remain in academic medicine, either at their institutions or elsewhere. DESIGN: A survey was designed to evaluate institutional retention-linked factors, programs and interventions, their impact, and women's intent to remain at their institutions and within academic medicine. Survey data were analyzed using non-parametric statistics and regression analyses. PARTICIPANTS: Women with faculty appointments within departments of medicine recruited from national organizations and specific social media groups. MAIN MEASURES: Institutional factors that may be associated with women's decision to remain at their current institutions or within academic medicine. KEY RESULTS: Of 410 surveys of women at institutions across the USA, fair and transparent family leave policies and opportunities for work-life integration showed strong associations with intent to remain at one's institution (leave policies: OR 2.22, 95% CI 1.20-4.18, p = 0.01; work-life: OR 4.82, 95% CI 2.50-9.64, p < 0.001) and within academic medicine (leave policies: OR 2.31, 95% CI 1.09-5.03, p = 0.03; work-life: OR 4.66, 95% CI 2.04-11.36, p < 0.001). Other institutional factors associated with intent to remain in academics include peer mentorship (OR 3.16, 95% CI 1.56-6.57, p < 0.01) and women role models (OR 2.21, 95% CI 1.04-4.68, p = 0.04). Institutions helping employees recognize bias, fair compensation and provision of resources, satisfaction with mentorship, peer mentorship, and women role models within the institutions were associated with intent to remain at an institution. CONCLUSIONS: Our findings suggest that institutional factors such as support for work-life integration, fair and transparent policies, and meaningful mentorship opportunities appear impactful in the retention of women in academic medicine.

A Framework for Inclusive Graduate Medical Education Recruitment Strategies: Meeting the ACGME Standard for a Diverse and Inclusive Workforce.

To help address health care disparities and promote higher-quality, culturally sensitive care in the United States, the Accreditation Council for Graduate Medical Education and other governing bodies propose cultivating a more diverse physician workforce. In addition, improved training and patient outcomes have been demonstrated for diverse care teams. However, prioritizing graduate medical education (GME) diversity and inclusion efforts can be challenging and unidimensional diversity initiatives typically result in failure.Little literature exists regarding actionable steps to promote diversity in GME. Building on existing literature and the authors' experiences at different institutions, the authors propose a 5-point inclusive recruitment framework for diversifying GME training programs. This article details each of the 5 steps of the framework, which begins with strong institutional support by setting diversity as a priority. Forming a cycle, the other 4 steps are seeking out candidates, implementing inclusive recruitment practices, investing in trainee success, and building the pipeline. Practical strategies for each step and recommendations for measurable outcomes for continued support for this work are provided. The proposed framework may better equip colleagues and leaders in academic medicine to prioritize and effectively promote diversity and inclusion in GME at their respective institutions.

The Crossroads of Health Policy and Academic Medicine: An Early Introduction to Health Policy Skills to Facilitate Change.

Introduction: Despite significant health care reform in the past 10 years, health disparities persist in marginalized and low-resource communities. Although there are a lot of reasons for health disparities, many of which are not related to health care, changes in health policy can lead to improved health equity. Redefining health policy as an important aspect of medical education could popularize the teaching and application of health policy competencies within academic health centers. Methods: The Kern model was applied to develop a workshop to educate medical students on basic health policy concepts and opportunities for them to apply a health policy framework to facilitate organizational change. Specifically, the workshop helped trainees to define common concepts in health policy, to understand a framework for developing policy initiatives, and to identify areas of overlap between health policy and academic medicine. Instructional methods included a PowerPoint presentation, vignette-based small-group discussion, and career reflection. Results: The workshop was implemented at three national conferences with a total of 144 participants. Comparing pre- and postworkshop survey responses, participants felt health policy work was compatible with an academic medicine career. Over 95% of respondents agreed or strongly agreed that each objective had been met. Discussion: By viewing health policy through the lens of academia, trainees were able to develop a new appreciation for how health policy activities can contribute to peer-reviewed publications, teaching, and leadership opportunities. Participants were better situated to integrate health policy skills in their academic or nonacademic careers.

Ocular findings in human immunodeficiency virus patients in Washington, DC.

The purpose of the study was to determine the prevalence of ocular diseases in human immunodeficiency virus (HIV) patients in Washington, DC in the era of highly active antiretroviral therapy (HAART). This was a cross-sectional study of patients with HIV who were seen by the ophthalmology consultation service between September 2003 and May 2011 at a single academic institution in Washington, DC. Medical history and ophthalmic findings were reviewed. Patients with complete laboratory data dated within 3 months of their presenting eye examination were included. Descriptive statistics were performed. The records of 151 patients were included in the final analysis. All patients had complete laboratory data dated within 3 months of their presenting eye examination. Sixty-eight (45 %) patients and fifty-eight (50 %) of those with a diagnosis of acquired immune deficiency syndrome (AIDS) were diagnosed with an HIV-related ophthalmic disease. The leading anterior segment disease was herpes zoster ophthalmicus and the leading posterior segment disease was HIV retinopathy. Of the 151 included patients, 78 (52 %) were receiving HAART at the time of the examination. Thirty-one (42 %) of those not receiving HAART were diagnosed with an HIV-related ophthalmic disease. In this study, we find that the overall prevalence of ocular disease has decreased since the introduction of HAART. However, HIV patients continue to be predisposed to developing ophthalmic disease at higher rates than the general population. Visual dysfunction remains an important source of morbidity in HIV patients, particularly in those with AIDS. Measures for improvement include increased communication between infectious disease specialists and ophthalmologists to ensure adherence to HAART and routine eye examinations.

Race disparities in U.S. nephrology fellowship training.

BACKGROUND AND OBJECTIVES: Renal disease disproportionately affects African-American patients. Trust has been implicated as an important factor in patient outcomes. Higher levels of trust and better interpersonal care have been reported when race of patient and physician are concordant. The purpose of this analysis was to examine trends in the racial background of U.S. medical school graduates, internal medicine residents, nephrology fellows, and patients with ESRD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Data for medical school graduates were obtained from the Association of American Medical Colleges and data for internal medicine and nephrology trainees from GME Track. ESRD data were obtained from U.S. Renal Data System (USRDS) annual reports. RESULTS: A significant disparity continues to exist between the proportional race makeup of African-American nephrology fellows (3.8%) and ESRD patients (32%). The low numbers of African-American nephrology fellows, and consequently new nephrologists, in light of the increase in ESRD patients has important implications for patient-centered nephrology care. CONCLUSIONS: Efforts are needed to increase minority recruitment into nephrology training programs, to more closely balance the racial background of trainees and patients in hopes of fostering improved trust between ESRD caregivers and patients, increasing access to care, alleviating ESRD health care disparities, and improving patient care.