Business of Medicine: Developing Leaders in Academic Medicine and Learning Health Systems.

Purpose: To develop healthcare professionals as clinical leaders in academic medicine and learning health system; and uncover organizational barriers, as well as pathways and practices to facilitate career growth and professional fulfillment. Methods: The Department of Medicine strategic plan efforts prompted the development of a business of medicine program informed by a needs assessment and realignment between academic departments and the healthcare system. The business of medicine leadership program launched in 2017. This descriptive case study presents its 5th year evaluation. Competencies were included from the Physician MBA program and from specific departmental needs and goals. Results: The program hosted a total of 102 clinical faculty. We had a 37% response rate of those retained at Indiana University School of Medicine. Overall, responses conveyed a positive experience in the course. Over 80% of participants felt that they gained skills in professional reflection, professional socialization, goal orientation, critical thinking, and commitment to profession. Financial literacy was overwhelmingly the skill that was reported to be the most valuable. Finance and accounting were mentioned as the most difficult concepts to understand. Familiar concepts included communication, LEAN, and wellness related topics. One hundred percent of participants said they are utilizing the skills gained in this program in their current role and that they would recommend the course to others. Conclusion: Business of medicine courses are more common now with programs describing elements informed by health system operations. However, few programs incorporate aspects of wellness, equity, diversity, inclusion, and health equity. Our program makes the case for multiple ways to develop inclusive leaders through a focused five-month program. It also recognizes that to really impact the learning health system, health professionals need leadership development and leaders suited to work alongside career administrators, all aiming towards a common goal of equitable patient-centered care.

A Comparative Analysis of the Demographics and Zip Codes of Patients Seen at the Indiana University Student Outreach Clinic.

Within a small geographic area, Marion County contains a stark spectrum of health outcomes and socioeconomic statuses. The Indiana University Student Outreach Clinic (IUSOC) serves as a safety net provider, offering free health and social services in the Near Eastside neighborhood of Indianapolis. The aim of this study was to characterize the demographics and geographic distribution of the IUSOC's patient population. From January to September 2023, 612 patients visited the IUSOC, and 460 self-identified as Marion County residents. 63.9% of patients were between 45 and 64 years old. 66.8% were Non-Hispanic (NH) Black, and 23.3% were Hispanic. 18.9% spoke Spanish and had limited English proficiency. Based on the Distressed Communities Index (DCI), 58.7% lived in "Distressed" zip codes, indicating economic vulnerability and disparities. The zip code with the greatest number of IUSOC patients had the highest rate of uninsured adults in Marion County. IUSOC patients are primarily middle-aged minorities who live in zip codes with low socioeconomic rankings by DCI. This information can be used to improve community resource referral pathways in the clinic.

"I Am Interested!": The Voices of the Community and Their Participation in Health Advisory Boards.

Introduction: Researchers can often be challenged by meaningful efforts to involve the public and communities in research. Community and health advisory boards (HABs) offer an opportunity to create a fully intentional and honest relationship between researchers and the community. Objective: Most recently, the All Indiana (IN) for Health HAB had four openings and a call was published to our community of over 13,800 individuals in the All IN for Health newsletter. Four hundred eighty-eight individuals submitted applications to become part of the board. In what follows, we share the lessons in motivations and interests of individuals who responded. Methods: The application process included the following questions: What lived experiences and/or personal interests have motivated you to be involved in All IN for Health? Please explain why you are interested in being an All IN for HAB member. Our analysis approach was qualitative and centered on narrative research. Results: We organize the findings in two categories: Motivation and Interests. Individuals were motivated to participate based on family or friend diagnosis, personal diagnosis, roles as caregivers, desire to impact change and advocacy, role as health professional, and previous participation in research. Interests followed similar themes beginning with crediting their interest to a diagnosis. In addition, we categorized desire to share their experience, personal positionality, and previous research experience, and contributing to the education of student/trainee. Conclusion: By understanding motivations, we understand needs. This information can be used for other advisory boards, as well as recruitment into research participation and health care advocacy.

"Value my culture, value me": a case for culturally relevant mentoring in medical education and academic medicine.

INTRODUCTION: Mentoring programs are one mechanism used to increase diversity and participation of historically underrepresented groups in academic medicine. However, more knowledge is needed about the mentoring experiences and how culturally relevant concepts and perspectives may influence diverse students, trainees, and faculty success. This case study utilized the Culturally Engaging Campus Environments (CECE) model which examines the experiences of students in higher education. We used this model to examine the mentoring experiences of Black and Latine faculty and offer practical implications for the medical education continuum. METHODS: Our research approach is best understood through qualitative inquiry stemming from a single-case study which allowed for in-depth understanding of the contexts informing the phenomenon. Phenomenology is well positioned to contribute to understanding science and health professions. Selection criteria included individuals who self-identified as Black or Latine; inclusive of all faculty ranks and tracks. This analysis focuses on 8 semi-structured interviews, averaging 3 h in length. RESULTS: Findings centered on the area of cultural relevance, and participant narratives revealed the connection of mentoring with cultural familiarity, culturally relevant knowledge, cultural service and engagement, and cultural validation. CONCLUSION: The use of cultural relevance indicators can inform the creation and evolution of mentoring programs towards holistic support of historically underrepresented trainees and faculty. Implications also focus on the development of mentors and championing the incorporation of cultural humility in the mentoring process. The implications in praxis offers the possibility for a new framework for culturally relevant mentoring (CRM). Through this framework we aim to enhance and facilitate inclusive learning environments and career development.

A Framework for Developing Antiracist Medical Educators and Practitioner-Scholars.

With an increasing awareness of the disparate impact of COVID-19 on historically marginalized populations and acts of violence on Black communities in 2020, academic health centers across the United States have been prioritizing antiracism strategies. Often, medical students and residents have been educated in the concepts of equity and antiracism and are ready to tackle these issues in practice. However, faculty are not prepared to respond to or integrate antiracism topics into the curriculum. Leaders in faculty affairs, education, diversity, and other departments are seeking tools, frameworks, expertise, and programs that are best suited to meet this imminent faculty development need. In response to these demands for guidance, the authors came together to explore best practices, common competencies, and frameworks related to antiracism education. The focus of their work was preparing faculty to foster antiracist learning environments at traditionally predominantly White medical schools. In this Scholarly Perspective, the authors describe their collaborative work to define racism and antiracism education; propose a framework for antiracism education for faculty development; and outline key elements to successfully build faculty capacity in providing antiracism education. The proposed framework highlights the interplay between individual learning and growth and the systemic and institutional changes needed to advance antiracist policies and practices. The key elements of the framework include building foundational awareness, expanding foundational knowledge on antiracism, embedding antiracism education into practice, and dismantling oppressive structures and measuring progress. The authors list considerations for program planning and provide examples of current work from their institutions. The proposed strategies aim to support all faculty and enable them to learn, work, and educate others in an antiracist learning environment.

Reclaiming the mission of academic medicine: An examination of institutional responses to (anti)racism.

PURPOSE: The utility of institutional statements is said to provide clarity and reinforcement of an institution's goal. Unfortunately, it can also be argued that these statements are in clear misalignment between the words described and the environments that faculty, students, trainees, and staff of color face. The purpose of this study was to analyze academic medicine institutional statements that responded to 2020 racial tensions following the murders of George Floyd, among others, and the subsequent nationwide protests against police brutality. METHODS: We conducted a manifest content analysis of institutional statements generated by academic medical centers after George Floyd's murder. We used manifest content analysis to gain insights into how institutional statements connect structural racism to the mission of academic medicine. We collected and examined institutional statements from 26 academic medicine centers. Selection parameters included statements that were publicly available and published by the institutions during a 2-week period. We conducted a four-stage analysis: decontextualization, recontextualization, categorization, and compilation. To better understand the collection of statements, we plotted these institutional statements according to the most salient discussed themes. RESULTS: Overall, institutional statements discussed racism through three subthemes: identifying the racial implications of health disparities, issuing a call to action to address racism, and decentering race. Absent language is also noted. Second, institutional statements evoked institutional values by expressing an explicit connection with the academic medicine mission, naming the value of social justice, and emphasizing the concept of community. Finally, institutional statements largely discussed public health in connection with racism or with institutional values. CONCLUSION: Our study determines a much-needed reconnection to the mission of academic medicine. Reclaiming the social mission will be a major step toward recentering the foundation of institutional actions. This call is what ultimately will improve the health and well-being of marginalized populations.

Allies Welcomed to Advance Racial Equity (AWARE) Faculty Seminar Series: Program Design and Implementation.

INTRODUCTION: In the wake of George Floyd's murder, White faculty in our department began to express the desire to gain a greater understanding of structural racism and racial inequity. To facilitate this learning, support allyship, and mitigate the emotional labor and taxation that frequently falls on faculty of color to respond to these appeals, we developed AWARE (Allies Welcomed to Advance Racial Equity), a faculty seminar series primarily designed for and led by a majority White faculty to tackle the topics of structural racism, Whiteness, and Anti-racist action. METHODS: We developed a 6-session seminar series, identifying 5 White faculty as lecturers and a cadre of Black and White volunteer facilitators, to lead 60-minute sessions comprised of lecture, facilitated small group reflection, and large group sharing, that reviewed key topics/texts on structural racism, Whiteness, and Anti-racism. RESULTS: Attendance ranged from 26 to 37 participants at each session. About 80% of faculty participated in at least 1 session of the program. The majority of participants (85%) felt "more empowered to influence their current environment to be more inclusive of others" and were "better equipped to advocate for themselves or others." Most (81%) felt "more connected to their colleagues following completion of the program." Ultimately, faculty thought highly of the program upon completion with 26/27 (96%) stating they would recommend the program to a colleague. DISCUSSION: We offer a reproducible model to improve departmental climate by engaging in the shared labor of educating our colleagues and communities about structural racism, Whiteness, and Anti-racism to create a point of entry into reflection, dialogue, and deliberate actions for change.

A Survey of Internal Medicine Residents: Their Learning Environments, Bias and Discrimination Experiences, and Their Support Structures.

PURPOSE: While there is an emerging body of literature that demonstrates how racism and bias negatively impact the experiences of physicians and trainees from underrepresented groups in medicine in the US, little is known about the experiences of internal medicine trainees and their learning environments. The purpose of this study was to examine these learning environments and explore trainees' perceptions of race/ethnicity-related topics. METHODS: A 35-item confidential electronic survey was disseminated to trainees from 11 internal medicine training programs in the US. A total of 142 trainees participated. Purposive sampling ensured alignment with 2018 IM trainee demographics by sex, race and ethnicity. Analyses were performed including chi-square, Fisher's exact tests, and logistic regression. RESULTS: Key findings reveal 63% of respondents perceived disparities in the care provided to diverse patients. Two in three respondents were confident that their institution would respond to discrimination, but only 1/3 of respondents perceived appropriate reporting mechanisms. Black/African American trainees reported needing to minimize aspects of their race and were less likely to perceive their institutions as being supportive to people of color. CONCLUSION: Access to timely information about trainees' experiences with discrimination and bias in graduate medical education is imperative to disrupt systemic racism and health inequities. Findings suggest a perceived difference in health care provided to minoritized groups, a gap in formal mechanisms for reporting racism and discrimination experienced by trainees, and environments that challenge a sense of belonging. Findings add to current literature exposing the experience of underrepresented trainees in the US.

Perspectives of Internal Medicine Residency Program Directors on the Accreditation Council for Graduate Medical Education (ACGME) Diversity Standards.

BACKGROUND: To increase diversity and inclusion in graduate medical education, the Accreditation Council for Graduate Medical Education (ACGME) issued a revision to their Common Program Requirements during the 2019-2020 academic year mandating that all residency programs must have policies and practices to achieve appropriate diversity among trainees and faculty. OBJECTIVE: To explore the perspectives of internal medicine program directors (PDs) and associate program directors (APDs) on the ACGME diversity standard. DESIGN: Qualitative study of internal medicine residency program leadership from academic and community programs across the USA. PARTICIPANTS: Current PDs (n = 12) and APDs (n = 8) of accredited US internal medicine residency programs. APPROACH: We conducted semi-structured, in-depth qualitative interviews. Data was analyzed using the constant comparative method to extract recurrent themes. KEY RESULTS: Three main themes, described by participants, were identified: (1) internal medicine PDs and APDs had limited knowledge of the new Common Program Requirement relating to diversity; (2) program leaders expressed concern that the diversity standard reaches beyond the PDs' scope of influence and lack of institutional commitment to the successful implementation of diversity standards; (3) participants described narrow view of diversity and inclusion efforts focusing on recruitment strategies during the interview season. CONCLUSIONS: Our findings of lack of familiarity with the new diversity standards, and limited institutional investment in diversity and inclusion efforts raise a concern about successful implementation across GME programs. Nevertheless, our finding suggests that structured implementation in the form of education, guideposts, and financial allocation can alleviate some of the concerns of program leadership in meeting the new ACGME diversity standard in a meaningful way.

Equity + Wellness: A Call for More Inclusive Physician Wellness Efforts.

This article was migrated. The article was marked as recommended. The challenges, importance, and state of physician wellness and burnout have been well documented throughout the literature.Research continues to prove the value of tools and interventions while institutions appear to be listening and adapting important practices. However, although the wellness literature encourages a review of organizational challenges, local needs, and individual solutions, organizations may fail to align these efforts along with equity, diversity, inclusion, and belonging (EDIB). A pandemic and recent events in our society heightened awareness about health inequities, structural violence and racism, and demand that we look within our institutions and health systems. It also demands that we speak of wellness and equity together. We cannot engage in conversations about wellness without asking about equity...because equity and inclusion lead to wellness. We simply cannot expect our healthcare workforce, faculty, and physicians of color to be "well" if they are experiencing exclusion and inequality. In this article, we present the concepts of inclusive excellence and leading with wellness in mind while calling for more inclusive physician wellness efforts.

The Power of Social Media in the Promotion and Tenure of Clinician Educators.

Introduction: Social networking sites (or social media [SM]) are powerful web-based technologies used to bolster communication. SM have changed not only how information is communicated but also the dissemination and reception of a variety of topics. This workshop highlighted the benefits of SM for clinician educators. The use of SM was explored as a way to maximize opportunities for clinician educators to network, establish themselves as experts, and build a national reputation leading to promotion. The target audience for this submission is faculty developers who would like to implement a similar workshop, and clinician-educator faculty motivated by promotion and advancement. Methods: The training workshop involved an interactive session, with approximately 20 minutes of content, 20 minutes of individual and small-group activities, and 15 minutes of large-group discussion. The effectiveness of the workshop was evaluated by asking participants to complete a postsession survey of SM knowledge, attitude, and action. Results: Survey responses (n = 14) demonstrated an increase in participants' knowledge of SM platforms, ability to identify benefits of SM, skills to disseminate their work, and eagerness to build their personal brand. Discussion: This workshop provided a foundation for clinician educators to think strategically about SM use in ways that highlight access to a broader network of colleagues and potential collaborators and that influence the impact of publications and work.

"I Didn't Know What to Say": Responding to Racism, Discrimination, and Microaggressions With the OWTFD Approach.

Introduction: Academic medicine has long faced the challenge of addressing health inequities, reflecting on how these contribute to structural racism, and perpetuating negative social determinants of health. Most recently, we have constructed opportunities for dialogues about racism, discrimination, and microaggressions (RDM). As such, we created a professional development program that encouraged participants to (1) openly discuss RDM and the impact they have in academia, (2) learn about tools to address and respond to RDM, and (3) move towards the creation of inclusive environments. The target audience included institutional leaders, faculty, trainees, professional staff, and health care teams. Methods: We sought to meet workshop goals by integrating anti-racist dramaturgical teaching, introducing concepts knowledge, and practicing communication tools. To assess learning and evaluate our workshops, participants completed a pre- and postsurvey. Results: Results showed that 30 participants were more comfortable with discussing issues related to race/ethnicity, gender identity/expression, sexual orientation, and spirituality after participating in the workshops. Prior to the two workshops, the percentage of learners who felt confident initiating conversations ranged from 29% to 54%. After the workshops, the percentage of learners who felt confident ranged from 58% to 92%. The greatest increase, 100%, was observed in the levels of confidence in initiating conversations related to race/ethnicity. Discussion: Despite medical education's commitment to cultural competence and institutional mission statements that value diversity, equity, inclusion, and justice, professional development opportunities are limited. Participants strongly agreed their participation in such a workshop was relevant and important to their professional work.

(Dis)Incentivizing Patient Satisfaction Metrics: The Unintended Consequences of Institutional Bias.

Background: Patient satisfaction surveys as a metric for quality-based financial incentives carry a risk of bias toward women and underrepresented physicians. Previous assessments in our department of medicine found that most women faculty were rated in the bottom quartile of patient satisfaction scores, whereas analysis of scores for underrepresented physicians had not been performed. To investigate, we compared patient satisfaction scores and relevant demographics of faculty physicians during 1 year when quality-related financial incentives were offered based on this metric. Methods: Patient satisfaction and communication scores collected during academic year 2015-2016 were obtained for 369 physicians (119 women and 250 men) at Indiana University Health system. Independent variables included physician gender, race, ethnicity, and subspecialty or division; 190 physicians constituted the study cohort for whom data were available for comparison. Statistical analyses were performed to determine if there were differences between gender and race in patient satisfaction scores (mean, median, t-tests, and Chi-square tests). A factorial analysis of variance model was performed to incorporate both main effects and to determine if there was a significant interaction between them. Results: Median and mean of scores were lower for women physicians and underrepresented physicians. Analysis demonstrated nonsignificant effect between gender-segregated cohorts. Racially underrepresented physicians had significantly lower mean scores than their white colleagues [F(4, 185)=2.46, p=0.046]. Conclusion and Relevance: Our results indicate a significant difference in patient satisfaction scores between underrepresented and white physicians. These data may suggest a potential bias, among patients and institutional practices, ultimately leading to pay inequities through differences in financial incentives toward underrepresented physicians.

Human herpesvirus-8 infection of primary pulmonary microvascular endothelial cells.

Human herpesvirus-8 (HHV-8) is the causative agent of Kaposi's sarcoma and is associated with the angioproliferative disorders primary effusion lymphoma and multicentric Castleman's disease. Evidence of HHV-8 infection within the pulmonary vasculature of patients with idiopathic pulmonary arterial hypertension (IPAH) has been described. We hypothesize that HHV-8 infection of pulmonary microvascular endothelial cells results in an apoptotic-resistant phenotype characteristic of severe pulmonary arterial hypertension. Our objective was to investigate the ability of HHV-8 to infect human pulmonary microvascular endothelial cells in vitro and characterize the phenotypic effect of this infection. Human pulmonary microvascular endothelial cells were exposed to HHV-8 using two methods (direct virus and co-culture technique). The presence of lytic and latent infection was confirmed. Changes in endothelial cell gene and protein expression and effects on cellular apoptosis were measured. HHV-8 can both lytically and latently infect primary human pulmonary microvascular endothelial cells in vitro. HHV-8 infection results in significant changes in gene expression, including alterations of pathways important to cellular apoptosis. HHV-8 infection also alters expression of genes integral to the bone morphogenic protein pathway, including down-regulation of bone morphogenic protein-4. Other genes previously implicated in the development of PAH are affected by HHV-8 infection, and cells infected with HHV-8 are resistant to apoptosis.

Prostacyclin prevents pulmonary endothelial cell apoptosis induced by cigarette smoke.

RATIONALE: Impaired endothelial cell-dependent vasodilation, inflammation, apoptosis, and proliferation are manifestations of endothelial dysfunction in chronic obstructive pulmonary disease (COPD). Prostacyclin (PGI(2)) is a major product of the cyclooxygenase pathway with potent vasodilatory and antimitogenic properties and may be relevant to endothelial dysfunction in COPD. OBJECTIVES: To determine if PGI(2) expression is altered in smoking-related lung disease and if it may be protective in COPD-associated endothelial dysfunction. METHODS: We evaluated, by immunohistochemistry, Western blotting, and polymerase chain reaction, human emphysema tissue compared with normal tissue for expression of prostacyclin synthase (PGI(2)S). We examined the effects of cigarette smoke extract (CSE) and aldehyde components on eicosanoid expression in primary human pulmonary microvascular endothelial cells. Finally, we used a murine model of lung-specific PGI(2)S overexpression and in vitro studies to determine if PGI(2) expression has protective effects on cigarette smoke-induced endothelial apoptosis. MEASUREMENTS AND MAIN RESULTS: Human emphysema lung tissue exhibited lower PGI(2)S expression within the pulmonary endothelium than in normal lung. In vitro studies demonstrated that CSE, and in particular the alpha,beta unsaturated aldehyde acrolein, suppressed PGI(2)S gene expression, whereas CSE significantly induced the upstream mediators COX-2 and cytosolic phospholipase A2 in human pulmonary microvascular endothelial cells. Mice with lung-specific PGI(2)S overexpression exhibited less endothelial apoptosis after chronic smoke exposure. In vitro, iloprost exhibited protective effects on CSE-induced apoptosis. CONCLUSIONS: PGI(2) has protective effects in the pulmonary vasculature after acute and chronic cigarette smoke exposure. An imbalance in eicosanoid expression may be important to COPD-associated endothelial dysfunction.