Reflecting on Progress in and Establishing Benchmarks for Sex and Gender Health Education.

ABSTRACT: Sex and gender influence every aspect of human health; thus, sex- and gender-related topics should be incorporated in all aspects of health education curricula. Sex and gender health education (SGHE) is the rigorous, intersectional, data-driven integration of sex and gender into all elements of health education. A multisectoral group of thought leaders has collaborated to advance SGHE since 2012. This cross-sector collaboration to advance SGHE has been successful on several fronts, primarily developing robust interprofessional SGHE programs, hosting a series of international SGHE summits, developing sex- and gender-specific resources, and broadening the collaboration beyond medical education. However, other deeply entrenched challenges have proven more difficult to address, including accurate and consistent sex and gender reporting in research publications, broadening institutional support for SGHE, and the development and implementation of evaluation plans for assessing learner outcomes and the downstream effects of SGHE on patient care. This commentary reflects on progress made in SGHE over the first decade of the current collaboration (2012-2022), articulates a vision for next steps to advance SGHE, and proposes 4 benchmarks to guide the next decade of SGHE: (1) integrate sex, gender, and intersectionality across health curricula; (2) develop sex- and gender-specific resources for health professionals; (3) improve sex and gender reporting in research publications; and (4) develop evaluation plans to assess learner and patient outcomes.

Acute Esophageal Necrosis: A Retrospective Cohort Study Highlighting the Mayo Clinic Experience.

OBJECTIVE: To describe the clinical, endoscopic, and histologic features in patients with acute esophageal necrosis (AEN). PATIENTS AND METHODS: In this retrospective cohort study, patients who were diagnosed as having AEN at Mayo Clinic sites in Minnesota, Florida, and Arizona between January 1, 1996, and January 31, 2021, were included. Data were collected on patient clinical characteristics and endoscopic and pathologic findings. RESULTS: The study included 79 patients with AEN with a median (range) age of 64 years (12 to 91 years); 53 (67.1%) were men. Predominant presenting symptoms were hematemesis (49 of 79 [62.0%]), abdominal pain (29 [36.7%]), and melena (20 [25.3%]). Shock was the triggering event for AEN in 49 (62.0%). The 30- and 90-day mortality were 24.0% (19 of 79) and 31.6% (25), respectively. The presence of coexisting infection or bacteremia was significantly associated with 90-day mortality (P<.01). Endoscopically, involvement of the distal third only, distal two-thirds only, and entire esophagus was observed in 31.6% (24 of 76), 39.5% (30), and 29.0% (22), respectively. The length of esophageal involvement correlated with duration of hospitalization (P=.05). The endoscopic appearance of the esophageal mucosa ranged from predominantly white (21 of 44 [47.7%]) to mixed white and black (13 [29.6%]) to predominantly black (10 [22.7%]), and sloughing was present in 18 (40.9%). In the 26 patients with histopathologic findings available for review, 25 (96.1%) had necrosis and/or ulceration with abundant pigmentation. Among the 79 patients, 39 (49.4%) had a follow-up esophagogastroduodenoscopy; 26 of these 39 patients (66.7%) had resolution while 5 had persistent AEN, 4 of whom had improvement. Esophageal strictures developed in 7 of the 39 patients (18.0%). CONCLUSION: Acute esophageal necrosis is a serious condition observed in critically ill patients. Its endoscopic appearance can be highly variable. In patients with an unclear diagnosis, esophageal biopsies may be helpful given the characteristic histologic findings.

Randomized Phase II Trial of Polyphenon E versus Placebo in Patients at High Risk of Recurrent Colonic Neoplasia.

Polyphenon E (Poly E) is a green tea polyphenol preparation whose most active component is epigallocatechin gallate (EGCG). We studied the cancer preventive efficacy and safety of Poly E in subjects with rectal aberrant crypt foci (ACF), which represent putative precursors of colorectal cancers. Eligible subjects had prior colorectal advanced adenomas or cancers, and had ≥5 rectal ACF at a preregistration chromoendoscopy. Subjects (N = 39) were randomized to 6 months of oral Poly E (780 mg EGCG) daily or placebo. Baseline characteristics were similar by treatment arm (all P >0.41); 32 of 39 (82%) subjects completed 6 months of treatment. The primary endpoint was percent reduction in rectal ACF at chromoendoscopy comparing before and after treatment. Among 32 subjects (15 Poly E, 17 placebo), percent change in rectal ACF number (baseline vs. 6 months) did not differ significantly between study arms (3.7% difference of means; P = 0.28); total ACF burden was also similar (-2.3% difference of means; P = 0.83). Adenoma recurrence rates at 6 months were similar by arm (P > 0.35). Total drug received did not differ significantly by study arm; 31 (79%) subjects received ≥70% of prescribed Poly E. Poly E was well tolerated and adverse events (AE) did not differ significantly by arm. One subject on placebo had two grade 3 AEs; one subject had grade 2 hepatic transaminase elevations attributed to treatment. In conclusion, Poly E for 6 months did not significantly reduce rectal ACF number relative to placebo. Poly E was well tolerated and without significant toxicity at the dose studied. PREVENTION RELEVANCE: We report a chemoprevention trial of polyphenon E in subjects at high risk of colorectal cancer. The results show that polyphenon E was well tolerated, but did not significantly reduce the number of rectal aberrant crypt foci, a surrogate endpoint biomarker of colorectal cancer.

Efficacy of Difluoromethylornithine and Aspirin for Treatment of Adenomas and Aberrant Crypt Foci in Patients with Prior Advanced Colorectal Neoplasms.

Difluoromethylornithine (DFMO), an inhibitor of polyamine synthesis, was shown to act synergistically with a NSAID for chemoprevention of colorectal neoplasia. We determined the efficacy and safety of DFMO plus aspirin for prevention of colorectal adenomas and regression of rectal aberrant crypt foci (ACF) in patients with prior advanced adenomas or cancer. A double-blinded, placebo-controlled trial was performed in 104 subjects (age 46-83) randomized (1:1) to receive daily DFMO (500 mg orally) plus aspirin (325 mg) or matched placebos for one year. All polyps were removed at baseline. Adenoma number (primary endpoint) and rectal ACF (index cluster and total) were evaluated at a one year colonoscopy. ACF were identified by chromoendoscopy. Toxicity was monitored, including audiometry. Eighty-seven subjects were evaluable for adenomas or ACF modulation (n = 62). At one year of treatment, adenomas were detected in 16 (38.1%) subjects in the DFMO plus aspirin arm (n = 42) versus 18 (40.9%) in the placebo arm (n = 44; P = 0.790); advanced adenomas were similar (n = 3/arm). DFMO plus aspirin was associated with a statistically significant reduction in the median number of rectal ACF compared with placebo (P = 0.036). Total rectal ACF burden was also reduced in the treatment versus the placebo arm relative to baseline (74% vs. 45%, P = 0.020). No increase in adverse events, including ototoxicity, was observed in the treatment versus placebo arms. While adenoma recurrence was not significantly reduced by one year of DFMO plus aspirin, the drug combination significantly reduced rectal ACF number consistent with a chemopreventive effect.

Restoring Faculty Vitality in Academic Medicine When Burnout Threatens.

Increasing rates of burnout-with accompanying stress and lack of engagement-among faculty, residents, students, and practicing physicians have caused alarm in academic medicine. Central to the debate among academic medicine's stakeholders are oft-competing issues of social accountability; cost containment; effectiveness of academic medicine's institutions; faculty recruitment, retention, and satisfaction; increasing expectations for faculty; and mission-based productivity.The authors propose that understanding and fostering what contributes to faculty and institutional vitality is central to preventing burnout during times of change. They first look at faculty vitality and how it is threatened by burnout, to provide a framework for a greater understanding of faculty well-being. Then they draw on higher education literature to determine how vitality is defined in academic settings and what factors affect faculty vitality within the context of academic medicine. Next, they propose a model to explain and examine faculty vitality in academic medicine, followed by a discussion of the need for a greater understanding of faculty vitality. Finally, the authors offer conclusions and propose future directions to promote faculty vitality.The authors encourage institutional decision makers and other stakeholders to focus particular attention on the evolving expectations for faculty, the risk of extensive faculty burnout, and the opportunity to reduce burnout by improving the vitality and resilience of these talented and crucial contributors. Faculty vitality, as defined by the institution, has a critical role in ensuring future institutional successes and the capacity for faculty to thrive in a complex health care economy.

Evaluation of sex- and gender-based medicine training in post-graduate medical education: a cross-sectional survey study.

BACKGROUND: Addressing healthcare disparities is a national priority for initiatives in precision and individualized medicine. An essential component of precision medicine is the understanding that sex and gender influence health and disease. Whether these issues are addressed in post-graduate medical education curricula is unknown. METHODS: A questionnaire was designed and administered to residents across the Mayo Clinic enterprise to assess current knowledge of sex and gender medicine in a large program of post-graduate medical education and to identify barriers and preferred teaching methods for addressing sex and gender issues in health and disease. Descriptive and qualitative thematic analyses of the survey responses were compiled and analyzed. RESULTS: Responses were collected from 271 residents (response rate 17.2 %; 54 % female; 46 % male). A broad cross-section of training programs on all Mayo Clinic campuses (Arizona, Minnesota, and Florida) was represented. Sixteen percent of the respondents reported they had never had an instructor or preceptor discuss how a patient's sex or gender impacted their care of a patient; 55 % said this happened only occasionally. Of medical knowledge questions about established sex- and gender-related differences, 48 % were answered incorrectly or "unsure." Qualitative thematic analysis showed that many trainees do not understand the potential impact of sex and gender on their clinical practice and/or believe it does not pertain to their specialty. A higher percentage of female participants agreed it was important to consider a patient's sex and gender when providing patient care (60.4 vs. 38.7 %, p = 0.02), and more male than female participants had participated in research that included sex and/or gender as a variable (59.6 vs. 39.0 %, p < 0.01). CONCLUSIONS: Curriculum gaps exist in post-graduate medical training regarding sex- and gender-based medicine, and residents often do not fully understand how these concepts impact their patients' care. Reviewing the definition of sex- and gender-based medicine and integrating these concepts into existing curricula can help close these knowledge gaps. As the practice of medicine becomes more individualized, it is essential to equip physicians with an understanding of how a patient's sex and gender impacts their health to provide the highest value care.

Embedding concepts of sex and gender health differences into medical curricula.

Sex, a biological variable, and gender, a cultural variable, define the individual and affect all aspects of disease prevention, development, diagnosis, progression, and treatment. Sex and gender are essential elements of individualized medicine. However, medical education rarely considers such topics beyond the physiology of reproduction. To reduce health care disparities and to provide optimal, cost-effective medical care for individuals, concepts of sex and gender health need to become embedded into education and training of health professionals. In September 2012, Mayo Clinic hosted a 2-day workshop bringing together leading experts from 13 U.S. schools of medicine and schools of public health, Health Resources and Services Administration Office of Women's Health (HRSA OWH), the National Institutes of Health (NIH) Office of Research on Women's Health (ORWH), and the Canadian Institute of Health and Gender. The purpose of this workshop was to articulate the need to integrate sex- and gender-based content into medical education and training, to identify gaps in current medical curricula, to consider strategies to embed concepts of sex and gender health into health professional curricula, and to identify existing resources to facilitate and implement change. This report summarizes these proceedings, recommendations, and action items from the workshop.

What can medical education learn from the neurobiology of learning?

The last several decades have seen a large increase in knowledge of the underlying biological mechanisms that serve learning and memory. The insights gleaned from neurobiological and cognitive neuroscientific experimentation in humans and in animal models have identified many of the processes at the molecular, cellular, and systems levels that occur during learning and the formation, storage, and recall of memories. Moreover, with the advent of noninvasive technologies to monitor patterns of neural activity during various forms of human cognition, the efficacy of different strategies for effective teaching can be compared. Considerable insight has also been developed as to how to most effectively engage these processes to facilitate learning, retention, recall, and effective use and application of the learned information. However, this knowledge has not systematically found its way into the medical education process. Thus, there are considerable opportunities for the integration of current knowledge about the biology of learning with educational strategies and curricular design. By teaching medical students in ways that use this knowledge, there is an opportunity to make medical education easier and more effective. The authors present 10 key aspects of learning that they believe can be incorporated into effective teaching paradigms in multiple ways. They also present recommendations for applying the current knowledge of the neurobiology of learning throughout the medical education continuum.

Commentary: improving medical education during financially challenging times.

The expectation exists that medical education will continue to improve even during financially challenging times. The authors reviewed their recent experiences in effecting positive changes and improvements in Mayo Medical School during a time of fiscal constraint. They successfully implemented numerous changes, including a major curriculum reform, while modestly reducing overall costs of the medical school and improving student satisfaction and learner outcomes. These improvements resulted from careful alignment among the institutional mission of serving the needs of the patient, communication with the faculty, involvement of the students, and streamlining of multiple processes throughout the school. The authors sought to eliminate excessive resource utilization while retaining the essence of Mayo Medical School's education process. The authors' experience can both encourage and inspire other schools to continue to improve the educational experience for their students in concert with meeting increasing financial pressures.

Putting the needs of the patient first: Mayo Clinic's core value, institutional culture, and professionalism covenant.

From its inception more than a century ago, Mayo Clinic's founders instilled the core value, the needs of the patient come first, into the institution's culture. Today, this core value of professionalism continues to guide the clinic's leadership practices, management strategies, and daily activities. Members of the Mayo Clinic staff embrace and reinforce this core value and regard it as a professionalism covenant: a collective, tacit agreement that everyone will earnestly collaborate to put the needs and welfare of patients first. This covenant is articulated for patients and learners in two key documents, both crafted in 2001--the Mayo Clinic Model of Care, and the Mayo Clinic Model of Education--and is reaffirmed through Mayo Clinic's mission to provide the best outcomes, service, and value in health care to every patient, every day. Mayo's value-based culture serves as a powerful, positive hidden curriculum that facilitates the accomplishment of desired practice and educational outcomes and fosters the development of health care professionals with the highest standards of professionalism. The profound allegiance of Mayo Clinic staff and students to its patient-centered culture connects all to the purpose and meaning of their work, elicits collaboration and voluntary efforts, and fosters an environment that is committed to excellence and continuous improvement. In the context of contemporary challenges and competing commitments facing academic health centers, the authors discuss key initiatives that Mayo Clinic has implemented to preserve the institution's culture, honor the professionalism covenant, and enable faculty, staff, and learners to align their behaviors, work activities, and resources to accomplish the institution's mission.

Advancing educators and education by defining the components and evidence associated with educational scholarship.

OBJECTIVE: This study aimed to establish documentation standards for medical education activities, beyond educational research, for academic promotion consistent with principles of excellence and scholarship. METHODS: In 2006 a Consensus Conference on Educational Scholarship was convened by the Association of American Medical Colleges (AAMC) Group on Education Affairs (GEA) to outline a set of documentation standards for use by educators and academic promotion committees. Conference participants' work was informed by more than 15 years of literature on scholarship, educator portfolios and academic promotion standards. RESULTS: The 110 conference participants, including medical school deans, academic promotion committee members, department chairs, faculty and AAMC leaders, re-affirmed the 5 education activity categories (teaching, curriculum, advising and/or mentoring, education leadership and/or administration, and learner assessment), the contents of each category, and cross-category documentation standards. Educational excellence requires documentation of the quantity and quality of education activities. Documenting a scholarly approach requires demonstrating evidence of drawing from and building on the work of others, and documenting scholarship requires contributing work through public display, peer review and dissemination; both involve engagement with the community of educators. Implementation of these standards - quantity, quality and engagement with the education community - should occur in parallel with the development of an infrastructure to support educators, including sustained faculty development for educators, access to educational resources and journals, peer review mechanisms and consultation and support specific to each activity category. CONCLUSIONS: Educators' contributions to their institutions must be visible to be valued. The establishment of documentation standards for education activities provides the foundation for academic recognition of educators.

Case studies in outcome-based education.

Outcome-based education is one of the most significant global developments in medical education in recent years. This paper presents four case studies of outcome-based education from medical schools in different parts of the world; Scotland; USA; Pakistan; and Singapore. The outcome-based curricula have either been in place for some time, are evolving or are at the planning proposal stage. The outcomes, change process and implementation of the outcome-based approach are described. Variation in the extent to which each medical school has implemented outcome-based education is discussed and key points for successful implementation are highlighted. This paper is based on the pre-conference symposium "outcome-based curricula: global perspectives" presented by the authors at the 4th Asia Pacific Medical Education Conference (APMEC) in Singapore, 8-11 February, 2007.

Leadership and professionalism curriculum in the Gross Anatomy course.

INTRODUCTION: Today's physicians must demonstrate both professionalism and leadership skills in order to succeed in largely team-based healthcare environments. The purpose of this study was to determine if professionalism attributes, leadership style, and leadership style adaptability are associated with academic performance among first-year students early in their medical curriculum. MATERIALS AND METHODS: Students were divided into 4-member dissection groups for the duration of the Gross and Developmental Anatomy course. Leadership responsibility was randomly assigned to a team member on a rotating basis every 5 weeks. After each 5-week block, student performance was measured by written and practical examinations, and each student assessed their leader's or their own professionalism attributes and leadership style using validated survey instruments. RESULTS: Most students demonstrated either a "selling" only (57%) or "participating" only (30%) leadership style with low to moderate leadership adaptability. "Participating" and "delegating" leadership styles have the highest average group written exam scores (89.4%, P <0.008). "Telling" only or "selling" only leaders have the lowest average group exam scores (83.5%, P <0.001). "Selling" and "participating" leaders have significantly lower average group practical exam scores than other styles (81.5%, P <0.007). Positive associations were observed between the written and practical examination scores and the leader's integrity (P = 0.003, P = 0.002) and responsibility (P <0.001, P = 0.037). CONCLUSIONS: This study demonstrates that various situational leadership styles and aspects of professionalism are associated with written and practical examination scores in the Gross and Developmental Anatomy course. Furthermore, it demonstrates that first-year medical students are in need of leadership skill development.