Vital Signs: Mammography Use and Association with Social Determinants of Health and Health-Related Social Needs Among Women - United States, 2022.

Introduction: Approximately 40,000 U.S. women die from breast cancer each year. Mammography is recommended to screen for breast cancer and reduce breast cancer mortality. Adverse social determinants of heath (SDOH) and health-related social needs (HRSNs) (e.g., lack of transportation and social isolation) can be barriers to getting mammograms. Methods: Data from the 2022 Behavioral Risk Factor Surveillance System were analyzed to estimate the prevalence of mammography use within the previous 2 years among women aged 40-74 years by jurisdiction, age group, and sociodemographic factors. The association between mammography use and measures of SDOH and HRSNs was assessed for jurisdictions that administered the Social Determinants and Health Equity module. Results: Among women aged 50-74 years, state-level mammography use ranged from 64.0% to 85.5%. Having health insurance and a personal health care provider were associated with having had a mammogram within the previous 2 years. Among women aged 50-74 years, mammography prevalence was 83.2% for those with no adverse SDOH and HRSNs and 65.7% for those with three or more adverse SDOH and HRSNs. Life dissatisfaction, feeling socially isolated, experiencing lost or reduced hours of employment, receiving food stamps, lacking reliable transportation, and reporting cost as a barrier for access to care were all strongly associated with not having had a mammogram within the previous 2 years. Conclusions and Implications for Public Health Practice: Identifying specific adverse SDOH and HRSNs that women experience and coordinating activities among health care providers, social services, community organizations, and public health programs to provide services that help address these needs might increase mammography use and ultimately decrease breast cancer deaths.

Digital adaptation of the Standing up for Myself intervention in young people and adults with intellectual disabilities: the STORM feasibility study.

Background: Stigma contributes to the negative social conditions persons with intellectual disabilities are exposed to, and it needs tackling at multiple levels. Standing Up for Myself is a psychosocial group intervention designed to enable individuals with intellectual disabilities to discuss stigmatising encounters in a safe and supportive setting and to increase their self-efficacy in managing and resisting stigma. Objectives: To adapt Standing Up for Myself to make it suitable as a digital intervention; to evaluate the feasibility and acceptability of Digital Standing Up for Myself and online administration of outcome measures in a pilot; to describe usual practice in the context of the coronavirus disease 2019 pandemic to inform future evaluation. Design: Adaptation work followed by a single-arm pilot of intervention delivery. Setting and participants: Four third and education sector organisations. Individuals with mild-to-moderate intellectual disabilities, aged 16+, members of existing groups, with access to digital platforms. Intervention: Digital Standing Up for Myself intervention. Adapted from face-to-face Standing Up for Myself intervention, delivered over four weekly sessions, plus a 1-month follow-up session. Outcomes: Acceptability and feasibility of delivering Digital Standing Up for Myself and of collecting outcome and health economic measures at baseline and 3 months post baseline. Outcomes are mental well-being, self-esteem, self-efficacy in rejecting prejudice, reactions to discrimination and sense of social power. Results: Adaptation to the intervention required changes to session duration, group size and number of videos; otherwise, the content remained largely the same. Guidance was aligned with digital delivery methods and a new group member booklet was produced. Twenty-two participants provided baseline data. The intervention was started by 21 participants (four groups), all of whom were retained at 3 months. Group facilitators reported delivering the intervention as feasible and suggested some refinements. Fidelity of the intervention was good, with over 90% of key components observed as implemented by facilitators. Both facilitators and group members reported the intervention to be acceptable. Group members reported subjective benefits, including increased confidence, pride and knowing how to deal with difficult situations. Digital collection of all outcome measures was feasible and acceptable, with data completeness ≥ 95% for all measures at both time points. Finally, a picture of usual practice has been developed as an intervention comparator for a future trial. Limitations: The pilot sample was small. It remains unclear whether participants would be willing to be randomised to a treatment as usual arm or whether they could be retained for 12 months follow-up. Conclusions: The target number of groups and participants were recruited, and retention was good. It is feasible and acceptable for group facilitators with some training and supervision to deliver Digital Standing Up for Myself. Further optimisation of the intervention is warranted. Future work: To maximise the acceptability and reach of the intervention, a future trial could offer the adapted Digital Standing Up for Myself, potentially alongside the original face-to-face version of the intervention. Study registration: This study was registered as ISRCTN16056848. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 17/149/03) and is published in full in Public Health Research; Vol. 12, No. 1. See the NIHR Funding and Awards website for further award information.

People with intellectual disabilities (or 'learning disabilities' in United Kingdom language) are more likely to experience poor physical and mental health than the general population. Stigma (negative stereotypes, prejudice and discrimination) has been linked to lower self-esteem, quality of life, and mental and physical ill health. Efforts to empower people with intellectual disabilities themselves to challenge stigma with a view to improving well-being, health and self-esteem are lacking. In 2017, we developed Standing Up for Myself, a brief group-based programme for people with mild-to-moderate intellectual disabilities aged 16+ to address this gap. As this study got underway, face-to-face meetings were suspended due to the coronavirus disease 2019 pandemic. We used the opportunity to assess whether Standing Up for Myself could be delivered through web-based meetings. We adapted Standing Up for Myself for digital delivery, with close input from advisors with intellectual disabilities and experienced group facilitators. We then tested the digital version in charity and education settings to evaluate if Digital Standing Up for Myself could be delivered as planned and how acceptable it was to group facilitators and participants. Four groups, with a total of 22 members, signed up to try Digital Standing Up for Myself. One participant dropped out before starting Standing Up for Myself, and the other 21 continued until the end of the programme. Retention and attendance were good; participants on average attended four of the five sessions. Ninety per cent of the core programme requirements were fully delivered as detailed in the Digital Standing Up for Myself manual. Problems with technology were manageable, although facilitators found using the Standing Up for Myself Wiki platform (an online platform for storage and sharing of resources) difficult, particularly when sharing video content. Facilitators felt acceptable levels of privacy were achieved and there were no reports of undue distress. All facilitators and many group members said they would recommend Digital Standing Up for Myself to others. Group members shared how the programme benefitted them, noting increased awareness about disabilities, and for some increased confidence, pride and independence. Some had learnt how to stand up for themselves and manage difficult situations and took pride in this. Completing outcome and health cost measures via web-based meetings was acceptable and data were largely fully complete and useable.

Implementing Interventions to Address Gender and Power Inequalities in Early Adolescence: Utilizing a Theory of Change to Assess Conditions for Success.

PURPOSE: To create a set of criteria to assess facilitators and barriers to implementation among gender transformative interventions that target very young adolescents (VYAs) across different cultural settings. METHODS: Interventionists and researchers involved in the Global Early Adolescent Study created a Theory of Change (ToC) based on summarizing intervention components from five different gender transformative intervention curricula. Embedded within the ToC is a set of criteria labeled, 'Conditions of Success' which were developed to illustrate that change cannot happen unless interventions are implemented successfully. To test the feasibility of these criteria, implementation data collected across the five interventions in Global Early Adolescent Study were mapped onto the 'Conditions for Success' criteria and used to identify common facilitators and barriers to implementation. RESULTS: Using the 'Conditions for Success' criteria, we found that gender transformative interventions targeting VYAs were most challenged in meeting program delivery and facilitation conditions and needed to build more multisectoral support to shift rigid gender norms. Parents and caregivers also needed to be engaged in the program either as a separate target population or as codesigners and implementers for the interventions. DISCUSSION: The Conditions for Success criteria provide a useful framework for assessing facilitators and barriers to implementation among gender transformative interventions for VYAs. Additional research is underway to examine whether interventions that meet more conditions of success result in greater program impact, which will be used to further refine the overall ToC.

'First in family' experiences in a Canadian medical school: A critically reflexive study.

BACKGROUND: Medical students from affluent and highly educated backgrounds remain overrepresented in Canadian medical schools despite widespread efforts to improve diversity. Little is known of the medical school experiences of students who are first in their family (FiF) to attend university. Drawing on Bourdieu and a critically reflexive lens, this study explored the experiences of FiF students in a Canadian medical school to better understand the ways in which the medical school environment can be exclusive and inequitable to underrepresented students. METHODS: We interviewed 17 medical students who self-identified as being FiF to attend university. Utilising theoretical sampling, we also interviewed five students who identified as being from medical families to test our emerging theoretical framework. Participants were asked to discuss what 'first in family' meant to them, their journey into medical school and their experiences at medical school. Bourdieu's theories and concepts were used as sensitising concepts to explore the data. RESULTS: FiF students discussed the implicit messages they received about who belongs in medical school, challenges in shifting from their pre-medical lives to a medical identity and competing with peers for residency programmes. They reflected on the advantages they perceived they had over their fellow students due to their less 'typical' social backgrounds. CONCLUSION: While medical schools continue to make strides when it comes to increasing diversity, inclusivity and equity require increased attention. Our findings highlight the ongoing need for structural and cultural change at admissions and beyond-change that recognises the much-needed presence and perspectives that underrepresented medical students, including those who are FiF, bring to medical education and healthcare. Engaging in critical reflexivity represents a key way that medical schools can continue to address issues of equity, diversity and inclusion.

Translating an Economic Analysis into a Tool for Public Health Resource Allocation in Cancer Survivorship.

Background. The complexity of decision science models may prevent their use to assist in decision making. User-centered design (UCD) principles provide an opportunity to engage end users in model development and refinement, potentially reducing complexity and increasing model utilization in a practical setting. We report our experiences with UCD to develop a modeling tool for cancer control planners evaluating cancer survivorship interventions. Design. Using UCD principles (described in the article), we developed a dynamic cohort model of cancer survivorship for individuals with female breast, colorectal, lung, and prostate cancer over 10 y. Parameters were obtained from the National Program of Cancer Registries and peer-reviewed literature, with model outcomes captured in quality-adjusted life-years and net monetary benefit. Prototyping and iteration were conducted with structured focus groups involving state cancer control planners and staff from the Centers for Disease Control and Prevention and the American Public Health Association. Results. Initial feedback highlighted model complexity and unclear purpose as barriers to end user uptake. Revisions addressed complexity by simplifying model input requirements, providing clear examples of input types, and reducing complex language. Wording was added to the results page to explain the interpretation of results. After these updates, feedback demonstrated that end users more clearly understood how to use and apply the model for cancer survivorship resource allocation tasks. Conclusions. A UCD approach identified challenges faced by end users in integrating a decision aid into their workflow. This approach created collaboration between modelers and end users, tailoring revisions to meet the needs of the users. Future models developed for individuals without a decision science background could leverage UCD to ensure the model meets the needs of the intended audience. Highlights: Model complexity and unclear purpose are 2 barriers that prevent lay users from integrating decision science tools into their workflow.Modelers could integrate the user-centered design framework when developing a model for lay users to reduce complexity and ensure the model meets the needs of the users.

Development and assessment of a hospital-led, community-partnering COVID-19 testing and prevention program for homeless and congregate living services in Toronto, Canada: a descriptive feasibility study.

BACKGROUND: Outbreaks of SARS-CoV-2 in shelters and congregate living settings are a major concern because of overcrowding and because resident populations are often at high risk for infection. The objective of this study was to describe the development, implementation and assessment of the COVID-19 Community Response Team, a program that enabled Women's College Hospital in Toronto, Ontario, to work in partnership with shelters and congregate living settings to prevent outbreaks. METHODS: The Community Response Team, associated with Women's College Hospital, an academic ambulatory hospital, carried out mobile testing for SARS-CoV-2, supported outbreak management and prevention through ongoing onsite partnership with medical staff, and conducted infection prevention and control (IPC) training to shelter staff. We conducted a descriptive analysis of the sites supported by the program between Apr. 20, 2020, and Aug. 15, 2020. We also assessed the program's feasibility (number of completed needs assessments, mobile testing events and IPC training events, and median time from referral to service delivery), adoption (number of nasopharyngeal swabs, number of pre- and post-program outbreaks and IPC uptake) and acceptability or satisfaction. RESULTS: The Community Response Team supported 32 sites. Of those, 30 completed an intake needs assessment, 24 completed mobile testing for SARS-CoV-2 and 15 received IPC support. Mobile testing resulted in the collection of 1566 nasopharyngeal swabs, of which 64 were positive for SARS-CoV-2 infection. Three sites had confirmed outbreaks. The median time from referral to needs assessment was 4 days (interquartile range [IQR] 1-13 days), and the median time to the testing day was 9 days (IQR 1-49 days). The median time from referral to IPC staff training was 14 days (IQR 4-79 days), and 100% of respondents reported being pleased or very pleased with the training. During the follow-up period, the 3 facilities with outbreaks overcame those outbreaks. Three sites supported by the Community Response Team had further single cases, but no site reported subsequent or secondary outbreaks. INTERPRETATION: The Community Response Team program led to the transfer of IPC knowledge, allowed for the management and prevention of SARS-CoV-2 outbreaks, and demonstrated feasibility. Collaborative supports between hospitals and the community housing sector may serve as models for ongoing system integration beyond the COVID-19 pandemic.

Computable Guidelines and Clinical Decision Support for Cervical Cancer Screening and Management to Improve Outcomes and Health Equity.

Cervical cancer is highly preventable when precancerous lesions are detected early and appropriately managed. However, the complexity of and frequent updates to existing evidence-based clinical guidelines make it challenging for clinicians to stay abreast of the latest recommendations. In addition, limited availability and accessibility to information technology (IT) decision supports make it difficult for groups who are medically underserved to receive screening or receive the appropriate follow-up care. The Centers for Disease Control and Prevention (CDC), Division of Cancer Prevention and Control (DCPC), is leading a multiyear initiative to develop computer-interpretable ("computable") version of already existing evidence-based guidelines to support clinician awareness and adoption of the most up-to-date cervical cancer screening and management guidelines. DCPC is collaborating with the MITRE Corporation, leading scientists from the National Cancer Institute, and other CDC subject matter experts to translate existing narrative guidelines into computable format and develop clinical decision support tools for integration into health IT systems such as electronic health records with the ultimate goal of improving patient outcomes and decreasing disparities in cervical cancer outcomes among populations that are medically underserved. This initiative meets the challenges and opportunities highlighted by the President's Cancer Panel and the President's Cancer Moonshot 2.0 to nearly eliminate cervical cancer.

The KAIROS Blanket Exercise: Engaging Indigenous ways of knowing to foster critical consciousness in medical education.

PURPOSE: Indigenous Peoples across Turtle Island (North America) experience ongoing health disparities tied to the effects of colonization and persistent racism toward Indigenous Peoples. Educating future clinicians to develop a critical consciousness is an important way to work toward cultural safety and improve the health care experiences of Indigenous patients. The present study evaluated the ability of the KAIROS Blanket Exercise (KBE) to foster critical consciousness. METHODS: Two hundred thirteen medical students at the University of Toronto participated in the KBE. Subsequently, 174 students completed a paper evaluation, designed to capture concepts of cultural safety and critical consciousness. Data were analyzed using quantitative and qualitative methods to identify shifts in perspectives. RESULTS: The majority of students reported the exercise altered the way they viewed those from backgrounds different from their own, and comments regarding bias, power and privilege were highlighted throughout the responses. Engaging in critical reflection through dialogue and revealing the complex sociopolitical context of Indigenous Peoples' history were emphasized as central to this transformation. CONCLUSIONS: Following participation in the KBE, medical students demonstrated a shift in their perspectives. This suggests that creating curricular space for critical pedagogy may be effective in fostering critical consciousness, ultimately encouraging reflexive practice and social action.

A population study of screening history and diagnostic outcomes of women with invasive cervical cancer.

BACKGROUND: Despite advances to prevent and detect cervical cancer, national targets for screening have not been met in the United States. Previous studies suggested that approximately half of women who developed cervical cancer were not adequately screened. This study aimed to provide an updated examination of women's screening and diagnostic practices five years prior to an invasive cervical cancer diagnosis. METHODS: The study included women age 21 years and older diagnosed with invasive cervical cancer in 2013-2016 from three population-based state cancer registries in the United States. Medical records abstraction identified screening history and diagnostic follow-up. A mailed survey provided sociodemographic data. Screening was a Pap or human papillomavirus (HPV) test between 6 months and 5 years before diagnosis. Adequate follow-up was defined per management guidelines. RESULTS: Of the 376 women, 60% (n = 228) had not been screened. Among women who received an abnormal screening result (n = 122), 67% (n = 82) had adequate follow-up. Predictors of: (a) being screened were younger age, having a higher income, and having insurance; (b) adequate follow-up were having a higher income, and (c) stage 1 cervical cancer were being screened and younger age. CONCLUSION: Unlike other cancer patterns of care studies, this study uses data obtained from medical records supplemented with self-report information to understand a woman's path to diagnosis, her follow-up care, and the stage of her cervical cancer diagnosis. This study provides findings that could be used to reach more unscreened or under screened women and to continue lowering cervical cancer incidence in the United States.

Pursuing Data Modernization in Cancer Surveillance by Developing a Cloud-Based Computing Platform: Real-Time Cancer Case Collection.

Cancer surveillance is a field focused on collection of data to evaluate the burden of cancer and apply public health strategies to prevent and control cancer in the community. A key challenge facing the cancer surveillance community is the number of manual tasks required to collect cancer surveillance data, thereby resulting in possible delays in analysis and use of the information. To modernize and automate cancer data collection and reporting, the Centers for Disease Control and Prevention is planning, developing, and piloting a cancer surveillance cloud-based computing platform (CS-CBCP) with standardized electronic reporting from laboratories and health-care providers. With this system, automation of the cancer case collection process and access to real-time cancer case data can be achieved, which could not be done before. Furthermore, the COVID-19 pandemic has illustrated the importance of continuity of operations plans, and the CS-CBCP has the potential to provide such a platform suitable for remote operations of central cancer registries.

Finding "Bright Spots": Using Multiple Measures to Examine Local-Area Racial Equity in Cancer Mortality Outcomes.

In this article, we present a variety of measures that quantify equity in cancer mortality outcomes, demonstrate how the measures perform with various cancer types, and identify counties, or "bright spots," that meet the criteria of those measures. Using county-level age-adjusted mortality rates for 2007-2016 from the National Center for Health Statistics, we identified counties that had both equitable and optimal outcomes for Black and White death rates across 5 types of cancer: cancers of the lung/bronchus, prostate, female breast, colorectum, and liver. The number of counties that met the criteria ranged from 0 to 442, depending on cancer type and measure used. Prostate cancer and male liver cancer consistently had the lowest number of "bright spots," with a maximum of 3 counties meeting the most lenient criteria. This paper presents several ways to examine equity, using rate ratios and standard error measures, in cancer mortality outcomes. It highlights areas with positive progress toward equity and areas with a potential need for equity-focused cancer-control planning. Examining local areas of positive deviance can inform cancer-control programming and planning around health equity.

Outcomes and costs of skilled support for people with severe or profound intellectual disability and complex needs.

BACKGROUND: With increasing reductions in funding for social care across many countries, the need to ensure that resources are used to best effect is becoming increasingly important, in particular for those with severe and complex needs. METHODS: In order to explore the outcomes and costs of skilled support for this group of people, quality of life was assessed for 110 people in 35 services in England. Information on costs was also collected. RESULTS: People who received consistently good active support experienced better outcomes in terms of several quality of life domains. Good support did not require significantly more staff time, and there was no evidence of higher total costs for those receiving good support. CONCLUSIONS: The inclusion of active support in government guidance and local commissioning practices related to people with severe intellectual disabilities is likely to improve user outcomes. Observation should be an important element in measuring service quality.

Building Governmental Public Health Capacity to Advance Health Equity: Conclusions Based on an Environmental Scan of a Local Public Health System.

Vast health inequities persist in cities across the United States. Although recommendations exist to guide governmental public health institutions seeking to advance population health equity, local contexts are likely to influence how these pursuits take shape. We review recommendations for pursuing equity that were developed from an environmental scan conducted in the city of New Orleans. The recommendations, which are based on perspectives provided by city and state public health leaders, leaders from other city governmental departments, and community-based health department partners, center around the enduring impact of systemic racism, working across sectors, and prioritizing community engagement.

Economic Evaluation of Interventions to Increase Colorectal Cancer Screening at Federally Qualified Health Centers.

The Centers for Disease Control and Prevention (CDC) has a long-standing commitment to increase colorectal cancer (CRC) screening for vulnerable populations. In 2005, the CDC began a demonstration in five states and, with lessons learned, launched a national program, the Colorectal Cancer Control Program (CRCCP), in 2009. The CRCCP continues today and its current emphasis is the implementation of evidence-based interventions to promote CRC screening. The purpose of this article is to provide an overview of four CRCCP awardees and their federally qualified health center partners as an introduction to the accompanying series of research briefs where we present individual findings on impacts of evidence-based interventions on CRC screening uptake for each awardee. We also include in this article the conceptual framework used to guide our research. Our findings contribute to the evidence base and guide future program implementation to improve sustainability, increase CRC screening, and address disparities in screening uptake.

Using Population Health Measures to Evaluate the Environmental Burden of Cancer at the County Level.

INTRODUCTION: Burden of disease is often defined by using epidemiologic measures. However, there may be latent aspects of disease burden that are not factored into these types of estimates. This study quantified environmental burden of disease by using population health indicators and exploratory factor analysis at the county level across the United States. METHODS: Ninety-nine variables drawn from public use data sets from 2010 to 2016 were used to create a multifactor index - the burden index. We applied principal components analysis with promax rotation to allow the factors to correlate. Correlation coefficients for each factor and the outcome of interest, age-adjusted cancer death rate, were calculated. We used both unadjusted and adjusted linear regression techniques. RESULTS: The final additive county-level index included 9 factors that explained 68.3% of the variance in the counties and county equivalents. The burden index had a moderate association with the age-adjusted cancer death rates (r =.48, P <.001), and adjusted linear regression with all 9 factors explained 34% of the variance in the age-adjusted cancer death rate. Results were mapped, and the geographic distribution of both the burden index and age-adjusted cancer mortality were assessed. There are distinct geospatial patterns for both. CONCLUSIONS: Results from this study show potential areas of need, as well as the importance of including environmental variables in the study of cancer etiology. Future studies can aim to validate these findings by quantifying burden as it relates to overall cancer mortality by using epidemiologic measures, along with other confirmatory statistical methods.

Uterine Cancer Incidence and Mortality - United States, 1999-2016.

Uterine cancer is one of the few cancers with increasing incidence and mortality in the United States, reflecting, in part, increases in the prevalence of overweight and obesity since the 1980s (1). It is the fourth most common cancer diagnosed and the seventh most common cause of cancer death among U.S. women (1). To assess recent trends in uterine cancer incidence and mortality by race and ethnicity, CDC analyzed incidence data from CDC's National Program of Cancer Registries (NPCR) and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program and mortality data from the National Vital Statistics System (2). Most recent data available are through 2015 for incidence and through 2016 for mortality. Uterine cancer incidence rates increased 0.7% per year during 1999-2015, and death rates increased 1.1% per year during 1999-2016, with smaller increases observed among non-Hispanic white (white) women than among women in other racial/ethnic groups. In 2015, a total of 53,911 new uterine cancer cases, corresponding to 27 cases per 100,000 women, were reported in the United States, and 10,733 uterine cancer deaths (five deaths per 100,000 women) were reported in 2016. Uterine cancer incidence was higher among non-Hispanic black (black) and white women (27 cases per 100,000) than among other racial/ethnic groups (19-23 per 100,000). Uterine cancer deaths among black women (nine per 100,000) were higher than those among other racial/ethnic groups (four to five per 100,000). Public health efforts to help women achieve and maintain a healthy weight and obtain sufficient physical activity can reduce the risk for developing cancer of the endometrium (the lining of the uterus), the most common uterine cancer. Abnormal vaginal bleeding, including bleeding between periods or after sex or any unexpected bleeding after menopause, is an important symptom of uterine cancer (3). Through programs such as CDC's Inside Knowledge* campaign, promoting awareness among women and health care providers of the need for timely evaluation of abnormal vaginal bleeding can increase the chance that uterine cancer is detected early and treated appropriately.

Dialogues on the Threshold: Dialogical Learning for Humanism and Justice.

Given the constant pressures of overflowing clinics, hospital wards, and emergency departments; shortened duty hours; and increased accreditation requirements, overburdened clinician teachers ask, "How does one teach for humanism and justice?" How does one step away-even momentarily-and focus teaching on the individual in front of us, the person who requires our attention and care? This approach must not only involve content (the patient's perspective of illness, social context, and life story) but also must be tightly linked with the ways in which these lessons in living are learned and taught. In this article, the authors propose recognition and use of a style of communication that is already implicitly present in clinical conversations and that is uniquely capable of stimulating reflection on the human dimensions of medicine: that of dialogue.Dialogue involves committing one's whole self to communicative exchange and emphasizes interpersonal relationships and trust. Its result is often not a specific answer; rather, it is enhanced understanding through the generation of new questions and possibilities and action in implementing solutions. It requires a reorientation of the teacher-learner relationship from top-down to one of open exchange and shared authority and responsibility. In the context of professional identity development, these conversations become dialogues on the threshold of transformative change. Through an exploration of dialogical teaching, the authors envision clinical education as constantly stepping in and out of goal-oriented discussions and reflective dialogues, all with the overall goal to educate physicians who practice with excellence, compassion, and justice.