Critical Perspectives to Advance Educational Equity and Health Justice.

A robust body of research supports the centrality of K-12 education to health and well-being. Critical perspectives, particularly Critical Race Theory (CRT) and Dis/ability Critical Race Studies (DisCrit), can deepen and widen health justice's exploration of how and why a range of educational inequities drive health disparities. The CRT approaches of counternarrative storytelling, race consciousness, intersectionality, and praxis can help scholars, researchers, policymakers, and advocates understand the disparate negative health impacts of education law and policy on students of color, students with disabilities, and those with intersecting identities. Critical perspectives focus upon and strengthen the necessary exploration of how structural racism, ableism, and other systemic barriers manifest in education and drive health disparities so that these barriers can be removed.

Cardiac electrophysiology and pacing educational and training needs among early-career cardiologists: a national survey of the Young Committee of the Italian Association of Arrhythmology and Cardiac Pacing.

BACKGROUND: Over the past three decades, cardiac electrophysiology and pacing, including device therapy and catheter ablation of arrhythmias, has rapidly developed as a subspecialty in cardiology. Currently, there is no clear perception about the needs in cardiac electrophysiology and pacing among early-career cardiologists. METHODS: To address these concerns, the Young Committee of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) carried out a survey among those under the age of 40 years to obtain detailed information on practical activities and formal lessons during the fellowship in cardiology and their satisfaction and proficiency level at the end of the fellowship. RESULTS: We obtained 334 answers to the survey. In invasive cardiac electrophysiology and pacing, the percentage of participants attending the activity for a longer time (3-6 months) is lower compared with those in noninvasive subspecialties. About 40% of participants did not receive lessons on interventional cardiology, cardiac electrophysiology and pacing. On the contrary, 71% of participants received an adequate number of lessons on clinical arrhythmology. The vast majority of the participants expressed satisfaction for the education received in the echocardiographic, cardiac interventional laboratories and clinical arrhythmology, but about half of the participants were unsatisfied with the education received in cardiac electrophysiology and pacing. In interventional arrhythmology, the majority of the participants declare their lack of proficiency with two peaks for more complex procedures, namely interventional electrophysiology procedures (82%) and cardiac resynchronization therapy (CRT) procedures (76%). CONCLUSION: The present survey among Italian early-career cardiologists suggests that the majority of participants consider themselves not confident in performing cardiac electrophysiology and pacing procedures. Due to the complexity of the treatment for heart rhythm disorders and the long learning curve, structured additional training in cardiac electrophysiology and pacing procedures is required after cardiology fellowship.

Effects of the COVID-19 pandemic on the formation of fellows in training in cardiology.

CoronaVIrus Disease-19 (COVID-19) had a huge impact on human health and economy. However, to this date, the effects of the pandemic on the training of young cardiologists are only partially known. To assess the consequences of the pandemic on the education of the cardiologists in training, we performed a 23-item national survey that has been delivered to 1443 Italian cardiologists in training, registered in the database of the Italian Society of Cardiology (SIC). Six hundred and thirty-three cardiologists in training participated in the survey. Ninety-five percent of the respondents affirmed that the training programme has been somewhat stopped or greatly jeopardized by the pandemic. For 61% of the fellows in training (FITs), the pandemic had a negative effect on their education. Moreover, 59% of the respondents believe that they would not be able to fill the gap gained during that period over the rest of their training. A negative impact on the psycho-physical well being has been reported by 86% of the FITs. The COVID-19 pandemic had an unparalleled impact on the education, formation and mental state of the cardiologists in training. Regulatory agencies, universities and politicians should make a great effort in the organization and reorganization of the teaching programs of the cardiologists of tomorrow.

Scholarly Research Productivity among Otolaryngology Residency Graduates and its Relationship to Future Academic Achievement.

OBJECTIVE: Scholastic activity through research involvement is a fundamental aspect of a physician's training and may have a significant influence on future academic success. Here, we explore publication rates before, during, and after otolaryngology residency training and whether publication efforts correlate with future academic achievement. METHODS: This cross-sectional analysis included a random sample of 50 otolaryngology residency programs. From these programs, we assembled a list of residents graduating from the years in 2013, 2014, and 2015. Using SCOPUS, PubMed, and Google Scholar, we compiled the publications for each graduate, and data were extracted in an independent, double-blinded fashion. RESULTS: We included 32 otolaryngology residency programs representing 249 residents in this analysis. Graduates published a mean of 1.3 (SD = 2.7) articles before residency, 3.5 (SD = 4.3) during residency, and 5.3 (SD = 9.3) after residency. Residents who pursued a fellowship had more total publications (t247 = -6.1, P < .001) and more first author publications (t247 = -5.4, P < .001) than residents without fellowship training. Graduates who chose a career in academic medicine had a higher number of mean total publications (t247 = -8.2, P < .001) and first author publications (t247 = -7.9, P < .001) than those who were not in academic medicine. There was a high positive correlation between residency program size and publications during residency (r = 0.76). CONCLUSION: Research productivity correlated with a number of characteristics such as future fellowship training, the pursuit of an academic career, and overall h-index in this study.

Gastroenterology Fellowship Applicants' Perspectives on GI Program Preferences.

Gastroenterology fellowship continues to be highly competitive among internal medicine subspecialties. Recruiting excellent applicants is also important for GI fellowship program directors. We aim to examine factors that influence GI fellowship applicants' perspectives about a fellowship program. The authors conducted an anonymous online survey of applicants focusing on program characteristics including location, faculty, research/clinical opportunities, website, and interview day experience. Anonymous survey responses were recorded regarding program characteristics, and subsequent candidate preferences were evaluated for factors influencing their decision. Candidates were also asked to evaluate their interview experience and share other comments about the program. Though GI fellowship applicants have varying preferences regarding the ideal training program, some opinions converged. The study of these trends can inform program directors regarding areas for improvement that in turn can help attract the best applicants.

COVID-19 Pandemic Among Immigrant Latinx Farmworker and Non-farmworker Families: A Rural-Urban Comparison of Economic, Educational, Healthcare, and Immigration Concerns.

COVID-19 has revealed social and health inequities in the United States. Structural inequalities have increased the likelihood of immigrants contracting COVID-19, by being essential workers and through poverty that forces this population to continue working. Rural and urban immigrant families may face different concerns. Using a telephone survey in May 2020 of 105 Latinx families in an existing study, quantitative and qualitative data were gathered on work and household economics, childcare and education, healthcare, and community climate. Analyses show that, although rural and urban groups experienced substantial economic effects, impacts were more acute for urban families. Rural workers reported fewer workplace protective measures for COVID-19. For both groups, fear and worry, particularly about finances and children, dominated reports of their situations with numerous reports of experiencing stress and anxiety. The experience of the pandemic is interpreted as an example of contextual vulnerability of a population already experiencing structural violence through social injustice. Policy implications are highlighted.

Aligning geriatric medicine fellowships with the Program of All-Inclusive Care for the Elderly (PACE).

Geriatric medicine fellowship programs provide comprehensive training to one-year clinical fellows and must demonstrate successful progression of competence among fellows by reporting on 23 milestones to the Accreditation Council for Graduate Medical Education (ACGME). The Program of All-inclusive Care for the Elderly (PACE) is a model of care located throughout the United States and can serve as a training venue for fellows. We surveyed 113 fellowship program directors with a response rate of 42% (n = 48). The purpose of the survey was to assess: (1) familiarity and access to PACE and (2) perceived value of PACE to the fellowship program with regard to training and ability to achieve success in the 23 reporting milestones. Milestones involving communication and team management skills were most consistently identified as very valuable with a PACE clinical rotation. We then convened a focus group of four PACE medical directors who developed a fellowship curriculum for use in training fellows at PACE. We discuss the limitations of our design as well as the opportunities to build on the strengths of that model as a training site for fellows.

Reasons geriatrics fellows choose geriatrics as a career, and implications for workforce recruitment.

Objectives: Although the population of older adults is rising, the number of physicians seeking geriatrics training is decreasing. This study of fellows in geriatrics training programs across the United States explored motivating factors that led fellows to pursue geriatrics in order to inform recruitment efforts. Design: Semi-structured telephone interviews with geriatrics fellows. Setting: Academic medical centers. Participants: Fifteen geriatrics fellows from academic medical centers across the United States. Measurements: This qualitative telephone study involved interviews that were transcribed and descriptively coded by two independent reviewers. A thematic analysis of the codes was summarized. Results: Fellows revealed that mentorship and early exposure to geriatrics were the most influential factors affecting career choice. Conclusion: The results of this study have the potential for a large impact, helping to inform best practices in encouraging trainees to enter the field, and enhancing medical student and resident exposure to geriatrics.

Desamparo e ações específicas de cuidados com um adolescente na rede pública / La impotencia y las acciones específicas del cuidado com un adolescente en la red pública / Helplessness and specific care actions for an adolescent in the public system

RESUMO. Este trabalho apresenta dados preliminares de pesquisa pós-doutoral que investiga, a partir da psicanálise, a noção de 'desamparo' em jovens em situação de vulnerabilidade, na busca por 'ações específicas' de cuidado na prática institucional em dispositivos de políticas públicas. Partimos da interface entre psicanálise e direito, bem como da supervisão de caso sob ação da Justiça Restaurativa. Analisamos, pela metodologia do caso único, um caso de adolescente sob medida protetiva e socioeducativa, do qual são extraídas duas observações orientadoras: a dimensão da transmissão e filiação e do 'desamparo' e da 'ação específica' na adolescência. Como resultado, sistematizamos quatro lógicas de orientação para composição da 'ação específica': o sujeito e a dimensão simbólica, o sujeito e o circuito pulsional, a implicação e a retificação no campo do Outro, e as inflexões sobre a equipe. Concluímos que o desamparo é uma chave de leitura psicanalítica para a noção de vulnerabilidade e que a supervisão institucional favorece a construção melhor orientada para a ação específica de cuidados.

RESUMEN. El documento presenta datos preliminares de la investigación postdoctoral que investiga, desde el psicoanálisis, la noción de impotencia en los jóvenes vulnerables, en busca de coordinadas que establezcan acciones específicas de atención en la práctica clínica e institucional en dispositivos de políticas públicas. Partimos de la interfaz entre el Psicoanálisis y la ley, basada en la supervisión de casos bajo la acción de justicia restaurativa. El estudio de caso analizó un caso de adolescente bajo medidas protectoras y socioeducativas, de las cuales se toman tres observaciones para guiar la discusión: la dimensión de transmisión y afiliación; impotencia y acción específica ante la adolescencia. Como resultado de la supervisión institucional, hemos reunido cuatro planes de lectura guía para su composición: el sujeto y la dimensión simbólica, el sujeto y el circuito de conducción, la implicación y rectificación en el campo del Otro, y las inflexiones en el equipo. Concluimos que la impotencia es una lectura psicoanalítica clave para la noción de vulnerabilidad y que la supervisión institucional favorece una mejor construcción de la atención orientada a la acción.

ABSTRACT This paper presents preliminary data from a postdoctoral research that investigates, from psychoanalysis, the notion of helplessness in vulnerable young people, in the search for specific care actions in clinical and institutional practice in public policy devices. We start from the interface between Psychoanalysis and law, based on a case under supervision for restorative justice action. The study analyzed a case of an adolescent under protective and socio-educational measures, from which two observations are taken to guide the discussion: the dimension of transmission and affiliation, and the helplessness and specific action in the face of adolescence. As a result, we have gathered from institutional supervising four guiding plans for its lecture: the subject and the symbolic dimension, the subject and the drive circuit, the implication and rectification in the Other's field, and the inflections on the team. We conclude that helplessness is a psychoanalytic key for the notion of vulnerability and that institutional supervision favors the construction better oriented towards specific care actions.

Cardiac Pacing Training in Africa: Endorsed by the Africa Heart Rhythm Association (AFHRA): JACC International.

The field of pacing in Africa has evolved in an uncoordinated way across the continent with significant variation in local expertise, cost, and utilization. There are many countries where pacemaker services do not meet one-hundredth of the national demand. Regional, national, and institutional standards for pacemaker qualification and credentials are lacking. This paper reviews the current needs for bradycardia pacing and evaluates what standards should be set to develop pacemaker services in a resource-constrained continent, including the challenges and opportunities of capacity building and training as well as standards for training programs (training prerequisites, case volumes, program content, and evaluation).

Egalitarianism in surgical training: let equity prevail.

This study aimed to quantify core surgical trainee (CST) differential attainment (DA) related to three cohorts; white UK graduate (White UKG) versus black and minority ethnic UKG (BME UKG) versus international medical graduates (IMGs). The primary outcome measures were annual review of competence progression (ARCP) outcome, intercollegiate Membership of the Royal College of Surgeons (iMRCS) examination pass and national training number (NTN) selection. Intercollegiate Surgical Curriculum Programme (ISCP) portfolios of 264 consecutive CSTs (2010-2017, 168 white UKG, 66 BME UKG, 30 IMG) from a single UK regional post graduate medical region (Wales) were examined. Data collected prospectively over an 8-year time period was analysed retrospectively. ARCP outcomes were similar irrespective of ethnicity or nationality (ARCP outcome 1, white UKG 60.7% vs BME UKG 62.1% vs IMG 53.3%, p=0.395). iMRCS pass rates for white UKG vs BME UKG vs IMG were 71.4% vs 71.2% vs 50.0% (p=0.042), respectively. NTN success rates for white UKG vs BME UKG vs IMG were 36.9% vs 36.4% vs 6.7% (p=0.023), respectively. On multivariable analysis, operative experience (OR 1.002, 95% CI 1.001 to 1.004, p=0.004), bootcamp attendance (OR 2.615, 95% CI 1.403 to 4.871, p=0.002), and UKG (OR 7.081, 95% CI 1.556 to 32.230, p=0.011), were associated with NTN appointment. Although outcomes related to BME DA were equitable, important DA variation was apparent among IMGs, with iMRCS pass 21.4% lower and NTN success sixfold less likely than UKG. Targeted counter measures are required to let equity prevail in UK CST programmes.

Measuring and forecasting progress towards the education-related SDG targets.

Education is a key dimension of well-being and a crucial indicator of development1-4. The Sustainable Development Goals (SDGs) prioritize progress in education, with a new focus on inequality5-7. Here we model the within-country distribution of years of schooling, and use this model to explore educational inequality since 1970 and to forecast progress towards the education-related 2030 SDG targets. We show that although the world is largely on track to achieve near-universal primary education by 2030, substantial challenges remain in the completion rates for secondary and tertiary education. Globally, the gender gap in schooling had nearly closed by 2018 but gender disparities remained acute in parts of sub-Saharan Africa, and North Africa and the Middle East. It is predicted that, by 2030, females will have achieved significantly higher educational attainment than males in 18 countries. Inequality in education reached a peak globally in 2017 and is projected to decrease steadily up to 2030. The distributions and inequality metrics presented here represent a framework that can be used to track the progress of each country towards the SDG targets and the level of inequality over time. Reducing educational inequality is one way to promote a fairer distribution of human capital and the development of more equitable human societies.

An Evaluation of a Continuing Education Workshop for Audiologists on the Assessment and Management of Tinnitus.

INTRODUCTION: Tinnitus assessment and management is an important component of audiology. The benefits of continuing education (CE) workshops in the field of tinnitus have not been published. This study evaluated the outcomes of a workshop centered around a Sound Therapy and Aural Rehabilitation for Tinnitus (START) framework. Our hypotheses were that a CE workshop would (1) be useful, (2) improve clinician's knowledge and willingness to undertake tinnitus practice, and (3) result in learners using knowledge gained in their practice. METHODS: Twenty-five participants attending a 3-day tinnitus workshop were invited to complete an evaluation immediately and 3 months after the workshop's completion. The workshop consisted of seminars and practical sessions. The pedagogical approaches employed were experiential (theory building, reflection, and testing) and community of practice (shared experiences). RESULTS: Participants reported on a 5-point Likert scale (1 = not useful-5 = excellent) a high level of satisfaction both immediately after the workshop (ratings of usefulness: mean, 4.8; SD, 0.4; willingness to practice: 4.6; SD. 0.6; ability to manage: 4.6; SD, 0.5; all "excellent" ratings) and 3 months later (ratings of usefulness: mean, 4.2; SD, 0.9, "very useful;" willingness to practice: 4.6; SD, 0.6, "excellent;" ability to manage: 4.1; SD. 0.5, "very useful"). Open-ended questions indicated participants made changes in their practice that reflected material provided in the CE. CONCLUSION: The workshop was successful in improving knowledge and confidence of audiologists in undertaking tinnitus assessment and management, but the need for ongoing support and supervision was a common theme.

Three Decades and Counting: HIV Service Provision in Outpatient Mental Health Settings.

OBJECTIVE: People with serious mental illness in the United States have higher human immunodeficiency virus (HIV) infection rates than the general U.S. population. This study aimed to assess delivery of HIV services in New York State's outpatient mental health programs. Greater access would enhance efforts to improve HIV prevention and care outcomes. METHODS: The authors surveyed directors of licensed outpatient mental health care programs statewide to investigate their HIV service delivery. Data were compared with surveys conducted in 1997 and 2004 in order to examine differences in services between geographic regions and time periods. RESULTS: Outpatient mental health programs have improved in the volume and range of HIV services offered, but their provision of preexposure prophylaxis, condoms, HIV testing, and HIV antiretroviral treatment monitoring has lagged. CONCLUSIONS: New York's initiative to end the HIV epidemic is not optimized to reach people with serious mental illness in settings designed for their care.

Addressing Health Disparities in Medical Education and Clinical Practice.

Health and health care disparities are present in every medical specialty, and stem from multiple etiologies. Within health care itself, issues mostly arise within medical providers and across a system with an inequitable distribution of care and resources. One potential way to address disparities is to educate our workforce, to not only know about disparities but to also actively advocate for underresourced and marginalized patients. In this review, the authors describe efforts being conducted in graduate medical education and seek to elucidate some of the curricula currently being developed and implemented in rheumatology.

Standard Setting of Competency in Mastoidectomy for the Cross-Institutional Mastoidectomy Assessment Tool.

OBJECTIVE: Competency-based surgical training involves progressive autonomy given to the trainee. This requires systematic and evidence-based assessment with well-defined standards of proficiency. The objective of this study is to develop standards for the cross-institutional mastoidectomy assessment tool to inform decisions regarding whether a resident demonstrates sufficient skill to perform a mastoidectomy with or without supervision. METHODS: A panel of fellowship-trained content experts in mastoidectomy was surveyed in relation to the 16 items of the assessment tool to determine the skills needed for supervised and unsupervised surgery. We examined the consensus score to investigate the degree of agreement among respondents for each survey item as well as additional analyses to determine whether the reported skill level required for each survey item was significantly different for the supervised versus unsupervised level. RESULTS: Ten panelists representing different US training programs responded. There was considerable consensus on cut-off scores for each item and trainee level between panelists, with moderate (0.62) to very high (0.95) consensus scores depending on assessment item. Further analyses demonstrated that the difference between supervised and unsupervised skill levels was significantly meaningful for all items. Finally, minimum-passing scores for each item was established. CONCLUSION: We defined performance standards for the cross-institutional mastoidectomy assessment tool using the Angoff method. These cut-off scores that can be used to determine when trainees can progress from performance under supervision to performance without supervision. This can be used to guide training in a competency-based training curriculum.

The Association of Urologic Oncology Fellowship Training and Diagnostic Yield of Prostate Biopsy.

OBJECTIVE: To determine the relationship between urologic oncology fellowship training (UOFT) and diagnostic yield of prostate biopsy. METHODS: Retrospective review was conducted of patients who underwent prostate biopsy across the Cleveland Clinic between 2000 and 2018. Biopsies done by urologists with and without UOFT were detailed via descriptive statistics and appropriate (chi-square, Student t, Wilcoxon rank-sum) tests. Multivariate logistic regression was used to examine the association between UOFT and positive prostate biopsy, adjusting for relevant covariates. RESULTS: A total of 11,241 biopsies by 129 urologists had complete information available for review. Sixteen urologists (12.4%) had UOFT; 113 either completed a different fellowship or no fellowship. Those with UOFT were more likely to use MRI-guided biopsy (7.80% vs 3.05%, P <.0001), more likely to get a positive biopsy (41.25% vs 32.72%, P <.0001), and more likely to obtain an adequate number (by ≥12) of cores (90.25% vs 74.53%, P <.0001). UOFT remained a significant predictor of positivity when adjusting for patient age and race, PSA, 5-alpha-reductase-inhibitor use, year of biopsy, years in practice, and type of biopsy (MRI or transrectal ultrasound guided). UOFT also predicted higher-risk biopsy (Gleason sum ≥7), adjusting for the same variables, though this association lost significance when adjusting for adequacy of biopsy. The learning curve to achieve a higher percentage of positive biopsies was steeper for nonurologic oncology fellowship trained than for UOFT urologists. CONCLUSION: UOFT is associated with higher diagnostic yield on prostate biopsy, higher uptake of MRI-guided biopsy, and less steep learning curve. This may be due to patient selection, technique, or, as we demonstrate here, adherence to guidelines.

Workshop Report: FDA Workshop on Improving Cardiotoxicity Assessment With Human-Relevant Platforms.

Given that cardiovascular safety concerns remain the leading cause of drug attrition at the preclinical drug development stage, the National Center for Toxicological Research of the US Food and Drug Administration hosted a workshop to discuss current gaps and challenges in translating preclinical cardiovascular safety data to humans. This white paper summarizes the topics presented by speakers from academia, industry, and government intended to address the theme of improving cardiotoxicity assessment in drug development. The main conclusion is that to reduce cardiovascular safety liabilities of new therapeutic agents, there is an urgent need to integrate human-relevant platforms/approaches into drug development. Potential regulatory applications of human-derived cardiomyocytes and future directions in employing human-relevant platforms to fill the gaps and overcome barriers and challenges in preclinical cardiovascular safety assessment were discussed. This paper is intended to serve as an initial step in a public-private collaborative development program for human-relevant cardiotoxicity tools, particularly for cardiotoxicities characterized by contractile dysfunction or structural injury.

Educational expansion and health disparities in Ethiopia, 2005-2016.

Research shows that basic education improves population health, yet it remains unclear whether the expansion of primary education decreases health disparities. In this paper, I assess whether disparities in healthcare utilization decreased in conjunction with educational expansion among women of reproductive age in Ethiopia. Healthcare utilization rates in low-resource countries are often confounded with simultaneous developments in education and access to basic healthcare. Using decomposition of rates, I first disentangle the changes in health disparities induced by educational expansion from the overall increase in healthcare utilization. Then, I use the Blinder-Oaxaca decomposition method to investigate the determinants of disparities in healthcare utilization and how these determinants changed over a 10-year period as primary education became more prevalent. Overall, disparities in healthcare utilization in Ethiopia decreased over time, yet the association between educational expansion and health disparities varies by region. Literacy explains much of the disparities in healthcare utilization, yet it loses significance over time as primary education becomes widespread. Economic factors remain persistent sources of disparities, and non-financial barriers such as the distance to travel and women's ability to travel alone become more significant. Heterogeneity in healthcare utilization across regions has distinct implications for how educational expansion may shift health disparities.