The effects of the Veterans Health Administration's Referral Coordination Initiative on referral patterns and waiting times for specialty care.

OBJECTIVE: To investigate whether the Veterans Health Administration's (VA) 2019 Referral Coordination Initiative (RCI) was associated with changes in the proportion of VA specialty referrals completed by community-based care (CC) providers and mean appointment waiting times for VA and CC providers. DATA SOURCES/STUDY SETTINGS: Monthly facility level VA data for 3,097,366 specialty care referrals for eight high-volume specialties (cardiology, dermatology, gastroenterology, neurology, ophthalmology, orthopedics, physical therapy, and podiatry) from October 1, 2019 to May 30, 2022. STUDY DESIGN: We employed a staggered difference-in-differences approach to evaluate RCI's effects on referral patterns and wait times. Our unit of analysis was facility-month. We dichotomized facilities into high and low RCI use based on the proportion of total referrals for a specialty. We stratified our analysis by specialty and the staffing model that high RCI users adopted: centralized, decentralized, and hybrid. DATA COLLECTION/EXTRACTION METHODS: Administrative data on referrals and waiting times were extracted from the VA's corporate data warehouse. Data on staffing models were provided by the VA's Office of Integrated Veteran Care. PRINCIPAL FINDINGS: We did not reject the null hypotheses that high RCI use do not change CC referral rates or waiting times in any of the care settings for most specialties. For example, high RCI use for physical therapy-the highest volume specialty studied-was associated with -0.054 (95% confidence interval [CI]: -0.114 to 0.006) and 2.0 days (95% CI: -4.8 to 8.8) change in CC referral rate and waiting time at CC providers, respectively, among centralized staffing model adopters. CONCLUSIONS: In the initial years of the RCI program, RCI does not have a measurable effect on waiting times or CC referral rates. Our findings do not support concerns that RCI might be impeding Veterans' access to CC providers. Future evaluations should examine whether RCI facilitates Veterans' ability to receive care in their preferred setting.

US Postgraduate Trainee Racial, Ethnic, and Gender Representation and Faculty Compensation By Specialty.

This study compares postgraduate trainee racial, ethnic, and gender representation and faculty compensation for 21 clinical specialties using 2015-2022 data.

Workplace Harassment, Cyber Incivility, and Climate in Academic Medicine.

Importance: The culture of academic medicine may foster mistreatment that disproportionately affects individuals who have been marginalized within a given society (minoritized groups) and compromises workforce vitality. Existing research has been limited by a lack of comprehensive, validated measures, low response rates, and narrow samples as well as comparisons limited to the binary gender categories of male or female assigned at birth (cisgender). Objective: To evaluate academic medical culture, faculty mental health, and their relationship. Design, Setting, and Participants: A total of 830 faculty members in the US received National Institutes of Health career development awards from 2006-2009, remained in academia, and responded to a 2021 survey that had a response rate of 64%. Experiences were compared by gender, race and ethnicity (using the categories of Asian, underrepresented in medicine [defined as race and ethnicity other than Asian or non-Hispanic White], and White), and lesbian, gay, bisexual, transgender, queer (LGBTQ+) status. Multivariable models were used to explore associations between experiences of culture (climate, sexual harassment, and cyber incivility) with mental health. Exposures: Minoritized identity based on gender, race and ethnicity, and LGBTQ+ status. Main Outcomes and Measures: Three aspects of culture were measured as the primary outcomes: organizational climate, sexual harassment, and cyber incivility using previously developed instruments. The 5-item Mental Health Inventory (scored from 0 to 100 points with higher values indicating better mental health) was used to evaluate the secondary outcome of mental health. Results: Of the 830 faculty members, there were 422 men, 385 women, 2 in nonbinary gender category, and 21 who did not identify gender; there were 169 Asian respondents, 66 respondents underrepresented in medicine, 572 White respondents, and 23 respondents who did not report their race and ethnicity; and there were 774 respondents who identified as cisgender and heterosexual, 31 as having LGBTQ+ status, and 25 who did not identify status. Women rated general climate (5-point scale) more negatively than men (mean, 3.68 [95% CI, 3.59-3.77] vs 3.96 [95% CI, 3.88-4.04], respectively, P < .001). Diversity climate ratings differed significantly by gender (mean, 3.72 [95% CI, 3.64-3.80] for women vs 4.16 [95% CI, 4.09-4.23] for men, P < .001) and by race and ethnicity (mean, 4.0 [95% CI, 3.88-4.12] for Asian respondents, 3.71 [95% CI, 3.50-3.92] for respondents underrepresented in medicine, and 3.96 [95% CI, 3.90-4.02] for White respondents, P = .04). Women were more likely than men to report experiencing gender harassment (sexist remarks and crude behaviors) (71.9% [95% CI, 67.1%-76.4%] vs 44.9% [95% CI, 40.1%-49.8%], respectively, P < .001). Respondents with LGBTQ+ status were more likely to report experiencing sexual harassment than cisgender and heterosexual respondents when using social media professionally (13.3% [95% CI, 1.7%-40.5%] vs 2.5% [95% CI, 1.2%-4.6%], respectively, P = .01). Each of the 3 aspects of culture and gender were significantly associated with the secondary outcome of mental health in the multivariable analysis. Conclusions and Relevance: High rates of sexual harassment, cyber incivility, and negative organizational climate exist in academic medicine, disproportionately affecting minoritized groups and affecting mental health. Ongoing efforts to transform culture are necessary.

Black men in white coats - Barriers black men face in medicine, implications to decreased representation, and potential interventions at the uniformed services university of the health sciences.

The number of black male applicants to US medical schools has remained stagnant over the last 30 years. The etiology behind the lack of applicants is multifaceted and involves greater systemic barriers, specifically, educational and social barriers. The lack of representation of black males in medicine also has downstream implications for the health of the African American/black community. African Americans exhibit some of the lowest levels of trust in the healthcare system, have less access to care than their non-minority peers, and have, comparatively, poorer healthcare outcomes than other populations in the US. Research has demonstrated that patient-provider race concordance improves communication, outcomes, culturally competent care, and satisfaction with care. The greater the gap between these two populations, the harder it becomes to improve healthcare outcomes, maintain a medically ready fighting force in the US military, and improve trust in the healthcare system. This article provides an analysis of the multifactorial barriers black male applicants face applying, matriculating, and graduating medical school and how decreased representation may affect healthcare delivery. Furthermore, this review explores next steps and potential implementations at the Uniformed Services University of the Health Sciences to address the above deficiencies.

Medicine, Machines, and Medical Education.

While advances in science and technology continue to be at the forefront of the evolution of medical practice, the 21st century is also undergoing a unique and profound cultural shift that is changing the very nature of what it means to be a medical professional, namely humankind's transition to an information-based internet society. Medical care will increasingly depend on computer-generated probabilities guided and supported by a growing variety of individuals in health care-related professions, including statisticians, technologists, and information managers. Perhaps the biggest challenge to the profession will come from the erosion of professional autonomy, driven by smart machines, social networks, and internet search engines. As a result of these and other changes, physicians are facing a systematic loss of control, often without the direct input and leadership of the profession itself. In this commentary, the author urges the profession to adopt several strategies, including shifting its focus from reimbursement to the care patients value most, meaningfully addressing critical issues in health policy, becoming the definitive source for publicly available medical information, reimagining medical education, and overhauling the existing accreditation and licensing systems. Medical education must go beyond a focus on physicians whose professional identity revolves around being the exclusive source of medical knowledge. In the digitized 21st century, medical education should emphasize the centrality of the humanistic interface with patients such that the doctor-patient relationship is paramount in the complex medical world of machines and social media. Removing the roadblocks to successful professional reform is no small task, but the process can begin with a grassroots movement that empowers physicians and facilitates organizational and behavioral change. Failure to take action may well hasten the diminishment of patient care and the profession's trusted role in society.

COVID-19 Threatens Progress Toward Gender Equity Within Academic Medicine.

Women remain underrepresented within academic medicine despite past and present efforts to promote gender equity. The authors discuss how the COVID-19 pandemic could stymie progress toward gender parity within the biomedical workforce and limit the retention and advancement of women in science and medicine. Women faculty face distinct challenges as they navigate the impact of shelter-in-place and social distancing on work and home life. An unequal division of household labor and family care between men and women means women faculty are vulnerable to inequities that may develop in the workplace as they strive to maintain academic productivity and professional development without adequate assistance with domestic tasks and family care. Emerging data suggest that gender differences in academic productivity may be forthcoming as a direct result of the pandemic. Existing gender inequities in professional visibility, networking, and collaboration may be exacerbated as activities transition from in-person to virtual environments and create new barriers to advancement. Meanwhile, initiatives designed to promote gender equity within academic medicine may lose key funding due to the economic impact of COVID-19 on higher education. To ensure that the gender gap within academic medicine does not widen, the authors call upon academic leaders and the broader biomedical community to support women faculty through deliberate actions that promote gender equity, diversity, and inclusion. The authors provide several recommendations, including faculty needs assessments; review of gender bias within tenure-clock-extension offers; more opportunities for mentorship, sponsorship, and professional recognition; and financial commitments to support equity initiatives. Leadership for these efforts should be at the institutional and departmental levels, and leaders should ensure a gender balance on task forces and committees to avoid overburdening women faculty with additional service work. Together, these strategies will contribute to the development of a more equitable workforce capable of transformative medical discovery and care.

Admissions Is Not Enough: The Racial Achievement Gap in Medical Education.

The achievement gap is a disparity in academic and standardized test performance that exists between White and underrepresented minority (URM) students that begins as early as preschool and worsens as students progress through the educational system. Medical education is not immune to this inequality. URM medical students are more likely to experience delayed graduation and course failure, even after accounting for science grade point average and Medical College Admission Test performance. Moreover, URM students are more likely to earn lower scores on licensing examinations, which can have a significant impact on their career trajectory, including specialty choice and residency competitiveness. After the release of preliminary recommendations from the Invitational Conference on USMLE Scoring (InCUS) and public commentary on these recommendations, the National Board of Medical Examiners and Federation of State Medical Boards announced that the United States Medical Licensing Examination (USMLE) Step 1 would transition from a 3-digit numeric score to pass/fail scoring. Given that another of InCUS's recommendations was to "minimize racial demographic differences that exist in USMLE performance," it is paramount to consider the impact of this scoring change on URM medical students specifically. Holistic admissions are a step in the right direction of acknowledging that URM students often travel a further distance to reach medical school. However, when residency programs emphasize USMLE performance (or any standardized test score) despite persistent test score gaps, medical education contributes to the disproportionate harm URM students face and bolsters segregation across medical specialties. This Perspective provides a brief explanation of the achievement gap, its psychological consequences, and its consequences in medical education; discusses the potential effect of the Step 1 scoring change on URM medical students; and provides a review of strategies to redress this disparity.

Equity in utilization of health care services in Turkey: an index based analysis.

BACKGROUND: Equity in the use of health care services is an issue which has increasingly been on the health policy agenda over recent years in both middle- and low-income countries. AIMS: The purpose of this study was to investigate the degree and progress of equity in health care utilization in Turkey during 2008-2012. METHODS: Wed use data from health surveys (2008, 2010, 2012) conducted by the Turkish Statistical Institute. The concentration index (CI) and the horizontal equity index (HI) were calculated as a measure of equity, and a Blinder-Oaxaca decomposition analysis was applied. RESULTS: The general practitioner (GP), specialist and inpatient visits display a pro-poor orientation. Averages of the CI and HI indices for 2008-2012 were 0.74 and -0.17 for GP visits, 0.75 and -0.13 for specialist visits, 0.83 and -0.31 for inpatient visits. CONCLUSION: Our findings indicate that health care utilization in Turkey appears to have become equitable over the years; however, the sustainability of equity is an issue of concern.

Characteristics, management and medical costs of patients with depressive disorders admitted in primary and specialised care centres in Spain between 2011 and 2016.

More than 10% of the population will suffer from a depressive disorder during their lifetime, which represents a substantial economic and social burden for healthcare systems and societies. Nonetheless, studies suggest that an important percentage of patients receive inadequate treatment. This study aimed to evaluate the characteristics of patients with depressive disorder in Spain, the current management of these disorders and the costs of specialised care. A retrospective multicentre study was designed including admission records from patients admitted due to a depressive disorder between 2011 and 2016, extracted from a Spanish claims database. The records obtained corresponded to 306,917 patients attended in primary care centres and 27,963 patients registered in specialised care settings. The number of admissions per patient progressively increased over the study period. A correlation was found with socioeconomic factors as the unemployment rate, increased versus the general population (OR = 1.41; 95%CI = 1.38-1.43). Equally, comorbid conditions as hypertension, disorders of lipoid metabolism, diabetes type II, other mood disorders and thyroid disorders were associated with severe presentations of a depressive disorder. In terms of disease management, patients with a severe disorder were the majority in specialised care settings, and most admissions were urgent and inpatient admissions. The use of both electroconvulsive therapy and drug therapy increased during the study period. In terms of costs, specialised care represented an annual cost of €9,654 per patient, and a total annual cost of €44,839,196. Altogether, improved detection and treatment protocols could contribute in reducing the burden that depressive disorders represent for the Spanish National Healthcare System.

Factors involved in seeking care at a specialty service among alcoholic rural French women: A cross-sectional study of rural women.

BACKGROUND: Few studies of mental health or substance abuse have focused on rural life. This study aimed to evaluate the association between socio-demographic and clinical characteristics and the probability of rural alcoholic women seeking help on their own at a specialty treatment service. METHODS: This exploratory study used a cross-sectional design to collect data from alcoholic women upon admission to a French outpatient department. Multiple logistic regression models tested whether the socio-demographic and clinical characteristics of these women predicted the likelihood that they would seek treatment at a specialty service on their own. RESULTS: Among 50 rural alcoholic women, the probability of seeking help on their own at a specialty treatment service was 5.6 times greater (95% CI 1.2-25.7, P=0.03) for participants with a history of physical and/or sexual trauma and 5.1 times greater (95% CI 1.1-24, P=0.03) among women with no complementary health insurance. CONCLUSION: Increased knowledge of the specific characteristics of rural alcoholic women is needed to develop programs that will increase awareness of and access to specialty treatment services among these women.

Stress among medical students during clinical courses: a longitudinal study using contextual activity sampling system.

OBJECTIVES: To investigate medical students' experiences of stress and other emotions related to their professional roles, as defined by the CanMEDS framework, by using the Contextual Activity Sampling System (CASS). METHODS: Ninety-eight medical students agreed to participate of whom 74 completed this longitudinal cohort study. Data was collected between 6th and 8th term via CASS methodology: A questionnaire was e-mailed to the participants every 3rd week(21questionnaires/measurements) during clinical rotations and scientific project work term. Emotions were measured by a 7-point Likert scale (e.g., maximum stress = 7). Answers were registered through mobile technology. We used a linear mixed-model regression approach to study the association between stress over time in relation to socio-demographic and learning activities related to CanMEDS roles. RESULTS: Participants completed 1390 questionnaires. Mean stress level over all time points was 3.6. Stress was reported as highest during the scientific project term. Learning activities related to 'Communicator,' 'Collaborator,' 'Scholar,' 'Manager' and 'Professional' were associated with increased stress, e.g. 'Scholar' increased stress with 0.5 points (t(1339)=3.91, p<0.001). A reduced level of stress was associated with 'Health Advocate' of 0.39 points (t(1338)=-2.15, p=0.03). No association between perceived stress and demographic factors, such as gender or age was found. CONCLUSIONS: An association between different learning activities related to CanMEDS Roles and feelings of stress were noted. The CASS methodology was found to be useful when observing learning experiences and might support educational development by identifying course activities linked to stress.

The Prevalence of Faculty Physician Burnout in Military Graduate Medical Education Training Programs: A Cross-Sectional Study of Academic Physicians in the United States Department of Defense.

INTRODUCTION: In military populations, physician burnout has potential to adversely affect medical readiness to deploy in support of joint operations. Burnout among Graduate Medical Education (GME) faculty may further threaten the welfare of the medical force given the central role these officers have in training and developing junior physicians. The primary aim of this investigation was to estimate the prevalence of burnout among faculty physicians in United States (US) Army, Navy, and Air Force GME programs. MATERIALS AND METHODS: We conducted a cross-sectional study of faculty physicians at US military GME training programs between January 2018 and July 2018. Through direct coordination with Designated Institutional Officials, we administered the Maslach Burnout Inventory Health Services Survey (MBI-HSS) via online web link to faculty physicians listed in Accreditation Data System at each sponsoring institution. In addition to the MBI-HSS, we collected demographic data and queried physicians about common occupational stressors in order to assist institutional leaders with identifying at-risk physicians and developing future interventions to address burnout. RESULTS: Sixteen of 21 institutions that currently sponsor military GME programs agreed to distribute the MBI-HSS survey to core faculty. We received completed assessments from 622 of the 1,769 (35.1%) reported physician core faculty at these institutions. Of the 622 physician respondents, 162 demonstrated high levels of emotional exhaustion and depersonalization for an estimated 26% prevalence of burnout. We identified only one independent risk factor for burnout: increasing numbers of deployments (OR 1.38, 95% CI 1.07-1.77). Physicians in our cohort who reported a desire to stay beyond their initial active duty service obligation were less likely to be classified with burnout (OR 0.45, 95% CI 0.26-0.77). The most common drivers of occupational distress were cumbersome bureaucratic tasks, insufficient administrative support, and overemphasis on productivity metrics. CONCLUSIONS: We estimate that 26% of physician faculty in military GME programs are experiencing burnout. No specialty, branch of service, or specific demographic was immune to burnout in our sample. Institutional leaders in the MHS should take action to address physician burnout and consider using our prevalence estimate to assess effectiveness of future interventions.

Challenges and Opportunities for Using Big Health Care Data to Advance Medical Science and Public Health.

Methodological advancements in epidemiology, biostatistics, and data science have strengthened the research world's ability to use data captured from electronic health records (EHRs) to address pressing medical questions, but gaps remain. We describe methods investments that are needed to curate EHR data toward research quality and to integrate complementary data sources when EHR data alone are insufficient for research goals. We highlight new methods and directions for improving the integrity of medical evidence generated from pragmatic trials, observational studies, and predictive modeling. We also discuss needed methods contributions to further ease data sharing across multisite EHR data networks. Throughout, we identify opportunities for training and for bolstering collaboration among subject matter experts, methodologists, practicing clinicians, and health system leaders to help ensure that methods problems are identified and resulting advances are translated into mainstream research practice more quickly.

[Health care claims per medical specialty in the Netherlands: a 10-year overview]. / Schadeclaims per medisch specialisme.

OBJECTIVE: To analyse the quantity and size of health care claims per medical specialty in the past 10 years. DESIGN: Descriptive, evaluative and comparative study. METHOD: Anonymised damage claim data from Centramed and MediRisk were used for this study. The numbers and sizes of the claims per specialty have been analysed over a ten-year period and plotted against production numbers of the various specialties, calculated on the basis of DBC data. All damage claims were related to regular hospital care in the Netherlands and were submitted or closed in the period from 1 January 2007 to 31 December 2016. RESULTS: A total of 15,115 claims were submitted during the period under study. 16.2% of these were related to non-surgical specialties, 64.7% to surgical specialties, 10.8% to supporting specialties, 0.7% to paramedics working at the hospital and the specialty was impossible to find out for 7.6% of them. The total cost of all damage claims closed during the study period was € 229,224,433. Of the total damage burden, 19% was paid out to patients with claims against non-surgical specialties and 63% to patients with claims against surgical specialties. General surgery, orthopaedics and gynaecology together were responsible for 47% of all submitted claims for damages and for 52% of the damage burden. CONCLUSION: General surgery, orthopaedics and gynaecology invariably are, just as in previous studies, the specialties with the highest number of damage claims and the largest damage burden. Even when corrected for production volumes, these specialties comparatively have the most and most expensive damage claims.