Quantifying hierarchy and dynamics in US faculty hiring and retention.

Faculty hiring and retention determine the composition of the US academic workforce and directly shape educational outcomes1, careers2, the development and spread of ideas3 and research priorities4,5. However, hiring and retention are dynamic, reflecting societal and academic priorities, generational turnover and efforts to diversify the professoriate along gender6-8, racial9 and socioeconomic10 lines. A comprehensive study of the structure and dynamics of the US professoriate would elucidate the effects of these efforts and the processes that shape scholarship more broadly. Here we analyse the academic employment and doctoral education of tenure-track faculty at all PhD-granting US universities over the decade 2011-2020, quantifying stark inequalities in faculty production, prestige, retention and gender. Our analyses show universal inequalities in which a small minority of universities supply a large majority of faculty across fields, exacerbated by patterns of attrition and reflecting steep hierarchies of prestige. We identify markedly higher attrition rates among faculty trained outside the United States or employed by their doctoral university. Our results indicate that gains in women's representation over this decade result from demographic turnover and earlier changes made to hiring, and are unlikely to lead to long-term gender parity in most fields. These analyses quantify the dynamics of US faculty hiring and retention, and will support efforts to improve the organization, composition and scholarship of the US academic workforce.

Job-search basics: how to convert a CV into a resume.

For broad scientific careers, resumes serve as critical job-search tools. This Commentary provides a strategy for writing an effective resume for searching for a nonacademic job.

Quality Indicators for Major Depressive Disorder in Adults: A Review of Performance Measures by the American College of Physicians.

Major depressive disorder (MDD) is a severe mood disorder that affects at least 8.4% of the adult population in the United States. Characteristics of MDD include persistent sadness, diminished interest in daily activities, and a state of hopelessness. The illness may progress quickly and have devastating consequences if left untreated. Eight performance measures are available to evaluate screening, diagnosis, and successful management of MDD. However, many performance measures do not meet the criteria for validity, reliability, evidence, and meaningfulness.The American College of Physicians (ACP) embraces performance measurement as a means to externally validate the quality of care of practices, medical groups, and health plans and to drive reimbursement processes. However, a plethora of performance measures that provide low or no value to patient care have inundated physicians, practices, and systems and burdened them with collecting and reporting of data. The ACP's Performance Measurement Committee (PMC) reviews performance measures using a validated process to inform regulatory and accreditation bodies in an effort to recognize high-quality performance measures, address gaps and areas for improvement in performance measures, and help reduce reporting burden. Out of 8 performance measures, the PMC found only 1 measure (suicide risk assessment) that was valid at all levels of attribution. This paper presents a review of MDD performance measures and highlights opportunities to improve performance measures addressing MDD management.

The Leaders in Epidemiology, Antimicrobial Stewardship, and Public Health (LEAP) Fellowship, a Novel Training Program in Public Health for Infectious Diseases Physicians.

The severe acute respiratory syndrome coronavirus 2 pandemic demonstrated a critical need for partnerships between practicing infectious diseases (ID) physicians and public health departments. The soon-to-launch combined ID and Epidemic Intelligence Service fellowship can only address a fraction of this need, and otherwise US ID training lacks development pathways for physicians aiming to make careers working with public health departments. The Leaders in Epidemiology, Antimicrobial Stewardship, and Public Health (LEAP) fellowship is a model compatible with the current training paradigm with a proven track record of developing careers of long-term collaboration. Established in 2017 by the ID Society of America, Society for Healthcare Epidemiology of America, Pediatric ID Society, and supported by the Centers for Disease Control and Prevention, LEAP is a single-year in-place, structured training for senior trainees and early career ID physicians. In this viewpoint, we describe the LEAP fellowship, its outcomes, and how it could be adapted into ID training.

Metformin and other anti-diabetic medication use and breast cancer incidence in the Nurses' Health Studies.

We aimed to examine the association between the use of metformin and other anti-diabetic medications and breast cancer incidence within two large prospective cohort studies. We followed 185,181 women who participated in the Nurses' Health Study (NHS; 1994-2016) and the NHSII (1995-2017), with baseline corresponding to the date metformin was approved for type 2 diabetes (T2D) treatment in the US Information on T2D diagnosis, anti-diabetes medications, and other covariates was self-reported at baseline and repeatedly assessed by follow-up questionnaires every 2 years. Breast cancer cases were self-reported and confirmed by medical record review. Hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between medication use and breast cancer were estimated using Cox proportional hazards regression models, adjusting for breast cancer risk factors. During 3,324,881 person-years of follow-up, we ascertained 9,192 incident invasive breast cancer cases, of which 451 were among women with T2D. Compared with women without T2D (n = 169,263), neither metformin use (HR = 0.97; 95% CI = 0.81-1.15) nor other anti-diabetic medications use (HR = 1.11; 95% CI = 0.90-1.36) associated with significantly lower breast cancer incidence. Among women with T2D (n = 15,918), compared with metformin never users, metformin ever use was not significantly inversely associated with breast cancer (HR = 0.92; 95% CI = 0.74-1.15). Although we observed that past use of metformin was inversely associated with breast cancer in the T2D population (HR = 0.67; 95% CI = 0.48-0.94), current use (HR = 1.01; 95% CI = 0.80-1.27) and longer duration of metformin use were not associated with breast cancer (each 2-year interval: HR = 1.01; 95% CI = 0.95-1.07). Overall, metformin use was not associated with the risk of developing breast cancer among the overall cohort population or among women with T2D.

At the Intersection of Intersectionality: Race and Gender Diversity Among Surgical Faculty and Trainees.

OBJECTIVE: To compare the representation of intersectional (ie, racial/ethnic and gender) identities among surgical faculty versus medical students. BACKGROUND: Health disparities are pervasive in medicine, but diverse physicians may help the medical profession achieve health equity. METHODS: Data from the Association of American Medical Colleges for 140 programs (2011/2012-2019/2020) were analyzed for students and full-time surgical faculty. Underrepresented in medicine (URiM) was defined as Black/African American, American Indian/Alaskan Native, Hispanic/Latino/Spanish Origin, or Native Hawaiian/Other Pacific Islander. Non-White included URiM plus Asian, multiracial, and non-citizen permanent residents. Linear regression was used to estimate the association of year and proportions of URiM and non-White female and male faculty with proportions of URiM and non-White students. RESULTS: Medical students were comprised of more White (25.2% vs 14.4%), non-White (18.8% vs 6.6%), and URiM (9.6% vs 2.8%) women and concomitantly fewer men across all groups versus faculty (all P < 0.01). Although the proportion of White and non-White female faculty increased over time (both P ≤ 0.001), there was no significant change among non-White URiM female faculty, nor among non-White male faculty, regardless of whether they were URiM or not. Having more URiM male faculty was associated with having more non-White female students (estimate = +14.5% students/100% increase in faculty, 95% CI: 1.0% to 8.1%, P = 0.04), and this association was especially pronounced for URiM female students (estimate = +46.6% students/100% increase in faculty, 95% CI: 36.9% to 56.3%, P < 0.001). CONCLUSIONS: URiM faculty representation has not improved despite a positive association between having more URiM male faculty and having more diverse students.

Impact of Medical Training Programs on Time-to-Fill Physician Vacancies at the Veterans Health Administration.

BACKGROUND: The Department of Veterans Affairs (VA) provides the largest Graduate Medical Education (GME) training platform for health professionals in the United States. Studies on the impact of VA GME programs on physician recruitment were lacking. OBJECTIVES: To examine the impact of the size of residency training programs at a VA facility on the facility's time-to-fill physician vacancies, and whether the impact differs by the socioeconomic deprivation and public school quality of the geographic area. PROJECT DESIGN: We constructed an instrumental variable for training program size by interacting the facility clinicians share with the total training allocation nationally. SUBJECTS: Our evaluation used national data on filled physician vacancies in the VA that were posted between 2020 and 2021. MEASURES: The outcome evaluated was time-to-fill physician vacancies. Our explanatory variable was the facility-year level number of physician residency slots. RESULTS: For positions posted in 2020, an increase of one training slot was significantly associated with a decrease of 1.33 days to fill physician vacancies (95% CI, 0.38-2.28) in facilities in less deprived areas, a decrease of 1.50 days (95% CI, 0.75-2.25) in facilities with better public schools, a decrease of 3.30 days (95% CI, 0.85-5.76) in facilities in both less deprived areas and better public schools. We found similar results for positions posted in 2020 and 2021 when limiting time-to-fill to <500 days. CONCLUSIONS: We found that increasing the size of the residency program at a VA facility could decrease the facility's time-to-fill vacant physician positions in places with less socioeconomic deprivation or better public schools.

Better Nurse Practitioner Primary Care Practice Environments Reduce Hospitalization Disparities Among Dually-Enrolled Patients.

BACKGROUND: Over 12 million Americans are dually enrolled in Medicare and Medicaid. These individuals experience over twice as many hospitalizations for chronic diseases such as coronary artery disease and diabetes compared with Medicare-only patients. Nurse practitioners (NPs) are well-positioned to address the care needs of dually-enrolled patients, yet NPs often work in unsupportive clinical practice environments. The purpose of this study was to examine the association between the NP primary care practice environment and hospitalization disparities between dually-enrolled and Medicare-only patients with chronic diseases. METHODS: Using secondary cross-sectional data from the Nurse Practitioner Primary Care Organizational Climate Questionnaire and Medicare claims files, we examined 135,648 patients with coronary artery disease and/or diabetes (20.0% dually-eligible, 80.0% Medicare-only), cared for in 450 practices employing NPs across 4 states (PA, NJ, CA, FL) in 2015. We compared dually-enrolled patients' odds of being hospitalized when cared for in practice environments characterized as poor, mixed, and good based on practice-level Nurse Practitioner Primary Care Organizational Climate Questionnaire scores. RESULTS: After adjusting for patient and practice characteristics, dually-enrolled patients in poor practice environments had the highest odds of being hospitalized compared with their Medicare-only counterparts [odds ratio (OR): 1.48, CI: 1.37, 1.60]. In mixed environments, dually-enrolled patients had 27% higher odds of a hospitalization (OR: 1.27, CI: 1.12, 1.45). However, in the best practice environments, hospitalization differences were nonsignificant (OR: 1.02, CI: 0.85, 1.23). CONCLUSIONS: As policymakers look to improve outcomes for dually-enrolled patients, addressing a modifiable aspect of care delivery in NPs' clinical practice environment is a key opportunity to reduce hospitalization disparities.

A Qualitative Study of Drivers for Use of the Primary Care Exception Among Internal Medicine Teaching Faculty.

BACKGROUND: The Primary Care Exception (PCE) is a billing rule from the Centers for Medicare and Medicaid Services (CMS) that allows supervising physicians to bill for ambulatory care provided by a resident without their direct supervision. There has been increased focus on entrustment as a method to assess readiness for unsupervised practice. OBJECTIVE: To understand the factors influencing attending physicians' use of the PCE in ambulatory settings and identify common themes defining what motivates faculty preceptors to use the PCE. APPROACH: This was a qualitative exploratory study. Participants were interviewed one-on-one using a semi-structured template informed by the entrustment literature. Analysis was conducted using a thematically framed, grounded theory-based approach to identify major themes and subthemes. PARTICIPANTS: Twenty-seven internal medicine teaching faculty took part in a multi-institutional study representing four residency training programs across two academic medical centers in Connecticut. KEY RESULTS: Four predominant categories of themes influencing PCE use were identified: (1) clinical environment factors, (2) attending attitudes, (3) resident characteristics, and (4) patient attributes. An attending's "internal rules" drawn from prior experiences served as a significant driver of PCE non-use regardless of the trainee, patient, or clinical context. A common conflict existed between using the PCE to promote resident autonomy versus waiving the PCE to promote safety. CONCLUSIONS: The PCE can serve as a tool to support resident autonomy, confidence, and overall clinical efficiency. Choice of PCE use by attendings involved complex internal decision-making schema balancing internal, patient, resident, and environmental-related factors. The lack of standardized processes in competency evaluation may increase susceptibility to biases, which could be mitigated by applying standardized modes of assessment that encompass shared principles.

Compliance with U.S. Government Nutrition Advice and Concurrent Obesity Trends Using Nurses' Health Study Data, 1980-2011.

BACKGROUND: Beginning in 1977, the U.S. Government began formally issuing dietary advice, a main objective of which was to reduce and prevent the prevalence of obesity in the American population. Concurrently, the Harvard School of Public Health began conducting dietary intake surveys and collecting body mass index (BMI) (kg/m2) data on female nurses in the Nurses' Health Study I (NHSI) and II (NHSII). OBJECTIVES: We aimed to assess whether compliance with the nutrition guidance from the U.S. Government to restrict dietary intake regarding total fat, saturated fat, and cholesterol was meaningfully associated with the prevalence of obesity. METHODS: We analyzed nutrition survey data from 1980 to 2011, grouping the sample into "compliers," those who complied with guidance on the intake of total fat, saturated fat, and cholesterol, and "noncompliers," those who did not. We then compared the means, medians, and distributions of BMI for compliers and noncompliers over the period for both the full survey population and an age-controlled sample. Finally, we plotted raw NHS data to examine respondents' Fat Proportion intake of energy and concurrent BMI. RESULTS: The mean and median BMI for both compliers and noncompliers increased throughout the sample period, and the BMI distributions shifted toward obese and severely obese overall and for an age-controlled subset compared with the 1980 NHSI and 1990 NHSII baselines. Compliers had slightly lower mean BMI increases than noncompliers but saw a relatively higher increase in the growth of the prevalence of those with BMI >30. We also found no linear relationship between Fat Proportion of energy intake and concurrent BMI. CONCLUSIONS: Guidance from the U.S. Government to limit fat, saturated fat, and cholesterol consumption was widely adopted by American female nurses during the study period. Our results show that compliance with this guidance had little if any effect in mitigating population-wide BMI increases during our study period.

The First Generation of Asian American Pediatric Surgical Trainees in North America.

INTRODUCTION: Pediatric surgical trainees come from diverse races and ethnicities. However, Asian-Americans (AAs) including West, South, and East Asians may represent a unique group of individuals. We sought to identify any unique challenges and experiences. METHODS: Pediatric surgical trainees were identified from, "The Genealogy of North American Pediatric Surgery: From Ladd to Now" and "Celebrating 50 Years: Canadian Association of Paediatric Surgeons/Association Canadienne de Chirurgie Pediatrique". A database was compiled, and AAs identified who completed their pediatric surgical training on or before 1980. Personal interviews and online sources provided further information. RESULTS: Of 635 pediatric surgical trainees in North America (NA) there were 49 AA trainees (7.7%). There was insufficient information for seven, thus leaving 42 (41 male, one female) for review. The region of Asia of origin included 16 East, 16 West, and 10 South. Thirty-seven (88.0%) had moved to NA for training. The most frequent training programs included seven from Toronto and four each at Buffalo, Detroit, Pittsburgh, and Chicago (Children's Memorial). Thirty-five (83%) trainees spent most of their careers in NA while 7 (17%) practiced in their home country. CONCLUSIONS: The first AA pediatric surgical trainees voiced few examples of discrimination but indicated needs to adjust to the NA culture and often confusion over non-Western names. Mentorship was valued and gratitude expressed over the opportunity offered to train in NA. While some had intended to return to their home countries, plans changed due to meeting spouses or political turmoil. Many of those reviewed sought each other out at national meetings.

Initial interactions with the FDA on developing a validation dataset as a medical device development tool.

Quantifying tumor-infiltrating lymphocytes (TILs) in breast cancer tumors is a challenging task for pathologists. With the advent of whole slide imaging that digitizes glass slides, it is possible to apply computational models to quantify TILs for pathologists. Development of computational models requires significant time, expertise, consensus, and investment. To reduce this burden, we are preparing a dataset for developers to validate their models and a proposal to the Medical Device Development Tool (MDDT) program in the Center for Devices and Radiological Health of the U.S. Food and Drug Administration (FDA). If the FDA qualifies the dataset for its submitted context of use, model developers can use it in a regulatory submission within the qualified context of use without additional documentation. Our dataset aims at reducing the regulatory burden placed on developers of models that estimate the density of TILs and will allow head-to-head comparison of multiple computational models on the same data. In this paper, we discuss the MDDT preparation and submission process, including the feedback we received from our initial interactions with the FDA and propose how a qualified MDDT validation dataset could be a mechanism for open, fair, and consistent measures of computational model performance. Our experiences will help the community understand what the FDA considers relevant and appropriate (from the perspective of the submitter), at the early stages of the MDDT submission process, for validating stromal TIL density estimation models and other potential computational models. © 2023 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.

Rising Prices and Lower Medicare Reimbursement Rates Create Outrage Among Clinicians.

In a recent Hot Topics article, reimbursement rates for Medicare physicians are discussed, and how it will impact their practice.

Rising Prices and Lower Medicare Reimbursement Rates Create Outrage Among Clinicians.

In a recent Hot Topics article, reimbursement rates for Medicare physicians are discussed, and how it will impact their practice.

Physician responses to insurance benefit restrictions: The case of ophthalmology.

This study examines the impact of social insurance benefit restrictions on physician behaviour, using ophthalmologists as a case study. We examine whether ophthalmologists use their market power to alter their fees and rebates across services to compensate for potential policy-induced income losses. The results show that ophthalmologists substantially reduced their fees and rebates for services directly targeted by the benefit restriction compared to other medical specialists' fees and rebates. There is also some evidence that they increased their fees for services that were not targeted. High-fee charging ophthalmologists exhibited larger fee and rebate responses while the low-fee charging group raise their rebates to match the reference price provided by the policy environment.

Performance of Progressive Generations of GPT on an Exam Designed for Certifying Physicians as Certified Clinical Densitometrists.

BACKGROUND: Artificial intelligence (AI) large language models (LLMs) such as ChatGPT have demonstrated the ability to pass standardized exams. These models are not trained for a specific task, but instead trained to predict sequences of text from large corpora of documents sourced from the internet. It has been shown that even models trained on this general task can pass exams in a variety of domain-specific fields, including the United States Medical Licensing Examination. We asked if large language models would perform as well on a much narrower subdomain tests designed for medical specialists. Furthermore, we wanted to better understand how progressive generations of GPT (generative pre-trained transformer) models may be evolving in the completeness and sophistication of their responses even while generational training remains general. In this study, we evaluated the performance of two versions of GPT (GPT 3 and 4) on their ability to pass the certification exam given to physicians to work as osteoporosis specialists and become a certified clinical densitometrists. The CCD exam has a possible score range of 150 to 400. To pass, you need a score of 300. METHODS: A 100-question multiple-choice practice exam was obtained from a 3rd party exam preparation website that mimics the accredited certification tests given by the ISCD (International Society for Clinical Densitometry). The exam was administered to two versions of GPT, the free version (GPT Playground) and ChatGPT+, which are based on GPT-3 and GPT-4, respectively (OpenAI, San Francisco, CA). The systems were prompted with the exam questions verbatim. If the response was purely textual and did not specify which of the multiple-choice answers to select, the authors matched the text to the closest answer. Each exam was graded and an estimated ISCD score was provided from the exam website. In addition, each response was evaluated by a rheumatologist CCD and ranked for accuracy using a 5-level scale. The two GPT versions were compared in terms of response accuracy and length. RESULTS: The average response length was 11.6 ±19 words for GPT-3 and 50.0±43.6 words for GPT-4. GPT-3 answered 62 questions correctly resulting in a failing ISCD score of 289. However, GPT-4 answered 82 questions correctly with a passing score of 342. GPT-3 scored highest on the "Overview of Low Bone Mass and Osteoporosis" category (72 % correct) while GPT-4 scored well above 80 % accuracy on all categories except "Imaging Technology in Bone Health" (65 % correct). Regarding subjective accuracy, GPT-3 answered 23 questions with nonsensical or totally wrong responses while GPT-4 had no responses in that category. CONCLUSION: If this had been an actual certification exam, GPT-4 would now have a CCD suffix to its name even after being trained using general internet knowledge. Clearly, more goes into physician training than can be captured in this exam. However, GPT algorithms may prove to be valuable physician aids in the diagnoses and monitoring of osteoporosis and other diseases.

Health as a Human Right: A Position Paper From the American College of Physicians.

The relationship of health to rights or human rights is complex. Although many find no right of any kind to health or health care, and others view health care as a right or human right, the American College of Physicians (ACP) instead sees health as a human right. The College, in the ACP Ethics Manual, has long noted the interrelated nature of health and human rights. Health as a human right also has implications for the social and structural determinants of health, including health care. Any rights framework is imperfect, and rights, human rights, and ethical obligations are not synonymous. Individual physicians and the profession have ethical obligations to patients, and these obligations can go beyond matters of rights. Society, too, has responsibilities-the equitable and universal access to appropriate health care is an ethical obligation of a just society. By recognizing health as a human right based in the intrinsic dignity and equality of all patients and supporting the patient-physician relationship and health systems that promote equitable access to appropriate health care, the United States can move closer to respecting, protecting, and fulfilling for all the opportunity for health.

Implementation of Exercise Management Services Among Sports Medicine Physicians in the United States.

OBJECTIVE: Assessment of physical activity and exercise prescription has been widely supported by many organizations, yet provision of such services remains limited in the United States. We sought to uncover why such services have not been widely adopted. DESIGN: The American Medical Society for Sports Medicine organized a task force to canvas physicians and survey the American Medical Society for Sports Medicine membership. SETTING: Peer-to-peer and telecommunication discussions and web-based questionnaires. PARTICIPANTS: Sports medicine physicians in the United States. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Percentage of sports medicine physicians who provide exercise management services and mechanisms of billing for exercise management, identify barriers to such services, and identify industry collaborations for promoting physical activity through physicians. RESULTS: Three of 4 sports medicine physicians spend at least 1 min encouraging exercise with patients, using Evaluation and Management codes to bill or receive credit. Exercise counseling is often bundled within other patient care. Few health plans leverage the patient's relationship with a primary care physician to promote exercise. Most employed sports medicine physicians do not receive incentives to incorporate exercise counseling into practice, and only 1 in 6 have decision-making authority to hire an exercise professional. Major obstacles are the lack of a business model and knowledge about exercise prescription. CONCLUSION: The existing E&M codes adequately characterize the work, but physicians desire greater payment or credit for providing exercise management services. Physicians desire to do more exercise prescription, but health system bureaucracy, inadequate support, and economic disincentives are barriers to the provision of exercise management services.

Intent to stay, moral distress, and nurse practice environment among long-term care nurses: A cross-sectional questionnaire survey study.

BACKGROUND: Many long-term care facilities in the United States face significant problems with nurse retention and turnover. These challenges are attributed, at least in part, to moral distress and a negative nurse practice environment. OBJECTIVE: The purpose of the study was divided into two parts: first, to investigate the relationships among nurse practice environment, moral distress, and intent to stay; second, to explore the potential mediating effect of the nurse practice environment on the intent to stay among those with high levels of moral distress. DESIGN: This study was a descriptive, cross-sectional survey using targeted sampling. PARTICIPANTS: A total of 215 participants completed the surveys. Participants were nationally representative of long-term care nurses by age, years of experience, employment status, and type of health setting. METHODS: This study was an online national survey of long-term care nurses' perceptions of their intent to stay, moral distress level (Moral Distress Questionnaire), and nurse practice environment (Direct Care Staff Survey). Structural equation modeling analysis explored intent to stay, moral distress, and the nurse practice environment among long-term care nurses. RESULTS: The mean moral distress score was low, while the mean nurse practice environment and intent to stay scores were high. Moral distress had a significant, moderately negative association with the nurse practice environment (ß = -0.41), while the nurse practice environment had a significant, moderately positive association with intent to stay (ß = 0.46). The moral distress had a significant, moderately negative association with intent to stay (ß = -0.20). The computed structural equation modeling suggested a partially mediated model (indirect effect = -0.19, p = 0.001). CONCLUSION: Since the nurse practice environment partially mediates the relationship between moral distress and intent to stay, interventions to improve the nurse practice environment are crucial to alleviating moral distress and enhancing nurses' intent to stay in their jobs, organizations, and the nursing profession. CLINICAL RELEVANCE: Our study demonstrated that the nurse practice environment mediates moral distress and intent to stay. Interventions to improve the nurse practice environment are crucial to alleviating moral distress and enhancing nurses' intent to stay in their jobs, organizations, and the nursing profession.