Correction to: Medical School Factors Associated with Changes in Implicit and Explicit Bias Against Gay and Lesbian People among 3492 Graduating Medical Students.

Due to a tagging error, two authors were incorrectly listed in indexing systems. Brook W. Cunningham should be B.A. Cunningham and Mark W. Yeazel should be M.W. Yeazel for indexing purposes.

Medical School Factors Associated with Changes in Implicit and Explicit Bias Against Gay and Lesbian People among 3492 Graduating Medical Students.

BACKGROUND: Implicit and explicit bias among providers can influence the quality of healthcare. Efforts to address sexual orientation bias in new physicians are hampered by a lack of knowledge of school factors that influence bias among students. OBJECTIVE: To determine whether medical school curriculum, role modeling, diversity climate, and contact with sexual minorities predict bias among graduating students against gay and lesbian people. DESIGN: Prospective cohort study. PARTICIPANTS: A sample of 4732 first-year medical students was recruited from a stratified random sample of 49 US medical schools in the fall of 2010 (81% response; 55% of eligible), of which 94.5% (4473) identified as heterosexual. Seventy-eight percent of baseline respondents (3492) completed a follow-up survey in their final semester (spring 2014). MAIN MEASURES: Medical school predictors included formal curriculum, role modeling, diversity climate, and contact with sexual minorities. Outcomes were year 4 implicit and explicit bias against gay men and lesbian women, adjusted for bias at year 1. KEY RESULTS: In multivariate models, lower explicit bias against gay men and lesbian women was associated with more favorable contact with LGBT faculty, residents, students, and patients, and perceived skill and preparedness for providing care to LGBT patients. Greater explicit bias against lesbian women was associated with discrimination reported by sexual minority students (b = 1.43 [0.16, 2.71]; p = 0.03). Lower implicit sexual orientation bias was associated with more frequent contact with LGBT faculty, residents, students, and patients (b = -0.04 [-0.07, -0.01); p = 0.008). Greater implicit bias was associated with more faculty role modeling of discriminatory behavior (b = 0.34 [0.11, 0.57); p = 0.004). CONCLUSIONS: Medical schools may reduce bias against sexual minority patients by reducing negative role modeling, improving the diversity climate, and improving student preparedness to care for this population.

Objective burden, resources, and other stressors among informal cancer caregivers: a hidden quality issue?

UNLABELLED: A great deal of clinical cancer care is delivered in the home by informal caregivers (e.g. family, friends), who are often untrained. Caregivers' context varies widely, with many providing care despite low levels of resources and high levels of additional demands. BACKGROUND: Changes in health care have shifted much cancer care to the home, with limited data to inform this transition. We studied the characteristics, care tasks, and needs of informal caregivers of cancer patients. METHODS: Caregivers of seven geographically and institutionally defined cohorts of newly diagnosed colorectal and lung cancer patients completed self-administered questionnaires (n = 677). We combined this information with patient survey and chart abstraction data and focused on caregivers who reported providing, unpaid, at least 50% of the patient's informal cancer care. RESULTS: Over half of caregivers (55%) cared for a patient with metastatic disease, severe comorbidity, or undergoing current treatment. Besides assisting with activities of daily living, caregivers provided cancer-specific care such as watching for treatment side effects (68%), helping manage pain, nausea or fatigue (47%), administering medicine (34%), deciding whether to call a doctor (30%), deciding whether medicine was needed (29%), and changing bandages (19%). However, half of caregivers reported not getting training perceived as necessary. In addition, 49% of caregivers worked for pay, 21% reported poor or fair health, and 21% provided unpaid care for other individuals. One in four reported low confidence in the quality of the care they provided. CONCLUSIONS: Much assistance for cancer patients is delivered in the home by informal caregivers, often without desired training, with a significant minority having limited resources and high additional demands. Future research should explore the potentially high yield of addressing caregiver needs in improving quality of cancer care and both survivors' and caregivers' outcomes.

Personal Manuscript Acceptance Rates: Metrics for Self-assessment in Scholarship.

INTRODUCTION: There is no established baseline for how frequently clinical researchers personally encounter manuscript rejection, making it difficult for faculty to put their own evolving experience in context. The purpose of this study was to determine the feasibility of obtaining personal acceptance per submission (APS) and acceptance per manuscript (APM) rates for individual faculty members. METHODS: We performed a cross-section survey pilot study of clinical faculty members of two departments (family medicine and pediatrics), in one academic health center in the academic year 2017-2018. The survey asked participants to report the number of attempted submissions required per journal article they have had accepted in the prior 2 years as well as any submissions that did not lead to publication. RESULTS: Sixty-eight of 136 eligible faculty (50%) completed the questionnaire. Academic clinicians in the sample eventually published 80% of the manuscripts submitted, with 39% of papers rejected per submission attempt. Associate professors had the highest APS (0.71) and APM (0.88). CONCLUSIONS: In this pilot, we demonstrated the feasibility of retrospectively collecting data that could identify baseline manuscript acceptance rates and were able to generate department averages and rank specific averages for manuscript acceptance and rejection. We confirmed that rejection is common among academic clinicians. The APS and APM can be used by academic clinicians to track their own progress from day one of their publishing careers as a method of self-assessment, rather than having to wait for citations to accumulate.

Menstrual phase effects on smoking relapse.

AIMS: To examine if menstrual phase affects relapse in women attempting to quit smoking. DESIGN: An intent-to-treat randomized smoking cessation trial where women were assigned to quit smoking in either the follicular (F) or luteal (L) menstrual phase and were followed for up to 26 weeks. They were assessed for relapse by days to relapse and relapse phase to determine if those who begin a quit attempt during the F phase were more successful than those who begin during the L phase. SETTING: Tobacco Use Research Center, University of Minnesota, Minneapolis, Minnesota. PARTICIPANTS: A total of 202 women. MEASUREMENTS: Latency to relapse from continuous and prolonged abstinence, point prevalence, phase of relapse, first slip within the first 3 and 5 days post-quit date, subject completion rates and symptomatology (i.e. withdrawal and craving). FINDINGS: The mean days to relapse from continuous abstinence and relapse from prolonged abstinence for the F group were 13.9 and 20.6 days, respectively, and 21.5 and 39.2 days, respectively, for the L group. Using point prevalence analysis at 14 days, 84% of the F group had relapsed compared with 65% of the L group [chi(2)=10.024, P=0.002; odds ratio (OR) = 2.871, 95% confidence interval (CI), 1.474-5.590]. At 30 days, 86% of the F group relapsed, compared with 66% of the L group (chi(2)=11.076, P=0.001; OR=3.178, 95% CI, 1.594-6.334). CONCLUSION: Women attempting to quit smoking in the F phase had less favorable outcomes than those attempting to quit in the L phase. This could relate to ovarian hormones, which may play a role in smoking cessation for women.

Quality of life among postmenopausal women enrolled in the Minnesota Green Tea Trial.

BACKGROUND: Postmenopausal symptomatology has not been elucidated in large, long-term human clinical trials. Our objective was to measure quality of life in postmenopausal women aged 50-70 years. METHODS: A Menopause-Specific Quality of Life-Intervention (MENQOL) questionnaire was completed by women enrolled in the Minnesota Green Tea Trial (n=932) to assess vasomotor, physical, sexual, and psychosocial symptoms in the years following menopause. Responses were coded; mean overall and domain scores ranged from 1 to 8. A higher score indicated more severe symptoms. RESULTS: Mean overall MENQOL scores were highest in women aged 50-54.9 years. A pattern of reduced symptom severity with increasing age was observed overall and within each domain. Women aged 50-54.9 years had more severe night sweats and sweating than other age groups (P≤0.001) and more severe hot flashes than women aged≥60years (P≪0.001). No differences between age groups were seen on mean score in the Sexual domain. Compared with women aged 50.0-54.9 years (the reference group), study participants aged 60-64.9 and≥65years had lower MENQOL scores in the Psychosocial domain (P=0.029 and P≪0.001). Women aged 50-54.9 years had more severe symptoms related to negative mood than women ≥65 years (P≤0.009). Compared with women aged 50-54.9 years, those in the age groups 60-64.9 and≥65 years had lower scores for "poor memory" (2.98±1.75 and 2.66±1.68 vs. 3.43±1.87, P≪0.001). Women≥65 years reported lower scores for "feeling tired or worn out", "difficulty sleeping", and "lack of energy" than all other age groups (P≤0.003). CONCLUSION: The findings of this descriptive analysis of postmenopausal women may help clinicians counsel women about expectations and treatment options to address menopause-associated symptoms and the relationship between postmenopausal symptoms and overall health.

A theoretical, practical, predictive model of faculty and department research productivity.

PURPOSE: Although numerous characteristics impact faculty research productivity, and although researchers have suggested comprehensive theoretical models to explain the relationship between these characteristics and levels of faculty research productivity, few studies have assessed these models. This study tests the ability of the Bland et al. (2002) model-based on individual, institutional, and leadership variables influencing faculty research productivity-to explain individual and group (department) research productivity within the context of a large medical school. METHOD: This study used data from a University of Minnesota Medical School-Twin Cities vitality survey conducted in 2000 that had a response rate of 76% (n = 465 faculty). A statistical software package was used to conduct t tests, logistic regressions, and multiple regressions on these data. RESULTS: The validity of faculty, department, and leadership characteristics identified in the Bland et al. (2002) model were confirmed as necessary for high levels of research productivity. Faculty productivity was influenced more by individual and institutional characteristics; group productivity was more affected by institutional and leadership characteristics. CONCLUSION: The characteristics and groupings (individual, institutional, and leadership) in the Bland et al. (2002) model predict faculty research productivity. Research productivity is influenced by the interaction of the three broad groupings, and it is the dynamic interplay of individual and institutional characteristics, supplemented with effective leadership, that determines the productivity of individuals and departments.

One school's strategy to assess and improve the vitality of its faculty.

The authors report how one medical school took an evidence-based, collaborative approach to assessing and improving faculty vitality by building on previous research and including important shareholders (e.g., faculty and administrators). In 1999, the dean and faculty senate asked all full-time faculty (615) at the University of Minnesota Medical School-Twin Cities to complete a survey to (1) identify vitality areas (individual, institutional, or leadership) in which the school was strong and ones that needed improvement, (2) identify strategies for addressing weak areas, and (3) provide a baseline against which to measure the impact of any vitality efforts initiated. The survey was based on features that research studies have found to be associated with academic productivity. Seventy-six percent responded. Summaries of the survey findings were prepared for use at the school level, department level, and special group level (e.g., women, clinical-scholar-track faculty). Three key school-level findings were that (1) there is a disconnect between the stated vision of the school and the departments' visions and actions, (2) there is not enough time for scholarly activity, particularly in the clinical departments, and (3) faculty lack the support of a collegial atmosphere and appreciation for the work they do. In response to the survey's findings every department identified priority faculty needs and initiated tailored development strategies. School-wide strategies were also initiated to address faculty needs common across departments and needs unique to special groups. Together these strategies provide a multi-level, systematic approach to maintaining faculty vitality.

Relating mentor type and mentoring behaviors to academic medicine faculty satisfaction and productivity at one medical school.

PURPOSE: To examine relationships among having formal and informal mentors, mentoring behaviors, and satisfaction and productivity for academic medicine faculty. METHOD: In 2005, the authors surveyed full-time faculty at the University of Minnesota Medical School to assess their perceptions of variables associated with job satisfaction and productivity. This analysis focused on perceptions of mentoring as related to satisfaction with current position and productivity (articles published in peer-reviewed journals [article production] and role as a primary investigator [PI] or a co-PI on a grant/contract). RESULTS: Of 615 faculty, 354 (58%) responded. Satisfied faculty were not necessarily productive, and vice versa. Outcomes differed somewhat for mentor types: Informal mentoring was more important for satisfaction, and formal mentoring was more important for productivity. Regardless of mentor type, the 14 mentoring behaviors examined related more to satisfaction than productivity. Only one behavior-serves as a role model-was significantly, positively related to article production. Although participants reported that formal and informal mentors performed the same mentoring behaviors, mentees were more satisfied or productive when some behaviors were performed by formal mentors. CONCLUSIONS: The results emphasize the importance of having both formal and informal mentors who perform mentoring behaviors associated with satisfaction and productivity. The results provide a preliminary indication that mentor types and specific mentoring behaviors may have different effects on satisfaction and productivity. Despite the differences found for some behaviors, it seems that it is more essential that mentoring behaviors be performed by any mentor than by a specific type of mentor.

An adaptive approach to facilitating research productivity in a primary care clinical department.

Efforts to foster the growth of a department's or school's research mission can be informed by known correlates of research productivity, but the specific strategies to be adopted will be highly context-dependent, influenced by local, national, and discipline-specific needs and resources. The authors describe a multifaceted approach-informed by a working model of organizational research productivity-by which the University of Minnesota Department of Family Medicine and Community Health (Twin Cities campus) successfully increased its collective research productivity during a 10-year period (1997-2007) and maintained these increases over time.Facing barriers to recruitment of faculty investigators, the department focused instead on nurturing high-potential investigators among their current faculty via a new, centrally coordinated research program, with provision of training, protected time, technical resources, mentoring, and a scholarly culture to support faculty research productivity. Success of these initiatives is documented by the following: substantial increases in the department's external research funding, rise to a sustained top-five ranking based on National Institutes of Health funding to U.S. family medicine departments, later-stage growth in the faculty's publishing record, increased research capacity among the faculty, and a definitive maturation of the department's research mission. The authors offer their perspectives on three apparent drivers of success with broad applicability-namely, effective leadership, systemic culture change, and the self-awareness to adapt to changes in the local, institutional, and national research environment.

Is there equivalency between students in a longitudinal, rural clerkship and a traditional urban-based program?

BACKGROUND: Demonstrating the equivalency between the traditional metro-based clerkships within close proximity to the academic health center and the nontraditional rural preceptorships is important. The University of Minnesota has had a 9-month longitudinal rural elective for third-year medical students for 40 years, the Rural Physician Associate Program (RPAP). In the metro area, traditional students rotate through clerkships of 4 to 8 weeks in length. Both cohorts of students are evaluated in similar ways. METHODS: We analyzed the test scores and demographic data for two cohorts of students: RPAP (n=201) and traditional (n=1,129) who graduated between 2004 and 2009. Tests included pre-medical school data (Medical College Admission Tests, college grade point averages) as well as National Board of Medical Examiners subject examinations (shelf), US Medical Licensing Examination Step One and Two (Clinical Knowledge and Clinical Skills), and an Objective Structured Clinical Examination (OSCE). Scores were analyzed using descriptive/comparative statistics for the two groups of students. RESULTS: For the most part, RPAP students performed similarly to students in the traditional metro-based curriculum on the standard educational outcome metrics. On the obstetrics shelf, while a similar proportion of the RPAP students passed, they scored statistically significantly lower (traditional: median 72 (range 50-98) versus RPAP: 71 (51-89). DISCUSSION: This study is the largest cohort demonstrating equivalency between students taking a rural longitudinal clerkship and their metro-trained colleagues.

Efforts to graduate more primary care physicians and physicians who will practice in rural areas: examining outcomes from the university of Minnesota-duluth and the rural physician associate program.

PURPOSE: To compare practice choices (primary care or specialty) and practice locations (rural or metropolitan) of medical students at the Duluth and Twin Cities (Minneapolis and St. Paul; TC) campuses of the University of Minnesota (UMN). In the early 1970s, Minnesota created two medical education programs at UMN to increase the number of rural and primary care physicians: the first two years of medical school at UMN-Duluth, where the program focuses on recruiting students who will be rural family physicians, and the Rural Physician Associate Program (RPAP) elective, a nine-month, longitudinal immersion experience with a preceptor in a rural community. METHOD: In 2008, the authors analyzed outcomes for four student groups: (1) UMN-Duluth and (2) UMN-TC medical students who participated in RPAP and (3) UMN-Duluth and (4) UMN-TC students who did not participate in RPAP. UMN medical students complete their first two years on either campus; they can apply to RPAP for their third year. Non-RPAP students spend most of their third- and fourth-year rotations in the Twin Cities metropolitan area. RESULTS: The UMN-Duluth and RPAP students were most likely to select a rural location and primary care practice. UMN-TC, non-RPAP students followed national trends, choosing predominantly metropolitan and specialty practices. CONCLUSIONS: RPAP and UMN-Duluth provide significant, complementary educational programs that lead more graduates to choose rural and primary care practices. Efforts across the nation to address the crisis in rural primary care should build on these successful efforts.

Organizational climate and family life: how these factors affect the status of women faculty at one medical school.

PURPOSE: To compare men and women faculty's family situations and perceptions of organizational climate. METHOD: In 2005, the authors sent an electronic survey to full-time faculty at the University of Minnesota Medical School to assess their perceptions of professional relationships, mentoring, obstacles to satisfaction, policies, circumstances that contribute to departure, gender equality, family situations, and work life. RESULTS: Of 615 faculty, 354 (57%) responded. Women and men were equally productive and worked similar total hours. Women were less likely to have partners/spouses, were more likely to have partners/spouses who were employed, and devoted more time to household tasks. Compared with men, women reported more experience with obstacles to career success and satisfaction and with circumstances that contribute to departure. More women than men perceived that they were expected to represent the perspective of their gender, that they were constantly under scrutiny by colleagues, that they worked harder than colleagues worked in order to be perceived as legitimate, and that there were "unwritten rules" and bias against women. Few faculty reported overt discrimination; however, more women than men perceived gender discrimination in promotion, salary, space/resources, access to administrative staff, and graduate student/fellow assignment. CONCLUSIONS: Work-life and family-life factors served as obstacles to satisfaction and retention of the women faculty studied. Many of these factors reflect challenges attributable to subtle gender bias and the intersection of work and family life. The authors provide examples showing that medical schools can implement policy changes that support faculty who must balance work and family responsibilities. Identification and elimination of gender bias in areas such as promotion, salary, and resource allocation is essential.

Recruitment and retention of rural physicians: outcomes from the rural physician associate program of Minnesota.

CONTEXT: Founded in 1971 with state funding to increase the number of primary care physicians in rural Minnesota, the Rural Physician Associate Program (RPAP) has graduated 1,175 students. Third-year medical students are assigned to primary care physicians in rural communities for 9 months where they experience the realities of rural practice with hands-on participation, mentoring, and one-to-one teaching. Students complete an online curriculum, participate in online discussion with fellow students, and meet face-to-face with RPAP faculty 6 times during the 9-month rotation. Projects designed to bring value to the community, including an evidence-based practice and community health assessment, are completed. PURPOSE: To examine RPAP outcomes in recruiting and retaining rural primary care physicians. METHODS: The RPAP database, including moves and current practice settings, was examined using descriptive statistics. FINDINGS: On average, 82% of RPAP graduates have chosen primary care, and 68% family medicine. Of those currently in practice, 44% have practiced in a rural setting all of the time, 42% in a metropolitan setting and 14% have chosen both, with more than 50% of their time in rural practice. Rural origin has only a small association with choosing rural practice. CONCLUSION: RPAP data suggest that the 9-month longitudinal experience in a rural community increases the number of students choosing primary care practice, especially family medicine, in a rural setting.

The rural physician associate program: the value of immersion learning for third-year medical students.

CONTEXT: Changes in health care and new theories of learning have prompted significant changes in medical education. Some US medical schools employ immersion learning in rural communities to increase the number of physicians who choose to practice in these areas. Founded in 1971, the rural physician associate program (RPAP) is a longitudinal immersion learning experience for students during their third year of medical school. Students are assigned to a primary care preceptor(s) in a rural community ranging in population from 1,000 to 30,000 for 36 weeks. PURPOSE: To describe students' perceived value of this immersion learning experience. METHODS: Data from 3 classes (2004, 2005, 2006) of students (n = 95) were analyzed, including final essays that reflect on their experiences and logs of their patient encounters and procedures. Themes from students' essays related to the hands-on learning experience are presented. Frequencies of ambulatory encounters and procedures were calculated and compared with those of metropolitan area colleagues where possible. FINDINGS: The continuity experience allows for one-to-one mentoring and long-term relationships. Students see physicians, clinic/hospital staff, and patients as their teachers. The environment is nurturing, but nudges them outside their comfort zone. Students gain increasing competence with their skills and do best if they are independent and seek out learning opportunities. They report more hands-on experience, more confidence and autonomy than their peers in the metropolitan area. CONCLUSIONS: The RPAP experience provides a nurturing, longitudinal, immersion learning experience that facilitates the gradual but steady development of clinical skills alongside a personal and professional mentor.