Galvanizing for the future: a bottom-up departmental approach to diversity, equity, and inclusion.

As an academic department, we sought to identify effective strategies to engage our faculty and staff in diversity, equity, and inclusion initiatives and programs to build an inclusive department that would address our needs and those of our community and partners. Over a 4-year period, our faculty and staff have participated in town hall meetings, focus group discussions, surveys, and community-building activities to foster stakeholder engagement that will build a leading academic department for the future. We noted that our faculty and staff were committed to building diversity, equity, and inclusion, and our mission and vision were reflective of this. However, communication and transparency may be improved to help support a more inclusive department for all. In the future, we hope to continue with the integration of diversity, equity, and inclusion into our department's business processes to achieve meaningful, sustained change and impact through continued focus on recruitment, selection, retention, development, and wellness of faculty and staff-in addition to the continued recruitment of faculty and staff from underrepresented minority groups. Our findings should serve as a call to action for other academic obstetrics and gynecology departments to improve the health and well-being of the individuals we serve.

Embedding international medical student electives within a 30-year partnership: the Ghana-Michigan collaboration.

BACKGROUND: Global health experiences are an increasingly popular component of medical student curricula. There is little research on the impact of international medical electives embedded within long-standing, sustainable partnerships. Our research explores the University of Michigan medical student elective experience in Ghana within the context of the Ghana-Michigan collaborative. METHODS: Study participants are University of Michigan medical students who completed an international elective in Ghana between March 2006 and June 2017. Post-elective reports were completed by students, including a description of the experience, highlights, disappointments, and the impact of the experience on interest in future international work and future practice of medicine. A retrospective thematic analysis of reports was carried out using NVivo 12 (QSR International, Melbourne, Australia). RESULTS: A total of 57 reports were analyzed. Benefits of the elective experience included building cross-cultural relationships, exposure to different healthcare environments, hands-on clinical and surgical experience, and exposure to different patient populations. Ninety-five percent of students planned to engage in additional international work in the future. Students felt that the long-standing bidirectional exchange allowed them to build cross-cultural relationships and be incorporated as a trusted part of the local clinical team. The partnership modeled collaboration, and many students found inspiration for the direction of their own careers. CONCLUSIONS: Embedding clinical rotations within a well-established, sustained partnerships provides valuable experiences for trainees by modeling reciprocity, program management by local physicians, and cultural humility-all of which can help prepare learners to ethically engage in balanced, long-term partnerships in the future.

Better late than never: why obstetricians must implement enhanced recovery after cesarean.

Despite persistent concerns about high cesarean delivery rates internationally, there has been less attention on improving perioperative outcomes for the millions of women who will experience a cesarean delivery each year. Enhanced recovery after surgery, a standardized, evidence-based, interdisciplinary protocol, has been successfully used in other surgical specialties including gynecology to improve quality of care and patient satisfaction while reducing overall health care costs through reduced length of stay. Enhanced recovery after surgery society guidelines for cesarean delivery were just released in August 2018. Obstetric patients, who face the dual challenge of being postpartum and postoperative, could benefit greatly from protocols that optimize their return to physiological function and reduce surgical morbidity. Although enhanced recovery after surgery has been widespread in other surgical specialties, uptake of this protocol in obstetrics has lagged behind. We believe enhanced recovery after surgery for cesarean delivery can effectively address 3 challenges faced by obstetrician/gynecologists. These are: (1) improving care for the high number of women undergoing cesarean deliveries; (2) using evidence-based care bundles to prevent maternal morbidity and mortality, address disparities, and reduce costs; and (3) limiting postoperative opioid prescribing in response to the opioid crisis. Enhanced recovery after surgery for cesarean delivery and other standardized care protocols have the potential to reduce the disproportionately high rates of maternal morbidity and mortality in the United States, and ensure all patients, regardless of demographics or location, receive the same level of high-quality peripartum care.

Stressful Life Events Around the Time of Unplanned Pregnancy and Women's Health: Exploratory Findings from a National Sample.

Objective Little is known about how women's social context of unintended pregnancy, particularly adverse social circumstances, relates to their general health and wellbeing. We explored associations between stressful life events around the time of unintended pregnancy and physical and mental health. Methods Data are drawn from a national probability study of 1078 U.S. women aged 18-55. Our internet-based survey measured 14 different stressful life events occurring at the time of unintended pregnancy (operationalized as an additive index score), chronic disease and mental health conditions, and current health and wellbeing symptoms (standardized perceived health, depression, stress, and discrimination scales). Multivariable regression modeled relationships between stressful life events and health conditions/symptoms while controlling for sociodemographic and reproductive covariates. Results Among ever-pregnant women (N = 695), stressful life events were associated with all adverse health outcomes/symptoms in unadjusted analyses. In multivariable models, higher stressful life event scores were positively associated with chronic disease (aOR 1.21, CI 1.03-1.41) and mental health (aOR 1.42, CI 1.23-1.64) conditions, higher depression (B 0.37, CI 0.19-0.55), stress (B 0.32, CI 0.22-0.42), and discrimination (B 0.74, CI 0.45-1.04) scores, and negatively associated with ≥ very good perceived health (aOR 0.84, CI 0.73-0.97). Stressful life event effects were strongest for emotional and partner-related sub-scores. Conclusion Women with adverse social circumstances surrounding their unintended pregnancy experienced poorer health. Findings suggest that reproductive health should be considered in the broader context of women's health and wellbeing and have implications for integrated models of care that address women's family planning needs, mental and physical health, and social environments.

Cross-cultural perspectives on the patient-provider relationship: a qualitative study exploring reflections from Ghanaian medical students following a clinical rotation in the United States.

BACKGROUND: In international health experiences, learners are exposed to different culturally-based patient care models. Little is known about student perceptions of patient-provider interactions when they travel from low-to high-resource settings. The purpose of this study was to explore these reflections among a subset of Ghanaian medical students who participated in clinical rotations at the University of Michigan Medical School (UMMS). METHODS: In-depth, semi-structured interviews lasting 60-90 min were conducted with 15 individuals who had participated in 3-to 4-week clinical rotations at UMMS between January 2008 and December 2011. Interviews were conducted from March to August 2012 and transcribed verbatim, then independently coded by three investigators. Investigators compared open codes and reached a consensus regarding major themes. RESULTS: Participating Ghanaian medical students reported that their perspectives of the patient-provider relationship were significantly affected by participation in a UMMS rotation. Major thematic areas included: (1) observations of patient care during the UMMS rotation, including patient comfort and privacy, physician behavior toward patients, and patient behavior; (2) reflections on the role of humanism and respect within patient care; (3) barriers to respectful care; and (4) transformation of student behaviors and attitudes. Students also reported integrating more patient-centered care into their own medical practice upon return to Ghana DISCUSSION: Participation in a US-based clinical rotation has the potential to introduce medical students from resource-limited settings to a different paradigm of patient-provider interactions, which may impact their future behavior and perspectives regarding patient care in their home countries. CONCLUSIONS: Students from under-resourced settings can derive tremendous value from participation in clinical electives in more affluent settings, namely through exposure to a different type of medical care.

Human embryos donated for human embryonic stem cell derivation.

Human embryonic stem cells (hESCs), produced from human embryos, are demonstrating: utility and promise in disease modeling; enhanced and unique understanding of early events in basic genetic or molecular or cellular or epigenetic development; novel human approaches to pharmaceutical screening; pathways toward the discoveries of disease treatments and cures; and foundational importance for regenerative medicine. The regulatory landscape is rigorous, and rightly so. Here, we discuss the current US federal and state regulatory environment. A unique approach of presenting anonymized embryo donor statements is provided to personalize the decision-making process of human embryo donation for hESC derivation. From the uses of preimplantation genetic-tested and affected human embryos to derived disease-specific hESCs, one can glean the much needed information on early human genetics and developmental biology, which are presented here. Finally, we discuss the future uses of hESCs, and other pluripotent stem cells, in general and reproductive medicine.

Gender Differences of Endowed Professorship in Obstetrics and Gynecology Departments at Top Academic Institutions.

Background: Gender equity is a critical issue in academic medicine. Whether there is equitable access to the prestige and resources of endowed professorships merits evaluation. We investigated this question in obstetrics and gynecology, a field that focuses on the health of women and in which women are much better represented than other specialties of medicine. Materials and Methods: We compiled a list of the top 25 United States departments of obstetrics and gynecology and contacted department chairs (and used department websites) to obtain lists of faculty and their positions. Scopus, department websites, and National Institutes of Health (NIH) RePORTER were used to collect h-Index, number of publications and citations, graduation year, degrees, gender, and NIH-funding. We conducted a bivariate comparison of endowed professorship attainment by gender using a chi-square test and created a multiple variable regression model. Results: Of the 680 obstetrics and gynecology faculty across 23 departments that had endowed chairs, 64 out of 400 women (16%) and 66 out of 280 men (24%) held endowed chairs (p = 0.01). The multivariable model suggested no independent gender difference in attainment of an endowed chair after adjusting for covariates. Conclusion: To our knowledge, this study is the first to examine gender as a variable in endowed chair allocation in top obstetrics and gynecology academic departments. Our findings suggest a significant gender difference in the allocation of endowed chairs. That difference is driven by gender differences in academic rank, graduation year, publications, and funding. To promote the intraprofessional equity necessary to optimally advance women's health, further research and intervention are necessary.

Study protocol for Women of Color and Asthma Control: a randomized controlled trial of an asthma-management intervention for African American women.

BACKGROUND: Among adults in the United States, asthma prevalence is disproportionately high among African American women; this group also experiences the highest levels of asthma-linked mortality and asthma-related health care utilization. Factors linked to biological sex (e.g., hormonal fluctuations), gender roles (e.g., exposure to certain triggers) and race (e.g., inadequate access to care) all contribute to the excess asthma burden in this group, and also shape the context within which African American women manage their condition. No prior interventions for improving asthma self-management have specifically targeted this vulnerable group of asthma patients. The current study aims to evaluate the efficacy of a culturally- and gender-relevant asthma-management intervention among African American women. METHODS/DESIGN: A randomized controlled trial will be used to compare a five-session asthma-management intervention with usual care. This intervention is delivered over the telephone by a trained health educator. Intervention content is informed by the principles of self-regulation for disease management, and all program activities and materials are designed to be responsive to the specific needs of African American women. We will recruit 420 female participants who self-identify as African American, and who have seen a clinician for persistent asthma in the last year. Half of these will receive the intervention. The primary outcomes, upon which the target sample size is based, are number of asthma-related emergency department visits and overnight hospitalizations in the last 12 months. We will also assess the effect of the intervention on asthma symptoms and asthma-related quality of life. Data will be collected via telephone survey and medical record review at baseline, and 12 and 24 months from baseline. DISCUSSION: We seek to decrease asthma-related health care utilization and improve asthma-related quality of life in African American women with asthma, by offering them a culturally- and gender-relevant program to enhance asthma management. The results of this study will provide important information about the feasibility and value of this program in helping to address persistent racial and gender disparities in asthma outcomes. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01117805.

Formal Reporting of Identity-Based Harassment at an Academic Medical Center: Incidence, Barriers, and Institutional Responses.

PURPOSE: To examine the incidence of, barriers to, and institutional responses to formal reporting of experiences of identity-based harassment at an academic medical center. METHOD: The authors invited 4,545 faculty and medical trainees at the University of Michigan Medical School to participate in a 2018 survey about civility and respect. This analysis focused on respondents who indicated experiencing at least 1 form of identity-based harassment (sexual harassment, gender policing harassment, heterosexist harassment, racialized sexual harassment) within the past year, perpetrated by staff, students, and faculty or by patients and patients' families. The authors assessed the incidence of formally reporting harassment to someone in authority, barriers to reporting, and institutional responses following reporting. RESULTS: Among the 1,288 (28.3%) respondents with usable data, 83.9% (n = 1,080) indicated experiencing harassment. Of the harassed individuals, 10.7% (114/1,067), including 13.1% (79/603) of cisgender women and 7.5% (35/464) of cisgender men, indicated they formally reported their harassment experiences. Among these reporters, 84.6% (66/78) of cisgender women and 71.9% (23/32) of cisgender men indicated experiencing positive institutional remedies. Many reporters indicated experiencing institutional minimization (42.9% [33/77] of cisgender women; 53.1% [17/32] of cisgender men) or retaliation (21.8% [17/78] of cisgender women; 43.8% [14/32] of cisgender men). Cisgender men were significantly more likely to indicate experiencing specific negative institutional responses, such as being considered a troublemaker (OR 3.56, 95% CI: 1.33-9.55). Among respondents who did not formally report harassment experiences, cisgender women were significantly more likely to cite concerns about institutional retaliation, such as being given an unfair performance evaluation or grade (OR 1.90, 95% CI: 1.33-2.70). CONCLUSIONS: Most respondents who experienced harassment did not formally report it to anyone in authority. Many reporters faced institutional minimization and retaliation. These findings suggest a need to reshape institutional harassment prevention and response systems in academic medicine.

Negative perceptions and emotional impact of striae gravidarum among pregnant women.

BACKGROUND: The impact of striae gravidarum (SG), or stretch marks of pregnancy, on quality of life (QoL) is unclear. OBJECTIVE: The purpose of this study was to investigate how SG affect QoL in pregnant women. METHODS: In this cross-sectional survey study of healthy pregnant women who developed SG during their current pregnancy, we asked about the impact of lesions on emotional, psychological, and life-quality facets. Spearman product-moment correlation coefficients were generated to determine the strength of relationships between variables. RESULTS: We analyzed 116 valid surveys. Participants reported permanency of SG as the top physical concern (n = 87; 75%). With regard to severity, nearly three-quarters of participants rated their lesions as very prominent (n = 24; 21%) or moderate (n = 57; 49%). Among the life-quality facets queried, embarrassment/self-consciousness was the most frequently associated with SG, with over one-third of participants reporting "a lot" (n = 19; 16%) or a "moderate" (n = 26; 22%) amount of embarrassment/self-consciousness related to having SG. Lesion severity significantly correlated with the degree of embarrassment/self-consciousness (r = .543), as well as the impact of SG on other life-quality facets, including overall QoL (r = .428), clothing choice (r = .423), self-image/self-esteem (r = .417), feelings of anxiety/depression (r = .415), and social activities (r = .313; all p ≤ .001). Nearly one-quarter of participants believed that emotional distress related to SG was similar or greater than that caused by other skin problems, such as acne, psoriasis, or eczema. CONCLUSION: SG can be associated with a host of negative reactions reflecting increased psychological and emotional distress, including embarrassment and decreased QoL. These consequences may compound the emotional stress of pregnancy, potentially warranting psychological support and adjustment strategies.

Incidence and Group Comparisons of Harassment Based on Gender, LGBTQ+ Identity, and Race at an Academic Medical Center.

Background: A key recommendation from the landmark National Academies report called for research examining experiences of underrepresented and/or vulnerable groups, including people of color and sexual- and gender-minority people. We examine the prevalence of gender policing harassment (GPH), heterosexist harassment (HH), and racialized sexual harassment (RSH), by gender, LGBTQ+, race, and department grouping, which has not been previously examined in academic medicine. Materials and Methods: All faculty (n = 2723), fellows, residents, and first through third year medical students (n = 1822) at the University of Michigan Medical School (UMMS) who had been working at the organization for at least 1 year were invited to complete a 20-minute online survey. We assessed harassment within the past year, perpetrated by insiders (i.e., staff, students, and faculty) and from patients and patients' families. Results: A total of 705 faculty (25.9% of the targeted sample) and 583 trainees (32.0% of the targeted sample) were in the analytic sample. Women were significantly more likely to experience GPH from both sources than men, and LGBTQ+ individuals were more likely to face HH from both sources than cisgender heterosexual participants. Underrepresented minorities, Asian/Asian American, and female participants had higher rates of RSH perpetrated by insiders. There were significant department-group differences across harassment types. Conclusions: Less-studied forms of harassment are common within academic medicine and are perpetrated from various sources. Identity-based harassment should be investigated further to gain a comprehensive understanding of its impact within academic medicine. Clinical Trial Registration Number not applicable.

Trusted Colleagues or Incompetent Hacks? Development of the Attitudes About Abortion-Providing Physicians Scale.

BACKGROUND: Many physicians who provide abortion care report feeling marginalized within medicine. Because abortion care can require consultation with many types of physicians, physician opinions of providers may have implications for quality of care. However, no measure of physicians' attitudes about abortion-providing colleagues currently exists. METHODS: We developed a 24-item pool to measure perceptions of the motivations, competence, and standing within the medical profession of physicians who provide abortion care. We administered the survey to a sample of 1,640 faculty physicians at a Midwestern teaching hospital. We used Stata SE/14.0 for all analyses. RESULTS: Our response rate was 34% (n = 560), comparable with other studies of physicians. Exploratory factor analysis resulted in a three-factor solution: opinion, motivations, and competence. The scale demonstrated good internal consistency. Attitudes were largely favorable: 84% of participants agreed that abortion providers provide necessary care for women and 81% felt that abortion providers contribute positively to society. Compared with those who felt abortion should be illegal in all circumstances, attitudes were more favorable among those who felt that abortion should be legal. We observed an inverse relationship between religious attendance and attitudes. Participants with children held more favorable attitudes compared with those without children. CONCLUSIONS: The Attitudes About Abortion-Providing Physicians Scale captures physicians' perceptions of their abortion-providing colleagues along three important dimensions: opinion, motivations, and competence. This sample of physicians held generally favorable views of their colleagues who provide abortion care.

#MedToo: A Large-Scale Examination of the Incidence and Impact of Sexual Harassment of Physicians and Other Faculty at an Academic Medical Center.

Background: A landmark National Academies report highlighted the need for rigorous evaluation of sexual harassment in medicine. We examined the prevalence and impact of sexual harassment using the Sexual Experiences Questionnaire, the standard for measurement of sexual harassment, but which has not been previously applied within academic medicine. Materials and Methods: A 20-minute online survey was administered to all faculty who had been working at University of Michigan Medical School for at least 1 year (n = 2723). We assessed sexual harassment within the past year from insiders (i.e., from staff, students, and faculty) and from patients and patients' families. We also evaluated mental health, job satisfaction, sense of safety at work, and turnover intentions. Results: In the final sample (n = 705; which included 25.9% of the originally targeted population), most respondents, 82.5% of women and 65.1% of men, reported at least one incident of sexual harassment from insiders in the past year; 64.4% of women and 44.1% of men reported harassment from patients and patients' families. The most frequently experienced dimension of sexual harassment for women and men was sexist gender harassment. Increased experiences of harassment were independently associated with lower mental health, job satisfaction, and sense of safety at work, as well as increased turnover intentions, with no significant interactions by gender. Conclusions: Sexual harassment against medical faculty is alarmingly common at an institution that is not expected to be atypical. Interventions must address sexual harassment, which affects mental health and career outcomes of male and female physicians.

Gynecologic Oncology Sub-Specialty Training in Ghana: A Model for Sustainable Impact on Gynecologic Cancer Care in Sub-Saharan Africa.

African women have double the risk of dying from cancer than women in high-income countries. In Ghana, most women with gynecological malignancies present with advanced-stage disease when treatment is less effective. Barriers to improved cancer outcomes include the availability of cancer screening, affordability of treatment, and access to gynecologic oncology specialists. In response to a paucity of gynecologic oncology providers, an in-country fellowship training program was established at Komfo Anokye Teaching Hospital (KATH) in 2013. Historically, Ghanaian resident physicians were sent to other countries for fellowship training and were unlikely to repatriate. The establishment of an in-country training program not only addresses the challenge of "brain drain," but also builds local capacity in gynecologic oncology education and emphasizes culturally relevant and accessible healthcare. The four-years gynecologic oncology fellowship program at KATH was developed as part of a longitudinal multi-decade partnership between the University of Michigan and academic medical centers in Ghana. The fellowship trains obstetricians and gynecologists to provide subspecialist clinical and surgical care to patients with gynecologic malignancies. Fellows collaborate with the radiation, oncology and pathology departments, participate in monthly inter-institutional tumor board meetings, conduct research, advise on health policy issues, and train subsequent cohorts. This fellowship is representative of emerging twenty-first-century trends in which subspecialty training programs in low-income countries are strengthened by international collaborations. Providing specialized training in gynecologic oncology can help develop and maintain resources that will improve clinical outcomes for women in low-resources settings.

Ethical issues in global health engagement.

With an increasing number of clinicians participating in global health work, such engagement is now more than ever in need of critical ethical scrutiny. Exemplary initiatives in research, academics and publication, and other special considerations, provide potential approaches for overcoming ethical challenges in global health work. These methods demonstrate that successful global health work includes a commitment to foundational ethical principles such as trust, honesty, open communication and transparency, sustainability, capacity building, and appreciation for multiple perspectives - principles that surpass the traditional considerations of clinical practice. From this perspective, successful interventions to reduce neonatal and perinatal mortality must be strategically focused on building in-country capacity and sustainability.

Predictors of physician career satisfaction, work-life balance, and burnout.

OBJECTIVE: To explore factors associated with physician career satisfaction, work-life balance, and burnout focusing on differences across age, gender, and specialty. METHODS: A cross-sectional, mailed, self-administered survey was sent to a national sample of 2,000 randomly-selected physicians, stratified by specialty, age, and gender (response rate 48%). Main outcome measures included career satisfaction, burnout, and work-life balance. Scales ranged from 1 to 100. RESULTS: Both women and men report being highly satisfied with their careers (79% compared with 76%, P<.01), having moderate levels of satisfaction with work-life balance (48% compared with 49%, P=.24), and having moderate levels of emotional resilience (51% compared with 53%, P=.09). Measures of burnout strongly predicted career satisfaction (standardized beta 0.36-0.60, P<.001). The strongest predictor of work-life balance and burnout was having some control over schedule and hours worked (standardized beta 0.28, P<.001, and 0.20-0.32, P<.001, respectively). Physician gender, age, and specialty were not strong independent predictors of career satisfaction, work-life balance, or burnout. CONCLUSION: This national physician survey suggests that physicians can struggle with work-life balance yet remain highly satisfied with their career. Burnout is an important predictor of career satisfaction, and control over schedule and work hours are the most important predictors of work-life balance and burnout. LEVEL OF EVIDENCE: II.

Why and how a Department of Obstetrics and Gynecology stopped doing routine newborn male circumcision.

In 2004, the Department of Obstetrics and Gynecology at the University of Michigan decided to stop offering routine circumcision for specialty and disciplinary, logistic, and educational reasons. The Pediatric Hospitalist Service assumed responsibility for the procedures and the educational process with resultant patient and staff satisfaction, educational, logistical and economic benefits.