Men and Women Pursue Nonlinear Career Paths, but Impacts Differ: a Cross-Sectional Study of Academic Hospitalists.

BACKGROUND: Nonlinear career paths are increasingly common. Women in academia pursuing nonlinear career paths experience negative impacts on career trajectory. No published studies have examined how pursuit of nonlinear career paths might perpetuate gender inequities within academic hospital medicine. OBJECTIVE: (1) Compare the frequency of nonlinear career paths by gender among academic hospitalists; (2) assess the perceived impact of two types of nonlinear career paths-extended leave (EL) and non-traditional work arrangements (NTWA) on hospitalists' personal lives and careers. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional descriptive survey study of adult hospitalist physicians in three academic centers within the USA. INTERVENTION: Electronic survey including closed- and open-ended items assessing respondent utilization of and experiences with nonlinear career paths. MAIN OUTCOMES AND MEASURES: (1) Associations between EL and demographic variables as well as gender differences in leave length and NTWA strategies using Fisher's exact test; 2) grounded theory qualitative analysis of open-text responses. KEY RESULTS: Compared with men, women reported taking EL more often (p = 0.035) and for longer periods (p = 0.002). Men and women reported taking NTWA at similar rates. Women reported negative impacts of EL within domains of personal life, career, well-being, and work-life integration whereas men only reported negative impacts to career. Men and women described positive impacts of NTWA across all domains. CONCLUSIONS: Women academic hospitalists reported taking EL more often than men and experienced disproportionately more adverse impacts to personal lives and careers. Surprisingly, men reported taking NTWA to address burnout and childbirth at similar rates to women. Our findings lay the groundwork for additional exploration of cultural and policy interventions, particularly improved paid leave policies.

Childbearing and maternity leave in residency: determinants and well-being outcomes.

PURPOSE: To characterise determinants of resident maternity leave and their effect on maternal and infant well-being. Among non-parents, to identify factors that influence the decision to delay childbearing STUDY DESIGN: In 2016, a survey was sent to female residents at a large academic medical centre on their experiences with maternity leave, the impact of personal and programme factors on length of leave, reasons for delaying childbearing and measures of well-being. RESULTS: Forty-four percent (214/481) of residents responded. Fifty (23%) residents were parents, and 25 (12%) took maternity leave during training. The average maternity leave length was 8.4 weeks and did not differ across programme type, size or programme director gender but was longer for programmes with fewer women than men. The most common self-reported determinant of leave was financial. Residents with >8 weeks of leave were less likely to have postpartum depression or burnout and more likely to breastfeed longer, perceive support from colleagues and programme directors, and be satisfied with resident parenthood. Among 104 non-parents who were married or partnered, 84 (81%) were delaying childbearing, citing busy work schedules, concern for burdening colleagues and finances. CONCLUSIONS: This study suggests that multiple aspects of resident wellbeing are associated with longer maternity leaves, yet finances and professional relationships hinder length of leave and lead to delayed childbearing. These issues could be addressed at a programme level with clear policies describing how work is redistributed during parental leave and at an institutional and state level through provision of paid family leave.

Interprofessional model on speaking up behaviour in healthcare professionals: a qualitative study.

OBJECTIVES: Despite training and the recognition that speaking up can mitigate harm to patients and save lives, healthcare professionals do not consistently speak up when they have patient safety concerns. The purpose of this study was to identify barriers to and facilitators of speaking up about patient safety concerns to inform the development of interventions that will increase this behaviour. DESIGN: From October 2017 to February 2018, the study team conducted focus groups and interviews with nurses, advanced practice providers and physicians at three healthcare facilities. Participants were prompted to share their personal experiences with and perspectives on speaking up about patient safety concerns and to discuss strategies for communicating those concerns. SETTING: Tertiary academic healthcare centre. PARTICIPANTS: 62 healthcare professionals participated in the study. Purposeful sampling was used to include participants of different health professions and experience levels. MAIN OUTCOME MEASURES: We planned to answer questions about why more healthcare professionals do not consistently speak up when they have legitimate patient safety concerns and to identify ways to enhance current interventions on speaking up behaviours, RESULTS: Twelve focus group discussions and two interviews were conducted with 62 participants. We identified two recurring themes: (1) The predominantly hierarchical culture of medicine is a barrier to speaking up and (2) Institutional, interpersonal and individual factors can modulate the impact of medicine's hierarchical culture on speaking up behaviours and inform the strategies employed. CONCLUSIONS: The data highlighted the importance of moving beyond targeting front-line healthcare professionals for training in the skills of speaking up and engaging institutional leaders and systems to actively promote and reward speaking up behaviours.

Parental Leave Policies in Residency: A National Survey of Internal Medicine Program Directors.

PURPOSE: To characterize the existence, accessibility, and content of parental leave policies, as well as barriers to program-level policy implementation among internal medicine (IM) program directors (PDs) and to assess the willingness of PDs to implement a national standardized policy. METHOD: In 2019, the Association of Program Directors in Internal Medicine conducted a survey of 422 IM PDs. Along with other content, 38 questions addressed 4 primary outcomes: parental leave policy existence, accessibility, content, and barriers. The authors compared programs with and without a program-level policy and applied qualitative content analysis to open-ended questions about barriers to policy implementation and openness to a national standard. RESULTS: The response rate was 69.4% (293/422). Of responding programs, 86% (250/290) reported a written parental leave policy with 43% (97/225) of these originating at the program level. Program-level policies, compared with policies at other levels, were more likely to address scheduling during pregnancy (38%, 36/95 vs 22%, 27/124; P = .018); peer coverage (24%, 21/89 vs 15%, 16/109; P = .037), how the duration of extended training is determined (81%, 72/89 vs 44%, 48/109; P < .001), and associated pay and benefits 61%, 54/89 vs 44%, 48/109; P = .009). PDs without program-level policy reported lacking guidance to develop policy, deferring upward to institutional policies, and wishing to retain flexibility. More than half of PDs (60%, 170/282) expressed agreement that a national standard for a residency program-level parental leave policy should exist. Those not in favor cited organization equity, lack of resources, implementation challenges, loss of flexibility, and potentially disadvantaging recruitment. CONCLUSIONS: While existing program-level policies included important content, most PDs reported not having them. A national standard to guide the development of program-level parental leave policies could be embraced if it provided flexibility for programs with limited resources.

Deliberate practices of speaking up and responding skills: the Speak-PREP e-learning module for healthcare professionals.

PURPOSE: Speaking up and responding to others' concerns promotes patient safety. We describe health professionals' utilisation of these important skills. METHOD: We developed an interactive e-learning module, Speak-PREP, to train healthcare professionals in speaking up and responding strategies. Participants completed interactive video-based exercises that engaged them with entering speaking up and responding statements, augmenting strategies from a list of prompting phrases and responding to a pushback. We report strategy utilisation. RESULTS: A total of 101 health professionals completed Speak-PREP training. Most frequently used speaking up strategies were: brainstorming to explore solutions (50%), showing consideration of others (45%) and encouraging others' opinions through invitations (43%). Responding strategies included reflecting the concern expressed by colleagues, discussing next steps and expressing gratitude (70%, 67% and 50%, respectively). When prompted, participants augmented their statements with reframing concerns, asking questions to deepen understanding, using how or what to start questions and expressing curiosity (p<0.00001, p=0.003, p=0.0002 and p<0.0001, respectively). Pushbacks lead to increased use of reflecting the concern and decreasing consideration, curiosity, empathy, expressing gratitude and encouraging others' opinions (p<0.05 for all). CONCLUSIONS: The Speak-PREP module targeted deliberate practice in speaking up and responding skills. Future work should examine the application of these strategies in the clinical environment.

Occurrence of Aeromonas spp. in a random sample of drinking water distribution systems in the USA.

Aeromonads are aquatic bacteria found in drinking water supplies worldwide. Some species, such as Aeromonas hydrophila, can cause disease in humans. For this survey, 293 United States public water systems were selected using random sampling, stratified by water source and system type. Water samples were collected during one year from three sites (six samples per site) in each system. Temperature, pH, turbidity, total and free chlorine were measured using standard methods. Aeromonads were detected in 130 of 5,042 valid samples (2.6%) from 42 (14.3%) systems using the ampicillin-dextrin agar with vancomycin culture method with oxidase, trehalose and indole confirmation tests. Concentrations of aeromonads in positive samples were 0.2 to 880 (median 1.6) colony-forming units (CFU) per 100 mL. Adjusted odds ratios of Aeromonas detection were 1.6 (95% confidence limits 1.0, 2.5) during the summer season, 3.3 (1.8, 6.2) for turbidity above 0.5 nephelometric units and 9.1 (3.5, 24) at 0 mg/L compared with 0.25 mg/L total chlorine. Geographic region, system size and type of water source were not significant predictors of Aeromonas detection in multivariate regression analysis. The results of this survey demonstrate the importance of maintaining adequate residual chlorine and low turbidity for preventing drinking water contamination with aeromonads.

Maximizing Career Advancement During the COVID-19 Pandemic: Recommendations for Postgraduate Training Programs.

The ongoing novel Coronavirus disease 2019 (COVID-19) pandemic has created many threats as well as opportunities for the career development of physicians-in-training. Institutional responses to the demand for patient care reduced the time many residents have to pursue clinical electives, scholarship projects, and other experiences meant to clarify and advance their personal and professional goals. Moreover, many academic medical centers experienced profound fiscal losses that require thoughtful revisions to budgets and curricula. In this article, the authors recommend strategies for residency programs to mitigate these losses and capitalize on growth in virtual education, scholarship opportunities, and relationships arising from the pandemic. Drawing from career development guidelines from the National Career Development Association and existing literature about factors associated with positive career outcomes, the authors suggest leadership roles, curricula, and events that training programs can quickly and inexpensively implement to help residents grow as professionals, achieve personal training goals, produce scholarship, and attain future employment. To help trainees manage their careers, the authors recommend structured mentorship and education in career pathways and the preparation of job application materials. To foster attainment of specific knowledge and cultivate lifelong learning, the authors recommend leveraging existing resources to provide time, funding, academic coaching, and skills training for scholarship projects. To promote development of effective work relationships and community, the authors recommend appointment of a faculty champion for career advancement, scholarship showcases, attendance at virtual journal clubs, and networking through social media outlets. These recommendations for supporting career advancement may apply to early career faculty development as well as undergraduate and postgraduate medical education beyond the pandemic era. Outcomes studies will be needed to evaluate the impact of these recommendations.

Parenthood and Parental Leave Decisions in Pediatric Residency.

OBJECTIVES: The demands of residency training may impact trainees' decision to have children. We examined characteristics of pediatric residents' decisions regarding childbearing, determinants of resident parental leave, and associations with well-being. METHODS: A survey of 845 pediatric residents at 13 programs was conducted between October 2019 and May 2020. Survey items included demographics, desire for future children, and logistics of parental leave. Outcomes included parental leave length, burnout and depression screening results, satisfaction with duration of breastfeeding, and satisfaction with parental leave and parenthood decisions. RESULTS: Seventy-six percent (639 of 845) of residents responded to the survey. Fifty-two percent (330) of respondents reported delaying having children during residency, and 29% (97) of those were dissatisfied with their decision to do so. Busy work schedule (89.7%), finances (50.9%), and a desire not to extend residency (41.2%) were the most common reasons for delay. Of respondents, 16% were parents and 4% were pregnant or had pregnant partners. Sixty-one parental leaves were reported, and 67% of parents reported dissatisfaction with leave length. The most frequently self-reported determinant of leave duration was the desire not to extend residency training (74%). Program mean leave length was negatively associated with burnout, measured as a dichotomous outcome (odds ratio = 0.81 [95% confidence interval 0.68-0.98]; P = .02). CONCLUSIONS: Many pediatric trainees delay parenthood during residency and are not satisfied with their decision to do so. Pediatric resident parental leave remains short and variable in duration, despite the positive association between longer leaves and overall well-being.

Representation of Women on Journal Editorial Boards Affiliated with the Association of American Medical College's Council of Faculty and Academic Societies.

Background: The Council of Faculty and Academic Societies (CFAS) comprises representatives from medical schools and professional societies who guide the Association of American Medical Colleges (AAMC). Given the AAMC's stated mission to improve diversity and inclusion, we used gender-related representation on journal editorial boards as a proxy for evaluating CFAS member societies' commitments to equity. Methods: From screenshots of journal mastheads (n = 44) collected June 3-6, 2019, individuals were categorized by editorial position. Outcome measures included numbers of men and women among faculty, deans, department chairs, physicians, and nonphysicians on editorial boards. Outcomes were compared with 2018 AAMC and US Bureau of Labor Statistics workforce data. Results: Overall, the proportion of women among journal editors was 29.0% (364 of 1,255), range 0%-53.3%. This proportion was significantly less than the proportion of women among US medical school faculty and medical scientists. The lowest percentages of women were found among journals' section or topic editors (19.2%) and editors-in-chief (20.4%). Men were significantly more likely to be a professor or department chair and women were significantly more likely to be an associate professor or assistant professor, suggesting a bidirectional process between rank and editorial position that may inhibit the advancement of academic women, particularly women physicians. Conclusions: This study revealed disparities in the equitable representation of women among CFAS member-affiliated journal editors. Because CFAS member societies participate in a mutually beneficial relationship with the AAMC, they should strive to attain the equity goals set forth by the AAMC.

Childbearing Decisions in Residency: A Multicenter Survey of Female Residents.

PURPOSE: To characterize how female residents make decisions about childbearing, factors associated with the decision to delay childbearing, and satisfaction with these decisions. METHOD: In 2017, the authors sent a voluntary, anonymous survey to 1,537 female residents enrolled across 78 graduate medical education programs, consisting of 25 unique specialties, at 6 U.S. academic medical centers. Survey items included personal, partner, and institutional characteristics, whether the respondent was delaying childbearing during residency, and the respondent's satisfaction with this decision. RESULTS: The survey response rate was 52% (n = 804). Among the 447 (56%) respondents who were married or partnered, 274 (61%) were delaying childbearing. Residents delaying childbearing were significantly more likely to be younger (P < .001), not currently a parent (P < .001), in a specialty with an uncontrollable lifestyle (P = .001), or in a large program (P = .004). Among self-reported reasons for delaying childbearing, which were not mutually exclusive, the majority cited a busy work schedule (n = 255; 93%) and desire not to extend residency training (n = 145; 53%). Many cited lack of access to childcare (n = 126; 46%), financial concerns (n = 116; 42%), fear of burdening colleagues (n = 96; 35%), and concern for pregnancy complications (n = 74; 27%). Only 38% (n = 103) of respondents delaying childbearing were satisfied with this decision, with satisfaction decreasing with increasing age. CONCLUSIONS: Decisions to delay childbearing are more common in certain specialties, and many residents who delay childbearing are not satisfied with that decision. These findings suggest that greater attention is needed overall, and particularly in certain specialties, to promote policies and cultures that both anticipate and normalize parenthood in residency, thus minimizing the conflict between biological and professional choices for female residents.

A regulatory role for the C5a anaphylatoxin in type 2 immunity in asthma.

Complement component 5 (C5) has been described as either promoting or protecting against airway hyperresponsiveness (AHR) in experimental allergic asthma, suggesting pleomorphic effects of C5. Here we report that local pharmacological targeting of the C5a receptor (C5aR) prior to initial allergen sensitization in murine models of inhalation tolerance or allergic asthma resulted in either induction or marked enhancement of Th2-polarized immune responses, airway inflammation, and AHR. Importantly, C5aR-deficient mice exhibited a similar, increased allergic phenotype. Pulmonary allergen exposure in C5aR-targeted mice resulted in increased sensitization and accumulation of CD4+ CD69+ T cells associated with a marked increase in pulmonary myeloid, but not plasmacytoid, DC numbers. Pulmonary DCs from C5aR-targeted mice produced large amounts of CC chemokine ligand 17 (CCL17) and CCL22 ex vivo, suggesting a negative impact of C5aR signaling on pulmonary homing of Th2 cells. In contrast, C5aR targeting in sensitized mice led to suppressed airway inflammation and AHR but was still associated with enhanced production of Th2 effector cytokines. These data suggest a dual role for C5a in allergic asthma, i.e., protection from the development of maladaptive type 2 immune responses during allergen sensitization at the DC/T cell interface but enhancement of airway inflammation and AHR in an established inflammatory environment.

The FIRST Curriculum: Cultivating Speaking Up Behaviors in the Clinical Learning Environment.

Expressing concerns that arise during patient care is essential to protecting patient safety. A speaking up episode occurs within a power hierarchy and carries high potential for personal and professional consequences. Existing curricula that promote speaking up, such as TeamSTEPPS™, extensively focus on verbal skills without recognizing the important emotional dimensions of speaking up. We developed the FIRST Speaking Up curriculum that covered the following: (a) inner barriers related to expectations of one's own identity, (b) cognitive distortions associated with speaking up, (c) the speaking up environment, (d) dialogue skills for the speaker and the listener, and (e) resilience strategies. The curriculum was delivered via 2 to 3 hours of interactive workshops to 109 participants, including 40 nursing staff and leaders, 24 plastic surgery residents, and 45 internal medicine residents. Evidence showed that training improved participants' motivations to speak up concerns. Our work expands on existing strategies for speaking up training by targeting both verbal and emotional skills. [J Contin Educ Nurs. 2019;50(8):355-361.].

Parenthood During Graduate Medical Education: A Scoping Review.

PURPOSE: To conduct a scoping review of the literature on parenthood during graduate medical education (GME) and to develop a conceptual framework to inform policy and guide research. METHOD: The authors searched PubMed and Embase for articles published from January 1993 through August 7, 2017, using a query framework that combined the concepts of "person" (e.g., "trainee") and "parenthood" (e.g., "breastfeeding"). They included studies describing parenthood or pregnancy of trainees in U.S. GME training programs. Two authors independently screened citations and abstracts and performed kappa coefficient tests to evaluate interreviewer reliability. Two authors performed a full-text review of and extracted data from each included article, and 4 authors coded data for all articles. The authors used descriptive statistics and qualitative synthesis to analyze data. RESULTS: Ninety articles met inclusion criteria, and nearly half (43/90; 48%) were published between 2010 and 2017. The authors developed 6 themes that surround resident parenthood: well-being, maternal health, others' perceptions, relationships, program preparation, and policy. They mapped these themes by relationship of stakeholders (e.g., infant and family, institutions) to the resident-parent to create a conceptual framework describing parenthood during GME. CONCLUSIONS: The findings from this scoping review have implications for policy and research. Those authoring parental leave policies could collaborate with national board leaders to develop consistent standards and include nontraditional families. Gaps in the literature include the effect of resident parenthood on patient care, postpartum health, and policy execution. Research in these areas would advance the literature on parenthood during residency.

Maternity Leave in Residency: A Multicenter Study of Determinants and Wellness Outcomes.

PURPOSE: To characterize determinants of resident maternity leave and the effect of length of leave on maternal well-being. METHOD: In 2017, the authors sent a voluntary, anonymous survey to female residents at 78 programs, in 25 unique specialties, at 6 institutions. Survey items included personal, partner, and child demographics, and logistics of leave, including whether leave was paid or vacation or sick leave was used. Outcomes were maternity leave length; duration of breastfeeding; burnout and postpartum depression screens; perceptions of support; and satisfaction with length of leave, breastfeeding, and childbearing during residency. RESULTS: Fifty-two percent (804/1,537) of residents responded. Among 16% (126) of respondents who were mothers, 50% (63) had their first child during residency. Seventy-seven maternity leaves were reported (range, 2-40 weeks), with most taking 6 weeks (32% of leaves; 25) and including vacation (81%; 62) or sick leave (64%; 49). Length of leave was associated with institution, use of sick leave or vacation, and amount of paid leave. The most frequently self-reported determinant of leave was the desire not to extend residency training (27%; 59). Training was not extended for 53% (41) of mothers; 9% (7) were unsure. Longer breastfeeding duration and perceptions of logistical support from program administration were associated with longer maternity leaves. Burnout affected approximately 50% (38) of mothers regardless of leave length. CONCLUSIONS: This study illustrates variability in administration of resident maternity leaves. Targets for intervention include policy clarification, improving program support, and consideration of parent wellness upon return to work.

Anticipation of affect in dysthymia: behavioral and neurophysiological indicators.

Anticipation for future affective events and prediction uncertainty were examined in healthy controls and individuals with dysthymia (DYS) using behavioral responses and the contingent negative variation (CNV) and post-imperative negative variation (PINV) event-related potential (ERP) components. Warning stimuli forecasted the valence of subsequently presented adjectives ("+", positive; "=", neutral; "-", negative), and participants indicated whether each adjective would describe them over the next two weeks. Controls expected fewer negative, and individuals with DYS expected fewer positive, adjectives to apply to them. CNV amplitudes were enhanced in controls prior to positive versus other adjectives. Response times and PINV amplitudes were greater following neutral compared to other adjectives, and PINV was larger overall in dysthymics compared to controls. In sum, healthy controls and individuals with DYS exhibit different behavioral and neurophysiological biases in anticipation for future affective events. These results are discussed in the context of cognitive theories of depression.

Second generation anticoagulant rodenticides in tawny owls (Strix aluco) from Great Britain.

Secondary exposure of vertebrate predators to second generation anticoagulant rodenticides (SGARs) is widespread in Britain. Tawny owl (Strix aluco) populations in the UK are thought to have declined since the 1970s, when SGARs were first introduced, and these compounds may have contributed to any decline in owl numbers. Our aims were to conduct the first systematic survey of SGAR exposure in tawny owls and ascertain whether there had been a change in the proportion of exposed birds that was concurrent with the decline in the population. Liver difenacoum, bromadiolone, flocoumafen and brodifacoum concentrations in British tawny owls from two periods (1990-1993 and 2003-2005) were quantified. In total, some 20% of birds contained detectable residues of one or more SGAR. The extent of exposure (% of birds exposed, magnitude of residues) to different SGARs did not change consistently between time periods. Of the raptors analysed to date in Britain, tawny owls had the lowest proportion of individuals that contained detectable liver residues and so appear to be the least vulnerable to exposure and/or assimilation of SGARs. We found no clear evidence to implicate SGARs as a major factor affecting tawny owl numbers in Britain between 1990 and 2005.

The Predatory Bird Monitoring Scheme: identifying chemical risks to top predators in Britain.

The Predatory Bird Monitoring Scheme (PBMS) is a long term (>40 y), UK-wide, exposure monitoring scheme that determines the concentration of selected pesticides and pollutants in the livers and eggs of predatory birds. This paper describes how the PBMS works, and in particular highlights some of the key scientific and policy drivers for monitoring contaminants in predatory birds and describes the specific aims, scope, and methods of the PBMS. We also present previously unpublished data that illustrates how the PBMS has been used to demonstrate the success of mitigation measures in reversing chemical-mediated impacts; identify and evaluate chemical threats to species of high conservation value; and finally to inform and refine monitoring methodologies. In addition, we discuss how such schemes can also address wider conservation needs.