A mandala of faculty development: using theory-based evaluation to explore contexts, mechanisms and outcomes.

Demonstrating the impact of faculty development, is an increasingly mandated and ever elusive goal. Questions have been raised about the adequacy of current approaches. Here, we integrate realist and theory-driven evaluation approaches, to evaluate an intensive longitudinal program. Our aim is to elucidate how faculty development can work to support a range of outcomes among individuals and sub-systems in the academic health sciences. We conducted retrospective framework analysis of qualitative focus group data gathered from 79 program participants (5 cohorts) over a 10-year period. Additionally, we conducted follow-up interviews with 15 alumni. We represent the interactive relationships among contexts, mechanisms, and outcomes as a "mandala" of faculty development. The mandala illustrates the relationship between the immediate program context, and the broader institutional context of academic health sciences, and identifies relevant change mechanisms. Four primary mechanisms were collaborative-reflection, self-reflection and self-regulation, relationship building, and pedagogical knowledge acquisition. Individual outcomes, including changed teaching practices, are described. Perhaps most interestingly, secondary mechanisms-psychological and structural empowerment-contributed to institutional outcomes through participants' engagement in change leadership in their local contexts. Our theoretically informed evaluation approach models how faculty development, situated in appropriate institutional contexts, can trigger mechanisms that yield a range of benefits for faculty and their institutions. The adopted methods hold potential as a way to demonstrate the often difficult-to-measure outcomes of educational programs, and allow for critical examination as to how and whether faculty development programs can accomplish their espoused goals.

What do I do? Developing a competency inventory for postgraduate (residency) program directors.

BACKGROUND: Few new Residency Program Directors (PD) are formally trained for the demands and responsibilities of the leadership aspect of their role. Currently, there are no comprehensive frameworks that describe specific leadership competencies that can inform PD self-reflection or faculty development. METHODS: The authors developed a Postgraduate Program Director Competency Inventory (PPDCI) in order to frame the performance of PDs for a multisource feedback (MSF) program. The development of the PPDCI occurred in five phases which involved: development of an initial inventory, implementation of a key informant survey of national opinion leaders, execution of a validity survey with postgraduate education leaders and committee members and implementation of a further refined inventory with 17 PD and 147 raters as part of a pilot MSF program. OUTCOMES: Five distinct domains of leadership competence were identified which included: Communication and relationship management, leadership, professionalism and self-management, environmental engagement, and management skills and knowledge. The content validity of the PPDCI was endorsed by 85% of the key informants. The validity survey indicated strong endorsement of the PPDCI domains and recognition of its utility for both orientation of new PD as well as a frame for self-assessment. The pilot MSF program yielded a further refined and reduced inventory of 26 items of competence as well as recommendations for its utility. CONCLUSIONS: Use of this leadership inventory has the potential to ensure effective leadership of postgraduate programs.

From Industry to Generativity: The First 12 Years of the Association for Academic Psychiatry Master Educator Program.

OBJECTIVE: This study presents a mixed-methods evaluation of the first 12 years of the Association for Academic Psychiatry (AAP) Master Educator (ME) program, developed in 2003 to help academic psychiatrists hone their skills as educators. Participants attend two 3-h workshops at the annual meeting, organized in 3-year cycles, for a total of 18 h. Core topics include assessment, curriculum design, and program evaluation. METHODS: Overall session rating scores from 2003 to 2014 were analyzed using descriptive statistics. A 20-question survey was sent to 58 program graduates in October 2014, exploring participant perspectives on the impact of the ME program on their careers and on the educational programs they were affiliated with. Survey responses were analyzed quantitatively (for multiple choice questions) and qualitatively (for open-ended questions). RESULTS: The mean overall session scores ranged between 4.1 and 4.9 (on a Likert-type scale of 1-5) for each 3-year cycle. Twenty-nine graduates completed the survey (50 % response rate). Survey responses indicated a positive perception of the impact of the ME program on participants' careers. Most respondents noted improvement in their teaching methods and curriculum development skills and being able to link educational theory with their individual practices. There was a significant increase in perceived confidence, leadership, and further contributions to their educational milieu. Fifteen (52 %) participants also reported generative behaviors that directly impacted others, such as developing new programs, enhancing existing programs at their institutions, or contributing to national educational efforts. CONCLUSION: The AAP ME program has demonstrated significant benefit over its 12 years of existence. This program represents one strategy to sustain and grow an international community of like-minded educators working to develop their own and future generations' skills in providing high-quality education in psychiatry.

Toward a common understanding: supporting and promoting education scholarship for medical school faculty.

CONTEXT: Education scholarship (ES) is integral to the transformation of medical education. Faculty members who engage in ES need encouragement and recognition of this work. Beginning with the definition of ES as 'an umbrella term which can encompass both research and innovation in health professions education', and which as such represents an activity that is separate and distinct from teaching and leadership, the purpose of our study was to explore how promotion policies and processes are used in Canadian medical schools to support and promote ES. METHODS: We conducted an analysis of the promotion policies of 17 Canadian medical schools and interviews with a key informant at each institution. We drew on an interpretive approach to policy analysis to analyse the data and to understand explicit messages about how ES was represented and supported. RESULTS: Of the 17 schools' promotion documents, only nine contained specific reference to ES. There was wide variation in focus and level of detail. All key informants indicated that ES is recognised and considered for academic promotion. Barriers to the support and recognition of ES included a lack of understanding of ES and its relationship to teaching and leadership. This was manifest in the variability in promotion policies and processes, support systems, and career planning and pathways for ES. CONCLUSIONS: This lack of clarity may make it challenging for medical school faculty members to make sense of how they might successfully align ES within an academic career. There is a need therefore to better articulate ES in promotion policies and support systems. Creating a common understanding of ES, developing guidelines to assess the impact of all forms of ES, developing an informed leadership and system of mentors, and creating explicit role descriptions and guidelines are identified as potential strategies to ensure that ES is appropriately valued.

What do we do? Practices and learning strategies of medical education leaders.

BACKGROUND: Continuous changes in undergraduate and postgraduate medical education require faculty to assume a variety of new leadership roles. While numerous faculty development programmes have been developed, there is little evidence about the specific practices of medical education leaders or their learning strategies to help inform their design. AIM: This study aimed to explore what medical education leaders' actually do, their learning strategies and recommendations for faculty development. METHOD: A total of 16 medical education leaders from a variety of contexts within the faculty of medicine of a large North American medical school participated in semi-structured interviews to explore the nature of their work and the learning strategies they employ. Using thematic analysis, interview transcripts were coded inductively and then clustered into emergent themes. RESULTS: Findings clustered into four key themes of practice: (1) intrapersonal (e.g., self-awareness), (2) interpersonal (e.g., fostering informal networks), (3) organizational (e.g., creating a shared vision) and (4) systemic (e.g. strategic navigation). Learning strategies employed included learning from experience and example, reflective practice, strategic mentoring or advanced training. CONCLUSIONS: Our findings illuminate a four-domain framework for understanding medical education leader practices and their learning preferences. While some of these findings are not unknown in the general leadership literature, our understanding of their application in medical education is unique. These practices and preferences have a potential utility for conceptualizing a coherent and relevant approach to the design of faculty development strategies for medical education leadership.

Who am I? Key influences on the formation of academic identity within a faculty development program.

INTRODUCTION: Professional identity encompasses how individuals understand themselves, interpret experiences, present themselves, wish to be perceived, and are recognized by the broader professional community. For health professional and health science educators, their 'academic' professional identity is situated within their academic community and plays an integral role in their well being and productivity. This study aims to explore factors that contribute to the formation and growth of academic identity (AI) within the context of a longitudinal faculty development program. METHODS: Using a qualitative case study approach, data from three cohorts of a 2-year faculty development program were explored and analyzed for emerging issues and themes related to AI. RESULTS: Factors salient to the formation of AI were grouped into three major domains: personal (cognitive and emotional factors unique to each individual); relational (connections and interactions with others); and contextual (the program itself and external work environments). DISCUSSION: Faculty development initiatives not only aim to develop knowledge, skills, and attitudes, but also contribute to the formation of academic identities in a number of different ways. Facilitating the growth of AI has the potential to increase faculty motivation, satisfaction, and productivity. Faculty developers need to be mindful of factors within the personal, relational, and contextual domains when considering issues of program design and implementation.

Health-related quality of life in adults with sickle cell disease (SCD): a report from the comprehensive sickle cell centers clinical trial consortium.

Adults with Sickle Cell Disease (SCD) experience multiple disease-related complications, but few studies have examined relationships between these events and health-related quality of life (HRQOL). We determined the number and type of previous or co-occurring SCD-related complications and their reported HRQOL in a cohort of 1,046 adults from the Comprehensive Sickle Cell Centers (CSCC). Participants had a median age of 28.0 years (48% male, 73% SS or Sß° thalassemia) and had experienced several SCD-related complications (mean 3.8 ± 2.0), which were influenced by age, gender, and hemoglobinopathy type (P < 0.0001). In multivariate models, increasing age reduced all SF-36 scales scores (P < 0.05) except mental health, while female gender additionally diminished physical function and vitality scale scores (P < 0.01). Of possible complications, only vaso-occlusive crisis, asthma, or avascular necrosis diminished SF-36 scale scores. Chronic antidepressants usage predominantly diminished scores on bodily pain, vitality, social functioning, emotional role, and mental health scales, whereas chronic opioid usage diminished all scale scores (P < 0.01). Our study documents substantial impairment of HRQOL in adults with SCD that was influenced by only a few of many possible medical complications. It suggests that more effective treatments of persistent pain and depression would provide the largest HRQOL benefit.

Definitions of the phenotypic manifestations of sickle cell disease.

Sickle cell disease (SCD) is a pleiotropic genetic disorder of hemoglobin that has profound multiorgan effects. The low prevalence of SCD ( approximately 100,000/US) has limited progress in clinical, basic, and translational research. Lack of a large, readily accessible population for clinical studies has contributed to the absence of standard definitions and diagnostic criteria for the numerous complications of SCD and inadequate understanding of SCD pathophysiology. In 2005, the Comprehensive Sickle Cell Centers initiated a project to establish consensus definitions of the most frequently occurring complications. A group of clinicians and scientists with extensive expertise in research and treatment of SCD gathered to identify and categorize the most common complications. From this group, a formal writing team was formed that further reviewed the literature, sought specialist input, and produced definitions in a standard format. This article provides an overview of the process and describes 12 body system categories and the most prevalent or severe complications within these categories. A detailed Appendix provides standardized definitions for all complications identified within each system. This report proposes use of these definitions for studies of SCD complications, so future studies can be comparably robust and treatment efficacy measured. Use of these definitions will support greater accuracy in genotype-phenotype studies, thereby achieving a better understanding of SCD pathophysiology. This should nevertheless be viewed as a dynamic rather than final document; phenotype descriptions should be reevaluated and revised periodically to provide the most current standard definitions as etiologic factors are better understood, and new diagnostic options are developed.

Health-related quality of life in children with sickle cell disease: a report from the Comprehensive Sickle Cell Centers Clinical Trial Consortium.

BACKGROUND: Pediatric health-related quality of life (HRQOL) questionnaires have been validated in children with sickle cell disease (SCD), but small sample sizes in these studies have limited clinical comparisons. We used the baseline clinical data from the Collaborative Data (C-Data) Project of the Comprehensive Sickle Cell Centers (CSCC) Clinical Trial Consortium to perform a detailed, descriptive study of HRQOL using the PedsQL version 4.0 generic core and fatigue scales. METHODS: Retrospective clinical data were obtained via medical record abstraction. Staff-administered health history, psychosocial, and health behavior interviews were completed by a parent or guardian. PedsQL forms were completed separately by the child and a parent/guardian. RESULTS: The study enrolled 1,772 subjects (53% boys) with a mean age of 9.6 years (SD 4.7). SS or Sbeta(0) thalassemia occurred in 68% and 32% had SC or Sbeta(+) thalassemia. The occurrences of pain, priapism, avascular necrosis of hips/shoulders (AVN), or asthma were the most common complications/conditions reported. Multiple regression models controlling for hemoglobinopathies, gender, and age suggested that parent reports of physical functioning and sleep/rest fatigue declined in response to pain or AVN, while school functioning scales declined in response to pain or asthma. Sickle pain, and to a lesser extent asthma, negatively influenced child reports on almost all functioning and fatigue scales. CONCLUSIONS: While longitudinal studies will be necessary to determine sensitivity to change, the current study suggests the potential utility of several PedsQL HRQOL scales as patient-reported outcome measures for observational or interventional treatment studies of children and adolescents with SCD.

Recommendations for staff education and training for older people with mental illness in long-term aged care.

BACKGROUND: This paper was written as a result of the International Psychogeriatric Association Task Force on Mental Health Services in Long-Term Care. The appraisal presented here aims to (1) identify the best available evidence that underpins best practice for geriatric mental health education and training of staff working in long-term care, and (2) summarize the appraisal of the literature to provide recommendations for practice. METHODS: An initial search of databases found 138 papers related to the search strategy. Selected papers were summarized and compared against set inclusion criteria. This resulted in 17 papers suitable for review. RESULTS: The majority of papers focused on behavior skills training. A number of key factors were identified that determine the success of geriatric mental health education and training and recommendations are outlined. CONCLUSIONS: Methodological weaknesses are common and highlight the need for further replication studies using strong research designs.

Canadian residents' perceived manager training needs.

BACKGROUND: Despite widespread endorsement for administrative training during residency, teaching and learning in this area remains intermittent and limited in most programmes. AIM: To inform the development of a Manager Train-the-Trainer program for faculty, the Royal College of Physicians and Surgeons of Canada undertook a survey of perceived Manager training needs among postgraduate trainees. METHODS: A representative sample of Canadian specialty residents received a web-based questionnaire in 2009 assessing their perceived deficiencies in 13 Manager knowledge and 11 Manager skill domains, as determined by gap scores (GSs). GSs were defined as the difference between residents' perceived current and desired level of knowledge or skill in selected Manager domains. Residents' educational preferences for furthering their Manager knowledge and skills were also elicited. RESULTS: Among the 549 residents who were emailed the survey, 199 (36.2%) responded. Residents reported significant gaps in most knowledge and skills domains examined. Residents' preferred educational methods for learning Manager knowledge and skills included workshops, web-based formats and interactive small groups. CONCLUSION: The results of this national survey, highlighting significant perceived gaps in multiple Manager knowledge and skills domains, may inform the development of Manager curricula and faculty development activities to address deficiencies in training in this important area.

Exploring the Networking of Academic Health Science Leaders: How and Why Do They Do It?

PURPOSE: Networking is essential to leadership effectiveness in the business context. Yet little is known about leadership networking within the academic health science context. If we are going to train academic leaders, we must first understand the relational, network-based activities of their work. The purpose of this study was to explore how academic health science leaders engage in networking activities in the academic health science context. METHOD: A constructivist grounded theory approach guided our study. The authors interviewed 24 academic health science leaders who were enrolled in the New and Evolving Academic Leadership program at the University of Toronto and used social network mapping as an elicitation method. Interviews, which were conducted between September 2014 and June 2015, explored participants' networks and networking activities. Constant comparative analysis was used to analyze the interviews, with attention paid to identifying key networking activities. RESULTS: Academic health science leaders were found to engage in 4 types of networking activities: role bound, project based, goal/vision informed, and opportunity driven. These 4 types were influenced by participants' conception of their role and their perceived leadership work context, which in turn influenced their sense of agency. CONCLUSIONS: The networking activities identified in this study of academic health science leaders resonate with effective networking activities found in other fields. The findings highlight that these activities can be facilitated by focusing on leaders' perceptions about role and work context. Leadership development should thus attend to these perceptions to encourage effective networking skills.

The research innovation and scholarship in education program: an innovative way to nurture education.

OBJECTIVE: Education is becoming a recognized career path in psychiatry. Yet, there are few published accounts of how to create sustainable structures within departments to support this academic focus. The authors document the creation and 5-year progress of the Research Innovation and Scholarship in Education (RISE) program at the largest psychiatry department in Canada. METHODS: The authors analyzed the RISE archive of early proposals for enhancing scholarship in the department, the 5-year plan, annual reports, and curricular vitae of members and also gathered testimonials from inaugural residents and fellows of the program. Materials were analyzed using Boyer's framework of scholarship. RESULTS: Organizationally, RISE has embodied all four tenets of Boyer's model of scholarship. The program has allowed education research, teaching, and creative professional development to flourish in the department, and there are considerably fewer barriers to pursuing an education career path. However, as the program expands, more work needs to be done to increase funding and protected time so that even more residents, fellows, and faculty can engage in educational scholarship. CONCLUSION: Enhancing medical education scholarship through a model that actively integrates research with teaching, creative professional development, and mentorship can help the trajectories of faculty and students wishing to make education a priority in their careers.

UGT1A1 promoter polymorphisms and the development of hyperbilirubinemia and gallbladder disease in children with sickle cell anemia.

Genetic modifiers contribute to phenotypic variability in patients with sickle cell anemia (SCA). The influence of the bilirubin UDP-glucuronosyltransferase (UGT) 1A1 (TA)(n)TAA promoter polymorphism on bilirubin levels and gallbladder disease in SCA was examined using prospectively collected data from the Cooperative Study of Sickle Cell Disease. A total of 324 children with HbSS (median age 6.9 years) had UGT1A1 genotyping; 243 (75%) had common (TA)(6) or (TA)(7) alleles, whereas 81 (25.0%) had variant (TA)(5) or (TA)(8) alleles. The UGT1A1 genotype significantly influenced average bilirubin levels for the common alleles: 6/6 genotype = 2.36 +/- 1.13 mg/dL, 6/7 genotype = 2.90 +/- 1.54 mg/dL, and 7/7 genotype = 4.24 +/- 2.11 mg/dL (P < 0.0001). Thirty-nine percent of children with the 7/7 genotype had documented gallbladder disease, compared with 18.2% with the 6/7 genotype and only 9.9% with the wildtype 6/6 UGT1A1 genotype (P = 0.001). To analyze the (TA)(5) and (TA)(8) variant alleles, three groups were generated, showing increasing bilirubin levels with increasing TA repeats and age. Group 3 (genotypes 6/8, 7/7, and 7/8) had a significantly greater rate of bilirubin change than Groups 1 (genotypes 5/6, 5/7, and 6/6) or 2 (genotype 6/7). These results validate previous smaller studies and confirm that the UGT1A1 promoter polymorphism exerts a powerful influence on bilirubin levels and the development of gallbladder disease in children with SCA. UGT1A1 genotyping should be considered as a screening tool for predicting children most likely to develop gallbladder disease at a young age.

How to Lead the Way Through Complexity, Constraint, and Uncertainty in Academic Health Science Centers.

Academic medicine is in an era of unprecedented and constant change due to fluctuating economies, globalization, emerging technologies, research, and professional and educational mandates. Consequently, academic health science centers (AHSCs) are facing new levels of complexity, constraint, and uncertainty. Currently, AHSC leaders work with competing academic and health service demands and are required to work with and are accountable to a diversity of stakeholders. Given the new challenges and emerging needs, the authors believe the leadership methods and approaches AHSCs have used in the past that led to successes will be insufficient. In this Article, the authors propose that AHSCs will require a unique combination of old and new leadership approaches specifically oriented to the unique complexity of the AHSC context. They initially describe the designer (or hierarchical) and heroic (military and transformational) approaches to leadership and how they have been applied in AHSCs. While these well-researched and traditional approaches have their strengths in certain contexts, the leadership field has recognized that they can also limit leaders' abilities to enable their organizations to be engaged, adaptable, and responsive. Consequently, some new approaches have emerged that are taking hold in academic work and professional practice. The authors highlight and explore some of these new approaches-the authentic, self, shared, and network approaches to leadership-with attention to their application in and utility for the AHSC context.

Progressive periodontal disease and risk of very preterm delivery.

OBJECTIVE: The goal was to estimate whether maternal periodontal disease was predictive of preterm (less than 37 weeks) or very preterm (less than 32 weeks) births. METHODS: A prospective study of obstetric outcomes, entitled Oral Conditions and Pregnancy (OCAP), was conducted with 1,020 pregnant women who received both an antepartum and postpartum periodontal examination. Predictive models were developed to estimate whether maternal exposure to either periodontal disease at enrollment (less than 26 weeks) and/or periodontal disease progression during pregnancy, as determined by comparing postpartum with antepartum status, were predictive of preterm or very preterm births, adjusting for risk factors including previous preterm delivery, race, smoking, social domain variables, and other infections. RESULTS: Incidence of preterm birth was 11.2% among periodontally healthy women, compared with 28.6% in women with moderate-severe periodontal disease (adjusted risk ratio [RR] 1.6, 95% confidence interval [CI] 1.1-2.3). Antepartum moderate-severe periodontal disease was associated with an increased incidence of spontaneous preterm births (15.2% versus 24.9%, adjusted RR 2.0, 95% CI 1.2-3.2). Similarly, the unadjusted rate of very preterm delivery was 6.4% among women with periodontal disease progression, significantly higher than the 1.8% rate among women without disease progression (adjusted RR 2.4, 95% CI 1.1-5.2). CONCLUSION: The OCAP study demonstrates that maternal periodontal disease increases relative risk for preterm or spontaneous preterm births. Furthermore, periodontal disease progression during pregnancy was a predictor of the more severe adverse pregnancy outcome of very preterm birth, independently of traditional obstetric, periodontal, and social domain risk factors. LEVEL OF EVIDENCE: II-2.

Integrating Quality Improvement and Continuing Professional Development: A Model From the Mental Health Care System.

PURPOSE: To explore the perspectives of leaders in psychiatry and continuing professional development (CPD) regarding the relationship, opportunities, and challenges in integrating quality improvement (QI) and CPD. METHOD: In 2013-2014, the authors interviewed 18 participants in Canada: 10 psychiatrists-in-chief, 6 CPD leaders in psychiatry, and 2 individuals with experience integrating these domains in psychiatry who were identified through snowball sampling. Questions were designed to identify participants' perspectives about the definition, relationship, and integration of QI and CPD in psychiatry. Interviews were recorded and transcribed. An iterative, inductive method was used to thematically analyze the transcripts. To ensure the rigor of the analysis, the authors performed member checking and sampling until theoretical saturation was achieved. RESULTS: Participants defined QI as a concept measured at the individual, hospital, and health care system levels and CPD as a concept measured predominantly at the individual and hospital levels. Four themes related to the relationship between QI and CPD were identified: challenges with QI training, adoption of QI into the mental health care system, implementation of QI in CPD, and practice improvement outcomes. Despite participants describing QI and CPD as mutually beneficial, they expressed uncertainty about the appropriateness of aligning these domains within a mental health care context because of the identified challenges. CONCLUSIONS: This study identified challenges with aligning QI and CPD in psychiatry and yielded a framework to inform future integration efforts. Further research is needed to determine the generalizability of this framework to other specialties and health care professions.

Pulmonary hypertension in sickle cell disease.

BACKGROUND: Recurrent vaso-occlusive episodes lead to progressive end-organ damage in patients with sickle cell disease. We sought to determine the prevalence of pulmonary hypertension in adult patients with sickle cell disease and to identify factors associated with this life-threatening complication. METHODS: Sixty patients (> or =18 years of age; mean [+/- SD] age, 37 +/- 13 years) followed at a University Medical Center were evaluated. They were selected by a systematic sampling of patients presenting to the clinic for routine follow-up visits. All enrolled subjects underwent a clinical examination, Doppler echocardiography, pulmonary function tests, and hematologic tests during a single visit. Pulmonary hypertension was defined using an age- and body mass index-adjusted nomogram. RESULTS: The prevalence of pulmonary hypertension was 30% (18/60). Ten patients had mild pulmonary hypertension (up to 44 mm Hg), 5 had moderate pulmonary hypertension (45 to 74 mm Hg), and 2 had severe pulmonary hypertension (> or =75 mm Hg). In a logistic regression model, both lower fetal hemoglobin level and lower systolic blood pressure were associated with the presence of pulmonary hypertension. CONCLUSION: We found that the prevalence of pulmonary hypertension in adult patients with sickle cell disease was substantial, particularly in those with lower levels of fetal hemoglobin and lower systolic blood pressure.