Building Equity, Inclusion, and Diversity Into the Fabric of a New Medical School: Early Experiences of the Kaiser Permanente Bernard J. Tyson School of Medicine.

In July 2020, the Kaiser Permanente Bernard J. Tyson School of Medicine opened in Pasadena, California, with an inaugural class of 50 students. The school endeavors to address systemic barriers that have contributed to health care and educational disparities in the United States. To realize its vision for change, equity, inclusion, and diversity (EID) have been woven throughout the school. Board members were chosen in part based on their commitment to the core values of EID. The board developed mission, vision, and values statements that explicitly avow a commitment to EID and recruited a dean (and the dean recruited leaders) who espoused and evinced these values. Leaders, faculty, and staff received training to foster an inclusive environment and ensure accountability. The school developed a curriculum that has been thoroughly evaluated for its representative and inclusive content by a team drawn from all departments. The diverse first class, selected through a holistic admissions approach, has access to student support systems that emphasize an appreciation of the distinct experiences and context of each student. The school plans a rigorous evaluation program to assess its performance in EID. Although the school may well fall short of achieving all of its EID objectives, by learning from its experiences and from evidence of others in academic medicine, the school recognizes its opportunity to continue to come closer to achieving its goals and to help shape and contribute to the national and international discourse on EID.

Cognitive trajectories and spectrum of neuropathology in SuperAgers: The first 10 cases.

On average, memory capacity is significantly higher in populations of 50-60 year olds than in populations of 80 year olds. We define SuperAgers as individuals 80 or older whose episodic memory capacity is at least as good as that of cognitively average individuals in their 50s and 60s. SuperAgers therefore have memory capacity that is superior for age. Previous work showed that SuperAgers have greater cortical volumes and greater resistance to age-related cortical atrophy than "cognitively average" individuals of the same age. Here we report on the cognitive, personality, and neuropathologic characteristics of the first 10 autopsy cases in the Northwestern SuperAging Program. During the follow-up period, seven SuperAgers maintained episodic memory performance within or above the average range for 50-65 year-old norms and all 10 SuperAgers maintained episodic memory scores within normal limits for their own age. Extraversion scores tended to be high on the NEO-PI-R measure of personality. The 10 autopsy specimens showed variable findings within the spectrum of Alzheimer pathology. The hippocampus and entorhinal cortex contained neurofibrillary degeneration mostly in the Braak II-III stages. However, even these limbic areas contained many healthy appearing neurons and the neocortex was generally free of neurofibrillary degeneration. In contrast, neocortical areas in at least five of the cases contained moderate to high densities of neuritic plaques. These findings need to be placed in context by comparing them to the neuropathology of cognitively average individuals of the same age. Future research on SuperAgers is likely to offer insights into factors that either prevent the emergence of involutional changes in the brain or that makes cognitive function more resistant to their consequences.

Annual Performance Reviews Of, For and By Faculty: A Qualitative Analysis of One Department's Experiences.

PURPOSE: Although annual performance reviews and feedback are recommended for faculty development, best practices and faculty perceptions have not been documented. The authors sought to evaluate the process in one medical school department that established and has sustained an innovative review tradition for 25 years. METHOD: Content analysis of faculty reports and immersion/crystallization to analyze interviews. RESULTS: Faculty reports described satisfaction and dissatisfaction; facilitators and barriers to goals; and requests for feedback, with community, collaboration and mentorship integral to all three. Interviewees emphasized practical challenges, the role of the mentor and the power of the review to establish community norms. CONCLUSION: Respondents generally found reviews constructive and supportive. The process informs departmental expectations and culture.

Advancing Professional Development Through a Community of Practice: the New England Network for Faculty Affairs.

INTRODUCTION: In an era of competing priorities, funding is increasingly restricted for offices of faculty affairs and development. Opportunities for professional staff to grow and network through attendance at national meetings and to share best practices are limited. We sought to describe a community of practice established to enhance the professional development of faculty affairs professionals and to document its impact. METHODS: We outlined the process of formation of the New England Network for Faculty Affairs (NENFA), reviewed the pedagogical approaches to professional development, and surveyed members to evaluate the impact of NENFA on their activities, professional network and their institutions. RESULTS: After a successful 2011 initial meeting, NENFA created an organizing committee and conducted a needs assessment among potential members. NENFA's charter, mission, goals, and structure were based on survey results. NENFA's regional community of practice grew to 31 institutions and held 10 meetings over 5 years. Meetings have examined a faculty development topic in depth using multiple learning formats to engage participants from academic medical centers and allied professions. Results from a 2015 member survey confirmed the value of NENFA. Multiple members documented changes in practice as a result of participating. DISCUSSION: NENFA has been sustained by volunteer leadership, collaboration, and the value that the group has brought to its members. We propose that a "community of practice" offers an effective model for collaborative learning among individuals at different institutions within a competitive health care environment. We recommend that the approach be replicated in other regions.

The Impact of a Junior Faculty Fellowship Award on Academic Advancement and Retention.

PURPOSE: Academic faculty experience barriers to career development and promotion. In 1996, Harvard Medical School (HMS) initiated an intramural junior faculty fellowship to address these obstacles. The authors sought to understand whether receiving a fellowship was associated with more rapid academic promotion and retention. METHOD: Junior faculty fellowship recipients and all other instructor and assistant professors at HMS between 1996 and 2011 were identified. Using propensity score modeling, the authors created a matched comparison group for the fellowship recipients based on educational background, training, academic rank, department, hospital affiliation, and demographics. Time to promotion and time to leaving were assessed by Kaplan-Meier curves. RESULTS: A total of 622 junior faculty received fellowships. Faculty who received fellowships while instructors (n = 480) had shorter times to promotion to assistant professor (P < .0001) and longer retention times (P < .0001) than matched controls. There were no significant differences in time to promotion for assistant professors who received fellowships (n = 142) compared with matched controls, but assistant professor fellowship recipients were significantly more likely to remain longer on the faculty (P = .0005). Women instructors advanced more quickly than matched controls, while male instructors' rates of promotions did not differ. CONCLUSIONS: Fellowships to support junior faculty were associated with shorter times to promotion for instructors and more sustained faculty retention for both instructors and assistant professors. This suggests that relatively small amounts of funding early in faculty careers can play a critical role in supporting academic advancement and retention.

Evaluating potential live-renal donors: Causes for rejection, deferral and planned procedure type, a single-centre experience.

BACKGROUND: Renal transplantation is the preferred therapy to extend life expectancy and quality of life for patients with chronic kidney disease. There are many barriers in the process of live kidney donation that prevent the timely progression from organ requirement to transplantation, including the progression of the live donor through a medical evaluation. We assess how easily patients complete the donor workup, how often the medical evaluation identifies significant incidental findings, and which surgical procedure is planned for organ retrieval. METHODS: We reviewed our donor database and the minutes from our multidisciplinary rounds from 2002 to 2008 to assess how medical, radiological and psychological findings were used to decide on the candidacy of potential donors. RESULTS: Half (50.2%) of patients did not pass the initial health screen. Of the 467 patients who progressed beyond the health screen to the computed tomographic angiogram evaluation, 48 (10.3%) were excluded as donors and 419 (89.7%) were accepted. Of those accepted, 136 (32.5%) were conditional on further medical workup. Of the patients accepted (n=419), 375 (89.5%) were planned for laparoscopic left-sided approach. CONCLUSIONS: The vast majority of patients who passed the initial health screen for kidney donation will be accepted as donors, but about one-third will require further workup. It is rare to identify life-threatening disease on screening computerized tomographic angiograph for kidney donor workup.

Academic women faculty: are they finding the mentoring they need?

BACKGROUND: Although women comprise an increasing proportion of US medical school faculty, they are underrepresented at higher ranks. Lack of effective mentoring may contribute to this disparity. We examined the role of academic rank, research focus, parenting, and part-time work on mentoring importance, needs, and gaps. METHODS: In 2009, women faculty members of Harvard Medical School and Harvard School of Dental Medicine were invited by e-mail to participate in a 28-item structured questionnaire. Descriptive statistics and adjusted logistic regressions were used to identify relevant themes. RESULTS: Of the 1179 women faculty who responded, 54% had a mentor, and 72% without a mentor desired mentoring. The most important mentor characteristic identified was availability. Respondents endorsed most mentoring areas as important (range 51%-99%); 52% of respondents identified mentoring gaps (area important and unmet) in developing and achieving career goals and negotiation skills. Interest in mentorship for skills needed for advancement (research and lecturing skills and getting national recognition) was significantly associated with lower rank. Assistant professors were most likely to identify mentoring related to writing and publishing articles, whereas associate professors identified program development/strategic planning as important. Faculty who are parents identified gaps in finding collaborators and balancing work and family life. CONCLUSIONS: This survey identified a desire for both comprehensive and targeted mentoring to address gaps that varied by faculty rank, research focus, parenting, and work time status. Strategies to enhance mentoring should address career stages and include a structured framework for assessing mentoring gaps.

A model of integrative care for low-back pain.

OBJECTIVES: While previous studies focused on the effectiveness of individual complementary and alternative medical (CAM) therapies, the value of providing patients access to an integrated program involving multiple CAM and conventional therapies remains unknown. The objective of this study is to explore the feasibility and effects of a model of multidisciplinary integrative care for subacute low-back pain (LBP) in an academic teaching hospital. DESIGN: This was a pilot randomized trial comparing an individualized program of integrative care (IC) plus usual care to usual care (UC) alone for adults with LBP. SUBJECTS: Twenty (20) individuals with LPB of 3-12 weeks' duration were recruited from an occupational health clinic and community health center. INTERVENTIONS: Participants were randomized to 12 weeks of individualized IC plus usual care versus UC alone. IC was provided by a trained multidisciplinary team offering CAM therapies and conventional medical care. OUTCOME MEASURES: The outcome measures were symptoms (pain, bothersomeness), functional status (Roland-Morris score), SF-12, worry, and difficulty performing three self-selected activities. RESULTS: Over 12 weeks, participants in the IC group had a median of 12.0 visits (range 5-25). IC participants experienced significantly greater improvements at 12 weeks than those receiving UC alone in symptom bothersomeness (p=0.02) and pain (p=0.005), and showed greater improvement in functional status (p=0.08). Rates of improvement were greater for patients in IC than UC in functional status (p=0.02), bothersomeness (p=0.002), and pain scores (p=0.001). Secondary outcomes of self-selected most challenging activity, worry, and the SF-12 also showed improvement in the IC group at 12 weeks. These differences persisted at 26 weeks, but were no longer statistically significant. CONCLUSIONS: It was feasible for a multidisciplinary, outpatient IC team to deliver coordinated, individualized intervention to patients with subacute LBP. Results showed a promising trend for benefit of treating patients with persistent LBP with this IC model, and warrant evaluation in a full-scale study.

Hormone therapy initiation after the Women's Health Initiative.

OBJECTIVES: To describe hormone therapy (HT) initiation after the 2002 publication of the Women's Health Initiative. DESIGN: Observational cohort (1999-2003) of women ages 40 to 79 years, five health plans, used HT in July 2002 and subsequently discontinued or never used before August 2002. RESULTS: Of discontinuers, 15.8% (3,203 of 20,205) reinitiated HT. Reinitiation was higher among estrogen users (23.8%) versus estrogen with progestin users (11.3%), and lower among those with diabetes (relative risk [RR]=0.68, 95% CI: 0.61-0.76), cardiovascular disease (RR=0.87, 95% CI: 0.83-0.92), and hyperlipidemia (RR=0.83, 95% CI: 0.79-0.88). Only 2.3% (2,072 of 90,261) of never users initiated (August 2002 to December 2003). First-time initiation was associated with cardiovascular disease (RR=1.17, 95% CI: 1.10-1.25) and hyperlipidemia (RR=1.24, 95% CI: 1.17-1.33) and was less common among those with diabetes (RR=0.70, 95% CI: 0.63-0.79). CONCLUSIONS: After the Women's Health Initiative, a minority of women reinitiated or became first-time initiators of HT. Women with cardiovascular disease, diabetes, and hyperlipidemia were less likely to reinitiate; women with cardiovascular disease and hyperlipidemia were more likely to be first-time initiators.

Patient expectations as predictors of outcome in patients with acute low back pain.

BACKGROUND: Few studies have evaluated the association between patient expectations for recovery and clinical outcomes, and no study has evaluated whether asking patients to choose their therapy modifies such an association. OBJECTIVE: To evaluate the association between patients' expectations and functional recovery in patients with acute low back pain (LBP), and to determine whether that association is affected by giving patients choice of therapy. DESIGN AND PARTICIPANTS: A secondary analysis of a randomized controlled trial comparing usual care alone to usual care plus choice of chiropractic, acupuncture, or massage in 444 adults with acute LBP, lasting less than 21 days. MEASUREMENTS AND MAIN RESULTS: Primary outcome was functional disability (Roland score) at 5 and 12 weeks. Patients' general expectations for improvement were associated with improvement in functional status (beta = 0.96, 95% CI = 0.56, 1.36). A 1-point increase in general expectations was associated with a 0.96-point improvement in Roland score. The association of expectation with outcome was 2-3 times greater in the usual care group than the choice group. However, these differences did not reach statistical significance. CONCLUSIONS: In patients with acute LBP, higher expectations for recovery are associated with greater functional improvement. Eliciting patient expectations for improvement may be a simple way to identify patients with the highest (or lowest) likelihood of experiencing functional improvement. Incorporating questions about patient expectations in future trials may clarify the role of this important correlate of clinical outcomes.

How the Women's Health Initiative (WHI) influenced physicians' practice and attitudes.

BACKGROUND: The landmark Women's Health Initiative (WHI) Postmenopausal Hormone Therapy Trial published in 2002 showed that the health risks of combination hormone therapy (HT) with estrogen and progestin outweighed the benefits in healthy postmenopausal women. Dissemination of results had a major impact on prescriptions for, and physician beliefs about HT. No study has fully examined the influence of the widely publicized WHI on physicians' practice and attitudes or their opinions of the scientific evidence regarding HT; in addition, little is known about how physicians assist women in their decisions regarding HT. DESIGN AND PARTICIPANTS: We conducted in-depth telephone interviews with family practitioners, internists, and gynecologists from integrated health care delivery systems in Washington State (n = 10 physicians) and Massachusetts (n = 12 physicians). Our objectives were to obtain qualitative information from these physicians to understand their perspectives on use of HT, the scientific evidence regarding its risks and benefits, and counseling strategies around HT use and discontinuation. APPROACH: We used Template Analysis to code transcribed telephone interviews and identify themes. RESULTS: Physicians were conflicted about the WHI results and its implications. Seven themes identified from in-depth interviews suggested that the WHI (1) was a ground-breaking study that changed clinical practice, including counseling; (2) was not applicable to the full range of patients seen in clinical practice; (3) raised concerns over the impact of publicized health information on women; (4) created uncertainty about the risks and benefits of HT; (5) called for the use of decision aids; (6) influenced discontinuation strategies; and (7) provided an opportunity to discuss healthy lifestyle options with patients. As a result of the WHI, physicians reported they no longer prescribe HT for prevention and were more likely to suggest discontinuation, although many felt women should be in charge of the HT decision. CONCLUSIONS: Physicians varied in their opinions of HT and the scientific evidence (positive and negative). Whereas the WHI delineated the risks and benefits of HT, physicians reported that decision aids are needed to guide discussions with women about menopause and HT. Better guidance at the time of WHI study publication might have been valuable to ensure best practices.

The effects of Tai Chi on bone mineral density in postmenopausal women: a systematic review.

OBJECTIVE: To evaluate the evidence for Tai Chi as an intervention to reduce rate of bone loss in postmenopausal women. DATA SOURCES: Literature search using Medline, Science Citation Index, Cochrane databases, China Biological Medicine Database, and additional manual reference searches of retrieved articles and personal libraries. STUDY SELECTION: Randomized controlled trials (RCTs), prospective cohort studies, and cross-sectional studies that included Tai Chi as an intervention, and had at least 1 outcome related to measurement of bone mineral density (BMD). DATA EXTRACTION: Authors critically reviewed studies, evaluated methodologic quality, and synthesized study results in a summary table. DATA SYNTHESIS: Six controlled studies were identified by our search. There were 2 RCTs, 2 nonrandomized prospective parallel cohort studies, and 2 cross-sectional studies. The 2 RCTs and 1 of the prospective cohort studies suggested that Tai Chi-naive women who participated in Tai Chi training exhibited reduced rates of postmenopausal declines in BMD. Cross-sectional studies suggested that long-term Tai Chi practitioners had higher BMD than age-matched sedentary controls, and had slower rates of postmenopausal BMD decline. No adverse effects related to Tai Chi were reported in any trial. CONCLUSIONS: Conclusions on the impact of Tai Chi on BMD are limited by the quantity and quality of research to date. This limited evidence suggests Tai Chi may be an effective, safe, and practical intervention for maintaining BMD in postmenopausal women. In combination with research that indicates Tai Chi can positively impact other risk factors associated with low BMD (eg, reduced fall frequency, increased musculoskeletal strength), further methodologically sound research is warranted to better evaluate the impact of Tai Chi practice on BMD and fracture risk in postmenopausal women.

Addition of choice of complementary therapies to usual care for acute low back pain: a randomized controlled trial.

STUDY DESIGN: A randomized controlled trial. OBJECTIVE: To investigate the effectiveness and cost of usual care plus patient choice of acupuncture, chiropractic, or massage therapy (choice) compared with usual care alone in patients with acute low back pain (LBP). SUMMARY OF BACKGROUND DATA: Few studies have evaluated care models with facilitated access to and financial coverage for adjunctive complementary and alternative medicine therapies. METHODS: A total of 444 patients with acute LBP (<21 days) were recruited from 4 clinical sites and randomized into 2 groups: usual care or choice. Outcomes included symptoms (bothersomeness), functional status (Roland), and satisfaction between baseline and 5 weeks, and cost of medical care in the 12 weeks after randomization. RESULTS: After 5 weeks, providing patients with a choice did not yield clinically important reductions in symptoms (median -4, [interquartile range -7, -2] for usual care, and -5 [-7, -3] for choice; P = 0.002) or improvements in functional status (-8 [-13, -2] for usual care, and -9 [-15, -4] for choice; P = 0.15). Although there was a significantly greater satisfaction with care in the choice group, this came at a net increase in costs of 244 dollars per patient. This consisted of a 99 dollars reduction in the average cost to the insurer for medical care but an additional cost of 343 dollars, for an average of 6.0 complementary and alternative medicine treatments per patient. CONCLUSIONS: A model of care that offered access to a choice of complementary and alternative medicine therapies for acute LBP did not result in clinically significant improvements in symptom relief or functional restoration. This model was associated with greater patient satisfaction but increased total costs. Future evaluations of this choice model should focus on patients with chronic conditions (including chronic back pain) for which conventional medical care is often costly and of limited benefit.

Low 25-hydroxyvitamin D and osteopenia are prevalent in persons > or =55 yr with fracture at any site: a prospective, observational study of persons fracturing in the community.

Ethnic diversity and lower socioeconomic populations are poorly captured in most studies of osteoporosis and fracture risk. This article describes a prospective, observational study designed to analyze risk factors for fracture in an ambulatory, ethnically diverse, urban population aged > or =55 yr. The goal of the study was to determine the number of fractures associated with hypovitaminosis D (< or =15 ng/mL serum 25-hydroxyvitamin D) and osteopenia (T-score <-1.5) by bone mineral density (BMD). From January 1 to July 31, 2001, we identified 262 persons who fractured in our community; 83 chose to enroll in the study. Enrolled patients had a BMD examination at two sites; their blood was drawn for 25-hydroxyvitamin D (25VitD), calcium, phosphorus, albumin, and alkaline phosphatase. At the completion of the study a letter was sent to the patients detailing the findings, and a copy sent to their physician. Of the 83 persons enrolled, 73 (88%) had evidence of osteopenia or osteoporosis (T-score <-1.5) and/or low 25VitD. All fractures in the community in person > or =55 yr, with or without a history of antecedent trauma, should be assessed with BMD and screening for 25VitD.

Changes in women's use of hormones after the Women's Health Initiative estrogen and progestin trial by race, education, and income.

BACKGROUND: We examined the impact of race, education, and household income on changes in rates of discontinuation and initiation of hormone therapy before and after release of the Women's Health Initiative estrogen plus progestin trial results. METHODS: We conducted an observational cohort study of 221 378 women aged 40-80 years enrolled in five health maintenance organizations to estimate the prevalence and rates of discontinuation and initiation of estrogen plus progestin and estrogen only between September 1, 1999, to June 31, 2002 (baseline), and December 31, 2002 (follow-up). We identified the census block group for each participant by geocoding her 2003 residential address. We categorized women into racial, education, and income groups based on the distribution of these characteristics in her community from year 2000 census data and the distributions of these characteristics within her HMO. RESULTS: There were significant differences in estrogen plus progestin and estrogen only prevalence by race, education level, and household income, and in estrogen plus progestin initiation by race and education level, but not by household income at follow-up. However, there were no differences by community race, education, or household income in change in the prevalence of either hormone therapy use at follow-up or in the rates of hormone therapy discontinuation or initiation from baseline to follow-up. CONCLUSIONS: Given the wide spread media attention to the Women's Health Initiative estrogen plus progestin trial results, our findings suggest comparable dissemination of this information across diverse socioeconomic groups.

Health system responses to the Women's Health Initiative findings on estrogen and progestin: organizational response.

Recent randomized trials have indicated that the risks of hormone therapy for menopausal women may outweigh the benefits. The purpose of this study was to describe how health plans responded to the findings of the Women's Health Initiative (WHI) estrogen plus progestin trial. We surveyed five health plans affiliated with the HMO Research Network and the Cancer Research Network to document the response of each plan to the WHI in terms of patient and provider education and guidelines. Every health plan issued responses within 3 months of WHI's termination in a variety of formats. Recommendations were relatively consistent across the organizations. Given the documented changes in hormone therapy use in these five health plans in the post-WHI era, we conclude that attempts on the part of each organization to educate patients and providers about the implications of the WHI may have contributed to the observed changes in hormone therapy use.