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Background: Gender-affirming bilateral orchiectomy (GABO) may be completed as either a standalone procedure (sGABO) or at the same time as gender-affirming vaginoplasty (vGABO). GABO is postulated to decrease gender-affirming hormone therapy (GAHT) dosages and reduce gender dysphoria, but these phenomena are not empirically described in the medical literature. Aim: The primary aim of this study was to describe changes in GAHT dosages after sGABO and vGABO. A secondary aim was to assess sGABO patients' preoperative decision-making priorities and postoperative satisfaction. Methods: A retrospective chart review identified 204 patients who completed GABO as either a standalone procedure (64% of patients) or at the same time as vaginoplasty (36%). Patient demographic data, surgical outcomes, and pre- and postoperative GAHT dosage data were recorded. Patients completed an opinion questionnaire to assessed decision-making priorities, as well as postoperative satisfaction and changes in quality-of-life measures. Outcomes: Primary outcomes included pre- and postoperative dosages of estradiol, progesterone, and spironolactone. Secondary outcomes included sGABO patient priorities, satisfaction with sGABO, changes in quality-of-life measures between sGABO and vGABO patients, and sGABO recommendations to future patients. Results: The sGABO and vGABO patients experienced a statistically significant dosage reduction in all three GAHT assessed: estradiol, progesterone, and spironolactone (P < .05). All patients discontinued spironolactone postoperatively. Zero complications related to GABO were recorded for patients in either group. The patient questionnaire revealed that sGABO patients prioritize decreasing endogenous testosterone and reducing their GAHT as most important in their decision to undergo sGABO prior to vaginoplasty. A majority of sGABO patients reported improvement in all nine quality-of-life indices. None of the sGABO patients would recommend against sGABO to a friend who is waiting for vaginoplasty. Clinical Implications: For patients who are interested in vaginoplasty, sGABO may serve as a more immediate, low-risk, intermediary step that comes with the benefits of GABO, including significant GAHT medication reduction and gender dysphoria relief. Strengths and Limitations: This study offers a comprehensive evaluation of the impact of GABO on patients, combining empirical data with subjective patient feedback. Limitations include the retrospective design and the use of unvalidated survey questions. Conclusion: Prevaginoplasty GABO is a viable option to more immediately alleviate gender dysphoria and reduce GAHT medications for patients who are interested in gender-affirming vaginoplasty.
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BACKGROUND: The topics of healthcare for lesbian, gay, bisexual, transgender, and queer (LGBTQ+) patients and inclusion of LGBTQ+ health providers remain overlooked. Some specialties may be perceived as less inclusive to LGBTQ+ trainees. This study aimed to describe the perspectives of current medical students regarding LGBTQ+ education and the acceptance of LGBTQ+ trainees among different specialties. MATERIALS AND METHODS: A cross-sectional voluntary and anonymous online survey was distributed through REDCap to all medical students (n = 495) at a state medical school. Medical students' sexuality and gender identity were queried. A descriptive statistical analysis was performed, and the responses were classified into two groups: LGBTQ+ and non-LGBTQ+. RESULTS: A total of 212 responses were queried. Of the respondents who agreed that certain specialties are less welcoming to LGBTQ+ trainees (n = 69, 39%), orthopedic surgery, general surgery and neurosurgery were identified most frequently (84%, 76%, and 55%, respectively). After analyzing sexual orientation as an influence on choosing a future specialty for residency, only 1% of non-LGBTQ+ students indicated that their sexual orientation influences their specialty of choice in comparison with 30% of LGBTQ+ students (P < 0.001). Finally, more non-LGBTQ+ students indicated that they believe they are receiving appropriate education on caring for LGBTQ+ patients as compared to LGBTQ+ students (71% and 55%, respectively, P < 0.05). CONCLUSIONS: LGBTQ+ students are still hesitant to pursue careers in General Surgery as compared to their non-LGBTQ+ peers. The perception that surgical specialties are the least welcoming to LGBTQ+ students continues to be a concern for all students. Further strategies of inclusivity and their effectiveness need to be studied.
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Minorías Sexuales y de Género , Especialidades Quirúrgicas , Estudiantes de Medicina , Humanos , Femenino , Masculino , Estudios Transversales , Identidad de Género , Conducta SexualRESUMEN
OBJECTIVE: To evaluate the influence of facility case volume and type on skull base chordoma treatment and overall survival (OS). METHODS: The 2004-2016 National Cancer Database was queried for skull base chordoma patients receiving definitive treatment. Facilities were categorized into 2 cohorts by calculating the mean number of patients treated per facility and using cutoff numbers that were 0.5 SD above and below the computed mean to separate the groups. As, by definition of the inclusion criteria, all included facilities treated at least 1 patient, low-volume facilities were defined as treating 1 patient, and high-volume facilities were defined as treating ≥7 patients; mid-volume facilities (facilities treating ≥2 but ≤6 patients) were excluded. Differences in treatment course, outcomes, and OS by facility type were assessed. RESULTS: The study included 658 patients (44.8% female, 79.5% White). The 187 unique facilities were categorized into 95 low-volume facilities (treating 1 patient during timeline) and 26 high-volume facilities (treating ≥7 patients during timeline). Kaplan-Meier log-rank analysis demonstrated a significant positive association between facility volume and OS (P < 0.001) and an improvement in OS in patients at academic facilities (P = 0.018). On Cox proportional hazards multivariate regression after adjusting for sex, age, Charlson-Deyo comorbidity index, and insurance type, high-volume facilities and academic facilities were associated with a lower mortality risk than low-volume facilities and nonacademic facilities (P < 0.001 and P = 0.03, respectively). CONCLUSIONS: Higher facility case volume and academic facility type appear to be associated with improved survival outcomes in treatment of skull base chordomas.
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Cordoma , Neoplasias de Cabeza y Cuello , Neoplasias de la Base del Cráneo , Cordoma/cirugía , Femenino , Humanos , Masculino , Estudios Retrospectivos , Base del Cráneo , Neoplasias de la Base del Cráneo/cirugía , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
Objective: To explore qualitative patient experience comments before and after a relationship-centered communication skills training to understand patient experience, program impact, and opportunities for improvement. Methods: Qualitative patient experience evaluation data was captured from January 2016 to December 2018 for 483 health care clinicians who participated in the skills training. A random sampling of available open-ended patient comments (N = 33,223) were selected pre-training (n = 668) and post-training (n = 566). Comments were coded for valence (negative/neutral/positive), generality versus specificity, and based on 12 communication behaviors reflective of training objectives. Results: No significant difference was found in the valence of comments, or generality versus specificity of comments before and after the training. A significant decrease was present in perceived clinician concern. "Confidence in care provider" was the communication skill most frequently identified in comments both pre- and post-training. Conclusion: Perceptions of interactions largely remained the same following training. Key relationship-centered communication skills require further attention in future training efforts. Measurements of patient satisfaction and engagement may not adequately represent patient experience. Innovation: This study identified areas for improvement in the training program and offers a model for utilizing patient experience qualitative data in understanding communication training impact.
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The number of health disparities disproportionately affecting minority communities continue to rise. Thus, it is imperative to assess whether equity within medical school enrollment and along the academic pipeline has mirrored this growth, especially among elite surgical specialties such as otolaryngology. Census and educational data from 2010 and 2018 were used to assess the current otolaryngology, surgery, and internal medicine physician and faculty workforce diversity across each stage of the academic medicine trajectory by race and ethnicity. We found that disparities exist in medical school enrollment for minority students such that Hispanic/Latinx representation was only 30% and Black representation only 50% of their respective proportions in the US population in 2018. Disparities in achieving full professorship were also observed across all 3 specialties but most prominently in otolaryngology, with 1% Black representation among otolaryngology professors in 2018. A collective strategy toward diversifying the otolaryngology workforce should be explored.
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Otolaringología/educación , Médicos/estadística & datos numéricos , Grupos Raciales , Facultades de Medicina , Estudiantes de Medicina/estadística & datos numéricos , Diversidad Cultural , Femenino , Humanos , Masculino , Estados UnidosRESUMEN
As educators, researchers, clinicians, and administrators, faculty serve pivotal roles in academic medical centers (AMCs). Thus, the quality of faculty members' experiences is inseparable from an AMC's success. In seeking new methods to assess equity in advancement in academic medicine, the authors developed the Rank Equity Index (REI)-adapted from the Executive Parity Index, a scale previously implemented within the business sector-to examine national data on gender and racial/ethnic equity across faculty ranks. The REI was employed on self-reported demographic data, collected by the Association of American Medical Colleges, from U.S. medical school faculty in 2017, to make pairwise rank comparisons of the professoriate by demographic characteristics and department. Overall results indicated that women did not attain parity at any pairwise rank comparison, while men were above parity at all ranks. Similar results were observed across all departments surveyed: women in the basic sciences had REIs closest to parity, women in pediatrics had the highest representation but had REIs that were further from parity than REIs in the basic sciences, and women in surgery demonstrated the lowest REIs. Nationally, REIs were below 1.00 for all racial/ethnic group rank comparisons except for White and, in one case, multiple-race non-Hispanic/Latinx. Across all analyzed departments, Black/African American, Asian, Hispanic/Latinx, and multiple-race Hispanic/Latinx faculty had REIs below parity at all ranks except in 2 cases. In a comparison of 2017 and 2007 data, REIs across both race/ethnicity and gender were lower in 2007 for nearly all groups. REI analyses can highlight inequities in faculty rank that may be masked when using aggregate faculty proportions, which do not account for rank. The REI provides AMCs with a new tool to better analyze institutional data to inform efforts to increase parity across all faculty ranks.
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Centros Médicos Académicos , Movilidad Laboral , Diversidad Cultural , Educación de Postgrado en Medicina , Equidad en Salud , Humanos , Estados UnidosRESUMEN
The increasing diversity in the US population is reflected in the patients who healthcare professionals treat. Unfortunately, this diversity is not always represented by the demographic characteristics of healthcare professionals themselves. Patients from underrepresented groups in the United States can experience the effects of unintentional cognitive (unconscious) biases that derive from cultural stereotypes in ways that perpetuate health inequities. Unconscious bias can also affect healthcare professionals in many ways, including patient-clinician interactions, hiring and promotion, and their own interprofessional interactions. The strategies described in this article can help us recognize and mitigate unconscious bias and can help create an equitable environment in healthcare, including the field of infectious diseases.