LGBTQ+ Worker Protections: Implications for Academic Medicine Today and in the Future.

The Supreme Court's 2020 ruling prohibiting workplace discrimination based on sexual orientation or gender identity ( Bostock v Clayton County ) offers new legal protections for LGBTQ+ employees and allies and new opportunities for academic medicine to advance LGBTQ+ inclusion at their institutions. In this perspective piece, the authors examine the history of LGBTQ+ community recognition, tolerance, protections, and ongoing inclusion and the advocacy efforts led by LGBTQ+ patients, community activists, and medical colleagues. They also examine the current limitations of the court's ruling and recommend future actions to advance workplace and health equity. While recent advancements in equality have not erased chronic barriers to inclusion and advancement, they can pave the way for leaders in research, education, and clinical care to shape national health guidelines and policies that impact the health of all Americans.

A phase sensitive x-ray breast tomosynthesis system: Preliminary patient images with cancer lesions.

Phase-sensitive x-ray imaging continues to attract research for its ability to visualize weakly absorbing details like those often encountered in biology and medicine. We have developed and assembled the first inline-based high-energy phase sensitive breast tomosynthesis (PBT) system, which is currently undergoing patient imaging testing at a clinical site. The PBT system consists of a microfocus polychromatic x-ray source and a direct conversion-based flat panel detector coated with a 1 mm thick amorphous selenium layer allowing a high detective quantum efficiency at high energies. The PBT system scans a compressed breast over 15° with 9 angular projection views. The high-energy scan parameters are carefully selected to ensure similar or lower mean glandular dose levels to the clinical standard of care systems. Phase retrieval and data binning are applied to the phase contrast angular projection views and a filtered back-projection algorithm is used to reconstruct the final images. This article reports the distributions of radiation dose versus thickness of the compressed breasts at 59 and 89 kV and sample PBT images acquired from 3 patients. Preliminary PBT images demonstrate the feasibility of this new imaging modality to acquire breast images at lower radiation dose as compared to the clinical digital breast tomosynthesis system with enhanced lesion characteristics (i.e. lesion spiculation and margins).

Providing Diverse Trainees an Early and Transparent Introduction to Academic Appointment and Promotion Processes.

Introduction: The growth in number of medical schools and increased numbers of faculty tracks have combined with evolving criteria for promotion to trigger a call for greater transparency of academic appointment and promotion processes. Most vulnerable to confusion about these changes are first-generation and diverse medical students and residents, the upstream pipeline of the academic medicine workforce. Diverse medical students have expressed diminished interest in academia because of perceived obstacles in appointment and promotion processes. Methods: This workshop was designed to utilize didactics and career reflection exercises to help trainees learn: (1) how to define core terms related to academic appointment and promotion processes, (2) how to compare data elements for different CVs and portfolios, (3) common steps in submitting a promotion package, and (4) that they can immediately begin to document content for academic CVs, portfolios, and promotion packages. Results: One hundred forty-five diverse participants completed an evaluation at eight conferences across the U.S. More than 90% strongly agreed or agreed that the aforementioned objectives were met. Participants commented that the workshop was "illuminating," was "very informative," and "provided an inside look of how faculty are evaluated." Results showed an immediate impact on participants' self-reported confidence to negotiate appointment and promotion processes. Discussion: Increases in self-rated confidence to negotiate appointment and promotion processes may help sustain trainees' interest in becoming future faculty. Further monitoring will be needed to determine if early exposure to these concepts improves probability of seeking, obtaining, and maintaining appointments.

Using a Retreat to Develop a 4-Year Sexual Orientation and Gender Identity Curriculum.

OBJECTIVE: Lesbian, gay, bisexual, and transgender (LGBT) populations experience significant health disparities, yet medical schools report devoting little educational time to the care of this population. In light of this, one School of Medicine utilized a daylong retreat to design a 4-year sexual orientation and gender identity (SOGI) curriculum. METHODS: The participants completed pre-and post-surveys on their perspectives and knowledge towards SOGI learning, and the school's curriculum database was reviewed 2 years later to ascertain the degree of implementation of the proposed curriculum. RESULTS: Significant improvements were observed in participants' confidence in creating an SOGI curriculum, knowledge of SOGI teaching resources, and where in the curriculum SOGI competencies are and should be taught. A 6-month follow-up survey yielded a lower response rate, but suggested strong ongoing support for the new curriculum and some continuing challenges to implementing the proposed curriculum. A review of the school's curriculum database 2 years later showed an implementation rate of 76 %. CONCLUSION: A focused and systematic retreat can be an effective tool for curriculum design and implementation.

Introducing sexual orientation and gender identity into the electronic health record: one academic health center's experience.

Many U.S. populations experience significant health disparities. Increasing health care providers' awareness of and education about sexual orientation (SO) and gender identity (GI) diversity could help reduce health disparities among lesbian, gay, bisexual, and transgender (LGBT) patients. The authors share the University of California, Davis, Health System's (UCDHS's) experience as it became the first U.S. academic health center to formally introduce patient SO/GI demographic data into its electronic health record (EHR) as a step toward reducing LGBT health disparities. Adding these data to the EHR initially met with resistance. The authors, members of the UCDHS Task Force for Inclusion of SO/GI in the EHR, viewed this resistance as an invitation to educate leaders, providers, and staff about LGBT health disparities and to expose providers to techniques for discussing SO/GI with patients. They describe the strategies they employed to effect institutional culture change, including involvement of senior leadership, key informant interviews, educational outreach via grand rounds and resident workshops, and creation of a patient safety net through inviting providers to self-identify as welcoming LGBT patients. The ongoing cultural change process has inspired spin-off projects contributing to an improved climate for LGBT individuals at UCDHS, including an employee organization supporting SO/GI diversity, support for and among LGBT medical learners through events and listservs, development and implementation of an LGBT health curriculum, and creation of peer navigator programs for LGBT patients with cancer. The authors reflect on lessons learned and on institutional pride in and commitment to providing quality care for LGBT patients.

Eliminating LGBTIQQ Health Disparities: The Associated Roles of Electronic Health Records and Institutional Culture.

For all humans, sexual orientation and gender identity are essential elements of identity, informing how we plan and live our lives. The historic invisibility of sexual minorities in medicine has meant that these important aspects of their identities as patients have been ignored, with the result that these patients have been denied respect, culturally competent services, and proper treatment. Likely due to historic rejection and mistreatment, there is evidence of reluctance on the part of LGBT patients to disclose their sexual orientation (SO) or gender identity (GI) to their health care providers. There is some perception of risk in sharing SO and GI for many patients who have had bad prior experiences. Despite these risks, we argue that we can improve the quality of care provided this population only by encouraging them to self-identify and then using that information to improve quality of care. One strategy both to prompt patient self-identification and to store and use SO and GI data to improve care centers on the use of electronic health records. However, gathering SO and GI data in the EHR requires a workforce that knows both how to obtain and how to use that information. To develop these competencies, educational programs for health professionals must prepare students and educators to elicit and to use sexual orientation and gender identity information to improve care while simultaneously ensuring the safety of patients, trainees, and staff and faculty members as SO and GI become openly discussed and integral parts of ongoing medical discussion and care. As determination of SO and GI demographics becomes more common in health research, we will more fully understand the health risks for all the LGBTIQQ populations.

First Annual LGBT Health Workforce Conference: Empowering Our Health Workforce to Better Serve LGBT Communities.

The Institute of Medicine has identified significant health disparities and barriers to health care experienced by lesbian, gay, bisexual, and transgender (LGBT) populations. By lowering financial barriers to care, recent legislation and judicial decisions have created a remarkable opportunity for reducing disparities by making health care available to those who previously lacked access. However, the current health-care workforce lacks sufficient training on LGBT-specific health-care issues and delivery of culturally competent care to sexual orientation and gender identity minorities. The LGBT Healthcare Workforce Conference was developed to provide a yearly forum to address these deficiencies through the sharing of best practices in LGBT health-care delivery, creating LGBT-inclusive institutional environments, supporting LGBT personal and professional development, and peer-to-peer mentoring, with an emphasis on students and early career professionals in the health-care fields. This report summarizes the findings of the first annual LGBT Health Workforce Conference.

The effectiveness of telemental health: a 2013 review.

INTRODUCTION: The effectiveness of any new technology is typically measured in order to determine whether it successfully achieves equal or superior objectives over what is currently offered. Research in telemental health-in this article mainly referring to telepsychiatry and psychological services-has advanced rapidly since 2003, and a new effectiveness review is needed. MATERIALS AND METHODS: The authors reviewed the published literature to synthesize information on what is and what is not effective related to telemental health. Terms for the search included, but were not limited to, telepsychiatry, effectiveness, mental health, e-health, videoconferencing, telemedicine, cost, access, and international. RESULTS: Telemental health is effective for diagnosis and assessment across many populations (adult, child, geriatric, and ethnic) and for disorders in many settings (emergency, home health) and appears to be comparable to in-person care. In addition, this review has identified new models of care (i.e., collaborative care, asynchronous, mobile) with equally positive outcomes. CONCLUSIONS: Telemental health is effective and increases access to care. Future directions suggest the need for more research on service models, specific disorders, the issues relevant to culture and language, and cost.

Issues and challenges of non-tenure-track research faculty: the UC Davis School of Medicine experience.

Nationally, medical schools are appointing growing numbers of research faculty into non-tenure-track positions, paralleling a similar trend in universities. The American Association of University Professors (AAUP) issued a statement expressing concern that the marked growth in non-tenure-track faculty can undermine educational quality, academic freedom, and collegiality. Like other medical schools, the UC Davis School of Medicine has had a rise in non-tenure-track faculty in order to enhance its research mission, in particular in the Salaried Adjunct faculty track (SalAdj). SalAdj faculty have more difficulty in achieving promotion, report inequitable treatment and less quality of life, have less opportunity to participate in governance, and feel second-class and insecure. These issues reflect those described by the AAUP. The authors describe the efforts at UC Davis to investigate and address these issues, implementation of a plan for improvement based on task force recommendations, and the lessons learned. Supporting transfer to faculty tracks in the academic senate, enhancing financial support, ensuring eligibility for internal grants, and equitable space assignments have contributed to an improved career path and more satisfaction among SalAdj faculty. Challenges in addressing these issues include limited availability of tenure-track positions, financial resources, adequate communication regarding change, and compliance with existing faculty search policies.

Strategies to reduce HIV risk behavior in HIV primary care clinics: brief provider messages and specialist intervention.

Reducing HIV transmission is a critical goal worldwide, prompting new strategies to slow the spread of the virus. This paper describes the theoretical underpinnings of the Comprehensive Harm Reduction Protocol (CHRP) and the process of its implementation in one large urban HIV clinic and two smaller rural primary care clinics. Patients enrolled in CHRP complete the Risk Diagnostic Questionnaire (RDQ), self-reporting HIV transmission risk behavior at most clinic visits. Clinicians review RDQs to trigger dialogue using motivational interviewing and the stages of health behavior change to reduce high-risk behaviors (drug use, alcohol use, or high-risk sexual behavior). In the ongoing evaluation study, CHRP patients receive two provider-only visits before being randomized to continue with provider brief prevention messages only or to receive additional intensive counseling with a risk-reduction specialist following the provider visit. If outcome data support one or both interventions, CHRP could be a useful model for widespread adoption. Observations from the implementation of this protocol are presented in order to facilitate the adoption of this protocol in interested clinics. Later, results of the evaluation of the implementation of the protocol may have value in developing prevention policy in HIV treatment clinics.

A randomized, controlled trial of disease management modules, including telepsychiatric care, for depression in rural primary care.

Introduction. Disease management modules (DMM), including education, tracking, support, and medical care, have improved health for patients with asthma and diabetes. For rural patients, novel ways of delivery are needed to access clinical expertise from urban or academic specialists. Telemedicine (telephone and televideo) could be instrumental in this process, though no randomized, controlled trials have assessed their effectiveness.Methods. Self-report and structured psychiatric interviews were used to screen potential depressed subjects. Subjects were randomized to: 1) usual care with a DMM using telephone and self-report questionnaires; or 2) a DMM using telephone, questionnaires, and monthly televideo psychiatric consultation emphasizing primary care physician (PCP) skill development. Subjects' depressive symptoms, health status, and satisfaction with care were tabulated at three, six, and 12 months after study entry.Results. There was significant clinical improvement for depression in both groups, with a trend toward significance in the more intensive module. Satisfaction and retention was superior in the more intensive group. There was no overall change in health functioning in either group.Conclusions. Intensive modules using telepsychiatric educational interventions toward PCPs may be superior, but the most critical ingredient may be administrative tracking of patients, prompted intervention by PCPs, and (when necessary) new ideas by a specialist.

Partnering with community-based professionals to improve substance abuse screening and intervention for youth and young adults.

The paper describes the process by which a team conducted a needs assessment and developed training programs to address service gaps in substance abuse prevention for young people.

Patient pain in primary care: factors that influence physician diagnosis.

BACKGROUND: The accurate recognition of patient pain is a crucial, but sometimes difficult, task in medical care. This study explored factors related to the physician's diagnosis of pain in primary care patients. METHODS: New adult patients were prospectively randomized to care by primary care providers at a university medical center clinic. Study participants were interviewed prior to the initial visit, and their level of self-reported pain was measured with the Visual Analog Pain Scale and the Medical Outcomes Study Short Form-36. The medical encounter was videotaped in its entirety and later analyzed using the Davis Observation Code to characterize physician practice style. Patient satisfaction was measured immediately after the visit. A review of the medical record was used to assess physician recognition of patient pain. RESULTS: For all patients (N = 509), as the amount of pain increased, the percentage of patients having pain diagnosed by the physician also increased. Female patients reported a greater amount of pain than male patients. When women were in severe pain, they were more likely than men to have their pain accurately recognized by their physician. The correct diagnosis of pain was not significantly related to patient satisfaction. Physician practice styles emphasizing technically oriented activities and health behavior discussions were strongly predictive of the physician diagnosing patient pain. CONCLUSIONS: The diagnosis of pain is influenced by the severity of patient pain, patient gender, and physician practice style. If the routine use of pain assessment tools is found to be effective in improving physician recognition and treatment of patients' pain, then application of these tools in patient care settings should be encouraged.

Physician-elder interaction in community family practice.

OBJECTIVE: To determine whether outpatient visits by elders seeing community family physicians differ in length or content from visits by younger patients; socioemotional preferences predict visit content; and satisfaction correlates with visit content differentially across age. METHODS: In a multimethod cross-sectional study of 84 community family practices in northeastern Ohio, 3453 adult patient visits with 138 community family physicians were observed; 2362 of these patients completed self-report questionnaires. Three age groups were compared: 18 to 64, 65 to 74, and over 74 years. Length and content of the physician-patient encounter was determined using the Davis Observation Code (DOC); satisfaction was assessed using the MOS 9-item Visit Rating Scale. RESULTS: Controlling for reason for visit and demographics, visit length averaged 10.7 minutes for each group. Visit content differed significantly on 13 of 20 DOC codes between one of the older groups and the younger group; in 4 instances, content varied between the 2 older groups. Although visit content varied as predicted by socioemotional theory, no consistent patterns of association between visit content and satisfaction emerged. DISCUSSION: Older patient visits differ from those of younger patients as might be predicted by socioemotional selectivity theory; however, there was little association of visit content with patient satisfaction.

Does time use in outpatient residency training reflect community practice?

BACKGROUND: The degree to which the ideals practiced during residency training persist amidst the pressures of community practice is unknown. Therefore, this paper compares time use during outpatient visits to family practice residents and experienced family physicians. METHODS: Visits of 244 new adult outpatients to 33 second- and third-year residents in a university clinic in Northern California were compared to 277 new adult outpatient visits to 92 community family physicians in Northeast Ohio, using the Davis Observation Code (DOC). The DOC uses observation to classify visit time into 20 different behavioral categories, reflecting different physician styles of interaction with patients. RESULTS: Controlling for patient mix, residents had longer visits, a less technical focus, and spent a greater percent of the visit on efforts to promote health behavior change, patient activation, preventive services, discussion of substance abuse, and counseling. CONCLUSIONS: Experienced family physicians provide more technical and less preventive and psychosocially oriented care than residents. This may reflect differences in patient mix, practice setting, physician experience, and the time and financial pressures of community practice. These findings may be used to modify residency training to better reflect actual community practice and to guide future studies of the effects of experience and different practice environments on physician style with patients.

Patient pain: its influence on primary care physician-patient interaction.

BACKGROUND AND OBJECTIVES: Heightened awareness of the importance of appropriate pain management in health care delivery has stimulated researchers to examine the impact of patient pain on medical encounters. In this study, we explored how patient pain might influence the physician-patient interaction during medical visits. METHODS: New adult patients (n = 509) were randomized to see primary care physicians in videotaped visits at a university medical center Self-reported patient pain was measured before the visit using the Visual Analog Scale and the Medical Outcomes Study Short Form-36 (MOS SF-36) pain scale; patient sociodemographics were also measured. Physician practice style during the visit was analyzed with the Davis Observation Code (DOC). RESULTS: Regression analyses revealed that patient pain during the medical visit was associated with the physician spending a greater portion of the visit on technical tasks and a smaller portion on preventive services and other activities designed to encourage the patients' active participation in their own health care. CONCLUSIONS: Patient pain may influence the physician-patient interaction and its outcomes. Primary care physicians should be aware that there may be less focus on patients' active involvement in their own care and less emphasis on providing disease prevention when treating patients who are experiencing pain.

Association of higher costs with symptoms and diagnosis of depression.

OBJECTIVES: We examined the relationships among depressive symptoms, physician diagnosis of depression, and charges for care. STUDY DESIGN: We used a prospective observational design. POPULATION: Five hundred eight new adult patients were randomly assigned to senior residents in family practice and internal medicine. OUTCOMES MEASURED: Self-reports of health status assessment (Medical Outcomes Study Short Form-36) and depressive symptoms (Beck Depression Inventory) were determined at study entry and at 1-year follow-up. Physician diagnosis of depression was determined by chart audit; charges for care were monitored electronically. RESULTS: Symptoms of depression and the diagnosis of depression were associated with charges for care. Statistical models were developed to identify predictors for the occurrence and magnitude of medical charges. Neither depressive symptoms nor diagnosis of depression significantly predicted the occurrence of charges in the areas studied, but physician diagnosis of depression predicted the magnitude of primary care and total charges. CONCLUSIONS: A complex relationship exists among depressive symptoms, the diagnosis of depression, and charges for medical care. Understanding these relationships may help primary care physicians diagnose depression and deliver primary care to depressed patients more effectively while managing health care expenditures.

A comparison of ambulatory services for patients with managed care and fee-for-service insurance.

OBJECTIVES: To determine whether family physicians provide different ambulatory care to patients with health insurance from managed care organization (MCO) versus fee-for-service (FFS) plans. STUDY DESIGN: Multimethod cross-sectional observational study. PATIENTS AND METHODS: A total of 4454 patients made office visits to 138 family physicians in northeastern Ohio. Direct observation with the Davis Observation Code and a structured checklist were used to assess the process of care. Patient satisfaction was measured with the Medical Outcomes Study 9-Item Visit Rating Form. RESULTS: Among 1588 patients with MCO insurance and 876 with FFS insurance, no differences were noted in the number of visits per year, length of visits, percentage of visits for well care, or the percentage of visits in which medicines were prescribed in analyses controlling for patient mix. Visits by patients with MCO insurance were more likely to involve referrals to another physician than visits by patients with FFS insurance. Patient satisfaction and time use during visits were comparable for the 2 groups. CONCLUSIONS: Managed care insurance appears to increase involvement of the primary care provider in the referral process. However, in a healthcare market with moderate managed care penetration in which the same physicians see patients with different types of insurance, the process of care is affected little by type of insurance coverage.