Codesigning Policy-Based Solutions to Discrimination and Harassment in Academic Medicine: An Inclusive Approach.

ABSTRACT: Academic medicine institutions have historically employed policies as a means to tackle various types of discrimination and harassment within educational and professional settings, thereby affirming their dedication to promoting diversity, equity, and inclusion. However, the implementation and effectiveness of policies are constrained by limitations, including a lack of awareness and barriers to reporting. Due to concerns about accountability and transparency, many groups and individuals experiencing discrimination have lost trust in policy-based solutions to address equity in academic medicine. To address such challenges, the authors offer an evidence-informed policy framework with actionable recommendations. First, policy should be cowritten through meaningful and participatory engagement. Second, organizations should publicly report on metrics of policy effectiveness. Third, to ensure accountability, external organizations or adjudicators should be involved in oversight of policy-based processes. Fourth, leadership commitment is essential for success. Overall, policy can be an effective mechanism to address discrimination and harassment; however, a more inclusive approach is needed.

Exploring medical students' perspectives of physician leadership.

BACKGROUND: Leadership has been recognized as an important competency in medicine. Nevertheless, leadership curricula for Canadian medical students lacks standardization and may not be informed by medical students' perspectives of physician leadership. The purpose of this study was to elicit these perspectives on physician leadership. METHODS: The present study utilized semi-structured interviews to ascertain the views of medical student participants, including students in their first, second and third years of medical school, on physician leadership. Interview questions were based on 'the 3-C model' of physician leadership, which includes three aspects of leadership, namely character, competence and commitment. The interviews were audio-recorded, transcribed and then coded using thematic analysis. RESULTS: The medical students of this study provided rich examples of resident and staff physicians demonstrating effective and ineffective leadership. The participants identified the importance of character to effective physician leadership, but some participants also described a feeling of disconnect with the relevance of character at their stage of training. When discussing physician competence, medical students described the importance of both medical expertise and transferable skills. Lastly, the leadership aspect of commitment was identified as being relevant, but medical students cautioned against the potential for physician burnout. The medical student participants' suggestions for improved leadership development included increased experiences with examples of physician leadership, opportunities to engage in leadership and participation in reflection exercises. CONCLUSIONS: Overall, the study participants demonstrated an appreciation for three aspects of leadership; character, competence and commitment. Furthermore, they also provided recommendations for the future design of medical leadership curricula.

When donor T cells attack: The curious case of liver transplant-associated acute graft-versus-host-disease.

Graft versus host disease is a rare but deadly complication of solid organ transplant. Clinical features of graft-versus-host-disease are non-specific, which may lead to delayed diagnosis as more common conditions including infections or drug reactions are considered. We describe a 54-year-old male patient who underwent liver transplantation for alcohol use disorder-related cirrhosis and developed acute graft-versus-host disease. Initial clinical presentation included dermatitis, bone marrow failure and enteritis. Results of skin biopsy and cytogenetic studies were consistent with liver transplant-associated acute graft-versus-host disease. The importance of this case is to highlight to transplant physicians and surgeons the challenges of diagnosing graft-versus-host-disease. In our case, pre-existing partnerships among the liver and hematopoietic stem cell transplant teams, transfusion medicine specialists, critical care specialists and facilitated timely communication relevant to confirming graft-versus-host disease. We propose an algorithm to assist in the workup of suspected graft-versus-host disease. Because this condition is characterized by high mortality, a high index of suspicion is imperative for prompt diagnosis and optimal management of the donor-recipient immune interaction when patients present with classic clinical features.

Perspectives on physician leadership: The role of character-based leadership in medicine.

INTRODUCTION: Physician leadership is multifaceted, but leadership training in medicine often is not. Leadership education and training for physicians are rarely grounded in conceptual leadership frameworks and suffer from a primary focus on cognitive leadership domains. Character-based leadership is a conceptual leadership framework that moves beyond cognitive competencies and articulates dimensions of character that promote effective leadership. The purpose of this study was to explore the relevance of character-based leadership in the medical context. METHODS: This qualitative descriptive study used semi-structured interviews to explore health care professionals' perceptions of character in relation to effective leadership in medicine. All interviews were audiorecorded and transcribed. Consistent with descriptive qualitative inquiry, a qualitative latent content analysis was used. Simultaneous data collection and analysis incorporating character-based leadership as a theoretical framework was used to help organise the analysis of the data. The researchers met regularly to clarify coding structures and categorise codes until sufficiency was reached. RESULTS: Twenty-six individuals (12 doctors, 5 nurses, 2 social workers, 2 directors and a pharmacist, dietician, coordinator, administrator and unit clerk) participated. Character-based leadership resonated with participants; they deemed character essential for effective physician leadership. Participants reflected on different character dimensions they attributed to an effective physician leader, in particular, collaboration, humility and humanity. They shared examples of working in interdisciplinary health care teams to illustrate these in practice. Moreover, participants believed that effective physician leaders need not be in a positional leadership role and asserted that physicians who demonstrate character stand out as leaders regardless of their career stage. DISCUSSION: Our findings suggest a role for a character-based leadership framework in medical education. Participants recognised the execution of character in everyday practice, associated character with effective leadership and understood leadership in dispositional rather than positional terms. These findings provide important insights for expanding and enhancing existing leadership training interventions.

Freedom from discrimination or freedom to discriminate? Discursive tensions within discrimination policies in medical education.

The importance of advancing equity, diversity, and inclusion for all members of the academic medical community has gained recent attention. Academic medical organizations have attempted to increase broader representation while seeking structural reforms consistent with the goal of enhancing equity and reducing disproportionality. However, efforts remain constrained while minority groups continue to experience discrimination. In this study, the authors sought to identify and understand the discursive effects of discrimination policies within medical education. The authors assembled an archive of 22 texts consisting of publicly available discrimination and harassment policy documents in 13 Canadian medical schools that were active as of November 2019. Each text was analysed to identify themes, rhetorical strategies, problematization, and power relations. Policies described truth statements that appear to idealize equity, yet there were discourses related to professionalism and neutrality that were in tension with these ideals. There was also tension between organizations' framing of a shared responsibility for addressing discrimination and individual responsibility on complainants. Lastly, there were also competing discourses on promoting freedom from discrimination and the concept of academic freedom. Overall, findings reveal several areas of tension that shape how discrimination is addressed in policy versus practice. Existing discourses regarding self-protection and academic freedom suggest equity cannot be advanced through policy discourse alone and more substantive structural transformation may be necessary. Existing approaches may be inadequate to address discrimination unless academic medical organizations interrogate the source of these discursive tensions and consider asymmetries of power.

Impact of university re-opening on total community COVID-19 burden.

BACKGROUND: University students have higher average number of contacts than the general population. Students returning to university campuses may exacerbate COVID-19 dynamics in the surrounding community. METHODS: We developed a dynamic transmission model of COVID-19 in a mid-sized city currently experiencing a low infection rate. We evaluated the impact of 20,000 university students arriving on September 1 in terms of cumulative COVID-19 infections, time to peak infections, and the timing and peak level of critical care occupancy. We also considered how these impacts might be mitigated through screening interventions targeted to students. RESULTS: If arriving students reduce their contacts by 40% compared to pre-COVID levels, the total number of infections in the community increases by 115% (from 3,515 to 7,551), with 70% of the incremental infections occurring in the general population, and an incremental 19 COVID-19 deaths. Screening students every 5 days reduces the number of infections attributable to the student population by 42% and the total COVID-19 deaths by 8. One-time mass screening of students prevents fewer infections than 5-day screening, but is more efficient, requiring 196 tests needed to avert one infection instead of 237. INTERPRETATION: University students are highly inter-connected with the surrounding off-campus community. Screening targeted at this population provides significant public health benefits to the community through averted infections, critical care admissions, and COVID-19 deaths.

Leadership Development in Postgraduate Medical Education: A Systematic Review of the Literature.

PURPOSE: To evaluate and interpret evidence relevant to leadership curricula in postgraduate medical education (PGME) to better understand leadership development in residency training. METHOD: The authors conducted a systematic review of peer-reviewed, English-language articles from four databases published between 1980 and May 2, 2017 that describe specific interventions aimed at leadership development. They characterized the educational setting, curricular format, learner level, instructor type, pedagogical methods, conceptual leadership framework (including intervention domain), and evaluation outcomes. They used Kirkpatrick effectiveness scores and Best Evidence in Medical Education (BEME) Quality of Evidence scores to assess the quality of the interventions. RESULTS: Twenty-one articles met inclusion criteria. The classroom setting was the most common educational setting (described in 17 articles). Most curricula (described in 13 articles) were isolated, with all curricula ranging from three hours to five years. The most common instructor type was clinical faculty (13 articles). The most commonly used pedagogical method was small group/discussion, followed by didactic teaching (described in, respectively, 15 and 14 articles). Study authors evaluated both pre/post surveys of participant perceptions (n = 7) and just postintervention surveys (n = 10). The average Kirkpatrick Effectiveness score was 1.0. The average BEME Quality of Evidence score was 2. CONCLUSIONS: The results revealed that interventions for developing leadership during PGME lack grounding conceptual leadership frameworks, provide poor evaluation outcomes, and focus primarily on cognitive leadership domains. Medical educators should design future leadership interventions grounded in established conceptual frameworks and pursue a comprehensive approach that includes character development and emotional intelligence.

Navigating complexity in team-based clinical settings.

CONTEXT: Educators must prepare learners to navigate the complexities of clinical care. Training programmes have, however, traditionally prioritised teaching around the biomedical and the technical, not the socio-relational or systems issues that create complexity. If we are to transform medical education to meet the demands of 21st century practice, we need to understand how clinicians perceive and respond to complex situations. METHODS: Constructivist grounded theory informed data collection and analysis; during semi-structured interviews, we used rich pictures to elicit team members' perspectives about clinical complexity in neurology and in the intensive care unit. We identified themes through constant comparative analysis. RESULTS: Routine care became complex when the prognosis was unknown, when treatment was either non-existent or had been exhausted or when being patient and family centred challenged a system's capabilities, or participants' training or professional scope of practice. When faced with complexity, participants reported that care shifted from relying on medical expertise to engaging in advocacy. Some physician participants, however, either did not recognise their care as advocacy or perceived it as outside their scope of practice. In turn, advocacy was often delegated to others. CONCLUSIONS: Our research illuminates how expert clinicians manoeuvre moments of complexity; specifically, navigating complexity may rely on mastering health advocacy. Our results suggest that advocacy is often negotiated or collectively enacted in team settings, often with input from patients and families. In order to prepare learners to navigate complexity, we suggest that programmes situate advocacy training in complex clinical encounters, encourage reflection and engage non-physician team members in advocacy training.

The impact of delayed critical care outreach team activation on in-hospital mortality and other patient outcomes: a historical cohort study.

PURPOSE: Early warning scores (EWS) and critical care outreach teams (CCOT) have been developed to respond to decompensating patients. Nevertheless, controversy exists around their effectiveness. The primary objective of this study was to determine if a delay of ≥ 60 min between when a patient was identified as meeting EWS criteria and the CCOT was activated impacted in-hospital mortality. METHODS: This was a historical cohort study evaluating all new CCOT activations over a four-year study period (1 June 2007 to 31 August 2011) for inpatients ≥ 18 yr of age at two academic tertiary care hospitals in London, Ontario, Canada. Multivariable logistic regression accounting for repeated measures was used to determine the effect of delayed CCOT activation on in-hospital mortality (primary outcome). Differences in outcomes between medical and surgical patients were also examined. RESULTS: There were 3,133 CCOT activations for 1,684 (53.8%) medical patients and 1,449 (46.2%) surgical patients during the study period. The CCOT was activated < 60 min of a patient meeting EWS criteria in 2,160 (68.9%) cases and ≥ 60 min in 973 (31.1%) cases. Patients with ≥ 60 min delay were more likely be admitted to the intensive care unit (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.07 to 1.47) and to suffer in-hospital mortality (OR, 1.30; 95% CI, 1.08 to 1.56). Irrespective of delay, surgical patients were less likely to experience in-hospital mortality than medical patients (OR, 0.46; 95% CI, 0.39 to 0.55). CONCLUSION: Including the rates of delay in CCOT activation and the admitting service could be an additional step in exploring the conflicting results seen in the current literature assessing the impact of CCOT on patient outcomes.

Triiodothyronine replacement in critically ill adults with non-thyroidal illness syndrome.

PURPOSE: Non-thyroidal illness syndrome is commonly encountered in critically ill patients, many of whom are treated with thyroid hormones despite uncertainty regarding their safety and effectiveness. This retrospective observational study sought to evaluate the utilization, safety, and effectiveness of triiodothyronine (T3) supplementation in critically ill adults admitted to either of two non-cardiac surgery mixed-medical/surgical intensive care units (ICU). METHODS: Consecutive adults admitted to an ICU and treated with enterally administered T3 were identified over a two-year period. Data pertaining to demographics, T3 utilization, safety, and clinical outcomes were collected. RESULTS: Data were extracted from the medical records of 70 consecutive patients. All had baseline serum free T3 concentrations below the lower limit of our laboratory's reference range and 22 (31%) patients also had low thyroxine (T4) concentrations. The most commonly prescribed replacement doses were 25 and 50 µg for a median of seven days and almost half of the patients also received concomitant T4 supplementation. Serum thyroid hormones were available in 48 of 70 patients (69%) at a median [interquartile range (IQR)] of 7 [6-38] days. Normalization of free T3 serum concentrations occurred in 30 of 48 patients (63%) at a median [IQR] of 8 [7-33] days. A dose-response relationship was identifiable. New adverse events (atrial fibrillation/flutter, hypertension, sinus tachycardia, myocardial infarction) during therapy were less frequent than at baseline. CONCLUSIONS: This study suggests that with T3 supplementation there was evidence of serum free T3 normalization without evidence of associated harms. A definitive trial is needed to evaluate clinical effectiveness.

Unique ECG Findings in Acute Pulmonary Embolism: STE with Reciprocal Changes and Pathologic Q Wave.

A 68-year-old male presented to the emergency department with retrosternal chest pain, presyncope, and then a pulseless electrical activity cardiac arrest. An ECG prior to his arrest revealed ST elevations in leads V1-V3, Q waves in lead V2, and reciprocal ST depressions in the lateral and inferior leads. He received thrombolytic therapy for a presumptive diagnosis of ST elevation myocardial infarction. Return of spontaneous circulation was achieved and he underwent a coronary angiogram. No critical disease was found and his left ventriculogram showed normal contraction. His ongoing metabolic acidosis and dependence on an intra-aortic balloon pump, despite adequate cardiac output, prompted a CT pulmonary angiogram which showed multiple segmental filling defects. He was treated for a pulmonary embolism and was discharged 5 days later. Acute pulmonary embolism (APE) has variable clinical presentations. To our knowledge, this is the first case report of an APE presenting with these ECG findings suggestive of myocardial ischemia. In this case report, we discuss the underlying physiological mechanisms responsible and offer management suggestions for emergency department and critical care physicians to better expedite the treatment of APE mimicking acute coronary syndrome on ECG.

Exploring the premise of lost altruism: content analysis of two codes of ethics.

As an ideal, altruism has long enjoyed privileged status in medicine and medical education. As a practice, altruism is perceived to be in decline in the current generation. A number of educational efforts are underway to reclaim this "lost value" of medicine. In this paper we explore constructions of altruism over a defined period of time through a content analysis of the Canadian and Australian Medical Associations (CMA and AMA respectively) Codes of Ethics. We analyzed all editions of both Codes (1868-2004), using a content analysis approach, including thematic analysis. We coded as altruistic or non-altruistic, respectively, statements in which the interest of the patient is placed ahead of the physician's and statements in which the interest of the physician is given primacy. We examined the pattern of appearance and disappearance of these statements over time. We identified 13 altruistic and 2 non-altruistic statements across all editions. There is a gradual and uneven loss of altruistic content over time. The CMA Codes of 1938, 1970 and 2004 and the AMA code of 1992 represent significant change points. The most recent versions of both Codes contain only 1 altruistic statement and both non-altruistic statements. We conclude that altruism appears to be a fluid and changing concept over time. Loss of altruism is not merely a current generational issue but extends through the past century and is likely due to political and social forces. These results call into question current educational attempts to reclaim altruism, and point to the social evolution of the ideal.

Soft tissue oxygenation and risk of mortality (STORM): an early marker of critical illness?

PURPOSE: Tissue oxygen saturation (StO2) is a noninvasive measure that reflects changes in tissue perfusion. Rapid response teams (RRTs) assess sick inpatients to determine need for intensive care unit (ICU) admission. This determination is subjective based on parameters such as systolic blood pressure, heart rate, and pulse oximetry. Our objective was to determine if parameters readily available at RRT bedside assessment (vital signs and StO2) can predict ICU admission and inhospital mortality. MATERIALS AND METHODS: All inpatients assessed by RRT at a tertiary Canadian hospital were consecutively sampled for 3 months. After clinical assessment, the RRT physician (blinded to StO2) made the ultimate ICU admission decision. RESULTS: In 134 included patients, mean age was 65.5 ± 15.2 years, and 53% (n = 71) were males. There were 49 ICU admissions (36.6%) and 31 mortalities (23.1%). Two multivariable models significantly predicted ICU admission and inhospital mortality. The only independent predictor of ICU admission was pulse oximetry (adjusted odds ratio, 0.88; 95% confidence interval, 0.80-0.96; P = .007). Tissue oxygen saturation did not predict ICU admission but was the only independent predictor of mortality (adjusted odds ratio, 1.06; 95% confidence interval, 1.01-1.12; P = .04). CONCLUSIONS: Tissue oxygen saturation may identify critical illness in patients who would not traditionally meet ICU admission criteria and thus may identify patients who benefit from closer monitoring.

Are we all on the same page? A discourse analysis of interprofessional collaboration.

PURPOSE: Interprofessional collaboration (IPC) has become a dominant idea in both medical education and clinical care as reflected in its incorporation into competency-based educational frameworks and hospital accreditation models. This study examined the published literature to explore whether a shared IPC discourse underpins these current efforts. METHOD: Using a critical discourse analysis methodology informed by Michel Foucault's approach, the authors analyzed an archive of 188 texts published from 1960 through 2011. The authors identified the texts through a search of PubMed and CINAHL. RESULTS: The authors identified two major discourses in IPC: utilitarian and emancipatory. The utilitarian discourse is characterized by a positivist, experimental approach to the question of whether IPC is useful in patient care and, if so, what features best promote successful outcomes. This discourse uses the language of "evidence" and "validity." The emancipatory discourse is characterized by a constructivist approach concerned primarily with equalizing power relations among health practitioners; its language includes "power" and "dominance." CONCLUSIONS: This study suggests that IPC is not a single, coherent idea in medical education and health care. At least two different IPC discourses exist, each with its own distinctive truths, objects, and language. The extent to which educators and health care practitioners may tacitly align with one discourse or the other may explain the tensions that have accompanied the conceptualization, implementation, and assessment of IPC. Explicit acknowledgment of and attention to these discourses could improve the coherence and impact of IPC efforts in educational and clinical settings.

Oral and intravenous thyroxine (T4) achieve comparable serum levels for hormonal resuscitation protocol in organ donors: a randomized double-blinded study.

BACKGROUND: Thyroxine (T4) administration is advocated in the management of organ donors; however, the bioavailability of oral thyroxine is unknown in this patient population. OBJECTIVE: The primary objective of this study was to compare the percentage of the study time (from study drug administration to organ procurement) that patients in the oral vs the intravenous group required inotropic support. Secondary objectives included plasma levels of T3 and T4 and number of organs donated following oral vs intravenous T4 administration. DESIGN: Randomized double-blinded study. SETTING: Adult medical-surgical intensive care unit. PATIENTS: Thirty-two adult solid organ donors. INTERVENTIONS: Patients were randomized to receive either an oral or intravenous dose of T4 (2 µg·kg⁻¹). All patients received an oral and intravenous study drug preparation, one of which was a placebo. The study was double-blinded, and randomization occurred in blocks of four and six. MEASUREMENTS: The number and duration of inotropic/vasopressor therapies and free serum levels of T3 and T4 were determined hourly until procurement. MAIN RESULTS: Following T4 administration, all patients remained on inotropic/vasopressor therapy for the same mean (SD) duration [93 (3)%] of the study period. There was a similar and gradual decrease in the number and dosages of inotropes/vasopressors required in both groups. There was no difference in T3 or T4 levels between groups. Oral bioavailability of T4 was 93% of the intravenous group at six hours and 91% overall. At six hours, the mean area under the curve for T4 was similar between the intravenous group [92.2 (33); 95% confidence interval (CI) 76 to 108.4] and the oral group [86.1 (14); 95% CI 79.4 to 92.8]. CONCLUSIONS: Orally administered T4 is well absorbed and achieves a bioavailability of approximately 91-93% of intravenous T4 in organ donors. Inotropic/vasopressor requirements and hemodynamic responses following oral or intravenous thyroxine administration were comparable. Oral T4 is suitable for hormonal therapy for organ donors. This trial was registered at www.clinicaltrials.gov : NCT00238030.

Categorizing patients in a forced-choice triad task: the integration of context in patient management.

BACKGROUND: Studies of experts' problem-solving abilities have shown that experts can attend to the deep structure of a problem whereas novices attend to the surface structure. Although this effect has been replicated in many domains, there has been little investigation into such effects in medicine in general or patient management in particular. METHODOLOGY/PRINCIPAL FINDINGS: We designed a 10-item forced-choice triad task in which subjects chose which one of two hypothetical patients best matched a target patient. The target and its potential matches were related in terms of surface features (e.g., two patients of a similar age and gender) and deep features (e.g., two diabetic patients with similar management strategies: a patient with arthritis and a blind patient would both have difficulty with self-injected insulin). We hypothesized that experts would have greater knowledge of management categories and would be more likely to choose deep matches. We contacted 130 novices (medical students), 11 intermediates (medical residents), and 159 experts (practicing endocrinologists) and 15, 11, and 8 subjects (respectively) completed the task. A linear mixed effects model indicated that novices were less likely to make deep matches than experts (t(68) = -3.63, p = .0006), while intermediates did not differ from experts (t(68) = -0.24, p = .81). We also found that the number of years in practice correlated with performance on diagnostic (r = .39, p = .02), but not management triads (r = .17, p = .34). CONCLUSIONS: We found that experts were more likely than novices to match patients based on deep features, and that this pattern held for both diagnostic and management triads. Further, management and diagnostic triads were equally salient for expert physicians suggesting that physicians recognize and may create management-oriented categories of patients.