Severity of COVID-19 Respiratory Complications during Pregnancy are Associated with Degree of Lymphopenia and Neutrophil to Lymphocyte Ratio on Presentation: A Multicenter Cohort Study.

OBJECTIVE: This study aimed to determine if laboratory inflammatory markers can predict critical disease in symptomatic COVID-19 pregnant women. STUDY DESIGN: Multicenter, retrospective cohort study of all pregnant women presenting to New York City Health + Hospitals emergency departments from March 1 to May 30, 2020. We assessed all symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive pregnant women with room air oxygen saturation <95% on presentation. Logistic regression modeled the relationship of inflammatory markers to outcomes. Area under receiver operating characteristic (ROC) curve and maximum Youden index determined prognostic ability and optimal predictive cut-off values. RESULTS: A total of 498 of 5,002 pregnant women were SARS-CoV-2 RT-PCR positive of which 77 presented with hypoxemia. The absolute lymphocyte count (ALC) and neutrophil to lymphocyte ratio (NLR) were highly sensitive for progression to severe illness. ROC curve analysis identified predictive cutoffs: ALC < 1.49 × 109/L (96% sensitivity, 52% specificity, area under the receiver operating characteristic curve [AUC] = 0.80 (95% confidence interval [CI]: 0.70-0.90) and NLR >8.1 (100% sensitivity, 70% specificity, AUC = 0.86 (95% CI: [0.76-0.96]). CONCLUSION: ALC and NLR on presentation are sensitive markers of progression to critical COVID-19 disease in symptomatic pregnant women. This finding provides a practical, rapid method for assessment and can assist clinicians with decision-making regarding triage, level of care, and patient management. KEY POINTS: · Few tools exist to gauge risk of severe COVID-19 disease in pregnancy.. · ALC and NLR are sensitive predictive markers of disease progression in symptomatic women.. · Cut-off values for ALC and NLR will help direct patient triage and management..

Family medicine residency characteristics associated with practice in a health professions shortage area.

BACKGROUND AND OBJECTIVES: While some family medicine residency programs are designed to train residents in community health centers (CHCs) for future careers serving underserved populations, there are few outcome studies on such programs. Our residency program provides three options for ambulatory health center training, but otherwise residents participate in the same curriculum. We analyzed relationships between ambulatory training site and likelihood of practice in health professions shortage areas (HPSAs). METHODS: We sent a mail survey to all graduates of one family medicine residency about practice locations, types, and populations; influences on practice choice; and sociodemographic characteristics. RESULTS: Training in a CHC had a statistically significant association with the likelihood of practice in an HPSA for both initial and current practice. Training in a rural residency site was associated with initial and current rural practice. Logistic regression analysis showed that physicians who completed ambulatory training in the CHC were nearly six times more likely to report having practiced initially and four times more likely to cite current practice in an HPSA. CONCLUSIONS: Outpatient CHC residency training increases the likelihood of practice in an underserved setting. This finding has policy implications for supporting workforce training in practice settings that care for underserved populations.

Community dimensions and HPSA practice location: 30 years of family medicine training.

BACKGROUND AND OBJECTIVES: Our objective was to assess practicing family physicians' confidence and participation in a range of community-related activities. Additionally, we assessed the strength of the relationship between the physicians' reported medical school and residency training in community-related activities and their current community activities, as well as whether they were practicing in an underserved location. METHODS: All 347 graduates of the University of Massachusetts Family Medicine Residency were surveyed about practice location and type, involvement and training in community work, confidence in community-related skills, and sociodemographic characteristics. Analyses were conducted by residency graduation decade (1976-1985, 1986-1995, and 1996-2005). RESULTS: Earlier graduates (19761985) were significantly more likely to engage in an array of community-related activities, but recent graduates (1996-2005) were more likely to report having been trained in these skills. There was a significant positive association between practice in an underserved area and confidence in issues related to sociocultural aspects of care. While recent graduates were more likely to locate both initial and current practices in a Health Professions Shortage Area (HPSA), 20.6% of all graduates reported an initial practice in a HPSA. CONCLUSIONS: While family physician involvement in community-related activities increases with years out of residency, a higher proportion of recent graduates report having learned community-related skills while in medical school. Physician relocation tends to be away from HPSA toward non-HPSA sites.

The impact of a physician awareness group and the first year of training on hematology-oncology fellows.

PURPOSE: To assess the impact of a Balint-like physician awareness group on hematology-oncology fellows' attitudes and measure changes in attitudes during the first fellowship year. PATIENTS AND METHODS: We used a modified crossover design in which one half of a fellowship class at a time was exposed to the group intervention over a 2-year period (2000 to 2002). Two 14-fellow classes were followed for 1 year each and were given three "attitudes" questionnaires, at the beginning, middle, and end of the academic year. RESULTS: Forty Balint group sessions were held during the 2-year study period; 82 questionnaires of the 84 administered (98%) were recovered. Instrument content and criterion validity were demonstrated, as was topic domain reliability. Overall, mean attitude scores increased following the group intervention, from 3.6 (95% CI, 3.5 to 3.7) to 3.7 (95% CI, 3.6 to 3.8; P =.09). Within domains, scores increased in a "fellow's views of him/herself as a physician," from 3.8 (95% CI, 3.6 to 3.9) to 4.1 (95% CI, 3.9 to 4.2; P =.008) and "comfort dealing with emotional patient/clinical situations," from 3.5 (95% CI, 3.3 to 3.7) to 3.7 (95% CI, 3.6 to 3.9; P =.11). Changes in responses to individual questions included: an increase in fellows' comfort with the technical aspects of being an oncologist (P <.03); an increase in fellows' comfort with discussing the stress of home at work (P <.023); and an increase among fellows in feeling pressed for time to discuss psychosocial issues with patients (P =.035). CONCLUSION: A physician awareness group was feasible and enhanced fellows' development as physicians. Further research is needed to determine how to incorporate such groups into oncology fellowships.

Family medicine educators' perceptions of the future of faculty development.

BACKGROUND AND OBJECTIVES: Faculty development has been an important part of academic family medicine for 3 decades. However, few studies examine the effectiveness of various faculty development delivery methods. With little quantitative data from the literature with which to recommend future directions, this study examined key stakeholders'perceptions. METHODS: A total of 127 family medicine faculty participated in 14 different focus groups. Department chairs, full-time and part-time faculty, and volunteer preceptors responded to seven questions about delivery methods. RESULTS: Discussants emphasized that future faculty development methods must be proven effective, woven into the fabric of clinical practice, and deal with increasing time and financial pressures. Much discussion was related to the need for national and regional strategies allowing for emphasis on outcome evaluation, flexibility, and access. Web-based delivery methods and preceptor needs were emphasized. CONCLUSIONS: Study participants called for a more rigorous evidence-based approach to faculty development. A more systematic and stable approach could include the establishment of new federal criteria for funding projects that address different levels of development and implementation. For example, one set of review criteria would be applicable to systematic case-control studies of new interventions while another set would relate to dissemination studies of proven methodologies.

Using differences between perceptions of importance and competence to identify teaching needs of primary care preceptors.

BACKGROUND: An important goal of a comprehensive faculty development plan is to improve teaching. This is especially important for clinical preceptors. PURPOSE: This study used a novel approach to assessing the teaching needs of preceptors, an essential and often neglected first step in faculty development. Measurement focused on discrepancies between importance and current performance related to a rich variety of teaching behaviors. This study also considered differences in perceived teaching needs among primary care specialties. METHOD: Twenty-six clerkship directors from 13 participating medical schools in the Northeast United States invited randomly selected family medicine, internal medicine, and pediatric preceptors to complete a teaching needs survey. One hundred five preceptors responded. RESULT: Findings revealed that preceptors most need to develop general teaching skills that will help them save time such as selecting appropriate teaching behaviors, assessing learners' needs and providing appropriate feedback, and helping learners learn independently. On the other hand, preceptors expressed less need to improve teaching related to cost containment, disease prevention, clinical decision making, office management, and using computers to aid teaching. Family practice preceptors rated their current teaching performance significantly higher than pediatric preceptors despite no differences in previous faculty development experience. CONCLUSION: Faculty development for preceptors should focus on general teaching skills relative to teaching skills tied to specific medical areas. Novel approaches to teaching while practicing medicine that increase efficiency should be explored. Faculty developers should consider differences in confidence among preceptors from different specialties.