Hidden curricula in academic medicine: Streamlining success for early career scholars from majority and diverse backgrounds.

The hidden curriculum (HC), or implicit norms and values within a field or institution, affects faculty at all career stages. This study surveyed affiliates of a junior faculty training program (n = 12) to assess the importance of HC topics for junior faculty, mentors, and institutional leaders. For non-diverse junior faculty and their mentors, work-life balance, research logistics, and resilience were key HC topics. Coping with bias and assertive communication were emphasized for diverse junior faculty and mentors. Institutional norms and vision were essential for leaders, while networking was important for all groups. Future research should explore HC needs and potential interventions.

Financial Toxicity in the Clinical Encounter: A Paired Survey of Patient and Clinician Perceptions.

Objective: To compare the agreement between patient and clinician perceptions of care-related financial issues. Patients and Methods: We surveyed patient-clinician dyads immediately after an outpatient medical encounter between September 2019 and May 2021. They were asked to separately rate (1-10) patient's level of difficulty in paying medical bills and the importance of discussing cost issues with that patient during clinical encounters. We calculated agreement between patient-clinician ratings using the intraclass correlation coefficient and used random effects regression models to identify patient predictors of paired score differences in difficulty and importance of ratings. Results: 58 pairs of patients (n=58) and clinicians (n=40) completed the survey. Patient-clinician agreement was poor for both measures, but higher for difficulty in paying medical bills (intraclass correlation coefficient=0.375; 95% CI, 0.13-0.57) than for the importance of discussing cost (-0.051; 95% CI, -0.31 to 0.21). Agreement on difficulty in paying medical bills was not lower in encounters with conversations about the cost of care. In adjusted models, poor patient-clinician agreement on difficulty in paying medical bills was associated with lower patient socioeconomic status and education level, whereas poor agreement on patient-perceived importance of discussing cost was significant for patients who were White, married, reported 1 or more long-term conditions, and had higher education and income levels. Conclusion: Even in encounters where cost conversations occurred, there was poor patient-clinician agreement on ratings of the patient's difficulty in paying medical bills and perceived importance of discussing cost issues. Clinicians need more training and support in detecting the level of financial burden and tailoring cost conversations to the needs of individual patients.

Video-based observation research: A systematic review of studies in outpatient health care settings.

OBJECTIVE: To examine the use of video-based observation research in outpatient health care encounter research. METHODS: We conducted a systematic search of MEDLINE, Scopus, Cochrane and other databases from database inception to October 2020 for reports of studies that used video recording to investigate ambulatory patient-clinician interactions. Two authors independently reviewed all studies for eligibility and extracted information related to study setting and purpose, participant recruitment and consent processes, data collection procedures, method of analysis, and participant sample characteristics. RESULTS: 175 articles were included. Most studies (65%) took place in a primary care or family practice setting. Study objectives were overwhelmingly focused on patient-clinician communication (81%). Reporting of key study elements was inconsistent across included studies. CONCLUSION: Video recording has been used as a research method in outpatient health care in a limited number and scope of clinical contexts and research domains. In addition, reporting of study design, methodological characteristics, and ethical considerations needs improvement. PRACTICE IMPLICATIONS: Video recording as a method has been relatively underutilized within many clinical and research contexts. This review will serve as a practical resource for health care researchers as they plan and execute future video-based studies.

Changing the face of academic medicine: an equity action plan for institutions.

In recent years, there have been concerted efforts to better recruit, support, and retain diverse faculty, staff, and trainees in academic medicine. However, many institutions lack comprehensive and strategic plans to provide support to retain and recruit individuals from historically underrepresented groups. In this article, we itemize specific mechanisms through which institutions can support diverse individuals with the goal of improving inclusion and belonging in the workforce to better reflect the diversity of the intended patient and research participant population.

Rural Patient Experiences of Accessing Care for Chronic Conditions: A Systematic Review and Thematic Synthesis of Qualitative Studies.

PURPOSE: Access to health care is a long-standing concern for rural patients; however, administrative measures fail to capture the subjective patient experience of accessing health care. The purpose of this review was to synthesize the qualitative literature on patient and caregiver experiences of accessing health care services for chronic disease management among US residents of rural areas. METHODS: We searched Embase, MEDLINE, PsycInfo, CINAHL, and Scopus to identify qualitative studies published during 2010-2019. A thematic synthesis approach was used to analyze findings from included studies. RESULTS: A total of 62 studies involving 1,354 unique participants were included. The largest share of studies (24.2%) was focused on the experience of patients with cancer, followed by behavioral health (16.1%), HIV and AIDS (14.5%), and diabetes (12.9%). We identified 4 primary analytic themes of barriers and facilitators associated with the experience of accessing health care services for chronic disease management in rural areas: (1) navigating the rural environment, (2) navigating the health care system, (3) financing chronic disease management, and (4) rural life (ie, common elements of a distinct "rural" way of thinking and behaving). CONCLUSIONS: In this comprehensive review, we found that important cultural, structural, and individual factors influenced the rural patient's experience of health care access and use, including barriers and facilitators posed by geographic and built environments, and distinct rural mores. Our findings can inform policies and programs that both facilitate structural aspects of access and include culturally appropriate interventions.VISUAL ABSTRACT.

Documentation of Psychosocial Distress and Its Antecedents in Children with Rare or Life-Limiting Chronic Conditions.

Children with rare or life-limiting chronic conditions and their families are at high risk of psychosocial distress. However, despite its impact on patient and family health and functioning, psychosocial distress and its antecedents may not routinely be captured in medical records. The purpose of this study was to characterize current medical record documentation practices around psychosocial distress among children with rare or life-limiting chronic conditions and their families. Medical records for patients with rare or life-limiting chronic conditions (n = 60) followed by a pediatric complex care program were reviewed. Study team members extracted both structured data elements (e.g., diagnoses, demographic information) and note narratives from the most recent visit with a clinician in the program. Psychosocial topics were analyzed using a mixed quantitative (i.e., frequency counts of topics) and qualitative approach. Topics related to psychosocial distress that were documented in notes included child and parent emotional problems, parent social support, sibling emotional or physical problems, family structure (e.g., whether parents were together), and financial concerns. However, 35% of notes lacked any mention of psychosocial concerns. Although examples of psychosocial concerns were included in some notes, none were present in over one-third of this sample. For both patients with rare or life-limiting chronic conditions and their caregivers, more active elicitation and standard documentation of psychosocial concerns may improve the ability of healthcare providers to identify and intervene on psychosocial concerns and their risk factors.

Building a framework for inclusion in health services research: Development of and pre-implementation faculty and staff attitudes toward the Diversity, Equity, and Inclusion (DEI) plan at Mayo Clinic.

OBJECTIVE: To mitigate the impact of racism, sexism, and other systemic biases, it is essential for organizations to develop strategies to address their diversity, equity and inclusion (DEI) climates. The objective of this formative evaluation was to assess Mayo Clinic Department of Health Sciences Research (HSR) faculty and staff perceptions toward a proposed departmental DEI plan and to explore findings by diversity and professional subgroups. MATERIALS AND METHODS: Key plan components include recruitment and support for diverse individuals; training for all HSR employees and leaders; and a review system to capture diversity and inclusion feedback for leaders. Additional activities include building inclusion "nudges" into existing performance reviews. To assess pre-implementation beliefs about specific plan components, we polled attendees at a departmental staff meeting in July 2020. RESULTS: Overall, respondents (n = 162) commonly endorsed a blinded promotion review process and DEI training for all staff and leaders as most important. In contrast, respondents expressed less support for plan activities related to "nudges." However, attitudes among certain diversity or professional groups toward specific plan activities diverged from their non-diversity group counterparts. Qualitative feedback indicated awareness of the need to address DEI issues. DISCUSSION: Overall, HSR faculty and staff respondents conveyed support for the plan. However, some specific plan activities were perceived differently by members of certain diversity or professional subgroups. CONCLUSION: These findings present a DEI framework on which other institutions can build and point to future directions for how DEI activities may be differentially perceived by impacted faculty and staff.

An Electronic Tool to Support Patient-Centered Broad Consent: A Multi-Arm Randomized Clinical Trial in Family Medicine.

PURPOSE: Patients are frequently asked to share their personal health information. The objective of this study was to compare the effects on patient experiences of 3 electronic consent (e-consent) versions asking patients to share their health records for research. METHODS: A multi-arm randomized controlled trial was conducted from November 2017 through November 2018. Adult patients (n = 734) were recruited from 4 family medicine clinics in Florida. Using a tablet computer, participants were randomized to (1) a standard e-consent (standard), (2) an e-consent containing standard information plus hyperlinks to additional interactive details (interactive), or (3) an e-consent containing standard information, interactive hyperlinks, and factual messages about data protections and researcher training (trust-enhanced). Satisfaction (1 to 5), subjective understanding (0 to 100), and other outcomes were measured immediately, at 1 week, and at 6 months. RESULTS: A majority of participants (94%) consented to future uses of their health record information for research. No differences in study outcomes between versions were observed at immediate or 1-week follow-up. At 6-month follow-up, compared with the standard e-consent, participants who used the interactive e-consent reported greater satisfaction (B = 0.43; SE = 0.09; P <.001) and subjective understanding (B = 18.04; SE = 2.58; P <.001). At 6-month follow-up, compared with the interactive e-consent, participants who used the trust-enhanced e-consent reported greater satisfaction (B = 0.9; SE = 1.0; P <.001) and subjective understanding (B = 32.2; SE = 2.6, P <.001). CONCLUSIONS: Patients who used e-consents with interactive research details and trust-enhancing messages reported higher satisfaction and understanding at 6-month follow-up. Research institutions should consider developing and further validating e-consents that interactively deliver information beyond that required by federal regulations, including facts that may enhance patient trust in research.

The hidden curriculum in health care academia: An exploratory study for the development of an action plan for the inclusion of diverse trainees.

INTRODUCTION: The hidden curriculum encompasses the norms, values, and behaviors within a learning environment. Navigating the hidden curricula of academia is crucial for doctoral trainees, particularly those from underrepresented backgrounds. Faculty mentors have an important role in helping trainees uncover and cope with the hidden curriculum. The purpose of this paper is to explore perceptions of the hidden curriculum among diverse doctoral trainees and mentors. METHODS: Following a presentation on the hidden curriculum at the Association for Clinical and Translational Science annual meeting in March 2021, attendees were asked to brainstorm ideas for diverse trainees and their mentors. Breakout room discussions were held for specific hidden curriculum topics; participants voted on which topics to discuss from a list of topics defined during the presentation. Ideas from these discussions were presented to the larger group to upvote. RESULTS: Participants (n = 116) voted to discuss the following hidden curriculum topics: "coping with bias," "assertive communication," "knowing how things work," and "developing a career." Many suggestions emphasized the role of institutions in empowering mentors to help diverse trainees and, more generally, to meaningfully support policies and programs that facilitate the career success of trainees and faculty from underrepresented backgrounds. CONCLUSIONS: This work generated a list of suggested action items for trainees, mentors, and institutions to ameliorate the hidden curricula of academia, especially for diverse trainees. However, institutions need to support changes that will facilitate these discussions as well as more broadly enable the success of faculty and students from diverse backgrounds.

Patient Experiences and Perceptions Associated with the Use of Desiccated Thyroid Extract.

Background and objectives: It is unclear why many patients with hypothyroidism prefer the use of desiccated thyroid extract (DTE) as a thyroid hormone replacement formulation over levothyroxine (LT4) treatment, as recommended by clinical practice guidelines. We analyzed patient-reported information from patient online forums to better understand patient preferences for and attitudes toward the use of DTE to treat hypothyroidism. Materials and Methods: We conducted a mixed-methods study by evaluating the content of online posts from three popular hypothyroidism forums from patients currently taking DTE (n = 673). From these posts, we extracted descriptive information on patient demographics and clinical characteristics and qualitatively analyzed posts' content to explore patient perceptions on DTE and other therapies further. Results: Nearly half (46%) of the patients reported that a clinician initially drove their interest in trying DTE. Patients described many reasons for switching from a previous therapeutic approach to DTE, including lack of improvement in hypothyroidism-related symptoms (58%) and the development of side effects (22%). The majority of patients described DTE as moderately to majorly effective overall (81%) and more effective than the previous therapy (77%). The most frequently described benefits associated with DTE use were an improvement in symptoms (56%) and a change in overall well-being (34%). One-fifth of patients described side effects related to the use of DTE. Qualitative analysis of posts' content supported these findings and raised additional issues around the need for individualizing therapy approaches for hypothyroidism (e.g., a sense of each patient has different needs), as well as difficulties obtaining DTE (e.g., issues with pharmacy availability). Conclusions: Lack of individualized treatment and a feeling of not been listened to were recurrent themes among DTE users. A subset of patients may prefer DTE to LT4 for many reasons, including perceived better effectiveness and improved overall well-being, despite the risks associated with DTE.

Does an interactive trust-enhanced electronic consent improve patient experiences when asked to share their health records for research? A randomized trial.

OBJECTIVE: In the context of patient broad consent for future research uses of their identifiable health record data, we compare the effectiveness of interactive trust-enhanced e-consent, interactive-only e-consent, and standard e-consent (no interactivity, no trust enhancement). MATERIALS AND METHODS: A randomized trial was conducted involving adult participants making a scheduled primary care visit. Participants were randomized into 1 of the 3 e-consent conditions. Primary outcomes were patient-reported satisfaction with and subjective understanding of the e-consent. Secondary outcomes were objective knowledge, perceived voluntariness, trust in medical researchers, consent decision, and time spent using the application. Outcomes were assessed immediately after use of the e-consent and at 1-week follow-up. RESULTS: Across all conditions, participants (N = 734) reported moderate-to-high satisfaction with consent (mean 4.3 of 5) and subjective understanding (79.1 of 100). Over 94% agreed to share their health record data. No statistically significant differences in outcomes were observed between conditions. Irrespective of condition, black participants and those with lower education reported lower satisfaction, subjective understanding, knowledge, perceived voluntariness, and trust in medical researchers, as well as spent more time consenting. CONCLUSIONS: A large majority of patients were willing to share their identifiable health records for research, and they reported positive consent experiences. However, incorporating optional additional information and messages designed to enhance trust in the research process did not improve consent experiences. To improve poorer consent experiences of racial and ethnic minority participants and those with lower education, other novel consent technologies and processes may be valuable. (An Interactive Patient-Centered Consent for Research Using Medical Records; NCT03063268).

Employment Trends Among Public Health Doctoral Recipients, 2003-2015.

OBJECTIVES: To examine postgraduation employment trends among graduates of doctoral programs in public health from 2003 to 2015. METHODS: We analyzed pooled cross-sectional data from a census of graduates receiving a research doctorate from US accredited institutions. The outcome of interest was employment status. Covariates included public health discipline, sociodemographic characteristics, and institutional attributes. RESULTS: Of 11 771 graduates, nearly two thirds secured employment in either academic (34.8%) or nonacademic (31.4%) settings at the time of graduation. The proportion of those still seeking employment increased over time. Individuals who were White, younger, trained in either biostatistics or epidemiology, or from an institution with the highest level of research intensity were significantly more likely to secure employment. Academic employment was the most common setting for all 5 public health disciplines, but we observed differences in employment patterns (e.g., government, nonprofit, for-profit) across disciplines. CONCLUSIONS: Certain characteristics among public health doctoral recipients are correlated with postgraduation employment. More research is needed, but the observed increase in individuals still seeking employment may be attributable to increases in general public health graduates from for-profit institutions.

Interdisciplinary Dissertation Research Among Public Health Doctoral Trainees, 2003-2015.

OBJECTIVES: Given the call for more interdisciplinary research in public health, the objectives of this study were to (1) examine the correlates of interdisciplinary dissertation completion and (2) identify secondary fields most common among interdisciplinary public health graduates. METHODS: We analyzed pooled cross-sectional data from 11 120 doctoral graduates in the Survey of Earned Doctorates, 2003-2015. The primary outcome was interdisciplinary dissertation completion. Covariates included primary public health field, sociodemographic characteristics, and institutional attributes. RESULTS: From 2003 to 2015, a total of 4005 of 11 120 (36.0%) doctoral graduates in public health reported interdisciplinary dissertations, with significant increases observed in recent years. Compared with general public health graduates, graduates of environmental health (odds ratio [OR] = 1.74; P < .001) and health services administration (OR = 1.38; P < .001) doctoral programs were significantly more likely to report completing interdisciplinary dissertation work, whereas graduates from biostatistics (OR = 0.51; P < .001) and epidemiology (OR = 0.76; P < .001) were less likely to do so. Completing an interdisciplinary dissertation was associated with being male, a non-US citizen, a graduate of a private institution, and a graduate of an institution with high but not the highest level of research activity. Many secondary dissertation fields reported by interdisciplinary graduates included other public health fields. CONCLUSION: Although interdisciplinary dissertation research among doctoral graduates in public health has increased in recent years, such work is bounded in certain fields of public health and certain types of graduates and institutions. Academic administrators and other stakeholders may use these results to inform greater interdisciplinary activity during doctoral training and to evaluate current and future collaborations across departments or schools.

Patient preferences toward an interactive e-consent application for research using electronic health records.

OBJECTIVE: The purpose of this study was to assess patient perceptions of using an interactive electronic consent (e-consent) application when deciding whether or not to grant broad consent for research use of their identifiable electronic health record (EHR) information. MATERIALS AND METHODS: For this qualitative study, we conducted a series of 42 think-aloud interviews with 32 adults. Interview transcripts were coded and analyzed using a modified grounded theory approach. RESULTS: We identified themes related to patient preferences, reservations, and mixed attitudes toward consenting electronically; low- and high-information-seeking behavior; and an emphasis on reassuring information, such as data protections and prohibitions against sharing data with pharmaceutical companies. Participants expressed interest in the types of information contained in their EHRs, safeguards protecting EHR data, and specifics on studies that might use their EHR data. DISCUSSION: This study supports the potential value of interactive e-consent applications that allow patients to customize their consent experience. This study also highlights that some people have concerns about e-consent platforms and desire more detailed information about administrative processes and safeguards that protect EHR data used in research. CONCLUSION: This study contributes new insights on how e-consent applications could be designed to ensure that patients' information needs are met when seeking consent for research use of health record information. Also, this study offers a potential electronic approach to meeting the new Common Rule requirement that consent documents contain a "concise and focused" presentation of key information followed by more details.

Understanding Perceptions of School Administrators Related to School Breakfast in a Low School Breakfast Participation State.

BACKGROUND: The National School Breakfast Program (SBP) is a federally funded program that allows states to offer nutritious breakfast to K-12 students. However, rates of SBP participation are low in some rural states, and the reasons are not well understood. The purpose of the study was to explore administrators' perceptions, attitudes, and beliefs related to the SBP, and factors they identify as barriers or facilitators to increased participation. METHODS: Data were collected from a cross-sectional, online survey of K-12 school administrators (N = 152) in a rural, midsized Midwestern state fielded over an academic year. Descriptive statistics were calculated and open-ended questions were coded and analyzed for relevant themes. RESULTS: Administrators identified busing schedules, time constraints, and a lack of flexibility within the school schedule to accommodate breakfast as primary structural barriers to SBP participation. Administrators described family-centered norms as reasons for low participation in rural areas. Administrators are at varying stages of readiness to work on improving participation. CONCLUSIONS: Low SBP participation can be explained in part by a convergence of factors related to access, community norms, and structural barriers. Results may be used to inform ways in which administrators at the state, district, and school level can work to increase participation.

Exploring the Parents' Attitudes and Perceptions About School Breakfast to Understand Why Participation Is Low in a Rural Midwest State.

OBJECTIVE: To explore parental attitudes and perceptions about the school breakfast program in a state with low school breakfast participation. DESIGN: A cross-sectional study design that used an online survey completed by parents supplemented with district data from a state department of education. The survey included quantitative and qualitative components. SETTING: A rural Midwestern state with low school breakfast participation. PARTICIPANTS: Parents and caregivers of children in grades 1-12 were recruited through schools to complete a survey (n = 7,209). MAIN OUTCOME MEASURES: Participation in a school breakfast program. ANALYSIS: A generalized estimating equation model was used to analyze the data and account for the possible correlation among students from the same school district. Open-end survey items were coded. RESULTS: Parents identified several structural and logistic barriers in response to open-ended survey items. Factors associated with breakfast participation include perceived benefits, stigma related to those for whom breakfast is intended, and the importance of breakfast. CONCLUSIONS AND IMPLICATIONS: Interventions should be designed to test whether changing parent perceptions and decreasing stigma will lead to increased breakfast participation. Policy, systems, and environment changes addressing the structural and logistic barriers also may have the potential to increase participation.

The importance of matching the evaluation population to the intervention population: Using Medicaid data to reach hard-to-reach intervention populations.

Subject recruitment is a challenge for researchers and evaluators, particularly with populations that are traditionally hard to reach and involve in research, such as low-income and minority groups. However, when the evaluation sample does not reflect a program's intended audience, the discrepancy may lead to evaluation results that are not valid for that audience. We conducted evaluation activities for a state Supplemental Nutrition Assistance Program-Education (SNAP-Ed) intervention that promotes consumption of fruits and vegetables (F&V) in low-income areas. Previous program evaluations efforts had failed to obtain a sufficient proportion of individuals identified as low-income based on their participation in SNAP. We used state Medicaid data as a means of identifying low-income families to recruit for a telephone survey (n=311) and an in-depth qualitative interview (n=30) that we designed for the program being evaluated. We chose to focus on the dynamics of parent-child communication around F&V because we considered this previously unevaluated component of the intervention vital to understanding program effectiveness. Our results indicated that the Medicaid database provided an appropriate sample and that parents reported frequent F&V requests from their children. Parents also reported that they would positively respond to requests in many different settings, such as grocery stores (92.6%), restaurants (88.1%), and fast food restaurants (80.4%).