A Systematic Review of Metrics Utilized in the Selection and Prediction of Future Performance of Residents in the United States.

Background Aligning resident and training program attributes is critical. Many programs screen and select residents using assessment tools not grounded in available evidence. This can introduce bias and inappropriate trainee recruitment. Prior reviews of this literature did not include the important lens of diversity, equity, and inclusion (DEI). Objective This study's objective is to summarize the evidence linking elements in the Electronic Residency Application Service (ERAS) application with selection and training outcomes, including DEI factors. Methods A systematic review was conducted on March 30, 2022, concordant with PRISMA guidelines, to identify the data supporting the use of elements contained in ERAS and interviews for residency training programs in the United States. Studies were coded into the topics of research, awards, United States Medical Licensing Examination (USMLE) scores, personal statement, letters of recommendation, medical school transcripts, work and volunteer experiences, medical school demographics, DEI, and presence of additional degrees, as well as the interview. Results The 2599 identified unique studies were reviewed by 2 authors with conflicts adjudicated by a third. Ultimately, 231 meeting inclusion criteria were included (kappa=0.53). Conclusions Based on the studies reviewed, low-quality research supports use of the interview, Medical Student Performance Evaluation, personal statement, research productivity, prior experience, and letters of recommendation in resident selection, while USMLE scores, grades, national ranking, attainment of additional degrees, and receipt of awards should have a limited role in this process.

Global "systemness" in medical education: A rationale and framework to assess performance.

Healthcare is global. The challenges of the "triple aim" - achieving high-quality healthcare, maximal value, and an excellent patient experience and outcomes - are universal. Medical education is similarly global with worldwide efforts towards competency-based reform, the adoption and adaptation of accreditation standards, and the expansion of international collaborations between healthcare organizations (HCOs). The focus of many of these efforts centers around recognizing education as a talent pipeline to serve local and global healthcare needs. Accordingly, many U.S.-based academic medical centres are pursuing an increasingly global footprint by developing international partnerships between HCOs. The educational leadership at the Cleveland Clinic (an HCO that has ventured internationally in Canada, the United Kingdom, and the United Arab Emirates) has adopted a "systemness" approach to medical education collaboratives. Systemness describes the ability of academic health systems to leverage existing structures, expertise, and other resources to address broadly shared educational needs across geographies, disseminate best practices, and ultimately improve the care that is delivered. The rationale for systemness, a concept derived from the healthcare administration and business world, affords the opportunity to achieve educational outcomes through synergy that exceeds the capability of any single component of a system. In this perspective, we posit a "systemness" taxonomy to be used to assess the performance and success of international collaborations in medical education and provide examples of its application to existing international partnerships in medical education. This framework is grounded in developmental assessment approaches, akin to those used in assessing learner performance, and defines levels of educational collaboration proficiencies, ultimately towards the alignment of these efforts with the health needs of the communities they serve. As global medical education collaboratives advance, ongoing assessment of existing partnerships and further research will be needed to define competencies and integrative activities that define high-performing medical education partnerships.

Trajectory of a medical career: a perspective regarding a proposed model.

A career as a physician offers so many options-clinical care, research, education, leadership, etc. Still, a general trajectory of a medical career can be usefully modelled. Based on a USA-centric lens, this proposed model-which is based on a personal reflection and conversation with colleagues-consists of an initial two-component linear phase, followed later by a non-linear phase. The linear phase requires mastery of a large body of knowledge, acquiring cognitive and technical skills, and achieving prescribed milestones. Two components of the linear trajectory are early education through medical school, and then graduate medical education through the initial career path. A non-linear phase follows, characteristically beginning after graduate medical training and the initial 'hitting stride' in the first post-training position.At this point, the physician's choices regarding career direction are wide open. Yet, the intense focus needed to master the prolonged linear phase of the physician's career can exert opposing effects on preparedness for the subsequent non-linear phase; years of satisfying prescribed curricula and examinations may blunt the self-directed learning and intrinsic motivation needed for the non-linear phase while also stimulating the appetite to get beyond the guardrails of the linear phase.This model has implications for early training, namely encouraging a focus on mindfulness and introducing this model as part of professional identity formation. Given differences in medical training across the globe, generalisability of the model to settings outside the United States would require validation by others.

Authentic leadership at the Cleveland Clinic: psychological safety in the midst of crisis.

OBJECTIVES: The goal of this research was to examine the leadership experiences of senior leaders at the Cleveland Clinic during the recent COVID-19 pandemic crisis. A secondary goal was to examine lessons that could inform other healthcare organisations as they move into subsequent crisis situations. DESIGN: The authors examined publicly available podcast transcripts where interviewees shared their leadership experiences on the Cleveland Clinic Beyond Leadership Podcast. SETTING/PARTICIPANTS: Twenty-one publicly available qualitative transcripts were examined inductively and deductively to assess how authentic leadership principles were applied to the experiences noted. PRINCIPAL FINDINGS: Deductively, the four leadership behaviours of authentic leadership (ie, relational transparency, internalised moral perspectives, balanced processing of information and self-awareness) were noted in the transcripts. Inductively, the participants also identified the importance of developing an organisational culture rooted in psychological safety which allowed individuals from all levels of the organisation to voice their ideas, concerns and thoughts. As part of a psychologically safe culture, it was also important to understand the influence of hierarchy in healthcare, ways to encourage employee voice and the uniqueness of leadership during crisis. PRACTICAL APPLICATIONS: We first offer insights about the importance of psychological safety, particularly during a crisis. Second, we offer a number of ways that other healthcare organisations might strive to build on their own approach to authentic leadership and develop an organisational culture built on psychological safety.

Advancing Research in Health Professions Education Through an Innovative Accelerator Panel.

INTRODUCTION: Research and scholarship are critical to advance the effective design, implementation, and evaluation of health professions education activities as well as to study outcomes and disseminate observations to the community. Yet, many educators are neither involved in nor equipped to conduct quality education research. This gap underscores the continuing education need to guide and train health professions educators to rigorously investigate, prepare, and report their educational research. METHODS: A novel session called the Education Research Accelerator was designed to increase knowledge about education research methods and resources and to improve participants' competence and performance in implementing studies. A panel helped prospective researchers develop ideas or advance projects toward completion by offering real-time feedback to pitched ideas; a live audience of learners participated virtually, expanding the impact of the session, facilitating connections, and potentially inspiring other research ideas. The outcomes of the Education Research Accelerator were evaluated immediately after the session and 18 months later. RESULTS: The Education Research Accelerator conferred favorable outcomes for participants' competence in designing education research studies and awareness of using available resources. Long-term follow-up confirmed actual benefits to use effective methodology to advance education research projects and to use resources and connections established in the Education Research Accelerator. CONCLUSIONS: Although further study is needed, the Education Research Accelerator model is a novel intervention to enhance learning, forge needed connections, and increase the sophistication of conducting education research. We propose that the model can be replicated and applied in other settings.

Radiographic Distribution as a Diagnostic Clue in Pulmonary Disease.

Because some disease processes produce radiographic abnormalities that occur in characteristic distributions in the chest, classifying the position and appearance of these suggestive features and the underlying diseases provides a tool by which diagnostic accuracy might be improved. The goal of this review is to offer to the chest clinician a taxonomy of these disease entities that can produce characteristic chest radiographic distributions. These radiographic distributions often reflect anatomic or physiologic conditions that drive the radiographic appearance; for example, foramen of Morgagni diaphragmatic hernias most commonly present in the right ventral chest, consistent with the anatomic location of the diaphragmatic foramen. This taxonomy includes 3 distributional categories: (1) upper versus lower lung zone-predominant processes, (2) central versus peripheral processes, and (3) processes with distinctive focal locations, eg, "photonegative appearance" as in chronic eosinophilic pneumonia. It is hoped that this taxonomy aids the chest clinician in generating and streamlining a differential diagnosis and in ascertaining the specific cause of diseases with radiographic abnormalities.

Estimating the costs of physician turnover in hospital medicine.

BACKGROUND AND OBJECTIVE: Costs of physician turnover are lacking for specialties organized around a site of care. We sought to estimate the cost of physician turnover in adult hospital medicine (HM). DESIGN, SETTING, PARTICIPANTS: A retrospective cohort study within a large integrated health system between July 2017 and June 2020. To understand likely variation across the country, we also simulated costs using national wage data and a range of assumptions. MAIN OUTCOME AND MEASURES: Direct costs of turnover borne by our department and institution and indirect costs from reduced hospital billing. In our simulation, we measured costs per hired hospitalist. RESULTS: Between July 2017 and June 2020, 34 hospitalists left the practice, 97 hospitalists were hired, and a total of 234 hospitalists provided adult care at six hospitals. Direct costs of turnover totaled $6166 per incoming physician. Additional clinical coverage required at times of transition was the largest expense, followed by physician time recruiting and interviewing prospective candidates. The salary difference between outgoing and incoming hospitalists was cost-saving, while reduced billing would add to indirect costs per hire. In our simulation using national wage data, programs hiring one hospitalist would spend a mean of $56,943 (95% CI: $27,228-$86,659), programs hiring five hospitalists would spend a mean of $33,333 per hospitalist (95% CI: $9375-$57,292), and programs hiring 10 hospitalists would spend a mean of $30,382 per hospitalist (95% CI: $6877-$53,887). CONCLUSIONS: The financial cost of turnover in HM appears to be substantially lower than earlier estimates of the cost of turnover from non-hospitalist specialties.

Area under the expiratory flow-volume curve: normative values in the National Health and Nutrition Survey (NHANES) study.

The area under the expiratory flow-volume (AEX-FV) loop has been evaluated before as a spirometric tool for assessing respiratory functional impairment. We computed the AEX-FV curves in spirometry tests performed on 20,313 participants in the National Health and Nutrition Examination Survey (NHANES) study.We analyzed 108,939 spirometry tests performed between 2007 and 2012 (5964 children; 14,349 adults). In these tests, we computed the three areas from existing NHANES raw data on instantaneous expiratory flows measured at 0.01 s intervals.Mean best-trial measurements for AEX-FV were 3.4 in boys, 2.8 in girls, 11.8 in men and 7.7 L2/s in women. We characterized indices of central tendency and dispersion of the measurements (eg, means and fifth percentiles-lower limits of normal) by age group (children vs adults), gender, race or ethnicity group and effort grading. Simple regression equations using logarithmic transformations of the above areas and using age, gender and height as inputs provided good predictive ability for the variable AEX-FV.Regular, digital spirometry could and should make available to clinicians and researchers the area under the curves for flow versus volume graph, providing additional tools in our armamentarium to evaluate ventilatory impairments and patterns, and possibly respiratory disability.

A 21-Year-Old Man With Dyspnea, Wheezing, and Cough.

CASE PRESENTATION: A 21-year-old male college student presented for a second opinion with low alpha-1 antitrypsin (AAT) levels and complaints of episodic dyspnea with wheezing and cough. He was a never smoker with a medical history of frequent respiratory tract infections in early childhood and allergy to dander, dust mites, peanuts, and eggs. There was no travel history outside of the continental United States. His mother had asthma. His symptoms were not controlled on inhaled corticosteroids and bronchodilators. His AAT genotype was found to be PI∗SZ, and augmentation therapy (with pooled human-plasma derived AAT) was recommended locally.

Designing Clinical Trials in "Regular" COPD Versus Alpha-1 Antitrypsin Deficiency-Associated COPD: "More Alike Than Unalike?"

Alpha-1 antitrypsin deficiency (AATD) predisposes to emphysema, liver disease, and panniculitis. This emphysema risk naturally invites a comparison between "regular" chronic obstructive pulmonary disease (COPD) (i.e., unrelated to AATD) and AATD-associated emphysema. Several features characterize both conditions. Both can be life-limiting and highly debilitating. Both are highly under-recognized. An important corollary of this comparison between "regular" COPD and AATD-associated COPD is whether both should be treated similarly and whether clinical trials to assess new therapies can be conducted similarly in both. Here, the distinctions between "regular" COPD and AATD-associated COPD are quite pronounced. Therapeutically, sparse available data suggest that lung volume reduction surgery confers less improvement in forced expiratory volume in 1 second (FEV1) in AATD and that such benefits are shorter-lived. Perhaps the most striking contrast between the 2 conditions is that clinical trial designs and conduct are necessarily very different. The relative scarcity of diagnosed individuals with AATD hampers recruitment to trials. Furthermore, primary outcome measures in trials of "regular" COPD must differ markedly from those of AATD-associated emphysema. Specifically, power calculations show that FEV1 and exacerbation frequency, which are amply represented as endpoints in large COPD trials, are infeasible in studies of AATD-associated emphysema. Rather, in the 3 available randomized controlled trials of intravenous augmentation therapy, the rate of emphysema progression based on serial computed tomography densitometry measurements has been the only feasible primary outcome measure. These considerations underscore the distinctive challenges and needs of conducting treatment trials in AATD-associated emphysema and emphasize that, with regard to clinical study design, the 2 conditions are "more unalike than alike."

Prevalence of Alpha-1 Antitrypsin Deficiency, Self-Reported Behavior Change, and Health Care Engagement Among Direct-to-Consumer Recipients of a Personalized Genetic Risk Report.

BACKGROUND: Alpha-1 antitrypsin deficiency (AATD) is an autosomal co-dominant condition that predisposes to emphysema, cirrhosis, panniculitis, and vasculitis. Underrecognition has prompted efforts to enhance early detection and testing of at-risk individuals. Direct-to-consumer (DTC) genetic testing represents an additional method of detection. RESEARCH QUESTION: The study addressed three questions: (1) Does a DTC testing service identify previously undetected individuals with AATD? (2) What was the interval between initial AATD-related symptoms and initial diagnosis of AATD in such individuals? and (3) What was the behavioral impact of learning about a new diagnosis of AATD through a DTC test? STUDY DESIGN AND METHODS: In this cross-sectional study, 195,014 individuals responded to a survey within the 23andMe, Inc. research platform. RESULTS: Among 195,014 study participants, the allele frequency for the PI∗S and PI∗Z AATD variants was 21.6% (6.5% for PI∗Z and 15.1% for PI∗S); 0.63% were PI∗ZZ, half of whom reported having a physician confirm the diagnosis. Approximately 27% of those with physician-diagnosed AATD reported first becoming aware of AATD through the DTC test. Among those newly aware participants, the diagnostic delay interval was 22.3 years. Participants frequently shared their DTC test results with health care providers (HCPs) and the reported impact of learning a diagnosis of AATD was high. For example, 51.1% of PI∗ZZ individuals shared their DTC result with an HCP. The OR for PI∗ZZ smokers to report smoking reduction as a result of receiving the DTC result was 1.7 (95% CI = 1.4-2.2) compared with those without a Z allele and for reduced alcohol consumption this was 4.0 (95% CI = 2.6-5.9). INTERPRETATION: In this largest available report on DTC testing for AATD, this test, in combination with clinical follow-up, can help to identify previously undiagnosed AATD patients. Moreover, receipt of the DTC AATD report was associated with positive behavior change, especially among those with risk variants.

A Novel Detection Method to Identify Individuals with Alpha-1 Antitrypsin Deficiency: Linking Prescription of COPD Medications with the Patient-Facing Electronic Medical Record.

BACKGROUND: Alpha-1 antitrypsin deficiency (AATD) is under-recognized, prompting the need for enhanced detection strategies. The primary aim of this study is to determine the feasibility of using the electronic medical record (EMR) and linked electronic patient messages (EPM) to encourage AATD testing by patients with chronic obstructive pulmonary disease (COPD). METHODS: Study participants were eligible, untested adult patients who were prescribed an inhaled medication which is exclusively Food and Drug Administration-approved for treating COPD. Eligible patients received a message with basic information about AATD and availability of free, home-based AATD testing. Through a collaboration with the Alpha-1 Foundation's Alpha-1 Coded Testing (ACT) study, patients referred to home-based testing through EPM were flagged. The effectiveness of the electronic message was evaluated by the proportion of patients who underwent testing, and the rate of detecting individuals with severe deficiency of AAT among those tested. RESULTS: A total of 12,369 patients on eligible inhalers were screened; 5430 patients met all criteria and received an EPM. During the study, 396 patients (7.3%) fully requested an ACT kit. Of these, 209 patients (52.8%) returned the test sample and received genotyping results; 65.5%, had a normal AAT genotype (PI*MM), 31.6% were heterozygotes for a deficient allele (PI*MS, PI*MZ and PI*M/Null rare), and 2.9% had severe deficiency of alpha-1 antitrypsin (PI*SZ, PI*ZZ, PI*S/Null rare). CONCLUSIONS: While the response rate and test return rate were low, the rate of detecting individuals with AATD using this detection strategy exceeds that of many prior strategies. As such, while requiring independent validation in other populations, this detection strategy holds promise.

Observations from Transforming a Continuing Education programme in the COVID-19 Era and Preparing for the Future.

The COVID-19 pandemic has significantly disrupted and transformed continuing education in the health professions to be reliant on digital learning modalities. This retrospective observational study of a large, international health system's continuing education programme compares educational activities offered, participation, and learning outcomes pre- and intra-pandemic to assess the impact of digitisation advanced because of the pandemic. There was a significant increase in internet-based activities that filled the gap of cancelled or postponed live, in-person activities to keep healthcare professionals up to date in their specialities and prepared to handle the clinical and hospital demands of the pandemic. Compared to live, in-person education, virtual activities were offered in shorter increments, reached a much larger amount of participants, and were equally effective in achieving learning outcomes. Questions remain regarding business model implications to generate adequate revenues to cover costs of virtual education. Additionally, there is a general inadequacy of digital learning environments to coalesce groups and meet social needs. Regardless, the efficiencies and effectiveness of digital modalities will be a primary method of teaching healthcare professionals going forward.

The spectrum of clinical sequelae associated with alpha-1 antitrypsin deficiency.

Alpha-1 antitrypsin (AAT) deficiency (AATD) is an autosomal co-dominant condition that predisposes to the development of lung disease, primarily emphysema. Emphysema results from the breakdown of lung matrix elastin by proteases, including neutrophil elastase, a protease normally inhibited by AAT. AATD also predisposes to liver (cirrhosis) and skin (panniculitis) disease, and to vasculitis. The prevalence of AATD is estimated to be approximately 1 in 3,500 individuals in the United States. However, lack of awareness of AATD among some physicians, misperceptions regarding the absence of effective therapy, and the close overlap in symptoms with asthma and non-AATD chronic obstructive pulmonary disease are thought to contribute to under-recognition of the disease. In patients with AATD, treatment with intravenous AAT augmentation therapy is the only currently available treatment known to slow the progression of emphysema. Moreover, smoking cessation and other lifestyle interventions also help improve outcomes. Early diagnosis and intervention are of key importance due to the irreversible nature of the resultant emphysema. Liver disease is the second leading cause of death among patients with AATD and a minority of patients present with panniculitis or antineutrophil cytoplasmic antibody-associated vasculitis, thought to be directly related to AATD. Though no randomized trial has assessed the effectiveness of augmentation therapy for AATD-associated panniculitis, clinical experience and case series suggest there is a benefit. Other diseases putatively linked to AATD include aneurysmal disease and multiple neurological conditions, although these associations remain speculative in nature.

Epidemiology of Adult Pleural Disease in the United States.

BACKGROUND: Comprehensive US epidemiologic data for adult pleural disease are not available. RESEARCH QUESTION: What are the epidemiologic measures related to adult pleural disease in the United States? STUDY DESIGN AND METHODS: Retrospective cohort study using Healthcare Utilization Project databases (2007-2016). Adults (≥ 18 years of age) with malignant pleural mesothelioma, malignant pleural effusion, nonmalignant pleural effusion, empyema, primary and secondary spontaneous pneumothorax, iatrogenic pneumothorax, and pleural TB were studied. RESULTS: In 2016, ED treat-and-discharge (T&D) visits totaled 42,215, accounting for charges of $286.7 million. In 2016, a total of 361,270 hospitalizations occurred, resulting in national costs of $10.1 billion. A total of 64,174 readmissions contributed $1.16 billion in additional national costs. Nonmalignant pleural effusion constituted 85.5% of ED T&D visits, 63.5% of hospitalizations, and 66.3% of 30-day readmissions. Contemporary sex distribution (male to female ratio) in primary spontaneous pneumothorax (2.1:1) differs from older estimates (6.2:1). Decadal analyses of annual hospitalization rates/100,000 adult population (2007 vs 2016) showed a significant (P < .001) decrease for malignant pleural mesothelioma (1.3 vs 1.09, respectively), malignant pleural effusion (33.4 vs 31.9, respectively), iatrogenic pneumothorax (17.9 vs 13.9, respectively), and pleural TB (0.20 vs 0.09, respectively) and an increase for empyema (8.1 vs 11.1, respectively) and nonmalignant pleural effusion (78.1 vs 100.1, respectively). Empyema hospitalizations have high costs per case ($38,591) and length of stay (13.8 days). The mean proportion of readmissions attributed to a pleural cause varied widely: malignant pleural mesothelioma, 49%; malignant pleural effusion, 45%; nonmalignant pleural effusion, 31%; empyema, 27%; primary spontaneous pneumothorax, 27%; secondary spontaneous pneumothorax, 27%; and iatrogenic pneumothorax, 20%. Secondary spontaneous pneumothorax had the shortest time to readmission in 2016 (10.3 days, 95% CI, 8.8-11.8 days). INTERPRETATION: Significant epidemiologic trends and changes in various pleural diseases were observed. The analysis identifies multiple opportunities for improvement in management of pleural diseases.