How Financial Aid Policy Shortchanges American Healthcare.

Issue: Medical school debt is increasing. This trend may reduce access to medical school at a time of historic recognition of the need for greater openness and diversity in medical education by disadvantaging candidates who are underrepresented in medicine. The effects of high education-related debt for medical school needs greater consideration. Evidence: The implementation staircase model is employed as lens for understanding the impact of debt on trainees who are underrepresented in medicine and the healthcare system overall. Higher debt burdens are associated with worse mental health outcomes and increased odds of attrition in medical school. Trainees cite debt as a concern in considering primary care careers. Those with greater debt are less likely to pursue or remain in academic careers. Implications: The current financial aid system's reliance on high debt burden undermines goals to improve the representation of underrepresented candidates in primary care and academic medicine. Alternative models requiring less debt could facilitate the creation of a more diverse workforce in healthcare.

Prioritizing Diversity in Otolaryngology-Head and Neck Surgery: Starting a Conversation.

Academic centers embody the ideals of otolaryngology and are the specialty's port of entry. Building a diverse otolaryngology workforce-one that mirrors society-is critical. Otolaryngology continues to have an underrepresentation of racial and ethnic minorities. The specialty must therefore redouble efforts, becoming more purposeful in mentoring, recruiting, and retaining underrepresented minorities. Many programs have never had residents who are Black, Indigenous, or people of color. Improving narrow, leaky, or absent pipelines is a moral imperative, both to mitigate health care disparities and to help build a more just health care system. Diversity supports the tripartite mission of patient care, education, and research. This commentary explores diversity in otolaryngology with attention to the salient role of academic medical centers. Leadership matters deeply in such efforts, from culture to finances. Improving outreach, taking a holistic approach to resident selection, and improving mentorship and sponsorship complement advances in racial disparities to foster diversity.

An Analysis of K-12 School Reopening and Its' Impact on Teachers.

Teachers are vulnerable non-essential workers that continue to have significant misgivings about in-person school reopening. Dialogue around pandemic management has relatively neglected these concerns so far. This perspective offers a broad framework for risk assessment related to COVID-19 and in-person instruction. The accumulated general body of knowledge related to COVID-19 is particularized to the special dynamics of education. We highlight the impact of historic investments and underinvestment in education on the viability of adapting best practices to mitigate risk. Gaps in public health planning to supply educators with needed personal protective equipment and vaccination are explored. The challenges for low-income and minority-predominant districts receive special attention. We place these problems within the broader context of socioeconomic disparities and the societal consequences of the pandemic. The local level of community transmission, resources, and circumstances should dictate reopening dates. Without effective infection control, teachers are justified to fear infection. The transparency and scientific rigor that would allow teachers to assess their personal health risk and characterize the process for decision-making has been largely absent.

The Long-Term Effectiveness of Empathic Interventions in Medical Education: A Systematic Review.

The Association of American Medical Colleges recognizes that empathy is an important part of providing excellent patient care and lists empathy as a Core Entrustable Professional Attribute for physicians. This study is a review of the literature focusing on studies with an educational intervention to promote empathy and at least one year follow-up data. After reviewing the 4910 abstracts retrieved from PubMed, PsycInfo, Cochrane, Web of Science, CINAHL, and Embase; the coauthors selected 61 articles for full-text review and completed a medical education research study quality instrument (MERSQI) to ensure all selected studies scored at least 7 or above. Five studies from the US and seven international studies met our inclusion criteria and formed the basis for the study. Few longitudinal studies with a post-intervention follow-up exist to confirm or disprove the effectiveness and durability of empathy training. Of the published studies that do conduct long-term follow-up, study design and measures used to test empathy are inconsistent. Despite the high degree of heterogeneity, the overwhelming majority demonstrated declining empathy over time. Little evidence was identified to support the ability to augment the empathy of physician trainees in sustained fashion. A model is presented which explains the observed changes. Alternative solutions are proposed, including the selection of more prosocial candidates.

Communication training is inadequate: the role of deception, non-verbal communication, and cultural proficiency.

In this commentary, we argue that the limited experiential exposure of medical students to different cultures makes the instruction devoted to communication skills inadequate. The relationship of these dynamics to honesty in clinical encounters is explored. Absent significant experiential exposure to differing group cultures to counter the natural tendency to favor one's own, discrimination prevails. Knowledge or awareness of cultural differences does not necessarily equate to communication proficiency. Critically, interactions based on lived experience offer a deeper knowledge and understanding of culturally meaningful nuances than that imparted through other formats. Medical students' lack of experiential exposure to different cultures results in communication miscues. When the stakes are high, people detect those miscues diminishing trust in the doctor-patient relationship. Greater experiential cultural exposure will enhance the facility and use of culturally specific communication cues. At its core, the requisite transformation will require medical students to adapt to other cultures and greater representation by marginalized and stigmatized populations not only among the studentry but staff and faculty. The time is now to ensure that the physicians we produce can care for all Americans. What cannot be taught must be identified by the selection process. Competence with half the population is a failure for American medicine.

The Evolution of Social Beliefs 1960-2016 in the United States and Its Influence on Empathy and Prosocial Expression in Medicine.

This perspective surveys healthcare's response to the increased prominence of racial, ethnic, religious and sexual minorities as well as females in American culture. It argues for understanding physicians both as products of the broader society and its changes. Starting in the 1960s, empiric evidence for the rise of reactionary viewpoints in response to major social movements is outlined. Structural reasons for the prevalence of such ideologies within medicine are highlighted. Its negative consequences for minority health are addressed. Finally, the author turns to compensatory strategies to improve the social environment within healthcare. Alternative selection strategies for medical school are proposed, with a stronger focus on empathetic candidates.

The dynamics of poverty, educational attainment, and the children of the disadvantaged entering medical school.

Approximately one-third of the US population lives at or near the poverty line; however, this group makes up less than 7% of the incoming medical students. In the United Kingdom, the ratio of those of the highest social stratum is 30 times greater than those of the lowest to receive admission to medical school. In an effort to address health disparities and improve patient care, the authors argue that significant barriers must be overcome for the children of the disadvantaged to gain admission to medical school. Poverty is intergenerational and multidimensional. Familial wealth affects opportunities and educational attainment, starting when children are young and compounding as they get older. In addition, structural and other barriers exist to these students pursuing higher education, such as the realities of financial aid and the shadow of debt. Yet the medical education community can take steps to better support the children of the disadvantaged throughout their education, so they are able to reach medical school. If educators value the viewpoints and life experiences of diverse students enriching the learning environment, they must acknowledge the unique contributions that the children of the disadvantaged bring and work to increase their representation in medical schools and the physician workforce. We describe who the disadvantaged are contrasted with the metrics used by medical school admissions to identify them. The consequences of multiple facets of poverty on educational attainment are explored, including its interaction with other social identities, inter-generational impacts, and the importance of wealth versus annual income. Structural barriers to admission are reviewed. Given the multi-dimensional and cumulative nature of poverty, we conclude that absent significant and sustained intervention, medical school applicants from disadvantaged backgrounds will remain few and workforce issues affecting the care patients receive will not be resolved. The role of physicians and medical schools and advocating for necessary societal changes to alleviate this dynamic are highlighted.

I Am an African American: Distinguishing Between African American and African Applicants in Medical School Admissions Matters.

Ignoring the diverse and rich cultures and histories of Africa and the African diaspora by applying the term African American to anyone of sub-Saharan African ancestry in medical school admissions does a disservice to applicants, medical schools, and the communities they serve. To determine how applicants can contribute to a diverse educational environment, admissions decisions must go beyond racial and ethnic self-reporting and recognize the diversity that applicants bring to their medical school. Using a holistic approach, institutions can fairly evaluate applicants and strategically fill their incoming classes. What each medical school is looking for based on its mission and how each student reflects that mission and enhances the educational environment should be revisited as each application is considered. Medical schools must adopt practices that strategically enroll applicants who help achieve their mission and better the communities they serve. The benefits of diversity are not achieved in a linear fashion but require a critical mass for each diverse group. Different strategies are needed to enhance the educational environment, address underrepresentation in medicine, and eliminate health disparities. If racial justice and health equity are to be realized, diversity policies need to recognize the differences between African and Afro Caribbean immigrants and African Americans.In this Perspective, the author argues for distinguishing between these groups in medical school admissions. He explores the differences in their history, culture, and experiences and demonstrates their uniqueness. He concludes by discussing diversity in medicine and offering suggestions for considering diversity in medical school admissions.

Levers of change: a review of contemporary interventions to enhance diversity in medical schools in the USA.

A growing body of research illustrates the importance of aligning efforts across the operational continuum to achieve diversity goals. This alignment begins with the institutional mission and the message it conveys about the priorities of the institution to potential applicants, community, staff, and faculty. The traditional themes of education, research, and service dominate most medical school mission statements. The emerging themes of physician maldistribution, overall primary-care physician shortage, diversity, and cost control are cited less frequently. The importance and salience of having administrative leaders with an explicit commitment to workforce and student diversity is a prominent and pivotal factor in the medical literature on the subject. Organizational leadership shapes the general work climate and expectations concerning diversity, recruitment, and retention. Following the Bakke decision, individual medical schools, supported by the Association of American Medical Colleges, worked to expand the frame of reference for evaluating applicants for medical school. These efforts have come together under the rubric of "holistic review", permitted by the US Supreme Court in 2003. A large diverse-applicant pool is needed to ensure the appropriate candidates can be chosen for the incoming medical school class. Understanding the optimal rationale and components for a successful recruitment program is important. Benchmarking with other schools regionally and nationally will identify what should be the relative size of a pool. Diversity is of compelling interest to us all, and should pervade all aspects of higher education, including admissions, the curriculum, student services and activities, and our faculties. The aim of medical education is to cultivate a workforce with the perspectives, aptitudes, and skills needed to fuel community-responsive health-care institutions. A commitment toward diversity needs to be made.

Creating physicians of the 21st century: assessment of the clinical years.

Medical education has been under a constant state of revision for the past several years. The overarching theme of the curriculum revisions for medical schools across the USA has been creating better physicians for the 21st century, with the same end result: graduating medical students at the optimal performance level when entering residency. We propose a robust, thorough assessment process that will address the needs of clerkships, residents, students, and, most importantly, medical schools to best measure and improve clinical reasoning skills that are required for the learning outcomes of our future physicians. The Accreditation Council for Graduate Medical Education (ACGME) evaluates and accredits medical school graduates based on competency-based outcomes and the assessment of specialty-specific milestones; however, there is some evidence that medical school graduates do not consistently meet the Level 1 milestones prior to entering/beginning residency, thus starting their internship year underprepared and overwhelmed. Medical schools should take on the responsibility to provide competency-based assessments for their students during the clinical years. These assessments should be geared toward preparing them with the cognitive competencies and skills needed to successfully transition to residency. Then, medical schools can produce students who will ultimately be prepared for transition to their residency programs to provide quality care.

Curricular integration of social medicine: a prospective for medical educators.

In the United States, the health of a community falls on a continuum ranging from healthy to unhealthy and fluctuates based on several variables. Research policy and public health practice literature report substantial disparities in life expectancy, morbidity, risk factors, and quality of life, as well as persistence of these disparities among segments of the population. One such way to close this gap is to streamline medical education to better prepare our future physicians for our patients in underserved communities. Medical schools have the potential to close the gap when training future physicians by providing them with the principles of social medicine that can contribute to the reduction of health disparities. Curriculum reform and systematic formative assessment and evaluative measures can be developed to match social medicine and health disparities curricula for individual medical schools, thus assuring that future physicians are being properly prepared for residency and the workforce to decrease health inequities in the United States. We propose that curriculum reform includes an ongoing social medicine component for medical students. Continued exposure, practice, and education related to social medicine across medical school will enhance the awareness and knowledge for our students. This will result in better preparation for the zero mile stone residency set forth by the Accreditation Council of Graduate Medical Education and will eventually lead to the outcome of higher quality physicians in the United States to treat diverse populations.

Development and characterization of erythrosine nanoparticles with potential for treating sinusitis using photodynamic therapy.

BACKGROUND: Antimicrobial therapy for sinusitis has been shown to reduce or eliminate pathologic bacteria associated with rhinosinusitis and improve the symptoms associated with the disease. However, the continuing rise in antibiotic resistance, the ongoing problem with patient compliance, and the intrinsic difficulty in eradication of biofilms complicates antibiotic therapy. The introduction of photodynamic antimicrobial therapy (PAT) using erythrosine, a photosensitizer, could eliminate the bacteria without inducing antibiotic resistance or even requiring daily dosing. In the present study, erythrosine nanoparticles were prepared using poly-lactic-co-glycolic acid (PLGA) and evaluated for their potential in PAT against Staphylococcus aureus cells. METHODS: PLGA nanoparticles of erythrosine were prepared by nanoprecipitation technique. Erythrosine nanoparticles were characterized for size, zeta potential, morphology and in vitro release. Qualitative and quantitative uptake studies of erythrosine nanoparticles were carried out in S. aureus cells. Photodynamic inactivation of S. aureus cells in the presence of erythrosine nanoparticles was investigated by colony forming unit assay. RESULTS: Nanoprecipitation technique resulted in nanoparticles with a mean diameter of 385nm and zeta potential of -9.36mV. Erythrosine was slowly released from nanoparticles over a period of 120h. The qualitative study using flow cytometry showed the ability of S. aureus cells to internalize erythrosine nanoparticles. Moreover, erythrosine nanoparticles exhibited a significantly higher uptake and antimicrobial efficacy compared to pure drug in S. aureus cells. CONCLUSION: In conclusion, erythrosine-loaded PLGA nanoparticles can be a potential long term drug delivery system for PAT and are useful for the eradication of S. aureus cells.

Lingual tonsil abscess with parapharyngeal extension: a case report.

Lingual tonsil abscess is a rare disorder previously reported only once in the English literature. Because of their similar structure to that of the palatine tonsils, the lingual tonsils have the propensity to develop infection in the same way. The progression of infection, however, is different in that the lingual tonsils lack a capsule, thus preventing the formation of a peritonsillar abscess. Therefore, the only place for infection to spread is either into the tongue or into the parapharyngeal space. Here we present our experience with the latter, and we provide radiographic evidence of the disease. Lingual tonsil abscess, although rare, is an important potential cause of airway obstruction and must be considered in the case of a sore throat with a normal oropharyngeal exam.

Relative value units and payer mix analysis of facial trauma coverage at a level 1 trauma center: is the current model sustainable?

PURPOSE: We aimed to approximate the annual clinical work that is performed during facial trauma coverage and analyze the economic incentives for subspecialty surgeons providing the coverage. METHODS: A retrospective, clinical productivity data analysis of 6 consecutive years of facial trauma coverage at an American College of Surgeons-verified Level I trauma center was performed by the use of a trauma database and relative value unit (RVU) data. A payer mix analysis also was completed. SPSS V19 was used for analysis. RESULTS: Between 2006 and 2011, 526 patients were treated for facial injuries. The annual nonoperative RVUs ranged from 371 to 539, whereas the annual operative RVUs range was 235-426. Trend analysis displayed that most of the annual RVUs were nonoperative until the year 2011, when the operative RVUs surpassed the nonoperative. Payer mix analysis revealed that commercial insurance coverage was the most common (range 21-54%, median 41%) followed by self-pay coverage (18-32%, median 29%). This finding was a consistent phenomenon except in the year 2009, when self-pay covered the majority of the RVUs (32%). Nasal bone fractures (24%) and mandibular fractures (16%) were the two most common diagnoses. Open reduction and internal fixation of mandibular fractures (17%), open reduction and internal fixation orbital bone fractures (15%), and complex facial repair (12%) constituted the most common operative procedures. Facial trauma consultations were obtained 22% (16-24%) of covered days. The percent of days requiring emergency procedures was (0.5-1%). CONCLUSION: The infrequency of subspecialty consultations and operative interventions, and significant payer mix differences between facial trauma patients relative to the current ambulatory surgery population of the covering subspecialties poses economical challenges for both the hospitals and providers that use the traditional coverage models.