Perception of Quiet Students in Emergency Medicine: An Exploration of Narratives in the Standardized Letter of Evaluation.

INTRODUCTION: The Standardized Letter of Evaluation (SLOE) is designed to assist emergency medicine (EM) residency programs in differentiating applicants and in selecting those to interview. The SLOE narrative component summarizes the student's clinical skills as well as their non-cognitive attributes. The purpose of this qualitative investigation was to explore how students described in the SLOE as quiet are perceived by faculty and to better understand how this may impact their residency candidacy. METHODS: This retrospective cohort study included all SLOEs submitted to one EM residency program during one application cycle. We analyzed sentences in the SLOE narrative describing students as "quiet," "shy," and/or "reserved." Using grounded theory, thematic content analysis with a constructivist approach, we identified five mutually exclusive themes that best characterized the usage of these target words. RESULTS: We identified five themes: 1) quiet traits portrayed as implied-negative attributes (62.4%); 2) quiet students portrayed as overshadowed by more extraverted peers (10.3%); 3) quiet students portrayed as unfit for fast-paced clinical settings (3.4%); 4) "quiet" portrayed as a positive attribute (10.3%); and 5) "quiet" comments deemed difficult to assess due to lack of context (15.6%). CONCLUSION: We found that quiet personality traits were often portrayed as negative attributes. Further, comments often lacked clinical context, leaving them vulnerable to misunderstanding or bias. More research is needed to determine how quiet students perform compared to their non-quiet peers and to determine what changes to instructional practices may support the quiet student and help create a more inclusive learning environment.

The Standardized Letter of Evaluation: How We Perceive the Quiet Student.

INTRODUCTION: The Standardized Letter of Evaluation (SLOE) is an emergency medicine (EM)-specific assessment designed to help EM residency programs differentiate applicants. We became interested in SLOE-narrative language referencing personality when we observed less enthusiasm for applicants described as "quiet" in their SLOEs. In this study our objective was to compare how quiet-labeled, EM-bound applicants were ranked compared to their non-quiet peers in the global assessment (GA) and anticipated rank list (ARL) categories in the SLOE. METHODS: We conducted a planned subgroup analysis of a retrospective cohort study of all core EM clerkship SLOEs submitted to one, four-year academic EM residency program in the 2016-2017 recruitment cycle. We compared SLOEs of applicants who were described as "quiet," "shy," and/or "reserved" - collectively referred to as "quiet" - to SLOEs from all other applicants, referred to as "non-quiet." We compared frequencies of quiet to non-quiet students in GA and ARL categories using chi-square goodness-of-fit tests with a rejection criteria (alpha) of 0.05. RESULTS: We reviewed 1,582 SLOEs from 696 applicants. Of these, 120 SLOEs described quiet applicants. The distributions of quiet and non-quiet applicants across GA and ARL categories were significantly different (P < 0.001). Quiet applicants were less likely than non-quiet applicants to be ranked in the top 10% and top one-third GA categories combined (31% vs 60%) and more likely to be in the middle one-third category (58% vs 32%). For ARL, quiet applicants were also less likely to be ranked in the top 10% and top one-third categories combined (33% vs 58%) and more likely to be in the middle one-third category (50% vs 31%). CONCLUSION: Emergency medicine-bound students described as quiet in their SLOEs were less likely to be ranked in the top GA and ARL categories compared to non-quiet students. More research is needed to determine the cause of these ranking disparities and address potential biases in teaching and assessment practices.

Executive summary of the SAEM 2022 consensus conference to address racism in emergency medicine clinical research, training, and leadership.

INTRODUCTION: Racism has not only contributed to disparities in health care outcomes, but also has negatively impacted the recruitment, retention, and promotion of historically excluded groups in academic medicine. The 2022 Society for Academic Emergency Medicine (SAEM) consensus conference, "Diversity, Equity, and Inclusion: Developing a Research Agenda for Addressing Racism in Emergency Medicine," convened a diverse group of researchers, educators, administrative leaders, and health care providers to help address the impact of racism in three domains in academic emergency medicine: clinical research, education and training, and academic leadership. The main goals of the consensus process were to identify current knowledge gaps and create a research agenda within each domain using an iterative consensus-building methodology. METHODS: The planning committee identified three fundamental domains to develop a research agenda and created workgroups who completed a literature search to identify gaps in knowledge. After a consensus building process, potential questions were presented at the in-person consensus conference. Ninety SAEM members representing faculty and trainees participated in breakout groups in each domain to generate consensus recommendations for priority research. RESULTS: For clinical research, three research gaps with six questions (n) were identified: remedies for bias and systematic racism (3), biases and heuristics in clinical care (2), and racism in study design (1). For education and training, three research gaps with seven questions were identified: curriculum and assessment (2), recruitment (1), and learning environment (4). For academic leadership, three research gaps with five questions were identified: understanding the current diversity, equity, and inclusion (DEI) landscape and culture (1), analyzing programs that improve DEI and identifying factors that lead to improved diversity (3), and quantifying the value of professional stewardship activities (1). CONCLUSION: This article reports the results of the consensus conference with the goal of influencing emergency care research, education, and policy and facilitating collaborations, grant funding, and publications in these domains.

The Politics of Sources Meets the Practices of the Librarian: An Interview with Esther Chen.

[I] want to single out one phenomenon that could be called the 'politics of sources'. It points to the extent to which the histories that both scientists and historians can write are artifacts of the available sources. The Rockefeller Foundation not only opened its archives very early on for historical work but also invested a lot in making the archives readily available for historical exploration. During the 1980s, many young historians took advantage of this opportunity. Thus, in a relatively early phase of the professional historiography of molecular biology, one could have gained the impression that the development of the new biology as a whole was a bio-politically directed enterprise of the Rockefeller Foundation sustained by the vision that social processes could ultimately be controlled by biological processes.

Magnetic resonance imaging of tumor-associated-macrophages (TAMs) with a nanoparticle contrast agent.

In the tumor micro-environment, tumor associated macrophages (TAMs) represent a predominant component of the total tumor mass, and TAMs play a complex and diverse role in cancer pathogenesis with potential for either tumor suppressive, or tumor promoting biology. Thus, understanding macrophage localization and function are essential for cancer diagnosis and treatment. Typically, tissue biopsy is used to evaluate the density and polarization of TAMs, but provides a limited "snapshot" in time of a dynamic and potentially heterogeneous tumor immune microenvironment. Imaging has the potential for three-dimensional mapping; however, there is a paucity of macrophage-targeted contrast agents to specifically detect TAM subtypes. We have previously found that sulfated-dextran coated iron oxide nanoparticles (SDIO) can target macrophage scavenger receptor A (SR-A, also known as CD204). Since CD204 (SR-A) is considered a biomarker for the M2 macrophage polarization, these SDIO might provide M2-specific imaging probes for MRI. In this work, we investigate whether SDIO can label M2-polarized cells in vitro. We evaluate the effect of degree of sulfation on uptake by primary cultured bone marrow derived macrophages (BMDM) and found that a higher degree of sulfation led to higher uptake, but there were no differences across the subtypes. Further analysis of the BMDM showed similar SR-A expression across stimulation conditions, suggesting that this classic model for macrophage subtypes may not be ideal for definitive M2 subtype marker expression, especially SR-A. We further examine the localization of SDIO in TAMs in vivo, in the mammary fat pad mouse model of breast cancer. We demonstrate that uptake by TAMs expressing SR-A scales with degree of sulfation, consistent with the in vitro studies. The TAMs demonstrate M2-like function and secrete Arg-1 but not iNOS. Uptake by these M2-like TAMs is validated by immunohistochemistry. SDIO show promise as a valuable addition to the toolkit of imaging probes targeted to different biomarkers for TAMs.

Helping the learner to deal with microaggressions in the workplace: Individual, programmatic, and institutional-level responses.

Microaggressions are frequently experienced by learners in the workplace and can create a hostile learning environment. Many faculty educators lack formal training in supporting their learners after incidents of microaggressions. Supervising faculty should be able to recognize and respond to microaggressions against trainees in the clinical environment. In this commentary, we will briefly review the definition of microaggressions, summarize the impact of microaggressions on trainees, provide a framework for managing microaggressions on an individual level when the patient offends the learner, and highlight strategies to mitigate microaggressions on a programmatic and institutional level.

Caring for Transgender Patients: Complications of Gender-Affirming Genital Surgeries.

Patients who undergo gender-affirming genital surgeries may present to the emergency department for their postsurgical complications. In this paper, we briefly describe the transfeminine and transmasculine genital procedures, review the diagnosis and management of both common and potentially life-threatening complications, and discuss the criteria for hospitalization and time frame for surgical consultation and referral.

Financial Incentives to Enhance Participation of Resident Physicians in Hospital-Based Quality Improvement Projects.

BACKGROUND: Methods to promote successful trainee participation in quality improvement projects are poorly studied. This project studied the effects of a trainee pay-for-performance program and quality improvement education at a safety-net hospital. METHODS: In this program, trainees worked with quality improvement faculty, participated in projects aligned with the hospital's priorities, and designed their program-specific project. Each trainee who worked at least 88 days in the institution was eligible to earn $400 for every target achieved for at least six months (maximum of $1,200). RESULTS: Among hospitalwide goals, needlestick injuries per quarter decreased from [mean (standard deviation; SD)] 18 (4.6) to 12 (2.6), 95% confidence interval (CI) = -10.1-1.9, p = 0.02; percentage of excellent provider communication improved from 76.8% to [mean (SD)] 80.5% (2.9), 95% CI = 0.8-8.3, p = 0.08; and mean length of stay for discharged emergency department patients requiring specialist consultation decreased from [mean (SD)] 523 (120) to 461 (40) minutes, 95% CI = -162-37.2, p = 0.11. Among resident-initiated projects, the percentage of Family Medicine patients undergoing colorectal screening increased from 65.1% to [mean (SD)] 67.7% (0.4), 95% CI = 1.7-3.5, p = 0.01; percentage of at-risk patients receiving naloxone at hospital discharge increased from 9% to [mean (SD)] 63% (7.2), 95% CI = 36.1-71.9, p = 0.01; percentage of adolescents screened for chlamydia increased from 34% to [mean (SD)] 55.8% (6.4), 95% CI = 5.9-37.6, p = 0.03; and percentage of high-dose opioid prescriptions following cesarean section decreased from 28% to [mean (SD)] 1.7% (2.9), 95% CI = -33.5 to -19.2, p = 0.001. Eleven of 14 programs achieved three goals. All resident-led goals were met. CONCLUSION: A pay-for-performance improvement program that aligns educational and hospital priorities can provide meaningful experiential learning for trainees and improve patient care.

YAP-mediated mechanotransduction tunes the macrophage inflammatory response.

Macrophages are innate immune cells that adhere to the extracellular matrix within tissues. However, how matrix properties regulate their function remains poorly understood. Here, we report that the adhesive microenvironment tunes the macrophage inflammatory response through the transcriptional coactivator YAP. We find that adhesion to soft hydrogels reduces inflammation when compared to adhesion on stiff materials and is associated with reduced YAP expression and nuclear localization. Substrate stiffness and cytoskeletal polymerization, but not adhesive confinement nor contractility, regulate YAP localization. Furthermore, depletion of YAP inhibits macrophage inflammation, whereas overexpression of active YAP increases inflammation. Last, we show in vivo that soft materials reduce expression of inflammatory markers and YAP in surrounding macrophages when compared to stiff materials. Together, our studies identify YAP as a key molecule for controlling inflammation and sensing stiffness in macrophages and may have broad implications in the regulation of macrophages in health and disease.

Shared Decision Making for the Emergency Provider: Engaging Patients When Seconds Count.

Introduction: Physicians need to be able to communicate the myriad of management options clearly to patients and engage them in their health care decisions, even in the fast-paced environment of the emergency department. Shared decision making (SDM) is an effective communication strategy for physicians to share diagnostic uncertainty, avoid potentially harmful tests, and solicit patients' preferences for their care. Role-playing with just-in-time feedback is an effective method to learn and practice SDM before having these conversations with patients. Methods: This flipped classroom workshop featured precourse materials and an in-class session incorporating a short lecture outlining a framework for SDM, followed by role-playing through patient scenarios. Learners took turns playing the physician or patient role and received feedback on their communication skills while in the physician role. A faculty examiner subsequently assessed skill attainment using a simulated patient encounter and checklist of critical actions. Results: The workshop was an interactive and effective way to teach SDM to 28 PGY 1 and PGY 2 emergency medicine residents. Two months after attending the workshop, over 75% of the first-year residents were able to complete all the elements of the SDM process in a simulated patient encounter; four residents required no prompting by the examiner. Discussion: A communications workshop that incorporates role-playing with different patient encounters is an interactive way to teach SDM for the emergency setting. Residents early in their clinical training can benefit from learning and practicing SDM in a simulated setting.

Effects of Surface-Bound Collagen-Mimetic Peptides on Macrophage Uptake and Immunomodulation.

The interaction between collagen/collagen-like peptides and the commonly expressed immune cell receptor LAIR-1 (leukocyte-associated immunoglobulin-like receptor-1) regulates and directs immune responses throughout the body. Understanding and designing these interactions within the context of biomaterials could advance the development of materials used in medical applications. In this study, we investigate the immunomodulatory effects of biomaterials engineered to display a human collagen III-derived ligand peptide (LAIR1-LP) that targets LAIR-1. Specifically, we examine the effects of LAIR1-LP functionalized surfaces on uptake of polymeric particles and cell debris by macrophages polarized toward inflammatory or healing phenotypes. We observed that culture of macrophages on LAIR1-LP functionalized surfaces increased their uptake of PLGA micro- and nano-particles, as well as apoptotic fibroblasts, while reducing their secretion of TNFα in response to LPS/IFNγ pro-inflammatory stimulation, when compared to cells seeded on control surfaces. To investigate the role of LAIR-1 in the observed LAIR1-LP-induced effects, we used siRNA to knock down LAIR-1 expression and found that cells lacking LAIR-1 exhibited enhanced particle uptake on LAIR1-LP and control surfaces. Furthermore, analysis of gene expression showed that LAIR-1 knockdown led to increase expression of other receptors involved in cell uptake, including CD-36, SRA-1, and beta-2 integrin. Together, our study suggests that LAIR1-LP enhances macrophage uptake potentially through interactions with collagen-domain binding surface receptors, and inhibits inflammation through interaction with LAIR-1.

An Institutional Approach to Fostering Inclusion and Addressing Racial Bias: Implications for Diversity in Academic Medicine.

Issue: While an increasingly diverse workforce of clinicians, researchers, and educators will be needed to address the nation's future healthcare challenges, underrepresented in medicine (UIM) perspectives remain relatively absent from academic medicine. Evidence: Prior studies have identified differential experiences within the learning environment, lack of social supports, and implicit bias in evaluations as barriers to the academic interests and successes of UIM learners. The UCSF Differences Matter initiative has shown that interventions focused on recruiting diverse academic faculty, building strong social communities, facilitating cross-cultural communication and understanding, and mitigating disparities in summative assessments can positively affect the educational experience for UIM learners and contribute to their academic success. Implications: Institution-level initiatives are needed to foster a culture of inclusion, teach cultural humility, and build a culture of trust within academic medicine. Such initiatives should aim to teach a common language to discuss diversity issues and place the responsibility of fostering inclusion on all members of the academic community. Our own institutional experience with systemic cultural reform challenges others to develop novel approaches toward fostering inclusion in academic medicine.

Developing mechanically robust, triazole-zwitterionic hydrogels to mitigate foreign body response (FBR) for islet encapsulation.

Zwitterionic hydrogels such as those based on polycarboxybetaine (PCB) or polysulfobetaine (PSB) have potential for various biomedical applications, due to their biocompatibility and low biofouling properties. However, the poor mechanical properties of zwitterionic hydrogels developed to date remain a challenge, severely limiting their practical uses. To improve the mechanical properties without compromising their zwitterionic feature or biocompatibility, we designed a new class of zwitterionic hydrogels by introducing triazole moieties into the hydrogel monomers that could form energy-dissipating π-π stacking. Compared to conventional zwitterionic hydrogels, the triazole-zwitterionic (TR-ZW) ones exhibited similarly excellent antifouling properties, but were much more mechanically robust with higher stretchability (250% tensile strain), better compression-resistance (89% compressive strain and 65% compression for at least 10 cycles without any crack) and better folding-resistance. In addition, upon subcutaneous implantation in mice, the TR-ZW hydrogels induced significantly lower foreign body responses (FBR) (i.e. less fibrosis and more blood vessel formation relative to a poly(2-hydroxyethyl methacrylate) hydrogel control). As an example of their potential applications, we showed the use of the TR-ZW hydrogels for islet encapsulation and transplantation and demonstrated diabetes correction up to ~1 month in mice in the convenient subcutaneous site.

Zwitterionically modified alginates mitigate cellular overgrowth for cell encapsulation.

Foreign body reaction (FBR) to implanted biomaterials and medical devices is common and can compromise the function of implants or cause complications. For example, in cell encapsulation, cellular overgrowth (CO) and fibrosis around the cellular constructs can reduce the mass transfer of oxygen, nutrients and metabolic wastes, undermining cell function and leading to transplant failure. Therefore, materials that mitigate FBR or CO will have broad applications in biomedicine. Here we report a group of zwitterionic, sulfobetaine (SB) and carboxybetaine (CB) modifications of alginates that reproducibly mitigate the CO of implanted alginate microcapsules in mice, dogs and pigs. Using the modified alginates (SB-alginates), we also demonstrate improved outcome of islet encapsulation in a chemically-induced diabetic mouse model. These zwitterion-modified alginates may contribute to the development of cell encapsulation therapies for type 1 diabetes and other hormone-deficient diseases.

L&D in the ED: A Game-Based Approach to Learning High-Risk Obstetric Emergencies.

Introduction: Teaching emergency medicine residents the principles of obstetric emergencies is a challenging task, as these emergencies are uncommon in general practice and include specific maneuvers for difficult and precipitous deliveries. These requirements are not easy to satisfy in a standard lecture and are labor intensive for small groups. This resource is a board game that leverages near-peer teaching, engages student collaboration, and supports friendly competition. Methods: The game was designed to be used by emergency medicine residents and emphasized the evaluation and management of acute issues related to labor and delivery (L&D). To play the game, three to four learners took turns answering questions. Each correct answer was awarded points for forward movement on the game board. The first person to reach the end of the game won. A faculty moderator circulated among the players to clarify questions or answers as needed. Results: Our residents loved this resource. They were able to teach each other throughout the game while using reference materials. Participants rated the educational value of the L&D board game as 4.81 (out of 5), as compared to 4.37 for prior lectures covering the same topics. The game was rated similarly to delivery procedural skills workshops implemented in prior years (4.62-4.82). Discussion: Game-based exercises are low-tech, highly interactive teaching tools enabling students to learn from each other in a fun and engaging way. Although we did not assess knowledge retention, this activity's educational value was rated similarly to delivery procedural skills sessions.