Learning From Clinical Supervisor Practice Variability: Exploring Medical Resident and Fellow Experiences and Interpretations.

PURPOSE: Clinical practice variability is characterized by 2 or more clinicians making different treatment decisions despite encountering a similar case. This study explores how medical residents and fellows experience and interpret intersupervisor clinical practice variability and how these variations influence learning. METHOD: Seventeen senior residents or fellows in internal medicine, hematology, or thrombosis medicine (postgraduate year 3 or above) participated in semistructured interviews after a clinical rotation in thrombosis medicine from December 2019 to March 2021. Data collection and analysis occurred iteratively and concurrently in a manner consistent with constructivist grounded theory. Variation theory was used to guide the development of some interview questions. A central tenet of this theory is that learning occurs by experiencing 3 sequential patterns of variation: contrast, generalization, and fusion. Participants were recruited purposively with respect to specialty until theoretical sufficiency was reached. RESULTS: Clinical practice variability was experienced by all participants. Residents and fellows attributed practice variability to intrinsic differences among supervisors; interinstitutional differences; selection and interpretation of evidence; patient preferences, priorities, and fears; and their own participation in the decision-making process. Clinical practice variability helped residents and fellows discern key features of cases that influenced decision-making (contrast), group similar cases so that the appropriate evidence could be applied (generalization), and develop attitudes consistent with providing individualized patient care (fusion). Observing practice variability was more helpful for fifth- and sixth-year residents and less helpful for third- and fourth-year residents. CONCLUSIONS: Clinical practice variability helped residents and fellows discern critical aspects, group similar patients, and practice individualized medicine. Future research should characterize how clinical practice variability influences learning across the spectrum of training, how supervisors could encourage learning from practice variability, and how curricula could be modified to allow learners greater opportunity to reflect on and consolidate the practice differences they observe.

An immediate way to lower pandemic risk: (not) seizing the low-hanging fruit (bat).

What is the least that humanity can do to mitigate the risks of future pandemics, to prevent worldwide surges in human deaths, illness, and suffering-and more waves of multitrillion US dollar impacts on the global economy? The issues around our consumption and trading of wildlife are diverse and complex, with many rural communities being dependent on wild meat for their nutritional needs. But bats might be one taxonomic group that can be successfully eliminated from the human diet and other uses, with minimal costs or inconvenience to the vast majority of the 8 billion people on Earth. The order Chiroptera merits genuine respect given all that these species contribute to human food supplies through pollination services provided by the frugivores and to disease risk mitigation delivered by insectivorous species. The global community missed its chance to stop SARS-CoV and SARS-CoV-2 from emerging-how many more times will humanity allow this cycle to repeat? How long will governments ignore the science that is in front of them? It's past time for humans to do the least that can be done. A global taboo is needed whereby humanity agrees to leave bats alone, not fear them or try to chase them away or cull them, but to let them have the habitats they need and live undisturbed by humans.

Global governance for pandemic prevention and the wildlife trade.

Although ideas about preventive actions for pandemics have been advanced during the COVID-19 crisis, there has been little consideration for how they can be operationalised through governance structures within the context of the wildlife trade for human consumption. To date, pandemic governance has mostly focused on outbreak surveillance, containment, and response rather than on avoiding zoonotic spillovers in the first place. However, given the acceleration of globalisation, a paradigm shift towards prevention of zoonotic spillovers is warranted as containment of outbreaks becomes unfeasible. Here, we consider the current institutional landscape for pandemic prevention in light of ongoing negotiations of a so-called pandemic treaty and how prevention of zoonotic spillovers from the wildlife trade for human consumption could be incorporated. We argue that such an institutional arrangement should be explicit about zoonotic spillover prevention and focus on improving coordination across four policy domains, namely public health, biodiversity conservation, food security, and trade. We posit that this pandemic treaty should include four interacting goals in relation to prevention of zoonotic spillovers from the wildlife trade for human consumption: risk understanding, risk assessment, risk reduction, and enabling funding. Despite the need to keep political attention on addressing the current pandemic, society cannot afford to miss the opportunity of the current crisis to encourage institution building for preventing future pandemics.

Interventions to Reduce Risk for Pathogen Spillover and Early Disease Spread to Prevent Outbreaks, Epidemics, and Pandemics.

The pathogens that cause most emerging infectious diseases in humans originate in animals, particularly wildlife, and then spill over into humans. The accelerating frequency with which humans and domestic animals encounter wildlife because of activities such as land-use change, animal husbandry, and markets and trade in live wildlife has created growing opportunities for pathogen spillover. The risk of pathogen spillover and early disease spread among domestic animals and humans, however, can be reduced by stopping the clearing and degradation of tropical and subtropical forests, improving health and economic security of communities living in emerging infectious disease hotspots, enhancing biosecurity in animal husbandry, shutting down or strictly regulating wildlife markets and trade, and expanding pathogen surveillance. We summarize expert opinions on how to implement these goals to prevent outbreaks, epidemics, and pandemics.

Conservation resource allocation, small population resiliency, and the fallacy of conservation triage.

Some conservation prioritization methods are based on the assumption that conservation needs overwhelm current resources and not all species can be conserved; therefore, a conservation triage scheme (i.e., when the system is overwhelmed, species should be divided into three groups based on likelihood of survival, and efforts should be focused on those species in the group with the best survival prospects and reduced or denied to those in the group with no survival prospects and to those in the group not needing special efforts for their conservation) is necessary to guide resource allocation. We argue that this decision-making strategy is not appropriate because resources are not as limited as often assumed, and it is not evident that there are species that cannot be conserved. Small population size alone, for example, does not doom a species to extinction; plants, reptiles, birds, and mammals offer examples. Although resources dedicated to conserving all threatened species are insufficient at present, the world's economic resources are vast, and greater resources could be dedicated toward species conservation. The political framework for species conservation has improved, with initiatives such as the UN Sustainable Development Goals and other international agreements, funding mechanisms such as The Global Environment Facility, and the rise of many nongovernmental organizations with nimble, rapid-response small grants programs. For a prioritization system to allow no extinctions, zero extinctions must be an explicit goal of the system. Extinction is not inevitable, and should not be acceptable. A goal of no human-induced extinctions is imperative given the irreversibility of species loss.

Asignación de Recursos para la Conservación, Resiliencia de Poblaciones Pequeñas y la Falacia del Triaje de Conservación Resumen Algunos métodos de priorización de la conservación están basados en el supuesto de que las necesidades de la conservación superan a los actuales recursos y que no todas las especies pueden ser conservadas; por lo tanto, se necesita un esquema de triaje (esto es, cuando el sistema está abrumado, las especies deben dividirse en tres grupos con base en su probabilidad de supervivencia y los esfuerzos deben enfocarse en aquellas especies dentro del grupo con las mejores probabilidades de supervivencia y a aquellas en el grupo sin probabilidades de supervivencia o aquellas en el grupo que no necesita esfuerzos especializados para su conservación se les deben reducir o negar los esfuerzos de conservación) para dirigir la asignación de recursos. Discutimos que esta estrategia para la toma de decisiones no es apropiada porque los recursos no están tan limitados como se asume con frecuencia y tampoco es evidente que existan especies que no puedan ser conservadas. Por ejemplo, tan sólo un tamaño poblacional pequeño no es suficiente para condenar a una especie a la extinción; contamos con ejemplos en plantas, reptiles, aves y mamíferos. Aunque actualmente todos los recursos dedicados a la conservación de todas las especies amenazadas son insuficientes, los recursos económicos mundiales son vastos y se podrían dedicar mayores recursos a la conservación de especies. El marco de trabajo político para la conservación de especies ha mejorado, con iniciativas como los Objetivos de Desarrollo Sustentable de la ONU y otros acuerdos internacionales, el financiamiento de mecanismos como el Fondo para el Medio Ambiente Mundial, y el surgimiento de muchas organizaciones no gubernamentales mediante programas de subsidios pequeños hábiles y de respuesta rápida. Para que un sistema de priorización no permita las extinciones, las cero extinciones deben ser un objetivo explícito del sistema. La extinción no es inevitable y no debería ser aceptable. El objetivo de cero extinciones inducidas por humanos es imperativo dada la irreversibilidad de la pérdida de especies.

The Berlin principles on one health - Bridging global health and conservation.

For over 15-years, proponents of the One Health approach have worked to consistently interweave components that should never have been separated and now more than ever need to be re-connected: the health of humans, non-human animals, and ecosystems. We have failed to heed the warning signs. A One Health approach is paramount in directing our future health in this acutely and irrevocably changed world. COVID-19 has shown us the exorbitant cost of inaction. The time to act is now.

Dental sexual dimorphisms in some extant hominoids and ramapithecines from China: A quantitative approach.

Studies of sexual dimorphism in the dental dimensions of some extant and fossil hominoids have been carried out by means of univariate statistical methods [Oxnard et al., 1985]. The study reported here extended these studies with multivariate statistical methods (canonical variates analyses). The extant genera studied were Gorilla, Pan, Pongo, and Homo. The fossil teeth interpolated were those of the recently discovered ramapithecines from Yunnan Province, China. For both extant and fossil species, the lengths and breadths of all maxillary and mandibular teeth were used except for the third molar, which was excluded because of its absence in so many human subjects. The nature of sexual dimorphism in the dentition of extant apes and humans was assessed, and the positions of the fossil teeth within the multivariate results for the extant forms was examined. Among the apes, the greatest sexual dimorphism was seen in Gorilla; the least was seen in Pan. Three different patterns of sexual dimorphism were apparent among the three ape species. The maxillary and mandibular patterns were different in Gorilla and Pan but more similar in Pongo. The African apes showed greater differences between variances for each sex and of each jaw; these features may have evolved most recently. The conventional notion that sexual dimorphism is mainly due to size and size­related shape effects along a single continuum or axis was rejected. The interpolation of the fossil data placed Sivapithecus close to each of the more dimorphic apes, especially Pongo, but also showed that it had higher order differences from the extant forms studied. Ramapithecus was most similar to Homo. These results have implications both for the role of sexual dimorphism in the evolution of higher primates and for the phylogenetic relationships among them.

Sexual dimorphisms in dental dimensions of higher primates.

Dental dimensions and distributions of dental dimensions of males and females were compared for great apes (Pan, Gorilla, and Pongo, and humans (Homo). The results were examined and discussed with reference to fossil primates Sivapithecus and Ramapithecus. The analyses focused on patterns of sexual dimorphism, both with regard to mean dimensions and the distribution of those dimensions. Sex differences in mean canine dimensions were large and significant for Gorilla and Pongo, significant but smaller for Pan, and small but occasionally significant for Homo. The dispersions of measures were greater for males than for females in Gorilla and Pan but did not differ significantly for Pongo or Homo. Examination of the noncanine teeth revealed complex sex differences. In the anterior teeth, sex differences in mean dimensions were generally apparent for Gorilla and Pongo, less so for Pan, and least of all in Homo. The patterns of dispersion of measures of anterior teeth differed markedly from those of the canines. Pan exhibited the same pattern for anterior and canine teeth. Gorilla showed the opposite pattern. Pongo and Homo showed similar dispersions for males and females in many cases. Sex differences in posterior teeth followed the pattern of the canines for Gorilla and were absent for Pan. Pongo exhibited mean differences in dimensions across sex, but dispersions were similar. The pattern for Homo was most like that of Pongo, but with fewer significant differences. The genera differed with regard to the number of significant differences in means or dispersions along the tooth row. It is clear that the patterns of dimorphism differ qualitatively across all extant genera of great apes and humans. It appears that the pattern for Homo most closely resembles that of Ramapithecus, whereas Pongo most closely resembles Sivapithecus. The patterns for Gorilla and Pan appear to be unlike either of the fossil forms. It is suggested that the qualitatively distinct patterns of dental sexual dimorphism indicate substantial flexibility during recent primate evolution and that the degree of structural flexibility demonstrated provides a basis for appreciating potential for plasticity of gender differences in behavioral, social, and cultural systems.