Conflating race and ancestry: Tracing decision points about population descriptors over the precision medicine research life course.

Responding to calls for human genomics to shift away from the use of race, genomic investigators are coalescing around the possibility of using genetic ancestry. This shift has renewed questions about the use of social and genetic concepts of difference in precision medicine research (PMR). Drawing from qualitative data on five PMR projects, we illustrate negotiations within and between research teams as genomic investigators deliberate on the relevance of race and genetic ancestry for different analyses and contexts. We highlight how concepts of both social and genetic difference are embedded within and travel through research practices, and identify multiple points across the research life course at which conceptual slippage and conflation between race and genetic ancestry occur. We argue that moving beyond race will require PMR investigators to confront the entrenched ways in which race is built into research practices and biomedical infrastructures.

Rethinking Benefit and Responsibility in the Context of Diversity: Perspectives from the Front Lines of Precision Medicine Research.

INTRODUCTION: Federal agencies have instituted guidelines to prioritize the enrollment and retention of diverse participants in precision medicine research (PMR). Prior studies examining participation of minoritized communities have shown that potential benefits represent a key determinant. Human subject research guidance, however, conceptualizes potential benefits narrowly, emphasizing generalized advances in medical knowledge. Further, few studies have provided qualitative data that critically examine how the concept of "benefit" is interpreted or challenged in the context of research practice. This paper examines the experiences of PMR investigators and frontline research staff to understand how standard approaches to benefit are received, contested, and negotiated "on the ground." METHODS: Findings are drawn from a qualitative project conducted across five US-based, federally funded PMR studies. Data collection included 125 in-depth interviews with a purposive sample of investigators, research staff, community advisory board members, and NIH program officers associated with these PMR studies. RESULTS: Researchers report that the standard approach to benefit - which relies on the premise of altruism and the promise of incrementally advancing scientific knowledge - is frequently contested. Researchers experience moral distress over the unmet clinical, psychosocial, and material needs within the communities they are engaging. Many believe the broader research enterprise has a responsibility to better address these needs. CONCLUSION: Researchers frequently take issue with and sometimes negotiate what is owed to participants and to their communities in exchange for the data they provide. These experiences of moral distress and these improvisations warrant systematic redress, not by individual researchers but by the broader research ethics infrastructure.

Diversity in the Plastic Surgery Match: The Effect of Program Chair, Program Director, and Faculties' Race and Sex on Matched Applicants.

INTRODUCTION: Prior studies have identified the lack of diversity within the field of plastic surgery (PS) and associated residency matches. In this study, the authors aimed to examine the effect of PS program chairs (PCs), program directors (PD), and faculty members' race and sex on PS applicants and matriculants within the same program. METHODS: Deidentified applicant data from 2017 to 2021 submitted to the University of Wisconsin-Madison's integrated PS program were analyzed. Applicants' self-reported sex and race were collected. Integrated PS program websites were assessed to determine whether applicants matched the program. Race and sex of PCs, PDs, and faculty members were collected from each program's website. RESULTS: Overall, 79 integrated PS programs' websites and 1470 applicants were reviewed. The majority of PCs, PDs, and faculty members were male (87.3%, 81.0%, and 69.6%, respectively) and white (74.7%, 70.9%, and 68.8%, respectively). Most applicants were male (54.0%) and white (60.8%). For a given program, white PCs and PDs have 5 and 6 times the odds of matching an applicant of the same race ( P <0.001 for both). Having male PCs and PDs did not significantly increase the odds of matching an applicant of the same sex ( P =0.198 and 0.905, respectively). CONCLUSION: Although the field of PS has made great strides to close the sex gap within the residency match process, this study highlights ongoing racial disparities among nonwhite applicants.

Community Engagement in Precision Medicine Research: Organizational Practices and Their Impacts for Equity.

BACKGROUND: In the wake of mandates for biomedical research to increase participation by members of historically underrepresented populations, community engagement (CE) has emerged as a key intervention to help achieve this goal. METHODS: Using interviews, observations, and document analysis, we examine how stakeholders in precision medicine research understand and seek to put into practice ideas about who to engage, how engagement should be conducted, and what engagement is for. RESULTS: We find that ad hoc, opportunistic, and instrumental approaches to CE exacted significant consequences for the time and resources devoted to engagement and the ultimate impacts it has on research. Critical differences emerged when engagement and research decisionmaking were integrated with each other versus occurring in parallel, separate parts of the study organization, and whether community members had the ability to determine which issues would be brought to them for consideration or to revise or even veto proposals made upstream based on criteria that mattered to them. CE was understood to have a range of purposes, from instrumentally facilitating recruitment and data collection, to advancing community priorities and concerns, to furthering long-term investments in relationships with and changes in communities. These choices about who to engage, what engagement activities to support, how to solicit and integrate community input into the workflow of the study, and what CE was for were often conditioned upon preexisting perceptions and upstream decisions about study goals, competing priorities, and resource availability. CONCLUSIONS: Upstream choices about CE and constraints of time and resources cascade into tradeoffs that often culminated in "pantomime community engagement." This approach can create downstream costs when engagement is experienced as improvised and sporadic. Transformations are needed for CE to be seen as a necessary scientific investment and part of the scientific process.

Objective Residency Applicant Assessment Using a Linear Rank Model.

OBJECTIVES: Residency applicant assessment is imperfect, with little objectivity built into the process, which, unfortunately, impacts recruitment diversity. Linear rank modeling (LRM) is an algorithm that standardizes applicant assessment to model expert judgment. Over the last 5 years, we have used LRM to assist with screening and ranking integrated plastic surgery (PRS) residency applicants. This study's primary objective was to determine if LRM scores are predictive of match success and, secondarily, to compare LRM scores between gender and self-identified race categories. DESIGN: Data was collected on applicant demographics, traditional application metrics, global intuition rank, and match success. LRM scores were calculated for screened and interviewed applicants, and scores were compared by demographic groups. Univariate logistic regression was used to evaluate the association of LRM scores and traditional application metrics with match success. SETTING: University of Wisconsin, Division of Plastic and Reconstructive Surgery. Academic institution. PARTICIPANTS: Six hundred seventeen candidates who applied to a single institution over 4 application cycles (2019-2022). RESULTS: Using area under the curve modeling, LRM score was the most predictive indicator for match success. With every one-point increase in LRM score, there was an 11% and 8.3% increase in the likelihood of screened and interviewed applicant match success (p < 0.001). An algorithm was developed to estimate the probability of match success based on LRM score. No significant differences in LRM scores were appreciated for interviewed applicant gender or self-identified race groups. CONCLUSIONS: LRM score is the most predictive indicator of match success for PRS applicants and can be used to estimate an applicant's probability of successfully matching into an integrated PRS residency. Furthermore, it provides a holistic evaluation of the applicant that can streamline the application process and improve recruitment diversity. In the future, this model could be applied to assist in the match process for other specialties.

Quality improvement study on the effectiveness of intranasal povidone-iodine decolonization on surgery patients.

Background: Surgical site infection prevention and treatment remains a challenge in healthcare settings globally. The routine use of intranasal mupirocin for decolonization has challenges and preoperative intranasal povidone-iodine decolonization is another option. The purpose of this quality improvement study was to assess if a one-time preoperative intranasal povidone-iodine application could reduce the risk of the likelihood of nasal carriage of Staphylococcus aureus after surgery. Methods: Ambulatory Surgery Center patients were enrolled in an intranasal povidone-iodine decolonization quality improvement study as they reported at the pre-operative holding area. Pre-decolonization intranasal samples were collected, followed by intranasal application of povidone-iodine. Patients waited for a minimum of 20 minutes after application before proceeding with surgery. Nasal samples were again collected after surgery. Each sample was tested for S. aureus colonization using the 16S rRNA-mecA-nuc triplex polymerase chain reaction, standard biochemical tests, and qualitative culturing. Findings: In the 98 patients enrolled, 36% of these patients had intranasal colonization with S. aureus by 16S rRNA-mecA-nuc triplex polymerase chain reaction before surgery. Using a qualitative culture technique, 28% of patients tested positive for S. aureus before surgery and 20% of patients tested positive for S. aureus after surgery (P = 0.039). Conclusion: Intranasal preoperative povidone-iodine is an effective strategy in the decolonization of S. aureus from the nares if properly implemented.

Making Headway in Surgical Education at Home and Abroad: Use of an Inexpensive Three-Dimensional Learning Model to Improve Plastic Surgery Resident Confidence in Mohs Defect Assessment and Closure Planning.

BACKGROUND: The development of simulation, particularly low-cost models, has become a focus of interest within plastic surgery education. Current simulators for Mohs reconstruction are either expensive or not reusable. The authors hypothesize that using a Styrofoam head model during an interactive teaching session will positively affect plastic surgery trainee comfort in designing Mohs reconstructive options. METHODS: A cohort of integrated plastic surgery residents at a single institution performed a preactivity questionnaire to obtain baseline comfort in defect assessment and design for five Mohs defects. They subsequently underwent an interactive learning session and were instructed to design flaps on life-size Styrofoam heads with feedback from the senior author (M.L.B.). A postactivity questionnaire was completed to assess improvement in comfort in defect assessment and flap design. Three attending surgeons then compared trainee designs with the senior author's design to assess accuracy. All surveys were based on a five-point Likert scale. RESULTS: When analyzing all defects, average postactivity scores increased by 0.63 (SD, ±0.24) ( P = 0.008). Junior residents ( n = 8) had a greater increase in average score responses [mean, 1.07 (0.5 to 1.75)] compared with senior residents ( n = 9) [mean, 0.27 (0 to 1)] ( P < 0.001). When assessed by senior-level surgeons, senior residents had significantly greater accuracy in design for each defect ( P < 0.05) except cheek advancement flap ( P = 0.08). CONCLUSION: Participation in an interactive educational activity using a Styrofoam head model demonstrated significant improvements in trainee assessment and design of reconstructive options for Mohs defects.

USMLE Step 1 Pass/Fail is Here: Are Plastic Surgery Applicants Really Better Off?

OBJECTIVE: As of January 26, 2022, the United States Medical Licensing Examination(USMLE) Step 1 score reporting will be changed from a numeric scoring system to pass/fail. Although the new scoring policy is expected to benefit medical students, there is concern that it will also amplify preexisting disadvantages and worsen disparities for students applying in the already-competitive plastic surgery match. Whether the reporting change will tangibly benefit applicants to plastic surgery has yet to be elucidated. DESIGN: A cross-sectional survey was distributed to medical students and graduates via social media platforms. Data were analyzed using Student t test and Chi-squared statistic, with an alpha level set at 0.05. SETTING: Data collection and analysis was performed at Johns Hopkins University School of Medicine. PARTICIPANTS: This study included a sample of 120 American Medical Trainees (AMTs) and International Medical Trainees (IMTs) who are interested in plastic surgery. RESULTS: The plurality of respondents were against the new Step 1 score reporting (AMT: 40.7%; IMT: 44.3%), but differences existed between AMTs when compared to IMTs, especially regarding opinions about the reporting change on stress levels and competitiveness of highly competitive specialties. Regardless of training status, respondents felt that the pass/fail scoring system would increase their likelihood to engage with more research, dual apply, prioritize studying for Step 2 CK, and consider a dedicated research year. CONCLUSIONS: While a pass/fail reporting system for Step 1 may alleviate some stress for medical trainees, other issues arise that may perpetuate disparities and bias against students with little resources in the field of plastic surgery. Residency programs should offer anticipatory guidance regarding prioritization of aspects of application to ease this psychosocial and financial pressure, as well as help students reorganize their constrained time.

A quality improvement study on the relationship between intranasal povidone-iodine and anesthesia and the nasal microbiota of surgery patients.

INTRODUCTION: The composition of the nasal microbiota in surgical patients in the context of general anesthesia and nasal povidone-iodine decolonization is unknown. The purpose of this quality improvement study was to determine: (i) if general anesthesia is associated with changes in the nasal microbiota of surgery patients and (ii) if preoperative intranasal povidone-iodine decolonization is associated with changes in the nasal microbiota of surgery patients. MATERIALS AND METHODS: One hundred and fifty-one ambulatory patients presenting for surgery were enrolled in a quality improvement study by convenience sampling. Pre- and post-surgery nasal samples were collected from patients in the no intranasal decolonization group (control group, n = 54). Pre-decolonization nasal samples were collected from the preoperative intranasal povidone-iodine decolonization group (povidone-iodine group, n = 97). Intranasal povidone-iodine was administered immediately prior to surgery and continued for 20 minutes before patients proceeded for surgery. Post-nasal samples were then collected. General anesthesia was administered to both groups. DNA from the samples was extracted for 16S rRNA sequencing on an Illumina MiSeq. RESULTS: In the control group, there was no evidence of change in bacterial diversity between pre- and post-surgery samples. In the povidone-iodine group, nasal bacterial diversity was greater in post-surgery, relative to pre-surgery (Shannon's Diversity Index (P = 0.038), Chao's richness estimate (P = 0.02) and Inverse Simpson index (P = 0.027). Among all the genera, only the relative abundance of the genus Staphylococcus trended towards a decrease in patients after application (FDR adjusted P = 0.06). Abundant genera common to both povidone-iodine and control groups included Staphylococcus, Bradyrhizobium, Corynebacterium, Dolosigranulum, Lactobacillus, and Moraxella. CONCLUSIONS: We found general anesthesia was not associated with changes in the nasal microbiota. Povidone-iodine treatment was associated with nasal microbial diversity and decreased abundance of Staphylococcus. Future studies should examine the nasal microbiota structure and function longitudinally in surgical patients receiving intranasal povidone-iodine.

Targeting Representation: Interpreting Calls for Diversity in Precision Medicine Research.

Scientists have identified a "diversity gap" in genetic samples and health data, which have been drawn predominantly from individuals of European ancestry, as posing an existential threat to the promise of precision medicine. Inadequate inclusion as articulated by scientists, policymakers, and ethicists has prompted large-scale initiatives aimed at recruiting populations historically underrepresented in biomedical research. Despite explicit calls to increase diversity, the meaning of diversity - which dimensions matter for what outcomes and why - remain strikingly imprecise. Drawing on our document review and qualitative data from observations and interviews of funders and research teams involved in five precision medicine research (PMR) projects, we note that calls for increasing diversity often focus on "representation" as the goal of recruitment. The language of representation is used flexibly to refer to two objectives: achieving sufficient genetic variation across populations and including historically disenfranchised groups in research. We argue that these dual understandings of representation are more than rhetorical slippage, but rather allow for the contemporary collection of samples and data from marginalized populations to stand in as correcting historical exclusion of social groups towards addressing health inequity. We trace the unresolved historical debates over how and to what extent researchers should procure diversity in PMR and how they contributed to ongoing uncertainty about what axes of diversity matter and why. We argue that ambiguity in the meaning of representation at the outset of a study contributes to a lack of clear conceptualization of diversity downstream throughout subsequent phases of the study.

Strategies of inclusion: The tradeoffs of pursuing "baked in" diversity through place-based recruitment.

US funding agencies have begun to institutionalize expectations that biomedical studies achieve defined thresholds for diversity among research participants, including in precision medicine research (PMR). In this paper, we examine how practices of recruitment have unfolded in the wake of these diversity mandates. We find that a very common approach to seeking diverse participants leverages understandings of spatial, geographic, and site diversity as proxies and access points for participant diversity. That is, PMR investigators recruit from a diverse sampling of geographic areas, neighborhoods, sites, and institutional settings as both opportunistic but also meaningful ways to "bake in" participant diversity. In this way, logics of geographic and institutional diversity shift the question from who to recruit, to where. However, despite seeing geographic and site diversity as social and scientific 'goods' in the abstract and as key to getting diverse participants, PMR teams told us that working with diverse sites was often difficult in practice due to constraints in funding, time, and personnel, and inadequate research infrastructures and capacity. Thus, the ways in which these geographic and institutional diversity strategies were implemented resulted ultimately in limiting the meaningful inclusion of populations and organizations that had not previously participated in biomedical research and reproduced the inclusion of institutions that are already represented. These prevailing assumptions about and practices of "baked-in" diversity in fact exacerbate and produce other forms of inequity, in research capacity and research representation. These findings underscore how structural inequities in research resources must be addressed for diversity to be achieved in both research sites and research participants.

Beyond inclusion: Enacting team equity in precision medicine research.

PURPOSE: To identify meanings of and challenges to enacting equitable diversification of genomics research, and specifically precision medicine research (PMR), teams. METHODS: We conducted in-depth interviews with 102 individuals involved in three U.S.-based precision medicine research consortia and conducted over 400 observation hours of their working group meetings, consortium-wide meetings, and conference presentations. We also reviewed published reports on genomic workforce diversity (WFD), particularly those relevant to the PMR community. RESULTS: Our study finds that many PMR teams encounter challenges as they strive to achieve equitable diversification on scientific teams. Interviewees articulated that underrepresented team members were often hired to increase the study's capacity to recruit diverse research participants, but are limited to on-the-ground staff positions with little influence over study design. We find existing hierarchies and power structures in the academic research ecosystem compound challenges for equitable diversification. CONCLUSION: Our results suggest that meaningful diversification of PMR teams will only be possible when team equity is prioritized as a core value in academic research communities.

Diversity in Plastic Surgery Authorship: A 14-Year Analysis of 2688 Articles Published in Plastic and Reconstructive Surgery.

BACKGROUND: Publication in peer-reviewed journals is a duty and privilege. It is essential to the advancement of evidence-based medicine and often used as a proxy for academic achievement, contributing to decisions around promotion in academia. Within plastic surgery, authors have historically been male surgeons affiliated with academic institutions, lacking representation of women, private practice, medical students, and international collaboration. This study analyzes differences in authors' gender, practice affiliation, degree of education, and international collaboration in articles published in Plastic and Reconstructive Surgery, which was chosen as the representative journal given its high impact factor (3.946) and consistent ranking as the number one journal in plastic surgery worldwide. METHODS: A list of Breast, Cosmetic, and Hand/Peripheral Nerve articles published between 2006 and 2019 was compiled from the online archive of Plastic and Reconstructive Surgery. Demographic author characteristics were recorded, and statistical analyses were performed to identify trends over time. RESULTS: A total of 2688 articles were analyzed. The proportion of articles written by female authors in the Breast category, authors in private practice with academic affiliation in the Cosmetic section, and U.S. collaboration with other countries increased over time (p = 0.038, p = 0.029, p < 0.001, respectively). First authors with bachelor's, master's, and doctorate degrees have also been contributing increasingly. CONCLUSIONS: This analysis revealed increasing demographic heterogeneity of authors in Plastic and Reconstructive Surgery over time, with increasing contributions from women, surgeons in private practice with academic affiliation, medical students, and international collaborations. The Journal is capturing contributions from an increasingly diverse authorship, consistent with the changing demographics of plastic surgeons.

Communicating Critical Information to Cancer Survivors: an Assessment of Survivorship Care Plans in Use in Diverse Healthcare Settings.

Survivorship care plans (SCPs) serve to communicate critical information needed for cancer survivors' long-term follow-up care. The extent to which SCPs are tailored to meet the specific needs of underserved patient populations is understudied. To fill this gap, this study aimed to assess the content and communication appropriateness of SCPs collected from diverse healthcare settings. We analyzed collected SCPs (n = 16) for concordance with Institute of Medicine (IOM) recommendations for SCP content and for communication appropriateness using the Suitability Assessment of Materials (SAM) instrument. All plans failed to incorporate all IOM criteria, with the majority of plans (n = 11) incorporating less than 60% of recommended content. The average reading grade level of all the plans was 14, and only one plan received a superior rating for cultural appropriateness. There is significant variation in the format and content of SCPs used in diverse hospital settings and most plans are not written at an appropriate reading grade level nor tailored for underserved and/or minority patient populations. Co-designing SCPs with diverse patient populations is crucial to ensure that these documents are meeting the needs and preferences of all cancer survivors.

Nasal povidone-iodine implementation for preventing surgical site infections: Perspectives of surgical nurses.

INTRODUCTION: Preoperative nasal decolonization of surgical patients with nasal povidone-iodine (PI) has potential to eliminate pathogenic organisms responsible for surgical site infections. However, data on implementation of PI for quality improvement in clinical practice is limited. The purpose of this study was to evaluate the implementation feasibility, fidelity and acceptability of intranasal PI solution application by surgical nurses using the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) conceptual framework. MATERIALS AND METHODS: Using the i-PARIHS framework to frame questions and guide interview content areas, we conducted 15 semi-structured interviews of pre- and post-operative care nurses in two facilities. We analyzed the data using deductive content analysis to evaluate nurses' experience and perceptions on preoperative intranasal PI solution decolonization implementation. Open coding was used to analyze the data to ensure all relevant information was captured. RESULTS: Each facility adopted a different quality improvement implementation strategy. The mode of facilitation, training, and educational materials provided to the nurses varied by facility. Barriers identified included lack of effective communication, insufficient information and lack of systematic implementation protocol. Action taken to mitigate some of the barriers included a collaboration between the study team and nurses to develop a systematic written protocol. The training assisted nurses to systematically follow the implementation protocol smoothly to ensure PI administration compliance, and to meet the goal of the facilities. Nurses' observations and feedback showed that PI did not cause any adverse effects on patients. CONCLUSIONS: We found that PI implementation was feasible and acceptable by nurses and could be extended to other facilities. However further studies are required to ensure standardization of PI application.

Academic Productivity in Plastic Surgery: A Comparison of US and International Medical Graduates.

INTRODUCTION: International medical graduates (IMGs) make up nearly 10% of plastic surgeons in the United States, yet there is little information regarding their relative contributions to the field of academic plastic surgery. This study compares the research productivity and academic rank of IMG academic plastic surgeons and their US medical graduate (USMG) counterparts. METHOD: A cross-sectional study was performed to include all IMG and USMG full-time academic plastic surgeons in the United States. For each IMG and USMG academic plastic surgeon, bibliometric variables such as the Hirsch index (h-index), i10-index, total number of publications, total number of citations, and greatest number of citations for a single published work were computed. RESULTS: One-hundred and forty-four full-time IMG and 828 USMG academic plastic surgeons met inclusion criteria. There were no significant differences between IMGs and USMGs regarding h-index, i10-index, total number of publications, and total number of citations. Both IMGs and USMGs have higher numbers of publications following graduation from a plastic surgery residency or fellowship as compared to pre-residency or fellowship (37.2 ±â€Š71.5 versus 8.0 ±â€Š19.2 and 45.0 ±â€Š73.1 versus 9.1 ±â€Š15.5, respectively). CONCLUSIONS: IMG and USMG plastic surgeons have nearly equivalent research productivity. Both cohorts continue to have high research outputs following graduation from a plastic surgery residency or fellowship.