Physician Specialty Differences in Unprofessional Behaviors Observed and Reported by Coworkers.

Importance: Because unprofessional behaviors are associated with patient complications, malpractice claims, and well-being concerns, monitoring concerns requiring investigation and individuals identified in multiple reports may provide important opportunities for health care leaders to support all team members. Objective: To examine the distribution of physicians by specialty who demonstrate unprofessional behaviors measured through safety reports submitted by coworkers. Design, Setting, and Participants: This retrospective cohort study was conducted among physicians who practiced at the 193 hospitals in the Coworker Concern Observation Reporting System (CORS), administered by the Vanderbilt Center for Patient and Professional Advocacy. Data were collected from January 2018 to December 2022. Exposure: Submitted reports concerning communication, professional responsibility, medical care, and professional integrity. Main Outcomes and Measures: Physicians' total number and categories of CORS reports. The proportion of physicians in each specialty (nonsurgeon nonproceduralists, emergency medicine physicians, nonsurgeon proceduralists, and surgeons) who received at least 1 report and who qualified for intervention were calculated; logistic regression was used to calculate the odds of any CORS report. Results: The cohort included 35 120 physicians: 18 288 (52.1%) nonsurgeon nonproceduralists, 1876 (5.3%) emergency medicine physicians, 6743 (19.2%) nonsurgeon proceduralists, and 8213 (23.4%) surgeons. There were 3179 physicians (9.1%) with at least 1 CORS report. Nonsurgeon nonproceduralists had the lowest percentage of physicians with at least 1 report (1032 [5.6%]), followed by emergency medicine (204 [10.9%]), nonsurgeon proceduralists (809 [12.0%]), and surgeons (1134 [13.8%]). Nonsurgeon nonproceduralists were less likely to be named in a CORS report than other specialties (5.6% vs 12.8% for other specialties combined; difference in percentages, -7.1 percentage points; 95% CI, -7.7 to -6.5 percentage points; P < .001). Pediatric-focused nonsurgeon nonproceduralists (2897 physicians) were significantly less likely to be associated with a CORS report than nonpediatric nonsurgeon nonproceduralists (15 391 physicians) (105 [3.6%] vs 927 [6.0%]; difference in percentages, -2.4 percentage points, 95% CI, -3.2 to -1.6 percentage points; P < .001). Pediatric-focused emergency medicine physicians, nonsurgeon proceduralists, and surgeons had no significant differences in reporting compared with nonpediatric-focused physicians. Conclusions and Relevance: In this cohort study, less than 10% of physicians ever received a coworker report with a concern about unprofessional behavior. Monitoring reports of unprofessional behaviors provides important opportunities for health care organizations to identify and intervene as needed to support team members.

Variation in Oral Board Examination Accommodations Among Specialties.

Importance: Board certification can have broad implications for candidates' career trajectories, and prior research has found sociodemographic disparities in pass rates. Barriers in the format and administration of the oral board examinations may disproportionately affect certain candidates. Objective: To characterize oral certifying examination policies and practices of the 16 Accreditation Council for Graduate Medical Education (ACGME)-accredited specialties that require oral examinations. Design, Setting, and Participants: This cross-sectional study was conducted from March 1 to April 15, 2023, using data on oral examination practices and policies (examination format, dates, and setting; lactation accommodations; and accommodations for military deployment, family emergency, or medical leave) as well as the gender composition of the specialties' boards of directors obtained from websites, telephone calls and email correspondence with certifying specialists. The percentages of female residents and residents of racial and ethnic backgrounds who are historically underrepresented in medicine (URM) in each specialty as of December 31, 2021, were obtained from the Graduate Medical Education 2021 to 2022 report. Main Outcome and Measures: For each specialty, accommodation scores were measured by a modified objective scoring system (score range: 1-13, with higher scores indicating more accommodations). Poisson regression was used to assess the association between accommodation score and the diversity of residents in that specialty, as measured by the percentages of female and URM residents. Linear regression was used to assess whether gender diversity of a specialty's board of directors was associated with accommodation scores. Results: Included in the analysis were 16 specialties with a total of 46 027 residents (26 533 males [57.6%]) and 233 members of boards of directors (152 males [65.2%]). The mean (SD) total accommodation score was 8.28 (3.79), and the median (IQR) score was 9.25 (5.00-12.00). No association was found between test accommodation score and the percentage of female or URM residents. However, for each 1-point increase in the test accommodation score, the relative risk that a resident was female was 1.05 (95% CI, 0.96-1.16), and the relative risk that an individual was a URM resident was 1.04 (95% CI, 1.00-1.07). An association was found between the percentage of female board members and the accommodation score: for each 10% increase in the percentage of board members who were female, the accommodation score increased by 1.20 points (95% CI, 0.23-2.16 points; P = .03). Conclusions and Relevance: This cross-sectional study found considerable variability in oral board examination accommodations among ACGME-accredited specialties, highlighting opportunities for improvement and standardization. Promoting diversity in leadership bodies may lead to greater accommodations for examinees in extenuating circumstances.

The effects of gender discrimination on medical students' choice of specialty for their (junior) residency - a survey among medical students in Germany.

BACKGROUND: Gender discrimination is known to affect societies in many different settings. Medical education is no exception. This study focusses on the consequences, gender discrimination can have on medical students and their choice of (junior) residency specialty. METHODS: An online questionnaire was developed and distributed among the 40 medical faculties in Germany. The study population contained medical students in their fifth and sixth academic year. RESULTS: The survey's participants consisted of 759 students from 31 universities. Female medical students experienced significantly more gender discrimination compared to their male colleagues (f = 487, 87.9% vs. m = 76, 45.8%, p < 0.0001). The specialties with the most reported gender discrimination were family medicine (f = 180, 42.9% vs. m = 15, 23.8%, p < 0.05), followed by surgery (f = 369, 87.4% vs. m = 44, 69.8%, p < 0.05), internal medicine (f = 282, 67.3% vs. m = 37, 58.7%, ns), orthopaedics/casualty surgery (f = 270, 65.1% vs. m = 32, 50.8%, p < 0.05), and gynaecology (women (f = 142, 34.1% vs. m = 34, 54.0%, p < 0.05). Gynaecology was the only specialty, men experienced more discrimination compared to women. Among the students that ever changed their specialty of choice (f = 346 (73.3%) m = 95 (72%)), significantly more women than men claimed gender discrimination to be one of the main three reasons for their specialty choice (f = 42, 12.1% vs. m = 1, 1.1%, p < 0.05). In addition, 53 students (f = 50 (10.6%) m = 3 (2.3%)) stated to rule out a specialty from the beginning due to gender discrimination. CONCLUSION: Gender discrimination is frequently experienced by medical students in Germany. It influences their choice of medical specialty directly. Our data suggest a fundamental problem that proposes and implicates certain specialties to be attractive for only one gender.

Accountable care organization initiatives to improve the cost and outcomes of specialty care.

OBJECTIVES: To assess initiatives to manage the cost and outcomes of specialty care in organizations that participate in Medicare accountable care organizations (ACOs). STUDY DESIGN: Cross-sectional analysis of 2023 ACO survey data. METHODS: Analysis of responses to a 12-question web-based survey from 101 respondents representing 174 ACOs participating in the Medicare Shared Savings Program or the Realizing Equity, Access, and Community Health ACO model in 2023. RESULTS: Improving specialist alignment was a high priority for 62% of the 101 respondents and a medium priority for 34%. Only 11% reported that employed specialists were highly aligned and 7% reported that contracted specialists were highly aligned. A subset of ACOs reported major efforts to engage specialists in quality improvement projects (38%) and to convene specialists to develop evidence-based care pathways (30%). They also reported supporting primary care physicians through providing specialist directories (44%), specialist e-consults (23%), and sharing specialist cost data (20%). The most common challenges reported were the influence of fee-for-service payment on specialist behavior (58%), lack of data to evaluate specialist performance (53%), and insufficient bandwidth or ACO resources to address specialist alignment (49%). CONCLUSIONS: Engaging specialists in accountable care is an emerging area for ACOs but one with numerous challenges. Making better data on specialist costs and outcomes available to Medicare ACOs is essential for accelerating progress.

Specialties preference by gender among medical students at Sefako Makgatho Health Sciences University, South Africa.

BACKGROUND:  To determine the speciality preferences and the gender differences in the choice of speciality among medical students at Sefako Makgatho Health Sciences University, South Africa. METHODS:  This cross-sectional study was conducted among fourth- to sixth-year medical students. A structured self-administered questionnaire was used to collect the data. Data analysis was performed using STATA version 16 (StataCorp, College Station, TX, United States). RESULTS:  A total of 174 students participated (response rate of 74%). Their median age was 23 years with interquartile range of 2 years. More than half (57%) were females. About 83% had no previous qualifications. Most (89%) have shown interest in pursuing specialist training. Surgery, obstetrics and gynaecology and internal medicine were the most selected specialities, while family medicine, ophthalmology, forensic medicine, public health medicine, ear, nose and throat, and accident and emergency medicine were the least preferred. Males were more likely interested in surgery and internal medicine, while females preferred obstetrics and gynaecology. CONCLUSION:  The majority of the medical students intends to pursue their postgraduate medical training. Even though the results were not statistically significant, there are gender differences in speciality preferences. There is a need to develop and implement career guidance and recruitment plans to deal with specialities with poor recruitment and gender imbalance.Contribution: To deal with specialties with poor and gender imbalance, career guidance and recruitment plans must be developed and implemented.

Psychobiographical reflections on Viktor von Weizsäcker within the cultural framework of salutogenesis and medical anthropology.

This article explores the life of Viktor von Weizsäcker (VvW, 1886-1957), a German medical doctor, philosopher and founder of the Heidelberg School of Anthropological Medicine, from a psychobiographical and salutogenic perspective. The authors use salutogenesis and sense of coherence (SOC), and take crucial cultural, historical, and socio-structural frameworks into account to explore the life during the 19th and 20th Centuries in Germany. They present the exploration of a strong SOC in the life of VvW and show how SOC is created within the tight family bonds of the family clan, which has produced many extraordinary theologists, philosophers, scientists and politicians over six generations. In a complex, interconnected and holistic way, SOC is evident in von VvW's individual life, and is also shown to be a family resource. This article contributes to psychobiography in three ways: it develops the salutogenetic perspective in psychobiography, explores the life of VvW within a specific sociocultural context, and investigates the life from a salutogenetic and socio-cultural perspective. Finally, conclusions are drawn, and recommendations for theory and practice are given.

Patient characteristics of, and remedial interventions for, complaints and medico-legal claims against doctors: a rapid review of the literature.

BACKGROUND: It is uncertain if patient's characteristics are associated with complaints and claims against doctors. Additionally, evidence for the effectiveness of remedial interventions on rates of complaints and claims against doctors has not been synthesised. METHODS: We conducted a rapid review of recent literature to answer: Question 1 "What are the common characteristics and circumstances of patients who are most likely to complain or bring a claim about the care they have received from a doctor?" and Question 2 "What initiatives or interventions have been shown to be effective at reducing complaints and claims about the care patients have received from a doctor?". We used a systematic search (most recently in July 2023) of PubMed, Scopus, Web of Science and grey literature. Studies were screened against inclusion criteria and critically appraised in duplicate using standard tools. Results were summarised using narrative synthesis. RESULTS: From 8079 search results, we reviewed the full text of 250 studies. We included 25 studies: seven for Question 1 (6 comparative studies with controls and one systematic review) and 18 studies for Question 2 (14 uncontrolled pre-post studies, 2 comparative studies with controls and 2 systematic reviews). Most studies were set in hospitals across a mix of medical specialties. Other than for patients with mental health conditions (two studies), no other patient characteristics demonstrated either a strong or consistent effect on the rate of complaints or claims against their treating doctors. Risk management programs (6 studies), and communication and resolution programs (5 studies) were the most studied of 6 intervention types. Evidence for reducing complaints and medico-legal claims, costs or premiums and more timely management was apparent for both types of programs. Only 1 to 3 studies were included for peer programs, medical remediation, shared decision-making, simulation training and continuing professional development, with few generalisable results. CONCLUSION: Few patient characteristics can be reliably related to the likelihood of medico-legal complaints or claims. There is some evidence that interventions can reduce the number and costs of claims, the number of complaints, and the timeliness of claims. However, across both questions, the strength of the evidence is very weak and is based on only a few studies or study designs that are highly prone to bias.

Professional Experiences and Career Trajectories of Mid- to Senior-Career Women Clinician-Scientists: A Qualitative Study.

Importance: Despite increasing evidence and recognition of persistent gender disparities in academic medicine, qualitative data detailing the association of gender-based experiences with career progression remain sparse, particularly at the mid- to senior-career stage. Objective: To investigate the role gender has played in everyday professional experiences of mid- to senior-career women clinician-scientists and their perceptions of gender-related barriers experienced across their careers. Design, Setting, and Participants: In this qualitative study, a total of 60 of 159 invited clinician-scientists who received National Institutes of Health K08 or K23 awards between 2006 and 2009 and responded to a survey in 2021 agreed to participate. Invitees were selected using random, purposive sampling to support sample heterogeneity. Semistructured in-depth interviews were conducted January to May 2022. For this study, interviews from 31 women were analyzed using the framework approach to thematic analysis. Data analyses were performed between August and October 2023. Main Outcomes and Measures: Descriptive themes of participant experiences of gender and gender-based barriers in academic medicine. Results: A total of 31 women clinician-scientists (8 identifying as Asian [25.8%], 14 identifying as White [45.2%], and 9 identifying as members of a minority group underrepresented in medicine [29.0%]; 14 aged 40-49 years [45.2%] and 14 aged 50-59 years [45.2%]) were included. Among them, 17 participants (54.8%) had children who required adult supervision or care, 7 participants (22.6%) had children who did not require supervision or care, and 6 participants (19.4%) did not have children. There were 4 dominant themes identified within participant experiences in academic medicine: the mental burden of gendered expectations at work and home, inequitable treatment of women in bureaucratic processes, subtle and less subtle professional exclusion of women, and value of communities built on shared identities, experiences, and solidarity. Conclusions and Relevance: This study found that women perceived the institution of academic medicine as a male-centric system misaligned with the needs of women, with associated feelings of exclusion, disillusionment, and loss of trust in their institutions. Findings suggest that the confluence of domestic obligations and unaccommodating institutional environments may make it difficult for women clinician-scientists to achieve established timelines of career progression and productivity; these findings may have long-term implications for the well-being and retention of women in academic medicine.

Gender and Clinical Status in Burnout in Medicine.

This survey study assesses feelings of satisfaction, stress, and burnout by gender and clinical status among health care workers at a single academic center.

The Need to Widen the Concept of Health and to Include the Spiritual Dimension.

For many, the World Health Organization's (WHO) definition of health does not reflect their own understanding of health, because it lacks aspects such as spiritual wellbeing. Responding to these concerns, the WHO called in 2023 for a vision of health that integrates physical, mental, psychological, emotional, spiritual, and social wellbeing. To date, medical practitioners are often reluctant to consider spiritual aspects, because of a perceived lack of statistical evidence about the strength of relations. Research on this topic is emerging. A recent study among 800 young people living with HIV in Zimbabwe showed how study participants navigated three parallel, at times contradicting health systems (religious, traditional, medical). Conflicting approaches led to multifaceted dilemmas (= spiritual struggles), which were significantly related to poorer mental and physical health. This illustrates the need for inclusion of spiritual aspects for health and wellbeing in research, and of increased collaboration between all stakeholders in healthcare.

Application of causal inference methods in individual-participant data meta-analyses in medicine: addressing data handling and reporting gaps with new proposed reporting guidelines.

Observational data provide invaluable real-world information in medicine, but certain methodological considerations are required to derive causal estimates. In this systematic review, we evaluated the methodology and reporting quality of individual-level patient data meta-analyses (IPD-MAs) conducted with non-randomized exposures, published in 2009, 2014, and 2019 that sought to estimate a causal relationship in medicine. We screened over 16,000 titles and abstracts, reviewed 45 full-text articles out of the 167 deemed potentially eligible, and included 29 into the analysis. Unfortunately, we found that causal methodologies were rarely implemented, and reporting was generally poor across studies. Specifically, only three of the 29 articles used quasi-experimental methods, and no study used G-methods to adjust for time-varying confounding. To address these issues, we propose stronger collaborations between physicians and methodologists to ensure that causal methodologies are properly implemented in IPD-MAs. In addition, we put forward a suggested checklist of reporting guidelines for IPD-MAs that utilize causal methods. This checklist could improve reporting thereby potentially enhancing the quality and trustworthiness of IPD-MAs, which can be considered one of the most valuable sources of evidence for health policy.

Do medical specialists accept claims-based Audit and Feedback for quality improvement? A focus group study.

OBJECTIVES: Audit and Feedback (A&F) is a widely used quality improvement (QI) intervention in healthcare. However, not all feedback is accepted by professionals. While claims-based feedback has been previously used for A&F interventions, its acceptance by medical specialists is largely unknown. This study examined medical specialists' acceptance of claims-based A&F for QI. DESIGN: Qualitative design, with focus group discussions. Transcripts were analysed using discourse analysis. SETTING AND PARTICIPANTS: A total of five online focus group discussions were conducted between April 2021 and September 2022 with 21 medical specialists from varying specialties (urology; paediatric surgery; gynaecology; vascular surgery; orthopaedics and trauma surgery) working in academic or regional hospitals in the Netherlands. RESULTS: Participants described mixed views on using claims-based A&F for QI. Arguments mentioned in favour were (1) A&F stimulates reflective learning and improvement and (2) claims-based A&F is more reliable than other A&F. Arguments in opposition were that (1) A&F is insufficient to create behavioural change; (2) A&F lacks clinically meaningful interpretation; (3) claims data are invalid for feedback on QI; (4) claims-based A&F is unreliable and (5) A&F may be misused by health insurers. Furthermore, participants described several conditions for the implementation of A&F which shape their acceptance. CONCLUSIONS: Using claims-based A&F for QI is, for some clinical topics and under certain conditions, accepted by medical specialists. Acceptance of claims-based A&F can be shaped by how A&F is implemented into clinical practice. When designing A&F for QI, it should be considered whether claims data, as the most resource-efficient data source, can be used or whether it is necessary to collect more specific data.

Medicine, emotience, and reason.

Medicine is faced with a number of intractable modern challenges that can be understood in terms of hyper-intellectualization; a compassion crisis, burnout, dehumanization, and lost meaning. These challenges have roots in medical philosophy and indeed general Western philosophy by way of the historic exclusion of human emotion from human reason. The resolution of these medical challenges first requires a novel philosophic schema of human knowledge and reason that incorporates the balanced interaction of human intellect and human emotion. This schema of necessity requires a novel extension of dual-process theory into epistemology in terms of both intellect and emotion each generating a distinct natural kind of knowledge independent of the other as well as how these two forms of mental process together construct human reason. Such a novel philosophic schema is here proposed. This scheme is then applied to the practice of medicine with examples of practical applications with the goal of reformulating medical practice in a more knowledgable, balanced, and healthy way. This schema's expanded epistemology becomes the philosophic foundation for more fully incorporating the humanities in medicine.

Importance of Patient History in Artificial Intelligence-Assisted Medical Diagnosis: Comparison Study.

Background: Medical history contributes approximately 80% to a diagnosis, although physical examinations and laboratory investigations increase a physician's confidence in the medical diagnosis. The concept of artificial intelligence (AI) was first proposed more than 70 years ago. Recently, its role in various fields of medicine has grown remarkably. However, no studies have evaluated the importance of patient history in AI-assisted medical diagnosis. Objective: This study explored the contribution of patient history to AI-assisted medical diagnoses and assessed the accuracy of ChatGPT in reaching a clinical diagnosis based on the medical history provided. Methods: Using clinical vignettes of 30 cases identified in The BMJ, we evaluated the accuracy of diagnoses generated by ChatGPT. We compared the diagnoses made by ChatGPT based solely on medical history with the correct diagnoses. We also compared the diagnoses made by ChatGPT after incorporating additional physical examination findings and laboratory data alongside history with the correct diagnoses. Results: ChatGPT accurately diagnosed 76.6% (23/30) of the cases with only the medical history, consistent with previous research targeting physicians. We also found that this rate was 93.3% (28/30) when additional information was included. Conclusions: Although adding additional information improves diagnostic accuracy, patient history remains a significant factor in AI-assisted medical diagnosis. Thus, when using AI in medical diagnosis, it is crucial to include pertinent and correct patient histories for an accurate diagnosis. Our findings emphasize the continued significance of patient history in clinical diagnoses in this age and highlight the need for its integration into AI-assisted medical diagnosis systems.