'Yourself in all your forms': A grounded theory exploration of identity safety in medical students.

INTRODUCTION: Identity threats, such as stereotype threat and microaggressions, impair learning and erode well-being. In contrast to identity threat, less is known about how learners experience feelings of safety regarding their identity. This exploratory study aims to develop a theory of identity safety in the clinical learning environment. METHODS: This multi-institutional, qualitative interview study was informed by constructivist grounded theory and critical pedagogy. Participants were clinical students at three public medical schools in the United States in 2022. Investigators purposively sampled participants for interviews based on their responses to an 11-item survey with an open-ended question soliciting students' personal identities and responses to both the racial/ethnic and gender Stereotype Vulnerability Scales. The investigators interviewed, coded, constantly compared and continued sampling until the codes could be developed into categories, then concepts and finally into a theory. The team engaged in critical reflexivity throughout the analytic process to enrich data interpretations. RESULTS: Sixteen diverse students were interviewed. We organised their identity-salient experiences into identity threat, threat mitigation and identity safety. Participants experienced identity threat through unwelcoming learning environments, feeling compelled to change their behaviour in inauthentic ways or sociopolitical threat. Threat mitigation occurred when a participant or supervisor intervened against an identity threat, dampening but not eliminating the threat impact. Participants characterised identity safety as the ability to exist as their authentic selves without feeling the need to monitor how others perceive their identities. Identity safety manifested when participants demonstrated agency to leverage their identities for patient care, when others upheld their personhood and saw them as unique individuals and when they felt they belonged in the learning environment. DISCUSSION: Attending to identity safety may lead to educational practices that sustain and leverage team members' diverse identities. Identity safety and threat mitigation may work together to combat identity threats in the learning environment.

Ambulatory Clinician's Guide to Inpatient Service: An Innovative Rapid Onboarding Strategy for the COVID-19 Pandemic.

BACKGROUND AND SIGNIFICANCE: When hospitals are subject to prolonged surges in patients, such as during the coronavirus disease 2019 (COVID-19) pandemic, additional clinicians may be needed to care for the rapid increase of acutely ill patients. How might we quickly prepare a large number of ambulatory-based clinicians to care for hospitalized patients using the inpatient workflow of the electronic health record (EHR)? OBJECTIVES: The aim of the study is to create a successful training intervention which prepares ambulatory-based clinicians as they transition to inpatient services. METHODS: We created a training guide with embedded videos that describes the workflow of an inpatient clinician. We delivered this intervention via an e-mail hyperlink, a static hyperlink inside of the EHR, and an on-demand hyperlink within the EHR. RESULTS: In anticipation of the first peak of inpatients with COVID-19 in April 2020, the training manual was accessed 261 times by 167 unique users as clinicians anticipated being called into service. As our institution has not yet needed to deploy ambulatory-based clinicians for inpatient service, usage data of the training document is still pending. CONCLUSION: We intend that our novel implementation of a multimedia, highly accessible onboarding document with access from points inside and outside of the EHR will improve clinician performance and serve as a helpful example to other organizations during the COVID-19 pandemic and beyond.

They Don't See a Lot of People My Color: A Mixed Methods Study of Racial/Ethnic Stereotype Threat Among Medical Students on Core Clerkships.

PURPOSE: Stereotype threat is an important psychological phenomenon in which fear of fulfilling negative stereotypes about one's group impairs performance. The effects of stereotype threat in medical education are poorly characterized. This study examined the prevalence of racial/ethnic stereotype threat amongst fourth-year medical students and explored its impact on students' clinical experience. METHOD: This was an explanatory sequential mixed methods study at 2 institutions in 2019. First, the authors administered the quantitative Stereotype Vulnerability Scale (SVS) to fourth-year medical students. The authors then conducted semistructured interviews among a purposive sample of students with high SVS scores, using a qualitative phenomenographic approach to analyze experiences of stereotype threat. The research team considered reflexivity through group discussion and journaling. RESULTS: Overall, 52% (184/353) of students responded to the survey. Collectively, 28% of students had high vulnerability to stereotype threat: 82% of Black, 45% of Asian, 43% of Latinx, and 4% of White students. Eighteen students participated in interviews. Stereotype threat was a dynamic, 3-stage process triggered when students experienced the workplace through the colored lens of race/ethnicity by standing out, reliving past experiences, and witnessing microaggressions. Next, students engaged in internal dialogue to navigate racially charged events and workplace power dynamics. These efforts depleted cognitive resources and interfered with learning. Finally, students responded and coped to withstand threats. Immediate and deferred interventions from allies reduced stereotype threat. CONCLUSIONS: Stereotype threat is common, particularly among non-White students, and interferes with learning. Increased minority representation and developing evidence-based strategies for allyship around microaggressions could mitigate effects of stereotype threat.

SPEAKers at the National Society of Hospital Medicine Meeting: A Follow-UP Study of Gender Equity for Conference Speakers from 2015 to 2019. The SPEAK UP Study.

Women continue to be underrepresented as speakers at national conferences, and research has shown similar trends in hospital medicine. The Society of Hospital Medicine (SHM) Annual Meeting has historically had an open call peer review process for workshop speakers and, in 2019, expanded the process for didactic speakers. We aimed to assess the overall conference trends for women speakers and whether the systematic processes in recruitment procedures (ie, open call) resulted in improved representation of women speakers. We also sought to understand how the proportion of women speakers might affect overall scores of the conference. From 2015 to 2019, the overall representation of women speakers increased, as did evaluation scores during the same time period. When selection processes included the open call peer review process, there were higher proportions of women speakers. An open call process with peer review for speakers may be a systematic process that national meetings could replicate to reduce gender inequities.

Hospital Readmission From the Perspective of Medicaid and Uninsured Patients.

BACKGROUND: Patients with little or no health insurance are frequently readmitted to the hospital, yet few previous studies have listened to patients' explanations of why they returned to the hospital after discharge. Enhanced understanding of patient perspectives may facilitate targeted services and improve care. METHODS: We enrolled 18 patients with Medicaid or no insurance during a hospital readmission within 30 days in a major metropolitan area, and conducted semi-structured qualitative interviews to explore the impact of patients' experiences around readmission using a grounded theory approach. RESULTS: We identified five themes contributing to readmission: (1) therapeutic misalignment; (2) accountability; (3) social fragility; (4) access failures; and (5) disease behavior. Medical conditions were complicated by social influences and insufficiently addressed by our health system. Patients understood the need to manage their own health but were unable to effectively execute care plans because of competing life demands and compromised relationships with health providers. CONCLUSIONS: Our study using interviews of readmitted Medicaid and uninsured patients revealed complex illnesses complicated by social instability and health system failures. Improved patient-provider trust and shared decision-making, while addressing social determinants and expanding care coordination with community partners, provide opportunity to better meet patients' needs and decrease hospital readmission in high-risk patients.