Ethics and Academic Discourse, Scientific Integrity, Uncertainty, and Disinformation in Medicine: An American College of Physicians Position Paper.

Respect for the scientific process and a diversity of views; open discourse and debate based on principles of ethics, best available evidence, and scientific inquiry and integrity; and an understanding of evidence gaps and uncertainty and how to communicate about them are important values in the advancement of science and the practice of medicine. Physicians often must make decisions about their recommendations to patients in the face of scarce or conflicting data. Are these characteristics of medicine and science widely understood and effectively communicated among members of the profession and to patients and the public? Issues of scientific integrity are longstanding, but COVID-19 brought them to the forefront, in an environment that was sometimes characterized by communication missteps as guidance came and went-or changed-quickly. Today, is open debate flourishing? Have some debates shed more heat than light? Are people losing confidence in science and medicine? In health care institutions? The American College of Physicians explores these issues and offers guidance in this position paper.

Reducing Firearm Injuries and Deaths in the United States: A Position Paper From the American College of Physicians.

For more than 20 years, the American College of Physicians (ACP) has advocated for the need to address firearm-related injuries and deaths in the United States. Yet, firearm violence continues to be a public health crisis that requires the nation's immediate attention. The policy recommendations in this paper build on, strengthen, and expand current ACP policies approved by the Board of Regents in April 2014, based on analysis of approaches that the evidence suggests will be effective in reducing deaths and injuries from firearm-related violence.

Addressing Social Determinants to Improve Patient Care and Promote Health Equity: An American College of Physicians Position Paper.

Social determinants of health are nonmedical factors that can affect a person's overall health and health outcomes. Where a person is born and the social conditions they are born into can affect their risk factors for premature death and their life expectancy. In this position paper, the American College of Physicians acknowledges the role of social determinants in health, examines the complexities associated with them, and offers recommendations on better integration of social determinants into the health care system while highlighting the need to address systemic issues hindering health equity.

Achieving Gender Equity in Physician Compensation and Career Advancement: A Position Paper of the American College of Physicians.

Women comprise more than one third of the active physician workforce, an estimated 46% of all physicians-in-training, and more than half of all medical students in the United States. Although progress has been made toward gender diversity in the physician workforce, disparities in compensation exist and inequities have contributed to a disproportionately low number of female physicians achieving academic advancement and serving in leadership positions. Women in medicine face other challenges, including a lack of mentors, discrimination, gender bias, cultural environment of the workplace, imposter syndrome, and the need for better work-life integration. In this position paper, the American College of Physicians summarizes the unique challenges female physicians face over the course of their careers and provides recommendations to improve gender equity and ensure that the full potential of female physicians is realized.

Population representation among anatomical donors and the implication for medical student education.

Dissection provides a unique opportunity to integrate anatomical and clinical education. Commonly, cadavers are randomly assigned to courses, which may result in skewed representation of patient populations. The primary aim of this study was to determine if the anatomical donors studied by students at the University of Massachusetts Medical School (UMMS) accurately represent the disease burden of the local patient population. This cross-sectional study compared the University of Massachusetts Memorial Medical Center patient claims data and body donation data from the UMMS Anatomical Gift Program (AGP). This study examined age, race, sex, and morbidities within a 10-year timeframe in 401,258 patients and 859 anatomical donors who met inclusion criteria. An independent t test was conducted to compare the mean ages of the two populations. Chi square analysis was conducted on race, sex, and 10 morbidity categories. A Fischer's exact test was conducted for two morbidity categories with n < 10. Demographic analysis showed a significant difference in age, and racial representation between the populations. No statistical difference was found regarding sex. Morbidities were separated into 22 ICD-10 categories. Twelve categories were excluded and 10 were analyzed for population comparison. Two categories were over represented and seven were under-represented in the AGP population. One category showed no significant difference between populations. Targeted selection of cadavers in anatomy courses would improve morbidity variability in the anatomy lab. In addition, AGP acceptance guidelines should be evaluated to increase disease variation among the donor population. Clin. Anat. 31:250-258, 2018. © 2017 Wiley Periodicals, Inc.

Access to transportation for Chittenden County Vermont older adults.

BACKGROUND: Aging often leads to decreased independence and mobility, which can be detrimental to health and well-being. The growing population of older adults will create a greater need for reliable transportation. AIMS: Explore whether and how lack of transportation has compromised areas of daily lives in older adults. METHODS: 1221 surveys with 36 questions assessing transportation access, usage, and impact on activities were distributed to Chittenden County, Vermont older adults; 252 met criteria for analysis. RESULTS: Older adults reported overwhelming difficulty getting to activities considered important, with 69 % of participants delaying medical appointments due to transportation barriers. Although family and friends represent a primary method of transportation, older adults reported difficulty asking them for help. DISCUSSION: Lack of accessible transportation leads to missed healthcare appointments and social isolation, which may have detrimental effects on older adults' quality of life. CONCLUSION: Many older adults face significant transportation challenges that negatively affect their health and well-being.

Public and Population Health in U.S. Medical Education: A Review of Guidance in Extraordinary Times.

ABSTRACT: Generations of medical educators have recommended including public and population health (PPH) content in the training of U.S. physicians. The COVID-19 pandemic, structural racism, epidemic gun violence, and the existential threats caused by climate change are currently unsubtle reminders of the essential nature of PPH in medical education and practice. To assess the state of PPH content in medical education, the authors reviewed relevant guidance, including policies, standards, and recommendations from national bodies that represent and oversee medical education for physicians with MD degrees.Findings confirm that guidance across the medical education continuum, from premedical education to continuing professional development, increasingly includes PPH elements that vary in specificity and breadth. Graduate medical education policies present the most comprehensive approach in both primary care and subspecialty fields. Behavioral, quantitative, social, and systems sciences are represented, although not uniformly, in guidance for every phase of training. Quantitative PPH skills are frequently presented in the context of research, but not in relation to the development of population health perspectives (e.g., evidence-based medicine, quality improvement, policy development). The interdependence between governmental public health and medical practice, environmental health, and the impact of structural racism and other systems of oppression on health are urgent concerns, yet are not consistently or explicitly included in curricular guidance. To prepare physicians to meet the health needs of patients and communities, educators should identify and address gaps and inconsistencies in PPH curricula and related guidance.Re-examinations of public health and health care systems in the wake of the COVID-19 pandemic support the importance of PPH in physician training and practice, as physicians can help to bridge clinical and public health systems. This review provides an inventory of existing guidance (presented in the appendices) to assist educators in establishing PPH as an essential foundation of physician training and practice.

Patients' Perspectives of Diagnostic Error: A Qualitative Study.

OBJECTIVES: The Institute of Medicine (IOM) defines diagnostic error as the failure to establish an accurate or timely explanation for the patient's health problem(s) or effectively communicate the explanation to the patient. Using this definition, we sought to characterize diagnostic errors experienced by patients and describe patient perspectives on causes, impacts, and prevention strategies. METHODS: We conducted interviews of adults hospitalized at an academic medical center. We used the framework of the IOM definition of diagnostic error to perform thematic analysis of qualitative data. Descriptive statistics were used to summarize quantitative data. RESULTS: Based on the IOM's definition of diagnostic error, 27 of the 69 included patients reported at least one diagnostic error in the past 5 years. The errors were distributed evenly across the following three dimensions of the IOM definition: accuracy, communication, and timeliness. Limited time with doctors, communication, clinical assessment, and clinical management emerged as major themes for causes of diagnostic error and for strategies to reduce diagnostic error. Impacts of errors included emotional distress, adverse health outcomes, and impaired activities of daily living. CONCLUSIONS: This study uses the recent IOM definition of diagnostic error to provide insights into diagnostic error from the patient perspective. We found that diagnostic errors were commonly reported by hospitalized adults and have a profound impact on patients' well-being. Patients' insights regarding potential causes and prevention strategies may help identify opportunities to reduce diagnostic errors.

Jobs, Housing, and Mask Wearing: Cross-Sectional Study of Risk Factors for COVID-19.

BACKGROUND: Many studies have focused on the characteristics of symptomatic patients with COVID-19 and clinical risk factors. This study reports the prevalence of COVID-19 in an asymptomatic population of a hospital service area (HSA) and identifies factors that affect exposure to the virus. OBJECTIVE: The aim of this study is to measure the prevalence of COVID-19 in an HSA, identify factors that may increase or decrease the risk of infection, and analyze factors that increase the number of daily contacts. METHODS: This study surveyed 1694 patients between April 30 and May 13, 2020, about their work and living situations, income, behavior, sociodemographic characteristics, and prepandemic health characteristics. This data was linked to testing data for 454 of these patients, including polymerase chain reaction test results and two different serologic assays. Positivity rate was used to calculate approximate prevalence, hospitalization rate, and infection fatality rate (IFR). Survey data was used to analyze risk factors, including the number of contacts reported by study participants. The data was also used to identify factors increasing the number of daily contacts, such as mask wearing and living environment. RESULTS: We found a positivity rate of 2.2%, a hospitalization rate of 1.2%, and an adjusted IFR of 0.55%. A higher number of daily contacts with adults and older adults increases the probability of becoming infected. Occupation, living in an apartment versus a house, and wearing a face mask outside work increased the number of daily contacts. CONCLUSIONS: Studying prevalence in an asymptomatic population revealed estimates of unreported COVID-19 cases. Occupational, living situation, and behavioral data about COVID-19-protective behaviors such as wearing a mask may aid in the identification of nonclinical factors affecting the number of daily contacts, which may increase SARS-CoV-2 exposure.

Public Health Is Essential: COVID-19's Learnable Moment for Medical Education.

The COVID-19 pandemic, an unprecedented challenge for this generation of physicians and for the health care system, has reawakened calls to strengthen the United States' public health systems. This global event is also a "learnable moment" for medical education-an opportunity to decisively incorporate public health, including public health systems, through the continuum of medical education. Although medical educators have made progress in integrating public health content into medical curricula, "public health" is not a phrase that is consistently used in curricular standards, and public health colleagues are not identified as unique and critical partners to improve and protect health. The COVID-19 crisis has demonstrated how a strong public health system is necessary to support the health of patients and populations, as well as the practice of medicine. Partnerships between medical and public health communities, through individual- and population-based interventions, can also more effectively combat more common threats to health, such as chronic diseases, health inequities, and substance abuse.To achieve a more effective medicine-public health relationship in practice, curricula across the continuum of medical education must include explanations of public health systems, the responsibilities of physicians to their local and state governmental public health agencies, and opportunities for collaboration. Medical education should also prepare physicians to advocate for public health policies, programs, and funding in order to improve and protect the health of their patients and communities. Pandemic COVID-19 demonstrates with laser focus that all physicians are part of public health systems and that public health content has a distinct and essential place across the continuum of medical education to prepare physicians to participate in, collaborate with, and advocate for public health systems.

Teaching Public and Population Health in Medical Education: An Evaluation Framework.

Curriculum models and training activities in medical education have been markedly enhanced to prepare physicians to address the health needs of diverse populations and to advance health equity. While different teaching and experiential learning activities in the public health and population health sciences have been implemented, there is no existing framework to measure the effectiveness of public and population health (PPH) education in medical education programs. In 2015, the Association of American Medical Colleges established the Expert Panel on Public and Population Health in Medical Education, which convened 20 U.S. medical faculty members whose goal was to develop an evaluation framework adapted from the New World Kirkpatrick Model. Institutional leaders can use this framework to assess the effectiveness of PPH curricula for learners, faculty, and community partners. It may also assist institutions with identifying opportunities to improve the integration of PPH content into medical education programs. In this article, the authors present outcomes metrics and practical curricular or institutional illustrations at each Kirkpatrick training evaluation level to assist institutions with the measurement of (1) reaction to the PPH education content, (2) learning accomplished, (3) application of knowledge and skills to practice, and (4) outcomes achieved as a result of PPH education and practice. A fifth level was added to measure the benefit of PPH curricula on the health system and population health. The framework may assist with developing a locally relevant evaluation to further integrate and support PPH education at U.S. medical schools and teaching hospitals.

Community-academic partnerships: a "community-first" model to teach public health.

CONTEXT: Physicians face complex public health issues in clinical practice today. We describe an innovative "community-first" model that teaches public health to medical students. METHODS: The United Way of Chittenden County Volunteer Center (UWCCVC) in the State of Vermont, U.S.A., was chosen as the focal point for projects because of its documented history, success, and credibility. A simple form, sent to local community agencies, facilitated participation and identified Healthy People 2010 focus areas as the public health framework. Community agencies identified the health needs of populations that were served through this process. Projects were subsequently jointly developed and following student completion, assessed jointly by university faculty and community agency mentors. RESULTS: A total of 41 projects have been completed, spanning 11 different areas of Healthy People 2010. Many different local community agencies have participated. An annual poster session is held at project completion. Assessment includes both faculty mentor and community agency assessment of student groups' progress and project quality. Community agencies are surveyed following project completion. Nearly all community agencies agreed that projects benefited the populations served and anticipated continuing the partnership. CONCLUSIONS: Putting community public health needs first, in developing projects, was critical to success. This "community-first" model provides opportunities to teach public health and benefit health in local communities.

Death Certification Errors and the Effect on Mortality Statistics.

OBJECTIVE: Errors in cause and manner of death on death certificates are common and affect families, mortality statistics, and public health research. The primary objective of this study was to characterize errors in the cause and manner of death on death certificates completed by non-Medical Examiners. A secondary objective was to determine the effects of errors on national mortality statistics. METHODS: We retrospectively compared 601 death certificates completed between July 1, 2015, and January 31, 2016, from the Vermont Electronic Death Registration System with clinical summaries from medical records. Medical Examiners, blinded to original certificates, reviewed summaries, generated mock certificates, and compared mock certificates with original certificates. They then graded errors using a scale from 1 to 4 (higher numbers indicated increased impact on interpretation of the cause) to determine the prevalence of minor and major errors. They also compared International Classification of Diseases, 10th Revision (ICD-10) codes on original certificates with those on mock certificates. RESULTS: Of 601 original death certificates, 319 (53%) had errors; 305 (51%) had major errors; and 59 (10%) had minor errors. We found no significant differences by certifier type (physician vs nonphysician). We did find significant differences in major errors in place of death ( P < .001). Certificates for deaths occurring in hospitals were more likely to have major errors than certificates for deaths occurring at a private residence (59% vs 39%, P < .001). A total of 580 (93%) death certificates had a change in ICD-10 codes between the original and mock certificates, of which 348 (60%) had a change in the underlying cause-of-death code. CONCLUSIONS: Error rates on death certificates in Vermont are high and extend to ICD-10 coding, thereby affecting national mortality statistics. Surveillance and certifier education must expand beyond local and state efforts. Simplifying and standardizing underlying literal text for cause of death may improve accuracy, decrease coding errors, and improve national mortality statistics.

An Exploratory Analysis of Public Awareness and Perception of Ionizing Radiation and Guide to Public Health Practice in Vermont.

Exposure to ionizing radiation has potential for acute and chronic health effects. Within the general public of the United States, there may be a discrepancy between perceived and actual health risks. In conjunction with the Vermont Department of Health, a survey designed to assess public perception and knowledge of ionizing radiation was administered at 6 Vermont locations (n = 169). Descriptive and inferential statistical analyses were conducted. Eighty percent of respondents underestimated the contribution of medical imaging tests to total ionizing radiation exposure. Although only thirty-nine percent of participants were confident in their healthcare professional's knowledge of ionizing radiation, most would prefer to receive information from their healthcare professional. Only one-third of individuals who received a medical imaging test in the past year were educated by their healthcare professional about the risks of these tests. Those who tested their home for radon were twice as likely to choose radon as the greatest ionizing radiation risk to self. Although respondents had an above-average education level, there were many misperceptions of actual risks of exposure to ionizing radiation, particularly of medical imaging tests. Educating healthcare professionals would therefore have a profound and positive impact on public understanding of ionizing radiation.

Factors contributing to suboptimal rates of childhood vaccinations in Vermont.

Childhood immunizations are invaluable in preventing contagious diseases. Nonetheless, vaccines have become increasingly controversial with growing numbers of caregivers refusing to vaccinate their children. The percentage of fully vaccinated children in Vermont is one of the lowest nationally. This study set out to determine Vermont caregivers' attitudes toward immunizations to better explain why the percentage of fully vaccinated children has fallen in Vermont. A survey regarding caregivers' health care knowledge about children, their vaccination concerns, and their children's vaccination status was sent to participants in the Vermont Women, Infants and Children's Program from two districts. In total, 83% (n = 379) of respondents reported their children received all recommended vaccinations for their age. Respondents who considered themselves highly knowledgeable regarding their children's health care and confident about the safety of vaccinations were significantly associated with reporting their children as being current on vaccinations and with their intent to continue vaccinations. Respondents indicated highest concern regarding the safety and number of vaccinations administered during one visit. Primary care providers were indicated as important resources for addressing concerns about vaccinations and health care knowledge of children. The results help to understand low vaccination rates in Vermont and can be used for targeting health campaigns to improve vaccination rates.

Relationships of a brief measure of youth assets to health-promoting and risk behaviors.

PURPOSE: To test the utility of a brief measure of developmental assets for predicting risk and health-promoting behaviors. METHODS: Six "assets" questions were added to an existing school-based survey of health-related behaviors. "Asset" questions dealt with students' grades in school, their communication with parents about school, students' perceptions of their role in school decision-making, students' participation in after-school activities and volunteering, and students' perceptions that they "matter" in their community. Participants were 30,916 Vermont students in grades 8-12. The sample included approximately equal numbers of girls and boys. It was 92% white. Fifty-nine percent of students' mothers had completed at least some postsecondary education (according to student report). Data were analyzed by Chi-square techniques and logistic regression. RESULTS: Number of assets (0-6) was negatively related to students' engagement in each of seven risk behaviors, and positively related to three health-promoting behaviors. The effects of number of assets were in most cases independent of demographic variables. Among the six assets, academic success (grades in school) contributed the greatest effect for most of the outcome measures; however, each of the assets contributed significant independent effects to multiple risk- and health-behaviors. CONCLUSIONS: Students' assets, even if relatively few, may make important contributions to wellness, independent of other well-established demographic factors.

Prevalence of food insecurity and utilization of food assistance program: an exploratory survey of a Vermont middle school.

BACKGROUND: Access to sufficient food--in terms of both quality and quantity--is especially critical for children. Undernourishment during childhood and adolescence can have health implications, both short and long term. The prevalence of food insecurity was assessed in a sample of Vermont school children, as well as the relationship between food insecurity, participation in school breakfast or lunch, exercise and body mass index (BMI), all with a goal to identify needs to improve effectiveness of current programs. METHODS: A cross-sectional, 23-item self-administered survey of students attending a public middle school in Vermont. RESULTS: Twenty percent of the children were residing in a food insecure household. No statistically significant differences were observed in terms of age, sex or BMI percentile and food security status. Food insecure (with or without hunger) participants were less likely to eat breakfast at home compared to food secure participants (67.1% vs 81.4%, p = .007). However, such differences were not observed between eating school breakfast or lunch. Sixty-two percent of food insecure (with or without hunger) participants engaged in daily exercise compared to 75.9% food secure participants (p = .014). CONCLUSION: Children in food insecure households were less likely to be physically active and to eat breakfast at home. However, the school breakfast program is negating any difference between the 2 groups in terms of eating breakfast at all. We consider this a success given the short- and long-term implications of food insecurity in children. We believe these findings have important implications for schools, policy makers, and programs to reduce food insecurity.

Evaluation of a modified prescription form to address prescribing errors.

PURPOSE: The impact of a modified paper prescription form on the occurrence of prescribing errors was evaluated. METHODS: Rural primary care providers practicing in the United States who wrote paper prescriptions in English were eligible for study participation. The prescribers agreed to use only the prescription pads provided to them during the study. The study prescription pads contained 50 prescription forms, each with a duplicate. Each prescription and duplicate contained a unique serial number for data identification purposes. When a prescriber wrote a prescription, the original was provided to the patient per usual practice, and the duplicate was retained as the study data. Two prescription pads contained modified forms and two prescription pads were similar to the prescription pads the prescriber had been using. Providers completed 100 standard and 100 modified prescriptions. Pharmacist consultants reviewed each prescription for the presence or absence of errors. The primary outcome measure was the number of errors. Secondary outcomes were risk differences between standard and modified prescription forms for various error types. RESULTS: Of the 327 prescribers who were eligible and expressed interest in the study, 111 started the study and 84 completed the study. A total of 16,061 prescriptions were eligible for analysis. Pharmacists identified at least one prescribing problem in 987 prescriptions (6.1%). Modified prescription forms were associated with significantly more prescribing problems than standard prescription forms (odds ratio, 1.85; 95% confidence interval, 1.5-2.2; p < 0.001). CONCLUSION: Modified prescription forms were associated with more errors than were standard prescription forms in a sample of rural prescribers.