Stereotype Threat and Gender Bias in Internal Medicine Residency: It is Still Hard to be in Charge.

BACKGROUND: Despite similar numbers of women and men in internal medicine (IM) residency, women face unique challenges. Stereotype threat is hypothesized to contribute to underrepresentation of women in academic leadership, and exploring how it manifests in residency may provide insight into forces that perpetuate gender disparities. OBJECTIVE: To quantify the prevalence of stereotype threat in IM residency and explore experiences contributing to that stereotype threat. DESIGN: We used a mixed methods study design. First, we surveyed IM residents using the Stereotype Vulnerability Scale (SVS) to screen for stereotype threat. Second, we conducted focus groups with women who scored high on the SVS to understand experiences that led to stereotype threat. PARTICIPANTS: The survey was sent to all IM residents at University of California, San Francisco (UCSF), in September-November 2019. Focus groups were conducted at UCSF in Spring 2020. APPROACH: The survey included an adapted version of the SVS. For focus groups, we developed a focus group guide informed by literature on stereotype threat. We used a thematic approach to data analysis. The mixed methods design enabled us to draw metainferences by integrating the two data sources. KEY RESULTS: Survey response rate was 61% (110/181). Women were significantly more likely than men to have a score indicating stereotype threat vulnerability (77% vs 0%, p < 0.001). Four themes from focus groups characterized women's experiences of gender bias and stereotype threat: gender norm tension, microaggressions and sexual harassment, authority questioned, and support and allyship. CONCLUSIONS: Gender-based stereotype threat is highly prevalent among women IM residents. This phenomenon poses a threat to confidence and ability to execute patient care responsibilities, detracting from well-being and professional development. These findings indicate that, despite robust representation of women in IM training, further attention is needed to address gendered experiences and contributors to women's vulnerability to stereotype threat.

Sex-Based Role Misidentification and Burnout of Resident Physicians: An Observational Study.

OBJECTIVE: This cross-sectional study characterized associations between sex, role misidentification, and burnout among surgical and nonsurgical residents. SUMMARY BACKGROUND DATA: Limited evidence suggests that female resident physicians are more likely to be misidentified as nonphysician team members, with potential negative implications for wellbeing. The prevalence and impact of role misidentification on the trainee experience in surgical as compared to nonsurgical specialties is unknown. METHODS: An anonymous electronic survey was distributed to fourteen different residency programs at 2 academic medical centers in August 2018. The survey included questions about demographics, symptoms of burnout, the frequency of misidentification as another member of the care team, and the effect of misidentification on respondents' well-being. Results: Two-hundred sixty out of 419 (62.1% response rate) resident physicians completed the survey, of whom 184 (77.3%) reported being misidentified as a nonphysician at least weekly. Female sex was associated with a significantly increased odds of being misidentified at least weekly (adjusted OR 23.7, 95% CI 10.9-51.5; P < 0.001), as was training in a surgical program (adjusted OR 3.7, 95% CI 1.7-8.0; P = 0.001). Frequent role misidentification was associated with burnout (OR 2.6, 95% CI 1.2-5.5; P = 0.01). In free-text responses, residents reported that being misidentified invoked a sense of not belonging, caused emotional exhaustion, and interfered with patient communication. CONCLUSIONS: Role misidentification is more prevalent among female residents and surgical residents, compared to male residents and nonsurgical residents, respectively. Physician role misidentification is associated with burnout and has negative implications for resident wellbeing; interventions to reduce role misidentification are needed.

Appropriateness of inpatient stress testing: Implications for development of clinical decision support mechanisms and future criteria.

BACKGROUND: An upcoming national mandate will require consultation of appropriate use criteria (AUC) through a clinical decision support mechanism (CDSM) for advanced imaging. We aimed to evaluate our current ability to ascertain test appropriateness. METHODS: We prospectively collected data on 288 consecutive stress tests and coronary computed tomography angiography studies for medical inpatients. Study appropriateness was determined independently by two physicians using the 2013 Multimodality AUC. RESULTS: The median age of the study population was 66 years [interquartile range (IQR) 56, 75], 40.8% were female, and 52.8% had a history of coronary artery disease. Review of the electronic health record (EHR) alone was sufficient to deem appropriateness for 87.2% of cases. The most common reason it was insufficient was inability to determine if the patient could exercise (59.5%). After reviewing the EHR and pilot CDSM data together, appropriateness could be determined for 95.8% of the cases. The most common reason appropriateness could not be determined was that the exam indication was not addressed by an AUC criterion (83.3%). CONCLUSION: In preparing for the mandate, it will be important for future CDSM to obtain information on the patient's ability to exercise and for future AUC to include additional indications that are not currently addressed.

Smear Campaign: Misattribution of Pancytopenia to a Tick-Borne Illness.

We report the case of a 51-year-old woman presenting with a targetoid rash and pancytopenia after a tick bite. Initial evaluation was notable for severe neutropenia on the complete blood cell count differential, a positive Lyme IgM antibody, and a peripheral blood smear demonstrating atypical lymphocytes. While her pancytopenia was initially attributed to tick-borne illness, peripheral flow cytometry showed 7% myeloblasts, and a bone marrow biopsy confirmed 60% blasts. The patient was ultimately diagnosed with acute myelogenous leukemia, in addition to early, localized Lyme disease. This case highlights the differential diagnosis for pancytopenia, cytopenia patterns for different tick-borne illnesses, the risk of premature closure in internal medicine, and management of Lyme disease in hosts with altered immunity.

Mutations in FGF17, IL17RD, DUSP6, SPRY4, and FLRT3 are identified in individuals with congenital hypogonadotropic hypogonadism.

Congenital hypogonadotropic hypogonadism (CHH) and its anosmia-associated form (Kallmann syndrome [KS]) are genetically heterogeneous. Among the >15 genes implicated in these conditions, mutations in FGF8 and FGFR1 account for ~12% of cases; notably, KAL1 and HS6ST1 are also involved in FGFR1 signaling and can be mutated in CHH. We therefore hypothesized that mutations in genes encoding a broader range of modulators of the FGFR1 pathway might contribute to the genetics of CHH as causal or modifier mutations. Thus, we aimed to (1) investigate whether CHH individuals harbor mutations in members of the so-called "FGF8 synexpression" group and (2) validate the ability of a bioinformatics algorithm on the basis of protein-protein interactome data (interactome-based affiliation scoring [IBAS]) to identify high-quality candidate genes. On the basis of sequence homology, expression, and structural and functional data, seven genes were selected and sequenced in 386 unrelated CHH individuals and 155 controls. Except for FGF18 and SPRY2, all other genes were found to be mutated in CHH individuals: FGF17 (n = 3 individuals), IL17RD (n = 8), DUSP6 (n = 5), SPRY4 (n = 14), and FLRT3 (n = 3). Independently, IBAS predicted FGF17 and IL17RD as the two top candidates in the entire proteome on the basis of a statistical test of their protein-protein interaction patterns to proteins known to be altered in CHH. Most of the FGF17 and IL17RD mutations altered protein function in vitro. IL17RD mutations were found only in KS individuals and were strongly linked to hearing loss (6/8 individuals). Mutations in genes encoding components of the FGF pathway are associated with complex modes of CHH inheritance and act primarily as contributors to an oligogenic genetic architecture underlying CHH.

Pocket-sized ultrasound as an aid to physical diagnosis for internal medicine residents: a randomized trial.

BACKGROUND: Proficiency and self-confidence in the physical examination is poor among internal medicine residents and interest in ultrasound technology has expanded. OBJECTIVE: We aimed to determine whether a pocket-sized ultrasound improves the diagnostic accuracy and confidence of residents after a 3-h training session and 1 month of independent practice. DESIGN: This was a randomized parallel group controlled trial. PARTICIPANTS: Forty internal medicine residents in a single program at an academic medical center participated in the study. INTERVENTION: Three hours of training on use of pocket-sized ultrasound was followed by 1 month of independent practice. MAIN MEASURES: The primary outcome was a comparison of the diagnostic accuracy of a physical exam alone versus a physical examination augmented with a pocket-sized ultrasound. Other outcomes included confidence in exam findings and a survey of attitudes towards the physical exam and the role of ultrasound. KEY RESULTS: Residents in the intervention group using a pocket-sized ultrasound correctly identified an average of 7.6 of the 17 abnormal findings (accuracy rate of 44.9 %). Those in the control group correctly identified an average of 6.4 abnormal findings (accuracy rate of 37.6 %, p = 0.11). Residents in the intervention group identified on average 15.9 findings as abnormal when no abnormality existed (false positive rate of 16.8 %). Those in the control group incorrectly identified an average of 15.5 positive findings (false positive rate of 16.3 %). There was no difference between groups regarding self-assessed confidence in physical examination. Residents in the intervention group identified 6.1 of 13 abnormal cardiac findings versus the control group's 4.5 of 13, an accuracy rate of 47.0 % versus 34.6 % (p = 0.023). CONCLUSIONS: The diagnostic ability of internal medicine residents did not significantly improve with use of a pocket-sized ultrasound device after a 3-h training session and 1 month of independent practice. TRIAL REGISTRATION: clinicaltrials.gov: number NCT01948076; URL http://clinicaltrials.gov/ct2/show/study/NCT01948076?term=ultrasound+physical+exam&rank=2.

Association of Perceived Role Misidentification With Use of Role Identity Badges Among Resident Physicians.

Importance: Role misidentification of resident physicians occurs frequently and is associated with decreased well-being. Objective: To evaluate the role misidentification and burnout rates among resident physicians after disbursement of role identity badges. Design, Setting, and Participants: This quality improvement study was conducted during the 2018 to 2019 academic year. Residents in 13 surgical and nonsurgical residency programs at 2 large academic medical centers (Massachusetts General Hospital and Brigham and Women's Hospital) were eligible to receive the intervention and complete 2 surveys (before and after the intervention). Data were analyzed from December 4, 2021, to February 7, 2022. Intervention: Role identity badges that displayed "Doctor" and could be attached to mandatory hospital identification badges were distributed to residents in August 2018 at Massachusetts General Hospital and in March 2019 at Brigham and Women's Hospital. Residents were not required to wear the badge. Main Outcomes and Measures: The primary outcome was self-reported role misidentification at least once per week during the previous 3 months. The change from pre- to post-badge distribution surveys was assessed with McNemar's test. A secondary outcome was any reduction in the frequency of role misidentification after badge distribution. Multivariable logistic regression was used to assess the association between reduced frequency of role misidentification and demographic characteristics. A separate analysis evaluated the change in self-reported burnout after badge distribution. Results: A total of 161 residents (39%) completed both surveys, which included 79 men (49%), 72 (45%) who were younger than 30 years, 20 (12%) with an underrepresented in medicine status, and 74 (46%) who were in surgical specialties. The proportion of residents reporting at least weekly role misidentification decreased from 50% (n = 81 of 161) before badge distribution to 35% (n = 57 of 161; P < .001) after badge distribution. Female residents were more likely to report reduced role misidentification frequency after receiving a badge compared with male residents (adjusted odds ratio, 2.32; 95% CI, 1.18-4.63; P = .01). Residents who wore badges demonstrated no change in burnout before vs after badge distribution (39% [n = 33 of 85] vs 34% [29 of 85]; P = .87) compared with an increase among residents who did not wear a badge (27% [n = 15 of 55] vs 45% [n = 25 of 55]; P = .03). Conclusions and Relevance: This study found that the distribution of role identity badges was associated with less frequent perception of role misidentification among resident physicians across specialties, particularly among female residents. Role identity badges were a well-received, low-cost intervention that could be used to reduce role misidentification and address burnout among residents.

The Relationship Between Applicant Gender and Internal Medicine Residency Interview Scores.

BACKGROUND: Gender inequity is widespread in academic medicine, including in the promotion, academic recognition, and compensation of female faculty. OBJECTIVE: To assess whether these inequities extend to the GME intern selection process, this study examines differences in the interview scores assigned to male and female applicants at one large internal medicine residency program. METHODS: Subjects include 1399 applicants who completed 3099 interviews for internship positions for the Brigham and Women's Hospital internal medicine residency in Electronic Residency Application Service (ERAS) cycles 2015-2016, 2017-2018, 2018-2019, and 2019-2020. Unadjusted and multivariable linear regressions were used to assess the simultaneous effect of applicant gender, interviewer gender, and applicant academic characteristics on pre-interview, post-interview, and change in interview scores. RESULTS: Our analysis included 3027 interviews (97.7%) of 1359 applicants (97.1%). There were no statistically significant differences in the interview scores assigned to female versus male applicants. This was true across pre-interview scores (difference = 0.03, P = .61), post-interview scores (difference = 0.00, P = .98), and change in interview scores (difference = 0.01, P = .24) as well as when adjusting for the baseline academic characteristics of both male and female applicants. This was also true when analyzing individual application years, individual residency tracks, and accounting for the gender of the faculty interviewers. CONCLUSIONS: The findings do not support the presence of gender inequity in the interview scores assigned to male and female applicants included in this study.

"Make the Implicit Explicit": Measuring Perceptions of Gender Bias and Creating a Gender Bias Curriculum for Internal Medicine Residents.

BACKGROUND: Gender bias in clinical training has been well established; however, little is known about how perceptions differ between men and women. Furthermore, few curricular options have been developed to discuss gender bias. OBJECTIVE: To measure the prevalence of gender bias, examine qualitative differences between men and women, and create a gender bias curriculum for internal medicine residents. METHODS: We surveyed 114 residents (response rate of 53.5%) to identify the prevalence and types of gender bias experienced in training. We compared estimates between genders and organized qualitative results into shared themes. We then developed a curriculum to promote and normalize discussions of gender bias. RESULTS: Among surveyed residents, 61% reported personal experiences of gender bias during training, with 98% of women and 19% of men reporting experiences when stratified by gender. We identified two domains in which gender bias manifested: role misidentification and a difficult working environment. Residents identified action items that led to the development of a gender bias curriculum. The curriculum includes didactic conferences and training sessions, a microaggression response toolkit, dinners for men and women residents, participation in a WhatsApp support group, and participation in academic projects related to gender bias in training. CONCLUSION: We confirmed a wide prevalence of gender bias and developed a scalable curriculum for gender bias training. Future work should explore the long-term impacts of these interventions.

Impact of acute biochemical castration on insulin sensitivity in healthy adult men.

INTRODUCTION: Evidence supports an inverse relationship between serum testosterone (T) and insulin resistance in men. However, data with respect to causality are limited. The aim of this study was to explore the impact of acute biochemical castration on insulin sensitivity in healthy adult men. METHODS: Ten healthy, adult males (mean age 41.0 +/- 3.9 yr) were studied. Subjects were studied at baseline and after 2 and 4 weeks of biochemical castration. Outpatient hospital research setting. Body composition (dual-energy x-ray absorptiometry), energy expenditure (indirect calorimetry), abdominal and visceral adiposity (MRI), skeletal muscle intramyocellular lipid content ([IMCL] (1)H-MR spectroscopy), and insulin sensitivity (hyperinsulinemic-euglycemic clamp) were assessed before and after 2 and 4 weeks of biochemical castration induced by a GnRH antagonist (acyline 300 mug/kg subcutaneous every 10-14 days). Serum T, insulin and glucose levels, body composition, abdominal visceral fat, IMCL, and glucose disposal rate (M) were measured. RESULTS AND CONCLUSION: Acyline administration suppressed serum T to frankly hypogonadal levels in all subjects for the duration of the study (P <0.009). No significant changes in body composition, energy expenditure, or M were observed at either 2 or 4 weeks of castration. Acyline is an effective GnRH antagonist inducing acute castration in all subjects. ii) Four weeks of biochemical castration has no impact on insulin sensitivity in healthy men likely due to unchanged body composition variables. iii) Insulin resistance associated with chronic low T levels may be largely driven by decreased fat free mass, increased percent body fat, and/or other metabolic regulatory factors.

Residents Take the Lead: A Modern Collaborative Approach to Research During Residency.

BACKGROUND: Participation in scholarship is a requirement for Internal Medicine (IM) residencies, but programs struggle to successfully integrate research into busy clinical schedules. In 2013, the IM residency at Brigham and Women's Hospital implemented the Housestaff Research Project (HRP)- a novel residency-wide research initiative designed to facilitate participation in scholarship. The HRP had two components-a formal research curriculum and an infrastructure that provided funding and mentorship for resident-led, housestaff wide projects. METHODS: This is a mixed-methods study of 190 IM residents and two HRP-supported research projects. Seventy-seven residents responded to an electronic survey about their interests in research exposure in residency. Fifty-six residents responded to an electronic survey about their participation in the HRP. The success of HRP-supported projects was evaluated through resident comments, interviews with three residents leading the first two HRPs and a description of the success of the projects based on resident involvement and dissemination of the results. RESULTS: Eighty-seven percent (n= 67/77) of residents were interested in additional research exposure during residency. Ninety-five percent (n = 53/56) of residents had heard of the HRP, and 77% had participate in at least one aspect of it. Approximately 20 residents were directly involved in the two resident-led projects. HRP-supported projects resulted in presentations at three local and three national conferences, one manuscript in press, and one manuscript in preparation. The resident project leaders felt that a strength and unique aspect of the HRP was the collaboration with co-residents. CONCLUSION: The HRP successfully created a culture of research and scholarship within the residency. The HRP leaders and residents that participated in HRP-supported projects expressed the most direct benefits from the program. All residents were exposed to research concepts and methods. Future directions for the HRP include selecting projects that maximize the number of resident participants and integrating a more robust research curriculum.

A Framework for Inclusive Graduate Medical Education Recruitment Strategies: Meeting the ACGME Standard for a Diverse and Inclusive Workforce.

To help address health care disparities and promote higher-quality, culturally sensitive care in the United States, the Accreditation Council for Graduate Medical Education and other governing bodies propose cultivating a more diverse physician workforce. In addition, improved training and patient outcomes have been demonstrated for diverse care teams. However, prioritizing graduate medical education (GME) diversity and inclusion efforts can be challenging and unidimensional diversity initiatives typically result in failure.Little literature exists regarding actionable steps to promote diversity in GME. Building on existing literature and the authors' experiences at different institutions, the authors propose a 5-point inclusive recruitment framework for diversifying GME training programs. This article details each of the 5 steps of the framework, which begins with strong institutional support by setting diversity as a priority. Forming a cycle, the other 4 steps are seeking out candidates, implementing inclusive recruitment practices, investing in trainee success, and building the pipeline. Practical strategies for each step and recommendations for measurable outcomes for continued support for this work are provided. The proposed framework may better equip colleagues and leaders in academic medicine to prioritize and effectively promote diversity and inclusion in GME at their respective institutions.

Bridging the Divide: Student Grand Rounds at the Interface of Basic Science and Clinical Medicine.

PROBLEM: As biomedical research and clinical medicine become increasingly complex, physician-scientists and clinically oriented biomedical researchers play important roles in bridging the gap between disciplines. A lack of educational programming that addresses the unique needs of students preparing for careers at the interface of basic science and clinical medicine may contribute to trainee attrition. APPROACH: The MD-PhD/LHB Grand Rounds was introduced in 2008 as a trainee-driven collaborative effort of the Harvard/Massachusetts Institute of Technology MD-PhD program at Harvard Medical School (HMS MD-PhD program), Harvard's Leder Human Biology and Translational Medicine (LHB) program, and the Brigham and Women's Hospital (BWH) Internal Medicine Department. Each of the program's approximately 4 sessions per year begins with dinner, followed by a clinical case presentation led by a BWH MD-PhD resident with a master clinician faculty discussant, then a research presentation by an LHB PhD student or an MD-PhD student on a basic science topic related to the clinical case, and time for socialization. OUTCOMES: In a July 2017 survey of participating students and residents, respondents reported being highly satisfied with the program. Mean satisfaction ratings were 4.3 (SD 0.5) for 12 MD-PhD students, 4.2 (SD 0.7) for 31 LHB students, and 4.4 (SD 0.9) for 5 residents on a 5-point scale (5 = very satisfied). Free-text responses suggested MD-PhD students valued opportunities for active engagement with the resident presenter and faculty discussant. LHB students appreciated the absence of medical jargon in the clinical presentations. Residents' reported reasons for participating included enjoyment of teaching and interaction with students. NEXT STEPS: The Harvard MD-PhD/LHB Grand Rounds can serve as a template for developing similar programs at other institutions. Research is needed to determine whether such grand rounds programs can help fix the leaky pipeline in the training of future physician-scientists and clinically oriented biomedical researchers.

Rapid vascular glucose uptake via enzyme-assisted subcutaneous infusion: enzyme-assisted subcutaneous infusion access study.

BACKGROUND: Enzyme-assisted subcutaneous infusion (EASI), with subcutaneous human recombinant hyaluronidase pretreatment, may offer an alternative to standard intravenous (IV) access. OBJECTIVES: This study's objectives were to assess paramedic (Emergency Medical Technician-Paramedic [EMTP])-placed EASI access in volunteers to determine (1) feasibility of EMTP EASI access placement; (2) subject/EMTP ratings of placement ease, discomfort, and overall EASI vs IV preference; and (3) speed of intravascular uptake of EASI infusate. METHODS: Twenty adults underwent 20-gauge IV placement by 4 EMTPs, receiving a 250-mL maximal-rate IV bolus of normal saline. Next, each subject received in the other arm a 20-gauge EASI access line (with 1-mL injection of 150 U of human recombinant hyaluronidase), through which was infused 250 mL D5NS (1 g glucose was labeled with stable tracer 13C). Blood draws enabled gas chromatography/mass spectrometry (GC/MS) assessment of 13C-glucose uptake. Intravenous access and EASI access were compared for time parameters and subject/EMTP ratings. Data were analyzed with median and interquartile range, Kruskal-Wallis testing, Fisher exact test, and regression (GC/MS data). RESULTS: Intravenous access and EASI access were successful in all 20 subjects. Compared with EASI access (all placed in <15 seconds), IV access took longer; but the 250-mL bolus was given more quickly via IV access. EMTPs rated EASI easier to place than IV; pain ratings were similar for IV and EASI. The GC/MS showed intravascular uptake at all time points. CONCLUSIONS: Enzyme-assisted subcutaneous infusion is faster and easier to initiate than IV access; intravascular absorption of EASI-administered fluids begins within minutes.