Transcription factor Tox2 is required for metabolic adaptation and tissue residency of ILC3 in the gut.

Group 3 innate lymphoid cells (ILC3) are the major subset of gut-resident ILC with essential roles in infections and tissue repair, but how they adapt to the gut environment to maintain tissue residency is unclear. We report that Tox2 is critical for gut ILC3 maintenance and function. Gut ILC3 highly expressed Tox2, and depletion of Tox2 markedly decreased ILC3 in gut but not at central sites, resulting in defective control of Citrobacter rodentium infection. Single-cell transcriptional profiling revealed decreased expression of Hexokinase-2 in Tox2-deficient gut ILC3. Consistent with the requirement for hexokinases in glycolysis, Tox2-/- ILC3 displayed decreased ability to utilize glycolysis for protein translation. Ectopic expression of Hexokinase-2 rescued Tox2-/- gut ILC3 defects. Hypoxia and interleukin (IL)-17A each induced Tox2 expression in ILC3, suggesting a mechanism by which ILC3 adjusts to fluctuating environments by programming glycolytic metabolism. Our results reveal the requirement for Tox2 to support the metabolic adaptation of ILC3 within the gastrointestinal tract.

Infection induces tissue-resident memory NK cells that safeguard tissue health.

Tissue health is dictated by the capacity to respond to perturbations and then return to homeostasis. Mechanisms that initiate, maintain, and regulate immune responses in tissues are therefore essential. Adaptive immunity plays a key role in these responses, with memory and tissue residency being cardinal features. A corresponding role for innate cells is unknown. Here, we have identified a population of innate lymphocytes that we term tissue-resident memory-like natural killer (NKRM) cells. In response to murine cytomegalovirus infection, we show that circulating NK cells were recruited in a CX3CR1-dependent manner to the salivary glands where they formed NKRM cells, a long-lived, tissue-resident population that prevented autoimmunity via TRAIL-dependent elimination of CD4+ T cells. Thus, NK cells develop adaptive-like features, including long-term residency in non-lymphoid tissues, to modulate inflammation, restore immune equilibrium, and preserve tissue health. Modulating the functions of NKRM cells may provide additional strategies to treat inflammatory and autoimmune diseases.

Tissue-resident memory NK cells: Homing in on local effectors and regulators.

Natural killer (NK) cells are the prototype innate effector lymphocyte population that plays an important role in controlling viral infections and tumors. Studies demonstrating that NK cells form long-lived memory populations, akin to those generated by adaptive immune cells, prompted a revaluation of the potential functions of NK cells. Recent data demonstrating that NK cells are recruited from the circulation into tissues where they form long-lived memory-like populations further emphasize that NK cells have properties that mirror those of adaptive immune cells. NK cells that localize in non-lymphoid tissues are heterogeneous, and there is a growing appreciation that immune responses occurring within tissues are subject to tissue-specific regulation. Here we discuss both the immune effector and immunoregulatory functions of NK cells, with a particular emphasis on the role of NK cells within non-lymphoid tissues and how the tissue microenvironment shapes NK cell-dependent outcomes.

TRM cells: not born this way.

Human tissue-resident memory T (TRM) cells seeded early in life undergo an age-associated functional maturation and residency acquisition throughout childhood.

Kidney-resident innate-like memory γδ T cells control chronic Staphylococcus aureus infection of mice.

γδ T cells are involved in the control of Staphylococcus aureus infection, but their importance in protection compared to other T cells is unclear. We used a mouse model of systemic S. aureus infection associated with high bacterial load and persistence in the kidney. Infection caused fulminant accumulation of γδ T cells in the kidney. Renal γδ T cells acquired tissue residency and were maintained in high numbers during chronic infection. At day 7, up to 50% of renal γδ T cells produced IL-17A in situ and a large fraction of renal γδ T cells remained IL-17A+ during chronic infection. Controlled depletion revealed that γδ T cells restricted renal S. aureus replication in the acute infection and provided protection during chronic renal infection and upon reinfection. Our results demonstrate that kidney-resident γδ T cells are nonredundant in limiting local S. aureus growth during chronic infection and provide enhanced protection against reinfection.

The glioblastoma multiforme tumor site promotes the commitment of tumor-infiltrating lymphocytes to the TH17 lineage in humans.

Although glioblastoma multiforme (GBM) is not an invariably cold tumor, checkpoint inhibition has largely failed in GBM. In order to investigate T cell-intrinsic properties that contribute to the resistance of GBM to endogenous or therapeutically enhanced adaptive immune responses, we sorted CD4+ and CD8+ T cells from the peripheral blood, normal-appearing brain tissue, and tumor bed of nine treatment-naive patients with GBM. Bulk RNA sequencing of highly pure T cell populations from these different compartments was used to obtain deep transcriptomes of tumor-infiltrating T cells (TILs). While the transcriptome of CD8+ TILs suggested that they were partly locked in a dysfunctional state, CD4+ TILs showed a robust commitment to the type 17 T helper cell (TH17) lineage, which was corroborated by flow cytometry in four additional GBM cases. Therefore, our study illustrates that the brain tumor environment in GBM might instruct TH17 commitment of infiltrating T helper cells. Whether these properties of CD4+ TILs facilitate a tumor-promoting milieu and thus could be a target for adjuvant anti-TH17 cell interventions needs to be further investigated.

Single-cell analysis of CD4+ tissue residency memory cells (TRMs) in adult atopic dermatitis: A new potential mechanism.

The pathophysiology of atopic dermatitis (AD) is complex. CD4+ T cells play an essential role in the development of lesions in AD. However, the underlying mechanism remains unclear. In the present study, we investigated the differentially expressed genes (DEGs) between adult AD lesioned and non-lesioned skin using two datasets from the Gene Expression Omnibus (GEO) database. 62 DEGs were shown to be related to cytokine response. Compared to non-lesioned skin, lesioned skin showed immune infiltration with increased numbers of activated natural killer (NK) cells and CD4+ T memory cells (p < 0.01). We then identified 13 hub genes with a strong association with CD4+ T cells using weighted correlation network analysis. Single-cell analysis of AD detected a novel CD4+ T subcluster, CD4+ tissue residency memory cells (TRMs), which were verified through immunohistochemistry (IHC) to be increased in the dermal area of AD. The significant relationship between CD4+ TRM and AD was assessed through further analyses. FOXO1 and SBNO2, two of the 13 hub genes, were characteristically expressed in the CD4+ TRM, but down-regulated in IFN-γ/TNF-α-induced HaCaT cells, as shown using quantitative polymerase chain reaction (qPCR). Moreover, SBNO2 expression was associated with increased Th1 infiltration in AD (p < 0.05). In addition, genes filtered using Mendelian randomization were positively correlated with CD4+ TRM and were highly expressed in IFN-γ/TNF-α-induced HaCaT cells, as determined using qPCR and western blotting. Collectively, our results revealed that the newly identified CD4+ TRM may be involved in the pathogenesis of adult AD.

Foxp3+ regulatory T cells in the central nervous system and other nonlymphoid tissues.

Foxp3+ regulatory T (Treg) cells are indispensable for the maintenance of immunologic self-tolerance as well as for the confinement of autoimmune inflammation after the breach of self-tolerance. In order to fulfill these tasks, Treg cells operate in secondary lymphoid tissues and nonlymphoid tissues. The conditions for Treg cell stability and for their modes of action are different according to their compartment of residence. In addition, Treg cells initiate residency programs to inhabit niches in nonlympoid tissues (NLT) in steady state and after re-establishment of previously deflected homeostasis for extended periods of time. These NLT Treg cells are different from lymphoid tissue residing Treg cells and are functionally specialized to subserve not only immune functions but support intrinsic functions of their tissue of residence. This review will highlight current ideas about the functional specialization of NLT Treg cells in particular in the central nervous system (CNS) and discuss challenges that we are facing in an effort to exploit the power of NLT Treg cells for maintenance of tissue homeostasis and perhaps also tissue regeneration.

Research Training and Scholarly Activity during General Pediatric Residency in Canada.

OBJECTIVE: To describe the characteristics of research training and scholarly activity during pediatrics residency in Canada and identify facilitators and barriers to resident scholarly activity. STUDY DESIGN: We conducted a mixed-methods, cross-sectional survey of pediatrics residents in Canada from April to June 2023. Trainees and medical education experts developed the 55-item survey, pilot tested, and distributed electronically to residents in all 17 Canadian residency programs. Responses were complemented with program-level data from pediatrics residency program directors. RESULTS: Of 644 Canadian pediatrics residents, 230 (36%) responded. Resident respondents conducted various types of scholarly projects, including retrospective clinical study (22%), qualitative research (15%), quality improvement (13%), and medical education research (12%). Discordance between the field of career interests and primary scholarly projects was common. Among respondents, 20% had abstracts accepted at national or international conferences, and 12% had manuscripts submitted to peer-reviewed journals. Resident respondents' self-perceived progress in their scholarly projects were discrepant from their actual progress. Key themes related to barriers and facilitators to scholarly activity included protected time for research, mentorship, and research skills training. CONCLUSIONS: The research training and scholarly activity of pediatrics residents in Canada is variable. Establishing national standards, implementing progress monitoring mechanisms with tailored support, and offering flexible protected research time are important next steps.

A Multi-Institutional Study from the US ROPE Consortium Examining Factors Influencing Vascular Surgery Specialization among General Surgery Residents.

BACKGROUND: There remains a progressive projected deficit in the vascular surgery (VS) workforce for decades yet to come. Despite the rise of an expanding integrated VS residency pathway, the fellowship training model remains critical in supporting our future workforce. Therefore, it is imperative to understand the resident and program-specific factors that influence VS specialization among general surgery (GS) residents. METHODS: Data from the US Resident OPerative Experience (ROPE) Consortium, comprising 20 Accreditation Council for Graduate Medical Education (ACGME)-accredited GS residency programs across the United States, were queried for resident demographics and residency program-related details. Logistic regression analysis was used to identify factors associated with VS specialization. RESULTS: From 2010 to 2020, a total of 1343 graduating GS residents were included in the study. Of these, 135 (10.1%) pursued VS fellowship training. Residents pursuing VS were more frequently male (80.7% vs 62.8%, p<0.0001) and younger (median 32 vs 33 yr, p=0.03) compared with other GS residents. Racial and ethnic group, underrepresented in medicine (URiM) status, and international medical graduate (IMG) status were similar between VS and non-VS groups. Residency program-level details were also similar between groups, including program type (university vs community-based), region, size, resident volume, dedicated research experience, and National Institutes of Health funding. Dedicated vascular rotations were common among all GS programs (95.4%), and total months spent on a VS rotation (median 4 vs 4.5 mo, p=0.11) did not differ among residents pursuing VS and all other residents. The presence of a collocated traditional (5+2) VS fellowship (91.1% vs 90.4%, p=0.79) or integrated (0+5) VS residency (56.3% vs 55.0%, p=0.77) were also similar between groups. On multivariate analysis, only male sex (odds ratio 2.34, 95% confidence interval, 1.50-3.81, p<0.001) was associated with pursuing VS fellowship. Factors that did not impact VS specialization included resident age, URiM status, IMG status, program volume, dedicated research experience, or total months spent on a VS rotation. CONCLUSIONS: In this multi-institutional study, we did not find any program-specific factors that influence VS specialization among GS residents. Notably, the presence of a collocated 0+5 residency or 5+2 fellowship program did not appear to deter GS residents from pursuing VS fellowship. These data suggest that individual factors, such as mentorship, may be more impactful in recruiting GS residents to the VS specialty.

Predicting the future caretakers of traumatic vascular injury management via operative exposure among surgical trainees.

BACKGROUND: The management of vascular trauma requires specialized training and expertise. Although traumatic vascular injury is treated currently by both vascular and trauma surgeons in modern practice, it remains unclear who will inherit the role of managing vascular trauma in the coming decades. In this study, we examined disparities in operative experience in vascular trauma among surgical trainees across different surgical specialties. METHODS: Accreditation Council for Graduate Medical Education national operative log reports were collected for graduating vascular surgery residents (VSRs), vascular surgery fellows (VSFs), and general surgery residents (GSRs) from 2012 to 2022. Total operative volume for traumatic vascular injury was examined, as were the five major contributing operative domains (neck, thoracic, abdominal, peripheral, and fasciotomy). RESULTS: A total of 22,052 GSRs, 334 VSRs, and 1672 VSFs graduated over the 10-year study period. VSR had the highest vascular trauma case volume (24.9 ± 3.9 cases/5 years), followed by VSF (22.1 ± 1.5 cases/2 years) then GSR (2.4 ± 0.3 cases/5 years; P < .001). Thoracic vessel exploration/repair (0.7 cases vs 0.6 cases vs 0.0 cases), abdominal vessel exploration/repair (1.0 cases vs 0.9 cases vs 0.0 cases), neck vessel exploration/repair (4.0 cases vs 3.4 cases vs 0.2 cases), peripheral vessel exploration/repair (12.1 cases vs 9.5 cases vs 1.1 cases), and lower extremity fasciotomy for trauma (7.2 cases vs 7.6 cases vs 1.1 cases) were most frequent among the VSR and VSF groups (P < .001 each). On linear regression analysis, both VSF (+0.5 cases/y; R2 = 0.81; P < .001) and GSR (+0.1 cases/y; R2 = 0.75; P = .001) groups experienced a growth in vascular trauma volume. Contrariwise, vascular trauma volume did not change among graduating VSRs (R2 = 0.13; P = .31). CONCLUSIONS: Dedicated vascular surgical training provides the highest operative exposure to civilian vascular trauma in the United States.

Vascular In-person for Students In the match Trial: An investigation of postinterview site visits to address the limitations of virtual interviews.

PURPOSE: The graduate medical education community implemented virtual residency interviews in response to travel restrictions during the COVID-19 pandemic, and this approach has persisted. Although many residency applicants wish to visit in-person prospective training sites, such opportunities could bias programs toward those who are able to meet this financial burden, exacerbating equity concerns. One proposed solution is to offer applicants the opportunity to visit only after a program's rank list is "locked," avoiding favoritism to applicants who visit, but allowing applicants to experience some of the camaraderie, geography, and local effects of an in-person visit. As debate about the optimal format of residency interviews continues, it is important to investigate whether in-person program visits, completed after program rank list certification, provide meaningful benefits to applicants in the residency match process. METHODS: All vascular programs entering the 2023 integrated vascular surgery residency match were invited to participate. Programs agreed to certify their National Resident Matching Program rank lists by February 1, 2023. Applicants then had the opportunity to visit the programs at which they interviewed. The particulars of the visit were determined by the individual programs. Applicants completed their standard rank list and locked on the standard date: March 1, 2023. Applicants then completed a survey regarding the impact of the visits on their rank order list decision-making. Program directors (PDs) completed a survey regarding their experiences as well. Data were collected using REDCap. RESULTS: Twenty-one of the 74 (28%) programs participated. Nineteen PDs completed the postinterview site visit survey (response rate 90%). Applicants interviewing at the participating programs (n = 112) were informed of the study, offered the opportunity to attend postinterview site visits, and received the survey. Forty-seven applicants responded (response rate 42%). Eighty-six percent of applicants stated that the visit impacted their rank list. Most important factors were esprit de corps of the program (86%), the faculty/trainees/staff (81%), and the physical setting (62%). Seventy-one percent of those participating spent ≤$800 on their visit. Eighty-one percent were satisfied with the process. Twenty-one percent of PDs would have changed their rank list if they could have based on the applicants' in-person visit. Sixty-three percent of the visit sessions cost the programs ≤$500, and 63% were satisfied with the process. CONCLUSIONS: This study is the first to document the impact of in-person site visits by applicants on a graduate medical education match process in one specialty. Our results suggest that this process provides meaningful data to applicants that helped them with their decision-making evidenced by most altering their rank lists, while avoiding some of the critical equity issues that accompany traditional in-person interviews. This may provide a model for future interview processes for residency programs.

Perception of shared learning environment differs between vascular surgery and general surgery residents.

BACKGROUND: An enriching learning environment is integral to resident wellness and education. Integrated vascular (VS) and general surgery (GS) residents share 18 months of core GS rotations during the postgraduate years 1-3 (PGY1-3); differences in their experiences may help identify practical levers for change. METHODS: We used a convergent mixed-methods design. Cross-sectional surveys were administered after the 2020 American Board of Surgery In-Training Examination and Vascular Surgery In-Training Examination, assessing eight domains of the learning environment and resident wellness. Multivariable logistic regression models identified factors associated with thoughts of attrition between categorical PGY1-3 residents at 57 institutions with both GS and VS programs. Resident focus groups were conducted during the 2022 Vascular Annual Meeting to elicit more granular details about the experience of the learning environment. Transcripts were analyzed using inductive and deductive logics until thematic saturation was achieved. RESULTS: Surveys were completed by 205 VS and 1198 GS PGY1-3 residents (response rates 76.8% for VS and 82.5% for GS). After adjusting for resident demographics, PGY level, and program type, GS residents were more likely than their VS peers to consider leaving their programs (odds ratio [OR]: 2.61, 95% confidence interval [CI]: 1.37-4.99). This finding did not persist after adjusting for differences in perceptions of the learning environment, specifically: GS residents had higher odds of mistreatment (OR: 1.99, 95% CI: 1.36-2.90), poorer work-life integration (OR: 2.88, 95% CI: 1.41-5.87), less resident camaraderie (OR: 3.51, 95% CI: 2.26-5.45), and decreased meaning in work (OR: 2.94, 95% CI: 1.80-4.83). Qualitative data provided insight into how the shared learning environment was perceived differently: (1) vascular trainees expressed that early specialization and a smaller, more invested faculty allow for an apprenticeship model with early operative exposure, hands-on guidance, frequent feedback, and thus early skill acquisition (meaning in work); (2) a smaller program is conducive to closer relationships with co-residents and faculty, increasing familiarity (camaraderie and work-life integration); and (3) due to increased familiarity with program leadership, vascular trainees feel more comfortable reporting mistreatment, allowing for prompt responses (mistreatment). CONCLUSIONS: Despite sharing a learning environment, VS and GS residents experience training differently, contributing to differential thoughts of attrition. These differences may be attributable to intrinsic features of the integrated training paradigm that are not easily replicated by GS programs, such as smaller program size and higher faculty investment due to early specialization. Alternative strategies to compensate for these inherent differences should be considered (eg, structured operative entrustment programs and faculty incentivization).

Impact of the endovascular revolution on vascular training through analysis of national data case reports.

BACKGROUND: In the last couple of decades, there has been a shift in use of endovascular procedures in vascular surgery. We aim to examine the impact of this endovascular shift on vascular trainees, determine whether the surgical experiences of trainees in the integrated residency and fellowship program changed over time, and identify differences between the two training paradigms. METHODS: Data were extracted from the Accreditation Council for Graduate Medical Education National Data Case Logs for the vascular surgery fellowship (1999-2021) and integrated residency (2012-2021) programs. Every procedure was categorized as open or endovascular, then designated into the following subcategories: thoracic aneurysm repairs, cerebrovascular, abdominal aneurysm repairs, venous, vascular access, peripheral arterial disease, visceral, or miscellaneous. We compared the prevalence of open and endovascular cases in the fellowship and integrated residency using data from overlapping years (2012-2021). In addition, we compared the mean number of cases per trainee per year within designated time intervals. The vascular surgery fellowship was grouped into three intervals: 1999 to 2006, 2006 to 2013, and 2013 to 2021; the integrated vascular surgery residency was grouped into two intervals: 2012 to 2017 and 2017 to 2021. Data were standardized to represent the average number of cases per trainee per year. RESULTS: Within the fellowship, we found a 362.37% increase in endovascular procedures (mean, 56.80 ± 32.57 vs 262.63 ± 9.91; P < .001), although there was only a 32.47% increase in open procedures (220.19 ± 4.55 vs 291.68 ± 8.20) between the first and last time intervals. There was a decrease in abdominal aneurysm repair (24.46 ± 7.30 vs 13.85 ± 0.58; P < .001) and visceral (6.41 ± 0.44 vs 5.80 ± 0.42; P = .039) open procedures. For the integrated residency, there was an increase in open procedures by 8.52% (352.18 ± 8.23 vs 382.20 ± 5.84; P < .001). Residents had greater total, open, and endovascular procedures per year than fellows (all P < .001). Chief residents had approximately one-half as many cases as vascular fellows per year. Fellows performed more open abdominal aneurysm repair (14.04 ± 0.80 vs 12.40 ± 1.32; P = .007) and visceral (5.83 ± 0.41 vs 4.88 ± 0.46; P > .001) procedures than residents. Overall, 52% to 53% of cases performed by trainees per year were open procedures in both the fellowship and integrated residency (288.56 ± 12.10 vs 261.27 ± 10.13, 365.52 ± 17.23 vs 319.58 ± 6.62; both P < .001). Within the subcategories, only cerebrovascular, vascular access, and miscellaneous had more open procedures performed per trainee. CONCLUSIONS: Vascular surgery training has incorporated new endovascular techniques and technologies while maintaining operative training in open procedures. Despite changes in vascular surgery training, trainees are still performing more open procedures than endovascular procedures per year. However, there are evolving deficits in specific types of procedures.

Burnout is not associated with trainee performance on the Vascular Surgery In-Training Exam.

OBJECTIVE: The Vascular Surgery In-Training Examination (VSITE) is a yearly exam evaluating vascular trainees' knowledge base. Although multiple studies have evaluated variables associated with exam outcomes, few have incorporated training program-specific metrics. The purpose of this study is to evaluate the impact of the learning environment and burnout on VSITE performance. METHODS: Data was collected from a confidential, voluntary survey administered after the 2020 to 2022 VSITE as part of the SECOND Trial. VSITE scores were calculated as percent correct then standardized per the American Board of Surgery. Generalized estimating equations with robust standard errors and an independent correlation structure were used to evaluate trainee and program factors associated with exam outcomes. Analyses were further stratified by integrated and independent training paradigms. RESULTS: A total of 1385 trainee responses with burnout data were collected over 3 years (408 in 2020, 459 in 2021, 498 in 2022). On average, 46% of responses reported at least weekly burnout symptoms. On unadjusted analysis, burnout symptoms correlated with a 14 point drop in VSITE score (95% confidence interval [CI], -24 to -4; P = .006). However, burnout was no longer significant after adjusted analysis. Instead, higher postgraduate year level, being in a relationship, identifying as male gender with or without kids, identifying as non-Hispanic white, larger programs, and having a sense of belonging within a program were associated with higher VSITE scores. CONCLUSIONS: Despite high rates of burnout, trainees generally demonstrate resilience in gaining the medical knowledge necessary to pass the VSITE. Performance on standardized exams is associated with trainee and program characteristics, including availability of support systems and program belongingness.

Evaluating the Impact of the Novel Geographic Preferences Section on Interview Rate and Residency Match Outcomes.

BACKGROUND: The American Association of Medical Colleges trialed residency application initiatives including geographic preferences and preference signals in 2022. OBJECTIVE: To assess the impact of geographic preferences on application outcomes during the 2022 residency match year. DESIGN: Cross-sectional. PARTICIPANTS: Applicants to categorical and preliminary internal medicine during the 2022 application cycle who completed the Texas Seeking Transparency in Applications to Residency survey. MAIN MEASURES: The primary outcome was interview rate (interview offers/total applications) and whether an application resulted in a match. The key dependent variables were geographic preferences and program-specific preference signals. We also assessed differences in utilization of geographic preferences between specialties. KEY RESULTS: A total of 970 applicants into categorical (n = 884) and preliminary (n = 86) internal medicine were included in our study. A total of 704 (72.6%) applicants submitted at least one geographic preference and 424 (43.7%) submitted three preferences. On average, applicants who submitted a geographic preference had a higher interview rate than those who did not (46.0% vs. 41.8%). Applications submitted with both a preference signal and geographic preference were significantly more likely to receive an interview offer (OR: 3.2, p < 0.01) and match (OR: 6.4, p < 0.01) than applications with neither a preference signal nor a geographic preference. Geographic preferences were associated with an increase in the odds of an application receiving an interview offer, even in the setting of a preference signal (OR: 1.4, p < 0.01). CONCLUSIONS: Both preference signals and geographic preferences have significant associations with odds of an application receiving an interview and matching for both categorical and preliminary internal medicine applicants. This study can be used to inform applicants, advisors, and programs how novel application strategies can affect important application outcomes for US medical school graduates. As more specialties pilot alternative processes, it will be important to study all application outcomes among varying applicant populations.

Internal Medicine Residency Program Applicant Perceptions of the SPLIT Recruitment Model Before and After Universal Virtual Interviews.

BACKGROUND: Enhancing residency recruitment with modifications to interviews has been an area of national interest, further catalyzed by the transition to universal virtual interviewing (UVI). In 2018, our internal medicine residency program redesigned the recruitment process using virtual interviews. OBJECTIVE: Evaluating this recruitment model allows programs to identify applicant perceptions of each component as they consider enhancements. DESIGN: The new model, termed "SPLIT," included separating optional applicant visit days (AVD) from interviews (S), a pre-interview supplemental form (P), learning program information from a dedicated website (L), virtual interviews (I), and flexible timing (remote interview day and site visit) (T). PARTICIPANTS: Applicants for the 2019 to 2023 Match who interviewed at one university-based internal medicine residency program. MAIN MEASURES: After rank list certification and before the annual Match, interviewed applicants were surveyed regarding their perceptions of the SPLIT process. Responses before (2019-2020 Matches) and after (2021-2023 Matches) UVIs were compared. KEY RESULTS: A total of 386 (75%) of 515 respondents favored video interviews. This preference was stronger in the post-UVI group (92%) than in the pre-UVI group (57%) (p < 0.001). In total, 76% of respondents attended an AVD (virtual or in-person). Applicants in the post-UVI group also favored having interviews separated from the AVD (p = 0.006) and optional AVDs (p < 0.001), more than those in the pre-UVI group. In the pre-UVI cohort, those who attended an in-person AVD tended to report a higher program understanding (OR 7.8), satisfaction with SPLIT (OR 2.1), and a better recruitment experience (OR 2.0). CONCLUSIONS: Virtual interviews were highly rated with increased preference following universal adoption. Optional AVDs separated from virtual interviews enhance applicant understanding of the program and were more effective when offered in-person before the pandemic-related restrictions. As programs begin to reintroduce in-person elements, the SPLIT recruitment model offers an innovative approach that addresses applicant and program needs.

Comparisons of Explicit Weight Bias Across Common Clinical Specialties of US Resident Physicians.

BACKGROUND: Patients with high body weight are persistently stigmatized in medical settings, with studies demonstrating that providers endorse negative stereotypes of, and have lower regard for, higher-weight patients. Very little is known about how this weight bias varies across specialties. OBJECTIVE: The purpose of this study is to examine how explicit weight bias varies between resident providers among sixteen of the largest residency specialties in the USA. The identification of these differences will guide the prioritization and targeting of interventions. DESIGN: The current study utilized cross-sectional, observational data. PARTICIPANTS: Forty-nine allopathic medical schools were recruited to participate in this national, longitudinal study. The current study utilized data from 3267 trainees in Year 2 of Residency among those who specialized in one of the most common sixteen residency programs in 2016. MAIN MEASURES: Participants reported demographic information and residency specialties and completed three sets of measures pertaining to explicit weight bias. KEY RESULTS: A significant minority (13-48%) of residents reported slight-to-strong agreement with each anti-fat statement. There was a significant relationship between residency specialty and anti-fat blame (F(15, 3189 = 12.87, p < .001), η2 = .06), anti-fat dislike (F(15, 3189 = 7.01, p < .001), η2 = .03), and attitudes towards obese patients (F(15, 3208 = 17.78, p < .001), η2 = .08). Primary care residents (e.g., family medicine, pediatrics) consistently reported lower levels of weight bias than those in specialty programs (e.g., orthopedic surgery, anesthesiology). CONCLUSIONS: This study is the first to report on weight bias in a large, heterogeneous sample of US resident physicians. Problematic levels of weight bias were found in all specialties, with residents in specialty programs generally reporting more bias than those in primary care residencies. Future research should examine which factors contribute to these differences to guide intervention.

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.

An Opportunity for Change: Principles for Reforming Internal Medicine Inpatient Conferences.

Inpatient educational conferences are a key part of internal medicine residency training. Many residencies made conferences virtual during the COVID-19 pandemic, and are now returning to in-person sessions. As we navigate this change, we can seize this opportunity to re-evaluate the role that inpatient conferences serve in resident education. In this paper, we briefly review the history of inpatient educational conferences before offering five recommendations for improvement. Our recommendations include grounding conference formats in educational theory, leveraging the expertise of all potential educators, broadening content to include health equity and justice throughout all curricula, and explicitly focusing on cultivating community among participants. Recognizing that each residency program is different, we anticipate that these recommendations may be implemented differently based on program size, available resources, and current institutional practices. We also include examples of prior successful curricular reforms aligned with our principles. We hope these recommendations ensure inpatient conferences continue to be a central part of residency education for future generations of internal medicine residents.