Gender and Inconsistent Evaluations: A Mixed-methods Analysis of Feedback for Emergency Medicine Residents.

Objectives: Prior research has demonstrated that men and women emergency medicine (EM) residents receive similar numerical evaluations at the beginning of residency, but that women receive significantly lower scores than men in their final year. To better understand the emergence of this gender gap in evaluations we examined discrepancies between numerical scores and the sentiment of attached textual comments. Methods: This multicenter, longitudinal, retrospective cohort study took place at four geographically diverse academic EM training programs across the United States from July 1, 2013-July 1, 2015 using a real-time, mobile-based, direct-observation evaluation tool. We used complementary quantitative and qualitative methods to analyze 11,845 combined numerical and textual evaluations made by 151 attending physicians (94 men and 57 women) during real-time, direct observations of 202 residents (135 men and 67 women). Results: Numerical scores were more strongly positively correlated with positive sentiment of the textual comment for men (r = 0.38, P < 0.001) compared to women (r = -0.26, P < 0.04); more strongly negatively correlated with mixed (r = -0.39, P < 0.001) and negative (r = -0.46, P < 0.001) sentiment for men compared to women (r = -0.13, P < 0.28) for mixed sentiment (r = -0.22, P < 0.08) for negative; and women were around 11% more likely to receive positive comments alongside lower scores, and negative or mixed comments alongside higher scores. Additionally, on average, men received slightly more positive comments in postgraduate year (PGY)-3 than in PGY-1 and fewer mixed and negative comments, while women received fewer positive and negative comments in PGY-3 than PGY-1 and almost the same number of mixed comments. Conclusion: Women EM residents received more inconsistent evaluations than men EM residents at two levels: 1) inconsistency between numerical scores and sentiment of textual comments; and 2) inconsistency in the expected career trajectory of improvement over time. These findings reveal gender inequality in how attendings evaluate residents and suggest that attendings should be trained to provide all residents with feedback that is clear, consistent, and helpful, regardless of resident gender.

Fat grafting in aesthetics.

Autologous fat transfer is an increasingly popular aesthetic and reconstructive technique for facial rejuvenation, breast contouring and augmentation, and buttock augmentation. The grafted fat is a living tissue and contains stem cells with tissue regenerative properties, which makes this a very unique filler. Historically, a major issue with this technique has been long-term graft viability and retention; however, each step of the autologous fat transfer process is being optimized in pursuit of the ideal protocol that maximizes graft survival. We review the major variations in the autologous fat transfer method, its aesthetic applications, and our own experiences.

Who Gets the Benefit of the Doubt? Performance Evaluations, Medical Errors, and the Production of Gender Inequality in Emergency Medical Education.

Why do women continue to face barriers to success in professions, especially male-dominated ones, despite often outperforming men in similar subjects during schooling? With this study, we draw on role expectations theory to understand how inequality in assessment emerges as individuals transition from student to professional roles. To do this, we leverage the case of medical residency so that we can examine how changes in role expectations shape assessment while holding occupation and organization constant. By analyzing a dataset of 2,765 performance evaluations from a three-year emergency medicine training program, we empirically demonstrate that women and men are reviewed as equally capable at the beginning of residency, when the student role dominates; however, in year three, when the colleague role dominates, men are perceived as outperforming women. Furthermore, when we hold resident performance somewhat constant by comparing feedback to medical errors of similar severity, we find that in the third year of residency, but not the first, women receive more harsh criticism and less supportive feedback than men. Ultimately, this study suggests that role expectations, and the implicit biases they can trigger, matter significantly to the production of gender inequality, even when holding organization, occupation, and resident performance constant.

Gender Differences in Attending Physicians' Feedback to Residents: A Qualitative Analysis.

BACKGROUND: Prior research has shown a gender gap in the evaluations of emergency medicine (EM) residents' competency on the Accreditation Council for Graduate Medical Education (ACGME) milestones, yet the practical implications of this are not fully understood. OBJECTIVE: To better understand the gender gap in evaluations, we examined qualitative differences in the feedback that male and female residents received from attending physicians. METHODS: This study used a longitudinal qualitative content analysis of narrative comments by attending physicians during real-time direct observation milestone evaluations of residents. Comments were collected over 2 years from 1 ACGME-accredited EM training program. RESULTS: In total, 1317 direct observation evaluations with comments from 67 faculty members were collected for 47 postgraduate year 3 EM residents. Analysis of the comments revealed that the ideal EM resident possesses many stereotypically masculine traits. Additionally, examination of a subset of the residents (those with 15 or more comments, n = 35) showed that when male residents struggled, they received consistent feedback from different attending physicians regarding aspects of their performance that needed work. In contrast, when female residents struggled, they received discordant feedback from different attending physicians, particularly regarding issues of autonomy and assertiveness. CONCLUSIONS: Our study revealed qualitative differences in the kind of feedback that male and female EM residents received from attending physicians. The findings suggest that attending physicians should endeavor to provide male and female residents with consistent feedback and guard against gender bias in their perceptions of residents' capabilities.

Comparison of Male vs Female Resident Milestone Evaluations by Faculty During Emergency Medicine Residency Training.

Importance: Although implicit bias in medical training has long been suspected, it has been difficult to study using objective measures, and the influence of sex and gender in the evaluation of medical trainees is unknown. The emergency medicine (EM) milestones provide a standardized framework for longitudinal resident assessment, allowing for analysis of resident performance across all years and programs at a scope and level of detail never previously possible. Objective: To compare faculty-observed training milestone attainment of male vs female residency training. Design, Setting, and Participants: This multicenter, longitudinal, retrospective cohort study took place at 8 community and academic EM training programs across the United States from July 1, 2013, to July 1, 2015, using a real-time, mobile-based, direct-observation evaluation tool. The study examined 33 456 direct-observation subcompetency evaluations of 359 EM residents by 285 faculty members. Main Outcomes and Measures: Milestone attainment for male and female EM residents as observed by male and female faculty throughout residency and analyzed using multilevel mixed-effects linear regression modeling. Results: A total of 33 456 direct-observation evaluations were collected from 359 EM residents (237 men [66.0%] and 122 women [34.0%]) by 285 faculty members (194 men [68.1%] and 91 women [31.9%]) during the study period. Female and male residents achieved similar milestone levels during the first year of residency. However, the rate of milestone attainment was 12.7% (0.07 levels per year) higher for male residents through all of residency (95% CI, 0.04-0.09). By graduation, men scored approximately 0.15 milestone levels higher than women, which is equivalent to 3 to 4 months of additional training, given that the average resident gains approximately 0.52 levels per year using our model (95% CI, 0.49-0.54). No statistically significant differences in scores were found based on faculty evaluator gender (effect size difference, 0.02 milestone levels; 95% CI for males, -0.09 to 0.11) or evaluator-evaluatee gender pairing (effect size difference, -0.02 milestone levels; 95% CI for interaction, -0.05 to 0.01). Conclusions and Relevance: Although male and female residents receive similar evaluations at the beginning of residency, the rate of milestone attainment throughout training was higher for male than female residents across all EM subcompetencies, leading to a gender gap in evaluations that continues until graduation. Faculty should be cognizant of possible gender bias when evaluating medical trainees.

Expanded terminal fields of gustatory nerves accompany embryonic BDNF overexpression in mouse oral epithelia.

Brain-derived neurotrophic factor (BDNF) is expressed in gustatory epithelia and is required for gustatory neurons to locate and innervate their correct target during development. When BDNF is overexpressed throughout the lingual epithelium, beginning embryonically, chorda tympani fibers are misdirected and innervate inappropriate targets, leading to a loss of taste buds. The remaining taste buds are hyperinnervated, demonstrating a disruption of nerve/target matching in the tongue. We tested the hypothesis here that overexpression of BDNF peripherally leads to a disrupted terminal field organization of nerves that carry taste information to the brainstem. The chorda tympani, greater superficial petrosal, and glossopharyngeal nerves were labeled in adult wild-type (WT) mice and in adult mice in which BDNF was overexpressed (OE) to examine the volume and density of their central projections in the nucleus of the solitary tract. We found that the terminal fields of the chorda tympani and greater superficial petrosal nerves and overlapping fields that included these nerves in OE mice were at least 80% greater than the respective field volumes in WT mice. The shapes of terminal fields were similar between the two groups; however, the density and spread of labels were greater in OE mice. Unexpectedly, there were also group-related differences in chorda tympani nerve function, with OE mice showing a greater relative taste response to a concentration series of sucrose. Overall, our results show that disruption in peripheral innervation patterns of sensory neurons have significant effects on peripheral nerve function and central organization of their terminal fields.

Structural and immunologic characterization of bovine, horse, and rabbit serum albumins.

Serum albumin (SA) is the most abundant plasma protein in mammals. SA is a multifunctional protein with extraordinary ligand binding capacity, making it a transporter molecule for a diverse range of metabolites, drugs, nutrients, metals and other molecules. Due to its ligand binding properties, albumins have wide clinical, pharmaceutical, and biochemical applications. Albumins are also allergenic, and exhibit a high degree of cross-reactivity due to significant sequence and structure similarity of SAs from different organisms. Here we present crystal structures of albumins from cattle (BSA), horse (ESA) and rabbit (RSA) sera. The structural data are correlated with the results of immunological studies of SAs. We also analyze the conservation or divergence of structures and sequences of SAs in the context of their potential allergenicity and cross-reactivity. In addition, we identified a previously uncharacterized ligand binding site in the structure of RSA, and calcium binding sites in the structure of BSA, which is the first serum albumin structure to contain metal ions.