National science foundation grant awardees' perspectives on Article X and sexual harassment in science.

Federal scientific agencies seek to make an impact on the continued prevalence of sexual harassment in the scientific academic community beyond institutional self-regulation. The National Science Foundation's Article X, released in 2018, is one of the most significant and ambitious federal policy initiatives to address sexual harassment. The present article presents the results of the first study to examine scientists' knowledge and attitudes about this important recent policy. We found, although overall knowledge about Article X was fairly low, the majority of participants responded positively to it. Crucially, impressions of the policy varied based on past experience and demographic factors. Individuals who had experienced harassment in the past year were less likely to believe the policy would help reduce sexual harassment in the sciences compared to those who had not experienced harassment (OR = 0.47, 95% CI:0.23-0.97, p = .034) and had greater odds of endorsing that the policy failed to go far enough (OR = 2.77, 95% CI:1.15-6.66, p = .023). Associations between demographic factors and views of the policy were less pronounced, but it is notable that, compared to their White counterparts, Black participants were more likely to believe the policy went too far (OR = 5.87, 95% CI:1.04-33.17, p = .045). Additionally, concerns were raised about the institutional enforcement of these policies and the existence of sufficient protections for survivors. Our work has implications for NSF's continued evaluation of the efficacy of this program as well as for other federal agencies implementing or considering similar policies.

Formal Reporting of Identity-Based Harassment at an Academic Medical Center: Incidence, Barriers, and Institutional Responses.

PURPOSE: To examine the incidence of, barriers to, and institutional responses to formal reporting of experiences of identity-based harassment at an academic medical center. METHOD: The authors invited 4,545 faculty and medical trainees at the University of Michigan Medical School to participate in a 2018 survey about civility and respect. This analysis focused on respondents who indicated experiencing at least 1 form of identity-based harassment (sexual harassment, gender policing harassment, heterosexist harassment, racialized sexual harassment) within the past year, perpetrated by staff, students, and faculty or by patients and patients' families. The authors assessed the incidence of formally reporting harassment to someone in authority, barriers to reporting, and institutional responses following reporting. RESULTS: Among the 1,288 (28.3%) respondents with usable data, 83.9% (n = 1,080) indicated experiencing harassment. Of the harassed individuals, 10.7% (114/1,067), including 13.1% (79/603) of cisgender women and 7.5% (35/464) of cisgender men, indicated they formally reported their harassment experiences. Among these reporters, 84.6% (66/78) of cisgender women and 71.9% (23/32) of cisgender men indicated experiencing positive institutional remedies. Many reporters indicated experiencing institutional minimization (42.9% [33/77] of cisgender women; 53.1% [17/32] of cisgender men) or retaliation (21.8% [17/78] of cisgender women; 43.8% [14/32] of cisgender men). Cisgender men were significantly more likely to indicate experiencing specific negative institutional responses, such as being considered a troublemaker (OR 3.56, 95% CI: 1.33-9.55). Among respondents who did not formally report harassment experiences, cisgender women were significantly more likely to cite concerns about institutional retaliation, such as being given an unfair performance evaluation or grade (OR 1.90, 95% CI: 1.33-2.70). CONCLUSIONS: Most respondents who experienced harassment did not formally report it to anyone in authority. Many reporters faced institutional minimization and retaliation. These findings suggest a need to reshape institutional harassment prevention and response systems in academic medicine.

"I'm Being Forced to Make Decisions I Have Never Had to Make Before": Oncologists' Experiences of Caring for Seriously Ill Persons With Poor Prognoses and the Dilemmas Created by COVID-19.

PURPOSE: The COVID-19 pandemic has created a new set of problems for clinicians. This study examines the experiences of oncologists providing care to seriously ill persons near the end of life in the context of the COVID-19 pandemic. METHODS: Between January 2020 and August 2020, we conducted semistructured, in-depth individual interviews with 22 purposefully sampled oncologists from practices enrolled in the Michigan Oncology Quality Consortium. Deidentified transcripts of the interviews were examined using thematic analysis. RESULTS: Our respondents described several novel problems created by the COVID-19 pandemic, including: (1) ethical challenges, (2) the need to manage uncertainty-physically and emotionally-on the part of both patients and oncologists, and (3) the difficulty of integrating technology and communication for seriously ill persons. These problems were made more complex by features of the pandemic: resource scarcity (and the need to fairly allocate poor resources), delays in care, high levels of fear, and the increased importance of advance care planning. Nonabandonment served as a way to cope with increased stress, and the use of telemedicine became an increasingly important medium of communication. CONCLUSION: This study offers an in-depth exploration of the problems faced by oncologists as a result of the COVID-19 pandemic and how they navigated them. Optimal decision making for seriously ill persons with cancer during the COVID-19 pandemic must include open acknowledgment of the ethical challenges involved, the emotions experienced by both patients and their oncologists, and the urgent need to integrate technology with compassionate communication in determining patient preferences.

Incidence and Group Comparisons of Harassment Based on Gender, LGBTQ+ Identity, and Race at an Academic Medical Center.

Background: A key recommendation from the landmark National Academies report called for research examining experiences of underrepresented and/or vulnerable groups, including people of color and sexual- and gender-minority people. We examine the prevalence of gender policing harassment (GPH), heterosexist harassment (HH), and racialized sexual harassment (RSH), by gender, LGBTQ+, race, and department grouping, which has not been previously examined in academic medicine. Materials and Methods: All faculty (n = 2723), fellows, residents, and first through third year medical students (n = 1822) at the University of Michigan Medical School (UMMS) who had been working at the organization for at least 1 year were invited to complete a 20-minute online survey. We assessed harassment within the past year, perpetrated by insiders (i.e., staff, students, and faculty) and from patients and patients' families. Results: A total of 705 faculty (25.9% of the targeted sample) and 583 trainees (32.0% of the targeted sample) were in the analytic sample. Women were significantly more likely to experience GPH from both sources than men, and LGBTQ+ individuals were more likely to face HH from both sources than cisgender heterosexual participants. Underrepresented minorities, Asian/Asian American, and female participants had higher rates of RSH perpetrated by insiders. There were significant department-group differences across harassment types. Conclusions: Less-studied forms of harassment are common within academic medicine and are perpetrated from various sources. Identity-based harassment should be investigated further to gain a comprehensive understanding of its impact within academic medicine. Clinical Trial Registration Number not applicable.

Workplace resources, mentorship, and burnout in early career physician-scientists: a cross sectional study in Japan.

BACKGROUND: Physician-scientists are a vital segment of the healthcare workforce, but they may face significant challenges balancing and integrating clinical responsibilities, scientific research, and domestic responsibilities. This study investigates factors associated with burnout among highly successful early career physician-researchers in Japan. METHOD: Among 1790 physician awardees of Grant-in-Aid for Young Scientists by the Japanese Ministry in 2014-2015, 490 participated in this cross-sectional survey in 2016 (usable response rate 23.8%). The primary outcome was psychological burnout, measured by the Copenhagen Burnout Inventory (i.e., personal burnout, work-related burnout, and patient-related burnout). "Workplace resources" in our study refers to the presence of career education in the workplace, promotion of gender equity, well-being consultation services on "career and work," "research," "harassment," and/or "mental health," as well as the presence of a role model in the workplace who has perceived good work-life balance. RESULTS: Among 408 physician-researchers (75% male, mean age 37 yrs), personal burnout scores were slightly higher in women than in men (mean score, 41.9 points vs. 36.7 points, difference, 5.2, 95% confidence interval, 0.5-9.9, p = 0.029), but work-related and patient-related burnout scores did not differ significantly between genders. Over half of women (64%) and men (58%) had a mentor (p = 0.374). In multivariable general linear regression models, personal burnout scores were higher for women (ß = 4.98, p = 0.045), and lower among those who had a mentor (ß = - 5.82, p = 0.010) and whose workplaces had well-being consultation services (ß = - 0.79, p = 0.022). Work-related burnout scores were lower among those with larger amounts of grant funding (ß = - 4.70, p = 0.013), a mentor (ß = - 6.12, p = 0.002), well-being consultation services (ß = - 0.78, p = 0.008) and a role model with a perceived good work-life balance (ß = - 4.00, p = 0.038). Patient-related burnout scores were higher among physician-scientists aged older than 37 years (ß = 6.25, p = 0.002) and those who had board certification (ß = 9.01, p = 0.017), while these scores were lower among those had larger amounts of funding (ß = - 5.01, p = 0.006) or a mentor (ß = - 5.35, p = 0.006). CONCLUSIONS: Workplace resources and mentorship appear to be associated with lower levels of psychological burnout for both men and women early career physician-scientists.

Understanding End-of-Life Preferences: Predicting Life-Prolonging Treatment Preferences Among Community-Dwelling Older Americans.

OBJECTIVES: To determine how demographic, socioeconomic, health, and psychosocial factors predict preferences to accept life-prolonging treatments (LPTs) at the end of life (EOL). METHODS: This is a retrospective cohort study of a nationally representative sample of community-dwelling older Americans (N = 1648). Acceptance of LPT was defined as wanting to receive all LPTs in the hypothetical event of severe disability or severe chronic pain at the EOL. Participants with a durable power of attorney, living will, or who discussed EOL with family were determined to have expressed their EOL preferences. The primary analysis used survey-weighted logistic regression to measure the association between older adult characteristics and acceptance of LPT. Secondarily, the associations between LPT preferences and health outcomes were measured using regression models. RESULTS: Approximately 31% of older adults would accept LPT. Nonwhite race/ethnicity (odds ratio [OR] 0.54; 95% CI 0.41, 0.70; white vs. nonwhite), self-realization (OR 1.34; 95% CI 1.01, 1.79), attendance of religious services (OR 1.44; 95% CI 1.07, 1.94), and expression of preferences (OR 0.54; 95% CI 0.40, 0.72) were associated with acceptance of LPT. LPT preferences were not independently associated with mortality or disability. CONCLUSIONS: Approximately one-third of older Americans would accept LPT in the setting of severe disability or severe chronic pain at the EOL. Adults who discussed their EOL preferences were more likely to reject LPT. Conversely, minorities were more likely to accept LPT. Sociodemographics, physical capacity, and health status were poor predictors of acceptance of LPT. A better understanding of the complexities of LPT preferences is important to ensuring patient-centered care.

Surgery Residents' Experiences With Seriously-Ill and Dying Patients: An Opportunity to Improve Palliative and End-of-Life Care.

OBJECTIVE: To describe how and when surgery residents provided primary palliative care and engaged specialty palliative care services. DESIGN: Phase I consisted of a previously validated survey instrument supplemented with additional questions. We then conducted semistructured interviews with a subset of the survey respondents (Phase II). Using thematic analysis, we characterized surgery residents' perceptions of palliative care delivery among surgical patients. SETTING: General surgery residency programs across the state of Michigan. PARTICIPANTS: General surgery residents across the state of Michigan. All residents in participating programs were invited to complete the survey in Phase I. Phase II consisted of a subset of the survey respondents who underwent semistructured interviews. Interview respondents were sampled to reflect the overall surveyed group. RESULTS: Among 119 survey respondents (response rate 70%), all had encountered a palliative care specialist but only 58.8% had been taught when to consult or to refer to palliative care. Survey respondents reported on a multitude of barriers within the clinician, patient and family, and systemic domains. Interviews expanded on survey findings and 4 influential factors of palliative care delivery emerged: (1) Resident Education and Training; (2) Resident Attitudes Toward Palliative Care; (3) Knowledge of Palliative Care; and (4) Training within a Surgical Culture. CONCLUSIONS: This study reveals how surgery resident training and experiences impact palliative and end-of-life care for surgical patients at teaching institutions. Knowledge of how and when residents are providing primary palliative care and engaging with palliative care services will inform future knowledge and behavioral interventions for trainees who often provide care for patients nearing the end of life.

Sexual Harassment in Radiology: Prevalence and Opportunities for Improvement.

Radiologists have a key role in the delivery of modern medicine and interface with almost every medical subspecialty within health care systems. Radiology requires collaborative team science and continued communication across providers. Essential to these ends is an inclusive and respectful environment. Therefore, sexual harassment cannot be tolerated. This perspective provides an overview of the existing literature on sexual harassment in medicine and sexual harassment in radiology and suggestions for creating change within the field of radiology to address sexual harassment. This article also discusses specific ways that radiologists can be engaged as bystanders who intervene effectively to stop or mitigate problematic situations as they occur. Although individual changes in behavior can be impactful, ultimately, wholesale cultural transformation is key to preventing sexual harassment. Leaders in radiology, like leaders everywhere, must make clear that harassing behaviors will not be tolerated and that those who have committed harassment will be held accountable.

Which Ethical Considerations Should Inform Hospice Decisions About Caring for Patients With Obesity?

Hospice and palliative care clinicians have the potential to advocate for high-quality medical care for patients with obesity. This article explores current evidence on obesity at the end of life and ethical questions that emerge when a decision is made to enroll a patient with obesity in hospice.

Direct and Indirect Harassment Experiences and Burnout among Academic Faculty in Japan.

The purpose of this study is three-fold: (1) to compare harassment (sexual, gender, and academic harassment both directly and indirectly experienced - i.e. "directly harassed" and "have seen or heard of someone who experienced harassment", respectively) experienced by males and females, (2) to investigate whether such experiences correlate with burnout, and (3) to explore whether social support might mitigate any such relationship between harassment and burnout. This cross-sectional study was conducted at a private university in Japan in February 2014 and is based on a work-life balance survey obtained from 330 academic faculty members. We investigated the association between each of the six subcategories of harassment (direct and indirect forms of each of the three types) and burnout using general linear regression models; we then evaluated interactions between harassment and social support in these models. The prevalence of direct and indirect experiences of harassment was higher in females than in males for all three types of harassment. Males showed higher burnout scores if they had direct experiences of harassment. There were significant interactions between social support and the direct experience of harassment; high social support mitigated the effect size of direct harassment on burnout among males. Females showed higher burnout scores if they had indirect experiences of harassment. However, the same buffering effect of social support on burnout as observed in males was not observed in females. Direct harassment experiences increased the risk of burnout in males, and indirect harassment experiences increased burnout in females.

Geographic access to assisted reproductive technology health care in the United States: a population-based cross-sectional study.

OBJECTIVE: To evaluate the geographic distribution of assisted reproductive technology (ART) clinics and the number of ART clinics within U.S. Census metropolitan areas and to estimate the number of reproductive-age women who have geographic access to ART services in the United States. DESIGN: A population-based cross-sectional study. SETTING: Not applicable. PATIENT(S): None. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Number of U.S. reproductive-age women living in areas with no ART clinic, a single ART clinic, or more than one ART clinic. RESULT(S): There were 510 ART clinics in the United States in 2009-2013. Multiple ART clinics were present in 76 metropolitan areas (median population of 1.45 million people), where a total of 442 clinics were located. A single ART clinic was present in 68 metropolitan areas (median population of 454,000 people). Among U.S. reproductive-age women in 2010, 38.1 million (60.4% of the U.S. population) lived in an area with multiple ART clinics, 6.8 million (10.8% of the U.S. population) lived in an area with a single clinic, and 18.2 million (28.8% of the U.S. population) lived in an area (metropolitan and nonmetropolitan) with no ART clinics. CONCLUSION(S): Nearby geographic access to ART services is limited or absent for more than 25 million reproductive-age women (39.6% of the U.S. population) in the United States. This population estimate should spur continued policy and technological progress to increase access to ART services.

The Relationship of Obesity to Hospice Use and Expenditures: A Cohort Study.

BACKGROUND: Obesity complicates medical, nursing, and informal care in severe illness, but its effect on hospice use and Medicare expenditures is unknown. OBJECTIVE: To describe the associations between body mass index (BMI) and hospice use and Medicare expenditures in the last 6 months of life. DESIGN: Retrospective cohort. SETTING: The HRS (Health and Retirement Study). PARTICIPANTS: 5677 community-dwelling Medicare fee-for-service beneficiaries who died between 1998 and 2012. MEASUREMENTS: Hospice enrollment, days enrolled in hospice, in-home death, and total Medicare expenditures in the 6 months before death. Body mass index was modeled as a continuous variable with a quadratic functional form. RESULTS: For decedents with BMI of 20 kg/m2, the predicted probability of hospice enrollment was 38.3% (95% CI, 36.5% to 40.2%), hospice duration was 42.8 days (CI, 42.3 to 43.2 days), probability of in-home death was 61.3% (CI, 59.4% to 63.2%), and total Medicare expenditures were $42 803 (CI, $41 085 to $44 521). When BMI increased to 30 kg/m2, the predicted probability of hospice enrollment decreased by 6.7 percentage points (CI, -9.3 to -4.0 percentage points), hospice duration decreased by 3.8 days (CI, -4.4 to -3.1 days), probability of in-home death decreased by 3.2 percentage points (CI, -6.0 to -0.4 percentage points), and total Medicare expenditures increased by $3471 (CI, $955 to $5988). For morbidly obese decedents (BMI ≥40 kg/m2), the predicted probability of hospice enrollment decreased by 15.2 percentage points (CI, -19.6 to -10.9 percentage points), hospice duration decreased by 4.3 days (CI, -5.7 to -2.9 days), and in-home death decreased by 6.3 percentage points (CI, -11.2 to -1.5 percentage points) versus decedents with BMI of 20 kg/m2. LIMITATION: Baseline data were self-reported, and the interval between reported BMI and time of death varied. CONCLUSION: Among community-dwelling decedents in the HRS, increasing obesity was associated with reduced hospice use and in-home death and higher Medicare expenditures in the last 6 months of life. PRIMARY FUNDING SOURCE: Robert Wood Johnson Foundation Clinical Scholars Program.

Milestones for the Final Mile: Interspecialty Distinctions in Primary Palliative Care Skills Training.

CONTEXT: Primary palliative care (PPC) skills are useful in a wide variety of medical and surgical specialties, and the expectations of PPC skill training are unknown across graduate medical education. OBJECTIVES: We characterized the variation and quality of PPC skills in residency outcomes-based Accreditation Council for Graduate Medical Education (ACGME) milestones. METHODS: We performed a content analysis with structured implicit review of 2015 ACGME milestone documents from 14 medical and surgical specialties chosen for their exposure to clinical situations requiring PPC. For each specialty milestone document, we characterized the variation and quality of PPC skills in residency outcomes-based ACGME milestones. RESULTS: We identified 959 occurrences of 29 palliative search terms within 14 specialty milestone documents. Within these milestone documents, implicit review characterized 104 milestones with direct saliency to PPC skills and 196 milestones with indirect saliency. Initial interrater agreement of the saliency rating among the primary reviewers was 89%. Specialty milestone documents varied widely in their incorporation of PPC skills within milestone documents. PPC milestones were most commonly found in milestone documents for Anesthesiology, Pediatrics, Urology, and Physical Medicine and Rehabilitation. PPC-relevant milestones were most commonly found in the Interpersonal and Communication Skills core competency with 108 (36%) relevant milestones classified under this core competency. CONCLUSIONS: Future revisions of specialty-specific ACGME milestone documents should focus on currently underrepresented, but important PPC skills.