Affirming Care for Transgender Patients.

Gender identity is a deeply felt internal sense of self, which may correspond (cisgender) or not correspond (transgender) with the person's assigned sex at birth. Transgender, nonbinary, and gender diverse people may choose to affirm their gender in any number of ways including medical gender affirmation. This is a primer on the medical care of transgender individuals which covers an introduction to understanding a common language, history of transgender medical care, creating a welcoming environment, hormone therapy, surgical therapies, fertility considerations, and cancer screening in transgender people.

The use of podcasts as a tool to teach clinical reasoning: a pseudorandomized and controlled study.

OBJECTIVES: Podcasts have emerged as an efficient method for widespread delivery of educational clinical reasoning (CR) content. However, the impact of such podcasts on CR skills has not been established. We set out to determine whether exposure to expert reasoning in a podcast format leads to enhanced CR skills. METHODS: This is a pseudo-randomized study of third-year medical students (MS3) to either a control group (n=22) of pre-established online CR modules, or intervention group (n=26) with both the online modules and novel CR podcasts. The podcasts were developed from four "clinical unknown" cases presented to expert clinician educators. After completing these assignments in weeks 1-2, weekly history and physical (H&P) notes were collected and graded according to the validated IDEA rubric between weeks 3-7. A longitudinal regression model was used to compare the H&P IDEA scores over time. Usage and perception of the podcasts was also assessed via survey data. RESULTS: Ninety control and 128 intervention H&Ps were scored. There was no statistical difference in the change of average IDEA scores between intervention (0.92, p=0.35) and control groups (-0.33, p=0.83). Intervention participants positively received the podcasts and noted increased discussion of CR principles from both their ward (3.1 vs. 2.4, p=0.08) and teaching (3.2 vs. 2.5, p=0.05) attendings. CONCLUSIONS: This is the first objective, pseudo-randomized assessment of CR podcasts in undergraduate medical education. While we did not demonstrate significant improvement in IDEA scores, our data show that podcasts are a well-received tool that can prime learners to recognize CR principles.

Correlation of Coping, Mentorship, and Life Events with Burnout in Internal Medicine Residents.

Physician burnout is a widespread problem. We examined how coping, mentorship, and life events correlated with burnout in Internal Medicine Residents. We performed a cross-sectional study of survey data collected over multiple time points and used Spearman correlation of coping, mentorship, and life events to emotional exhaustion (EE) and cynicism (CYN). Burnout was assessed using the Maslach Burnout Inventory-General Survey (MBI-GS), coping skills were measured using the Brief COPE, mentorship with an institutional mentoring survey, and life events with a shortened Social Readjustment Rating Scale (SRRS). Two thousand one surveys were distributed to 616 residents from 2010 to 2015. There were 1144 cases of completion of both the Brief COPE and the MBI-GS (58%), 744 of the MBI-GS and the Mentoring survey (47%), and 1138 of the MBI-GS and Life Events Scale (57%). There were correlations between acceptance (ρ 0.1-0.24), denial (ρ 0.13-0.20), substance abuse (ρ 0.15-0.22), behavioral disengagement (ρ 0.18-.037), self-blame (ρ 0.27-0.45), self-distraction (ρ 0.18-0.32) and venting (ρ 0.15-0.47) and EE. There were correlations with acceptance (ρ 0.11-0.15), denial (ρ 0.18-0.26), humor (ρ 0.13-0.20), substance abuse (ρ 0.10-0.29), behavioral disengagement (ρ 0.19-0.40), self-blame (ρ 0.24-0.35), self-distraction (ρ 0.14-0.34) and venting (ρ 0.12-0.38) and CYN. There was a negative correlation between mentorship and EE (ρ - 0.15, - 0.18) and CYN (ρ - 0.30 to - 0.20). There were correlations between life events and EE (ρ 0.15-0.20) and CYN (ρ = 0.14-0.15). Maladaptive coping mechanisms, acceptance, and life stressors correlate with burnout in internal medicine residents and mentoring may be protective.

Mentorship of Women in Academic Medicine: a Systematic Review.

BACKGROUND: Women remain underrepresented in academic medicine, particularly in leadership positions. This lack of women in leadership has been shown to have negative implications for both patient care and educational outcomes. Similarly, the literature demonstrates that female physicians are less likely to have mentors, despite the proven benefits of mentorship for career advancement. The objective of this review is to identify and describe models of mentorship for women in academic medicine. METHODS: We searched PubMed, PsycINFO, Education Resources Information Center, and Cochrane Databases of Systematic Reviews following PRISMA guidelines in June 2017. We included original English language studies that described a mentorship program in the USA that involved academic medical doctorates and that were created for women or provided results stratified by gender. RESULTS: Our search returned 3625 results; 3309 references remained after removal of duplicates. Twenty articles met inclusion criteria. The majority of the programs were designed for junior faculty and used the dyad model of mentoring (i.e., one mentor/one mentee). Frequently cited objectives of these programs were to improve scholarship, promotion, and retention of female faculty. Program evaluations were primarily survey-based, with participant-reported satisfaction being the most frequent measured outcome. Most results showed very high satisfaction. Gender concordance between mentor and mentee did not impact satisfaction. Eight articles reported objective outcomes, including publications, retention, and promotion, and each of these demonstrated an improvement after program implementation. DISCUSSION: Our review suggests that mentorship programs designed for women, regardless of the model, are met with high satisfaction and can help promote and retain women in academic medicine. No clear best practices for mentorship emerged in the literature. Institutions, therefore, can individualize their mentorship programs and models to available resources and goals. These results demonstrate the importance of more widespread implementation of mentorship programs to more effectively facilitate professional development and success of women in academic medicine.

The Impact of Women's Health Residency Tracks on Career Outcomes.

BACKGROUND: Women's health residency tracks within several internal medicine residencies provide gender-specific education to residents. The impact of these programs has not been evaluated. The objective of this study was to determine the impact that women's health residency tracks have on career outcomes. MATERIALS AND METHODS: The participants in the study were women's health track (WHT) graduates from three different programs. To account for the impact of gender, we also surveyed female graduates who did not participate in WHT from the same programs, paired by year of graduation (non-WHT). Participants completed an online survey and provided a copy of their updated curriculum vitae (CV). Survey responses and CV data were analyzed separately. RESULTS: Of the 218 eligible graduates, 133 completed the survey and 86 provided a CV for a response rate of 63.8%. Regarding clinical care, 31.8% of WHT graduates focused on women's health in practice compared with only 16.1% of non-WHT graduates (Cohen's h 0.43). WHT graduates were more likely to have presented nationally on women's health topics (53.3% vs. 16.7%, p-value 0.030) and teach women's health topics (51.4% vs. 26.7%%, Cohen's h 0.51). WHT graduates were more likely to have assumed a women's health leadership role (34.5% vs. 0.0%, p-value 0.018). CONCLUSION: Graduates of women's health residency tracks remain involved in women's health in clinical practice, scholarship, teaching, and leadership. While all internal medicine residents should receive comprehensive women's health education, WHTs are an effective way of promoting women's healthcare and scholarship.

Identification of facilitators and barriers to residents' use of a clinical reasoning tool.

BACKGROUND: While there is some experimental evidence to support the use of cognitive forcing strategies to reduce diagnostic error in residents, the potential usability of such strategies in the clinical setting has not been explored. We sought to test the effect of a clinical reasoning tool on diagnostic accuracy and to obtain feedback on its usability and acceptability. METHODS: We conducted a randomized behavioral experiment testing the effect of this tool on diagnostic accuracy on written cases among post-graduate 3 (PGY-3) residents at a single internal medical residency program in 2014. Residents completed written clinical cases in a proctored setting with and without prompts to use the tool. The tool encouraged reflection on concordant and discordant aspects of each case. We used random effects regression to assess the effect of the tool on diagnostic accuracy of the independent case sets, controlling for case complexity. We then conducted audiotaped structured focus group debriefing sessions and reviewed the tapes for facilitators and barriers to use of the tool. RESULTS: Of 51 eligible PGY-3 residents, 34 (67%) participated in the study. The average diagnostic accuracy increased from 52% to 60% with the tool, a difference that just met the test for statistical significance in adjusted analyses (p=0.05). Residents reported that the tool was generally acceptable and understandable but did not recognize its utility for use with simple cases, suggesting the presence of overconfidence bias. CONCLUSIONS: A clinical reasoning tool improved residents' diagnostic accuracy on written cases. Overconfidence bias is a potential barrier to its use in the clinical setting.

Update in Women's Heart Disease: Prevention and Screening.

The goal in selecting these recent articles was to help identify literature that may change the clinical practice of women's health for internists. Articles were identified by reviewing the high-impact medical and women's health journals, national guidelines, ACP JournalWise, and NEJM Journal Watch. Cardiovascular (CV) disease remains the leading cause of death in women. The emphasis of this review is on identifying opportunities for CV risk reduction to prevent disease and on early identification of women with preexisting atherosclerotic disease to allow for early initiation of medical treatment.

New Developments in Breast Cancer Screening and Treatment.

The clinical update serves as a brief review of recently published, high-impact, and potentially practice-changing journal articles summarized for our readers. In this clinical update, we selected top recent articles regarding breast health that may change the clinical practice of women's health providers. We identified articles by reviewing high-impact medical and women's health journals as well as national practice guidelines. Three of our articles are dedicated to the rapid changes in breast cancer screening. With regard to breast cancer treatment, we focused on two articles that impact who we treat with traditional aggressive regimens.

Establishing Consensus on Residency Education in Women's Health.

BACKGROUND: Internal medicine residents are expected to be able to provide gender-specific care. The objective of this study was to develop a consensus list of core topics and procedural skills in women's health to allow residency program directors to prioritize and standardize educational efforts in women's health. METHODS: We conducted a two-round Delphi of women's health experts. Participants were given a list of topics and asked to: (1) rank each topic based on how important they felt each topic was for internal medicine residents to be proficient in upon graduation, and (2) identify which topics were critical for a women's health curriculum. Mean importance ratings for all topics and mean agreement ratings for the critical topics were calculated. The list of critical topics mirrored the list of important topics; therefore, our consensus list included any topic that received a mean importance rating of ≥4. RESULTS: Of the 41 experts invited to participate, 46% (19) completed the first round with 100% (19/19) completing the second round. The majority (62.5%, n = 35) of topics received an importance rating of ≥4. The highest-ranking topics included cervical cancer screening, screening for osteoporosis, and diagnosis of sexually transmitted infections (mean rating of 4.95/each). Other highly rated topics included those related to contraception/reproductive planning, breast disease, menopause, and performing the breast and pelvic examinations. The diagnosis of gender-specific conditions was generally rated as more important than the management of the conditions. In addition, pregnancy-related topics were overall deemed as less important for internal medicine training. CONCLUSION: Our study generated a consensus list of 35 core topics in women's heath that should serve as a guide to residency programs for the development of women's health curricula.

The Toxicity of Self-Blame: Sex Differences in Burnout and Coping in Internal Medicine Trainees.

BACKGROUND: Burnout is a significant problem facing internal medicine residents contributing to increased risk of depression and suicidal ideation. Coping mechanisms and burnout may differ based on sex. METHODS: The study was a retrospective cross-sectional study of reported burnout and coping mechanisms used by internal medicine residents in June 2014 at a large academic center and its community affiliate. Two hundred eighty-five postgraduate year (PGY)-1, 2, 3, and 4 and incoming PGY-1 residents were surveyed. The Maslach Burnout Inventory-General Survey and Brief Coping Orientation to Problems Experienced were given to measure levels of burnout and frequency of use of coping mechanisms. Percentages of residents who met criteria for burnout and high levels on each of the subscales of emotional exhaustion, cynicism and professional efficacy, were calculated and stratified by sex. Chi-squared tests were used for statistical significance. Average frequency of use of each coping mechanism by sex was calculated with statistical significance determined by two sided t-tests. RESULTS: There was a 69% completion rate (198/285) with 100 men and 98 women. Woman had higher levels of burnout (30% vs. 15%, p = 0.014) and emotional exhaustion (22% vs. 9%, p = 0.005). Women used the adaptive coping mechanisms of emotional support (p = 0.001) and instrumental support (p = 0.018) more frequently but also used the maladaptive coping mechanism of self-blame more frequently (p = 0.022). CONCLUSIONS: Greater use of self-blame as a coping mechanism may be a major factor in the higher rates of burnout and emotional exhaustion in women resident physicians as compared to men. Educators must pay attention to use of self-blame by female residents and as it may be a red flag for resident distress.

Evaluation of VA Women's Health Fellowships: developing leaders in academic women's health.

BACKGROUND: The Department of Veterans Affairs (VA) instituted the VA Women's Health Fellowship (VAWHF) Program in 1994, to accommodate the health needs of increasing numbers of female veterans and to develop academic leaders in women's health. Despite the longevity of the program, it has never been formally evaluated. OBJECTIVE: To describe the training environments of VAWHFs and career outcomes of female graduates. DESIGN AND PARTICIPANTS: Cross-sectional web-based surveys of current program directors (2010-2011) and VAWHF graduates (1995-2011). RESULTS: Responses were received from six of seven program directors (86 %) and 42 of 74 graduates (57 %). The mean age of graduates was 41.2 years, and mean time since graduation was 8.5 years. Of the graduates, 97 % were female, 74 % trained in internal medicine, and 64 % obtained an advanced degree. Those with an advanced degree were more likely than those without an advanced degree to pursue an academic career (82 % vs. 60 %; P<0.01). Of the female graduates, 76 % practice clinical women's health and spend up to 66 % of their time devoted to women's health issues. Thirty percent have held a VA faculty position. Seventy-nine percent remain in academics, with 39 % in the tenure stream. Overall, 94 % had given national presentations, 88 % had received grant funding, 79 % had published in peer-reviewed journals, 64 % had developed or evaluated curricula, 51 % had received awards for teaching or research, and 49 % had held major leadership positions. At 11 or more years after graduation, 33 % of the female graduates in academics had been promoted to the rank of associate professor and 33 % to the rank of full professor. CONCLUSIONS: The VAWHF Program has been successful in training academic leaders in women's health. Finding ways to retain graduates in the VA system would ensure continued clinical, educational, and research success for the VA women veteran's healthcare program.