Twelve tips for responding to microaggressions and overt discrimination: When the patient offends the learner.

Microaggressions and expressions of overt discrimination negatively affect the experience of medical trainees at all levels. Mistreatment of trainees, including abusive and discriminatory behavior by patients and families, occurs commonly and is receiving increased attention in both the medical literature and popular press. Heightened awareness of the problem has sparked a call to engage in substantive conversations about bias in health professions education. The emphasis on direct observation in medical education makes the bedside a common setting for educators to witness these behaviors firsthand. Many educators are committed to developing a positive climate for learners but lack the training and skills to facilitate discussions about discrimination. As a result, these difficult but important conversations may not occur. The authors present a three-phase approach to responding to microaggressions and discrimination toward trainees from patients, and offer a communication toolkit that frontline medical educators can use in their daily practice.

Specialty Care Access in the Safety Net-the Role of Public Hospitals and Health Systems.

Access to specialty care in the United States safety net, already strained, is fac-ing increasing pressure with an influx of patients following the passage of the Affordable Care Act (ACA). We surveyed 18 public hospitals and health systems across the country to describe the current state of specialty care delivery in safety-net systems. We elicited information regarding challenges, provider models, metrics of access and productivity, and strategies for improving access. Based on our findings, we propose a framework for assessing and improving specialty care access with a focus on population health planning.

Inter-laboratory variability in in vitro spinal segment flexibility testing.

In vitro spine flexibility testing has been performed using a variety of laboratory-specific loading apparatuses and conditions, making test results across laboratories difficult to compare. The application of pure moments has been well established for spine flexibility testing, but to our knowledge there have been no attempts to quantify differences in range of motion (ROM) resulting from laboratory-specific loading apparatuses. Seven fresh-frozen lumbar cadaveric motion segments were tested intact at four independent laboratories. Unconstrained pure moments of 7.5 Nm were applied in each anatomic plane without an axial preload. At laboratories A and B, pure moments were applied using hydraulically actuated spinal loading fixtures with either a passive (A) or controlled (B) XY table. At laboratories C and D, pure moments were applied using a sliding (C) or fixed ring (D) cable-pulley system with a servohydraulic test frame. Three sinusoidal load-unload cycles were applied at laboratories A and B while a single quasistatic cycle was applied in 1.5 Nm increments at laboratories C and D. Non-contact motion measurement systems were used to quantify ROM. In all test directions, the ROM variability among donors was greater than single-donor ROM variability among laboratories. The maximum difference in average ROM between any two laboratories was 1.5° in flexion-extension, 1.3° in lateral bending and 1.1° in axial torsion. This was the first study to quantify ROM in a single group of spinal motion segments at four independent laboratories with varying pure moment systems. These data support our hypothesis that given a well-described test method, independent laboratories can produce similar biomechanical outcomes.

Spatial coherence function of partially coherent Gaussian beams in atmospheric turbulence.

We introduce a new method of estimating the coherence function of a Gaussian-Schell model beam in the inertial subrange of atmospheric turbulence. It is compared with the previously published methods based on either the quadratic approximation of the parabolic equation or an assumed independence between the source's randomness and the atmosphere using effective beam parameters. This new method, which combines the results of the previous two methods to account for any random source/atmospheric coupling, was shown to more accurately estimate both the coherence radius and coherence functional shape across much of the relevant parameter space. The regions of the parameter space where one method or another is the most accurate in estimating the coherence radius are identified along with the maximum absolute estimation error in each region. By selecting the appropriate estimation method for a given set of conditions, the absolute estimation error can generally be kept to less than 5%, with a maximum error of 7%. We also show that the true coherence function is more Gaussian than expected, with the exponential power tending toward 9/5 rather than the theoretical value of 5/3 in very strong turbulence regardless of the nature of the source coherence.

Coupling of gaussian Schell-model beams into single-mode optical fibers.

We develop analytic equations that describe the mean and normalized variance of the coupling efficiency of gaussian Schell-model beams into single-mode optical fibers. Numerical methods and computer simulations are used to evaluate the accuracy of the various approximations used in this analysis, and, with some insight, empirical compensation is made for the identified shortcomings. The simulations make use of both speckled and nonspeckled beams by employing two different Monte Carlo methods to generate randomly drawn optical fields. While the analytic approximations break down in certain cases, the use of empirical compensation demonstrated accuracies of better than 5% for the mean coupling efficiency in all cases, and generally better than 40% for the coupling efficiency variance. By optimizing the compensation for particular beam characteristics, even higher accuracies can be achieved.

Biomechanical comparison of transosseous versus suture anchor repair of the subscapularis tendon.

PURPOSE: The purpose of this study was to compare the biomechanical properties of transosseous versus suture anchor repair of the subscapularis tendon. We also performed real-time measurement of contact area and pressure of the repair site under rotational loads. METHODS: Six paired human cadaveric shoulders were subjected to rotational loading after repair of the subscapularis tendon. Both shoulders were randomized to transosseous or suture anchor repairs. Real-time pressure sensors were placed between the subscapularis tendon and lesser tuberosity. The repair was subjected to cyclical rotational loading and load-to-failure testing. RESULTS: No significant difference was detected in initial pressurized contact area between transosseous repairs (1.70 +/- 0.99 cm(2), 57.88 +/- 30.02% footprint) and suture anchor repairs (1.08 +/- 0.58 cm(2), 34.26% +/- 17.32% footprint). Under cyclical loading, the conditioning elongation of transosseous repairs (0.64 +/- 0.40 mm) was significantly lower (P < .05) than that of suture anchor repairs (2.38 +/- 1.58 mm). No significant difference was found in mean pressurized contact area between the transosseous repairs (2.72 +/- 1.25 cm(2), 94.2% +/- 37.4% footprint) and suture anchor repairs (2.01 +/- 0.89 cm(2), 65.9% +/- 27.9% footprint). For suture anchor repairs, repair-site contact area was significantly (P < .05) smaller than the area of corresponding native insertional footprints; for transosseous repairs, no significant difference was detected. There were no significant differences in peak pressures between the 2 repairs. In the load-to-failure tensile test, there was no significant difference between transosseous repairs (453.2 +/- 66.1 N) and suture anchor repairs (392.6 +/- 78.0 N). CONCLUSIONS: Transosseous and suture anchor repairs of the subscapularis tendon have comparable biomechanical properties. Despite increased conditioning elongation in suture anchor repairs, we found no significant differences in mean contact area between the 2 repairs under cyclical loading. The suture anchor repairs do have a smaller contact area than the native insertional area. Real-time pressure and contact area measurements enabled mapping of the repair site throughout cyclical loading. CLINICAL RELEVANCE: Rotational loading of the subscapularis tendon may provide a more accurate representation of subscapularis tendon injuries. Both techniques showed adequate repair strength; however, neither surgical technique exhibited normal insertional behavior in this time-zero biomechanical study.