Qualitative Exploration of the #MeTooMedicine Online Discourse: "Holding Beacons of Light to Shine in the Corners They Are Hoping to Keep Dark".

PURPOSE: The MeToo movement forced a social reckoning, spurring women in medicine to engage in the #MeTooMedicine online discourse. Given the risks of reporting sexual violence, discrimination, or harassment, it is important to understand how women in medicine use platforms like Twitter to publicly discuss their experiences. With such knowledge, the profession can use the public documentation of women in medicine for transformative change. METHOD: Using reflexive thematic analysis, 7,983 tweets (posted between November 2017-January 2020) associated with #WomenInMedicine, #MeTooMedicine, and #TimesUpHC were systematically analyzed in 2020-2022, iteratively moving from describing their content, to identifying thematic patterns, to conceptualizing the purpose the tweets appeared to serve. RESULTS: The Twitter engagement of women in medicine was likened to "holding beacons of light to shine in the corners [harassers] are hoping to keep dark," both reinforcing the message that "gender bias is alive and well" and calling for a "complete transformation in how we approach" the problem. The tweets of women in medicine primarily seemed aimed at disrupting complacency; encouraging bystanders to become allies; challenging stereotypes about women in medicine; championing individual women leaders, peers, and trainees; and advocating for reporting mechanisms and policies to ensure safety and accountability across medical workplaces. CONCLUSIONS: Women in medicine appeared to use Twitter for a host of reasons: for amplification, peer support, advocacy, and seeking accountability. By sharing their experiences publicly, women in medicine seemed to make a persuasive argument that time is up, providing would-be allies with supporting evidence of sexual violence, discrimination, and harassment. Their tweets suggest a roadmap for what is needed to achieve gender equity, ensure that lack of awareness is no longer an excuse, and ask bystanders to grapple with why women's accounts continue to be overlooked, ignored, or dismissed and how they will support women moving forward.

Composite Bioprinted Hydrogels Containing Porous Polymer Microparticles Provide Tailorable Mechanical Properties for 3D Cell Culture.

The mechanical and architectural properties of the three-dimensional (3D) tissue microenvironment can have large impacts on cellular behavior and phenotype, providing cells with specialized functions dependent on their location. This is especially apparent in macrophage biology where the function of tissue resident macrophages is highly specialized to their location. 3D bioprinting provides a convenient method of fabricating biomaterials that mimic specific tissue architectures. If these printable materials also possess tunable mechanical properties, they would be highly attractive for the study of macrophage behavior in different tissues. Currently, it is difficult to achieve mechanical tunability without sacrificing printability, scaffold porosity, and a loss in cell viability. Here, we have designed composite printable biomaterials composed of traditional hydrogels [nanofibrillar cellulose (cellulose) or methacrylated gelatin (gelMA)] mixed with porous polymeric high internal phase emulsion (polyHIPE) microparticles. By varying the ratio of polyHIPEs to hydrogel, we fabricate composite hydrogels that mimic the mechanical properties of the neural tissue (0.1-0.5 kPa), liver (1 kPa), lungs (5 kPa), and skin (10 kPa) while maintaining good levels of biocompatibility to a macrophage cell line.

Investigating relationships among stress, reproduction, and immunity in three species of watersnake.

Energy is a finite resource required for all physiological processes and must be allocated efficiently among essential activities to ensure fitness and survival. During the active season, adult organisms are expected to prioritize investment in reproduction over other energetically expensive processes, such as responding to immunological challenges. Furthermore, when encountering a stressor, the balance between reproduction and immunity might be disrupted in order to fuel the stress response. Because of the distinct differences in life histories across species, watersnakes provide a unique group of study in which to examine these tradeoffs. Over a two-year period, we captured three watersnake species throughout Northeast Arkansas. Animals were subjected to restraint stress and blood samples were collected throughout the acute stress response. Blood samples were used to assess innate immunity and steroid hormone concentrations. We found the peak in corticosterone concentration is season-specific, potentially because energetic reserves fluctuate with reproductive activities. We also found body condition was positively related to acute stress and negatively related to immunity. Watersnakes evidently prioritize reproduction over immunity, especially during the energetically intensive process of vitellogenesis. Energetic tradeoffs between reproduction, immunity, and the stress response are complex, and this study contributes to our understanding of energetic shifts in free-living organisms in the context of stress.

Assessment of glucocorticoids, sex steroids, and innate immunity in wild red-eared slider turtles (Trachemys scripta elegans).

When access to resources is limited, organisms must shift energy investment among physiological processes to survive, reproduce, and respond to unpredictable events. The shifting of these limited resources among processes may result in physiological tradeoffs, often mediated by glucocorticoids. We assessed relationships among the physiological processes of immunity, reproduction, and the stress response in wild adult red-eared slider turtles (Trachemys scripta elegans). Red-eared sliders exhibit a multi-clutching reproductive strategy that requires high energetic investment in reproduction at the beginning of the nesting season in females. Males mate in spring and undergo spermatogenesis and mating in late summer/early fall. We expected to observe tradeoffs when investment toward reproductive processes was particularly demanding. To test this, we subjected 123 individuals to a standardized acute stressor and collected blood to measure innate immunocompetence and circulating steroid hormone concentrations. Tradeoffs between female reproduction and immunocompetence occurred early in the nesting season. This high reproductive investment was evident by heightened circulating progesterone and reduced baseline innate immunity. Corticosterone (CORT) was also high during this period, indicating a role in facilitating allocation of energy. Tradeoffs were not as evident in males, though males upregulated innate immune function, baseline CORT, and testosterone prior to fall spermatogenesis and mating. Throughout the entire sampling period, both males and females increased CORT and immunocompetence following the acute standardized stressor. Taken together, we concluded that reproduction requires shifts in energy allocation in during the highest reproductive period for females but all individuals in this population remain able to respond to the standardized stressor even during increased reproductive investment. These findings reinforce the continuing evidence that physiological relationships are context-dependent and resource demands are dynamic across the reproductive season.

Immune and stress physiology of two captively-housed tortoise species.

Ecoimmunology affords us the ability to better understand immunological processes through consideration of external factors, such as the thermal microenvironment. This consideration is imperative when examining the immunological processes of ectothermic organisms like reptiles. Reptiles uniquely rely heavily on their innate immune function but remain poorly understood in immunological studies. In this study, we examined innate immunity in two zoo-housed tortoise species, the Indian star tortoise (Geochelone elegans, Schoepff, 1795) and northern spider tortoise (Pyxis arachnoides brygooi, Vuillemin & Domergue, 1972). Bacterial killing assays (BKAs) were optimized and used to assess the monthly immunocompetence of these tortoises to three different bacteria: Escherichia coli, Salmonella enterica, and Staphylococcus aureus. We evaluated differences in blood biochemistry values (lactate and glucose) among months and species as well as fecal corticosterone (CORT) between species. Lastly, we examined the potential influences of individual thermal microenvironments on bactericidal ability. Both G. elegans and P. a. brygooi demonstrated immunocompetence against all bacterial challenges, but only bactericidal ability against E. coli varied over months. Optimal BKA serum dilutions, blood glucose levels, and fecal CORT concentrations differed between the two species. Finally, there was evidence that the thermal microenvironment influenced the tortoises' bactericidal ability against E. coli. Through use of nonmodel organisms, such as tortoises, we are given insight into the inner workings of innate immunity and a better understanding of the complexities of the vertebrate immune system.

'For the most part it works': Exploring how authors navigate peer review feedback.

BACKGROUND: Peer review aims to provide meaningful feedback to research authors so that they may improve their work, and yet it constitutes a particularly challenging context for the exchange of feedback. We explore how research authors navigate the process of interpreting and responding to peer review feedback, in order to elaborate how feedback functions when some of the conditions thought to be necessary for it to be effective are not met. METHODS: Using constructivist grounded theory methodology, we interviewed 17 recently published health professions education researchers about their experiences with the peer review process. Data collection and analysis were concurrent and iterative. We used constant comparison to identify themes and to develop a conceptual model of how feedback functions in this setting. RESULTS: Although participants expressed faith in peer review, they acknowledged that the process was emotionally trying and raised concerns about its consistency and credibility. These potential threats were mitigated by factors including time, team support, experience and the exercise of autonomy. Additionally, the perceived engagement of reviewers and the cultural norms and expectations surrounding the process strengthened authors' willingness and capacity to respond productively. Our analysis suggests a model of feedback within which its perceived usefulness turns on the balance of threats and countermeasures. CONCLUSIONS: Feedback is a balancing act. Although threats to the productive uptake of peer review feedback abound, these threats may be neutralised by a range of countermeasures. Among these, opportunities for autonomy and cultural normalisation of both the professional responsibility to engage with feedback and the challenge of doing so may be especially influential and may have implications beyond the peer review setting.

Ecological interchangeability: supporting team adaptive expertise in moments of disruption.

While undesirable, unexpected disruptions offer unique opportunities to enact adaptive expertise. For adaptive expertise to flourish, individuals and teams must embrace both efficiency and adaptation. While some industries do it readily, others continue to struggle with the tension between efficiency and adaptation, particularly when otherwise stable situations are unexpectedly disrupted. For instance, in healthcare settings, the efficiency mandate for strict compliance with scopes of practice can deter teams from using the adaptive strategy of making their members interchangeable. Yet, interchangeability has been hinted as a key capacity of today' teams that are required to navigate fluid team structures. Because interchangeability - as an adaptive strategy - can generate antagonistic reactions, it has not been well studied in fluid teams. Thus, in this exploratory qualitative study we sought to gain insights into how interchangeability manifests when fluid teams from five different contexts (healthcare, emergency services, orchestras, military, and business) deal with disruptive events. According to our participants, successful interchangeability was possible when people knew how to work within one's role while being aware of their teammates' roles. However, interchangeability included more than just role switching. Interchangeability took various forms and was most successful when teams capitalized on the procedural, emotional, and social dimensions of their work. To reflect this added complexity, we refer to interchangeability in fluid teams as Ecological Interchangeability. We suggest that ecological interchangeability may become a desired feature in the training of adaptive expertise in teams, if its underlying properties and enabling mechanisms are more fully understood.

Reptilian Innate Immunology and Ecoimmunology: What Do We Know and Where Are We Going?

Reptiles, the only ectothermic amniotes, employ a wide variety of physiological adaptations to adjust to their environments but remain vastly understudied in the field of immunology and ecoimmunology in comparison to other vertebrate taxa. To address this knowledge gap, we assessed the current state of research on reptilian innate immunology by conducting an extensive literature search of peer-reviewed articles published across the four orders of Reptilia (Crocodilia, Testudines, Squamata, and Rhynchocephalia). Using our compiled dataset, we investigated common techniques, characterization of immune components, differences in findings and type of research among the four orders, and immune responses to ecological and life-history variables. We found that there are differences in the types of questions asked and approaches used for each of these reptilian orders. The different conceptual frameworks applied to each group has led to a lack of unified understanding of reptilian immunological strategies, which, in turn, have resulted in large conceptual gaps in the field of ecoimmunology as a whole. To apply ecoimmunological concepts and techniques most effectively to reptiles, we must combine traditional immunological studies with ecoimmunological studies to continue to identify, characterize, and describe the reptilian immune components and responses. This review highlights the advances and gaps that remain to help identify targeted and cohesive approaches for future research in reptilian ecoimmunological studies.

Adapting despite "walls coming down": Healthcare providers' experiences of COVID-19 as an implosive adaptation.

INTRODUCTION: The COVID-19 pandemic has been a daunting exercise in adaptation for healthcare providers. While we are beginning to learn about the challenges faced by teams during the COVID-19 pandemic, what remains underexplored are the strategies team members used to adapt to these challenges. The goal of this study is therefore to explore how healthcare providers navigated and adapted to on-the-ground challenges imposed by COVID-19. METHODS: We interviewed 20 healthcare workers at various hospitals in Ontario, who provided care as part of clinical teams during the COVID-19 pandemic. Data were collected and analyzed following Constructivist Grounded Theory principles including iteration, constant comparison and theoretical sampling. RESULTS: Participants' accounts of their experiences revealed the process of 'implosive adaptation'. The 'reality check', the 'scramble' and the 'pivot' comprised this process. The reality check described the triggers, the scramble detailed the challenges they went through and the pivot prescribed the shifting of mindset as they responded to challenges. These stages were iterative, rather than linear, with blurred boundaries. DISCUSSION: According to our participants, not all adaptations have to be successful during a crisis. The language of reality check, scramble and pivot provides a framework for teams to talk about and make sense of their approaches to crisis, even beyond the COVID-19 pandemic.

Interchangeability in Military Interprofessional Health Care Teams: Lessons Into Collective Self-healing and the Benefits Thereof.

INTRODUCTION: Interchangeability-i.e., the capacity to change places with another-is necessary for military interprofessional health care teams (MIHTs) to provide around-the-clock patient care. However, while interchangeability is clearly a necessity for modern health care delivery, it raises uncomfortable questions for civilian health care teams where it is usually labeled as unsafe. This perception surfaces because interchangeability runs counter to some of health care's cultural beliefs including those around patient ownership and professional scopes of practice. It is, therefore, not surprising that little is known about whether and how some level of interchangeability can be harnessed to improve the productivity of health care teams overall. In this article, we explore the notion of interchangeability in the particular context of MIHTs given that these health care teams are familiar with it. This exploration will offer insights into how interchangeability could maximize civilian health care teams' capacity to adapt. MATERIALS AND METHODS: We conducted a secondary analysis of interview data as an analytic expansion: "the kind of study in which the researcher makes further use of a primary data set in order to ask new or emerging questions that derive from having conducted the original analysis but were not envisioned within the original scope of the primary study aims". Within our secondary analysis approach, we used thematic analysis as our analytical tool to describe (1) what interchangeability looks like in MIHT teams, (2) how it is fostered in MIHTs, and (3) how it is enacted in MIHTs. RESULTS: Interchangeability was realized in MIHTs when individual team members adapted to take on roles and/or tasks that were not clearly niched in their specific areas of expertise but instead drew on the broad foundation of their clinical skill set. Cross-training and distributed leadership were ways in which MIHT members described how interchangeability was fostered. Furthermore, five features of working within MIHT teams were identified as key conditions to enact interchangeability: knowing your team members; being able to work with what/who you have; actively seeking others' expertise; situating your role within the broader picture of the mission; and maintaining a learning/teaching mindset. CONCLUSIONS: Interchangeability can be understood through the theoretical lens of Swarm Intelligence and more specifically, the principle of collective self-healing-which is the ability of collectives to continue to successfully perform despite disruption, challenges, or the loss of a team member. Our findings highlight how MIHTs have adopted interchangeability in a wide array of contexts to realize collective self-healing. Despite the discomfort it provokes, we suggest that interchangeability could be a powerful asset to civilian health care teams.

Not wanted on the voyage: highlighting intrinsic CanMEDS gaps in Competence by Design curricula.

BACKGROUND: As governing bodies design new curricula that seek to further incorporate principles of competency-based medical education within time-based models of training, questions have been raised regarding the continued centrality of existing CanMEDS competencies. Although efforts have been made to align these new curricula with CanMEDS, we don't yet know to what extent these competencies are meaningfully integrated. METHODS: A content analysis approach was used to systematically evaluate national Canadian curricula for 18 residency-training programs and determine the number of times each enabling CanMEDS competency was represented. RESULTS: Clear trends persisted across all programs. Medical Expert and Collaborator competencies were well integrated into curriculum (81% and 86% mapped to assessment) while competencies related to the Leader, Professional, and Health Advocate roles were less frequently mapped to assessment (41%, 36%, and 40%) and were often absent from the new curricula altogether (59%, 64%, and 60%). CONCLUSION: Deliberate planning in curriculum development affords the early identification of gaps. These gaps can inform current assessment practice and future curricular development by providing direction for innovation. If we are to ensure that any new curricula meaningfully address all CanMEDS roles, we need to think carefully about how to best teach and assess underrepresented competencies.

CONTEXTE: Alors que les instances dirigeantes conçoivent de nouveaux programmes d'études visant une intégration plus poussée des principes de l'éducation médicale fondée sur les compétences, notamment dans des modèles de formation axés sur la durée, la question se pose de savoir si l'on parvient à y préserver le caractère central des compétences CanMEDS actuelles. Malgré les efforts consacrés pour aligner les nouveaux programmes d'études sur CanMEDS, nous ne savons pas encore si l'intégration de ces compétences se fait avec discernement. MÉTHODES: L'approche d'analyse de contenu a été utilisée pour évaluer systématiquement 18 programmes de résidence au Canada et pour déterminer le nombre de fois que chaque compétence habilitante CanMEDS est représentée dans ces programmes. RÉSULTATS: Des tendances claires se dégagent pour l'ensemble des programmes. Tandis que les compétences d'expert médical et de collaborateur sont bien intégrées aux programmes (elles se retrouvent à hauteur de 81 % et 86 % respectivement dans l'évaluation), celles liées aux rôles de leader, de professionnel et de promoteur de la santé se répercutent moins souvent dans l'évaluation (41 %, 36 % et 40 %) et elles sont même souvent absentes des nouveaux programmes (59 %, 64 % et 60 %). CONCLUSION: Une planification rigoureuse dans le cadre du développement de cursuspermettrait de rapidement cibler les lacunes. La mise en lumière de ces lacunes peut éclairer les pratiques d'évaluation actuelles et orienter les programmes d'études futurs vers des pistes d'innovation. Si nous voulons nous assurer que tout nouveau programme d'études aborde de manière efficace l'ensemble des rôles CanMEDS, nous devons porter attention à la meilleure façon d'enseigner et d'évaluer les compétences sous-représentées.

The fatigue paradox: Team perceptions of physician fatigue.

OBJECTIVES: Ongoing calls to implement fatigue risk management in residency education assume a shared understanding of physician fatigue as a workplace hazard, yet we lack empirical evidence that all health care team members maintain this assumption. Thus, this study seeks to explore how health care team members understand the role of physician fatigue in an effort to inform the implementation of fatigue risk management in residency training and medical practice. METHODS: This study uses constructivist grounded theory to explore perceptions of workplace fatigue and its impact on clinical practice. We conducted individual semi-structured interviews with physicians, nurses and senior residents across four hospitals in 8 different specialties for a total of 40 participants. Constant comparative analysis guided data analysis and led to the final grounded theory. RESULTS: While participants outlined multiple problematic manifestations of physician fatigue on clinical performance, they were reluctant to acknowledge any negative impact of fatigue on patient care. We refer to these contradictions as the fatigue paradox. Four key themes sustain the fatigue paradox: the indefatigable physician, blind spots, faith in safety nets and the minimisation of fatigue-related events. CONCLUSIONS: This study suggests that health care team members do not universally feel that physician fatigue is problematic for patient care, despite providing multiple examples to the contrary. This paradoxical understanding of fatigue likely exists because the system relies on fatigued physicians, particularly trainees, and provides few mechanisms to critically examine fatigue. Successful implementation of fatigue risk management in residency training may prove elusive if clinical supervisors are skeptical of the potentially negative impact of workplace fatigue.

Going against the grain: An exploration of agency in medical learning.

BACKGROUND: Learner-centred medical education relies on learner agency. While attractive in principle, the actual exercise of agency is a complicated process, potentially constrained by social norms and cultural expectations. In this study, we explored what it means to be an agentic learner in medicine, and how individuals experience and harness agency in their learning. METHODS: Using a constructivist grounded theory approach, we interviewed 19 physicians or physicians-in-training who identified as 'learning mavericks'; this strategy facilitated recruiting participants with a strong sense of themselves as agentic learners. We asked them about atypical learning choices they had made, about support and resistance they encountered and about how they managed to carve a distinct path for themselves. Data collection and analysis were concurrent and iterative, grounded in the constant comparative approach. RESULTS: We identified one overarching concept: agency is work. The work of exercising agency was compounded by a system of professional training that was perceived to promote conformity and to resist individual learner agency. Individuals' capacity to exercise agency appeared to be bolstered by social capital, self-knowledge and mentorship. DISCUSSION AND CONCLUSIONS: Our work extends and elaborates the understanding of learner agency in medicine, highlighting the exercise of agency as a sometimes counter-cultural act that requires learners to resist considerable pressure to conform to social and professional expectations. Agency may come more easily to strong learners who have established their ability to succeed within the system's expectations. Enhancing learner agency thus requires careful attention to learner support. Mentorship that both helps learners to identify appropriate learning paths and shields them from the pull of social expectations may be especially fruitful.

Qualitative investigation of trace-based communication: how are traces conceptualised in healthcare teamwork?

OBJECTIVES: This interview-based qualitative study aims to explore how healthcare providers conceptualise trace-based communication and considers its implications for how teams work. In the biological literature, trace-based communication refers to the non-verbal communication that is achieved by leaving 'traces' in the environment and other members sensing them and using them to drive their own behaviour. Trace-based communication is a key component of swam intelligence and has been described as a critical process that enables superorganisms to coordinate work and collectively adapt. This paper brings awareness to its existence in the context of healthcare teamwork. DESIGN: Interview-based study using Constructivist Grounded Theory methodology. SETTING: This study was conducted in multiple team contexts at one of Canada's largest acute-care teaching hospitals. PARTICIPANTS: 25 clinicians from across professions and disciplines. Specialties included surgery, anesthesiology, psychiatry, internal medicine, geriatrics, neonatology, paramedics, nursing, intensive care, neurology and emergency medicine. INTERVENTION: Not relevant due to the qualitative nature of the study. PRIMARY AND SECONDARY OUTCOME: Not relevant due to the qualitative nature of the study. RESULTS: The dataset was analysed using the sensitising concept of 'traces' from Swarm Intelligence. This study brought to light novel and unique elements of trace-based communication in the context of healthcare teamwork including focused intentionality, successful versus failed traces and the contextually bounded nature of the responses to traces. While participants initially felt ambivalent about the idea of using traces in their daily teamwork, they provided a variety of examples. Through these examples, participants revealed the multifaceted nature of the purposes of trace-based communication, including promoting efficiency, preventing mistakes and saving face. CONCLUSIONS: This study demonstrated that clinicians pervasively use trace-based communication despite differences in opinion as to its implications for teamwork and safety. Other disciplines have taken up traces to promote collective adaptation. This should serve as inspiration to at least start exploring this phenomenon in healthcare.

What is the state of complexity science in medical education research?

CONTEXT: 'Complexity' is fast becoming a 'god term' in medical education, but little is known about how scholars in the field apply complexity science to the exploration of education phenomena. Complexity science presents both opportunities and challenges to those wishing to adopt its approaches in their research, and debates about its application in the field have emerged. However, these debates have tended towards a reductive characterisation of complexity versus simplicity. We argue that a more productive discussion centres on the multiplicity of complexity orientations, with their diverse disciplinary roots, concepts and terminologies. We discuss this multiplicity and use it to explore how medical education researchers have taken up complexity science in prominent journals in the field. METHODS: We synthesised the health sciences and medical education literature based on 46 papers published in the last 18 years (2000-2017) to describe the patterns of use of complexity science in medical education and to consider the consequences of those patterns for our ability to advance scholarly conversations about 'complex' phenomena in our field. RESULTS: We identified four patterns in the use of complexity science in medical education research. Firstly, complexity science is described in a variety of ways. Secondly, multiple approaches to complexity are used in combination in single papers. Thirdly, the type of complexity science used tends to be left implicit. Fourthly, the complexity orientation used is much more commonly located using secondary source citation rather than primary source citation. CONCLUSIONS: The presence of these four patterns begs the question: Do medical education scholars understand that there are multiple legitimate orientations to complexity science, deriving from distinct disciplinary origins, drawing on different metaphors and serving distinct purposes? If we do not understand this, a cascade of potential consequences awaits. We may assume that complexity science is singular in that there is only one way to do it. This assumption may cause us to perceive our way as the 'right' way and to disregard other approaches as illegitimate. However, this perception of illegitimacy may limit our ability to enter into productive dialogue about our complexity science-inspired research.

Navigating complexity in team-based clinical settings.

CONTEXT: Educators must prepare learners to navigate the complexities of clinical care. Training programmes have, however, traditionally prioritised teaching around the biomedical and the technical, not the socio-relational or systems issues that create complexity. If we are to transform medical education to meet the demands of 21st century practice, we need to understand how clinicians perceive and respond to complex situations. METHODS: Constructivist grounded theory informed data collection and analysis; during semi-structured interviews, we used rich pictures to elicit team members' perspectives about clinical complexity in neurology and in the intensive care unit. We identified themes through constant comparative analysis. RESULTS: Routine care became complex when the prognosis was unknown, when treatment was either non-existent or had been exhausted or when being patient and family centred challenged a system's capabilities, or participants' training or professional scope of practice. When faced with complexity, participants reported that care shifted from relying on medical expertise to engaging in advocacy. Some physician participants, however, either did not recognise their care as advocacy or perceived it as outside their scope of practice. In turn, advocacy was often delegated to others. CONCLUSIONS: Our research illuminates how expert clinicians manoeuvre moments of complexity; specifically, navigating complexity may rely on mastering health advocacy. Our results suggest that advocacy is often negotiated or collectively enacted in team settings, often with input from patients and families. In order to prepare learners to navigate complexity, we suggest that programmes situate advocacy training in complex clinical encounters, encourage reflection and engage non-physician team members in advocacy training.

Living Day by Day: The Meaning of Living With HIV/AIDS Among Women in Lebanon.

We examined the meaning of living with HIV/AIDS among women in Lebanon. Ten women living with HIV/AIDS (WLWHA) described their experiences via semistructured in-depth interviews. They navigated a process of HIV diagnosis acceptance that incorporated six overlapping elements: receiving the news, accessing care, starting treatment, navigating disclosure decisions, negotiating stigma, and maintaining stability. Through these elements, we provide a framework for understanding three major themes that were constructed during data analysis: Stand by my side: Decisions of disclosure; Being "sick" and feeling "normal": Interacting with self, others, and society; and Living day by day: focusing on the present. We contribute to the existing literature by providing a theoretical framework for understanding the process of diagnosis and sero-status acceptance among WLWHA. This was the first study of its kind to examine the meaning of living with HIV/AIDS among women in a Middle Eastern country.