Implementation experience and initial assessment of a rural women's health training program in support of the U.S. Department of Veterans Affairs as a learning health system.

Introduction: The increasing number of women Veterans receiving health care from the Veterans Health Administration (VHA) has spurred the need for more women's health primary care providers (PCPs) and nurses, including in rural areas nationwide. Here we report on the implementation of a women's health rural workforce training program, demonstrate initial evidence of its effectiveness within VHA as a Learning Health System, and present lessons learned and implications for other workforce training programs. Methods: The Women's Health Primary Care Mini-Residency for Rural Providers and Nurses (Rural WH-MR) is a mobile VHA training initiative adapted from a national training model. The Rural WH-MR uses asynchronous blended learning paired with in-person hands-on instruction delivered directly at rural VHA sites. Mixed methods evaluation using quantitative data, qualitative interviews, and observational feedback assessed the program's implementation feasibility, fidelity, acceptability, and appropriateness. Longitudinal survey data were used to assess the initial program impact via changes in participating PCP and nurse knowledge, attitudes, practices, and skills (KAPS). Results: Inclusive of the pilot and fiscal years 2018 and 2019 Rural WH-MR trainings, 181 PCPs, and 320 nurses were trained through 56 training events nationwide. Cumulative survey data using 5-point measures showed high participant satisfaction, achievement of program-specific objectives, and usefulness of training activities to the rural practice of both PCPs and nurses. Both a pre-training and 6-month-follow-up survey were completed by 52 PCPs (32.9%) and 93 nurses (32.2%) and revealed significant sustained improvements in 18 out of 22 KAPS (p < 0.01-0.03) areas assessed for PCPs and all 17 KAPS (p < 0.01) areas assessed for nurses. Conclusions: This adapted training program benefitted VHA's rural clinical workforce thereby contributing to the VHA goal of increasing the numbers of rural women Veterans with access to PCPs and nurses with women's health expertise.

Retaining Providers with Women's Health Expertise: Decreased Provider Loss Among VHA Women's Health Faculty Development Program Attendees.

BACKGROUND: The Veterans Health Administration (VHA) provides care for over 500,000 women. In 2010 VHA instituted a policy requiring each facility to identify a designated women's health provider (WH-PCP) who could offer comprehensive gender-specific primary care. Access to WH-PCPs remains a challenge at some sites with high turnover among WH-PCPs. Faculty development programs have been demonstrated to foster professional development, networks, and mentorship; these can enhance job satisfaction and provide one potential solution to address WH-PCP turnover. One such program, the VHA's Women's Health Mini-Residency (WH-MR), was developed in 2011 to train WH-PCPs through case-based hands-on training. OBJECTIVE: The objective of this program evaluation was to determine the association of WH-MR participation with WH-PCP retention. DESIGN: Using the Women's Health Assessment of Workforce Capacity-Primary Care survey, we assessed the relationship between WH-MR participation and retention of WH-PCP status between fiscal year 2018 and 2019. PARTICIPANTS: All WH-PCPs (N = 2664) at the end of fiscal year 2018 were included. MAIN MEASURES: We assessed retention of WH-PCP status the following year by WH-MR participation. For our adjusted analysis, we controlled for provider gender, provider degree (MD, DO, NP, PA), women's health leadership position, number of clinical sessions per week, and clinical setting (general primary care clinic, designated women's health clinic, or a combination). KEY RESULTS: WH-MR participants were more likely to remain WH-PCPs in FY2019 in both unadjusted analyses (OR 1.91, 95%CI 1.54-2.36) and adjusted analyses (OR 1.96, 95%CI 1.58-2.44). CONCLUSIONS: WH-PCPs who participate in WH-MRs are more likely to remain WH-PCPs in the VHA system. Given the negative impact of provider turnover on patient care and the significant financial cost of onboarding a new WH-PCP, the VHA should continue to encourage all WH-PCPs to participate in the WH-MR.

How Gender Stereotypes May Limit Female Faculty Advancement in Communication Sciences and Disorders.

Purpose: The field of communication sciences and disorders (CSD) faces a critical shortage of the faculty essential to train the future workforce of speech-language pathologists and audiologists. Despite a predominance of women in the field, men receive doctoral degrees, tenure status, academic leadership positions, and American Speech-Language-Hearing Association awards at disproportionately higher rates than women. The purpose of this review is to explore how implicit gender bias may contribute to female faculty advancement, including current and projected faculty workforce shortages, and to propose tangible solutions. Method: The authors present proportions of men and women who receive doctoral degrees, advance to each faculty rank, receive tenure status, hold department chairs in CSD, and receive American Speech-Language-Hearing Association honors and awards. They review ways in which cultural stereotypes give rise to implicit gender bias and discuss myriad ways that implicit gender bias may influence the decisions of students considering an academic career in CSD and their career trajectories. Conclusions: Cultural stereotypes about men and women lead to implicit gender bias that may have real consequences for female faculty advancement in CSD. Such implicit bias can influence career selection and outcomes within the field in multiple ways. To ensure that CSD continues to attract top talent and maintain a robust pipeline of future faculty in doctoral training programs, the field must recognize the existence of implicit gender bias and implement evidence-based strategies to minimize its potentially damaging effects on the future of the profession.

Post-Code PTSD Symptoms in Internal Medicine Residents Who Participate in Cardiopulmonary Resuscitation Events: A Mixed Methods Study.

BACKGROUND: Internal medicine (IM) residents participate in cardiopulmonary resuscitation events (or "codes"), stressful events that involve the death or near death of patients. Experiencing traumatic stress can lead to posttraumatic stress disorder (PTSD). OBJECTIVE: We examined whether IM residents who participate in codes developed PTSD symptoms. METHODS: We conducted this research as a 2-phase, mixed methods study. In the first phase, we analyzed interview transcripts from 25 IM residents at 9 institutions for content relevant to PTSD. In the second phase, we surveyed 82 IM residents at 1 midwestern institution for symptoms reported post-code that are associated with PTSD (post-code PTSD symptoms). RESULTS: A total of 7 of 25 residents (28%) interviewed characterized codes as traumatic or described experiencing PTSD symptoms, including intrusive thoughts about the code, avoidance and emotional numbing, and hyperarousal, irritability, or hypervigilance. Of the 82 residents, 51 (62%) responded to the questionnaire. Of the 42 respondents who had participated in a code, 6 (14%) reported at least 1 PTSD symptom, and 3 (7%) women screened positive for potential PTSD with 2 or more PTSD symptoms. Endorsing any PTSD symptom was associated with residents' perception that code participation negatively affected their work performance. CONCLUSIONS: Our study found that some IM residents reported symptoms of PTSD after being involved in a code.

Why is John More Likely to Become Department Chair Than Jennifer?

This article reviews some of our research on how gender stereotypes and their accompanying assumptions and expectations can influence the careers of male and female physicians and scientists in a myriad of subtle ways. Although stereotype-based cognitive biases may be invisible and unintentional, they nevertheless shape the experiences of women in academic medicine in ways that frequently constrain their opportunities. We present research on the following: 1) subtle differences in the evaluation of male and female medical students as revealed through text analysis of written evaluations at a critical career juncture, 2) how cultural assumptions about the way men and women should and should not behave influence medical residents' experiences as leaders, and 3) how approaching gender bias among faculty in academic medicine, science, and engineering as a remedial habit can be successful in changing individual behaviors and in improving department climate.

Intrauterine devices and other forms of contraception: thinking outside the pack.

A variety of contraception options are available in addition to traditional combined oral contraceptive pills. Newer long-acting reversible contraceptive (LARC) methods such as intrauterine devices and subcutaneous implants are preferred because they do not depend on patient compliance. They are highly effective and appropriate for most women. Female and male sterilization are other effective but they are irreversible and require counseling to minimize regret. The contraceptive injection, patch, and ring do not require daily administration, but their typical efficacy rates are lower than LARC methods and similar to those for combined oral contraceptive pills.

"Oops! I forgot HIV": resident physician self-audits and universal HIV screening.

BACKGROUND: Innovations are needed to increase universal HIV screening by primary care providers. One potential intervention is self-audit feedback, which describes the process of a clinician reviewing their own patient charts and reflecting on their performance. METHODS: The effectiveness of self-audit feedback was investigated using a mixed methods approach. A total of 2111 patient charts were analyzed in a quantitative pre-post intervention study design, where the intervention was providing self-audit feedback to all internal medicine residents at one institution through an annual chart review. Qualitative data generated from the subsequent resident focus group discussions explored the motivation and mechanism for change using a knowledge-attitude-behavior framework. RESULTS: The proportion of primary care patients screened for HIV increased from 17.9% (190/1060) to 40.3% (423/1051). The adjusted odds ratio of a patient being screened following resident self-audited feedback was 3.17 (95% CI 2.11, 4.76, p<0.001). Focus group participants attributed the improved performance to the self-audit feedback. CONCLUSIONS: Self-audit feedback is a potentially effective intervention for increasing universal HIV screening in primary care. This strategy may be most useful in settings where (1) baseline performance is low, (2) behavioral change is provider-driven, and (3) resident trainees are targeted.

Afraid of being "witchy with a 'b'": a qualitative study of how gender influences residents' experiences leading cardiopulmonary resuscitation.

PURPOSE: Ineffective leadership during cardiopulmonary resuscitation ("code") can negatively affect a patient's likelihood of survival. In most teaching hospitals, internal medicine residents lead codes. In this study, the authors explored internal medicine residents' experiences leading codes, with a particular focus on how gender influences the code leadership experience. METHOD: The authors conducted individual, semistructured telephone or in-person interviews with 25 residents (May 2012 to February 2013) from 9 U.S. internal medicine residency programs. They audio recorded and transcribed the interviews and then thematically analyzed the transcribed text. RESULTS: Participants viewed a successful code as one with effective leadership. They agreed that the ideal code leader was an authoritative presence; spoke with a deep, loud voice; used clear, direct communication; and appeared calm. Although equally able to lead codes as their male colleagues, female participants described feeling stress from having to violate gender behavioral norms in the role of code leader. In response, some female participants adopted rituals to signal the suspension of gender norms while leading a code. Others apologized afterwards for their counternormative behavior. CONCLUSIONS: Ideal code leadership embodies highly agentic, stereotypical male behaviors. Female residents employed strategies to better integrate the competing identities of code leader and female gender. In the future, residency training should acknowledge how female gender stereotypes may conflict with the behaviors required to enact code leadership and offer some strategies, such as those used by the female residents in this study, to help women integrate these dual identities.

Barriers and facilitators of universal HIV screening among internal medicine residents.

BACKGROUND: Adoption of universal HIV screening has been low despite national recommendations. OBJECTIVE: To describe the barriers and facilitators to adoption of universal HIV screening in a low-prevalence setting. DESIGN: Qualitative, thematic analysis of focus group discussions among internal medicine residents who introduced universal HIV screening into their primary care practice in Madison, Wisconsin. APPROACH: Deductive and inductive codes constructed a hybridized thematic analysis model. Deductive codes stemmed from a knowledge-attitude-behavior framework for physician nonadherence to guidelines. Inductive codes emerged from the focus group discussions and were embedded into broader deductive codes to provide an HIV-specific model. KEY RESULTS: Residents were knowledgeable and had positive attitudes toward recommendations for universal HIV screening. Residents felt the majority of their patients were receptive to HIV screening, especially when introduced with normalizing techniques and reference to an expert authority such as the Centers for Disease Control and Prevention (CDC). They still perceived patient discussions as challenging due to stigma surrounding HIV and patients' perceptions of being at low risk. Residents employed individualized electronic medical record cues as a memory aid to discuss the issue. CONCLUSION: This qualitative study of internal medicine residents training in an area with low HIV prevalence suggests that stigma and patient perception of being at low risk are barriers that should be addressed to effectively integrate universal HIV screening into primary care.