The Gendered Work/Role of Program Directors in International Graduate Medical Education.

Healthcare organizations offer numerous clinical and academic leadership pathways for physicians, among which the position of program director (PD) is considered to be a prominent educational leadership role. As PDs are instrumental in the recruitment and training of the next generations of physicians, PD gender distribution can affect the present and future of a medical specialty. This study offers a dialectical perspective in understanding how international PDs negotiate gendered understanding of their work/role by using the framework of Relational Dialectics Theory 2.0. Thirty-three interviews of PDs from Qatar, Singapore, and the United Arab Emirates were conducted and, using contrapuntal analysis, the competing discourses of meanings of gender in the PD work/role were examined. Competing discourses where structural, cultural, and professional meanings of gender were interrogated revealed inherent multiple meanings of how gender is understood in PD work/roles. In making sense of these meanings of gender, PDs express dilemmas of traditional gender binaries of masculine/feminine work/role meanings to explain the term in different ways in their everyday organizational and cultural struggles. The findings have implications for PD recruitment and retention in teaching hospitals.

Recognizing Gender Parity in Military Medicine: An Analysis of Plenary Speakers and Award Recipients at Military American College of Physicians Chapter Meetings.

INTRODUCTION: Despite the advances toward gender parity in medicine, a gap exists in the recognition of women physicians at academic and subspecialty medical conferences as plenary speakers and award winners. Conferences are cornerstones in the practice of medicine because they serve as platforms to showcase physicians' successes and disseminate work. The selection of who is honored at such events can impact an individual's career by creating networks that may lead to future opportunities. Additionally, the trend of who is honored may create expectations in the minds of trainees and early career physicians about what qualities help an individual achieve success. Our group sought to determine whether there was a gender gap in award recognition and speakership opportunities at the American College of Physicians (ACP) annual military chapter meetings. METHODS: This was a cross-sectional study with data extracted from publicly available conference programs for the Army-Air Force annual ACP meetings and the Navy annual ACP meetings. Five years of data erewere reviewed for invited plenary speakers. Ten years of data were reviewed for award recipients. For an award to be included, it had to have a preset description and criteria for recipient selection. Awards not given annually or awards given for less than 3 years were excluded. Individuals' gender was determined based on the first name and confirmed through internet searches of pronoun descriptors from professional websites. Comparisons were done using Fisher's exact test and chi-square tests when appropriate, with statistical significance set at a two-tailed P-value of <.05. RESULTS: Women comprised 26-30% of the chapter membership and there was no significant difference in gender distribution between the chapters. Fourteen of the 69 plenary speakers were women (20%), with significantly fewer women presenters in the Navy as compared to men. Thirty-six of the 134 award winners were women (27%), which was not significantly different from the overall chapter gender distributions. While women recipients of lifetime, teaching, research, and medical student awards were not significantly different from chapter gender distribution, women faculty were significantly more likely to receive an award for teaching than for research, with women receiving 13 of the 28 teaching awards (41%), and none of the 10 faculty research awards. CONCLUSIONS: The military chapter ACP meetings reviewed mirrored civilian data in many ways, although military plenary speaker and award recipient distributions were more representative of the gender distribution of the branches. Review of the nomination process, planning committee selection, and opportunities for diversity training could be optimized to ensure that future conferences have a gender-balanced representation of individuals being honored. Improving upon current practices is important for the growth and retention of women military physicians.

"I Find It Quite a Privilege to Be Involved in Their Lives": A Multinational Qualitative Study of Program Directors' Perspectives on Their Relationships with Residents.

PHENOMENON: Program director (PD)-resident relationships are important in shaping resident experiences and educational outcomes. Yet, there is limited literature on the development or meaning of these relationships, particularly from the PD perspective. Through qualitative interviews, we explore how PDs navigate their role to develop and maintain relationships with their trainees, and elucidate how these relationships impact the PDs personally and professionally. APPROACH: Qualitative study using individual semi-structured interviews of former and current PDs (n = 33) from multiple specialties and hospitals in accredited residency programs in Qatar, Singapore, and the United Arab Emirates. We used attachment theory and narrative analysis to investigate how PDs perceive and describe relationship building with their residents amidst tensions of familiarizing themselves with their new role. FINDINGS: PD-resident relationships are complex and multidimensional, shifting over time, changing patterns and evolving to respond to different contexts. PDs initially negotiate their own roles, while navigating their relationships with residents and other stakeholders to create their professional identities. PDs develop professional alliances, defining for the resident the profession and its expectations. As residents negotiate the various challenges of their training, the role of the PD emerges into one of providing emotional support and advocacy. The support and attachment are often enduring and extend beyond the period of residency training. INSIGHTS: Our study examines the experiences of program directors as they negotiate complex educator-learner relationships. The PDs described roles that extended beyond their job description. Although all interviewees reported that the PD position was challenging, they focused on the rewarding aspects of the job and how their relationships helped sustain them through the difficulties. Through their reflections, the PDs described the personal satisfaction and benefits of their interactions with the residents, and how the engagement contributed to personal and professional success.

International Residency Program Directors on Implementing Educational Transformation: A Qualitative Study of Their Experiences and Strategies for Overcoming Challenges.

BACKGROUND: Residency program directors (PDs) need to navigate diverse roles and responsibilities as clinical teachers, administrators, and drivers of educational improvement. Little is known about the experience of PDs leading transformation of international residency programs. OBJECTIVE: We explored the lived experiences of international residency PDs and developed an understanding of how PDs manage educational program transformation. METHODS: Using a phenomenological approach, semi-structured interviews were conducted with current and former PDs involved in the transformation to competency-based medical education in the first international settings to be accredited by the Accreditation Council for Graduate Medical Education-International (ACGME-I). Thirty-three interviews with PDs from Qatar, Singapore, and the United Arab Emirates were conducted from September 2018 to July 2019, audio-recorded, and transcribed. Data were independently coded by 2 researchers. A thematic analysis was conducted and patterns that reflected coping and managing educational reform were identified. RESULTS: PDs described distinctive patterns of navigating the educational transformation. Five themes emerged: PDs (1) embraced continuous learning and self-development; (2) managed change in the context of their local settings; (3) anticipated problems and built support networks to effectively problem-solve; (4) maintained relationships with stakeholders for meaningful and constructive interactions; and (5) focused on intrinsic qualities that helped them navigate challenges. CONCLUSIONS: International PDs were presented with significant challenges in implementing educational transformation but coped successfully through distinctive patterns and methods.

Program Director Retention and Attrition Rates in International Graduate Medical Education.

BACKGROUND: Program directors (PDs) are integral to the education of the next generation of physicians. Yet, administrative burdens, substantial patient care responsibilities, and lack of protected time for teaching may contribute to work-life imbalance and physician burnout, leading to high rates of attrition. Data on international residency program leadership turnover are lacking. OBJECTIVE: This study aimed to quantify PD turnover in Accreditation Council for Graduate Medical Education-International (ACGME-I) accredited programs in Singapore, United Arab Emirates (UAE), and Qatar, and to compare to US PD attrition rates. METHODS: Data on PD turnover in international programs was extracted from the ACGME-I Accreditation Data System for academic years 2010-2011 through 2018-2019 for Singapore and 2013-2014 through 2018-2019 for UAE and Qatar. Rates of PD turnover were calculated by country and by ACGME-I medical-, surgical-, and hospital-based specialty groupings and compared using χ2 test. Annual US PD turnover data was extracted from the ACGME's Data Resource Book. RESULTS: Seventy programs met inclusion criteria. International PD attrition was high, with 56 programs (80%) changing PDs since program inception, and 16 programs (29%) having 2 or more PD turnovers. There was no significant difference between PD turnover rates in hospital (83%), medical (79%), or surgical (78%) specialties. International PD attrition rates varied from 7% to 20% annually and were comparable to PD turnover in US programs (range 12%-15%). CONCLUSIONS: High PD turnover rates in newly accredited international residency programs were noted, although annual attrition rates were comparable to US residency programs.

Point of Care Exome Sequencing Reveals Allelic and Phenotypic Heterogeneity Underlying Mendelian disease in Qatar.

The effectiveness of next generation sequencing at solving genetic disease has motivated the rapid adoption of this technology into clinical practice around the world. In this study, we use whole exome sequencing (WES) to assess 48 patients with Mendelian disease from 30 serial families as part of the "Qatar Mendelian Disease pilot program" - a coordinated multi-center effort to build capacity and clinical expertise in genetic medicine in Qatar. By enrolling whole families (parents plus available siblings), we demonstrate significantly improved discriminatory power for candidate variant identification over trios for both de novo and recessive inheritance patterns. For the same index cases, we further demonstrate that even in the absence of families, variant prioritization is improved up to 8-fold when a modest set of population-matched controls is used vs large public databases, stressing the poor representation of Middle Eastern alleles in presently available databases. Our in-house pipeline identified candidate disease variants in 27 of 30 families (90%), 23 of which (85%) harbor novel pathogenic variants in known disease genes, pointing to significant allelic heterogeneity and founder mutations underlying Mendelian disease in the Middle East. For 6 of these families, the clinical presentation was only partially explained by the candidate gene, suggesting phenotypic expansion of known syndromes. Our pilot study demonstrates the utility of WES for Middle Eastern populations, the dramatic improvement in variant prioritization conferred by enrolling population-matched controls and/or enrolling additional unaffected siblings at the point-of-care, and 25 novel disease-causing alleles, relevant to newborn and premarital screening panels in regional populations.

Twelve tips for developing and running a successful women's group in international academic medicine.

Gender inequity in academic medicine remains an important issue worldwide. While institutional programs and policies can help promote equity in recruitment, retention, scholarship, promotion, and leadership, they often do not address the physical and social isolation that many women in international academic medicine face. Creating networking opportunities through building women's groups can provide a personal and professional support structure that decreases isolation and promotes the advancement of women. Based on a multidisciplinary literature review on change processes, group formation, and women's empowerment, as well as lessons learned from personal experience, we offer 12 tips to successfully create, maintain, and support physician women's groups, employing Kotter's change-management framework. We believe that these groups can provide a structured platform for networking opportunities to advance women physicians in academic medicine worldwide.

Exome sequencing-based identification of novel type 2 diabetes risk allele loci in the Qatari population.

BACKGROUND: Type 2 diabetes (T2D) susceptibility is influenced by genetic and lifestyle factors. To date, the majority of genetic studies of T2D have been in populations of European and Asian descent. The focus of this study is on genetic variations underlying T2D in Qataris, a population with one of the highest incidences of T2D worldwide. RESULTS: Illumina HiSeq exome sequencing was performed on 864 Qatari subjects (574 T2D cases, 290 controls). Sequence kernel association test (SKAT) gene-based analysis identified an association for low frequency potentially deleterious variants in 6 genes. However, these findings were not replicated by SKAT analysis in an independent cohort of 12,699 exomes, primarly due to the absence of low frequency potentially deleterious variants in 5 of the 6 genes. Interestingly one of the genes identified, catenin beta 1 (CTNNB1, ß-catenin), is the key effector of the Wnt pathway and interacts with the nuclear receptor transcription factor 7-like 2 (TCF7L2), variants which are the most strongly associated with risk of developing T2D worldwide. Single variant analysis did not identify any associated variants, suggesting the SKAT association signal was not driven by individual variants. None of the 6 associated genes were among 634 previously described T2D genes. CONCLUSIONS: The observation that genes not previously linked to T2D in prior studies of European and Asian populations are associated with T2D in Qatar provides new insights into the complexity of T2D pathogenesis and emphasizes the importance of understudied populations when assessing genetic variation in the pathogenesis of common disorders.

Characterization and Perceptions of Surgical Clinician Educators: An International Survey.

OBJECTIVE: Surgeons worldwide face unique time and practice pressures differentiating them from other types of physicians, specifically as clinician educators (CEs). The purpose of this study is to identify and describe academic surgical clinician educators (SCEs) in international graduate medical education systems, characterize their perceptions of roles, preparedness, and factors affecting job satisfaction and retention, as compared to nonsurgical international CEs. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional survey of CEs was conducted June 2013-June 2014 at academic medical centers in Singapore, Qatar, and the United Arab Emirates that adopted competency-based graduate medical education and received accreditation by the Accreditation Council for Graduate Medical Education-International. RESULTS: Two hundred seventy-six (76.3%) of 359 eligible physicians responded; 64 (23.2%) were SCEs. SCEs were predominantly male (80%), less than 50 years of age (83%), with 64% having been in their current position less than 5 years. Overall, SCEs were significantly less confident, as compared to nonsurgical CEs, in aspects of educational programs, including curriculum development, assessment, and mentorship. SCEs spent significantly more time engaged in patient care activities, as compared to nonsurgeon colleagues. There were no significant differences between SCEs and nonsurgical CEs in terms of work-life balance and satisfaction with responsibilities, position, or potential promotion, with most SCEs intending to stay in academic medicine. CONCLUSIONS: Academic SCEs working in the international programs reported overall job satisfaction with a desire to remain in academic medicine. However, SCEs have several faculty development needs. International surgical training programs can develop and expand offerings in teaching and education to improve skills and maintain SCE satisfaction and retention, necessary to successfully train the next generation of surgeons.

Twelve tips to promote gender equity in international academic medicine.

Gender inequity in academic medicine remains an important issue worldwide, with more female faculty entering academic medicine internationally. Some academic institutions have initiated programs and created policies to promote gender equity, but disparities remain in faculty numbers, promotions rates, research productivity and access to funding and resources. We offer 12 tips for best practices in the broad domains of faculty recruitment, retention and scholarship, promotion and leadership that institutions and individual faculty can adopt to promote gender equity. While the 12 tips form a comprehensive approach, each tip can be implemented individually depending on institutional needs and culture. Each tip includes practical advice for implementation supported by a successful example from the literature.

Gender and international clinician educators.

OBJECTIVES: To describe gender differences of international clinician educators (CEs) and leaders, and CEs' perceptions by gender of preparation, roles, rewards and factors affecting job satisfaction and retention in emerging international competency-based residency programmes. METHODS: Cross-sectional surveys of CEs and leadership were conductedJune 2013-June 2014 at institutions that had adopted competency-based graduate medical education and were accredited by the Accreditation Council for Graduate Medical Education-International. RESULTS: 274 (76.3%) of 359 eligible participants responded; 69 (25.2%) were female. Two (18%) of 11 chief executive officers and 1 (9%) of 11 chief medical officers were women. Female CEs were younger, more likely to be single and childless. They were less likely to hold academic appointments, despite no gender differences in length of time at current institution or in current position. A greater proportion of female CEs felt they were 'never' rewarded by academic promotion. Satisfaction rates were similar between the genders. Single female CEs were five times as likely to report being 'extremely likely' to stay in the country. Female CEs with children <21 were less likely to report high likelihood of staying in academia. Marital status and children were not associated with outcomes for male CEs. CONCLUSIONS: In the international academic medicine programmes studied, there were fewer female CEs in the pipeline and they perceived a gender gap in appointment and advancement. Stakeholders at international programmes need to develop contextualised strategies to expand entry and decrease attrition of women into CE tracks, and promote gender equity.

Correction: Type 2 Diabetes Risk Allele Loci in the Qatari Population.

[This corrects the article DOI: 10.1371/journal.pone.0156834.].

The Qatar genome: a population-specific tool for precision medicine in the Middle East.

Reaching the full potential of precision medicine depends on the quality of personalized genome interpretation. In order to facilitate precision medicine in regions of the Middle East and North Africa (MENA), a population-specific genome for the indigenous Arab population of Qatar (QTRG) was constructed by incorporating allele frequency data from sequencing of 1,161 Qataris, representing 0.4% of the population. A total of 20.9 million single nucleotide polymorphisms (SNPs) and 3.1 million indels were observed in Qatar, including an average of 1.79% novel variants per individual genome. Replacement of the GRCh37 standard reference with QTRG in a best practices genome analysis workflow resulted in an average of 7* deeper coverage depth (an improvement of 23%) and 756,671 fewer variants on average, a reduction of 16% that is attributed to common Qatari alleles being present in QTRG. The benefit for using QTRG varies across ancestries, a factor that should be taken into consideration when selecting an appropriate reference for analysis.

Type 2 Diabetes Risk Allele Loci in the Qatari Population.

BACKGROUND: The prevalence of type 2 diabetes (T2D) is increasing in the Middle East. However, the genetic risk factors for T2D in the Middle Eastern populations are not known, as the majority of studies of genetic risk for T2D are in Europeans and Asians. METHODS: All subjects were ≥3 generation Qataris. Cases with T2D (n = 1,124) and controls (n = 590) were randomly recruited and assigned to the 3 known Qatari genetic subpopulations [Bedouin (Q1), Persian/South Asian (Q2) and African (Q3)]. Subjects underwent genotyping for 37 single nucleotide polymorphisms (SNPs) in 29 genes known to be associated with T2D in Europeans and/or Asian populations, and an additional 27 tag SNPs related to these susceptibility loci. Pre-study power analysis suggested that with the known incidence of T2D in adult Qataris (22%), the study population size would be sufficient to detect significant differences if the SNPs were risk factors among Qataris, assuming that the odds ratio (OR) for T2D SNPs in Qatari's is greater than or equal to the SNP with highest known OR in other populations. RESULTS: Haplotype analysis demonstrated that Qatari haplotypes in the region of known T2D risk alleles in Q1 and Q2 genetic subpopulations were similar to European haplotypes. After Benjamini-Hochberg adjustment for multiple testing, only two SNPs (rs7903146 and rs4506565), both associated with transcription factor 7-like 2 (TCF7L2), achieved statistical significance in the whole study population. When T2D subjects and control subjects were assigned to the known 3 Qatari subpopulations, and analyzed individually and with the Q1 and Q2 genetic subpopulations combined, one of these SNPs (rs4506565) was also significant in the admixed group. No other SNPs associated with T2D in all Qataris or individual genetic subpopulations. CONCLUSIONS: With the caveats of the power analysis, the European/Asian T2D SNPs do not contribute significantly to the high prevalence of T2D in the Qatari population, suggesting that the genetic risks for T2D are likely different in Qataris compared to Europeans and Asians.

Clinician-educators in emerging graduate medical education systems: description, roles and perceptions.

OBJECTIVES: To describe clinician-educators (CEs) in new graduate medical education (GME) systems and characterize perception of preparedness, roles and rewards, and factors affecting job satisfaction and retention. METHODS: A cross-sectional survey of all CEs of institutions using competency-based GME and accredited by the Accreditation Council for Graduate Medical Education-International (ACGME-I). RESULTS: 274 of 359 eligible participants (76.3%) responded, representing 47 residency programs across 17 specialties. CEs were predominantly married men aged in their 40s, employed at their current institution 9.3 years (±6.4 years). CEs judged themselves competent or expert in teaching skills (91.5%), trainee assessment (82%) and mentoring (75%); less so in curriculum development (44%) and educational research skills (32%). Clinical productivity was perceived by the majority (62%) as the item most valued by their institutions, with little or no perceived value for teaching or educational efforts. Overall, 58.3% were satisfied or very satisfied with their roles, and 77% expected to remain in academic medicine for 5 years. A strong negative correlation was found between being a program or associate program director and likelihood of staying in academic medicine (aOR 0.42; 0.22 to 0.80). CONCLUSIONS: In the GME systems studied, CEs, regardless of country or programme, report working in environments that value clinical productivity over educational efforts. CEs feel competent and prepared for many aspects of their roles, have positive attitudes towards teaching, and report overall job satisfaction, with most likely to remain in academic medicine. As medical training advances internationally, the impact on and by CEs requires ongoing attention.

Copy number variations in the genome of the Qatari population.

BACKGROUND: The populations of the Arabian Peninsula remain the least represented in public genetic databases, both in terms of single nucleotide variants and of larger genomic mutations. We present the first high-resolution copy number variation (CNV) map for a Gulf Arab population, using a hybrid approach that integrates array genotyping intensity data and next-generation sequencing reads to call CNVs in the Qatari population. METHODS: CNVs were detected in 97 unrelated Qatari individuals by running two calling algorithms on each of two primary datasets: high-resolution genotyping (Illumina Omni 2.5M) and high depth whole-genome sequencing (Illumina PE 100bp). The four call-sets were integrated to identify high confidence CNV regions, which were subsequently annotated for putative functional effect and compared to public databases of CNVs in other populations. The availability of genome sequence was leveraged to identify tagging SNPs in high LD with common deletions in this population, enabling their imputation from genotyping experiments in the future. RESULTS: Genotyping intensities and genome sequencing data from 97 Qataris were analyzed with four different algorithms and integrated to discover 16,660 high confidence CNV regions (CNVRs) in the total population, affecting ~28 Mb in the median Qatari genome. Up to 40% of all CNVs affected genes, including novel CNVs affecting Mendelian disease genes, segregating at different frequencies in the 3 major Qatari subpopulations, including those with Bedouin, Persian/South Asian, and African ancestry. Consistent with high consanguinity levels in the Bedouin subpopulation, we found an increased burden for homozygous deletions in this group. In comparison to known CNVs in the comprehensive Database of Genomic Variants, we found that 5% of all CNVRs in Qataris were completely novel, with an enrichment of CNVs affecting several known chromosomal disorder loci and genes known to regulate sugar metabolism and type 2 diabetes in the Qatari cohort. Finally, we leveraged the availability of genome sequence to find suitable tagging SNPs for common deletions in this population. CONCLUSION: We combine four independently generated datasets from 97 individuals to study CNVs for the first time at high-resolution in a Gulf Arab population.

Perceptions of Leaders and Clinician Educators on the Impact of International Accreditation.

BACKGROUND: Graduate medical education (GME) is responding to calls for reform by adopting competency-based frameworks and, in some countries, by rapidly implementing external accreditation systems. The Accreditation Council for Graduate Medical Education International (ACGME-I) began accrediting institutions in 2009. This study aimed to describe ACGME-I-accredited institutions and explore perceptions of their leaders and clinician educators (CEs) regarding preparedness, challenges, and initial impact of accreditation. METHOD: Cross-sectional surveys of all ACGME-I-accredited institutions' leaders and CEs were conducted from June 2013 to June 2014. Eligible participants were identified through institution Web sites and GME offices. Combinations of Web- and paper-based surveys were employed. RESULTS: Completed surveys were received from 24 (70.6%) of 34 institutional leaders and 274 (76.3%) of 359 CEs, representing 3 countries, 8 academic medical centers, 2 affiliated teaching hospitals, and 47 residency programs. Leaders and CEs felt prepared in the domains of knowledge and implementation of the competencies. Top challenges were excessive "demands on faculty time" and "bureaucratic procedures." The majority of both groups perceived a positive impact of accreditation on all learner, faculty, institution, and patient outcomes; most perceived no impact on patient satisfaction. Overall, 79.2% of leaders and 75.8% of CEs agreed or strongly agreed that seeking ACGME-I accreditation was worthwhile. CONCLUSIONS: This study indicates that despite the challenges identified, initial perceptions of the impact of ACGME-I accreditation are positive. Findings from this study may be useful to institutions and countries considering similar GME reform, though long-term outcome data are needed.