Brita Roy

The Career Advising Program: A Strategy to Achieve Gender Equity in Academic Medicine.

S ignificant gender disparities in academic rank exist at US medical schools, even after controlling for age, time since training, specialty, and measures of productivity, and despite increasing numbers of women entering medicine over the past 30 years. Within internal medicine nationally, only 19% of full professors are women. Moreover, only 12% of internal medicine department chairs are female, and women lead a minority of general internal medicine or hospitalist divisions., 2 Given that women now constitute half of US medical school graduates, identifying strategies to support their career development in order to capitalize on the untapped leadership potential of this large segment of our health care workforce is critical. Other industries have addressed similar gender gaps in part by creating formal sponsorship programming. Academic medicine could follow suit. Specialty societies like the Society of General Internal Medicine (SGIM) are well-positioned to spearhead efforts to cultivate underutilized female talent by providing them the access to senior leaders and professional networks that is so important to advancement. We describe SGIM’s novel sponsorship initiative, the Career Advising Program, and how it might serve as a model for this type of endeavor. Attempts to improve the status of women in academic medicine must first account for their professional context. Perhaps because so few women are in leadership positions, certain biases may persist within organizations. Structural bias, also termed institutional bias, is the tendency for policies, procedures, or practices of an institution to advantage certain groups and potentially contributes to gender inequities in salary and research support within academic medicine. This disparity begins upon entry into the workforce through initial offers of lower-ranked positions (e.g., instructor in lieu of assistant professor), lower starting salaries, and smaller start-up packages. Implicit bias, or unconscious attitudes and stereotypes, is developed during childhood and informs assumptions about adult gender roles. Assumptions of women’s primary roles in child rearing or housekeeping, men’s superiority in leadership capability, or women’s inclination to work part-time are just a few examples. These implicit biases may influence whether women are considered for leadership responsibilities in the workplace and how fairly women’s contributions are appraised compared with those of their male counterparts. Finally, socialization and consistent discrimination may lead women to internalize some of these negative beliefs. After a professional lifetime of being marginalized, they themselves may feel inadequate and be less likely to seek leadership roles, self-nominate for committees, or negotiate for a fair salary. Sponsorship differs from mentorship in its focus on spotlighting and advocating for highly talented individuals. By definition, a sponsor must have significant organizational influence and a seat at the table where important decisions are made. A sponsor publicly advocates for his/her protegees with regard to competitive assignments, leadership opportunities, and high-impact committee membership. He or she also enhances a protegee’s credibility, visibility, and professional networks. In contrast, mentorship typically centers on personal and professional development, particularly related to skillbuilding and goal-setting. An effective mentor is a guide who takes time to listen, provide constructive feedback, and offer specific expertise. The impact does not necessarily depend on a mentor’s rank or position within an institution. Research from the business community demonstrates that sponsorship programming systematically enhances women’s ability to gain promotion, increases satisfaction with the rate of advancement, facilitates stretch assignments, creates upward pressure in pay, and improves gender parity in career advancement. As such, it may be an important strategy for mitigating the biases described above and accelerating women’s professional advancement within academic medicine. Since professional medical societies are an ideal platform for offering access to senior leaders and networks of colleagues, SGIM’s Women and Medicine Task Force launched a model sponsorship initiative, the Career Advising Program (CAP), in 2013. CAP is a longitudinal experience intended to foster advancement of women in medicine by helping female junior faculty successfully navigate the academic promotion process. Specific objectives focus on curriculum vitae preparation, highReceived August 23, 2016 Revised November 23, 2016 Accepted December 14, 2016 Published online January 3, 2017

Moving Into the Neighborhood

Improving national cardiovascular health (CVH) is the American Heart Association’s 2020 Strategic Impact Goal.1 To achieve this ambitious goal, there is an appropriate strong focus on counseling and educating our patients about hypertension, diabetes mellitus, and healthy behaviors. However, there is an additional opportunity that may ultimately be critical to our success. Too often neglected, contextual factors also have a strong influence on cardiovascular risk. By contextual variables, we mean the environment in which we live, to include the structural or built environment (eg, buildings, sidewalks, parks, recreational facilities) and the social environment (ie, the trust and bonds between community members). Emerging research is showing that these factors may influence risk through their effect on health behaviors and risk factors, as well as through other pathways. Importantly, these factors may be essential in efforts to shift the risks and improve the health of populations. Articles see p 524 In this issue of Circulation: Cardiovascular Quality and Outcomes , we have an example of the emerging literature directing our attention toward contextual factors associated with cardiovascular health. Unger et al2 report the association of a range of neighborhood characteristics with a global measure of cardiovascular health using data from the Multi-Ethnic Study of Atherosclerosis (MESA). The MESA is well designed to examine the environmental context on health because it includes a cohort of both sexes and 4 race/ethnic groups without clinical cardiovascular disease at the time of enrollment from 6 communities in different regions of the United States and captures information about the participants’ cardiovascular risk and perception of their neighborhood along with current and prior addresses that can be used to identify elements of the neighboring structural environment. Although initial studies from MESA focused …

Collective Well-Being to Improve Population Health Outcomes: An Actionable Conceptual Model and Review of the Literature

Objectives: To propose collective well-being as a holistic measure of the overall “health” of a community. To define collective well-being as a group-level construct measured across 5 domains (vitality, opportunity, connectedness, contribution, and inspiration) and introduce an actionable model that demonstrates how community characteristics affect collective well-being. To review the literature describing each domain’s association with health outcomes and community characteristics’ associations with collective well-being. Methods: We came to consensus on topics describing each component of our conceptual model. Because “well-being” is not indexed in MEDLINE, we performed topic-specific database searches and examined bibliographies of papers retrieved. We excluded articles that were limited to narrow subtopics or studies within small subpopulations. Preference was given to quasi-experimental or randomized studies, systematic reviews, or meta-analyses. Consensus was reached on inclusion or exclusion of all articles. Results: Reviewed literature supported each of the proposed domains as important aspects of collective well-being and as determinants of individual or community health. Evidence suggests a broad range of community characteristics support collective well-being. Conclusions: The health and quality of life of a community may be improved by focusing efforts on community characteristics that support key aspects of well-being. Future work should develop a unified measure of collective well-being to evaluate the relative impact of specific efforts on the collective well-being of communities.

For the General Internist: A Review of Relevant 2013 Innovations in Medical Education

We conducted a review of articles published in 2013 to identify high-quality research in medical education that was relevant to general medicine education practice. Our review team consisted of six general internists with expertise in medical education of varying ranks, as well as a professional medical librarian. We manually searched 15 journals in pairs, and performed an online search using the PubMed search engine for all original research articles in medical education published in 2013. From the total 4,181 citations identified, we selected 65 articles considered most relevant to general medicine educational practice. Each team member then independently reviewed and rated the quality of each selected article using the modified Medical Education Research Study Quality Instrument. We then reviewed the quality and relevance of each selected study and grouped them into categories of propensity for inclusion. Nineteen studies were felt to be of adequate quality and were of moderate to high propensity for inclusion. Team members then independently voted for studies they felt to be of the highest relevance and quality within the 19 selected studies. The ten articles with the greatest number of votes were included in the review. We categorized the studies into five general themes: Improving Clinical Skills in UME, Inpatient Clinical Teaching Methods, Advancements in Continuity Clinic, Handoffs/Transitions in Care, and Trainee Assessment. Most studies in our review of the 2013 literature in general medical education were limited to single institutions and non-randomized study designs; we identified significant limitations of each study. Selected articles may inform future research and practice of medical educators.

Emotion regulation moderates the association between chronic stress and cardiovascular disease risk in humans: a cross-sectional study

Abstract Chronic stress is a risk factor for incident cardiovascular (CV) disease. Emotion regulation is the ability to modulate one’s state or behavior in response to a given situation or stressor, and may mitigate the effect of chronic stress on CV disease risk. Data from a cohort of 754 community-dwelling young to middle-aged adults who were assessed between 2007 and 2012 on stress, emotion regulation, and CV risk measures were used to test the hypothesis that emotion regulation mitigates the effect of chronic stress on CV risk. Emotion regulation was measured using the Difficulties in Emotion Regulation Scale (DERS). We created a composite stress score using data from the Cumulative Adversity Interview and the Perceived Stress Scale. Our outcomes included blood pressure, body mass index, and insulin resistance separately and combined into a composite CV risk score. Covariates included age, sex, race, years of education, and smoking status. We used multivariable logistic regression to evaluate associations between stress measures and CV risk among participants and the impact of emotion regulation (DERS scores) on this association. We found that composite stress interacted significantly with the DERS score to affect CV risk (p = .007). A median split of the DERS scores indicated that CV risk was associated with the composite stress score in the fully adjusted model (ß = 0.206; p = .005) among participants with low emotion regulation, but not among those with high emotion regulation (ß = 0.048; p = .59). Chronic stress was associated with CV risk only among participants with poor emotion regulation. Emotion regulation is a teachable skill, and may play a role in preventing CV disease. Lay summary Emotion regulation is the ability to modify one’s reaction to a negative or stressful event, and is a teachable skill. Effective emotion regulation dampens the negative effect of chronic stress on the body, which may reduce risk for cardiovascular disease.

Predicting Barriers to Treatment for Depression in a U.S. National Sample: A Cross-Sectional, Proof-of-Concept Study

OBJECTIVE Even though safe and effective treatments for depression are available, many individuals with a diagnosis of depression do not obtain treatment. This study aimed to develop a tool to identify persons who might not initiate treatment among those who acknowledge a need. METHODS Data were aggregated from the 2008-2014 U.S. National Survey on Drug Use and Health (N=391,753), including 20,785 adults given a diagnosis of depression by a health care provider in the 12 months before the survey. Machine learning was applied to self-report survey items to develop strategies for identifying individuals who might not get needed treatment. RESULTS A derivation cohort aggregated between 2008 and 2013 was used to develop a model that identified the 30.6% of individuals with depression who reported needing but not getting treatment. When applied to independent responses from the 2014 cohort, the model identified 72% of those who did not initiate treatment (p<.01), with a balanced accuracy that was also significantly above chance (71%, p<.01). For individuals who did not get treatment, the model predicted 10 (out of 15) reasons that they endorsed as barriers to treatment, with balanced accuracies between 53% and 65% (p<.05 for all). CONCLUSIONS Considerable work is needed to improve follow-up and retention rates after the critical initial meeting in which a patient is given a diagnosis of depression. Routinely collected information about patients with depression could identify those at risk of not obtaining needed treatment, which may inform the development and implementation of interventions to reduce the prevalence of untreated depression.

Population well-being and electoral shifts

Population wellbeing, an aggregate measure of positive mental, physical, and emotional health, has previously been used as a marker of community thriving. We examined whether several community measures of wellbeing, and their change since 2012, could be used to understand electoral changes that led to the outcome of the 2016 United States presidential election. We found that areas of the US which had the largest shifts away from the incumbent party had both lower wellbeing and greater drops in wellbeing when compared with areas that did not shift. In comparison, changes in income were not related to voting shifts. Well-being may be more useful in predicting and understanding electoral outcomes than some more conventional voting determinants.

Identifying county characteristics associated with resident well-being: A population based study

Background Well-being is a positively-framed, holistic assessment of health and quality of life that is associated with longevity and better health outcomes. We aimed to identify county attributes that are independently associated with a comprehensive, multi-dimensional assessment of individual well-being. Methods We performed a cross-sectional study examining associations between 77 pre-specified county attributes and a multi-dimensional assessment of individual US residents’ well-being, captured by the Gallup-Sharecare Well-Being Index. Our cohort included 338,846 survey participants, randomly sampled from 3,118 US counties or county equivalents. Findings We identified twelve county-level factors that were independently associated with individual well-being scores. Together, these twelve factors explained 91% of the variance in individual well-being scores, and they represent four conceptually distinct categories: demographic (% black); social and economic (child poverty, education level [<high school, high school diploma/equivalent, college degree], household income, % divorced); clinical care (% eligible women obtaining mammography, preventable hospital stays per 100,000, number of federally qualified health centers); and physical environment (% commuting by bicycle and by public transit). Conclusions Twelve factors across social and economic, clinical care, and physical environmental county-level factors explained the majority of variation in resident well-being.

Gender Pay Gaps in Medicine: Moving from Explanations to Action

A lmost one half of medical school students are now women, and women make up over one third of the total physician workforce. Yet gender inequities in physician compensation persist, with reported gender-based pay gaps of 16 to 37%. Many potential explanations for this pay gap have been suggested, including prioritization of work-life balance, rates of working part-time, specialty choice, years of experience, fewer women in leadership roles and in senior positions, and lack of mentorship and sponsorship for women to promote career advancement. Prior studies have sought to control for many of these and found persistent gender disparities, but have thus far failed to account for the exact quantity and composition of hours worked (e.g., performing procedures versus teaching). The study by Apaydin et al. in this issue of the Journal of General Internal Medicine sought to address this gap in the literature by using survey data from 30 diverse physician practices across six states to assess how much of the gender pay disparity could be explained by specialty choice, time worked and composition of those work hours, fraction of procedural time, type of compensation, number of years in practice, and demographics. The authors report a raw, absolute difference of close to

Association of the Overall Well-being of a Population With Health Care Spending for People 65 Years of Age or Older

100k in yearly salary between men and women. Approximately