Faculty Bibliography

BACKGROUND:There is a lack of diversity in the Internal Medicine (IM) workforce with respect to race, ethnicity, sex, and socioeconomic background. Evaluating sociodemographic predictors and student interest in IM residency may provide insights for support at the medical school level to promote diverse interest in IM. OBJECTIVE:To examine associations between student ethnoracial identity, sex, and socioeconomic background with IM interest from matriculation to graduation. DESIGN/METHODS:Retrospective cohort study. PARTICIPANTS/METHODS:US MD matriculants from 2014-2015 and 2015-2016 cohorts. MAIN MEASURES/METHODS:A sustained interest was defined as IM interest at matriculation and subsequent IM residency placement. A cultivated interest was defined as initial non-IM interest and placement into IM residency. Poisson regressions estimated associations between ethnoracial identity, sex, and family income with sustained or cultivated interest in IM, adjusting for IM clerkship satisfaction, USMLE Step 1 and Step 2 score. KEY RESULTS/RESULTS:Among 18,765 matriculants, 51.7% identified as female, 61.5% as White, and 24.3% as low-income. IM clerkship satisfaction was associated with IM residency placement (p < 0.001). Among students initially interested in IM, females (aRR 0.87, 95% CI [0.80-0.94]) were less likely to sustain interest. Among initially uninterested students, Asian (aRR 1.65, 95% CI [1.54-1.76]), Hispanic (aRR 1.31, 95% CI [1.16-1.48]), and Black (aRR 1.22, 95% CI [1.07-1.39]) students were more likely to report cultivated interest compared to White students, while females were less likely compared to male students (aRR 0.77, 95% CI [0.72-0.82]). CONCLUSION/CONCLUSIONS:Disparities in IM workforce diversity may originate in medical school, where female students were less likely to sustain IM interest, while Asian, Black, and Hispanic students were more likely to develop interest. Such results necessitate targeted support by medical schools and graduate medical education programs.

BACKGROUND:Achieving racial equity in sepsis care is a complex challenge that requires organizational readiness across multiple domains, such as culture and capacity. OBJECTIVES/OBJECTIVE:This study provides a validated tool to empirically measure health system readiness to address structural racism in sepsis care, essential for improving health equity and patient outcomes. METHODS:This study employed a mixed methods approach involving three key steps: adaptation, cognitive interviews, and psychometric analysis. The novel survey was first adapted based on a literature review and expert input. Cognitive interviews were conducted with healthcare professionals to refine the survey items. Finally, reliability testing was performed for psychometric analysis in measuring health system readiness to address structural racism in sepsis care. The survey was developed in the context of Champions Advancing Racial Equity in Sepsis (CARES), a coalition-based leadership intervention to equip health systems and their surrounding communities to identify and address racial inequities in sepsis care and outcomes. Senior and mid-level and front-line champions from across disciplines and departments that influence sepsis care (N = 30) participated in the survey. RESULTS:The survey consisted of five domains: learning and problem solving (10 items, Cronbach's α = 0.815), stress/pressure in the system (4 items, Cronbach's α = .779), psychological safety (7 items, Cronbach's α = .515), senior leadership support (4 items, Cronbach's α = .744), and strategic planning process (5 items, Cronbach's α = .918). Overall, the entire scale (30 items) was found to have excellent reliability (Cronbach's α = .908). CONCLUSIONS:This study adapted and validated a novel survey to measure health system readiness to address structural racism in sepsis care, providing a reliable tool for identifying areas for improvement and guiding targeted interventions to enhance health equity.

IMPORTANCE/UNASSIGNED:First-generation undergraduate students are underrepresented in medicine and face challenges that affect their application and matriculation to medical school. OBJECTIVE/UNASSIGNED:To understand the barriers and available support at the individual, interpersonal, and organizational levels for first-generation students in premedical programs. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This qualitative study was part of a larger project on professional identity formation among US medical students from low socioeconomic backgrounds with a focus on first-generation undergraduate students. Semistructured online interviews of 48 students (37 of whom were first-generation students) from 27 US medical schools were conducted from November 1, 2021, through April 30, 2022, and secondary analyses regarding their premedical experiences were performed. Interviews were recorded, transcribed, deidentified, assigned an alphanumeric code, and analyzed using an inductive thematic approach from June 1 through December 30, 2024. Participants were offered a $20 gift card in appreciation for their time. EXPOSURE/UNASSIGNED:Experiences of students identifying as first-generation college students in premedical training. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Main outcomes included themes and subthemes at the individual, interpersonal, and organizational levels constructed from interview data. Bronfenbrenner's ecological systems theory was used as a guiding interpretive framework to analyze participants' experiences within their broader social and environmental contexts. This model allowed examination of how individual perspectives were shaped by interactions across personal, social, and structural contexts. The team engaged in reflexive discussions, memos, and consensus-based refinement to identify key themes. RESULTS/UNASSIGNED:Among 37 participants identified as first-generation students, 21 (56.8%) identified as female (mean [SD] age, 27.3 [2.8] years). One participant (2.7%) identified as American Indian or Alaska Native; 7 (18.9%) as Hispanic, Latino, or Spanish origin; 8 (21.6%) as non-Hispanic Asian or Asian American; 9 (24.3%) as non-Hispanic Black or African American; and 12 (32.4%) as non-Hispanic White. Analyses revealed key themes across all 3 levels of the ecological systems model: individual, interpersonal, and organizational. Individual themes included personal and family background, such as financial instability and lack of clinical exposure. Interpersonal themes included access to premedical advisors, faculty mentors, and peer networks. Organizational themes included limited institutional resources and pathway programs. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this qualitative study of first-generation students, financial instability, limited medical school-related social connections and resources, and unfamiliarity with academic systems were found to uniquely burden these students. By identifying and improving resources such as tailored mentorship, individualized advising, and participation in pathway programs, medical schools can help reduce structural barriers for aspiring physicians who are first-generation college students.

BACKGROUND:Endotracheal intubation in the emergency department (ED) is a critical and time-sensitive procedure requiring both technical skills and cognitive-based reasoning. Evidence on supervised resident-attending dyads with differing years of seniority on decision making during clinical encounters with endotracheal intubations is nascent. OBJECTIVE:To investigate the intersection of postgraduate years in clinical practice between resident and attending supervisor dyads and its associations for clinician choice of laryngoscopy technique and paralytic agent during ED intubations. METHODS:We conducted a retrospective analysis of intubations performed at a multi-site, urban, academic emergency medicine training program, analyzing institutional airway registry data from 2013 to 2023. Using a standardized predictor that accounted for similarity in years of clinical experience within a dyad between a resident and their supervising attending, we performed adjusted mixed-effects logistic regression examining the association of this dyad on two primary outcomes in endotracheal intubation decision making. Our primary outcome measures were the selection of a laryngoscopy technique (either DL or VL), and of a paralytic agent (either short-acting or long-acting) analyzed as categorical variables with a linear mixed effects model, using a binomial response distribution. RESULTS:We examined 2969 intubations for choice of laryngoscopy technique (n = 1117, 37.6 %) and paralytic agent (n = 967, 32.6 %). Higher adjusted odds (aOR) were associated with resident choice of DL over VL when years of experience between residents and supervising attendings were more concordant (aOR 3.05, 95 % CI: 1.1-8.2). Choice of paralytic agent was not associated with differing years of experience. CONCLUSION/CONCLUSIONS:Concordant years of experience between residents and their attendings were associated with technical skill-based laryngoscopy technique choice but not for cognitive-based reasoning in paralytic agent choice among ED intubations, suggesting supervising attending's years in clinical practice may influence decision making during time-sensitive procedures.

IMPORTANCE/UNASSIGNED:Previous research has documented the prevalence of discrimination based on race, ethnicity, sex, and sexual orientation among medical students; however, discrimination experienced by medical students with disabilities, and the impact of intersecting identities on these experiences, remains underexplored. OBJECTIVE/UNASSIGNED:To examine the association of general, gender-based, and race-based discrimination with disability status, sex, race, and ethnicity during medical school. DESIGN, SETTINGS, AND PARTICIPANTS/UNASSIGNED:This cross-sectional study surveyed graduating medical students in US accredited MD-granting medical schools from 2020 to 2022. Analyses were conducted from October to November 2024. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Modified Poisson regression was used to estimate the relative risk of disability status, sex, race, and ethnicity with self-reported experiences of general, gender-based, and race-based discrimination and the intersection of disability status, sex, race, and ethnicity. RESULTS/UNASSIGNED:Among 45 705 graduating medical students, 3863 (8.5%) reported having a disability; 24 163 (52.9%) identified as female; and 10 100 (22.1%) identified as Asian, 2661 (5.8%) as Black, 4524 (9.9%) as Hispanic, 25 154 (55.0%) as White, and 3266 (7.1%) as other race or ethnicity. Medical students with disability (MSWD) were more likely than their peers without disability to report general discrimination (relative risk [RR], 1.57; 95% CI, 1.50-1.65), gender-based discrimination (RR, 1.64; 95% CI, 1.57-1.72), race-based discrimination (RR, 1.55; 95% CI, 1.44-1.67), and multiple types of discrimination (RR, 1.82; 95% CI, 1.71-1.91). Asian, Black, and Hispanic female MSWD were more likely to report general and race-based discrimination than their White male peers without disability, with the prevalence of general, gender-based, and race-based discrimination among female Asian, Black, and Hispanic MSWD being greater than 25%. Compared with White male students without disability, Asian and Black female MSWD reported the highest risk of general discrimination (Asian: RR, 2.40; 95% CI, 2.09-2.77; Black: RR, 2.58; 95% CI, 2.17-3.06). White and Asian female MSWD reported the highest risk of gender-based discrimination (White: RR, 4.65; 95% CI, 4.30-5.04; Asian: RR, 4.41; 95% CI, 3.85-5.05). Asian and Black female MSWD reported the highest risk of race-based discrimination (Asian: RR, 8.53; 95% CI, 7.26-10.01; Black: RR, 12.48; 95% CI, 10.76-14.47). Finally, Asian and Black female MSWD reported the highest risk of multiple types of discrimination (Asian: RR, 6.50; 95% CI, 5.63-7.52; Black: RR, 7.21; 95% CI, 6.10-8.52). CONCLUSIONS/UNASSIGNED:In this cross-sectional study of US medical students, Asian, Black, and Hispanic female MSWD were more likely to report general and race-based discrimination, whereas White and Asian female MSWD were more likely to report gender-based discrimination during medical school. These findings highlight the need to address intersecting forms of discrimination for medical students with disabilities.

BACKGROUND:Fall injury is a sentinel event for mortality among older adults, and activity intensity may play a role in mitigating this outcome. This study assessed the relationship between activity intensity and all-cause mortality following fall injury among community-dwelling U.S. older adults. METHODS:For this retrospective cohort study, we pooled 12 years of data from the National Health Interview Survey and identified older adults (aged 65 years and older) who sustained fall injuries (N = 2454). The outcome variable was time to death following a fall injury. We defined activity intensity as a binary variable, none-to-low and normal-to-high, using the American Heart Association's weekly 500 Metabolic Equivalent of Task (MET) as a cutoff. We controlled for sociodemographic, healthcare access, and health characteristics; performed survey-weighted Cox proportional hazard regression analysis; and reported the adjusted mortality risks (plus 95% confidence interval (CI)). RESULTS:The survey comprised 2454 older adults with fall injuries, representing 863,845 US older adults. The population was predominantly female (68%), non-Hispanic White (85%), and divorced/separated (54%). During the follow-up period, 45% of the study population died. Approximately 81% of the study population had low activity levels. However, between 2006 and 2017, the proportion of the study population with low physical activity decreased from 90% to 67%. After adjusting for sociodemographic, healthcare access, and health characteristics, none-to-low activity intensity was associated with 50% increased mortality risk (aHR: 1.50; 95% CI: 1.20-1.87). CONCLUSIONS:Promoting higher physical activity levels may significantly reduce the all-cause mortality risk following fall injury among older adults.

PURPOSE/OBJECTIVE:Racial and ethnic underrepresentation in medicine (URiM) threatens the capacity of the cancer physician workforce to provide accessible, culturally competent care. We projected racial and ethnic diversity of the workforce through 2060 under three scenarios. METHODS:We assessed workforce composition using data from the American Medical Association (physician specialty and age) and Association of American Medical Colleges (race/ethnicity) in 2020. We defined URiM as American Indian/Alaska Native; Black or African American; Hispanic, Latino, or of Spanish origin; or Native-Hawaiian/Pacific-Islander. We used stock-and-flow models based on 2020 data to project the racial and ethnic distribution of the workforce by decade from 2030 to 2060 across three scenarios: baseline (URiM distribution remains at 2020 levels); trajectory (growth of URiM% physicians continues at current rates); and doubling (URiM growth is twice the rate of non-URiM growth). We calculated representation ratios (RR) by dividing workforce share by population share for each race group. Finally, we estimated growth in URiM physicians required for the workforce to reach parity with the 2060 US population. RESULTS:In 2020, there were 66,450 cancer physicians (11.3% URiM overall, radiation oncology 8.2%, medical oncology 9.9%, surgical oncology 10.2%, palliative care 11.8%, general surgery 13.6%) compared with 31% of the US population. Under baseline conditions, 12.5% of the workforce would be URiM in 2060, compared with 43.2% of the US population (RR, 0.29). Continuing 2010-2020 trends would raise 2060 URiM representation to 16.5% (RR, 0.38). Doubling URiM growth relative to non-URiM would raise 2060 URiM representation to 19.1% (RR, 0.44). Achieving parity would require increasing URiM physicians entering the workforce by 9.5% per decade. CONCLUSION/CONCLUSIONS:Across various scenarios of physician recruitment, URiM representation in the cancer physician workforce will remain below half the US population share by 2060.