Academic Medical Institution Research Articles

Well-Being Parameters and Intention to Leave Current Institution Among Academic Physicians

Physician turnover interrupts care delivery and creates health care system financial burden. To describe the prevalence of burnout, professional fulfillment, and intention to leave (ITL) among physicians at academic-affiliated health care systems and identify institutional and individual factors associated with ITL. This cross-sectional study administered a survey to 37 511 attending-level medical specialists at 15 academic medical institutions participating in the Healthcare Professional Well-Being Academic Consortium. Data were collected from October 2019 to July 2021. Statistical analysis was performed from May 2022 to March 2023. Hypothesized institutional and individual determinants of occupational well-being. The main outcome was ITL, defined as having at least a moderate intention (a score of 2 on a 0-4 scale) to leave one's institution within the next 2 years. Additional outcomes included burnout and professional fulfillment, defined using published Professional Fulfillment Index cut points. Of 18 719 academic physician survey respondents (8381 [44.8%] male; 2388 [12.8%] Asian, 10 599 [56.6%] White, 1039 [5.6%] other race, 4693 [25.1%] unknown race; 294 [1.6%] Hispanic or Latina/Latino/Latinx), 6903 of 18 217 (37.9%) met criteria for burnout and 7301 of 18 571 (39.3%) for professional fulfillment; 5177 of 15 890 (32.6%) reported moderate or greater ITL. Burnout, professional fulfillment, and ITL varied across specialties. After adjusting for demographics, each 1-point increase (range 0-10) in burnout was directly associated with ITL (odds ratio [OR], 1.52 [95% CI, 1.49-1.55])c, and each 1-point increase in professional fulfillment was inversely associated with ITL (OR, 0.64 [95% CI, 0.63-0.65]). After adjusting for demographics, burnout, and professional fulfillment, each 1-point increase (range 0-10) in supportive leadership behaviors (OR, 0.83 [95% CI, 0.82-0.84]), peer support (OR, 0.93 [95% CI, 0.91-0.95]), personal-organizational values alignment (OR, 0.81 [95% CI, 0.80-0.82]), perceived gratitude (OR, 0.95 [95% CI, 0.92-0.97]), COVID-19 organizational support (OR, 0.88 [95% CI, 0.85-0.91]), and electronic health record helpfulness (OR, 0.95 [95% CI, 0.93-0.97]) were inversely associated with ITL, whereas each 1-point increase (range 0-10) in depression (OR, 1.08 [95% CI, 1.05-1.10]) and negative impact of work on personal relationships (OR, 1.09 [1.07-1.11]) were directly associated with ITL. In this cross-sectional study of academic physicians, 32.6% indicated moderate or higher ITL within 2 years. Burnout, lack of professional fulfillment, and other well-being factors were associated with ITL, suggesting the need for a comprehensive approach to reduce physician turnover.

Identification of Choroidal Vascular Abnormalities in Patients with Hereditary Hemorrhagic Telangiectasia (HHT)

Purpose: To evaluate the frequency of ocular imaging in patients with HHT at a large academic medical institution; characterize the choroidal vascular changes on indocyanine green angiography (ICGA) and optical coherence tomography (OCT); and explore the relationship of these ocular features with HHT genotypes and systemic manifestations. Methods: Retrospective review of patients with HHT who were seen in the Mayo Clinic ophthalmology department between 2011 to 2021. Results: Of the 71 patients with HHT identified, 7 (10%) individuals had qualifying imaging defined as radial or raster spectral-domain OCT scans and/or ICGA. 4 (57%) patients had enlarged choroidal vessels detected on OCT and/or ICGA. 3 (43%) patients had retinal telangiectasias. Patients with choroidal changes (mean age 67 years) had the endoglin gene mutation, gastrointestinal arteriovenous malformations (AVM), and facial and mucocutaneous telangiectasias. In contrast, patients without choroidal changes (mean age 45 years) included the activin A receptor type-like kinase 1 gene mutation. Conclusion: Only a small proportion of patients with HHT undergo ophthalmic imaging at our institution. The presence of choroidal abnormalities is associated with the endoglin gene mutation, older age, corroborating retinal vascular changes, and increased systemic manifestations.

Peripheral Nerve Stimulation in Chronic Knee Pain: A Case Series.

Introduction Chronic knee pain is increasing in prevalence and is associated with substantial limitations in functional mobility. Peripheral nerve stimulation (PNS) has been increasingly used to treat various chronic pain conditions. However, there is a paucity of research exploring the potential therapeutic benefit of PNS for chronic knee pain. Methods This research is a retrospective case series of all patients who received PNS for the treatment of chronic knee pain performed at a single-center academic medical institution between March 2021 and June 2022. The primary outcome was percent pain reduction six months after implantation. Outcome data was obtained via chart review and phone calls to patients. Secondary outcomes included percent pain reduction two weeks and two months after implantation and adverse medical events related to the procedure and nerve stimulation. Results Fourteen individual patients received PNS for chronic knee pain during the study period. Three of these patients received bilateral PNS for a total of 17 cases. The mean percent pain reduction six months after implantation was 52% (SD=28.2) (N=12). A total of 75.0% of participants (9/12) reported≥50% reductions in pain six months after implantation. No adverse events were reported relating to the implantation procedure and/or nerve stimulation. Conclusion PNS is a safe and efficacious treatment modality for chronic knee pain with demonstrated long-term benefit. Further research should clarify patient factors associated with improved treatment response.

The Applications of Augmented Reality (AR) and Virtual Reality (VR) in Teaching Medical and Dentistry Students: A Review on Advantages and Disadvantages

An interactive three-dimensional (3D) experience known as augmented reality (AR) employs computers to superimpose virtual data over the real world. Virtual reality (VR) is the artificial computer reconstruction of a real-life environment or experience. In the last decade, academic medical and dental institutions have witnessed the emergence of teaching technologies created using extended reality technology, such as AR and VR. It has been suggested that these technological advancements might support and further improve the medical and dentistry student teaching process. However, some medical and dentistry educationists are still sceptical about the usage of these technologies. This is because, throughout the centuries, the students in both fields were trained via established conventional methods. The purpose of this paper is to understand the benefit and impediments use of both technologies. We aim to review the advantages and disadvantages of AR and VR applications in the teaching process of medical and dentistry students.

Evaluation of an Advanced Practice Provider Onboarding and Development Program.

To evaluate the impact of implementing a comprehensive secondary onboarding and development program within a hospital medicine group at a large tertiary academic medical institution. This was a mixed-methods study with physician and advanced practice providers (APPs) at an academic medical institution. For quantitative methods, improvement in competencies was determined using a pre-and posttest for APPs and pre- and postevaluation scores from collaborating physicians. APPs also participated in a pre- and post-self-assessment. For qualitative methods, experiences in the secondary onbo.arding and development program were assessed using semistructured interviews. For quantitative results, there were a total of 25 APPs who completed the pre- and posttest and were evaluated by at least 9 physicians. The average pretest score for APPs was 71.7% and the average posttest score was 83.0%. The average score for physicians' evaluations of APPs was 4.24/5 and increased to 4.38/5 in the postprogram evaluations. The average score for APP self-assessment pretraining was 3.52/5 and after the 12-month onboarding training, average scores increased to 3.84/5. For qualitative results, 4 APPs and 6 physicians were interviewed. Three of the APPs reported having more confidence in treating patients, whereas 1 APP viewed the program as a refresher course. All of the APPs mentioned that they would recommend the program to other APPs. Physicians reported that the program was beneficial in standardizing the care provided among the different types of APPs (physician assistants and nurse practitioners). All of the physicians also would recommend the program to other physicians and APPs.

Factors associated with delayed referral and hearing rehabilitation for congenital sensorineural hearing loss

ObjectivesTo identify the impact of social determinants of health and clinical status on referral and intervention for congenital sensorineural hearing loss. Study designRetrospective chart review of children with confirmed sensorineural or mixed hearing loss between 2013 and 2021 at a single academic medical institution. MethodsReferral rates and timing for hearing rehabilitation, rates and timing of completed evaluation, and rate and timing of amplification were recorded. Patient demographics included gestational age, race, ethnicity, sex, hearing loss severity, and CMV status. ResultsThere were 216 children with confirmed sensorineural or mixed hearing loss, of which 77 had a unilateral hearing loss and 89 a severe or profound hearing loss. Delayed referral for hearing aid evaluation was noted in premature patients (median 375 days premature, median 147 term; p < 0.01) and publicly insured patients (median 215 days, median 123 private; p = 0.04). Delayed time to hearing aid fitting was noted for non-white patients (median 325 days, median 203 white patients; p < 0.01), publicly insured patients (median 309 days, median 212 private insurance; p < 0.02), and premature patients (median 462 days, median 224 term; p = 0.03). White patients were more likely to be referred for cochlear implant (p = 0.03).Privately insured patients and patients with a positive CMV test were more likely to be referred for cochlear implant evaluation, be seen in the cochlear implant clinic, and undergo implantation (p < 0.05). Non-white patients had a delay in cochlear implantation referral (median 928 days, median 398 days white patients; p = 0.05). Prolonged interval between evaluation in cochlear implant clinic to implantation was noted for privately insured patients (median 125 days; median 78 days publicly insured; p = 0.05). ConclusionsSociodemographic factors were significantly associated with hearing amplification referral rates and time until amplification for children with identified congenital sensorineural hearing loss. For cochlear implantation, insurance type, CMV status were significantly associated with rate and timing of cochlear implant pathway.

Structured Resident Training in Robotic Surgery: Recommendations of the Robotic Surgery Education Working Group

A universal resident robotic surgery training pathway that maximizes proficiency and safety has not been defined by a consensus of surgical educators or by surgical societies. The objective of the Robotic Surgery Education Working Group was to develop a universal curriculum pathway and leverage digital tools to support resident education. The two lead authors (JP and YN) contacted potential members of the Working Group. Members were selected based on their authorship of peer-review publications, their experience as minimally invasive and robotic surgeons, their reputations, and their ability to commit the time involved to work collaboratively and efficiently to reach consensus regarding best practices in robotic surgery education. The Group's approach was to reach 100% consensus to provide a transferable curriculum that could be applied to the vast majority of resident programs. Virtual and in-person meetings in the United States. Eight surgeons (2 females and 6 males) from five academic medical institutions (700-1541 beds) and three community teaching hospitals (231-607 beds) in geographically diverse locations comprised the Working Group. They represented highly specialized general surgeons and educators in their mid-to-late careers. All members were experienced minimally invasive surgeons and had national reputations as robotic surgery educators. The surgeons initially developed and agreed upon questions for each member to consider and respond to individually via email. Responses were collated and consolidated to present on an anonymized basis to the Group during an in-person day-long meeting. The surgeons self-facilitated and honed the agreed upon responses of the Group into a 5-level Robotic Surgery Curriculum Pathway, which each member agreed was relevant and expressed their convictions and experience. The current needs for a universal robotic surgery training curriculum are validated objective and subjective measures of proficiency, access to simulation, and a digital platform that follows a resident from their first day of residency through training and their entire career. Refinement of current digital solutions and continued innovation guided by surgical educators is essential to build and maintain a scalable, multi-institutional supported curriculum.

Automated classification of fat-infiltrated axillary lymph nodes on screening mammograms.

Fat-infiltrated axillary lymph nodes (LNs) are unique sites for ectopic fat deposition. Early studies showed a strong correlation between fatty LNs and obesity-related diseases. Confirming this correlation requires large-scale studies, hindered by scarce labeled data. With the long-term goal of developing a rapid and generalizable tool to aid data labeling, we developed an automated deep learning (DL)-based pipeline to classify the status of fatty LNs on screening mammograms. Our internal data set included 886 mammograms from a tertiary academic medical institution, with a binary status of the fat-infiltrated LNs based on the size and morphology of the largest visible axillary LN. A two-stage DL model training and fine-tuning pipeline was developed to classify the fat-infiltrated LN status using the internal training and development data set. The model was evaluated on a held-out internal test set and a subset of the Digital Database for Screening Mammography. Our model achieved 0.97 (95% CI: 0.94-0.99) accuracy and 1.00 (95% CI: 1.00-1.00) area under the receiver operator characteristic curve on 264 internal testing mammograms, and 0.82 (95% CI: 0.77-0.86) accuracy and 0.87 (95% CI: 0.82-0.91) area under the receiver operator characteristic curve on 70 external testing mammograms. This study confirmed the feasibility of using a DL model for fat-infiltrated LN classification. The model provides a practical tool to identify fatty LNs on mammograms and to allow for future large-scale studies to evaluate the role of fatty LNs as an imaging biomarker of obesity-associated pathologies. Our study is the first to classify fatty LNs using an automated DL approach.

Factors influencing second victim experiences and support needs of OB/GYN and pediatric healthcare professionals after adverse patient events

There is growing recognition that clinical and nonclinical healthcare professionals may become “second victims” following adverse patient events, medical errors, or patient-related injuries. In addition to the trauma-associated symptoms experienced by second victims, unprocessed second victim experience (SVE) can lead to burnout and leaving the healthcare workforce. To better understand the risk factors and support needs of affected healthcare professionals after a SVE, we conducted in-depth qualitative interviews with twelve staff in obstetrics &amp; gynecology and pediatrics at a large academic medical institution in the upper Midwest of the U.S. Several participants indicated that it was not the patient outcome itself that precipitated the SVE, but associated factors such as moral distress or communication challenges. Participants discussed the role of their work unit culture in post-SVE processing, expressing that units perceived as blame-seeking or where adverse events were not openly discussed, hindered their recovery. While desired support mechanisms were individualized, participants stressed the importance of immediate and proactive support, such as through a peer support program, and long-term support mechanisms for lingering symptoms. As attrition of the healthcare workforce continues to be a significant concern, it is essential that we understand and meet the post-SVE support needs of affected staff, to promote holistic care following adverse patient events.

Promises and challenges of a decentralized CAR T-cell manufacturing model.

Autologous chimeric antigen receptor-modified T-cell (CAR T) products have demonstrated un-precedent efficacy in treating many relapsed/refractory B-cell and plasma cell malignancies, leading to multiple commercial products now in routine clinical use. These positive responses to CAR T therapy have spurred biotech and big pharma companies to evaluate innovative production methods to increase patient access while maintaining adequate quality control and profitability. Autologous cellular therapies are, by definition, manufactured as single patient batches, and demand has soared for manufacturing facilities compliant with current Good Manufacturing Practice (cGMP) regulations. The use of a centralized production model is straining finite resources even in developed countries in North America and the European Union, and patient access is not feasible for most of the developing world. The idea of having a more uniform availability of these cell therapy products promoted the concept of point-of-care (POC) manufacturing or decentralized in-house production. While this strategy can potentially decrease the cost of manufacturing, the challenge comes in maintaining the same quality as currently available centrally manufactured products due to the lack of standardized manufacturing techniques amongst institutions. However, academic medical institutions and biotech companies alike have forged ahead innovating and adopting new technologies to launch clinical trials of CAR T products produced exclusively in-house. Here we discuss POC production of CAR T products.

Characteristics of Sexual Assault Among Men Receiving a Forensic Medical Examination

ABSTRACT Sexual assault is a form of violence disproportionately perpetrated against women by men; however, men also experience high rates of sexual victimization. While recent research exploring victimization of sexual assault among men does exist, little is known about situational characteristics and consequences surrounding men’s assault experiences. Therefore, the current study examines narratives of men’s sexual assault to further understand the unique experiences of men receiving a sexual assault medical forensic examination. To accomplish this, we conducted a retrospective medical chart review of sexual assault narratives from N = 45 men receiving a sexual assault medical forensic examination at a large academic medical institution in the southeastern United States. Three general constructs were identified within the records: a) Perpetrator use of coercive tactics, b) Memory loss, and c) Contextual factors. Nested within these constructs, five specific themes emerged, including: a1) Use of weapons and physical force; a2) Tactical administration of alcohol and drugs; b1) Difficulties remembering assault; c1) Consensual sexual activity turned non-consensual; c2) Incarceration. Findings from the present study common identified characteristics of sexual assaults among men receiving a sexual assault medical forensic examination, including coercive tactics used by perpetrators, consequences of sexual assault, and high-risk settings for male victimization.

The Performance of Molecular Tests for Selected Indeterminate Thyroid Nodules (AUS and FN) in an Academic Medical Institution

The Performance of Molecular Tests for Selected Indeterminate Thyroid Nodules (AUS and FN) in an Academic Medical Institution

Appropriateness of serum free light chain orders in an academic medical institution.

Appropriateness of serum free light chain orders in an academic medical institution.

Predictive role of culture-based MIC testing vs. genotyping for carbapenem-resistant Enterobacterales in a non-universal screening, highly resourced setting

A lack of evidence of accuracy for various testing modalities for carbapenem-resistant Enterobacterales (CRE) reduces the efficiency of screening and delays the isolation of carriers. This study examined the performance of phenotypic detection of CRE in comparison to molecular testing. A cross-sectional study was conducted in an academic medical institution in Saudi Arabia on CRE-screened patients during a 36-month period (April 1, 2019, through March 31, 2022). Cases were followed up for their susceptibility status by the phenotypic gradient method and genotypes. Of 3,116 samples tested, 359 carbapenemase genes were detected in 297 strains (9.5%) belonging to 292 patients. Oxacilliniase-48 (OXA-48) was the most frequently detected genotype (n=190, 64%), followed by a combined New Delhi metallo-B-lactamase (NDM)/OXA-48 genotype (n=77, 25.9%). Variable missed isolation days were encountered for various genotypes (0-18.5 days), with an excellent clinical utility index obtained for screening the OXA-48 genotype phenotypically. The data provided some insights into the predictive role and shortcomings of the e-test alone in CRE screening. While it provided a reasonable approach in a CRE population dominated by OXA-48 genotypes, it was more likely to miss the NDM-incurred carbapenemase. Thus, local epidemiology in an institution must be considered when designing a local screening protocol in addition to consideration of cost and turnaround time.

To the History of Scientific Concepts of the XIX Century Domestic Psychiatry: P.A. Butkovskiy’s Textbook

Background: the elaboration of problems of clinical psychiatry in Russia had already begun in the end of the XVIII — beginning of the XIX centuries by professors of internal medicine and of other branches of medical academic institutions, and from the thirties years of XIX century gradually moved to the hands of the doctors who were specialized in psychiatry (V.F. Sabler, A.I. Gerzog, I.F. Rjul, I.P. Malinovskiy and others).The aim was to analyze the history of the formation of scientific concepts in Russian psychiatry in comparison with the relevant German and French psychiatric concepts at that time.Method: narrative review.Conclusion: the author of the first domestic textbook of psychiatry “Diseases of the soul” (1834) was Professor of department of surgery and mental diseases of Kharkov’s University P.A. Butkovskiy. Creating his textbook P.A. Butkovskiy grounded on the textbook of one of the founders of german “school of psychics” J.Ch. Heinroth (1818) and took as a basis of classification of mental diseases Heinroth’s systematics. The forms of mental diseases according to P.A. Butkovskiy and J.Ch. Heinroth were distinguished by two principal signs: predomination of affection of the one among three areas of psyche: imagination, intellect and volition, and due to the changes in its functions: amplification or weakening. Wherein P.A. Butkovskiy connected with the affection of the brain only the group of “paranoiс” diseases (general paranoia, ecnoia, paraphrosyne, moria) and acquired stupidity (anoia) that were explained by exaggeration or weakening of the brain functioning respectively. P.A. Butkovskiy also introduced in Russian psychiatry the notion of “dynamics” and “psychosomatic” that were borrowed from J.Ch. Heinroth, and the concept of “general feeling” (coenesthesis) of J. Reil. The forms of mental disorders distinguished by J.Ch. Heinroth represented the next progressive step in the differentiation of syndrome pictures of mental diseases (but not in psychiatric nosology as the author considered), and the fact that P.A. Butkovskiy, the author of the first Russian Textbook on Psychiatry, created the similar systematics on the same principles, contributed to the building of mutual understanding between national psychiatric schools that were in the process of being formed.

Women physicians receive lower Press Ganey patient satisfaction scores in a multicenter study of outpatient gynecology care

Emerging data suggest that patient satisfaction data are subject to inherent biases that negatively affect women physicians. This study aimed to describe the association between the Press Ganey patient satisfaction survey and physician gender in a multi-institutional study of outpatient gynecologic care. This was a multisite, observational, population-based survey study using the results of Press Ganey patient satisfaction surveys from 5 unrelated community-based and academic medical institutions with outpatient gynecology visits between January 2020 and April 2022. The primary outcome variable was the likelihood to recommend a physician, and individual survey responses served as the unit of analysis. Patient demographic data were collected through the survey, including self-reported age, gender, and race and ethnicity (categorized as White, Asian, or Underrepresented in Medicine, which groups together Black, Hispanic or LatinX, American Indian or Alaskan Native, and Hawaiian or Pacific Islander). Bivariate comparisons between demographics (physician gender, patient and physician age quartile, patient and physician race) and likelihood to recommend were assessed using generalized estimating equation models clustered by physician. Odds ratios, 95% confidence intervals, and P values for these analyses are reported, and results were considered statistically significant at P<.05. Analysis was performed using SAS, version 9.4 (SAS Institute Inc., Cary, NC). Data were obtained from 15,184 surveys for 130 physicians. Most physicians were women (n=95 [73%]) and White (n=98 [75%]), and patients were also predominantly White (n=10,495 [69%]). A little over half of all visits were race-concordant, meaning that both patient and physician reported the same race (57%). Women physicians were less likely to receive a topbox survey score (74% vs 77%) and in the multivariate model had 19% lower odds of receiving a topbox score (95% confidence interval, 0.69-0.95). Patient age had a statistically significant relationship with score, with patients aged ≥63 years having >3-fold increase in odds of providing a topbox score (odds ratio, 3.10; 95% confidence interval, 2.12-4.52) compared with the youngest patients. After adjustment, patient and physician race and ethnicity showed similar effects on the odds of a topbox likelihood-to-recommend score, with Asian physicians and Asian patients having lower odds of a topbox likelihood-to-recommend score when compared with White physicians and patients (odds ratio: 0.89 [95% confidence interval, 0.81-0.98] and 0.62 [95% confidence interval, 0.48-0.79], respectively). Underrepresented in medicine physicians and patients showed significantly increased odds of a topbox likelihood-to-recommend score (odds ratio: 1.27 [95% confidence interval, 1.21-1.33] and 1.03 [95% confidence interval, 1.01-1.06], respectively). The physician age quartile was not significantly associated with odds of a topbox likelihood-to-recommend score. Women gynecologists were 18% less likely to receive top patient satisfaction scores compared with men in this multisite, population-based survey study using the results of Press Ganey patient satisfaction surveys. The results of these questionnaires should be adjusted for bias given that they provide data currently being used to understand patient-centered care.

Results of Immediate Postpartum Long Acting Reversible Contraception Provision After Expanded Reimbursement Policy Implementation at an Academic Medical Institution.

Immediate postpartum (IPP) Long Acting Reversible Contraception (LARC) is effective in reducing short birth spacing, which is highest among minoritized and younger women with lower socioeconomic status. The structural barrier of cost for pregnant people who desire IPP LARC insertion was alleviated in 2016 when New York State provided statewide reimbursement for Medicaid recipients. Analyses of existing electronic medical records (EMR) were conducted on women who received IPP LARC between 3/2/17 and 9/2/19 at two hospitals after a term delivery, defined as gestational age 37 0/7 weeks or greater. Descriptive and bivariate statistics, including chi-square tests and Fischer's exact tests, based on cell sizes, were calculated using SAS (version9.4). Prior to the study period, IPP LARC was not placed in these hospitals. After reimbursement policy changes, electronic medical record data identified 501 women with full term delivery and IPP LARC placed, of which the majority were single (82.8%), Black (49.1%), and had public insurance (Medicaid and Medicaid Managed Care) (79.2%). Removing structural economic barriers for people using public insurance may increase health equity in contraceptive access and choice.

Data driven insights from multiple OCM practices to optimize care for managing high-risk cancer patients across multiple cancer types.

6576 Background: Medicare’s Oncology Care Model (OCM) aims to improve the quality and coordination of care for cancer patients. Previously, Integra Connect (IC) developed machine learning (ML) based risk prediction models called Integra Predict (IP) for In-Patient Admissions, Emergency Department Visits and End-of-Life in active chemotherapy patients within the next six months. The patients were risk-stratified with the purpose of optimizing clinical resources utilization. Our objective is to demonstrate the insights derived from an updated IP version applied to OCM patients from three IC network practices: P1 (a multi-state network of community oncology practices), P2 (a single site community oncology practice) and P3 (a regional network of oncology practices connected to academic medical institution). Methods: For training the ML models, 90,417 OCM reconciliation episodes from PP4–PP8 (Jan. 2018-June 2020) from 10 distinct IC practices were used. The models comprise 37 features: 12 adverse events (within last 6 month of episode start date), 7 comorbidities (in the past irrespective of lookback period), 7 latest vital sign measurements recorded within 30 days of date of prediction, 11 demographic and other clinical attributes. Based on LogLoss, 54 ML experiments were performed leading to three best algorithms to predict the risk for In-Patient Admissions, Emergency Department Visits and End of Life. To generalize our ML approach, we leveraged an additional holdout dataset in periods PP9 and PP10 (July 2020 - June 2021) pertaining to practices P1, P2 and P3 with 6378, 973 and 5921 episodes, respectively. Matthew Correlation Coefficient (MCC) was chosen as the metric to test the generalizability of the models. For each model, the variance of MCC was then computed. To uncover secondary factors influencing clinical care, top-3 frequently reported adverse events and top-5 comorbidities were determined. Results: For each ML model, the variance of MCC applied to the holdout dataset was low (order of 10-4). Types of cancers reported differed within P1, P2 and P3. However, across these practices, irrespective of the cancer type, the most frequently reported adverse events (pain, anemia, and cachexia) and comorbidities (cardiovascular disease, chronic pulmonary disease, dyspnea at rest, dorsopathies and renal disease or failure) observed were the same. Conclusions: Low variance in MCC implies ML models are applicable to different types of community oncology practices. A care coordination program for high-risk cancer patients involving the monitoring of pain, cachexia and anemia can lead to optimal utilization of clinical resources within these practices. Program expansion involving optimal management of comorbidities such as cardiovascular disease, chronic pulmonary disease, diabetes, dyspnea at rest and renal disease or failure may yield additional benefits.

On missional medicine: institution building, fragile places, and sheep among wolves

From the healing narratives of Jesus in the Gospels to the genesis of the first hospital to the practice of modern medicine, questions surrounding health and care for those who are sick and dying run through the heart of the Christian story. One way that individuals and communities have sought to live into their faith has been through missional medicine, that is, seeking to intentionally use the tools of medicine in step with and to bear witness to the life of Christ, particularly in cross-cultural and global contexts. In this commentary, we take up the incisive question of the late missionary physician Raymond Downing, “is there a distinctive Christian approach to global health?” Or, what sets (and should set) Christian approaches to global health apart from other interventions? Here, we argue that there are at least three distinctive Christian contributions to global health. First, missional medicine movements have been committed to the building of long-standing hospitals and academic medical institutions that have left indelible marks on long-term health outcomes for people and communities. Second, practitioners motivated by Christian convictions disproportionately serve and remain long-term in marginalized, rural, and underserved areas; many of which are connected to fragile or under-developed health systems. Thirdly, Christian medical missionaries and global health workers ought to be, in the words of Jacques Ellul: preserving salt, revealing light, and “sheep in the midst of wolves.” This is a theologically framed vocation that accepts suffering and sacrifice, embracing solidarity through accompaniment. This paper is not meant to be a comprehensive history of missional medicine nor a defence of its problematic manifestations over the centuries. Rather, we candidly explore examples of the distinctive contributions that have been made, and we hope will continue to be made, by medical missionaries and global health workers who are motivated by their faith.

Review of “Conflicted Care: Doctors Navigating Patient Welfare, Finances, and Legal Risk”

There is a quote in Hyeyoung Oh Nelson’s Conflicted Care: Doctors Navigating Patient Welfare, Finances, and Legal Risk, which captures the book’s substance beautifully. In an interview excerpt with the director of residency training at the hospital Nelson studied, the doctor explains the “single biggest dilemma” physicians face in an academic medical institution. He addresses an imaginary trainee to illustrate the problem: “Look, this is the time when you are learning to be a doctor: we want you to be cost-effective but we also want you to be thorough and humanistic and use physical diagnostic skills that you have learned appropriately, and not overorder tests. And you have to do all that within two and a half days…” (p. 37). Abundant research by medical and organizational sociologists has underscored the inescapable tension of the healthcare system in the United States: caught between the “do no harm” oath, which directs physicians to put patients’ wellbeing above everything else, and the financial and bureaucratic structuring of healthcare provision, which has introduced the principle of efficiency in every healthcare institution. In an ideal world, these mandates would align: providing the best care would also be cost-efficient (and such is the promise of managed care policies). In the real world, unsurprisingly, health logics and financial logics tend to clash.