Residents In June Research Articles

Cannabis Retail Market Indicators in Five Legal States in the United States: A Public Health Perspective

Adult-use cannabis markets are operating in multiple US states and abroad. Sales and licensing data for alcohol and tobacco are often used to understand consumption patterns and evaluate policy changes. Cannabis market data may provide similar insights, although these newly legal markets are complex and evolving, and the state data structures can differ. This study describes variations in market indicators and discusses the utility of cannabis market metrics from a public health perspective. We collected data from 5 early-adopting adult-use cannabis states: Alaska, Colorado, Massachusetts, Oregon, and Washington. Analyses focused on licensed retail outlets and retail sales revenues (pretax). Monthly data were collected from the opening of each state's adult-use market through June 2022. Joinpoint software was used to assess state trends and identify points of inflection in trends. Average sales per retailer for June 2019 and June 2022 were compared. Also described are retailers and revenue per population for 2022. All states showed 4 distinct periods of growth in retail licensee numbers. The greatest increases typically occurred in the first 3 to 4 months. Growth rates slowed to <1% per month for Colorado, Oregon, and Washington at months 25, 24, and 34, respectively. The number of cannabis retailers per 100,000 residents in June 2022 ranged widely, from 16.8 in Oregon to 3.0 in Massachusetts. Colorado, Oregon, and Washington each showed 4 distinct trend periods in adult-use retail sales: early rapid growth lasting <1 year, subsequent varied growth periods, and then declining sales in the most recent months, following early coronavirus disease 2019 period increases. Sales in Alaska and Massachusetts displayed more stable, consistent growth patterns. Sales per state resident for July 2021 to June 2022 also ranged widely, from $382.97 in Alaska to $180.94 in Washington. We found some consistencies and some variations in both point-in-time measures and trends in states' adult-use cannabis markets. Differences may relate to varied state policies and general contexts (eg, economies). Market data can be useful for public health monitoring, including understanding the effects of policies intended to protect health and safety. States providing publicly accessible cannabis market data create opportunities for such use. Our results underscore the importance of considering individual state regulatory frameworks and implementation timelines in studies of cannabis legalization.

Association Between In-Training Exam Scores and Clinical Exposure During the COVID-19 Pandemic

BackgroundWe sought to evaluate changes in In-Training Examination (ITE) scores and associations with clinical work during the COVID-19 pandemic. We hypothesized that residents saw a decrease in clinical encounters during the pandemic and that this would be associated with smaller gains in ITE scores. MethodsWe compared ITE score changes with data on patient notes for three classes of pediatric residents at four residency programs: one not exposed to the pandemic during their intern year who entered residency in 2018, one partially exposed to COVID-19 in March of their intern year (2019–2020), and one that was fully exposed to the pandemic, starting residency in June of 2020. ResultsITE scores on average improved from the PGY1 to PGY2 year in the “no covid” and “partial COVID” cohorts. The “full COVID” cohort had little to no improvement, on average. The total number of patient encounters was not associated with a change in ITE scores from PGY1 to PGY2. There was a small but statistically significant association between change in ITE score and number of inpatient H+P notes. ConclusionsA drop in ITE scores occurred in pediatric residents who entered residency during the COVID-19 pandemic. This change was largely unrelated to clinical encounter number changes.

Residency Match Rates in Orthopaedic Surgery Based on Sex, Under-Represented in Medicine Status, and Degree Type.

A retrospective review of the Electronic Residency Application Service (ERAS) application data from the 2017 to 2021 application cycles was performed, and the total number of applicants, sex, race/ethnicity, and degree type of all students applying for orthopaedic surgery were recorded. A separate database, the Orthopaedic Residency Information Network (ORIN), which is a database self-reported by residency programs to provide information to applicants, was also queried to identify the total number of residents, sex, race/ethnicity, and degree type of all current residents in June 2022, corresponding to those residents who matched in 2017 to 2021. From the ERAS application data, a total of 7,903 applicants applied to orthopaedic surgery during the study period. A total of 1,448 applicants (18%) were female, 1,307 (18%) were URiM, and 1,022 (15%) were from an osteopathic medical school. Based on the ORIN database, 688 of 3,574 residents (19%) were female, 1,131 of 7,374 (19%) were URiM, and 1,022 of US medical school graduates (12%) had a DO degree. The application and match rates were not significantly different for female (p = 0.249) and URiM (0.187) applicants; however, there was a significant difference in the application and match rates (15% vs 12%; p = 0.035) for US medical graduates with a DO degree. In recent years, there has been a significant and necessary push to increase diversity in the field of orthopaedic surgery. From 2017 to 2021, match rates of female and URiM candidates are reflective of their application rates. Osteopathic applicants in orthopaedic surgery have a lower match rate than their allopathic counterparts. III.

Dialogic Health Education to Reduce COVID-19 Disparities and Increase Health Literacy in Community and Correctional Settings: Protocol for a Two-Pronged Health Education Program.

BackgroundCOVID-19 vaccines significantly reduce rates of hospitalization and death for those infected with the SARS-CoV-2 virus. Those facing social oppression, including people of color, experience heightened risk for COVID-19 and comorbidities, but are often mistrustful of governmental agencies and initiatives, contributing to low vaccine uptake and a reluctance to access vital health care services. Dialogue-based health literacy interventions may mitigate mistrust and increase access to health services and information, subsequently increasing rates of vaccination and other behaviors that reduce COVID-19 risk.ObjectiveTo improve health literacy and reduce COVID-19 disparities, the Westchester County Department of Health, in partnership with two universities, community- and faith-based organizations, and the Westchester County Department of Correction, co-developed a health education program for community members, correctional officers, and incarcerated jail residents in Westchester, New York. Specific objectives are to increase preventative health behaviors, positive attitudes toward use of public health protocols, full vaccination or intentions to vaccinate, health care information understanding, health provider care access, clear communication with health care providers, and personal health care decision-making.MethodsGrounded in dialogic learning, the program entails training community-based “trusted messengers” and correctional officers to lead health information sessions in community and correctional settings. During the grant period, the program intends for 80 community-based trusted messengers to receive training from the Department of Health and will be expected to reach a goal of 100 members (N=8000) of their communities. Correctional staff with experience delivering educational programs will be trained to facilitate sessions among 400 correctional facility residents and 600 correctional staff.ResultsPre-post surveys will assess changes in health behaviors, attitudes, and perceptions. The program has been administered in the correctional facility since February 2022, with information sessions expected to cease for correctional staff and residents in June 2022 and November 2022, respectively. An initial cohort of community-based trusted messengers began training in February 2022, and information sessions have been scheduled in various virtual and community settings since March 2022. As of April 2022, the two-pronged health education program has reached 439 correctional officers, 98 jail residents, and 201 community members countywide. Program evaluation findings will be released in future publications after study implementation is complete.ConclusionsFew studies have evaluated the combined effects of training-of-trainers (ToT) and dialogical learning models on behavior and health literacy. As the first known COVID-19–specific dialogue-based health education program that applies a ToT model in the community-based, correctional, and virtual settings simultaneously, this study fills a gap in current knowledge about health literacy and health behavior in marginalized populations. Thus, this evidence-based framework can remedy COVID-19 disparities while also addressing risks for a host of health-related issues at the community level, potentially serving as a best-practice model for future health programs.International Registered Report Identifier (IRRID)PRR1-10.2196/37713

The relationship between empathy and the quality of the educational environment in Canadian emergency medicine residents.

PurposeEmpathy and quality of educational environment appear to be inversely correlated with burnout but the relationship between the two is largely unknown. Our primary objective was to examine the relationship between postgraduate educational environment and empathy. Secondary objectives included impact of gender, residency year and on- versus off-service context on levels of empathy and educational environment.MethodsA modified Dillman approach was used to conduct an email survey of Canadian Royal College Emergency Medicine residents in June 2020. The survey instrument included: demographic data, Toronto Empathy Questionnaire (TEQ) and Scan of Postgraduate Educational Environment Domains (SPEED). Logistic and linear regressions evaluated the association between TEQ and SPEED, and mean SPEED scores and covariates, respectively.ResultsResponse rate was 38% (138/363) with representation from all programs. Respondents were mean 30 years of age, 59% men and 25%, 20%, 18%, 24%, and 13% in postgraduate year (PGY) 1–5, respectively. There was no statistically significant association between high/low TEQ scores and mean SPEED score (p = 0.97). There were no statistically significant associations between any of the covariates and high/low TEQ scores (gender, p = 0.21; PGY, p = 0.58; on-versus off-service, p = 0.46) or mean SPEED score (gender, p = 0.95; PGY, p = 0.48; on- versus off-service, p = 0.07). Emergency medicine residents rated their educational environment on average 3.44 (+/- 0.43) out of four. 39 of 134 residents were found to have low empathy.ConclusionThere was no association between empathy and educational environment. Further research is needed to elucidate modifiable factors contributing to the development of low empathy in emergency medicine residents.

Impacto de la pandemia COVID-19 en la formación sanitaria especializada en un centro docente

ObjectiveEvaluation of the impact of the health crisis caused by the Covid-19 pandemic on specialized healthcare training in a teaching center. MethodsCross-sectional descriptive study, by means of an electronic questionnaire sent to 167 residents in June 2020, to evaluate the burden of care, suspension of rotations and Covid-19 symptoms. The impact on the acquisition of professional competencies was measured using a four-level Likert scale (none, a little, quiet, a lot). The profile of acquired competencies was constructed and its association with the professional profile was studied using Generalized Linear Models. The qualitative approach was carried out through an open question on how it influenced their learning and the different categories were extracted through triangulation. ResultsThe impact on learning was important for 94.8% of the residents. A total of 81.4% left the rotations they were doing and reported high workload, loss of training opportunities, uncertainty and ethical conflicts. They appreciated significant learning in the competencies of teamwork (93.2%), professionalism (86.2%), ethics (79.9%) and communication (78%). Technical competencies were deficient. The final balance of learning was perceived as positive by 54.4%, especially residents in central services and medical specialties. A total of 67.8% felt overwhelmed at times due to fatigue-emotional impact, care overload, ethical conflicts and lack of resources. ConclusionsThe Covid-19 pandemic had an exceptional impact on specialized health care training. It is necessary to re-evaluate training programs to ensure the acquisition of the technical competencies that are lacking.

How Does Black History Help Doctors? Addressing Cultural Competency through Cinemeducation at a Diverse Medical School.

Racial minorities will account for >50% of the United States population by 2045, yet race and ethnicity persist as leading predictors of morbidity. Although minorities achieve better outcomes when treated by racially concordant providers, the number of minority physicians is disproportionately low compared with the rapidly growing minority population. This imbalance creates a cultural gap between many minority patients and their healthcare providers. Research suggests that educational initiatives addressing health inequity through a historical lens can help providers better understand the root causes of disparities; however, extensive clinical demands severely limit the time providers can dedicate to non-medical learning. To address this gap, the University of Miami/Jackson Memorial Hospital System developed and piloted a short film about the history of Black people in South Florida, highlighting significant events that shaped the health-seeking behaviors of this population. A 20-minute documentary exploring the sociocultural history of Black communities in Miami-Dade County was presented to 188 first-year postgraduate residents in June 2017. Residents completed pre-post surveys to measure changes in knowledge and care delivery intentions. Analyses performed between March and July 2018 revealed moderate improvements in the knowledge and awareness of the socioeconomic history of Miami's Black communities. Before watching the video, a majority indicated that increasing awareness of the sociocultural history of their patient population was a valuable learning activity. These findings suggest that brief videos focused on the history of culturally distinct populations may be a successful pedagogical strategy to introduce physicians to the communities they serve and improve provider knowledge.

Lactation challenges of resident physicians- results of a national survey

BackgroundThere are unique challenges to parenting in residency and there is limited data to guide policy regarding lactation facilities and support for female physicians-in-training. We aimed to assess issues surrounding breast-feeding during graduate medical training for current residents or recent graduates from United States (US) residency programs.MethodsA national cross-sectional survey was sent to current and recently graduated (2017 and later) female residents in June 2020. This questionnaire was administered using the Qualtrics Survey tool and was open to each participating woman’s organization for 4 weeks. Summary statistics were used to describe characteristics of all respondents and free-text responses were reviewed to identify common themes regarding avenues for improvement.ResultsThree hundred twelve women responded to the survey, representing a 15.6% response rate. The median duration of providing breastmilk was 9 months (IQR 6–12). 21% of residents reported access to usable lactation rooms within their training hospital, in which 12% reported a computer was present. 60% of lactating residents reported not having a place to store breast milk. 73% reported residency limited their ability to lactate, and 37% stopped prior to their desired goal. 40% reported their faculty and/or co-residents made them feel guilty for their decision to breastfeed, and 56% reported their difficulties with breastfeeding during residency impacted their mental health.ConclusionResidents who become mothers during training face significant obstacles to meeting their breastfeeding/pumping needs and goals. With these barriers defined, informed policy change can be instituted to improve the lactation experience for physicians-in-training.

ON COMING HOME AFTER THE FIRES

When I first became the Program Director of the Sutter Santa Rosa Family Medicine Residency in June of 2017, I thought I had my hands full. Learning the ropes of running a community-based residency program, continuing to be a teacher, and trying to maintain my small outpatient panel seemed like an

Medical Student Attitudes Towards People with Mental Illness in China: A Qualitative Study.

Stigma towards people with mental illness is a worldwide concern. A five-nation survey of medical student attitudes towards people with mental illness recently reported far lower levels of social acceptance among Chinese medical students compared to those from the US, Brazil, Ghana, and Nigeria. This qualitative study presented recent Chinese medical school graduates with probes based on questions used in the aforementioned cross-national study to elicit their views of factors underlying the negative attitudes towards social acceptance of people with mental illness. One-hour interviews were conducted with twenty psychiatry residents in June, 2016. Of 241 coded responses concerning negative attitudes, 51.5% were coded as reflecting fear of violent behavior, 22.8% as loss of face (i.e. shame from interpersonal associations), 17.0% lowered social status, 4.98% nonconforming social behavior, and 3.73% the heritability of mental illness. Low levels of social acceptance of individuals with mental illness among medical students in China are largely related to fears of violence of and loss of face. Understanding the attitudes of medical students may inform efforts to reduce stigma through educational initiatives targeted at both medical students and the general public.

The Toxicity of Self-Blame: Sex Differences in Burnout and Coping in Internal Medicine Trainees

Burnout is a significant problem facing internal medicine residents contributing to increased risk of depression and suicidal ideation. Coping mechanisms and burnout may differ based on sex. The study was a retrospective cross-sectional study of reported burnout and coping mechanisms used by internal medicine residents in June 2014 at a large academic center and its community affiliate. Two hundred eighty-five postgraduate year (PGY)-1, 2, 3, and 4 and incoming PGY-1 residents were surveyed. The Maslach Burnout Inventory-General Survey and Brief Coping Orientation to Problems Experienced were given to measure levels of burnout and frequency of use of coping mechanisms. Percentages of residents who met criteria for burnout and high levels on each of the subscales of emotional exhaustion, cynicism and professional efficacy, were calculated and stratified by sex. Chi-squared tests were used for statistical significance. Average frequency of use of each coping mechanism by sex was calculated with statistical significance determined by two sided t-tests. There was a 69% completion rate (198/285) with 100 men and 98 women. Woman had higher levels of burnout (30% vs. 15%, p = 0.014) and emotional exhaustion (22% vs. 9%, p = 0.005). Women used the adaptive coping mechanisms of emotional support (p = 0.001) and instrumental support (p = 0.018) more frequently but also used the maladaptive coping mechanism of self-blame more frequently (p = 0.022). Greater use of self-blame as a coping mechanism may be a major factor in the higher rates of burnout and emotional exhaustion in women resident physicians as compared to men. Educators must pay attention to use of self-blame by female residents and as it may be a red flag for resident distress.

Physician Satisfaction With Clinical Pharmacist Services in an Obstetrics and Gynecology Teaching Clinic

Objective: To evaluate physician satisfaction with clinical pharmacy services in an obstetrics teaching clinic. Study Design: A 35-question survey was created to evaluate demographics and provider satisfaction with clinical pharmacy services using 5-point Likert scale and open response questions. Surveys were administered to all clinic attendings, maternal fetal medicine fellows, and OB/Gyn residents in June 2014 via Survey Monkey. Results: Thirty-one physicians (83.8%) completed the survey. The first set of questions utilized a 5-point Likert-type scale ranging from “poor” (1) to “excellent” (5) and evaluated respondents’ impressions of the clinical pharmacists’ clinical knowledge and professional behavior. The median score was 5 (“excellent”) on all items in the survey, and many demonstrated an average response of 4.81 to 4.9 or higher, demonstrating that almost all respondents chose “excellent.” The next set of questions assessed the clinical pharmacist’s role with the clinic’s multidisciplinary team and asked respondents to answer questions based on a 5-point Likert-type scale ranging from “strongly disagree” (1) to “strongly agree” (5). The majority of responses to questions in this section were between 4.19 and 4.84. Reasons for referring patients to the clinical pharmacist were smoking cessation, asthma management, psych medication use/issues, adherence/polypharmacy, medication reconciliation, counseling on medication safety in pregnancy, insulin/heparin administration, and substance abuse. Conclusions: Overall, the survey identified a positive response and high level of physician satisfaction with clinical pharmacy services. Clinical pharmacy has the capacity to enhance pregnancy care and should be more routinely integrated into the prenatal care team.

Clinical Menopause Resident Training in an Academic Medical Center [387

INTRODUCTION: There is a growing and unmet need for health care providers trained in the care of perimenopausal and menopausal women. This study compares clinical menopause knowledge and experience of obstetrics and gynecology residents at the Hospital of the University of Pennsylvania who participated in Menopause Clinic with those who had never participated. METHODS: Thirteen postgraduate year 1 and postgraduate year 4 residents rotated through the Menopause Clinic from June 2013 to July 2014. Twelve postgraduate year 2 and postgraduate year 3 residents did not experience the Menopause Clinic because of scheduling. An online test and survey measuring clinical menopause knowledge and experience was completed by all 25 current Hospital of the University of Pennsylvania obstetrics and gynecology residents in June 2014. RESULTS: The 13 residents participating in menopause clinic scored 64.04% on the test and 12 nonparticipating residents scored 54.48% (P=.029). Residents who participated in the Menopause Clinic were more likely to have experience counseling and managing hormone therapy (HT) (P=.01) and sexual dysfunction (P=.067). Residents not participating reported this for pessary use for prolapse (P=.006). Exposed residents felt mostly or very competent managing use of HT (P<.01), vasomotor symptoms (P<.01), lifestyle change and non-HT for vasomotor symptoms (P<.01), bone health and fracture prevention (P=.035), vaginal dryness and pain with sex (P=.08), sexual dysfunction (P=.085), and depression, mood changes, and sleep issues (P=.014). They were more likely to have written a prescription for HT (P=.012) or for vaginal estrogen (P=.029). There was no difference in experience writing for bisphosphonates (P=.28). All 25 residents had had experience counseling and managing patients with vaginal dryness and pain with sex. CONCLUSION: A Menopause Clinic improves clinical knowledge and experience of residents. It is an effective way to prepare clinicians both for future practice and this expanding patient demographic.

The Psychological and Physiological Effects of Acute Occupational Stress in New Anesthesiology Residents

BACKGROUND Occupational stress in resident physicians has profound implications for wellness, professionalism, and patient care. This observational pilot trial measured psychological and physiological stress biomarkers before, during, and after the start of anesthesia residency. METHODS Eighteen physician interns scheduled to begin anesthesia residency were recruited for evaluation at three time points: baseline (collected remotely before residency in June 2013); first-month visit 1 (July); and follow-up visit 2 (residency months 3 to 5, September-November). Validated scales were used to measure stress, anxiety, resilience, and wellness at all three time points. During visits 1 and 2, the authors measured resting heart-rate variability, responses to laboratory mental stress (hemodynamic, catecholamine, cortisol, and interleukin-6), and chronic stress indices (C-reactive protein, 24-h ambulatory heart rate and blood pressure, 24-h urinary cortisol and catecholamines, overnight heart-rate variability). RESULTS Thirteen interns agreed to participate (72% enrollment). There were seven men and six women, aged 27 to 33 yr. The mean ± SD of all study variables are reported. CONCLUSION The novelty of this report is the prospective design in a defined cohort of residents newly exposed to the similar occupational stress of the operating environment. Because of the paucity of literature specific to the measures and stress conditions in this investigation, no data were available to generate a priori definition of primary outcomes and a data analytic plan. These findings will allow power analysis for future design of trials examining occupational stress and stress-reducing interventions. Given the importance of physician burnout in our country, the impact of chronic stress on resident wellness requires further study.

The Psychological and Physiological Effects of Acute Occupational Stress in New Anesthesiology Residents

Occupational stress in resident physicians has profound implications for wellness, professionalism, and patient care. This observational pilot trial measured psychological and physiological stress biomarkers before, during, and after the start of anesthesia residency. Eighteen physician interns scheduled to begin anesthesia residency were recruited for evaluation at three time points: baseline (collected remotely before residency in June 2013); first-month visit 1 (July); and follow-up visit 2 (residency months 3 to 5, September-November). Validated scales were used to measure stress, anxiety, resilience, and wellness at all three time points. During visits 1 and 2, the authors measured resting heart-rate variability, responses to laboratory mental stress (hemodynamic, catecholamine, cortisol, and interleukin-6), and chronic stress indices (C-reactive protein, 24-h ambulatory heart rate and blood pressure, 24-h urinary cortisol and catecholamines, overnight heart-rate variability). Thirteen interns agreed to participate (72% enrollment). There were seven men and six women, aged 27 to 33 yr. The mean ± SD of all study variables are reported. The novelty of this report is the prospective design in a defined cohort of residents newly exposed to the similar occupational stress of the operating environment. Because of the paucity of literature specific to the measures and stress conditions in this investigation, no data were available to generate a priori definition of primary outcomes and a data analytic plan. These findings will allow power analysis for future design of trials examining occupational stress and stress-reducing interventions. Given the importance of physician burnout in our country, the impact of chronic stress on resident wellness requires further study.

Psychiatrist on Mission to Help Mentally Ill People in Poor Countries

Brandon Kohrt, M.D., Ph.D., studied to become a medical anthropologist and psychiatrist. With his formal education completed, he sees his destiny as helping people in low-income countries.

William Mark Armstrong, MD: A Conversation with the Editor

Mark Armstrong (Figure ​(Figure11) is the John Binion Professor of General Internal Medicine and chief of the Division of General Internal Medicine at Baylor University Medical Center (BUMC). He has held these positions since 1993. Dr. Armstrong was born in Cull-man, Alabama, and grew up in Scottsboro, Alabama. He went to the University of the South in Sewanee, Tennes-see, on an academic scholarship and lettered on the basketball team all 4 years. After graduating cum laude in 1968, he went to the University of Alabama School of Medicine in Birmingham, finishing in 1972. His internship in internal medicine was at the Dallas Veterans Administration (VA) Hospital, and his 2-year medical residency was at the University of Texas Southwestern Medical School and Parkland Memorial Hospital. After completion of the residency in June 1975, he came to BUMC to practice general internal medicine, and he has been here ever since.

地域意見を反映した海岸保全計画の策定

This paper reports drawing up a shore protection plan reflecting the opinions of local residents in the southwest-coast of Ise Bay. In the meeting that two mayors, a town headman and scholars are member for discussion about shore protection in the coast, it was decided to organize the regional informal gathering for discussion about shore protection in three areas, Matsuzaka City, Meiwa Town and Ise City as opinion hearing method of the regional residents in June, 2002. Several ideas that were obtained from the opinion exchange of the meeting with the regional informal gathering were reflectedto the shore protection plan in the coast.

The Night the Lights Went Out

The Night the Lights Went Out

Graduating neurology residents' experience with IV tPA for acute stroke.

In 1996 IV tissue-type plasminogen activator (tPA) was approved by the Food and Drug Administration for treatment of acute ischemic stroke. Although it is recommended by consensus statements and practice guidelines,1,2⇓ considerable data suggest that tPA is underused.3,4⇓ Lack of physician experience and training may limit its use.5 Indeed, most practicing neurologists completed their residency training before its approval and thus have had little formal education in its use. Neurology residents who completed their residency in June 2000 were the first physicians to have received their entire 4 years of training after the Food and Drug Administration approved the use of tPA. Using the American Medical Association Graduate Medical Education Database (© 1999; Chicago, IL), all adult neurology residents expected to complete their final year of training in the United States in June 2000 were identified. An anonymous 12-item questionnaire was mailed in March 2000. Experience with tPA and related issues was assessed using a five-point Likert scale. The presence of a dedicated stroke team at the residents’ …