Socially Accountable Academic Health Centers: Pursuing a Quadripartite Mission

Closing the Chasm: Understanding and Addressing the Anesthesia Workforce Supply and Demand Imbalance

The imbalance in anesthesia workforce supply and demand has been exacerbated post-COVID due to a surge in demand for anesthesia care, especially in non-operating room anesthetizing sites, at a faster rate than the increase in anesthesia clinicians. The consequences of this imbalance or labor shortage compromise healthcare facilities, adversely affect the cost of care, worsen anesthesia workforce burnout, disrupt procedural and surgical schedules, and threaten academic missions and the ability to educate future anesthesiologists. In developing possible solutions, one must examine emerging trends that are affecting the anesthesia workforce, new technologies that will transform anesthesia care and the workforce, and financial considerations, including governmental payment policies. Possible practice solutions to this imbalance will require both short- and long-term multifactorial approaches that include increasing training positions and retention policies, improving capacity through innovations, leveraging technology, and addressing financial constraints.

Sociotechnical imaginaries in academic medicine strategic planning: a document analysis

Purpose Along with other industries, healthcare is becoming increasingly digitized. Our study explores how the field of academic medicine is preparing for this digital future. Method Active strategic plans available in English were collected from faculties of medicine in Canada (n = 14), departments in medical schools (n = 17), academic health science centres (n = 23) and associated research institutes (n = 5). In total, 59 strategic plans were subjected to a practice-oriented form of document analysis, informed by the concept of sociotechnical imaginaries. Results On the one hand, digital health is discursively treated as a continuation of the academic medicine vision, with expansions of physician competencies and of research institutes contributions. These imaginaries do not necessarily disrupt the field of academic medicine as currently configured. On the other hand, there is a vision of digital health pursuing a robust sociotechnical future with transformative implications for how care is conducted, what forms of knowledge are prioritized, how patients and patienthood will be understood, and how data work will be distributed. This imaginary may destabilize existing distributions of knowledge and power. Conclusions Looking through the lens of sociotechnical imaginaries, this study illuminates strategic plans as framing desirable futures, directing attention towards specific ways of understanding problems of healthcare, and mobilizing the resources to knit together social and technical systems in ways that bring these visions to fruition. There are bound to be tensions as these sociotechnical imaginaries are translated into material realities. Many of those tensions and their attempted resolutions will have direct implications for the expectations of health professional graduates, the nature of clinical learning environments, and future relationships with patients. Sociology of digital health and science and technology studies can provide useful insights to guide leaders in academic medicine shaping these digital futures.

Exploring the development of a framework of social accountability standards for healthcare service delivery: a qualitative multipart, multimethods process

OBJECTIVES

Social accountability is an equity-oriented health policy strategy that requires institutions to focus on local population needs. This strategy is well established in health professional education, but there is limited understanding of its application in healthcare service delivery. Building on what is known in the education setting, this study aimed to explore the development of a framework of comprehensive, evidence-based social accountability standards for healthcare service delivery institutions.

DESIGN

This qualitative, multipart, multimethods study consisted of a modified Delphi process guided by an evidence-based social accountability tool for health professional education and complementary methods including developmental evaluation and a review of select literature to capture emerging evidence and contextual relevance.

SETTING

The study took place in Northern Ontario, Canada at a medical school and a tertiary, regional academic health sciences centre that are both grounded in social accountability.

PARTICIPANTS

Eight expert participants from diverse, multidisciplinary backgrounds, including a patient advocate, were purposefully recruited from both institutions, enrolled and seven completed the study.

MAIN OUTCOME

The resulting framework of social accountability standards is organised into 4 major sections that capture broad and critical concepts; 17 key component reflective questions that address key themes; 39 aspirations that describe objective standards and 197 indicators linked to specific expectations.

RESULTS

Three modified Delphi rounds were completed producing a framework of consensus derived standards. Developmental evaluation helped identify facilitators, barriers and provided real-time feedback to the study's processes and content. The literature reviewed identified 10 new concepts and 43 amendments.

CONCLUSION

This study highlights the development of a comprehensive, evidence-based framework of social accountability standards for healthcare service delivery institutions. Future studies will aim to evaluate the application of these standards to guide equity-oriented social accountability health policy strategies in healthcare service delivery.

Creating Socially Accountable Health Conferences: Guidance from Around the World

BACKGROUND

Very little attention has been given to the social accountability of conferences, either in action or in scholarship, in particular, of scientific conferences. Concerns that have been raised include: (1) Local communities and regions suffer from ecological pressure caused by conferences, (2) There is limited value to the local community, (3) International conferences take place at locations irrelevant to the topics discussed; hence there is no connection with locals, and (4) It has been the observation of the authors that <10% of participants may come from the region where the conference is organized, which makes it challenging to make a "positive societal impact" locally. We conducted a natural experiment investigating the interactions between academia, conference organizers, and community leaders.

METHODS

We utilized a case study approach to report on the outcomes of two 2022 annual international conferences that seek to improve community health. We used a mixed-methods approach of surveys and interviews. Thematic analysis was conducted to identify the key themes.

RESULTS

We obtained 358 responses from all six World Health Organization regions. Results from both conferences were split into two categories: the why and the how. A strong consensus among participants is that bi-directional learning between conference organizers and local communities leads to shared understanding and mutual goals. The data emphasize that including communities in academic conferences helps us progress forward from intentions toward demonstrating accountability and reporting impact.

DISCUSSION

A diversity of perspectives is needed to advance socially accountable health system transformation. Five best practices from conference participants are laid out as a framework to assist in the change: (1) Build trust, (2) provide funding for community member participation, (3) appreciation of local community knowledge, (4) involve the local community in the planning stages, and (5) make the local community part of the conference and learning.

Evolution of Population Health Within US Schools of Medicine and Academic Medical Centers

Schools of medicine are increasingly focusing on efforts beyond the immediate needs of individual patients and addressing the needs of whole populations. This study examined the characteristics of population health departments and related programs within, and affiliated with, schools of medicine and how these programs address the schools' educational, clinical care, research, and service missions. Structured reviews of school of medicine websites were used to identify population health departments and related programs. An on-line survey was distributed to a subset of these programs to capture details on their activities and organizational characteristics. The authors convened leaders of population health programs to elaborate on core themes. Of 154 school of medicine websites reviewed, 37 (24%) had affiliated population health programs, including 28 (18%) with distinct departments of population health. Departments reported a variety of teaching activities related to undergraduate medical education, graduate degree programs, and certificate programs addressing a variety of population health domains including public health, health administration, epidemiology, biostatistics, informatics, and research methods. Research was a core activity for most departments with significant support coming from federal funding, with many playing major roles in clinical and translational research institutes and cancer centers. Most departments had research, data sharing, and other collaborations with affiliated health systems. All departments engaged in community service activities, including activities supporting the response to the COVID-19 pandemic. Population health programs are playing an increasingly important role in the teaching, clinical care, research, and community service missions in schools of medicine and academic medical centers.

Evolution of the Chief Medical Officer Role in Teaching Hospitals and Health Systems

GOAL

Clinical physician leaders have become an increasingly important asset to hospitals and hospital systems in a changing healthcare environment. Specifically, the role of the chief medical officer (CMO) has expanded and evolved amid the shift to value-based payment models and sharpened focus on patient safety, quality, community engagement, and equity in healthcare, as well as a global pandemic. In light of these changes, this study examined the transformation of CMOs and similar roles and evaluated the current needs, challenges, and responsibilities of clinical leaders today.

METHODS

The primary data source used in this analysis was a survey fielded to 391 clinical leaders in 290 Association of American Medical Colleges-member hospitals and health systems in 2020. In addition, this study compared responses to the 2020 survey with findings from two prior iterations of the survey from 2005 and 2016. The surveys collected information regarding demographics, compensation, administrative titles, qualifications for the position, and the scope of the role, among other questions. All surveys consisted of multiple-choice, free response, and rating questions. The analysis was conducted using frequency counts and percentage distributions.

PRINCIPAL FINDINGS

Thirty percent of eligible clinical leaders responded to the 2020 survey. Twenty-six percent of the clinical leader respondents identified as female. Ninety-one percent of the CMOs were members of the senior management team in their hospital or health system. CMOs reported that they were responsible for five hospitals, on average, with 67% indicating they were responsible for more than 500 physicians.

PRACTICAL APPLICATIONS

This analysis provides hospital and health systems with insight into the expanding scope and complexity of CMOs as they take on greater leadership responsibilities within their institutions amidst a shifting healthcare landscape. In reflecting on our results, hospital leaders can understand the current needs, barriers, and responsibilities of today's clinical leaders.

A conceptual framework to describe and evaluate a socially accountable learning health system: Development and application in a northern, rural, and remote setting

Health care and academic institutions are increasingly committing to social accountability, a strategic shift that requires priorities, activities, and evaluations to be co-determined with all relevant partners. Consequently, governments, accreditors, funders, and communities are calling for these institutions to communicate their progress towards social accountability. The purpose of this study was to develop a conceptual framework around a socially accountable learning health system. This article presents an integrated analysis of two studies: (i) a narrative review of 11 prominent social accountability and health services conceptual frameworks and (ii) a reflexive thematic analysis of 18 key informant interviews. Using a systematic conceptual framework development and integrated theory of change/realist evaluation methodologies, we describe a synthesis of these findings to develop a conceptual framework for describing and evaluating socially accountable health professional education. The resulting framework describes assessment phases of social accountability, transitions between phases, learning cycles, and the actors and systems that collectively mobilise social accountability at multiple levels in health and education systems. The framework can be used to evaluate interventions or characterise progress towards social accountability in different settings, as illustrated in the example at the end of the paper. The framework emphasises the significance of designing, mobilising, and evaluating social accountability as part of a contextualised learning health system.

Comparing and using prominent social accountability frameworks in medical education: moving from theory to implementation in Northern Ontario, Canada

BACKGROUND

Social accountability in medical education is conceptualized as a responsibility to respond to the needs of local populations and demonstrate impact of these activities. The objective of this study was to rigorously examine and compare social accountability theories, models, and frameworks to identify a theory-informed structure to understand and evaluate the impacts of medical education in Northern Ontario.

METHODS

Using a narrative review methodology, prominent social accountability theories, models, and frameworks were identified. The research team extracted important constructs and relationships from the selected frameworks. The Theory Comparison and Selection Tool was used to compare the frameworks for fit and relevance.

RESULTS

Eleven theories, models, and frameworks were identified for in-depth analysis and comparison. Two realist frameworks that considered community relationships in medical education and social accountability in health services received the highest scores. Frameworks focused on learning health systems, evaluating institutional social accountability, and implementing evidence-based practices also scored highly.

CONCLUSION

We used a systematic theory selection process to describe and compare social accountability constructs and frameworks to inform the development of a social accountability impact framework for the Northern Ontario School of Medicine. The research team examined important constructs, relationships, and outcomes, to select a framework that fits the aims of a specific project. Additional engagement will help determine how to combine, adapt, and implement framework components to use in a Northern Ontario framework.

The population health role of academic health centres: a multiple-case exploratory study in Australia and England

BACKGROUND

Academic health centres (AHCs) are organisations that aim to mobilise knowledge into practice by improving the responsiveness of health systems to emerging evidence. This study aims to explore the population health role of AHCs in Australia and England, where AHCs represent novel organisational forms.

METHODS

A multiple-case study design using qualitative methods was used to explore population health goals and activities in four discrete AHCs in both countries during 2017 and 2018. Data from 85 interviews with AHC leaders, clinicians and researchers, direct observation, and documentation were analysed within and across the cases.

RESULTS

Comparison across cases produced four cross-case themes: health care rather than population health; incremental rather than major health system change; different conceptions of "translation" and "innovation"; and unclear pathways to impact. The ability of the AHCs to define and enact a population health role was hindered during the study period by gaps in knowledge mobilisation strategies at a health system and policy level, the biomedical orientation of government designation schemes for AHCs in Australia and England, and competing expectations of the sovereign partner organisations in AHCs against a backdrop of limited operational resources.

DISCUSSION

The study identifies several institutional elements that are likely to be needed for AHCs in Australia and England to deliver on both internal and external expectations of their population health role.

Population Health at the Academic Health Center: An Interactive, Multipart, Case-Based Session for Executives, Faculty, and Administrators

INTRODUCTION

Academic health centers (AHCs) play critical roles in population health by providing health care, conducting population health research, and providing population health training and education. This publication describes an interactive, multipart, case-based session targeted at AHC executives, faculty, and administrators about population health initiatives at AHCs and how the AHC structure can be leveraged to promote population health.

METHODS

This 90-minute virtual session was conducted during the Association of Academic Health Centers' 2020 annual meeting. The session opened with 5-minute, Ignite-style presentations showcasing population health innovations. Next, in small groups, participants discussed a case introducing a fictional AHC charged with assisting its local government's population health efforts. Participants self-selected into one of four small groups (analytics, education and training, community engagement, and implementation) and were provided additional case content and tailored prompts. In the large group, participants debriefed their discussions. Participants completed a postsession survey.

RESULTS

Forty-six individuals from 31 AHCs participated. Eighteen participants completed the survey. Sixteen respondents (89%) agreed the session was valuable and provided ideas for implementation at their AHC. Fifteen participants (83%) indicated that they planned to follow up with their colleagues regarding how to leverage the AHC structure to improve population health.

DISCUSSION

This session provides an interactive forum to discuss population health in the context of an AHC and examine how its structure can facilitate population health. While offered at a conference, the session can also be implemented at a single AHC to foster local understanding of population health and inform future initiatives.

Advancing our field by academically advancing pediatric rehabilitation medicine physicians

Academic promotion is desired by many faculty practicing at academic medical institutions, but the criteria for promotion often appear opaque to many physician faculty. In nearly all cases, evidence of scholarship is required regardless of academic track. Academic advancement can be stymied by unclear expectations, lack of protected time to engage in scholarly projects, insufficient evidence of dissemination, and limited guidance, mentorship and sponsorship. In addition to being important for promotion, scholarship is an essential aspect of academic medicine because it helps inform and advance the science. Pursuing academic excellence is an important goal for pediatric rehabilitation medicine faculty members because it helps advance the care of children with disabilities and the field itself. Pediatric rehabilitation medicine faculty in the clinician educator or clinician leader tracks are encouraged to understand the criteria for advancement, seek out mentorship, scholarize their career ikigai and identify opportunities to demonstrate academic excellence.

The triple helix of clinical, research, and education missions in academic health centers: A qualitative study of diverse stakeholder perspectives

INTRODUCTION

Academic health centers are poised to improve health through their clinical, education, and research missions. However, these missions often operate in silos. The authors explored stakeholder perspectives at diverse institutions to understand challenges and identify alignment strategies.

METHODS

Authors used an exploratory qualitative design and thematic analysis approach with data obtained from electronic surveys sent to participants at five U.S. academic health centers (2017-18), with four different types of medical school/health system partnerships. Participants included educators, researchers, system leaders, administrators, clinical providers, resident/fellow physicians, and students. Investigators coded data using constant comparative analysis, met regularly to reconcile uncertainties, and collapsed/combined categories.

RESULTS

Of 175 participants invited, 113 completed the survey (65%). Three results categories were identified. First, five higher-order themes emerged related to aligning missions, including (a) shared vision and strategies, (b) alignment of strategy with community needs, (c) tension of economic drivers, (d) coproduction of knowledge, and (e) unifying set of concepts spanning all missions. Second, strategies for each mission were identified, including education (new competencies, instructional methods, recruitment), research (shifting agenda, developing partnerships, operations), and clinical operations (delivery models, focus on patient factors/needs, value-based care, well-being). Lastly, strategies for integrating each dyadic mission pair, including research-education, clinical operations education, and research-clinical operations, were identified.

CONCLUSIONS

Academic health centers are at a crossroads in regard to identity and alignment across the tripartite missions. The study's results provide pragmatic strategies to advance the tripartite missions and lead necessary change for improved patient health.

Impact of External Environmental Dimensions on Financial Performance of Major Teaching Hospitals in the U.S

Teaching hospitals have a unique mission to not only deliver graduate medical education but to also provide both inpatient and ambulatory care and to conduct clinical medical research; therefore, they are under constant financial pressure, and it is important to explore what types of external environmental components affect their financial performance. This study examined if there is an association between the short-term and long-term financial performance of major teaching hospitals in the United States and the external environmental dimensions, as measured by the Resource Dependence Theory. Data for 226 major teaching hospitals spanning 46 states were analyzed. The dependent variable for short-term financial performance was days cash on hand, and dependent variable for long-term financial performance was return on assets, both an average of most recently available 4-year data (2014-2017). Utilizing linear regression model, results showed significance between outpatient revenue and days cash on hand as well as significant relationship between population of the metropolitan statistical area, unemployment rate of the metropolitan statistical area, and teaching hospital's return on assets. Additionally, system membership, type of ownership/control, and teaching intensity also showed significant association with return on assets. By comprehensively examining all major teaching hospitals in the U.S. and analyzing the association between their short-term and long-term financial performance and external environmental dimensions, based upon Resource Dependence Theory, we found that by offering diverse outpatient services and novel delivery options, administrators of teaching hospitals may be able to increase organizational liquidity.

A Review of Research on Disparities in the Care of Black and White Patients With Cancer in Detroit

Racial disparities in cancer incidence and outcomes are well-documented in the US, with Black people having higher incidence rates and worse outcomes than White people. In this review, we present a summary of almost 30 years of research conducted by investigators at the Karmanos Cancer Institute's (KCI's) Population Studies and Disparities Research (PSDR) Program focusing on Black-White disparities in cancer incidence, care, and outcomes. The studies in the review focus on individuals diagnosed with cancer from the Detroit Metropolitan area, but also includes individuals included in national databases. Using an organizational framework of three generations of studies on racial disparities, this review describes racial disparities by primary cancer site, disparities associated with the presence or absence of comorbid medical conditions, disparities in treatment, and disparities in physician-patient communication, all of which contribute to poorer outcomes for Black cancer patients. While socio-demographic and clinical differences account for some of the noted disparities, further work is needed to unravel the influence of systemic effects of racism against Black people, which is argued to be the major contributor to disparate outcomes between Black and White patients with cancer. This review highlights evidence-based strategies that have the potential to help mitigate disparities, improve care for vulnerable populations, and build an equitable healthcare system. Lessons learned can also inform a more equitable response to other health conditions and crises.

Practicing Hope: Enhancing Empowerment in Primary Health Care through Community-based Participatory Research

The World Health Organization's (WHO's) Declaration of Alma Ata in 1978 made Primary Health Care (PHC) the official health policy of all WHO member countries, stressing the importance of multisectoral collaboration and community empowerment as critical for delivering quality primary healthcare and public health services to achieve social justice and health equity. Over forty years later, a divide remains between seeing individual patients in the traditional biomedical model and addressing population-level social determinants of health. One promising approach for the intentional and active integration of multi-sectoral partnering practices and community empowerment into Primary Health Care is the use of community-based participatory research (CBPR). The power of CBPR lies in its systematic approach to facilitating equitable collaboration of partners based on community priorities and strengths and is increasingly recognized for improving health equity outcomes. This paper highlights the use of CBPR as a promising practice for healthcare organizations to bridge the gap between the traditional individual patient focus and the comprehensive primary healthcare approach from WHO. We use a narrative case study from A Ministry of Sharing (AMOS) Health and Hope, a PHC organization in Nicaragua, to illustrate the use of the CBPR model as an implementation framework that facilitated the transformation of structures, policies, and practices as AMOS created multi-sector partnerships and embraced community empowerment as part of its strategic and comprehensive approach to health equity.

Importance of Community Impact as the Fourth Academic Mission: A Qualitative Study

Most US medical schools have 3 primary missions: education, research, and clinical service. Recently there have been calls for a fourth primary mission focused on improving health in their surrounding communities. To date, few medical schools have done so. To identify factors supporting and challenges to establishing a sustainable community impact mission, the authors conducted semi-structured key informant interviews with the dean, associate deans, departments chairs, and institute and center directors at a new US medical school that established a fourth "community impact" mission at its conception. Interviewees believed that it was appropriate for a community-focused tax-supported medical school to embrace community impact as a fourth mission to enhance community health outside of its hospitals and clinics. Many also felt that community impact should be an overriding framework for activities in the 3 primary missions. Achieving community impact would require creating a "learning health community" via partnerships with community organizations and linking faculty effort and funding to specific and valid measures of community health improvement. Sustainable funding would require core school funds and a broad portfolio of extramural funding. Faculty promotions with community impact as a focus would need explicit, achievable, and unique milestones. Interviewees made specific suggestions on the support and structure needed to launch and sustain this fourth mission. Establishing a fourth mission of community impact can extend medical schools' influence beyond typical health care venues to enhance the health of their communities and their residents. Doing so requires rethinking organizational structures, support, and measures of success.

Impact of a 50-Year Premedical Postbaccalaureate Program in Graduating Physicians for Practice in Primary Care and Underserved Areas

PURPOSE

To evaluate the effectiveness of Wayne State University School of Medicine's (WSUSOM's) 50-year premedical postbaccalaureate program (PBP)-the first and oldest in the United States-in achieving its goals, as measured by medical school matriculation and graduation, primary care specialization, and current practice location.

METHOD

A retrospective study of a complete comparative dataset of 9,856 WSUSOM MD graduates (1979-2017) was performed in July-August 2018. This included 539 graduates who were admitted to the PBP between 1969 and 2012. Data collected included PBP students' sociodemographics, postgraduate specialization, residence location at time of admission to the PBP, and current medicine practice location. Health professional shortage areas (HPSAs) and medically underserved areas/populations (MUA/Ps) were determined for residence at admission to the PBP and current medicine practice location.

RESULTS

Of the 539 PBP students, 463/539 (85.9%) successfully completed the PBP and matriculated to WSUSOM. Of those, 401/463 (86.6%) obtained an MD, and of those, 233/401 (58.1%) were female and 277/401 (69.1%) were African American. Average investment per PBP student was approximately $52,000 and for an MD graduate was approximately $77,000. The majority of PBP MD graduates with current practice information resided in HPSAs or MUA/Ps at admission to PBP (204/283, 72.1%) and were currently practicing in HPSAs or MUA/Ps (232/283, 82.0%), and 139/283 (49.1%) became primary care physicians (PCPs). Comparison of WSUSOM PBP and non-PBP MD graduates showed PBP physicians become PCPs and practice in HPSAs or MUA/Ps at higher rates than non-PBP physicians (P < .001).

CONCLUSIONS

The PBP was successful in graduating a large proportion of physicians from socioeconomically disadvantaged and diverse backgrounds, who practice as PCPs and who practice in HPSAs and MUA/Ps, thereby accomplishing the PBP's goals of helping to address the broad health care needs of all people in the United States.

Medical students attitudes toward and intention to work with the underserved: a systematic review and meta-analysis

BACKGROUND

Experts in the field of medical education emphasized the need for curricula that improve students' attitudes toward the underserved. However, some studies have shown that medical education tends to worsen these attitudes in students. We aimed at systematically reviewing the literature assessing the change in medical students' attitudes toward the underserved and intention to work with the underserved throughout medical education, the sociodemographic and educational factors associated with favorable medical student attitudes toward and/or intention to work with the underserved and the effectiveness of educational interventions to improve medical student attitudes toward and/or intention to work with the underserved.

METHOD

We conducted a systematic review on MEDLINE, Scopus, and Web of Science databases. Three investigators independently conducted the electronic search. We assessed the change in medical students attitudes toward the underserved by computing a weighted mean effect size of studies reporting scores from validated scales. The research team performed a meta-analysis for the sociodemographic and educational factors associated with medical students attitudes toward and/or intention to work with the underserved.

RESULTS

Fifty-five articles met the inclusion criteria, including a total of 109,647 medical students. The average response rate was 73.2%. Most of the studies were performed in the USA (n = 45). We observed a significant decline of medical students attitudes toward the underserved throughout medical education, in both US and non-US studies. A moderate effect size was observed between the first and fourth years (d = 0.51). Higher favorable medical students attitudes toward or intention to work with the underserved were significantly associated with female gender, being from an underserved community or ethnic minority, exposure to the underserved during medical education and intent to practice in primary care. Regarding educational interventions, the effectiveness of experiential community-based learning and curricula dedicated to social accountability showed the most positive outcome.

CONCLUSIONS

Medical students attitudes toward the underserved decline throughout medical education. Educational interventions dedicated to improving the attitudes or intentions of medical students show encouraging but mixed results. The generalizability of our results is impeded by the high number of studies from the global-North included in the review.

A Medical School's Community Engagement Approach to Improve Population Health

The U.S. spends trillions annually on health care that affects only 16% of health outcomes, with 84% driven by social factors, behaviors, and the physical environment. Medical schools are focusing more on these social determinants of health. We describe an academic community engagement unit with unique methods for partnering with the surrounding community to improve its members' health. Annually, a Call for Ideas asked community members to identify important health problems and propose solutions. A panel of community members and academic researchers reviewed submitted ideas and selects those addressing significant issues, that are also feasible, can be accomplished in a year, and are potentially scalable. Financial, project development, and evaluation support is provided where needed. Three Calls for Ideas generated 268 ideas from 249 individuals: 35% focused on social and behavioral factors, 33% on health behaviors, 16% on health care, and 6% on the physical environment. Half were submitted by individuals and half by community service organizations. Twenty-four (9%) were selected for implementation; 19 have been successfully implemented while 5 are under development. People with lived experience can identify barriers to health in their communities and effective mitigating interventions. By seeking community leadership and mutual benefit, academicians can gain community members' trust and meet both community and academic needs by establishing true partnerships, recognizing power dynamics and structural biases, and using language and approaches that respect the importance and power of lived experiences in identifying approaches to enhancing community health.

Establishing a Multi-Institutional Quality and Patient Safety Consortium: Collaboration Across Affiliates in a Community-Based Medical School

The landscape of health care delivery and medical education is evolving. Institutions must continually reassess priorities, strategies, and partnerships to align the knowledge and skills of the health care workforce with the delivery of quality, socially accountable, collaborative health care that meets the needs of diverse populations in communities. This article describes the development, implementation, and early outcomes of the University of Missouri-Kansas City's Health Care Quality and Patient Safety Consortium. Inspired by an actual patient safety event, the consortium aimed to improve patient outcomes by establishing quality improvement and patient safety (QIPS) education and scholarship as foundational within its unique, horizontal-matrix academic health center, which comprises 6 affiliated hospitals and 4 university-based health sciences schools. The consortium established a governance structure with leaders who, collectively, represent the diverse members and stakeholders of the consortium. The members share a common agenda and mutual goals. The consortium measures success by applying published conceptual frameworks for evaluating the outcomes of educational programs on learners (Kirkpatrick) and patients (Bzowyckyj and colleagues). Consortium learner and patient outcomes span all levels of these frameworks. Undergraduate and graduate QIPS-based projects with meaningful health system or improved individual health outcomes signify a Level 4 outcome (the highest level) for learners and patients alike. Factors critical to success include a financial gift, leadership buy-in and support, a clear champion, shared goals and a united vision, a willingness to collaborate across health systems with varied strengths and priorities, and a stable communication platform. Aspirational goals of the consortium include increasing involvement across health professional schools, incorporating simulation into QIPS activities, and aligning the consortium's projects with broader community needs.

Reconsidering Systems-Based Practice: Advancing Structural Competency, Health Equity, and Social Responsibility in Graduate Medical Education

Health inequities stem from systematic, pervasive social and structural forces. These forces marginalize populations and create the circumstances that disadvantage these groups, as reflected in differences in outcomes like life expectancy and infant mortality and in inequitable access to and delivery of health care resources. To help eradicate these inequities, physicians must understand racism, sexism, oppression, historical marginalization, power, privilege, and other sociopolitical and economic forces that sustain and create inequities. A new educational paradigm emphasizing the knowledge, skills, and attitudes to achieve health equity is needed.Systems-based practice is the graduate medical education core competency that focuses on complex systems and physicians' roles within them; it includes topics like multidisciplinary team-based care, patient safety, cost containment, end-of-life goals, and quality improvement. This competency, however, is largely health care centric and does not train physicians to engage with the complexities of the social and structural determinants of health or to partner with systems and communities that are outside health care.The authors propose a new core competency centered on health equity, social responsibility, and structural competency to address this gap in graduate medical education. For the development of this new competency, the authors draw on existing, innovative undergraduate and graduate medical pedagogy and public health, health services research, and social medicine frameworks. They describe how this new competency would inform graduate medical education and clinical care and encourage future physicians to engage in the work of health equity.

Describing the density of high-level trauma centers in the 15 largest US cities

Background

There has been a proliferation of urban high-level trauma centers. The aim of this study was to describe the density of high-level adult trauma centers in the 15 largest cities in the USA and determine whether density was correlated with urban social determinants of health and violence rates.

Methods

The largest 15 US cities by population were identified. The American College of Surgeons' (ACS) and states' department of health websites were cross-referenced for designated high-level (levels 1 and 2) trauma centers in each city. Trauma centers and associated 20 min drive radius were mapped. High-level trauma centers per square mile and per population were calculated. The distance between high-level trauma centers was calculated. Publicly reported social determinants of health and violence data were tested for correlation with trauma center density.

Results

Among the 15 largest cities, 14 cities had multiple high-level adult trauma centers. There was a median of one high-level trauma center per every 150 square kilometers with a range of one center per every 39 square kilometers in Philadelphia to one center per596 square kilometers in San Antonio. There was a median of one high-level trauma center per 285 034 people with a range of one center per 175 058 people in Columbus to one center per 870 044 people in San Francisco. The median minimum distance between high-level trauma centers in the 14 cities with multiple centers was 8 kilometers and ranged from 1 kilometer in Houston to 43 kilometers in San Antonio. Social determinants of health, specifically poverty rate and unemployment rate, were highly correlated with violence rates. However, there was no correlation between trauma center density and social determinants of health or violence rates.

Discussion

High-level trauma centers density is not correlated with social determinants of health or violence rates.

Level of evidence

VI.

Study type

Economic/decision.

Two-eyed seeing: A useful gaze in Indigenous medical education research

CONTEXT

Medical education has a role in preparing future health care practitioners to have the skills to meaningfully address health disparities while providing effective clinical care considerate of diversity in our societies. This calls for medical education researchers to approach their craft in ways that prioritise and value inputs from a broader range of perspectives and worldviews in an effort to redress the negative impacts of social, political and structural forces on health outcomes.

METHODS

Given the entrenched health inequities experienced by Indigenous populations across the globe, this paper details an approach to medical education research put forward by Canadian Mi'kmaw Elders Murdena and Albert Marshall and named 'two-eyed seeing'. This approach provides the opportunity for medical education researchers to address the ongoing impacts of colonisation, racism and marginalisation on health outcomes by prioritising Indigenous worldviews in medical curricula. The need for researchers and medical academies to critically consider Indigenous governance and processes of respectful knowledge sharing within the wider institutional and societal contexts is addressed.

CONCLUSIONS

The benefits of two-eyed seeing in the context of better preparing the future workforce to effectively meet the needs of those most vulnerable, and to action change against health inequities, situate it as a promising research approach in medical education.

The color of health: how racism, segregation, and inequality affect the health and well-being of preterm infants and their families

Racism, segregation, and inequality contribute to health outcomes and drive health disparities across the life course, including for newborn infants and their families. In this review, we address their effects on the health and well-being of newborn infants and their families with a focus on preterm birth. We discuss three causal pathways: increased risk; lower-quality care; and socioeconomic disadvantages that persist into infancy, childhood, and beyond. For each pathway, we propose specific interventions and research priorities that may remedy the adverse effects of racism, segregation, and inequality. Infants and their families will not realize the full benefit of advances in perinatal and neonatal care until we, collectively, accept our responsibility for addressing the range of determinants that shape long-term outcomes.

Can a Woman of Color Trust Medical Education?

In this Invited Commentary, the author-a second-generation immigrant, a first-generation college graduate, and a woman of color-reflects on the experiences during medical school that shaped her trust in the medical education system. She describes her reasons for entering medicine-to become the kind of doctor she wished she had had growing up. Then she considers how the words physicians use with patients and to talk about patients, which can reinforce problematic narratives and indicate complicity with structural injustices, negatively affect the care they provide. Trainees learn what is acceptable behavior from this hidden curriculum, perpetuating these harmful practices. The author challenges readers to consider how leaders in medical education can work to change this culture to create an education system that trains a physician workforce that keeps patients' voices and experiences at the center of their care and serves the needs of all patients, regardless of their identities.