A logic framework for addressing medical racism in academic medicine: an analysis of qualitative data

BACKGROUND

Despite decades of anti-racism and equity, diversity, and inclusion (EDI) interventions in academic medicine, medical racism continues to harm patients and healthcare providers. We sought to deeply explore experiences and beliefs about medical racism among academic clinicians to understand the drivers of persistent medical racism and to inform intervention design.

METHODS

We interviewed academically-affiliated clinicians with any racial identity from the Departments of Family Medicine, Cardiac Sciences, Emergency Medicine, and Medicine to understand their experiences and perceptions of medical racism. We performed thematic content analysis of semi-structured interview data to understand the barriers and facilitators of ongoing medical racism. Based on participant narratives, we developed a logic framework that demonstrates the necessary steps in the process of addressing racism using if/then logic. This framework was then applied to all narratives and the barriers to addressing medical racism were aligned with each step in the logic framework. Proposed interventions, as suggested by participants or study team members and/or identified in the literature, were matched to these identified barriers to addressing racism.

RESULTS

Participant narratives of their experiences of medical racism demonstrated multiple barriers to addressing racism, such as a perceived lack of empathy from white colleagues. Few potential facilitators to addressing racism were also identified, including shared language to understand racism. The logic framework suggested that addressing racism requires individuals to understand, recognize, name, and confront medical racism.

CONCLUSIONS

Organizations can use this logic framework to understand their local context and select targeted anti-racism or EDI interventions. Theory-informed approaches to medical racism may be more effective than interventions that do not address local barriers or facilitators for persistent medical racism.

The effect of goal-directed fluid therapy on delayed graft function in kidney transplant recipients: A systematic review and meta-analysis

Delayed graft function (DGF) is a common post-operative complication with potential long-term sequelae for many kidney transplant recipients, and hemodynamic factors and fluid status play a role. Fixed perioperative fluid infusions are the standard of care, but more recent evidence in the non-transplant population has suggested benefit with goal-directed fluid strategies based on hemodynamic targets. We searched MEDLINE, EMBASE, Cochrane Controlled Trials Registry and Google Scholar through December 2022 for randomized controlled trials comparing risk of DGF between goal-directed and conventional fluid therapy in adults receiving a living or deceased donor kidney transplant. Effect estimates were reported with odds ratios (OR) and pooled using random effects meta-analysis. We identified 4 studies (205 participants) that met the inclusion criteria. The use of goal-directed fluid therapy had no significant effect on DGF (OR 1.37 95% CI, 0.34-5.6; p = 0.52; I2 = 0.11). Subgroup analysis examining effects among deceased and living kidney donation did not reveal significant differences in the effects of fluid strategy on DGF between subgroups. Overall, the strength of the evidence for goal-directed versus conventional fluid therapy to reduce DGF was of low certainty. Our findings highlight the need for larger trials to determine the effect of goal-directed fluid therapy on this patient-centered outcome.

Implementation of a surgical site infection prevention bundle in gynecologic oncology patients: An enhanced recovery after surgery initiative

OBJECTIVE

To evaluate the clinical outcomes pre- and post-implementation of an evidence-informed surgical site infection prevention bundle (SSIPB) in gynecologic oncology patients within an Enhanced Recovery After Surgery (ERAS) care pathway.

METHODS

Patients undergoing laparotomy for a gynecologic oncology surgery between January-June 2017 (pre-SSIPB) and between January 2018-December 2020 (post-SSIPB) were compared using t-tests and chi-square. Patient characteristics, surgical factors, and ERAS process measures and outcomes were abstracted from the ERAS® Interactive Audit System (EIAS). The primary outcomes were incidence of surgical site infections (SSI) during post-operative hospital admission and at 30-days post-surgery. Secondary outcomes included total postoperative infections, length of stay, and any surgical complications. Multivariate models were used to adjust for potential confounding factors.

RESULTS

Patient and surgical characteristics were similar in the pre- and post-implementation periods. Evaluation of implementation suggested that preoperative and intraoperative components of the intervention were most consistently used. Infectious complications within 30 days of surgery decreased from 42.1% to 24.4% after implementation of the SSIPB (p < 0.001), including reductions in wound infections (17.0% to 10.8%, p = 0.02), urinary tract infections (UTI) (12.7% to 4.5%, p < 0.001), and intra-abdominal abscesses (5.4% to 2.5%, p = 0.05). These reductions were associated with a decrease in median length of stay from 3 to 2 days (p = 0.001). In multivariate analysis, these SSI reductions remained statistically significant after adjustment for potential confounders.

CONCLUSION

Implementation of SSIPB was associated with a reduction in SSIs and infectious complications, as well as a shorter length of stay in gynecologic oncology patients.

Cohort profile: recruitment and retention in a prospective cohort of Canadian healthcare workers during the COVID-19 pandemic

PURPOSE

Healthcare workers were recruited early in 2020 to chart effects on their health as the COVID-19 pandemic evolved. The aim was to identify modifiable workplace risk factors for infection and mental ill health.

PARTICIPANTS

Participants were recruited from four Canadian provinces, physicians (medical doctors, MDs) in Alberta, British Columbia, Ontario and Quebec, registered nurses (RNs), licensed practical nurses (LPNs) and healthcare aides (HCAs) in Alberta and personal support workers (PSWs) in Ontario. Volunteers gave blood for serology testing before and after vaccination. Cases with COVID-19 were matched with up to four referents in a nested case-referent study.

FINDINGS TO DATE

Overall, 4964/5130 (97%) of those recruited joined the longitudinal cohort: 1442 MDs, 3136 RNs, 71 LPNs, 235 PSWs, 80 HCAs. Overall, 3812 (77%) were from Alberta. Prepandemic risk factors for mental ill health and respiratory illness differed markedly by occupation. Participants completed questionnaires at recruitment, fall 2020, spring 2021, spring 2022. By 2022, 4837 remained in the cohort (127 had retired, moved away or died), for a response rate of 89% (4299/4837). 4567/4964 (92%) received at least one vaccine shot: 2752/4567 (60%) gave postvaccine blood samples. Ease of accessing blood collection sites was a strong determinant of participation. Among 533 cases and 1697 referents recruited to the nested case-referent study, risk of infection at work decreased with widespread vaccination.

FUTURE PLANS

Serology results (concentration of IgG) together with demographic data will be entered into the publicly accessible database compiled by the Canadian Immunology Task Force. Linkage with provincial administrative health databases will permit case validation, investigation of longer-term sequelae of infection and comparison with community controls. Analysis of the existing dataset will concentrate on effects on IgG of medical condition, medications and stage of pregnancy, and the role of occupational exposures and supports on mental health during the pandemic.

Barriers to High-quality Postoperative Glycemic Management by Surgical Teams: A Theory-informed Qualitative Analysis

OBJECTIVE

Our aim in this study was to identify the barriers to following recommendations for postoperative glycemic management among surgical team members.

METHODS

We conducted semistructured interviews with surgical team members guided by 2 theoretical frameworks for understanding the barriers and drivers of health-care behaviours: the Theoretical Domains Framework and the Consolidated Framework for Implementation Research. Interview data were coded deductively by 2 study team members.

RESULTS

Sixteen surgical team members from 7 surgical disciplines at a single hospital participated in this investigation. The most important barriers to management of postoperative hyperglycemia were knowledge of glycemic targets, belief about consequences of hyper- and hypoglycemia, available resources to manage hyperglycemia, adaptability of usual insulin regimens to complex postoperative patients, and skills to initiate insulin.

CONCLUSIONS

Interventions to reduce postoperative hyperglycemia are unlikely to be effective unless they use implementation science to address local barriers to high-quality management among surgical team members, including setting and systems-level barriers.

Female Reproductive Health and Contraception Use in CKD: An International Mixed-Methods Study

Rationale & Objective

Female reproductive health is recognized as a predictor of morbidity, mortality, and quality of life, although data in the setting of chronic kidney disease (CKD) are limited.

Study Design

A mixed-methods study was employed. Phase 1 was an anonymous, internet-based survey. Phase 2 was semistructured interviews offered to all respondents upon survey completion.

Setting & Participants

The survey was disseminated internationally from October 4, 2021, to January 7, 2022, to individuals aged 18-50 years with both a uterus and CKD diagnosis.

Outcomes

Menstrual health and contraceptive use by CKD stage (dialysis, nondialysis CKD, and transplant).

Analytical Approach

Survey data were analyzed using descriptive statistics. Interview data were analyzed using the framework method of analysis.

Results

Of 152 respondents, 98 (mean age 33 ± 0.7 years; n = 20 dialysis, n = 59 nondialysis CKD, n = 19 transplant) satisfied the inclusion criteria, representing 3 continents. The most common causes of CKD among survey respondents were hereditary causes in dialysis (n = 6, 30%) and glomerulonephritis in nondialysis CKD (n = 22, 37%) and transplant (n = 6, 32%). The majority reported heavy menstrual bleeding (n = 12, 86% dialysis; n = 46, 94% nondialysis CKD; n = 14, 100% transplant). Less than half of participants were consistently able to afford period products. Condoms were the most common contraceptive reported. Most participants reported no contraceptive use (n = 10, 50% dialysis; n = 37, 63% nondialysis CKD; n = 7, 37% transplant), primarily because of "fear". Interviews (n = 6) revealed a perception of a relationship between kidney function and menstrual health, concerns about contraceptive use, and a desire for greater multidisciplinary care to improve kidney and reproductive health.

Limitations

Self-reported outcomes, need for internet access and a device.

Conclusions

Abnormal menstruation and period poverty (ie, inability to afford period products and the socioeconomic consequences of menstruation) were common, and contraceptive use was low among female individuals with CKD, highlighting an important gap in the sex-specific care of this population.

Plain-Language Summary

Chronic kidney disease (CKD) in female individuals is accompanied by menstrual disorders and low contraceptive use. However, most data are limited to the dialysis and transplant populations. Therefore, this mixed-methods study aimed to describe self-assessed menstruation and contraceptive use across all stages of CKD. People aged 18-50 years with a uterus and CKD diagnosis were invited to participate in an online survey shared internationally as well as an optional telephone interview. Abnormal menstruation and period poverty (ie, inability to afford period products and the socioeconomic consequences of menstruation) were common, and contraceptive use was low among female individuals with CKD, highlighting an important gap in the sex-specific care of this population.

Equity, Diversity, and Inclusion moments to raise Equity, Diversity, and Inclusion literacy among physician leaders

Previous research in our department on equity-deserving groups revealed that physician leaders could improve their understanding of barriers faced by physicians from these groups. We developed EDI Moments, a brief, recurring educational intervention, to raise the EDI literacy of physician leaders in our Department of Medicine. In addition to being considered a good use of time by attendees, EDI Moments have led to new processes and policies to improve EDI in our department. Teams that implement EDI Moments should leverage local EDI expertise and select topics suited for their audience's baseline knowledge.

Prediction of major postoperative events after non-cardiac surgery for people with kidney failure: derivation and internal validation of risk models

BACKGROUND

People with kidney failure often require surgery and experience worse postoperative outcomes compared to the general population, but existing risk prediction tools have excluded those with kidney failure during development or exhibit poor performance. Our objective was to derive, internally validate, and estimate the clinical utility of risk prediction models for people with kidney failure undergoing non-cardiac surgery.

DESIGN, SETTING, PARTICIPANTS, AND MEASURES

This study involved derivation and internal validation of prognostic risk prediction models using a retrospective, population-based cohort. We identified adults from Alberta, Canada with pre-existing kidney failure (estimated glomerular filtration rate [eGFR] < 15 mL/min/1.73m² or receipt of maintenance dialysis) undergoing non-cardiac surgery between 2005-2019. Three nested prognostic risk prediction models were assembled using clinical and logistical rationale. Model 1 included age, sex, dialysis modality, surgery type and setting. Model 2 added comorbidities, and Model 3 added preoperative hemoglobin and albumin. Death or major cardiac events (acute myocardial infarction or nonfatal ventricular arrhythmia) within 30 days after surgery were modelled using logistic regression models.

RESULTS

The development cohort included 38,541 surgeries, with 1,204 outcomes (after 3.1% of surgeries); 61% were performed in males, the median age was 64 years (interquartile range [IQR]: 53, 73), and 61% were receiving hemodialysis at the time of surgery. All three internally validated models performed well, with c-statistics ranging from 0.783 (95% Confidence Interval [CI]: 0.770, 0.797) for Model 1 to 0.818 (95%CI: 0.803, 0.826) for Model 3. Calibration slopes and intercepts were excellent for all models, though Models 2 and 3 demonstrated improvement in net reclassification. Decision curve analysis estimated that use of any model to guide perioperative interventions such as cardiac monitoring would result in potential net benefit over default strategies.

CONCLUSIONS

We developed and internally validated three novel models to predict major clinical events for people with kidney failure having surgery. Models including comorbidities and laboratory variables showed improved accuracy of risk stratification and provided the greatest potential net benefit for guiding perioperative decisions. Once externally validated, these models may inform perioperative shared decision making and risk-guided strategies for this population.

Beyond guideline knowledge: a theory-based qualitative study of low-value preoperative testing

BACKGROUND

Choosing Wisely Canada and most major anesthesia and preoperative guidelines recommend against obtaining preoperative tests before low-risk procedures. However, these recommendations alone have not reduced low-value test ordering. In this study, the theoretical domains framework (TDF) was used to understand the drivers of preoperative electrocardiogram (ECG) and chest X-ray (CXR) ordering for patients undergoing low-risk surgery ('low-value preoperative testing') among anesthesiologists, internal medicine specialists, nurses, and surgeons.

METHODS

Using snowball sampling, preoperative clinicians working in a single health system in Canada were recruited for semi-structured interviews about low-value preoperative testing. The interview guide was developed using the TDF to identify the factors that influence preoperative ECG and CXR ordering. Interview content was deductively coded using TDF domains and specific beliefs were identified by grouping similar utterances. Domain relevance was established based on belief statement frequency, presence of conflicting beliefs, and perceived influence over preoperative test ordering practices.

RESULTS

Sixteen clinicians (7 anesthesiologists, 4 internists, 1 nurse, and 4 surgeons) participated. Eight of the 12 TDF domains were identified as the drivers of preoperative test ordering. While most participants agreed that the guidelines were helpful, they also expressed distrust in the evidence behind them (knowledge). Both a lack of clarity about the responsibilities of the specialties involved in the preoperative process and the ease by which any clinician could order, but not cancel tests, were drivers of low-value preoperative test ordering (social/professional role and identity, social influences, belief about capabilities). Additionally, low-value tests could also be ordered by nurses or the surgeon and may be completed before the anesthesia or internal medicine preoperative assessment appointment (environmental context and resources, beliefs about capabilities). Finally, while participants agreed that they did not intend to routinely order low-value tests and understood that these would not benefit patient outcomes, they also reported ordering tests to prevent surgery cancellations and problems during surgery (motivation and goals, beliefs about consequences, social influences).

CONCLUSIONS

We identified key factors that anesthesiologists, internists, nurses, and surgeons believe influence preoperative test ordering for patients undergoing low-risk surgeries. These beliefs highlight the need to shift away from knowledge-based interventions and focus instead on understanding local drivers of behaviour and target change at the individual, team, and institutional levels.

Prevalence and characteristics of anti-Indigenous bias among Albertan physicians: a cross-sectional survey and framework analysis

OBJECTIVE

Recent deaths of Indigenous patients in the Canadian healthcare system have been attributed to structural and interpersonal racism. Experiences of interpersonal racism by Indigenous physicians and patients have been well characterised, but the source of this interpersonal bias has not been as well studied. The aim of this study was to describe the prevalence of explicit and implicit interpersonal anti-Indigenous biases among Albertan physicians.

DESIGN AND SETTING

This cross-sectional survey measuring demographic information and explicit and implicit anti-Indigenous biases was distributed in September 2020 to all practising physicians in Alberta, Canada.

PARTICIPANTS

375 practising physicians with an active medical licence.

OUTCOMES

Explicit anti-Indigenous bias, measured by two feeling thermometer methods: participants slid an indicator on a thermometer to indicate their preference for white people (full preference is scored 100) or Indigenous people (full preference, 0), and then participants indicated how favourably they felt toward Indigenous people (100, maximally favourable; 0, maximally unfavourable). Implicit bias was measured using an Indigenous-European implicit association test (negative scores suggest preference for European (white) faces). Kruskal-Wallis and Wilcoxon rank-sum tests were used to compare bias across physician demographics, including intersectional identities of race and gender identity.

MAIN RESULTS

Most of the 375 participants were white cisgender women (40.3%; n=151). The median age of participants was 46-50 years. 8.3% of participants felt unfavourably toward Indigenous people (n=32 of 375) and 25.0% preferred white people to Indigenous people (n=32 of 128). Median scores did not differ by gender identity, race or intersectional identities. White cisgender men physicians had the greatest implicit preferences compared with other groups (-0.59 (IQR -0.86 to -0.25); n=53; p<0.001). Free-text responses discussed 'reverse racism' and expressed discomfort with survey questions addressing bias and racism.

CONCLUSIONS

Explicit anti-Indigenous bias was present among Albertan physicians. Concerns about 'reverse racism' targeting white people and discomfort discussing racism may act as barriers to addressing these biases. About two-thirds of respondents had implicit anti-Indigenous bias. These results corroborate the validity of patient reports of anti-Indigenous bias in healthcare and emphasise the need for effective intervention.

Pregnancy, obstetrical and neonatal outcomes in women exposed to physician-related occupational hazards: a scoping review

OBJECTIVE

Evidence is needed to guide organisational decision making about workplace accommodations for pregnant physicians. Our objective was to characterise the strengths and limitations of current research examining the association between physician-related occupational hazards with pregnancy, obstetrical and neonatal outcomes.

DESIGN

Scoping review.

DATA SOURCES

MEDLINE/PubMed, EMBASE, CINAHL/ EBSCO, SciVerse Scopus and Web of Science/Knowledge were searched from inception to 2 April 2020. A grey literature search was performed on 5 April 2020. The references of all included articles were hand searched for additional citations.

ELIGIBILITY CRITERIA

English language citations that studied employed pregnant people and any 'physician-related occupational hazards', meaning any relevant physical, infectious, chemical or psychological hazard, were included. Outcomes included any pregnancy, obstetrical or neonatal complication.

DATA EXTRACTION AND SYNTHESIS

Physician-related occupational hazards included physician work, healthcare work, long work hours, 'demanding' work, disordered sleep, night shifts and exposure to radiation, chemotherapy, anaesthetic gases or infectious disease. Data were extracted independently in duplicate and reconciled through discussion.

RESULTS

Of the 316 included citations, 189 were original research studies. Most were retrospective, observational and included women in any occupation rather than healthcare workers. Methods for exposure and outcome ascertainment varied across studies and most studies had a high risk of bias in data ascertainment. Most exposures and outcomes were defined categorically and results from different studies could not be combined in a meta-analysis due to heterogeneity in how these categories were defined. Overall, some data suggested that healthcare workers may have an increased risk of miscarriage compared with other employed women. Long work hours may be associated with miscarriage and preterm birth.

CONCLUSIONS

There are important limitations in the current evidence examining physician-related occupational hazards and adverse pregnancy, obstetrical and neonatal outcomes. It is not clear how the medical workplace should be accommodated to improve outcomes for pregnant physicians. High-quality studies are needed and likely feasible.

Strategies for intraoperative glucose management: a scoping review

PURPOSE

Perioperative hyperglycemia is associated with adverse outcomes for patients with and without diabetes. Guidelines and published protocols for intraoperative glycemic management have substantial variation in their recommendations. We sought to characterize the current evidence-guiding intraoperative glycemic management in a scoping review.

SOURCES

Our search strategy included MEDLINE (Ovid and EBSCO), PubMed, PubMed Central, EMBASE, CINAHL, Cochrane Library, SciVerse Scopus, and Web of Science and a gray literature search of Google, Google Scholar, hand searching of the reference lists of included articles, OAISter, institutional protocols, and ClinicalTrails.gov.

PRINCIPAL FINDINGS

We identified 41 articles that met our inclusion criteria, 24 of which were original research studies. Outcomes and exposures were defined heterogeneously across studies, which limited comparison and synthesis. Investigators often created arbitrary and differing categories of glucose values rather than analyzing glucose as a continuous variable, which limited our ability to combine results from different studies. In addition, the study populations and surgery types also varied considerably, with few studies performed during day surgeries and specific surgical disciplines. Study populations often included more than one type of surgery, indication, and urgency that were expected to have varying physiologic and inflammatory responses. Combining low- and high-risk patients in the same study population may obscure the harms or benefits of intraoperative glycemic management for high-risk procedures or patients.

CONCLUSION

Future studies examining intraoperative glycemic management should carefully consider the study population, surgical characteristics, and pre- and postoperative management of hyperglycemia.

Perioperative management for people with kidney failure receiving dialysis: A scoping review

BACKGROUND

People with kidney failure receiving dialysis (CKD-G5D) are more likely to undergo surgery and experience poorer postoperative outcomes than those without kidney failure. In this scoping review, we aimed to systematically identify and summarize perioperative strategies, protocols, pathways, and interventions that have been studied or implemented for people with CKD-G5D.

METHODS

We searched MEDLINE, EMBASE, CINAHL Plus, Cochrane Database of Systematic Reviews, and Cochrane Controlled Trials registry (inception to February 2020), in addition to an extensive grey literature search, for sources that reported on a perioperative strategy to guide management for people with CKD-G5D. We summarized the overall study characteristics and perioperative management strategies and identified evidence gaps based on surgery type and perioperative domain. Publication trends over time were assessed, stratified by surgery type and study design.

RESULTS

We included 183 studies; the most common study design was a randomized controlled trial (27%), with 67% of publications focused on either kidney transplantation or dialysis vascular access. Transplant-related studies often focused on fluid and volume management strategies and risk stratification, whereas dialysis vascular access studies focused most often on imaging. The number of publications increased over time, across all surgery types, though driven by non-randomized study designs.

CONCLUSIONS

Despite many current gaps in perioperative research for patients with CKD-G5D, evidence generation supporting perioperative management is increasing, with recent growth driven primarily by non-randomized studies. Our review may inform organization of evidence-based strategies into perioperative care pathways where evidence is available while also highlighting gaps that future perioperative research can address.

Experiences and Perceptions of Racism and Sexism Among Alberta Physicians: Quantitative Results and Framework Analysis of a Cross-Sectional Survey

BACKGROUND

The prevalence of harassment and discrimination in medicine differs by race and gender. The current evidence is limited by a lack of intersectional analysis.

OBJECTIVE

To evaluate the experiences and perceptions of harassment and discrimination in medicine across physicians stratified by self-identified race and gender identity.

DESIGN

Quantitative and framework analysis of results from a cross-sectional survey study.

PARTICIPANTS

Practicing physicians in the province of Alberta, Canada (n=11,688).

MAIN MEASURES

Participants completed an instrument adapted from the Culture Conducive to Women's Academic Success to capture the perceived culture toward self-identified racial minority physicians (Black, Indigenous, and People of Color (BIPOC)), indicated their perception of gender inequity in medicine using Likert responses to questions about common experiences, and were asked about experiences of reporting harassment or discrimination. Participants were also able to provide open text comments.

KEY RESULTS

Among the 1087 respondents (9.3% response rate), 73.5% reported experiencing workplace harassment or discrimination. These experiences were least common among White cisgender men and most common among BIPOC cisgender women (52.4% and 85.4% respectively, p<0.00001). Cisgender men perceived greater gender equity than cisgender women physicians, and White cisgender men physicians perceived greatest racial equity. Participant groups reporting the greatest prevalence of harassment and discrimination experiences were the least likely to know where to report harassment, and less than a quarter of physicians (23.8%) who had reported harassment or discrimination were satisfied with the outcome. Framework analysis of open text responses identified key types of barriers to addressing racism, including denial of racism and greater concern about other forms of discrimination and harassment.

CONCLUSIONS

Our results document the prevalence of harassment and discrimination by intersectional identities of race and gender. Incongruent perceptions and experiences may act as a barrier to preventing and addressing harassment and discrimination in the Canadian medical workplace.

Diversity of physicians in leadership and academic positions in Alberta: a cross-sectional survey

BACKGROUND

Efforts to reduce barriers and disparities faced by marginalised physicians are limited by a lack of data on the current diversity of the Canadian physician workforce. We aimed to characterise the diversity of the Albertan physician workforce.

METHODS

This cross-sectional survey, open to all Albertan physicians from 1 September 2020 to 6 October 2021, measured the proportion of physicians from traditionally under-represented groups, including those with diverse gender identities, disabilities and from racial minorities.

RESULTS

There were 1087 respondents (9.3% response rate); of whom 33.4% identified as cisgender men (n=363), 46.8% as cisgender women (n=509) and less than 3% as gender diverse. Fewer than 5% were members of the LGBTQI2S+community. Half were white (n=547), 4.6% were black (n=50) and fewer than 3% were Indigenous or Latinx. Over one-third reported a disability (n=368, 33.9%). There were 303 white cisgender women (27.9%), 189 white cisgender men (17.4%), 136 black, Indigenous or person of colour (BIPOC) cisgender men (12.5%) and 151 BIPOC cisgender women (13.9%). Compared with BIPOC physicians, white participants were over-represented in leadership positions (64.2% and 32.1%; p=0.06) and academic roles (78.7% and 66.9%; p<0.01). Cisgender women had less often applied for academic promotion than cisgender men (85.4% and 78.3%, respectively, p=0.01), and BIPOC physicians had been denied promotion more frequently (7.7% compared with 4.4%; p=0.47).

CONCLUSION

Many Albertan physicians may experience marginalisation through at least one protected characteristic. There were race-based and gender-based differences in experiences of medical leadership and academic promotion which may explain observed disparities in these positions. To increase diversity and representation in medicine, medical organisations should focus on inclusive cultures and environments. Universities should focus efforts on supporting BIPOC physicians, especially BIPOC cisgender women, in applying for promotion.

Implementation of a Perioperative Glycemic Management Quality Improvement Pathway in Gynecologic Oncology Patients: A Single-cohort Interrupted Time-series Analysis

OBJECTIVE

We evaluated implementation and clinical outcomes of a perioperative glycemic management pathway in gynecologic oncology.

METHODS

Interrupted time-series analysis was used to compare process, balancing and outcome measures and clinical outcomes from 18 months preimplementation to 18 months postimplementation.

RESULTS

Compared with in the preimplementation period, the proportion of patients who underwent preoperative screening with glycated hemoglobin in the postimplementation period increased by 11.3% (95% confidence interval [CI], 5.0% to 17.7%; p=0.001). The proportion of patients with diabetes who had at least 1 blood glucose measurement after surgery increased by 15.3% (95% CI, -3.2% to 33.8%; p=0.10). There was no change in the proportion of patients who had any hyperglycemia or moderate or severe hyperglycemia. The median length of stay decreased by 0.42 days (95% CI, -0.91 to 0.07 days; p=0.09). There were major quality gaps in perioperative glycemic management that did not clearly improve after implementation of a multidisciplinary care pathway.

CONCLUSION

Optimal strategies for improvement of perioperative glycemic management are not yet known.

Anti-Indigenous bias of medical school applicants: a cross-sectional study

BACKGROUND

Structural and interpersonal anti-Indigenous racism is prevalent in Canadian healthcare. The Truth and Reconciliation Commission calls on medical schools to address anti-Indigenous bias in students. We measured the prevalence of interpersonal anti-Indigenous bias among medical school applicants to understand how the medical school selection process selects for or against students with high levels of bias.

METHODS

All applicants to a single university in the 2020-2021 admissions cycle were invited to participate. Explicit anti-Indigenous bias was measured using two sliding scale thermometers. The first asked how participants felt about Indigenous people (from 0, indicating 'cold/unfavourable' to 100, indicating 'warm/favourable') and the second asked whether participants preferred white (scored 100) or Indigenous people (scored 0). Participants then completed an implicit association test examining preferences for European or Indigenous faces (negative time latencies suggest preference for European faces). Explicit and implicit anti-Indigenous biases were compared by applicant demographics (including gender and racial identity), application status (offered an interview, offered admission, accepted a position), and compared to undergraduate medical and mathematics students.

RESULTS

There were 595 applicant respondents (32.4% response rate, 64.2% cisgender women, 55.3% white). Applicants felt warmly toward Indigenous people (median 96 (IQR 80-100)), had no explicit preference for white or Indigenous people (median 50 (IQR 37-55), and had mild implicit preference for European faces (- 0.22 ms (IQR -0.54, 0.08 ms)). There were demographic differences associated with measures of explicit and implicit bias. Applicants who were offered admission had warmer feelings toward Indigenous people and greater preference for Indigenous people compared to those were not successful.

CONCLUSIONS

Medical school applicants did not have strong interpersonal explicit and implicit anti-Indigenous biases. Outlier participants with strong biases were not offered interviews or admission to medical school.

Closing the empathy gap towards equitable outcomes: gender equity in the medical workforce

Background

Empathy failures lead to equity failures. Women and men physicians experience work differently. Men physicians, however, may be unaware how these differences impact their colleagues. This constitutes an empathy gap; empathy gaps are associated with harm to outgroups. In our previous published work, we found that men had divergent views from women about the experiences of women relating to gender equity; senior men differed most from junior women. Since men physicians hold disproportionately more leadership roles than women, this empathy gap warrants exploration and remediation.

Analysis

Gender, age, motivation and power each seems to influence our empathic tendencies. Empathy, however, is not a static trait. Empathy can be developed and displayed by individuals through their thoughts, words and actions. Leaders can also influence culture by enshrining an empathic disposition in our social and organisation structures.

Conclusions

We outline methods to increase our empathic capacities as individuals and organisations through perspective-taking, perspective-giving and verbal commitments to institutional empathy. In doing so, we challenge all medical leaders to herald an empathic transformation of our medical culture in pursuit of a more equitable and pluralistic workplace for all groups of people.

The contribution of undergraduate medical education dress codes to systemic discrimination: A critical policy analysis

PURPOSE

Critical review of institutional policies is necessary to identify and eliminate structural discrimination in medical schools. Dress code policies are well known to facilitate discrimination in other settings.

METHODS

In this critical policy analysis, the authors used qualitative inquiry guided by feminist critical policy analysis (FCPA) and critical race feminism (CRF) frameworks to understand how Canadian undergraduate medical school dress code policies may contribute to discrimination and a hostile culture for marginalised groups. Dress code policies were obtained from 14 of 17 Canadian medical schools in September 2021. Deductive content analysis of dress codes was performed independently and in parallel by all four members of a racially diverse study team using Edwards and Marshalls' established framework for applying FCPA and CRF to dress code policy statements. Inductive content analysis was used to classify statements that fell outside this framework. Using a historical and contemporary legal understanding of how dress code policies have been used to discriminate against marginalised groups, the authors analysed how recommendations or restrictions may contribute to discrimination of marginalised medical students.

RESULTS

Fourteen dress code policies were analysed. Overall, there were five feminine-coded restrictions for every one masculine-coded restriction (n = 77/213 and n = 16/213, respectively). Some policies prohibited feminine-coded items (e.g. perfumes and bracelets) while specifically allowing masculine-coded items (e.g. cologne and watches). A discourse of 'professionalism' based on patient preferences prioritised Eurocentric patriarchal norms for appearance, potentially penalising racially and culturally diverse students. Most policies did not include a policy for appeals or accommodations.

CONCLUSION

Canadian undergraduate medical school dress code policies overregulate women and gender, racially and culturally diverse students by explicitly and implicitly enforcing white patriarchal social norms. Administrators should apply best practices to these policies to avoid discrimination and a hostile culture to marginalised groups.

Using the Revised Cardiac Risk Index to Predict Major Postoperative Events for People With Kidney Failure: An External Validation and Update

Background

People with kidney failure have high risk of postoperative morbidity and mortality. Although the revised cardiac risk index (RCRI) is used to estimate the risk of major postoperative events, it has not been validated in this population. We aimed to externally validate the RCRI and determine whether updating the model improved predictions for people with kidney failure.

Methods

We derived a retrospective, population-based cohort of adults with kidney failure (maintenance dialysis or sustained estimated glomerular filtration rate < 15 mL/min per 1.73 m²) who had surgery in Alberta, Canada between 2005 and 2019. We categorized participants based on RCRI variables and assigned risk estimates of death or major cardiac events, and then estimated predictive performance. We re-estimated the coefficients for each RCRI variable and internally validated the updated model. Net benefit was estimated with decision curve analysis.

Results

After 38,541 surgeries, 1204 events (3.1%) occurred. The estimated C-statistic for the original RCRI was 0.64 (95% confidence interval: 0.62, 0.65). Examination of calibration revealed significant risk overestimation. In the re-estimated RCRI model, discrimination was marginally different (C-statistic 0.67 [95% confidence interval: 0.66, 0.69]), though calibration was improved. No net benefit was observed when the data were examined with decision curve analysis, whereas the original RCRI was associated with harm.

Conclusions

The RCRI performed poorly in a Canadian kidney failure cohort and significantly overestimated risk, suggesting that RCRI use in similar kidney failure populations should be limited. A re-estimated kidney failure-specific RCRI may be promising but needs external validation. Novel perioperative models for this population are urgently needed.

Experiences and Impacts of Harassment and Discrimination Among Women in Cardiac Medicine and Surgery: A Single-Centre Qualitative Study

Background

Gender- and sex-based harassment and discrimination are consistently reported by about 50% of women physicians, and the prevalence may be even greater among women in cardiology. An exploration of these experiences and their impacts on women in healthcare is necessary to design interventions, create supports, and facilitate empathy, support, and allyship among leadership.

Methods

To understand and describe the experiences of harassment and discrimination among women working in cardiac sciences, to inform the design of interventions and supports, we performed one-on-one, semi-structured interviews with women in the Department of Cardiac Sciences in a single institute. Interviews were coded independently in parallel using thematic analysis and reconciled by trained qualitative researchers. Experiences were categorized as harassment using the Canadian Human Rights Act. Codes were grouped into themes by iterative discussion.

Results

There were 15 participants, including trainees, physicians in a variety of cardiac subdisciplines, and nurse practitioners. All participants had experienced sex- or gender-based discrimination at work, though the impact and perception of these experiences varied. Whereas some participants felt that these experiences had little influence on their careers or personal lives, others changed practice specialties or locations due to harassment. Several participants had been sexually assaulted at work. Interviews revealed modifiable barriers to reporting harassment.

Conclusions

This qualitative dataset enriches the prevalence data on sex- and gender-based harassment among women working in cardiology by describing the impacts and perceptions of this harassment. Organizations should address commonly described barriers to reporting harassment, including addressing retaliation, and create systems-level supports for those affected by harassment.

Barriers and facilitators of following perioperative internal medicine recommendations by surgical teams: a sequential, explanatory mixed-methods study

Background

Preoperative medical consultations add expense and burden for patients and the impact of these consults on patient outcomes is conflicting. Previous work suggests that 10–40% of preoperative medical consult recommendations are not followed. This limits measurement of the effect of perioperative medical consultation on patient outcomes and represents a quality gap, given the patient time and healthcare cost associated with consultation. We aimed to measure, characterize, and understand reasons for missed recommendations from preoperative medical consultation.

Methods

This explanatory, sequential mixed-methods study used chart audits followed by semi-structured interviews. Chart audit of consecutive patients seen in preoperative medical clinic were reviewed to measure the proportion and characterize the type of recommendations that were not completed (“missed”). This phase informed the interview participants and questions. The interview guide was developed using the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Template analysis was used to understand drivers and barriers of missed recommendations

Results

Chart audit included 255 patients (n=161, 63.1% female) seen in preadmission clinic between April 1 and April 30, 2019. 55.7% of patients had all recommendations followed (n=142). Postoperative anticoagulation management and postoperative cardiac biomarker surveillance recommendations were least commonly followed (50.0%, n=28, and 68.9%, n=82, respectively).

Eighteen surgical team members were interviewed. Missed recommendations were both unintentional and intentional, and the key drivers differed by these categories. Unintentionally missed recommendations occurred due to individual-level factors (drivers: knowledge of the consultation note, lack of routine for reviewing the consultation note, and competing demands on time) and systems-level factors (driver: lack of role clarity). Intentionally missed recommendations occurred due to user error due (drivers: lack of knowledge of guidelines or evidence) and appropriate modifications (driver: need to adapt a preoperative plan for a complicated postoperative course).

Conclusions

Only 55.7% of consult notes had all recommendations followed, suggesting a quality gap in perioperative medical care. Qualitative data suggests multiple drivers of missed recommendations that should be targeted to improve the efficiency of care for these patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13741-021-00236-x.

Healthcare workers' perception of gender and work roles during the COVID-19 pandemic: a mixed-methods study

OBJECTIVES

A high functioning healthcare workforce is a key priority during the COVID-19 pandemic. We sought to determine how work and mental health for healthcare workers changed during the COVID-19 pandemic in a universal healthcare system, stratified by gender factors.

DESIGN

A mixed-methods study was employed. Phase 1 was an anonymous, internet-based survey (7 May-15 July 2020). Phase 2 was semistructured interviews offered to all respondents upon survey completion to describe how experiences may have differed by gender identity, roles and relations.

SETTING

National universal healthcare system (Canada).

PARTICIPANTS

2058 Canadian healthcare worker survey respondents (87% women, 11% men, 1% transgender or Two-Spirit), including 783 health professionals, 673 allied health professionals, 557 health support staff. Of the 63 unique healthcare worker types reported, registered nurses (11.5%), physicians (9.9%) and pharmacists (4.5%) were most common. Forty-six healthcare workers were interviewed.

MAIN OUTCOME MEASURES

Reported pandemic-induced changes to occupational leadership roles and responsibilities, household and caregiving responsibilities, and anxiety levels by gender identity.

RESULTS

Men (19.8%) were more likely to hold pandemic leadership roles compared with women (13.4%). Women (57.5%) were more likely to report increased domestic responsibilities than men (45%). Women and those with dependents under the age of 10 years reported the greatest levels of anxiety during the pandemic. Interviews with healthcare workers further revealed a perceived imbalance in leadership opportunities based on gender identity, a lack of workplace supports disproportionately affecting women and an increase in domestic responsibilities influenced by gender roles.

CONCLUSIONS

The COVID-19 pandemic response has important gendered effects on the healthcare workforce. Healthcare workers are central to effective pandemic control, highlighting an urgent need for a gender-transformative pandemic response strategy.

Challenges to Navigating Pregnancy and Parenthood for Physician Parents: a Framework Analysis of Qualitative Data

BACKGROUND

Some gender-based disparities in medicine may relate to pregnancy and parenthood. An understanding of the challenges faced by pregnant physicians and physician parents is needed to design policies and interventions to reduce these disparities.

OBJECTIVE

Our objective was to characterize work-related barriers related to pregnancy and parenthood described by physicians.

DESIGN

We performed framework analysis of qualitative data collected through individual, semi-structured interviews between May and October 2018. Data related to pregnancy or parenthood were organized chronologically to understand barriers throughout the process of pregnancy, planning a parental leave, taking a parental leave, returning from parental leave, and parenting as a physician.

PARTICIPANTS

Physician faculty members of all genders, including parents and non-parents, from a single department at a large academic medical school in Canada were invited to participate in a department-wide study broadly exploring gender equity.

APPROACH

Thematic analysis guided by constructivism.

KEY RESULTS

Twenty-eight physicians were interviewed (7.2% of eligible physicians), including 22 women and 6 men, of which 18 were parents (15 mothers and 3 fathers). Common barriers included a lack of systems-level guidelines for pregnancy and parental leave, inconsistent workplace accommodations for pregnant physicians, a lack of guidance and support for planning parental leaves, and difficulties obtaining clinical coverage for parental leave. Without systems-level guidance, participants had to individually navigate challenges and resolve these difficulties, including negotiating with their leadership for benefits. This led to stress, wasted time and effort, and raised questions about fairness within the department.

CONCLUSIONS

Physician parents face unique challenges navigating institutional policies as well as planning and taking parental leave. Systems-level interventions such as policies for pregnancy, parental leave, and return to work are needed to address barriers experienced by physician parents.

Mortality and cardiovascular events in adults with kidney failure after major non-cardiac surgery: a population-based cohort study

BACKGROUND

People with kidney failure have a high incidence of major surgery, though the risk of perioperative outcomes at a population-level is unknown. Our objective was to estimate the proportion of people with kidney failure that experience acute myocardial infarction (AMI) or death within 30 days of major non-cardiac surgery, based on surgery type.

METHODS

In this retrospective population-based cohort study, we used administrative health data to identify adults from Alberta, Canada with major surgery between April 12,005 and February 282,017 that had preoperative estimated glomerular filtration rates (eGFRs) < 15 mL/min/1.73m2 or received chronic dialysis. The index surgical procedure for each participant was categorized within one of fourteen surgical groupings based on Canadian Classification of Health Interventions (CCI) codes applied to hospitalization administrative datasets. We estimated the proportion of people that had AMI or died within 30 days of the index surgical procedure (with 95% confidence intervals [CIs]) following logistic regression, stratified by surgery type.

RESULTS

Overall, 3398 people had a major surgery (1905 hemodialysis; 590 peritoneal dialysis; 903 non-dialysis). Participants were more likely male (61.0%) with a median age of 61.5 years (IQR 50.0-72.7). Within 30 days of surgery, 272 people (8.0%) had an AMI or died. The probability was lowest following ophthalmologic surgery at 1.9% (95%CI: 0.5, 7.3) and kidney transplantation at 2.1% (95%CI: 1.3, 3.2). Several types of surgery were associated with greater than one in ten risk of AMI or death, including retroperitoneal (10.0% [95%CI: 2.5, 32.4]), intra-abdominal (11.7% [8.7, 15.5]), skin and soft tissue (12.1% [7.4, 19.1]), musculoskeletal (MSK) (12.3% [9.9, 15.5]), vascular (12.6% [10.2, 15.4]), anorectal (14.7% [6.3, 30.8]), and neurosurgical procedures (38.1% [20.3, 59.8]). Urgent or emergent procedures had the highest risk, with 12.1% experiencing AMI or death (95%CI: 10.7, 13.6) compared with 2.6% (1.9, 3.5) following elective surgery.

CONCLUSIONS

After major non-cardiac surgery, the risk of death or AMI for people with kidney failure varies significantly based on surgery type. This study informs our understanding of surgery type and risk for people with kidney failure. Future research should focus on identifying high risk patients and strategies to reduce these risks.

Quality gaps in screening and monitoring for postoperative hyperglycemia in a Canadian hospital: a retrospective cohort study

INTRODUCTION

Evidence-based preoperative, intraoperative and postoperative glycemic management may reduce poor surgical outcomes. Previous studies suggest that quality gaps in perioperative glycemic management may be common.

RESEARCH DESIGN AND METHODS

This retrospective cohort study used administrative health and laboratory data from a single center to estimate quality gaps in perioperative glycemic management in patients with and without diabetes between April 2019 and March 2020. We examined the proportion of patients with preoperative hemoglobin A1c (HbA1c) measurement, postoperative point-of-care testing (POCT) for glucose, hyperglycemia, and basal bolus insulin regimens. We compared the median length of stay (LOS) in patients with and without postoperative hyperglycemia, adjusted for age and sex.

RESULTS

There were 6576 patients in our cohort; 1165 (17.8%) had diabetes. Most patients with diabetes had an HbA1c measured prior to surgery (n=697, 59.8%). Postoperatively, 16.9% of patients with diabetes had no POCT monitoring (n=197) and 65.7% had hyperglycemia (n=636). Only 35.9% of patients who received insulin had a basal bolus insulin regimen (n=229). Patients with diabetes who had postoperative hyperglycemia had a longer median LOS compared with those who did not have postoperative hyperglycemia (8.4 days (95% CI 7.5 to 9.4) and 6.7 days (95% CI 6.3 to 7.1), respectively). In patients without diabetes, median LOS was 7.4 days (95% CI 4.4 to 10.4) for those with hyperglycemia and 5.2 days (95% CI 5.1 to 5.4) for those with in-target glucose.

CONCLUSIONS

Quality gaps in perioperative glycemic management include measurement of blood glucose after surgery and treatment of postoperative hyperglycemia. These gaps may contribute to longer LOS.

The Perioperative Surgical Home, Enhanced Recovery After Surgery and how integration of these models may improve care for medically complex patients

Perioperative medicine is changing rapidly, and with this change comes the opportunity to improve upon current models of care delivery and integration within the health care system. Perioperative models of care are structured or conceptual arrangements for surgical patients before, during and after their surgery. Models of care such as the Perioperative Surgical Home and Enhanced Recovery After Surgery pathways are increasingly used to guide the structure of perioperative care delivery with an aim to improve patient outcomes and experience in Canadian settings. In this narrative review, we summarize the origins of these perioperative models of care. They are fundamentally different in scope and level of evidence. Both models have potential benefits and limitations to their broad implementation in our health care system. As currently developed, both models are limited in their application to patients with chronic disease. We discuss how these models of care can be used to develop integrated horizontal and vertical perioperative pathways in a Canadian setting. Such integration is a potential solution that will improve their applicability to patients with medically complex conditions and in times when health care systems are under pressure. We describe this approach using the example of patients with kidney failure receiving dialysis.

Description of a Multi-faceted COVID-19 Pandemic Physician Workforce Plan at a Multi-site Academic Health System

BACKGROUND

The evolving COVID-19 pandemic has and continues to present a threat to health system capacity. Rapidly expanding an existing acute care physician workforce is critical to pandemic response planning in large urban academic health systems.

INTERVENTION

The Medical Emergency-Pandemic Operations Command (MEOC)-a multi-specialty team of physicians, operational leaders, and support staff within an academic Department of Medicine in Calgary, Canada-partnered with its provincial health system to rapidly develop a comprehensive, scalable pandemic physician workforce plan for non-ventilated inpatients with COVID-19 across multiple hospitals. The MEOC Pandemic Plan comprised seven components, each with unique structure and processes.

METHODS

In this manuscript, we describe MEOC's Pandemic Plan that was designed and implemented from March to May 2020 and re-escalated in October 2020. We report on the plan's structure and process, early implementation outcomes, and unforeseen challenges. Data sources included MEOC documents, health system, public health, and physician engagement implementation data.

KEY RESULTS

From March 5 to October 26, 2020, 427 patients were admitted to COVID-19 units in Calgary hospitals. In the initial implementation period (March-May 2020), MEOC communications reached over 2500 physicians, leading to 1446 physicians volunteering to provide care on COVID-19 units. Of these, 234 physicians signed up for hospital shifts, and 227 physicians received in-person personal protective equipment simulation training. Ninety-three physicians were deployed on COVID-19 units at four large acute care hospitals. The resurgence of cases in September 2020 has prompted re-escalation including re-activation of COVID-19 units.

CONCLUSIONS

MEOC leveraged an academic health system partnership to rapidly design, implement, and refine a comprehensive, scalable COVID-19 acute care physician workforce plan whose components are readily applicable across jurisdictions or healthcare crises. This description may guide other institutions responding to COVID-19 and future health emergencies.

The Gender of COVID-19 Experts in Newspaper Articles: a Descriptive Cross-Sectional Study

BACKGROUND

Pre-existing gender-based disparities in academia may have worsened during the COVID-19 pandemic. Being cited as an expert source in newspaper articles about COVID-19 may increase an individual's research or leadership profile. In addition, visibility in a newspaper article is an important component of representation in academia.

OBJECTIVE

To determine whether women were underrepresented as COVID-19 expert sources in print newspapers in the USA.

DESIGN

We undertook a cross-sectional study of English-language newspaper articles that addressed the COVID-19 pandemic and that were published in the top 10 most widely read newspapers in the USA between April 1 and April 15, 2020.

MAIN MEASURES

We extracted the names of all people cited as expert sources and categorized the gender of each expert source based on pronoun usage within the article or on a business, university, or organization website. The professional role of each expert was assigned based on their description in the article.

KEY RESULTS

Of 2297 expert sources identified, 35.9% (95% confidence interval [CI] 33.9-37.8%; n = 824) were women and 63.7% were men (95% CI 61.8-65.7%; n = 1464). This result was similar when considering unique experts in each newspaper and for all included newspapers; of the 1738 unique experts per newspaper, 34.6% were women (95% CI 32.3-36.8%; n = 601), and of the 1593 unique experts in all newspapers, 36.5% were women (95% CI 34.1-38.9%; n = 581). Of articles with multiple experts referenced (n = 374), 102 cited only men experts (27.3%) and 44 cited only women experts (11.8%). Women were underrepresented as experts as Healthcare Workers and Professionals, Non-STEM Experts, Public Health Leaders, and STEM Scientists. There were no differences in the proportion of women experts between newspapers or between different regions of the USA.

CONCLUSIONS

Altogether, our findings support that men academics outnumber women as COVID-19 experts in newspaper articles.

Experiences of breast feeding at work for physicians, residents and medical students: a scoping review

OBJECTIVE

To review and summarise the available literature regarding breastfeeding experiences of medical students, residents and physicians.

ELIGIBILITY CRITERIA

Articles of any design, including non-peer reviewed data that examine the experiences of breast feeding of medical students, residents and staff physicians.

INFORMATION SOURCES

Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Ovid EMBASE, Scopus and Web of Science.

RISK OF BIAS

All peer-reviewed studies underwent risk-of-bias assessment using relevant tools, depending on the study design.

INCLUDED STUDIES

We included 71 citations; 51 surveys, 3 narrative descriptions, 9 editorials or letters to the editor, and 3 reviews.

SYNTHESIS OF RESULTS

Included articles were heterogeneous with respect to their study design, target population and outcomes reported. Most articles had a high risk of bias. Only five articles reported the impact of an intervention.

DESCRIPTION OF EFFECT

Despite heterogeneity, the majority of articles described important barriers to breast feeding for physicians, residents and medical students. These barriers were similar across studies, and included inadequate and inaccessible space, time constraints and inflexible scheduling, and lack of colleague support. The consequences of these barriers included low milk supply and early discontinuation of breast feeding.

STRENGTHS AND LIMITATIONS OF EVIDENCE

Due to the observed heterogeneity of articles identified in this review, we are unable to assess trends in barriers or duration of breastfeeding over time.

INTERPRETATION

Interventions to overcome systemic and cultural barriers to breast feeding are needed to meet legal obligations of workplaces for physicians and trainees. These interventions should be formally evaluated using implementation science or quality improvement methods.

Estimated GFR and Incidence of Major Surgery: A Population-Based Cohort Study

RATIONALE & OBJECTIVE

Kidney disease is associated with an increased risk for postoperative morbidity and mortality. However, the incidence of major surgery on a population level is unknown. We aimed to determine the incidence of major surgery by level of kidney function.

STUDY DESIGN

Retrospective cohort study with entry from January 1, 2008, through December 31, 2009, and outcome surveillance from January 1, 2010, through December 31, 2016.

SETTING & PARTICIPANTS

Population-based study using administrative health data from Alberta, Canada; adults with an outpatient serum creatinine measurement or receiving maintenance dialysis formed the study cohort.

EXPOSURE

Participants were categorized into 6 estimated glomerular filtration rate (eGFR) categories: ≥60 (G1-G2), 45 to 59 (G3a), 30 to 44 (G3b), 15 to 29 (G4), and<15mL/min/1.73m² with (G5D) and without (G5) dialysis. eGFR was examined as a time-varying exposure based on means of measurements within 3-month ascertainment periods throughout the study period.

OUTCOME

Major surgery defined as surgery requiring admission to the hospital for at least 24 hours.

ANALYTICAL APPROACH

Incidence rates (IRs) for overall major surgery were estimated using quasi-Poisson regression and adjusted for age, sex, income, location of residence, albuminuria, and Charlson comorbid conditions. Age- and sex-stratified IRs of 13 surgery subtypes were also estimated.

RESULTS

1,455,512 cohort participants were followed up for a median of 7.0 (IQR, 5.3) years, during which time 241,989 (16.6%) underwent a major surgery. Age and sex modified the relationship between eGFR and incidence of surgery. Men younger than 65 years receiving maintenance dialysis experienced the highest rates of major surgery, with an adjusted IR of 243.8 (95% CI, 179.8-330.6) per 1,000 person-years. There was a consistent trend of increasing surgery rates at lower eGFRs for most subtypes of surgery.

LIMITATIONS

Outpatient preoperative serum creatinine measurement was necessary for inclusion and outpatient surgical procedures were not included.

CONCLUSIONS

People with reduced eGFR have a significantly higher incidence of major surgery compared with those with normal eGFR, and age and sex modify this increased risk. This study informs our understanding of how surgical burden changes with differing levels of kidney function.

Experiences of breastfeeding among women residents in Alberta: a cross-sectional survey

OBJECTIVES

Breastfeeding at work is recommended by pediatric society guidelines and is protected by employment and human rights law in many countries. Despite this, previous studies have found that residents report important structural barriers to breastfeeding at work.

METHOD

We administered a cross-sectional, electronic, multicenter survey of all women residents in Alberta who were parents in 2017. The study aimed to characterize respondents' experiences of breastfeeding, including duration, goals, barriers, and support from colleagues.

RESULTS

There were 110 respondents, of whom 53 individuals had breastfed 83 children during residency. While nearly all felt that breastfeeding was important to them, only 69.2% reported meeting their breastfeeding duration goal. Surgical residents were less likely to meet their breastfeeding duration goal than residents in other disciplines (40.0% (n = 6/15) compared to 80.0% of non-surgical (n = 28/35) and 80.0% of family medicine residents (n = 12/15)). Residents reported stopping breastfeeding earlier than they desired due to lack of adequate space (48.7%, n = 19) and lack of time (57.1%, n = 24). Twelve participants (10.9%) reported hearing a derogatory comment from a staff physician about their breastfeeding.

CONCLUSIONS

Women residents face barriers to breastfeeding at work which require systems-level intervention. Residents from surgical programs may be the most vulnerable to these barriers. Program directors, residency wellness committees, and hospital administrators should prioritize addressing these barriers for women residents returning to work after maternity leave. Examples of interventions that may address these barriers include policies, designation of lactation spaces, and flexible return-to-work schedules.

Perioperative management for people with chronic kidney disease receiving dialysis undergoing major surgery: a protocol for a scoping review

INTRODUCTION

People with chronic kidney disease receiving dialysis (CKD G5D) have an increased risk of poor postoperative outcomes and a high incidence of major surgery. Despite the high burden of these combined risks, there is a paucity of evidence to support tailored perioperative strategies to manage this population. A comprehensive evidence synthesis would inform the management of these patients in the perioperative period and identify knowledge gaps. We describe a protocol for a scoping review of the literature to identify existing perioperative strategies, protocols, pathways and interventions for people with CKD G5D undergoing major surgery.

METHODS AND ANALYSIS

We will conduct a scoping review in accordance with the Joanna Briggs Institute methodology and report per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. In February 2020, we will complete our search of MEDLINE, EMBASE, CINAHL Plus, Cochrane Database of Systematic Reviews, and Cochrane Controlled Trials Registry for published literature from inception to present. All study types are eligible for inclusion, without language restriction. Studies reporting a perioperative intervention in adult patients with CKD G5D are eligible for inclusion. Studies in prevalent kidney transplant patients or patients with acute kidney injury, and studies that report on surgical approaches without consideration of perioperative management strategies, will be excluded. Reviewers will independently assess abstracts for all identified studies in duplicate, and again at the full-text stage. Following published literature searches, a search of the grey literature will be developed. We will extract and narratively report study, participant and intervention details. This will include a summary table outlining the strategies employed, organised into post hoc developed perioperative domains.

ETHICS AND DISSEMINATION

Ethical considerations do not apply to this scoping review. Findings will be disseminated through relevant conference presentations and publications.

Proportion of female recipients of resident-selected awards across Canada from 2000 to 2018: a retrospective observational study

BACKGROUND

Female physicians have been shown to receive fewer awards from medical societies than their male colleagues. We examined the sex distribution of recipients of Canadian residency association awards.

METHODS

We conducted a retrospective observational study of the sex of staff and resident physician recipients of resident-selected awards from provincial and national residency associations using data from 2000-2018. We classified awards into professionalism, advocacy and wellness awards, and education and teaching awards based on award names and descriptions, and compared the proportion of male and female recipients in these categories.

RESULTS

We identified 314 recipients of staff physician awards and 129 recipients of resident physician awards. Male staff and resident physicians had higher odds of receiving awards than their female counterparts (odds ratio [OR] 1.45, 95% confidence interval [CI] 1.13-1.89 and OR 1.70, 95% CI 1.18-2.46, respectively). There was a reduction in the odds of male residents' receiving an award over the study period (OR 0.94, 95% CI 0.90-0.98). Male physicians had higher odds of receiving education and teaching awards than female physicians as staff but not as residents (OR 3.21, 95% CI 1.72-5.95 and OR 1.96, 95% CI 0.84-4.60, respectively).

INTERPRETATION

Male staff and resident physicians in Canada had higher odds of receiving awards from provincial and national residency associations between 2000 and 2018 than their female counterparts. Given this disparity, it would be prudent for organizations that distribute awards to physicians, residents and medical students to examine their nomination criteria and processes for potential bias.

Applicant gender and matching to first-choice discipline: a cross-sectional analysis of data from the Canadian Resident Matching Service (2013-2019)

BACKGROUND

Previous studies examining potential sex and gender bias in the Canadian Resident Matching Service (CaRMS) match have had conflicting results. We examined the results of the CaRMS match over the period 2013-2019 to determine the potential association between applicants' gender and the outcome of matching to their first-choice discipline.

METHODS

In this cross-sectional analysis, we determined the risk of matching to one's first-choice discipline in CaRMS by applicant gender and year, for all Canadian medical students who participated in the first iteration of the R-1 match for the years 2013 to 2019. We analyzed data in 3 categories of disciplines according to CaRMS classifications: family medicine, nonsurgical disciplines and surgical disciplines. We excluded disciplines with fewer than 10 applicants.

RESULTS

Match results were available for 20 033 participants, of whom 11 078 (55.3%) were female. Overall, female applicants were significantly more likely to match to their first-choice discipline (relative risk [RR] 1.03, 95% confidence interval [CI] 1.02-1.04). After adjustment for match year and stratification by discipline categories, we found that female applicants were more likely to match to family medicine as their first choice (RR 1.04, 95% CI 1.03-1.05) and less likely to match to a first-choice surgical discipline (RR 0.95, 95% CI 0.91-1.00) than their male peers. There was no significant difference between the genders in matching to one's first-choice nonsurgical discipline (RR 1.01, 95% CI 0.99-1.03).

INTERPRETATION

These results suggest an association between an applicant's gender and the probability of matching to one's first-choice discipline. The possibility of gender bias in the application process for residency programs should be further evaluated and monitored.

Association Between the Proportion of Women on a Conference Planning Committee and the Proportion of Women Speakers at Medical Conferences

This cross-sectional study examines the association of the proportion of women on a medical conference planning committee with the proportion of women speakers at the conference.

Peri-operative cardiac biomarker screening: a narrative review

Peri-operative risk estimation has traditionally focused on assessing the likelihood of postoperative morbidity and mortality using pre-operative functional assessment. Although this strategy is currently recommended by most major society guidelines, contemporary evidence suggests that cardiac biomarker measurement has important advantages over pre-operative functional assessment. These advantages include superior predictive discrimination and inclusion of the postoperative course in risk estimation. In this review, we provide an overview of the evidence supporting the peri-operative utilisation, compare risk estimation methods and discuss which patients may benefit most from cardiac biomarker screening. We also discuss protocols for biomarker screening and management of patients with abnormal results.

Association of Physician Characteristics With Perceptions and Experiences of Gender Equity in an Academic Internal Medicine Department

IMPORTANCE

The persistence of inequities that disadvantage women physicians remains empirically underexplained. Understanding the cultural factors that are associated with disparities in harassment, discrimination, remuneration, and career trajectory are critical to addressing inequities.

OBJECTIVES

To explore how physicians perceive the climate for women physicians and compare perceptions and experiences of gender inequity among physicians based on characteristics including gender, faculty status, parental status, and years in practice.

DESIGN, SETTING, AND PARTICIPANTS

This sequential, explanatory, mixed-methods qualitative study used the Culture Conducive to Women's Academic Success (CCWAS; range 45-225, with higher scores indicating better perceived culture toward women), followed by individual semistructured interviews with physicians at the Department of Medicine of the University of Calgary. All 389 physician members of the Department of Medicine, including academic and clinical physicians and those of any gender, were invited to participate in the survey and interview phases.

MAIN OUTCOMES AND MEASURES

The culture within the department for women physicians was assessed using the CCWAS score. Scores were compared between respondents' gender and years in practice. Interviews with physicians were used to further explore findings from the CCWAS and to understand experiences and perceptions of gender disparities.

RESULTS

A total of 169 of 389 physicians completed the survey (response rate, 43.4%; 102 [59.9%] women; 65 [38.9%] men; and 2 [1.2%] who did not disclose gender); 28 participants (7.2%) elected to participate in an interview (22 [78.6%] women; 6 [21.4%] men). Women physicians perceived the culture of the department toward women as significantly worse than men physicians (median [interquartile range] CCWAS score, 137.0 [118.0-155.0] vs 164.5 [154.0-183.4]; P < .001). Physicians with more than 15 years in practice perceived the culture toward women as significantly more favorable than physicians with 15 years or less in practice (median [interquartile range] CCWAS score, 157.0 [138.8-181.3] vs 147.0 [127.5-164.3]; P = .02). Qualitative data demonstrated that experiences of junior women (ie, physicians who graduated medical school after 1996, when an equal number of men and women in medical school was achieved in Canada) and perceptions of senior men (ie, those who graduated before 1996) were most different; junior women reported high rates of discrimination and harassment, while senior men perceived that the Department of Medicine had achieved gender equity.

CONCLUSIONS AND RELEVANCE

In this study, senior men physicians' perceptions of gender equity were different from lived experiences of gender inequity reported by junior women physicians. This demographic mismatch between perceptions and experiences of gender equity in medicine may explain the lack of action by leaders and decision-makers in medicine to mitigate disparities.

Trends in the Proportion of Female Speakers at Medical Conferences in the United States and in Canada, 2007 to 2017

IMPORTANCE

Gender equity is a prominent issue in the medical profession. Representation of female physicians at academic meetings has been identified as an important component of gender equity; however, this topic has not been systematically assessed.

OBJECTIVE

To determine the trend during the last decade in the proportion of speakers who were women at major academic medical conferences held in Canada and in the United States.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional analysis was conducted examining the gender of speakers listed in meeting programs of medical conferences held in Canada and in the United States in 2007 and from 2013 through 2017. Eligible conferences were identified using a sensitive search strategy, and a previously validated tool was used to analyze each meeting speaker list and to assign a proportion of female speakers. Conferences held in English language, hosted in Canada or the United States, and targeted to a physician audience with 100 or more attendees were included. The comparison group was active physicians in Canada and in the United States.

MAIN OUTCOMES AND MEASURES

The mean of the proportion of female speakers at each conference per year.

RESULTS

In total, 181 conferences with 701 individual meetings were analyzed, including 100 medical and 81 surgical specialty conferences. The proportion of women ranged from 0% to 82.6% of all speakers. The mean (SD) proportion of female conference speakers for all meetings analyzed significantly increased from 24.6% (14.6%) for 40 meetings in 2007 to 34.1% (15.1%) for 181 meetings in 2017 (P < .001). The mean proportion of female speakers at medical specialty conferences was 9.8% higher (SE, 1.9%; P < .001) than the mean proportion of female speakers at surgical specialty conferences for all years analyzed. The mean proportion of female speakers at conferences was similar to the mean proportion of active female physicians across all specialties in the United States and in Canada for all years analyzed.

CONCLUSIONS AND RELEVANCE

Although our findings indicate that the proportion of female speakers at medical conferences increased during the last decade, women continue to be underrepresented. Speaker invitation and selection at conferences represent important opportunities to influence gender equity within medicine.