Diversity in the Emerging Critical Care Workforce: Analysis of Demographic Trends in Critical Care Fellows From 2004 to 2014

Current landscape and future directions: a cross-sectional study of diversity among dermatology leadership in Canada

BACKGROUND/OBJECTIVES

Medical leadership and education which reflects the diversity of patient populations are crucial to equitable healthcare experiences and outcomes. This study aims to assess the current landscape of diversity in dermatology leadership and educational curricula in Canada. We also sought to collect and summarise recommendations made by current dermatology leaders about how to improve diversity in the field.

METHODS

This cross-sectional study assessed the self-reported racial/ethnic backgrounds and Fitzpatrick skin types of Canadian dermatology leaders. Individuals who held one or more leadership positions in the past 10 years were identified and sent an anonymous, online survey. Respondent's demographic information and perspectives on diversity in dermatology were analysed with proportions and thematic analysis, respectively.

RESULTS

The survey response rate was 50.0% (55/110). 65.5% (36/55) of respondents identified as White/Caucasian. More respondents identified as having Fitzpatrick skin types 1-2 (65.5%) compared with Fitzpatrick skin types 3-6 (34.5%). More respondents (68.9%) holding leadership positions in national, provincial or regional societies identified as White/Caucasian compared with leaders in academic or research roles (56.5%). Most respondents believed that Black, Indigenous and people of colour are not sufficiently represented in Canadian dermatology leadership and that skin of colour is not adequately represented in dermatology educational curricula.

CONCLUSIONS

Our study suggests a potential underrepresentation of racial and ethnic minorities in Canadian dermatologists in national, provincial and regional society leadership positions. Most Canadian dermatologists previously or currently holding leadership roles believe that further efforts are necessary to improve equity, diversity and inclusion in the field.

A Descriptive Qualitative Study of Religion and Spirituality's Role in Critical Illness Decision-Making Among Black and White Family Caregivers

BACKGROUND

Spiritual beliefs and spiritual support from clinicians can affect medical decision-making and coping during times of serious illness.

RESEARCH QUESTION

How do religion and spirituality affect the critical illness experience of Black and White family caregivers of patients who are critically ill?

STUDY DESIGN AND METHODS

Twenty-one semistructured interviews were conducted with Black and White family caregivers of patients admitted to ICUs in a southeastern United States health system between January 3, 2023, and May 11, 2023. Eligible family caregivers either reported unmet spiritual needs or a high degree of importance of spirituality in their lives. Participants were asked how spirituality affected medical decision-making and coping while their loved ones were seriously ill. Coders were masked to participant race during thematic analysis.

RESULTS

Of 21 family caregivers, 9 caregivers (42.9%) were Black and 12 caregivers (57.1%) were White. Black and White family caregivers generally were middle-aged (mean [SD]: 50.6 [13.6] years and 61.7 [10.7] years, respectively) and female (n = 7 [77.8%] and n = 9 [75.0%], respectively). We observed that clinicians showed less engagement about spirituality with Black compared with White family caregivers in this sample. Black family caregivers felt more comfortable discussing their spirituality with members of their community, such as pastors or friends. A common belief among all family caregivers in this sample was that God, rather than the medical team, was in control of their loved one's outcome. This was accompanied by a shared desire for accessible spiritual spaces in the ICU and proactive clinician engagement in their spirituality.

INTERPRETATION

Although spirituality served as an important coping mechanism for all family caregivers in this sample, racial differences in spiritual support offered to family caregivers were identified. Ensuring that multidisciplinary critical care teams are prepared to deliver culturally competent spiritual care is a priority.

Exploring the Historical Context of American Indian/Alaska Native Intensive Care Inequities: A Narrative Review

INTRODUCTION

This narrative review aims to frame the historical context of American Indian/Alaska Native (AI/AN) pediatric intensive care and offers suggestions for mitigating the impact of unique social drivers.

METHODS

Recent literature was surveyed to determine pertinent studies describing intensive care outcomes in AI/AN children and was summarized in a narrative review.

RESULTS

American Indian/Alaska Native people experience disproportionate health inequites due to unique social drivers of health, including settler colonialism, historical trauma, and systemic racism. These factors contribute to inequities in the pediatric intensive care experience, including rates of admission for injury and infectious diseases and mortality due to injuries and following cardiac surgery.

DISCUSSION

These inequities are understudied and require dedicated evaluation. Institutions and providers are responsible for educating, modeling, and providing culturally competent care and aiming to achieve workforce equity to improve outcomes for AI/AN children receiving intensive care.

Racial disparities in end-of-life suffering within surgical intensive care units

Background

End-of-life (EOL) care is associated with high resource utilization. Recognizing and effectively communicating that EOL is near promotes more patient-centered care, while decreasing futile interventions. We hypothesize that provider assessment of futility during the surgical intensive care unit (SICU) admission would result in higher rates of Do Not Resuscitate (DNR).

Methods

We performed a retrospective review of a prospective SICU registry of all deceased patients across a health system, 2018-2022. The registry included a subjective provider assessment of patient's expected survival. We employed multivariable logistic regression to adjust for clinical factors while assessing for association between code status at death and provider's survival assessment with attention to race-based differences.

Results

746 patients-105 (14.1%) traumatically injured and 641 (85.9%) non-traumatically injured-died over 4.5 years in the SICU (mortality rate 5.9%). 26.3% of these deaths were expected by the ICU provider. 40.9% of trauma patients were full code at the time of death, compared with 15.6% of non-traumatically injured patients. Expected death was associated with increased odds of DNR code status for non-traumatically injured patients (OR 1.8, 95% CI 1.03 to 3.18), but not for traumatically injured patients (OR 0.82, 95% CI 0.22 to 3.08). After adjusting for demographic and clinical characteristics, black patients were less likely to be DNR at the time of death (OR 0.49, 95% CI 0.32 to 0.75).

Conclusion

20% of patients who died in our SICU had not declared a DNR status, with injured black patients more likely to remain full code at the time of death. Further evaluation of this cohort to optimize recognition and communication of EOL is needed to avoid unnecessary suffering.

Level of evidence

Level III/prognostic and epidemiological.

Racial Differences in Shared Decision-Making About Critical Illness

Importance

Shared decision-making is the preferred method for evaluating complex tradeoffs in the care of patients with critical illness. However, it remains unknown whether critical care clinicians engage diverse patients and caregivers equitably in shared decision-making.

Objective

To compare critical care clinicians' approaches to shared decision-making in recorded conversations with Black and White caregivers of patients with critical illness.

Design, Setting, and Participants

This thematic analysis consisted of unstructured clinician-caregiver meetings audio-recorded during a randomized clinical trial of a decision aid about prolonged mechanical ventilation at 13 intensive care units in the US. Participants in meetings included critical care clinicians and Black or White caregivers of patients who underwent mechanical ventilation. The codebook included components of shared decision-making and known mechanisms of racial disparities in clinical communication. Analysts were blinded to caregiver race during coding. Patterns within and across racial groups were evaluated to identify themes. Data analysis was conducted between August 2021 and April 2023.

Main Outcomes and Measures

The main outcomes were themes describing clinician behaviors varying by self-reported race of the caregivers.

Results

The overall sample comprised 20 Black and 19 White caregivers for a total of 39 audio-recorded meetings with clinicians. The duration of meetings was similar for both Black and White caregivers (mean [SD], 23.9 [13.7] minutes vs 22.1 [11.2] minutes, respectively). Both Black and White caregivers were generally middle-aged (mean [SD] age, 47.6 [9.9] years vs 51.9 [8.8] years, respectively), female (15 [75.0%] vs 14 [73.7%], respectively), and possessed a high level of self-assessed health literacy, which was scored from 3 to 15 with lower scores indicating increasing health literacy (mean [SD], 5.8 [2.3] vs 5.3 [2.0], respectively). Clinicians conducting meetings with Black and White caregivers were generally young (mean [SD] age, 38.8 [6.6] years vs 37.9 [8.2] years, respectively), male (13 [72.2%] vs 12 [70.6%], respectively), and White (14 [77.8%] vs 17 [100%], respectively). Four variations in clinicians' shared decision-making behaviors by caregiver race were identified: (1) providing limited emotional support for Black caregivers, (2) failing to acknowledge trust and gratitude expressed by Black caregivers, (3) sharing limited medical information with Black caregivers, and (4) challenging Black caregivers' preferences for restorative care. These themes encompass both relational and informational aspects of shared decision-making.

Conclusions and Relevance

The results of this thematic analysis showed that critical care clinicians missed opportunities to acknowledge emotions and value the knowledge of Black caregivers compared with White caregivers. These findings may inform future clinician-level interventions aimed at promoting equitable shared decision-making.

Analysis of the National Resident Matching Program for Surgical Critical Care Training in the United States: 2008-2022

BACKGROUND

Few studies have assessed the pipeline for surgical intensivists despite projected shortages in the United States' critical care workforce. We had 3 primary objectives in analyzing the Surgical Critical Care Match: (1) understand growth in the number of applicants relative to training positions; (2) compare match rates for United States Allopathic Graduates versus non-United States Allopathic Graduates; and (3) analyze the number of unfilled training positions over time.

METHODS

This was a national cohort study of Surgical Critical Care Match applicants (2008-2022). Annual match rates and applicant-to-training position ratios were calculated. Cochrane-Armitage tests elucidated temporal trends during the study period.

RESULTS

There was a greater increase in the number of annual applicants (276% increase) relative to training positions (128% increase) during the study period (P < .001). The applicant-to-training position ratio increased (0.5-0.9, P < .001). Annual match rates increased for both United States Allopathic (92%-97%, P = .015) and non-United States Allopathic (81%-96%, P < .001) Graduates. Match rates for United States Allopathic Graduates exceeded those for non-United States Allopathic Graduates (P < .05) but were similar from 2020 to 2022 (P > .05). The percentage of applicants that matched at their top fellowship choice decreased from 69%-50% (P < .001). From 2008 to 2022, fewer available training positions went unfilled (52%-13%, P < .001).

CONCLUSION

The pipeline for surgical intensivists in the United States appears to be increasing along with rising interest in Surgical Critical Care training. Future research is needed to understand disparities in match rates by applicant and fellowship program characteristics.

Defining the Time-limited Trial for Patients with Critical Illness: An Official American Thoracic Society Workshop Report

In critical care, the specific, structured approach to patient care known as a "time-limited trial" has been promoted in the literature to help patients, surrogate decision makers, and clinicians navigate consequential decisions about life-sustaining therapy in the face of uncertainty. Despite promotion of the time-limited trial approach, a lack of consensus about its definition and essential elements prevents optimal clinical use and rigorous evaluation of its impact. The objectives of this American Thoracic Society Workshop Committee were to establish a consensus definition of a time-limited trial in critical care, identify the essential elements for conducting a time-limited trial, and prioritize directions for future work. We achieved these objectives through a structured search of the literature, a modified Delphi process with 100 interdisciplinary and interprofessional stakeholders, and iterative committee discussions. We conclude that a time-limited trial for patients with critical illness is a collaborative plan among clinicians and a patient and/or their surrogate decision makers to use life-sustaining therapy for a defined duration, after which the patient's response to therapy informs the decision to continue care directed toward recovery, transition to care focused exclusively on comfort, or extend the trial's duration. The plan's 16 essential elements follow four sequential phases: consider, plan, support, and reassess. We acknowledge considerable gaps in evidence about the impact of time-limited trials and highlight a concern that if inadequately implemented, time-limited trials may perpetuate unintended harm. Future work is needed to better implement this defined, specific approach to care in practice through a person-centered equity lens and to evaluate its impact on patients, surrogates, and clinicians.

Workforce diversity in specialist physicians: Implications of findings for religious affiliation in Anaesthesia & Intensive Care

BACKGROUND

Minority ethnic identification between physician and patient can reduce communication and access barriers, improve physician-patient relationship, trust, and health outcomes. Religion influences health beliefs, behaviours, treatment decisions, and outcomes. Ethically contentious dilemmas in treatment decisions are often entangled with religious beliefs. They feature more in medical specialties such as Anaesthesia & Intensive Care, with issues including informed consent for surgery, organ donation, transplant, transfusion, and end-of-life decisions.

METHODS

We investigate diversity in religious affiliation in the UK medical workforce, using data from the General Medical Council (GMC) specialist register and Health Education England (HEE) trainee applications to medical specialties. We performed conservative Bonferroni corrections for multiple comparisons using Chi-squared tests, as well as normalised mutual-information scores. Robust associations that persisted on all sensitivity analyses are reported, investigating whether ethnicity or foreign primary medical qualification could explain the underlying association.

FINDINGS

The only significant and robust association in both GMC and HEE datasets affecting the same religious group and specialty was disproportionately fewer Anaesthesia & Intensive Care physicians with a religious affiliation of "Muslim", both as consultants (RR 0.57[0.47,0.7]) and trainee applicants (RR 0.27[0.19,0.38]. Associations were not explained by ethnicity or foreign training. We discuss the myriad of implications of the findings for multi-cultural societies.

CONCLUSIONS

Lack of physician workforce diversity has far-reaching consequences, especially for specialties such as Anaesthesia and Intensive Care, where ethically contentious decisions could have a big impact. Religious beliefs and practices, or lack thereof, may have unmeasured influences on clinical decisions and on whether patients identify with physicians, which in turn can affect health outcomes. Examining an influencing variable such as religion in healthcare decisions should be prioritised, especially considering findings from the clinician-patient concordance literature. It is important to further explore potential historical and socio-cultural barriers to entry of training medics into under-represented specialties, such as Anaesthesia and Intensive Care.

Gender, Race, and Ethnicity in Critical Care Fellowship Programs in the United States From 2016 to 2021

A diverse and inclusive critical care workforce is vital to the provision of culturally appropriate and effective care to critically ill patients of all backgrounds.

OBJECTIVES

The purpose of this study is to determine the trends in gender, race, and ethnicity of U.S. critical care fellowships over the past 6 years (2016-2021).

METHODS

Data on gender, race, and ethnicity of critical care fellows in five Accreditation Council on Graduate Medical Education-accredited training programs (internal medicine, pulmonary and critical care, anesthesiology, surgery, and pediatrics) from 2015 to 2016 to 2020-2021 were obtained from the joint reports of the American Medical Association (AMA) and Association of American Medical Colleges published annually in the Journal of the AMA.

RESULTS

From 2016 to 2021, the number of U.S. critical care fellows increased annually, up 23.8%, with the largest number of fellows in pulmonary critical care medicine (60.1%). The percentage of female critical care fellows slightly increased from 38.7% to 39.4% (p = 0.57). White fellows significantly decreased from 57.4% to 49.3% (p = 0.0001); similarly, Asian fellows significantly decreased from 30.8% to 27.5% (p = 0.004). The percentage of Black or African American fellows was not statistically significantly different (4.9% vs 4.4%; p = 0.44). The number of fellows who self-identified as multiracial significantly increased from 52 (1.9%) to 91 (2.7%) (p = 0.043). The percentage of fellows who identified as Hispanic was not significantly different (6.7% vs 7.5%; p = 0.23).

CONCLUSIONS

The percentage of women and racially and ethnically minoritized fellows (Black and Hispanic) remain underrepresented in critical care fellowship programs. Additional research is needed to better understand these demographic trends in our emerging critical care physician workforce and enhance diversity.

The Current State of Workforce Diversity and Inclusion in Pediatric Critical Care

Literature suggests the pediatric critical care (PCC) workforce includes limited providers from groups underrepresented in medicine (URiM; African American/Black, Hispanic/Latinx, American Indian/Alaska Native, Native Hawaiian/Pacific Islander). Additionally, women and providers URiM hold fewer leadership positions regardless of health-care discipline or specialty. Data on sexual and gender minority representation and persons with different physical abilities within the PCC workforce are incomplete or unknown. More data are needed to understand the true landscape of the PCC workforce across disciplines. Efforts to increase representation, promote mentorship/sponsorship, and cultivate inclusivity must be prioritized to foster diversity and inclusion in PCC.

Health and Well-Being of Intensive Care Unit Physicians: How to Ensure the Longevity of a Critical Specialty

A second epidemic of burnout, fatigue, anxiety, and moral distress has emerged concurrently with the coronavirus disease 2019 (COVID-19) pandemic, and critical care physicians are especially affected. This article reviews the history of burnout in health care workers, presents the signs and symptoms, discusses the specific impact of the COVID-19 pandemic on intensive care unit caregivers, and attempts to identify potential strategies to combat the Great Resignation disproportionately affecting health care workers. The article also focuses on how the specialty can amplify the voices and highlight the leadership potential of underrepresented minorities, physicians with disabilities, and the aging physician population.

Influence of Diversity Nursing on Patients' Rehabilitation in Cardiology Treatment

With the improvement of living standards, people have more and more physical health problems. Among them, high-risk cardiovascular diseases such as hypertension, diabetes, and coronary heart disease are the most prominent. The number of cardiology patients is increasing year by year. Effectively improving the treatment of cardiology patients and speeding up the recovery of cardiology patients have become a social problem. This article aims to explore the impact of diverse nursing care on patients in cardiology treatment. This article first gives a detailed introduction to the treatment of diverse nursing and cardiology diseases, then takes 300 cardiology patients in our hospital as experimental subjects, and conducts a controlled experiment of nursing intervention, which is categorized into an experimental group of 150 cases (including 35 cases of hypertension, 46 cases of diabetes, 28 cases of coronary heart disease, 24 cases of angina pectoris, and 17 cases of multiple complications) and a control group of 150 cases (including 30 cases of hypertension, 47 cases of diabetes, 39 cases of coronary heart disease, 21 cases of angina pectoris, and 13 cases of multiple complications). The experimental results showed the following: the general information of the two groups of patients was not statistically different (P > 0.05); after the nursing intervention, the blood glucose levels of the two groups of patients decreased, but the experimental group decreased more significantly and the blood glucose control effect was more obvious; after the intervention, in the experimental group that implemented diversified nursing interventions, the patient's condition management effect was better and their scores were between 8 and 10; the mental state self-evaluation of the two groups of patients was significantly different from the domestic reference value (P < 0.05), and there is a very significant statistical difference between the two groups after nursing intervention (P < 0.01); after nursing intervention, compared with the control group, the quality of life of the experimental group improved more significantly and the highest score reached about 70; the overall satisfaction of the experimental group with nursing work reached 92%, while the satisfaction of the control group with nursing work was only 44.67%. Studies have shown that diversified care has a positive impact on the rehabilitation of patients in cardiology treatment.

Penn Access Summer Scholars program: a mixed method analysis of a virtual offering of a premedical diversity summer enrichment program

In the USA, numerous summer programs are available for undergraduate students that seek to increase the number of individuals from groups underrepresented in medicine (URM) that matriculate to medical school. These programs have typically been conducted at research-focused institutions, involving hands-on-research and various enrichment experiences. For 2020, the COVID-19 pandemic resulted in the suspension of on-campus student activities at American universities, necessitating a switch to a virtual format for these URM-focused programs. Outcomes, however, from these programs conducted virtually, necessitated by the COVID-19 pandemic, have not been reported. The Penn Access Summer Scholars (PASS) program at the Perelman School of Medicine (PSOM) targets URM undergraduates, providing two consecutive summers of mentored research and enrichment experiences, with the goal of enabling participants' matriculation to PSOM. PASS has been an 8 week on-campus experience, but during summer 2020, virtual programming of 6 weeks was provided due to the COVID-19 pandemic. Participants in the 2020 virtual offering of PASS completed pre- and post-program surveys that included 5-point Likert-style and open-ended questions to determine the impact of the programing on self-assessments of research skills, familiarity with the physician identity, and preparedness to be a PSOM student. Post-program, participants also assessed program administration and content. With respect to program objectives, participants reported significant increases in their self-reported confidence in conducting research, understanding of physician identity, and sense of preparedness for medical school. The educational value of the program content, their level of engagement in the program and the overall quality of the program were rated as excellent or outstanding by large majorities of respondents. Content analyses of participant comments were consistent with these quantitative results. Therefore, a premedical summer enrichment program targeting URM undergraduates can be successfully conducted virtually to achieve program objectives and may increase the availability to these initiatives.

Antiracism in Academic Medicine: Fixing the Leak in the Pipeline of Black Physicians

Black physicians remain severely underrepresented in academic medicine despite the documented benefits of a diverse medical faculty. Only 3.6% of academic medical faculty self-report as Black or African American. Efforts to improve faculty diversity at academic medical institutions nationwide have not made meaningful impacts. Sustained improvements in faculty diversity cannot be achieved without an actively antiracist approach, including the intentional transformation of policies, practices, and systems that persistently produce worse outcomes for Black medical students, trainees, and faculty.

Diversity, Inclusion and Cultural Competency in Pediatric Hospital Medicine Fellowship Programs

OBJECTIVES

The objectives with this study were to describe the current state of Pediatric Hospital Medicine (PHM) fellowship programs with regards to (1) diversity of fellows and programs' leadership, (2) current diversity and inclusion (D&I) programs and measures of their success, and (3) the state of cultural competency training.

METHODS

In 2018, fellowship directors of the 35 active PHM fellowship programs were invited to participate in a survey of diversity, inclusion, and cultural competency at PHM fellowship programs. Participants were invited via in-person invitations at the annual PHM fellowship directors meeting and through e-mail invitations from July to September to complete an online survey.

RESULTS

There was an 89% response rate of the survey. Most fellows, faculty, and program directors in PHM were female (74%, 70%, and 70%, respectively) and white (53%, 67%, and 60%, respectively). There were no African American, American Indian or Alaskan Native, or Native Hawaiian or other Pacific Islander program directors. Forty-five percent of programs reported that neither the fellowship program nor their hospital had a strategic plan that addresses D&I. Approximately 61% of programs had cultural competency training for fellows.

CONCLUSIONS

This is the first survey to report on the state of D&I in PHM fellowship programs. There is lack of racial and ethnic diversity in programs fellows, faculty, and directors. Although most programs have cultural competency training, strategic planning to promote D&I is not widely implemented among PHM fellowship programs.

Improving racial disparities in unmet palliative care needs among intensive care unit family members with a needs-targeted app intervention: The ICUconnect randomized clinical trial

INTRODUCTION

The technologies used to treat the millions who receive care in intensive care unit (ICUs) each year have steadily advanced. However, the quality of ICU-based communication has remained suboptimal, particularly concerning for Black patients and their family members. Therefore we developed a mobile app intervention for ICU clinicians and family members called ICUconnect that assists with delivering need-based care.

OBJECTIVE

To describe the methods and early experiences of a clustered randomized clinical trial (RCT) being conducted to compare ICUconnect vs. usual care.

METHODS AND ANALYSIS

The goal of this two-arm, parallel group clustered RCT is to determine the clinical impact of the ICUconnect intervention in improving outcomes overall and for each racial subgroup on reducing racial disparities in core palliative care outcomes over a 3-month follow up period. ICU attending physicians are randomized to either ICUconnect or usual care, with outcomes obtained from family members of ICU patients. The primary outcome is change in unmet palliative care needs measured by the NEST instrument between baseline and 3 days post-randomization. Secondary outcomes include goal concordance of care and interpersonal processes of care at 3 days post-randomization; length of stay; as well as symptoms of depression, anxiety, and post-traumatic stress disorder at 3 months post-randomization. We will use hierarchical linear models to compare outcomes between the ICUconnect and usual care arms within all participants and assess for differential intervention effects in Blacks and Whites by adding a patient-race interaction term. We hypothesize that both compared to usual care as well as among Blacks compared to Whites, ICUconnect will reduce unmet palliative care needs, psychological distress and healthcare resource utilization while improving goal concordance and interpersonal processes of care. In this manuscript, we also describe steps taken to adapt the ICUconnect intervention to the COVID-19 pandemic healthcare setting.

ENROLLMENT STATUS

A total of 36 (90%) of 40 ICU physicians have been randomized and 83 (52%) of 160 patient-family dyads have been enrolled to date. Enrollment will continue until the end of 2021.

Building Capacity for Productive Indigenous Community-University Partnerships

This paper describes capacity development as a key aspect of community-based research with indigenous communities. University research engagement with indigenous communities includes extensive, and often negative, historical antecedents. We discuss strategies for developing effective, egalitarian, and balanced indigenous community-university relationships to build research capacity of these communities, and to create sustainable partnerships to improve health and wellness, and to reduce health disparities. We draw on the experience of eight investigators conducting research with indigenous communities to assess effective strategies for building and enhancing partnerships, including (1) supporting indigenous investigator development; (2) developing university policies and practices sensitive and responsive to Indigenous community settings and resources, and training for research; (3) developing community and scientifically acceptable research designs and practices; (4) aligning indigenous community and university review boards to enhance community as well as individual protection (e.g., new human subjects training for Indigenous research, joint research oversight, adaptation of shorter consent forms, appropriate incentives, etc.); (5) determining appropriate forms of dissemination (i.e., Indian Health Services provider presentation, community reports, digital stories, etc.); (6) best practices for sharing credit; and (7) reducing systematic discrimination in promotion and tenure of indigenous investigators and allies working in indigenous communities.

Diversity Within the Most Competitive Internal Medicine Fellowships: Examining Trends from 2008 to 2018

BACKGROUND

Prior studies have demonstrated the importance of diversity among physicians. Identifying trends in diversity within the most competitive internal medicine (IM) fellowships can guide focused efforts to address barriers to equal representation.

OBJECTIVE

To examine the racial and gender composition of resident applicants and accepted fellows to the top five most competitive IM specialties.

DESIGN

Survey data from the AAMC, JAMA, and NRMP were obtained. Fisher's exact tests were conducted to compare differences in representation between fellows in the most competitive specialties, resident applicants into those specialties, and categorical IM residents. Linear regression was used to analyze trends within each group.

PARTICIPANTS

Categorical IM residents and fellows at ACGME-accredited M.D. programs in the USA.

MAIN MEASURES

Proportion of each population by gender and race/ethnicity KEY RESULTS: Women saw an increase in representation among accepted fellows to the most competitive IM fellowships from 2008 to 2013 (+ 4.4%, p < 0.011), but the trend has since plateaued at a level (34%) significantly lower than their representation among IM residents (43%, p < 0.001). Black representation among accepted fellows (4.6%) has been increasing from 2008 to 2018 (+ 1.2%, p = 0.001), but is still significantly lower than their representation among IM residents (5.6%, p < 0.001). Hispanic resident applicant and fellow representation have seen minimal change.

CONCLUSION

Despite trends towards better representation among women and underrepresented minorities (URMs) among fellows in the most competitive IM specialties from 2008 to 2013, there has been a stagnation in both gender and racial diversity over the past 5 years. Further efforts must be undertaken to address barriers to entry and advocate for better representation of women and URMs in fellowship programs.

The Importance of Diversity and Inclusion in the Healthcare Workforce

BACKGROUND

Diversity and inclusion are terms that have been used widely in a variety of contexts, but these concepts have only been intertwined into the discussion in healthcare in the recent past. It is important to have a healthcare workforce which represents the tapestry of our communities as it relates to race/ethnicity, gender, sexual orientation, immigration status, physical disability status, and socioeconomic level to render the best possible care to our diverse patient populations.

METHODS

We explore efforts by the Liaison Committee on Medical Education (LCME), the Institute of Medicine (IOM), and other medical organizations to improve diversity and inclusion in medicine.

CONCLUSION

Finally, we report on best practices, frameworks, and strategies which have been utilized to improve diversity and inclusion in healthcare.

Diversity in the Pulmonary and Critical Care Medicine Pipeline. Trends in Gender, Race, and Ethnicity among Applicants and Fellows

Background: The diversity in pulmonary and critical care medicine (PCCM) training programs in the United States has not been systematically evaluated, despite emphasis on workforce diversity and its role in improving gender and racial healthcare disparities.

Objectives: We analyzed the diversity of the PCCM pipeline by gender, race, and ethnicity over the last 10 years.

Methods: The PCCM pipeline was defined as internal medicine residents, fellowship applicants, and fellows in pulmonary-only, critical care medicine–only, and combined PCCM programs. Data on gender, race, and ethnicity were obtained from 2009 to 2018 graduate medical education census data and the Association of American Medical Colleges Electronic Resident Application Service. We used the Association of American Medical Colleges definition of “underrepresented in medicine” (UIM), which comprises African American/black, Hispanic/Latino, American Indian/Alaska Native, or Native Hawaiian/Pacific Islander physicians.

Results: Over the last decade, the percentage of female fellows was unchanged in pulmonary (range, 19.4–37.1%), critical care medicine (range, 17.6–31.9%), and PCCM programs (range, 29.5–35.2%). To capture the current snapshot of data across residents, applicants, and fellows, we analyzed 2018 data and found that there was a drop-off from the percentage of female internal medicine residents (41.9%) to the percentage of female applicants and fellows (⩽33% in all three programs). The percentage of UIM fellows decreased in PCCM programs over the last decade to 10.3%. In 2018, there was a drop-off from the percentage of UIM residents (13.7%) to the percentage of UIM fellows in all three programs (<12.9% in all three programs).

Conclusions: Striking disparities remain in gender, race, and ethnicity in the pipeline of trainees in PCCM programs; these have not improved (for gender) or have even worsened (for race and ethnicity) over the last decade.

Fostering belonging in academic anaesthesiology: faculty and department chair perspectives on supporting women anaesthesiologists

An increasing number of global initiatives aim to address the disconnection between the increasing number of women entering medicine and the persistence of gender imbalance in the physician anaesthesiologist workforce. This commentary complements the global movement's efforts to increase women's representation in academic anaesthesiology by presenting considerations for fostering inclusion for women in academic anaesthesiology from both the faculty and departmental leadership perspectives in a US academic anaesthesiology department.

Self-Assessment of Preparedness among Critical Care Trainees Transitioning from Fellowship to Practice

This study evaluated the subjective assessment of preparedness needs of critical care trainees and recent graduates between 2013 and 2014. A questionnaire was developed and validated by the subcommittee of the In-Training Section of Society of Critical Care Medicine (SCCM). The survey was deployed twice between December 2013 and January 2014 via email to any trainee or individual graduated from a critical care fellowship within the previous three years. Six percent (180) of all individuals completed the survey, and 67% of respondents had recently interviewed for a job. Northeast was the preferred location for a job (47%), and academia was favored over private practice (80% vs. 15%). Of the respondents that secured an interview, 55% felt prepared for the interview, 67% felt prepared to build an adequate job portfolio, 33% received formal guidance from their mentor/training program. 89% of total respondents agreed it is important to participate in a formal training course in job search, portfolio development, and interviewing process. The preferred sources of training were equally distributed between their home institution, webinars, and SCCM. There is an ongoing need in education regarding the transition period from fellowship to practice.

Aligning use of intensive care with patient values in the USA: past, present, and future

For more than three decades, both medical professionals and the public have worried that many patients receive non-beneficial care in US intensive care units during their final months of life. Some of these patients wish to avoid severe cognitive and physical impairments, and protracted deaths in the hospital setting. Recognising when intensive care will not restore a person's health, and helping patients and families embrace goals related to symptom relief, interpersonal connection, or spiritual fulfilment are central challenges of critical care practice in the USA. We review trials from the past decade of interventions designed to address these challenges, and present reasons why evaluating, comparing, and implementing these interventions have been difficult. Careful scrutiny of the design and interpretation of past trials can show why improving goal concordant care has been so elusive, and suggest new directions for the next generation of research.

Staffing and workforce issues in the pediatric intensive care unit

The health care industry is in the midst of incredible change, and unfortunately, change is not easy. The intensive care unit (ICU) plays a critical role in the overall delivery of care to patients in the hospital. Care in the ICU is expensive. One of the best ways of improving the value of care delivered in the ICU is to focus greater attention on the needs of the critical care workforce. Herein, we highlight three major areas of concern-the changing model of care delivery outside of the traditional four walls of the ICU, the need for greater diversity in the pediatric critical care workforce, and the widespread problem of professional burnout and its impact on patient care.

Evaluation of Sex, Ethnic, and Racial Diversity Across US ACGME-Accredited Orthopedic Subspecialty Fellowship Programs

In recent years, there has been an increasing trend toward subspecialization in orthopedic surgery via fellowships. This study sought to characterize sex, ethnic, and racial representation within each fellowship program and to examine their changes over time to identify trends and/or gaps. Demographic data were obtained from the National Graduate Medical Education Census. Diversity was assessed using proportions of minority and female trainees. The trends in racial, ethnic, and sex diversity from 2006 to 2015 for orthopedics as a whole and within each subspecialty were analyzed. Of 3722 orthopedic fellows, 2551 identified as white (68.5%), 648 as Asian (17.4%), 175 as Hispanic (4.7%), 161 as black (4.3%), 8 as Native Hawaiian/Pacific Islander (0.21%), and 3 as American Indian/Alaskan Native (0.08%). Further, 479 identified as female (12.9%). Racial and ethnic minority representation among orthopedic fellows did not increase over time. Female representation did increase proportionally with female residents. Asian fellows preferred reconstructive adult and spine, whereas white fellows preferred sports medicine, hand surgery, and trauma. Female fellows preferred pediatrics, hand surgery, and musculoskeletal oncology. Although sex diversity among orthopedic fellows has increased in the past 10 years, racial and ethnic minority representation lacked similar growth. Asian and female fellows preferred specific subspecialties over others. These data are presented as an initial step in determining factors that attract minority groups to different orthopedic subspecialties. Further research should define specific factors and identify ways to increase minority distribution among fellowship programs. [Orthopedics. 2018; 41(5):282-288.].