A Society of General Internal Medicine Position Statement on the Internists’ Role in Social Determinants of Health

The Society of General Internal Medicine (SGIM) represents the world’s leading academic general internists, dedicated to creating a just system of care in which all people can achieve optimal health. SGIM recognizes that to achieve this vision, we must expand our reach beyond the medical office and hospital bedside to identify and address the broader structures and living conditions that influence health—the social determinants of health (SDOH). Centuries of institutionalized oppression in the form of racism, sexism, and other forms of bigotry have created and perpetuated disadvantage. These underlying social values have translated into public policies and structures which affect the distribution ofmoney and power across society. These in turn have shaped living conditions and access to resources, which influence health behaviors and access to care, and ultimately health outcomes. SGIM acknowledges the full spectrum of SDOH including upstream policies, midstream environmental and behavioral factors, and downstream individual and clinical issues. We highlight an important distinction between societal SDOH that require policy and systems-level change, with downstream unmet individual social needs, like homelessness or food insecurity. The entire range of SDOH impacts the work we do, our ability to care for our individual patients, our partnerships with local community organizations, and our impact on population health and equity. SDOH should also be integrated in how we teach future physicians and collaborate with our colleagues in public health, social work, government, research, and partners in non-health sectors

School Stock Inhaler Statutes and Regulations in the United States: A Systematic Review*

BACKGROUNDChildren with asthma should have immediate access to rescue medication. Yet, <15% of children have access to this life‐saving drug while at school.METHODSA search was conducted in the all states database of Westlaw to identify which the US states, territories, and the District of Columbia have a law for K‐12 schools. Terms searched included (inhaler or asthma/s medic!) and school and (prescription or order) from conception to December 2020. Demographic data from states with and without a policy were compared. All policies were examined for the following components: (1) type of law (statute or regulation); (2) type of school (charter, private/parochial or public); (3) training requirements; (4) devices; (5) prescriptive authority/safe harbor; (6) medication requirements; and (7) mandated documentation, reporting and funding.RESULTSOur systematic search revealed 15 locations with existing laws. States with a law had a higher percentage of children under 17‐years than states without a law (p = .02). Common components described were the applicability to various types of schools, training requirements for those empowered to administer, and civil liability protections for trained school personnel.CONCLUSIONSExisting stock inhaler laws differ vastly across the United States that may impact access to stock albuterol for children at their schools.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/172094/1/josh13142.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/172094/2/josh13142-sup-0001-Supinfo.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/172094/3/josh13142_am.pd

Gender Bias in Resident Assessment in Graduate Medical Education: Review of the Literature

BackgroundCompetency-based medical education relies on meaningful resident assessment. Implicit gender bias represents a potential threat to the integrity of resident assessment. We sought to examine the available evidence of the potential for and impact of gender bias in resident assessment in graduate medical education.MethodsA systematic literature review was performed to evaluate the presence and influence of gender bias on resident assessment. We searched Medline and Embase databases to capture relevant articles using a tiered strategy. Review was conducted by two independent, blinded reviewers. We included studies with primary objective of examining the impact of gender on resident assessment in graduate medical education in the USA or Canada published from 1998 to 2018.ResultsNine studies examined the existence and influence of gender bias in resident assessment and data included rating scores and qualitative comments. Heterogeneity in tools, outcome measures, and methodologic approach precluded meta-analysis. Five of the nine studies reported a difference in outcomes attributed to gender including gender-based differences in traits ascribed to residents, consistency of feedback, and performance measures.ConclusionOur review suggests that gender bias poses a potential threat to the integrity of resident assessment in graduate medical education. Future study is warranted to understand how gender bias manifests in resident assessment, impact on learners and approaches to mitigate this bias

Association of Gender with Learner Assessment in Graduate Medical Education

Importance: Gender bias may affect assessment in competency-based medical education.Objective: To evaluate the association of gender with assessment of internal medicine residents.Design, Setting, and Participants: This multisite, retrospective, cross-sectional study included 6 internal medicine residency programs in the United States. Data were collected from July 1, 2016, to June 30, 2017, and analyzed from June 7 to November 6, 2019. Exposures: Faculty assessments of resident performance during general medicine inpatient rotations.Main Outcomes and Measures: Standardized scores were calculated based on rating distributions for the Accreditation Council for Graduate Medical Education's core competencies and internal medicine Milestones at each site. Standardized scores are expressed as SDs from the mean. The interaction of gender and postgraduate year (PGY) with standardized scores was assessed, adjusting for site, time of year, resident In-Training Examination percentile rank, and faculty rank and specialty.Results: Data included 3600 evaluations for 703 residents (387 male [55.0%]) by 605 faculty (318 male [52.6%]). Interaction between resident gender and PGY was significant in 6 core competencies. In PGY2, female residents scored significantly higher than male residents in 4 of 6 competencies, including patient care (mean standardized score [SE], 0.10 [0.04] vs 0.22 [0.05]; P =.04), systems-based practice (mean standardized score [SE], -0.06 [0.05] vs 0.13 [0.05]; P =.003), professionalism (mean standardized score [SE], -0.04 [0.06] vs 0.21 [0.06]; P =.001), and interpersonal and communication skills (mean standardized score [SE], 0.06 [0.05] vs 0.32 [0.06]; P Conclusions and Relevance: In this study, resident gender was associated with differences in faculty assessments of resident performance, and differences were linked to PGY. In contrast to male residents' scores, female residents' scores displayed a peak-and-plateau pattern whereby assessment scores peaked in PGY2. Notably, the peak-and-plateau pattern was seen in assessments by male and female faculty. Further study of factors that influence gender-based differences in assessment is needed.</p

Association of Gender and Race/Ethnicity with Internal Medicine In-Training Examination Performance in Graduate Medical Education

BackgroundDisparities in objective assessments in graduate medical education such as the In-Training Examination (ITE) that disadvantage women and those self-identifying with race/ethnicities underrepresented in medicine (URiM) are of concern.ObjectiveExamine ITE trends longitudinally across post-graduate year (PGY) with gender and race/ethnicity.DesignLongitudinal analysis of resident ITE metrics at 7 internal medicine residency programs, 2014-2019. ITE trends across PGY of women and URiM residents compared to non-URiM men assessed via ANOVA. Those with ITE scores associated with less than 90% probability of passing the American Board of Internal Medicine certification exam (ABIM-CE) were identified and odds of being identified as at-risk between groups were assessed with chi square.ParticipantsA total of 689 IM residents, including 330 women and URiM residents (48%).Main measuresITE score KEY RESULTS: There was a significant difference in ITE score across PGY for women and URiM residents compared to non-URiM men (F(2, 1321) 4.46, p=0.011). Adjusting for program, calendar year, and baseline ITE, women and URiM residents had smaller ITE score gains (adjusted mean change in score between PGY1 and PGY3 (se), non-URiM men 13.1 (0.25) vs women and URiM residents 11.4 (0.28), p&lt;0.001). Women and URiM residents had greater odds of being at potential risk for not passing the ABIM-CE (OR 1.75, 95% CI 1.10 to 2.78) with greatest odds in PGY3 (OR 3.13, 95% CI 1.54 to 6.37).ConclusionDifferences in ITE over training were associated with resident gender and race/ethnicity. Women and URiM residents had smaller ITE score gains across PGY translating into greater odds of potentially being seen as at-risk for not passing the ABIM-CE. Differences in ITE over training may reflect differences in experiences of women and URiM residents during training and may lead to further disparities

Exploring gender and thematic differences in qualitative assessments of internal medicine resident performance

Introduction: Evidence suggests gender disparities in medical education assessment, including differences in ratings of competency and narrative comments provided in resident performance assessments. This study explores how gender manifests within the content of qualitative assessments (i.e., narrative comments or performance feedback) of resident performance. Methods: Qualitative content analysis was used to explore gender-based differences in narrative comments included in faculty assessments of resident performance during inpatient medicine rotations at six Internal Medicine residency programs, 2016-2017. A blinded, multi-analyst approach was employed to identify themes across comments. Patterns in themes with resident gender and post-graduate year (PGY) were explored, focusing on PGY2 and PGY3 when residents are serving in the team leader role. Results: Data included 3,383 evaluations with narrative comments of 385 men (55.2%) and 313 women residents (44.8%). There were thematic differences in narrative comments received by men and women residents and how these themes manifested within comments changed with training time. Compared to men, comments about women had a persistent relationship-orientation and emphasized confidence over training including as interns and in PGY2 and PGY3, when serving as team leader. The relationship-orientation was characterized not only by the residents' communal attributes but also their interpersonal and communication skills, including efforts supporting others and establishing the tone for the team. Comments about women residents often highlighted confidence, including recommendations around behaviors that convey confidence in decision-making and team leadership. Discussion: There were gender-based thematic differences in qualitative assessments. Comments about women resident team leaders highlight relationship building skills and urge confidence and actions that convey confidence as team leader. Persistent attention to communal skills suggests gendered expectations for women resident team leaders and a lost opportunity for well-rounded feedback to the disadvantage of women residents. These findings may inform interventions to promote equitable assessment, such as providing feedback across the competencies.</p