Journal of General Internal Medicine

BackgroundThe COVID-19 pandemic dramatically altered the landscape of medical education. While patients overwhelmed hospital systems, lockdowns and social distancing recommendations took priority, and medical education was pushed online. Early in 2020, New York State (NYS) was hit especially hard by COVID-19. ObjectiveThis study sought to understand the effect of the COVID-19 pandemic on medical students well-being and education. MethodsNYS medical students responded to a six-question survey during April and May 2020. Questions assessed self-reported changes in stress levels, academic performance, and board preparation efforts. Open-ended data was analyzed using a modified grounded theory approach. Results488 responses across 11 medical schools were included (response rate of 5.8%). Major themes included: standardized test-related stressors (23%), study-related changes (19%), education and training concerns (17%), financial stressors (12%), and additional family obligations (12%). Second year students reported more stress/anxiety than students in other years (95.9%, p-value< 0.00001). Reported stress/anxiety, effects on exam preparation, and anticipated academic effect varied by geographics. ConclusionsWhile all NYS medical students reported being greatly affected, those closest to the NY City pandemic epi-center and closest to taking the Step 1 exam were the most distressed. Lack of flexibility of the medical education system during this public health emergency contributed to worsened student well-being. It is time to make plans for supporting the long-term mental health needs of these physicians-in-training and to examine ways the academic medical community can better adapt to the needs of students affected by a large public health emergency in the future.

ObjectivesTo characterize emergency department (ED) clinician engagement with electronic health record (EHR)-based social drivers of health (SDOH) data; test whether engagement differs in encounters with opioid use disorder (OUD); and, among OUD encounters, assess whether engagement is associated with medications for OUD (MOUD) treatment. Materials and MethodsWe conducted a cross-sectional study of adult ED encounters (January 2023-October 2024). OUD encounters, identified with a structured phenotype, were matched (1:2) to non-OUD encounters. Audit logs captured clinician engagement with structured SDOH questions ("SDOH Wheel"), ICD-10 Z codes in the Problem List, Social History free text, and social work notes. Engagement was any SDOH documentation or review of preexisting SDOH data during the encounter. Logistic regression estimated associations. ResultsAmong 17,103 encounters (5,701 OUD; 11,402 non-OUD), clinician SDOH documentation was rare (<1%). Clinicians most often reviewed Z codes (610/620; 98.4%), followed by the SDOH Wheel (1,103/3,953; 27.9%), social work notes (1,711/10,670; 16.0%), and Social History free text (232/6,942; 3.3%). Engagement occurred in 19.5% of encounters and was higher with OUD (26.6% vs 16.0%; adjusted odds ratio [aOR] 1.91, 95% CI 1.77-2.07). Among OUD encounters, engagement showed no clear association with MOUD (aOR 1.11, 95% CI 0.84-1.47), yet racial and ethnic disparities persisted. DiscussionED clinicians infrequently document but do review structured, accessible SDOH data. Engagement is higher in OUD encounters yet shows no definitive link with MOUD, while disparities persist. Interface designs that surface SDOH and targeted EHR decision support warrant evaluation to inform equitable, time-sensitive ED care.

In July 2020, four months into the disruption of normal life caused by the Covid-19 pandemic, we assessed the institutional climate within the School of Medicine. Voluntary surveys were completed by 135 graduate students in 11 PhD-granting programs and by 83 members of the graduate training faculty. Several themes emerged. PhD students work hard, but the number of hours spent on research-related activities has declined during the pandemic. The students are worried about the pandemics impact on their research productivity, consequent delays in their graduation, and diminished future job prospects. Many late stage PhD students feel they do not have adequate time or resources to plan for their future careers. Symptoms of anxiety and/or depression are prevalent in 51% of the students, based on answers to standardized questions. Most students report they have strong mentoring relationships with their faculty advisors and like their programs, but they identify to a lesser extent with the medical school as a whole. Faculty think highly of their graduate students and are also worried about the pandemics impact upon productivity and the welfare of students. Students are interested in access to an Ombuds office, which is currently being organized by the medical school. Moving forward, the school needs to address issues of bias, faculty diversity, support for mentor training, professional development, and the imposter syndrome. We must also work to create a climate in which many more graduate students feel that they are valued members of the academic medicine community.

The regulatory body for psychologists in Ontario, the College of Psychologists and Behavior Analysts of Ontario, has proposed sweeping reductions in competency requirements. These include elimination of the doctoral degree requirement, dramatic reductions in clinical training, and elimination of specializations and would make Ontario the largest jurisdiction with the lowest competency standards in North America. There has been considerable public opposition from active practitioners, but public attitudes toward these changes are unknown. The current study assessed attitudes in 1,141 general community adults in Ontario (mean age = 42.7, 62.1% female) in an ongoing longitudinal observational cohort study. The large majority disapproved of the proposed changes (71%), whereas 20% reported no opinion and 9% approved of the changes. The modal response was strong disapproval (44%), which was more than half of those who disapproved, whereas among those who approved, only a small proportion expressed strong approval (2%). In order of frequency, reasons for disapproval were reduced quality of healthcare (94%), more healthcare providers with a lower skillset and competencies (85%), higher probability of misdiagnosis (78%), and increased risk in high-stakes contexts (69%), increased likelihood of conflicting medical opinions (55%), and adverse impacts on the current workforce and trainees (both 54%). When asked about the single most important concern, 62% identified reduced quality of healthcare followed by an increased number of healthcare providers with lower professional competency (22%). Responses to open text options were highly consistent with the quantitative results (e.g., "We dont need fewer professional standards--we need highly skilled professionals to deal with an increasingly complex world."). Collectively, the results suggest strong disapproval for the proposed reductions in psychologist competency standards among general community adults in Ontario. VISUAL ABSTRACT O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=71 SRC="FIGDIR/small/25340610v1_ufig1.gif" ALT="Figure 1"> View larger version (19K): org.highwire.dtl.DTLVardef@cdba53org.highwire.dtl.DTLVardef@83de21org.highwire.dtl.DTLVardef@16c75edorg.highwire.dtl.DTLVardef@1b2380e_HPS_FORMAT_FIGEXP M_FIG Simplified Distribution of Public Attitudes toward Psychologist Competency Reductions (n=1,141) C_FIG

ImportanceDiscriminatory language in clinical documentation impacts patient care and reinforces systemic biases. Scalable tools to detect and mitigate this are needed. ObjectiveDetermine utility of a frontier large language model (GPT-4) in identifying and categorizing biased language and evaluate its suggestions for debiasing. DesignCross-sectional study analyzing emergency department (ED) notes from the Mount Sinai Health System (MSHS) and discharge notes from MIMIC-IV. SettingMSHS, a large urban healthcare system, and MIMIC-IV, a public dataset. ParticipantsWe randomly selected 50,000 ED medical and nursing notes from 230,967 MSHS 2023 adult ED visiting patients, and 500 randomly selected discharge notes from 145,915 patients in MIMIC-IV database. One note was selected for each unique patient. Main Outcomes and MeasuresPrimary measure was accuracy of detection and categorization (discrediting, stigmatizing/labeling, judgmental, and stereotyping) of bias compared to human review. Secondary measures were proportion of patients with any bias, differences in the prevalence of bias across demographic and socioeconomic subgroups, and provider ratings of effectiveness of GPT-4s debiasing language. ResultsBias was detected in 6.5% of MSHS and 7.4% of MIMIC-IV notes. Compared to manual review, GPT-4 had sensitivity of 95%, specificity of 86%, positive predictive value of 84% and negative predictive value of 96% for bias detection. Stigmatizing/labeling (3.4%), judgmental (3.2%), and discrediting (4.0%) biases were most prevalent. There was higher bias in Black patients (8.3%), transgender individuals (15.7% for trans-female, 16.7% for trans-male), and undomiciled individuals (27%). Patients with non-commercial insurance, particularly Medicaid, also had higher bias (8.9%). Higher bias was also seen in health-related characteristics like frequent healthcare utilization (21% for >100 visits) and substance use disorders (32.2%). Physician-authored notes showed higher bias than nursing notes (9.4% vs. 4.2%, p < 0.001). GPT-4s suggested revisions were rated highly effective by physicians, with an average improvement score of 9.6/10 in reducing bias. Conclusions and RelevanceA frontier LLM effectively identified biased language, without further training, showing utility as a scalable fairness tool. High bias prevalence linked to certain patient characteristics underscores the need for targeted interventions. Integrating AI to facilitate unbiased documentation could significantly impact clinical practice and health outcomes.

Stress is a significant contributor to suicide ideation and attempts. This paper (1) describes the frequency of clinic visits in which physicians record stress management counseling; and (2) identifies visit-, physician-, and patient-related predictors of stress management counseling. We conducted a secondary analysis of the 2018 and 2019 National Ambulatory Medical Care Survey (NAMCS) clinic visit datasets. We identified clinic-, patient-, and physician-related predictors of stress management counseling. All analyses used weighted adjustment to account for the complex survey design. The weighted sample included 1,495,326,615 visits (unweighted (n=14,175) in 2018-2019. Combined, 1.32 per 100 visits (95% CI=0.72-1.92) included stress management counseling. Stress management counseling was less likely to occur when the visit occurred in a rural area (OR=0.22, 95% CI=0.09-0.53), among other characteristics. Stress management counseling rarely occurs during physician office visits in rural areas, despite rural areas suffering disproportionately worse health outcomes than urban areas.

ObjectivesTo assess the value of an AI-powered conversational agent in supporting diabetes self-management among adults with diabetic retinopathy and limited educational backgrounds. MethodsIn this cross-sectional study, 51 adults with Type{square}II diabetes and diabetic retinopathy participated in moderated Q-and-A sessions with ChatGPT. Non-English-speaking and visually impaired participants interacted through trained human support. Each question- response pair was assigned to one of seven thematic categories and independently evaluated by endocrinologists and ophthalmologists using the 3C{square}+{square}2 framework (clarity, completeness, correctness, safety, recency). Inter-rater reliability was calculated with intraclass correlation coefficients (ICC) and Fleiss{square}Kappa. ResultsThe cohort generated 137 questions, and 98{square}% of the conversational agents answers were judged informative and empathetic. Endocrinologists awarded high mean scores for clarity (4.66/5) and completeness (4.52/5) but showed limited agreement (ICC{square}={square}0.13 and{square}0.27). Ophthalmologists gave lower mean scores for clarity (3.09/5) and completeness (2.94/5) yet demonstrated stronger agreement (ICC{square}={square}0.70 and{square}0.52). Reviewers detected occasional inaccuracies and hallucinations. Participants valued the agent for sensitive discussions but deferred to physicians for complex medical issues. ConclusionsAn AI conversational agent can help bridge communication gaps in diabetes care by providing accurate, easy-to-understand answers for individuals facing language, literacy, or vision-related barriers. Nonetheless, hallucinations and variable specialist ratings underscore the need for continuous physician oversight and iterative refinement of AI outputs. Practice implicationsIntroducing conversational AI into resource-limited clinics could enhance patient education and engagement, provided that clinicians review and contextualise the advice to ensure safety, accuracy, and personalisation. Future development should prioritise reducing hallucinations and bolstering domain-specific reliability so the tool complements, rather than replaces, professional care.

ObjectiveThis study compared primary care physicians self-reported experiences with Electronic Health Records (EHR) interoperability, as reported across three surveys: the 2022 Continuous Certification Questionnaire (CCQ) from the American Board of Family Medicine, the 2022 University of California San Franciscos (UCSF) Physician Health IT Survey, and the 2021 National Electronic Health Records Survey (NEHRS). Materials and MethodsWe used descriptive analyses to identify differences between survey pairs. To account for weighting in NEHRS and UCSF, we assessed the significance of differences using the Rao-Scott corrected chi-square test. ResultsCCQ received 3,991 responses, UCSF received 1,375 from primary care physicians, and NEHRS received 858 responses from primary care physicians. Response rates were 100%, 3.6%, and 18.2%, respectively. Substantial and largely statistically significant differences in response were detected across the three surveys. For instance, 22.2% of CCQ respondents said it was very easy to document care in their EHR, compared to 15.2% in NEHRS, and 14.8% in the UCSF survey. Approximately one-third of respondents across surveys said documenting care in their EHR was somewhat or very difficult. The surveys captured different respondent types with CCQ respondents trending younger, and NEHRS respondents more likely to be in private practice. DiscussionAll surveys pointed to room for improvement in EHR usability and interoperability. The differences observed, likely driven by differences in survey methodology and response bias, were likely substantial enough to impact policy decisions. ConclusionDiversified data sources, such as those from specialty boards, may aid in capturing physicians experiences with EHRs and interoperability.

ObjectiveTo determine the extent to which family physicians closed their doors altogether or for in-person visits during the pandemic, their future practice intentions, and related factors. MethodsBetween March and June 2021, we conducted a cross-sectional survey using email, fax, and phone of 1,186 family doctors practicing comprehensive family medicine in Toronto, Ontario. We asked about practice patterns in January 2021, use of virtual care, and practice intentions. ResultsOf the 1,016 (86%) that responded to the survey, 99.7% (1001/1004) indicated their practice was open in January 2021 with 94.8% (928/979) seeing patients in-person and 30.8% (264/856) providing in-person care to patients reporting COVID-19 symptoms. Respondents estimated spending 58.2% of clinical care time on phone visits and an additional 5.8% on video and 7.5% on email. 17.2% (77/447) were planning to close their current practice in the next five years. There was a higher proportion of physicians who worked alone in a clinic among those who did not see patients in-person (27.6% no vs 12.4% yes, p<0.05), did not see symptomatic patients (15.6% no vs 6.5 % yes, p<0.001), and those who planned to close their practice in the next 5 years (28.9% yes vs 13.9% no, p<0.01). InterpretationThe vast majority of family physicians in Toronto were open to in-person care in January 2021 but almost one-fifth are considering closing their practice in the next five years. Policy-makers need to prepare for a growing family physician shortage and better understand factors that support recruitment and retention.

BACKGROUNDThe social media site Twitter has been widely embraced in medical circles for its ability to connect individuals and support rapid information sharing. Critics say that the messages shared may not accurately reflect what was said and that sharing meeting content could devalue conferences themselves. It is unclear how it is used at SSIEM and what value it may bring. METHODSTwitters tweetdeck software was used to find all tweets containing the conference hashtag #SSIEM2018. All tweets were reviewed to identify the author, see what had been shared and count replies, likes and retweets. Authors were grouped by professional background and tweet content was broken down by type of material shared and theme. RESULTS122 relevant tweets were sent during the fortnight at the beginning of September 2018, creating over 400,000 impressions. There were a further 73 replies with approximately 13 engagements (likes, replies or retweets) per tweet. 36 people wrote tweets (rate: 3.4 per person [1-33]). One quarter of the tweets shared poster content and over one third of tweets related to Phenylketonuria materials. 50 of the tweets were produced by just two accounts, both intended to provide information to patients and their families. DISCUSSIONTweets where no hashtag was used cannot be identified and restrictions within Twitter prevent certain analyses on tweet data greater than 30 days old. However, Twitter uptake within metabolic medicine is significantly behind other specialities where conference tweets can exceed 20,000. Information shared is typically intended for patients rather than other health professionals; this suggests a different uptake to more mainstream specialities. Presenting teams should be aware that their work may be received directly by patients and families and consider how best to present their messages for all who may receive them.

BackgroundLong-acting injectable buprenorphine (LAI-BUP) is safe and effective, however is dramatically underutilized in comparison to oral formulations. Little is known regarding how buprenorphine prescribers view LAI-BUP, and which medication attributes they prioritize when selecting treatment for opioid use disorder (OUD). MethodsA secondary analysis of a national, cross-sectional online survey of U.S. physicians who prescribe buprenorphine for OUD was conducted. Respondents reported OUD caseload, LAI-BUP use, and the importance of medication attributes relevant to treatment selection (e.g., efficacy, safety, ease of administration, ease of prescribing, and administrative requirements). Providers were categorized as no LAI-BUP use or, among LAI-BUP prescribers, Low vs High use based on a median split. Group comparisons used chi-square (or Fishers exact) tests for categorical variables and Jonckheere-Terpstra tests for ordinal responses. ResultsAmong 125 respondents, 39 (31.2%) reported no patients receiving LAI-BUP. The remaining 86 (68.8%) were LAI-BUP prescribers, split evenly into Low and High (ns=43; 34.4%) groups using a median cut of 23.2%. LAI-BUP use did not differ meaningfully by specialty, region, or practice setting. Greater LAI-BUP use was reported by providers with larger OUD panels. Ratings of key medication attributes were uniformly high. ConclusionsLAI-BUP remains underused, with uptake highest among clinicians managing larger OUD caseloads. Measured attitudes toward medication attributes did not explain these differences. Future work should assess clinic workflow, staffing, reimbursement, and REMS burden, testing targeted implementation strategies using mixed-methods trials. Identifying what shifts clinicians from no use to low and high use may guide scalable implementation interventions.

Despite the persistent underrepresentation of women--particularly those from racially and ethnically minoritized groups--in clinical research, little is known about their perspectives on participation. This study examined healthcare experiences, access, and attitudes toward clinical trials among U.S. women and assessed how race, socioeconomic status, and healthcare access intersect to shape willingness to participate (WTP). We conducted a national cross-sectional online survey (January-March 2023) of 5,301 women aged 18-70 years. The 81-item questionnaire assessed demographics, health status, healthcare access, and clinical trial experiences. Among 4,987 respondents reporting race (77% White, 14% Black, 7% Asian, 2% Other), nearly 80% expressed interest in participating in clinical trials, yet only 11% had been invited and 7% had enrolled. In adjusted models, WTP was lower among Black ({beta} = -0.06; P = .04) and Asian ({beta} = -0.09; P = .01) women than among White women, whereas higher educational attainment and multimorbidity predicted greater WTP. Altruism, clear study explanations, and financial compensation were key motivators, while time burden and concerns about side effects were major barriers, with the salience of these factors varying by race. Most respondents (88%) endorsed the importance of womens inclusion and sex-specific reporting, though neutrality on these issues was more frequent among racially minoritized women. Despite high interest, structural and informational barriers continue to constrain womens engagement in clinical research, underscoring the need for trust-building, burden-reducing, and culturally responsive strategies to promote equitable participation and improve representation across racial groups.

The COVID-19 pandemic has claimed nearly one million lives and has drastically changed how patients interact with the healthcare system. Emergency medical services (EMS) are essential for emergency response, disaster preparedness, and responding to everyday emergencies. We therefore examined differences in EMS utilization and call severity in 2020 (pandemic period) compared to trends from 2015-2019 (pre-pandemic period) in a large, multi-state advanced life support EMS agency serving the U.S. Upper Midwest. Specifically, we analyzed all 911 calls made to Mayo Clinic Ambulance, the sole advanced life support EMS provider serving a large area in Minnesota and Wisconsin, in 2020 compared to those made between 2015-2019. We compared the number of emergency calls made in 2020 to the number of calls expected based on trends from 2015-2019. We similarly compared caller demographics, call severity, and proportions of calls made for overdose/intoxication, behavioral health, and motor vehicle accidents. Subgroup analyses were performed for rural vs. urban areas. We identified 262,232 emergent EMS calls in the pre-pandemic period and 53,909 calls in the pandemic period, corresponding to a decrease of 28.7% in call volume during the pandemic period. Caller demographics shifted towards older patients (mean age 59.7 [SD, 23.0] vs. 59.1 [SD, 23.7] years; p<0.001) and to rural areas (20.4% vs. 20.0%; p=0.007). Call severity increased, with 95.3% of calls requiring transport (vs. 93.8%; p<0.001) and 1.9% resulting in death (vs. 1.6%; p<0.001). The proportion of calls for overdose/intoxication increased from 4.8% to 5.5% (p<0.001), while the proportion of calls for motor vehicle collisions decreased from 3.9% to 3.0% (p<0.001). All changes were more pronounced in urban areas. These findings underscore the extent to which the COVID-19 pandemic impacted healthcare utilization, particularly in urban areas, and suggest that patients may have delayed calling EMS with potential implications on disease severity and risk of death.

BackgroundBurnout among medical residents is common. One source of burnout is the need to complete redundant administrative tasks such as onboarding processes at various hospitals. ObjectivesTo quantify the time residents at the University of Toronto spend onboarding at teaching hospitals, to identify areas of redundancy in onboarding processes, and to identify trainee perceptions of onboarding processes. MethodsWe conducted a quality improvement survey of core internal medicine residents at the University of Toronto where residents rotate through multiple different teaching hospitals. The primary outcome was time spent onboarding. Secondary outcomes included perceptions of the onboarding process, and impact on well-being. Results41% (N=93) of all Internal Medicine residents completed the survey. Most (n=81, 87%) rotated through at least four hospitals and 24 (26%) rotated through more than 5 in the preceding year. The median number of hours spent on the onboarding process was 5 hours per hospital (IQR 1-8) and these tasks were often completed when trainees were post-call (82%, n=76) or outside of work hours (97%, n= 90). The cumulative number of hours spent each year on onboarding tasks by the 93 trainees was 2325 hours (97 days) which extrapolates to 5625 hours (234 days) for all 225 trainees in the core internal medicine program. Most residents reported high levels of redundancy across hospital sites (n=79, 85%) and felt that their well-being was negatively affected (73%, n=68). ConclusionsThe median internal medicine resident at the University of Toronto spent 5 hours onboarding for each hospital. There is considerable redundancy and the process contributes to self-reported burnout.

Importance Missed outpatient appointments, including no-shows and cancellations, may disrupt continuity of care and be associated with worse outcomes, but long-term system-wide patterns and clinical implications are not well characterized. Objective To characterize variation in missed appointment rates in the Veterans Health Administration (VHA) over time and by geographic location, visit modality, and preexisting conditions, and to evaluate associations between missed appointment rates and adverse outcomes among veterans with posttraumatic stress disorder (PTSD) or traumatic brain injury (TBI). Design Cohort study using VHA Corporate Data Warehouse outpatient appointment data from January 1, 2000, through December 31, 2024. Setting National integrated health care system of the VHA. Participants System analysis includes all scheduled outpatient appointments with a valid status, and outcome analysis includes veterans with PTSD (n = 1 429 890) or TBI (n = 554 553), diagnosed before 2023. Exposures For system -level analyses, missed appointment rates were calculated. In outcome analyses, 2023 missed appointment rates were categorized into tertiles within the cohort and appointment type. Main Outcomes and Measures One year risks of all-cause hospitalization, all-cause mortality, and hospitalization or death beginning January 1, 2024. Results Among 2,162,520,880 outpatient appointments from 2000 to 2024, 6.5% were no-shows and 25.4% were canceled. Across facilities, no-show rates ranged from 3.5% to 14.1%, patient-initiated cancellation rates from 9.7% to 26.0%, and clinic-initiated cancellation rates from 8.5% to 17.9%. In 2023, veterans with amputation, Parkinson disease, PTSD, or TBI had higher missed appointment rates than veterans without these conditions. Among veterans with PTSD, the highest no-show tertile, compared with none, was associated with higher mortality (HR, 1.91; 95% CI, 1.84-1.98) and hospitalization or death (HR, 1.07; 95% CI, 1.05-1.08). Among veterans with TBI, the highest no-show tertile was associated with hospitalization or death (HR, 1.65; 95% CI, 1.61-1.69). Conclusions and Relevance Missed outpatient appointments were common in the VHA and varied substantially across facilities and over time. Among veterans with PTSD or TBI, higher missed appointment rates, particularly no-shows, were associated with increased risks of hospitalization and mortality, suggesting that these patterns may help identify high-risk veterans for targeted outreach.

IntroductionThe COVID-19 pandemic exacerbated long-standing healthcare disparities, disproportionately affecting racial, ethnic, sexual, and gender minoritized populations. Structural inequities fuel medical mistrust and hinder equitable vaccine access. Culturally responsive communication (CRC) is a critical strategy in primary care that has the potential to improve patient-provider interactions and vaccine acceptance. ObjectivesThis scoping review examines how CRC is conceptualized and implemented in clinical interactions related to COVID-19 vaccination and booster screening for minoritized populations. It assesses the scope of CRC research, the clarity of definitions, the extent of implementation, and its clinical applicability. MethodsFollowing Arksey and OMalleys framework and PRISMA-ScR guidelines, we conducted a literature search across four databases, analyzing studies published between November 2019 and 2022. Extracted data included CRC definitions, communication strategies, and interventions from 22 eligible studies. ResultsResearch on CRC in the context of COVID-19 vaccination is limited and inconsistent. Most studies focused on Black and Hispanic populations, with a critical gap in research addressing sexual and gender minorities. CRC terminology was often interchangeable with concepts like cultural competence, leading to definitional inconsistencies. Because public health messaging was a primary focus, direct clinical applications of CRC were underexplored. DiscussionOur findings highlight an urgent need for a standardized CRC framework to enhance healthcare equity. The absence of a clear, universally accepted definition hinders CRCs practical application and measurability in clinical settings. Future research should refine CRC conceptualization, establish measurable interventions, and expand inclusivity to sexual and gender minorities to foster more equitable healthcare practices.

BackgroundLittle is known about public perceptions of antivirals for the treatment of mild-to-moderate COVID-19 in the United States (US). Our objective was to explore adult perceptions toward COVID-19 antivirals with the goal of improving outreach communications about antivirals for COVID-19. MethodsDuring July 2022, potential respondents 18 years and older were randomly sampled from a national opt-in, non-representative, cross-sectional internet panel, with oversampling of African Americans, Hispanics, and adults 65 years and older. Respondents were asked about sociodemographic factors, and knowledge, attitudes, and perceptions regarding COVID-19 antivirals. Results were weighted to represent the non-institutionalized US adult population. ResultsAmong 1,155 respondents, 51% were female, 60% were 18-49 years, 21% were 50-64 years, and 19% were 65 years or older. Compared to those aged 18-49 years and 50-64 years, a greater proportion of adults 65 years and older were knowledgeable about COVID-19 antivirals and would take them if they tested positive or their doctor recommended them. Adults 65 years and over and those reporting immunosuppression or disability had the highest rates of willingness to take antivirals. For all groups, the proportion of people willing to take antivirals increased by >20% if recommended by their doctor. Respondents in the 50-64 and 65+ groups who were sure they would take COVID-19 antivirals were more likely to be fully vaccinated and less likely to be living in isolation. ConclusionGroups that are less likely to have been vaccinated, those living in isolation, and those not sure about whether they would take an antiviral or not may be at risk for not receiving treatment to prevent severe COVID-19 outcomes. However, trust in doctor recommendations may be enough to overcome individual patient concerns about COVID-19 antivirals. Targeted initiatives to educate those at risk for severe COVID-19 outcomes about the effectiveness of antivirals, including those who are unvaccinated given their increased risk of severe disease, may be needed to further lower this populations risk of severe COVID-19.

BackgroundRandomized trials evaluating emergency treatments may be conducted with Exception from Informed Consent (EFIC) when prospective informed consent is infeasible. In EFIC trials, a period of community consultation and public disclosure precedes initiation of enrollment. The Randomized Trial of Sedative Choice for Intubation (RSI) is a 2,364-patient randomized trial being conducted with EFIC in 14 emergency departments and intensive care units across the United States. This manuscript reports the approach to community consultation and public disclosure in the RSI trial. MethodsCommunity consultation and public disclosure were conducted locally in each of the 5 regions of enrolling sites. The coordinating center provided sites with templates and access to an engagement coordinator to assist with developing and executing site plans. ResultsCommunity consultation and public disclosure occurred at the coordinating center from February 2021-January 2022 and in the regions of the five additional enrolling sites from September 2023-June 2024. Community consultation included in-person surveys with 789 patients or family members in emergency department or intensive care unit waiting rooms and invitation of more than 200 local groups to town halls or community engagement studios. Public disclosure included (i) social media advertisements viewed more than 1.2 million times, (ii) a trial website with more than 16,000 unique visitors, (iii) informational flyers in hospitals and public settings, and (iv) featured information in traditional media. Completing local community consultation and public disclosure required an average of 139 hours of research personnel time and approximately $18,822 at each site, in addition to coordinating center effort and costs. ConclusionsPre-trial community consultation activities in the RSI trial engaged over 1,000 patients, families, and community members and public disclosure reached over 1.2 million community members. While the total cost and duration of activities at sites were substantially lower than reported in prior EFIC trials, these costs remained significant.

BackgroundCare fragmentation has been linked to overuse and higher costs. Evidence on how fragmentation relates to outpatient imaging in the general U.S. population remains limited. ObjectiveTo quantify the association between care fragmentation and outpatient imaging utilization and radiology expenditures among U.S. adults, and to test whether associations differ by multimorbidity and insurance. DesignCross-sectional, survey-weighted analysis using the Medical Expenditure Panel Survey (MEPS) 2020. ParticipantsAdults aged[&ge;] 18 years in MEPS 2020 with non-missing survey design variables. ExposuresCare fragmentation category (None/Low/Medium/High), defined using person-level utilization breadth and intensity from the Full-Year Consolidated file. Main outcomes and measuresPrimary outcomes included any advanced imaging (receipt of at least one MRI, CT, or ultrasound during office-based visits) and total radiology expenditures (sum of payments for imaging-flagged office-based visits). Secondary outcomes included any imaging, imaging visit count, and radiology spending as a proportion of total expenditures. ResultsIn survey-weighted models (reference = Low; "None" excluded from regressions), Medium fragmentation was associated with higher odds of any advanced imaging (OR 1.42, 95% CI 1.23-1.64), whereas High did not further increase the probability (OR 0.92, 0.71-1.19). Fragmentation substantially increased intensity: imaging visit counts (RR 2.51 Medium; 3.96 High vs Low) and radiology spending among spenders (2.36x Medium; 3.96x High vs Low). Older age (50-64, 65+), female sex, and Medicare coverage independently raised both imaging probability and spend. ConclusionsCare fragmentation is associated with both increased probability and intensity of advanced imaging utilization, with particularly strong effects on radiology expenditures among adults with positive spending. Findings support targeted interventions to improve care coordination and reduce potentially unnecessary imaging in fragmented care environments.

IntroductionThe COVID-19 pandemic disrupted research globally. How it impacted Canadian early-career health researchers (ECHRs) remains unclear. We administered a survey to understand the composition of ECHRs in Canada, their job experiences, and experiences of burnout during the COVID-19 pandemic. MethodsA cross-sectional survey was conducted in May 2023 of Canadian ECHRs defined as within 7 years of their first independent research position. Quantitative analyses included a description of respondents by research pillar, socio-demographic and workplace characteristics, and the prevalence of burnout, disengagement or exhaustion. Sample characteristics were compared to national data on ECHRs from a Canadian funding agency. Thematic analysis of free-text responses was also conducted. ResultsA total of 225 respondents met the eligibility criteria. Most respondents were assistant professors and characteristics of our sample were like the national data. The COVID-19 pandemic posed many challenges to student recruitment, and emotional support of students, with over half of the respondents reporting a moderate to significant decline in mental health compared to pre-pandemic. A significant proportion of respondents were experiencing high burnout (62%, 95%CI:56-67%), exhaustion (64%, 95%CI: 57-70%) or disengagement (91%, 95%CI: 87-95%). Thematic analysis identified three themes: ongoing benefits/problems preceding the pandemic, unintended outcomes of strategies to manage/prevent/contain COVID-19, and reasons to stay in their current position. ConclusionsOur survey revealed that Canadian ECHRs reported many diverse challenges during the COVID-19 pandemic and high burnout, putting the sustainability of this workforce at risk. Improved systems are needed to understand the long-term impacts and support the future of the Canadian health research ecosystem.