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Background and Objectives: Faculty development (FD) is required for medical educators, yet few studies address its long-term career impact on graduates. This project presents the impact of FD on career development, as perceived by physician faculty graduates of a longitudinal primary care FD educator program, compared to nonenrollees. Methods: Between 2011 and 2016, 33 physician faculty from three departments participated in monthly half-day in-class FD for 20 months, emphasizing educator skills and career development. After physician-graduates were stratified by year, 10 were randomly selected and matched with 10 nonparticipants (controls) by specialty, gender, academic rank, and time in academic medicine. Narrative responses from semistructured interviews were recorded in a common template. Qualitative analysis methods identified themes, with agreement obtained by researchers. Results: Median time in academic medicine for FD graduates (50% male) was 5.5 years; controls 7.5 years (40% male). Common themes across all respondents included that they: value their roles as clinical teachers; define success as training high-quality, competent physicians; align their professional aims with organizational priorities; manage commitments; develop and sustain colleague networks; and seek continued growth. Within themes, FD graduates differed from controls, detailing greater perceived success and growth as educators, placing higher value on scholarly products and academic promotion, and having more expansive local and national colleague networks. Conclusions: FD graduates, compared to matched controls, report expanded clinician-educator scope and roles, and a greater value on scholarly activity. This evaluation provides the groundwork for further investigations.

Objective To explore leadership perspectives on how to maintain high quality efficient care that is also person-centered and humanistic. Methods The authors interviewed and collected narrative transcripts from a convenience sample of 32 institutional healthcare leaders at seven U.S. medical schools. The institutional leaders were asked to identify factors that either promoted or inhibited humanistic practice. A subset of authors used the constant comparative method to perform qualitative analysis of the interview transcripts. They reached thematic saturation by consensus on the major themes and illustrative examples after six conference calls. Results Institutional healthcare leaders supported vision statements, policies, organized educational and faculty development programs, role modeling including their own, and recognition of informal acts of kindness to promote and maintain humanistic patient-care. These measures were described individually rather than as components of a coordinated plan. Few healthcare leaders mentioned plans for organizational or systems changes to promote humanistic clinician-patient relationships. Conclusions Institutional leaders assisted clinicians in dealing with stressful practices in beneficial ways but fell short of envisaging systems approaches that improve practice organization to encourage humanistic care. PRACTICE IMPLICATIONS: To preserve humanistic care requires system changes as well as programs to enhance skills and foster humanistic values and attitudes.

Background Changes in the organization of medical practice have impeded humanistic practice and resulted in widespread physician burnout and dissatisfaction. Objective To identify organizational factors that promote or inhibit humanistic practice of medicine by faculty physicians. Design From January 1, 2015, through December 31, 2016, faculty from eight US medical schools were asked to write reflectively on two open-ended questions regarding institutional-level motivators and impediments to humanistic practice and teaching within their organizations. Participants Sixty eight of the 92 (74%) study participants who received the survey provided written responses. All subjects who were sent the survey had participated in a year-long small-group faculty development program to enhance humanistic practice and teaching. As humanistic leaders, subjects should have insights into motivating and inhibiting factors. Approach Participants’ responses were analyzed using the constant comparative method. Key Results Motivators included an organizational culture that enhances humanism, which we judged to be the overarching theme. Related themes included leadership supportive of humanistic practice, responsibility to role model humanism, organized activities that promote humanism, and practice structures that facilitate humanism. Impediments included top down organizational culture that inhibits humanism, along with related themes of non-supportive leadership, time and bureaucratic pressures, and non-facilitative practice structures. Conclusions While healthcare has evolved rapidly, efforts to counteract the negative effects of changes in organizational and practice environments have largely focused on cultivating humanistic attributes in individuals. Our findings suggest that change at the organizational level is at least equally important. Physicians in our study described the characteristics of an organizational culture that supports and embraces humanism. We offer suggestions for organizational change that keep humanistic and compassionate patient care as its central focus. Electronic supplementary material The online version of this article (10.1007/s11606-018-4470-2) contains supplementary material, which is available to authorized users.

Supplemental Digital Content is available in the text., The authors describe the first 11 academic years (2005–2006 through 2016–2017) of a longitudinal, small-group faculty development program for strengthening humanistic teaching and role modeling at 30 U.S. and Canadian medical schools that continues today. During the yearlong program, small groups of participating faculty met twice monthly with a local facilitator for exercises in humanistic teaching, role modeling, and related topics that combined narrative reflection with skills training using experiential learning techniques. The program focused on the professional development of its participants. Thirty schools participated; 993 faculty, including some residents, completed the program. In evaluations, participating faculty at 13 of the schools scored significantly more positively as rated by learners on all dimensions of medical humanism than did matched controls. Qualitative analyses from several cohorts suggest many participants had progressed to more advanced stages of professional identity formation after completing the program. Strong engagement and attendance by faculty participants as well as the multimodal evaluation suggest that the program may serve as a model for others. Recently, most schools adopting the program have offered the curriculum annually to two or more groups of faculty participants to create sufficient numbers of trained faculty to positively influence humanistic teaching at the institution. The authors discuss the program’s learning theory, outline its curriculum, reflect on the program’s accomplishments and plans for the future, and state how faculty trained in such programs could lead institutional initiatives and foster positive change in humanistic professional development at all levels of medical education.

Rapid changes in healthcare organization and practice environments, increasingly driven by business models and commercial interests, are associated with widespread burnout and dissatisfaction among healthcare professionals and pose barriers to humanistic relationship-centered quality care. Studies show burnout and significant stress currently affect over half of US physicians and nurses. Clinicians’ ability to provide compassionate care is significantly challenged. Most solutions to date have included individual interventions designed to enhance well-being and promote resilience. We examined organizational factors that inhibit or promote humanistic practice by faculty physicians in today’s healthcare environment. In this qualitative study, physician faculty who completed a one-year faculty development program in humanism at eight US academic medical centers provided written answers to two open-ended questions: a) What institutional or specific organizational unit-related factors promote humanism for you and others? b) What institutional or specific organizational unit-related factors inhibit or pose barriers, to humanism for you and others? 74% (68/92) of the physicians participated. The constant comparative method was used to analyze responses. We found that organizational culture was the central theme. Motivators of humanism included leadership supportive of humanistic practice, responsibility to role model humanism, organized activities promoting humanism, and practice structures that facilitate humanism. Factors that inhibited humanism included “top down” organizational culture, non-supportive leadership, time and bureaucratic pressures, and non-facilitative practice structures. Our findings suggest that organizational culture is, at a minimum, equally important as individual interventions. We describe features of organizational culture that reinforce humanistic practice and care in healthcare institutions and offer recommendations for organizational change that support the primacy of humanistic, compassionate, high quality patient care.

Objective Major reorganizations of medical practice today challenge physicians’ ability to deliver compassionate care. We sought to understand how physicians who completed an intensive faculty development program in medical humanism sustain their humanistic practices. Methods Program completers from 8 U.S. medical schools wrote reflections in answer to two open-ended questions addressing their personal motivations and the barriers that impeded their humanistic practice and teaching. Reflections were qualitatively analyzed using the constant comparative method. Results Sixty-eight physicians (74% response rate) submitted reflections. Motivating factors included: 1) identification with humanistic values; 2) providing care that they or their family would want; 3) connecting to patients; 4) passing on values through role modelling; 5) being in the moment. Inhibiting factors included: 1) time, 2) stress, 3) culture, and 4) episodic burnout. Conclusions Determination to live by one’s values, embedded within a strong professional identity, allowed study participants to alleviate, but not resolve, the barriers. Collaborative action to address organizational impediments was endorsed but found to be lacking. Practice implications Fostering fully mature professional development among physicians will require new skills and opportunities that reinforce time-honored values while simultaneously partnering with others to nurture, sustain and improve patient care by addressing system issues.

Objective Decision-making at menopause remains a challenge for women and their health care providers as the paradigm for hormone therapy continues to evolve. The role of decision-support for this process remains to be defined. Methods A randomized controlled trial of a computer-based hormone therapy (HT) decision-aid versus a control intervention consisting of a printed pamphlet among 177 post-menopausal women receiving care in a Veterans Affairs Medical Center. Results Participants found the computer-based decision-aid easy to use and retained risk information incorporated from emerging scientific data. There was no difference between groups with respect to the primary outcomes of knowledge, satisfaction with decision, decisional conflict or HT use. A trend was reported towards decreased decisional conflict in the evidence in decision-making ( p =0.07) and factors of uncertainty ( p =0.06) domains among the subset of participants who were on HT at baseline and used the computer-based decision-aid. Conclusion The computer-based decision-aid was able to effectively incorporate emerging scientific information but was no more effective than a printed pamphlet control with regard to improving decision-process outcomes. Practice implications The incremental benefit of a complex versus simpler decision-aid for post-menopausal women remains to be established prior to widespread dissemination of interactive computer-based HT decision-aids.

Objectives. We examined the association between number of breast cancer operations performed in a hospital (hospital volume) and all-cause and breast cancer–specific mortality using a national database and statistical methods appropriate for clustering and reducing confounding. Methods. In a retrospective cohort study, we linked Surveillance, Epidemiology, and End Results tumor registry data with Medicare claims data. The cohort included 11225 Medicare patients who had undergone surgery for early-stage breast cancer from 1994 to 1996 in 457 different hospitals. Primary outcomes were all-cause and breast cancer–specific survival rates at a mean follow-up time of 62.5 months. Results. In comparison with treatment in a low-volume hospital, treatment in a high-volume hospital was associated with hazard ratios of 0.83 (95% confidence interval [CI]=0.75, 0.92) for all-cause mortality and 0.80 (CI=0.66, 0.97) for breast cancer–specific mortality. Conclusions. An association between the volume of breast cancer operations performed in a hospital and 5-year survival rates was observed for both all-cause and breast cancer–specific mortality. Further work investigating the aspects of hospital volume that contribute to increased survival is warranted.

A multi-attribute utility (MAU) decision model for menopausal hormone replacement therapy (HRT) was developed using structured interviews (n=40) to identify decision factors, and a telephone survey (n=97) to ascertain utility scores. Utility scores for individual factors and composite scores reflecting the HRT decision were compared according to HRT use. Composite utility scores (range of -1.0 to 1.0, with higher values supporting HRT use) were 0.55, -0.27, and -0.19 for the 48 HRT users, 23 former users, and 26 never users, respectively (P

The large-scale Women's Health Initiative has confirmed that, in postmenopausal women, combined estrogen/ progestin therapy entails an increased risk of invasive breast cancer. The investigators have now explored this relationship in detail, characterizing the cancers that developed and seeking to learn whether hormonal effects on the mammogram can influence diagnosis. A total of 16,608 postmenopausal women 50 to 79 years of age, all with an intact uterus, were randomly assigned to receive active treatment (0.625 mg conjugated equine estrogens plus 2.5 mg medroxyprogesterone acetate daily in a single tablet) or placebo. The participants, seen at 40 clinical centers, were to be followed from 1993 to 1998 by annual clinical breast examinations and mammograms, but the trial was ended after a mean interval of 5.2 years. Intent-to-treat analyses demonstrated a hazard ratio of 1.24 for both total cancers and invasive cancers in women given hormone therapy compared with the placebo group. There was some suggestion of an increased risk for in situ breast cancer in hormone-treated women. An increased risk of breast cancer in treated women emerged after 3 years in those not receiving hormones previously and after 2 years in previously treated women. The findings were similar when women in specific risk categories were analyzed, and race and ethnicity were not significant factors. Invasive cancers associated with combined hormone therapy were larger than those in placebo recipients, more likely to be node-positive, and diagnosed when more advanced. There was, however, no difference in tumor grade or in the distribution of histologic types of breast cancer. After the first year, hormone-treated women more often had abnormal or highly suspicious mammograms than did those given placebo. In this prospective, randomized trial, combined estrogen/progestin treatment of postmenopausal women increased both breast cancer risk and the frequency of abnormal mammograms requiring medical assessment. In addition, cancers in treated women were more advanced when diagnosed than was the case for placebo recipients.

Health numeracy is associated with increased understanding of cancer risk reduction information and improved control of chronic disease. A cross-sectional survey was conducted among a primary care population to evaluate the effect of health numeracy on breast, cervical, and colorectal cancer screening. No association was found between health numeracy and cancer screening. However, at a baseline screening rate of 85%, increased knowledge (RR 1.06, 95% CI 1.02–1.08) and decreased perceived barriers (RR 0.93, 95% CI 0.92–0.95) were associated with increased screening rates. In conclusion, health numeracy was not predictive of cancer screening among a primary care population.

Our objective of this study is to develop a conceptual framework for the construct of health numeracy based on patient perceptions, using a cross-sectional, qualitative design. Interested participants (n=59) meeting eligibility criteria (age 40-74, English speaking) were assigned to one of six focus groups stratified by gender and educational level (low, medium, high). Fifty-three percent were male, and 47% were female. Sixty-one percent were white non-Hispanic, and 39% were of minority race or ethnicity. Participants were randomly selected from three primary care sites associated with an academic medical center. Focus group discussions were held in May 2004 and focused on how numbers are used in the health care setting. Data were presented from clinical trials to further explore how quantitative information is used in health communication and decision making. Focus groups were audio and videotaped; verbatim transcripts were prepared and analyzed. A framework of health numeracy was developed to reflect the themes that emerged. Three broad conceptual domains for health numeracy were identified: primary numeric skills, applied health numeracy, and interpretive health numeracy. Across domains, results suggested that numeracy contains an emotional component, with both positive and negative affect reflected in patient numeracy statements. We conclude that health numeracy is a multifaceted construct that includes applied and interpretive components and is influenced by patient affect.

The effect of combined hormone therapy on breast cancer detection is not established.We examined the effect of combined hormone therapy on breast cancer detection in the Women's Health Initiative trial, which randomized 16,608 postmenopausal women to receive conjugated equine estrogens (0.625 mg/d) plus medroxyprogesterone acetate (2.5 mg/d) or placebo. Mammography and breast examinations were performed at baseline and annually per protocol, with breast biopsies based on clinical findings. The effects of conjugated equine estrogens plus medroxyprogesterone acetate on breast cancer detection was determined throughout 5.6 years of intervention using receiver operating characteristic analyses to evaluate mammography results.Conjugated equine estrogens plus medroxyprogesterone acetate increased the cumulative frequency of mammograms with abnormalities vs placebo (35.0% vs 23.0%; P.001), which had less sensitivity for cancer detection and increased cumulative breast biopsy frequency (10.0% vs 6.1%; P.001). Although breast cancers were significantly increased and were diagnosed at higher stages in the combined hormone group, biopsies in that group less frequently diagnosed cancer (14.8% vs 19.6%; P = .006). After discontinuation of combined hormone therapy, its adverse effect on mammograms modulated but remained significantly different from that of placebo for at least 12 months (P.001).Use of conjugated equine estrogens plus medroxyprogesterone acetate for approximately 5 years resulted in more than 1 in 10 and 1 in 25 women having otherwise avoidable mammogram abnormalities and breast biopsies, respectively, and compromised the diagnostic performance of both. This adverse effect on breast cancer detection should be incorporated into risk-benefit discussions with women considering even short-term combined hormone therapy.clinicaltrials.gov Identifier: NCT00000611.

Background:Arelationshipbetweenhighersurgeonvolume and lower mortality has been described for breast cancer, but selection bias has not been rigorously evaluated. We studied potential bias in the surgeon volume– outcome relationship by comparing the relationship of surgeon volume to breast cancer mortality and to mortality from other causes of death. Methods:We conducted an observational cohort study from tumor registry and Medicare claims data on 12216 women, 66 years or older, with stage I or II breast cancer,whowereoperatedonby1856surgeons.Breastcancer mortality and other-cause mortality were determinedfromdeathcertificatesourcesandsurgeonvolume from Medicare claims. Results: Treatment by a high-volume surgeon was associated with younger patient age, white race, less comorbidity, and residence in a more affluent zip code. Patients treated by low-, medium-, and high-volume surgeons had small differences in breast cancer mortality (17.4, 15.7, and 13.0 deaths per 1000 person-years, respectively; P=.03) but larger differences in non– breast cancer mortality (46.0, 36.8, and 31.7 deaths per 1000 person-years, respectively; P.001). After adjustment for multiple patient and disease factors, women treated by high-volume surgeons, compared with those treated by low-volume surgeons, were not less likely to die of breast cancer (relative risk, 0.94; 95% confidence interval, 0.76-1.16) but were significantly less likely to die of other causes (relative risk, 0.86; 95% confidence interval, 0.75-0.98). Conclusions: The surgeon volume–outcome relationship for these patients with breast cancer was attributablenottomortalityfrombreastcancerbuttoothercauses of death. The lack of specificity of this relationship raises the possibility of selection bias as an explanatory factor.

Hypothesis Adherence to National Institutes of Health consensus statement recommendations for early-stage breast cancer will vary by surgeon characteristics. Design Secondary data analysis using the Surveillance, Epidemiology, and End Results national tumor registry linked with Medicare claims data. Logistic regression was used to analyze data on a cohort of 1045 surgeons who operated on 9449 Medicare patients with early-stage breast cancer. Main Outcome Measure Care adherent to the 1990 National Institutes of Health consensus statement recommendations. Results Surgeon age and specialty were not associated with adherent care overall, nor among breast-conserving surgery or mastectomy subgroups. Patients of higher-volume surgeons were significantly more likely to undergo adherent care overall because of greater use of lymph node dissection among women who received either breast-conserving surgery or mastectomy. Patients of female surgeons and surgeons with a medical school affiliation were less likely to undergo adherent care overall, which was related to greater use of breast-conserving surgery and lesser use of lymph node dissection among patients who underwent breast-conserving surgery. Conclusions Several surgeon characteristics are significantly associated with variations in breast cancer treatment received. These results warrant further investigation into the association between these surgeon characteristics and cancer care outcomes.

BACKGROUND Physician volume of at least 15–30 annual breast cancer operations has been associated with higher 5-year survival rates. The authors sought to determine whether surgical volumes for breast cancer in the United States frequently reach this threshold. METHODS The authors conducted a retrospective cohort study of 987 surgeons who operated on 8105 Medicare patients with breast cancer during 1994–1995 in 6 areas in the Surveillance, Epidemiology and End Results tumor registry. The 2-year physician volume of breast cancer operations was estimated among Medicare patients (approximating the on-average annual volumes for patients of all ages) and its association was examined with physician characteristics and with 3 measures of surgical care. RESULTS The median 2-year Medicare volume for breast cancer surgeons was 6, and 79% of physicians performed ≤ 12 operations. Approximately 50% of patients were cared for by physicians who performed ≤ 12 operations over 2 years, and 10% of patients were cared for by physicians who performed ≥ 30 operations. Surgeon characteristics of age, female gender, general surgery board certification, and academic affiliation were associated with modestly higher volumes of breast cancer surgery. Higher surgeon volumes were associated with higher patient receipt of breast-conserving surgery, testing for hormone receptors, and lymph node dissection during mastectomy. CONCLUSIONS Most physicians who perform breast cancer surgery perform few annual operations in Medicare patients, and lower volumes are associated with differences in surgical processes of care. Because patients in the Medicare age group comprise almost 50% of all incident breast cancer cases, surgical volumes for patients of all ages also are likely to be low. It is likely that only approximately 10% of patients in the United States are treated by surgeons who performing at least 30 annual operations. Cancer 2004. © 2004 American Cancer Society.

There is increasing demand for prediction of individual women's risk for breast cancer from women, clinicians, researchers, and health planners. Risk assessment for breast cancer is the process of identifying characteristics of an individual woman that are relevant to her risk, and combining those characteristics into a quantitative or qualitative risk profile. This article reviews and compares available methods of predicting risk, discusses benefits and drawbacks to the methods, and compares risk estimates for several hypothetical subjects using the different methods. Current and future uses for risk assessment are described. Risk assessment, while a promising tool for research now, and for clinical areas in the future, is still too imprecise for accurate prediction of breast cancer occurrence in individuals.

ContextThe Women's Health Initiative trial of combined estrogen plus progestin was stopped early when overall health risks, including invasive breast cancer, exceeded benefits. Outstanding issues not previously addressed include characteristics of breast cancers observed among women using hormones and whether diagnosis may be influenced by hormone effects on mammography.ObjectiveTo determine the relationship among estrogen plus progestin use, breast cancer characteristics, and mammography recommendations.Design, Setting, and ParticipantsFollowing a comprehensive breast cancer risk assessment, 16 608 postmenopausal women aged 50 to 79 years with an intact uterus were randomly assigned to receive combined conjugated equine estrogens (0.625 mg/d) plus medroxyprogesterone acetate (2.5 mg/d) or placebo from 1993 to 1998 at 40 clinical centers. Screening mammography and clinical breast examinations were performed at baseline and yearly thereafter.Main Outcome MeasuresBreast cancer number and characteristics, and frequency of abnormal mammograms by estrogen plus progestin exposure.ResultsIn intent-to-treat analyses, estrogen plus progestin increased total (245 vs 185 cases; hazard ratio [HR], 1.24; weighted P