Letters
2. Vivante A, Golan E, Tzur D, et al. Body mass index in 1.2 million adolescents and risk for end-stage renal disease. Arch Intern Med. 2012;172(21):16441650.
2. Page KR, Castillo-Page L, Poll-Hunter N, Garrison G, Wright SM. Assessing the evolving definition of underrepresented minority and its application in academic medicine. Acad Med. 2013;88(1):67-72.
3. Potter EV, Lipschultz SA, Abidh S, Poon-King T, Earle DP. Twelve to seventeen-year follow-up of patients with poststreptococcal acute glomerulonephritis in Trinidad. N Engl J Med. 1982;307(12):725-729.
3. Yu PT, Parsa PV, Hassanein O, Rogers SO, Chang DC. Minorities struggle to advance in academic medicine: a 12-y review of diversity at the highest levels of America’s teaching institutions. J Surg Res. 2013;182(2):212-218.
4. Perlman LV, Herdman RC, Kleinman H, Vernier RL. Poststreptococcal glomerulonephritis: a ten-year follow-up of an epidemic. JAMA. 1965;194(1):63-70.
4. Fang D, Moy E, Colburn L, Hurley J. Racial and ethnic disparities in faculty promotion in academic medicine. JAMA. 2000;284(9):1085-1092.
5. Trompeter RS, Lloyd BW, Hicks J, White RH, Cameron JS. Long-term outcome for children with minimal-change nephrotic syndrome. Lancet. 1985;1(8425):368-370. 6. Koskimies O, Vilska J, Rapola J, Hallman N. Long-term outcome of primary nephrotic syndrome. Arch Dis Child. 1982;57(7):544-548.
COMMENT & RESPONSE
Minority Faculty Development Programs at US Medical Schools To the Editor Dr Guevara and colleagues1 examined the association of minority faculty development programs at US medical schools with minority faculty representation, recruitment, and promotion, focusing on groups that are underrepresented in medicine relative to the general population. However, most contemporary faculty diversity initiatives also include Asian faculty among the groups targeted.2 Although Asian faculty accounted for 13% of all academic physicians in 2008, the group constituted only 7.4% of full professors, 3.8% of chairpersons, and 0% of deans at US medical schools.3 Thus, Asian faculty are underrepresented in academic leadership compared with more junior ranks and because they make up 6% of the general population. Because Guevara et al 1 grouped Asians with whites under nonunderrepresented minority faculty, their analyses leave unanswered questions regarding advances in the representation of Asians associated with faculty development programs. Such a grouping also obscures barriers that may affect Asian physicians trying to advance in academic medicine.4,5 We propose that when discussing workforce equity and diversity, it is useful to identify minority groups that are underrepresented relative to trainee and faculty candidate pools as well as relative to the general public. Whether or not a “bamboo ceiling” actually exists in academic medicine, definitional oversights in research will leave the issue unaddressed. Francis Deng, AB Jenny X. Chen, AB Author Affiliations: Washington University School of Medicine, St Louis, Missouri (Deng); Harvard Medical School, Boston, Massachusetts (Chen). Corresponding Author: Francis Deng, AB, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Guevara JP, Adanga E, Avakame E, Carthon MB. Minority faculty development programs and underrepresented minority faculty representation at US medical schools. JAMA. 2013;310(21):2297-2304.
5. Peterson NB, Friedman RH, Ash AS, Franco S, Carr PL. Faculty self-reported experience with racial and ethnic discrimination in academic medicine. J Gen Intern Med. 2004;19(3):259-265.
To the Editor A national study conducted by Dr Guevara and colleagues1 did not find an association between targeted faculty development programs and greater representation, recruitment, or promotion of underrepresented minority faculty at US allopathic medical schools over a 10-year period. However, this finding should be placed in context. Comparing schools of medicine is difficult, considering the complexity of factors that influence such organizations. The composition of the local community and mission of the institution may influence faculty demographics, which are dimensions not considered in the authors’ model. Two important additional factors that should be incorporated are institutional structure and program quality. Faculty composition may differ in a medical school that is part of an integrated health system, in which the entire organization is administered under 1 umbrella, from in an institution that is only affiliated with a teaching hospital. A faculty development program in an affiliated model may have less effect on faculty demographics than a program in an integrated model. Conversely, an affiliated hospital may sponsor its own faculty development program,2 augmenting the effect of a program in the school of medicine. Additionally, if programs at outlying facilities have a different focus than systemwide initiatives, these programs can mitigate the effect of such initiatives. The quality and objectives of programs should be better characterized to assist with any comparative analysis. For example, a mentoring program can range from an assignment of mentoring pairs at the beginning of the academic year to intense oversight of mentoring pairings, with educational offerings and evaluation metrics as part of the program. These programs would not be considered comparable but would have been considered the same in the model used by Guevara et al. 1 It is possible that the significant variation among medical schools and programs overrode the ability to detect important factors associated with minority faculty representation. On the positive side, the authors found that intensity matters. This finding supports literature that documents the benefits of faculty development programs, particularly related to the retention of junior faculty.3 Future studies should go beyond observations of websites and seek to determine specific characteristics of programs and the culture within which they reside. Joan Y. Reede, MD, MPH, MS Author Affiliation: Harvard Medical School, Boston, Massachusetts.
jama.com
JAMA March 19, 2014 Volume 311, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Fudan University User on 05/16/2015
1157
Letters
Corresponding Author: Joan Y. Reede, MD, MPH, MS, Harvard Medical School, 164 Longwood, Ste 210, Boston, MA 02115 ([email protected]). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported receiving grants from the Department of Health and Human Services Office of Minority Health, Commonwealth Fund, Josiah Macy Jr Foundation, Biomedical Science Careers Program, Health Resources and Services Administration, the National Institutes of Health (NIH), National Hispanic Medical Association, California Endowment, Novartis, Genzyme, and Merck; being the chair-elect of the Group on Diversity and Inclusion of the Association of American Medical Colleges; serving on the advisory committee and subcommittee on peer review to the NIH Director’s Working Group on Diversity; and serving on the advisory subcommittee to the deputy director for intramural research at the NIH. No other disclosures were reported. 1. Guevara JP, Adanga E, Avakame E, Carthon MB. Minority faculty development programs and underrepresented minority faculty representation at US medical schools. JAMA. 2013;310(21):2297-2304. 2. Massachusetts General Hospital Center for Faculty Development. Past events and programs. http://www2.massgeneral.org/facultydevelopment/cfd/past -events.html. Accessed December 19, 2013. 3. Ries A, Wingard D, Gamst A, Larsen C, Farrell E, Reznik V. Measuring faculty retention and success in academic medicine. Acad Med. 2012;87(8):1046-1051.
In Reply Mr Deng and Ms Chen raise concerns that the categorization of Asian faculty as nonunderrepresented minority faculty obscures barriers that Asian faculty continue to face. We concur that the underrepresentation of Asian faculty in senior leadership positions is a cause for concern. However, Asian faculty are not underrepresented among medical school faculty relative to their proportion in the general population.1 In data from the 124 eligible schools included in our study, Asian faculty accounted for 15.0% of all faculty in 2010, including 12.7% of all new faculty hires, 15.5% of all faculty promotions, and 8.6% of all full professors. The great strides in faculty representation achieved by Asian faculty in recent years are a cause for celebration, although clearly more work needs to be done at the top ranks. The focus of our study was on the more modest success in faculty representation achieved by black, Hispanic, Native American, Alaskan Native, Native Hawaiian, and Pacific Islander faculty. In 2010, these underrepresented minority faculty accounted for only 8.0% of all faculty, including 12.1% of all new faculty hires, 7.9% of all faculty promotions, and 4.3% of all full professors; all less than the proportions of Asian faculty. Dr Reede raises concerns that our study did not address institutional structure and program quality in its assessment of the association of minority faculty development programs with minority faculty representation. She relates that minority faculty development programs may affect minority representation differently in integrated health systems vs affiliated structures. She also suggests that program quality and variation may affect the results. We certainly agree. Palermo et al2 reviewed minority faculty development programs at 9 institutions and found significant heterogeneity in institutional and program structure. However, validated measures of institutional structure and program quality were lacking and development of such measures was beyond the scope of our study. We used public/private status, faculty size, and reputation ranking as proxy measures of institutional structure and for proxy measures of program quality, we used pro1158
gram duration, program components, and program intensity (duration × components). Future national studies of minority faculty development programs should develop and incorporate validated contextual measures of institutional structure and program quality into analyses. James Guevara, MD, MPH Emem Adanga, BA Margo Brooks Carthon, PhD Author Affiliations: Policylab, Center to Bridge Research, Practice, and Policy, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (Guevara, Adanga); Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia (Carthon). Corresponding Author: James Guevara, MD, MPH, Children’s Hospital of Philadelphia, 34th and Civic Center Boulevard, Room 1531, Philadelphia, PA 19104 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Association of American Medical Colleges. Striving Toward Excellence: Faculty Diversity in Medical Education. Washington, DC: Association of American Medical Colleges; 2009. 2. Palermo AG, Soto-Greene ML, Taylor VS, et al. Diversity in academic medicine No. 5 successful programs in minority faculty development: overview. Mt Sinai J Med. 2008;75(6):523-532.
Patient Engagement Programs and Treatment of Depression To the Editor Dr Kravitz and colleagues1 reported results from a trial that compared depression outcomes among primary care patients who received a tailored interactive multimedia computer program (IMCP) on depression, a depression engagement video (DEV), or a control video unrelated to depression. Depression screening was an important component of the IMCP intervention. In the trial registration, Kravitz et al1 reported that the primary study outcomes were provision of minimally acceptable initial care, reductions in depression-related stigma, and improvement in depression symptoms. Minimally acceptable depression care included: (1) antidepressant prescription, (2) mental health referral, or (3) timely follow-up. In the published study protocol, which was submitted for review 9 months after completion of data collection2 and in the article reporting trial outcomes, Kravitz et al1 described only 1 primary outcome, provision of minimally acceptable depression care, although the definition no longer included timely follow-up. The authors reported that IMCP, but not DEV, significantly increased minimally acceptable depression care compared with control. Of the other registered primary outcomes, stigma was not discussed in the outcomes report. Depression symptoms were described as a secondary outcome, and neither IMCP nor DEV significantly reduced symptoms.1 Kravitz et al1 concluded that IMCP successfully increased appropriate depression care and that further research is needed to “determine effects on clinical outcomes and whether the benefits outweigh possible harms.” However, the depression care in this case would almost certainly have been inappro-
JAMA March 19, 2014 Volume 311, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Fudan University User on 05/16/2015
jama.com
2. Vivante A, Golan E, Tzur D, et al. Body mass index in 1.2 million adolescents and risk for end-stage renal disease. Arch Intern Med. 2012;172(21):16441650.
2. Page KR, Castillo-Page L, Poll-Hunter N, Garrison G, Wright SM. Assessing the evolving definition of underrepresented minority and its application in academic medicine. Acad Med. 2013;88(1):67-72.
3. Potter EV, Lipschultz SA, Abidh S, Poon-King T, Earle DP. Twelve to seventeen-year follow-up of patients with poststreptococcal acute glomerulonephritis in Trinidad. N Engl J Med. 1982;307(12):725-729.
3. Yu PT, Parsa PV, Hassanein O, Rogers SO, Chang DC. Minorities struggle to advance in academic medicine: a 12-y review of diversity at the highest levels of America’s teaching institutions. J Surg Res. 2013;182(2):212-218.
4. Perlman LV, Herdman RC, Kleinman H, Vernier RL. Poststreptococcal glomerulonephritis: a ten-year follow-up of an epidemic. JAMA. 1965;194(1):63-70.
4. Fang D, Moy E, Colburn L, Hurley J. Racial and ethnic disparities in faculty promotion in academic medicine. JAMA. 2000;284(9):1085-1092.
5. Trompeter RS, Lloyd BW, Hicks J, White RH, Cameron JS. Long-term outcome for children with minimal-change nephrotic syndrome. Lancet. 1985;1(8425):368-370. 6. Koskimies O, Vilska J, Rapola J, Hallman N. Long-term outcome of primary nephrotic syndrome. Arch Dis Child. 1982;57(7):544-548.
COMMENT & RESPONSE
Minority Faculty Development Programs at US Medical Schools To the Editor Dr Guevara and colleagues1 examined the association of minority faculty development programs at US medical schools with minority faculty representation, recruitment, and promotion, focusing on groups that are underrepresented in medicine relative to the general population. However, most contemporary faculty diversity initiatives also include Asian faculty among the groups targeted.2 Although Asian faculty accounted for 13% of all academic physicians in 2008, the group constituted only 7.4% of full professors, 3.8% of chairpersons, and 0% of deans at US medical schools.3 Thus, Asian faculty are underrepresented in academic leadership compared with more junior ranks and because they make up 6% of the general population. Because Guevara et al 1 grouped Asians with whites under nonunderrepresented minority faculty, their analyses leave unanswered questions regarding advances in the representation of Asians associated with faculty development programs. Such a grouping also obscures barriers that may affect Asian physicians trying to advance in academic medicine.4,5 We propose that when discussing workforce equity and diversity, it is useful to identify minority groups that are underrepresented relative to trainee and faculty candidate pools as well as relative to the general public. Whether or not a “bamboo ceiling” actually exists in academic medicine, definitional oversights in research will leave the issue unaddressed. Francis Deng, AB Jenny X. Chen, AB Author Affiliations: Washington University School of Medicine, St Louis, Missouri (Deng); Harvard Medical School, Boston, Massachusetts (Chen). Corresponding Author: Francis Deng, AB, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Guevara JP, Adanga E, Avakame E, Carthon MB. Minority faculty development programs and underrepresented minority faculty representation at US medical schools. JAMA. 2013;310(21):2297-2304.
5. Peterson NB, Friedman RH, Ash AS, Franco S, Carr PL. Faculty self-reported experience with racial and ethnic discrimination in academic medicine. J Gen Intern Med. 2004;19(3):259-265.
To the Editor A national study conducted by Dr Guevara and colleagues1 did not find an association between targeted faculty development programs and greater representation, recruitment, or promotion of underrepresented minority faculty at US allopathic medical schools over a 10-year period. However, this finding should be placed in context. Comparing schools of medicine is difficult, considering the complexity of factors that influence such organizations. The composition of the local community and mission of the institution may influence faculty demographics, which are dimensions not considered in the authors’ model. Two important additional factors that should be incorporated are institutional structure and program quality. Faculty composition may differ in a medical school that is part of an integrated health system, in which the entire organization is administered under 1 umbrella, from in an institution that is only affiliated with a teaching hospital. A faculty development program in an affiliated model may have less effect on faculty demographics than a program in an integrated model. Conversely, an affiliated hospital may sponsor its own faculty development program,2 augmenting the effect of a program in the school of medicine. Additionally, if programs at outlying facilities have a different focus than systemwide initiatives, these programs can mitigate the effect of such initiatives. The quality and objectives of programs should be better characterized to assist with any comparative analysis. For example, a mentoring program can range from an assignment of mentoring pairs at the beginning of the academic year to intense oversight of mentoring pairings, with educational offerings and evaluation metrics as part of the program. These programs would not be considered comparable but would have been considered the same in the model used by Guevara et al. 1 It is possible that the significant variation among medical schools and programs overrode the ability to detect important factors associated with minority faculty representation. On the positive side, the authors found that intensity matters. This finding supports literature that documents the benefits of faculty development programs, particularly related to the retention of junior faculty.3 Future studies should go beyond observations of websites and seek to determine specific characteristics of programs and the culture within which they reside. Joan Y. Reede, MD, MPH, MS Author Affiliation: Harvard Medical School, Boston, Massachusetts.
jama.com
JAMA March 19, 2014 Volume 311, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Fudan University User on 05/16/2015
1157
Letters
Corresponding Author: Joan Y. Reede, MD, MPH, MS, Harvard Medical School, 164 Longwood, Ste 210, Boston, MA 02115 ([email protected]). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported receiving grants from the Department of Health and Human Services Office of Minority Health, Commonwealth Fund, Josiah Macy Jr Foundation, Biomedical Science Careers Program, Health Resources and Services Administration, the National Institutes of Health (NIH), National Hispanic Medical Association, California Endowment, Novartis, Genzyme, and Merck; being the chair-elect of the Group on Diversity and Inclusion of the Association of American Medical Colleges; serving on the advisory committee and subcommittee on peer review to the NIH Director’s Working Group on Diversity; and serving on the advisory subcommittee to the deputy director for intramural research at the NIH. No other disclosures were reported. 1. Guevara JP, Adanga E, Avakame E, Carthon MB. Minority faculty development programs and underrepresented minority faculty representation at US medical schools. JAMA. 2013;310(21):2297-2304. 2. Massachusetts General Hospital Center for Faculty Development. Past events and programs. http://www2.massgeneral.org/facultydevelopment/cfd/past -events.html. Accessed December 19, 2013. 3. Ries A, Wingard D, Gamst A, Larsen C, Farrell E, Reznik V. Measuring faculty retention and success in academic medicine. Acad Med. 2012;87(8):1046-1051.
In Reply Mr Deng and Ms Chen raise concerns that the categorization of Asian faculty as nonunderrepresented minority faculty obscures barriers that Asian faculty continue to face. We concur that the underrepresentation of Asian faculty in senior leadership positions is a cause for concern. However, Asian faculty are not underrepresented among medical school faculty relative to their proportion in the general population.1 In data from the 124 eligible schools included in our study, Asian faculty accounted for 15.0% of all faculty in 2010, including 12.7% of all new faculty hires, 15.5% of all faculty promotions, and 8.6% of all full professors. The great strides in faculty representation achieved by Asian faculty in recent years are a cause for celebration, although clearly more work needs to be done at the top ranks. The focus of our study was on the more modest success in faculty representation achieved by black, Hispanic, Native American, Alaskan Native, Native Hawaiian, and Pacific Islander faculty. In 2010, these underrepresented minority faculty accounted for only 8.0% of all faculty, including 12.1% of all new faculty hires, 7.9% of all faculty promotions, and 4.3% of all full professors; all less than the proportions of Asian faculty. Dr Reede raises concerns that our study did not address institutional structure and program quality in its assessment of the association of minority faculty development programs with minority faculty representation. She relates that minority faculty development programs may affect minority representation differently in integrated health systems vs affiliated structures. She also suggests that program quality and variation may affect the results. We certainly agree. Palermo et al2 reviewed minority faculty development programs at 9 institutions and found significant heterogeneity in institutional and program structure. However, validated measures of institutional structure and program quality were lacking and development of such measures was beyond the scope of our study. We used public/private status, faculty size, and reputation ranking as proxy measures of institutional structure and for proxy measures of program quality, we used pro1158
gram duration, program components, and program intensity (duration × components). Future national studies of minority faculty development programs should develop and incorporate validated contextual measures of institutional structure and program quality into analyses. James Guevara, MD, MPH Emem Adanga, BA Margo Brooks Carthon, PhD Author Affiliations: Policylab, Center to Bridge Research, Practice, and Policy, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (Guevara, Adanga); Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia (Carthon). Corresponding Author: James Guevara, MD, MPH, Children’s Hospital of Philadelphia, 34th and Civic Center Boulevard, Room 1531, Philadelphia, PA 19104 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Association of American Medical Colleges. Striving Toward Excellence: Faculty Diversity in Medical Education. Washington, DC: Association of American Medical Colleges; 2009. 2. Palermo AG, Soto-Greene ML, Taylor VS, et al. Diversity in academic medicine No. 5 successful programs in minority faculty development: overview. Mt Sinai J Med. 2008;75(6):523-532.
Patient Engagement Programs and Treatment of Depression To the Editor Dr Kravitz and colleagues1 reported results from a trial that compared depression outcomes among primary care patients who received a tailored interactive multimedia computer program (IMCP) on depression, a depression engagement video (DEV), or a control video unrelated to depression. Depression screening was an important component of the IMCP intervention. In the trial registration, Kravitz et al1 reported that the primary study outcomes were provision of minimally acceptable initial care, reductions in depression-related stigma, and improvement in depression symptoms. Minimally acceptable depression care included: (1) antidepressant prescription, (2) mental health referral, or (3) timely follow-up. In the published study protocol, which was submitted for review 9 months after completion of data collection2 and in the article reporting trial outcomes, Kravitz et al1 described only 1 primary outcome, provision of minimally acceptable depression care, although the definition no longer included timely follow-up. The authors reported that IMCP, but not DEV, significantly increased minimally acceptable depression care compared with control. Of the other registered primary outcomes, stigma was not discussed in the outcomes report. Depression symptoms were described as a secondary outcome, and neither IMCP nor DEV significantly reduced symptoms.1 Kravitz et al1 concluded that IMCP successfully increased appropriate depression care and that further research is needed to “determine effects on clinical outcomes and whether the benefits outweigh possible harms.” However, the depression care in this case would almost certainly have been inappro-
JAMA March 19, 2014 Volume 311, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Fudan University User on 05/16/2015
jama.com
