Publications by authors named "Katrina Armstrong"

232 Publications

Factors Associated with Physician Tolerance of Uncertainty: an Observational Study.

J Gen Intern Med 2021 Apr 26. Epub 2021 Apr 26.

Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.

Background: Physicians need to learn and work amidst a plethora of uncertainties, which may drive burnout. Understanding differences in tolerance of uncertainty is an important research area.

Objective: To examine factors associated with tolerance of uncertainty, including well-being metrics such as burnout.

Design: Online confidential survey.

Setting: The Massachusetts General Physicians Organization (MGPO).

Participants: All 2172 clinically active faculty in the MGPO.

Main Measures: We examined associations for tolerance of uncertainty with demographic information, personal and professional characteristics, and physician well-being metrics.

Key Results: Two thousand twenty (93%) physicians responded. Multivariable analyses identified significant associations of lower tolerance of uncertainty with female gender (OR, 1.23; 95% CI, 1.03-1.48); primary care practice (OR, 1.56; 95% CI, 1.22-2.00); years since training (OR, 0.99; 95% CI, 0.98-0.995); and lacking a trusted advisor (OR, 1.25; 95% CI, 1.03-1.53). Adjusting for demographic and professional characteristics, physicians with low tolerance of uncertainty had higher likelihood of being burned-out (OR, 3.06; 95% CI, 2.41-3.88), were less likely to be satisfied with career (OR, 0.37; 95% CI, 0.26-0.52), and less likely to be engaged at work (RR, 0.87; 95% CI, 0.84-0.90).

Conclusion: At a time when concern about physician well-being is high, with much speculation about causes of burnout, we found a strong relationship between tolerance of uncertainty and physician well-being, across specialties. Particular attention likely needs to be paid to those with less experience, those in specialties with high rates of undifferentiated illness and uncertainty, such as primary care, and ensuring all physicians have access to a trusted advisor. These results generate the potential hypothesis that efforts focused in understanding and embracing uncertainty could be potentially effective for reducing burnout. This concept should be tested in prospective trials.
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http://dx.doi.org/10.1007/s11606-021-06776-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8074695PMC
April 2021

Biomarkers of Clinician Burnout.

J Gen Intern Med 2021 Apr 26. Epub 2021 Apr 26.

Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.

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http://dx.doi.org/10.1007/s11606-021-06757-xDOI Listing
April 2021

Covid-19 and the Investigator Pipeline.

N Engl J Med 2021 Mar 24. Epub 2021 Mar 24.

From the Department of Medicine, Massachusetts General Hospital, Boston.

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http://dx.doi.org/10.1056/NEJMp2100086DOI Listing
March 2021

Use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers associated with lower risk of COVID-19 in household contacts.

PLoS One 2021 2;16(3):e0247548. Epub 2021 Mar 2.

Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America.

Background: Use of angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) has been hypothesized to affect COVID-19 risk.

Objective: To examine the association between use of ACEI/ARB and household transmission of COVID-19.

Methods: We conducted a modified cohort study of household contacts of patients who tested positive for COVID-19 between March 4 and May 17, 2020 in a large Northeast US health system. Household members were identified by geocoding and full address matching with exclusion of addresses with >10 matched residents or known congregate living functions. Medication use, clinical conditions and sociodemographic characteristics were obtained from electronic medical record (EMR) data on cohort entry. Cohort members were followed for at least one month after exposure to determine who tested positive for SARS-CoV-2. Mixed effects logistic regression and propensity score analyses were used to assess adjusted associations between medication use and testing positive.

Results: 1,499 of the 9,101 household contacts were taking an ACEI or an ARB. Probability of COVID-19 diagnosis during the study period was slightly higher among ACEI/ARB users in unadjusted analyses. However, ACEI/ARB users were older and more likely to have clinical comorbidities so that use of ACEI/ARB was associated with a decreased risk of being diagnosed with COVID-19 in mixed effect models (OR 0.60, 95% CI 0.44-0.81) or propensity score analyses (predicted probability 18.6% in ACEI/ARB users vs. 24.5% in non-users, p = 0.03). These associations were similar within age and comorbidity subgroups, including patients with documented hypertension, diabetes or cardiovascular disease, as well as when including other medications in the models.

Conclusions: In this observational study of household transmission, use of ACEIs or ARBs was associated with a decreased risk of being diagnosed with COVID-19. While causality cannot be inferred from these observational data, our results support current recommendations to continue ACEI/ARB in individuals at risk of COVID-19 exposure.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0247548PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7924745PMC
March 2021

Household Transmission of SARS-CoV-2.

JAMA Netw Open 2021 02 1;4(2):e210304. Epub 2021 Feb 1.

Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamanetworkopen.2021.0304DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7910814PMC
February 2021

Clinical Decision Making During the COVID-19 Pandemic.

Ann Intern Med 2021 Feb 2. Epub 2021 Feb 2.

Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (J.P.M., K.A.A.).

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http://dx.doi.org/10.7326/M20-8179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7888345PMC
February 2021

The Need for More and Better Testing for COVID-19.

JAMA 2020 Dec;324(21):2153-2154

Department of Medicine, Massachusetts General Hospital, Boston.

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http://dx.doi.org/10.1001/jama.2020.21694DOI Listing
December 2020

Diversifying the biomedical workforce during the COVID-19 pandemic.

Nat Med 2020 12;26(12):1811

Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1038/s41591-020-1134-7DOI Listing
December 2020

SARS-CoV-2 viral load is associated with increased disease severity and mortality.

Nat Commun 2020 10 30;11(1):5493. Epub 2020 Oct 30.

Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

The relationship between SARS-CoV-2 viral load and risk of disease progression remains largely undefined in coronavirus disease 2019 (COVID-19). Here, we quantify SARS-CoV-2 viral load from participants with a diverse range of COVID-19 disease severity, including those requiring hospitalization, outpatients with mild disease, and individuals with resolved infection. We detected SARS-CoV-2 plasma RNA in 27% of hospitalized participants, and 13% of outpatients diagnosed with COVID-19. Amongst the participants hospitalized with COVID-19, we report that a higher prevalence of detectable SARS-CoV-2 plasma viral load is associated with worse respiratory disease severity, lower absolute lymphocyte counts, and increased markers of inflammation, including C-reactive protein and IL-6. SARS-CoV-2 viral loads, especially plasma viremia, are associated with increased risk of mortality. Our data show that SARS-CoV-2 viral loads may aid in the risk stratification of patients with COVID-19, and therefore its role in disease pathogenesis should be further explored.
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http://dx.doi.org/10.1038/s41467-020-19057-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7603483PMC
October 2020

Avoiding Cognitive Errors in Clinical Decision Making.

Ann Intern Med 2020 10;173(8):679

Massachusetts General Hospital and Harvard Medical School; Boston, Massachusetts (K.A.A., J.P.M.).

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http://dx.doi.org/10.7326/L20-1060DOI Listing
October 2020

Revisiting the Roles of Primary Care Clinicians in Genetic Medicine.

JAMA 2020 Oct;324(16):1607-1608

Massachusetts General Hospital, Boston.

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http://dx.doi.org/10.1001/jama.2020.18745DOI Listing
October 2020

Bridging Polarization in Medicine. Reply.

N Engl J Med 2020 07;383(3):294

University of Pennsylvania, Philadelphia, PA.

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http://dx.doi.org/10.1056/NEJMc2009528DOI Listing
July 2020

Case 16-2020: A 47-Year-Old Woman with Recurrent Melanoma and Pulmonary Nodules.

N Engl J Med 2020 May;382(21):2034-2043

From the Departments of Medicine (K.A.A., J.V.C., E.E.F., M.K.M.), Radiology (J.-A.O.S.), and Pathology (J.A.S.), Massachusetts General Hospital, and the Departments of Medicine (K.A.A., J.V.C., E.E.F., M.K.M.), Radiology (J.-A.O.S.), and Pathology (J.A.S.), Harvard Medical School - both in Boston.

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http://dx.doi.org/10.1056/NEJMcpc1916258DOI Listing
May 2020

Genetic Testing May Help Reduce Breast Cancer Disparities for African American Women.

J Natl Cancer Inst 2020 12;112(12):1179-1180

Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1093/jnci/djaa042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7735768PMC
December 2020

Different associations of tumor PIK3CA mutations and clinical outcomes according to aspirin use among women with metastatic hormone receptor positive breast cancer.

BMC Cancer 2020 Apr 23;20(1):347. Epub 2020 Apr 23.

Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA.

Introduction: The relationships among PIK3CA mutations, medication use and tumor progression remains poorly understood. Aspirin use post-diagnosis may modify components of the PI3K pathway, including AKT and mTOR, and has been associated with lower risk of breast cancer recurrence and mortality. We assessed time to metastasis (TTM) and survival with respect to aspirin use and tumor PIK3CA mutations among women with metastatic breast cancer.

Methods: Patients with hormone receptor positive, HER2 negative (HR+/HER2-) metastatic breast cancer treated in 2009-2016 who received tumor genotyping were included. Aspirin use between primary and metastatic diagnosis was extracted from electronic medical records. TTM and survival were estimated using Cox proportional hazards regression.

Results: Among 267 women with metastatic breast cancer, women with PIK3CA mutated tumors had longer TTM than women with PIK3CA wildtype tumors (7.1 vs. 4.7 years, p = 0.008). There was a significant interaction between PIK3CA mutations and aspirin use on TTM (p = 0.006) and survival (p = 0.026). PIK3CA mutations were associated with longer TTM among aspirin non-users (HR = 0.60 95% CI:0.44-0.82 p = 0.001) but not among aspirin users (HR = 1.57 0.86-2.84 p = 0.139). Similarly, PIK3CA mutations were associated with reduced mortality among aspirin non-users (HR = 0.70 95% CI:0.48-1.02 p = 0.066) but not among aspirin users (HR = 1.75 95% CI:0.88-3.49 p = 0.110).

Conclusions: Among women who develop metastatic breast cancer, tumor PIK3CA mutations are associated with slower time to progression and mortality only among aspirin non-users. Larger studies are needed to confirm this finding and examine the relationship among aspirin use, tumor mutation profile, and the overall risk of breast cancer progression.
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http://dx.doi.org/10.1186/s12885-020-06810-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7181475PMC
April 2020

Annals Clinical Decision Making: Translating Population Evidence to Individual Patients.

Ann Intern Med 2020 05 21;172(9):610-616. Epub 2020 Apr 21.

Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (K.A.A., J.P.M.).

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http://dx.doi.org/10.7326/M19-3496DOI Listing
May 2020

Clinical Decision Making: Communicating Risk and Engaging Patients in Shared Decision Making.

Ann Intern Med 2020 05 21;172(10):688-692. Epub 2020 Apr 21.

Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (K.A.A., J.P.M.).

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http://dx.doi.org/10.7326/M19-3495DOI Listing
May 2020

Clinical Decision Making: Incorporating Perspective Into Clinical Decisions.

Ann Intern Med 2020 06 21;172(11):743-746. Epub 2020 Apr 21.

Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (J.P.M., K.A.A.).

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http://dx.doi.org/10.7326/M19-3469DOI Listing
June 2020

Annals Clinical Decision Making: Weighing Evidence to Inform Clinical Decisions.

Ann Intern Med 2020 05 21;172(9):599-603. Epub 2020 Apr 21.

Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (J.P.M., K.A.A.).

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http://dx.doi.org/10.7326/M19-1941DOI Listing
May 2020

Clinical Decision Making: Avoiding Cognitive Errors in Clinical Decision Making.

Ann Intern Med 2020 06 21;172(11):747-751. Epub 2020 Apr 21.

Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (D.R., K.A.A., J.P.M.).

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http://dx.doi.org/10.7326/M19-3692DOI Listing
June 2020

Annals Clinical Decision Making: Using a Diagnostic Test.

Ann Intern Med 2020 05 21;172(9):604-609. Epub 2020 Apr 21.

Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (K.A.A., J.P.M.).

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http://dx.doi.org/10.7326/M19-1940DOI Listing
May 2020

Bridging Polarization in Medicine - From Biology to Social Causes.

N Engl J Med 2020 Mar;382(10):888-889

From the Department of Medicine, Massachusetts General Hospital, and Harvard Medical School - both in Boston (K.A.); and the University of Pennsylvania and the Corporal Michael J. Crescenz VA Medical Center - both in Philadelphia (D.A.A.).

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http://dx.doi.org/10.1056/NEJMp1913051DOI Listing
March 2020

Continuation of Annual Screening Mammography and Breast Cancer Mortality in Women Older Than 70 Years.

Ann Intern Med 2020 03 25;172(6):381-389. Epub 2020 Feb 25.

Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (J.H.).

Background: Randomized trials have shown that initiating breast cancer screening between ages 50 and 69 years and continuing it for 10 years decreases breast cancer mortality. However, no trials have studied whether or when women can safely stop screening mammography. An estimated 52% of women aged 75 years or older undergo screening mammography in the United States.

Objective: To estimate the effect of breast cancer screening on breast cancer mortality in Medicare beneficiaries aged 70 to 84 years.

Design: Large-scale, population-based, observational study of 2 screening strategies: continuing annual mammography, and stopping screening.

Setting: U.S. Medicare program, 2000 to 2008.

Participants: 1 058 013 beneficiaries aged 70 to 84 years who had a life expectancy of at least 10 years, had no previous breast cancer diagnosis, and underwent screening mammography.

Measurements: Eight-year breast cancer mortality, incidence, and treatments, plus the positive predictive value of screening mammography by age group.

Results: In women aged 70 to 74 years, the estimated difference in 8-year risk for breast cancer death between continuing and stopping screening was -1.0 (95% CI, -2.3 to 0.1) death per 1000 women (hazard ratio, 0.78 [CI, 0.63 to 0.95]) (a negative risk difference favors continuing). In those aged 75 to 84 years, the corresponding risk difference was 0.07 (CI, -0.93 to 1.3) death per 1000 women (hazard ratio, 1.00 [CI, 0.83 to 1.19]).

Limitations: The available Medicare data permit only 8 years of follow-up after screening. As with any study using observational data, the estimates could be affected by residual confounding.

Conclusion: Continuing annual breast cancer screening past age 75 years did not result in substantial reductions in 8-year breast cancer mortality compared with stopping screening.

Primary Funding Source: National Institutes of Health.
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http://dx.doi.org/10.7326/M18-1199DOI Listing
March 2020

The 2019 Partial Government Shutdown and Its Impact on Health Care for American Indians and Alaska Natives.

J Health Care Poor Underserved 2020 ;31(1):75-80

The 2018-9 partial government shutdown created a 35-day gap in federal appropriations for the Indian Health Service and tribal health programs. With ongoing challenges for American Indian and Alaska Native health systems, including clinician shortages and poor health outcomes, the funding gap engendered substantial health risks. Other federal health systems have been sheltered from this and past shutdowns through receiving their appropriations in advance. Several approaches exist to implementing advance appropriations, including instituting advance appropriations across Bureau of Indian Affairs and Indian Health Service programs; or by moving Indian Health Service funding to the same appropriation as the Department of Health and Human Services. Furthermore, building and strengthening health partnerships with non-federal institutions, such as academic medical centers, may help distribute financial risk and strengthen care systems.
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http://dx.doi.org/10.1353/hpu.2020.0009DOI Listing
January 2020

Association Between Poverty and Appropriate Statin Prescription for the Treatment of Hyperlipidemia in the United States: An Analysis From the ACC NCDR PINNACLE Registry.

Cardiovasc Revasc Med 2020 08 27;21(8):1016-1021. Epub 2019 Dec 27.

Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America; Massachusetts General Physicians Organization, Boston, MA, United States of America. Electronic address:

Background: Poverty is associated with a higher risk of myocardial infarction and cardiac death, both of which are decreased by treatment of hyperlipidemia. There may be differences in the appropriate treatment of hyperlipidemia between richer and poorer Americans. In this study, we aimed to evaluate the association between income level and appropriate lipid-lowering therapy.

Methods: We identified outpatient visits in the National Cardiovascular Data Registry's Practice Innovation and Clinical Excellence (PINNACLE) Registry and determined appropriateness of lipid-lowering therapy among patients in different income quintiles (Quintile 5 being the highest income quintile). Logistic regression at the patient level was performed to evaluate the independent association of income and the primary outcome of appropriate statin therapy. The analysis was repeated before and after November 2013 given a change in guideline definitions.

Results: The study included 1,655,723 patients. Overall, 68-73% of patients were treated appropriately under the ATP III Guidelines and 57-62% of patients were treated appropriately under the ACC/AHA Guidelines. Patients in the wealthiest quintile had higher odds of appropriate statin therapy under both guidelines relative to patients in the poorest quintile (OR 1.06 [1.05-1.07] for ATP III and OR 1.03 [1.01-1.04] for ACC/AHA). In the whole sample, patients with higher estimated income had a small but significant increased likelihood of appropriate statin therapy (point-biserial correlation 0.035 [p < 0.001] for ATP III and 0.026 [p < 0.001] for ACC/AHA).

Conclusions: Here we describe a small association between appropriate statin use and income. Further investigation into barriers in the use of evidence-based therapies in poorer populations is needed.
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http://dx.doi.org/10.1016/j.carrev.2019.12.026DOI Listing
August 2020

Opportunities and Challenges in Valuing and Evaluating Aging Physicians.

JAMA 2020 01;323(2):125-126

Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jama.2019.19706DOI Listing
January 2020

Calling on Primary Care to Prevent BRCA-Related Cancers.

J Gen Intern Med 2020 03 21;35(3):903-905. Epub 2019 Oct 21.

Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.

With the USPSTF reaffirming the importance of screening, counseling, and testing appropriate women for BRCA1/2 mutations, primary care has both an opportunity and a responsibility to lead in the implementation of these recommendations. Since the last UPSTF recommendations about preventing BRCA-related cancers in 2013, progress in incorporating risk assessment, counseling, and testing into primary care has been slow. There are multiple barriers to implementation outside of primary care, including limitations of the electronic medical record, availability of genetic counseling, and the administrative burden associated with obtaining insurance coverage. However, the early imbalance between hype and evidence in genomics led to a general skepticism among primary care providers about the importance of genomic medicine-a sharp contrast with many other areas of internal medicine. As a growing number of companies offer genetic testing directly to consumers and new models of genetic counseling are developed, primary care should capitalize on the opportunity to lead in the prevention of BRCA-related cancers-both to ensure that these services are delivered appropriately and in coordination with ongoing primary care and that primary care is not left behind as genomic medicine becomes a reality across internal medicine.
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http://dx.doi.org/10.1007/s11606-019-05469-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7080886PMC
March 2020

The Unintentional Perpetuation of the Gender Divide.

J Gen Intern Med 2020 03 21;35(3):910-912. Epub 2019 Oct 21.

Massachusetts General Hospital Cancer Center and Department of Medicine, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1007/s11606-019-05360-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7080880PMC
March 2020

Gender Differences in Retention and Promotion Among Generalists Who Graduated From Research-Intensive Fellowships.

J Grad Med Educ 2019 Oct;11(5):535-542

Background: Generalists who pursue research-intensive fellowships develop research skills and mentor-mentee relationships. Whether gender disparities in retention and promotion exist among this research-trained cohort is understudied.

Objective: We measured whether disparities exist among graduates of research-intensive fellowships and how mentorship influences them.

Methods: We surveyed generalists (internal medicine, pediatrics, family medicine, combined internal medicine-pediatrics) between July and August 2016 who graduated from research-intensive fellowships. Generalists ("mentees") were asked whether they remained or were promoted, and to name up to 10 influential mentors during or within 5 years of fellowship. Multivariable logistic regression estimated associations between mentee gender and retention and promotion. Next, we separately included 3 network characteristics: (1) mentee degrees (number of mentors reported per mentee); (2) mean mentor betweenness centrality (importance of each mentor within the network); and (3) largest community membership (mentee status in the largest interconnected mentor-mentee group within the network). All models adjusted for generalists' race, specialty, fellowship institution, and publications.

Results: One hundred sixty-two graduates (51%) representing 19 institutions responded. In adjusted analyses, compared to men, women were as likely to remain in academic medicine (odds ratio [OR] 1.88; 95% confidence interval [CI] 0.72-4.89; = .20), but less likely to be promoted within 5 years of fellowship (OR 0.26; 95% CI 0.09-0.80; = .018). Inclusion of network measures did not alter these associations.

Conclusions: Despite remaining in academic medicine as frequently as their male counterparts, fellowship-trained women were promoted less often. Features of mentors, measured using network analysis, may not explain these observed differences.
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http://dx.doi.org/10.4300/JGME-D-19-00016.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6795323PMC
October 2019

Maximizing the Outcomes of Breast Cancer Prevention.

JAMA Intern Med 2019 Dec;179(12):1621-1623

Department of Medicine, Massachusetts General Hospital, Boston.

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http://dx.doi.org/10.1001/jamainternmed.2019.4666DOI Listing
December 2019