A new system was implemented by the Association of American Medical Colleges called the preference signaling program for the 2022 to 2023 orthopaedic surgery residency match. Applicants were able to signal 30 orthopaedic surgery programs to indicate high interest in a specific program. The purpose of this study was to address how important signaling was to an orthopaedic surgery program this 2022 to 2023 application cycle.A five-question survey was sent to orthopaedic surgery residency programs participating in the Electronic Residency Application Service this application cycle. Contact information was gathered through the Accreditation Council for Graduate Medical Education residency website and program websites.Responses were obtained from 69 of the 151 programs (46%) contacted. The average number of applicants per program was 727 . Thirty-four of 61 respondents (56%) stated that 100% of their interviewees signaled their program. Fifty-five of 61 respondents (90%) indicated that their interviewee pool consisted of 75% or more applicants who signaled. Applicants who signaled had a 24.4%  chance of receiving an interview. Applicants who did not signal had just a 0.92%  chance of receiving an interview. Fifty-four of the 63 applicants (86%) answered that signaling played an important role in considering an applicant for an interview.P < 0.0001). With this information, applicants can narrow down their list of programs to apply to, knowing that their signal to a program will give them a better chance at receiving an interview.Over half of the responding programs only interviewed applicants who signaled their program, and over 90% of programs' interview lists consisted of at least 75% of signaling applicants. Eighty-six percent of programs indicated that signaling played an important role in considering an applicant for an interview. Applicants who signaled were 26.5 times more likely to receive an interview than those who did not ( In the 2021 to 2022 application cycle, applications increased from 72 to 90, a 25% increase from the previous year.3 Understanding how to better narrow down the applicant pool has been a topic of interest over the years with different variations of how to score and rank interviewees.5 To date, very little emphasis has been placed on helping minimize the increasing application phenomenon, with no systems in place to guide students to find the best programs for them. A recent survey showed that program directors of orthopaedic surgery programs ranked signaling the third most important factor in receiving an interview, only behind away rotations and personal knowledge of the applicant.6 This new PSP may be a simple and effective way to narrow down an applicant's list of programs to apply to, if signaling proves to be a useful way to show interest in a program and further increase their likelihood of receiving an interview.Orthopaedic surgery continues to be a highly sought-after field in medicine and continues to increase in competitiveness each year.In this study, a survey of programs participating in the PSP would help both programs and students alike by knowing whether this is a useful tool for programs to know which applicants have high interest in their program and for students to show interest in their most desirable programs. The primary purpose of this study was to survey program directors and coordinators to evaluate whether signaling in this 2022-2023 application cycle was an effective method to receive an interview from a program. The secondary purpose of this study was to evaluate whether signaling played an important role in deciding whom to interview from a program’s perspective.https://www.surveymonkey.com/r/VN5VF8D) in an anonymous fashion. The survey is available for review in Supplement 1. Data were analyzed using data analytics software built into Microsoft Excel. Fractions were rounded to their nearest whole number to represent applicants. Fractional numbers were carried to two decimal places when not representing applicants. A Student t-test was used to calculate the P value associated with the mean percentage chance of receiving an interview.In total, 200 orthopaedic surgery residency programs were found to be participating in the 2022 to 2023 Electronic Residency Application Service and the National Residency Matching Program. Of the 200 programs, 90 programs publicly listed their program director's e-mail and 151 programs publicly listed a program coordinator's e-mail. If a program had both the e-mails of the program director and the program coordinator listed, an e-mail was sent to both. A five-question survey was issued to 151 programs in total. The survey consisted of three main components: the percentage of applicants who signaled the program, the percentage of interviewees who signaled the program, and a yes/no question regarding the significance of signaling in interview consideration. All responses were recorded through SurveyMonkey .Responses were obtained from 69 of the 151 programs (46%) contacted. Six programs indicated that they were not participating in the signaling process and, therefore, declined to submit responses. There were 61 responses to the interviews section, 60 responses to the applications section, and 63 responses to the signaling significance section.The average number of applicants per program was 727 . The average number of applicants who signaled a program was 261 . Thus, approximately 36% of applicants to a program had signaled that program .The average number of interviews extended was 65 . Of the interviews extended, the average number of interviewees who signaled was 61 . The average percentage of interviewees who signaled the program was 93% . Thirty-four of the 61 respondents (56%) stated that 100% of their interviewees signaled their program. Fifty-five of the 61 respondents (90%) indicated that their interviewee pool consisted of 75% or more applicants who signaled. Only one responding program reported that less than half of their interviewees signaled their program. For additional analysis, the resulting percentages were grouped by quartile and are presented in Figures P < 0.0001)  chance of receiving an interview. Contrarily, applicants who did not signal had just a 0.92%  chance of receiving an interview. In other words, applicants who signaled were 26.5 times more likely to receive an interview than those who did not  answered that signaling played an important role in considering an applicant for an interview Figure .The most important finding of our study is that, on average, over 90% of orthopaedic interviewees signaled the program they were interviewing at. With the implementation of the PSP, the results show that programs heavily favored interviewing applicants who signaled their program. Over half of the responding programs only interviewed applicants who signaled their program, and over 90% of programs' interview lists consisted of at least 75% of signaling applicants. Only one program had an interviewee pool consisting of less than 50% of signaled applicants. This is consistent with the program responses to the importance of signaling because an overwhelming majority thought that signaling played an important role during their interview process. These data show that the importance of signaling a program is highly valuable for both orthopaedic surgery programs and applicants.7 For many years, step 1 scores were considered the benchmark for filtering unqualified applicants in highly competitive fields. Orthopaedic surgery programs consistently ranked step 1 score as the most important factor when deciding whom to interview.8 With arguably the most important filter terminated, programs will need a new tool to help filter hundreds of applications received each year. A recent survey of program directors showed that a new emphasis for applicants will shift toward United States Medical Licensing Examination step 2 scores.9 The implementation of the PSP will also allow programs to have a new ability to easily gauge the interest of applicants in their program and potentially add a new filter in the application process. In the review of applications, there could be a role of subgrouping of applicants as “signaled” in addition to the rotating pool that could enhance the quality of the review process in an otherwise diluted process of review among so many applicants for programs.For the 2023 to 2024 application cycle, programs will have one less crucial statistic in their toolbox, a United States Medical Licensing Examination step 1 score. The US Medical Licensing Examination announced in 2021 that the first board examination for medical students would not have a numerical value.P < 0.001).10 Otolaryngology applications increased from 72.2 to 77.7 from the 2021 cycle to the 2022 cycle, but this is likely because of this study being published after the 2022 cycle had begun. Additional insight can be gathered with this coming 2023 application cycle and the potential effect of signaling in otolaryngology.11Regarding the growing competitiveness of orthopaedic surgery residencies and increased applications, this new information about signaling shows that applicants are much more likely to interview at a program they signaled. Understanding this crucial information could potentially start a new shift toward diminishing applications to programs. Otolaryngology residency programs implemented a signaling system in the 2020 to 2021 cycle in which applicants could signal five programs. They found that signaling greatly increased the likelihood of receiving an interview when compared with not signaling a program  offered an interview only to applicants who signaled their program. 86% of the programs also thought that signaling was an important factor in deciding who to interview this application cycle. Applicants who signaled a program were over 26 times more likely to receive an interview than those who did not. With this information, applicants can narrow down their list of programs to apply to, knowing that their signal to a program will give them a better chance at receiving an interview. Additional analysis is needed of the statistical outcomes from orthopaedic surgery applicants after this match cycle has been completed.


Tubulointerstitial nephritis with IgM-positive plasma cells (IgMPC-TIN) is a newer disease about which there are many unclear points. Glucocorticoid therapy is effective in many cases of IgMPC-TIN; however, relapse during glucocorticoid tapering has been reported. Relapse and its treatment are poorly defined.Case 1 was a 61-year-old man with renal dysfunction and proteinuria. Tubulointerstitial nephritis and IgM-positive plasma cells were observed in a renal biopsy. He was diagnosed with IgMPC-TIN accompanied by Fanconi syndrome and distal renal tubular acidosis (d-RTA). Prednisolone  treatment was highly effective, and PSL was gradually tapered and discontinued after 1 year. However, 1 month after PSL discontinuation, therapeutic markers were elevated. Therefore, PSL  was administered, and the markers indicated improvement.Case 2 was a 43-year-old woman referred for renal dysfunction and proteinuria. Laboratory data revealed that she had primary biliary cholangitis (PBC), d-RTA, and Fanconi syndrome. A renal biopsy showed accumulation of IgM-positive plasma cells in the tubulointerstitium without any glomerular changes. A diagnosis of IgMPC-TIN was made and the patient was started on PSL . Therapeutic markers decreased immediately and PSL was discontinued after 1 year. Three months later, the proteinuria and Fanconi syndrome worsened. PSL treatment was restarted  and markers indicated improvement.Case 3 was a 45-year-old woman with renal dysfunction and proteinuria. Tubulointerstitial nephritis and IgM-positive plasma cells were observed in a renal biopsy. The patient had PBC, Sjögren syndrome, d-RTA, and Fanconi syndrome, and the diagnosis of IgMPC-TIN was made. The patient was started on PSL  and disease markers decreased immediately. However, when PSL was tapered to 15 mg daily (0.2 mg/kg/day), the patient’s serum IgM levels increased; therefore, we maintained the PSL at 15 mg daily (0.2 mg/kg/day).2-microglobulin, proteinuria, and glycosuria. We recommend monitoring serum IgM levels while tapering glucocorticoids; a maintenance dose of glucocorticoid should be considered if relapse is suspected or anticipated.We report three cases of relapsed IgMPC-TIN associated with reduction or discontinuation of glucocorticoid therapy. In these cases, elevation of serum IgM preceded that of other markers such as urinary β Various causes of tubulointerstitial nephritis (TIN) have been identified, including infectious and drug-related causes, as well as autoimmune causes such as Sjögren syndrome, sarcoidosis, and IgG4-related diseases . However2-microglobulin (u-β2MG), proteinuria, and glycosuria. Thus, s-IgM may be a useful marker for detecting disease relapse.Here, we report three patients with IgMPC-TIN and relapse during glucocorticoid tapering. In these cases, elevation of s-IgM level preceded that of other disease activity markers, including urinary β2MG (19.6 μg/mL). Venous blood gas analysis revealed normal anion gap metabolic acidosis with alkaline urinary pH, which were suggestive of d-RTA. On renal biopsy, lymphocytes and plasma cells showed diffuse infiltration in the tubules and interstitium  was re-administered, and levels of these markers indicated improvement , s-IgM (333 mg/dL), and AMA-M2 antibody (144 U/mL). Serum potassium (3.4 mEq/L), phosphorus (2.8 mg/dL), and uric acid (2.0 mg/dL) levels were low. Urinalysis showed proteinuria (0.4 g/day), glycosuria (4.0 g/day), panamino-aciduria, and elevated u-β2), s-IgM (948 mg/dL), and hepatobiliary enzyme levels, and decreased serum potassium (3.3 mEq/L), phosphorus (2.5 mg/dL), and uric acid (2.2 mg/dL) levels. The patient was positive for AMA-M2 antibodies (289 U/mL). Urinalysis findings were as follows: proteinuria (0.5 g/day), glycosuria (10.1 g/day), pan-aminoaciduria, and u-β2MG (20.3 μg/mL). Venous blood gas analysis revealed normal anion gap metabolic acidosis with alkaline urinary pH. Renal biopsy showed diffuse lymphocyte and plasma cell infiltration into the tubules and interstitium . Venous blood gas analysis revealed normal anion gap metabolic acidosis with alkaline urinary pH. Renal biopsy results showed severe lymphocyte and plasma cell infiltration in the tubules, and moderate interstitial fibrosis was observed  6 months after starting treatment. However, s-IgM level increased to 566 mg/dL prior to re-elevation of proteinuria, glycosuria, and u-β2MG. Therefore, we continued treatment with PSL at 15 mg daily (0.2 mg/kg/day) , s-IgM (449 mg/dL), biliary enzyme levels, and AMA-M2 antibodies (57.6 U/mL). Serum potassium 3.4 mEq/L), phosphorus (2.8 mg/dL), and uric acid (2.0 mg/dL) levels were low. Urinalysis showed proteinuria (1.0 g/day), glycosuria (7.5 g/day), pan-aminoaciduria, and elevated u-β.4 mEq/L,Here, we report three cases of relapse following diagnosis and treatment of IgMPC-TIN. Pathologically, this disease is characterized by infiltration of IgM-positive plasma cells, identified by IgM/CD138 immunohistochemistry, in the interstitium, whereas conventional TIN is mainly infiltrated by IgG-positive plasma cells. Before Takahashi et al. proposed IgMPC-TIN in 2017, cases of TIN complicated with PBC had been reported –15. Alth2MG trends during the glucocorticoid taper were described in detail [2MG was 45.5 ± 23.6 μg/mL. All patients were treated with PSL, and the initial dose was 36 ± 7 mg/day. At the time of relapse, s-Cr was 1.34 ± 0.30 mg/dL, s-IgM was 858 ± 555 mg/dL, and PSL had been discontinued in four of six patients. The period from treatment initiation to relapse was 12 ± 4 months.Although initial glucocorticoid therapy is reported to be effective , there in detail –8. The c2MG, and s-IgM are useful markers for detecting relapse [2MG, urine protein levels, and renal dysfunction. Thus, we consider that s-IgM may be the most sensitive marker for IgMPC-TIN relapse. In the renal biopsies, there were 34 ± 26 IgM-PCs/HPF in five relapsed patients, including the previously reported cases, and 65 ± 30 IgM-PCs/HPF in 11 patients without relapse who were taking glucocorticoids, which was not significantly different by t-test (p = 0.09). Serum IgM at the first visit was 935 ± 428 mg/dL in non-relapsed patients and 627 ± 199 mg/dL in relapsed patients, which was not significantly different by t-test (p = 0.07). Our results indicate that we should pay attention to relapse, regardless of the s-IgM level at initial presentation or the number of IgM-PCs in renal biopsy.Matsuoka-Uchiyama et al. reported that proteinuria, glycosuria, u-β relapse . In all Additionally, careful glucocorticoid tapering is required to prevent relapse: four of the six relapses, including previously reported cases, occurred after glucocorticoid therapy discontinuation. In relapse cases of IgMPC-TIN, a maintenance glucocorticoid dose may be required. However, the adverse effects associated with long-term administration of glucocorticoid should be considered . One of 2MG, proteinuria, and glycosuria in our three cases. We recommend carefully tapering the glucocorticoid dose while monitoring s-IgM levels. A maintenance glucocorticoid dose should be considered if relapse is suspected or anticipated. In addition, we recommend close monitoring for relapse regardless of the s-IgM level at initial presentation or the number of IgM-PCs in a renal biopsy.In conclusion, we propose that s-IgM may be the most sensitive marker for relapse of IgMPC-TIN; elevation of s-IgM preceded changes in other markers such as u-β


Community health workers (CHWs) are health professionals that connect the populations they serve to health services. They play a valuable role in assessing patients’ needs, linking patients with health and human resources, educating patients toward achieving optimal health, and advocating for their patients to have accessible resources to improve their health and wellbeing. Pharmacies are readily accessible and frequently utilized health locations that could employ CHWs. We describe a program to cross-train pharmacy professionals as CHWs. Pharmacy professionals were recruited to sign up for a 13-week CHW core competencies course that was offered in partnership with the state university Continuing Education Workforce Training. From March 2022 to June 2023, 23 pharmacy professionals completed the course. Post-course and program evaluations were completed by 10 participants, and they showed positive responses to their participation in the program. Participants appreciated learning the role of a CHW, and noted increased skills, and awareness of additional tools and resources. Participants reported 47 referrals to chronic disease programs and community resources. The program pilot results show successful partnerships for cross-training pharmacy professionals as CHWs. Cross-trained pharmacy professionals provide benefits to the communities they serve, by being a valuable resource for their patients. Community health workers (CHWs) are health professionals that connect the populations they serve to health services. Many patients face barriers to navigating the healthcare system, and CHWs help by providing resources that patients may not know are available. CHWs play a valuable role in their communities, by assessing patients’ needs, linking patients with health services and resources, educating patients toward achieving optimal health, and advocating for patient resources, to improve health and wellbeing ,2. Some In Idaho, there are 410 CHWs, according to the latest data (May 2022) from the U.S. Bureau of Labor Statistics . The optCHWs work in numerous community locations, including clinics, hospitals, nursing homes, and pharmacies. Pharmacies are highly accessible places of healthcare, with estimates that ~90% of people live within 5 miles of a community pharmacy . In addiIn Idaho, pharmacies may even offer expanded health services, as pharmacists have independent prescriptive authority  . PharmacPharmacy professionals, including pharmacists, student pharmacists, and pharmacy technicians are a vital asset in the communities they serve. The provision of CHW training to these professionals allows them to serve their communities with additional services that will benefit their patients beyond the typical scope of pharmacy practice. Given the potential synergistic impact of CHWs in the pharmacy setting, a program was created to cross-train pharmacy professionals as CHWs.This initiative represents a partnership between the Idaho Department of Health and Welfare (IDHW), the state university Community Education Workforce Training (CEWT), and the university departments of Community and Public Health and Pharmacy Practice. In January 2022, IDHW and the state university partnered to implement a pilot project to cross-train pharmacy professionals as CHWs. This pilot was conducted in Idaho, due to the state priorities of the funding partner, IDHW. The goal of this project was to increase the number of trained CHWs in the state. A secondary goal was to expand referrals from CHWs based in pharmacies to CDC-recognized diabetes prevention and management programs and lifestyle change programs for cardiovascular disease ; this was to encourage CHWs to immediately utilize their new skills to educate patients and link them with new resources.The state university CEWT has provided training on the CHW core competencies since 2016, with those completing the course receiving a certificate of completion. The course was originally developed with IDHW support and CHW working group input, and revised over time. It is facilitated through the state university’s Department of Community and Public Health. The 13-week course (48 contact hours) is currently offered as a hybrid online web-based classroom, and consists of asynchronous (self-paced) modules, as well as three live online classroom sessions, where CHWs practice skills such as presenting a case, discussion, and roleplay skills. The courses are team-taught, with at least one instructor being a current CHW. Each week, students are required to complete online learning, unit assignments, and a quiz. Throughout the course, 19 units or modules are covered  that include the key concepts of public health, outreach, advocacy, community and individual assessments, social determinants of health, health education, navigating insurance, stages of behavior change, and service coordination. The curriculum has been mapped to the C3 project’s CHW competencies and skills, and covers content in each area. In addition to the online coursework, there is a final assignment, for which students interview a current CHW in Idaho, and present their findings to the class about the CHW and their organization, and the impact that they have on their community. The goal of the presentations is to learn about programs that are being implemented in Idaho, broaden students’ network, and help them to understand CHW programs that they can partner with in the future. At the beginning and end of the course, students self-report their self-efficacy for the CHW competencies. The course is offered multiple times throughout the year.Through IDHW, funds were provided for 25 pharmacy professionals, to cover the registration fees for the CEWT CHW course, as well as their time in completing the course ($20–22/h × 48 h = $960–$1056). The exact amount varied by year, with a maximum of 25 potential participants, due to funding. Tuition waivers were also utilized to offset registration costs. Individuals interested in participating in the program had to complete an online form, providing their contact information , a few sentences on how they might utilize their CHW skills, and an agreement to comply with the program requirements. The program requirements were to: provide at least two referrals to CDC-recognized programs for diabetes or cardiovascular disease, report referral information to the project personnel, and complete the CHW course. The completion of program evaluations was also requested, although not required for funding.The project personnel created and distributed a recruitment flier describing the program and requirements. The flier was distributed through the Community Pharmacy Enhanced Services Network of Idaho (CPESN-ID) and other project personnel contacts. Project personnel also called select independent community pharmacies in Idaho, to inform them of this opportunity. Lastly, student pharmacists at the state university were invited to apply for program participation via email.Program participants were invited to meet with pharmacy project personnel to discuss the sustainable implementation of their new skills at their worksite; this was optional. To assist with referrals, a Google website was created that contained a list  of CDC-recognized pre-diabetes, diabetes, and lifestyle change programs. Patient handouts were also available, in color and in black and white. Referral resources were provided by the region. Lastly, the Google website also contained a form for program participants to submit referral information .Program participants were asked to complete course evaluations as part of the CEWT CHW course. In addition, program-specific questions were also asked that inquired about participants’ preparedness to utilize CHW skills in the pharmacy setting, their likelihood of making patient referrals to CDC-recognized disease management programs, and other general feedback .Project personnel met with four participants after training, to hear feedback, and learn of how they might use their new skills; these were optional 1:1 meetings with participants. In these meetings, and in open-ended evaluation questions, participants expressed appreciation for the training opportunity. They learned the role of a CHW, and noted increased soft skills, such as motivational interviewing, and awareness of additional tools and resources. One pharmacist participant had already expanded their clinical patient intake forms to capture further details on patients’ social determinants of health; this pharmacist is also pursuing advanced CHW training. One consistent area of improvement noted with the training was organization, and the updating of the online course learning management system.Throughout the pilot program, 25 pharmacy professionals were selected to participate in the program. However, two individuals withdrew from the course, resulting in 23 individuals completing the course from March 2022 to June 2023. Four participants were pharmacists, seven were pharmacy technicians, and twelve were student pharmacists.The post-course evaluation was completed by 10 individuals . The resn = 41) were passive, i.e., program information provided to the patient or patient representative.Across all the program participants, 47 referrals were made . More thWe were able to partner with existing programs/resources to recruit pharmacy professionals and train them as CHWs. While the formal feedback on program participation was limited, the results were generally positive, and also indicated opportunities to continue bolstering the program in subsequent years.Although CHW roles and competencies have been proposed on the national level, there is no national formalized structured curriculum for training CHWs in the United States , nor is To some extent, the CHW requirements in different states have been driven by fee-for-service payment models and reimbursement from payers . In Idaho, this may explain the lack of official certification, as there is a desire to limit state spending and Medicaid-reimbursable services. However, some states have still chosen not to pursue formal certification, despite reimbursement incentives, to limit barriers to potential CHWs entering the workforce.Similarly, Idaho has no certification or continuing education requirements for pharmacy technicians . PharmacAnother challenge in cross-training other healthcare personnel as CHWs is that, while cross-training may allow for some increased competencies of skills in the healthcare staff being cross-trained, these individuals may still feel that their agency would benefit from a full-time CHW . AdminisThe state university’s CHW training program was initially funded through a Centers for Medicaid and Medicare Services State Innovation grant to the State of Idaho. While it has continued to be offered since this initial funding, it recently received funding from IDHW to update the curriculum, and develop advanced CHW training beyond the core competencies that will allow for more topics and specialization tracks (community- and clinic-based), and experiential learning through rotations. A 2000 h registered CHW apprenticeship program was established between the state university and the Idaho Department of Labor in June 2022 that would allow pharmacies to act as apprenticeship employer sites and that has employer incentives to host apprenticeships. In the next few years, the updated CHW core competencies, advanced CHW training, and CHW apprenticeship program will strengthen CHWs and CHW programs in Idaho, through tiered levels of training and experiential learning. Such tiered training will continue to be available in the form of cross-training options for pharmacy professionals. In addition to these changes, two elective modules specifically for CHWs in the pharmacy setting were offered in fall 2023. These electives are offered through a partnership with CEImpact, and also provide pharmacy-accredited continuing education.There are some limitations to this work. The number of participants in the CHW training program was small, making it difficult to effectively understand the impact of the course. Furthermore, our response rate to the program evaluation questions was limited, with only ten respondents. In addition, the generalizability of this project to other sites and states may be limited, due to funding and state-specific CHW requirements.While the total time commitment involved in the course was estimated to be 48 h, this can still represent a substantial time demand on pharmacy personnel who may already have time constraints. The course itself was also relatively short (13 weeks), and there are limited long-term data on what happened after the participants received their CHW certification, including how the course content was utilized and implemented in the participants’ careers. Future work may consider looking at the implementation of CHW skills, and the facilitators and barriers to doing so .Despite these limitations, the integration of cross-trained pharmacy professionals as CHWs appears to be advantageous, given the presence and opportunities of pharmacies in communities.Our pilot results show successful partnerships for cross-training pharmacy professionals as CHWs. Cross-trained pharmacy professionals provide benefits to the communities they serve, by being a valuable resource for their patients.


Among animals, humans stand out in their consummate propensity to self-induce altered states of mind. Archaeology, history and ethnography show these activities have taken place since the beginnings of civilization, yet their role in the emergence and evolution of the human mind itself remains debatable. The means through which modern humans actively alter their experience of self and reality frequently depend on psychoactive substances, but it is uncertain whether psychedelics or other drugs were part of the ecology or culture of pre-human ancestors. Moreover, (nonhuman) great apes in captivity are currently being retired from medical research, rendering comparative approaches thus far impracticable. Here, we circumvent this limitation by harnessing the breadth of publicly available YouTube data to show that apes engage in rope spinning during solitary play. When spinning, the apes achieved speeds sufficient to alter self-perception and situational awareness that were comparable to those tapped for transcendent experiences in humans (e.g. Sufi whirling), and the number of revolutions spun predicted behavioural evidence for dizziness. Thus, spinning serves as a self-sufficient means of changing body-mind responsiveness in hominids. A proclivity for such experiences is shared between humans and great apes, and provides an entry point for the comparative study of the mechanisms, functions, and adaptive value of altered states of mind in human evolution.The online version contains supplementary material available at 10.1007/s10329-023-01056-x. Seeking altered mental states is seemingly a human universal, historically and culturally  for publicly posted and publicly available videos of great apes spinning. We used image-based measures to quantify rotational speeds and rotational duration (see Supplementary Methods). We focused on rope spinning  = 31.101, P < 0.001], with higher speeds being achieved with more revolutions  = 4.003, P = 0.02] and the number of grip holds during spinning , with specific types of grip allowing longer spins  = 7.761, P = 0.001], with orangutans spinning at significantly faster speeds than gorillas  indicated that rotational velocity was proportional to revolution count  or between great apes and each specific traditional style   = 23.516, P < 0.001], with more support leveraging more revolutions  = 3.163, P = 0.054], with orangutans spinning for more revolutions per bout than gorillas , suggesting that they experienced dizziness. Closer inspection of the 43 cases when individuals released the rope revealed further evidence of dizziness: in 30 of the bouts, the animal immediately sat or laid down; in seven of the bouts, the animal moved a short distance and then sat or laid down; and in only six bouts did the animal keep its balance and remain on its feet.Total number of revolutions in the great apes was influenced by their contact with the ground [Our findings show that great apes spin at speeds that induce physiological “highs” in humans. In untrained humans, spinning at similar rates inescapably produces severe dizziness . Notably, by comparing “recreational” spinning behaviour of apes to professional spinning in humans, our analyses were inherently conservative. Our findings, while exploratory, provide a proof of concept and a new charter for the study and comparison of spinning and altered mental states between humans and great apes.Our preliminary findings point to several directions for the future study of spinning behaviour in apes and other species. One is to investigate questions related to evo-ecological constraints on spinning. For example, differences in spinning between orangutans  and gorillas (which are mostly ground-dwelling) could suggest neurological adaptation against motion sickness or vertigo , similar to the reduction of the vestibular cerebellum observed in ballerinas and figure skaters .Although beyond the scope of analysis here, we have also observed videos of rope spinning by other primate species, including gibbons and monkeys. Future research may seek to determine whether other primates spin as frequently as great apes and in such a way that elicits dizziness and altered mental states. Increasing phylogenetic distance will, however, reduce interpretative power based on the physiological and cognitive homology of these species with humans.To establish clear comparative benchmarks for future ape-human comparisons, it would be relevant to determine the minimum spinning speeds and lengths of time engaged in spinning necessary to induce altered states in humans, and how training affects and extends these limits. Ethnographic and anthropological studies of how children and adults use spinning and other non-pharmacological means to deliberately disrupt body and situational awareness  could provide complementary information about the role that these experiences play in our lives and, by extension, those of our ancestors over evolutionary time. Interestingly, some accredited zoos are reported to have re-used equipment from children’s playgrounds as enclosure enrichment for apes . Widespread adoption of devices that make up typical children’s playgrounds for use in great ape facilities could provide dynamic stimulation and motoric challenge to individuals, while potentially helping to reveal more comprehensively, and in a controlled fashion, how and why great apes engage in mind-altering behaviours.The findings reported here show that, like humans, great apes voluntarily seek and engage in altered experiences of self-perception and situational awareness. In our last common ancestors, these behaviours probably enhanced the nervous system and musculature Byrne , which hSupplementary file1 (DOCX 31 KB)Supplementary file2 (DOCX 24 KB)Below is the link to the electronic supplementary material.


Interest in applying systems thinking (ST) in public health and healthcare improvement has increased in the past decade, but its practical use is still unclear. ST has been found useful in addressing the complexity and dynamics of organizations and welfare systems during periods of change. Exploring how ST is used in practice in national policy programs addressing complex and ill-structured problems can increase the knowledge of the use and eventually the usefulness of ST during complex changes. In ST, a multi-level approach is suggested to coordinate interventions over individual, organizational, and community levels, but most attempts to operationalize ST focus on the individual level. This study aimed to investigate how ST is expressed in policy programs addressing wicked problems and describe the specific action strategies used in practice in a national program in Sweden, using a new conceptual framework comprising ST principles on the organizational level as an analytical tool. The program addresses several challenges and aims to achieve systems change within women's healthcare.The case study used a rich set of qualitative, longitudinal data on individual, group, and organizational levels, collected during the implementation of the program. Deductive content analysis provided narrative descriptions of how the ST principles were expressed in actions, based on interviews, observations, and archival data.The results showed that the program management team used various strategies and activities corresponding to organizational level ST. The team convened numerous types of actors and used collaborative approaches and many different information sources in striving to create a joint and holistic understanding of the program and its context. Visualization tools and adaptive approaches were used to support regional contact persons and staff in their development work. Efforts were made to identify high-leverage solutions to problems influencing the quality and coordination of care before, during, and after childbirth, solutions adaptable to regional conditions.The organizational level ST framework was useful for identifying ST in practice in the policy program, but to increase further understanding of how ST is applied within policy programs, we suggest a multi-dimensional model to identify ST on several levels. Many public health and social issues are complex and so are the interventions that can affect them. Such multi-dimensional issues often represent ‘wicked problems', i.e., problems that involve multiple sectors, multiple organizational levels, and many actors, and that are dynamic and difficult to define –4. This An approach based on systems thinking (ST) can be useful for tackling complex issues when leading soft-law initiatives , 10. ST Systems thinking is a theoretical approach found to be useful in addressing the complexity and dynamics of organizations and welfare systems when trying to change a current situation , 13, 18.There are challenges in studying how ST is manifested in practice. At the same time, identifying how ST can be expressed in actions and strategies is an important step in building knowledge about the practical application of ST in public health  and the individual level relating ST to individuals' understandings, abilities, skills, and cognitive processes. Studies on ST emphasize individuals' knowledge and abilities, for example, to be able to understand how the system is organized, managed, and led; to understand and be able to manage system stakeholders and networks; and to have the ability to conceptualize, model, and understand dynamic change  but mainly due to its complexity, representing a comprehensive policy program aimed at several large improvement areas representing wicked problems within a large, complex national setting comprising many geographical areas , types of care providers , types of care , units , and actors. The study was reviewed by the Regional Ethical Review Board in Stockholm, and they found a formal ethical approval was not needed (ref no. 2018/620-31).The Swedish healthcare system is comparatively decentralized and divided into 21 regional self-governing authorities and 290 municipalities. The regions, which vary in size and demography, are responsible for the provision of healthcare services, and the municipalities for providing home healthcare and social care. The Swedish Association of Local Authorities and Regions (SALAR) is a member organization representing the self-governing regions and municipalities and, as such, is an influential policy actor. Healthcare is mainly tax-funded, and most care providers are publicly owned. Maternal healthcare is provided at outpatient maternal healthcare clinics led by midwives . These cImproving Women's Health and Care before, during, and after Pregnancy program (WHCP program) aims to affect an extensive system, i.e., maternity care, antenatal care, delivery care, post-partum care, and, from 2018, neonatal care, in all 21 regions. The organizations of these subsystems have regional variations. Maternity can be part of the same subsystem as delivery care and gynecology or be organized under primary healthcare. The variation also concerns the number of private care providers, mainly offering maternity care before childbirth. Private care providers were essentially absent in some regions and more common in the large urban regions.The program was initiated in late 2015 to be implemented between 2016 and 2019. It is based on agreements between the national and regional political levels, i.e., between the Ministry of Health and Social Affairs and SALAR, the latter a national organization representing the 21 self-governed regions that attend to, support, and coordinate the regions' common interests. Instead of addressing the complex challenges and (wicked) problems via laws or regulations, they were addressed by an agreement that the regions would put efforts into improving certain areas, based on and adapted to the local situation, and receive funding for this from the government. The agreements were based on mutual trust rather than on control or enforcement. The first agreement was followed by several additional agreements, increasing the scope of the program, and extending the implementation period until the end of 2023. Thus, the implementation of the policy program stretches over almost 9 years. The program aims to improve women's sexual and reproductive health and maternity, antenatal, and post-partum care. The agreement is more decentralized than some previous ones e.g., –53] wher wher53)]In 2015, a national program team was formed at SALAR, responsible for leading, coordinating, supporting, and following up on the program's progress and its outcomes. This team had little mandate to enforce the program and did not influence the allocation of the program's finances, which were sent directly to the regions. In 2018, the national program team developed a strategic plan based on the agreement, see The program is decentralized, implying that the 21 regions are responsible for identifying needs, prioritizing, and implementing interventions to improve their work within the strategic areas of the program. Regional contact persons, appointed by the director of health in each region, function as the nodes for contact and interaction with the WHCP program team at SALAR. The funding was distributed directly to the regions based on the size of their population, with a smaller amount designated to the program team, and the funding for some special missions was given to public authorities, e.g., the National Board of Health and Welfare (NBHW). Thus, the regions could decide how to distribute the funding to reach the goals of the program, based on their knowledge of the regional and local conditions. The Swedish Agency for Health and Care Services Analysis was given the mission to evaluate the program's outcomes.Since 2017, data about the program have been collected and compiled in a comprehensive case study database by external researchers , as a part of a longitudinal (still ongoing) research project. The database consists of semi-structured individual and group interviews conducted with program team members (2018–2021), contact persons from all regions (2018 and 2020–2021), and external program evaluators (2020); non-participant observations of meetings (2017–2022); and documents , survey data, quality registry data, and national and regional publicly available statistics.In this study, we have used a representative sample of interviews, observations, and archival data sources chosen to represent various types of data, content, actors, and time periods from the database which cover a 5-year period (March 2017 to March 2022), excluding outcome data, i.e., quality registries . The samThe definitions of the eight ST principles see  in the rFirst, the researchers familiarized themselves with the eight ST principles by discussing examples of what type of program content and data potentially could contain indications of the principles . Then, rAn iterative approach based on deductive content analysis  was applIn this section, narrative descriptions are presented about how the organizational level ST principles (P1–8), put forward by Wilkins et al. , were apThe principle Convene Partners concerns identifying, reaching, involving, and engaging the right actors at the right time and comprises both the variety of involved stakeholders and partners and what they do together, which includes the forthcoming principles. How to identify, reach, and involve the right actors at the right time depends on the complexity of the program and its setting.analyses of challenges, problems, and contextual influences and in problem-solving, planning, and follow-up activities, either regularly or for limited periods of time. This ensured that many perspectives could be considered when planning and implementing program activities. The regular interaction with other national authorities and programs was perceived by the program team members to reduce the risk of launching competing activities. The interaction with and consideration of the different actors and their interests require significant amounts of time and skills on behalf of the program team. Reaching and involving higher regional decision-makers was difficult. They were informed when the program was initiated and later in their monthly national meetings. Depending on the chosen regional contact person and regional strategy meant that key actors on a higher regional level could have been more or less involved in the realization of the program intentions. The team coordinating the program at the national level was based at SALAR, which is a members' and an employers' organization for all the regions in Sweden. This created unique opportunities for the team to get a national overview and facilitate linkages between national and regional levels. This platform secured a mandate to facilitate collaborations and coordinate ongoing system changes. Due to the decentralized approach regarding regional power over the choices of problem areas and interventions, the regional contact persons were key actors in stimulating regional change. The five main action strategies identified are described in To address the issues and reach the WHCP program goals of a more equal, accessible, safe, knowledge-based, and person-centered care for women over the entire country meant identifying and involving many different actors and professions from different parts and levels of the healthcare system, from politicians to patient representatives. This was recognized by the program team members and described in interviews as being important from the start of the program. It was also visible in the amount and type of actors involved in the various program activities over time see . DiffereThe principle Seek Understanding concerns gathering information from the context to better understand what contributes to challenges and strengths, how these contributions relate to each other, and how making changes to these contributions may influence outcomes and potentially lead to unintended consequences.The WHCP program comprised several multi-faceted issues, e.g., equity in care, attracting and keeping competent staff, patient safety, availability of care, person-centered care, and integrated care. How to understand this range of issues, what contributes to the challenges and also consider regional variations and context-specific conditions for providing healthcare, was addressed in meetings and some team members expressed in interviews as a challenge.The analyses of problems and needs were an important strategy on behalf of the program team. Mappings and gap analyses were conducted and presented in reports and then communicated, discussed, and reflected on during several meetings with regional actors. Monitoring different media also became important for understanding the region's various conditions and challenges. The program team's efforts to gather information to better understand regional and contextual challenges, often together with program stakeholders and partners, were perceived to contribute to a better understanding of both the system features and the complex improvement areas the program aimed to affect, especially for new members in the program team and contact persons, and also for others involved, for example, from national authorities. The strategic plan developed in 2018  was an iThe principle Surface Assumption concerns identifying partners' and stakeholders' assumptions about the focus areas and the program and the challenges and solutions needed to improve care and women's health. The overarching goals and structure of the program were set in negotiation between actors representing the government, politicians, and decision-makers from the regions and representatives from SALAR. Thus, the agreement was originally based on the mental models and assumptions of those involved in negotiating, writing, and signing the agreement, mirroring mainly a political perspective on issues and on what constitutes good care for women before, during, and after pregnancy. The negotiations resulted in a high degree of freedom regarding the implementation of the agreement, and the goals were rather general to suit stakeholders with divergent needs see . Due to The program team worked to surface assumptions held by stakeholders directly involved in the implementation, and those held by the contracting parties in the policy agreement, i.e., the government and SALAR. This is partly expressed in Principle 2 in the ways the team tried to seek understanding by involving different actors, but it was not explicitly described in the team members' interviews as a strategy. For program team members and contact persons, the knowledge gained on different perspectives and assumptions would increase their awareness of the existing and contradicting views when planning or adapting program activities. However, most of the analysis of actors' assumptions, mental models, and potential conflicts of interest did not occur during the actual meetings with the invited stakeholders, but rather in discussions after these meetings. Deeper analyses of stakeholders' mental models and the potential effect of contradicting assumptions did not occur as often as the discussions aimed to reveal or clarify them. We found no indication that this principle was used with the higher-level regional decision-makers, whose assumptions can affect the program implementation. The three main action strategies identified are described in The principle Reflect and Learn concerns continually reviewing new information, assumptions, and learnings to jointly be able to develop and refine a shared vision for, in this case, the improvement of women's sexual and reproductive healthcare. An important part of this principle is to create environments where people are encouraged to reflect and learn.Initially, the program team focused mostly on spreading information about the program and less on creating opportunities for mutual interaction. However, the focus shifted and efforts to create opportunities and arenas for reflection and learning increased over time. We found many indications of the use of this principle in the program activities and in the described action strategies see . The areThe principle Finding Leverage concerns identifying solutions, innovations, and actions that are efficient, have a high impact, are sustainable, and meet the needs of the community, in this case, those delivering care to women in all regions before, during, and after childbirth. The solutions should be based on data, address “upstream” factors, be tailored to the local context, provide support, aid coordination among involved partners, and improve infrastructure (in the area focused on).Finding high-leverage solutions to the many issues in the WHCP program that could have a high effect nationwide, and in the complex settings of 21 different regional systems, was important but challenging for the program team. Efforts were made to identify and analyze problem areas, spread existing knowledge, and successfully test innovations in each of the program's main goals and strategies . AnalyseThe principle Manage Resources concerns levering and coordinating resources in terms of funding, people, technology, and equipment. To manage resources means to allocate them in a strategic way, so they support any chosen intervention's impact and follow-up on the results. This can, for example, involve temporal aspects, choices of high-leverage solutions, or prioritizing between target areas.In the WHCP program, the needed changes outlined in the national policy agreement were to take place in, and ultimately be managed by, the self-governing regions. This limited the mandate of the program team to manage resources in relation to the change process, compared to what might be the case in organizations. Since the program was based on a series of separate, but related, policy agreements between the government and SALAR as a representative for all the regions, funding varied over time as new agreements were settled. The program team at SALAR received funding for coordinating national activities to support the regions' improvement efforts, but the main part of the resources was directly transferred to the regions, based on their population size. The regions then allocated these program resources according to local needs and regional priorities. Thus, in practice, the national level had little control over how the resources were allocated and had to find ways to get information from the regions. Initially, the program's reporting requirements were neither very strict nor detailed, but successively requirements changed and increased, and the regional activity reports gained more importance over time.The national level had two primary means to influence the allocation of resources within the regions. The first was the selection of indicators from National Quality Registries and the National Pregnancy Survey used for follow-ups and presented to the regions. The other was the design of the questionnaire-like template for the regions' yearly activity report, highlighting the importance of thinking about the whole change process, including how the resources were used. Therefore, the program team also offered support sessions to the contact persons when it was time to compile the activity reports. For the 2021 agreement, there was a specific request for detailed information on how the funding had been used in the areas highlighted in this agreement. The four main action strategies identified are described in The principle Respond Rapidly concerns taking actions and continuously improving solutions or discontinuing unsuccessful strategies, catalyzing action among stakeholders and partners, and re-evaluating when needed. A long-term, nationwide program in a decentralized setting that involves many regions, organizations, and people puts special demands on the interaction between the national and the regional and local levels.The close interaction that the program team developed with the regional representatives led to expectations on the team to respond swiftly to highlighted problems and needs, expressed in interviews and during meetings. The strategies, both for how to find signals and how to respond to them, constantly evolved as information was accumulated and needs discovered, based on discussions with involved actors, mappings, and data from the National Pregnancy Survey and the quality registries. The three main action strategies identified are described in The principle Translate Findings means synthesizing and sharing relevant findings, data, and information with partners, stakeholders, and the public. In this process, key partners and stakeholders will be engaged to determine the importance of information and how to spread it. This process can be more or less of a challenge, depending on the complexity of the problems addressed, interventions used, data collected, and settings where information and findings shall be disseminated. In a large improvement initiative such as the WHCP program, this was a rather complex task.The intention to translate relevant findings, i.e., prioritizing what information was important to share, with whom, how, and why, together with key actors, permeated the entire program. The ability to translate and use findings in the program increased over time, as more data became available via National Quality Registries, the National Pregnancy Survey, and the yearly regional activity reports. Team members described the use of findings and data to support both improvements and learning. Sharing of data and findings created both an interest in and a better understanding of the program and its focus, challenges, and effects on both partners and stakeholders and in media.Aiming to increase the knowledge of how ST is used in practice in national policy programs addressing wicked problems, we searched for indications of ST in data describing the main program activities and action strategies in a national program addressing complex issues in women's healthcare in Sweden. We used a conceptual framework comprising principles of organizational level ST  as an anThe proposed ST principles  may seemImproving healthcare, or the health of the population, means dealing with complex issues or wicked problems , 3. It iTo convene actors with a different perspective (ST Principle 1) involve them as partners or use collaborative approaches are not exclusively connected to ST or a policy program. Collaborative approaches are the most often promoted ways to tackle complex issues and ensure that important perspectives of those affected by changes and those that can affect them are incorporated into interventions . IndividThe mix of actors involved aided the processes of understanding and identifying leverage that integrated the perspectives of multiple levels. Engaging actors with decision-making power in the ST processes was also a way for the program team to indirectly try to influence the allocation of resources to enable the intended changes. Still, it was difficult to reach higher-level decision-makers, and the use of separate regional dialogue meetings with a group of regional representatives for each of the 21 regions was one activity that was described as having some impact. For stakeholders, especially higher-level decision-makers, to engage, there needs to be a will and an understanding of the needs and benefits of getting involved in an interactive process of building a shared mental model of the system and the issues to be solved. In a complex program context, it might also be beneficial to further define expectations on a program partner or stakeholder, as their interest and agendas can vary . CarefulThe composition of individuals in a team leading a program is of special importance. If ST is a guiding approach in large and complex programs, this requires some attention in the initial forming of a team. A clear strategy in the studied program was to include members with different competencies and perspectives, some with connections to other related national agreements, and some with their basic employment in the regions. It is unlikely even for skilled program managers to possess all the capabilities needed to manage a national program focusing on large system transformation. This strategy was also seen as an effective way to extend the team's network, improve communication with stakeholders and partners, and promote an understanding of the program as part of a larger system transformation, i.e., to enhance ST in the team. Previous research on program management has focused on individual program managers and their competencies and actions, but less is known about the nature of the distributed capabilities among other actors in the core and extended program team and how they may contribute to a more holistic view of the program and its change process .The need to address complex and interrelated issues and wicked problems in healthcare in Sweden or elsewhere is not new, but there has been an increase in more complex national initiatives over time. The WHCP program is one example where the goals concern development in a diversity of areas, comprising great challenges. Challenges faced by decision-makers, care providers, and patients may be similar in a general sense, but the dynamic regional and local conditions must be considered when aiming for more sustainable changes . Thus, tIn a large, complex, and long-term policy program, there are many dimensions and conditions that must be considered to enable reflection, learning, and collaboration among the involved actors. The challenge is to create opportunities and communication arenas that can support collaboration, reflection, and learning, and find and develop ways to deal with ill-structured and complex issues. Achieving deeper learning and changing people's behavior and action strategies takes time. This requirement may not fit very well with the restricted time and/or resources of a program, or with the expectations and views of involved stakeholders and partners.An important aspect of the program was to provide opportunities and arenas for reflection, feedback, and learning, on group and individual levels. The frequent use of group discussions in meetings is one example. In meetings, there was often a mix of participants from different levels of the healthcare system, which enabled learning and exchange of experiences across national, regional, and local levels. Sometimes, single participants have multiple perspectives, e.g., a regional contact person could also be involved in national groupings, such as producing guidelines. Altogether, the large number of activities designed for enabling interaction, reflection, and learning, such as network meetings, the teams' regular half-day meetings, and numerous workshops and courses, can be interpreted as representing a learning culture within the program, especially on behalf of the program team and the contact persons' network. Active reflection and learning opportunities are at the core of a change process, especially when aiming to achieve double-loop learning for more substantial behavioral changes in both individuals and organizations , 61.Synthesizing and sharing relevant findings and using them to enhance learning and change was a core task for the program team. Interactions and relations with partners and stakeholders were central to the program's communication strategy, which emphasized responsiveness and an adaptive approach regarding how to reach different target groups and audiences. Strategic communication within the program involved a meta-process of integrating information, understandings, and learnings on the program level, making sense of the results in a larger perspective, and choosing the best way to package the information and feed it back to key actors. Management of such processes requires ST skills , 33.One aspect of the learning approach applied in the program was to engage a variety of actors in developing interventions that could affect and improve issues identified in each program focus area. ST has been suggested to aid the process of identifying high-leverage solutions that can address multiple health outcomes . The proUnderstanding ST in use in a policy program involves an understanding of the overlapping nature of the hierarchical system levels in the program context, i.e., national, regional, and local system levels , and theIn the WHCP program, it was important to achieve a holistic view and a common understanding of the program issues among actors in different parts of the system, e.g., politicians, authorities, and professional organizations on the national level, and politicians, public management, and care providers in the autonomous regions. Even so, in-depth discussions to identify gaps between mental models together with partners were less frequent and gaps would typically become evident after some time and discussed in other group constellations. Reasons for this might be the complex political landscape and the dual role of SALAR as both the coordinator of change initiatives stemming from the government and the organization representing the rather independent regions and municipalities , 53.Much of the previous research on how ST can be used in practice has focused either on the individual, group, or organizational level. Combined approaches are scarcer but exist . FigureOne reason for the limited empirical studies of the use of ST in practice, especially within public health –17, mighA general observation when applying the ST principles to our qualitative data is that the principles are somewhat overlapping. A holistic view is more evident in some of the principles, and it emerges as the principles are added to one another. Another observation was that as we analyzed the data, we found that multiple principles were enacted simultaneously in each of the main program activities. This study describes the nuances of how ST is used in practice within a policy program context.It is difficult to judge the effects of the use of the ST principles on the outcomes of the ongoing program as this would require a more extensive understanding of both the issues addressed and the mechanisms underlying the ST principles and the action strategies related to them. In addition, the way ST is used, or not, in the 21 regions needs to be addressed. Also, wicked problems cannot be seen as having linear cause–symptom–effect relationships, they evolve unpredictably over time and involve value conflicts among actors . This maThe study is limited to one case, a policy program. The WCHP program was chosen for several reasons: It represents a complex system  as it adThere are some main learnings and implications from using the organizational-level ST framework to identify and describe how ST is applied in practice in the context of a national policy program addressing several wicked problems in a decentralized national healthcare system. Some practical implications may also aid future attempts both to understand and to facilitate the use of ST in policy programs.First, engaging the right partners in the change process, who represent a broad range of different perspectives and have a mandate to act, is key for enabling ST on the organizational level, but even more so in a national program aiming for impact in 21 self-governing regional systems. Thus, this first ST principle forms the basis for applying the other seven principles described in Wilkins et al.'s framework.Second, the high degree of complexity of the program content and the variety and dynamics of the settings that a national policy program often encounters create conditions that need special attention from the actors involved. A high degree of program dynamic and complexity executed in a complex program setting require a deeper understanding of underlying principles guiding ST, and more time and effort to plan and execute ST-informed action strategies. The strategies must be used, and adjusted, repeatedly during an extended time period. Such programs will need more resources, time, and competence during their implementation than programs with less complexity.Third, even very basic use of ST tools  can function as important levers for ST in practice in a large policy program aiming for system change. Visualization is a practical tool of special importance if the program and setting complexity are high.Furthermore, the narrative descriptions of the action strategies related to ST principles provided in this study, as well as the described difficulties encountered by the program team when using them, provide details that can aid others who lead and support the implementation of soft-law initiatives and policy programs.Detailed, systematic descriptions of action strategies used to support changes in large systems initiatives are still scarce. A multi-level approach is needed to fully grasp how ST is expressed in practice, as individual, group, and organizational-level ST are all inherent in a policy program. To increase the understanding of how to identify and learn more about the practical use of ST in policy programs and public health, we suggest further studies of how ST is used in practice in other policy programs, both in similar and different national contexts. The framework of the organizational ST principles used in this study, together with our observations of the interrelationships between different levels and dimensions of ST in practice, can contribute to such studies.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The study was reviewed by the Regional Ethical Review Board in Stockholm, and they found not to need for a formal ethical approval and issued a statement of this (Ref. No. 2018/620-31).MN and HS designed the study and drafted the manuscript. MN, ST, and VS collected the data. MN, ST, VS, and HS conducted the analyses. All authors read, contributed to the article, and approved the final manuscript.


Faculty members require mentoring in all stages of their professional development. Aga Khan University (AKU) has initiated mentorship programs for students and faculty at AKU Medical College (AKU- MC) and AKU School of Nursing and Midwifery (AKU-SONAM). This study aimed to explore perceptions of mentors, mentees, administrators  and leadership and further investigate the strengths and challenges faced by ‘Faculty Mentorship Program’ at AKU- MC.We conducted a qualitative exploratory study from February till December 2021 after approval from AKU using purposive criterion sampling. Mentors, mentees, administrators and dean of AKU- MC were included in the study. The interview guide was developed, validated and reviewed by experts. After piloting, four focused group discussions and 8 in-depth interviews were conducted in AKU- MC.The findings described the transition from informal to formal mentorship, identified challenges faced by mentors and mentees and suggested the role of leadership / administrators. The themes identified were “Continuous improvement of mentoring practices”, “Building strong foundations for mentoring relationships”, and “Growth and development through challenging experiences”The faculty mentorship program at AKU-MC was in line with the goals and vision of the institution. All participants identified the need of additional resources, administrative support, rewards, incentives and recognition of mentors for sustainability of the program. Mentorship persists as a relationship between two individuals usually a senior and a junior for focused and proficient development of the later.2The support by a mentor is provided informally or through an organized systematic plan.6There is a dire need to institute faculty mentorship programs to ensure personal development, provide career guidance and monitor academic productivity of mentees through a structured format.A qualitative exploratory study was carried out from February till December 2021 following endorsement from ‘Ethical Review Committee of the Aga Khan University, Karachi: (2021-6127-17832)’. Mentors, mentees, administrators and leadership were recruited by purposive sampling technique. Mentors and mentees in FMF for at least one year with participation in at least two mentoring sessions were included. Chairs, co-chairs, founder members and coordinators of the FMP with at least one-year service were counted as administrators. Leadership comprised of Dean of AKU-MC and Associate Dean Faculty AKU-MC. We aimed to include leadership and administrators for in depth interview (IDIs) to capture their unique experiences and perspectives, allowing for a deeper exploration and providing confidentiality.However, focus groups were chosen for mentors and mentees to gather a range of perspectives allowing a more comprehensive understanding and encouraging discussion for a deeper exploration. With the help of relevant literature, the researchers formulated a semi-structured guide with open ended, introductory, probing and concluding questions for both IDIs and focus group discussion (FGDs). The guide underwent Delphi rounds of review by experts selected on the basis of their experience in mentoring and qualitative studies. Both interview guides were piloted after which interviews were conducted in a private setting ensuring a comfortable environment. All the interviews were video recorded, and transcribed. Participants were given a chance to review the transcript to confirm accuracy which helped in avoiding bias (Member Check). In order to control biases, the researcher maintained reflective logs after the IDIs and FGDs regarding the perceptions about mentorship program. The reflective logs were shared with thesis committee members and supervisor to maintain the objectivity of data as well as to minimize personal biases. Data collections like IDIs, FGDs were triangulated with Document review. Data collected from different study groups such as leadership, administrators, mentors and mentees was triangulated amongst themselves. The triangulation of results of the researcher, investigators and committee members (investigators triangulation) was carried out simultaneously to enhance validity, credibility and rigor of the study.For the analysis of data, codes were developed by the authors independently to maintain trustworthiness. These codes were then shared in a meeting with the committee members where a consensus was obtained to finalize them. Similar codes were combined together, grouped into sub-categories and categories to identify and then finalize the respective themes.10Seventeen individuals from AKU-MC  participated in the study .Category ‘Challenges in the Development of formal mentorship program’ explained evolution of formal program as; “In 2014, the Dean formulated a committee which presented a report on the need of mentorship programs. The findings assisted the formation of a formal committee that worked from March 2017 till June 2019 from June 2019 onwards, name of committee was changed to Faculty Mentorship Forum” described in an IDI with one of the administrators. A mentor added; “Informal mentorship existed a couple of years back, before the introduction of formal mentorship program. The mentees used to work with mentors of their own department who helped them to achieve desired goal”.Importance of formal feedback was highlighted in the category of ‘Lessons learnt from feedback; way forward’. All participants recommended the importance of documentation of all mentorship activities with emphasis to develop guidelines, handbook and mentorship curriculum. A mentee emphasized, “I think there should be slightly more structured and formal role of university to document the process and outcomes”. In the plans for further development participants highlighted the importance of informal gatherings where mentee could deliberate their doubts, sorrows and concerns with their mentor. A mentor mentioned, “There should be breakfast and tea meetings between new and old mentors at regular intervals so that they could share their experiences. This way the new mentors will learn the traits of a previous role model” (IDI-02). The category of: “Relationship-building through trust and confidence “accentuated the responsibilities of Role Models One mentor shared his experience in terms of, “I remember my mentor would never leave the lecture hall before erasing the whiteboard / chalkboard for the next person. This small gesture sets a path. There are so many lessons for young students who can learn from a simple piece of role modelling”. Theme “Building strong foundations for mentoring relationships”  discusseIn its category of ‘Connection provides energy to learn and innovate’, , one mentee shared, “I think a good mentee should try to find means to be in touch with their mentor especially when the mentor is extremely busy and not available on emails”. An administrator mentioned; “The list of mentors is available on website which is reviewed every two years. FMF follow a Dyad Model of MentorshipFig.3In this theme all the barriers, challenges like lack of commitment and effective communication between both mentors and mentees, limited resources such as time, budget, and administrative support required for sustainability of the program was highlighted. Improper pairing with limited access to mentors was also an additional issue identified in this study. In the category of ‘Challenges and hardships are inevitable’, communication gap was identified as the biggest challenge faced by mentors and mentees.Mentees mentioned the difficulty in scheduling of meetings whereas mentors mentioned lack of protected time as one of the biggest challenges. A mentee verbalized; “Many young faculty members were facing difficulty to interact with some of the senior faculty members. The culture of face to face communication has to be revived instead of exchanging emails or WhatsApp messages. A solution to improve the communication gap is participation in departmental and coffee meetings.” (FGD-01 P-03). Both mentors and mentees recognized the importance of time management to overcome all the hurdles. One mentor commented, “The first year of my mentorship, I had two mentees. I could never meet one mentee for the whole year and later the mentee went for some more training. I had about three good and interesting meetings with the second mentee”. (FGD-01 P-03)In the category of ‘Benefits of structured and intentional mentoring practices’, participants emphasized the importance of celebrations to recognize and reward the faculty at departmental as well institutional levels. An administrator stated, “The awareness and recognition of program needs attention. It is important to organize awareness sessions as well as disseminate success stories. Support group on education can help in coordination of activities. Mentors should be recognized in faculty assemblies by announcing their names. There should be university culture of awards and recognition” (IDI-01).Mentees strongly recommended that higher authorities should appreciate and motivate the mentors. A mentee added, “There should definitely be some areas or may be some components of support from the administration to appreciate the mentors. There should be a mechanism to recognize the mentors officially. There is a need to acknowledge mentoring, market and scale up the program and share successes stories so that other faculty members realize the benefits of the program”.The study explored the importance of faculty mentoring in promoting the personal and professional growth of mentees through effective communication, skill sharing, and role modeling. The study highlighted the prevalence of the dyad mentorship model, which pairs proficient mentors with junior mentees, and emphasized the importance of open communication and time commitment from both mentors and mentees. The availability of a mentor pool with volunteers of varying qualifications, trainings, and experiences was identified as a successful measure in our study. Mentors obtained ample opportunities to connect, share ideas and strategies, cultivate practical skills, and broaden perspectives that lead to personal growth and career progression of mentees which is supported by literature.12There are a number of mentoring models which support mentors to deliberate cognitive growth and personality development of mentees.11In depth exploration revealed that mentors enrolled in the program were eager to learn, transfer their wisdom to juniors and guide them in the career path. Literature also supports role of mentors in growth and development of mentees and students.17The study emphasized the importance of open communication and time commitment equally important for both mentors and mentees. Respect for mentees with positive feedback with sharing of relevant resources like guidelines, research papers and reading material enhance progressive prospects and promote career growth of mentees.The study also emphasized the importance of institutional support in preparing mentor-mentee meetings, conducting evaluations, and improving programs based on obtained feedback. It recommended the use of online mentoring and providing flexibility to individuals from all backgrounds who wish to participate in mentorship programs. The need to support consistency and permanence, mentorship guidelines with well-defined objectives, clear expectancies, and description of roles and responsibilities of mentors and mentees was also identified 24This is the first ever study conducted in Pakistan to evaluate the mentorship program in the health care system. The study achieved a high level of success in gathering comprehensive information from diverse hierarchical positions, enabling a range of perspectives and recommendations for improvement. The researcher’s involvement in the entire process of data collection and analysis contributed to the study’s strength and credibility. The rigor was further enhanced through data triangulation involving the researcher, research coordinator, and committee members. The information obtained by the in-depth exploration could be useful for healthcare organizations and institutions to design and implement mentorship programs for their faculty and enhance their personal and professional developmentTo gain a comprehensive understanding, a detailed and systematic collection and analysis of the program’s proposal, process, and implementation is necessary, which was beyond the scope of this study. Furthermore, the limited duration of the study made it challenging to assess both the short-term and long-term outcomes of the program, including proximal, enabling, and distal outcomes. However, the study provided preliminary insights into the effectiveness of the mentoring program and highlighted areas of improvementThe study interpreted alignment of FMF with vision and mission of AKU-MC representing effective formal mentoring practice which emerged from traditional informal mentoring. The forum followed Dyad mentoring model, organized mentor mentee pairing and followed the relationship with structured feedback system. The participants recognized the need of protected time, strong administrative support and continuation of recognition, rewards and incentives for the mentors.RR: Designed the study.TSA and RA: Supervised the whole project.RR and SK: Executed the study under supervision of STA and RA.RR: Is accountable for the accuracy and integrity of the study.All authors read the manuscript and revised the content.