The VLP + S participants were more likely than the other participants to have clinically significant weight loss . Compared with the VLB participants, the VLP participants were less likely to meet the recommendations for consuming fast food (p = 0.022) and sugar-sweetened beverages (p = 0.010). The VLP and VLP + S participants reported higher program satisfaction than the VLB participants. The VL program facilitates weight loss among school-district employees with overweight and obesity by increasing their PA and healthy diet.The effects of Vibrant Lives, a 6-month worksite-weight-loss program, were examined in a cohort of school-district employees with overweight or obesity. The VL Basic (VLB) participants received materials and tailored text messages, the VL Plus (VLP) participants additionally received WIFI-enabled activity monitors and scales and participated in health challenges throughout the school year, and the VL Plus with Support (VLP + S) participants additionally received coaching support. The levels of program satisfaction and retention and changes in weight, physical activity (PA), and diet were compared across groups using Pearson chi-square tests, repeated-measure mixed models, and logistic regression. After the program, the VLB ( Obesity is associated with several comorbidities, including cardiovascular disease and diabetes , and an Among employees with obesity, regular PA, healthy diet, and calorie reduction are effective strategies for achieving weight loss and, thus, reducing cancer risk. In the United States, the prevalence of obesity is increasing because of decreased occupational PA ,8 and inTraditional worksite-weight-loss programs that involve in-person or group-based interventions are not always scalable, which can limit their usefulness for larger groups of employees, and they can involve high cost and time burdens for both participants and providers. Since they feature few, if any, in-person activities, internet-based weight-loss interventions have smaller time and cost burdens . AlthougThe Diabetes Prevention Program (DPP) was demonstrated in a randomized controlled trial to be more effective in preventing diabetes among those at high risk than metformin or placebo , and hasThe aim of this study was to evaluate the effectiveness of Vibrant Lives (VL), a digital worksite-weight-loss program using the adapted DPP, in promoting weight loss, and PA, and diet among school-district employees with overweight or obesity. Participant retention in and satisfaction with the program were also assessed for the feasibility of the program.2 in Year 1 and a BMI greater than 27 kg/m2 in Year 2. The analysis of data from the program evaluation was reviewed by The University of Texas MD Anderson Cancer Center Institutional Review Board and was determined to be exempt.This program enrolled employees of the Pasadena Independent School District, a public-school district in southeast Texas, over the 2017–2018 school year (Year 1) and the 2018–2019 school year (Year 2). Eligible participants had a BMI greater than 25 kg/mThe VL program is a digital worksite-weight-loss program that promotes PA and healthy eating. The VL program was adapted from the Diabetes Prevention Program , whose rThe initial plan for the VL program was to offer a weight-loss program to school-district employees that included print materials from an adapted Diabetes Prevention Program , daily text messages that supported the DPP lessons (7–12 per week), an activity tracker  and WIFI-connected scale , and opportunities to participate in group challenges . In the second year, participants were also offered the opportunity to participate in a closed, secret Facebook group which provided nutrition, weight-loss, and exercise information and included weekly challenges, such as posting a recipe modified to be healthier, or a photograph of a new place to exercise. We also planned to randomly select approximately half of the schools to receive an additional support component; participants in these schools would receive an offer to participate in telephone coaching if they had not lost weight at the midpoint of the program . However, the demand for the program was high; we had funding to provide the VLP/VLP + S program to 100 participants per year and 400 expressed interest in the first year alone. Therefore, we worked with the school-district personnel to select schools that would receive the full VLP program  to enroll approximately 120 participants each year, and the employees in the other schools were offered Vibrant Lives Basic (VLB), a low-cost version that included the emailed materials, text messages, and, in the second year, access to a Facebook group. In the first year, the school/location selection for VLP and VLP + S prioritized employees working in the administrative office to build leadership support for the program and schools that were implementing the Coordinated Approach to Child Health (CATCH) program . SelectiWe used a survey to collect participants’ demographic data, including age, race, sex, education, and marital status. Participants reported their self-measured weights at baseline and follow-up. Participants in the VLP and VLS groups self-measured their weights on their WIFI-enabled scales.Participants reported their PA and dietary-intake behaviors at baseline and follow-up using the survey items from the Health Information National Trends Survey  and HealWe scored participants’ responses on the reports according to whether they met the recommendations of at least 150 min of moderate-to-vigorous PA per week and at least two sessions of strength exercise per week ; how often they consumed red meat , fast food , and sugar-sweetened beverages ; their daily consumption of fruit  and vegetables ; and how often they ate breakfast .Participants in the VLP and VLP + S groups used their Fitbits to measure their physical activity. After excluding non-valid days  and non-valid weeks , we summed the number of daily steps and “very active”, “fairly active”, and “lightly active” minutes. “Active minutes” represented the combination of the number of Fitbit-derived “fairly active” and “very active” minutes per day. Detailed information about Fitbit-data use in the VL program is provided elsewhere .The program-retention rate was the percentage of participants who completed both the baseline and follow-up assessments and a program-satisfaction survey. Program satisfaction was assessed with a Likert-scale survey  with the following prompts: “Being in the program has motivated me to increase my physical activity”; “Being in the program has motivated me to adopt a healthy diet”; “Being in the program has motivated me to lose weight”; “This program was effective for me”; and “I would recommend this program to a friend or family member”.p-value (p < 0.05).We used descriptive statistics to summarize the baseline characteristics of the participants. One-way analysis of variance and the Pearson’s chi-square test were used to detect differences in continuous variables  and categorical variables , respectively, between the participants who completed the program, “completers”, and those who did not complete the program, “non-completers”, among the three groups. Changes in weight, PA, and dietary intake between baseline and follow-up among the VLB, VLP, and VLP + S groups were analyzed using multi-level repeated-measure linear mixed models and logistic-regression models; in these analyses, we clustered participants by school and controlled for the study years  and race/ethnicity as covariates. Differences in program retention and satisfaction among the three groups were assessed using the Pearson’s chi-square test. Fitbit-derived daily step counts and active minutes were converted to weekly average, which were reported using linear regressions for each of the 26 weeks of the program and compared between VLP and VLP + S groups using repeated-measure mixed models. All statistical analyses were performed with the STATA 15.1 statistical software program . Results were reported using an unstandardized beta (β) or odds ratio (OR) with a standard error (SE) and 2 = 30.85, p < 0.001) and that in the VLP + S group .Of the 543 participants initially enrolled in the VL program, 306  completed the program and follow-up assessments and were included in the analyses. The percentage of program completion (program retention) by the groups is shown in The baseline characteristics of the completers and non-completers are provided in the 2 = 20.48, p = 0.025); no other significant differences among the groups were detected.The characteristics of the 306 completers by intervention arm are provided in p < 0.001) and increases in weekly moderate-to-vigorous PA , but these variables did not differ significantly among the groups. The participants in the VLP + S were more likely to have clinically significant weight loss (≥3%) than the other participants . All the groups had higher rates of moderate-to-vigorous PA  and strength exercise  at the end of the program, but these rates did not differ significantly among the groups. In addition, all the groups had significantly higher rates of consuming red meat two or fewer times per week , consuming fast food two or fewer times per week , and not consuming sugar-sweetened beverages in the past week . They also had higher rates of consuming at least one cup of fruit per day  and of consuming at least three cups of vegetables per day . Compared with the VLB group, at the end of the program, the VLP group had lower rates of consuming fast food fewer than two times per week , and not consuming sugar-sweetened beverages in the past week .The changes in weight, PA, and dietary intake between baseline and follow-up are shown in n = 175) are given in p = 0.028) and daily steps  between the VLP and VLP + S groups. The linear rate of daily active minutes was significant for the VLP group , but not for the VLP + S group . The linear rate of the daily number of steps was not significant for the VLP group  or for the VLP + S group .The weekly average numbers of daily active minutes and steps for the VLP and VLP + S groups  was significantly lower than those of the VLP and VLP + S groups (both 73%). Some of the outcomes of the VLB group may have been better than those of the VLP group because the 43% of VLB participants who completed the program may have been more motivated than the other subsets of participants, who received the two other versions of the program.During the program, the participants in the VLP and VLP + S groups logged more than 8000 steps per day on average, which is in line with a reasonable threshold of free-living PA (7000–8000 steps/day) and with current PA guidelines . The FitSome limitations should be considered when interpreting the results of our study. First, the participants’ self-reported PA did not capture increases in light PA or reductions in sedentary behavior, which also burns calories and can aid in weight loss. Second, the measurement of diet was limited by the need to reduce the assessment burden in this worksite-delivered program. The dichotomous variables of dietary intake, which indicated meeting healthy-eating recommendations, did not enable a direct association between diet changes and weight loss among the participants because the items do not capture all intake and do not allow the calculation of energy intake. Third, because all the participants were school-district employees from a specific geographic region  and most were women, it would be difficult to generalize our findings to other populations. Finally, because the study lacked a control arm, we cannot be certain that the effects we observed were caused by the intervention or by other programs or secular trends. However, given that adults in the US typically gain approximately one pound per year ,47, it sThe VL program is a promising approach to facilitating weight loss among school-district employees with overweight and obesity by increasing their PA and healthy eating behaviors. This scalable, light-touch intervention may help employees improve their behaviors, achieve their weight-loss goals, and, consequently reduce their cancer risk. While all the versions of the program had similar effects on weight loss and physical activity among those who completed it, the inclusion of more interactive components  may increase retention.


It takes decades and millions of dollars for a new scientific discovery to become part of clinical practice. In 2015, the Center for Health Innovation & Implementation Science (CHIIS) launched a Professional Certificate Program in Innovation and Implementation Sciences aimed at transforming healthcare professionals into Agile Change Conductors capable of designing, implementing, and diffusing evidence-based healthcare solutions.In 2022, the authors surveyed alumni from the 2016–2021 cohorts of the Certificate Program as part of an educational quality improvement inquiry and to evaluate the effectiveness of the program.Of the 60 alumni contacted, 52 completed the survey (87% response rate) with 60% of graduates being female while 30% were an under-represented minority. On a scale from 1 to 5, the graduates agreed that the certificate benefited their careers (4.308 with a standard deviation (SD) of 0.612); expanded their professional network ; and had a large impact on the effectiveness of their leadership , their change management , and their communication . Graduates claimed to use Agile Processes , storytelling, and nudging weekly. On a scale from 0 to 10 where 10 indicates reaching a mastery, the average score for different Agile competencies ranged from 5.37 (SD of 2.80) for drafting business proposals to 7.77 (SD of 1.96) for self-awareness. For the 2020 and 2021 cohorts with existing pre and post training competency data, 22 of the 26 competencies saw a statistically significant increase.The Graduate Certificate has been able to create a network of Agile Change Conductors competent to design, implement, and diffuse evidence-based care within the healthcare delivery system. Further improvements in building dissemination mastery and program expansion initiatives are advised. In United States healthcare delivery organizations, 40% of patients do not receive evidence-based care, ~25% of patients are harmed, and at least 30% of annual healthcare spending is wasted –3. Harm To address the gap between knowledge and practice, healthcare delivery organizations must acquire workforces with competency in designing, implementing, and diffusing evidence-based healthcare solutions. In 2015, the Indiana University Center for Health Innovation & Implementation Science (CHIIS) launched a Professional Certificate Program in Innovation and Implementation Sciences as an attempt to build a network of Agile Change Conductors. This graduate educational program sought to train established healthcare professionals, consisting of clinicians, educators, researchers, and administrators, to be able to leverage insights from Agile Science to design, implement, scale, sustain, and diffuse evidence-based care solutions within their local complex adaptive healthcare delivery organizations –18. The The purpose of this paper is to describe and evaluate the effectiveness of the Graduate Certificate from its inception in the Fall of 2015 until the Summer of 2021 and discuss areas for quality improvement.A survey of all alumni of the Certificate Program in Innovation and Implementation Sciences (IIS) was conducted to evaluate program effectiveness and as part of an educational quality improvement inquiry. The complete survey is available as The Certificate Program is offered as a graduate course through the Indiana University School of Medicine. The course is 12 months long with 4 hour-long video meetings and one weekend residency each month . From 20The weekly 1-h coaching sessions focus on real-world deliberate practice and open-space discussions. The format of Saturday weekend residencies: group reflection 8:00–10:00 a.m., guest speaker 10:00 a.m.−12:00 p.m., lunch break, guest speaker 1:00–3:00 p.m., group reflection 3:00–5:00 p.m. Speakers have ranged from CEOs to business founders to alumni of the program. During the allocated time for Agile Reflection, participants are asked to rate their experience from −10 and +10 and share two English words, what they found interesting, surprising, actionable, and anything worth converting into an artifact, nudge, or ritual see . Sunday The Certificate Program concentrates on knowledge acquisition through readings and lectures and demonstration of knowledge acquisition through deliberate practice coupled with personal and group feedback. The intention of the small group size, 16 students or less, is to foster strong interpersonal connections and create time for individual mentoring built on a foundation of psychological safety. To maximize learning, there must be enough trust to check assumptions and ask questions or voice concerns. In doing so, the sessions become one of collaboration and critical thinking rather than passive learning. This is done by building time and space for reflection as well as timely, actionable, and non-judgmental feedback. Students are encouraged to share when they apply Agile Science in their personal and professional spheres, creating group learning on how to fail quickly and providing examples detailing attributes of successful implementation.The Certificate Program is pass or fail, graded by weekly participation (25%), residency participation (25%), and the final project (50%). The first major assignment is to describe oneself as a company, detailing the tagline, mission, vision, and values. This is converted into a minimally viable story, used by students to introduce themselves to guest speakers, and can serve as a blueprint for branding. Students are encouraged to reach out to speakers after their presentations using LinkedIn™ to network for discovery. During the first 4 months of the certificate, students are encouraged to find ways to modify their physical, social, or digital environments through artifacts, nudges, or rituals. The next major assignment has students formally pitch a Nudge Unit, as if to a healthcare CEO, and receive feedback on their technique. A Nudge Unit provides system-wide expertise in identifying opportunities, designing, creating demand for, implementing, managing, and evaluating nudge projects to improve healthcare . After 6The curriculum is broken down into 6 primary sections: Innovation and Implementation Science I; Health Outcomes and Evaluation in Implementation Science; Innovation and Implementation Science II; Leading Change, Teams, and Projects; Practicum in Innovation and Implementation Science I; and Practicum in Innovation and Implementation Science II . The priAgile Science leverages insights from behavioral economics, complex adaptive systems theory, and network sciences to understand, predict, and steer the behavior of an individual or a social organization see . BehavioConstructed from the scientific foundation of behavioral economics, CAS, and network science, Agile processes for innovation, implementation, and diffusion provide steps to select, integrate, and scale evidence-based solutions within the constraints of healthcare delivery organizations see . All thrEach graduate from the 2016–2021 cohorts was sent a personalized survey in 2022 with their name, email, and graduation year pre-filled out to prevent repeat responses. A reminder email was sent after 3 weeks and after 4 weeks following the initial email to those who had yet to complete the survey. All 42 questions in the survey were multiple choice to minimize survey fatigue, with the estimated time to complete the survey under 10 min. The questions were chosen based on the ability to measure the expansion of learned Agile tools, processes, and strategies more widely into spheres of influence. The survey was broken down into three sections: professional application, current competency as an Agile Change Conductor, and frequency of usage for tools, processes, and strategies obtained in the program. In the professional application section, graduates were asked to complete the Net Promotor Score question “On a scale of 0 to 10, how likely are you to recommend our certificate to a friend or colleague?” Net Promoter Scores are a standardized metric with national data available for how different economic sectors rank . In addiAn additional database was created about graduates' professional advancements using public LinkedIn™ information and employer web pages. The data compiled consisted of current occupation, how long they had been in that position, the number of job updates following graduation, schooling updates since graduation, the number of followers if applicable, and any major accomplishments since program completion. No formal Certificate Program follow-ups had been conducted prior to this study. Hence, this served to track changes in professional development following the completion of the program. For ethical considerations, all information was anonymized following data acquisition and stored on a password-protected platform.t-tests at a 95% confidence interval. ANOVA testing was used to identify any significant temporal differences between cohort years.We used quantitative descriptive statistics and pre and post comparison statistics to assess the impact of the program. Given the numerical ranking of all 42 questions, overall averages and standard of deviations were computed for each question and each cohort. Pre and post training competency comparisons were computed for the 2020 and 2021 cohorts, a subsample of the study population, using 2-sample The first six cohorts included 25 physicians, nine nurses, 14 masters-level administrators, three social workers, and nine other clinically trained personnel. Participants for this study included all 60 past students of the program. Because the first cohort graduated in 2016, there were a total of six cohorts with varying amounts of participants in each, the most recent having graduated in August of 2021. Of the 60 alumni contacted, 52 completed the survey yielding an 87% response rate. Sixty percent of the graduates were female and 30% were of an under-represented minority . Using the Net Promotor Scale, 36 participants (69%) were promoters of the program with a score of 9 or 10; one participant (2%) was considered a detractor with a score below 7; and finally, 15 participants (29%) were neutral with a score of 7 or 8. Thus, the Net Promoter Score was 67 (promoters minus detractors). Neutral and detractor participants came from every cohort and a diverse range of healthcare occupations.In terms of the professional benefit of the program see , graduatp = 0.52). Existing competency data taken prior to course completion existed for the 2020–2022 cohorts (n = 34). There were no statistically significant differences between pre-completion scores over the 3 years (p = 0.99). Twenty-two out of the 26 competencies saw a statistically significant increase from pre to post training proficiency (n = 18). The exceptions were in writing papers, writing grants or business proposals, statistical analysis to pick up signal from noise, and traditional research methodology.Regarding the frequency of utilizing the tools, processes, and strategies obtained from the program see , the aveBased on information from publicly available databases, 65% of graduates had a promotion and/or have since pursued an additional degree or professional training. The average number of followers was 846 based on available LinkedIn™ accounts. The average number of years in their current position was 4.11 years (SD of 4.73). For career advancements, the average number increased from 0.25 one year out to two changes 6 years out see .We found that the IIS Certificate Program has impacted graduates in terms of their professional careers, network expansion, change management skills, communication, and leadership. The program was also successful in building a network of Agile Change Conductors who are strong promoters of the program and competent in implementing and diffusing evidence-based care in their local complex adaptive healthcare delivery organizations. This indicates the Certificate Program is an effective way to create Agile Change Conductors capable of designing, implementing, and diffusing evidence-based healthcare solutions.via the program exemplifies the success of the program in building an integrated network of Agile Change Conductors.We used the Net Promoter score to measure the graduates' attitudes toward the program. A score above 70 is considered excellent . The proThe frequency of usage section in the survey helps monitor the influence of the program on the daily activities of graduates. While the scores had more variation between graduates, the results were still overwhelmingly positive. No question had an average score below 2.5, which translates onto monthly use. Weekly use was the most common response for using Agile Processes , storytelling, and nudging, demonstrating a high amount of practice. The integration of course material into the habitual lives of the graduates is a testament to sustained impact that goes beyond knowledge acquisition.Majority of graduates did not have an active LinkedIn™ account prior to enrollment in the Certificate Program. Students without accounts were strongly encouraged to create a profile for the purposes of branding and networking for resources and discovery. Therefore, 92% of the graduates having an active account with an average of over 800 connections reasonably demonstrates the Certificate Program expanded professional networks. From profiles, there was professional advancement of most members (65%), in line with most graduates agreeing that the program benefited them professionally through position changes, continued education advances, and/or achievements.When looking at the success of the program in creating well-rounded Agile Change Conductors equipped with transferable change management skills, the proficiency test indicates graduates are competent and nearing mastery. For each of the 26 competencies, the data were skewed left with averages showing nearly all members were more competent than not. The standardized increase in competency for nearly all skills of an Agile Change Conductor in a subsample of the study population is indicative of some causal benefit from the program. Proficiency did not appear to decline, given no variation between the 2016 cohort surveyed 6 years following graduation and the 2021 cohort surveyed 1 year following graduation. There was no decline in competency for either the 2020 or 2021 cohorts despite the shift to fully virtual learning. These results indicate satisfactory improvements in each of the intended competencies, highlighting the Graduate Certificate Program has thus far met its professed goals of training members in innovation and implementation science.n = 54, 2008–2017), coming out in strong support of the benefits of graduate-level training in implementation science career development (n = 58), the program has been found to create a robust and transferable skillset for researchers and healthcare practitioners , the survey lacked eight responses to make the data complete. It is therefore possible the data is not completely representative of all past cohorts, especially early cohorts with lesser response rates. A significant limitation of this study is the lack of baseline competency data for cohorts 2016–2019, greatly reducing the comparative aspect of this study. Majority of conclusions are made using descriptive statistics. While the absence of variation in competency across cohorts may help generalize the 2020–2021 pre-post training findings more broadly, the small sample size limits direct causal attributions. Additionally, there are likely large parts of careers not posted on LinkedIn™. It is difficult to know the extent to which career advances seen online were due to the program, as is also the case with follower counts. Despite these limitations, the data overwhelmingly points to a beneficial impact of the program.In conclusion, the Certificate Program in Health Innovation and Implementation Sciences has been successful in creating Agile Change Conductors who have been able to act upon the set of learned tools, processes, and strategies to transform the healthcare delivery system.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Indiana University Institutional Review Board (#15824). The patients/participants provided their written informed consent to participate in this study.JM: primary author of the paper, designed, conducted, and analyzed the study, drafted and edited the paper, and developed all supplementary materials. MA: developed idea and initiative for paper and edited paper and survey throughout the process. AO'B, TB, RA, and DS: editors for the paper and made significant contributions to the rhetoric and outstanding ideas presented in the final version. MB: principle investigator, helped design, conducted, analyzed, and wrote about the study. All authors contributed to the article and approved the submitted version.


The COVID-19 pandemic led to many changes in healthcare including graduate medical education (GME). Residency and fellowship programs halted in-person recruitment and pivoted to virtual models. Residency selection and recruitment were practices ripe for redesign, as they relied on in-person interviewing as the major point of contact prior to match list creation. In this commentary, we review the state of virtual interviewing and propose a future state where virtual interactions are commonplace and integrated into a comprehensive recruitment process.Virtual recruitment has led to a reduction of expenses, improved time efficiency for all parties and a reduced carbon footprint. Residency match outcomes have not changed substantially with the advent of virtual interviewing. Hybrid approaches, including virtual and in-person options have significant drawbacks and pitfalls which may limit adoption. Given the upheaval in GME recruitment caused by the pandemic, and the limitations of current methods for candidate assessment and interactions with programs, further innovation is needed to achieve an optimal state for all stakeholders. Multiple technology innovations are on the horizon which may improve the ability to interact virtually. Adoption of new technology along with expanding the timeline for residency recruitment may further optimize the process for both applicants and programs.Virtual communication methods have substantially changed residency recruitment during the COVID -19 pandemic.COVID -19 related changes in residency recruitment, including wide adoption of virtual methods, should be maintained and strengthened.Efforts should be made to advance the gains in residency recruitment strategy during the pandemic by use of technologies that expand virtual interactions beyond the interview.The GME community was able to adopt technology for the recruitment interview rapidly due to the pandemic. As more opportunities for technology-based interactions grow, the opportunity exists to reimagine recruitment beyond the interview. While resources are constrained, some of the efficiencies gained by adopting virtual interviewing can be leveraged to expand the interactions between programs and applicants. Incorporation of in-person interaction may still be needed. Models will need to be developed to build upon the best characteristics of the virtual and in-person environments to optimize GME recruitment. The novel coronavirus 2019 (COVID-19) served as a catalyst for many changes in healthcare. Graduate medical education (GME) was no exception, as programs halted in-person recruitment and pivoted to virtual models. Residency selection and recruitment are practices ripe for redesign. For years, education leaders have discussed the challenges associated with the interview process such as effectiveness, expense, time away from learning, inequities, and bias while struggling to make meaningful changes [The Coalition for Physician Accountability (COPA) recommended virtual interviews to reduce the risks of travel during the COVID-19 pandemic . SimultaTwo years later, virtual recruitment and interviews are commonplace and prospective residents have adjusted. Innovation in residency recruitment has extended beyond the interview to include smartphone apps containing program information, virtual social events and social media to connect applicants with the program . Still, Options for interviewing candidates include in-person interviews, virtual interviews using real time voice and video, and a hybrid combining virtual and in-person methods. Before COVID-19, most GME programs used in-person interviews. Travel bans and concerns for putting interviewees and faculty at risk of infection led to changes toward complete virtual methods. As the pandemic wanes, questions remain as to the value of the virtual versus in-person interview and the potential value of a hybrid approach.In-person interviews are characterized by the presence of both parties’ physical presence for the interaction. Surveys in several different specialties indicate that applicants and program directors prefer in-person interviews . In addivia electronic means, usually consisting of real time video and audio feeds [Virtual interviews involve synchronous interaction of the two parties io feeds . The mosio feeds ,20. Concio feeds . In-persio feeds . In contio feeds . The cario feeds . ProgramWith the virtual process, applicants may be able to schedule and attend more interviews without the burden of interview expenses. The virtual process may also decrease applicants’ anxiety levels by interviewing in the comfort of their own personal spaces. Surveys show that most interviewees feel they could present themselves well and assess programs in virtual-only format ,27.Fears that virtual interviews preclude full candidate assessment or communication of program attributes may be unfounded. Studies of the virtual interview process found that programs perceived they could present themselves and their program and assess applicant candidacy virtually ,28. DuriWith increasing likelihood that residency recruitment will not return to pre-pandemic state, another model is for a virtual interview combined with an on-site experience as a hybrid approach. The on-site experience may be an additional interview used in the program’s decision on ranking, or as an opportunity for the applicant to explore the program’s physical environment without being evaluated. Although a hybrid approach can offer an opportunity to incorporate more customary interview practices, such as social events and campus and facilities tours; a hybrid approach unravels many of the virtual recruitment benefits such as cost-effectiveness, reduced applicant and program expenses, and increased geographic applicant diversity. Furthermore, it presents at least two major risks and pitfalls.First, post interview interactions and communications between applicants and programs increase opportunities for misinterpretation of commitment and therefore, risk breach of the National Residency Matching Program (NRMP) Match Participation Agreement governing such practices . A hybriSecond, there are risks of increasing inequity in a hybrid approach. Applicants may feel pressure to travel for increased visibility and perceptions of a campus visit influencing final ranking. There are concerns that some underrepresented minority (URM) applicants may feel a disproportionate obligation to travel versus their non-URM peers . The NRMA comparison of the three interview methods, focusing on the practical aspects, technological benefits and limitations is presented in Given the upheaval in GME recruitment caused by the pandemic, and the limitations of current methods for candidate assessment and interactions with programs, further innovation is needed to achieve an optimal state for all stakeholders. In our view, future GME recruitment should include a change in paradigm from an antiquated process, based on brief, in-person, and choreographed personal interactions, to a new system that is continuous, frequent, organic, and mostly based on digital interactions. This aligns with major industry-wide changes  and harmLooking to the horizon of the human connection landscape needed for virtual recruitment, creativity, connectivity, and technology are coming together in unique ways. Novel models build upon digital platforms allowing more natural and unintrusive mingling to facilitate spontaneous conversations: essentially virtual networking between people. These platforms allow applicants to learn about programs or interact with program leaders frictionlessly. The currently used technologies for virtual interviewing such as Facetime, Zoom, Skype and Webex all work to establish a direct 2-dimensional synchronous communication between people. In addition, digital collaboration tools like Slack  and Teams  add on options for asynchronous communication through text or chat features that exist even when the participants are not interacting at the same time. These platforms are commonly used for interviews and open houses; however, the execution can be unique. Mayo Clinic Emergency Medicine residents and candidates engage in interactive games and exercises through Zoom . In addition, these applications can be used in other ways, for example, the Mayo Clinic Internal Medicine residency began using Zoom on a tablet device to allow approximately 900 applicants over the past two recruitment seasons to experience live clinical rounds to showcase their collegiality and patient focused culture . In this way, novel uses for these newly adopted technologies may create more meaningful and natural connections between applicants and programs, providing applicants more insight into the overall culture of programs.Building upon these platforms, there are tools that allow participants to move on a 2-dimensional space before interacting with each other. This allows virtual mingling and regrouping of people to facilitate spontaneous and variable conversations: essentially virtual networking between people. Remo , founded in 2019, allows participants to move their avatar around a flat virtual set of tables and create different and spontaneous groupings of people who then have 2-dimensional video conferencing ability. Gather  takes a creative twist upon that and allows gamification of a similar concept. People can move avatars similar to video game characters around a large flat-world and create spontaneous interactions with others. The American Academy of Physical Medicine and Rehabilitation held a national recruitment event where multiple training institutions hosted virtual tables in a Remo environment and applicants were able to move from virtual table to table and learn about or interact with individual program leaders: just as they would have in an in-person residency fair event. Certainly, the effectiveness or impact of residency fair events is not formally proven, however, this example shows how technology is already being used to recreate traditional applicant-program encounters in virtual ways.Evolving the experience from a synchronous 2-dimensional one to a 3-dimensional one, Cisco Systems Inc. is developing a version of Webex that permits users to see holographic versions of each other and interact with virtual 3D objects simultaneously. This technology is expected to be available for widespread use potentially in 2024 or even earlier. When the environment also becomes 3-dimensional, the metaverse may be more completely realized. Facebook  rebranded itself to Meta in 2021, taking a step into this future of metaverse where increasingly lifelike avatars of people interact with each other in virtual 3-dimensional worlds. Specific interweb platforms using hardware like Meta Quest , such as VRChat  and RecRoom , would permit training programs to create a virtual world or space and invite potential applicants to engage with them in that 3-dimensional multisensory environment . With thThese possibilities can surely feel distant, impossible, or impractical. An example of disruptive technology adoption is the smartphone, such as the Apple iPhone, introduced 15 years ago. This new technology, which integrated a portable music player, camera, cellular phone, and computer into a single device, in such a small portion of time, made email management, text messaging, social media interactions, remote learning all possible on a scale that was previously not present. We believe it is very possible that metaverse technology may also catalyze change in the way humans connect in the same or even shorter period.An effective residency match cannot occur with scant and extemporaneous data. A good relationship can only happen if it is based on deep knowledge built on rich and long interactions. The recruitment and matching process needs to become longitudinal, broad, and deep. The process may start earlier than the fourth year of medical school. Prospective applicants could regularly interact with residents, faculty, and program directors, attend didactics on-line, meet periodically with partners and families and learn about the community offerings. Expanded access to program leadership may require an incremental investment of time and effort. The Accreditation Council for Graduate Medical Education (ACGME) has recently redefined requirements for program director dedicated time; however, this additional time may not be sufficient to adopt the reforms we propose. Costs of acquiring modern technology may be a significant barrier to program adoption. Programs that expand their recruitment timeline should measure the effectiveness of their efforts and the incremental resources needed. Data from the early adopters of expanded recruitment practice will help to inform institutional leaders and ACGME as to the need for changes in faculty effort and other resources needed for success.A longer relationship may provide improved data points. Medical students could have a better understanding of culture and operation of the program, grasp group dynamics, explore financial opportunities, and assess the community impact of each institution. For program directors, longer engagement may permit a global understanding of the applicant, including interactions with other learners and faculty, skill development and understanding the potential contributions of each applicant to the program.The future presents a bold opportunity to reimagine GME recruitment, seizing the opportunities created by the pandemic. New technologies may increase interactions beyond the interview and provide better data to programs and applicants. Adoption of new technology and processes will reduce some burdens on both applicants and programs, while requiring additional program resources. The role of in-person interactions in this new era is still unclear. Hybrid models may be adopted but with safeguards in place for the protection of all parties. Now is the time to build on the momentum created during a worldwide crisis and embrace a new virtual and forward-thinking recruitment model for GME programs.


Carvedilol is recommended for chronic heart failure (HF) treatment in children. However, the ideal dosage and administration are not standardized, and data on its long-term effects are lacking. This study aimed to assess the effect of a high dosage regimen of carvedilol on cardiac outcomes in children with HF.We conducted a retrospective cohort study including all children with HF and dilated cardiomyopathy. We analyzed medical records before starting treatment, at 1 and 3 years after reaching the maximum therapeutic dosage. All data were compared with a historical control group. Kaplan–Meier analysis and Cox proportional hazard regression have been used to evaluate the effect of high dosage carvedilol therapy. The main outcome was a composite of all-cause mortality and heart transplant.p < 0.0001) and ejection fraction improvement  were statistically significant in those. Long-term survival and freedom from heart transplant were significantly improved in those treated with high dosage carvedilol therapy (p = 0.00001).One hundred thirty-five were included in the study and 65 treated with a high dosage of carvedilol regimen (up to 1 mg/kg/day). Heart rate reduction (mean reduction 30%, Treatment with the high dosage of carvedilol, in addition to standard HF therapy, significantly improves ventricular function and survival in children with dilated cardiomyopathy and chronic HF. Chronic heart failure (HF) due to dilated cardiomyopathy (DCM) remains a significant medical challenge in a pediatric population, leading to transplantation or death in 40% of children and adolescents . There iThe present study aimed to evaluate the efficacy of different dosages of carvedilol in children and adolescents with symptomatic chronic HF due to DCM at long-term follow-up.A retrospective cohort study has been performed to evaluate the effect of carvedilol at high dosage in HF children affected by DCM at long-term follow-up. All children diagnosed with DCM referred to Bambino Gesù Hospital from 2013 to 2017 were assessed for inclusion in the cohort.Among those, patients matching the following criteria have been included: (1) age at clinical presentation ≥1 year and <18 years; (2) diagnosis of DCM, according to the current cardiomyopathy classification ; (3) lefAll cases of acute lymphocytic myocarditis and/or inflammatory cardiomyopathy assessed by endomyocardial biopsy and/or cardiac magnetic resonance imaging were excluded from the study.The medical records of the included patients were assessed through a retrospective review of clinical charts.The individual patient follow-up started from the first medical record available of the Bambino Gesù Children Hospital in which an LVEF < 45% was recorded and lasted to the date of death/heart transplant or to the last available medical record within the study follow-up.The following data have been collected at 1 and 3 years of follow-up: New York Heart Association/Ross functional class, blood pressure measurement, standard electrocardiogram, echocardiogram, brain natriuretic peptide (BNP) dosage, and pharmacological treatment.Two blinded expert cardiologists separately reanalyzed standard electrocardiograms and echocardiograms.Echocardiographic images in two dimensions were digitally stored, and measurements were made offline. LV volumes  were analyzed on three consecutive beats; apical four-chamber and two-chamber views were used in accordance with guidelines of the American Society of Echocardiography . Wall thClinical outcomes (death and heart transplant) were collected throughout the follow-up.Patients matching the inclusion criteria mentioned earlier and treated with carvedilol were considered in this group. Carvedilol was uptitrated every 2 weeks to reach a high dosage (≥ 0.8 ≤ 1 mg/kg/day). Reason for interruption of uptitration was noticed and way of administration and uptitration assessed. All concomitant drugs  have been recorded. All adverse effects reported were noted.To evaluate the effect of carvedilol, we compared patients exposed to carvedilol regimen with patients undergoing other pharmacological treatment only . We considered as “control group” all patients who did not undergo carvedilol therapy or other types of β-blockers. This group of patients was extrapolated by our historical database, followed by primary cardiologists between 2003 and 2013. Clinical characteristics were comparable and reported in The primary outcome measure of the study was a composite of all-cause mortality and heart transplantation.Secondary endpoints were echocardiographic measures  and clinical measurements .p < 0.05 was considered significant. All statistical analyses were performed by SPSS Statistics 21 .Continuous variables are presented as mean values and standard deviations. Categorical variables are expressed as absolute numbers and percentages. Paired t-test was used to compare continuous variables. Univariate and multivariate analyses were performed by Cox regression analysis. All variables that resulted significantly in univariate analysis were entered in multivariate analysis to determine the independent predictors of long-term outcomes. Results are expressed as the hazard ratio, with 95% confidence intervals (CIs). Survival data and freedom from adverse events (death and heart transplant) were analyzed and graphically reported by the Kaplan–Meier method. Patients who did not experience any events were censored at the time of the last follow-up. The difference in survival between groups was analyzed using the log-rank test. A n = 65) and patients not treated with carvedilol “control group” (n = 70). In the carvedilol group, a high dosage of carvedilol was achieved in 60 (92.3%).One hundred thirty-five matched the inclusion criteria and were included in our cohort. The mean (standard deviation) duration of follow-up was 4.8 (±1.4) years. According to carvedilol exposure, we divided all cases into two groups: patients on carvedilol  occurred in any patients on treatment with high dosage carvedilol. All patients in this group survived, and four of four patients were delisted from the transplant waiting list. In the carvedilol group, all patients changed New York Heart Association/Ross class except one (1.5%), who remained in functional class III; among the remaining 64 patients, the functional class decreased to class II in 37% and to class I in 61.5%. No changes in drug regimen over time were reported.p < 0.0001) , and 24 patients were transplanted (34%) after 1 year of follow-up. The multivariate Cox regression analysis showed that the use of β-blockers and reduction in heart rate are the only independent predictor of long-term survival and freedom from heart transplant ( 0.0001) . Kaplan– 0.0001) .p < 0.0001) was reported.A significant difference between the high dosage of carvedilol and the control group (No significant differences between mean HR and EF at baseline were observed between the two groups .p < 0.001).In the carvedilol group, the mean level of serum BNP at 1-year follow-up decreased from the baseline value of 91.6 to 45 pg/ml; BNP level in the control group at the same time increased from a mean baseline value of 102 to 330 pg/ml (p < 0.0001)  . In the  0.0001) .In the carvedilol group, mean LVEDV and LVESV and LV diameters  at baseline and at the achievement of the maximum dose differed significantly .p < 0.0001)  , with a p < 0.001)  .p = 0.038 and p = 0.007, respectively), whereas LVEDV showed a trend toward significance (p = 0.06). In the group > 12 years, we do not observe the same significant difference. This is due to seven Duchenne patients whose ventricular function remained unchanged or improved <10%. The idiopathic DCM group showed a significant reduction of LVEDD , but LVEDV and LVESV did not decrease significantly despite showing a positive trend . A significant improvement of LVEF was recorded in all groups, regardless of the DCM etiology.According to age and type of DCM, we observed several differences among the carvedilol group. Patients younger than 6 years appeared to have the most pronounced increase in mean LVEF (20.6%) when treated with the high dosage of carvedilol. Accordingly, LVEDD and LVESV reductions from baseline were statistically significant only in patients younger than 6 years  is effective in reducing major cardiovascular events, such as death or orthotopic heart transplantation, when compared with only ACE inhibitors and diuretics. Multivariate Cox regression demonstrates that carvedilol is the only independent protective factor for improving prognosis. This finding is well displayed by Kaplan–Meier curves and evidenced by log-rank analysis, confirming how survival is significantly better in the treated group, especially in the long-term follow-up. The efficacy seems to be confirmed in the clinical scenario, as all four patients on the waiting list for transplant have been delisted. Ventricular function resulted also significantly improved during follow-up in those treated with intermediate and high dosage. More important, this beneficial effect of carvedilol with these dosages appears to be sustained over the years. Considering a 3-year period, these data confirm that a high dosage of carvedilol may have a significant impact on ventricular function recovery.So far, different studies have been published on carvedilol use in pediatric HF, but to our knowledge, no one exceeded 6 months of follow-up. In the clinical arena, carvedilol dosage in pediatric patients ranged between 0.2 and 0.8 mg/kg/day , 13–18. More recently, Huang et al.  performe2- and α1-adrenergic receptors. Such actions are noteworthy, as children are more sensitive to potassium depletion for the concomitant use of diuretics. This consideration might be especially important for children with HF, whose potassium balance may be disturbed by furosemide (Our data show that a high dosage of carvedilol reduces heart rate significantly as an induced negative chronotropic effect. Uptitration of the drug reaching 1 mg/kg/day, as required by reduction of heart rate and/or improvement of ventricular function, showed to have a beneficial effect. In the adult population, HR is considered an important key point for treatment strategy. According to literature, a meta-regression analysis demonstrated that the beneficial effect of β-blockers on mortality was achieved when HR was reduced to 60 bpm in an adult with HF , corresprosemide , 23.The importance of prescribing a high dosage of carvedilol is also supported by PK studies . Albers Our subgroup analysis by age also confirmed the evidence obtained from PK simulations , 9. The This study was limited by the fact that data were evaluated retrospectively. In our analysis, we excluded subjects with age <1 year. This group of patients has a poor prognosis. Applying a definition of chronic HF is difficult because most of them are presenting with acute HF and rapidly deteriorate, so we decided not to include them. It is important to underline that our result should be considered only for children >1 year of age. Further studies are needed for this subgroup. Another point should be considered: in such a long follow-up, the adjustment of therapy over time was made, and in eight patients of the carvedilol group, ivabradine was added to carvedilol, as their LVEF did not increase above 40%. Although the improvement in ventricular function and the clinical outcome appears to be beneficial in those taking a higher dosage of carvedilol, larger studies are needed. The effect of carvedilol on HR should be considered in future studies for pediatric HF not only under a safety profile but also as an efficacy outcome. In our study, we obtained a reduction of HR of 30% from baseline, but more studies on the prognostic impact of HR in the pediatric population are warranted.Effective strategies for managing severe LV dysfunction in children with DCM that could reduce or delay the need for transplantation remain the goal of pharmacological therapy. The results of this study suggest that a high dosage of carvedilol regimen, in accordance with previous observations of PK in children, could improve clinical outcomes. The sustained beneficial effect of carvedilol remains over the years.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.RA and NC contributed to conception and design of the study. NC organized the database. NC and MC performed the statistical analysis. RA wrote the first draft of the manuscript. RA, NC, and MC wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Practice-integrated education and professional development programs , have been available to pharmacists in America and the United Kingdom for many years. In 2016, the Society of Hospital Pharmacists of Australia launched Australia’s novel Foundation Residency Program to support the development of early-career pharmacists, and has been implemented across many hospitals nationally. This model was adopted by the South Australian (SA) public hospital pharmacy statewide service and was granted full accreditation. The study aimed to explore key stakeholders’ expectations and early perceptions of the structure, role and impact of the SA program and in that process, to identify key influencing factors and strategies informing future program planning and design.TM (version 10) and analysed using reflexive thematic analysis through the lens of the PRECEDE-PROCEED logic model framework.Purposeful sampling was adopted to recruit participants who oversee preceptors and residents, across all employment levels and pharmacy service sites. Stakeholders participated in individual semi-structured interviews. Each interview was audio-recorded and transcribed verbatim. The transcribed dataset was managed using NVivo softwareThirty-three staff consented to participate. Participants were de-identified with a randomly assigned code number. Three key themes were identified using reflexive thematic analysis; alignment of program goals and visions, culture shift to prioritising workforce development as core business, program structure supports focused workforce development.Participants view the residency as beneficial for development of the residents, preceptors, and the hospital pharmacy workforce. The multisite structure was a strength of the program. Whilst it was acknowledged that the rotations, cross-site rotations, and research project presented challenges, they were deemed worth the investment. Overall, it was felt that incremental increases in program capacity will occur over time, as culture changes, and as investing in workforce development becomes core business. The findings have led to several key recommendations to guide program expansion. Healthcare delivery demands a human health workforce, core to every healthcare system globally. The World Health Organisation  Global SIn Australia, entry to workforce typically involves an undergraduate Bachelor of Pharmacy  or a graduate-entry Masters of Pharmacy accredited by the Australian Pharmacy Council. The new graduate is then required to undertake a one-year accredited structured workplace internship or pre-registration program. Full pharmacist registration is granted upon passing a national board examination . Beyond In 2017, the South Australian public hospital pharmacy statewide service received provisional accreditation and the program was initially adopted by 2 out of the total of 5 local health networks. The program expanded state-wide in 2018 and was granted full SHPA accreditation in 2019. Residents consist predominantly of pharmacists either in their post-registration foundation years or relatively new to hospital pharmacy entering from non-hospital sectors, and are recruited from the pre-existing employee pool. The residency program consists of 4 core rotations over 6 months each, feedback-centered assessments, a research project and a local university-affiliated postgraduate qualification. At the end of the 2-year program, residents graduate with an accredited SHPA certificate as well as a Graduate Certificate in Clinical Pharmacy. The South Australian Pharmacy Foundation Residency currently represents Australia’s only state-wide multicentered program and with an integrated university-affiliated post-graduate curriculum. Resident pharmacists are recruited via a selection process with a limited pre-determined resident quota.At present, there is only a single Australian publication of a qualitative study that explored stakeholders’ perspectives of program adoption nationwide which subsequently informed the diffusion and ongoing maintenance of pharmacy practice-integrated education and training programs . To idenA written ethics approval for this study was obtained from the Central Adelaide Local Health Network  and the University of South Australia Human Research Ethics Committee (application ID: 202859).A qualitative descriptive design was chosen to maintain descriptive and interpretive validity. This was achieved by keeping findings close to the robust data collected, in common language and within an identifiable context . QualitaA purposive sampling strategy was adopted to target information-rich participants . EligiblData were collected through individual semi-structured interviews by two independent allied health colleagues external to the program with extensive experience in qualitative research. Interviews were undertaken to capture the distinctive views and perspectives of participants in keeping with the exploratory nature of this research . An inteTM (version 10) and was subjected to reflexive thematic analysis (TA) Despite variability in opinions, there was some common ground, with participants acknowledging that the structured developmental pathway streamlined the development of a skilled workforce.“for us to have a workforce that further has a set of skills, further educated, further developed, further experiences to be able to operate at a higher level of functioning.” [P12]There were three points of commonality amongst the participants. Participants agreed that the rotational structure facilitates transferability of skills through the sharing of knowledge, exposure and experiences across the state. This transferability of skills was perceived to ultimately improve patient care outcomes.“you’re trying to develop a better workforce which at the end of the day is for the patients that come into our hospital.” [P1]“increase the profile of [statewide organisation] nationally and…internationally.” [P18] The program was also perceived to contribute to workforce retention because “we bring them into an environment where they’re valued and they’re appreciated…” [P31]The second point of agreement was the value of some of the residency requirements (such as research), seen to increase interprofessional collaboration. The final point of agreement was participants seeing the program as important quality assurance for staff and services with the potential to One of the competing program goals that were debated was whether the vision should be for an all-inclusive program roll-out versus the current exclusive resident recruitment process. Having the program available to all would widen the opportunity for all pharmacists to receive the structured support versus a selective process that limits the intake to only include high performing individuals.“I would really like to see that the program was offered to anyone that would like to participate.” [P14]The selection process was perceived by participants to be exclusive with concerns raised about creating an elitist workforce. There were references to the initial high performing cohort as well as isolated second-hand perceptions that residents view themselves as superior to non-residents. Exclusivity was also seen to potentially create negativity amongst those that applied to be part of the program but were unsuccessful.“Concerns about elitism, … would certain people get opportunities that other people wouldn’t and did I feel comfortable with that? I think because the idea [program] is foundation[al], I found that hard to deal with…” [P17]In contrast, there were observations that the limited selection process drove competition and opportunistically recruited motivated candidates. Participants were also concerned that all- inclusiveness would dilute program value and candidate caliber.I don’t think we want to get to a point where everyone goes down the path… there’s nothing special about it, if you like, everyone might end up with that certification at the end of it, that they completed a residency…what’s the deciding factor between people?” [P5]“Another participant was open to the program being used in different ways depending on candidate situation and development needs:you’ve got different benefits…Whether you’re developing someone to really excel and work towards a senior or a specialised position… Or whether you’re allowing staff that … are new to hospital practice to really embed and integrate and develop a knowledge base at a quicker rate” [P30]“When asked to identify the target cohort for the program, participants saw enrolment as being a personal choice, that acknowledges various contexts and personal circumstances rather than there being a general mandate with no choice.“You wanted to make sure that if it’s something we’re rolling out further, that it’s not a forcing function for everybody, because it may not suit everybody to do it.” [P12]There were pre-conceptions of significant value for pharmacists who were early career to hospital pharmacy, usually within 1 to 3 years post registration. The benefits were deemed especially profound for pharmacists who did not complete a prior structured hospital internship pathway and for those who had entered hospital practice from a different setting regardless of number of years of practice as a registered pharmacist.“It’s a great way for us to help with the training of pharmacists that have come into the hospital system through other avenues. They might come in five, six, seven years down the track, from their registration, but this would still be a great program for them to start in a hospital, which can be quite different from what they’ve already experienced in other areas.” [P14]One of the more recent adjustments to program recruitment is that new to hospital pharmacists can only apply upon completion of a certain period of basic orientation training. The decision to make this adjustment has been well-received and aligns with this participant’s view.“I think that the residency program has developed …they have to have a bit of hospital knowledge first, which I think is essential because it is a huge thing going into hospital from any other setting and you do need to have your foundation time to do that before you start this sort of intensive assessment thing on top of that…” [P22]Some participants identified barriers to their investment in the program and workforce development in general. These included: time and resource commitment for both the residents and preceptors, unclear expectations and the need for further integration and communication about the program to embed a culture of acceptance.“I do think it’s some of that cultural stuff … the messaging around the importance and why, because often then people are quick to find reasons not to support things and sometimes if you lose sight of the why, you get lost in the weeds of the logistics … not the bigger picture stuff, which is the end goal.” [P24]There also appears to have been a culture shift of awareness towards the importance of prioritising and investing in workforce development as a result of the residency program. Many participants viewed contributing to the professional upskilling of the early career workforce through the residency as core business for the entire statewide workforce.“But definitely the intention, the hope is that we actually have a … shift in culture. That providing support to our less experienced pharmacists in our team is part of just everybody’s business … so that people are not left floundering.” [P14]“It’s just the next stage of their development is what I think it should be.” [P21]Awareness of the core purpose of the program plays a part towards developing a culture that focuses on workforce development as a priority and as a sustainable investment. Participants shared their perceptions of core values; to improve patient care, to increase workforce quality and capacity, to invest in a workforce that is valued by the organisation thus increasing retention. To achieve these purposes, participants raised the importance of clarity around roles and responsibilities for all involved in the program.“I had a discussion with my management team last week and I’m pretty clear with them that we should get to a stage eventually… where everyone does it… it’s more expected they participate.” [P24] Similarly, another participant suggested the possibility of expanding the workforce development program beyond the early career pharmacists to include pharmacy assistants and senior pharmacists: “But can the program—is there plans to roll it out? Not just for the junior pharmacist, but is it going to be a similar program for all of the workforce?” [P10]A participant reflected that leadership in decision-making from a management level was pivotal for shifting the gear in culture change toward program expansion: Several participants raised observations of comparison between the local statewide program with other national and international pharmacy residency models as well as the medical model of career progression. They saw a need to adopt a similar ‘business as usual’ culture in South Australian hospital pharmacy that promotes an adaptable and contemporary workforce.“from an academic point of view or professional development point of view it’s perfectly aligned with what other countries offer, so I think it’s very important to have this program … in our workforce, to align with contemporary offers.” [P8]“…I would sincerely hope that they would read through the job pack properly and understand what it entails, rather than entering the program and then dropping afterwards for whatever reason.” [P4] For preceptors, this is dependent on having realistic expectations around their respective roles and responsibilities: “Some preceptors probably going in think[ing], it’s too much hard work, because I have to catch up with them all the time. But it’s actually not any different to teaching on the run [embedding teaching moments in practice].” [P6] For the overall workforce, participants felt a need for understanding of organisational expectations for addressing their core development needs.Participants clearly reiterated that program uptake is dependent on all parties engaging and investing in the program, across all levels of involvement. This applies to residents embracing a culture of being informed, Acknowledging that culture change is a gradual process, further integration of the program into current workflows is required. Better communication of program structure and outcomes to the pharmacy managers would support overall awareness and program advocacy.“…the message is clearly not getting through [to] me in a way that means something to me.” [P33]The program structure is key to success in focused development for residents and potentially for the rest of the workforce. The residency is viewed as a bridge over a gap in training pathways for the early career and early to hospital pharmacists. Beyond the already established pharmacy internship program, there is a perceived lack of structured and consistent workplace developmental pathways prior to the residency program construct.“There’s always been a very structured intern program for our new pharmacists…and there was a gap afterwards… It was almost like a year where people would be really supportive, and then it was let loose in the wild worlds of pharmacy… Similarly, for people who worked in community, when they came to hospital, they initially had periods of support, it’s development but then there was no real support and oversight. So, for me that’s really where the residency fits in…” [P26]The structure effectively enforces learning opportunities through intentional self-reflection, regular mentor feedback and focused development through the practice-integrated structured assessments, research and post-graduate components. Some of the residency assessment tools have also been used to support non-residents, further extending the influence of the program structure.“I think in having those structures, everybody sort of comes along with that journey, even if you’re not a resident… the advantage is it pushes the individual to seek those opportunities out…” [P17]“…osmosis…” [P6] whereby preceptor and resident mentoring occurs through “…learning to give feedback…” [P26]. Visibility of this teaching and learning environment also motivates non-residents to be involved and in turn “…all the team is lifted up somehow…” [P8]As a result, the residency structure appears to promote a culture of shared teaching and learning through Participants highlighted that the credibility of the program is strengthened by adopting the SHPA-accredited framework model. Unique to Australia, the South Australian program is the only statewide-run and governed residency program. The program offers strategic exposure and upskilling through the opportunity to rotate to various practice areas across metropolitan and regional settings and draws its strengths from being supported through a statewide service framework and training resource.“[South Australian statewide public hospital pharmacy service] has been incredibly supportive with offering various types of workshops…offering all that sort of opportunities for the resident…I think certainly would steer the outcome…in the positive direction…… Remembering, as well, that the residency program is also adapted from SHPA, so all of the tools that we have all came from SHPA…And we’ve set up the state-wide support network… has been very beneficial for all of us. There is also a residency leadership group.” [P4]Interestingly, the residency has broken down barriers to staff movement across sites which was perceived as uncommon across Australia, and thus builds the ability to flex and cover where needed due to working knowledge of different parts of the service.“We’re siloed at sites sometimes, we’re also siloed still within the regions, but the residency program has really broken that open so that people go to any region.” [P5]“…pass on some of our learnings that they can go out and take to their own sites as well… if we have gaps in our staffing, we can now draw on some other people that have the skills to come in to help us out as well… more consistency across the board…” [P1]The fixed rotations were frequently mentioned, appraised as an enabler to providing the residents with an essential and well-balanced exposure to four core foundational areas i.e. medical, surgical, operational and a suitable strategic area. P4 and P6 affirmed that the program and rotation duration, 2 years and 6 months respectively, enable adequate exposure.And so I think in terms of the pillars or the structure of the program, the fixed rotations, which gives the pharmacist a core understanding in those really core clinical pharmacy areas, so the surgical and medical rotations for instance, coupled with that constant feedback loop is what makes the program successful” [P15]““practicalities of the rotations” [P34] and “…they’re quite rigid…potentially limiting growth” [P14] Barriers to the cross-site rotations focused on additional efforts to streamline daily operational and logistical challenges. These challenges were particularly observed to arise from staffing gaps due to a premature exit of a resident from the program, time spent to provide orientation, differences in staffing resource allocation across the statewide service as well as concerns around a correct balance of skill mix to flexibly integrate a resident rotating from a different local health network in an area of need.Conversely, the rotations were seen as a barrier to expansion of the program due to the “The other cons are how we …incorporate a resident who may be rotated to different hospitals? So, if the resident rotates to one hospital, and then we get someone else here, do they have the right skill mix for where we need[cover]?” [P10]Regular movements across the rotation sites were also seen to hamper continuity and timely completion of the research project, creating challenges for residents and supervising preceptors.“…the rotational nature of the residency…doesn’t particularly lend itself very well to a research project… so it’s difficult then to coordinate the continuation of that project…with the research project running over full two years, whilst the rotations are only every six months.” [P15]“…we all need to think of us as SA [South Australian] Pharmacy, not as individual sites. And that if we’re committing to this that there needs to be an understanding that all the residents will rotate….” [P6] A recent adjustment to the number of cross-site rotations to address the above challenges was favourably noted “But from this year we’ve reduced the [cross-site] rotation to one instead of two…Two was too much.” [P3]In contrast, a participant reframed this perceived problem in terms of considering the service as a collective “…for a residency program which is promoting general experience, I think the country sites have a lot to offer.” [P29] versus views about the organisational logistical and training resource limitations in regional areas “… we don’t run like a metropolitan hospital…So. the intention of having a resident is that I don’t have to train them, they already have the basic knowledge, I just have to teach them the local differences of what happens in country.” [P13] as well as an understanding that residents may have competing life circumstances which discourages this as a forcing function “… it’s a bit more challenging when you’ve got to change your life for six months of the year and go elsewhere…” [P2]Rural and regional rotations have also been raised as a point of contention. There are two different perspectives; a regional rotation is integral as it provides a unique generalist experience There is limited research evaluating the implementation of practice-integrated education and professional development programs across Australia. This gap in knowledge is likely due to the historical context of there being no structured practice-integrated pathways in pharmacy post-registration prior to the nationwide rollout in 2016. In a historical sense, the SHPA residency program is still in its early days, with only 63 out of the total 300 resident pharmacists having completed the 2-year program . As one There were varying perspectives about program goals and visions amongst the stakeholders. Commonly agreed upon aims included to strategically create an upskilled workforce with transferable skills across the statewide service, to develop well-rounded and motivated health professionals, to improve patient care outcomes, to increase pharmacy presence through interprofessional engagements and to increase staff retention. Common timelines for program entry are consistent with 1 to 3 years of hospital practice as defined by SHPA although some acknowledged that number of years may not be a definitive factor if individuals seek the development opportunity. Collectively, participants advocated for an optional and voluntary program entry with some intensive orientation and basic training prior to residency entry. Wang, Clavarino  affirms On competing program goals, views differed from being a ‘business as usual’ foundational skill-development program to support all early career pharmacists to being a special elite program that selectively supports higher performing pharmacists towards senior role reclassifications. Similar concerns of inequity between residents and non-residents were also reported across other Australian residency sites . HoweverInterestingly, the statewide residency program appears to have already initiated a culture shift of awareness towards prioritising and investing in workforce development. Many participants viewed contributing to the professional upskilling of the early career workforce as an expected core business and a natural career progression for the entire workforce . FurtherAs part of an educational and ecological assessment , predispThe findings from this research also clearly identified the residency program structure and core elements as vital and modifiable environmental factors influencing program planning . The devThe streamlined and targeted development pathway upskills and supports the early to hospital career cohort ,10,25 asThe strength of this study lies in the large sample size, use of independent external interviewers, as well as a structured interview guide that was piloted and refined consistent with best practice standards . HoweverThis research, has shed light on perspectives about common and competing views of key stakeholders about the residency program role, its structure and vision. Overall, these findings suggest that incremental increases in program capacity will occur over time, as culture changes. It is recommended that focus be placed on supporting and sustaining the change in culture that has begun and that there be continued investment in workforce development. Furthermore, it advisable that the core program purpose and workforce expectations be established with the view to the hospital pharmacy foundation residency program becoming core business. Doing so, will increase resource capacity and enable structural and recruitment flexibilities. While this study has addressed an important knowledge gap, ongoing research is required to strengthen the evidence base for residency programs across disciplines . For exaS1 File(PDF)Click here for additional data file.S2 FileInterview guide and data collection form.(PDF)Click here for additional data file.


KSI significantly reduced the time per experiment and increased the sample throughput . The model recapitulated the cellular responses during NMP, namely increased endoplasmic reticulum stress (ER stress). Using KSI, five pharmacological interventions against ER stress taken from the literature were tested. While four were ineffective and excluded, one, β-Nicotinamide-adenine-dinucleotide (NADH), ameliorated ER stress significantly during KSI. The test of NADH in mouse kidney NMP replicated the positive effects against ER stress. This suggests that testing the addition of NADH during clinical kidney NMP might be warranted.Kidney transplantation is the only definitive therapy for end-stage kidney disease. The shortage of organs for transplantation is the main limitation of this life-saving treatment. Normothermic machine perfusion (NMP) is a novel preservation technique with the potential to increase the number of transplantable kidneys through reducing delayed graft function and organ evaluation under physiological conditions. To date, the cellular effects and possible pharmacological interventions during machine perfusion are incompletely understood. A major limitation is the technically complex, time-consuming, and small-scale replication of NMP in rodent models. To overcome this, we developed a 3D-printed, high throughput  End-stage kidney disease (ESKD) is a global health burden with four to seven million estimated patients in need of renal replacement therapy worldwide. The increasing prevalence of risk factors for ESKD, such as hypertension, diabetes mellitus, obesity, and general aging of the population, further drives the incidence of ESKD . Kidney Kidney normothermic machine perfusion (NMP) has gained attention as a promising preservation technique during transplantation due to the theoretical advantages it offers in improving ischemic damage, as well as organ conditioning, analysis, and treatment . NMP forex-vivo mouse kidney slice incubation model (KSI) working under “NMP-like” conditions, which recapitulates ER stress as seen during NMP and can be used for drug pre-screening before the time-consuming testing in NMP.We have recently established a cell-free rodent NMP model for the rigorous preclinical study of potential interventions during NMP . HoweverAnimal experiments were carried out with the approval of the Hamburg University Hospital-Eppendorf and the Hamburg State Department for Animal Welfare . Age- and weight-matched male wildtype C57/Bl6 mice were housed under a 12-h light-dark pattern in an accredited animal facility at UKE Hamburg with free access to chow and water.KSI consists of a beaker with an inset 3D printed chamber, with slots for up to nine kidney slices. Please see 2 and 5% CO2. For the intervention, b-nicotinamide adenine dinucleotide  was dissolved in GBSS to a concentration of 0.07 mM. Perfusion flow was continuously recorded at the arterial tip using a pressure transducer , a three-channel cannula , a TAM-D plugsys transducer  and recording software  (Mouse kidney NMP was performed as previously described . After mGermany) . After pFor Western blot analysis, kidney samples were lysed for 30 min in 0.5–1 ml of RIPA buffer with the Minilys personal homogenizer . Subsequently, samples were centrifuged at 4.600 rpm for 15 min, the supernatant was transferred to a new tube for the adjustment of protein concentration. Protein content was determined by a BCA assay  with a Tecan sunrise scanner . Before protein electrophoresis, the samples were diluted with 2x Laemmli buffer (1:1) and cooked at 95°C for 5 min. For each lane, 50 µg of protein were loaded. The sample proteins and a protein ladder in one lane were separated in pre-cast gels of 4%–20%  for 20 min at 80 V and 1 h at 120 V. Immunoblotting was performed with Trans-Blot Turbo Mini 0.2 µm PVDF transfer packs  for 7 min at 25 V, 1.3 A, using a Trans-Blot Turbo Transfer System . Blocking was performed with a 5% bovine-serum-albumin-  PBST solution (0.1% Tween) for 1 h. The membranes were incubated with a primary antibody solution at 4°C overnight. Incubation with horseradish peroxidase-conjugated secondary antibodies was performed at room temperature for 1 h. Imaging was performed after incubation of the membranes with ECL Western Blot Substrate  with a chemiluminescence detector (Amersham Imager 600). Analysis was performed with ImageJ .Total RNA was extracted with QIAzol Lysis Reagent  and the isolation was performed with the miRNeasy Plus Universal Mini Kit . The RNase-Free DNase Set  was used for DNA digestion. For reverse transcription, Protoscript II First Strand cDNA Synthesis Kit  was applied. Quantitative PCR was performed on a QuantStudio 3 System  using 0.5 µg of cDNA, gene-specific TaqMan™ primers, and TaqMan™ Fast Universal PCR Master Mix . Glyceraldehyde-3-phosphate dehydrogenase  was used for normalization. The qPCR data were analyzed with the double delta CT method.Samples diffusion-fixed in 4% formaldehyde and stored at 4°C were embedded in paraffin and stained with periodic acid-Schiff (PAS) reagent following standard protocol. Incubation times were 1 hour in Schiff’s reagent and staining of nuclei in hematoxylin for 3 min. Tubular damage was evaluated by two researchers. For TUNEL staining, Deadend Colorimetric TUNEL System  was used according to the manufacturer’s specifications. The incubation time of proteinase K was 20 min, the staining time of DAB 12 min. PAS damage scores were graded by two researchers according to t-test with Welch’s correction or one-way ANOVA combined with Tukey’s multiple comparisons test were used for determination of statistical significance when data were normally distributed (see figure legends for details). If data were not normally distributed, Mann-Whitney test was used. Data were considered statistically significant if p < 0.05.Statistical analysis was performed with GraphPad Prism. For statistics, Shapiro-Wilk test was used to ascertain normal distribution. All data passed the Shapiro-Wilk test, except when explicitly mentioned in figure legends. Following this procedure, an unpaired two-tailed n = 54 kidney slices incubated under 6 different conditions at the same time  take comparable approaches , and the molecular improvement with addition of NAD has also been described for AKI in vivo   is small and does not completely rule out that results may differ when large groups of animals are used. Lastly, we did not perform testing of all drugs under both KSI- and NMP and can thus not exclude that drugs not working in KSI would have worked in NMP.There are several limitations to the KSI model and this study. We found the optimal time period for analysis of the ER stress response in KSI was 30 min. This is a shorter time than used in rodent NMP models  . Most prTo conclude, we developed a kidney slice model that can be used to study drug targeting of ER stress signaling and associated cell death responses. Comparison to NMP suggests that successful results may, at least in part, be transferrable. KSI provides a solution for rapid large-scale drug testing and could lead the way to generating a library of promising drug candidates for clinical testing during NMP. Further testing of NADH for clinical perfusion buffers might be warranted.