It is widely recognized that socio-emotional learning (SEL) interventions can contribute to supporting students’ positive development of socio-emotional skills (SES) and positive relationships with peers and teachers. Thus, interest in promoting students’ SES through universal evidence-based programs is spreading around the world, including in Portuguese schools.Mage = 8.72; SD = 0.61); 65 in the comparison group . Measures included: Study on Social and Emotional Skills, parent, child, and teacher versions; and Classroom Peer Context Questionnaire, completed by students. The study followed a pre- and post-test design, with a 16-week intervention.This quasi-experimental study examines the efficacy of a SEL classroom-based program, infused into the curriculum, on students’ communication, self-regulation, and classroom peer relationships. Participants included 208 third- to fourth-grade students from three Portuguese public elementary schools: 143 in the intervention group , peer conflict and peer cooperation. Effects were analyzed separately by school grade. A statistically significant positive effect of the program on third-grade students’ assertiveness and sociability was found. For fourth-grade students, a positive effect was found on - emotional control). classroom conflicts, isolation, cooperation and cohesion behaviors.These positive effects support the expansion of universal interventions when aiming at strengthening SEL in Portuguese school settings, underlining the relevance of embedding SEL into the curricula and daily practices at schools. SEL is usually defined as the process through which students develop a set of interrelated competencies that allow them to recognize and manage their emotions, set and achieve goals, and engage in responsible decision-making processes and positive interactions through the development, for instance, of perspective-taking, conflict management, and relationship skills e.g., . In the Schools are in a pivotal position to foster students’ SES, as children and adolescents spend a significant amount of their time in these environments and face several challenges, both academic and social, during schooling that require SES for positive development and learning . Therefo1.1.Schools are considered a primary developmental context for children and adolescents, playing a central role in the promotion of students’ development of important life skills, including SES . TherefoSchool-based universal SEL programs have been associated with positive outcomes for students , such as the improvement of academic performance and SES and the reduction of stress levels and behavioral problems . In theiNevertheless, there are contradictory findings e.g., , with soIn Portugal, in the past few years, the number of SEL programs in educational settings has also increased , particu1.2.Although there are a multitude of frameworks that address the field of socio-emotional skills, sometimes using different terminology to define and organize this research area , all fra1.3.Schools, and particularly classrooms, are pivotal contexts for social interactions, challenging children to develop interactions and relationships among each other, promoting a positive classroom climate e.g., . The litPeer relationships in classroom context are described as a relevant dimension for processual quality of classroom contexts e.g., , which mRegarding the role of SEL in fostering classroom peer relationships, there is an assumption that SEL can function as means for children to acquire peer conflict resolution strategies, thus reducing impulsive behaviors e.g., . Which i1.4.Despite the increased investment of both practitioners and researchers in developing, implementing, and evaluating school-based SEL programs in the past years, the effectiveness of such programs remains unclear, particularly in Portugal, where few quasi-experimental studies have been conducted within this field e.g., . ConsideOverall, self-regulation and communication are critical outcomes of SEL interventions once these can provide children with the tools they need to navigate the social and emotional challenges they face in and out of school. Moreover, literature has shown that peer classroom relationships are pivotal to promote a positive and inclusive classroom environment, improve academic outcomes, and develop essential social and collaborative skills that children need to succeed in school and across their lives. Regarding the self-regulation skills, the study focuses on two specific sub-dimensions, namely self-control and emotional control. Concerning communication skills, the study focuses on assertiveness, cooperation, and sociability specific subdimensions. Furthermore, and considering that research provides ample evidence that children participating in SEL-based programs tend to develop important skills for peer interaction, this study also explores potential effects of the SEL-based intervention program  on children’s perception of their peer classroom relationships. More specifically, we aim to analyze if the program has positive effects on key variables of peer relationships, namely (i) the child level of comfort in peer relations in the classroom; (ii) the levels of cooperation and conflicts between peers in the classroom; (iii) the levels of mutual affection between peers in the classroom; and (iv) the levels of classroom group cohesion and isolation. Moreover, the study analyzes the effects of the program separately the whole group of elementary school, aged children participating, as well as for third and fourth grade students.Building on previous research showing that SEL universal intervention can have a positive effect in several SES and classroom social climate variables, the following hypothesis were formulated: (i) the intervention program “Calmly - Learning to Learn Yourself” will lead to a statistically significant improvement in children’s self-regulation skills, specifically in the sub-dimensions of self-control and emotional control for third and fourth grade students, when comparing to children not attending the program; (ii) the intervention program “Calmly - Learning to Learn Yourself” will lead to a statistically significant improvement in children’s communication skills, specifically in the sub-dimensions of assertiveness, cooperation, and sociability, both for third and fourth grade students, when comparing to children not attending the program; (iii) children who participate in the intervention program “Calmly - Learning to Learn Yourself” will report a statistically significant increase in their level of comfort in peer relations, level of cooperation and group cohesion in the classroom, and levels of mutual affection between peers in the classroom, both for third and fourth grade students, when comparing to children not attending the program; (iv) children who participate in the intervention program “Calmly – Learning to Learn Yourself” will report statistically significant lower levels of conflicts between peers in the classroom and a decrease in isolation in classrooms, for third and fourth grade students, when comparing to children not attending the intervention program.2.This study uses a quasi-experimental design, with a pre- and post-assessment and an intervention period of 16 weeks. An intervention group (IG) and a comparison group (CG) were included, with schools randomly assigned to each group. A multi-informant approach was employed, using self- and hetero-report measures.2.1.N = 12) were included in the study, namely eight teachers in the IG and four teachers in the CG. Overall, the teachers were all female, with a mean age of 47 years . The average number of years teaching was 23.36 years (SD = 8.64). All teachers had a higher education degree, with 16.7% teachers holding a master’s degree.The current study included 12 classrooms across three elementary schools in the North region of Portugal. Of these, six were third-grade classrooms and six were fourth-grade classrooms. Schools were randomly assigned to the IG  and to the CG . All lead teachers responsible for participating classrooms . From these, 145 children  were allocated to the IG and 67  to the CG. In the IG, 63 students attended the third grade and 82 attended the fourth grade. In the CG, 32 students were in the third grade and 35 in the fourth grade. Independent t-tests revealed that there were no significant differences between students in the CG and those in the IG with regard to their age, t(210) = 0.67, p = 0.45. A chi-squared test for independence indicated that there were no significant differences between the CG and the IG in terms of gender, χ2(1) = 0.01, p = 0.92. Fathers from students in the IG were aged between 27 and 72 years ; the mothers’ ages ranged between 26 and 52 years . In the CG, the fathers’ ages varied between 32 and 52 years , and the mothers were aged between 30 and 53 years .This study included 212 students  aged between 8 and 10 years  and after (post-test) the implementation of the intervention program.2.2.1.The Study on Social and Emotional Skills SSES;  aims to 2.2.2.The Classroom Peer Context Questionnaire CPCQ;  measuresThe CPCQ has shown good psychometric properties in its original study e.g., , as well2.2.3.Two sociodemographic questionnaires were developed. The student and family version of the sociodemographic questionnaire captures students’ and families’ sociodemographic characteristics . The teacher version of the sociodemographic questionnaire was developed to gather sociodemographic data and information on the professional experience of the teachers, such as gender, age, marital status, number of years teaching, training completed, and employment status.2.3.Data collection followed all the ethical procedures according to APA standards. One school cluster was selected by convenience among the network of the researchers. The study was presented to the school director in a brief meeting. After getting the school cluster director approval for the study, a meeting was conducted with all elementary school teachers to present the project, study goals, and explain the randomization process. All teachers agreed to participate. Then, parents received a flyer presenting the study, as well as an informed consent form. A participation rate in the study of 79.4% of children in the study was achieved. Overall, written informed consent was obtained from the school director, teachers, and families. Data were collected at two time points—pre-test (December 2020) and post-test (June 2021)—for all participants in the IG and the CG. In accordance with ethical guidelines, participants in the CG had the opportunity to participate in a brief version of the intervention delivered to the IG after post test data collection.Students completed the questionnaires in their school classroom in the presence of the researchers. The questionnaires for the families were sent in sealed envelopes, and families were asked to return them to their child’s teachers, also in sealed envelopes. Teachers completed the questionnaires individually. The same procedures were used both in pre- and post-test data collection, both to IG and CG. The intervention with the program “Calmly – Learning to Learn Yourself” [Calmamente–Aprendendo a Aprender-se] started in January 2021, after pre-test data collection, and lasted for 16 weeks. All students in the classroom participated in the intervention, as this was infused into the curricula, although not all students were included in the study due to lack of parental consent to be part of the study. The intervention was monitored through self-report measures completed by the facilitator, external observations, and regular supervision sessions. Pre- and post-test assessments were conducted by external researchers, with independent teams responsible for the external evaluation and for the intervention process. This procedure aimed to decrease the biases in the assessment procedures, particularly when completing the questionnaire with elementary school students.2.4.“Calmly – Learning to Learn Yourself” [Calmamente—Aprendendo a Aprender-se] is a SEL-inspired universal program aiming to promote SES, with a mindfulness and growth mindset component. It is a classroom-based program infused into the school curriculum and aimed at facilitating the harmonious development of social and emotional skills, namely self-knowledge, adaptability, emotional regulation, communication, resilience, and problem-solving, among children and young people. It is supported by a set of dynamic teaching materials ] designed to facilitate and enrich the intervention. Each session proposes the development of one or more socio-emotional competencies. The program is organized into 10 themes, such as Share, Breathe, and (being) Among Others, and it invites students to go a journey with several stops along the way, whenever a new theme emerges. Several strategies, such as posters, reflection/brainstorming, open questioning, modeling, social and self-reinforcing feedback, and group games, are used in the program sessions. Skills and concepts are typically presented through various challenges in each session.The program is structured as a set of weekly dynamic sessions and was specifically developed to be implemented in school contexts. It is expected to be implemented throughout the entire school year. In the present study, 16 developmentally appropriate sessions of 60-min each, delivered weekly by a trained facilitator in the presence of elementary school teachers responsible for each classroom, were implemented. The program was organized in 16 sessions in order to ensure a weekly presence in the classrooms across the school days calendar between January and May, as well as to fit the schools availability for the curricula infusion. Under this program, the facilitator is expected to work in collaboration with the teachers, encouraging them to promote the generalization of the skills developed in the program during the week by expanding activities and reminding children to use the strategies learned during the day . The program facilitator follows the session plans available in the program manual. For each session, the manual provides information about the SEL objectives, the strategies to be implemented, and the materials to be used.2.4.1.To implement the program “Calmly – Learning to Learn Yourself” [Calmamente—Aprendendo a Aprender-se], facilitators need to undergo certified training. The training program designed for the facilitators implementing the program with elementary school children within the scope of the “Gulbenkian Academies for Knowledge” encompasses 50 h, including both theoretical and practical sessions, with role-playing activities to train specific intervention competencies. The training was delivered by the program’s author. Throughout the whole intervention period, weekly supervision sessions lasting approximately 60 min were held individually with each facilitator to ensure program fidelity. Besides supervision sessions, facilitators also completed a questionnaire after each intervention session with the children in each classroom, making it possible to document the fidelity of the intervention, the dosage, and the children’s and teachers’ responsivity, and the implementation quality. The responsivity of the children, parents, and teachers was also captured through child, teacher, and parent satisfaction questionnaires, completed at the end of the intervention.Regarding program dosage, the 16 sessions of the program designed were implemented, with four sessions being implemented online due to the COVID-19 pandemic. Adaptation of activities to the online format was designed in collaboration between the program facilitators and the program’s author. On average, children received 93% of sessions.n = 12) revealed that on average, the sessions plans were almost completely accomplished . Responsiveness was, on average good. For this indicator, the facilitator scored students engagement, level of positive affect and levels of satisfaction with each session. An average of the scores of the three items scored was computed for each session. Mean values were 4.60 (SD = 0.21), meaning that, in a five-point scale, facilitators perceive high level of students’ responsiveness to the intervention throughout the sessions. Levels of satisfaction were also collected , at the end of intervention. Satisfaction questionnaires were completed by students, parents, and teachers. Results showed that students were very satisfied with the program, with average satisfaction levels of 4.41 (SD = 0.67), in a maximum of 5. Parents satisfaction levels were in a medium-high level, with an average score of 4.10 (SD = 0.50). Teachers reported an average satisfaction with the program of 4.29 (SD = 0.48), with lower levels of satisfaction regarding the adequacy of the program length , and with the program ability to engage parents . Teachers’ maximum levels of satisfaction—completely satisfied—were registered regarding the interest and adequacy of the activities of the program for children. Finally, the quality of each session was also self-reported by facilitators. Items included in this dimension focused on structural quality indicators such as: the adequacy of the materials provided; the physical condition of the session space; the adequacy of the session duration; and process quality indicators such as the quality of facilitator-students relationships and quality of peer relations during each session. Each item was coded in a five-point scale, with values closer to 5 indicating a more positive quality. Overall, the facilitator reported a quality of structural aspects of the intervention on a 4.48 average level (SD = 0.25), and an average value of process implementation quality of 4.32 (SD = 0.27).Implementation fidelity was self-reported by the facilitator of the intervention, for each session in each classroom. On a rating scale of five points, the facilitator registered the extent to which the session plan was accomplished according to the manual instructions and goals . Data from the face-to-face sessions  both for the overall sample and for fourth-graders, with CG presenting significantly higher levels of communication when compared with the IG, at pre-test, t(208) = −1.576, p < 0.001 and t(115) = −1.139 p = 0.002, respectively; and for sociability (reported by teachers) for third-graders, t(91) = −1,599, p = 0.001, also with the CG group presenting significantly higher levels of sociability according to teachers´ report.Average values obtained by the IG and the CG in the pre-test were compared using the Student’s Considering the absence of statistically significant differences between the IG and the CG at the pre-test for almost all variables, main effects of time and interactive effects of time with the group condition were examined and are presented below for variables related to SES  and variables classroom peer relationship variables .3.1.F = 3.747, p = 0.05, 2η = 0.020, with the IG showing greater gains in this dimension, compared to the CG. This indicates a positive effect of the intervention in students’ assertiveness. Nevertheless, a small effect size was found.Gain differences in all the SES are summarized in F = 6.448, p = 0.01, 2η = 0.074 ; and sociability, F = 5.60, p = 0.02, 2η = 0.07 (teacher report). Effects sizes were small to moderate. No effects were found on self-regulation, self-control, and emotional control, for either of the informants’ reports. For fourth-grade students  = 3.878, p = 0.05, 2η = 0.036 (child report); and emotional control, F = 5.836, p = 0.02, 2η = 0.047 (teacher report); Effects favoring the CG were found on sociability, F = 7.827, p = 0.006, 2η = 0.067 (teacher report). This provides partial support of the positive effect of the intervention for fourth-grade students SES, although effects sizes were small to moderate.Data were examined separately for third- and fourth-grade students. For third-grade students , a statistudents , a posit3.2.t(204) = −1.98, p = 0.049 and t(199) = −2.07, p = 0.039, respectively. The IG presented lower levels of conflicts and isolation at post-test, when compared to the CG, t(204) = −2.12, p = 0.032 and t(199) = −2.07, p = 0.039, respectively.Building on the absence of statistically significant differences between the IG and the CG at the pre-test, comparisons between the groups were computed for post-test data to examine main effects of group. Overall, results showed statistically significant differences between the groups at the post-test for levels of comfort, conflicts, mutual affection, and isolation. More specifically, the CG showed higher levels of comfort and mutual affection at the post-test, when compared to the IG, t(139) = −2.850, p = 0.005, d = 0.77. For the CG a statistically significant increase in level of mutual affection, t(63) = −2.683, p = 0.009, d = 1.34, from pre- to post-test. Furthermore, to understand if changes at post-test were due to the participation in the SEL intervention, six individual repeated measures ANCOVAs were conducted, exploring interactive effects of time with condition (IG or CG) for the overall group pf participants. A statistically significant interactive effect of time with group condition, supporting the hypothesis that the IG would present a more positive change in the variables, emerged for the following dimensions: level of conflicts, F = 5.045, p = 0.02, 2η = 0.026, and cooperation, F = 4.643, p = 0.003, 2η = 0.024. A statistically significant interactive effect of time with group condition, favoring the CG, was found on the levels of mutual affection, F = 7.103, p = 0.0008, 2 = 0η.037. No effects were found for the dimensions of comfort, isolation, and cohesion  = 7.013, p = 0.009, 2η = 0.063, with a significant advantage for the IG that sees levels of conflicts decreasing over time, while CG sees levels of conflict increasing. Also, an interactive effect, favoring the IG, is documented on levels of isolation, with CG having an increase of isolation levels, while the IG maintain the initial isolation levels, F = 5.248, p = 0.024, 2η = 0.048; in cooperation, F = 9.886, p = 0.002, 2η = 0.086, with the IG showing significant gains, while the CG decreases level of cooperation over time; and in levels of cohesion, F = 4.286, p = 0.016, 2η = 0.037, with the IG increasing their levels of cohesion, while the CG decreases in this variable  which can be considered narrow  based onWhile the positive indicators of the SEL intervention program show potential for improving children’s competencies and peer contexts in the classroom, there remains inconsistency among informants in reporting the effectiveness of the program. Therefore, additional research is necessary, particularly with regard to the implementation process, in order to better understand the potential of this specific intervention. It is important to identify the factors that may have contributed to the inconsistent results across informants, such as differences in perception or understanding of the intervention or the influence of other contextual factors. Further investigation about the implementation process can shed light on these factors, which in turn can inform the development of more effective interventions. Several authors have identified the difficulties in demonstrating SEL intervention results, arguing that the effectiveness of the SEL programs is closely linked with the quality of the intervention process e.g., . In our Research has also been stressing that SEL programs that are embedded in the school environment as a whole are more effective in promoting children’s competencies, rather than just having curriculum based SEL interventions e.g., . For ins4.1.This study provides preliminary evidence for the potential effectiveness of the “Calmly - Learning to Learn Yourself” [Calmamente—Aprendendo a Aprender-se] SEL program, however results must be interpreted carefully and some limitations must be acknowledged. Therefore, caution must be exercised when interpreting the results, and they should not be overgeneralized to other contexts, with the need of further research to confirm and expand our findings, as well as to explore the effectiveness of the program with different populations and in different settings. Given the heterogeneity of intervention outcomes, future research should consider a person-centered approach for identifying personal and contextual variables related to program effectiveness and for tracking different patterns of changes. The number of participants was limited with an uneven number of children in IG and CG. Future studies are needed with larger samples and balanced groups in terms of the number of participants. Then the implementation of the program only lasted 16 sessions/weeks over the course of one school year; the intervention did not start at the beginning of the school year, had to be adapted to the online format during the COVID-19 pandemic, and was only delivered in one school cluster. Additionally, although the program rationale considered the need to foster the generalization of the competencies promoted through teacher’s extension of the program’s activities, no control over how teachers implemented this aspect of the program was documented. This lack of control is problematic as it may have resulted in inconsistent implementation of the strategies in daily activities. To address this issue, future iterations of the program could include specific guidance and training for teachers on how to promote the use of the strategies and how to monitor implementation of the program in daily activities. Future studies should monitor how teachers embedded the program strategies in their classes and in their interaction with children in order to analyze differential effects of the program based on such extension. Furthermore, results from self-report measures completed by children may be affected by their reading and comprehension levels. For instance, third graders showed some difficulties in reading some questionnaire items. Results from teachers’ reports may also be interpreted carefully as both the IG and the CG school were part of the same school cluster and social desirability may have affected their responses. Although teacher ratings are generally considered as a valid method for documenting children’s competencies, it is possible that teachers’ knowledge of the experimental condition may have influenced results. It is recommended that future studies not only use a multiformat approach, as the one used on the present study, but also include observation measures of students in their natural environments to capture the effects of the interventions . Includi4.2.Theoretical and empirical evidence supports the assumption that SEL universal interventions are crucial in educational settings. Despite a growing interest in understanding and supporting SEL in schools, including in Portugal, the definition and scope of SEL interventions remain broad, with mixed evidence across studies. As the emphasis on the universal SEL approaches where all students and adults in schools are engaged in a coordinated learning process  is reinfThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.VC and CP contributed equally to the study design and manuscript. CP, VC, and FM made substantial contributions to the conception or design of the study, analysis, and interpretation of data. AE led the intervention team and is responsible for the conception of the intervention program. VC, HA, CP, MS, and FM made substantial contributions in drafting the paper and revising it critically. VC, CP, HA, FM, MS, and AE were involved in ensuring that questions related to the accuracy or integrity of any part of the work were appropriately investigated and resolved. All authors contributed to the article and approved the submitted version.This work was supported by the Calouste Gulbenkian Foundation, particularly within the scope of the “Gulbenkian Academies for Knowledge” [Academias do Conhecimento] program and also by the Portuguese Foundation for Science and Technology (UIDB/00050/2020).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.


Although the sharing of curricular content between health professional schools can reduce faculty burden, the literature provides little guidance to support these efforts. The objective of this investigation was to synthesize data from two prior studies to delineate recommendations guiding the future development of shared curricula in health professional education. Applying Rogers’ Diffusion of Innovations Theory as a guiding framework, relevant data were extracted from a two-phase mixed-methods study evaluating the long-term impact of the shared Rx for Change: Clinician-Assisted Tobacco Cessation program. Phase 1, a qualitative study, involved telephone interviews with faculty participants of train-the-trainer workshops conducted between 2003 and 2005. These results informed the development of a phase 2 national survey, administered electronically as a long-term follow-up (13 to 15 years later) with train-the-trainer workshop participants. Results from the two studies were synthesized and summarized, producing seven key recommendations to guide development of shared curricula: (1) appeal to attendees, (2) relate content to clinical practice, (3) deliver live, in-person training, (4) develop high-quality materials, delivered by experts, (5) provide support, (6) meet accreditation standards, and (7) demonstrate effectiveness. Future program developers should consider these recommendations to enhance dissemination, adoption, and long-term sustainability of shared curricular content. Health professional educators are responsible for improving students’ foundational knowledge and clinical skills. To achieve this goal, high-quality, engaging, evidence-based teaching materials are needed for relevant topics across multiple years of a degree program. Because individual faculty members typically create their own lecture materials, this translates into hundreds of faculty members creating comparable materials on similar topics—an approach that is costly and time-consuming.One solution to promote quality while reducing faculty burden is the concept of “shared curricula.” There is no universally accepted definition of a “shared curriculum,” thus we define it as an open access, comprehensive curriculum covering a specific topic that is created by a group of content experts, and which evolves over time based on input from faculty utilizing the materials. This paper describes the sharing component, including how a curriculum is shared among faculty members, and the necessity of ongoing updates and support ,2. CurreRx for Change: Clinician-Assisted Tobacco Cessation curriculum   work really well and some of them not.” This comment inspired us to investigate further why the Rx for Change dissemination workshops were successful and what could be learned from this experience. Although this study was focused on a unique tobacco-cessation program, it can be used as a model and offers important takeaway lessons for other topics that would benefit from shared curricula. Thus, the objective of this report was to synthesize data from our prior studies, described below, and delineate specific recommendations that could inform future shared curriculum development efforts. Such recommendations are intended to facilitate the dissemination, adoption, and long-term sustainability of newly created shared curricula.Results from this national initiative have shown long-term sustainability, with an estimated 73% of pharmacy schools using the Rx for Change content as part of their core curriculum 15 years later . This suDevelopment and dissemination of the Rx for Change program, as well as the long-term follow-up mixed-methods study described here, applied Rogers’ Diffusion of Innovations Theory as a guiding framework . This apRelevant data were extracted and synthesized from a two-phase mixed-methods study  evalPhase 1: This phase was conducted between 2017 and 2018 and applied a descriptive qualitative approach ,14, explQualitative analyses were conducted using an inductive approach with MAXQDA software . Two invPhase 2: The findings from phase 1 informed the development of a web-based survey that was administered between 2019 and 2020 to the entire cohort of train-the-trainer participants . The insThe phase 2 survey was estimated to take 15 min to complete. Because 15 or more years had elapsed since participating in a train-the-trainer program, extensive internet searches were conducted to locate individuals. Of 191 initial faculty participants, valid and current email addresses were identified for 137, and the survey was completed by 111 (81.0%), representing 75 (84.3%) of the 89 schools or colleges of pharmacy that participated in a train-the-trainer workshop . Most  help to improve patient counseling services in clinical practice.Participants emphasized that all training programs should be relevant to practice and should facilitate attendees’ confidence and competence for teaching the material and for helping students apply the material. Participants acknowledged that implementing a new clinical service is challenging and therefore suggested that training programs should address how to successfully implement such services in practice settings.Deliver live training (in person): Participants appreciated that Rx for Change was delivered as a face-to-face, live training program. They indicated that attending the program in person provided an opportunity to become “really immersed” in learning the material. They felt this format allowed for the use of a variety of methods of content delivery, including “hands-on” activities, decreased distractions, and opportunities to network and interact with other faculty members with similar teaching responsibilities and interests.I personally like the live training, particularly for the first time that you’re going through it.” Other participants, however, highlighted the advantages of web-based training programs including convenience  and the ability to reach a greater audience. Still other participants suggested that web-based training might not engage participants if trainees are not “truly invested in learning.” A participant commented, “When you do any kind of web-based [training], it’s easy to not feel connected to the rest of the people in the group and lose motivation.”Several participants valued a blended workshop, with live, in-person training followed by web-based sessions delivered regularly. One participant explained, “Develop high-quality materials, delivered by experts: Participants indicated that high-quality, evidence-based, turnkey (for implementation) materials contributed to the success of the Rx for Change program. They valued that experienced faculty with clinical expertise in teaching tobacco content delivered these workshops. Results from the survey confirmed that participants rated the quality of the Rx for Change curriculum highly, including the various “characteristics of the innovation” described by Rogers [y Rogers .…here’s a way of [implementing the curriculum using] team-based learning principles, here’s a way of doing it using online instruction, here’s the way of doing it in a flipped classroom. So, there is probably a wider range of methodologies that are being used to teach.” Some suggested adding discussions on recently published studies, and others suggested adding discussions on controversial topics. Several participants suggested adding instructions on how to deliver the content under curricular time constraints: “What [are] the best things to include if you had limited time? How to prioritize those things? Especially from a new faculty member’s perspective, it was all just a bit overwhelming…So if you don’t have the amount of time to [implement] everything or are overwhelmed with everything, what’s the best place to start?”Participants suggested enhancements to the structure and content of future training programs, including how to deliver curriculum using “newer” methods. As one participant illustrated, “Provide support: Participants appreciated the efforts devoted by the Rx for Change team to support faculty attendees. They described three types of perceived support. First, the availability of a website to access routinely updated teaching materials  [so definitely I and [my colleague] who did the training as well, she’s been a supporter.” Third, participants appreciated the placebo cessation aids  that were provided after the training, as it helped them to instruct students and patients on the proper use of these medications through hands-on demonstration.ne 2023) . Second,Meet accreditation standards: In phase 1, participants shared that Rx for Change was successful because it met accreditation standards and addressed required competencies for pharmacy school curricula. As such, faculty could easily “pitch” the content to the curriculum committee at their institution.Demonstrate effectiveness: Prior studies have demonstrated the widespread, sustained use [ined use  as well ined use ,20,21. WIn phase 1, participants suggested health topics for which a shared curriculum would be useful, and these were further explored in phase 2. Participants rated the following as very or extremely useful as a shared curriculum topic: opioid dependence (82.9%); drugs of abuse, including but not limited to opioids (76.6%); medical marijuana (71.1%); motivational interviewing (67.5%); pain management (63.0%); alcohol abuse (63.9%); obesity (59.4%); and law/jurisprudence (44.1%).The objective of this analysis was to synthesize findings from a mixed-methods study to craft recommendations for future developers of shared curricula. The Rx for Change program provides a unique framework and model for this type of analysis because it has been in existence since 1999 and was disseminated nationally, through train-the-trainer faculty development programs, to 98% of the schools of pharmacy in 2005 [Because it is an appropriate framework for exploring recommendations associated with the adoption of an innovation, Roger’s Diffusion of Innovations Theory guided the development and dissemination of the Rx for Change program, and results were mapped onto the domains of the theory . Data inThis study adds important information regarding the development and dissemination of shared curricula to enhance adoptions and maintenance of those adoptions. Participants indicated that certain aspects were important in making a training workshop appealing to faculty attendees (recommendation 1). These include removing cost burdens, focusing on a topic that addresses an important gap in health professions education, and training faculty to acquire skills needed as educators. These findings are consistent with guidance provided by Yelon et al., who reported that educational skills training is important for the success of a faculty development program . The phaBased on our results and the studies by Lupu et al. and Bookstaver et al., it is recommended that curricula be delivered in a way that boosts students’ confidence and competence to effectively apply what they learned in the classroom during actual patient encounters ,30. ThisBecause participants were interviewed or surveyed at least 15 years after their workshop training, it is likely that they had forgotten some aspects of the program. Yet, this time lapse is also a strength because it was more likely that participants recounted only the most salient or memorable aspects of their experiences, whether these were positive or negative. However, because of the time that had elapsed, 26.3% of our participants were unable to be located for the phase 2 survey study , and thiThis investigation indicates that faculty members view shared curricula as a cost-effective approach to teaching that should be more broadly considered for incorporation into pharmacy education. Results of this study provide evidence and guidance related to key recommendations that are likely to enhance the long-term success of shared curricula. To enhance participation and long-term engagement, future training program developers should consider the motivating factors that appeal to trainees. The sustainability of a program is likely to be enhanced if it includes practical application (hands-on) components in training workshops and high-quality, evidence-based materials that are developed and maintained by content experts. The validity of the guidance provided could be tested in the development of shared curricula for key topics identified, including opioid dependence, drugs of abuse, medical marijuana, and motivational interviewing. Future curriculum developers are encouraged to evaluate the effectiveness of their new program by estimating its impact on students and on patient care. Additionally, assessment is needed of (a) the extent of program adoption and (b) maintenance of adoption, over time, by institutions. The study’s findings contribute to the field of health professional education by identifying key factors that promote adoption and sustainability of shared curricula and by offering recommendations for future initiatives.


Intimate and romantic relationships are important in life for individuals, irrespective of mental health status. We developed a four-hour peer-led learning program for persons with mental disorders about intimate and romantic relationships through a co-creation process with service users and examined its preliminary effectiveness and feasibility of implementing the program.A one-group pretest–posttest trial was conducted using a mixed-method design for 45 individuals with mental disorders in Japan. Outcome data were collected at three time points: baseline, post-intervention, and one month after program completion. Mixed models for repeated measures (MMRM) were used to examine changes over time in the Rosenberg Self-Esteem Scale (RSES), Recovery Assessment Scale (RAS), Herth Hope Index (HHI), and the original items. Group interviews were conducted for process evaluation.MMRM showed significant changes over time on RSES, RAS, HHI, and two original items “I am able to communicate well with others about myself” and “I am able to listen to others well.” In multiple comparisons, RSES and HHI were significant one month after the program. Participants reported changes during the first month after attending the program in terms of their positive attitude toward romantic relationships (n = 14), taking romantic actions (n = 11), and feeling their overall communication improved (n = 11). Although two participants had an unscheduled psychiatric visit that could be attributed to attending the program, all recovered after one month.The program exhibited preliminary effectiveness to a moderate extent in improving recovery, particularly regarding self-esteem and hope. The program is feasible but requires further modifications regarding inclusion criteria for participants and the training of peer facilitators.UMIN000041743;09/09/2020.The online version contains supplementary material available at 10.1186/s12888-023-05254-1. Personaountries . Systemaountries –5. Amongountries . Accordiountries . Intimatountries . Such inountries , 10.In a systematic review of 20 studies of persons who experienced psychosis, 15% of participants were married , which iFor persons with psychosis, symptoms such as anxiety, depression, cognitive problems, and fatigue due to mental exhaustion can be barriers to initiating and engaging in romantic relationships, given the tendency by individuals experiencing such symptoms to isolate themselves . With prThrough a qualitative systematic review of the literature on experiences and support needs of persons with SMI regarding sexuality and intimacy, the investigators concluded that those with SMI possess the will and desire for intimate and romantic relationships despite potential barriers . TherefoPeer support is crucial for many people with mental disorders during the recovery process . SystemaThe program was developed with peers with mental disorders (peer collaborators) involved in all four processes in the co-creation of new knowledge .The first process is “co-ideation,” which involves engaging in open dialogue to share new and creative ideas for solving problems related to new programs . In thisSecond, the process of “co-design” developed a description of the technical details of the new program (prototype), as well as the research design to be used to evaluate the program (protocol) . We heldThe third process of “co-implementation” ensured that the co-designed program was in accordance with the research protocol . Four peThe final process of “co-evaluation” embeds data collection or other formal research techniques into the co-implementation process and jointly interprets the meaning and implications of the results . After tA one-group pretest–posttest trial was conducted using a mixed-method design. Participants were assessed for outcomes using self-administered questionnaires at baseline (T1), post-intervention , and one month after program completion (T3). The paper questionnaires were distributed and collected by the principal researcher. Group interviews  were conducted by the principal researcher at T3 for process evaluation (time span per person was 12–21 min). The intervention and data collection were conducted between March and December 2022. This project was registered in the Clinical Trial Registry .The program was named AIRIKI (“the power to love” in Japanese). This program offers essential elements for overcoming barriers related to forming and maintaining of intimate and romantic relationships among those with mental disorders. The program does not aim to provide knowledge per se but to enhance participants’ own awareness and develop their own ideas about relationships by considering those with their own loved ones through sharing their experiences and thoughts. This structured program is conducted face-to-face in small groups of at most 10 people and promotes peer-led learning in which both facilitators and participants are persons with mental disorders. The program provides detailed instructions, including principles such as respect for different values, including sexual diversity, and notes the number of minutes to be allotted to each component. With reference to a family peer learning program , 34, theTable Participants comprised adults (20 years of age or older) who met all of the following criteria: (1) diagnosed with a mental disorder and currently undergoing psychiatric outpatient treatment; (2) psychiatrist’s determination that the patients’ psychiatric symptoms were stable enough to allow participation in the study; (3) psychiatrist’s determination that participation in this study was not expected to interfere with psychiatric treatment; (4) able to communicate well enough to understand the explanation of the study and to make a decision on their own regarding study cooperation; and (5) able to participate in group discussion activities without difficulty using Japanese.The sample size was determined based on the effect size obtained from the results of a pilot randomized controlled trial (RCT) conducted prior to this study. An effect size of 0.5, α = 0.05, and β = 0.20, revealed the required sample size to be 33. The sample size was set to 40, considering dropouts. As the program was implemented on a group basis, the program implementation was planned and participants were recruited until more than 40 were enrolled. The final sample size was 45.Information on program implementation was widely publicized through the program’s website, e-mail lists, social networking services of several mental health self-help groups, and flyer distribution. Once we received a call from a potential participant, we planned an intervention near where the person lived, and distributed flyers in that area to encourage further participation with a reward ($23). The program was implemented face-to-face at eight sites across prefectures, thus covering a wide area in Japan. Once an application was received, the researcher sent a research description (instructions for the psychiatrist were enclosed) and the researcher explained the study over the phone. The applicant then gave the research description to his/her psychiatrist, who wrote a decision on whether or not he/she was approved to participate, subsequently sending it to the researcher by mail. The information regarding research participation was explained again on the day of the start of the program, and written informed consent was obtained from all participants.To measure the program’s objective of promoting recovery, the Rosenberg Self-Esteem Scale (RSES), Recovery Assessment Scale (RAS), and Herth Hope Index (HHI) were used as outcome measures. The RSES and HHI measure the major components of the concept of recovery .The RSES is a self-report scale that measures self-esteem. The validity and reliability of the Japanese version have been confirmed , 38. TheThe RAS is a self-report scale that measures the recovery process of persons with mental disorders using a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Higher total scores indicate being further along in the process of recovery, and the reliability and validity of the 24-item Japanese version of the RAS have been confirmed . In thisThe HHI is a self-report scale that measures levels of hope. The validity and reliability of the Japanese version have been confirmed , 41. TheProcess evaluation was conducted using originally developed items and interviews. We developed eleven items on relationships with significant others that were relevant to program content with input from peer collaborators. Peers felt it was important to determine if there were any changes in these process dimensions. For the following items, respondents were asked to choose the number that best fit their feelings and thoughts from not at all true (1) to totally true (7). The items were “I want to understand myself,” “I want to understand others,” ”I want to take care of myself,” “I want to take care of my friends,” “I want to take care of my partner,” “I want to take care of my family,” “ I am able to love others,” “I am able to appreciate the values of others,” “I am able to see the good side of things,” “I am able to communicate well with others about myself,” and “I am able to listen to others well.”The interview-based process evaluation was based on an in-person interview obtained at T3. One month after participating in the program (T3), participants were asked what impressed them and how they changed after participating in the program.Feasibility was determined by subjective ratings of satisfaction with the program and whether they thought it would help them in their lives, as well as by any negative effects of the program. Specifically, unscheduled visits to the psychiatrist up to one month after completion of the program (T3 questionnaire), the number and reasons for those who dropped out of the program, and deterioration of mental health condition after completion of the program (T3 interview) were assessed. For those who dropped out, they were contacted on the second day of the program and a few days later to check on their mental health status.p-value of 0.05 or less was treated as significant. Cohen’s d coefficients were considered correlation coefficients [The dataset included all participants who provided data at T1. Baseline characteristics are summarized as means and standard deviations for continuous variables and frequencies and proportions for categorical variables. For the outcome measures and process evaluation measures, we first compared the means of the three time points. Because this program was implemented on a group basis, data is nested by group. Therefore, we fitted mixed models for repeated measures (MMRM), with time points  as fixed effects and program sites as random effects. If the outcome measures showed significant changes in MMRM over time, T1–T2 and T1–T3 multiple comparison tests (Bonferroni correction) and effect sizes (Cohen’s d) were performed to examine the differences between time points. A ficients  and wereThe interviews were recorded and converted into textual data. The textual data were summarized for each statement made by the participant. The participants were classified according to their study IDs. The number of participants who reported about what impressed them regarding the program was counted based on the summarized statements for each program’s structural elements and content themes. The data on changes after program participation were categorized based on the similarity of the summarized statements, and the corresponding number of participants was counted. A principal researcher established the program’s structural elements, content themes, and categories. Counts were conducted separately by two researchers (MK and MN) for purposes of reliability (rate of agreement of 94.4%), and areas where there were differences in classification were reviewed by a third researcher (RO) to decide on the category.Figure Table As shown in Table As shown in Table Regarding program satisfaction, 29 (69.0%) were “very satisfied,“ 12 (28.6%) were “fairly satisfied,“ and 1 (2.4%) was “not very satisfied”; notably, 0 (0.0%) reported “not satisfied at all.” As for whether they thought it would be useful in their lives, 29 (69.0%) thought it would be “very useful,“ 11 (26.2%) thought it would be “fairly useful,“ and 2 (4.8%) thought it would be “not very useful”; no participant 0 (0.0%) thought it would be “not useful at all.”Interview data from one month after program participation were analyzed to determine what was impressive about the program Table  and the As shown in Table In Module 1, the most common response was the focus on “love and romance” (n = 9) left the greatest impression on participants, and it helped them clarify their own ideas by sharing their thoughts with others. The next most common response was “subjects to love” (n = 5), in which the theme of parent-child love in addition to heterosexual love was discussed, with some participants confirming that they had received love from their parents. In Module 2, the most impressive part was the communication skills and the role-playing exercise of gift-giving (n = 9). They indicated that it helped develop the skills of communicating in a respectful manner regarding their partner’s preferences and feelings. In Module 3, the most impressive part was the role-playing exercise regarding communicating about their illness (n = 6). They learned there were various ways to articulate their illness to others for it to be understood. In Module 4, the most impressive part was reflection and positive feedback (n = 6). The positive feedback provided by others helped participants gain their own confidence.As shown in Table Nine participants reported negative changes in their condition and/or feelings during and up to one month after participation in the program [Additional File We developed a peer-led learning program on intimate and romantic relationships aimed at promoting recovery in persons with mental disorders. This section discusses implications of the preliminary effectiveness and feasibility of the program.Although the study participants had a variety of primary illnesses, all but four were using disability services, indicating that most had some disability in their daily and social lives. However, 21 (46.7%) were working without support and 18 (40.0%) were living alone. According to a national survey of people with disabilities in Japan, 18.6% of people with mental disabilities under the age of 65 live alone, and 49.8% spend most of their daytime hours at home . Thus, tThis program was found to be associated with significant changes over time in self-esteem, comprehensive recovery, and a sense of hope; however, not all had high effect sizes. Comprehensive recovery showed significant effects after immediately attending the program; however, self-esteem and sense of hope were significant up to one month after the program. Therefore, the program was preliminarily effective to a moderate extent in improving recovery, especially in terms of self-esteem and hope.Participants also reported changes in their positive attitude toward romantic relationships (n = 14) and engaged in actions to further their romantic relationships (n = 11). In a previous study , it was Among the originally developed items for process evaluation, only “I am able to communicate well with others about myself” and “I am able to listen to others well” regarding communication skills showed significant improvements. In interviews one month later, eleven participants said their overall communication had improved. Communication skills themselves are not a component of recovery but are essential for connecting with others . For peoIn terms of program satisfaction and usefulness in life, the positive ratings were more than 95%. Therefore, we believe that this program meets the needs of the participants, although some of the participants experienced negative consequences. Two participants had an unscheduled psychiatric visit, and seven people reported being negatively affected, but they did not have an unscheduled psychiatric visit. Of these nine participants, seven experienced heightened psychological emotions due to the program. The reasons for the negative effects were as follows: the interactions with others made them feel less confident; listening to others reminded them of a painful past memory; a person was hurt by the words of a program facilitator.The program participants included people in a variety of situations: married, unmarried, and divorced. The program included content on parent-child relationship. Therefore, those who had not been successful in past marriages or who did not have a good relationship with their parents recalled unpleasant past events or compared themselves with others’ successes and lost confidence. Others felt stressed by people whose situations differed from their own. Many participants in the program described a positive change as they gained diverse ideas by sharing their thoughts and experiences with others, but others found it hard to compare themselves to others because of the diversity of program participants’ situations. Connectedness with others is an important part of recovery –5; howevFurthermore, the competence of the program facilitator may be related to participants’ negative experiences. The program’s structure of being a group focused on people with mental disorders and facilitated by peer facilitators was mentioned as a positive aspect of the program by many participants. Therefore, training must be strengthened to increase the capacity of peer facilitators. Additionally, trained professionals who support peer facilitators appear to be important element.Four of the applicants in this study were assessed by their psychiatrists to be unable to participate because of unstable psychiatric symptoms. It is undesirable for this program, which aims at recovery, to have individuals not deciding for themselves whether to participate in the program. However, some participants reported negative effects due to the program, although all recovered after one month. After this study was completed, we discussed with peer facilitators about whether we should continue to seek a psychiatrist’s permission to participate in the program. Many peer facilitators were concerned about the risk of worsening mental health conditions. Therefore, it was the peer facilitators’ decision to continue to encourage potential participants to consult a psychiatrist about program participation.The first limitation of this study is that it was not an RCT, but a one-group pretest-posttest design. Therefore, we cannot rule out the possibility of other factors affecting the changes in outcomes. Second, the program facilitators received two days of training to conduct the program; however, most of them did not have professional qualifications . Therefore, they are not as well-trained in the successful use of group dynamics as those with professional education and training. Third, participants had multiple diagnoses. Peer-led groups are particularly useful in contexts in which people can relate to their peers. Therefore, this method may be less effective than one where participants have a single diagnosis. Fourth, we recognize that originally developed items may not have good validity or reliability. Since this pilot study does suggest the importance of communication and listening skills, future research needs to measure these constructs with psychometrically sound scales. Finally, diagnoses were self-reported rather than clinically assessed. Therefore, a valid diagnosis was not confirmed.For future research, we believe that the program needs to focus on unmarried participants and to make use of peer facilitators (including those who are currently married) and to enhance the training of facilitators as well as provide professional support in conducting the program.This peer-led learning program on intimate and romantic relationships was effective to a moderate extent in improving recovery, especially in increasing self-esteem and enhancing hope. Two participants had unscheduled psychiatric visits that may have been due to their participation in the program, but all recovered after one month, so we consider the program feasible. For future research, the program needs modifications regarding the inclusion criteria of participants and the training of peer facilitators.Below is the link to the electronic supplementary material.Additional file 1: Table S1. Negative changes up to one month after the program


Physician parents encounter unique challenges in balancing new parenthood with work responsibilities, especially upon their return from parental leave. We designed a pilot program that incorporated 1:1 parental coaching to expectant and new physician parents and provided stipends for lactation support and help at home. Additional initiatives included launching a virtual new parent group during the COVID-19 pandemic and starting an emergency backup pump supplies program. There was positive feedback for our Parental Wellness Program (PWP), which was used to secure expanded funding. Pilot results showed that our program had a meaningful impact on parental wellness, morale, productivity, and lactation efforts. New physician parents and parents of young children are particularly vulnerable to burnout and reduced productivity. This is often due to child-rearing activities and lack of institutional support related to pregnancy, lactation, and parenthood . ChildbeA recent nationwide survey of physician mothers identified a lack of or inconvenience of lactation facilities, lack of time available for breast pumping, discrimination because of breastfeeding, and difficulty finding childcare as prevalent negative experiences when returning from parental leave . BecauseFemale physicians also further experience inequities at work, including a higher burden of after-hours documentation and over 25% more patient messages compared to men ,14. SurvPotential solutions to these challenges have been proposed, which include the creation of mentorship programs, increasing lactation and related child-rearing support, and reduction of maternal bias in medicine . HoweverReturn to work after parental leave is a stressful transition that can lead to a reduction in productivity and diminished wellness and work satisfaction. Thus, the goal of this pilot program, Supporting Our Physician Parents (SOPPort), was to (1) improve wellness, maintain productivity, and reduce burnout of expectant and new parents of all genders and gender identities; (2) provide lactation and feeding support; and (3) design a structured program that could be expanded across our institution.Interventions were designed to support junior faculty physicians who were expectant and/or new parents. The pilot program was supported by an internal Uplift Grant from the Massachusetts General (MGH) Physicians Organization (MGPO) Frigoletto Committee on Physician Well-Being. This grant supported faculty physicians of all genders and gender identities in the MGH Endocrine Division and Department of Obstetrics & Gynecology (OB/GYN) to participate in the program. Endocrine fellows were also eligible to participate through additional Endocrine Division financial support.The core pilot program was twofold: (1) one-on-one coaching for childbearing and non-childbearing expectant parents that provided practical advice over a maximum of four 1-hour sessions during the expectant phase through the first year of the child’s life, and (2) stipends for lactation support and help at home. We also designed and launched an emergency backup pump supplies program (MGPO Lactation Support Program) and created virtual new parent groups.Stipends: Female-identifying participants and/or participants planning to lactate received a $500 lactation stipend  and a $200 help-at-home stipend. All participants received the $200 help-at-home stipend, which was intended to cover the cost of preprepared meals, grocery delivery, emergency childcare, and/or housekeeping, with the goal of reducing stress for new parents.Coaching Program: A coaching program for childbearing and non-childbearing expectant parents was developed with a formal outline of suggested topics to cover during each session. Each participant was matched with an “experienced” parent coach from a small pool of physician parents with recent early parenting experience. The expectation was set that discussions between the participant and coach were confidential. Coaches were expected to use the outline of topics to facilitate a session based on the individual needs of the participant. These meetings generally took place virtually due to the COVID-19 pandemic. The core outline was typically covered in four sessions for childbearing parents  Reimbursement Program implemented in the Endocrine Division, which supported RVU reimbursement for one pumping slot per outpatient clinical session for a 1-year period.In addition, we partnered with the Frigoletto Committee on Physician Well-Being to start the MGPO Lactation Support Program, which provides an emergency stock of multi-user pumps and pumping supplies  across multiple brands that are conveniently located in a lactation room within the faculty physician lounge. Lactating individuals who inadvertently leave critical pump parts at home or encounter pump malfunctions while at work can access this room for needed items. We created a digital form with a QR code to track usage, allowing program staff to restock supplies.Additional Advocacy Efforts: We revised and formalized the clinical coverage system for parental leave in the Endocrine Division to make it more equitable and avoid disproportionally burdening childbearing physicians.Since this was a novel pilot program, the evaluation goals were to gather feedback and assess the impact of the program. At the end of the pilot, we administered an anonymous survey to participants. We separately surveyed Department of Medicine (DOM) physician parents who were not in the Endocrine Division and therefore did not have the opportunity to participate in the program. For the MGPO Lactation Support Program, we conducted an anonymous survey composed of 5-point Likert-type scales and open-ended questions. The Mass General Brigham IRB confirmed that our surveys were considered program evaluation and that no IRB oversight was required. Survey questions reported in the manuscript are available in the Supplementary Appendix.(n = 6 at the time of survey) suggested that all participants  felt that the program improved their productivity upon returning to work. Parental coaching  and lactation support grants  were particularly helpful.The pilot program ran from February 2020 to March 2022. A total of 12 individuals  received lactation stipends. Fifteen individuals  received help-at-home stipends. Eleven physicians were coached . All faculty participants were junior faculty members at our institution, either Instructors or Assistant Professors. Anonymous feedback from participants “I strongly believe that the program made me feel productive on my return to work during a really difficult time, made even more difficult by the uncertainties of childcare during this pandemic. I didn't have to choose between productivity and breastfeeding/pumping, and I didn't have to reinvent the wheel on return to work.” Another participant commented, “I cannot emphasize enough how much it meant to feel supported during this challenging time…I had my first child while involved with the program and was astounded by how hard having a baby and then returning to work can be…I am certain that this program positively impacted my mental health, work productivity, and the well-being of my family.” Additional testimonials are shown in Figure 2.One participant shared, n = 27 responders), 78% rated their return to work after becoming a new parent as “difficult” or “very difficult,” and 82% reported that they had nobody at work advising them on this difficult transition period. A resounding 96% of respondents stated that this pilot PWP would have been helpful to them, particularly in terms of well-being during parental leave (50%), well-being upon return to work (83%), and productivity upon return-to-work period (75%). Over 70% of respondents felt that small grants for lactation supplies (71%), individualized parental coaching (79%), and community building and connections to other new parents (79%) would have been helpful.In the DOM survey ,” while another emphasized, “Just caring that people have kids, trying to create an environment where having families is welcomed and celebrated—that will speak more than anything.”One faculty member reflected, “The return to work is very difficult for new parents and often times you feel isolated and afraid to voice your struggles…Support for new parents is essential. This should include acknowledgement from Division leaders on productivity goals for the first year of the child’s life. Physicians are often becoming parents while in training where financial resources to ease the stress of parents are limited. Support from MGH is essential to ensure our talented young physicians are able to remain productive and engaged physicians and parents.”To summarize the critical need for the program, a faculty member wrote, From June 2022 to February 2023, 10 unique individuals across multiple departments  utilized the program. Six individuals completed a program evaluation, of which half endorsed pumping at work to be “difficult” and 66% either agreed or strongly agreed that they were supported by the program in meeting their lactation goals. The number of hours saved due to the program was variable, ranging from 1 to 2 to more than 4 hours . A separate source of funding was available to fund stipends for Endocrine Division trainee participants (see Acknowledgments). The start-up costs for supplies for the MGPO Lactation Support Program totaled approximately $3,500.We established a clear and unmet need for a PWP in our survey of physician parents who did not have access to a specific parental support program. Many endorsed the lack of an advocate to help navigate the transition back to work, the isolation of new parenthood, challenges of reduced productivity, and the importance of a supportive environment. In addition, there was overwhelming positive feedback from participants of the formalized PWP indicating that the program directly addressed some of these issues.Participant feedback specifically highlighted that the program enhanced well-being, promoted productivity, helped avoid “reinventing the wheel,” normalized the challenges of early parenting, increased perceptions of institutional support, and supported lactation efforts. This was consistent with previously published programs targeting breastfeeding support, of which one showed that having access to a wearable breast pump was associated with lactating physicians’ ability to meet their breastfeeding goals and take shorter lactation breaks . We alsoWe believe that this unique coaching model was particularly effective for multiple reasons: (1) coaches were experienced and knowledgeable individuals who had recently been new faculty parents themselves at our institution; (2) the coaching session outline targeted critical issues related to parental leave, lactation, and return to work that participants would not have otherwise anticipated; (3) coaching sessions permitted a safe space to discuss parental wellness-related concerns; and (4) participants had a supportive coach and advocate to help them during a truly vulnerable time. A limitation of this brief report is the lack of use of validated surveys, which are generally unavailable in the parental wellness space at this time. However, we believe that it is critical to report these data due to the lack of published experience with successful PWPs for physician parents.The cost of implementing the pilot program was relatively modest. This PWP was subsequently funded by a larger MGPO Phoenix Wellness Grant and was upscaled to serve all faculty in the MGH DOM. The program was smoothly expanded to this larger audience of nearly 70 participants , and it again received very positive testimonial feedback with formal surveys nearing completion. The growth and expansion of the program required physician leadership, administrative support, and organizational buy-in. It was critical to have physician leaders in the PWP who acted as champions for new parents, responded to feedback, established a sense of community, and developed new programming to meet the needs of physician parents.The authors hope to continue this important parental wellness work with an emphasis on supporting junior faculty parents in medicine and promoting a wider change in culture. Through these efforts, we hope to improve parental wellness, morale, and satisfaction, reduce burnout at a particularly vulnerable time, reduce gender disparities, and promote community building among parents of young children.Li et al. supplementary material


IntroductionIn this study, we aimed to investigate the importance of various characteristics used by diagnostic radiology subspecialty fellowship programs when selecting candidates for their fellowship programs.MethodsAn online survey was sent to program directors from multiple radiology fellowship programs in the United States. Multiple questions were asked, including applicant gender, personal statement, interview performance, research experience, United States Medical Licensing Exam (USMLE) performance, and residency program attended. Survey recipients were asked to rank these characteristics from least to most important. ResultsA total of 119 responses were collected (response rate of 26.2%), with a relatively balanced representation of the different subspecialties. An aggregate analysis of all the subspecialties showed interview performance, letters of recommendation, and residency program attended as the three most important factors considered by the program directors when selecting a candidate for their fellowship program. In contrast, the three least important factors were gender, prior subspecialty training, and minority status. The applicant's visa status, personal statement, and USMLE Step 3 performance were the only statistically significant (p<0.05) differences between the subspecialties. The women's and body imaging subspecialties rated the personal statement more important than musculoskeletal imaging and neuroradiology. Cardiothoracic and musculoskeletal imaging rated the applicant's visa status more important than neuroradiology. Women's and cardiothoracic imaging rated USMLE Step 3 performance as more important than musculoskeletal imaging.ConclusionSelecting the ideal candidate for a fellowship in radiology can be difficult. Our findings outline which applicant characteristics program directors believe are the most and least important when selecting an ideal candidate. For instance, personal characteristics such as interview performance and letters of recommendation are more valued than extracurricular activities such as research experience. Identifying these characteristics provides a better understanding of the fellowship application process and may guide future applicants. Diagnostic radiology training in the United States includes a four-year program preceded by a one-year prerequisite program. After completing five postgraduate years of training, the physician can pursue subsequent subspecialty fellowship training. The vast majority of residents pursue fellowship training for many reasons, some of which include educational interests and preferred employment. A survey conducted in 2009 found that 93.4% of residents pursued fellowship training after completing residency, whereas 80.1% of residents pursued fellowship training in 1999 [Institutional review board approval for this study was obtained from Saint Joseph Mercy, Oakland .SurveyMonkey.com LLC. A total of six different radiology subspecialties were surveyed: abdominal/body/cross-sectional imaging, breast/women's imaging, cardiothoracic imaging, musculoskeletal imaging, neuroradiology imaging, and pediatric imaging. The survey included a general yes/no consent question and a multiple choice question regarding the program director's subspecialty. The subsequent 22 questions were grouped into four categories of demographics, personal characteristics, extracurricular activities, and educational accomplishments . It should be noted that nine invitations were confirmed to have been automatically declined by the recipient's email platform or bounced; furthermore, it is uncertain how many of the email addresses were inactive. Therefore, the actual response rate to the survey may have been higher. Additionally, one of the respondents failed to identify their subspeciality and was excluded from the analysis. A relatively balanced response was collected from different subspecialty program directors . Cardiothoracic and musculoskeletal imaging ranked visa status significantly higher than other specialties , whereas neuroradiology ranked it the lowest (mean score of 4.1). Breast/Women’s imaging and abdominal/body/cross-sectional imaging ranked the personal statement significantly higher than other specialties . In contrast, musculoskeletal and neuroradiology imaging ranked it the lowest . There was no significant variation amongst the subspecialties in the general category of extracurricular activities. Cardiothoracic and breast/women’s imaging ranked the USMLE step 3 performance significantly higher than the other subspecialties (mean score of 6.2 and 5.8), whereas musculoskeletal imaging ranked it the lowest (mean score of 3.1). Figures The fellowship application can be daunting for a resident; therefore, early preparation is essential in obtaining a preferred spot. Often, residents have to select a subspecialty early in their residency and subsequently work on building their curriculum vitae. Research, teaching, and leadership experience require years of preparation and planning. Interestingly, this survey shows that the two most important applicant qualities are personal characteristics: interview performance and letters of recommendation. These findings are similar to a study conducted in 2012 demonstrating personal interviews, letters of recommendation, and personality as the most important subjective factors for selecting a fellow . The afoTo our knowledge, no other survey has been conducted to determine if any applicant characteristics differ between subspecialties. The applicant's personal statement was considered more important in women's imaging and body imaging and least important in musculoskeletal imaging. The reason for this is uncertain and further research may be needed. Although cardiothoracic and musculoskeletal imaging value visa status more than neuroradiology, it is unclear whether this had a detrimental or positive impact on the applicant's success. The study is limited with regard to sample size. Although nearly all the subspecialty fellowship programs were contacted, the response rate was lower than anticipated. Multiple reasons could explain this finding. For example, a web-based survey was utilized, which required email as the primary form of communication. Web-based surveys are easy to conduct, so the recipients may have received multiple surveys from various sources and perhaps chose to ignore a few of these surveys. Additionally, we chose a sample time spanning from January to April, which coincides with the fellowship cycle. Program directors may have been preoccupied with conducting interviews with limited time to complete the survey. It is uncertain to what extent, if any, this limited sample size affected the results. Nevertheless, our response rate is comparable to that obtained by a similar survey conducted in 2012 .Selecting the ideal candidate for a fellowship in radiology can be difficult. As a candidate, it is essential to know early on what the fellowship program is looking for so that the application can be tailored for success. Nonetheless, specific fixed characteristics, such as the residency program, are important and must be considered by the applicants.


Thoracic SMARCA4‐deficient undifferentiated tumors (SMARCA4‐UT) have a poor prognosis and are often diagnosed at an inoperable advanced stage. Herein, we report a case of SMARCA4‐UT diagnosed by endobronchial ultrasound‐guided transbronchial cryobiopsy (EBUS‐cryo). The patient was a 42‐year‐old man with a history of smoking. Chest computed tomography revealed a right upper lobe nodule and an enlarged #11s lymph node. Core tissues could not be obtained by EBUS‐guided transbronchial needle aspiration (EBUS‐TBNA) for diagnosis and mediastinal staging; hence, EBUS‐guided intranodal forceps biopsy (EBUS‐IFB) was performed. However, a detailed diagnosis beyond poorly differentiated carcinoma could not be obtained. Subsequent EBUS‐cryo provided sufficient specimens for immunohistochemical and molecular evaluation and SMARCA4‐UT was definitively diagnosed. Thus, EBUS‐cryo could be of additional diagnostic value for uncommon tumors, such as SMARCA4‐UT, conjointly with EBUS‐IFB as well as EBUS‐TBNA. We report a case of SMARCA4‐UT that was successfully diagnosed via EBUS‐cryo after unsuccessful EBUS‐TBNA and EBUS‐IFB. Conventional endobronchial ultrasonography‐guided procedures cannot provide sufficient biopsy samples for the diagnosis and staging of rare mediastinal tumors. Endobronchial ultrasonography‐guided transbronchial cryobiopsy helps obtain adequate tissue samples for histological, immunohistochemical, and molecular (including next‐generation sequencing) evaluations. Thoracic SMARCA4‐deficient undifferentiated tumor (SMARCA4‐UT) is a high‐grade malignancy, often affecting young adults with heavy smoking history and emphysema.Endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) is a well‐established method for diagnosing mediastinal and hilar lesions.Herein, we report a case of SMARCA4‐UT successfully diagnosed by adding EBUS‐cryo after EBUS‐TBNA and EBUS‐IFB.A 42‐year‐old man, a current smoker (22 pack‐years), was referred for a right hilar mass. Blood tests showed no abnormal carcinoembryonic antigen, cytokeratin 19 fragment, or progastrin‐releasing peptide levels. Chest computed tomography revealed a nodule and a pulmonary cyst between the right upper and middle lobes and an enlarged #11s lymph node, which revealed an abnormal uptake of fluorodeoxyglucose on positron emission tomography Figure . The #11STK11 and KEAP1 have been implicated for resistance to immunotherapy.In our case, EBUS‐cryo provided sufficient specimens for immunohistochemical and molecular evaluation to help determine the treatment strategy for resectable SMARCA4‐UT. Mutations in A recent randomized controlled trial demonstrated the additional diagnostic value of EBUS‐cryo over EBUS‐TBNA.A meta‐analysis of 21 studies including 1175 patients reported that the pooled proportion of adequate EBUS‐TBNA samples for NGS was 86.5%.The primary technical challenge of EBUS‐cryo is to establish a standard technique for creating a cryoprobe insertion tract into the lymph node. The high success rate of a high‐frequency needle‐knife incision technique has been demonstrated in two large randomized controlled trials.In summary, we report a case of SMARCA4‐UT diagnosed by EBUS‐cryo. Thus, EBUS‐cryo may provide additional diagnostic value to EBUS‐IFB and EBUS‐TBNA for the histological and molecular evaluation of mediastinal and hilar lesions.Writing – Original Draft: Chihiro Takemura. Patient Care: Tatsuya Imabayashi, Hideaki Furuse, Keigo Uchimura, Yuji Matsumoto, Shun‐ichi Watanabe, and Takaaki Tsuchida. Writing ‐ Review & Editing: Tatsuya Imabayashi, Hideaki Furuse, Keigo Uchimura, Yuji Matsumoto, Shun‐ichi Watanabe, and Takaaki Tsuchida.All authors read and approved the final manuscript. The authors declare that they have no competing interests.