Health organisations are increasingly implementing ‘embedded researcher’ models to translate research into practice. This paper examines the impact of an embedded researcher model known as the embedded Economist (eE) Program that was implemented in an Australian Primary Health Network (PHN) located in regional New South Wales, Australia. The site, participants, program aims and design are described. Insights into the facilitators, challenges and barriers to the integration of economic evaluation perspectives into the work of the PHN are provided.N= 34), observations (N=8) and a field diary kept by the embedded economists. A thematic analysis was undertaken through the triangulation of this data.The eE Program consisted of embedding a lead health economist on site, supported by offsite economists, part-time, for fifteen weeks to collaborate with PHN staff. Evaluation of the eE at the PHN included qualitative data collection via semi-structured interviews ; and because the eE provided ongoing support for PHN projects beyond the fifteen-week embedding period.This study provides the first detailed case description of an embedded health economics program. The results demonstrate how the process, context and relational factors of engaging and embedding the support of a health economist works and why. The findings reinforce international evidence in this area and are of practical utility to the future deployment of such programs.The online version contains supplementary material available at 10.1186/s12913-022-08208-7. Decisions are made daily in healthcare about the type of care that will be provided, not only to individual patients but also to improve people’s overall health and wellbeing. These decisions can be about new medicines, new technologies, improved models of care or approaches designed to promote health and prevent or manage avoidable illnesses within the population .Determining whether healthcare spending choices represent value - for governments, patients and taxpayers - depends on whose perspective is taken, but in general, ‘value’ can be assessed by examining the impacts of spending choices on health service efficiency and equity. While such evaluation is common at the national level, economic evaluations are relatively rare at the local level . The locpriorities of the health service and share their skills with staff, a focus that was often lacking when private sector or academic expertise was engaged [The gap in health economic skills in local health services was an important finding in a national report on local level evaluation . Insight engaged . The embThe paper firstly presents the distinct PHN context and the background that informed the ‘economist-in-residence’ approach. Following sections present methods, findings and impact of the eE Program, before distilling our study results into a more general argument in support of developing local capacity and capability in economic evaluation.st July 2015 by the Australian Federal Government to increase the effectiveness of medical services for patients, particularly those at risk of poor health outcomes, and to improve coordination of care. The PHNs are not-for-profit organisations which do not directly provide health services. Instead, they use a commissioning model to work with primary health care providers, secondary care providers and hospitals. Commissioning includes a range of activities to assess the needs of the population, plan and prioritise services, purchase those services and monitor the quality of the services being provided. PHN commissioning is intended to move the local health system towards more sustainable models of care by not only procuring new or additional services but also transforming and reorganising existing services [Australian PHNs were established on 1services –5.As a ‘newcomer’ to the Australian health services landscape, there is little research overall on PHNs and the effectiveness of their commissioning –5. RecenEmbedded researchers, or researchers-in-residence, are researchers who work as part of an operational team. Their role is not simply to bring new skills and expertise to the team. They are charged with ‘mobilising knowledge and creating new evidence for local use and wider dissemination’ . EmbeddeThis approach has been implemented in areas including education, the law, and social care . ResearcRegardless of jurisdiction or clinical setting, the literature on embedded researchers is rated by Ward and colleagues  as lackiprocess [contextual [relational factors [Despite the lack of formal evaluations to date, guidance on designing embedded initiatives is not lacking. The literature identifies and lists a number of key success factors for embedded research including various process , 22–25, ntextual , 26 and  factors .Against this background, this article now sets out results from embedding a health economist in the first of six program sites, a regional New South Wales (NSW) PHN. This site was unique – the others being large health services centred on hospitals. The full planned program protocol, including a brief literature review and overview has been reported in an earlier edition of this journal . The conTo increase health service staff awareness of the value economic evaluation can bring to decision-making.To develop health service staff knowledge and capacity to access and apply economic evaluation principles, methods and tools in decision-making through formal training and extended exposure to an embedded economist.To facilitate health service practice change and the routine application of economic evaluation principles in decision-making .By way of summary, the eE Program had three aims:The aims of the evaluation were to capture the outcomes and impact of embedding an economist and to evaluate the contextual, procedural and relational aspects that facilitated or acted as a barrier to the program . More deThe Hunter New England Central Coast Primary Health Network (HNECCPHN) is a new (approximately six years old) and medium-sized organisation, consisting of a chief executive; four senior executives; 11 board members; a clinical council; a community council; and approximately 100 full-time equivalent staff. The HNECCPHN region covers 130,000 square kilometres, as set out in Fig. N=4) and all staff employees (N=100) had some form of interaction with the eE over the three program phases. A lead health economist and four support health economists from the Hunter Medical Research Institute (HMRI) also participated. Specific details including number and type of participants are set in Supplementary file The chief executive, all senior executives  was embedded within the HNECCPHN from 15 October 2019 through to 29 February 2020. Allowing for Christmas and New Year breaks, the elapsed time was approximately fifteen weeks. The economist worked with PHN staff to conduct economic evaluations and advise on evaluation and impact design and the inclusion of economics principles, as appropriate, in day-to-day business. While the lead economist conducted all the face-to-face interactions with PHN staff, ‘back of house’ support economists were engaged from the HMRI Health Economics team to provide assistance in conducting the economic evaluations and to provide specialist expertise as needed. The program was structured into three phases: planning, embedding and post-embedding [The evaluation took place concurrently with the eE Program, with the last interviews conducted in mid-July 2020, approximately five months after the embedding phase was complete. Ethics approval was obtained from the Human Research Ethics Committee of the University of New England , with written consent provided by all participants. All methods were carried out in accordance with relevant guidelines and regulations.Potential evaluation participants were all HMRI economists and PHN senior executives and staff members participating in the eE Program. Complementary data was collected at each phase of the project to capture insights into the context, processes, relational aspects and outcomes of the program . MethodoThe data that were collected prior, during and after the economist embedded at the PHN are listed in Table Interviews were recorded with consent and professionally transcribed. Participants were invited to review their de-identified transcripts and request amendments before they are entered into QSR International’s NVivo qualitative data analysis software (Version 12) . DocumenA thematic analysis was conducted on the data by applying a coding framework using predetermined themes. The themes were based on a review of the embedded literature conducted by the researchers, used to design the program (and summarised in the introduction of this paper) as well as the program aims. The coding framework was tested and refined by two of the researchers (DP and CJ), with each blind coding six interviews and refining the manual and coding based on a comparison of their coding of these initial interviews. The refined coding manual was then applied to the remaining transcripts via an iterative, reflexive and concurrent process of refining themes , 32. TheThe key outputs include six projects that were undertaken by the HNECCPHN whilst the economist was embedded. A variety of economic evaluation skills and tools were developed and applied during the projects including: business case development; applying cost modelling principles and cost consequence tools and processes; developing and implementing a program logic model; and identifying and collecting appropriate outcome measures to support program evaluation and impact assessment. Supplementary file all program participants suggests the program successfully increased staff awareness of the benefits of economic evaluation. Increased awareness took the form of looking at work differently and thinking about evaluation more, from a program or initiatives inception. Both senior executive (N=2) and staff participants (N=10) believed the eE Program had developed their capacity to access and apply economic evaluation. It did so by providing additional information, knowledge and tools. For example, a variety of economic evaluation skills and tools were developed and applied via the six projects including: developing a business case; applying cost modelling / cost consequence tools and processes; developing and implementing a program logic model; and identifying and collecting appropriate outcome measures to support program evaluation and impact assessment (see Supplementary file N=3) suggest there was limited but emerging evidence to demonstrate practice change. However, senior executive (N=2) and staff participants (N=12) stated they wanted ongoing support if capacity building was to continue:Ongoing support would be ideal…what we found was we – we were sorry that the time was coming to an end because we saw an ongoing need for the embedded Economist in providing further support and upskilling, and capability development, which I suppose reflects the success of the initiative in its early stages. PHN PARTICIPANT 4Key impacts are summarised in Table Tables planning phase. The first was Board and active executive sponsorship within the HNECCPHN. The second was the seniority of the lead economist and applied experience of all the support economists. More than 20 years of applied experience working with health services, and an understanding of the regulatory context in which the PHN operated were considered crucial to encourage executive teams to consider new ways of thinking and working. Thirdly, the eE Program was facilitated by the appointment of a site lead, a PHN senior executive who ‘concierged’ the program from within the organisation, liaising with the program manager and acting as a gateway for staff to access the economists.Three process issues facilitated the embedding phase: the physical location of the economist in an open-plan office; a single contact point and administrative support to book formal meeting requests; and identification of existing in-house expertise.Three process issues facilitated the Process challenges in the embedded phase included: depth of embedding (economist time available per week); the need for a communication and visibility strategy; the need for an exit strategy; and the overall length of embedding period. The economist embedded for 328.7 hours - approximately 22 hours per week. This partially embedded model was implemented due to the available project resources. It meant however that the economist was not fully relieved from their everyday jobs and was constrained by competing interests and demands. Despite this, the economist was available outside of their physically-embedded time by telephone and via virtual meetings.The first two weeks of embedding resulted in less engagement than expected, with only 20 staff members engaging over this period. A more detailed communication strategy was then developed consisting of: three morning teas (one-face-to-face and two conducted via Skype with satellite offices) where the lead economist explained the program to managers; a ‘pitch’ emailed by the site lead to managers asking for project nominations to be ranked in order of organisational priority by executive; and a presentation by the lead economist at the annual ‘All Staff Day’ to increase program visibility and foster staff engagement. Given the success of the lead economist's presentation at the ‘All Staff Day’ and with the benefit of hindsight, the site lead thought earlier communication, engaging all staff, and clarifying the process for engaging with the economist to ensure a strategic approach to this limited resource, during the planning and embedding phases would have been beneficial. Staff also wanted improved communication throughout the embedded phase, including about what other projects the economist was working on. Overall, embedded research takes time to build visibility and momentum, timeframes may need to be adjusted to accommodate for this and staff need to be made aware that not everyone will have access, particularly when the economist was only intended to be placed at the PHN for a limited period.Despite a slow start, a crescendo of projects presented toward the end of the embedded period, predominantly as a result of visiting a satellite site for the first time during the last week of embedding, resulting in ongoing remote work. The desirability of developing an exit strategy and moderate expectations about how much work can be done and when the work will end earlier in the program was identified.The embedded component of the HNECCPHN project was scheduled for three months but actually went over time by approximately three weeks. Three months was perceived by all participants as the shortest possible timeframe, with six months cited as more realistic, as projects presented late into the embedded phase, right up to the last day of embedding. A longer lead time for the economist to immerse within the organisation and identify appropriate projects and priorities would have been beneficial.and eventual high demand for services. For instance, a slightly slow start may not have been identified as an issue with a different schedule or if the engagement was not perceived as very high value.These process issues are all interrelated as they represent consequences of limited economist time planning and embedding phases of the HNECCPHN program. The PHN’s medium size  cultivated an enthusiastic and receptive culture where employees would easily see the benefit and impact of the eE Program. These factors made it feasible for the eE Program to achieve broad organisational reach.A number of organisational characteristics impacted positively on the Relevance of the eE Program to organisational function was another facilitator. Given the focus of the eE Program was on upskilling participants in economic evaluation, its relevance to commissioning was easily understood. Senior executives and staff recognised the lack of skills and capability in relation to economic evaluation and were motivated to take the opportunity the eE Program presented.The eE Program therefore came along at a time that aligned with the PHN’s stage of organisational evolution. The organisation was moving from an establishment phase to attempting to commission services, support improvement in a range of services and demonstrate impact. It was hoped the eE Program would provide tools and training to inform more systematic or rigorous way of making decisions about planning and commissioning.Staff’s limited time impacted on engaging with the economists, with some participants expressing regret at the end of the program that they had not had time to engage more.Geography impacted negatively on the eE Program at HNECCPHN. Embedding at least partially face-to-face onsite was considered essential to the program by all participants, predominantly because of the opportunities this presented for quick, unplanned interactions and real-time feedback. There was the perception that staff in the Newcastle office benefited more from the project than staff in other offices because of the greater face-to-face contact Table The following three subsections set out the themes and sub-themes that emerged from data coded under ‘relationality and engagement.’ This code collected data that addressed: how and why engagement occurred or did not occur; and what relational processes, mechanisms, attributes and skills were required for engagement to occur.N=3) and staff participants (N=12) expressed a number of positive attributes held by the economist that they perceived as facilitative of the program, as set out in Table N=2) and PHN executives (N=2) and staff (N=16) provided insights on the ways of working.Senior executives (N=12) in four of the six projects undertaken with the economist commented on this coaching approach. ‘Coaching’ was characterised by the lead economist as problem solving rather than imposing a solution.These relational facilitators enabled the economist to provide tailored support and capacity building to facilitate the application of relevant tools and approaches to specific problems within the health service. Participants  enabled staff to seek informal support, which was greatly valued by staff in this particular location. Pain and colleagues suggest, ‘feelings produce impacts produce feelings’: emotional dimensions are not side-effects but are active in generating impact . The warThe form, size and culture of the site all contributed positively to the program . The PHNThe literature acknowledges the importance of embedded researchers having social and interpersonal skills as well as technical or topic specific expertise. Desirable interpersonal skills include inquisitiveness, receptiveness and enthusiasm as well as communication skills , 22, 24.However, our research goes further and adds to the importance of relational issues in embedded research. The greatest facilitator for this program was the way of working, the ‘coaching’ or ‘slow science’ , 29 apprIn line with our philosophic commitment to slow science , these rThese results must be considered in light of the following limitations: the eE Program embedded a particular skill set – health economics – in a particular context – a Primary Health Network located in regional Australia. The evaluation of future Local Health District (care provider) sites at which the economist will embed within the NSW Regional Health Partners' footprint may produce quite different results. This is a small scale, qualitative case study. Whilst all program participants from this site were approached to participate in the evaluation, participants self-selected which increases the risk of bias. The evaluation was conducted by a social scientist who also occupied the dual role of program manager. However, to ensure the research remained theoretically and methodologically sound, the embedded Economist program was overseen by the eE Social Science Research Committee.This article demonstrates the previously reported evaluation components of the study protocol  to be efDespite its stretched resources, this embedded research project had impressive outcomes. The organisational outputs, in the main, will not be reflected by academic outputs. Hopefully, this case study is the start of a journey where continued funded engagement will increase HNECCPHN staff skills and the development of research endeavors that are democratically designed and undertaken and also contribute to the academic literature. Elsewhere we outlined the view that healthcare research warrants adopting a more local, contextualised and practical approach in order to tackle health service complexity with requisite levels of fine-grained sensitivity and local relevance  .Overall, this project worked because the organisation was highly receptive and the skills offered were a perfect fit for a commissioning; because of the democratic stance taken by the economists  and the economists' efforts to encourage the accessibility of their tools and techniques (‘it’s not rocket science’) and; finally, due to the warmth and enthusiasm all parties brought to the engagement.Additional file 1.Additional file 2.Additional file 3.


BackgroundWith the evolving nature of telehealth services being supported across graduate medical programs, understanding changing attitudes among program directors is essential for training future physicians.ObjectiveThis 5-year longitudinal survey analysis provides details regarding the knowledge, skills, competency, and confidence levels present among program directors and the ways telehealth training  supports resident education.MethodsA longitudinal observation survey was sent to 77 program directors (48% completion) from an academic health system. Data were compared from survey responses from 2016 to 2021 with additional information collected about current training processes in 2021. Paired sample t-tests, quantitative data analysis, and qualitative thematic analysis results are reported based on a convenience sampling of all program and fellowship directors.ResultsResults show that while telehealth knowledge and use increased among program director faculty, systemic concerns about the feasibility of telehealth from a time and cost perspective remain high. In 2016 and 2021, most of those surveyed  were concerned about reimbursement. Directors remain committed to telehealth resident education, with over 60% stating that it is "essential to future practice". The qualitative thematic analysis highlighted the need for additional resources and support to conduct telehealth and the variability within disciplines of the use, therefore modeling, of telehealth in clinical settings.ConclusionsThe overall utilization of telehealth by graduate medical education programs has increased along with the continued need for training to prepare residents for current and future practice. Telehealth is an essential aspect of the future of healthcare. It has been crucial to many hospitals and practices during the COVID-19 pandemic - especially in its use to support Graduate Medical Education (GME) programs , teleheaSince the inception of formal GME training for telehealth, overall utilization of telehealth has increased along with the continued need for training to prepare trainees for current and future practice -6. MultiThese findings were previously presented at The Society for Education and the Advancement of Research in Connected Health (SEARCH) 2021 National Telehealth Research Symposium.To meet the educational and clinical goals for GME programs, we conducted a longitudinal survey of current residency and fellowship program directors on their self-assessed knowledge and confidence in practicing and supervising telehealth encounters. College of Medicine residency and fellowship program directors were surveyed in 2016 using the RedCap platform -11. An oSPSS  standardProgram and fellowship director respondents represent providers in various practice locations across the academic institution and are primarily based in hospitals or on-campus clinics, as detailed in Table As expected, between 2016 and 2021, directors gained knowledge regarding telehealth implementation and their actual telehealth practice levels   Figure . This daTelehealth knowledge and use are both subject to systemic barriers. In 2016 and 2021, most programs surveyed  were concerned about reimbursement as a significant barrier to telehealth, as shown in this descriptive comparison of total responses , remote patient monitoring activities (9.8%), and asynchronous text visits (2.4%). Overall, trainees primarily receive instruction through experience in a longitudinal clinic (73.3%) and through one-day (6.7%) or limited rotations (6.7%) that might last up to a month.Directors' enthusiasm for residents and fellows to learn more about telehealth remained consistent, with 61.1% in 2016 and 62.2% in 2021 stating it is "essential to their future practice". Respondents report that trainees were more likely to be trained through experiential clinic offerings (70.3%) than in online or in-person didactics (29.7%). Still, 24.3%, or nine programs, reported no training being provided in 2021. For programs providing education (n=26), multiple topics are being covered, including provider-side technologies (80.8%); billing/reimbursement (57.5%); compliance/legal (42.3%), and webside manner (30.8%). Directors feel that ongoing training modalities should be provided in the following ways: online, asynchronous modules (23.2%); online, synchronous lectures and walk-throughs (20.3%); in-person, technical training (30.4%) and experiential learning opportunities (34.8%).Finally, open-ended responses provided additional context to the types of education and clinical services being provided by the programs. A thematic analysis of the open-ended prompts noted two main themes: the practice and instruction related to telehealth are highly variable by discipline, and the general need for more resources and support to provide telehealth limits what can be modeled. Some nuances in the training continuum were noted, including this one statement: "As program director, I am responsible for the curriculum of telehealth, but a different provider does the supervision exclusively, and I do not have first-hand experience with that care delivery." These types of structural challenges within training programs warrant additional consideration.Some programs ran into limitations with telehealth when implemented to scale during COVID-19, and questions still need to be answered about the long-term capacity for telehealth consultations . With fuThe consistent percentage of respondents who consider telehealth essential to future practice (61.1% vs. 62.2%) likely reflects concerns about reimbursement and the time constraints needed to implement services in the current environment. While not statistically significant, program directors' comfort in determining how telehealth increases cost efficiency shows an average to less than average comfort level, with only 17% "knowing more than the average person in the health professions field" (p=0.068). Currently, the percentage of directors considering telehealth essential continues to be constrained due to regulatory and reimbursement advances. This is an area for additional provider engagement, stakeholder education, and health policy intervention to achieve a consistent policy roadmap that informs faculty and trainee development.The survey helped identify potential areas of curricula reform for GME programs that aligns with a shift to competency-based education in telehealth . IncorpoLimitations of the study included the discrepancy between the number of programs responding to the survey over time and the lack of longitudinal data by specialty. Additionally, the opinions were that of the program directors and not necessarily of the faculty training the residents and fellows. The initial survey responses in 2016 were provided by a small subset of specialties inclined to consider incorporating telehealth into their training programs and clinical operations. The respondents and their affiliated programs increased participation in the 2021 offering, most likely due to increased use and awareness of telehealth in the intervening years. The research question did not attempt to draw direct comparisons between specific programs longitudinally due to the low initial response rate in 2016. Program directors were selected as respondents as decision-makers informed about curriculum integration, but future studies could include the full faculty team by specialty.Further investigations of program director knowledge, comfort, and practice levels in relationship to the training provided for trainees are warranted within specific specialties and institutions as part of the internal continuous quality improvement process. Additionally, this study was limited in examining one academic health system's GME leadership. Although the institution has had a broad implementation of telehealth over many years, results from this research might not be generalizable to other GME programs or academic health systems. Internally, this data has been used to refine curriculum offerings across program years based on program support.Given the compression of didactic and experiential training due to the pandemic, additional opportunities for curriculum integration are needed to support in-person education and provide workforce support for GME programs investing in telehealth ,15. RegaSince the inception of formal GME training for telehealth in 2016 at MUSC, the overall utilization of telehealth has increased along with the continued need for training to prepare trainees for current and future practice. This study indicates that continuous telehealth policy adjustments are needed in areas of billing and reimbursement, and clinical workflow support is needed for programs to integrate telehealth fully. Similar surveys at the GME level can help identify curricular needs or reform. These structural changes and continued curriculum integration for trainees will ensure that the gap between current and future telehealth practice can be better addressed through formal didactic and experiential education methods.


ARID1A abnormalities disturb gene coding processes and correlate with immunotherapy responsiveness. We report the first blood sample-based genomic sequencing of ARID1A in DNA shed from tumors into the circulation (known as cell-free DNA (cfDNA) from liquid biopsy). Altogether, of 62,851 cancer patients with ≥1 cfDNA alteration in the blood, 3137 (5%) had ≥1 deleterious ARID1A alteration , suggesting this non-invasive test’s value in detecting ARID1A. ARID1A alterations were most frequent in endometrial (21.3% of patients) and bladder cancer (12.9% of patients). As compared to blood samples without ARID1A aberrations, those with a functional (deleterious) ARID1A abnormality had more DNA alterations/sample  and more frequent co-alterations in one or more genes in key pathways promoting cancer development/progression, which may inform therapeutic strategies.ARID1A abnormalities disturb transcriptional processes regulated by chromatin remodeling and correlate with immunotherapy responsiveness. We report the first blood-based cell-free DNA (cfDNA) next-generation sequencing (NGS) ARID1A analysis. From November 2016 through August 2019, 71,301 patients with advanced solid tumors underwent clinical blood-derived cfDNA testing. Of these patients, 62,851 (88%) had ≥1 cfDNA alteration, and 3137  (5%) had ≥1 deleterious ARID1A alteration , suggesting this non-invasive test’s value in interrogating ARID1A. ARID1A cfDNA alterations were most frequent in endometrial cancer, 21.3% of patients; bladder cancer, 12.9%; gastric cancer, 11%; cholangiocarcinoma, 10.9%; and hepatocellular carcinoma, 10.6%. Blood samples with a functional ARID1A abnormality had more alterations/sample  and more frequent co-alterations in ≥1 gene in key oncogenic pathways: signal transduction, RAS/RAF/MAPK, PI3K/Akt/mTor, and the cell cycle. Taken together, our data suggest that liquid (blood) biopsies identify ARID1A alterations at a frequency similar to that found in primary tumor material. Furthermore, co-alterations in key pathways, some of which are pharmacologically tractable, occurred more frequently in samples with functional (deleterious) ARID1A alterations than in those without such aberrations, which may inform therapeutic strategies. ARID1A loss-of-function alterations found in ~6% of solid tumor tissue samples [The AT-rich interaction domain 1A (ARID1A) protein is the DNA-binding subunit in SWItch/Sucrose Non-Fermentable (SWI/SNF) chromatin remodeling complexes , with AR samples .ARID1A mutations in oncology.The SWI/SNF chromatin remodeling complex controls transcription by way of an enzyme-assisted process that enables interaction with DNA by remodeling nucleosome conformation. This transcriptional regulation, combined with a high frequency of loss-of-function mutations in human cancers, points to a fundamental role of involved genes as tumor suppressors ,4. TheseARID1A impacts anti-tumor immunity and may influence responses to multiple therapies. ARID1A alterations interact with the mismatch repair protein MSH2 and, therefore, attenuate mismatch repair [ARID1A alterations predict better outcomes after immune checkpoint blockade in pan-cancer analysis, independent of microsatellite instability or tumor mutational burden [ARID1A alterations predicted better outcomes of anti-PD-(L)1 monotherapy [ARID1A has also been associated with impaired DNA damage repair, and, in colorectal cancer, ARID1A was enriched in patients who developed resistance to an anti-EGFR monoclonal antibody, suggesting it may play a role in resistance in this setting [Recent data indicate that h repair . Furtherl burden . In the otherapy . ARID1A  setting ,9.ARID1A gene alterations have been conducted using tissue-based sequencing. Liquid biopsies that interrogate cell-free circulating DNA (cfDNA) via next-generation sequencing (NGS) are a non-invasive alternative to tissue biopsies. Liquid biopsy is currently used clinically for therapeutic guidance, especially when tissue testing is challenging [ARID1A alterations, a gene gaining increasing attention for therapeutic targeting in cancer, in a pan-cancer cohort.Most studies of llenging ,12,13,14®, Guardant Health, Redwood City, CA, USA). Patients with any solid tumor cancer type (as reported by the ordering physician on the test order form) tested between November 2016 and August 2019 were included in this analysis. All patients had advanced disease (stage IIIB or higher), as reported by the ordering physician. This research was conducted in accordance with ethics standards and institutional review board approval, which waived the need for informed consent to analyze deidentified data (Advarra IRB Pro00034566/CR00218935).We queried a deidentified database containing results from consecutive patients who underwent clinical testing with a CLIA-accredited, College of American Pathologists-approved, New York State Department of Health-approved cfDNA assay  impact on function). Samples without a functional (deleterious) ARID1A variant were designated as wild-type ARID1A. Only samples with ≥1 cfDNA alteration reported were included in frequency calculations. The median number of alterations per sample was calculated using the total number of reported alterations per sample (including variants of uncertain significance and synonymous variants). Clonality was calculated using the following ratio: ARID1A loss-of-function alteration/maximum somatic allele fraction detected in the sample, with alterations having a ratio ≥ 0.5 defined as clonal.As loss-of-function ARID1A alteration. Sub-analyses were performed in the cohort of patients with NSCLC, as identified by the ordering physician on the test order form. The associations between functional ARID1A and several biomarkers in NSCLC were assessed, with differences in mutation frequencies compared using Fisher’s exact test. All statistical analyses were performed using GraphPad Prism version 9.1.0 for macOS .The frequencies of alterations in specific pathways by patient were compared using Fisher’s exact test, with variants of uncertain significance and synonymous variants excluded for the genes included in each pathway see . PatientARID1A alteration; and 50% of ARID1A alterations detected were clonal. The frequency of ARID1A alterations by cancer type is as follows (N = 517); urothelial (N = 146); bladder (N = 653); gastric/GE junction (N = 1764); cholangiocarcinoma (N = 1537); hepatocellular carcinoma (N = 481); carcinoma of unknown primary (N = 1589); cervical (N = 167); breast (N = 6880); head and neck (N = 582); colorectal (N = 5742); esophageal (N = 379); pancreatic (N = 3095); and lung .)From November 2016 through August 2019, 71,301 patients with advanced solid tumors underwent clinical cfDNA testing; 62,851 (88%) had ≥1 cfDNA alteration; 3137 (5%) had ≥1 deleterious  follows A: endomeARID1A alteration had a greater number of overall alterations per sample compared to those without a functional ARID1A alteration , including variants of unknown significance (VUS) and synonymous variants  (data not shown). Tumors with versus without functional ARID1A alterations also more frequently harbored alterations in at least one gene in many important pathways, including signal transduction, RAS/RAF/MAPK, and the cell cycle . Samples with a functional ll cycle B; anomalARID1A alteration status. We specifically focused on targetable alterations and alterations implicated in resistance or sensitivity to immunotherapy [EGFR driver alterations occurred more frequently in samples without ARID1A versus those with functional ARID1A alterations, while activating KRAS mutations  were seen more frequently in samples bearing functional ARID1A alterations versus those without  [ARID1A alterations occur in ~30–50% of ovarian clear cell carcinomas, ovarian clear cell cancers are a rare subset of ovarian cancer, and only one patient was designated with this pathologic entity in the dataset; hence, the frequency of ARID1A mutations in this histology was not evaluable [ARID1A alterations: ~40% in uterine endometrioid carcinomas and 20–36% in uterine carcinosarcomas, but they are less frequent in endometrial serous carcinoma [ARID1A alterations are derived from the literature, it is not clear why there are some differences in ARID1A alteration frequencies between tissue DNA and blood cfDNA . While certain tumor types did have higher rates of ARID1A alterations in the tissue than we found in the blood, others had lower frequencies: breast, ~5% vs. 6.1%; head and neck, ~4.5% vs. 5.3% (tissue versus blood). It is also plausible that tissue has been analyzed for a wider array of rare cancers that have fewer ARID1A alterations and that that diluted overall tissue numbers. Furthermore, certain tumor types may shed less tumor DNA into the circulation.In our dataset of over 60,000 patients with advanced solid cancers, 5% had cfDNA gnancies ,11,12. F. cfDNA) ,11,12 . Blood biopsies with versus without functional ARID1A alterations also more frequently harbored alterations in ≥1 gene in many important cancer-related pathways, such as signal transduction, RAS/RAF/MAPK, PI3K/Akt/mTor, and the cell cycle  ll cycle B. Importen noted . Co-occuARID1A alterations predicted longer PFS after checkpoint blockade, and this result was independent of microsatellite instability or mutational burden [We did not include tumor mutational burden in the analysis because many of the samples predated the inclusion of tumor mutational burden as a blood-based analysis. In addition, we have previously shown, in multivariate analysis, that l burden .ARID1A status. As an example, oncogenic EGFR driver alterations, which are associated with low efficacy of immune checkpoint therapy, occurred more frequently in samples without versus those with functional (deleterious) ARID1A abnormalities, while activating KRAS mutations  were seen more often in blood samples harboring functional ARID1A (deleterious) alterations versus those without these aberrations. These findings may be notable given recent data suggesting that KRAS mutations may be a positive predictor of immune checkpoint response in NSCLC [ARID1A co-alterations are seen in tumor tissue.A subgroup analysis of NSCLC was also performed because of the many crucial molecular abnormalities identified in this malignancy. Specific driver alterations segregated by in NSCLC ,20. AddiThe ARID1A protein binds specific motifs of DNA as part of an SWI/SNF complex and contributes to the remarkable specificity of these chromatin remodeling complexes. These complexes exploit ATP to alter nucleosome architecture in order to hide or expose regions of DNA as part of the process mediating transcriptional regulation . ThroughARID1A alterations at frequencies similar to those found in tissue. Furthermore, at a patient level, certain co-alterations occur more frequently in samples with functional (deleterious) ARID1A alterations than those without such aberrations, most prominently activation via mutation of the MAPK pathway and PI3k/Akt/mTor signals. Recent studies and ongoing research suggest ARID1A may be targetable via immune checkpoint inhibitors and/or several other agents, such as PARP, EZH2, HDAC, and ATR inhibitors [Taken together, our data from a validated cfDNA assay ,17 suggehibitors ,21,22. Thibitors ,24.


This manuscript describes the structure, management and outcomes of a multi‐institutional clinical and research medical physics residency program  to provide potentially useful information to the centers considering a multi‐institutional approach for their training programs.Data from the program documents and public records was used to describe HMPRP and obtain statistics about participating faculty, enrolled residents, and graduates. Challenges associated with forming and managing a multi‐institutional program and developed solutions for effective coordination between several clinical centers are described.HMPRP was formed in 2009 and was accredited by the Commission on Accreditation of Medical Physics Education Programs (CAMPEP) in 2011. It is a 3‐year therapy program, with a dedicated year of research and the 2 years of clinical training at three academic hospitals. A CAMPEP‐accredited Certificate Program is embedded in HMPRP to allow enrolled residents to complete a formal didactic training in medical physics if necessary. The clinical training covers the material required by CAMPEP. In addition, training in protons, CyberKnife, MR‐linac, and at network locations is included. The clinical training and academic record of the residents is outstanding. All graduates have found employment within clinical medical physics, mostly at large academic centers and graduates had a 100% pass rate at the oral American Board of Radiology exams. On average, three manuscripts per resident are published during residency, and multiple abstracts are presented at conferences.A multi‐institutional medical physics residency program can be successfully formed and managed. With a collaborative administrative structure, the program creates an environment for high‐quality clinical training of the residents and high productivity in research. The main advantage of such program is access to a wide variety of resources. The main challenge is creating a structure for efficient management of multiple resources at different locations. This report may provide valuable information to centers considering starting a multi‐institutional residency program. However, covering a wide range of topics on varied equipment requires extra time and creates a burden on the faculty and residents. Therefore, it is of interest to investigate if forming such a program is viable and beneficial.In this report, we describe our experience creating and managing the Harvard Medical Physics Residency Program (HMPRP).2In this section we describe the history, structure, and governance of HMPRP, highlighting its perceived benefits. In addition, we describe the metrics used to characterize the program's success. We also describe the perceived and encountered challenges and utilized solutions when forming HMPRP.2.1medical residents shared by these three hospitals (Harvard Radiation Oncology Program) has been in existence since 2002, and the goal of our medical physics residency program was to build on experience and follow the success of the medical residency program.HMPRP was formed as a combined program between three academic hospitals located in close geographical proximity to each other. The hospitals have well‐established Radiation Oncology Departments that are associated with a single Medical School and have employed and trained medical physicists over several decades, although no formal training program existed at the time. The discussions on the creation of a medical physics residency program among these academic hospitals initiated in 2007, and the program was formed in 2009. It received full CAMPEP accreditation in 2011 and two subsequent reaccreditations, one in 2015 and again in 2021. In addition, the program was approved by the graduate medical education (GME) committees of the respective hospitals. It is of note that a multi‐institutional program for 2.2The main objective of the program is to provide comprehensive training and experience in radiation oncology physics to the enrolled residents and ultimately educate the next generation of medical physicists, researchers, and leaders. With this goal, our program aims to attract outstanding candidates, including those with accredited medical physics graduate degrees as well as those from outside the field. To accommodate candidates who need to take didactic courses to satisfy the CAMPEP course requirement,2.3Ensuring administrative and financial support from all participating institutions. Lack of such support may affect the availability of faculty and the number of hired residents per year.Facilitating frequent and effective communication between members of the program leadership based at different institutions. Although the institutions are close geographically, they are located on different campuses in an urban environment, and commuting makes frequent in‐person communication challenging, requiring a comprehensive multilayered leadership structure.Developing an advanced yet realistic curriculum. Without careful coordination of resources and scheduling of clinical rotations, the training curriculum covering a wide variety of equipment is too intense and unwieldy.Coordination of multiple faculty in the resident training. Without proper coordination, effective communication, and oversight, many participating faculty may create the potential for scheduling conflicts, gaps in curriculum flow, redundancy, and overlap of covered material.Monitoring residents’ progress in a complicated structure involving many faculty and residents residing at different institutions may be especially challenging without well‐organized feedback mechanisms for both the faculty and the residents.The multi‐institutional nature of the program presents unique challenges for its management. The main challenges that were anticipated at the time of the program creation are summarized as follows:In the following sections, we describe several approaches developed in our program to help mitigate the challenges outlined above.2.4As the first step in creating a multi‐institutional program, support from the administration of all three institutions was solicited and received, both from the Department Chairs and Department Administrative Directors. This support is critical to ensure the allocation of faculty time for teaching and access of residents to training resources (treatment machines and equipment). However, financial support of the residents was considered separately. Only two institutions have committed at this time to provide salary to the residents, whereas the third institution provides faculty time allocation and resources only. Therefore, two residents are hired per year in our program, one resident to be supported by each financially contributing institution; however, both residents receive clinical training in all three institutions.To provide continuous operation and a solid oversight of the program, a comprehensive leadership structure with representatives from the three institutions was created, illustrated in Figure 2.4.1A sole Program Director is required to be responsible and accountable for ensuring that the residency program satisfies the CAMPEP standards.2.4.2To provide support and serve as a backup for the Program Director and the Associate Program Directors, an additional person is selected from each of the three institutions. These six individuals form the Program's Executive Committee (EXCOM) that is responsible for the operation, management, and continuous improvement of the training program. EXCOM meets on a monthly basis throughout the year and more frequently at the time of the candidate selection.2.4.3In addition to EXCOM, a Steering Committee  was formed to provide higher level support to the Program. The Steering Committee consists of the Program Director, the two Associate Program Directors, the Chiefs of the Medical Physics Divisions from the three hospitals, two attending physicians (from different institutions), and two additional physicists. As physicians bring a unique and complementary perspective to the committee, the commitment to attend the committee meetings and the residency interviews are important considerations for the candidates for this role. Familiarity with the medical residency management is an additional advantage, but not a requirement. The additional physicists are selected from those who are not directly involved in the management of the residency program on a day‐to‐day basis to help focus on a big picture perspective. Senior residents are invited to provide feedback on behalf of all residents prior to each Steering Committee meeting. The Steering Committee is co‐chaired by the Program Director and one of the Chiefs of the Medical Physics Divisions from a different institution than the Program Director. The Committee meets semi‐annually.2.4.4In 2017, the role of Senior Resident in HMPRP was introduced to provide guidance and leadership at a peer level for all residents enrolled in the program and to help coordinate various activities between residents in different years of enrollment. The initial reason for establishing a formal senior resident role was to provide a mentoring resource for newer residents; however, it was later recognized that this role also provides an opportunity to develop leadership skills. This duty is performed by the two third‐year residents at their respective locations.2.5In the following sections, we describe the multi‐institutional approach to curriculum implementation, the goals for the research year, the schedule and details of clinical rotations, and various approaches to creating the feedback mechanisms. Although more detailed information is available on the program's website2.5.1Each year, EXCOM collects from the faculty multiple clinically relevant projects that have a reasonable chance of substantial completion within one year. These projects are offered to the incoming residents for review. Each resident selects one of the projects and starts their research overseen by a mentor who monitors the progress of the resident throughout the year.One reason for designating the first year for research is that candidates who enter the program without a background in medical physics can take the necessary didactic courses to meet CAMPEP and ABR requirements through the embedded CAMPEP‐accredited Certificate Program. The course schedule in our program is designed to allow a resident to take the courses without violating the CAMPEP requirement to take no more than two courses during the clinical years.2.5.2The main challenge of designing a curriculum with a wide range of material to cover is allocating sufficient time for each module. Running the modules sequentially presented a practical challenge as every module would be too short to allow the residents sufficient opportunities to observe the procedures that are not frequently scheduled. For this reason, the decision was made to run several modules in parallel. The modules that can be successfully covered simultaneously are Treatment Planning, which can be performed mostly during the day, Treatment Equipment and Dosimetry with hands‐on practice after hours, and Radiation Safety that requires multiple observations of procedures performed infrequently . This model was implemented for the rotations in the first clinical year of training. In the second clinical year, the modules are more focused, and we found that it was more productive to run most of these modules sequentially.The second challenge was to find the right duration for each rotation. In the first years of the residency's existence, it was recognized that the residents need more time in the very first rotation to become familiar with the clinic and master the basics. For this reason, the first rotation was extended from 6 to 7 months, and the second rotation was shortened from 6 to 5 months. The modules in the second clinical year are 2–3 months in duration, which we found sufficient.Another challenge was to avoid redundancy when residents rotate between institutions. Based on the feedback from the residents and the results of the oral assessments, the curriculum in the first clinical year is designed to cover same modules in two different institutions with minimal overlap. Thus, a single curriculum is followed, whereas practical tasks are performed on different equipment in different institutions. For example, linac quality assurance (QA) is performed on Varian linacs in Institution 1 and on Elekta linacs in Institution 2, although specific QA topics are discussed in depth at one institution only. To allow for efficient integration of residents in a new clinic, they undergo a one‐week orientation to the clinic at the start of the first clinical year, and when rotating from Institution 1 to Institution 2. In the second clinical year, the modules are shorter and more focused, typically located at a single institution.Allocating time for educational conferences and seminars may also be challenging. In addition to the research, didactic course, and clinical rotation requirements, the residents are expected to attend clinical conferences, seminars, lectures, meetings that are relevant to their training and contribute to their continuing education, and present at journal clubs and departmental physics seminars. Each resident is also required to attend three workshops on ethics or professionalism per year and is expected to present at national and local chapter meetings. As these didactic sessions are an integral part of the resident's training, the attendance requirements as well as formal time allocation for these activities are important.In Table 2.62.6.1The biggest asset of HMPRP is the multi‐institutional faculty, spanning both the clinical and research aspects of medical physics.Clinical faculty: For each training module, a resident is assigned a single physicist mentor who is responsible for all aspects of the assigned module including review of didactic material and providing a resident with hands‐on experience. Although it is not required that a mentor should also be a section chief at their institutions, it is beneficial when they are as they can efficiently incorporate the residents in the group in a structured way and include the residents in routine procedures and the QA schedule. A mentor can invite other members of the department to teach the resident specific tasks, given their expertise in specific areas.Research supervisors: By its multi‐institutional nature, the program invites all faculty from the participating hospitals to mentor the residents and submit research proposals for a direct supervision of residents in their research year. Each year, residents select two projects from different institutions. Although there is a constraint that only one resident can be assigned to each of the two main institutions every year, the residents receive an abundance of projects to select from and residents are typically assigned their top choice.2.6.2Another reason to form a multi‐institutional program is to offer the residents unparalleled training utilizing a wide range of clinical resources. There are two distinct advantages of a multi‐institutional program: (1) It offers the possibility to cover same procedures on different equipment , and (2) it offers the possibility to include training in the modalities available only at one of the institutions, such as proton treatments, CyberKnife, MR‐linac, advanced image‐guided brachytherapy procedures, and adaptive treatments.The list of available resources combined between 3 institutions is presented in Appendix 2.7For HMPRP to be successful, several elements of formal feedback mechanism were developed within the program. They include evaluations of residents by the mentors, evaluations of mentors and the program by the residents, and various meetings and discussions with the mentors in the program.2.7.1Two commercially available web‐based residency management systems  inviting mentors to select EXCOM meetings; (2) creating a clear path of communication between the mentors of the same modules from different institutions; (3) organizing annual mentors’ meetings. Although informal communication is also encouraged, the formal approach to organizing these meetings and discussions ensures appropriate communication flow and work toward specific goals.2.8HMPRP recruits candidates for two positions each year. The main requirements for the prospective candidates are completion of a doctoral degree in physics, medical physics, or a closely related field and strong interest and potential in research, clinical innovation, and leadership. The entrance requirements for HMPRP do not include completion of a CAMPEP‐accredited program as the enrolled residents are able to fulfill all didactic requirements through the CAMPEP‐accredited Certificate Program embedded in HMPRP.To support the efforts of the medical physics community in providing fair opportunities to the candidates and standardize the application process, HMPRP has been participating in MedPhys MatchAlthough challenges still exist with the match process itself,As interest in the residency from the candidates can be used as one of the metrics of success of the program, we routinely collect and analyze statistics on the applicants to our program and the feedback of the finalists. These surveys are conducted after the results of MedPhys Match are released to avoid any potential conflicts of interests.2.9An ultimate measure of success of the residency is the success of its residents and graduates. To characterize the productivity and achievements of the residents, we collected statistics on the number of publications by the residents, the awards that the residents have received, employment and ABR exams passing rate of the graduates. It should be noted that the official exam pass rate is characterized by verifying the board certification status through the ABR website, and available on the program's website.3In this section, we describe the progress of HMPRP over 13 years since its inception and changes that were made along the way. Analysis of the residents’ productivity in the program and their success after the graduation is also presented.3.1Although the general structure of governance of HMPRP did not change since 2009, the individuals serving on the committee did rotate over time. The role of EXCOM proved to be instrumental for continuous operation of the program throughout these changes, and it was especially important when the Program Directors changed or rotated between the institutions (5 times in 13 years). Additional changes to the governance structure involved adjustments to the frequency of the committees meetings. The frequency of EXCOM meetings was reduced from every 3 to every 4 weeks, whereas the frequency of the Steering Committee meetings was changed from annual to semiannual basis. These changes were implemented when the program's day‐to‐day operation reached its stable state. The current structure and the new frequency of the meetings were found optimal for program operations and improvements.3.2The curriculum and schedule of rotations underwent multiple modifications and adjustments, based on the residents’ and mentors’ feedback. Over the years, the main changes involved rearrangement of the rotations in the second clinical year to allow for the most efficient training. When new technologies are introduced to any of the clinics, new modules are developed to allow the residents to receive formal training on current topics. For example, a formal MR‐linac rotation was developed when an MR‐linac was installed at one of our clinics. The order and the duration of these modules has been adjusted to accommodate new topics and will continue to be adjusted due to residents’ feedback, changes in equipment and available procedures, and changes in CAMPEP standards. In addition, an extra treatment planning rotation was added to the second year curriculum to provide some flexibility in the first year curriculum and allow the resident additional time to complete the planning requirements.3.3In all, there are more than 60 Ph.D. and M.S. physics faculty at the three participating institutions. Many of these faculty serve as Clinical or Research mentors to the residents, and in some cases, both. Currently, there are 15 faculty members that are the core members of the program in their capacity and commitment as clinical mentors, as shown in Table On average, 11 research proposals are submitted by faculty members every year for consideration by the incoming residents. The topics of the research projects selected by the residents are listed in Table When 2 research faculty members (directly supervising the residents during the research year) and 15 clinical mentors are included in the calculation, the faculty to resident ratio is 17:6 or 2.8:1.3.4Installation of new equipment and upgrades are common at our institutions. Since 2009, seven new treatment machines were installed  in 2011 and the highest (132) in 2016, Table 6 in 2011Out of 26 admitted residents, 12 (46%) residents entered the program after completing a CAMPEP‐accredited PhD or Certificate Program (3 out of 12 residents have completed our own Certificate Program before entering the residency), whereas 14 (54%) residents needed to take all or some didactic courses to fulfill the CAMPEP course requirements. All of these residents were able to complete the required coursework within our Certificate Program before graduating from the residency.All residents spent their first year working on research projects as summarized in Table As of May 2022, all eligible graduates have passed Part 3 of the ABR exam. Further, based on informal resident feedback and ABR data made available to program directors on request, we estimate that the initial pass rate for the ABR Part 3 exam is approximately 90%. All graduates found employment as medical physicists and 18 out of 19 graduates obtained jobs in major academic centers, see Table 4In this report we describe our experience creating and managing a multi‐institutional clinical and research medical physics residency program. To the best of our knowledge, this is the only multi‐institutional medical physics training program in the United States. The program was built upon a long‐standing strength of several academic hospitals in close geographical proximity to each other with an idea of creating a nourishing environment for training future medical physicists with research and leadership interests.There are multiple advantages to creating such a program. By combining the resources of several hospitals, the residents are offered access to a wide variety of equipment, clinical procedures, and faculty expertise. In addition to providing strong clinical training, this also allows a wide range of research topics to the residents and even the opportunity to pivot during their research should the residents encounter unanticipated barriers. The 3‐year nature of the program allows outstanding candidates without a degree in medical physics to take didactic courses and fulfill CAMPEP course requirements while in residency. In addition, the combined program offers multiple opportunities for collaboration and educational activities, such as seminars and lectures.Due to all of the aforementioned factors, HMPRP has been very successful. It solidified quickly after its formation in 2009 and has received CAMPEP accreditation followed by two successful required reaccreditations at 5‐year intervals. Judging by the number of applicants, HMPRP is positively viewed among prospective residents. The number of applicants has been steady since 2017 and currently averages at around 62. The admitted residents had excellent performance, completing all required clinical training and producing excellent research outcomes, resulting in multiple publications and awards. Although more than half (54%) of the candidates entered the residency without formal CAMPEP degree, the HMPRP residents were able to complete required course work before graduating from residency. The residency also gained a solid reputation among prospective employers. Most of the graduates were hired and are currently employed in large academic centers. Perhaps most importantly, the residents receive solid clinical training combined with research experience as evidenced by the fact that all graduates achieved ABR certification and remain employed at academic centers (one graduate changed fields to join a different but extremely competitive program outside of the field).It is also important to recognize that managing a program with a wide variety of resources and faculty, especially those from different institutions, poses significant logistical challenges.administrative and financial support from different hospitals from the time of formation of the program,a structure with built‐in collaboration and coordination between the institutions,formal curriculum and formal evaluation of the residents by multi‐institutional faculty,comprehensive structure of governance including sole Program Director for overall leadership, Associate Program Directors for direct oversight at respective institutions, EXCOM for program coordination and exchange of information between Director and Associate Directors, and Steering Committee for high‐level oversight,comprehensive feedback mechanism, frequent review of the program, and adjustments as necessary.Based on the progress of our program over 13 years, the following factors are crucial for successful multi‐institutional program coordination and management:There are several important considerations for programs that consider starting a multi‐institutional residency. The first consideration is recognizing that such a program requires much stronger coordination of resources, solid planning, and monitoring that may be needed for a program in a single institution. A comprehensive leadership structure is critical for the program's success. Another consideration is that the program should be structured in a way to allow for frequent adjustments, changes of individual mentors and members of the leadership team as well as changes in available resources. Some level of flexibility in the program's structure and curriculum should be built‐in to allow for the smooth operation of the program when adjustments are necessary. This should be considered when creating a well‐planned and optimized curriculum and schedule of modules. To allow for this flexibility, our program has built‐in an extra treatment planning rotation in the end of the clinical training to allow the residents to catch up with the training in the case of unexpected scheduling rearrangements. If research year is part of a program, it is critical to set the right expectations for both the residents and the research mentors. Frequent communication between the research mentors and the Program Directors should be an important part of the program operation. Finally, a complicated structure of the program creates substantial administrative burden. Appropriate resources need to be allocated at all institutions to provide administrative support and coordination and substantial time should be allocated to the Program Directors and Associate Program Directors not only to lead the program at each individual institution but also for frequent communications among different centers.It also should be recognized that although a 3‐year multi‐institutional program has distinct advantages, it may not be appealing to all residency candidates and should be viewed as one of several options that are available for incoming residents. Although some of the candidates consider an addition of extra year to their training an advantage and an opportunity to get introduced to the medical physics and develop productive research, for others a 2‐year program is more attractive as a faster career track. Some candidates may also prefer to start with a postdoctoral position before entering the residency. This path provides some flexibility of deciding on the next step of the career path after the postdoctoral training, whereas a 3‐year residency program requires a long‐term commitment from the beginning. In turn, the residents enrolled in a 3‐year program have a benefit of being integrated in the residency sooner, building ties with the current residents and mentors and becoming familiar with the clinical aspects of the field through research. In our experience, emphasizing these differences in programs is an important part of the interview to make sure that candidates develop a good understanding of their options and make the right decision about their future career.As our program continues to grow, it will likely face new challenges. The current structure of the program management and operation is designed to provide a solid foundation for addressing future challenges and making the appropriate adjustments to the program. Our experience in forming such program and optimizing its structure and operation may help other residencies to consider if a multi‐institutional program may be the right choice for them.5A multi‐institutional medical physics residency program can be successfully formed and managed. With a collaborative administrative structure, the program creates an environment for high‐quality clinical training of the residents and high productivity in research. The main advantage of this program is access to a wide variety of resources. The main challenge is creating a robust structure for efficient management of multiple resources at different locations. This report may provide valuable information to centers considering starting a multi‐institutional residency program.All authors contributed equally to this article.No conflict of interest.


With a rapidly ageing society, healthy ageing has become a key challenge for older adults. Engagement in physical activity, and particularly walking, is a key strategy that contributes to healthy ageing. The present study aimed to evaluate the efficacy of a group walking program for older adults that incorporates the 5R Shared Leadership Program (5RS), compared to a regular group walking program. By implementing a structure of shared leadership and strengthening peer leaders' identity leadership, 5RS has in other contexts been associated with greater performance and well-being.SD = 6.68), which all participated in a 12-week structured group walking program. Nine of these walking groups (n = 304) were randomly assigned to the intervention condition and received additionally the 5RS program.Our cluster randomised controlled trial included 19 older adult walking groups .We can conclude that by harnessing the capacity of the group and its peer leaders, 5RS constitutes a promising intervention to engage older adults in physical activity.


While fairly important, ‘Partnerships and Agency Supports’ was ranked least feasible (mean = 3.89). On average, clusters rated higher in importance than feasibility. Conclusion: Concept mapping draws from local knowledge, elicits strong engagement, and captured the holistic and client-centred approach of an Indigenous Housing First Model.Background: The lasting impact of colonization contributes to the disproportionate rates of homelessness experienced by Indigenous people in Canada. Methods: This study used participatory mixed methods to evaluate an urban, Indigenous-led Housing First program in Ontario to fill knowledge gaps on wise practices addressing the unique dimensions of Indigenous homelessness. Using concept mapping, staff perspectives were engaged to generate 65 unique statements describing program delivery and their interrelationships using a six-cluster map. Results: ‘Team’s Professional Skills’ and ‘Spiritual Practices’ rated high in importance ( At least 72% of the Indigenous population in Ontario live in urban areas . ResearcPolicies and programs to address homelessness at the provincial and federal level in Canada have shifted dramatically towards the Housing First model in recent years, which provides people experiencing homelessness with immediate access to permanent housing and supports . These cHousing Services  is a housing support program that assists Indigenous men, women, and families experiencing homelessness in finding and maintaining housing. This program was launched by De dwa da dehs nye>s Aboriginal Health Centre (DAHAC) in 2015 and follows a Housing First approach. Housing Services provides street and peer outreach services, cultural supports, and wellness and community resource referrals. Housing Services aims to provide direct access to sustainable, safe and affordable housing for Indigenous community by working with closely with community partners in Hamilton. In March 2022, during the COVID-19 pandemic services moved from DAHAC to the Hamilton Regional Indian CentreThere has been little research focused on describing and evaluating wise practices in Indigenous-led programs that meet the needs of Indigenous people who are experiencing homelessness, as well as a lack of funding for Indigenous-specific services and supports in housing . The goa®). A Research Agreement between MAP, Well Living House and DAHAC was generated to ensure relevance, respect, and representation in our protocols and processes. This ensured every stage of our project was shared by all decision-makers in our project governance. Ethics approval was provided by the DAHAC Board and the Research Ethics Board of St. Michael’s Hospital, Unity Health.This research was nested in a larger study called Walking our Journey: a Collaborative Evaluation of an Indigenous Housing First Program. The main objectives of our larger project were to document the unique Indigenous values and principles of the Housing Services program model and to evaluate their influence on client housing experiences. The evaluation was grounded in local community engagement, upholding First Nations ethical standards such as Ownership, Control, Access and Possession (OCAPAll Housing Services staff members were invited via email to participate in the study. Participants attended three concept mapping activities: (1) brainstorming, (2) sorting and rating, and (3) map interpretation or diagramming at the De dwa da dehs nye>s location in Hamilton. Participants were asked to complete a brief demographic survey before the sorting and rating session began. The survey was used to gather information about the De dwa da dehs nye>s staff participating in the concept mapping sessions.Concept mapping was selected as a research tool that supports local knowledge and establishes a conceptual foundation upon which data measurements and systems can be grounded ,12. ConcA 90-min brainstorming session was conducted by the research team. A facilitator asked participants to verbally provide statements in response to the following focal prompt:“Delivering Housing Services involves the following component or service…”135 statements were generated by the participants which were narrowed down through the statement synthesis process. Four members of the research team met twice to conduct this extensive process to review each statement in detail. Duplicate statements were removed, similar statements were combined and statements that did not answer the focal prompt were removed. The final statement list comprised of 65 statements.A two-hour sorting and rating session was conducted by the research team. The final list of 65 statements derived from the statement synthesis process was given to the participants. The facilitator reminded the participants of the focal prompt (the previous brainstorming activity) and then reviewed the statement synthesis process and the final list of 65 statements. They were then asked to complete two activities. First, participants were asked to work independently to sort the statements into groups (themes) that made sense to them and to name each group they created. Next, participants were asked to rate each group of statements on a Likert scale of 1–5 based on the group’s importance to having a positive Housing Services program experience and the group’s feasibility of implementation into Housing Services. ®—CS Global MAX software which conducted two statistical analyses—multi dimensional scaling and hierarchical cluster analysis—to display the maps in pictorial form for participant analysis in the mapping session. All participant input is measured equally through the multidimensional scaling and hierarchical cluster analysis. Multidimensional scaling combines the data collected in the sorting stage to create a point map. Each point on the map represents one of the statements from the final statement list. The closer the point is to another indicates they were sorted together by the majority of participants. Hierarchical cluster analysis is used to identify the clusters in the map through drawing boundaries around similarly sorted points. Each participant was given a unique, non-identifiable code that linked their data to their demographic information. Participants’ data were entered into the Concept SystemsA two-hour mapping session was conducted by the research team. A point map was shown to the participants first where each point represented one of the final 65 statements. Next, a cluster map was shown to the participants that displayed boundaries around the points to show each cluster’s reflection of how the majority of participants sorted the points into distinct groups during the sorting and rating sessions. The participants were instructed to analyze the cluster map, move any points that did not belong in a cluster into another, and provide a unique label for each cluster. Once the map was finalized, the group was then shown their importance and feasibility cluster rating maps based on how they rated each statement. The research team conducted further data analyses separately using the group specific final cluster and rating maps to create Go Zones and pattern matches. A Go Zone is a bivariate graph of the statement values comparing two variables and is divided into four quadrants based on statements rated above average and statements rated below average. The Go Zone displays areas of agreement and differences between two ratings, participants groups, etc. Pattern matching is a method that produces a ladder graph that compares the average cluster ratings for a single variable by single or multiple groups, incorporating data from the demographic questions. Out of 14 total Housing Services program staff, 13 unique individuals participated in at least one concept mapping activity. This included 12 participants for brainstorming, 11 for sorting and rating, and 9 for the mapping session. Of those in the mapping session, eight participants attended all three sessions and one participant attended one session. During the brainstorming session, participants completed a brief sociodemographic questionnaire. As Housing Services had been established for 4 years, staff employment ranged from 5 months to 4 years, with a mean of 1.9 years. Staff had worked in the homelessness sector and Indigenous organizations for mean 4.7 years and 5.2 years, respectively. Half of the participants identified as Indigenous and the majority were between the ages of 25 and 44. During the map interpretation session, the research team presented a seven-cluster and six-cluster computer-generated map to participants. Through an engaging discussion and review of cluster content, participants reached consensus that a six-cluster map was the best fit for the 65 statements. The stress value of the six-cluster map was 0.31. Stress value is a statistic that indicates the goodness of fit of the concept map. A low stress value indicates a better fit and the 0.31 of the six-cluster final map suggests a good fit. Trochim has noted an acceptable range for a stress value for a concept map to be between 0.205 and 0.365 . The sixParticipants articulated how the Housing Services program model supports clients with their needs in the Fostering Change cluster. The program ensures that clients’ basic needs are met in terms of housing, food, clothing, and crisis support. Once clients are housed, staff can work on strengthening community around the clients to foster change. Examples of statements in this cluster included: ‘working on client goals at their own pace’, ‘staff help clients to develop a toolbox with coping strategies, support and resources’, and ‘staff supporting clients self-image and growth once housed.’This cluster provides a comprehensive overview of the activities and services offered through the program. The statements in this cluster reflect the everyday practices and roles of staff on the Housing Services team. From referrals, to case-planning and special events, the Daily Practices cluster describes the activities performed on a regular, ongoing basis for clients. Statements included: ‘staff provide home healthcare visits’, staff accompany clients to appointments’, ‘program provides housing allotments to clients’, staff addressing food insecurity for clients’, and ‘program providing harm reduction supplies and supports.’ Participants shared how the Housing Services program works differently from mainstream Housing First programs by meeting the specific needs of the Indigenous community. The Program Uniqueness cluster consists of statements that highlight program activities and processes that align with and uphold Indigenous ways of knowing and doing. Examples of statements in this cluster included: ‘During intake, not relying on acuity and focusing on stories’, ‘Re-establishing connection to Indigenous community for clients’, ‘providing health services and education in community settings’, ‘program accepts referrals from all sources, family, community and By-Name list’, and ‘Program offering different housing options .’The statements within the Spiritual Practices cluster describe specific program elements such as access to ceremonial and traditional teachings and protocols. Statements included: ‘Program provides access to traditional culture for clients , ‘program re-established connection to Indigenous community for clients’, ‘Staff provide smudging in clients’ homes’, ‘Program housed within an agency that offers services from waters of life to returning to the spirit world’, and ‘Program housed within organization that has traditional healers.’Participants conceptualized this cluster around the types of relationships that are developed and required within the Housing Services Program. Statements in this cluster referred to relationships within the program itself, within the larger Aboriginal Health Access Centre, and across other agencies and stakeholders such as landlords and Ontario Aboriginal Housing. Partnerships that are built on trust allow for flexibility in response to community needs and have clear boundaries with respect to the roles and responsibilities that are critical to the Housing Services Program. Examples of statements were: ‘Staff build and manage trusting landlord relationships’, ‘Program has support from all levels of DAHAC management to address bureaucratic barriers’, ‘Team lead and senior management understanding and supporting all staff roles’, and ‘Program partners with Ontario Aboriginal Housing for supportive housing.’Participants grouped statements that described the values and priorities of program staff into the Team’s Professional Skills cluster. This included ways in which the staff supports one another and looks after their own wellbeing in addition to centering client needs and expectations within reasonable boundaries. Statements from this cluster included: ‘Staff recognizing and drawing boundaries with clients’, ‘Program consists of a supportive, close and trusting team’, ‘Program’s approach is inclusive of clients’ full identities’, ‘Staff engage in self-care’, ‘Staff self-reflecting on their biases in client relationships’, and ‘Managing and setting client expectations of program at intake.’The Team’s Professional Skills were rated as the most important cluster (mean = 4.75), and the third most feasible group to act on (mean = 4.31). The second most important cluster (mean = 4.73) of Spiritual Practices, as rated by participants, was also rated as the second most realistic cluster to implement (mean = 4.33). Partnerships and Agency Supports were identified as the third most important cluster (mean = 4.56), yet was ranked as the least feasible cluster of statements (mean = 3.89). Program Uniqueness was listed as the fourth important cluster and the second least feasible . Daily Practices were the second least important cluster, and the fourth feasible cluster . Finally, Fostering Change was rated the least important cluster (mean = 4.47), despite being rated as the most feasible cluster (mean = 4.36). As noted above, the ratings across the five clusters were high, however there are differences between the relative ratings of importance and feasibility by cluster to explore in the pattern matches and individual statements. The clusters had a mean rating of 4.57 for importance, and 3.88 for feasibility. p < 0.005). Consistently, all concept clusters were rated with a higher mean for importance than for feasibility. This was most strongly demonstrated by the fostering change cluster, where the average importance mean was ranked the lowest at 4.47, and the average feasibility mean the highest at 4.36. Multiple other clusters did not experience relatively significant changes in ranking from importance to feasibility or relative mean. This included the team’s professional skills and cultural practices clusters. The cluster with the largest change in mean ranking was the partnership and agency supports . When a t-test was run comparing the cluster rankings for importance and feasibility, the means were statistically significant (p < 0.005). While this was rated the third most important cluster, it was rated significantly lower for feasibility. We further explored rating data through pattern matching. This analysis compares the average ratings of the clusters between the two rating questions on a graph. ‘opening services to broader Indigenous community’, ‘program partners with Ontario Aboriginal Housing for supportive housing’ and ‘staff accompanying clients to appointments .’The Go Zone diagram represented in Concept mapping methods were used to elicit the program components and approaches of a unique Indigenous Housing First model in Hamilton, Ontario. Concept mapping aligns with Indigenous community processes and governance as an inclusive, participatory method that facilitates shared decision making and ownership at each stage ,12. PartOf the six clusters on the final map, participants rated the Spiritual Practices and Team’s Professional Skills as both the most important and most feasible compared to the other clusters. Evidence indicates that health and social programs and services in urban contexts that are grounded in Indigenous practices and ways of knowing and doing result in sustainable impacts that improve overall health and wellbeing for Indigenous people ,16,17. HCentral to the roles and responsibilities of staff at Housing Services is the way they work with their clients and honour them as full human beings. The Housing Services program aims to walk alongside their clients on their journey from the street to safe and appropriate housing of their choice. This work is realized through internal, organizational supports, and team building as prioritized by DAHAC. As reported elsewhere, housing program success stems from a foundation that centres around a localized understanding of the Indigenous population, their stories and strengths . As illuSome important limitations must be taken into account in interpreting the findings. Given the relatively small program size, a total of 13 staff members participated in the study. While this represents 93% participation from the team, the sample size for the study was low. As a result, we chose not to do any sub-group comparisons within the sample. This limitation was managed through triangulating these findings with other data sources in the form of key informant interviews and client focus groups in the larger nested study. A larger sample size may have been beneficial in reaching saturation, however concept mapping methods often do not aim for generalizability, and rather focus on learnings to be considered in developing other programs. Concept mapping is a mixed methods approach that provides a structure for multiple voices to be heard and supports community engagement in developing a visual representation of community knowledge and priorities. This method allowed for articulation of what makes the program unique as an Indigenous Housing First model. Through our community-based approach, we were able to achieve strong engagement and buy-in from the participants, generating more trustworthy and reliable results that could influence program learnings. Future research may explore sampling from multiple Indigenous Housing First programs to gain both a larger sample size and for comparisons across various program features. Housing Services is a unique Indigenous housing first model that delivers holistic, client-centred supports and promotes staff wellness and team building in Hamilton, Ontario. It is through a strengths-based, culturally safe and localized approach, that Housing Services can improve health, well-being, and quality of life for Indigenous people.