Self-guided mental health interventions that are disseminated via the Web have the potential to circumvent barriers to treatment and improve public mental health. However, self-guided interventions often fail to attract consumers and suffer from user nonadherence. Uptake of novel interventions could be improved by consulting consumers from the beginning of the development process in order to assess their interest and their preferences. Interventions can then be tailored using this feedback to optimize appeal.The aim of our study was to determine the level of public interest in a new mental health intervention that incorporates elements of self-help and peer counseling and that is disseminated via a Web-based training course; to identify predictors of interest in the program; and to identify consumer preferences for features of Web-based courses and peer support programs.We surveyed consumers via Amazon’s Mechanical Turk to estimate interest in the self-help and peer support program. We assessed associations between demographic and clinical characteristics and interest in the program, and we obtained feedback on desired features of the program.Overall, 63.9% (378/592) of respondents said that they would try the program; interest was lower but still substantial among those who were not willing or able to access traditional mental health services. Female gender, lower income, and openness to using psychotherapy were the most consistent predictors of interest in the program. The majority of respondents, although not all, preferred romantic partners or close friends as peer counselors and would be most likely to access the program if the training course were accessed on a stand-alone website. In general, respondents valued training in active listening skills.In light of the apparent public interest in this program, Web-disseminated self-help and peer support interventions have enormous potential to fill gaps in mental health care. The results of this survey can be used to inform the design of such interventions. In accordance with recommendations that consumer consultation be the first step in developing public health interventions ,25, we cThe specific research questions for this investigation were as follows. Although we had tentative hypotheses for some of these questions, this study should be viewed as exploratory, not confirmatory.Is consumer interest adequate to justify investment in development of the CMH program and interventions like it?A major goal of the survey was to gauge general public desire to participate in a program like CMH to estimate the potential reach of this program. Deciding upon a precise threshold for “adequate” interest would require knowledge of the cost-effectiveness of this program, which does not yet exist. However, we decided a priori that it would unquestionably be worthwhile to pursue the development of CMH if 30% of participants endorsed willingness to try the program. This was a conservatively high bar: even if the survey overestimated the proportion of users by 90%, this would mean about 10 million persons in the United States would try the program.Is consumer interest high enough among those who are not accessing or who do not plan to access traditional mental health care, and how does this group’s level of interest compare with that of people who do access traditional care?Common barriers to seeking mental health help from a professional include structural or practical impediments such as cost, inconvenience, and provider unavailability, as well as attitudinal barriers such as feeling that one’s problem is not severe enough to warrant professional help or wanting to avoid stigma . BecauseWhat user characteristics are associated with interest in the program?Characterizing the potential audience is a key step in tailoring health interventions . IdentifSome research has been conducted on predictors of attitudes toward mental health care or eHealth, but findings have not been consistent, and they may not apply to the nontraditional CMH program because it is intended to have broader appeal than traditional mental health services. Thus, further investigation is needed.On the basis of current literature, one might expect females to be more interested than males -30, peopWhom would prospective users most want to have as a partner?Most existing peer support programs have paired individuals with strangers, but to our knowledge there is no empirical justification for doing so. In fact, pairing users with individuals with whom they are already acquainted may have advantages, such as eliciting more disclosure , making Which peer counseling skills would prospective users want their partners to learn? Do these skills differ from the skills they would want to learn themselves?We also inquired about which counseling skills people wanted to learn most, as well as which counseling skills they want their partner to learn. Delivery of appropriate social support is notoriously fraught, and the support provided is often suboptimal, mismatching the situation or the recipient’s characteristics eg, -44). Per. Per44])How do 6 possible access channels compare in likelihood of use, appeal, trustworthiness, convenience, and ease of use?Finally, we investigated the ideal access channel, offering several options for the Web-based platform and the venues through which users would learn about the program. Respondents ranked 6 options , then rated each channel on attributes that have been shown to predict technology and service adoption: appeal , ease ofAlthough there is evidence that these attributes are important, there is surprisingly little academic research available regarding consumer perspectives on channels of eHealth access . With regard to Web-based platforms, we expected that respondents would report being more likely to use a stand-alone website than a mobile app or social networking site, given that a website can be accessed on a wide variety of devices; the percentage of US adults who own a laptop or desktop computer (73%) is slightly higher than those who own a smartphone  and thoSurvey respondents were drawn from a convenience sample of potential health care consumers: users of Amazon’s Mechanical Turk (MTurk), a work crowdsourcing website where any individual older than 18 years can complete simple tasks, including psychological experiments, for pay . AlthougAccess to the survey was limited to MTurk users with Internet protocol (IP) addresses in the United States. Users with the same IP address were prevented from completing the survey to avoid duplicate entries. We required MTurk users to have at minimum a 95% approval rate and at least 50 prior tasks completed on the MTurk website in order to access the survey.For their data to be included in the analyses, participants need to correctly answer 3 simple comprehension questions after reading a description of the program. Because these questions were extremely straightforward , incorrect responses were indicative of inattention or gross misunderstanding of the description, rendering respondents’ reactions to the program invalid.Because the majority of survey content was unique to this project and therefore had not been validated in prior research, we pilot-tested and refined the survey through cognitive interviewing  to enhanThe survey began with a description of the program accompanied by stick figure illustrations. The description explained that, in the program, 2 people who were already acquainted would take a Web-based course in scientifically supported talking and listening skills, then would meet weekly in person to put the skills to use, and it listed a variety of potential benefits of participating. The complete description appears in Interest in the program was assessed in 3 ways. Respondents indicated intention to try the program on a dichotomous yes or no item (“Would you try the program?”) and a 4-option forced-choice item. Additionally, participants responded to 12 items measuring attitudes toward the program , including 5 reverse-scored items , rated on a 7-point Likert scale with anchors from “strongly agree” to “strongly disagree.” The mean of the Likert-rated scale items was computed to create a composite continuous attitude score. This attitude scale was internally consistent . Finally, we gave respondents the opportunity to provide their email addresses in order to receive more information about the program with the assumption that this, as a behavioral indicator of interest, required more commitment than a verbal claim of hypothetical willingness to try the program.The survey also included items assessing desired features of the program. Participants were asked to rate their interest in learning 11 social support skills and in having an imagined partner learn the same skills. These skills were selected from those that, according to qualitative studies of social support, are frequently delivered by well-intentioned support providers, although they may or may not be perceived as helpful by support recipients -61.appealing to unappealing, trustworthy to untrustworthy, convenient to inconvenient, and, for the technological channels only, easy to use to hard to use.Survey respondents also ranked 5 possible types of people they would prefer to have as a partner, 5 possible channels through which to meet with their partner, and 6 possible ways to access the course. They rated their perceptions of the possible ways to access the course on 4 semantic differentials: Demographic characteristics and information on mental health service use were collected using straightforward, study-specific items. Rather than using total household income in subsequent analyses, we corrected for household size by dividing household income by the square root of the number of people in the household, an adjustment that assumes some economy of scale within the household, such that each additional household member costs the household less than the previous one .Psychological distress was assessed using the Brief Symptom Inventory (BSI) , a 53-itAll surveys were approved by the University of Massachusetts Amherst Institutional Review Board and were carried out in accordance with all applicable regulations. Before consenting, participants were informed about the investigator’s identity; the purpose, length, and risks and benefits of taking part in each survey; and the methods of data storage.We addressed missing data by using the package mice  for the To identify demographic and clinical predictors of interest in the program, we conducted a series of regressions for each of the 3 outcome variables: attitude score (continuous), willingness to try the program (dichotomous), and provision of an email address (dichotomous). In the first step of these exploratory analyses, predictors were entered hierarchically in blocks. This allowed for tests of the incremental predictive effect of a group of related variables; for example, all race or ethnicity dummy codes were entered in a block, enabling a test of whether race or ethnicity significantly improved model fit, which would not have been possible if all variables were entered simultaneously. We expected that some of the predictors entered in the same block would be collinear , but would act as indices of the same construct , and we would interpret the test of whether that block improved model fit as an indicator of whether the overall construct predicted interest in the program. The order of the blocks was based on what Cohen and colleagues  refer toP<.10). We then ran a final simultaneous regression in which we removed any individual predictors that did not approach significance when entered in order in the previous series of regressions (P<.10) in order to obtain estimates of the effect of each variable while controlling for all other relevant variables . Retaining “marginally significant” covariates in the final model  constitutes a more conservative test of the independent predictive ability of each variable, while eliminating those that did not approach significance in earlier models reduces noise and increases parsimony.After conducting these hierarchical regressions with all variables, we then repeated the procedure, omitting any blocks of predictors that did not marginally improve model fit  correctly answered all 3 comprehension questions and were therefore eligible for inclusion. Missing data were relatively rare; all 592 individuals responded to the majority of items such that there were no missing values for any attitude items, mental health and distress items, gender, race, marital status, or education; the maximum number of missing values for any variable was 8 (for income).Demographic, clinical, and service use characteristics of the sample are presented in More than half the respondents  indicated on the dichotomous item that they would try the program. When asked to choose from 4 options, 14.9% (88/592) indicated that they “would sign up now,” 46.5% (275/592) indicated that they “might try it in the future,” 29.2% (173/592) indicated that they “would probably not try it,” and 9.5% (56/592) indicated that they “would never try it.” For the behavioral indicator of interest, approximately one-third of the respondents  volunteered their email addresses in order to request more information about the program. The median score on the continuous attitude scale was 5.1 out of a possible range of 1 to 7 , corresponding to an anchor of “somewhat agree” on positively worded items.21=0.4, P=.51. Of those who said that they would not be willing to use therapy if they had a problem, 51.3% indicated they would try our program, while 69.7% of those who were willing to use therapy would try our program, χ21=18.1, P<.001. A similar pattern emerged with regard to psychiatric medication: 62.8% of those who had never taken psychiatric medication would try the program, and 66.3% of those who had ever been prescribed psychiatric medication would try the program, χ21=0.5, P=.48. Of those who would never consider using medication if needed, 57.8% would try our program, whereas 67.7% of those who would consider using medication would try our program, χ21=5.5, P=.02.To assess whether our program would appeal to those who lacked access to or interest in traditional mental health interventions, we computed the percentages of those who had not used psychotherapy or psychiatric medication but who would try our program, as well as the percentages of those who stated that they would not be willing to use those traditional interventions but who would try our program. Of those who never accessed psychotherapy, 62.5% indicated that they would try the program, compared with 65.5% of those who had used therapy, χIn the first hierarchical linear regression predicting continuous attitude score, the blocks containing race, age, and marital status failed to improve model fit even marginally. Therefore, as planned, these blocks were removed from the subsequent analyses, and the second hierarchical regression included blocks for gender, SES, psychological symptoms, past treatment use, and hypothetical treatment use. At this stage, the following variables significantly predicted more positive attitude toward CMH (at the step in which they were entered): female gender, past use of therapy, and willingness to consider using therapy. Greater psychological symptoms marginally predicted positive attitude, and greater income was marginally associated with worse attitude. Full results of these initial analyses appear in P<.10 were retained and all others were removed . In this analysis, presented in To summarize the significant results from the final models, female gender predicted favorable attitudes and email provision; Hispanic ethnicity predicted intention to try CMH; older age was associated with lower endorsement of willingness to try CMH; lower income predicted favorable attitudes and intention to try CMH; higher psychological distress was associated with email provision; and willingness to use psychotherapy predicted all 3 dependent variables.t tests of the difference in importance between one’s peer learning each skill and learning it oneself.In order to identify the skills that consumers believe would be most valuable to learn in a peer support program, the survey listed counseling skills and asked respondents to rate how important it was to them that their peer learn that skill, as well as how important it was that they themselves learn that skill, on a 1 to 7 Likert scale from “not at all important” to “extremely important.” The most highly prized skills involved simply listening attentively and taking an understanding, nonjudgmental stance. Generally, respondents considered it more important for their peer to learn each skill than themselves. However, this pattern was weaker or even reversed for skills related to intervening to resolve the other person’s distress, for example, by solving problems or comforting the other person. For those “intervention-like” skills, participants wanted to learn to deliver the skills to their peers more than they wanted their peers to learn the skills.To determine the method of access that would reach the most consumers, we provided respondents with a choice of 6 ways to access the peer counseling training course and intervention: through a stand-alone website, through a social networking website such as Facebook, as a mobile “app,” as a program offered through a doctor’s office or other health care provider, as a program offered through one’s workplace or school, or as a program offered through a community center such as a public library or the YMCA (Young Men’s Christian Association). Respondents were asked to indicate the way they would be most likely to access the program by rank-ordering the options. They also rated each option on several 6-point semantic differential scales: appealing-unappealing, trustworthy-untrustworthy, convenient-inconvenient, and easy to use–hard to use.The most popular access choice by far was stand-alone website, with 51.2% (303/592) of respondents ranking it as their most likely option, with doctor’s office and mobile app following see . On the The purpose of this investigation was to assess consumer interest in a Web-based self-help and peer support mental health intervention, to determine demographic and clinical predictors of interest in the intervention, and to evaluate consumer preferences for specific features of Web-disseminated peer support interventions.Respondents expressed fairly high interest in the CMH program: 63.9% verbally communicated that they would try the program, and 32.6% showed behavioral evidence of interest by offering their email addresses to request more information. More than half of respondents who indicated that they would never consider seeking psychotherapy or psychiatric medication were willing to try the CMH program. This proportion was significantly lower than it was among those who were willing to access these traditional mental health services, which indicates that programs like CMH are not a panacea; they cannot reach every person who is “left out” by traditional services. However, it appears that peer counseling still appeals to a substantive portion of that population.Several demographic and clinical characteristics were associated with 3 different indicators of interest in the CMH program: a multi-item measure of the program’s appeal (continuous), endorsement of intention to try the program (dichotomous), and provision of an email address in order to receive information about the program (dichotomous). Female gender, lower income, and openness to using psychotherapy were associated with positive attitude toward CMH while controlling for other variables. Younger age, Hispanic ethnicity, lower income, and openness to using psychotherapy predicted willingness to try the program while controlling for other variables. Female gender, higher symptom distress, and openness to using therapy were associated with provision of an email address while controlling for other variables.We predicted that females would be more interested in the CMH program than males in light of their greater willingness to seek both eHealth and traditional mental health services -30, whicThe association between gender and interest in the program suggests that CMH and other peer support programs do not completely avoid the barriers men face to seeking mental health care. This makes sense when one considers the demands of the male gender role. CMH has the potential to reduce stigma because users do not have to identify as mentally ill; however, it still requires that users seek support from one another and disclose their personal experiences, thoughts, and feelings. Such support-seeking and vulnerability violate cultural scripts of traditional masculinity ,73. HoweThe association between interest in CMH and lower income is particularly intriguing in light of previous research showing that people with lower income have more negative attitudes toward seeking professional psychological help . It mayOlder respondents were less likely to endorse willingness to try the CMH program; however, age did not predict participants’ attitudes toward the program or their likelihood of requesting more information via email. Older age is associated with lower technology adoption , includifamilismo, which features prominently in research on Hispanic cultural psychology  This result requires replication, given that it was not consistent across outcome measures and only 33 respondents selected this ethnic category. Furthermore, there is a great deal of cultural heterogeneity among Hispanic Americans. However, one can speculate that Hispanic respondents’ greater willingness to use the CMH program may be related to the value of ogy . Hispanogy  or by trying to change the discloser’s emotional response . Yet the recipients of such “support” tend to regard it as unhelpful or even disturbing ,59-61. Tprefer may not necessarily correspond with what is effective. Purely “supportive” psychotherapies are not as effective as those that contain more “active” ingredients [On the basis of this literature and the corroborating results of our survey, those who hope to create new peer support interventions should consider incorporating training in attentive, nonjudgmental listening and reflection skills, as well as education about the potential dangers of common “helping” behaviors such as giving reassurance and advice. However, one must recognize that what support seekers redients . If the Selecting from 6 options for learning about and accessing the Web-based training course, the overwhelming majority of respondents indicated that they would be most likely to use the program if it took the form of a stand-alone website. A notable minority indicated that a health care provider’s office or a mobile app would be the ideal point of access. A website and a mobile app were regarded as convenient, and health care providers were regarded as highly trustworthy but inconvenient. These results suggest that a training course is likely to have the greatest reach if offered via a stand-alone website. However, offering a mobile version of the course, or disseminating peer counseling resources through existing health care providers, could expand the population served, given that 11.6% and 14.6% of respondents, respectively, ranked those access options as the most likely way to reach them. Perhaps developers of Web-disseminated self-help or peer support courses could capitalize on the trustworthiness of health care providers by using doctors’ offices as a first point of contact but could increase convenience by enabling users to access the course and meet with peers at any location or on any device of their choosing.The chief limitation of this study was the use of a nonprobability sample. Although diverse, MTurk users are not representative of the population, and they may be somewhat more interested in this program than the general public because of their comfort with using technology.An additional limitation of this study is that the findings regarding interest in the program apply to the specific description of the program used in the survey. Interest may have differed if the program were presented in more detail or with other emphases. Furthermore, Web-disseminated self-help or peer support programs that include different features may engender different levels of consumer interest than the CMH program.why respondents were interested. It would be helpful to know which elements of this Web-based self-help and peer support training drive consumers’ attraction and which elements are neutral or even unappealing. Additionally, although we found some differences in interest among demographic groups, we could only speculate on reasons for the associations between interest and demographic characteristics. Further investigations could probe the underlying causes of these associations in order to inform how such programs could be more responsive to the values and life circumstances of diverse individuals. Finally, it may be especially fruitful to combine these two research threads and examine interactions between demographics and preferences for specific elements of such programs, thus identifying elements that are particularly desirable to certain demographic groups so that interventions can be tailored to their needs.Future research on such programs could expand upon the foundation laid here in a variety of ways. This exploratory study established that interest exists; however, it did not explain The results of this study substantiate the potential for CMH to fill gaps in mental health care. Diverse consumers would be interested in such an intervention, including those who are not already accessing services. Because they minimize stigma and utilize existing social support systems, reciprocal peer support interventions may be especially attractive to some groups who are underserved by professional mental health services.It appears that CMH’s appeal can be enhanced by allowing a variety of options for peer counselors and by teaching active listening skills. It also seems that the course will reach the greatest number of users if accessed via a website, although access through mobile apps or through health care providers’ offices may also be useful options.We hope that the results of these surveys will persuade readers of the potential utility of Web-disseminated self-help and peer support programs and will inform the creation and dissemination of other programs.


To continue the theme of my previous two editorials, I thought I would open a discussion on where we could find some common ground and workable solutions to the problems mentioned therein. In other words, I hope to meddle with the status quo! I trust most of you sense both the importance and urgency for the community to develop a consensus as to how these problems are conceived. To recapitulate:10%−15% of the graduates pursue doctoral degrees; most of the rest elect to compete for a CAMPEP residency program. The primary drawback of choosing medical physics as a career and matriculating in a CAMPEP MS program is that, currently, only about one in four MS graduates successfully compete for a CAMPEP residency slot, which is required for entry into the profession. Also, few MS programs provide free tuition and/or a stipend. This means that the typical MS student who wishes to have a clinical career will need to commit to borrowing up to $40,000 to pay for the CAMPEP MS with only a small (about one in four) chance of entering the profession as a Boarded Professional  Medical Physicist. The cost is similar to other medical professional degree programs, but the difference is students are guaranteed entry into the profession upon successful completion of the program. The question of whether this cost is too high I will leave for another editorial.Upon completion of a CAMPEP Master's degree in medical physics, I submitted this was unfair to the student, and that we would lose many excellent potential colleagues to other professions unless this situation was corrected. It is true that a clinical career does not suit everyone, and some medical physics MS graduates would be more interested in other opportunities. Removing those that elect to earn a PhD and those not interested in a clinical career from the pool of residency competition still means that, at best, fewer than one in three MS graduates will successfully complete a CAMPEP residency and enter the profession.While CAMPEP does have restrictions for the number of residents that may enter an accredited residency program at an institution (based on funding and the number of faculty and staff), there are no limits on the number of students a CAMPEP MS program may accept. Nor does CAMPEP's mandate currently extend to implementing such limits. Consider that increasing the number of residency slots requires both a proportionally increased effort on the part of existing faculty and staff, along with commensurate funding for any additional positions. Conversely, for academic MS programs, especially those that offer limited clinical exposure or experience, there is only a small increment of administrative effort required to accommodate additional students. Additionally, there is no policy disincentive for academic institutions to create new CAMPEP MS programs or expand existing ones. There are financial incentives for these programs to grow in size and number; in some cases additional tuition revenues can be used to compensate faculty for their teaching efforts, as well as provide some support for research activities that may not otherwise be funded.The modern medical school curriculum distributes a breadth of clinical experiences throughout the four‐year program. Medical specialty training is received in the physician's residency program. Medical physics programs mostly separate the classroom (academic MS) from the clinical (CAMPEP residency) experience. Some CAMPEP MS programs are being encouraged to reduce introductory clinical medical physics experience and increase research efforts, assuming all clinical components are now covered during the medical physicist's residency program's specialty (radiation therapy or imaging). Conversely, others are looking to add introductory clinical medical physics experiences to increase their graduates' chances of landing a CAMPEP residency. Unless CAMPEP MS programs add many more documented clinical experiences (requiring significant faculty and staff commitments), it would be highly unlikely CAMPEP would ever consider limiting class sizes for any accredited academic program. While almost every medical and allied health profession specifies limits on the class sizes and residency positions, to date this has not been an issue to consider respecting CAMPEP accreditation for academic programs. So where should such restrictions come from, if anywhere? Is there any alternative? Should our profession just continue to accredit new programs and build even larger programs every year with impunity? As I see it, there is simply not the political will within the universities or the AAPM to oppose the financial incentives of some MS program directors.Some would suggest that this is a supply and demand issue that will stabilize within a few years. Yes, several supply and demand economies govern the medical physics entry process, including competition for academic positions, residency positions, and employment. But is this an easy way to excuse the troubling ethics of asking MS students to borrow money to support institutional research programs (resulting in publications that support faculty promotion and tenure), knowing that the majority of these students will be denied entry to the profession? Some non‐board‐certified medical physicists are being employed as technicians or assistants in the US and Canada, and there may be a trend to eliminate qualified medical physicist positions in favor of these positions. I conclude there may be a conflict of job security interests between the town and gown of the medical physics community.The number of graduate programs seeking accreditation has fallen recently. With the introduction of the ABR requirement, CAMPEP saw an increase in applications of six to seven per year for 2009, 2010, and 2011, but the number dropped to four for 2012 and 2013, and for 2014, to date, CAMPEP has received two applications. Still, four new programs a year is probably six too many for our current supply/demand economy.So we have two issues: 1) creating too many MS physicists for the jobs available , and 2) not being fair to students facing both the potential of substantial debt along with a small chance of entering the profession. Do we really want a two‐tiered profession, like Health Physics, where only a fraction of members hold professional board certification? Is that where we are headed with the current incentives in place?Some would argue this is no different from graduate programs found in the fine arts, social sciences, etc., which students undertake with no guarantee of a job in the field at the end of the program. I believe the situation for medical physics to be conceptually different, as it is not a job but a CAMPEP residency program and entry to the profession that is more likely not to be obtained than otherwise. The fine art and social science program graduates have the degrees that admit them to entry‐level jobs; the unsuccessful CAMPEP MS graduate cannot enter the profession and get a job. The MS graduate may compete for the physics assistant positions, and yes, such a position may pay even more than a corresponding position in the fine arts and social sciences, but that was not the reason the student borrowed the money to enter the program.Medical Physics Residency Consortium: collaborative endeavors to meet the ABR 2014 certification requirements, by Brent C. Parker and colleagues.Please consider reviewing the following article published in a previous JACMP issue, To the Academic Program Director: Does your program immediately (at matriculation) guarantee any CAMPEP Residency Positions to graduates of the Academic Program? If so, to all students, or just to some? If to some, how many residency positions and what was the total number in your graduating academic class?The following questions are included in the required annual report and should be available on the academic program's website: Are residency positions (if any) offered to the student in competition with other students in the same graduating class? If so, how many positions are offered and what is the class size respecting your current graduating class? What are the criteria of selection for those students admitted to the residency program?Could CAMPEP do something to encourage other MS programs to likewise offer a guaranteed residency slot to selected applicants to their MS program? CAMPEP currently requires a lot of information to be posted on their website. Could these information items be offered as well?The statistics available on program graduates are published annually by the SDAMPP on its website. While this does not address the overall problem of overproduction of CAMPEP MS graduates, it would create some level of greater fairness for the students. If a student can obtain a guaranteed for a reserved residency position at (CAMPEP MS Academic Program) matriculation following a successful application, that would be a desirable outcome. I sincerely hope the LSU/MBPCC initiative challenges other schools to follow with similar programs. Schools that offer the residency at the beginning of MS matriculation should be able to compete for the best students, and prospective students should have the right to know where these options exist. At the moment this is rare, probably because graduate programs and residency programs are funded from different sources. Only a small percentage of the accredited graduate programs have strong links with residency programs and few of those are linked financially.If a school chooses to offer one or two guaranteed residencies to their best incoming student(s), the other students would still be able to compete for other CAMPEP residencies, perhaps in the same institution and perhaps in others. Finally, if a CAMPEP academic MS program chooses to wait until the program is 18 months completed before identifying the student(s) who is/are selected for the CAMPEP residency, it would be helpful to have the selection criteria specified on the website. Especially if factors other than GPA are considered in the evaluation, these factors should be specified before the student begins the program. For example, if a student with an alternative physics PhD decides to enroll in a CAMPEP MS program, would that student be preferred for an open residency slot above the top MS student despite having a lower GPA? If that is the case, it seems only fair to share that information up front.An incoming student facing enormous debt should have the maximum information possible. This means: Where can the student find those programs that fund their graduate students and/or guarantee opportunity for a reserved residency position? If the student cannot get such a guarantee, what does he/she need to do to qualify for one of the in‐house residency positions that would be available two years from now? Would this be a problem for CAMPEP to require programs to post such information? Perhaps the answers will support and affirm the dignity of our students while we collectively define the meaning of the MS degree in Medical Physics.I want to thank Brenda Clark for her contribution of insightful thoughts and comments on this editorial while completely exonerating her for its meddling content, which is exclusively my own.


A total of 52 schools participated in the experimental implementation phase of the project P.A.T.H.S. . After completion of the Tier 1 Program (Secondary 1 level), 344 teachers and social workers responded to the Subjective Outcome Evaluation Form (Form B), assessing their views of the program and their own performance. Qualitative data analyses based on the schools' evaluation reports showed that the program implementers had enhanced knowledge and skills, learned to establish instructor-student relationships and cooperate with colleagues, and fostered self-development. The workers also appreciated the program philosophy and values, program design and resources, process of implementation, interaction between instructors and students, and program effectiveness. The findings also revealed that the workers encountered difficulties in the program implementation and they also made suggestions on how the program design, program arrangement, manpower deployment, and support for the program implementation could be improved.


Adolescents with Juvenile Idiopathic Arthritis (JIA) are at risk for physical, emotional, social and role challenges that negatively impact quality of life. Peer mentoring has been shown to improve positive health behaviours in adolescents with chronic disease while simultaneously providing social support. The objectives of this paper are to examine the feasibility and acceptability of an online peer mentoring program (iPeer2Peer Program) for adolescents with JIA.The iPeer2Peer program was examined using a waitlist pilot randomized control trial (RCT). Participants were randomly allocated to the intervention or wait-list control group via a secure, web-based randomization service. Health care providers and investigators were blinded to participant group allocation. Trained peer mentors  were matched to participants  randomized to the intervention group to provide peer support and education for effective self-management of JIA. Participant-mentor pairings connected ten times over 8 weeks using Skype video calls. Primary outcomes focused on implementation (i.e. measures of feasibility and acceptability). Secondary outcomes focused on effectiveness .n = 16, control n = 14). Primary outcomes: One third (32 %) of adolescents approached agreed to participate, completed baseline measures and were randomized. Half of pairings completed ten calls within 8 weeks. Average call length was twice the required amount with call lengths of 44.72 ± 15.76 min. Participants reported satisfaction with the program and all reported that they would recommend it to their peers. Participants’ mean engagement level with the program was 8.53/10 (range = 7–10). Secondary outcomes: Participants who completed the iPeer2Peer Program demonstrated improvements in their perceived ability to manage JIA (p < 0.04), compared to controls. No adverse events were reported.Thirty adolescents  completed the RCT (intervention The iPeer2Peer Program is a promising intervention that improves acceptability of self-management and peer support treatments for adolescents with JIA. By using the Internet to connect mentors to adolescents with JIA it may also improve accessibility to these resources. Findings will be used to adapt the program and refine the methodology for a full-scale RCT.NCT01986400. Registered November 11, 2013.ClinicalTrials.gov Identifier:  Juvenile Idiopathic Arthritis (JIA) is the most common pediatric rheumatic disease with a prevalence of 132 per 100,000 children . AdolescPeer mentoring in health care is an explicit form of peer social support in which a trained peer mentor provides emotional, appraisal, and informational support to another person living with a similar condition . Peer meIn order to meet the informational, physical, emotional and social needs of adolescents with JIA, an online peer mentoring intervention, the iPeer2Peer Program, was developed , 18. TheA waitlist RCT design was used to examine the feasibility, acceptability, and effectiveness of the iPeer2Peer program in adolescents with JIA.Participants were recruited from a rheumatology clinic in one large urban Canadian pediatric tertiary hospital. Adolescents were eligible for participation if they were (a) 12–18 years old, (b) diagnosed with JIA according to the International League of Associations for Rheumatology (ILAR) criteria , (c) ablwww.randomize.net) was used to allocate participants to the trial groups. The CRPC then contacted participants to inform them of their group assignment and instruct them on the procedures to be followed , eligible adolescents who had a scheduled appointment at the rheumatology clinic at the tertiary care hospital were approached to participate by a Clinical Research Project Coordinator (CRPC). If interested, the CRPC provided further information and obtained informed consent. The CRPC obtained baseline data from participants (demographic and disease-related characteristics) and emailed participants online pre-intervention measures. Once these measures were complete, the participants were randomly allocated to the intervention or wait-list control group. A secure, web-based randomization service . The topics of each conversation were not predetermined or dictated by a protocol. Call content was open ended and tailored to each participant’s expressed needs and desires during the calls. However, mentors were trained (see below) in a standardized training protocol to focus the calls on providing social support and encouraging participants to develop and engage in self-management skills, and support the practice of these skills. Peer mentors were compensated $20 per call.All calls were audio-recorded and uploaded to a secure research server. Mentors were trained to flag concerns that needed immediate follow-up by a member of the research team . To ensure safety, a member of the research team reviewed all calls within 48 h. During this review, a log of all topics of conversation in each call was kept in order to determine the content of the iPeer2Peer Program for each participant. Although the goal of the iPeer2Peer program was to train mentors who would be able to provide self-management and social support individualized to the circumstances of each participant, the log was used in order to determine the proportion of calls that discussed various disease-related topics . This log was used as a measure of program adherence and mentor reliability during the mentoring calls.In addition to having a diagnosis of JIA, peer mentors were nominated by their health care team based on maturity, emotional stability, and verbal communication skills. Mentors were then screened by the research team based on the following criteria: 1) 16–25 years old, 2) diagnosed with JIA, 3) self-reported adherence to current treatment plan (minimum 80 % compliance), 4) self-reported successful transfer to an adult care facility, 5) do not currently meet DSM-IV-TR  criteriaPeer mentor training involved both self-directed in home reading and an on-site 2.5 day training session facilitated by a health psychologist and an adult living with JIA who’s occupation involves training young adult peer mentors. In-class training comprised of lectures, active group discussion, case examples, small group activities and role-play activities. All peer mentors received a manual, which included all training materials, additional resources  and reading lists. The training manual provided suggested topics of conversation for mentorship calls , advice on structuring conversations and guides to redirect conversation to self-management topics. Peer mentors also had access to research staff throughout the study and, if needed, mentors were given additional training to help improve mentoring skills. Training was based on a conceptual framework and focused on providing peer mentors with the skills necessary to provide informational, emotional and appraisal support to adolescents . The iPeThe control group received standard care but without the iPeer2Peer Program. Participants in the control group were offered the iPeer2Peer Program after completion of post-control outcome measures. If they chose to enroll in the iPeer2Peer Program, they were asked to complete outcome measures a third time upon completion of the program.Primary outcomes and endpoints of this study focused on implementation of the iPeer2Peer Program as measured by: (a) recruitment and withdrawal rates, (b) adherence with the iPeer2Peer Program , (c) proportion of completed questionnaires , and (d) engagement and satisfaction with the iPeer2Peer Program as measured through a semi-structured phone interview with participants following involvement in the iPeer2Peer Program .Secondary outcomes of this study focused on the effectiveness of the iPeer2Peer program. Given that the focus of this present study was feasibility, the secondary outcome measures were exploratory to examine variances to help determine appropriate outcomes and sample size for future full-scale RCTs. Measures were chosen based on the results of a systematic review of existing peer support interventions in youth with chronic disease . ParticiAdolescent participants  who completed the iPeer2Peer program were invited to complete a 15-min semi-structured telephone interview describing the strengths and weaknesses of the program. A trained research assistant who was not involved in the implementation of the iPeer2Peer program conducted all semi-structured interviews.Means and standard deviations were used to summarize continuous factors and frequencies and percentages were used to summarize categorical factors. The primary and secondary continuous outcomes were compared across experimental and control groups using marginal linear models assuming an exchangeable covariance matrix to account for the repeated measurements of some participants . Outcome measures were modeled onto intervention status, and adjusted for period of observation  and baseline score of the same measure . The semi-structured individual interviews were audio taped, transcribed and analyzed using qualitative content analysis .Thirty adolescent participants  aged 14.3 ± 1.7 years (range = 12–17 years) completed the trial. There were no significant differences in the age of adolescents who chose to participate in the study versus those who declined participation . Two adolescents completed the intervention after completing participation in the control group  agreed and completed consent, while 32.23 % (n = 39) completed baseline measures and were randomized. Of those who agreed to participate, 5.1 % (n = 2) withdrew after completing baseline measures, but prior to beginning the intervention. Time commitment was the stated reason for withdrawing from the program. There was less than 1 % missing data in the study measures. Three adolescents had to decline participation despite interest in the iPeer2Peer Program due to lack of sufficient and reliable Internet access to run Skype at home or at a nearby location . See Fig. Of those participants who were approached, eligible and able to participate, 44.63 % (n = 22). Fifty-five percent (n = 12) of participants completed all 10 calls, while the remaining completed, on average, 7.58 calls ± 3.05 . Of the 12 participants who completed 10 calls, 58 % of them were able to complete the program within the requested 2 months (60 days). Mean program length was 80.79 ± 53.98 days (range = 1–210 days). Of the participants who had a minimum of two calls (n = 21), pairings had video calls every 10.87 ± 5.52 days. The vast majority (93.4 %) of calls adhered to minimal call length of 20 min with average call lengths twice that amount . Of those participants who did not complete 10 calls, 94.74 % of their calls were adherent to call length with a mean of 38.53 ± 13.78 min long (range = 17.67–72.48 min). The most common reason for rescheduling mentorship calls were tests, assignments, or non-JIA related sickness in either participant or mentor.Data from all participants in the intervention group who completed a minimum of one call were included in this analysis .Call log data demonstrated that participant-mentor pairings spoke in every call about issues related to JIA but also often spoke about issues related to their life in general. The most common topics of conversation included lifestyle management , information about JIA and issues around medications. Notably, 37.5 % of calls involved conversations related to concerns for the future, whether related to education, occupation or relationships. Approximately 12.5 % of calls involved a structured goal-setting and action-planning task . See Fig. n = 17, one participant did not complete interview due to scheduling difficulties), participants reported mean engagement levels of 8.53 out of 10 . All participants reported satisfaction with their involvement in the iPeer2Peer program and all stated that they would recommend the program to another youth living with JIA. Participants most enjoyed a) meeting someone with JIA who they could relate to, b) meeting someone older who has already experienced what they are going through (both JIA-related and non-JIA related), c) having someone to talk to, and d) getting information about JIA. See Table During post-iPeer2Peer program telephone interviews of adolescents who were matched to a mentor . There were no significant differences between groups in ratings of pain, self-efficacy, or any domains of HRQL at study completion. See Table Marginal models were computed to examine group differences on each secondary outcome including pain, self-efficacy, HRQL and self-management. There were no significant group differences on secondary outcome measures at baseline. After controlling for baseline self-management score, adolescents in the intervention group had higher self-management scores after the iPeer2Peer program compared to those in the control group . This suggests the iPeer2Peer Program may not be appropriate in its current form for all youth with JIA but instead a specific sub-sample of adolescents who are in need of individualized social support . The iPeer2Peer Program would benefit from increased flexibility in the number of calls and the length of the program in order to increase acceptability to larger proportions of adolescent JIA populations. Adolescents sought support for both JIA-related and non-JIA-related issues from their mentors. Secondary outcome analysis indicated significant improvements in adolescents’ perceived ability to manage JIA after participating in the iPeer2Peer Program.The findings of this pilot study highlight the need for flexibility and individualization of the iPeer2Peer Program. Only 50 % of participants were able to complete ten calls within 8 weeks as suggested. However, call length was consistently twice as long as requested by the study parameters and adolescents reported enjoying the program. Moreover, there were no differences in call length between participants who completed all 10 calls and those who did not. Perhaps deviations from the suggested call schedule in the iPeer2Peer Program  is more reflective of the need for flexible individualized peer mentoring program as mentees have differing mentoring needs and desires. This is in keeping with the findings of our systematic review of peer support interventions for youth with chronic disease . Peer suThe call content of the mentoring calls varied across both JIA-related issues and general life issues. For example, adolescents sought support for transition to adult health care, and also for transition to post-secondary education. Adolescents shared many aspects of their life, not only JIA related concerns and issues. This finding is in contrast to adolescents living with chronic pain who completed the iPeer2Peer Program who focused mostly on pain-related topics . In compParticipants enrolled in the iPeer2Peer Program were mostly female. Although JIA clinical populations tend to be prominently female, the number of females recruited was over and above what would be expected based on clinical referrals or prevalence. This might be indicative of a gender difference in interest in the iPeer2Peer Program. The male participants who were enrolled in the program completed fewer than the 10 calls suggested. Male call content also differed from female call content as males tended to be factual and many conversations were in the form of questions and answers related to JIA disease information, medications, procedures and experiences. Male adolescents may prefer less intensive peer mentoring interventions or interventions that are geared towards having specific questions answered as opposed to personal sharing, which is typically uncharacteristic of male adolescent peer relationships . Future The iPeer2Peer Program is unique in the use of online Skype video calls to connect adolescents to their peer mentors. Research in adult mentorship for vulnerable and underprivileged youth via email alone found that deep connections between youth and mentors were rare . ResearcResults of this pilot study must be interpreted in light of several limitations. Despite favorable findings, sample size in this study was small, secondary analyses were underpowered, and multiple testing corrections were not applied thus significant p-values should be reviewed with caution. The limited sample size also prevented any examinations of outcomes by cultural or socio-economic status as well as mentor quality to account for differences between mentors. Future full scale RCTs with adequate sample sizes could address these limitations. Moreover, recruitment was limited to one tertiary care pediatric hospital thus limiting the generalizability of the results. The sample was also mostly female and mean disease activity ratings were low suggesting some adolescents may not have had active disease. This may, in part, be reflective of Research Ethics Board (REB) protections put in place by the hospital that prevents patients from being approached by numerous studies such that not all eligible participants were approached by our research team . Nevertheless, more work is needed to determine whether gender based and disease based  differences exist and how best to adapt the program for all youth with JIA. The REB at the tertiary care hospital also stipulates that a member of the health care team must first approach potential participants before a research assistant can introduce the study. This precaution may have resulted in potential participants being labeled by the health care team as ineligible for reasons such as personality , inactive JIA, or patient transitioning to a community clinic. This may have inadvertently inflated our number of ‘ineligible’ participants. Call log data did not take into account the length of time participant-mentor pairings spoke on each specific topic. Future work would benefit from detailed analysis of call log data. Lastly, this pilot study did not incorporate a cost-benefit analysis in order to determine whether peer mentoring is cost effective. The cost-benefit analysis would need to consider not only the mentor time commitment but also the staff requirements with respects to ongoing day-to-day management of the iPeer2Peer Program .In conclusion, the iPeer2Peer Program is a promising peer mentoring program for adolescents with JIA. Adolescents who completed the iPeer2Peer Program demonstrated significant improvements in self-management skills compared to controls. Adaptations to the iPeer2Peer Program to increase flexibility  as well as additions to the peer mentor training  are necessary to increase acceptability to larger proportions of adolescents with JIA. Qualitative work is also needed in order to determine necessary modifications to increase male adolescents’ interest in the iPeer2Peer Program. An RCT with adequate sample size is required to determine overall effectiveness and potential healthcare cost savings of the iPeer2Peer Program.


Emergency medicine (EM) is in different stages of development around the world. Colombia has made significant strides in EM development in the last two decades and recognized it as a medical specialty in 2005. The country now has seven EM residency programs: three in the capital city of Bogotá, two in Medellin, one in Manizales, and one in Cali. The seven residency programs are in different stages of maturity, with the oldest founded 20 years ago and two founded in the last two years. The objective of this study was to characterize these seven residency programs.We conducted semi-structured interviews with faculty and residents from all the existing programs in 2013–2016. Topics included program characteristics and curricula.Colombian EM residencies are three-year programs, with the exception of one four-year program. Programs accept 3–10 applicants yearly. Only one program has free tuition and the rest charge tuition. The number of EM faculty ranges from 2–15. EM rotation requirements range from 11–33% of total clinical time. One program does not have a pediatric rotation. The other programs require 1–2 months of pediatrics or pediatric EM. Critical care requirements range from 4–7 months. Other common rotations include anesthesia, general surgery, internal medicine, obstetrics, gynecology, orthopedics, ophthalmology, radiology, toxicology, psychiatry, neurology, cardiology, pulmonology, and trauma. All programs offer 4–6 hours of protected didactic time each week. Some programs require Advanced Cardiac Life Support, Pediatric Advanced Life Support and Advanced Trauma Life Support, with some programs providing these trainings in-house or subsidizing the cost. Most programs require one research project for graduation. Resident evaluations consist of written tests and oral exams several times per year. Point-of-care ultrasound training is provided in four of the seven programs.As emergency medicine continues to develop in Colombia, more residency programs are expected to emerge. Faculty development and sustainability of academic pursuits will be critically important. In the long term, the specialty will need to move toward certifying board exams and professional development through a national EM organization to promote standardization across programs. Colombia is a country of 47 million people located in the northwest corner of South America. The largest cities are Bogotá (pop 8.7 million), Medellin (pop 3.5 million), and Cali (pop 2.4 million) .1 Despit2Ley 100 [Law 100] of 1993 aimed to provide universal health insurance coverage. Although the level of health insurance coverage is high, access to healthcare varies greatly across geography, from small clinics with limited supplies and often staffed only by recent medical school graduates to tertiary hospitals in large cities, some with technology and resources like those of hospitals in developed nations.A new constitution in 1991 established healthcare as a fundamental right, and internado, is similar in structure and responsibility to that of the first year of residency in the United States. After completing a year of service in an underserved area, graduates may apply to a residency, work independently as general practitioners in primary care, or work under the supervision of a specialist.In Colombia students apply to medical school immediately after high school.What do we already know about this issue?Few countries have described their residency programs in the literature, and there is no universal standard curriculum for emergency medicine residencies.What was the research question?What is the current state of emergency medicine residency programs in Colombia and what are their characteristics?What was the major finding of the study?The seven emergency medicine residency programs in Colombia have different training approaches.How does this improve population health?In comparing EM residency programs, this study promotes the standardization of residency curricula with the potential to impact emergency care in Colombia and other countries.There is increasing demand for emergency medicine (EM)-trained providers in Colombia.Christian Arbelaez conducted site visits and semi-structured interviews with representatives from each of the seven EM residencies in Colombia between July 2013 and July 2016. Respondents included program directors, faculty, and residents. Phone calls and email communications were also used for follow-up questions. Topics covered in the interviews included the history of each program, number of residents, curricula, clinical sites, faculty, and challenges faced. Interviews were performed in Spanish, recorded, transcribed, and translated to English. We analyzed responses to create descriptions of each program and identify common themes. We also reviewed program websites and documents detailing curricula provided by the programs. This survey was granted exemption through the Partners Healthcare Institutional Review Board.Perspectiva en Urgencias, from the Asociación Colombiana de Especialistas de Emergencias, and Urgentia from Javeriana. The Asociación Colombiana de Especialistas de Emergencias (ACEM) is the largest EM organization in the country, representing over 200 emergency physicians and EM residents.Of the seven EM residency programs, three are in Bogotá, two in Medellin, one in Manizales, and one in Cali.Applicants come mostly from the cities where the programs are located, but also from many other regions of the country. Similar to the application process for residencies in other specialties, EM residency applications are not centralized. The first step for all physicians applying to an EM residency consists of a general medicine written exam created by each residency program. Then each program has different processes to select candidates. CES conducts interviews with emphasis on clinical knowledge and leadership skills. Rosario has applicants shadow in the ED for half a day and discuss patient management with preceptors and also interview with psychiatry, EM faculty, the chief EM resident, the chief of EM, and an invited professor. Antioquia requires an English-language test and does not require interviews. Javeriana invites applicants with the best scores for a clinical simulation test, an oral exam and interviews with faculty and the program director. FUCS invites the applicants with the top five test scores for interviews with the program director, the assistant coordinator, a psychologist and human resources staff. Caldas and ICESI require interviews. Programs receive between 30 and 60 applications every year. Some programs accept new residents on a yearly basis: CES accepts six, Antioquia four, Caldas three, and ICESI four. The remaining programs accept new residents every six months: Rosario accepts five, Javeriana four, and FUCS three . The graCrédito Ley 100 is a “forgivable” loan awarded to a limited number of residents through ICETEX, a government financial institution that provides financial aid for post-secondary education.5Most residency programs in Colombia charge tuition. Antioquia is affiliated with a public university that does not charge tuition. Further, it provides a stipend of approximately $650 USD  per semester. The rest of the programs do not provide a stipend and charge approximately $3,400 – $4,500 USD  per semester . CréditoThe curricula of the different programs are loosely based on those of U.S. EM residencies but with significant variations .6–1313At the time of this survey, the older programs, CES and Rosario, had the most EM faculty. CES had 15, and all EM rotations were done with EM faculty supervision. Rosario had 25 EM faculty, Javeriana nine EM faculty, FUCS two EM-trained faculty, and Antioquia had one full time and two part-time EM-trained faculty . All proAll Colombian programs cited point-of-care ultrasound (POCUS) as one of the weaknesses in their curricula in a 2014 study.Consejo Nacional de Acreditación de Colombia (CNA), or National Accreditation Council. The accreditation system begins with a self-assessment, with the purpose of formulating actions to improve the quality of the program. This self-assessment is followed by an external evaluation by peer review, referred to as Evaluación por Pares, which evaluates the accuracy of the self-assessment and results in a submitted report to the CNA. Accreditation is granted after a final review based on the self-evaluation and peer review. This is valid for a period of 4–10 years depending on the quality of the program.15The Ministry of Education plays an active role in ensuring the quality of postgraduate programs, including EM residencies, through the Most EM-residency graduates are finding jobs in community hospitals or in academic centers, usually in critical care areas within the ED. Since the specialty of EM is relatively young, these graduates are often the first EM-trained physicians and are often in charge of establishing the specialty in those institutions. Fellowship training in critical care is available in some programs. Fellowships such as ultrasound, EMS, pediatric EM or disaster medicine are not currently available. Many EM residency graduates go on to work in intensive care units rather than EDs, given better financial incentives.As the oldest program in the country with more than 20 years of experience, all EM rotations at CES are done with EM-trained faculty. The EM specialty and residency program are well established. Nonetheless, the program feels it needs to continue promoting itself within the university and hospitals to achieve the same level of recognition as older specialties.Rosario is the only four-year residency in the country and has 40 residents, the largest number in the country. Its seven clinical sites add expertise in trauma, toxicology, prehospital care, disaster preparedness, and cardiology. The program is working towards establishing a stronger academic connection with the university, since residents and faculty have felt disconnected from the larger university community.Antioquia is the only program in the country that offers free tuition. It has a strong emphasis on local epidemiology. Being part of the university faculty has significant financial benefits. Over the years the program has had to overcome political and administrative barriers within the hospitals and in relation to other specialties.Javeriana has a strong emphasis on academic production and has its own academic journal. A weakness initially identified by trainees was the lack of ultrasound training. However, ultrasound training is now provided. Another weakness is relatively low exposure to trauma patients locally. However, at the time of this study, there was a plan to have residents do a trauma rotation at Hospital Universitario del Valle in Cali, which has large numbers of trauma.FUCS has a strong emphasis on critical care and the larger university has a strong tradition of academic training with one of its hospitals having had the first residencies in any specialty in the country more than 120 years ago. Two weakness identified by the program are its lack of ultrasound training and absence of a formal university affiliation for program faculty.These two programs are new with a small faculty but have dynamic leaders as program directors. They are both located in urban settings and are affiliated with strong medical schools that offer excellent clinical training.Colombia is a land of contrasts. Its large cities have hospitals that rival those in the developed world, while healthcare in rural areas is more akin to that of a developing country with minimal infrastructure. EM professionals not only can improve the care Colombians receive in the ED but also bring expertise to strengthen prehospital and disaster care, both in urban and rural underserved areas. While Colombia’s Constitution of 1991 established healthcare as a right and Law 100 expanded health insurance coverage to cover greater than 90% of the population, access, quality and funding continue to be a challenge. Deficiencies in the system have led to ED crowding around the country. Most emergency care in Colombia is still being provided by non-residency trained providers. Emergency care requires expertise in the recognition and timely treatment of life-threatening conditions as well as the prioritization of resources for the flow of the ED. Now more than ever EM-trained physicians can help maximize ED resources to optimize throughput and clinical outcomes.Colombia has made important strides in the development of EM with its seven residency programs and official recognition of EM as a specialty. Curricula are similar to those of residencies in the U.S., though with important variation. For example, ACGME requires 60% of clinical time to be spent in the ED under the supervision of EM-trained faculty.Most EM residency graduates go on to work in community hospitals with most becoming the first EM specialist at their workplaces. Many go on to work in intensive care units given their extensive training in critical care and better compensation. As EM matures, the specialty must advocate for better compensation and working conditions in order to attract emergency physicians to EDs. As EM continues to develop in Colombia, more residency programs are expected to emerge along with a growing number of EM faculty. Standardization of training across programs, certifying board exams, strengthening of professional societies, and academic development will be important steps to further advance the specialty.A limitation for this study is its data collection over a three-year span, which with the rapid evolution of the residency programs may have resulted in some of the results not being up to date at the time of publication. Co-authors of the study are part of the different residency programs, which could have introduced bias. However, this is balanced by the fact that each residency is represented by a co-author in the study.Colombia has made great strides in the development of EM. EM continues to gain traction as a specialty and the number of residencies will likely continue to grow. There are seven EM residencies at this time with different curricula that will serve as models for future programs.


Bovine udder health in Switzerland is of a relatively high level. However, antimicrobial usage (AMU) seems high in comparison to other European countries also. A new udder health and AMU improvement program could improve this situation but it is uncertain whether there is support from the field. This study aimed to quantify preferences of dairy farmers and veterinarians for the start and design characteristics of a new national udder health and AMU improvement program in Switzerland. A total of 478 dairy farmers and 98 veterinarians completed an online questionnaire. Questions on their demographics and their mindset toward AMU were complemented with an adaptive choice-based conjoint interview, a novel conjoint analysis technique to quantify preferences of respondents for characteristics of a product for which multiple trade-off decisions must be made . The conjoint analysis was followed by a multivariate multiple regression analysis to identify groups of respondents with different program design preferences. Logistic regression models were used to associate covariates with respondents’ preference to start a new udder health and AMU improvement program. Most farmers (55%) and veterinarians (62%) were in favor of starting a new voluntary udder health and AMU improvement program, but the program design preferences agreed moderately between the two stakeholder groups. Farmers preferred an udder health and AMU improvement program that did not contain a penalty system for high AMU, was voluntary for all dairy herds, and aimed to simultaneously improve udder health and reduce AMU. Veterinarians preferred a program that had the veterinary organization and the government taking the lead in program design decision making, did not contain a penalty system for high AMU, and aimed to simultaneously improve udder health and reduce AMU. Differences between groups of farmers and veterinarians concerning their start preference were identified. Also, the magnitude of various program design preferences changed for farmers with different opinions toward AMU. The information obtained from this study may support the decision-making process and the communication to the field afterward, when discussing national strategies to improve udder health and AMU in Switzerland. Bovine mastitis negatively affects milk quality , 2, animBovine udder health in Switzerland is, from an international perspective, of a relative high level. Bulk milk and composite somatic cell counts are low and incidence rates of clinical mastitis are reported to be below estimates from other countries . The milA priori investigating these preferences offers a mechanism for shared decision making , its implementation (who should execute it?), and its financing (who should pay for it?). Designing a new animal health program is a complex task in which various stakeholders may have different program design preferences. n making , providen making . Incorpon making . This isn making , 24. It The aim of this study was to elicit preferences of Swiss dairy farmers and veterinarians for the start and design characteristics of a new national udder health and intramammary AMU improvement program. It was also investigated whether groups of farmers and veterinarians with different start and design preferences could be identified.Two questionnaires were conducted in this cross-sectional study; one aiming at farmers and one at veterinarians. The sampling frame for the farmer questionnaire consisted of 19,042 dairy farmers who were producing marketed milk, had ≥11 cows, and an email address deposited at the national milk quality payment organization in May 2014 . Seasonal communal pasture holdings and herds located in the Italian-speaking Canton of Ticino were excluded. Furthermore, 1,296 dairy herds randomly selected from the same sampling frame that were requested to participate in a parallel survey were excluded from the current study to avoid farmers receiving 2 questionnaires shortly after one another. The sampling frame for the veterinarian questionnaire consisted of all 438 Swiss cattle veterinarians that were registered with the Swiss Society for Ruminant Health .Since no prior information was available on the preference of farmers and veterinarians to start a new dairy health program, sample size calculations were estimated for the proportion with the largest variance . A higher level of precision was accepted for veterinarians (10%) than for farmers (5%) because lower levels resulted in sampling fractions that were deemed unachievable. The sample size needed with 95% confidence in the sample frames of 19,042 dairy herds and 438 cattle veterinarians was 385 and 79, respectively, using Winepiscope 2.0. Given an expected response rate of 30% , 26, 1,2Elicitation of farmers’ and veterinarians’ preferences toward udder health and AMU improvement program characteristics was investigated using the computer-based ACBC analysis method  within SIn conjoint analysis, products are characterized by attributes and levels . Following conjoint analysis terminology, attributes and levels for the “product” udder health and AMU improvement program were defined as program characteristics that decision makers have to consider. Program attributes and levels were initially defined based on a literature review and the authors’ experience with national mastitis control programs. A draft list of program attributes and levels was then discussed with five experts involved in dairy cattle disease control in Switzerland, including two experts from the Federal Food Safety and Veterinary Office, two researchers from the Faculty of Veterinary Medicine, University of Bern, and one experienced practicing cattle veterinarian. The list of program attributes and levels was finalized after consulting an expert from Sawtooth Software to optimize methodological and statistical efficiency.The two questionnaires consisted of four parts. The first part investigated the demography of respondents, their opinion on AMU in Switzerland Tables  and 2, aQuestionnaires were being conducted in German and French. Translation from German to French was conducted by a professional translator with a background in agriculture. Farmers received a personalized email explaining the purpose of the study and an individualized link to the online questionnaire in January 2015. Cattle veterinarians were contacted by email by the Swiss Society for Ruminant Health with a description of the project and a general link to the online questionnaire the same day. Reminder emails were sent after 3 and 5 weeks. To increase response rates, vouchers for an agricultural and a veterinary wholesale were provided to 110 randomly selected farmers and 50 veterinarians. Participants were also informed that they would receive a summary of the project’s results at the end of the study.The government, scientists, and the dairy industry would like to improve antimicrobial usage and udder health in Swiss dairy herds. A new voluntary program that would support farmers with this should be started. Would you be in favor of such a program?” Answers: “Yes”, “I do not know,” and “No”). Covariates potentially associated with the start preference of farmers  were retained for further investigation. When covariate pairs had an absolute correlation >0.50, the biological more meaningful covariate was selected to avoid multicollinearity. Multivariable statistical modeling subsequently consisted of a stepwise backward elimination process until all covariates were significantly (P < 0.05) associated with the preference of farmers to start a new udder health and AMU improvement program or considered a confounder. Confounding was assumed to occur when effect estimates changed >25% upon exclusion of a covariate from the model. Interaction terms were not evaluated.Preference of farmers and veterinarians to start a new voluntary udder health and AMU improvement program and their associations with potential covariates were evaluated first. Farmers’ and veterinarians’ start preference was assessed by a single question with three possible outcomes (“rs Table  were then = 9) resulted in quasicomplete separation for several covariates. The outcome categories “No” and “I do not know” were therefore merged and start preference was modeled as a binary outcome variable using binary logistic regression models.A similar model approach was used to associate covariates with the preference of veterinarians to start a new udder health and AMU improvement program. However, a low number of observations in the “No” category  of each attribute (iA) for each respondent was subsequently derived according to:iA represents the difference between the highest and lowest part-worth utility values of attribute i, with n being the number of attributes. The relative preference represents the preference each respondent has for this attribute. Preferred program-levels result in larger part-worth utility values and therefore also in a higher relative preference. Sum of the relative preference of all attributes is 100% for each respondent. Mean relative preference values were calculated for each attribute to elicit their relevance in the farmer and veterinarian population.The relative preference  and 1.0 for a perfect model .The preference of farmers and veterinarians for design characteristics of a new udder health and AMU improvement program was investigated next. First, it was assessed whether farmers and veterinarians preferred certain design attributes more than others. The sum of relative preference of all attributes (eight for farmers and seven for veterinarians) for each respondent equals 100%, implying that they would be equally preferred if the relative preference of each attribute would be 12.5 or 14.3% for farmers and veterinarians, respectively. Deviation from equal preference was determined using the Wilcoxon signed rank test. The most preferred attributes were defined as having a significant mean relative preference above the equal preference threshold value. Second, differences in mean standardized part-worth utilities of program attribute levels between farmers and veterinarians were assessed using the Wilcoxon rank sum test. A Bonferroni adjustment was applied to correct for multiple comparisons.Covariates associated with program design preferences were identified in three analytical steps. The first step was to identify a global  association of covariates with the relative preference of the eight (seven for the veterinarians) program attributes simultaneously. The second step elicited the individual  program attributes responsible for rejection of the global null hypothesis. The third and last step was to investigate which levels within identified program attributes were associated with the covariates significant in the previous steps. Statistical modeling was performed separately for farmers and veterinarians.F statistic was used to test the global hypothesis that all regression coefficients are zero across all program attributes for the evaluated covariate. Covariates deemed relevant (P < 0.25) were thereafter offered to a multivariate multiple regression in which a stepwise backward elimination process was conducted to identify all significant (P < 0.05) global associations between covariates and program attributes. Proportion of explained variance of the global model was derived as 1 − Wilks’ lambda, which is the multivariate counterpart of the univariate 2R (2p (Multivariate multiple regression models correct for correlation between multiple outcome variables (one for each program attribute) and multiple comparisons, thereby reducing Type 1 errors . Such muriate R2 . In stepe R2  being sent before respondents filled in the questionnaire was evaluated separately in all models evaluating the start and design preference of farmers and veterinarians.Regression modeling to associate covariates with start and program design preferences was performed using PROC LOGISTIC and PROC GLM in SAS 9.4 . Statistical significance was set at Of 1,300 farmers and 438 cattle veterinarians contacted initially, 478 farmers (36.8%) and 98 veterinarians 22.4%) filled out their respective questionnaires completely and were included in the statistical analysis. Seventy-three farmers were French speaking  and veterinarians  mostly agreed with this statement; 20.7%  and 9.1%  disagreed; and 23.8%  and 28.6%  did not know. These proportions were significantly different  between the two populations with veterinarians favoring the program more.Farmers and veterinarians were offered the following question: “Table Covariates associated with veterinarians’ preference to start a new voluntary udder health and AMU improvement program in the final multivariable logistic regression model are presented in Table Percent certainties of the final hierarchical Bayes models estimating program design preferences of farmers and veterinarians were 46.0 and 49.5%, respectively. Root likelihood of the farmer model was 0.63 and 0.65 for the veterinarian model.Relative preference of program attributes would have been 12.5% if farmers preferred them equally . Farmers therefore preferred the program attributes “Bonus” , “Herd” , and “Aim”  more than the other five attributes , “Bonus” , and “Aim”  more than the other four attributes . Further investigation of the univariate associations identified that farmers’ opinion on AMU was associated with the attributes “Bonus,” “Decision” and “Payment”  between the covariate describing whether veterinary practices were also servicing pig herds and veterinarians’ relative preference of program attributes. However, further investigation of the univariate associations did not reveal any significant relationship when applying a Bonferroni adjustment (data not shown). Associations of this covariate with program attribute levels were therefore not further scrutinized.The final multivariate multiple regression model for veterinarians’ design preferences identified one borderline significant association (P = 0.04) decreased to 49.4% for farmers receiving two reminding emails (late respondents). Such an association was not identified for the veterinarian dataset (P = 0.55). The number of reminders being sent was not globally associated with farmers’ (P = 0.33) or veterinarians’ (P = 0.96) program design preferences either.Farmers’ preference to start a new udder health and AMU improvement program was 64.3% for respondents not receiving an email reminder (early respondents) and significantly  to 20% (farmers) disapproved of this idea. There does seem to be support from the field to initiate a new voluntary udder health and AMU improvement program when the current Swiss strategy to improve AMU and antimicrobial will be extended to dairy herds. It is unclear, however, whether these proportions are high enough to warrant an actual start of a new program. Its acceptance is likely to improve if it is accompanied with a communication campaign promoting its potential benefits . MoreoveResponse rate of veterinarians was lower at 22%, but years of experience and proportion of male respondents were in agreement with a previous survey conducted among Swiss cattle veterinarians . MoreovePreferences of farmers and veterinarians for program design characteristics agreed moderately. Both stakeholder groups preferred a program that aimed to improve udder health and AMU simultaneously and did not include a penalty system for high AMU. These aims are in line with the strategy of the Federal Food Safety and Veterinary Office to intervene on farmers and veterinarians with a high antimicrobial consumption. Moreover, such achievements can potentially be made through the quality payment system existing in Switzerland. Farmers generally receive a bonus for their milk price when their bulk milk somatic cell count is below 100,000 cells/ml. There are no such thresholds on AMU currently. Incorporating such a threshold  as an extra criterion for farmers to receive a financial bonus is expected to result in an improvement on AMU. Previous research has shown that farmers are more sensitive to penalties than to bonuses, as investigated for bulk milk somatic cell counts in the Netherlands . A penalBesides a change in the milk quality payment scheme or another change in legislation, there are also other means to improve both udder health and AMU. This is evident by examples from national mastitis control programs successfully conducted elsewhere –19. UnfoFarmers and veterinarians differed in their preferences concerning other program design characteristics. Farmers preferred a program that is voluntary. That agreed with the preference of veterinarians but this stakeholder group deemed this attribute to be of less importance. Veterinarians, on the other hand, preferred a program that had the veterinary organization and the government taking the lead in the program design decision-making process whereas the farmers preferred the dairy industry to have the lead. However, farmers generally gave a lower relative preference value to this attribute, implying that this attribute was less important to them. It is therefore believed that they would not mutually exclude each other. A voluntary program with the veterinary organization and the government having the lead in the decision-making process would still satisfy the preferences of both stakeholder groups. Other preference differences between both stakeholder groups were also identified. But those concerned again program attributes and levels that were preferred less. Not much opposition from these two stakeholder groups is therefore expected if these aspects are not fully met during the decision-making process. Moreover, incorporating these aspects in the communication of the final program design is expected to take away some of the opposition.Farmers’ mindset toward AMU, as assessed by one single question, was the only covariate associated with farmers’ preference for starting a new udder health and AMU improvement program and for their preferred program design characteristics. None of the demographic variables explained any of the variation in start and program design preferences of farmers. Also, explained variation of the final multivariate multiple regression model was low. It can thus be hypothesized that farmers’ start and program design preferences for a new udder health and AMU improvement program may be more explained by their mindset toward udder health, AMU, or national disease control programs in general than by their demographic characteristics. Further research is needed to scrutinize this underlying sociopsychological construct. Nonetheless, some differences in start and program design characteristics between groups of farmers with various mindsets toward AMU were identified. Farmers had a stronger preference to start a new voluntary udder health and AMU reduction program when stating that AMU was too high in Swiss dairy herds or when they had no opinion on this. Those farmers, an approximate 60% of the population, therefore not only acknowledged the problem of high AMU (or were indifferent) but also supported national strategies to improve it. This included a less strong, but still existing, opposition toward the introduction of a penalty system for high AMU. Current debates in society and other strategies facilitating the recognition of high AMU could further contribute to a less strong opposition of stricter milk quality payment legislation. There were also some subtle, but significant, differences in preferences for sectoral organizations that should have a lead in decision making and that should pay for the new udder health and AMU improvement program between groups of farmers with various mindsets of toward AMU. The identification of such associations adds to the communication to the field after decision makers have discussed program alternatives.For veterinarians, on the other hand, differences in their preference to start a new udder health and AMU improvement program according to their demographics were identified. First, the observation that veterinarians, who are earning ≥10% from their antimicrobial sales from intramammary antimicrobials, are more motivated to start a new udder health and AMU improvement program than veterinarians earning less sounds contradictory at first. An improved on-farm udder health and AMU, resulting from implementing preventive mastitis management measures as advised by a new program, are expected to result in a decreased, rather than an increased, sales of intramammary antimicrobials at the veterinary practice level. However, herd health management is not commonly applied by Swiss cattle veterinarians, and practices selling more intramammary antimicrobials are therefore assumed to have such high sales because they attempt to improve udder health in their dairy herds by treating more  mastitis cases to lower the infectious pressure within the herd , 43. IncAdaptive choice-based conjoint analysis was used to elicit respondents’ preferences for design characteristics of a new udder health and AMU improvement program. ACBC is a novel quantitative methodology in the field of veterinary medicine and animal science. The novel aspect lies in the adaptive nature of the interview in comparison to a standard choice-based conjoint interview . RespondThis study was limited by its cross-sectional design. Preferences of farmers and veterinarians were assessed once but may change over time resulting from discussions in society and actions implemented by governmental bodies, industry, and others. Moreover, this study assessed stakeholders’ preferences for starting a new udder health and AMU improvement program and its design. Stakeholders’ preferences of potential interventions, e.g., the creation of peer study group meetings, financial support for culling mastitic cows, more affordable diagnostics, etc., were not scrutinized. Further research is thus needed to investigate stakeholders’ preferences for the actual implementation of a program. Moreover, it was not the aim of this study to identify the perceived monetary and non-monetary benefits or disadvantages of a new udder health and AMU improvement program. Preferred design characteristics of the new udder health and AMU improvement program may thus differ from the most beneficial or practical design. Nonetheless, the results of this study facilitate discussions among decision makers. It should be noted also that this study investigated the start and design preferences of stakeholders in the Swiss context . Results may therefore be difficult to apply in other countries or regions, except when having a similar dairy industry. This study serves as an example on how to assess stakeholders’ preferences for new national animal health control programs.In conclusion, most farmers and veterinarians enrolled in this survey preferred starting a new voluntary udder health and AMU improvement program in Switzerland. Particularly, they preferred a new program that aims to improve udder health and AMU simultaneously, does not contain a penalty system for high AMU, is voluntary for all dairy herds, and have the veterinary organization and the government taking the lead in the program design decision-making progress. Differences between groups of farmers and veterinarians concerning their start and program design preferences were also identified. The results of this study were not communicated with decision makers, yet they may support the decision-making process and to its communication afterward, when designing a new udder health and AMU improvement program for Switzerland.According to Swiss legislation, no ethical approval was required for this study since no sensitive data were collected. All participants were involved voluntarily, were informed about the research objectives of the study, and gave their consent for participation in the study. All participants were assured anonymity.BB conceived and designed the study, collected and analyzed the data, and drafted the manuscript. All other authors provided input on the design of the study, helped interpreting study results, and critically revised the manuscript. All authors have read and approved the final manuscript.None of the authors of this paper have a financial or personal relationship with other people or organizations that could inappropriately influence or bias the content of the paper.